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Adequate ventilation can reduce the transmission of infection in health-care settings. Natural ventilation can be one of the effective environmental measures to reduce the risk of spread of infections in health care. This guideline first defines ventilation and then natural ventilation. It explores the design requirements for natural ventilation in the context of infection control, describing the basic principles of design, construction, operation and maintenance for an effective natural ventilation system to control infection in health-care settings.

Current WHO guidelines recommend lifelong antiretroviral therapy (ART) for all HIV-positive individuals, including pregnant and breastfeeding women (Option B+) in settings with generalized HIV epidemics. While Option B+ is scaled-up in Kenya, insufficient adherence and retention to care could undermine the expected positive impact of Option B+. To explore challenges to the provision of Option B+ at the health facility level, we conducted forty individual gender-matched in-depth interviews with HIV-positive pregnant/postpartum women and their male partners, and four focus groups with thirty health care providers at four health facilities in western Kenya between September-November 2014. Transcripts were coded with the Dedoose software using a coding framework based on the literature, topics from interview guides, and emerging themes from transcripts. Excerpts from broad codes were then fine-coded using an inductive approach. Three major themes emerged: 1) Option B+ specific challenges (same-day initiation into treatment, health care providers unconvinced of the benefits of Option B+, insufficient training); 2) facility resource constraints (staff and drug shortages, long queues, space limitations); and 3) lack of client-friendly services (scolding of patients, inconvenient operating hours, lack of integration of services, administrative requirements). This study highlights important challenges at the health facility level related to Option B+ rollout in western Kenya. Addressing these specific challenges may increase linkage, retention and adherence to life-long ART treatment for pregnant HIV-positive women in Kenya, contribute towards elimination of mother-to-child HIV transmission, and improve maternal and child outcomes. Les directives actuelles de l’OMS recommandent une thérapie antirétrovirale permanente (ART) pour tous les individus séropositifs, y compris les femmes enceintes et allaintantes (Option Bþ) dans les environnements où l’épidémie de VIH est généralisée. Alors que l’Option Bþest renforcée au Kenya, un recours insuffisant aux soins, et le manque de leur maintien pourraient déstabiliser l’impact positif attendu de l’Option Bþ. Afin d’explorer les défis posés par la dispositin de l’Option Bþau niveau des établissements de santé, nous avons réalisé quarante entretiens individuels approfondis appariés auj genre auprès de femmes enceintes/postpartum séropositives et de leurs partenaires masculins, et organisé quatre groupes de discussion comprenant trente prestataires de soins dans quatre établissements de santé du Kenya occidental entre Septembre et Novembre 2014. Les transcriptions ont été codées à l’aide du logiciel Dedoose utilisant un système de codification basé sur les publications, les sujets tirés des guides des’entretiens, et les thèmes émergeant des notes. Des extraits de codes généraux ont alors été codés finement par ’une approche inductive. Trois thèmes majeurs ont émergé: 1) Défis spécifiques de l’Option Bþ(démarrage du traitement le jour même, prestataires de soins de santé peu convaincus des avantages de l’Option Bþ, formation insuffisante); 2) obstables aux ressources des établissements (pénurie de personnel et de médicaments, longues files d’attente, manque d’espace); 3) manque de services accueillants (réprimande des parents, horaires de fonctionnement peu pratiques, manque d’intégration des services, exigences administratives). Cette étude met l’accent sur les défis importants à relever au niveau des établissements de santé en matière de déploiement de l’Option Bþdans le Kenya occidental. Faire face à ces défis spécifiques peut favoriser le lien, l’adhésion et le maintien d’un traitement ART permanent pour les femmes enceintes séropositives au Kenya, contribuant ainsi à l’élimination de la transmission mère-enfant du VIH, et à l’amélioration des résultats maternels et infantiles. 现行WHO指南建议HIV阳性者终生接受抗逆转录病毒治疗 （ART）, 在HIV普遍流行地区, 妊娠和哺乳妇女也接受治疗 （B+选项）。虽然肯尼亚推广了B+选项, 但治疗依从性和续 检不足会削弱预期的效果。为了探讨卫生机构提供B+选项的 困难, 我们于2014年9月至11月在肯尼亚西部对HIV阳性孕产 妇及其男性伴侣进行了40次性别匹配的深度访谈, 并在四个卫 生机构对30位卫生服务提供者进行了四次焦点小组讨论。记 录采用Dedoose软件编码, 根据文献建立编码框架, 从访谈指 导中获取主题, 以及记录中反复出现的主题。采用归纳法, 对 宽泛编码中摘取的片段进行更细的编码。出现的三大主题 是： 1） B+选项特有的困难 （当天开始治疗、卫生服务提供 者不确信B+选项有益、培训不足）； 2）机构资源限制 （人 员和药物短缺、候诊人数多、空间有限）； 3）缺少对患者友 好的服务 （责骂患者、操作时间不便、服务未整合、行政要 求） 。本研究凸显了在肯尼亚西部, 与推行B+选项相关的卫 生机构层面的重要挑战。应对这些挑战可提高肯尼亚HIV阳 性孕妇对终生ART治疗的初检、续检和依从, 有利于消除HIV 母婴传播, 改善孕产妇和儿童健康。 Las pautas actuales de la OMS recomiendan la terapia antirretroviral (TAR) a lo largo de toda la vida para todas los individuos VIH-positivos, incluyendo las mujeres embarazadas y lactantes (Opción B+) en entornos con epidemias generalizadas de VIH. Si bien la Opción B+ ha sido implementada a escala en Kenia, la insuficiente adherencia y retención en el cuidado podrían debilitar el impacto positivo esperado de la Opción B+. Para explorar los desafíos a la provisión de la Opción B+ a nivel de la instalación de salud, llevamos a cabo cuarenta entrevistas individuales en profundidad con mujeres VIH-positivas embarazadas/postparto y sus parejas masculinas, y cuatro grupos focales con treinta proveedores de cuidado de la salud en cuatro instalaciones de salud en el oeste de Kenia entre septiembre y noviembre de 2014. Las transcripciones se codificaron con el software Dedoose usando un marco de codificación basado en la literatura, guías de temas de las entrevistas y temas emergentes de las transcripciones. Los extractos de los códigos amplios fueron codificados con precisión mediante un enfoque inductivo. Surgieron tres temas principales: 1) desafíos específicos a la Opción B+(iniciación del tratamiento el mismo día, proveedores de cuidado de la salud no convencidos de los beneficios de la Opción B+, formación insuficiente); 2) limitaciones de recursos de la instalación (escasez de personal y medicamentos, largas filas, limitaciones de espacio); y 3) falta de servicios amigables con el cliente (reprimendas de los pacientes, horarios de funcionamiento inconvenientes, falta de integración de servicios, requisitos administrativos). Este estudio destaca desafíos importantes a nivel de los establecimientos de salud relacionados con la Opción B+ implementada en el oeste de Kenia. Abordar estos desafíos específicos puede aumentar la vinculación, la retención y la adherencia al tratamiento de TAR para toda la vida de las mujeres embarazadas VIH-positivas en Kenia, contribuir a la eliminación de la transmisión del VIH de madre a hijo y mejorar los resultados maternos e infantiles.

Background Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities. Methods This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high). Results Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high. Conclusion Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.

All women should have access to high quality maternity services—but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.

Background Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)–US study. Methods Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables. Results Of eligible participants ( n  = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment. Conclusion This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

A routine health information system is one of the essential components of a health system. Interventions to improve routine health information system data quality and use for decision-making in low- and middle-income countries differ in design, methods, and scope. There have been limited efforts to synthesise the knowledge across the currently available intervention studies. Thus, this scoping review synthesised published results from interventions that aimed at improving data quality and use in routine health information systems in low- and middle-income countries. We included articles on intervention studies that aimed to improve data quality and use within routine health information systems in low- and middle-income countries, published in English from January 2008 to February 2020. We searched the literature in the databases Medline/PubMed, Web of Science, Embase, and Global Health. After a meticulous screening, we identified 20 articles on data quality and 16 on data use. We prepared and presented the results as a narrative. Most of the studies were from Sub-Saharan Africa and designed as case studies. Interventions enhancing the quality of data targeted health facilities and staff within districts, and district health managers for improved data use. Combinations of technology enhancement along with capacity building activities, and data quality assessment and feedback system were found useful in improving data quality. Interventions facilitating data availability combined with technology enhancement increased the use of data for planning. The studies in this scoping review showed that a combination of interventions, addressing both behavioural and technical factors, improved data quality and use. Interventions addressing organisational factors were non-existent, but these factors were reported to pose challenges to the implementation and performance of reported interventions.

Timely initiation of antenatal care (ANC) is an important component of ANC services that improve the health of the mother and the newborn. Mothers who begin attending ANC in a timely manner, can fully benefit from preventive and curative services. However, evidence in sub-Saharan Africa (sSA) indicated that the majority of pregnant mothers did not start their first visit timely. As our search concerned, there is no study that incorporates a large number of sub-Saharan Africa countries. Thus, the objective of this study was to assess the prevalence of timely initiation of ANC and its associated factors in 36 sSA countries. The Demographic and Health Survey (DHS) of 36 sSA countries were used for the analysis. The total weighted sample of 233,349 women aged 15-49 years who gave birth in the five years preceding the survey and who had ANC visit for their last child were included. A multi-level logistic regression model was used to examine the individual and community-level factors that influence the timely initiation of ANC. Results were presented using adjusted odds ratio (AOR) with 95% confidence interval (CI). In this study, overall timely initiation of ANC visit was 38.0% (95% CI: 37.8-38.2), ranging from 14.5% in Mozambique to 68.6% in Liberia. In the final multilevel logistic regression model:- women with secondary education (AOR = 1.08; 95% CI: 1.06, 1.11), higher education (AOR = 1.43; 95% CI: 1.36, 1.51), women aged 25-34 years (AOR = 1.20; 95% CI: 1.17, 1.23), ≥35 years (AOR = 1.30; 95% CI: 1.26, 1.35), women from richest household (AOR = 1.19; 95% CI: 1.14, 1.22), women perceiving distance from the health facility as not a big problem (AOR = 1.05; 95%CI: 1.03, 1.07), women exposed to media (AOR = 1.29; 95%CI: 1.26, 1.32), women living in communities with medium percentage of literacy (AOR = 1.51; 95%CI: 1.40, 1.63), and women living in communities with high percentage of literacy (AOR = 1.56; 95%CI: 1.38, 1.76) were more likely to initiate ANC timely. However, women who wanted their pregnancy later (AOR = 0.84; 95%CI: 0.82, 0.86), wanted no more pregnancy (AOR = 0.80; 95%CI: 0.77, 0.83), and women residing in the rural area (AOR = 0.90; 95%CI: 0.87, 0.92) were less likely to initiate ANC timely. Even though the WHO recommends all women initiate ANC within 12 weeks of gestation, sSA recorded a low overall prevalence of timely initiation of ANC. Maternal education, pregnancy intention, residence, age, wealth status, media exposure, distance from health facility, and community-level literacy were significantly associated with timely initiation of ANC. Therefore, intervention efforts should focus on the identified factors in order to improve timely initiation of ANC in sSA. This can be done through the providing information and education to the community on the timing and importance of attending antenatal care and family planning to prevent unwanted pregnancy, especially in rural settings.

High-quality obstetric delivery in a health facility reduces maternal and perinatal morbidity and mortality. This systematic review synthesizes qualitative evidence related to the facilitators and barriers to delivering at health facilities in low- and middle-income countries. We aim to provide a useful framework for better understanding how various factors influence the decision-making process and the ultimate location of delivery at a facility or elsewhere. We conducted a qualitative evidence synthesis using a thematic analysis. Searches were conducted in PubMed, CINAHL and gray literature databases. Study quality was evaluated using the CASP checklist. The confidence in the findings was assessed using the CERQual method. Thirty-four studies from 17 countries were included. Findings were organized under four broad themes: (1) perceptions of pregnancy and childbirth; (2) influence of sociocultural context and care experiences; (3) resource availability and access; (4) perceptions of quality of care. Key barriers to facility-based delivery include traditional and familial influences, distance to the facility, cost of delivery, and low perceived quality of care and fear of discrimination during facility-based delivery. The emphasis placed on increasing facility-based deliveries by public health entities has led women and their families to believe that childbirth has become medicalized and dehumanized. When faced with the prospect of facility birth, women in low- and middle-income countries may fear various undesirable procedures, and may prefer to deliver at home with a traditional birth attendant. Given the abundant reports of disrespectful and abusive obstetric care highlighted by this synthesis, future research should focus on achieving respectful, non-abusive, and high-quality obstetric care for all women. Funding for this project was provided by The United States Agency for International Development (USAID) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization.

BackgroundThe ability to capture the complexities of healthcare practices and the quick turnaround of findings make rapid ethnographies appealing to the healthcare sector, where changing organisational climates and priorities require actionable findings at strategic time points. Despite methodological advancement, there continue to be challenges in the implementation of rapid ethnographies concerning sampling, the interpretation of findings and management of field research. The purpose of this review was to explore the benefits and challenges of using rapid ethnographies to inform healthcare organisation and delivery and identify areas that require improvement.MethodsThis was a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the Mixed Methods Appraisal Tool to assess the quality of the articles. We developed the search strategy using the Population, Intervention, Comparison, Outcomes, Settingframework and searched for peer-reviewed articles in MEDLINE, CINAHL PLUS, Web of Science and ProQuest Central. We included articles that reported findings from rapid ethnographies in healthcare contexts or addressing issues related to health service use.Results26 articles were included in the review. We found an increase in the use of rapid ethnographies in the last 2‰years. We found variability in terminology and developed a typology to clarify conceptual differences. The studies generated findings that could be used to inform policy and practice. The main limitations of the studies were: the poor quality of reporting of study designs, mainly data analysis methods, and lack of reflexivity.ConclusionsRapid ethnographies have the potential to generate findings that can inform changes in healthcare practices in a timely manner, but greater attention needs to be paid to the reflexive interpretation of findings and the description of research methods.Trial registration numberCRD42017065874.

Lack of access to functional and hygienic toilets in healthcare facilities (HCFs) is a significant public health issue in low- and middle-income countries (LMICs), leading to the transmission of infectious diseases. Globally, there is a lack of studies characterising toilet conditions and estimating user-to-toilet ratios in large urban hospitals in LMICs. We conducted a cross-sectional study in 10-government and two-private hospitals to explore the availability, functionality, cleanliness, and user-to-toilet ratio in Dhaka, Bangladesh. From Aug-Dec 2022, we undertook infrastructure assessments of toilets in selected hospitals. We observed all toilets and recorded attributes of intended users, including sex, disability status, patient status (in-patient/out-patient/caregiver) and/or staff (doctor/nurse/cleaner/mixed-gender/shared). Toilet functionality was defined according to criteria used by the WHO/UNICEF Joint-Monitoring Programme in HCFs. Toilet cleanliness was assessed, considering visible feces on any surface, strong fecal odor, presence of flies, sputum, insects, and rodents, and solid waste. Amongst 2875 toilets, 2459 (86%) were observed. Sixty-eight-percent of government hospital toilets and 92% of private hospital toilets were functional. Only 33% of toilets in government hospitals and 56% in private hospitals were clean. A high user-to-toilet ratio was observed in government hospitals' outpatients service (214:1) compared to inpatients service (17:1). User-to-toilet ratio was also high in private hospitals' outpatients service (94:1) compared to inpatients wards (19:1). Only 3% of toilets had bins for menstrual-pad disposal and <1% of toilets had facilities for disabled people. A high percentage of unclean toilets coupled with high user-to-toilet ratio hinders the achievement of SDG by 2030 and risks poor infection-control. Increasing the number of usable, clean toilets in proportion to users is crucial. The findings suggest an urgent call for attention to ensure basic sanitation facilities in Dhaka's HCFs. The policy makers should allocate resources for adequate toilets, maintenance staff, cleanliness, along with strong leadership of the hospital administrators.