Search

Implementation research (IR) has proved to be a potential catalyst in facilitating the uptake of evidence-based innovations into routine practices and thereby maximizing public health outcomes. IR not only focuses on the effectiveness of the innovations but also identifies and addresses the barriers and facilitators to maximize their uptake into routine practices. This article describes the processes undertaken to implement a research project aimed at promoting access and rational use of antibiotics for children (PARAC). It also provides an overview of the lessons learnt during its implementation in Tanzanian hospital and community settings.

Background In 2017, Tanzania launched the National Action Plan for Antimicrobial Resistance (NAPAR), 2017–2022 and implementation of antibiotic stewardship programmes (ASPs) was one of the agendas. Since the launch of the National Action Plan, no study has been done to assess its implementation. Objectives To explore the experiences of prescribers and dispensers on implementing ASPs among paediatric patients attending Regional Referral Hospitals (RRHs) in Tanzania. Methods An exploratory qualitative study was conducted among key informants, in 14 RRHs in Tanzania between July and August 2020. A total of 28 key informants, 14 dispensers in charge of pharmacies and 14 medical doctors in charge of paediatric departments (prescribers), were interviewed. A hybrid thematic analysis was conducted on the gathered information. Results Most of the study participants were not conversant with the term ‘antibiotic stewardship’. Some had heard about the programmes but were not aware of the activities involved in the programme. Those who were knowledgeable on ASPs mentioned the lack of existence of such programmes in their settings. They further added that absence or limited knowledge of the stewardship concepts may have influenced the current poor practices. Barriers to the implementation of ASPs mentioned were lack of laboratory facilities to support culture and susceptibility tests, lack of materials and reagents, management pressure to prevent loss or to generate income, patients’ influence and limited training opportunities. Conclusions Despite launching the NAPAR in 2017, we found limited implementation of ASPs in the management of paediatric patients. This study highlighted some barriers and identified possible intervention points.

UNICEF operates in 190 countries and territories, where it advocates for the protection of children’s rights and helps meet children’s basic needs to reach their full potential. Embedded implementation research (IR) is an approach to health systems strengthening in which (a) generation and use of research is led by decision-makers and implementers; (b) local context, priorities, and system complexity are taken into account; and (c) research is an integrated and systematic part of decision-making and implementation. By addressing research questions of direct relevance to programs, embedded IR increases the likelihood of evidence-informed policies and programs, with the ultimate goal of improving child health and nutrition.This paper presents UNICEF’s embedded IR approach, describes its application to challenges and lessons learned, and considers implications for future work.From 2015, UNICEF has collaborated with global development partners (e.g. WHO, USAID), governments and research institutions to conduct embedded IR studies in over 25 high burden countries. These studies focused on a variety of programs, including immunization, prevention of mother-to-child transmission of HIV, birth registration, nutrition, and newborn and child health services in emergency settings. The studies also used a variety of methods, including quantitative, qualitative and mixed-methods.UNICEF has found that this systematically embedding research in programs to identify implementation barriers can address concerns of implementers in country programs and support action to improve implementation. In addition, it can be used to test innovations, in particular applicability of approaches for introduction and scaling of programs across different contexts (e.g., geographic, political, physical environment, social, economic, etc.). UNICEF aims to generate evidence as to what implementation strategies will lead to more effective programs and better outcomes for children, accounting for local context and complexity, and as prioritized by local service providers. The adaptation of implementation research theory and practice within a large, multi-sectoral program has shown positive results in UNICEF-supported programs for children and taking them to scale.

In this study the authors examine the relationship between “zero-dose” communities and access to other healthcare services. This was done by first ensuring the first dose of the Diphtheria Tetanus and Pertussis vaccine was a better measure of zero-dose communities than the measles-containing vaccine. Once the best variable was selected, it was used to examine the association with access to primary healthcare services for children and pregnant women residing in the Democratic Republic of Congo, Afghanistan, and Bangladesh, each of which are currently experiencing emergencies of various contexts and degrees. These services were divided into: a) unscheduled healthcare services such as birth assistance as well as seeking care and treatment for diarrheal diseases and cough/fever episodes and b) other scheduled health services such as antenatal care visits and vitamin A supplementation. Using the most recent Demographic Health Survey data from each country (2014: Democratic Republic of Congo, 2015: Afghanistan, 2018: Bangladesh), data was analyzed via Chi Squared analysis or Fischer’s Exact Test. If results were significant, a univariate linear regression analysis was performed to examine if the noted association was linear. While the linear relationship observed between children who had received the first dose of the Diphtheria Tetanus and Pertussis vaccine (the reverse to zero-dose communities) and coverage of other vaccines was expected, the results of the regression analysis depicted an unexpected split in behavior between scheduled (and birth assistance) and unscheduled illness treatment services. For scheduled and birth assistance health services, a linear relationship was generally observed. Meanwhile, for unscheduled services associated with infectious disease treatments, a linear relationship was generally not observed. While in our study it does not appear that first dose of the Diphtheria Tetanus and Pertussis vaccine, the best proxy of zero-dose communities, can be used to predict (at least in a direct linear manner) access to some primary (particularly infectious treatments) healthcare services in emergency/ humanitarian settings, it can serve as an indirect measure of health services not associated with the treatment of childhood infections such as antenatal care, skilled birth assistance, and to a lesser degree even vitamin A supplementation.

BackgroundThe health status of Rohingya refugees or Forcibly Displaced Myanmar Nationals (FDMNs), especially women and children, is a significant challenge for humanitarian workers in Bangladesh. Though the Government of Bangladesh, in partnership with other organizations, is offering health care services to FDMNs, a comprehensive understanding of the program implementation is required for continuation in the future. This study explores the challenges and potential solutions for effective implementation of maternal, newborn, and child health (MNCH) programs for FDMNs residing in camps of Cox's Bazar, Bangladesh.MethodsWe conducted a qualitative study conducted in Cox's Bazar district, Bangladesh, which involved 34 interviews (15 key informant interviews and 19 in-depth interviews) with relevant persons working in organizations responsible for MNCH services to FDMNs. We relied on both inductive and deductive coding and applied the Consolidated Framework for Implementation Research (CFIR) as a guide to our thematic analysis and presentation of qualitative data.ResultsOur study identified some key challenges hindering the effective implementation of MNCH service delivery for the FDMNs. High turnover and poor retention of staff, overlapping of service, weak referral mechanism, complex health information system, and lack of security of the front line health providers were some of the key challenges identified. Motivating the health workers, task shifting, capacity building on emergency obstetric care, training CHW & TBA on danger signs, and ensuring the security of the workers are the potential solutions suggested by the respondents. Selecting a few indicators and the introduction of E-tracker can harmonize the health information system.ConclusionProviding healthcare in an emergency setting has several associated challenges. Considering the CFIR as the base for identifying different challenges and their potential solutions at a different level of the program can prove to be an excellent asset for the program implementers in designing their plans. Two additional domains, context, and security should be included in the CFIR framework for any humanitarian settings.

To assess the costs associated with the provision of services for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus in two African countries.In 2009, the costs to health-care providers of providing comprehensive PMTCT services were assessed in 20 public health facilities in Namibia and Rwanda. Information on prices and on the total amount of each service provided was collected at the national level. The costs of maternal testing and counselling, male partner testing, CD4+ T-lymphocyte (CD4+ cell) counts, antiretroviral prophylaxis and treatment, community-based activities, contraception for 2 years postpartum and early infant diagnosis were estimated in United States dollars (US$).The estimated costs to the providers of PMTCT, for each mother-infant pair, were US$202.75-1029.55 in Namibia and US$94.14-342.35 in Rwanda. These costs varied with the drug regimen employed. At 2009 coverage levels, the maximal estimates of the national costs of PMTCT were US$3.15 million in Namibia and US$7.04 million in Rwanda (orUS$0.75 per capita in both countries). Adult testing and counselling accounted for the highest proportions of the national costs (37% and 74% in Namibia and Rwanda, respectively), followed by management and supervision. Treatment and prophylaxis accounted for less than 20% of the costs of PMTCT in both study countries.The costs involved in the PMTCT of HIV varied widely between study countries and in accordance with the protocols used. However, since per-capita costs were relatively low, the scaling up of PMTCT services in Namibia and Rwanda should be possible.Évaluer les coûts associés à la prestation de services pour la prévention de la transmission mère-enfant (PTME) du virus de l'immunodéficience humaine dans deux pays africains.En 2009, les coûts pour les prestataires de soins liés à l'offre de services complets de PTME ont été évalués dans 20 établissements de santé publics en Namibie et au Rwanda. Des informations sur les prix et sur le montant total de chaque service fourni ont été recueillies au niveau national. Les coûts des conseils fournis et des tests réalisés par les mères, des dépistages des partenaires masculins, des comptages des lymphocytes-T CD4+ (cellules CD4+), de la prophylaxie et du traitement antirétroviral ou encore des activités communautaires, de la contraception pendant 2 ans après l'accouchement et du diagnostic précoce des nourrissons ont été estimés en dollars.Les coûts pour les prestataires de PTME, pour chaque couple mère-enfant, ont été estimés à 202,75-1029,55 dollars en Namibie et à 94,14-342,35 dollars au Rwanda. Ces coûts variaient selon le protocole médicamenteux utilisé. Au niveau de la couverture atteinte en 2009, les coûts nationaux maximum de la PTME ont été estimés à 3,15 millions de dollars en Namibie et à 7,04 millions de dollars au Rwanda (soit0,75 dollars par habitant dans les deux pays). Les conseils fournis et les tests réalisés par les adultes ont représenté la plus grande proportion des coûts nationaux (37% et 74% en Namibie et au Rwanda, respectivement), suivis du traitement médical et de la surveillance. Le traitement et la prophylaxie ont représenté moins de 20% des coûts de la PTME dans les deux pays étudiés.Les coûts liés à la PTME du VIH ont varié considérablement d'un pays étudié à l'autre et selon les protocoles utilisés. Toutefois, étant donné que les coûts par habitant ont été relativement faibles, l'intensification des services de PTME en Namibie et au Rwanda devrait être possible.Evaluar los costes asociados con la prestación de servicios para la prevención de la transmisión maternofilial del virus de la inmunodeficiencia humana en dos países africanos.En el año 2009 se evaluaron los costes de los proveedores de atención sanitaria que prestaban servicios completos de prevención de la transmisión maternofilial en 20 centros sanitarios públicos en Namibia y Rwanda. La información sobre los precios y sobre la cantidad total de cada servicio prestado se recogió a nivel nacional. Los costes de las pruebas y el asesoramiento materno, las pruebas para las parejas masculinas, los recuentos de linfocitos T CD4+ (células CD4+), el tratamiento y profilaxis antirretrovirales, las actividades comunitarias, los anticonceptivos durante 2 años después del parto y el diagnóstico precoz de lactantes se calcularon en dólares americanos (US$).Para cada par madre-hijo, los costes estimados de los proveedores de servicios para prevenir la transmisión maternofilial fueron de US$ 202,75–1029,55 en Namibia y US$ 94,14–342,35 en Rwanda. Estos costes variaron según la terapia empleada. En los niveles de cobertura del 2009, las estimaciones máximas de los costes nacionales de la prevención de la transmisión maternofilial fueron de US$ 3,15 millones en Namibia y US$ 7,04 millones en Rwanda (oUS$ 0,75 per cápita en ambos países). Las pruebas y el asesoramiento de adultos representaron la mayor parte de los costes nacionales (37% en Namibia y 74% en Rwanda), seguidos por la gestión y la supervisión. El tratamiento y la profilaxis significaron menos del 20% de los costes de la prevención de la transmisión maternofilial en ambos países.Los costes implicados en la prevención de la transmisión maternofilial del VIH variaron mucho entre los países de estudio y según los protocolos empleados. Sin embargo, puesto que los costes per cápita fueron relativamente bajos, sí sería posible ampliar los servicios de prevención de la transmisión maternofilial tanto en Namibia como el Rwanda.تقييم التكاليف المرتبطة بتقديم الخدمات من أجل الوقاية من انتقال فيروس العوز المناعي البشري من الأم إلى الطفل (PMTCT) في بلدين أفريقيين.في عام 2009، تم تقييم التكاليف التي يتكبدها مقدمو الرعاية الصحية في تقديم خدمات الوقاية من انتقال العدوى من الأم إلى الطفل في 20 مرفقاً صحياً عمومياً في ناميبيا ورواندا. وتم جمع المعلومات الخاصة بالأسعار وبالمبلغ الإجمالي لكل خدمة مقدمة على الصعيد الوطني. وتم تقدير تكاليف فحوصات الأمومة وإسداء المشورة والفحوصات التي تجرى على الشريك الذكر وإحصاء الخلايا اللمفاوية التائية المساعدة (CD4+) والوقاية والعلاج بمضادات الفيروسات القهقرية والأنشطة المجتمعية واستعمال وسائل منع الحمل لمدة سنتين بعد الوضع والتشخيص المبكر للرضع بالدولار الأمريكي.بلغت التكاليف التي تكبدها مقدمو خدمات الوقاية من انتقال فيروس العوز المناعي البشري من الأم إلى الطفل عن كل أم ورضيعها وفق التقديرات ما بين 202.75 إلى 1029.55 دولاراً أمريكياً في ناميبيا وما بين 94.14 إلى 342.35 دولاراً أمريكياً في رواندا. واختلفت هذه التكاليف باختلاف النظام الدوائي المستخدم. وعلى مستويات التغطية في عام 2009، بلغت أقصى تقديرات للتكاليف الوطنية للوقاية من انتقال العدوى من الأم إلى الطفل 3.15 مليون دولار أمريكي في ناميبيا و7.04 مليون دولار أمريكي في رواندا (أو أكثر من 0.75 دولاراً أمريكياً للفرد في كلا البلدين). وتُعزى أعلى نسب التكاليف الوطنية (37 % و74 % في ناميبيا ورواندا، على التوالي) إلى فحوصات البالغين وإسداء المشورة، يليها التدبير العلاجي والإشراف. ويُعزى أقل من 20 % من تكاليف الوقاية من انتقال العدوى من الأم إلى الطفل في كلا بلدي الدراسة إلى العلاج والوقاية.اختلفت تكاليف الوقاية من انتقال فيروس العوز المناعي البشري من الأم إلى الطفل على نحو واسع بين بلدي الدراسة وحسب البروتوكولات المستخدمة. ولكن نظراً للانخفاض النسبي في التكاليف لكل فرد، ينبغي أن يكون تعجيل خدمات الوقاية من الانتقال العدوى من الأم إلى الطفل في ناميبيا ورواندا أمراً ممكناً.评估两?非洲国家提供预防母婴艾滋病毒传播（PMTCT）服务的相关成本。2009 年，对纳米比亚和卢旺达20 个公共卫生设施中卫生保健提供者提供全面PMTCT服务的成本进行评估。在国家层面上收集所提供每项服务的价格信息和合计金额。孕产妇检测和咨询、男性伴侣检测、CD4+T淋巴细胞（CD4+细胞）计数、抗逆转?病毒预防和治疗、社区活动、产后2 年避孕和婴儿早期诊?的成本以美元估计。纳米比亚每对母婴PMTCT的提供者的估计成本在是202.75-1029.55 美元，卢旺达是94.14-342.35 美元。这些成本因采用的用药方案而异。在2009 年的覆盖率水平下，PMTCT的最高估计成本在纳米比亚是315 万美元，在卢旺达是704 万美元（或两个国家人均都0.75 美元）。成人检测和咨询在全国成本中所占的比例最高（纳米比亚为37%，卢旺达?74%），其次是管理和监督。在这?个研究国家中，治疗和预防仅占PMTCT不到20%的成本比率。HIV的PMTCT所涉及的成本被研究国家之间差异很大，并与所使用的方案一致。然而，由于人均成本相对?低，在纳米比亚和卢旺达?大PMTCT服务规模应?是可能的。Оценить расходы, связанные с предоставлением услуги по профилактике передачи ВИЧ инфекции от матери к ребенку (ППВМР) в двух африканских странах.В 2009 году проведена оценка расходов медицинских учреждений, предоставляющих комплексные услуги по ППВМР, в 20 учреждениях общественного здравоохранения Намибии и Руанды. Сбор информации по ценам и общей стоимости каждой предоставляемой услуги проводился на национальном уровне. Стоимость проведения консультации и анализа на ВИЧ у матерей, анализа на ВИЧ у партнеров (мужчин), показателя числа CD4+ Т-лимфоцитов (CD4+ клеток), профилактики и лечения антиретровирусными препаратами, предоставления услуг по месту жительства, противозачаточных мероприятий в течении двух лет после родов и ранняя диагностика у детей оценивалась в долларах США.Подсчитанные расходы медицинских учреждений, предоставляющих услуги по ППВМР, из расчета на каждую пару мать-ребенок, составили 202,75–1029,55 долларов США в Намибии и 94,14–342,35 долларов США в Руанде. Эти расходы варьируются в зависимости от используемой схемы приема лекарственных средств. Исходя из величины покрытия в 2009 году, максимальная оценка расходов по ППВМР составила 3,15 миллионов долларов США в Намибии и 7,04 миллионов долларов США в Руанде (или 0,75 на душу населения в обеих странах). На проведение консультаций и анализов на ВИЧ у взрослых приходится наибольшая доля государственных расходов (37% и 74% в Намибии и Руанде, соответственно), за которыми следуют лечение и наблюдение. На лечение и профилактику приходится менее 20% всех расходов на ППВМР в обеих странах.Расходы на услуги по профилактике передачи ВИЧ инфекции от матери к ребенку широко варьируются в исследованных странах и в зависимости от программы действий. Однако так как стоимость услуг на душу населения была относительно низкой, расширение масштабов предоставления услуг по ППВМР в Намибии и Руанде представляется возможным.

Introduction: We sought to compare risk of death among children aged under-2 years born to HIV positive mother (HIV-exposed) and to HIV negative mother (HIV non-exposed), and identify determinants of under-2 mortality among the two groups in Rwanda. Methods: In a stratified, two-stage cluster sampling design, we selected mother-child pairs using national Antenatal Care (ANC) registers. Household interview with each mother was conducted to capture socio-demographic data and information related to pregnancy, delivery and post-partum. Data were censored at the date of child death. Using Cox proportional hazard model, we compared the hazard of death among HIV-exposed children and HIV nonexposed children. Results: Of 1,455 HIV-exposed children, 29 (2.0%; 95% CI: 1.3%-2.7%) died by 6 months compared to 18 children of the 1,565 HIV non-exposed children (1.2%; 95% CI: 0.6%-1.7%). By 9 months, cumulative risks of death were 3.0% (95%; CI: 2.2%-3.9%) and 1.3% (96%; CI: 0.7%-1.8%) among HIV-exposed and HIV non-exposed children, respectively. By 2 years, the hazard of death among HIVexposed children was more than 3 times higher (aHR:3.5; 95% CI: 1.8-6.9) among HIV-exposed versus non-exposed children. Risk of death by 9-24 months of age was 50% lower among mothers who attended 4 or more antenatal care (ANC) visits (aHR: 0.5, 95% CI: 0.3-0.9), and 26% lower among families who had more assets (aHR: 0.7, 95% CI: 0.5-1.0). Conclusion: Infant mortality was independent of perinatal HIV exposure among children by 6 months of age. However, HIV-exposed children were 3.5 times more likely to die by 2 years. Fewer antenatal visits, lower household assets and maternal HIV seropositive status were associated with increased mortality by 9-24 months. Key words: HIV, PMTCT, maternal HIV infection, infant mortality, child mortality, under-five mortality, Rwanda

Background Operational effectiveness of large-scale national programmes for the prevention of mother to child transmission (PMTCT) of HIV in sub-Saharan Africa remains limited. We report on HIV-free survival among nine- to 24-month-old children born to HIV-positive mothers in the national PMTCT programme in Rwanda. Methods We conducted a national representative household survey between February and May 2009. Participants were mothers who had attended antenatal care at least once during their most recent pregnancy, and whose children were aged nine to 24 months. A two-stage stratified (geographic location of PMTCT site, maternal HIV status during pregnancy) cluster sampling was used to select mother-infant pairs to be interviewed during household visits. Alive children born from HIV-positive mothers (HIV-exposed children) were tested for HIV according to routine HIV testing protocol. We calculated HIV-free survival at nine to 24 months. We subsequently determined factors associated with mother to child transmission of HIV, child death and HIV-free survival using logistic regression. Results Out of 1448 HIV-exposed children surveyed, 44 (3.0%) were reported dead by nine months of age. Of the 1340 children alive, 53 (4.0%) tested HIV positive. HIV-free survival was estimated at 91.9% (95% confidence interval: 90.4-93.3%) at nine to 24 months. Adjusting for maternal, child and health system factors, being a member of an association of people living with HIV (adjusted odds ratio: 0.7, 95% CI: 0.1-0.995) improved by 30% HIV-free survival among children, whereas the maternal use of a highly active antiretroviral therapy (HAART) regimen for PMTCT (aOR: 0.6, 95% CI: 0.3-1.07) had a borderline effect. Conclusions HIV-free survival among HIV-exposed children aged nine to 24 months is estimated at 91.9% in Rwanda. The national PMTCT programme could achieve greater impact on child survival by ensuring access to HAART for all HIV-positive pregnant women in need, improving the quality of the programme in rural areas, and strengthening linkages with community-based support systems, including associations of people living with HIV.

Background Mother-to-child transmission (MTCT) of HIV has been eliminated from the developed world with the introduction of multi-drug antiretroviral (md-ARV) regimens for the prevention of MTCT (PMTCT); but remains the major cause of HIV infection among sub-Saharan African children. This study compares two service delivery models of PMTCT interventions and documents the lessons learned and the challenges encountered during the transition from single-dose nevirapine (sd-nvp) to md-ARV regimens in a resource-limited setting. Methods Program data collected from 32 clinical sites was used to describe trends and compare the performance (uptake of HIV testing, CD4 screening and ARV regimens initiated during pregnancy) of sites providing PMTCT as a stand-alone service (stand-alone site) versus sites providing PMTCT as well as antiretroviral therapy (ART) (full package site). CD4 cell count screening, enrolment into ART services and the initiation of md-ARV regimens during pregnancy, including dual (zidovudine [AZT] +sd-nvp) prophylaxis and highly active antiretroviral therapy (HAART) were analysed. Results From July 2006 to December 2008, 1,622 pregnant women tested HIV positive (HIV+) during antenatal care (ANC). CD4 cell count screening during pregnancy increased from 60% to 70%, and the initiation of md-ARV regimens increased from 35.5% to 97% during this period. In 2008, women attending ANC at full package sites were 30% more likely to undergo CD4 cell count assessment during pregnancy than women attending stand-alone sites (relative risk (RR) = 1.3; 95% confidence interval (CI): 1.1-1.4). Enrolment of HIV+ pregnant women in ART services was almost twice as likely at full package sites than at stand-alone sites (RR = 1.9; 95% CI: 1.5-2.3). However, no significant differences were detected between the two models of care in providing md-ARV (RR = 0.9; 95% CI: 0.9-1.0). Conclusions All sites successfully transitioned from sd-nvp to md-ARV regimens for PMTCT. Full package sites offer the most efficient model for providing immunological assessment and enrolment into care and treatment of HIV+ pregnant women. Strengthening the capacity of stand-alone PMTCT sites to achieve the same objectives is paramount.