Estimating cause-specfic mortality from community- and facility-based data sources in the United Republic of Tanzania: options and implications for mortality burden estimates

Objective To compare mortality burden estimates based on direct measurement of levels and causes in communities with indirect estimates based on combining health facility cause-specific mortality structures with community measurement of mortality levels. Methods. Data from sentinel vital registration (SVR) with verbal autopsy (VA) were used to determine the cause-specific mortality burden at the community level in two areas of the United Republic of Tanzania. Proportional cause-specific mortality structures from health facilities were applied to counts of deaths obtained by SVR to produce modelled estimates. The burden was expressed in years of life lost. Findings. A total of 2884 deaths were recorded from health facilities and 2167 recorded from SVR/VAs. In the perinatal and neonatal age group cause-specific mortality rates were dominated by perinatal conditions and stillbirths in both the community and the facility data. The modelled estimates for chronic causes were very similar to those from SVR/VA. Acute febrile illnesses were coded more specifically in the facility data than in the VA. Injuries were more prevalent in the SVR/VA data than in that from the facilities. Conclusion. In this setting, improved International classification of diseases and health related problems, tenth revision (ICD-10) coding practices and applying facility-based cause structures to counts of deaths from communities, derived from SVR, appears to produce reasonable estimates of the cause-specific mortality burden in those aged 5 years and older determined directly from VA. For the perinatal and neonatal age group, VA appears to be required. Use of this approach in a nationally representative sample of facilities may produce reliable national estimates of the cause-specific mortality burden for leading causes of death in adults.

Is facility based neonatal care in low resource setting keeping pace? A glance at Uganda’s National Referral Hospital.

Objectives: To identify reasons for neonatal admission and death with the aim of determining areas needing improvement. Method: A retrospective chart review was conducted on records for neonates admitted to Mulago National Referral Hospital Special Care Baby Unit (SCBU) from 1st November 2013 to 31st January 2014. Final diagnosis was generated after analyzing sequence of clinical course by 2 paediatricians. Results: A total of 1192 neonates were admitted. Majority 83.3% were in-born. Main reasons for admissions were prematurity (37.7%) and low APGAR (27.9%).Overall mortality was 22.1% (Out-born 33.6%; in born 19.8%). Half (52%) of these deaths occurred in the first 24 hours of admission. Major contributors to mortality were prematurity with hypothermia and respiratory distress (33.7%) followed by birth asphyxia with HIE grade III (24.6%) and presumed sepsis (8.7%). Majority of stable at risk neonates 318/330 (i.e. low APGAR or prematurity without comorbidity) survived. Factors independently associated with death included gestational age <30 weeks (p 0.002), birth weight <1500g (p 0.007) and a 5 minute APGAR score of < 7 (p 0.001). Neither place of birth nor delayed and after hour admissions were independently associated with mortality. Conclusion and recommendations: Mortality rate in SCBU is high. Prematurity and its complications were major contributors to mortality. The management of hypothermia and respiratory distress needs scaling up. A step down unit for monitoring stable at risk neonates is needed in order to decongest SCBU.

Safety assessment in primary Mycobacterium tuberculosis smear microscopy centres in Blantyre Malawi: a facility based cross sectional survey

Introduction Tuberculosis (TB) is caused by Mycobacterium tuberculosis and is transmitted mainly through aerosolization of infected sputum which puts laboratory workers at risk in spite of the laboratory workers’ risk of infection being at 3 to 9 times higher than the general public. Laboratory safety should therefore be prioritized and optimized to provide sufficient safety to laboratory workers. Objective To assess the safety for the laboratory workers in TB primary microscopy centres in Blantyre urban. Methodology TB primary microscopy centers in Blantyre urban were assessed in aspects of equipment availability, facility layout, and work practice, using a standardized WHO/AFRO ISO 15189 checklist for the developing countries which sets the minimum safety score at ≥80%. Each center was graded according to the score it earned upon assessment. Results Only one (1) microscopy center out nine (9) reached the minimum safety requirement. Four (4) centers were awarded 1 star level, four (4) centers were awarded 2 star level and only one (1) center was awarded 3 star level. Conclusion In Blantyre urban, 89% of the Tuberculosis microscopy centers are failing to provide the minimum safety to the laboratory workers. Government and other stake holders should be committed in addressing the safety challenges of TB microscopy centres in the country to ensure safety for the laboratory workers. Recommendations It is recommended that the study be conducted at the regional or national level for both public and private laboratories in order to have a general picture of safety in Tb microscopy centres possibly across the country.

Facteurs contextuels dans l'évaluation d'une politique de santé maternelle au Burkina Faso

Cette thèse s’intéresse à l’influence des facteurs contextuels sur la mise en œuvre et les effets d’une politique de santé maternelle au Burkina Faso. Cette politique nommée la subvention SONU vise à faire augmenter la couverture des accouchements dans les établissements de santé publics en agissant sur l’accessibilité économique des ménages. La thèse propose une évaluation des processus de cette politique. Le cadre d’analyse repose sur des propositions théoriques issues du champ de l’étude des politiques sanitaires (les acteurs et leurs relations de pouvoir) et de l’anthropologie médicale critique (les représentations). L’étude s’est déroulée dans le district sanitaire de Djibo, situé dans la région du Sahel. Il s’agit d’une étude de cas multiples où chaque centre de santé représentait un cas. L’approche méthodologique employée était qualitative. Une enquête de terrain, des entretiens, des groupes de discussion, des observations non participantes et une analyse documentaire ont été les méthodes de collecte de données utilisées. Les résultats préliminaires de l’étude ont été présentés aux parties prenantes. Le premier article évalue l’implantation de cette subvention SONU au niveau d’un district et rend compte de l’influence des rapports de pouvoir sur la mise en œuvre de cette dernière. Les résultats indiquent que toutes les composantes de cette subvention sont mises en œuvre, à l’exception du fond d’indigence et de certaines composantes relatives à la qualité technique des soins telles que les sondages pour les bénéficiaires et l’équipe d’assurance qualité dans l’hôpital du district. Les professionnels et les gestionnaires de la santé expliquent les difficultés dans l’application de politique de subvention par un manque de clarté et de compréhension des directives officielles. Les relations de pouvoir entre les différents groupes d’acteurs ont une influence sur la mise en œuvre de cette politique. Les rapports entre gestionnaires du district et agents de santé sont basés sur des rapports hiérarchiques. Ainsi, les gestionnaires contrôlent le travail des agents de santé et imposent des changements à la mise en œuvre de la politique. Les rapports entre soignants et patients sont variables. Dans certains centres de santé, les communautés perçoivent positivement cette relation alors que dans d’autres, elle est perçue négativement. Les perceptions sur les relations entre les accoucheuses villageoises et les agents de santé sont également partagées. Pour les agents de santé, ces actrices peuvent être de potentielles alliées pour renforcer l’efficacité de la politique SONU en incitant les femmes à utiliser les services de santé, mais elles sont aussi perçues comme des obstacles, lorsqu’elles continuent à effectuer des accouchements à domicile. Les difficultés de compréhension des modalités de remboursement entrainent une rigidité dans les rapports entre agents de santé et comités de gestion. Le deuxième article vise à comprendre la variation observée sur la couverture des accouchements entre plusieurs centres de santé après la mise en œuvre de cette politique SONU. Les facteurs contextuels et plus spécifiquement humains ont une influence sur la couverture des accouchements assistés. Le leadership des agents de santé, caractérisé par l’initiative personnelle, l’éthique professionnelle et l’établissement d’un lien de confiance entre les populations et l’équipe sanitaire expliquent la différence d’effets observée sur la couverture des accouchements assistés après la mise en œuvre de cette dernière. Le troisième article analyse l’usage stratégique des référentiels ethnoculturels par certaines équipes sanitaires pour expliquer l’échec partiel de la politique SONU dans certains centres de santé. La référence à ces facteurs vise essentiellement à normaliser et légitimer l’absence d’effet de la politique sur la couverture des accouchements assistés. Elle contribue également à blâmer les populations. Enfin, le recours à ces référentiels tend à écarter les interprétations socioéconomiques et politiques qui sous-tendent la problématique des accouchements dans les établissements de santé publics. Sur le plan pratique, cette thèse permet de mieux comprendre le processus de mise en œuvre d’une politique de santé maternelle. Elle montre que les dimensions relatives à l’équité et à la qualité des soins sont négligées dans ce processus. Cette recherche met en lumière les difficultés auxquelles sont confrontés les agents de santé dans la mise en oeuvre de cette politique. Elle met également en exergue les facteurs qui expliquent l’hétérogénéité observée sur la couverture des accouchements assistés entre les centres de santé après la mise en œuvre de cette politique. Sur le plan théorique, cette thèse montre l’importance d’identifier les rapports de pouvoir qui s’exercent entre les différents acteurs impliqués dans les politiques sanitaires. Elle rappelle l’influence considérable des facteurs contextuels sur la mise en œuvre et les effets des politiques. Enfin, cette recherche révèle le poids des représentations sociales des acteurs dans la compréhension des effets des politiques. Cette thèse contribue au développement des connaissances dans le champ des politiques publiques sur le plan des thématiques abordées (mise en œuvre, rapports de pouvoir) et de l’approche méthodologique (enquête de terrain) utilisée. Elle participe aussi aux réflexions théoriques sur le concept de leadership des professionnels de la santé en Afrique.

Prevalence and predictors of giving birth in health facilities in Bugesera District, Rwanda.

BACKGROUND: The proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75% reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249-584 maternal deaths per 100,000 live births. The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services among women living in rural villages in Bugesera District, Eastern Province, Rwanda. METHODS: Using census data and probability proportional to size cluster sampling methodology, 30 villages were selected for community-based, cross-sectional surveys of women aged 18-50 who had given birth in the previous three years. Complete obstetric histories and detailed demographic data were elicited from respondents using iPad technology. Geospatial coordinates were used to calculate the path distances between each village and its designated health center and district hospital. Bivariate and multivariate logistic regressions were used to identify factors associated with delivery in health facilities. RESULTS: Analysis of 3106 lifetime deliveries from 859 respondents shows a sharp increase in the percentage of health facility deliveries in recent years. Delivering a penultimate baby at a health facility (OR = 4.681 [3.204 - 6.839]), possessing health insurance (OR = 3.812 [1.795 - 8.097]), managing household finances (OR = 1.897 [1.046 - 3.439]), attending more antenatal care visits (OR = 1.567 [1.163 - 2.112]), delivering more recently (OR = 1.438 [1.120 - 1.847] annually), and living closer to a health center (OR = 0.909 [0.846 - 0.976] per km) were independently associated with facility delivery. CONCLUSIONS: The strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health center. Recent structural interventions in Rwanda, including the rapid scale-up of community-financed health insurance, likely contributed to the dramatic improvement in the health facility delivery rate observed in our study.

Evaluating the efficiency of community-based HIV testing and counseling strategies in sub-Saharan Africa

Thesis (Ph.D.)--University of Washington, 2016-08

Are empowered women more likely to deliver in facilities? An explorative study using the Nepal Demographic and Health Survey 2011

Development literature has argued that empowering women can effectively increase the utilisation of maternal health care. This study examines this hypothesis in the context of Nepal where only 28% of women delivered in facilities. The two-level random intercept logit models were fitted for data from the Nepal Demographic and Health Surveys 2011. Women‟s empowerment was quantified with a single index constructed from many variables. These variables captured different aspects of women‟s lives and decision-making in their households, and were combined using the principal component analysis method. The results confirmed a positive relationship between women‟s as an inevitable product of the economic development process.

Economic evaluation of adolescent reproductive health education interventions in Chilinh, Vietnam

This research was an economic analysis of two novel health education interventions compared to existing practice for reproductive health among young people in northern Vietnam. The research showed that implementing an educational intervention including school-based and health facility-based components was cost effective for males and females. The findings will assist decision makers in efficient allocation of scarce resources for adolescent health promotion in Vietnam and similar socio-economic contexts in Asia.

基于棱镜实现三倍频谐波分离

基于棱镜的色散特性,提出一种楔形窗口与聚焦透镜组合的方式,解决了高功率激光装置三倍频谐波分离所存在的问题,即三倍频的高通量传输和靶面辐照。结合“神光Ⅱ”装置多功能高能激光系统有关参数进行系统设计,确定了楔形窗口参数,并对其所引起的B积分和间距误差进行了分析。通过实验测试,三倍频传输通量由0.7～1 J/cm2提高到2.8 J/cm2,同时靶面三倍频和二倍频分离间距达到2.85 mm,实现了高功率激光装置高通量传输的三倍频谐波分离。

Spatial distribution of bednet coverage under routine distribution through the public health sector in a rural district in Kenya.

Insecticide-treated nets (ITNs) are one of the most important and cost-effective tools for malaria control. Maximizing individual and community benefit from ITNs requires high population-based coverage. Several mechanisms are used to distribute ITNs, including health facility-based targeted distribution to high-risk groups; community-based mass distribution; social marketing with or without private sector subsidies; and integrating ITN delivery with other public health interventions. The objective of this analysis is to describe bednet coverage in a district in western Kenya where the primary mechanism for distribution is to pregnant women and infants who attend antenatal and immunization clinics. We use data from a population-based census to examine the extent of, and factors correlated with, ownership of bednets. We use both multivariable logistic regression and spatial techniques to explore the relationship between household bednet ownership and sociodemographic and geographic variables. We show that only 21% of households own any bednets, far lower than the national average, and that ownership is not significantly higher amongst pregnant women attending antenatal clinic. We also show that coverage is spatially heterogeneous with less than 2% of the population residing in zones with adequate coverage to experience indirect effects of ITN protection.

Characterisation of amorphous and nanocrystalline molecular materials by total scattering

The use of high-energy X-ray total scattering coupled with pair distribution function analysis produces unique structural fingerprints from amorphous and nanostructured phases of the pharmaceuticals carbamazepine and indomethacin. The advantages of such facility-based experiments over laboratory-based ones are discussed and the technique is illustrated with the characterisation of a melt-quenched sample of carbamazepine as a nanocrystalline (4.5 nm domain diameter) version of form III.

To achieve safe and respectful maternity care in tertiary level hospitals in Nepal, relatives are a valued addition to the provision of maternity care

Introduction: The White Ribbon Alliance for safe motherhood believes respectful maternity care is the universal right of every childbearing woman. Methods: NHRC in 2012 approved an inquiry of respectful care at facility-based childbirth. Individual-, focus group interviews and content analysis was used for gathering and analysis of data. Findings: The participating women and the SBAs shared similar views, and this was that together the SBAs and relatives ensured the women remained within the comfort and safety zone when giving birth in a tertiary level maternity unit. Conclusion: The SBAs strategy of having relatives provides basic care alongside the provision of medical care by the SBAs is a strategy that Nepal could use to improve the quality of its maternity care without any additional costs. Clinical implication: Prenatal classes might contribute to preparing relatives. Further Research: Further research could evaluate such a strategy in order to determine its effectiveness in reduction of morbidity and mortality.

Innovative Man Machine Interfaces In Aeronautics

The research activity focused on the study, design and evaluation of innovative human-machine interfaces based on virtual three-dimensional environments. It is based on the brain electrical activities recorded in real time through the electrical impulses emitted by the brain waves of the user. The achieved target is to identify and sort in real time the different brain states and adapt the interface and/or stimuli to the corresponding emotional state of the user. The setup of an experimental facility based on an innovative experimental methodology for “man in the loop" simulation was established. It allowed involving during pilot training in virtually simulated flights, both pilot and flight examiner, in order to compare the subjective evaluations of this latter to the objective measurements of the brain activity of the pilot. This was done recording all the relevant information versus a time-line. Different combinations of emotional intensities obtained, led to an evaluation of the current situational awareness of the user. These results have a great implication in the current training methodology of the pilots, and its use could be extended as a tool that can improve the evaluation of a pilot/crew performance in interacting with the aircraft when performing tasks and procedures, especially in critical situations. This research also resulted in the design of an interface that adapts the control of the machine to the situation awareness of the user. The new concept worked on, aimed at improving the efficiency between a user and the interface, and gaining capacity by reducing the user’s workload and hence improving the system overall safety. This innovative research combining emotions measured through electroencephalography resulted in a human-machine interface that would have three aeronautical related applications: • An evaluation tool during the pilot training; • An input for cockpit environment; • An adaptation tool of the cockpit automation.

Using the results of routine laboratory workplace surveillance activities to assess compliance with recommended biosafety guidelines

The biological safety profession has historically functioned within an environment based on recommended practices rather than regulations, so summary data on compliance or noncompliance with recommended practices is largely absent from the professional literature. The absence of safety performance outcome data is unfortunate since the concept of biosafety containment is based on a combination of facility based controls and workplace practices, and persistent failures in either type of controls could ultimately result in injury or death. In addition, the number of laboratories requiring biosafety containment is likely to grow significantly in the coming years in the wake of the terrorist events of 2001. In this study, the outcomes of 768 biosafety level 2 (BSL-2) safety surveys were analyzed for commonalities and trends. Items of non-compliance noted were classified as facility related or practice related. The most frequent item of noncompliance encountered was the failure to re-certify biosafety cabinetry. Not surprisingly, the preponderance of the other frequent items of non-compliance encountered were practice related, such as general housekeeping orderly, changes in compliance levels, as well as establish trends in the elements of items of non-compliance during the sequential survey period. The findings described in this study are significant because, for the first time, the outcomes of compliance with recommended biosafety practices can be characterized and thus used as the basis for focused interventions. Since biosafety is heavily reliant on adherence to specific safety practices, the ability to focus interventions on objectively identified practice-related items of non-compliance can assist in the reduction of worker risk in this area experiencing tremendous growth. The information described is also of heighten importance given the number of workplaces expected to involve potentially infectious agents in the coming years. ^

Providing 30Mbit/s to Spain’s final third. -A techno-economic assessment.

Since the Digital Agenda for Europe released the Europe2020 flagship, Member States are looking for ways of fulfilling their agreed commitments to fast and ultrafast internet deployment. However, Europe is not a homogenous reality. The economic, geographic, social and demographic features of each country make it a highly diverse region to develop best practices over Next Generation Access Networks (NGAN) deployments. There are special concerns about NGAN deployments for “the final third”, as referred to the last 25% of the country’s population who, usually, live in rural areas. This paper assesses, through a techno-economic analysis, the access cost of providing over 30 Mbps broadband for the final third of Spain`s population in municipalities, which are classified into area types, referred to as geotypes. Fixed and mobile technologies are compared in order to determine which is the most cost-effective technology for each geotype. The demographic limit for fixed networks (cable, fibre and copper) is also discussed. The assessment focuses on the supply side and the results show the access network cost only. The research completes a previous published assessment (Techno-economic analysis of next generation access networks roll-out. The case of platform competition, regulation and public policy in Spain) by including the LTE scenario. The LTE scenario is dimensioned to provide 30 Mbps (best effort) broadband, considering a network take-up of 25%. The Rocket techno-economic model is used to assess a ten-year study period deployment. Nevertheless, the deployment must start in 2014 and be completed by 2020, in order to fulfil the Digital Agenda’s goals. The feasibility of the deployment is defined as the ability to recoup the investment at the end of the study period. This ability is highly related to network take-up and, therefore, to service adoption. Network deployment in each geotype is compared with the cost of the deployment in the Urban geotype and broadband expected penetration rates for clarity and simplicity. Debating the cost-effective deployments for each geotype, while addressing the Digital Agenda’s goals regarding fast and ultrafast internet, is the main purpose of this paper. At the end of the last year, the independent Spanish regulation agency released the Spain broadband coverage report at the first half of 2013. This document claimed that 59% and 52% of Spain’s population was already covered by NGAN capable of providing 30 Mbps and 100 Mbps broadband respectively. HFC, with 47% of population coverage, and FTTH, with 14%, were considered as a 100 Mbps capable NGAN. Meanwhile VDSL, with 12% of the population covered, was the only NGAN network considered for the 30 Mbps segment. Despite not being an NGAN, the 99% population coverage of HSPA networks was also noted in the report. Since mobile operators are also required to provide 30 Mbps broadband to 90% of the population in rural areas by the end of 2020, mobile networks will play a significant role on the achievement of the 30 Mbps goal in Spain’s final third. The assessment indicates the cost of the deployment per cumulative households coverage with 4 different NGANs: FTTH, HFC, VDSL and LTE. Research shows that an investment ranging from €2,700 (VDSL) to €5,400 (HFC) million will be needed to cover the first half of the population with any fixed technology assessed. The results state that at least €3,000 million will be required to cover these areas with the least expensive technology (LTE). However, if we consider the throughput that fixed networks could provide and achievement of the Digital Agenda’s objectives, fixed network deployments are recommended for up to 90% of the population. Fibre and cable deployments could cover up to a maximum of 88% of the Spanish population cost efficiently. As there are some concerns about the service adoption, we recommend VDSL and mobile network deployments for the final third of the population. Despite LTE being able to provide the most economical roll-out, VDSL could also provide 50 Mbps from 75% to 90% of the Spanish population cost efficiently. For this population gap, facility based competition between VDSL providers and LTE providers must be encouraged. Regarding 90% to 98.5% of the Spanish population, LTE deployment is the most appropriate. Since costumers in less populated the municipalities are more sensitive to the cost of the service, we consider that a single network deployment could be most appropriate. Finally, it has become clear that it is not possible to deliver 30Mbps to the final 1.5% of the population cost-efficiently and adoption predictions are not optimistic either. As there are other broadband alternatives able to deliver up to 20 Mbps, in the authors’ opinion, it is not necessary to cover the extreme rural areas, where public financing would be required.