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In Latin America, community-acquired pneumonia remains a major cause of morbidity and mortality among children. Few studies have examined the etiology of pneumonia in Ecuador. This observational study was part of a randomized, double blind, placebo-controlled clinical trial conducted among children aged 2-59 months with severe pneumonia in Quito, Ecuador. Nasopharyngeal and blood samples were tested for bacterial and viral etiology by polymerase chain reaction. Risk factors for specific respiratory pathogens were also evaluated. Among 406 children tested, 159 (39.2%) had respiratory syncytial virus (RSV), 71 (17.5%) had human metapneumovirus (hMPV), and 62 (15.3%) had adenovirus. Streptococcus pneumoniae was identified in 37 (9.2%) samples and Mycoplasma pneumoniae in three (0.74%) samples. The yearly circulation pattern of RSV (P = 0.0003) overlapped with S. pneumoniae, (P = 0.03) with most cases occurring in the rainy season. In multivariable analysis, risk factors for RSV included younger age (adjusted odds ratio [aOR] = 1.9, P = 0.01) and being underweight (aOR = 1.8, P = 0.04). Maternal education (aOR = 0.82, P = 0.003), pulse oximetry (aOR = 0.93, P = 0.005), and rales (aOR = 0.25, P = 0.007) were associated with influenza A. Younger age (aOR = 3.5, P = 0.007) and elevated baseline respiratory rate were associated with HPIV-3 infection (aOR = 0.94, P = 0.03). These results indicate the importance of RSV and influenza, and potentially modifiable risk factors including undernutrition and future use of a RSV vaccine, when an effective vaccine becomes available. ClinicalTrials.gov NCT 00513929.

Background Saudi Arabia is implementing a comprehensive health system transformation in health services provision, governance, and financing. Given the high burden of non-communicable diseases (NCD), a key objective of the transformation is to integrate NCD prevention and treatment into primary care. The study objectives were to assess primary care service use for treatment of NCDs, to quantify existing inequities in preventive services utilization, and to identify regional and sociodemographic factors associated with these inequities. Methods Using the 2019 Kingdom of Saudi Arabia World Health Survey, multivariable logistic regression models were conducted to identify predictors of utilization of primary care services for NCD prevention and treatment, unmet need among those with a diagnosis of diabetes, hypertension, or dyslipidemia, and unmet need in breast and cervical cancer screening. Results Among those with an NCD diagnosis, living in a high-income household was associated with a lower probability of having an unmet need compared to those in low-income households. Furthermore, rural residents were less likely to have an unmet need compared to urban residents (OR 0.58, p =0.029). Individuals without a perceived need for healthcare within the last 12 months had three times the probability of unmet need in comparison to those with such a perceived need ( p <0.001). Women in all regions had a lower probability of ever having a mammogram compared to women in the central regions around Riyadh. Women with an education above a secondary level had five times the odds of undergoing cervical cancer screening and three times the likelihood of ever having a mammogram ( P =0.012, p =0.02) than other women. Compared to women in low-income households, those in middle (OR 1.99, P =0.026), upper middle (OR 3.47, p <0.001), or high-income households (OR 2.59, p <0.001) had a higher probability of having had cervical cancer screening. Conclusions Inequities in NCD treatment and prevention services’ utilization in Saudi Arabia are strongly associated with region of living, population density, wealth, income, education and perceived need for health care. More research is needed to better understand the extent of unmet primary care needs for NCD and how to address the underlying contributing factors to access inequities.

Introduction New or returning antiretroviral therapy (ART) clients are largely ineligible for differentiated service delivery (DSD) models. These clients are at increased risk of treatment interruption and may benefit from flexible care models, but stakeholder buy-in may limit progress on interventions for this population. We qualitatively explored stakeholder perceptions and decision-making criteria for scaling DSD models for new or returning ART clients in Malawi. Methods We conducted in-depth interviews with internationally-based stakeholders (from foundations, multilateral organizations, and non-governmental organizations (NGOs)) and Malawi-based stakeholders (from the Malawi Ministry of Health and local implementing partners). Interviews included two think-aloud scenarios in which participants rated and described their perceptions of (1) the relative priority of five criteria (cost, effectiveness, acceptability, feasibility, and equity) in determining which interventions to implement for new or returning ART clients and (2) the relative priority of seven potential interventions (monetary incentives, non-monetary incentives, community-based care, ongoing peer/mentor support and counseling, eHealth, facility-based interventions, and multi-month dispensing) for the same population. Interviews were completed in English via video conference and were audio-recorded. Transcriptions were coded using ATLAS.ti version 9. We examined the data using thematic content analysis and explored differences between international and national stakeholders. Results We interviewed twenty-two stakeholders between October 2021-March 2022. Thirteen were based internationally and nine were based in Malawi. Both groups prioritized client acceptability, but diverged on other criteria: international stakeholders prioritized effectiveness and Malawi-based stakeholders prioritized cost, feasibility, and sustainability. Both stakeholder groups were most interested in facility-based DSD models such as multi-month dispensing and extended facility hours. Nearly all stakeholders described person-centered care as a critical focus to incorporate into all DSD models. Conclusions National and international stakeholders support DSD models for new or returning ART clients. Client acceptability and sustainability should be prioritized to address the concerns of nationally-based stakeholders. Future studies should explore reasons for differences in national and international stakeholders’ priorities and how to ensure that local perspectives are incorporated into funding and programmatic decisions.

The midwifery model of care is a human rights-based approach (HRBA) that is unique and appropriate for the majority of healthy pregnant women, yet full expression may be limited within the medical model. Midwifery centers are facilities designed specifically to enable the practice of midwifery. In high resource countries, they have been shown to be cost effective, evidence-based, avoid over medicalization, and provide safe, efficient and satisfying care. A quasi-experimental design was used to assess the impact of three models of care on women's experiences of respect, and trust in maternity care provision, both before and during the pandemic in Bangladesh, as well as their fear and knowledge around COVID-19, during the pandemic. The models were: \"fully enabled midwifery\" (\"FEM\") in freestanding midwifery centers; \"midwifery and medicine\" (\"MAM\") in medical facilities with midwives working alongside nurses and doctors; and \"no midwifery\" (\"NoM\") in medical facilities without midwives. Phone survey data were collected and analyzed from all women (n = 1,191) who delivered from Jan 2020-June 2020 at seven health care facilities in Bangladesh. Comparison of means, ANOVA, post hoc Tukey, and effect size were used to explore the differences in outcomes across time periods. Pre-pandemic, women served by the FEM model reported significantly higher rates of trust and respect (p<0·001) compared to the NoM model, and significantly higher rates of trust (p<0·001) compared to MAM. During the pandemic, in the FEM model, the experiences of respect and trust did not change significantly from the pre-pandemic rates, and were significantly higher than both the MAM and NoM models (p < 0·001). Additionally, during the pandemic, women served by the FEM model had the lowest experience of COVID fear (p<0·001). Fully enabled midwifery in midwifery centers had a significantly positive effect on woman's experience of respect and trust in care compared to the other models, even in the context of a pandemic.

Background Hypertension and diabetes impose significant health and economic burdens in low-and middle-income countries like Bangladesh. This study aimed to estimate both direct and indirect costs associated with hypertension and diabetes care in Dinajpur, a rural district of Bangladesh, and identify factors influencing these costs. Methods This cross-sectional study used baseline data from a community survey conducted as part of an ongoing implementation research project. A multistage cluster sampling approach was used to randomly select adults aged 40 years and above from 45 wards across three subdistricts of Dinajpur. The analysis included 832 individuals who reported being on medication for hypertension ( n  = 635) and/or diabetes ( n  = 335). Data were collected through structured questionnaires, capturing direct (medical and non-medical) and indirect costs (productivity losses). Descriptive statistics, Wilcoxon rank-sum, and Kruskal-Wallis tests were used for univariate analyses. Multivariate linear regression models with log-transformed cost data were used to identify cost determinants. Results The average monthly total cost per patient was BDT 1,308 (USD 10.8) for hypertension and BDT 2,064 (USD 17.1) for diabetes. For both conditions, direct medical costs accounted for around 80% of total costs (60% for medicines), direct non-medical costs around 11% (mostly food and travel), and indirect costs approximately 9%. Direct costs were lower at public facilities compared to private dispensaries (Hypertension: GMR 0.46, 95% CI 0.33–0.64; Diabetes: GMR 0.15, 95% CI 0.10–0.24), while higher costs were observed for private clinics and NGO facilities. Level of education was associated with higher direct costs, particularly among patients with primary or secondary or higher education. Comorbidities were also associated with higher direct costs: in hypertension, cardiovascular disease (GMR 1.78, 95% CI 1.35–2.35) and high cholesterol (GMR 2.16, 95% CI 1.49–3.14) increased direct costs, with similar associations for diabetes costs. Indirect costs, reflecting productivity losses, were higher for private clinics, public facilities, and NGO facilities compared to private dispensaries. Conclusions In the sample taken from a rural region from Bangladesh, hypertension and diabetes care entails a considerable financial burden, driven largely by medicine costs and reliance on private healthcare providers. Improved access to essential services and financial protection strategies are needed to reduce out-of-pocket expenditures.

Background More than 80% of the global premature mortality from noncommunicable diseases (NCDs) occurs in low- and middle-income countries (LMICs). Nigeria, like most LMICs, has limited capacity to respond to diabetes and hypertension. As the Lagos State government accelerates the rollout of its mandatory health insurance, Lagos State Health Scheme (LSHS), the number of individuals with diabetes and hypertension seeking care will increase. This study aimed to determine service availability and service readiness for diabetes and hypertension among health facilities providing primary care for these conditions in Lagos State, and to explore the facility characteristics associated with service readiness. Methods We conducted a cross-sectional survey of 84 facilities enrolled in the baseline study of an impact evaluation of the Lagos State Health Scheme. We collected data using relevant modules of the World Health Organization’s Harmonized Health Facility Assessment tool. Service availability was defined as providing diagnosis or treatment for either condition, and service readiness scores were calculated as the proportion of tracer items available and functional at the facility on the survey day. Further, we used a multiple linear regression model to estimate associations between facility characteristics and service readiness. Results Service availability for both conditions was high. The mean diabetes and hypertension service readiness scores were 69% and 66%, respectively. The percentage of fully ready healthcare facilities was very low (2.6% for diabetes and 2.5% for hypertension). The staff and guidelines domain received the lowest score for both conditions. There was no association between service readiness and LSHS empanelment status. Providing only outpatient services had a negative association with service readiness for both conditions. Participation in a quality improvement program had a positive association with hypertension service readiness score. Conclusion While the mean service readiness scores for diabetes and hypertension were moderately high among sampled health facilities, only a very small percentage were fully service ready. There were critical deficits in service readiness domains that must be addressed to ensure the required inputs for high-quality diabetes and hypertension care is available in the State.

Background Healthcare resources have been concentrated in urban areas, leaving rural regions vulnerable to poorer health outcomes. The Problem Solving for Better Health (PSBH) program was implemented to enhance healthcare systems in resource-limited regions by training personnel to maximize existing resources in problem-solving. This study evaluated the implementation effectiveness of PSBH-Nursing (PSBHN), a nationally led initiative to train nurses in PSBH in Lesotho. Methods A mixed-methods study employing a single-group pre-test post-test design was conducted, guided by the RE-AIM theory. Training occurred from November 2021 to June 2022. Nurses completed the Problem-Solving Inventory (PSI) before and 3–6 months after training to measure changes in problem-solving efficacy. Quality scores were assigned to nurses’ planned quality improvement projects; project implementation was assessed 3–6 months after training. In-depth interviews (IDIs) explored changes in knowledge, problem-solving efficacy, and skills. Statistical analyses utilized paired T-tests and logistic regressions using STATA 17; content analysis was conducted on IDIs using NVivo12. Results Of 300 nurses, 89 were trained (30%) in the first year. Mainly medium or high-quality scores were achieved for the project designed. However, among 79 participants, only 49.4% reported initiating their projects. Overall problem-solving efficacy improved 3–6 months after training, but the increase was not statistically significant. Nurses reported improved knowledge, confidence and communication skills, enhanced problem-solving approaches, and increased emotional maturity in solving problems. A one-unit increase in project quality score correlated with a 35.0% increase in the odds of project initiation. Conclusion PSBHN demonstrated improved knowledge and minimal improvement in problem-solving efficacy among nurses 3–6 months post-training. However, application of skills gained in implementing their projects was insufficient. Still, PSBHN shows promise in addressing healthcare challenges in resource-limited settings. Some participants were able to start their projects but the inconsistency in follow-through suggests a need for more research into the factors that can improve completion of implementation for better health outcomes.

Background In India, Accredited Social Health Activists (ASHAs) deliver services for diagnosis and treatment of malaria, although unlicensed medical practitioners (UMPs) (informal health providers) are most preferred in communities. A cross sectional survey was conducted to: (i) assess knowledge and treatment-seeking practices in the community, and (ii) explore the diagnosis and treatment practices related to malaria of UMPs working in rural and tribal-dominated high malaria endemic areas of central India, and whether they adhere to the national guidelines. Methods A multi-stage sampling method and survey technique was adopted. Heads of the households and UMPs were interviewed using a structured interview schedule to assess knowledge and malaria treatment practices. Results Knowledge regarding malaria symptoms was generally accurate, but misconceptions emerged related to malaria transmission and mosquito breeding places. Modern preventive measures were poorly accessed by the households. UMPs were the most preferred health providers (49%) and the first choice in households for seeking treatment. UMPs typically lacked knowledge of the names of malaria parasite species and species-specific diagnosis and treatment. Further, irrational use of anti-malarial drugs was common. Conclusions UMPs were the most preferred type of health care providers in rural communities where health infrastructure is poor. The study suggests enhancing training of UMPs on national guidelines for malaria diagnosis and treatment to strengthen their ability to contribute to achievement of India’s malaria elimination goals.

Background South Africa bears a large HIV burden with 7.8 million people with HIV (PWH). However, due to suboptimal antiretroviral therapy (ART) adherence and retention in care, only 66% of PWH in South Africa are virally suppressed. Standard care only allows for suboptimal adherence detection when routine testing indicates unsuppressed virus. Several adherence interventions are known to improve HIV outcomes, yet few are implemented in routinely due to the resources required. Therefore, determining scalable evidence-based adherence support interventions for resource-limited settings (RLS) is a priority. The multiphase optimization strategy (MOST) framework allows for simultaneous evaluation of multiple intervention components and their interactions. We propose to use MOST to identify the intervention combination with the highest levels of efficacy and cost-effectiveness that is feasible and acceptable in primary care clinics in Cape Town. Methods We will employ a fractional factorial design to identify the most promising intervention components for inclusion in a multi-component intervention package to be tested in a future randomized controlled trial . We will recruit 512 participants initiating ART between March 2022 and February 2024 in three Cape Town clinics and evaluate acceptability, feasibility, and cost-effectiveness of intervention combinations. Participants will be randomized to one of 16 conditions with different combinations of three adherence monitoring components: rapid outreach following (1) unsuppressed virus, (2) missed pharmacy refill collection, and/or (3) missed doses as detected by an electronic adherence monitoring device; and two adherence support components: (1) weekly check-in texts and (2) enhanced peer support. We will assess viral suppression (<50 copies/mL) at 24 months as the primary outcome; acceptability, feasibility, fidelity, and other implementation outcomes; and cost-effectiveness. We will use logistic regression models to estimate intervention effects with an intention-to-treat approach, employ descriptive statistics to assess implementation outcomes, and determine an optimal intervention package. Discussion To our knowledge, ours will be the first study to use the MOST framework to determine the most effective combination of HIV adherence monitoring and support intervention components for implementation in clinics in a RLS. Our findings will provide direction for pragmatic, ongoing adherence support that will be key to ending the HIV epidemic. Trial registration ClinicalTrials.gov NCT05040841. Registered on 10 September 2021.

Background In 2014, Vietnam was the first Southeast Asian country to commit to achieving the World Health Organization’s 90–90-90 global HIV targets (90% know their HIV status, 90% on sustained treatment, and 90% virally suppressed) by 2020. This pledge represented further confirmation of Vietnam’s efforts to respond to the HIV epidemic, one feature of which has been close collaboration with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Starting in 2004, PEPFAR supported community outreach programs targeting high-risk populations (people who inject drugs, men who have sex with men, and sex workers). To provide early evidence on program impact, in 2007–2008 we conducted a nationwide evaluation of PEPFAR-supported outreach programs in Vietnam. The evaluation focused on assessing program effect on HIV knowledge, high-risk behaviors, and HIV testing among high-risk populations—results relevant to Vietnam’s push to meet global HIV goals. Methods We used a mixed-methods cross-sectional evaluation design. Data collection encompassed a quantitative survey of 2199 individuals, supplemented by 125 in-depth interviews. Participants were members of high-risk populations who reported recent contact with an outreach worker (intervention group) or no recent contact (comparison group). We assessed differences in HIV knowledge, risky behaviors, and HIV testing between groups, and between high-risk populations. Results Intervention participants knew significantly more about transmission, prevention, and treatment than comparison participants. We found low levels of injection drug-use-related risk behaviors and little evidence of program impact on such behaviors. In contrast, a significantly smaller proportion of intervention than comparison participants reported risky sexual behaviors generally and within each high-risk population. Intervention participants were also more likely to have undergone HIV testing (76.1% vs. 47.0%, p  < 0.0001) and to have received pre-test (78.0% vs. 33.7%, p  < 0.0001) and post-test counseling (80.9% vs. 60.5%, p  < 0.0001). Interviews supported evidence of high impact of outreach among all high-risk populations. Conclusions Outreach programs appear to have reduced risky sexual behaviors and increased use of HIV testing services among high-risk populations in Vietnam. These programs can play a key role in reducing gaps in the HIV care cascade, achieving the global 90–90-90 goals, and creating an AIDS-free generation.