Publications by authors named "Rachel P Chase"

17 Publications

  • Page 1 of 1

A stepped-wedge randomized trial and qualitative survey of HIV pre-exposure prophylaxis uptake in the Eswatini population.

Sci Transl Med 2020 09;12(562)

Heidelberg Institute of Global Health (HIGH), Heidelberg University, 69120 Heidelberg, Germany.

Clinical trials have shown that antiretroviral drugs used as pre-exposure prophylaxis (PrEP) are highly effective for preventing HIV acquisition. PrEP efforts, including in sub-Saharan Africa, have almost exclusively focused on certain priority groups, particularly female sex workers, men having sex with men, pregnant women, serodiscordant couples, and young women. As part of a PrEP demonstration project involving the general population at six primary health care facilities in Eswatini (formerly Swaziland), we conducted a randomized trial of a health care facility-based PrEP promotion package designed to increase PrEP uptake. Over the 18-month study duration, 33.6% (517 of 1538) of adults identified by health care workers as being at risk of acquiring HIV took up PrEP, and 30.0% of these individuals attended all scheduled appointments during the first 6 months after initiation of PrEP. The PrEP promotion package was associated with a 55% (95% confidence interval, 15 to 110%; = 0.036) relative increase in the number of individuals taking up PrEP, with an absolute increase of 2.2 individuals per month per health care facility. When asked how PrEP uptake could be improved in 217 accompanying in-depth qualitative interviews, interviewees recommended an expansion of PrEP promotion activities beyond health care facilities to communities. Although a health care facility-based promotion package improved PrEP uptake, both uptake and retention remained low. Expanding promotion activities to the community is needed to achieve greater PrEP coverage among adults at risk of HIV infection in Eswatini and similar settings.
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http://dx.doi.org/10.1126/scitranslmed.aba4487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023147PMC
September 2020

Effect Heterogeneity in Responding to Performance-Based Incentives: A Quasi-Experimental Comparison of Impacts on Health Service Indicators Between Hospitals and Health Centers in Malawi.

Health Syst Reform 2020 01;6(1):e1745580

Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University , Heidelberg, Germany.

Heterogeneity of effects produced by performance-based incentives (PBIs) at different levels of care provision is not well understood. This study analyzes effect heterogeneities between different facility types resulting from a PBI program in Malawi. Identical PBIs were applied to both district hospitals and health centers to improve the performance of essential health services provision. We conducted two complementary quasi-experiments comparing all 17 interventions with 17 matched independent control facilities (each 12 health centers, five hospitals). A pre- and post-test design with difference-in-differences analysis was used to estimate effects on 14 binary quality indicators; interrupted time series analysis of monthly routine data was used to estimate effects on 11 continuous quantity indicators. Effects were estimated separately for health centers and hospitals. Most quality indicators performed high at baseline, producing ceiling effects on further measurable improvements. Significant positive effects were observed for stocks of iron supplements (hospitals) and partographs (health centers). Four quantity indicators showed similar positive trend improvements across facility types (first-trimester antenatal visits, voluntary HIV-testing of couples, iron supplementation in pregnancy, vitamin A supplementation of children); two showed no change for either type of facility (skilled birth attendance, fully immunized one-year-olds); five indicators revealed different effect patterns for health centers and hospitals. In both health centers and hospitals, the largely positive PBI effects on antenatal care included resilience against interrupted supply chains and improvements in attendance rates. Observed heterogeneity might have been influenced by the availability of specific resources or the redistribution of service use.
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http://dx.doi.org/10.1080/23288604.2020.1745580DOI Listing
January 2020

Acute malnutrition recovery energy requirements based on mid-upper arm circumference: Secondary analysis of feeding program data from 5 countries, Combined Protocol for Acute Malnutrition Study (ComPAS) Stage 1.

PLoS One 2020 3;15(6):e0230452. Epub 2020 Jun 3.

Department of Population Health & Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, England, United Kingdom.

Background: Severe and moderate acute malnutrition (SAM and MAM) are currently treated with different food products in separate treatment programs. The development of a unified and simplified treatment protocol using a single food product aims to increase treatment program efficiency and effectiveness. This study, the first stage of the ComPAS trial, sought to assess rate of growth and energy requirements among children recovering from acute malnutrition in order to design a simplified, MUAC-based dosage protocol.

Methods: We obtained secondary data from patient cards of children aged 6-59 months recovering from SAM in outpatient therapeutic feeding programs (TFPs) and from MAM in supplementary feeding programs (SFPs) in five countries in Africa and Asia. We used local polynomial smoothing to assess changes in MUAC and proportional weight gain between clinic visits and assessed their normalized differences for a non-zero linear trend. We estimated energy needs to meet or exceed the growth observed in 95% of visits.

Results: This analysis used data from 5518 patients representing 33942 visits. Growth trends in MUAC and proportional weight gain were not significantly different, each lower at higher MUAC values: MUAC growth averaged 2mm/week at lower MUACs (100 to <110mm) and 1mm/week at higher MUACs (120mm to <125mm); and proportional weight gain declined from 3.9g/kg/day to 2.4g/kg/day across the same MUAC values. In 95% of visits by children with a MUAC 100mm to <125mm who were successfully treated, energy needs could be met or exceeded with 1,000 kilocalories a day.

Conclusion: Two 92g sachets of Ready-to-Use Therapeutic Food (RUTF) (1,000kcal total) is proposed to meet the estimated total energy requirements of children with a MUAC 100mm to <115mm, and one 92g sachet of RUTF (500kcal) is proposed to meet half the energy requirements of children with a MUAC of 115 to <125mm. A simplified, combined protocol may enable a more holistic continuum of care, potentially contributing to increased coverage for children suffering from acute malnutrition.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230452PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269364PMC
August 2020

Intended and unintended effects: community perspectives on a performance-based financing programme in Malawi.

BMJ Glob Health 2020 1;5(4):e001894. Epub 2020 Apr 1.

Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany.

Background: Several performance-based financing (PBF) evaluations have been undertaken in low-income countries, yet few have examined community perspectives of care amid PBF programme implementation. We assessed community members' perspectives of Support for Service Delivery Integration - Performance-Based Incentives ('SSDI-PBI'), a PBF intervention in Malawi, and explored some of the unintended effects that emerged amid implementation.

Methods: We conducted 30 focus group discussions: 17 with community leaders and 13 with mothers within catchment areas of SSDI-PBI implementing facilities. We analysed data using the framework approach.

Results: Community leaders and women had mixed impressions regarding the effect of SSDI-PBI on service delivery in facilities. They highlighted several improvements (including improved dialogue between staff and community, and cleaner, better-equipped facilities with enhanced privacy), but also persisting challenges (including inadequate and overworked staff, overcrowded facilities and long distances to facilities) related to services in SSDI-PBI-implementing facilities. Further, respondents described how four targeted service indicators related to maternal risk factor management, antenatal care (ANC) in the first trimester, skilled birth attendance and couple's HIV testing sparked unintended negative effects as experienced by women and communities. The unintended effects included women returning home for delivery, women feeling uncertain about their pregnancy status, women feeling betrayed or frustrated by the quality of care provided and partnerless women being denied ANC.

Conclusion: PBF programmes such as SSDI-PBI may improve some aspects of service delivery. However, to achieve system improvement, not only should necessary tools (such as medicines, equipment and human resources) be in place, but also programme priorities must be congruent with cultural expectations. Finally, facilities must be better supported to expect and then address increases in client load and heightened expectations in relation to services.
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http://dx.doi.org/10.1136/bmjgh-2019-001894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7170427PMC
April 2020

Child handwashing in an internally displaced persons camp in Northern Iraq: A qualitative multi-method exploration of motivational drivers and other handwashing determinants.

PLoS One 2020 3;15(2):e0228482. Epub 2020 Feb 3.

Department for Disease Control, London School of Hygiene and Tropical Medicine, London, England, United Kingdom.

Background: Children in humanitarian situations are particularly vulnerable to diseases such as diarrhoea. Handwashing with soap can greatly reduce transmission but handwashing rates are often low and traditional interventions ineffective. To aid future intervention design, this study aims to understand the determinants of child handwashing and the key motivational drivers of children's behaviour within a specific humanitarian setting.

Methods: In an internally displaced persons camp in Northern Iraq we conducted a series of 36 friendship-paired interviews with children aged 7-12 years, six semi-structured caregiver interviews, and three semi-structured hygiene promoter interviews. Perceived determinants of child handwashing were explored qualitatively, and motivational drivers were explored quantitatively with children in a rating exercise. Qualitative data were analysed thematically, using an inductive approach, and logistic regression analyses of motive rating data were performed to determine the predicted probabilities of motives being rated as important.

Results: Access to soap and water was perceived to be high across all participant groups. Children, caregivers and hygiene promoters all perceive the determinants of child handwashing to be associated with familial role, environmental factors pertaining to location and quality of handwashing materials and facilities, and level of exposure to hygiene promotion, and children also attribute their handwashing to social norms. We find that children in this context are motived most by play and nurture.

Conclusions: Provision of soap and water alone is not sufficient to encourage children to practice handwashing with soap in a humanitarian context. Our findings suggest that equal consideration should be given to the quality and location of handwashing materials and facilities and social norms could be leveraged to promote and enhance child handwashing. Motive-based interventions targeting play or nurture may be a promising approach and are likely most effective when used in conjunction, along with other motivational drivers such as affiliation and love.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228482PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996827PMC
May 2020

Effect of results-based financing on facility-based maternal mortality at birth: an interrupted time-series analysis with independent controls in Malawi.

BMJ Glob Health 2019 22;4(3):e001184. Epub 2019 Jun 22.

Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Heidelberg, Germany.

Introduction: The aim of this study was to assess the impact of a results-based financing (RBF) programme on the reduction of facility-based maternal mortality at birth. Malawi is a low-income country with high maternal mortality. The Results-Based Financing For Maternal and Newborn Health (RBF4MNH) Initiative was introduced at obstetric care facilities in four districts to improve quality and utilisation of maternal and newborn health services. The RBF4MNH Initiative was launched in April 2013 as a combined supply-side and demand-side RBF. Programme expansion occurred in October 2014.

Methods: Controlled interrupted time series was used to estimate the effect of the RBF4MNH on reducing facility-based maternal mortality at birth. The study sample consisted of all obstetric care facilities in 4 intervention and 19 control districts, which constituted all non-urban mainland districts in Malawi. Data for obstetric care facilities were extracted from the Malawi Health Management Information System. Facility-based maternal mortality at birth was calculated as the number of maternal deaths per all deliveries at a facility in a given time period.

Results: The RBF4MNH effectively reduced facility-based maternal mortality by 4.8 (-10.3 to 0.7, p<0.1) maternal deaths/100 000 facility-based deliveries/month after reaching full operational capacity in October 2014. Immediate effects (changes in level rather than slope) attributable to the RBF4MNH were not statistically significant.

Conclusion: This is the first study evaluating the effect of a combined supply-side and demand-side RBF on maternal mortality outcomes and demonstrates the positive role financial incentives can play in improving health outcomes. This study further shows that timeframes spanning several years might be necessary to fully evaluate the impact of health-financing programmes on health outcomes. Further research is needed to assess the extent to which the observed reduction in facility-based mortality at birth contributes to all-cause maternal mortality in the country.
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http://dx.doi.org/10.1136/bmjgh-2018-001184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6590974PMC
June 2019

Child's play: Harnessing play and curiosity motives to improve child handwashing in a humanitarian setting.

Int J Hyg Environ Health 2019 03 13;222(2):177-182. Epub 2018 Sep 13.

Department for Disease Control, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK.

In humanitarian emergency settings there is need for low cost and rapidly deployable interventions to protect vulnerable children, in- and out-of-school, from diarrhoeal diseases. Handwashing with soap can greatly reduce diarrhoea but interventions specifically targeting children's handwashing behaviour in humanitarian settings have not been tested. Traditional children's handwashing promotion interventions have been school-focused, resource-intensive and reliant on health-based messaging. However, recent research from non-humanitarian settings and targeting adults suggests that theory-based behaviour change interventions targeting specific motives may be more effective than traditional handwashing interventions. In this proof-of-concept study we test, for the first time, the distribution of a modified soap bar, designed to appeal to the motives of play and curiosity, in a household-level, rapidly deployable, handwashing promotion intervention for older children in a humanitarian setting - an internally displaced persons camp in Iraqi Kurdistan. Out of five total blocks within the camp, one was assigned to intervention and one to control. 40 households from each assigned block were then randomly chosen for inclusion in the study and the practice of handwashing with soap at key times was measured at baseline and four weeks after intervention delivery. Children in intervention households received transparent soaps with embedded toys, delivered within a short, fun, and interactive household session with minimal, non-health-based, messaging. The control group received plain soap delivered in a short standard, health-based, hygiene promotion session. At the 4-week follow-up, children in the intervention group were 4 times more likely to wash their hands with soap after key handwashing occasions than expected in the counterfactual (if there had been no intervention) based on the comparison to children in the control group (adjusted RR = 3.94, 95% CI 1.59-9.79). We show that distributing soaps with toys embedded inside, in a rapidly deployable intervention, can improve child handwashing behaviour in a humanitarian emergency context. Further studies are needed to determine the longer-term behavioural and health impact of such an intervention when delivered at a greater scale in a humanitarian context.
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http://dx.doi.org/10.1016/j.ijheh.2018.09.002DOI Listing
March 2019

Poverty, partner discord, and divergent accounts; a mixed methods account of births before arrival to health facilities in Morogoro Region, Tanzania.

BMC Pregnancy Childbirth 2016 09 27;16(1):284. Epub 2016 Sep 27.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205-2179, USA.

Background: Births before arrival (BBA) to health care facilities are associated with higher rates of perinatal morbidity and mortality compared to facility deliveries or planned home births. Research on such births has been conducted in several high-income countries, but there are almost no studies from low-income settings where a majority of maternal and newborn deaths occur.

Methods: Drawing on a household survey of women and in-depth interviews with women and their partners, we examined the experience of BBA in rural districts of Morogoro Region, Tanzania.

Results: Among survey respondents, 59 births (4 %) were classified as BBAs. Most of these births occurred in the presence of a family member (47 %) or traditional birth attendant (24 %). Low socioeconomic status was the strongest predictor of BBA. After controlling for wealth via matching, high parity and a low number of antenatal care (ANC) visits retained statistical significance. While these variables are useful indicators of which women are at greater risk of BBA, their predictive power is limited in a context where many women are poor, multiparous, and make multiple ANC visits. In qualitative interviews, stories of BBAs included themes of partner disagreement regarding when to depart for facilities and financial or logistical constraints that underpinned departure delays. Women described wanting to depart earlier to facilities than partners.

Conclusion: As efforts continue to promote facility birth, we highlight the financial demands associated with facility delivery and the potential for these demands to place women at a heightened risk for BBAs.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039800PMC
http://dx.doi.org/10.1186/s12884-016-1058-xDOI Listing
September 2016

"Tell Me What You Don't Remember": Care-Seeking Facilitators and Barriers in the Decade Following Repetitive Blast Exposure Among Army Combat Veterans.

Mil Med 2016 Feb;181(2):116-22

Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205.

Objectives: This study sought to understand facilitators and barriers to care seeking among blast-exposed veterans and service members who served before the implementation of systematic screening for traumatic brain injury.

Methods: Informed by principles of Grounded Theory, we used theoretical sampling and conducted 31 interviews with 15 veterans and 10 veteran family members. Data were iteratively collected and thematically analyzed.

Results: The most critical facilitator in initiating care was encouragement--verging on insistence--from a spouse, family member, or employer. Although respondents overwhelmingly described veteran and military health systems responding inadequately to patient needs, respondents also described exceptional health professionals who stood in contrast, dedicated to providing quality care. Barriers to ongoing care included: scheduling complications; redeployments; insufficient or inaccessible documentation of blast encounters or medical history; high provider turnover interrupting therapeutic progress; and poor patient-provider relationships. Respondents described providers as generally dismissive of or insensitive to many health needs. Respondents feared the system was incapable of helping them and described stigma against mental health care seeking in personal and professional spheres.

Conclusions: Veterans and their families struggle to address multiple, confusing transformations after repetitive blast exposures. Complex, impersonal, and skeptical health system processes place an undue burden on care-seeking veterans and service members.
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http://dx.doi.org/10.7205/MILMED-D-14-00471DOI Listing
February 2016

"You should go so that others can come"; the role of facilities in determining an early departure after childbirth in Morogoro Region, Tanzania.

BMC Pregnancy Childbirth 2015 Dec 9;15:328. Epub 2015 Dec 9.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205-2179, USA.

Background: Tanzania is among ten countries that account for a majority of the world's newborn deaths. However, data on time-to-discharge after facility delivery, receipt of postpartum messaging by time to discharge and women's experiences in the time preceding discharge from a facility after childbirth are limited.

Methods: Household survey of 1267 women who delivered in the preceding 2-14 months; in-depth interviews with 24 women, 12 husbands, and 5 community elders.

Results: Two-thirds of women with vaginal, uncomplicated births departed within 12 h; 90 % within 24 h, and 95 % within 48 h. Median departure times varied significantly across facilities (hospital: 23 h, health center: 10 h, dispensary: 7 h, p < 0.001). Quantitative and qualitative data highlight the importance of type of facility and facility amenities in determining time-to-discharge. In multiple logistic regression, level of facility (hospital, health center, dispensary) was the only significant predictor of early discharge (p = 0.001). However across all types of facilities a majority of women depart before 24 h ranging from hospitals (54 %) to health centers (64 %) to dispensaries (74 %). Most women who experienced a delivery complication (56 %), gave birth by caesarean section (90 %), or gave birth to a pre-term baby (70 %) stayed longer than 24 h. Reasons for early discharge include: facility practices including discharge routines and working hours and facility-based discomforts for women and those who accompany them to facilities. Provision of postpartum counseling was inadequate regardless of time to discharge and regardless of type of facility where delivery occurred.

Conclusion: Our quantitative and qualitative findings indicate that the level of facility care and comforts existing or lacking in a facility have the greatest effect on time to discharge. This suggests that individual or interpersonal characteristics play a limited role in deciding whether a woman would stay for shorter or longer periods. Implementation of a policy of longer stay must incorporate enhanced postpartum counseling and should be sensitive to women's perceptions that it is safe and beneficial to leave hospitals soon after birth.
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http://dx.doi.org/10.1186/s12884-015-0763-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4675015PMC
December 2015

Injury careers after blast exposure among combat veterans deployed to Iraq or Afghanistan.

Soc Sci Med 2015 Dec 17;147:309-16. Epub 2015 Nov 17.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA. Electronic address:

During the Iraq and Afghanistan wars, blasts were the most common cause of combat injuries, including traumatic brain injury (TBI). Prior to 2007, service members were not systematically screened for TBI, and estimates suggest that tens of thousands of mild TBIs went undiagnosed. This study sought to understand post-acute "injury careers," documenting the life- and health-related narratives of veterans who were at high risk of undocumented TBI due to being blast-exposed before 2007. Researchers conducted 38 in-depth interviews between May 2013 and August 2014 with Army veterans who served in combat-intense settings (n = 16) and their family members (n = 10). Respondents detailed a series of experiences in the months and years following blast exposure. We present this series as a model that draws upon the vernacular of participants who described veterans "downplaying" their injuries and later "detaching" themselves from friends, family, and communities, and "denying" or being "oblivious" to their circumstances until a "wake-up call" pushed them to "get help." Looking to the future, veterans grapple with uncertainties related to personal identity and professional or social expectations. This model is presented within a member-checked metaphor of an individual being hurled into--and emerging from--a canyon. Policies and programs addressing veteran health, particularly among those exposed to multiple blasts prior to systematic TBI documentation, must consider the personal, social, and health system challenges faced by veterans and their families throughout their injury careers.
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http://dx.doi.org/10.1016/j.socscimed.2015.11.015DOI Listing
December 2015

Sanitation, Stress, and Life Stage: A Systematic Data Collection Study among Women in Odisha, India.

PLoS One 2015 9;10(11):e0141883. Epub 2015 Nov 9.

Center for Applied Social Research, University of Oklahoma, Norman, Oklahoma, United States of America.

Emerging evidence demonstrates how inadequate access to water and sanitation is linked to psychosocial stress, especially among women, forcing them to navigate social and physical barriers during their daily sanitation routines. We examine sanitation-related psychosocial stress (SRPS) across women's reproductive lives in three distinct geographic sites (urban slums, rural villages, and rural tribal villages) in Odisha, India. We explored daily sanitation practices of adolescent, newly married, pregnant, and established adult women (n = 60) and identified stressors encountered during sanitation. Responding to structured data collection methods, women ranked seven sanitation activities (defecation, urination, menstruation, bathing, post-defecation cleaning, carrying water, and changing clothes) based on stress (high to low) and level of freedom (associated with greatest freedom to having the most restrictions). Women then identified common stressors they encountered when practicing sanitation and sorted stressors in constrained piles based on frequency and severity of each issue. The constellation of factors influencing SRPS varies by life stage and location. Overall, sanitation behaviors that were most restricted (i.e., menstruation) were the most stressful. Women in different sites encountered different stressors, and the level of perceived severity varied based on site and life stage. Understanding the influence of place and life stage on SRPS provides a nuanced understanding of sanitation, and may help identify areas for intervention.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0141883PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638353PMC
July 2016

Development of A Multidimensional Scale to Assess Attitudinal Determinants of Sanitation Uptake and Use.

Environ Sci Technol 2015 Nov 6;49(22):13613-21. Epub 2015 Nov 6.

Department of Environmental Health, Rollins School of Public Health, Emory University , Atlanta, Georgia 30322, United States.

Over 1 billion people still practice open defecation. Low uptake and use of new sanitation technologies in a number of settings has underscored our current limited understanding of the complex attitudinal factors that influence a household's decision to adopt and use new sanitation technologies. Mokken scaling techniques were applied to series of population-based surveys in Odisha, India between September 2011 and October 2013 (sample sizes 120, 500, 2200). Surveys contained simple, agree/disagree statements about attitudes toward sanitation use and sanitation technologies. Analysis produced two scales-a 10-question General Scale, reflecting attitudes toward defecation and norms regarding latrine use for all respondents, and a 6-question Experiential Scale, reflecting personal experiences with and perceived convenience of sanitation technologies targeted at respondents with a latrine. Among all respondents, a one-point change in the General Scale was associated with a 5-percentage point change in the marginal probability of having access to a functioning latrine. Among respondents with a functional latrine at home, a one-point increase in the General and Experiential Scales were associated with a 4- and 8-percentage point decrease in the probability of engaging in any open defecation in the last 7 days, respectively.
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http://dx.doi.org/10.1021/acs.est.5b02985DOI Listing
November 2015

Nègènègèn: Sweet talk, disrespect, and abuse among rural auxiliary midwives in Mali.

Midwifery 2015 Nov 30;31(11):1073-80. Epub 2015 Jul 30.

Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, 615 North Wolfe Street, Baltimore, MD 21205, United States. Electronic address:

Objective: the purpose of this study was to explore disrespect and abuse toward women in labor from the perspective of auxiliary midwives.

Design: this study uses a cross-sectional, descriptive mixed-methods design using surveys and interviews.

Setting: Koutiala, Mali.

Participants: 67 mostly rural auxiliary midwives.

Interventions: this was a descriptive study and had no intervention component. The variables of interest were Malian auxiliary midwives' reports of caring and respectful, as well as abusive and disrespectful, behaviours towards childbearing women.

Findings: participants reported abusive and disrespectful behaviour toward women, particularly yelling, insulting, and displaying a hostile or aggressive attitude. However, auxiliary midwives also stressed the importance of making women feel welcome and comfortable, sweet-talking to them throughout labor, and providing quality care. IMPLICATIONS FOR TRAINING AND PRACTICE: we recommend a strengths-based approach to pre-service and continuing education to ensure that auxiliary midwives meet the basic competencies for midwives and appreciate both the impact of their abusive and disrespectful behaviours and the value of the respectful care they already provide.
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http://dx.doi.org/10.1016/j.midw.2015.07.007DOI Listing
November 2015

Placental malaria is rare among Zanzibari pregnant women who did not receive intermittent preventive treatment in pregnancy.

Am J Trop Med Hyg 2014 Aug 2;91(2):367-373. Epub 2014 Jun 2.

Zanzibar has transitioned from malaria control to the pre-elimination phase, and the continued need for intermittent preventive treatment during pregnancy (IPTp) has been questioned. We conducted a prospective observational study to estimate placental malaria positivity rate among women who did not receive IPTp with sulfadoxine-pyrimethamine. A convenience sample of pregnant women was enrolled from six clinics on the day of delivery from August of 2011 to September of 2012. Dried placental blood spot specimens were analyzed by polymerase chain reaction (PCR); 9 of 1,349 specimens (0.7%; precision estimate = 0.2-1.1%) were PCR-positive for Plasmodium falciparum. Placental infection was detected on both Pemba (N = 3) and Unguja (N = 6). Placental malaria positivity in Zanzibar was low, even in the absence of IPTp. It may be reasonable for the Ministry of Health to consider discontinuing IPTp, intensifying surveillance efforts, and promoting insecticide-treated nets and effective case management of malaria in pregnancy.
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http://dx.doi.org/10.4269/ajtmh.13-0586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125264PMC
August 2014

Population estimates of undocumented incident traumatic brain injuries among combat-deployed US military personnel.

J Head Trauma Rehabil 2015 Jan-Feb;30(1):E57-64

Departments of International Health (Ms Chase) and Mental Health (Dr Nevin), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Objective: To estimate the number of undocumented incident traumatic brain injuries (TBIs) among active component US military personnel serving in Iraq and Afghanistan prior to policy changes implemented in late 2006 and 2010 that improved TBI documentation.

Methods: Negative binomial regression was used to model monthly incident TBI counts between December 2010 and June 2012 (N = 19) and then estimate expected monthly counts of incident TBIs during 2 periods: January 2003-October 2006 and November 2006-November 2010. Monthly amputation counts from Department of Defense surveillance data were used as a proxy for changing injury rates. Monthly active component deployment estimates derived from the Congressional Research Service, Brookings Institution, and Defense Manpower Data Center were used to estimate the size of the at-risk population each month. The difference between expected monthly incident TBI counts and reported counts is presented as the estimated number of undocumented incident TBIs.

Results: The full model estimates that 21 257 active component military personnel experienced undocumented incident TBIs while deployed in Iraq or Afghanistan between January 2003 and October 2006, more than 4 times the 5272 incident TBIs documented during that period.

Conclusions: A sizeable majority of Iraq and Afghanistan combat veterans who experienced incident TBI while deployed prior to November 2006 are likely to have had their injuries undocumented, creating challenges for clinical care, disability evaluation, and future research.
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http://dx.doi.org/10.1097/HTR.0000000000000061DOI Listing
September 2015

Reducing child global undernutrition at scale in Sofala Province, Mozambique, using Care Group Volunteers to communicate health messages to mothers.

Glob Health Sci Pract 2013 Mar 21;1(1):35-51. Epub 2013 Mar 21.

Department of International Health, Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA Correspondence to Henry Perry ,

Background: Undernutrition contributes to one-third of under-5 child mortality globally. Progress in achieving the Millennium Development Goal of reducing under-5 mortality is lagging in many countries, particularly in Africa. This paper shares evidence and insights from a low-cost behavior-change innovation in a rural area of Mozambique.

Intervention: About 50,000 households with pregnant women or children under 2 years old were organized into blocks of 12 households. One volunteer peer educator (Care Group Volunteer, or CGV) was selected for each block. Approximately 12 CGVs met together as a group every 2 weeks with a paid project promoter to learn a new child-survival health or nutrition message or skill. Then the CGVs shared the new message with mothers in their assigned blocks.

Methods Of Evaluation: Household surveys were conducted at baseline and endline to measure nutrition-related behaviors and childhood nutritional status.

Findings: More than 90% of beneficiary mothers reported that they had been contacted by CGVs during the previous 2 weeks. In the early implementation project area, the percentage of children 0-23 months old with global undernutrition (weight-for-age with z-score of less than 2 standard deviations below the international standard mean) declined by 8.1 percentage points (P<0.001), from 25.9% (95% confidence interval [CI] = 22.2%-29.6%) at baseline to 17.8% at endline (95% CI = 14.6%-20.9%). In the delayed implementation area, global undernutrition declined by 11.5 percentage points (P<0.001), from 27.1% (95% CI = 23.6%-30.6%) to 15.6% (95% CI = 12.6%-18.6%). Total project costs were US$3.0 million, representing an average cost of US$0.55 per capita per year (among the entire population of 1.1 million people) and US$2.78 per beneficiary (mothers with young children) per year.

Conclusion: Using the Care Group model can improve the level of global undernutrition in children at scale and at low cost. This model shows sufficient promise to merit further rigorous testing and broader application.
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http://dx.doi.org/10.9745/GHSP-D-12-00045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4168551PMC
March 2013