Factors found to be important in this study are similar to those from earlier studies in rural areas. While the data indicate that financial incentives are the most commonly discussed factor regarding CHW retention in urban slums, the results also suggest other avenues that could be strengthened to improve their retention.

Despite growing recognition of the importance of linking obstetric fistula prevention and treatment strategies with rehabilitation and social reintegration programmes, little research and programming has been oriented toward this goal. Using in-depth interviews, this study aimed to examine the experiences of 51 Ethiopian women after fistula repair surgery to identify priority post-repair interventions that could maximise their quality of life. The results showed that the majority of women felt a dramatic sensation of relief and happiness following repair, yet some continued to experience mental anguish, stigma, and physical problems regardless of the outcome of the procedure. All women suffered intense fear of developing another fistula, most commonly from sex or childbirth. Despite this, the majority of women had sex or planned to do so, while a smaller cohort avoided intercourse and childbearing, thus subjecting them to isolation, marital conflict, and/or economic vulnerability. Our findings suggest that obstetric fistula programmes should integrate (1) post-repair counselling about fistula and risk factors for recurrence, (2) community-based follow-up care, (3) linkages to income-generating opportunities, (4) engagement of women affected by fistula for community outreach, and (5) metrics for evaluating rehabilitation and social reintegration efforts to ensure women regain healthy, productive lives.

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Provision of Implanon at the community level through community health workers is effective in reaching women with the greatest need for contraception.

With increased access to HIV treatment throughout Africa, a generation of HIV positive children is now transitioning to adulthood while living with a chronic condition requiring lifelong medication, which can amplify the anxieties of adolescence. This qualitative study explored how adolescents in Tanzania with HIV experience their nascent sexuality, as part of an evaluation of a home-based care programme. We interviewed 14 adolescents aged 15-19 who had acquired HIV perinatally, 10 of their parents or other primary caregivers, and 12 volunteer home-based care providers who provided support, practical advice, and referrals to clinical services. Adolescents expressed unease about their sexuality, fearing that sex and relationships were inappropriate and hazardous, given their HIV status. They worried about having to disclose their status to partners, the risks of infecting others and for their own health. Thus, many anticipated postponing or avoiding sex indefinitely. Caregivers and home-based care providers reinforced negative views of sexual activity, partly due to prevailing misconceptions about the harmful effects of sex with HIV. The adolescents had restricted access to accurate information, appropriate guidance, or comprehensive reproductive health services and were likely to experience significant unmet need as they initiated sexual relationships. Care programmes could help to reduce this gap by facilitating open communication about sexuality between adolescents and their caregivers, providers, and HIV-positive peers.

The study assessed the impact of an EPI (Expanded Programme on Immunization) intervention package, implemented within the existing service-delivery system, to improve the child immunization coverage in urban slums of Dhaka, Bangladesh. This intervention trial used a pre- and post-test design. An intervention package was tested from September 2006 to August 2007 in two urban slums. The intervention package included: (a) an extended EPI service schedule; (b) training for service providers on valid doses and management of side-effects; (c) a screening tool to identify immunization needs among clinic attendants; and (d) an EPI support group for social mobilization. Data were obtained from random sample surveys, service statistics and qualitative interviews. Analysis of quantitative data was based on a 'before and after' assessment of selected immunization-coverage indicators. Qualitative data were analysed using content analysis. Ninety-nine per cent of the children were fully immunized after implementation of the interventions compared with only 43% before implementation. Antigen-wise coverage after implementation was also significantly higher compared with before implementation. Only 1% drop-out was observed after implementation of the interventions while it was 33% before implementation. At baseline, a significantly higher proportion of children of non-working mothers (75%) were fully immunized compared with children of working mothers (14%). Although the proportion of fully immunized children of both non-working and working mothers was significantly higher at endline, fully immunized children of working mothers dramatically improved at endline (99%) compared with baseline (14%). The findings suggest the effectiveness of a 'package of interventions' in improving child immunization coverage in urban slums. However, further research is needed to fully assess the effectiveness of the package, to assess the individual components in order to identify those that make the biggest contribution to coverage, and to assess the sustainability of this package within the existing service delivery system, particularly on a wider scale.

BackgroundVolunteer community health workers (CHWs) are a key approach to improving community-based maternal and child health services in developing countries. BRAC, a large Bangladeshi non-governmental organization (NGO), has employed female volunteer CHWs in its community-based health programs since 1977, recently including its Manoshi project, a community-based maternal and child health intervention in the urban slums of Bangladesh. A case–control study conducted in response to high dropout rates in the first year of the project showed that financial incentives, social prestige, community approval and household responsibilities were related to early retention in the project. In our present prospective cohort study, we aimed to better understand the factors associated with retention of volunteer CHWs once the project was more mature.MethodsWe used a prospective cohort study design to examine the factors affecting retention of volunteer CHWs who remained in the project after the initial start-up period. We surveyed a random sample of 542 CHWs who were working for BRAC Manoshi in December 2008. In December 2009, we revisited this cohort of CHWs and interviewed those who had dropped out about the main reasons for their dropping out. We used a multivariable generalized linear model regression analysis with a log link to estimate the relative risk (RR) of independent factors on retention.ResultsOf the 542 CHWs originally enrolled, 120 had dropped out by the end of one year, mainly because they left the slums. CHWs who received positive community appraisal (adjusted RR = 1.45, 95% confidence interval (CI) = 1.10 to 1.91) or were associated with other NGOs (adjusted RR = 1.13, 95% CI = 1.04 to 1.23) were more likely to have been retained in the project. Although refresher training was also associated with increased retention (adjusted RR = 2.25, 95% CI = 1.08 to 4.71) in this study, too few CHWs had not attended refresher training regularly to make it a meaningful predictor of retention that could be applied in the project setting.ConclusionFactors that affect retention of CHWs may change over time, with some factors that are important in the early years of a project losing importance as the project matures. Community health programs operating in fragile urban slums should consider changing factors over program duration for better retention of volunteer CHWs.

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