Participatory design approaches to develop global health interventions have gained traction in recent years. However, while broad frameworks for the application of design approaches exist, literature outlining concrete experiences of and guidance for navigating specific design challenges remains limited. This article proposes a design framework based on our own experiences when applying human-centered design principles to bolster sustainable hypertension medication financing in rural Uganda. In our case study, we embedded an mHealth platform within a community-led health intervention aiming to fund blood pressure medication through a shared financial pooling system. Over the course of this project and in close collaboration with intervention end-users, we developed a design framework that outlines challenges, decision-making processes, and design solutions. We iteratively refined the framework between November 2021 and April 2023 over two phases of extensive formative research and one phase of structured qualitative data collection, consisting of 55 in-depth interviews and 4 focus group discussions with clients with hypertension, health care providers, and key intervention stakeholders. The resulting MILEPOST framework consists of 7 domains to consider amid mHealth intervention co-development: medical (e.g., health challenge scope and management); interpersonal (e.g., communication, decision-making, and trust within and across communities); logistical (e.g., current processes and sustainable implementation pathways); ethical (e.g., research and implementation ethics); political (e.g., stakeholder buy-in and long-term support); scientific (e.g., rigorous and feasible approaches for data collection, management, and analysis); and technical (e.g., mHealth component development, refinement, and implementation). We define each domain, provide examples of design challenges and derived solutions as they emerged in our work, and outline starting points for operationalizing each domain in other contexts or studies. We discuss how MILEPOST can provide guidance to researchers and implementors by contributing specific and actionable insights for participatory health intervention design efforts.
BACKGROUND:HIV case management supports people living with HIV to be linked to and retained in care. HIV case management becomes virtual case management (VCM) when some or all these services are provided via virtual tools or platforms including mobile phones, chat messenger apps, other mobile or web apps, and/or electronic case management systems. The COVID-19 pandemic accelerated the use and expansion of virtual services, including health services, across the globe. PROGRAM DESCRIPTION:These case studies document how HIV programs in Indonesia and Nepal transitioned from in-person case management to VCM during the COVID-19 pandemic in 2020. As part of this transition, the program in Nepal implemented VCM in 37 districts that were providing services to 12,820 people living with HIV (PLHIV), and in Indonesia the program supported 18,244 PLHIV in 5 districts. Data on the transition from in-person support to VCM were collected on client clinical outcomes, costs of the virtual services, and case manager feedback. RESULTS:These case studies indicate that VCM is a feasible and affordable approach to implement in low- and middle-income country contexts. Between March and September 2020, 10,995 (82.1%) and 3,801 (51.5%) PLHIV in Nepal and Indonesia, respectively, were supported by VCM. Continuity of care remained high in both countries with only 1%-2% interruptions in treatment. Viral load suppression also remained high in both countries (91%-92% in Indonesia and 94%-95% in Nepal). Viral load coverage, however, was low, but this was influenced by clinic and laboratory closures. Startup costs were low (<US$2,500), and the monthly cost per person to provide VCM was $2.34 in Nepal and $4.67 in Indonesia. Case manager feedback was focused on compensation, expanded reach of virtual services, gaps in client mobile phone ownership or digital literacy, efficiency of services, and confidentiality and privacy. CONCLUSION:VCM has transformative potential to expand the reach of health services and provide differentiated options, meeting clients' preferences and needs. The experiences and lessons learned from these two case studies can guide the implementation of future VCM programs in other countries.
BACKGROUND:South African men have lower HIV testing uptake than their female counterparts, leading to lower antiretroviral treatment (ART) uptake and higher HIV-related mortality. A recent cluster-randomized trial in a high HIV prevalence area in Cape Town showed that relaying the "undetectable equals untransmittable" (U=U) message to South African men increased their HIV testing uptake compared to issuing standard testing invitations. We conducted an economic analysis based on this trial to inform decision-making regarding implementing U=U messaging in routine public-sector HIV care. METHODS:We analyzed the mean cost of the U=U intervention and its intermediate cost-effectiveness over the control arm. Costs were estimated from trial expenditure data in 2020 South African rand (ZAR), converted using March 2020 US$ exchange rates. Shared trial costs were allocated to each arm based on participant volume or days of operation; capital costs, including the creation of the U=U message via human-centered design workshops, were annualized over 8 years. In a second scenario, trial cost was adjusted for potential implementation in routine care. RESULTS:Peer promoters delivered 504 U=U invitations to test for HIV over 7 intervention days and 544 standard invitations over 5 control days in March 2020. Compared with standard invitations, men who received U=U messaging had 60% increased odds of getting tested for HIV. The average trial cost was $5.40 per U=U message delivered ($2.35 after adjustment for routine implementation), $388.47 per person testing HIV-positive ($168.99 adjusted), and $906.44 per person initiating ART ($394.31 adjusted). Within trial costs, staff, overhead, and research costs were the largest allocations, with each accounting for 20% to 30% of total costs. After routine implementation adjustment, the costs of message creation via human-centered design workshops, personnel (peer promoters, research staff), and supplies were the largest allocations. Cost of U=U messaging per person confirmed HIV-positive and initiating ART was lower than conventional HIV testing messaging and at the lower end of cost ranges of HIV self-test distribution models targeted at men ($62 to $7,936 per person confirmed positive and $117 to $8,198 per person initiating ART) established in previous work. CONCLUSION:Delivering tailored U=U messaging can increase HIV testing and ART uptake among men while saving costs over standard untargeted HIV testing messaging and other HIV self-test distribution models.
INTRODUCTION:Structural and service delivery barriers such as long waiting times, health care provider attitudes, and distance from services prevent access to HIV prevention and pre-exposure prophylaxis (PrEP) services, particularly for young people. The World Health Organization recommends differentiated service delivery models for HIV prevention and treatment services, including through mobile outreach. Mobile health clinics offer an opportunity to overcome barriers to service access by bringing services closer to places of work or study, improving convenience, minimizing stigma, and expanding the choice of service delivery locations and types. METHODS:We conducted a mixed-methods study describing a mobile service delivery model for HIV prevention and PrEP services in 3 provinces in South Africa. The study used routine program monitoring and evaluation data from 35,375 men and women aged ≥15 years accessing services at project fixed facility and mobile clinic sites between January 2019 and October 2022, in addition to data from 74 in-depth interviews with a purposively selected sample of adolescent girls and young women aged 15-24 years and men aged ≥15 years enrolled in a nested study cohort. RESULTS:Overall, 11,687 people were reached through mobile clinics between January 2019 and October 2022, of whom the majority were female (89.3%) and between 15-24 years (82.8%). Nearly all (96.0%) mobile clinic clients received an HIV test and 80.8% initiated oral PrEP, similar to HIV testing and PrEP initiation rates at the fixed facilities. Health care users demonstrated a high level of satisfaction with mobile health services, with benefits including a reduction in trips to fixed facilities, improved privacy, and reduced waiting times. However, some participants noted challenges with mobile services, including inconsistent schedules. CONCLUSION:Mobile health services with youth-friendly staff have the potential to reach young people in need of HIV prevention services and are feasible and acceptable in the South African setting. Mobile health services offered benefits such as convenience, privacy, and reduced need to travel to clinics, although they could be enhanced through improved consistency of services.
BACKGROUND:The health care system is a critical entry point for sexual violence response including care and linkages to auxiliary services. However, detailed data on quality and readiness of facility-based sexual violence care in African settings is sparse, hindering measurement and improvements. METHODS:We report results from the first wave of longitudinal mixed-methods study conducted between July and September 2022 to assess readiness and quality of sexual violence services in 4 counties in Kenya supported by the Accelerate program. Health facility assessments were conducted within all (N=123) program-supported facilities in the 4 counties, including provider interviews; visual inspection and audit of essential infrastructure and commodities; and chart abstraction. We computed descriptive data summaries, and in-depth interviews from 40 purposively selected providers were analyzed thematically. RESULTS:Of 123 study facilities, 54% had a provider who received GBV in-service training in the past 12 months. Most facilities (85%) routinely offered GBV care. Of facilities offering GBV care, most stocked antibiotic for sexually transmitted infections (STIs) (71%), any emergency contraception pill (ECP) option (88%), and tetanus vaccine (93%), and most provided GBV counseling (90%). However, availability of hepatitis B vaccine was low across facility tiers (14%-25%). Dispensaries/clinics documented low availability of HIV post-exposure prophylaxis (PEP) for children and adults (20% and 47%, respectively), SGBV register (20%), and post-rape care forms (27%). Of 285 abstracted charts, most were in hospitals (62%) and for survivors under 18 years (69%). Just 59% of survivors presented promptly, within 3 days, for health care services. Of survivors who were eligible for care, a considerable proportion missed psychosocial assessment (32%), PEP for HIV (22%), ECP (17%), and treatment for bacterial STIs (15%). Qualitative data revealed service delivery gaps driven by disruptions in supplies and provider capacity gaps. Many providers indicated concerns in the chain of evidence due to gaps in documentation and logistical support for health care providers when providing legal testimony in courts. CONCLUSIONS:Readiness to provide a minimum care package for sexual violence was low, with steep gradients across facility tiers. Delivery of timely and quality-assured sexual violence care requires addressing structural gaps driven by stock-out of supplies and inadequate providers' support including training. These corrective actions should be augmented by community-based interventions that link survivors to health care.
BACKGROUND:Community health workers (CHWs), most of whom are women, are the bedrock of primary health care provision in much of the world. CHWs are often employed at the bottom of health hierarchies where they have little voice; in state programs and vertical initiatives, accountability has generally flowed downwards. Yet many programs might function better if CHWs' needs and ideas were considered in program design. METHODS:From 2020-2022, we implemented a human-centered design process called IMPACT with CHWs working on polio vaccination in one district of Pakistan. The name IMPACT draws from the steps in the process: Identify problems and brainstorm innovations; Make and refine ideas; Present and evaluate ideas; and ACT to disseminate and implement. We held a facilitated competition for teams of CHWs, all of whom were women, to propose policy improvements to polio vaccination. In total, 417 CHWs participated in the design process facilitated by our team, and more than 500 additional CHWs participated in sessions facilitated by local supervisors. We worked with local policymakers to short-list the best ideas. Teams of CHWs presented the short-listed ideas to a panel of provincial and national-level policymakers, who selected ideas for implementation. We conducted interviews with CHWs and policymakers throughout the process to understand their experiences (n=82). RESULTS:We received 181 idea submissions over two rounds of the process; 9 ideas were chosen for implementation. CHWs valued the process enormously; most said it was the first time their insights had been considered, and they wanted more opportunities for such input. The second round of the process was more effective than the first, with workers generating more complex ideas and program staff running workshops themselves. We heard, across management levels, that the process had positively impacted CHW motivation and confidence. Overall, the innovations selected for implementation were in the form of adjustments rather than major programmatic changes. Yet CHWs reported that the changes made were helpful and that it was very meaningful to have contributed to program policy. CONCLUSION:IMPACT facilitated substantive engagement and collaboration from both male supervisors and frontline female workers in a highly gender-stratified setting. Structured processes can allow the least powerful actors in global health interventions to draw on their frontline experience to suggest policy innovations.
Digital health technologies have untapped potential to transform community health systems, and they are underutilized for chronic HIV care and electronic data management in low- and middle-income countries. We describe the design, development, and use of a mobile health application in community-based HIV prevention, care, and treatment programs implemented in Ethiopia since 2017. Initially, these programs utilized aggregate data collection methods, which were fragmented, non-uniform, and largely paper-based, posing challenges to data quality and data use. Local software developers applied user-centered methods to build a Unified Data System (UDS), an innovative digital health solution aimed at standardizing case management and routine data collection procedures. Developers involved end-users, including frontline community health workers (CHWs) and program managers, in the design and development process. They also conducted field visits to understand and assess user activities and needs. Developers and program staff conducted field testing, and they made design changes iteratively to incorporate user feedback. Local implementing partners deployed 950 CHWs to use the UDS for HIV service delivery and client-level data collection offline. Data were stored centrally in the CommCare HQ web service backed by a local analytics server. The UDS was linked to Power BI for advanced data analytics and visualization. Data validation tests were performed prior to indicator computation and reporting to the next level. 1,766 mobile accounts were opened for CHWs, of which 1,628 (92.2%; 95% confidence interval [CI]=90.8%, 93.4%) have submitted data. An additional 368 of 392 web accounts (93.9%; 95% CI=91.0%, 96.0%) have been used by program managers and monitoring and evaluation experts to access the dashboard. The UDS has eliminated the tedious, manual, paper-based work associated with data (dis)aggregation and reporting by frontline CHWs and local implementing partners. Hence, the number of days to access client-level data by the local partners was reduced from 1 month to just 1 day, and the time to report on activity performance was shortened from 5 days to a half-day. Data completeness was nearly 100% and data validation tests demonstrated no invalid data elements or errors. Generally, there was a high degree of digital health technology utilization by frontline CHWs and local implementing partners for standardized HIV care, high-quality data collection, and making data-informed decisions. Lessons learned from the UDS implementation could be adapted not only to support community HIV programming but also to strengthen national electronic community health information systems.
INTRODUCTION:The experiences of people who interact with a health system form a key component of overall quality of care in that system. Yet, client experience is rarely reflected in how health systems are designed and assessed. To make meaningful progress on delivering high-quality patient-centered care, health systems actors need valid measures of client experience of care. However, no cross-cutting measure of client experience of care exists at present that could facilitate measurement and benchmarking across multiple health service areas. METHODS:We conducted a phased literature search using multiple scholarly databases to identify peer-reviewed articles detailing the development, validation, or adaptation of measures relating to the concept of client experience in sexual and reproductive health care, HIV, primary care, noncommunicable disease management, and health services management and marketing. Measure domains were thematically analyzed and mapped against domains of an existing client experience of care framework-effective communication, respect and dignity, and emotional support. RESULTS:We identified 73 articles that met inclusion criteria and that recounted the development, validation, or adaptation of 61 different measures of health care quality and responsiveness. Numerous measures exhibited significant overlap with an existing conceptual framework for client experience, but few measures were used across health areas. DISCUSSION:Content of many of the measures identified in this review mapped closely to domains that appear in an existing framework for client experience of care, including effective communication, respect and dignity, and emotional support. These findings support the notion that developing a generalizable measure of client experience of care could be technically feasible.
INTRODUCTION:Tobacco endgame seeks to bring an end to tobacco use or drastically reduce prevalence to less than 5%. Discussions about tobacco endgame and the possible strategies to achieve this goal in sub-Saharan African are sparse. This study aimed to explore sub-Saharan African tobacco control stakeholders' perspectives about tobacco endgame and ascertain what strategies they perceive to be suitable for the region to achieve this goal. METHODS:This qualitative study involved a purposive sample of 29 stakeholders interviewed via online platforms guided by a semi-structured interview schedule. Stakeholders were from academia, civil society, and government departments in 12 sub-Saharan African countries. Interviews were conducted in English or French, transcribed verbatim (those in French were then translated to English), and thematically analyzed with the aid of NVivo version 12 software. RESULTS:There is support for the adoption of tobacco endgame in sub-Saharan Africa by tobacco control stakeholders in the region due to the negative impact of tobacco on health, the environment, and economy. Proposed endgame approaches for the region were recommended to be Afrocentric and sensitive to cultural and regional dynamics. Stakeholders believed that the success of endgame strategies depends on political will, multisectoral collaboration, availability of resources, buy-in from the public, and monitoring of the tobacco industry. Suggested endgame strategies were categorized into 5 themes: (1) product-focused (less addictive tobacco and regulation of novel products); (2) user-focused (smoke-free generation, cessation support, and promotion of sports); (3) market/supply-focused (licensing of sellers, increase in taxes, control of illicit trade, and alternative income for farmers); (4) institutional structure-focused (tobacco industry monitoring and regulation); and (5) legislation implementation-focused (effective implementation of international treaties aimed at lowering tobacco use prevalence). CONCLUSION:There is support for a tobacco endgame in sub-Saharan Africa. Collaboration from various departments/ministries and support from government and the public would be needed to make tobacco endgame a reality in the region.
BACKGROUND:Large-scale food fortification is a widely applied strategy to address micronutrient deficiencies, and in Kenya, all industrially processed and packaged maize flour is mandated to be fortified with micronutrients. However, policymakers lack information regarding the population's readiness to procure fortified foods. This study aims to measure the purchase rate of packaged (and presumably fortified) maize flour among households in two Kenyan cities and assess how food environment, household characteristics, and individual shopper perceptions influence consumption of this product. METHODS:We conducted a survey of 1,507 households in urban and peri-urban Kisumu and Nairobi from May to June 2022 to gather information on food purchases, food-shopping behavior, awareness of fortification, and household demographics and socioeconomic status. Between June and August 2022, we conducted a census of food outlets to characterize the households' home food environment. To analyze the data, we first conducted a descriptive analysis with statistics disaggregated by study-region, household poverty status, and/or status as a consumer of packaged maize flour. We then used a probit regression to determine the differential influence of various factors on the households' likelihood of purchasing packaged (presumably fortified) maize flour. RESULTS:Across Kisumu and Nairobi, 67% of households purchased packaged maize flour, with higher rates seen in urban and peri-urban Nairobi (68% and 70%, respectively) and lower rates seen in urban and peri-urban Kisumu (50% and 34%, respectively). While almost 100% of households had some access to packaged maize flour in their home food environment, the density of outlets that sell this product varied from 12/km2 in peri-urban Kisumu to 54/km2 in urban Nairobi. Moreover, households that purchased packaged maize flour resided in neighborhoods with approximately 11 more outlets/km2, on average, than other households. The local price premium charged for packaged maize flour compared to unpackaged maize flour was a negative and statistically significant driver of the purchase decision. CONCLUSIONS:If the goal is to enhance the population's uptake of fortified maize meal, the government should encourage the private sector to invest more in food outlets that sell packaged maize flour; reduce the retail cost of packaged maize flour; raise awareness of the benefits of fortification (particularly in peri-urban Kisumu); and make relevant technologies available at the scale of smaller mills.
The Uganda Public Health Fellowship Program (UPHFP) is a 2-year, non-degree-granting field epidemiology training program. It enrolls only post-Master's degree fellows, who are integrated during their training into key Ministry of Health (MOH) programs, such as the National Malaria Control Program, and supported technically and financially by the U.S. President's Malaria Initiative (PMI) and U.S. Centers for Disease Control and Prevention. However, the nature and extent of the UPHFP contributions to the malaria control programs have not been systematically documented. We describe how the UPHFP strategies contributed to malaria control programs and share implementation challenges and opportunities to inform future programming. From 2015 to 2022, UPHFP led or supported 50 malaria projects, including 14 malaria surveillance projects, 11 malaria outbreak investigations, 7 epidemiological studies, 5 case studies, 6 malaria quality improvement projects, 3 policy briefs, and 4 training and mentorship projects. These projects have informed policy decisions and strengthened surveillance, coordination, and response to malaria outbreaks. A key challenge is single-source funding that makes the program more vulnerable to changes in donor priorities. Our documentation demonstrates the critical value of UPHFP to the country's malaria control efforts by enhancing epidemiologic workforce capacity and strengthening epidemiological surveillance.
BACKGROUND:Promoting client-centered care (CCC) has been a long-standing goal for sexual and reproductive health (SRH) programs. MSI Reproductive Choices (MSI), a global SRH service delivery organization, set out to fully operationalize CCC delivery utilizing a new strategic framework and measurement approach. DEVELOPMENT OF THE APPROACH:The framework was developed by a global technical group at MSI, based on a literature review, country pilots in Nepal and Zambia, and practical experience in service delivery and quality improvement. It is based on a socioecological model, recognizing that SRH client experience is determined by the behavior of the provider, the managerial support given to providers, and the broader organizational culture. The accompanying composite CCC metric assesses performance across these 3 levels annually using program monitoring tools. A digital results dashboard links to a suite of guidance and tools to support CCC improvement. LESSONS LEARNED:SRH programs in 28 countries have been monitoring their progress on CCC since 2021, and a majority have made improvements in their CCC performance since then. Using the annual CCC results, global support staff and country managers have selected interventions based on local needs, including CCC training, client feedback systems, and client experience checklists. Implementation of a global staff engagement survey has been instrumental in CCC measurement, complementing preexisting client exit interview and quality audit processes. A global CCC monitoring process allows sharing of successes and positive practice, and staff have supported and championed CCC. CONCLUSION:Recognizing the critical influences of provider support and engagement as well as broader organizational culture has been pivotal in scaled operationalization of CCC within SRH programs. The simple framework and accompanying metric can be adapted to fit available tools and data systems in other institutions to support attainment of the highest standards of quality care and respect for client rights.
Introduction: Many pregnancy-related deaths can be avoided if health care workers reliably provide prompt, evidence-based care during the final stages of pregnancy and delivery. We report the impact on the institutional maternal mortality ratio (iMMR) of a quality improvement (QI) initiative that focused on establishing timely and reliable obstetric care in public Brazilian hospitals for the primary causes of maternal deaths.Methods: The QI initiative used a quasi-experimental time-series design implemented in 19 Brazilian maternity hospitals comparing 3 periods: baseline (January 2018 to November 2019), implementation (December 2019 to March 2021), and post-implementation (April 2021 to September 2021). We used a sequential approach, referred to as the "4Rs" (Recognize, Rescue, Reassess, and Refer), with the Modified Early Obstetric Warning Score (MEOWS) as a key tool, to identify clinical deterioration and implement care bundles directed at the management of 3 principal life-threatening conditions around the time of birth: postpartum hemorrhage, sepsis, and hypertensive disorders of pregnancy (HDPs). Clinical staff received tailored training and support within a structured learning system that brought multiple teams together to rapidly test and implement evidence-based changes.Results: Comparing the baseline with the implementation period, run charts detected an overall reduction of 34.2% in all causes of maternal deaths (from 83.7 to 55 deaths per 100,000 live births). Additionally, the iMMR due to the 3 analyzed life-threatening conditions decreased by 60.9% between baseline and the combined implementation and post-implementation periods (from 44.1 to 17.2 deaths per 100,000 live births); postpartum hemorrhage-related deaths were reduced by 72.9% (from 11.7 to 3.17 deaths per 100,000 live births) and sepsis-related deaths were reduced by 100% (from 20.4 to 0 deaths per 100,000 liv births). No changes by HDP-related deaths were observed. There was a 178% increase in iMMR by all causes (mainly attributed to COVID-19) during the post-implementation period, but deaths related to life-threatening conditions either remained stable or decreased even further.Conclusion: Optimization of the steps in a care sequence and reliable implementation of care bundles directed at the principal life-threatening conditions around the time of birth, using QI, tailored training, and the MEOWS tool, seem to be feasible and promising approaches for reducing iMMR.
In response to the 2020 COVID-19 pandemic, a nongovernmental organization in Nepal piloted a maternal and newborn health helpline program in partnership with the Government of Nepal and the Nepal Society of Obstetricians and Gynaecologists. The program connected service providers in remote areas with real-time clinical support during obstetric and neonatal emergencies via telephone consultations with clinical experts. 551 primary health care facilities across 14 districts of Nepal were included in the program and connected to a roster of 33 clinical expert volunteers from district or tertiary care hospitals. To assess the results of the program, we collected both quantitative and qualitative data, including monthly health facility record reviews from July 2020 to June 2021 and semi-structured interviews with clinical experts and service providers conducted in June 2021. Of the 551 health facilities included in the program, 160 facilities (29%) reported using the helpline during the study period, with 429 teleconsultation cases recorded. We found that 21% of these cases that otherwise would have been referred to a hospital were effectively managed by telephone on-site at rural health facilities, revealing the promising potential for impact using a low-tech solution. Of the health facilities that participated in the program, the helpline was predominantly used in remote facilities where access to higher-level referral centers for emergencies was limited. Feedback from both experts and service providers revealed that the program helped to improve clinical decision-making during emergencies, build confidence and skills of service providers, and improve referral efficiency. Implementation challenges included service providers' underreporting of helpline utilization, a lack of essential drugs at primary health care facilities, unreliable phone signals, and a lack of financial incentives for clinical experts. The results and implementation experiences shared in this article provide a template for the design and implementation of similar support programs for service providers managing clinical emergencies in rural contexts.
In the management of chronic conditions like HIV, the continuity of service delivery is necessary to achieve desired outcomes, such as HIV viral load suppression, behavioral change, improved health, and client satisfaction. The transition phase-when a project closes and another starts-is a potential period of service delivery disruption. Active management of this transition period is important to prevent disruptions, especially for key populations who may be stigmatized and have limited options for accessing HIV services. We analyzed this transition period between July and December 2022 between 2 projects that provided HIV prevention services, management of sexually transmitted infections, and linkage to HIV treatment and other complementary services to key populations in Zambia. To ensure a smooth project transition, we implemented a set of interventions, including joint planning for project transition, strategic leadership, trust-building initiatives, active community and stakeholder engagement, repeated stakeholder reassurance, open communication, and transparent data sharing. After transitioning to the new project, we noted that all 3 service types of interest experienced at least a 20% increase over the levels achieved in the last month of the closing project. This increase contrasts with the assumption that all service types delivered through project structures would decline to zero persons reached within 2 months of project closing if the next project did not commence seamlessly. The decrease in service delivery was averted with the intentional transition interventions. Additionally, we recorded operational gains, such as stakeholder satisfaction, adequate assets transfer, stability in project service delivery location, and reduced personnel anxiety. We conclude that active multipartite management of the transition phase for projects is essential for ensuring uninterrupted service delivery and sustaining good outcomes for clients. Donors, health system managers, and program managers should actively require and design sound transition management plans as part of their program designs. In the aftermath of recent abrupt cuts in US Government development sector funding that allowed no planned transitions, it is important that surviving programs carefully imbibe lessons shared in this paper to protect years-and sometimes decades-of program gains.
In 2018, the Government of India launched the Anemia Mukt Bharat (AMB) program to accelerate reductions in the prevalence of anemia among children aged 6-59 months, children aged 5-9 years, adolescents aged 10-19 years, pregnant women, and lactating mothers through 6 programmatic interventions and 6 institutional mechanisms. We describe the process of computing the AMB index, aimed at providing timely and systematic information on iron and folic acid (IFA) supplementation coverage across these groups to aid in evaluating the effectiveness of the program. This study presents data from fiscal year 2018-2019 to 2022-2023 on IFA supplementation coverage among these 5 groups. We calculated the AMB index that provides an average for IFA supplementation coverage for target groups. Data on the target groups were acquired from the AMB dashboard, and information on IFA supplementation coverage was sourced from the health management information system. The AMB index confirmed that between 2018-2019 and 2022-2023 IFA supplementation coverage increased overall in India by 22.1 percentage points, from 35.5% to 57.6%. During this period, IFA supplementation coverage increased for all target groups including pregnant women, children aged 6-59 months, children 5-9 years, adolescents aged 10-19 years, and lactating mothers. The supply chain management and reporting of the data on the portal were among the key factors that substantially impacted the IFA supplementation coverage. The IFA supplementation coverage will significantly increase if the IFA supply chain and reporting standards improve. We discuss the policy implications and suggestions to improve the overall IFA supplementation coverage across India.
BACKGROUND:Rapid analysis of community needs, perspectives, and concerns during global health emergencies is essential but technically challenging. In the past, emergency responders have struggled to listen to and engage affected communities because of perceptions about anticipated costs and time delays in receiving actionable results. TOOL DEVELOPMENT:The U.S. Centers for Disease Control and Prevention Excel Tool for Thematic Analysis was developed over 5 years of assisting with emergency responses for Ebola, COVID-19, Sudan Ebolavirus, mpox, and the Ukraine crisis. Beginning with a simple Excel spreadsheet for coding Ebola-related community feedback, we continued to add new features as needs arose, such as preloaded epidemic and health emergency coding schemes, preprogrammed results tables, step-by-step thematic analysis instruction, YouTube training videos, and planning and communication tools for effective use of the results. IMPLEMENTATION:The tool is a customized Excel workbook for qualitative text coding and thematic analysis that enables the user to code and derive key themes from texts, such as interview and focus group transcripts, notes, surveys with open-ended questions, and social media comments. We review the 10 programmed worksheets for planning, cataloguing, coding, and thematically analyzing any kind of text data. CONCLUSION:The strategies for rapid community feedback analysis during health emergencies are a special application of qualitative analysis methodology to the health emergency setting, enabling a deep reading and transparent and defensible interpretation of the text. Skills learned while using the tool are easily transferable to analyses using licensed software or fully manual methods. The tool offers a step-by-step guide for anyone to analyze text data to answer a relevant question in or outside the context of emergencies.
The application of human-centered design (HCD) is growing in global health, given its potential to generate innovative solutions to entrenched health problems by prioritizing human perspectives, needs, and desires. To address gaps in consolidated evidence on prior programs, we conducted a review of studies that applied a comprehensive HCD approach in low- and middle-income countries. A total of 535 articles were initially identified. Based on the inclusion and exclusion criteria, 22 articles were included. Most studies were conducted in sub-Saharan Africa and used qualitative or mixed methods throughout the HCD work. In the "discover and define" phase, user personas, journey maps, and interviews were commonly used to empathize with end users and key stakeholders. Studies used various strategies in the "ideation" phase, including idea generation based on feasibility and resource constraints. In the "testing" phase, low-fidelity prototypes were tested to obtain feedback from end users and stakeholders, enabling quick and cost-effective refinements. Prototype iterations occurred twice in most studies, but information about when iterations ceased was limited. Evaluations of design outcomes and health impacts were lacking. Studies cited multidisciplinary approaches, flexible methodology, and a sense of ownership among users and communities as strengths of HCD. Contrastingly, challenges in consistent participant engagement and limited scientific rigor were reported as weaknesses. Elements that enhanced program reporting included clear descriptions of HCD as cyclical, stakeholder maps (empathy tools), visual materials on design activities and prototypes, and transparency in failures. We recommend strengthening capacity among those applying HCD to optimize the effectiveness of the approach for global health. Although HCD is not inherently intended to serve as a rigorous research method, data triangulation and proper evaluations may ensure its usability as evidence in health research when appropriate. Also, a thorough reporting of design phases and providing detailed rationale behind design decisions can advance future HCD literature.
INTRODUCTION:Gender-based violence (GBV) not only poses significant public health and human rights challenges but is also closely associated with HIV. GBV acts as a barrier to HIV prevention, testing, and treatment adherence, and fear of GBV inhibits disclosure of HIV status to sexual partners. In Malawi, where both GBV and HIV prevalence is high, integrating GBV services into HIV care is crucial. We describe the integration of GBV services into Lighthouse Trust's HIV testing and treatment clinics in Malawi, including screening, documentation, intervention implementation, outcomes, and lessons learned. METHODS:We conducted a retrospective analysis from January 2020 to June 2024. Data on cases identified, post-GBV services, and perpetrator demographics were collected from the GBV register. We used descriptive statistics to describe the intervention outcomes. RESULTS:We documented 9,045 reported GBV cases among males and females from January 2020 to June 2024. Adolescent girls aged 10-19 years constituted a significant proportion of survivors. Psychosocial services were the most common type of service that was offered to GBV survivors (25%), followed by HIV testing (19%) and sexually transmitted infection screening (18%). Perpetrators were mostly known to survivors. CONCLUSION:We successfully integrated GBV services into the Lighthouse Trust HIV clinics in close collaboration with the one-stop centers in Malawi. Training health care providers enhanced support for GBV survivors, with a focus on increasing awareness, especially for children and adolescents. Recommended actions include improving access to GBV services, enhancing documentation, and promoting multi-sectoral collaboration to ensure comprehensive care aimed at creating a safer, more dignified health care environment for all, particularly GBV survivors.
