Background: Introduction of artemisinin combination therapy (ACT) has boosted interest in parasite-based malaria diagnosis, leading to increased use of rapid diagnostic tests (RDTs), particularly in rural settings where microscopy is limited. With donor support, national malaria control programmes are now procuring large quantities of RDTs. The scarcity of health facilities and trained personnel in many sub-Saharan African countries means that limiting RDT use to such facilities would exclude a significant proportion of febrile cases. RDT use by volunteer community health workers (CHWs) is one alternative, but most sub-Saharan African countries prohibit CHWs from handling blood, and little is known about CHW ability to use RDTs safely and effectively. This Zambia-based study was designed to determine: (i) whether Zambian CHWs could prepare and interpret RDTs accurately and safely using manufacturer's instructions alone; (ii) whether simple, mostly pictorial instructions (a "job aid") could raise performance to adequate levels; and (iii) whether a brief training programme would produce further improvement.

Objective Delivery by a skilled birth attendant (SBA) serves as an indicator of progress towards reducing maternal mortality worldwide -the fifth Millennium Development Goal. Though WHO tracks the proportion of women delivered by SBAs, we know little about their competence to manage common life-threatening obstetric complications. We assessed SBA competence in five high maternal mortality settings as a basis for initiating quality improvement. Methods The WHO Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines served as our competency standard. Evaluation included a written knowledge test, partograph (used to record all observations of a woman in labour) case studies and assessment of procedures demonstrated on anatomical models at five skills stations. We tested a purposive sample of 166 SBAs in Benin, Ecuador, Jamaica and Rwanda (Phase I). These initial results were used to refine the instruments, which were then used to evaluate 1358 SBAs throughout Nicaragua (Phase II). Findings On average, Phase I participants were correct for 56% of the knowledge questions and 48% of the skills steps. Phase II participants were correct for 62% of the knowledge questions. Their average skills scores by area were: active management of the third stage of labour -46%; manual removal of placenta -52%; bimanual uterine compression -46%; immediate newborn care -71%; and neonatal resuscitation -55%. Conclusion There is a wide gap between current evidence-based standards and provider competence to manage selected obstetric and neonatal complications. We discuss the significance of that gap, suggest approaches to close it and describe briefly current efforts to do so in Ecuador, Nicaragua and Niger. Une traduction en français de ce résumé figure à la fin de l'article. Al final del artículo se facilita una traducción al español.Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward Introduction BackgroundEach year obstetric complications kill over 500 000 women worldwide. 1,2Skilled attendance during labour, delivery and in the early postpartum period could prevent many of these deaths, though establishing a causal link between skilled attendance and maternal survival remains problematic.2-6 Still, the proportion of deliveries assisted by a skilled birth attendant (SBA) has become an indicator for measuring maternal mortality reduction, including the 75% reduction called for by the fifth Millennium Development Goal (MDG-5). 7,8 WHO defines an SBA as someone "trained to proficiency in the skills needed to manage normal (uncomplicated) But are skilled birth attendants really skilled? Do the health personnel enumerated by household surveys fit WHO's definition? This question was the focus of our two-phase study. In Phase I, we developed and piloted evaluation instruments, then carried out small-scale competency assessments in four countries. In Phase II, shortcomings identified in Phase I were corrected and the revised instruments used to conduct a large...

Malaria rapid diagnostic tests (RDTs) could radically improve febrile illness management in remote and low-resource populations. However, reliance upon community health workers (CHWs) remains controversial because of concerns about blood safety and appropriate use of artemisinin combination therapy. This study assessed CHW ability to use RDTs safely and accurately up to 12 months post-training. We trained 65 Zambian CHWs, and then provided RDTs, job-aids, and other necessary supplies for village use. Observers assessed CHW performance at 3, 6, and 12 months post-training. Critical steps performed correctly increased from 87.5% at 3 months to 100% subsequently. However, a few CHWs incorrectly read faint positive or invalid results as negative. Although most indicators improved or remained stable over time, interpretation of faint positives fell to 76.7% correct at 12 months. We conclude that appropriately trained and supervised CHWs can use RDTs safely and accurately in community practice for up to 12 months post-training.

BackgroundDespite targeted indoor residual spraying (IRS) over a six-year period and free mass distribution of long-lasting insecticide-treated nets (ITNs), malaria rates in northern Ghana remain high. Outdoor sleeping and other night-time social, cultural and economic activities that increase exposure to infective mosquito bites are possible contributors. This study was designed to document these phenomena through direct observation, and to explore the context in which they occur.MethodsDuring the late dry season months of February and March 2014, study team members carried out continuous household observations from dusk to dawn in one village in Ghana’s Northern Region and one in Upper West Region. In-depth interviews with health workers and community residents helped supplement observational findings.ResultsStudy team members completed observations of 182 individuals across 24 households, 12 households per site. Between the two sites, they interviewed 14 health workers, six community health volunteers and 28 community residents. In early evening, nearly all study participants were observed to be outdoors and active. From 18.00-23.00 hours, socializing, night school, household chores, and small-scale economic activities were common. All-night funerals, held outdoors and attended by large numbers of community members, were commonly reported and observed. Outdoor sleeping was frequently documented at both study sites, with 42% of the study population sleeping outdoors at some time during the night. While interviewees mentioned bed net use as important to malaria prevention, observed use was low for both indoor and outdoor sleeping. Net access within households was 65%, but only 17% of those with access used a net at any time during the night. Participants cited heat as the primary barrier and reported higher net use during the rainy season.DiscussionOutdoor sleeping and other night-time activities were extensive, and could significantly increase malaria risk. These findings suggest that indoor-oriented control measures such as ITNs and IRS are insufficient to eliminate malaria in this setting, especially given the low net use observed. Development and evaluation of complementary outdoor control strategies should be prioritized. A research agenda is proposed to quantify the relative risk of outdoor night-time activities and test potential vector control interventions that might reduce that risk.

Poor quality of antenatal care is likely to reduce its utilization. Policy and program interventions to improve the quality of care of antenatal care, especially for the poor and other disadvantaged population groups, more so in north India, are essential to improve maternal health outcomes. The India's National Rural Health Mission (NRHM), launched in 2005, should lay greater emphasis on improving the quality of antenatal care, among other things, to increase utilization of antenatal care and achieve better maternal health outcomes.

Many households in low- and middle-income countries cook with inefficient biomass-burning stoves, which cause high levels of household air pollution and threaten long-term health. Although clean stoves and fuels are available, uptake and consistent use has been low. Using observations and in-depth interviews, we assessed the attitudes, preferences, and beliefs about traditional versus liquefied petroleum gas (LPG) stoves in rural Puno, Peru. A total of 31 in-depth interviews were conducted with primary cooks and their families, health workers, community leaders, and improved stove contractors. Six in-home observations of meal preparation were also conducted. Six major barriers to consistent use of clean stoves were identified: (1) perceived differences in food taste and nutrition by stove type; (2) cooking niches filled by different stoves; (3) social norms related to cooking practices; (4) safety concerns; (5) comparative costs of using different stoves; and (6) lack of awareness and concern about long-term health risks. These findings suggest that to successfully reduce household air pollution, clean cooking programs and policies must consider the many factors influencing adoption beyond health, such as cost, taste, fears, and cultural traditions. These factors could be incorporated into community-based and national efforts to scale-up sustained and exclusive adoption of clean cooking.

The usefulness of rapid diagnostic tests (RDT) in malaria case management depends on the accuracy of the diagnoses they provide. Despite their apparent simplicity, previous studies indicate that RDT accuracy is highly user-dependent. As malaria RDTs will frequently be used in remote areas with little supervision or support, minimising mistakes is crucial. This paper describes the development of new instructions (job aids) to improve health worker performance, based on observations of common errors made by remote health workers and villagers in preparing and interpreting RDTs, in the Philippines and Laos. Initial preparation using the instructions provided by the manufacturer was poor, but improved significantly with the job aids (e.g. correct use both of the dipstick and cassette increased in the Philippines by 17%). However, mistakes in preparation remained commonplace, especially for dipstick RDTs, as did mistakes in interpretation of results. A short orientation on correct use and interpretation further improved accuracy, from 70% to 80%. The results indicate that apparently simple diagnostic tests can be poorly performed and interpreted, but provision of clear, simple instructions can reduce these errors. Preparation of appropriate instructions and training as well as monitoring of user behaviour are an essential part of rapid test implementation.

BackgroundParticipatory health initiatives ideally support progressive social change and stronger collective agency for marginalized groups. However, this empowering potential is often limited by inequalities within communities and between communities and outside actors (i.e. government officials, policymakers). We examined how the participatory initiative of Village Health, Sanitation, and Nutrition Committees (VHSNCs) can enable and hinder the renegotiation of power in rural north India.MethodsOver 18 months, we conducted 74 interviews and 18 focus groups with VHSNC members (including female community health workers and local government officials), non-VHSNC community members, NGO staff, and higher-level functionaries. We observed 54 VHSNC-related events (such as trainings and meetings). Initial thematic network analysis supported further examination of power relations, gendered “social spaces,” and the “discourses of responsibility” that affected collective agency.ResultsVHSNCs supported some re-negotiation of intra-community inequalities, for example by enabling some women to speak in front of men and perform assertive public roles. However, the extent to which these new gender dynamics transformed relations beyond the VHSNC was limited. Furthermore, inequalities between the community and outside stakeholders were re-entrenched through a “discourse of responsibility”: The comparatively powerful outside stakeholders emphasized community responsibility for improving health without acknowledging or correcting barriers to effective VHSNC action. In response, some community members blamed peers for not taking up this responsibility, reinforcing a negative collective identity where participation was futile because no one would work for the greater good. Others resisted this discourse, arguing that the VHSNC alone was not responsible for taking action: Government must also intervene. This counter-narrative also positioned VHSNC participation as futile.ConclusionsInterventions to strengthen participation in health systems can engender social transformation. However they must consider how changing power relations can be sustained outside participatory spaces, and how discourse frames the rationale for community participation.