# **Geneva Health Forum 2020 Poster Book**

### genevahealthforum.com

Antoine Flahault, Antoine Geissbuhler, Nicole Rosset Edited by

## Geneva Health Forum 2020 Poster Book

*Editors* Antoine Flahault, Antoine Geissbuhler, and Nicole Rosset

The cover image depicts a Malian radiologist training doctors and midwives to mobile and teleechography in a maternity in Nouakchott, Mauritania.

Cover image courtesy of Antoine Geissbuhler.

© 2021 by the authors. Articles in this book are Open Access and distributed under the Creative Commons Attribution (CC BY) license, which allows users to download, copy and build upon published articles, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. The book as a whole is distributed by MDPI under the terms and conditions of the Creative Commons license CC BY-NC-ND.

ISBN 978-3-0365-0951-8 (PDF)

*Editorial Office* MDPI St. Alban-Anlage 66 4052 Basel, Switzerland

### Table of Contents


Mai Arafa 8


v


Emilien Jeannot, Jean Michel Costes, Cheryl Dickson and Olivier Simon 38

AUGMENTING TB SCREENING THROUGH USE OF ARTIFICIAL INTELLIGENCE AND PCR TESTING FOR TB DETECTION IN NAGPUR, MAHARASHTRA

Vaishnavi Jondhale, Shibu Vijayan, Ravdeep Gandhi, Asha Hegde, Amera Khan, Anjali Borhade, Lucky Richardson and Suman Gupta 39

vi



BUILDING HEALTH PLANNING CAPACITY TO ENSURE EVIDENCE-BASED INTERVENTIONS AND FOSTER PARTICIPATION AND ACCOUNTABILITY

#### IN MOLDOVA: RESULTS OF HEALTH PROFILES DEVELOPMENT AND ROLL-OUT FOR HEALTH PLANNING IN TEN DISTRICTS OF RURAL MOLDOVA Constantin Rimis, Florence Sécula, Diana Berari, Laura Aaben, Ion Salaru, Helen Prytherch and Ala Curteanu 58


Girum Taye, Tigist Shumet, Theodros Getachew, Tefera Tadele, Atkure Defar, Misrak Getnet, Geremew Gonfa, Habtamu Teklie, Ambaye Tadese, Gebeyaw Mola,


viii

### Preface

The Geneva Health Forum is the forum that brings together key actors of Global Health. Created in 2006, and held every two years ever since, it is organized by the Geneva University Hospitals (HUG) and the University of Geneva in partnership with 30 global health organizations.

Building on the dynamic of International Geneva, the Geneva Health Forum is one of the most important international global health conferences.

The overall objective of the Geneva Health Forum is to contribute to the improvement of health and access to health care in the world. To achieve this goal, it aims to give visibility to innovative field experiences and to establish a critical and constructive dialogue between global health actors from different sectors, as well as to foster collaborations between them.

At each edition, the Geneva Health Forum gives an important place to the presentation of research projects. Research, whether carried out by students or established researchers, contributes to innovation and new practices in access to care.

The synthesis of research results in the form of a poster remains a quality exercise. Electronic dissemination offers new opportunities to meet a wider audience.

Favoring a multidisciplinary approach, the GHF is open to all professions working in the health field.

From 16 to 18 November 2020, the eighth edition of the Geneva Health Forum, which took place in the difficult context of the Covid 19 pandemic, hosted 165 posters. The present collection offers through 65 posters a wide range of topics discussed.

We look forward to seeing you at the next edition of the GHF, which will take place from 3 to 5 May 2022.

### Antoine Flahault

President, Geneva Health Forum

Director, Institute of Global Health, Faculty of Medicine, University of Geneva

### Antoine Geissbuhler

President, Geneva Health Forum

Director, Division of eHealth and telemedicine, Geneva University Hospitals. Director, Innovation center, Geneva University Hospitals

Vice-Rector for Digital transition and Innovation at the University of Geneva

Nicole Rosset

President, Geneva Health Forum

Deputy Director External Affairs Directorate, Geneva University Hospitals

ix

## ASSESSING OPPORTUNITIES FOR SAFE RADICAL CURE OF *PLASMODIUM VIVAX*  MALARIA IN INDIA

### Authors

E. Gerth-Guyette, A. Sharma, M. Kalnoky, E. Spark-DePass, S. Halstead, G. Domingo, R. Tandon and N. Agarwal

### Introduction

India bears nearly half the global burden of *Plasmodium (P.) vivax* malaria. The majority of these cases are concentrated in poor states and in rural areas, where atrisk populations often seek care in the private sector. The safe radical cure of *P. vivax* malaria requires greater access to testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency. Diagnostics that can identify people with low levels of G6PD activity should be used before treatment with primaquine.

### Aims and methods

The goal of this project was to understand the opportunities and challenges to expanding access to safe radical cure for *P. vivax* malaria management in India using the following approach:

### 1) Use case identification

Nine districts across four states were selected to include a range of malaria elimination contexts, both urban and rural populations, and the use of both public and private health facilities.


### 2) Primary research

Interviews and focus group discussions were conducted with 110 key informants across the use cases between August and November 2018 to better understand malaria case management and current G6PD testing practices and perceptions.

### 2) Primary research

Demographic and geospatial raster data were combined to generate district-level maps of India that enabled the visual exploratory analysis of demographic and epidemiologic data. Geospatial data were used in conjunction with geocoded health care infrastructure data to create proxies for access to care in seven high-burden districts. Access was defined by a surface travel speed map, which was used to estimate the time it takes to traverse any two geographic points. Data were

analyzed within the statistical programming language R.

### Results: Malaria case management and G6PD testing practices and perceptions


### Results: Geospatial modeling, an overlapping burden of *P. vivax* and G6PD deficiency

G6PD deficiency poses a challenge to several high burden *P. vivax*  states, as places with a high incidence of *P. vivax* malaria overlap with a significant

prevalence of G6PD deficiency.

*Sources: G6PD deficiency prevalence, Malaria Atlas Project; vivax incidence, 2017 Malaria Atlas Project, 2017 estimated cases data, Epidemiology of Plasmodium vivax in India, PATH geospatial modeling. Abbreviations: G6PD, glucose-6-phosphate dehydrogenase.*

### Results: Estimating access to best clinical practices for *P. vivax* patients

#### *Abbreviations: M, million; PQ, primaquine.*

*Source: PATH Geospatial modeling, estimated incidence: Malaria Atlas Project 2017 estimated incidence \*Primary research indicated that although PQ is givdosingen in the private sector, very few private providers are administering PQ in compliance with national treatment guidelines (e.g., administered as a cocktail or with incorrect).*


### Results


*PATH gratefully acknowledges GSK for their financial support of this research.*

1

## COMMENTS AFTER VIOLENCE AGAINST FAMILY PHYSICIAN IN TURKEY

### Authors

Bekir Aktura1,2 and Nilüfer Aktura2

<sup>1</sup> Istanbul University, Istanbul, Turkey <sup>2</sup> Istanbul Medipol University, Istanbul, Turkey

### Introduction

Violence is defined by the World Health Organization as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation". In Turkey, violence against health care workers has been increased significantly in recent years. In this study, it is aimed to examine the comments written about violence against family physician via internet journalism and thus to get an idea about common attitudes.

### Results

There were 206 news reviews and all have been examined. It is assumed that each comment is made by a separate person. Of the reviewers, 62.6% (n = 129) were anti-violent, 25.7% (n = 53) supported violence and 11.7% (n = 24) were undecided. In terms of subject categories; commenting directly on the incident was 10,7% (n=22), post-event judicial process was 28,6% (n=59), sociocultural status of the perpetrators was 29,6% (n=61), and health care defect was 31,1% (n=64). While 79.2% of the supporting violencers were commenting on the health care defect, 41.1% of the anti-violencers commented on the sociocultural status of the perpetrators and 39.5% of post- incident judicial process (p <0.001).

Contact: bekiraktura@gmail.com

### Methods

In this semi-quantitative study, the readers' comments for the news about the family physician who exposed to physical violence by 10 people have been examined. The comments were evaluated in three categories such as "anti-violence," "supporting violence", and "undecided" by two researchers independently, at the same time, they were divided into four subject categories according to the topics mentioned: "commenting directly on the incident", "post-incident judicial process", "sociocultural status of the perpetrators," and "health care defect". Both researchers' evaluations were found to be completely compatible with each other.

### Conclusion

We can conclude that all violence supporters were blaming the victim, who was the family physician in this case. The inadequate criminal sanctions imposed on violent people against healthcare workers may facilitate the use of violence as a means of seeking rights. The introduction of dissuasive penalties, together with public training

to develop a condemnation of violence, may provide a solution to this problem.

### Acknowledgment

Thanks to our mentor, Professor Selma Karabey, who guided us in every step of this study.


*Table 1. Relationship comments category and topics.*

### CLINICALLY RELEVANT ANTIBIOTIC RESISTANT PATHOGENS FROM HOSPITAL EFFLUENT AND THEIR ACCUMULATION IN VEGETABLE FRESH PRODUCE UNDER TROPICAL CONDITIONS

### Authors

Dhafer Al Salah1,3, Georgette N. Ngweme2 and John Pote1,2

1 University of Geneva, Faculty of Sciences, Department F.-A. Forel for Environmental and Aquatic Sciences, Boulevard Carl-Vogt 66, CH-1205 Geneva, Switzerland 2 School of Public Health, Faculty of Medicine, University of Kinshasa, B.P. 11850, Kinshasa XI, Democratic Republic of the Congo 3 King Abdulaziz City for Science and Technology, Joint Centers of Excellence

Program, Prince Turki the 1st st, Riyadh, 11442, Saudi Arabia

### Background

Hospital and urban wastewaters are a major cause of the spread of pathogens and antibiotic resistance. The study site, Kinshasa, DRC, has a history of outbreaks related to foodborne and waterborne pathogens. We investigated the significance of proliferation of antibiotic resistant and fecal indicators from hospital effluent. Then,

we sampled vegetable produce (lettuce and celery) and irrigation water from surrounding farms. We quantified the biological risk of infection associated with the consumption of vegetables.

*Figure 1. Sampling Sites.*

*Figure 2. The abundances of cultivable E. coli, Enterobacteriaceae, β-lactam resistant E. coli (B-lac E. coli) and Enterobacteriaceae (B-lac Enterobacteriaceae), and carbapenem resistant E. coli (Carbapenem R. E. coli )and Enterobacteriaceae (CRE) per gram of dry sediment in the wet and dry seasons.*

#### References

Alsalah, Dhafer et al. "Assessing the Groundwater Quality at a Saudi Arabian Agricultural Site and the Occurrence of Opportunistic Pathogens on Irrigated Food Produce." International journal of environmental research and public health vol. 12,10 12391-411. 5 Oct. 2015.

Pote, J., Bravo, A. G., Mavingui, P., Ariztegui, D. & Wildi, W. Evaluation of quantitative recovery of bacterial cells and DNA from different lake sediments by Nycodenz density gradient centrifugation. Ecol Indic 10, 234-240.

USEPA. Exposure Factors Handbook 2011. U.S. Environmental Protection Agency; Washington, DC, USA: 2011.

The QMRA was performed according to the guidelines of the Exposure Handbook by US EPA. Briefly, the guidelines included the frequency of salad consumption and percentage of vegetable in salads

*Table 1. The significance of the hospital contribution in relation to the upstream. If the p value is above 0.05, there is no significant difference between the upstream and the hospital discharge. If it is below 0.05, there is a significant difference.*

### Antibiotic Resistance Test

Isolates of *V. cholerae* and MRSA were subjected to 16 and 9 antibiotics, respectively. The susceptibility test was performed using the disk diffusion method. These antibiotic belong to different classes. All the *V. cholerae* isolates were resistant to at least 3 antibiotics from three different classes. The MRSA isolates were at least resistant to one antibiotic.

*Table 2. Risk of infection with pathogens from vegetables.*

#### Extraction of bacteria from:



#### Quantification of bacteria:

• Enterobacteria*, E. coli*, Coliforms

### QMRA

	- Exponential
	- Beta-Poisson


### III. Results A: Proliferation of antibiotic resistance

### III. Results B: QMRA

#### Quantification of markers and ARGs (qPCR)

• Relevant bacteria


*Figure 3. The biological quality of irrigation water.* 

### I. Objectives



Hospital effluent causes significant pollution of antibiotic resistance genes and fecal bacteria in the sediments in both seasons and water in the dry season (p<0.05). However, the effluent does not significantly pollute river water in the wet season (p>0.05).

### IV. Conclusion

In developing countries, untreated wastewaters cause wide spread of antibiotic resistance in the form of bacteria and genes. These untreated wastewaters lead to quality degradation of waterbodies. When compromised water is used for irrigation, the consequences can be catastrophic. In this study, we demonstrated the high infection rate caused by the consupmtion of raw vegetables in salads and the high frequency of antibiotic resistance among isolates. We suggest the termination of the use of compromised irrigation water and switch to a water that complies with WHO standards for irrigation water. We also recommend the reduction of the total number of bacteria, which can be achieved by washing the produce, allowing enough time to pass between last irrigation and harvest, and switch of irrigation method from overhead spray, which is quite common to drip irrigation.

### II. Methodology

We sampled two river systems receiving hospital wastewaters over two seasons and irrigation and vegetable produce (lettuce and celery) from three farms.

3

### HEALTH SYSTEM FACTORS INFLUENCING ACCESS AND UTILIZATION OF SEXUAL AND REPRODUCTIVE HEALTH SERVICES IN CONFLICT SETTINGS: YEMEN

### Authors

Haifaa H.M. Al Wajeah1 1MD MPH

### Introduction

Yemen is in an unstable situation since decades with different social characters which affect the sexual and reproductive health outcomes. This has deteriorated, since the current conflict resulting results in a fragile health system.The maternal mortality ratio in Yemen is considered one of the highest ratios globally with low utilization due to poor access. The study aims to analyse the health system factors that affect access and utilization of the sexual and reproductive health services during a conflict setting in Yemen.

*Figure 3. Percentage of THE between 2007-2015 by Revenue Source. Source: WHO, National Health Account Database, 2016, http://apps.who.int/nha/database/country\_profile/Index/en.*

### Methods

This study is based on a review of grey literature, peer-reviewed reports, published articles, international and national reports of the three core functions of the health system and the effect of conflict on these functions. In addition, to we feature a simple qualitative analysis of the Health Resource Availability Mapping System (HeRAMS) 2016 data of 16 governorates in Yemen out of 22. The study was guided and analysed by using WHO/WB model for Health System Strengthening, *Figure 1.*

*Figure 1. WHO/WB model for HSS (HSS towards UHC); Source: Healthy systems for Universal Health Coverage – a joint vision for healthy lives,* 

Service Delivery: Based on Yemen Humanitarian Needs Overview 2019 which reported by UNOCHA who mentioned that reproductive health services are limited to less than 55% in each level of health facilities. WHO minimum average standard of health providers is 22

The SRH services in Yemen were limited before the conflict and deteriorated during the current conflict which will decrease the utilization of services leading to increase the burden of disease and part of it maternal and newborn related diseases. This is a result of many factors of related to the service delivery; For example:

• The presence of poor quality of services which leads to loss of trust between the population and the health sector.


Regarding the supply point, based on HeRAMS 2016 data, there was a high availability of outpatient services with availability of all essential drugs in Al Dalae's hospitals with 80% availability. Though, the lowest percentage was in hospitals of Aden, Al Jawf, Al-Hodeidah and Lahaj with 20% and less. For health centres, it was less than 10% in Abyan, Marib, Sana'a, and Amran. And for the health units, it showed that in 15 governorates the availability of services was less than 20% except in Al-Hodeidah where it was 48%, *Table.1.*

Acknowledgments Royal Tropical Institute (KIT), Amsterdam – Netherlands.

Health Financing: There is a collapsed economy which will increase the dependency on external donors due to low governmental contribution to the health sector especially to SRH services. This decrease the sustainability of providing health projects, increase out of Pocket with limited coverage of insurance scheme, Figure 3. In addition, the inability of MoPHP to ensure the provision of health services, i.e. MoPHP has challenges to pay health staff's salaries and implement the policy of free of charge PHC services.

An inadequate access and low utilization due to financial challenges affect the SRH service delivery which deteriorated during the current crisis in Yemen. Conclusion

> The study found that lack of access and poor utilization of SRH services in Yemen is affected by the current fragile health system which was known to be fragmented already before the conflict, and worsened because of the current conflict. That collapse occurred by a deterioration of health system functioning especially characterised by low oversight and poor accountability, inadequate budget and low provision of services like SRH services. These factors resulted in poor SRH outcomes in Yemen with poor health system performance and lack of government commitments to implement the current policies largely because of the important shortage of critical resources, i.e. health workers, drugs and medical supplies. etc. In addition, the social and economic collapse increased the poverty rate and decreased SRH services utilization putting Yemen with countries with the highest MMR globally. There is a need to strengthen the health system to improve women health which will improve the health

providers per 10,000 population. 000 In HeRAMS 2016, there are 33,317 health care providers in the 16 governorates where the survey was done. However, the national average is 17.03 per 10,000 population which is below the international standard for the health workforce with low presence of midwives and speciality as Figure 4.

outcomes in Yemen.

*Figure 2. Percentile Rank of Yemen in Good Governance Indicators.* 

*Source: Author's summary based on MoPIC. Yemen Socio-Economic Update, 2019.* 

### Results

Utilization and access of SRH services in Yemen is affected by different factors and one of the most important factors is the health system functioning which facilitates or creates difficulties for the population to access SRH services.

Governance: The findings highlighted that weak governance is characterized by absent or weak oversight which deteriorated since the conflict started. That weakness resulted in increased corruption and ineffective management of the health sector in the presence of two MoPHP with lack of coordination. In 2017, Yemen had a percentile between 0%-6% of the good governance indicators and became one of the weak countries worldwide, Figure 2.

*Figure 4. Percentage of Availability of Health workforce by professional background. Source: Yemen HeRAMS, 2016.*


(b) Single commodities

*Table. 1. Percentage of Available selected services per HFs and per governorate. Source: Author's summary based on Yemen HeRAMS 2016.*

Challenges related to the conflict which cause a shortage in health providers, infrastructure and medical supplies causing poor quality life-threatening services'

provision for mothers and newborn. While prior to the conflict and based on the Yemeni National Health Demographic Survey 2013, the coverage of maternal health services was like 60% ANC and 45% deliveries attended by skilled providers and there is a maldistributed of services which is similar to other MENA countries. However, Yemen has the lowest coverage of less than 10% based on USAID reports 2018.

4

## PROMOTION OF FAMILY MEDICINE AT UNDERGRADUATE LEVEL

### Authors

Nursuluu Amatova, Nuraiym Turanova, Shirin Talapbek kyzy, Louis Loutan, Damira Mambetalieva and Nurlan Brimkulov

### Introduction

Due to the low image of family medicine in Kyrgyzstan, lack of scientific discipline and low salary, almost no student has previously chosen residency in family medicine. However, a couple years ago, This situation changed due to an initiative of the Ministry of Health and support of medical institutions within the framework of Medical Education Reforms Project.

In addition, the family medicine club was established for students, where they are can discuss some clinical cases in outpatient practice and conduct researche at PHC.

Finally, for the first time in 2019, the inter-university Olympiad in family medicine was organized, and in the same year, students could take part in the fourth congress of family doctors of Kazakhstan.

### Promoting actions at undergraduate levels


core role of family doctor in the health care system.

### Nursuluu Amatova

e-mail: nurs.amatova94@gmail.com Phone: +996779172497, Akhunbaeva 92, Bishkek 720020 Kyrgyzstan

As a result of measures taken in recent years in the field of health care, the promotion of family medicine in the country, an increase in the prestige of the specialty in the eyes of students, there is a positive trend.

### Basic teaching methods

Teaching is carried out on the basis of large centers of family medicine, at the ambulance station in the form of field duty and seminars, and at meetings for the medical and social assessment. Classes are conducted by experienced teachers, while 1/3 of the time is theoretical training and 2/3 is the practical management of patients at outpatient appointments, home patronage, ambulance duty.

### The number of graduates of family medicine

### Family medicine in Kyrgyzstan

### NEW COMPETENCES OF UKRAINIAN HEALTH CARE MANAGERS: HOW TO ADDRESS THE EXPECTATIONS An Online Survey Results

### New system–new competenses for health care managers

Since 2014, the Ukrainian health care system has been transformed: key policies and organizations have been adopted and launched to assure universal health coverage. Health care facilities are becoming autonomous and the primary health care providers are financed based on capitation.

All these changes require substantially new qualities of health care managers.

We aim to reveal the self-perceived need in knowledge and skills of health care managers, as well as to outline the available experience for the development of educational products.

### Methods

Online survey has been conducted in April–May 2019, based on the contact list of

the National Health Service of Ukraine and international projects. Overall, we have received 354 responses.

Moreover, the individual semi-structures interviews and group discussions took place with 35 key stakeholders.

### Results

The key findings show that primary care managers demonstrate interest to innovative modes of education: 37% managers participated in webinars and the most rated forms of education are distance learning (63%), blended learning (59%).

Still, 11% has not been involved in any kind of educational activity and about 10% have not any experience in self-education.

The most lacking knowledge is finance and accounting, customer service, computers, the English language and the lack of skills is in systems evaluation, monitoring operations analysis, management of material resources.

These results have been discussed by the representatives of the key stakeholders.

*Figure 1. Most used sources for self-education.*

**"We want them (the courses) to be more** 

**responsive to innovations, to be introduced into practice while fulfilling health care reform requirements in health care facility."**

*Figure 2. Medical managers report the lack of of the following knowledge the most.*

### Closing remarks

We observe a high interest of various stakeholders to the new and sustainable programs on health care management. One of the reasons for this demand is rapid transformation of the health care system in Ukraine in 2018–2019. Indeed, policy makers are interested in medical managers who have competences to run autonomous health care facilities. This would ensure the accessibility, quality, and efficiency of health care services. In parallel to this, health care managers feel the need to develop their growth, in general, and managerial skills, in particular.

Health care managers advanced in their career but do not have enough preparation for being managers under the new system, and are not comfortable with classroom education, and want to bring their new knowledge into practice immediately. In this case, the focus on competence-based education and innovative didactics is more important than theoretical teaching.

The needs of health care managers are of high importance when new educational program is launched. Good managerial practices are important for the successful implementation of new policies. **"The cources should be conducted using more** 


**modern methods of teaching (case study, etc.)"**

*Quotations of survey participants.*

**"We want more practice, more successful cases, more information on legislation under the conditions of health care system transformation."**

This presentation is prepared within the Ukrainian-Swiss project "Medical Education Development" that is executed in Ukraine by Swiss Tropical and Public Health Institute (Swiss TPH) funded by the Swiss Agency for Development and Cooperation.

### Authors

Tetiana Stepurko, Valentyna Anufriyeva, Wim Groot, Axel Hoffmann and Martin Raab

6

## PRIMARY HEALTH CARE REFORM IN UKRAINE: FINANCES AND ORGANIZATION

### Introduction

Since 2013 Ukraine and its health care system have been experiencing systematic changes. Legislation on new financing mechanisms and state medical guarantees was adopted in 2017. National Health Service of Ukraine (NHSU) was established in April 2018 as single national payer. It was decided to start the health financing reform from the primary level despite the ignorance of key stakeholders (e.g., patients, government) of primary health care. We aim to outline the process of change and achievements of primary health care transformation for better access and quality of the services.

### Methods

The case study methodology has been applied, including "Health index. Ukraine" survey data, "Family medicine perception in Ukraine", the National Health Service of Ukraine information system as well as individual and groups interviews with patients, medical students and educators, health care managers, policy-makers and other professionals.

*Figure 1. Example of the communication campaign developed by the Ministry of Health, 2018 to promote new practice of patients' choice of family doctors and declaration signing.*

### Results

Primary health care reform has provided the possibility to patients to choose family doctors according to patients' preferences and expectations. Since 2018, 28 out of 43 million have signed the declaration with a family doctor, or pediatrician, i.e. they selected their preferred provider. The declaration has been an "entry ticket" to the freeof-charge health care services at almost any point and to the medicines reimbursement program (e.g., affordable medicines reimbursement program). The registration-based principle in getting health care services was abolished when new

principles were approved. The tax-based system remained the same as the revenue collection in health care.

Facilities have become autonomous in 2018 and they are financed based on simple capitation (with age coefficient) as the first step of changes after the line-item budgets.

Both publicly and privately owned entities, both individuals and organizations, can be primary health care providers and are eligible to sign the contract with NHSU. Moreover, a new financing model stimulated the development of new private practices (mostly individual private practices), as it gave professional and financial independence to physicians. Importantly, it has been the first time in the history of Ukraine when the privately owned entities received funds from the state budget for the services provided to people. At the moment, the share of the contracts with private providers is ¼ of the NHSU contracts with primary health care providers. The growth of the privately owned share of the primary health care providers suggests the interest of this scheme and the support from the patients (as they receive the attributes of care which they are looking for).

Primary health care providers with autonomy and capitation payments obtained an opportunity to increase their salaries and to prioritize the investments in the quality of the service. However, as is presented in Figure 2 and Figure 3, medical educators and future health care providers do not consider family medicine as a profession which is appreciated by society.

The majority of the health care users are satisfied with the changes and among the reasons is that they can reach their provider by various means of communication, e.g. telephone, messenger etc. The team of the MoH and NHSU have assured wide-scale communication and good governance of change. The providers are reporting on higher income and opportunities for development.

This presentation is prepared within the Ukrainian-Swiss project "Medical Education Development" that is executed in Ukraine

by Swiss Tropical and Public Health Institute (Swiss TPH) funded by the Swiss Agency for Development and Cooperation.

### Closing remarks

It is the first system-wide change that Ukraine has experienced since its independence (or within 26 years) and the transformation is positively perceived by both users and providers. Further developments of primary health care are needed, including improving the competences of family doctors, considering more efficient task distribution among the nurses and medical doctors as well as measures to assure quality on primary health care and its connection with specialized and inpatient care.

"Family medicine should not be equal to narrow specialties. Salaries of family doctors should not be higher than of specialists"

> *Medical student, 3rd year*

"More than 70% of those who signed the declarations with family doctor are satisfied with his/her services vs 12% who report unsatisfaction. Patients report increase of the physicians' attention and politeness"

*National survey "Rating group"*

*Figure 2. Distribution of the responses on the question "Based on what considerations, have you chosen/planned to choose family doctor" / Health index.Ukraine, 2018.* 

### "Based on what considerations, have you chosen/plan to choose family doctor?"

### Authors

Pavlo Kovtoniuk, Nataliia Riabtseva, Tetiana Stepurko and Martin Raab

### ANALYSIS OF FACTORS INFLUENCING EMERGENCE AND SPREAD OF ANTIBIOTIC RESISTANCE IN EGYPT USING A ONE HEALTH APPROACH

### Introduction

Antibiotic resistance (ABR) is a massive threat to public health and leads to the loss of thousands of human lives each year. This study aims to identify the main contributing factors to the emergence and spread of antibiotic resistance in Egypt. A one health model was followed to develop useful recommendations for effective interventions to tackle the problem.

### Methods

A literature review of different published and unpublished articles, reports, and documents was used. The Lebov one health and Linton frameworks were merged to develop a new framework. This framework was formed and followed to match the study objectives and to guide the review.

*Figure 1. Adapted framework of Lebov et al. and Linton frameworks.*

### Acknowledgement

Special thanks to the Royal Tropical Institute, Vrije Universiteit Amsterdam, and the Dutch Organization for International Cooperation in Higher Education, who supported me during my journey working on this study.

### **Although some factors have more evidence to support their links to the effect of ABR in Egypt, it is hard to prioritize those factors, since they act as a network of combined elements.**

### Conclusion

ABR problem in Egypt is increasing, and integrated interventions are needed to tackle it. A national awareness campaign will help in behavior augmentation regarding antibiotic use. Encouraging research on ABR will find tailored opportunities based on the national situation. A wellestablished surveillance system will give a comprehensive figure on the circulating resistant bacteria. Strict regulations and regular monitoring will help in combating ABR in Egypt.

### Results

The review showed the main drivers to the emergence and spread of antibiotic resistance (ABR) in Egypt from a one health perspective. Extensive and inappropriate use of antibiotics in humans and weak awareness among community members and healthcare professionals increase ABR emergence and spread. Lack of strict regulations and monitoring on antibiotic dispensing facilitates ABR emergence. On the other hand, lack of data about the ABR pattern in Egypt due to limited surveillance system acts as a barrier to effective interventions, and it hinders efforts to combat ABR in Egypt.

### Results

Unregulated agricultural practices, antibiotic residues in wastewater, resistant bacteria in water, soil, air, and horizontal gene transfer, are the main environmental influencing factors. The main animal factors that influence ABR are extensive antibiotic use in animals and aquaculture. Challenges to controlling efforts were identified as lax regulations, lack of enforced policies, and limited surveillance.

*Figure 2. Antimicrobial consumption in livestock per country in 2013, with focusing on Egypt.*

*Reprinted by permission from the Center for Disease Dynamics, Economics & Policy, Animal Use, © 2019.*

*Chart 1: Distribution of consumed antibiotics in Egypt in 2015 (distributed by type in DDD/1000 population).*

*Table. 1. Recommendations with stakeholders that are responsible for implementing them.*


### Author

Mai Arafa

8

## ENGAGING LOCAL COMMUNITY ACTIVISTS TO RESPOND TO CYCLONE IDAI IN THE URBAN CONTEXT OF BEIRA, MOZAMBIQUE

### Authors

Andrea Atzori and Maria Brighenti Doctors with Africa CUAMM

### Abstract

Cyclone Idai had a dire impact on the city of Beira in Mozambique, devastating people's homes and agricultural production. Instead of creating new ad hoc emergency initiatives, Doctors with Africa CUAMM (CUAMM) could coordinate an effective disaster response with a network of community groups; assistance providers to the population prior to the disaster, they expanded their role in its aftermath to facilitate emergency communication and reporting.

*Figure 2. Training session for activists to respond to the emergency.*

### Cyclone Idai

On the night between 14 and 15 March 2019, tropical Cyclone Idai struck the city of Beira, capital of the Sofala province in central Mozambique, with horrific consequences for the local population of about 600,000. Some 239,682 homes were destroyed or severely damaged, and approximately 142,327 displaced people were housed at disaster accommodation centers. In the initial stages of the crisis, four main forms of direct damage were identified:

1) Destruction and interruption of the water supply and massive damage to sanitation facilities, with the lack of clean water putting the population at risk of contracting waterborne diseases including cholera.

2) Destruction of homes, loss of personal property and nonfood items, and further material damages, putting the population at risk of indefinite displacement and even greater personal insecurity, especially with regard to the most vulnerable population groups such as women and children.

3) Damages to health facilities, including loss of supplies and other materials. According to the local authorities, at least 24 health units were impacted in the provinces of Sofala, Manica, Zambezia and Inhambane, suspending health services for patients with acute, chronic and/or other conditions necessitating medium- to long-term care (e.g., tuberculosis and HIV).

4) Damage to agricultural production both in the short term, with crop losses and food shortages in local markets, and the medium to long term, with damage to the agricultural substrate and potential damage for upcoming harvests.

*Figure 1. The city of Beira right after the cyclone.*

### An Extra(ordinary) Service That Made It Possible To Guarantee The Ordinary As Well

Activists carried out prevention work, identifying cases of cholera, at-risk minors, and families with immediate needs, and providing basic humanitarian kits. A few days later, CUAMM used the same scheme in the rural districts of Dondo and Nhamatanda, training 94 activists and sending them to the field.

From the moment that the cyclone hit on through June 2019, these activists were able to reach 45,874 families in the city of Beira, 14,375 families in the Dondo district, and 8071 families in the Nhamatanda district, delivering a speedy response to their basic needs and mitigating the impact of the cyclone-related suspension of health services on patients who had been receiving treatment for HIV and related coinfections.

Additionally, a new electronic data-collection tool was introduced immediately after Idai to overcome the loss of data and improve monitoring. Activists were equipped with an Android smartphone to collect field data and monitor people living with HIV by confidential GPS tracing. Almost 4500 patients with HIV were reached from the time of Idai hitting to December 2019.

Doctors with Africa CUAMM https://doctorswithafrica. international@cuamm.org org/

Already existing community health networks in Africa are a crucial resource in crisis situations. With adequate training and leaveraging on human and material resources already "on the ground", it is possible to build resilient communities that are able to withstand disaster-related damage.

*Figure 3. Activists in the city of Beira.*

### Humanitarian and Community-Level Response

An international humanitarian response was launched in the immediate aftermath of the cyclone, with materials and emergency teams being sent in from all over the world through the only entry point available, Beira Airport. As material and human resources continued to accumulate, it became critical to find the most efficient ways to reach and distribute the aid to cyclone-affected communities.

Doctors with Africa CUAMM responded through an emergency relief intervention, leveraging on already existing local peer-to-peer HIV organizations instead of creating new ad hoc emergency initiatives. CUAMM engaged with 143 HIV activists from three local organizations: Kuplumussana, Anandjira, and Association Geraca̧ ̃o Saudavel (AGS). Themselves impacted by the cyclone, these groups had previously worked with CUAMM to implement a program for the education, counseling, testing, and support of HIV patients. Their indepth familiarity with the urban dynamics of Beira, and their ability to reach people and identify the worst situations made them ideal partnering networks with which to respond to the local population's needs as quickly and efficiently as possible.

CUAMM therefore decided to "reactivate" the three community groups by securing their offices, and providing them with basic livelihood necessities and communication means. Within 48 hours, working together with local health authorities and the national humanitarian response unit, an intensive training course was developed on:


Each activist was then given a kit containing posters, data-collection materials, disposable items, and so forth, and a coordinator-supervised work plan.

### Closing remarks

The ability of the three community groups (Kuplumussana, Anandjira, and AGS) to effectively respond to the crisis generated by Cyclone Idai underscores the utility of leveraging such networks in times of emergencies in order to create a resilient system. It is crucial to provide them with regular material stocks, and, most importantly, make available training courses and programs (vocational and otherwise) without creating vertical structures that can be very costly to create and maintain.

Now, almost a year since the cyclone, the Mozambican population and healthcare services with international partners remain resilient, and the work conducted by the activists has been fundamental to mitigate the effects of the disaster on the general health and wellbeing of patients' families and their community.


9

## HEALTH TECHNOLOGY AS COMMONS: TRUSTABLE, AFFORDABLE, ADAPTABLE

Geneva Health Forum 2020 · Open Village · www.openvillage.ch

6 in 10 humans still have no access to care, or do not adhere to it, despite rising investments. Alcohol-based hand rub and WikiMed illustrate how creating freely reproducible equipment and software with communities can: save millions of lives, increase integrity, cut costs by 90%. Cooperation-driven care is the only way to realize the 2030 agenda in time: health for everyone. We presente nine alternatives to the dominant proprietary excluding innovation model, to drive development towards a responsible, solidar society.

### Hand prosthesis to ease one's daily life

A prosthetic hand usually costs 6-10 K€. Enable brings together over 30000 volunteers who design and distribute 3D-printed prostheses to vulnerable people. www.enablingthefuture.org + www.gre-nable.fr + www.enablenepal.org

### Drugs produced with integrity

India has a pioneer approach in pharmaceutics. Open-Source Drug Discovery brings together 7900 people who collectively develop open-source, low-cost therapies for neglected diseases such as tuberculosis, malaria, leishmaniasis. www.osdd.net

### Open-sourcing MRI could save the German healthcare over 200 M=€ yearly

Medical imaging is crucial in diagnosing, understanding and treating a number of diseases. The Open-Source Imaging initiative gathers experts to create MRI scanners that can be built and maintained for a fraction of the cost of current MRls. www.opensourceimaging.org

### Ultrasound scanner in the pocket

One in three persons have access to medical imaging. A portable ultrasound device usually costs 8-22 K€. EchOpen develops a probe to visualise organs on a smartphone. It helps guide the diagnosis and make patient management more fluid. www.echopen.org

### Making air pollution a visible matter

In Switzerland, one in seven premature deaths is linked to air pollution. LogAir helps everyone to map the air quality (fine particles) using cheap devices. Generating data can help avoid bad air quality, but can also motivate policy changes for healthier cities. www.logair.io

### Collecting and visualizing data

Mindlogger makes it easy for anyone to collect, analyze, and visualize data using mobile devices. Users are able to build their own activities, such as surveys, quizzes, digital diaries, or cognitive tasks. www.mindlogger.org

### Detecting seizures with wearables

1 WHO and World Bank. Half the world lacks access to essential health services. 2018. 2 WHO. Adherence to long-term therapies: evidence for action. 2003. 3. World Bank. Current health expenditure (% of GDP). 2020. 4. WHO. Guide to Local Production: WHO-recommended Handrub Formulations. 5. WikiMedia. Wiki Project Med/App. 2020. 6. United Nations. #Envision2030 Goal 3: Good Health and Well-being. 7. Winter et al. Open Source Medical Devices for Innovation, Education and Global Health. 2018. Creative Commons BY-SA 10

50 million people have epilepsy, 1/3 are drug resistant. Epileptic seizures lead to daily stress and social exclusion. We develop wearables and software to log and analyse biological data.

www.aura.healthcare + www.openhumans.org + www.cri-paris.org

### Transforming gesture into sound

Fuga explores the potential of emerging technologies for preventing, diagnosing, monitoring, and rehabilitating mental health disorders in line with recent advances in psychiatry and neuroscience. www.hoosh.space/fuga

### Taking care of our breathing through play

Worldwide, one child in ten has asthma, one senior in twenty has COPD, a disease caused by pollution and smoking. Breathing Games is developing a multiplayer game and a breath sensor to promote respiratory health. www.breathinggames.net

We also discuss ageing, public policies, quality systems, and cryptocurrencies.

Videos and more Open Village · www.openvillage.ch ·Cite: wwww.doi.org/10.5281/zenodo.4327587

### Authors

Fabio BalliA, Mathilde MatringeB, Clement le CouedicC, Jon SchullD, Shikshya GautamD, Patrick JandardD, Emmanuel KellnerE, Afroditi AnastasakiF , Katerina SeradaG, Samir K BrahmachariH, Lukas WinterI Pierre LonchamptJ, Felix SchoellerK, Anirudh KrishnakumarL, Bastian GreshakeM, Kevin LhosteN, Christophe ParotO and Guillaume JeanmaireA

ABreathing Games BEchOpen CAura DEnable ELogAir FOpen Geneva GTondo HOpen Source Drug Discovery I Open Source Imaging JHelpful Engineering KFuga LMindLogger MOpen Humans NCRI Paris OJoin Seeds

## SPECCHIO

### Une e-plateforme genevoise pour le suivi dynamique de la santé de la population

### Objectifs

L'objectif est de mettre en place une étude longitudinale populationnelle en ligne auprès de résidents genevois volontaires afin de:


### Auteurs

Helene Baysson1, P. Collombet1, Stéphane Joost, Homa Attar Cohen, Idris Guessous and Silvia Stringhini

### Contexte


### Résultats


### Specchio-COVID19


La mise en place de la plateforme digitale Specchio-COVID19 va permettre:


Pendant les mois d'octobre et novembre 2020, 20'000 personnes seront invitées à rejoindre Specchio-COVID19.

### Perspectives


• Une attention particulière sera portée à l'inclusion des populations dites «vulnérables».

1 Faculté de Médecine, Université de Genève 2 Laboratoire des Systèmes d'Information Géographique, Ecole Polytechnique Fédérale de Lausanne, EPFL 3 Direction de la Santé, Département de la sécurité, de l'emploi et de la santé (DSES), Secteur de prévention et promotion de la santé, République et Canton de Genève

#### **SPECCHIO-COVID19 Suivi des participants SEROCoV-POP & SEROCoV-WORK+ SEROCoV-POP & SEROCoV-WORK+**  EPIDÉMIE DE COVID-19 **SPECCHIO Suivi longitudinal de l'état de santé de la population genevoise**

### Méthodes

Tous les résidents de Genève âgés de plus de 18 ans, seront invités à participer. Les données recueillies proviendront directement des participants via des questionnaires en ligne. Ceux-ci porteront sur la perception de leur état de santé, leurs comportements (alimentation, exercice physique, sommeil, etc.) et leur cadre de vie.

Elles seront complétées, avec leur accord, par d'autres sources d'informations telles que les bases de données médicoadministratives (ex: données de consommation de soins) ou les bases de données environnementales (ex: exposition au bruit).

Le suivi des participants sera longitudinal, sur plusieurs années.

*Figure 1. Les huit axes stratégiques pour la prévention et la promotion de la santé.* 

*Figure 2. Les étapes de la mise en place de la plateforme Specchio-COVID19.*

*Figure 3. Page d'accueil de la plateforme Specchio-COVID19. https*://www.specchio-COVID19.ch/.

11

### TOXIC METAL LEVEL AND DIETARY RISK ASSESSMENT OF *AMARANTHUS VIRIDIS* GROWN IN PERI-URBAN AREAS IN KINSHASA, DEMOCRATIC REPUBLIC OF THE CONGO

### Authors

Georgette N. Ngweme1, Emmanuel K. Atibu2, Dhafer Mohammed M. Al Salah3,4, Paola M. Mwanamoki5, Guillaume M. Kiyombo1, Crispin K. Mulaji2, Jean-Paul Otamonga2,6 and John W. Poté2,3,6\*

*1 School of Public Health, Faculty of Medicine, University of Kinshasa, B.P. 11850, Kinshasa XI, DR Congo 2 Faculty of Science, Department of Chemistry, University of Kinshasa, B.P. 190, Kinshasa XI, DR Congo 3 Faculty of science, F.-A. Forel Department and Institute of Environmental Sciences, University of Geneva,* 

*Switzerland, 66 Boulevard Carl-Vogt, CH – 1205, Geneva*

*4 King Abdulaziz City for Science and Technology, Joint Centers of Excellence Program, Prince Turki the 1st st, Riyadh 11442, Saudi Arabia* 

*5 Dietetic Nutrition Section, Higher Institute of Medical Technology, B.P. 774, Kinshasa XI, Democratic Republic of the Congo*

*6 National Pedagogic University (UPN), Croisement Route de Matadi et Avenue de la Libération. Quartier Binza/UPN, B.P. 8815 Kinshasa, Democratic Republic of the Congo*

\* Corresponding author. Tel.: +41-22-379-03-21; fax: + 41 22 379 03 29. *E-mail address*: john.pote@unige.ch (John Poté)

### I. Background

Vegetables are an essential part of the human healthy diet and considered as sources of many essential nutrients to maintain normal physiological functions, antioxidants, dietary fiber metabolites and to prevent several diseases.

In the Democratic Republic of the Congo (DRC), particularly in Kinshasa, its capital city, the urban agriculture plays an economic and social role in daily life of the population and provides more than 60% of the consumed fresh produce supply of the city. After cassava leaf, *Amaranthus viridis* (*A. viridis*) has been identified to be the second most consumed leaf vegetable in the DRC. However, the quality evaluation of water used for urban agriculture irrigation, as well as the accumulation of pollutants such as heavy metals in fresh produces like *A. viridis*, are still largely unstudied.

### III. Methodology

Water, soil and plant sampling took place in July/August 2018 from 8 main gardening sites of Kinshasa, when *A. viridis* reached the stage of harvest.

### References

Georgette N. Ngweme et al. 2020. Heavy metal concentration in irrigation water, soil and dietary risk assessment of Amaranthus viridis grown in peri-urban areas in Kinshasa, Democratic Republic of the Congo. *Watershed Ecology and the Environment* 2: 16–24.

Georgette N. Ngweme et al. 2021. Occurrence of organic micropollutants and human health risk assessment based on consumption of Amaranthus viridis, Kinshasa in the Democratic Republic of the Congo. *Science of the Total Environment* 754: 142175.

*Table 1. The mean of metal concentrations in mg kg-1±SD in A. viridis and their respective permissible limits as set by Food and Agriculture Organization*


	-

in urban agriculture to reduce potential health risks.



### IV. Results

### II. Objectives

• To investigate the levels of toxic metals (Cr, Co, Ni, Cu, Zn, As, Cd, Pb and Hg) in irrigation water and soil from 8 main gardening sites of *A. Viridis* cultivation in periurban areas in Kinshasa.

• To evaluate the accumulation of these metals in *A. viridis*

• To evaluate the potential environmental and consumer human health risks

### V. Conclusion and recommandation

*Table 2. The targeted hazard quotient (THQ) of metals through consumption of A. viridis.*


*Table 3. The estimated dietary intake (EDI) and the estimated weekly intake (EWI) (mg/kg bw /day or week) of Cr. Co. Cu. Zn. As. Cd. Pb. Hg from A. viridis leaf by consumers* 


### USE OF RESPONSIVE FEEDBACK TO DEVELOP A MATERNAL AND CHILD NUTRITION COUNSELLING BOT An Innovation Pilot Project

### Authors

Namrata Tomar, Sriya Srikrishnan, Neal Lesh and Brian Derenzi

Malnutrition prevalence is predominant in India, with nearly half of all deaths in children under 5 attributable to undernutrition. Despite the Indian government taking a multifaceted approach towards addressing this problem, there are insufficient touch points between the mothers and frontline workers of nutritionspecific schemes. It is almost impossible to imagine achieving the Sustainable Development Goals or Universal Health coverage without increasing the use of digital health technology.

*Figure 1. Extending digital health systems to direct-to-client innovation.*

### Direct-to-Client Engagement

Recognizing the increased ownership of smartphones in conjunction with the need for multiple touch points with clients in the health system, Dimagi identified direct-to-client tools as an important area for innovation. In partnership with the state and local government, a digital coach, Poshan Didi, was deployed in Katni, Madhya Pradesh to provide counseling to mothers on age-appropriate nutrition-related topics given the evidence of influencing positive household behavior through the reiteration of counseling messages.

*Figure 2. Visual representation of Poshan Didi.*

### Responsive Feedback Methodology

In order to accelerate the learning process, a few core characteristics were adopted:


### Continuous Monitoring of Data

### Implementation Design

A total of 100 mothers were enrolled, as shown in Figure 3. All participants completed a baseline survey, and 76 were included in the end-line survey. At midline, 26 qualitative one-on-one interviews were conducted.

*Figure 3. Summary of activities and enrollment of users for Poshan Didi Implementation*

### Acknowledgements

The authors are grateful to the Department of Women and Child Development, Madhya Pradesh, Bill and Melinda Gates Foundation and M&C Saatchi for their support.

### Dimagi is contributing to the next generation of digital technology by improving our existing products and developing new products, such as CommunityPulse, for direct-to-client engagement

*Figure 4. (X axis) Abbreviations for various modules in Poshan Didi content that are specific to the age range of children (e.g., cf: complementary feeding; kmm: kangaroo mother care). Percentage of users who engaged with each module. Denominator was determined by the total number of users exposed to the particular module.*

Just as digital tools like CommCare allow for organizations to deploy mobile apps for frontline workers across a wide range of use cases, CommunityPulse allows for organizations to extend health systems with conversational agents for a wide range of use cases. The first deployment of CommunityPulse is a chatbot called Poshan Didi ("nutrition sister").

### Results of Engagement

Women referred to Poshan Didi with respect, indicating that they viewed her as a higher authority and not just an automated system. In our pilot, 80% of clients replied at least once to a chatbotgenerated message, and 63% replied 5+ times over a 2 month period, while 64% engaged beyond the chatbot content by discussing at least one issue with a nurse that responded to

escalated messages. *Figure 5. Drawings of Poshan Didi by mothers that depict the personification of trust and how perceptions vary.*

> *Figure 6. Storytelling exercise with frontline workers to investigate user workflows and understand unique challenges.*

### Lessons For Future Direct-to-Client Research

Client-centered care requires many more contact points, and chatbots can act as an appropriate future health tool. It is important to facilitate collaborative decision making, rapid prototyping, and user acceptance by testing and developing locally appropriate digital solutions.

### STUDY THE EFFECT OF COMMUNITY NUTRITION EDUCATION ON FOOD SAFETY AND HEALTHY NUTRITION TO IMPROVE KNOWLEDGE, ATTITUDE, PRACTICE OF POPULATION FOR CREATING NEW NUTRITION POLICY

### Authors

Ramesh Allipour Birgani1, Amirhossein Takian2, Mohammadreza Shanesaz3, Abolghasem Djazayeri4 and Hamed Pouraram4

### Introduction

In a different part of the country, food and nutrition education in primary health care network and private sector educated people, but it was not effective enough, especially nutrition and unhealthy diet that related to the prevalence of non-communicable disease. Policy makers investigated an efficient approach to improve this part of the population's lifestyle.

> *Figure 1. Comparison of mean score of knowledge, Attitude, Practice of Intervention group before and after the study of Food Safety, Healthy Nutrition.*

### Methods

The study was conducted in two cities of the Isfahan province in Iran. For 12 weeks in two groups through a quasi-randomized clinical trial, 750 men and women (age 19-65 years) were selected from urban areas. Before and after 3 months, 580 participants came to an end the study (intervention group = 450) and (control group = 130) were assessed KAP of healthy nutrition and food safety via FFQ, 24-hour food record, and KAP questioner.

They participated (3 sessions per week) in 4 different classes of nutrition, including: food safety and processed food; healthy nutrition and diet; choose healthy food; cooking healthy food. A paired t-test and a student t-test were used for data analysis.

*Figure 2. Food Safety, healthy Nutrition Study.*

### Results

Comparing two groups before and after 3 months of interventions, demonstrated a significant increase in KAP of intervention group vs. control group respectively.


and after the study.

*Figure 3. Compare of mean score of knowledge, Attitude, Practice of Control group before and after the study of Food Safety, Healthy Nutrition.*

*.*

1 PhD candidate of food and Nutriton Policy; 2 Chair & Professor, Department of Global Health & Policy, School of Public Health; 3 Chief of Food and Drug Organization's Health Ministry of Iran; 4,5 Professor. Department of Community Nutrition, School of Nutritional Sciences and Dietitics

Tehran University of Medical Siences, Tehran, IRAN

: http://snsd.tums.ac.ir, http://en.tums.ac.ir/m8-alliance/en

### Conclusion and New Policy

The results of the study showed that


## New policy

Evidence from national food & nutrition surveys and STEPwise approach to surveillance (STEPS) in Iran shows that dietary habit indices and food safety KAP of Iranian are in concerning zone. in addition non- communicable diseases are prevalent especially in large cities such as Tehran. These results guided researchers to produce evidence by community nutrition education for policy decision.

*Figure 5. circulation of food and nutrition interventions in community New policy.*

*Figure 4. Comparison the mean score of knowledge, Attitude and Practice between Control group and intervention group after the end of study. Food Safety, Healthy Nutrition.*

*.*

This study explores the procedure to improve food and nutrition KAP of the population according to community needs and design policy to implement food and nutrition education in the PHC network in Iran.

> Student's Scientific Research Center(SSRC) of TUMS

### MAGNITUDE AND SOCIO-DEMOGRAPHIC DETERMINANTS OF ACCESS TO PRIMARY HEALTH CARE SERVICES AMONG ADULT MEN AND WOMEN IN ALBANIA

### Introduction

Access to healthcare services is central in the performance of global health systems.

### Conclusions

Decision makers and policymakers in Albania and other transitional countries should be aware of low access to PHC services in general, but particularly among vulnerable population groups including women, ethnic minorities, and the low socioeconomic categories.

### Objective

The objective of this study was to assess the magnitude and socio-demographic determinants of access to health services among adult primary health care (PHC) users in Albania.

### Methods

A cross-sectional study was conducted in 2018-19 in five major regions of Albania with a representative sample of 1553 adult PHC users (704 men and 849 women; overall mean age: 54.6 ± 16.4 years; response rate: 94%). A structured interviewer-administered questionnaire inquired about the access to and affordability of PHC services. Furthermore, information on a wide array of demographic factors and socioeconomic characteristics was collected.

### Results

Overall, 28% of survey participants reported not having been able to access medical services in the past year when needed. The inability to access health care services was considerably more prevalent among women (31%), Roma and Egyptian communities (76%) and among poor individuals (58%). The main reasons for the inability to access health care services included financial constrains, poor health status, distance to health centres, and lack of trust in the healthcare system. Furthermore, about 9% of participants (12% in women vs. 5.0% in men) reported that they had to pay (bribe) during their last health visit at the PHC centres.

A project of the Swiss Agency for Cooperation and Development SDC

### Authors

Genc Burazeri1, Alban Ylli1, Emanuela Ismaili2, Ervin Toci1 and Edmond Dragoti2

1 Department of Public Health, Faculty of Medicine, University of Medicine, Tirana, Albania 2 Department of Social Work, Faculty of Social Sciences, University of Tirana, Tirana, Albania

## DOES STRONGER PRIMARY HEALTH CARE IMPROVE HEALTH CARE ACCESS FOR PERSONS WITH SPINAL CORD INJURY?

### Authors

Olena Bychkovska1, Piotr Tederko2, Vegard Strøm3, Alvydas Juocevicius4 and Armin Gemperli1

1 Swiss Paraplegic Research, University of Lucerne (Switzerland); 2 Medical University of Warsaw (Poland); 3 Sunnaas Rehabilitation Hospital (Norway); 4 Vilnius University Hospita Santariskiu Clinics (Lithuania)

### Background

Spinal cord injury (SCI) is damage to the spinal cord. It is a complex life-long highcost condition, often accompanied by secondary conditions. SCI has low prevalence (<0.1% population). Approximately 80% of those with SCI are male.

Persons with SCI tend to have high:


Appropriate in-time health care can considerably reduce the risks of premature death and preventable secondary complications, which lead to unplanned rehospitalizations.

The more severe health condition a person has, the less likely they are to obtain comprehensive primary care. This is also due to the ineffective design of the healthcare system, which results in access barriers. Access should here be understood within its five dimensions: acceptability, approachability, availability and accommodation, affordability, and appropriateness. Primary healthcare (PHC) is viewed as the foundation for any healthcare system, which should allow better access. Access to primary care is specifically considered to be an optimal indicator of access, since it is a primary healthcare service and certain inequalities are manifested more with regard to general practitioners than specialists. There is ongoing discussion on the healthcare provision model for persons with SCI, whose needs cross the boundaries levels of care. The question is if the same positive outcomes of PHC would be applicable. Secondary conditions are often preventable and manageable in the community; hence, overutilization and duplication of services is unnecessarily increasing the cost of this already costly condition for both the patient and the system. Different factors like rural living and low income further impede access to services. Primary and preventive care needs are less met in persons with SCI, even if PHC is well-established. This highlights the necessity to not only think of a better provision model, but also to look for barriers that are specifically faced by persons with SCI.

Large-scale international comparisons/classifications and studies that include diverse countries on topics of SCI, healthcare utilization, and access are rare. This study will bridge the gap by analyzing and comparing countries with different characteristics.

### Objective

To examine the impact of a health care services provision model on access to healthcare services for persons with SCI across 11 European countries.

### Researsch questions

What component of access is mostly altered by the type of healthcare service provision model? What is the impact of the healthcare system on access to services for persons with SCI?

Does a stronger primary healthcare system allow improved access for persons with SCI? If so, to what extent?

### Hypothesis

Primary healthcare-oriented systems allow improved access to health care services.

### Methods

International Spinal Cord Injury Survey (InSCI) (2017–2019) is the first international survey that aims to comprehensively describe the lived experience of a specific health condition.

The survey is part of a larger project International Learning Health System for Spinal Cord Injury Study (LHS-SCI), embedded in WHO's Global Disability Plan. LHS-SCI was launched in 2017 with support of WHO, International Society for Physical and Rehabilitation Medicine (ISPRM) and the International Spinal Cord Society (ISCoS). Survey's role is to gather data for further changes implementation, aiming at strengthening the healthcare system.

Corresponding author: Olena Bychkovska, olena.bychkovska@paraplegie.ch

*This project has received funding from the European Union's Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 801076, through the SSPH+ Global PhD Fellowship Programme in Public Health Sciences (GlobalP3HS) of the Swiss School of Public Health.*

125 questions

### Sampling:


### Data collection method:


#### 6658 respondents 11 countries


### Expected conclusions

Primary healthcare-oriented systems allow improved access to health care services. Findings can be a guiding instrument for health care planning. Certain conclusions might be relevant to other groups with disability as well as the general population.

### Data analysis

#### 1. Strengths of primary care classified as strong, medium or weak: classification of Kringos et al (2013)

The classification is based on 77 indicators across various PHC dimensions: primary care governance, economic conditions of primary care, primary care workforce development, access to primary care, continuity of primary care, coordination of primary care, and comprehensiveness of primary care.

*2.* Descriptive statistics by each access dimension.

3*.* Association between access and strength of primary care: logistic regression.

The study population includes adults with SCI living in the community. Those receiving first rehabilitation or first acute care during the data collection were excluded from the study due to the lack of experience of living with SCI in the

community.

Each participation country had a National study center that led the data collection, including sampling, questionnaire translation and adaptation, reminder management etc. Swiss Paraplegic Research in Nottwil, Switzerland, coordinated InSCI and provided recommendations on sampling as well as data collection, storage, and analysis. Sampling strategy included random and non-random sampling with different sampling frames: national registries of persons with SCI; databases of: academic or level I trauma hospitals, specialized rehabilitation centers, and organizations for persons with disability or insurance agencies; samples from previous studies; and a combination of these frames. Each country obtained an ethical approval for conducting the survey and informed consent was signed by each study participant or authorized participant's representative. Collected data were de-identified and stored in a secure central database.

### Keywords

healthcare services; access; healthcare system; primary healthcare system; spinal cord injury (SCI)

## CHALLENGES IN HEALTHCARE DELIVERY AFTER MEGA-EARTHQUAKE IN NEPAL: FROM A HEALTH RESCUER'S PROSPECTIVE

### Authors

Shatdal Chaudhary and Subhank Singh

### Introduction

In Nepal, a major earthquake with a magnitude of 7.8 Mw struck on 25 April 2015. It killed more than 9000 people and injured more than 23,000. We in Bhairahawa planned a medical relief team to help the earthquake victim in partnership with the Indo-Nepal Doctors Association, Universal College of Medical Sciences (UCMS), and NAMUNA Integrated Development Council.

*Figure 1. A house damaged by the earthquake in Gorkha district, Nepal.*

### Methods

We total of 51 doctors in three teams were involved in the relief and rescue mission for a total 15 of days in the Gorkha district. We reached the Gorkha district headquarters after obtaining the necessary permission from our local district officials. All the data related to patients treated and problems faced during the treatment were noted and analyzed.

### Results

*Figure 2. Wound dressing of an injured patient.*

*Figure 3. Health camp in Aarukhet.*

There were multiple national and international medical teams from Israel, Switzerland, Red Cross, and various NGOs, which were mostly unused. The situation was complete chaos and there was a complete lack of coordination at the administrative level. We were advised to return back. We went to the District Public Health Officer who assigned us to Gumbda VDC, which is around 70 km via local routed including two days of walking. There was no coordination for transport, food, or medicine support. We went to Aarukhet with our vehicle; after that, the road was blocked due to landslides. No medical team had reached there and the local PHC was totally destroyed. We raise a local health camp, treated patients, provided dressings for wounds, distributed soap and water, provided treatment solutions, and health education for hand washing and sanitation. Adults had multiple cut wounds, nail pricks, fever, and diarrhea. Children were suffered the most, as most of houses were destroyed; they were suffering from fever, cold, pneumonia, diarrhea, scabies, and eczema. We went to Manbu health post after six hours of walking and arranged a health camp and returned.

For Correspondence Dr. Shatdal Chaudhary, M.D. Professor of Internal Medicine Universal College of Medical Sciences Bhairahawa, Nepal Email: shatdalchaudhary@yahoo.com Phone: +977-9817403804

*Figure 4. Our medical team.*

### Conclusions

Trauma, gastroenteritis, respiratory tract infection, and skin disease were the major public health problems. There was complete lack of coordination among medical relief efforts. A disaster management plan has to be formed that integrates transport, electricity, education, health, and all other departments to achieve the best outcome.

### Closing remarks

Earthquakes are inevitable. Local governments should make preparation to face these in the future to decrease human casualties and economic losses.

17

### AN ASSESSMENT OF LEADERSHIP TRAINING ON HEALTH SYSTEM PERFORMANCE IN SELECTED COUNTIES IN KENYA A Quasi-Experimental Study

### Authors

Tecla Chelagat, Jim Rice, Joseph Onyango and Gilbert Kokwaro

### Introduction

The provision of healthcare services in Kenya was assigned from the national government to the counties in 2013. Evidence suggests that health system performance in Kenya remains poor. The main issue is inadequate leadership, resulting in poor health system performance. However, most training in Kenya focuses on leader (individual) development as opposed to leadership training (development of groups from an organization). The purpose of this study was to explore the impact of leadership training on health system performance in selected counties in Kenya. *Figure 2. Average means per health system pillar indicator.*

### Methods

A quasi-experimental time-series design was used to assess the effect of leadership training on health system performance service indicators in health institutions in 19 counties in Kenya. Health workers from these counties had undergone nine-month leadership training, complimented with team coaching based on priority institutional service improvement projects undertaken by the trainees. The comparison group comprised other health institutions within the same counties where health workers had no training on leadership and no coaching during the same period. A total of 31 team-based projects were purposively selected, of which 14 (45%) were from public sector teams, 13 (42%) from the faith-based and NGO sector, and 4 (13%) from the private sector (Figure 1).

*Figure 1. Heath sector representation.* 

#### *Results of t-test*

Table 2 summarizes the results of before and after the leadership training program within pretest and posttest scores for the two groups. The pretest scores between the two groups indicate five out of six health system (HS) pillars from the trained group were pointedly different for the non-trained group prior to training. The training had a positive effect on the HS success metrics with posttest performance indicators for three pillars: service delivery, leadership and governance, and information showed substantial variances between the two groups (p < 0.05).

### Results

*Classification and implementation status of priority challenge projects* Table 1 provides concise statistics for the six main elements. A total of 31 projects aligned to their strategic plans were prioritized by the teams. We clustered the projects according to the WHO health system building blocks (World Health Organization, 2010) for analysis. Service delivery was the most chosen challenging area by the public, faith-based, and private sectors, and human resources, finance, and medical products were the least chosen challenge areas.

*Table 1. Challenge projects category and implementation status.*

*Table 2.. t-test results*

### Discussions

The positive changes observed, prioritization and implementation of learned knowledge through practice, were attributed to the leadership training. These factors are consistent with the existing leadership development literature (Kwamie et al., 2014; Mansour, Mansour, et al., 2010; Peterson et al., 2011; Seims et al., 2012; West et al., 2015), as evidence by a very high percentage (92.3%) of attained DMR for the priority institutional improvement projects. Service delivery was found to be the highly prioritized healthcare area of concern compared with other health system pillars. Human resources and finance emerged as the lowest areas of priority. The results indicated that incorporating institutional improvement projects and coaching into leadership training triggers immediate application of knowledge to the work environment. Therefore, Kenya needs to invest in leadership and coaching for health workers, together with strengthening other health system pillars (information, financing, human resource development, and medicines and technology) to improve the performance of sustainable health systems.

Performance differences between trained and non-trained managers Figure 2 presents the differences between trained and non-trained managers pre- and post-training. The highest pretest score of the treatment group was

service delivery (M = 82.32, SD = 89.20) and the lowest mean was for the medical products (0.00). The highest pretest score for the control group was service delivery as well (M = 50.36, SD = 75.17), whereas the lowest score was for human resource, finance, and medical products (M = 0.00). The posttest scores for both treatment and control groups showed a significant difference. In summary, the highest posttest for the treatment group was service delivery (M = 122.04, SD = 117.97), with human resource scoring the lowest (M = 62.5, SD = 53.03


### Conclusions

The findings revealed that the trained managers achieved highly significant desired measurable results compared to non-trained managers. The study, from a practical point of view, deliberated integrating challenge-based methods to boost the transmission of newly learned leadership skills and knowledge through practice.


Peterson, A., Dwye, D., Howze, -Shiplett, M., Davison, C., Wilson, K., & Noykhovich, E. (2011). Presence of Leadership and Management in Global Health Programs: Compendium of Case Studies (pp. 5–8).

Mansour, M., Bragar, J., & El Swesy, A. H. (2010). Scaling up proven public health interventions through a locally owned and sustained leadership development programme in rural Upper Egypt. *Human Resources for Health* 8(1).

Seddiq, K., Enarson, D., Shah, K., Hag, Z., & Khan, W. (2014). Implementing a successful tuberculosis programme within primary care services in a conflict area using the stop TB strategy: Afghanistan case study. *BioMed Central* 8(3).

Seims, L. R. K., Alegre, J. C., Murei, L., Bragar, J., Thatte, N., Kibunga, P., & Cheburet, S. (2012). Strengthening management and leadership practices to increase health-service delivery in Kenya: an evidence-based approach. *Human Resources for Health* 10 (25). https://doi.org/10.1186/1478-4491- 10-25.

### MHM EDUCATION WITHIN THE FRAMEWORK OF A WASH SCHOOL INTERVENTION IN LUANG PRABANG PROVINCE, LAOS

### Authors

Gabriela D. Zipper1,2 and Luang Prabang

1 Douglas Tosh Grant 2 Swiss Red Cross Bern

### Introduction

In Laos, understanding of menstruation is lacking, and prevailing social norms consider menstruation shameful, making it difficult to share knowledge in schools and homes. In order to address the needs and barriers around menstruation, menstrual hygiene education was introduced as integral part of a water, sanitation and hygiene programme in 10 lower secondary schools in Luang Prabang Province in Laos, targeting a total of 4'659 students. For MHM, 24 teachers and 12 nurses were trained as facilitators reaching out to 1'758 girl students. The project demonstrates how the introduction of Menstrual Hygiene Management (MHM) in schools has a positive effect on knowledge, attitudes, and supporting a more open and enabling environment for MHM.

### Methods

656 students (15% of the target population) were interviewed during a baseline Knowledge, Attitude and practice (KAP) survey right at the project start on issues concerning water, sanitation, hygiene, nutrition and menstrual hygiene. MHM workshops were provided to girls and male and female teachers in targeted lower-secondary schools since 2017. Information from girls was compared through pre- and post-tests during workshops and repeated annual Knowledge, Attitude and Practise (KAP) surveys.

*Figure 1. Comparison of baseline and midline KAP survey of girls, who already had their period.*

Integration of MHM into school WASH contributed to creating an enabling environment for MHM. This has laid a strong foundation for future sensitization of boys and girls towards MHM and beyond, resulting in expansion to other reproductive health topics for young people.

### Results

Pre- and post-test comparison showed that 98% of participants improved knowledge and attitudes of MHM with an average improvement rate of 49% on a six-point scale. After workshops with students, 93% of the girls said that they would seek advice on their first menstruation (69% pre-workshop), 97% thought they were able to attend school when menstruating (85% pre-workshop), 92% indicated understanding of MHM in relation to reproduction (65% pre-workshop), and 95% indicated understanding of the age and duration menstruation usually occurs (52% pre-workshop).

Baseline and midterm surveys confirmed these trends. At midterm, 65% of girls said they sought information from a teacher when they had their first period (0% baseline), 56% said they would speak to someone before their first period (35% baseline), and 87% said they received peer-to-peer education from other students (11% baseline).. In general, girls who already had their period at time of interview, had better knowledge. However, results also indicate that repetition and continuous education is useful, as some post-workshop results have dropped again at midline survey. Knowledge around the physical changes and reproduction remained low.

MHM Trainings for girls © SRC

### Conclusion

MHM education is much appreciated by the teachers and students. It also helped to involve local health workers and acted as a door-opener for young people to seek services at the local health center. Since knowledge on physical changes and relation to reproductive health did not improve a lot, the project will focus more on reproductive and adolescent health in the future. MHM prepared conducive ground for more "sensitive" topics to be addressed at school and to include men and boys in the discussions.

Copyright ©SRC 2020 Contact: tosh.grant@Redcross.ch / gabriela.zipper@redcross.ch

Classroom trainings by Red Cross staff © SRC

## SAFE MOTHERHOOD REVOLVING FUNDS

### Are They Really Life-Savers for the Poor? Practices and Impact in Nepal

### Authors

Anju Gautam, Raj Kumar Khsetri and Tulasa Bharati

Nepal Red Cross Society, Nepal

### Introduction

The maternal mortality ratio of Nepal declined significantly from 539 in 1996 to 239 in 2016 (MMR Asia-Pacific is 127/100,000 and SDG 79/100,000). Swiss Red Cross in collaboration with Nepal Red Cross Society implemented Safe Motherhood Revolving Funds (SMRF) in five districts (Dang, Rolpa, Rukum, Jajarkot, and Dolpa) in 2015 and 2016. Health mothers groups (HMGs) are anchored in the community and led by local Female Community Health Volunteer (Government staff) as part of Nepal's health policy. The HMGs were facilitated by the project or inactive HMGs reformed. Then they were trained in fee collection, fund operation, simple accounting, record keeping, and monitoring the disbursement of the fund to women in need for safe motherhood services. At the time of study, 163 HMGs autonomously ran the funds.

*Health mothers groups collecting the monthly fees for the safe motherhood revolving fund © SRC*

### Aim of the study

To enhance the understanding of the functionality and sustainability of the SMRFs for safe motherhood and its

potential for scale-up and integration in government policy.

*Paying for the transport costs to the distirict hopsital was possible through a loan from the SMRF. © SRC*

### Methodology

Focus group discussions (FGD) , semi-structured questionnaire surveys and key informant interviews (KII) were conducted with members of HMGs with SMRF, household heads of general community members, health facility in charge, and district (public) health officers. Of 163 HMGs in the project area, 66 HMGs were enrolled in the study based on prevalence (p) = 50%, sampling error (d) = 10% at 95% CI and non-response rate = 10%.

Copyright ©SRC 2020 For more details please contact at: tulasa.bharati@redcross.ch

### Conclusions


*HMG members visiting a mother at home after a safe delivery. © SRC*

**District health offices have appreciated the funds. Some local municipalities have started to include them in their local policy.**

### Results



• More than half of the HMGs (57.6%) are also using the fund for issues other than safe motherhood.

• All HMGs state that the poor and vulnerable have access to the fund. However, only 44% of HMGs support non- members.

*Figure 1. Study sampling frame.*

### Recommendations


needed to establish a possible relation and contribution to reducing the maternal mortality rate in Nepal.

### MENTORING AND SUPERVISION: A KEY COMPONENT TO ENSURING QUALITY PRIMARY HEALTH CARE SERVICES IN RAJSHAHI AND NAOGAON DISTRICTS IN BANGLADESH

### Authors

Farhana Akhter1, Shanta Ghatak1 and Akramul Haque2

<sup>1</sup> Swiss Red Cross Bangladesh

<sup>2</sup> DASCOH Bangladesh

### Introduction

The primary healthcare system in Bangladesh delivers an essential service package (ESP), which encompasses maternal and newborn care, integrated management of childhood illnesses, immunization, family planning, nutritional service, screening of non-communicable diseases, first aid, and general health issues. After initial training, health providers are often left alone to put theory in practice, subsequently compromising the quality of care. To help the health service providers to deliver quality maternal neonatal and child health services (MNCH), DASCOH, a reputed NGO, in collaboration with the Swiss Red Cross, initiated on-the-job supervision and mentorship¹ intervention carried out by the relevant government health authorities and project staff to enhance the service quality of 70 primary health care facilities.

*A DASCOHs upported Community Clinic © SRC*

### Methodology / Strategies

A quantitative supervision and mentorship checklist was developed and piloted together with the government in 14 community clinics (CCs). After the successful pilot intervention, the checklist was applied on a monthly basis in 49 CCs and 21 union health and family welfare centers in Rajshahi and Naogaon district. The checklist consisted of an array of tasks from a brief history taking up to examination and record keeping a health provider has to perform during consultation. Fulfilment of the tasks in a correct manner aimed at improving quality of care. Data were collected and evaluated over a period of two years.

### Results

A total of 752 supervision and mentorship visits were conducted both by project staff and government health officials between 2017 and 2019. The data of Rajshahi district indicated a 20% service improvement through supervision and mentorship visit in the CCS, and at union health and family welfare center level, a 12% service improvement was noted through supervision and 9% through mentorship visits. In Naogaon district, 23% service improvement was achieved through the supervision system in the CCs, and 35% by mentorship visits. At the union health and family welfare center level, a 37% service improvement was achieved through supervision and 36% by mentorship visits.

Data Source: DASCOH MIS For more details visit www.dascoh.org

#### Supervision and Mentorship Status (Feb 2017 to Jun 2019)

Supervision and Mentorship visits February 2017 to June 2019

*Figure 3. Supervision and Mentorship Status (February 2017 to June 2019).*

### Advocacy Impact

DASCOH introduced mentorship and supervision tools to enhance the quality of services in the CCs. After development and piloting operational tools with the government's health line directorates in 14 CCs, the mentorship and supervision activities were integrated by the government of Bangladesh to monitor maternal, neonatal, and child health services. To implement the tool, DASCOH obtained the legal approval for the checklist on behalf of the Directorate General of Health Services. Accordingly, DASCOH and the government of Bangladesh have committed to taking equal responsibilities in implementing the checklist at the CC and union health and family welfare centers.

### Conclusion

The project initiative proves that mentoring and supervision can produce lasting improvements and perceptible changes in generating quality service in the government health facilities. It also effectively demonstrates that this mechanism can be integrated into the primary healthcare system. While the supervision and mentorship appear to be effective, it needs to be organized more rigorously and better integrated into future plans and government budgets. More research is required to assess the long-term effectiveness of the supervision and mentoring process as well as to elicit other barriers for quality improvement.

*Figure 1. Project intervention areas in Bangladesh.*

### 1 Key Definitions:

Technical Supervision is the monitoring of health service accessibility according to the government guidelines; availability of basic amenities within the health facility; appropriate guidelines/SOP; essential equipment, drugs, and supplies; and completeness of service register.

Technical Mentorship is the monitoring of health service providers following the correct diagnosis and treatment protocol, and to provide on-the-job coaching to the health service providers to improve their performance in delivery of quality services.

### GIRLS' MHM KNOWLEDGE, ATTITUDES AND PRACTICES, INFLUENCING FACTORS, AND THE ROLE OF BOYS:

### Authors

Daniela Enzler1, Thomas Gass2 and Prisca Chisala3

1 IsGlobal - Institute of Global Health, University of Barcelona, Spain; 2 Swiss Red Cross, Bern, Switzerland; 3 Malawi Red Cross Society, Lilongwe, Malawi

### Introduction and aim

Menstrual hygiene management (MHM) is an intricate and still poorly understood phenomenon, especially in many contexts in sub-Saharan Africa. We sought to enhance the understanding of the relationship between knowledge, attitudes, and practices (KAP) and factors influencing MHM in girls in Malawi and to explore the role of boys' knowledge on MHM dynamics, a widely neglected aspect to date.

*MHM education under a tree*

### Methods

The mixed method study combined a cross-sectional survey (n = 522), 29 focus group discussions (n ≈ 200), and key informant interviews (n = 13).

The research involved pupils (standard 8) from 17 primary schools in two districts (Mzimba and Salima) in rural Malawi.

### Results

The onset of menstruation was a negative experience to most girls (85%); 52% had never heard about menstruation before. Girls had significantly higher levels of MHM knowledge than boys (r = 0.43; p = 0.000) and girls' knowledge was positively linked to a sister (r = 0.30; p = 0.000) or a mother group (r = 0.36; p = 0.000) as their source of information. School attendance during menses was higher in girls with more knowledge (r = 0.22; p = 0.002) and associated with the use of commercial sanitary pads (r = 0.30; p = 0.000). Boys' knowledge was connected with higher levels of teasing, resulting in girls' school absenteeism during menses (r = –0.21; p = 0.003). KAP, primary sources of knowledge, and absenteeism differed significantly between districts.

Copyright ©SRC 2020 Contact: daniela.enzler@hotmail.com / monika.christofori-khadka@redcross.ch

**"MHM education lifts a tabooed challenge for Malawian girls."**

*Individual counselling helps overcoming shyness © SRC*

*Girl-friendly toilet in a school in Mazimba district © SRC*

### Conclusion

The onset of menstruation presents a tabooed challenge for Malawian girls. The linkages between girls' school absenteeism and boys' MHM knowledge suggest, however, that breaking the taboo can initially expose girls to more harassment and increase their levels of discomfort, which needs to be addressed sensitively. Educators are thus required to address this topic in very sensitive ways. The study results indicate the scope for MHM and SRHR. Differences in districts call for context-specific MHM solutions.

### Findings From Malawi

*Self-made reusable sanitary pads © SRC*

### RAISING CHRONIC DISEASE PATIENTS' SELF-EFFICACY: PILOTING A CHRONIC DISEASE SELF-MANAGEMENT PROGRAMME IN RURAL MOLDOVA

### Results From a Pilot Project in Five Rural Localities

### Authors

Diana Berari1, Nicolaj Holm Ravn Faber N2, Florence Secula3,4, Constantin Rimis1, Ala Curteanu1 and Helen Prytherch3,4

### Introduction

High rates of chronic diseases in Moldova have a significant morbidity burden on the population and impact patients' quality of life, particularly in rural areas with lower access to health information and services.

Our study aimed to assess the acceptability and impact of a pilot Chronic Disease Self-Management Programme (CDSMP) on patients' self-efficacy in five rural localities of Moldova.

For 6 weeks between March and April 2018, groups of patients guided by two trained peer facilitators, engaged in workshops emphasising individual planning and action-taking to achieve lifestyle changes. The pilot intervention was implemented in the localities of Susleni, Boscana, Peresecina, Ohrincea and Marandeni.

### Methods

The pilot CDSMP was evaluated between March and May 2018 using mixed methods. The CDSMP six-item self efficacy scale questionnaire was administered before and after the intervention to assess impact. A focus group discussion (FGD) with facilitators and a satisfaction questionnaire with patients (adapted from an instrument developed by the Danish Committee for Health Education) were implemented after the intervention.

*Figure 1. Pre and post intervention self-efficacy scores on 6 items.*

### Affiliations

 Swiss Agency for Development & Cooperation (SDCs)'s Healthy Life Project to reduce the burden of non-communicable diseases, Chisinau, Republic of Moldova Danish Committee for Health Education, Copenhagen, Denmark Swiss Tropical and Public Health Institute, Basel, Switzerland University of Basel, Basel, Switzerland

*Figure 2. CDSMP participants practicing physical activity, Healthy Life - May 2018.*

### Conclusions

The CDSMP is an acceptable intervention in the Moldovan context provided that cultural adaptation is done to match the participants' characteristics. Increases in participants' self-efficacy after the CDSMP were demonstrated, suggesting it is a relevant intervention for the target population. The CDSMP is based on behavior changes techniques such as goal setting, social support, self-monitoring and feedback which are proven to be the most effective techniques for lifestyle behaviour change.

### Results

The pre-intervention self-efficacy questionnaire was administered to 63 participants at baseline vs. 59 participants at endline- as 4 participants dropped out. The FGD included the 10 facilitators. The participant satisfaction survey was completed by 59 participants. The participants included 55 women and 4 men.

Evaluation results revealed a statistically significant increase of participants' self-efficacy score, from 5,33 before the intervention to 8.32 after the intervention (paired-sample *t*-test).

Participants' satisfaction was high, with on average above 96% of respondents satisfied with content, format and delivery elements of the intervention.

The FGD revealed the importance of adapting language and content to participants in the Moldovan context. Facilitators highlighted a gradual shift in content of participants' individual actions plans as the workshops progressed, with increasing importance being given to psycho- emotional elements such as communication and stress management, while nutritionrelated goal setting and action plans remained stable throughout the intervention.

## HEALTHY LIVING HEALTHY AGEING: FIELDWORK METHODOLOGY FOR VITAMIN D ANALYSIS

### Authors

Keila Valente de Souza de Santana, Sofia Oliver Lizarralde, Helena Ribeiro, Karen Charlton and Susan Lanham-New

### Introduction

Vitamin D plays crucial role in metabolic processes ranging from calcium and phosphorus metabolism to cell maturation and growth1. Recent studies have shown high rates of vitamin D deficiency due to the behavior of avoiding the sun, the low consumption of foods rich in vitamin D, and the high prevalence of overweight and obesity. Job occupation and religious differences in clothing in temperate countries have also shown a direct relationship with the duration of skin exposure to the sun and correlate with vitamin D concentrations.

> *Table 1. Level of vitamin D according to skin color. ª Some authors defend an ideal plasma/serum 25 (OH) D status above 30 ng/mg (75 nmol/l).*

*Figure 1. On the left the poster used to advertise the project. On the right the instructional poster on vitamin D deficiency.*

### Sun exposure and food diary

The participant's exposure to UV radiation levels were measured by a solar dosimeter (polysulphone badge and sheet), provided by the University of Manchester, UK.

The badge measures the Standard Erythema Dose SED (1 SED equals to 100jm-2 of ultraviolet radiation) and it was used on clothes for four days (the same as the food diary), including weekdays and weekend.

We distributed sealed envelopes to participants for returning the badges and the food diaries to the university. Only 5% did not return.


### Questionnaires

Participants answered self-administered questionnaires about lifestyle, sun exposure, physical activity, and general health at the same place and in the same day, supervised by the project team.

*Figure 2. Photos of the participants` reception.*

### References

<sup>1</sup> Institute of Medicine (US), Committee to Review Dietary Reference Intakes for Vitamin D and Calcium, editors. Dietary reference intakes for calcium and vitamin D. Washington, DC: The National Academies Press; 2011.

*Figure 4. On the left a polysulphone badge and sheet and on the right a food diary.*

### Preliminary results

Currently, there is no universal consensus on the optimal concentration for plasma/serum 25-hydroxyvitamin D (25 (OH) D). The IoM USA defines vitamin D deficiency as a plasma/serum 25 (OH) D status below 12 ng/ml (30 nmol/L) and insufficiency as a 25 (OH) D status below 20 ng/ml (50nmol/l)1. Most women were white (72,3%), followed by brown (15,8%) and black (9,9%) (Table 1). Asian and indigenous were only 1% of the sample. More than half of the white women, 52.1%, had sufficient levels of vitamin D and 15.1% insufficient. Among black women, 90% presented sufficiency. More than 60% of the brown women had sufficient levels of vitamin D, 25% were insufficient and only 12.5% had ideal levels. All the women received the results of their exams within 2 weeks. We referred participants to a medical doctor if the blood test result was below 20 ng/ml.

### Objective and Methodology

This work is part of the multicenter project Healthy Living Healthy Ageing, developed by three universities (University of São Paulo, University of Surrey England, and University of Wollongong Australia) that are part of the Universities Global Partnership Network. The aim of this project is to investigate differences in vitamin D levels, vitamin D intake and lifestyle (including sun exposure) between countries, and to determinate associations with mental health.

For this it was necessary to collect data on the vitamin D levels, sun exposure, diet and lifestyle of 100 women in each country. The participants were screened according to exclusion criteria, such as potential cofounders likely to affect vitamin D metabolism (osteoporosis therapy, diabetes treatment, hypertension drugs, cancer treatment), and taking supplements containing vitamin D.

The aim of the manuscript is to describe the fieldwork methodology conducted in Araraquara (Brazil) by the University of São Paulo to collect these data. The paper reports the steps for data collection. This was used as a parameter followed by other countries participating in the project.





### Participants reception

A lab's experienced technician collected blood samples and the circulating serum 25-hydroxyvitamin D level from 101 women aged 35 + in a Health Center at the University of Sao Paulo. The blood samples were analyzed by the chemiluminescense method.

### Project advertising and recruitment

Informative posters were placed in local Primary Health Centers, churches, universities, gyms, beauty salons and clubs. Multiple communication channels were used for the project's diffusion and participant's recruitment, such as local radios, social media, and interview for local TV.

The first aim was to recruit women 55 years of age or older, but due to difficulties in reaching the sample size, the age for participation in the project was lowered to 35 years or older.

*Figure 3. First sheet of questionnaires applied to 101 project participants.*

### Future Perspectives and Conclusions

All blood samples collected by the partners of the multicenter project will have their levels of 25 hydroxyvitamin D analyzed by gas chromatography and spectrometry in a single laboratory at the University of São Paulo. Association analyses are being carried out with the data obtained through questionnaires, food diaries and solar dosimeters in the R program. The data show an association between profession and level of sun exposure. Older women (50+) showed higher levels of vitamin D than younger women (50-). White women had higher levels of vitamin D than brown and black women. Women with distress symptoms had lower levels of vitamin D. The results of this paper can be parameters for other population recruitment studies for vitamin D analysis.

## PATIENTS, ACTOR IN DECISION AND POLICY MAKING IN ALBANIA

### Patient Approaches and Challenges in the Health System

### Authors

Qamil Dika and Marsida Duli

### Patients and the Albanian Health System

In Albanian health system, patients are organized in associations that represent their rights since 1992, but they are small one, they do not have infrastructure, financing, collaboration of the institutions, representing in collegial decision making bodies. In general association that represent patient rights are paid by pharmaceutical

companies or different projects. They act locally and do not interact nationally or in international level.

In Albania different politicians argues that patients would be in the center of health system but they do not consult their needs and they act without them. They politics in general are not transparent and do not inform patient community for the impact that they would have. It is clear that during last 3 decades was no will from they who lead Albanian health institution to change the reality in patients favour. Also patients have weak selforganization.

*Figure 1. Report of patients with other state structures in the health system.*

### The role of patients in a health system


decision-making in the collegial bodies of administration of health care institutions, as

it has been practiced for many decades in Western countries.

4. Patients/citizens have a very important role to play in providing health care, as partners of health systems because they have to contribute to self-medication of pathologies.

*Figure 2. The role of patients in the health system.*

### The benefits of Patient empowerment

• Patients of course are the direct beneficiaries of this empowerment.

• Physicians will not only experience a less stressful situation in their relationships with patients, but their empowerment also means qualified "collaborators" in the application of medical procedures and more care on the part of patients / citizens for preservation of their health.

• The Public Health Sector is one of the beneficiaries because not only the citizens better informed about their pathologies, but also trained or educated in their management, will be a contribution to reducing the indicators of morbidity in the population and increasing life expectancy of patients carrying certain pathologies as a result of patient empowerment.

• The health system is not only interested in supporting patients but the main purpose of a health system is to serve the citizens who at some point in their lives will definitely access the services provided by the health service. All health systems aim to achieve the best possible results in terms of patient service, so its empowerment means a more efficient system.

• The society in an efficient system, itself would not only have more health but also save money which is mismanaged or misused properly to invest them in other sectors.

Participation and Decision-Making of Patients in the Albanian Health System, findings.

1. After about 30 years of transition of the Albanian society and the health system, we find that the patients are not the "owners" of the health system.

Since 1992, with the change of the political system in Albania, they have managed to gain the right to selforganization, but if we refer to their representation, we notice that they do not benefit sufficiently, much less qualitatively. Patients' associations:


• from time to time we notice their mercenarization by pharmaceutical companies thus serving the interests of them to be included in the list of reimbursable drugs. 2. There are only two institutions in which patients are represented in Albania (except for patient associations), the Durrës Hospital Board and the Administrative Council of the Compulsory Health Insurance Fund. Patients are uninformed about decision-making in the health system and there is no transparency in accessing information on their part. Patients cannot access accurate information on the budget spent on the health system, they also have difficulty accessing data on their medical treatments other issues administered by health care institutions.

3. The current situation is not only a matter of the health system but also a matter of culture of our society. Our patients do not have full confidence in the medical staf, result of the numerous problems faced by the medical staff of a health system in many difficulties, Albanian patients have recently manifested increased cases of tension in their relations with the medical staff.

4. According to the annual report of Power House, Albania ranks last in the European ranking of health systems, in 35th place with only 544 out of 1200 possible points. Among the special chapters of this assessment is the information and rights of patients. In this section, Albania is ranked with the lowest possible scores.

### Contacts

Dr. Qamil Dika, Sport University of Tirana, qamil\_dika@yahoo.com Dr. Marsida Duli, Tirana Medical University, marsiduli@hotmail.com

**The enhance of the role of patients in decision making is a patient revolution, and a central priority of the health policy and political will to consider them as real actor and create them the needed infrastructure and financing.** 

### Recommendations

• Improving the health system is first and foremost a matter of political will. Because it requires: more funding, good administration, transparency, strengthening the role of patients, reforming the health care sector at all three levels, further development of the hospital as an institution, reforming the pharmaceutical sector, strengthening public health, including the dental care sector in the health insurance scheme and many other elements no less important, but this improvement never will be complete if we do not have a "revolution" from the patients themselves to seek more quality and right.

• Empowerment of the patient is a democratization process and the result would be the decentralization of health system, the transfer of power or competencies from managers who in Albania manifest a marked lack of skills and prominent politicization, towards patients, which is the main goal of reforming the health system, putting the patients at the center of health system.


• Tightening of the criminal code in cases of tension between patients /citizens and medical staff.


to:


#### References


*Figure 6. European Health Consumer Index 2018, (Albania ranks 35th with 544 points, the last).*

### A PROJECT TO IMPROVE MENTAL HEALTH CARE IN TWO SMALL CENTRES IN KENYA (MERU COUNTY AND THARAKA-NITHI COUNTY)

### Author

Isabella D'Orta

Geneva University Hospitals

### Introduction

The aim of this study to share a project to improve mental health care in the areas of two little missionary facilities in Kenya (Chaaria Cottolengo Missionary Hospital, in Meru County and St Orsola Consolata Missionary Hospital in the County of Tharaka-Nithi). The ambition of this project is to offer to the local population the possibility to receive mental health care in the local community facilities and not to be obliged to move to some other far urban centres.

### Methods

The author was involved in a programme of assessment of the situation of mental health care in the catchment area of the two facilities.



The workshops were organized with people working in the hospitals to share the knowledge about the current situation of care of mental health condition as well as their concerns. They were open to all the professionals, but medical doctors and clinical officers were the main participants.

The focus of the interviews and of the workshops were the perceived needs and difficulties in term of mental health care, the management of the current situation with analysis of the strengths and the weakness of the existing system, and resources and ideas to improve.

Specific attention was paid to the difficulties and criticisms linked to the use of a Western taxonomy system in an African context. In order to pursue and to develop the discussion on main topics of mental health care, the investigator proposed delivering two brief presentations about two pathologies (depression and schizophrenia) to

share knowledge, differences in presentations, and care of these disorders, and to compare different experiences.

Afterwards, a clinical meeting took place, starting with many presentations of clinical cases by local doctors and clinical officers to share practical difficulties, challenges, and propositions.

The author would like to express special gratitude to all the participants who accepted to be involved in the survey. In particular, for their precious contribution, they sincerely thank: Dr G. Gaido, Dr. A. Mbungu, Mr. P. Mati Nchori, Mr. J. Mutugi Gaichu, Mr G. Chiesa, Mrs R. Drago, and Dr A. Bernardi.

### Some reflections:

	- 3. Ensuring access to care and welcoming of help-seeking behaviours.
	- 4. The opportunity given by the collaboration with traditional healers.
		- 5. Share information and reach the patients.

### Closing remarks

Finally, we would like to share our concern about how to adapt our Western psychiatric knowledge to a rural African context, to its particularities, empowering the local stakeholders and keeping a respectful attitude.

As highlighted by B. Saraceno (Saraceno, 2019), exporting treatment packages, even when they are of good quality, is no longer enough: we must adapt to the local context and help develop an optimal policy to reduce the treatment gap.

### Main references

Ariel Eytan, Alfred Ngirababyeyi, Charles Nkubili & Paul Nkubamugisha Mahoro (2018) Forensic psychiatry in Rwanda, Global Health Action, 11:1, 1509933, DOI: 10.1080/16549716.2018.1509933.

Saraceno B (2019). Rethinking global mental health and its priorities. Epidemiology and Psychiatric Sciences 1–3. https://doi.org/10.1017/ S204579601900060X.

## HEALTH CARE PROVIDERS ALSO HAVE A CULTURE

How Cultural Health Beliefs of Health Care Providers in the Interior of Suriname Relate to Their Delivery of Health Care

### Author

Celine Duijves

### Introduction

Culture influences the ways in which people perceive and deal with health. While much research has focused on culture in relation to patients, much less is known about how the culture of health care providers affects their professional work. This study explores cultural health beliefs of Maroon health care providers in the district of Brokopondo, Suriname, and their effect on health care delivery.

### Study area

Suriname is situated on the northern shores of the South American continent and became independent from the Netherlands in 1975. The Surinamese population counts 558.369 individuals. The majority of the population lives in the coastal districts, which also includes the capital city Paramaribo. Thirty-four percent of the population lives in rural areas, also referred to as 'the interior' (World Bank, 2018).

### Acknowledgements

KIT Health (Royal Tropical Institute) Medical Mission Primary Health Care Suriname

### Background

The main organization providing health services in the interior of Suriname is the Medical Mission Primary Health Care Suriname, a non-governmental organization that depends on funding from the government, supplemented by necessary funding from donors. The Medical Mission operates 56 rural health clinics spread over an area of 130,000 km2, serving about 54,000 people. Medical Mission health clinics have no conventional doctor/nurse team for service provision. Midlevel healthcare providers form the backbone of service delivery to the population of the many widely dispersed villages. The greater part of the health care providers and clinic assistants are persons from interior communities, who speak the local language and are familiar with, and share traditional customs and culture.

In the research area, the district of Brokopondo, the Medical Mission operates 11 clinics all in Maroon villages. Maroons are tribal people, who are the descendants of African slaves who fled from the plantations where they were forced to work under Dutch colonial rule. These run-aways established villages in the interior rainforests where they nowadays continue to adhere to many traditional cultural practices and speak their own Maroon language (Duijves and Heemskerk, 2017). Because of their history, the cultural identity of Maroons differs from that of the rest of Suriname's inhabitants. Maroon form their own group, and are seen by others as a separate group of people with deep knowledge of, among others, traditional medicine. Africa and African ancestors play an import role in Maroon culture, but practices are adapted to their current environment and to what people have learned from Indigenous peoples and the New World.

*Figure 1. Overview of Medical Mission clinics in the Brokopondo district. Adapted by author from Google Maps, 2019.*

### Methods

The research had a qualitative design. Multiple methods were used, including face-toface interviews (semi-structured), focus group discussions (FGDs), and observations. The methods provided rich information about cultural beliefs and health practices and helped facilitate deeper understanding of subjects. Information from key informants completed the analysis. Data collection instruments were designed in Dutch. All data collection was executed by the main researcher. Data collection during interviews with key informants and health care providers was executed in Dutch. Focus group discussions with patients were mainly executed in Dutch but supplemented with Sranantongo/Saamaka/Ndyuka. The languages used by patients and health care providers during observation were Dutch/Sranantongo/Saamaka and Ndyuka.

### Results

In practice, virtually all health care providers are people with a Maroon and, to a lesser extent, Indigenous, background, and most of them (at least partly) grew up in the interior. The health care provider sometimes finds him/herself between two worlds, the cultural and the biomedical world. The original identity of the health care provider is shaped by many factors, such as culture and socio-economic background. Traditional medicine is popular among inhabitants of the Brokopondo district and is used for health promotion, disease prevention, or to cure an illness.

Notable was the understanding of the word 'culture' by the respondents whom were being spoken to during data collection. Cultural health beliefs related to *winti* (Afro-Suriname religion) are referred to as spiritual cultural health beliefs; cultural health beliefs that are not linked to ancestral spirits are in this study described as non-spiritual health beliefs. Affiliation with a church, in particular, one of the new churches such as Jehovah's Witnesses or Evangelical Church was a strong determining factor for having – or not having - spiritual cultural health beliefs and practicing them.

All health care providers were familiar with cultural health beliefs and practiced nonspiritual health practices at home. In their approach to patients, however, they were loyal to the Medical Mission protocol. Additionally, respect for the patient and his/her culture was named by the majority of the respondents as an important aspect of health care delivery. It emerged that during health care provision, culture was barely discussed only when health care providers expected the cultural health belief and/or practice could do harm.

#### People already practice cultural practices, they do not come to the clinic for this. They come for medical advice. I never give cultural advice at the clinic. I also explain the risks. For example, the danger of the use of hot water after a C-section and that they have to be careful with dresi (traditional medicine) for children. *(Health care provider, male, 45 years old).*

Women from the community explained, in focus group discussions, that they were aware of the policy of the Medical Mission with regard to drinking herbal drinks at the clinic and stated that they do everything at home; however, they knew of women who brought herbal drinks in a thermos to secretly drink their drink.

Women here are accustomed to rubbing their body and drinking certain oso dresi (home made medication) when giving birth. We know that this is not allowed at the clinic, so we do it as much as possible at home. I do know that there are women who sometimes take it in a thermos and pretend it is water. *(Respondent FGD Brownsweg, females).*

### Conclusion

The study explored how health care providers in the interior of Suriname approach their own cultural health beliefs in a primary health care system imbued with Western biomedical perspectives. Cultural health beliefs cannot be neglected in a district inhabited by Ndyuka and Saamaka Maroons who have a strong cultural identity, distinct from the remainder of Suriname society.

In general, health care providers in Brokopondo follow biomedical protocols and guidelines. On the other hand, cultural health beliefs are part of their identity and cannot be viewed in isolation from health care delivery. That health care providers share the patients' culture has the obvious benefit that the health care provider understands and may anticipate on specific cultural health beliefs and practices, and can discuss these beliefs without alienating the patient. On the other hand, however, sharing the same culture can make the health care provider blind or non-reactive to common cultural practices. Traditional culture and cultural health beliefs are not an integral part of the

curriculum. Health care providers were convinced that more training in cultural beliefs of patients and awareness of their own perceptions and practices would improve the quality of health care delivery.

Because most research within health care has focused on culture among patients, this research contributed to a more in-depth understanding of the influence of culture on the side of the health care providers' health care delivery. That being said, we argue that for a comprehensive understanding of the ways in which culture influences health care delivery. Ideally, research needs to focus on both sides and their interaction.

### Objectives

The general objective of the study was to explore culturally informed health beliefs of health care providers,

and their potential effect on health care delivery. The specific objectives were formulated as follows:

• To explore existing health beliefs and practices of health care providers in Medical Mission clinics in Brokopondo and patients living in the district.


*Figure 2. Medical Mission health clinic in Klaaskreek, Brokopondo district.*

### PRIVATE HEALTH SECTOR ENGAGEMENT FOR UNIVERSAL HEALTH COVERAGE (UHC): THE CASE OF EGYPT

### Assessment Report 1

### Authors

Wafa Abu El Kheir-Mataria2 and Hany Gaballah1

### Introduction

The private health sector in Egypt is a prominent service provider. Nevertheless, it continues to pose serious challenges concerning quality, regulation and access to service. Although the government recognized the need to effectively mobilize the private sector to achieve the goal of Universal Health Coverage and meet the health-related SDGs, there is a need to assess the private health sector to ensure its effective engagement in service provision. This research is an assessment of the private health sector in Egypt in terms of: its policies, regulations, services provision, distribution, accessibility and quality.

> *Figure 14. Financing agents of Egypt's health care system.*

### Methodology

Quantitative descriptive methodology as well as qualitative approaches were used to conduct this research. Quantitative data from the Central Agency for Public Mobilization and Statistics (CAPMAS) was analyzed to describe the quantity, types and distribution of services provided by the private sector. Semi- structured interviews were conducted with different stakeholders to stand upon their perceptions of the current status of the private health sector, the governmental position on engaging the private sector and to identify what is needed to promote an effective engagement of the private sector in health services provision. The data obtained was then used to perform a SWOT analysis for the engagement of private sector in Egypt.

### 6. Legal, regulatory framework and governance in the Private health sector

Regulations and laws governing the private health sector in Egypt are numerous, several entities are responsible for these regulations. Any healthcare facility and even healthcare professionals are to abide to several and sometimes conflicting regulations. Nonetheless, private health sector regulations in Egypt are weakly enforced.

### The new health insurance and the private sector

A new insurance law has been enacted in January 2018. The new health insurance system in Egypt will affect the private health sector in three main levels: regulation, competition and investment.


### Health sector challenges in Egypt


*Figure 2. The total Number of medical facilities, beds, doctors and nurses in the governmental and private sectors in Egypt.*

1 Poster based on a report commissioned by WHO EMRO 2 GPH PhD Candidate, MPA, BSc Pharm, Homeopath-American University in Cairo wafamataria@aucegypt.edu

### Private health sector engagement

Although collaboration between the government and the private sector exists this collaboration is not systematic and do not reach the level of complete engagement or partnership.

Public Private Partnership (PPP) law in Egypt was issued in 2010. Nevertheless, no PPPs were executed in the health sector. The Ministry of health and population need to develop capacities to manage PPPs in the health sector.

*Figure 3. Investments in health services in the private sector.*

### SWOT analysis of private health sector engagement

### 2. Wide distribution of Private health sector facilities

Private health sectors facilities are distributed all around egypt. However, they are more concentrated in the big governorates (e.g. Cairo, Damietta, Giza)

*Figure 2. No. of private hospitals per governorate in Egypt.*

### Recommendations


### Characteristics of the Private Health sector

The private sector plays an important role in health services provision in Egypt.



1. High contribution in health service provision

### 3. Increasing investments in private health sector

Private investment in health has been increasing.

In 2014 the government started a reform program to incentivize the economy. A new investment law was enacted to provide incentives

for the private and encourage foreign investment. Health sector investors are very optimistic, notably after the signing of the new Universal Health Law. They prognosticate an increase demand on the private health services.

Private health expenditure through out-of- pocket (OOP), as a percentage of total health expenditure, reached 55.7% in 2014.

OOP resulted in 4.4% of population suffering from catastrophic health expenditure and 1.1% of the Population impoverished.

### 4. High private health expenditure

### 5. Quality of services in the private health sector

Quality of services in the private health sector in Egypt varies widely. Services in the private sectors range from low quality services to high quality services.

The low quality in certain private health services providers emerges from the absence of a governmental quality control follow-up and weak adherence of providers to regulations.



## Le RAI-HC Suisse: de l'analyse des données au niveau micro à l'analyse macro. Expérience de l'institution genevoise de maintien à domicile

### Authors

Christina Guéninchault, Fanny Vallet and Catherine Busnel Unité recherche et développement. Institution genevoise de maintien à domicile (imad), Avenue Cardinal Mermillod 36, 1227 Carouge, Suisse

### Introduction

La prévalence croissante des comorbidités (1) et les risques accrus de dépendance liés au vieillissement de la population modifient radicalement l'ampleur des besoins de santé des bénéficiaires de soins à domicile (2). En Suisse, les prestataires de soins à domicile recommandent l'utilisation du Resident Assessment Instrument-Home Care (RAI-HC) pour évaluer les besoins de santé et réaliser les plans de soins individualisés. À Genève, le RAI-HC est utilisé de manière systématique depuis 2005 par l'institution genevoise de maintien à domicile (imad) (institution publique). Chaque année, les 650 infirmières formées par imad effectuent près de 15'000 RAI-HC en routine clinique, fournissant des données pertinentes pour une description précise des besoins de santé des bénéficiaires actuels de soins à domicile.

### Objectifs

Les objectifs de l'étude sont les suivants:


Le RAI-HC fournit des indicateurs cliniques individuels et collectifs pertinents pour l'optimisation des soins aux niveaux: micro (patient), méso (équipe, infirmières) et

### macro (politique de santé).

Jusqu'à présent, ces développements n'étaient possibles qu'au niveau suisse, mais l'introduction de l'interRAI-HCSuisse offrira de nouvelles possibilités de comparaisons, de collaboration et de développement au niveau international.

#### Références bibliographiques


(5) Busnel, C., Marjolet, L., & Perrier-Gros-Claude, O. (2018). Complexité des prises en soins à domicile: développement d'un outil d'évaluation infirmier et résultat d'une étude d'acceptabilité. Revue internationale francophone en recherche infirmière. (6) Ludwig, C., & Busnel, C. (2019). Protocol of a case-control longitudinal study (fraXity) assessing frailty and complexity among Swiss home service recipients using interRAI-HC assessments. BMC Geriatrics, 19(1), 207. doi:10.1186/s12877-019-1230-z. (7) Ludwig, C., & Busnel, C. (2017). Derivation of a frailty index from the resident assessment instrument - home care adapted for Switzerland: a study based on retrospective data analysis. BMC Geriatrics, 17(1), 205. doi:10.1186/s12877-017-0604-3.

Les résultats de l'analyse descriptive de l'évaluation du RAI-HC présentés dans cette étude sont importants car ils:


### Discussion

### Méthode


Conclusion

Geneva Health Forum- Genève- mars 2020

*Adapted from (Busnel, Mastromauro, Zecca, & Ludwig, 2017) (3).*

## GLOBAL HEALTH DIPLOMACY IN MEXICO

Findings from an explanatory multi-case study of the integration of health into foreign policy in the Americas

### Authors

Germán Guerra1,2, Nelly Salgado de Snyder2, Emanuel Orozco Núñez2, Paulina Jiménez Medina2 and María Antonieta Moreno Reynosa2

1University of Geneva, Switzerland Background 2National Institute of Public Health - Global Health Program, Mexico

Global health diplomacy (GHD) focuses on the analysis of the responses of diverse stakeholders –governments, multilateral agents, and civil society – to phenomena that transcend national borders and can affect population health and its determinants. Global health risks, national health security, emergency health preparedness, and cross-border humanitarian health assistance are some of the topics of interest for GHD. Although conceptual advancements in GHD are based on the disciplinary intersection of International Relations theory and Public Health practice, their aims lie beyond the traditional focus of both disciplines, broadening the scope of study in terms of the relationship between actors (nation states) and subject of studies (population health). Most of the current GHD conceptual developments have been proposed by scholars from developed countries; however, empirically based studies about how health becomes an issue of relevance for foreign policy remain scarce. Even rarer are those studies conducted in the Latin American region.1-3

In this contribution we share some findings from a multi-case research project aiming to understand how health becomes an issue of concern in the foreign policy of four countries in the Americas region (Brazil, Canada, Chile, and Mexico). Particularly, we focus on the Mexican case as a mean to illustrate how GHD processes occur, based on the experiences of key actors from three different sectors and emphasizing that such processes entail an exercise of both political will and power, along with cyclical administration priorities that determine the success of some health concerns in entering foreign policy.

### Objectives

To analyze some GHD processes in Mexico based on the experiences of key informants from the Foreign Affairs (FAS), Health (HS) and Non-Government Organization (NGO) sectors, by describing:


### References


### Conclusion

The entering of health concerns into foreign policy in Mexico is a crucial aspect of GHD processes. As we have shown, there are different health issues supported by

the sectors here analyzed, and each of those sectors have an unpaired power of decision for priority setting. In a context of asymmetric power relationships, government actors have the highest influence, particularly the FAS (with the securitization of health issues and pandemics, and its relationship with economic interests), whereas NGO, in spite of strong advocacy to positioning chronic diseases-related problems in the agenda, is frequently left out from decision-making GHD processes, even in cases where government bodies call them for consultancy purposes.

These findings suggest the need to promote less hierarchical intersectoral collaboration within government sectors – mainly HS and FAS – and between NGO and government bodies, to improve participative GHD processes in Mexico, leading to more consensual and coherent responses to global health challenges. One limitation experienced during the development of this research was that some key informants were not possible to interview (congressmen) due to persistent conflicts with their agenda. As result, triangulation of findings between this and the rest of the key informants from other sectors was not conducted.

### Methods

Sampling: Purposive sampling of high-rank representatives of the three sectors involved in GHD including a former Mexican ambassador, the permanent representative of Mexico at the United Nations in Geneva, the General Director of Foreign Affairs at the Secretariat of Health, and the Head of Legislative Branch Liaison from NGO "Consortium for Parliamentary Dialog", among others.

Fieldwork and Analysis: Semi-structured interviews exploring the topics described in the objectives section were conducted between 2017 and 2018. Interviews were transcribed and coded into framework matrices based on a previously defined code tree, using QSR NVivo 10 software. All ethical considerations for research on human subjects from the Research Ethics Committee of the National Institute of Public Health, Mexico, were met.

### Results

The following table summarizes the main health concerns, processes, and impacts involved in foreign policy and the power of influence in GHD processes in Mexico by sector.


*+ = Limited: Sector is mostly out of negotiations and requires formal invitations from other sectors to exercise decision-making power or participate in priority setting processes*

*++ = Moderate: Sector requires intersectoral coordination/consensus to exercise decision-making power*

*+++ = Strong: Sector has the most decision-making power over agenda; intersectoral coordination is secondary to decision-making*

#### Acknowledgements

*We acknowledge the Canadian Institutes for Health Research (CIHR) for funding the study "Global Health Diplomacy: An explanatory multi-case study of the integration of health into foreign policy" through operating grant number 136792.*

### NERVE CONDUCTION STUDIES IN NEWLY DIAGNOSED CASES OF HYPOTHYROID PATIENT REFERRED FROM THE TELECONSULTATION SITES OF EASTERN NEPAL LINKED WITH BPKIHS-HUG-RAFT PROJECT ATBPKIHS

### Authors

Shital Gupta, Nirmala Limbu, Pramendra Prasad Gupta, Narendra Bhatta and Antoine Geissbuhler

### Introduction

Thyroid gland is one of the major endocrine gland which secretes thyroxine (T3) and triidothyronine (T4 ).Thyroid hormones acts on many organs including central and peripheral nervous system.

Electrophysiological parameters may be abnormal even in newly diagnosed cased of hypothyroid patients. Thus, we conducted this study to explore the effect of thyroid hormones on somatic nervous system assessed by Nerve conduction study (NCS).

> *Table 2.* Comparison of Sensory, Motor Parameters of Nerve Conduction Study (NCS) between healthy controls and hypothyroid patients*.*

### Materials and Methods

This was the cross-sectional study done in the patients who had telemedicine consultation in the rural setup form BPKIHS and was referred from there for investigations. The inclusion criteria were patient with diagnosed cases of hypothyroidism and newly diagnosed cases who had sign and symptoms of hypothyroidism and who also complaint of tingling sensation during the consultation. Those all patients were advised to do Thyroid Investigations and also Nerve Conduction Velocity (NCV) Test. Informed consent was taken from the patients. Ethical Clearance was taken from the Institutional Review Committee of BPKIHS.

The teleconsultation remote sites from where the patients were referred after consultation were Community Healthcare Centre, Patle and Parewadin Primary Health Care Centre, Sidua in Dhankutta District, Sub-Health Post, Fikkal in Ilam District.

All subjects which were included in the study were performed NCS in median, ulnar, tibial and sural nerves using Nihonkohden Machine (NM-420S, Japan).

### Results

Both the groups were comparable in term of their age, BMI, PR, SBP and DBP. onset latency of median sensory nerves on both sides were significantly high in hypothyroid patients as compared to healthy controls. Sensory parameters of NCS showed significant decrease in left median nerve SNAP amplitude and nerve conduction velocity of bilateral median nerves in hypothyroid patients as compared to healthy controls. In motor parameters of NCS, onset latencies of bilateral median nerves and right ulnar nerve were significantly increased in hypothyroid patients.

### Dr. Shital Gupta

Assistant Professor, Department of Basic and Clinical Physiology, B.P. Koirala Institute of Health Sciences, Dharan,Nepal.

Email ID: shitalgupta199@gmail.com

### Conclusions

In somatic nerves; median, ulnar, tibial and sural nerves were studied and mostly median nerve were found to be affected.


*Table 1. Comparison of anthropometric variables between healthy controls and hypothyroid patients*

There were no significant changes in any anthropometric parameters between healthy controls and hypothyroid patients in term of their age, height, weight, body mass index (BMI), upper limb length and lower limb length

Cardiorespiratory variables such as SBP, DBP, PR and RR of both healthy controls and hypothyroid patients were measured at rest. There were no significant changes in either group.


### Discussion

The increased sensory latency and decreased sensory NCV in any nerve indicate sensory conduction impairment of that nerve. The sensory nerve conduction impairment is frequent in early stage of neuropathy in thyroid deficiency. The mechanism involved in the development of neuropathy (sensory and motor) in hypothyroidism still remains unclear. Mononeuropathies secondary to compression caused by deposition of mucopolysaccharide or mucinous deposits in the soft tissues surrounding peripheral nerves and a polyneuropathy due to either a demyelinating process or primary axonal degeneration are the most commonly proposed mechanisms of peripheral nerve dysfunction in hypothyroidism. Myelin structure abnormalities and dysfunction of axonal oligodendroglia processes may also be responsible for neuropathy in patients with hypothyroidism.


(3 hospitals and 2 clinics)

### **REFERENCES:** References

Allen Repko, Interdisciplinary Research: Process and Theory, Universidad de Indiana (SAGE Publications, 2008).

Margaret E Kruk et al., "High-Quality Health Systems in the Sustainable Development Goals Era: Time for a Revolution," The Lancet Global Health 6, no. 11 (November 2018).

Trends in maternal mortality: 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva (World Health Organization, 2019).

### A WOMEN CENTERED QUALITATIVE MANAGEMENT TOOL TO IMPROVE MATERNITY CARE:

### A Transdisciplinary Approach

### EXPLORING THE GAPS IN THE CONTINUUM OF IMMUNIZATION SERVICE AMONG DEMOGRAPHIC SUBPOPULATIONS IN SIX SOUTH-ASIAN COUNTRIES

*An Application of Heckman Sample Selection Model*

### Author

Md Zabir Hasan School of Population and Public Health, University of British Columbia

### Background

South-Asia improved immunization coverage by mainstreaming the "Expanded Program on Immunization" within the primary-care system. This study explores the continuum of immunization service by assessing the dropout rates of the third-dose of diphtheriapertussis-tetanus (DPT3) and the first-dose of Measles vaccine in six South-Asian

countries. *Figure1. Prevalence of BCG, DPT3, and Measles vaccination among 12-35 months children.*

*Figure 2. Dropout rate of DPT3 and Measles vaccination among 12-35 months children across countries.*

### Method

This analysis is based on the Demographic Health Survey (DHS) from Afghanistan, Bangladesh, India, Nepal, Myanmar, and Pakistan from 2010-2016, including 12-35-month children (n= 105,562). DPT3 and measles dropout rates were measured as the proportion of children who received Bacille Calmette-Guérin (BCG) vaccination but not the DPT3 or measles vaccines. Heckman sample selection model was used to obtain associated factors for DPT3 and measles vaccination, conditional on BCG vaccination status.

### Results

The DPT3 dropout rate was – Afghanistan 27%, Bangladesh 6%, India 15%, Myanmar 12%, Nepal 27%, Pakistan 19%. Measles vaccine dropout was – Afghanistan 23%, Bangladesh 11%, India 11%, Myanmar 16%, Nepal 11%, Pakistan 22%. The probability of receiving DPT3 or measles vaccines for a child – who already received the BCG vaccine – significantly increased due to the mother's education and household wealth in all countries, except Afghanistan and Myanmar. While Afghanistan had the highest dropout rate, the likelihood of receiving DPT3 or Measles vaccine didn't significantly increase in any demographic subpopulations. Wealth was only associated with measles vaccination among children who already received the BCG vaccine in Myanmar.

*Table 1. Estimated adjusted coefficient of receiving DPT3 and Measles vaccinations (conditional on receiving BCG vaccination) among the 12-35 months children derived from Heckman Sample Selection models in six South-Asian countries (n= 105,562).*


*Figure 3. Predictive margins of maternal education and household wealth on the probability of receiving DPT3 and Measles vaccination among 12-35 months children.*

### Contact Information

https://www.linkedin.com/in/mdzabirhasan/ zabir.hasan@gmail.com +1-778-320-8652

## MODELLING HEALTHCARE ACCESS TO SUPPORT DISASTER RESPONSE

A Spatial Impact Analysis of Cyclones Idai and Kenneth in Mozambique

### Background

In March and May 2019 two cyclones made landfall in Mozambique (Idai and Kenneth). Damage to hospitals & roads, and extensive flooding caused severe disruption in health service delivery. The aim of this study was therefore to estimate post-disaster travel times to functional health facilities and analyze losses in accessibility coverage after these cyclones to target and prioritize disaster response.

### Methods

We modeled travel time of children under five to the nearest functional health facility in two cycloneaffected regions in Mozambique. Modelling was done using AccessMod version 5.6.30, where roads, rivers, lakes, flood extent, topography, and land cover datasets were overlaid with health facility coordinates and high-resolution population data of children under 5 to obtain accessibility coverage estimates under different travel scenarios.

### Results

Accessibility coverage decreased in the cyclone affected districts, as a result of reduced travel speeds, road constraints and non-functional health facilities. In Idai-affected districts, accessibility coverage in 2 hours travel time decreased from 78.8% to 52.5%, implying that 136,941 children lost access. In Kenneth-affected districts, accessibility coverage decreased from 82.2% to 71.5%, corresponding to 14,330 children losing access to care in 2 hours travel time.

### Authors

Fleur Hierink, Nelson Rodrigues, Maria Muñiz, Rocco Panciera and Nicolas Ray


*"In a post-disaster setting, access to health care is essential for effective response and recovery."*

### Cyclone Trajectories & Affected Districts

### Data Requirements

### Key Facts

Travel Time to Healthcare & Accessibility Coverage


*Figure 1: Abreu, S. (Photographer). (April, 2019). Aerial photo of the damage caused by Cyclone Kenneth. Retrieved October 15, 2020, from https://public.wmo.int/en/media/news/anotherunprecedented-tropical-cyclone-and-flooding-hits-Mozambique.*

*Figure 2: Bulawayo, P/Reuters (Photographer). (March, 2019). A man surveys a damaged bridge along Umvumvu river following Cyclone Idai in Chimanimani, Zimbabwe. Retrieved October 15 2020, from https://zimfact.org/fact-sheet-cyclone-idai-andzimbabwe/*

*Figure 3: Moreira, G/WHO (Photographer). (July, 2019). RD Visit. Retrieved October 15 2020, from https://www.afro.who.int/sites/default/files/2019-07/WHO-Gloria%20Moreira.JPG.*

### References

1. Office for the Coordination of Humanitarian Affairs, 'Southern Africa: Cyclones Idai and Kenneth snapshot', OCHA, 10 July

2019.

2. Matera, M. (2019). Project Information Document-Mozambique: Cyclone Idai Kenneth Emergency Recovery and Resilience Project-P171040 (No. PIDA26977, pp. 1-0). The World Bank. 34

### WORK-RELATED FACILITATORS AND BARRIERS FOR SELF-MANAGEMENT BY TYPE 2 DIABETES PATIENTS AMONG WORKING POPULATION

### A Qualitative Study

### Author

Heidi Hung

MSt (Oxon), The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong



Reference: (1) International Diabetes Federation., IDF Diabetes Atlas, 9th edn. Brussels, Belgium: 2019. Special acknowledgement to Dr Elaine YK Chow, Assistant Professor, Phase 1 Clinical Trial Centre and Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, for expert advice and on-site supervision.

Many participants found it challenging to balance between disease management and job performance.

There was a strong sentiment that it was their own problem to have diabetes, and they should not expect accommodation from their supervisors and co-workers.

Proposed enahmcents to the existing healthcare services to facilitate better self-management by diabetic patients with employment:

• Advice on physical activities that patients could perform at workplace or at home.


While concerted efforts from employers/ human resource personnel and legal protection are required to improve the self-management situation of diabetic patients at work, there should be redesinign of healthcare services to better accommodate the needs of Type 2 diabetes patients with employment, so as to facilitate adherence to self-management regiment.

### Background

### Methods

### Objectives


### Results

### Patient/ worker tension

### Enhancements to Diabetes Healthcare Services

### Conclusion

### Diabetes self-management at workplace

The majority of participants considered that working conditions have strong impact on their diabetes self-management activities, and the most challenging aspects are -

• Adherence to healthy diet: many regularly consume unhealthy foods at restaurants during work hours, and some have irregular meal time.

• Performance of physical activities: common to find it hard to perform physical activities.

• Self-monitoring of blood glucose (SMBG) at workplace: some have no time to do SMBG, with some finding it embarrassing.

• Attend follow-up appointments: some patients had pay deducted for attending follow-up appointment during working hours.

*"I start working at 9 am and off at 8 pm. It is already 9 pm when I arrive home and 10 pm when I finish dinner. I just do not have energy and time to exercise." (a ticketing officer at travel agent)*

*"When we are driving long haul, we do not even have toilet break; and we do not have regular meal time as it all depends on the traffic and number of orders we have to finish." (a delivery van driver)*

*"If I take sick leave for attending this appointment, my pay for the day will be deducted... So I use my annual leave." (a security guard)*

*"I feel very uncomfortable pricking my fingers at work because colleagues sometimes kept asking questions. I preferred somewhere with privacy." (a construction site painter)*

*Table 1. Summary of how certain working conditions could act as barriers/ facilitators to diabetes self-management by patients with employment.* 


## RETHINKING GENDER IN UNIVERSAL HEALTHCARE

### Authors

Javed Sumbal

### Leaving No One Behind

Those most visibly affected by healthcare inequalities stand to gain the most by applying a systematic gendered approach to key building blocks of the health system and a well-designed universal healthcare (UHC) program.

Advances have been made that support greater equity in UHC, but attention has mainly been focused on financing. Gender equity requires going beyond narrow considerations of income and affordability as often conceived under UHC.

A broader and more intersectional approach is required. Countries need to address a broad range of system reforms to reach UHC, involving all of the building blocks of the health system identified by the World Health Organization (WHO), governance, financing, service delivery, workforce, information, medical products and technologies.

*Figure1. Proportion of countries reporting to have at least one service-delivery point that provides one or more elements of postrape care (n = 114).*

### Power Play

As gender influences how people interact in complex, multifaceted, and contextspecific ways, we can examine how these markers interact, how power plays out at multiple levels and through diverse pathways to frame how vulnerabilities are experienced by using a combination of mixed, quantitative, and qualitative methods to demonstrate the applicability of diverse research methods for gender and intersectional analysis.

*Figure 2. Power-relation impact on health.*

### Conclusion

Experiences indicate that, for UHC to measurably improve equity, programs should include five critical factors in their design and implementation: essential-service packages, access to services, financial barriers, social barriers, and performance indicators. Strengthening health systems at multiple levels, including financing, human resources, and community involvement maximizes the benefits of UHC.

*during public health emergencies.*

Connell, R. (1987). Gender and power: Society, the person, and sexual politics. Palo Alto: Stanford University Press Bates, L., Hankivsky, O., and Springer, K. (2009). Gender and health inequities: a comment on the final report of the WHO commission on the social determinants of health. Social Science and Medicine, 69(7), 1002–1004.

Shannon K. (2014) Universal health coverage may not be enough to ensure universal access to sexual and reproductive health beyond 2014, Global Public Health, 9:6, 661-668, DOI: 10.1080/17441692.2014.920892 Ravindran, T.S. Universal access: making health systems work for women. BMC Public Health 12, S4 (2012). https://doi.org/10.1186/1471-2458-12-S1-S4.

Well-designed UHC programs have had a positive impact on reducing inequities. A substandard design can reinforce gender inequities where women slip through the cracks of patchwork insurance schemes and too narrow a range of available reproductive health services.

Contact Javed Sumbal Sumbalj@connect.hku.hk

### HUMAN PAPILLOMAVIRUS INFECTION AND VACCINATION: KNOWLEDGE, ATTITUDES, AND PERCEPTION AMONG UNDERGRADUATE MEN AND WOMEN HEALTHCARE UNIVERSITY STUDENTS IN SWITZERLAND

### Authors

Emilien Jeannot, Manuela Viviano, Marie-Christine Follonier, Christelle Kaech, Nadine Oberhauser, Emmanuel Kabengele, Pierre Vassilakos, Barbara Kaiser and Patrick Petignat

### Context

The human papillomavirus (HPV) vaccination program for young girls aged 11–26 years was introduced in Switzerland in 2008. Since then, important public funds have been committed to the program, requiring an evaluation of its impact on society.

### Objectives

The objective of this study was to evaluate basic knowledge and beliefs regarding the HPV infection and vaccine among male and female undergraduate healthcare students, and their attitudes toward the HPV vaccine.

### Methods


### Results


### Conclusions


### REVENUE DERIVED FROM PROBLEM GAMBLING AS A PUTATIVE INDICATOR FOR SOCIAL RESPONSIBILITY: RESULTS FROM THE SWISS HEALTH SURVEY

### Authors

Emilien Jeannot, Jean Michel Costes, Cheryl Dickson and Olivier Simon

### Context

Gambling behaviours represent a significant social and economic cost and an important public health problem. Related public health policies require ongoing monitoring to determine their effectiveness, and indicators provide essential information in this process.

### Objectives

Using this indicator, the present study aims to provide a first estimate of the proportion of gambling revenue generated by problem gambling in Switzerland according to the Swiss Health Survey (SHS).

### Methods

Data was obtained from the SHS 2017.. Self-reported spending on terrestrial and online gambling during the past 12 months was then used to calculate the portion of gambling revenue derived from problem gambling

### Results

12,191 respondents were included. Problem gambling was reported by 3,10 % of our sample, according to NODS-CLiP criteria. The findings showed that whilst 52% of people with problem gambling behaviour spend less than 100 francs per month on gambling, 31,3% of total spending is attributable to problem gambling.

### Contact: Emilien.Jeannot@chuv.ch

*Table 1. Distribution of players and spending according to gambling type.*

### Conclusions

In addition to pre-existing national prevalence studies, data on spending should be made readily available by gambling operators and regulators in keeping with their regulatory obligations. The revenue structure according to gambling type should also be provided, including data from third-party gambling operators. In an interdisciplinary effort to improve public health and consumer protection, organized national structural prevention measures should be developed and evaluated.


### AUGMENTING TB SCREENING THROUGH USE OF ARTIFICIAL INTELLIGENCE AND PCR TESTING FOR TB DETECTION IN NAGPUR, MAHARASHTRA

### Authors

Vaishnavi Jondhale, Shibu Vijayan, Ravdeep Gandhi, Asha Hegde, Amera Khan, Anjali Borhade, Lucky Richardson and Suman Gupta

### Public private mix intervention with Artificial intelligence

In India, more than 50% of patients seek care from the private sector, and informal providers are usually the first point of care. Through Stop TB's TB REACH Wave 6 funding, PATH engaged with informal providers in slum pockets of Nagpur and equipped them with the right tools. Informal providers offer free chest X-Ray (CXR) screening. Through qXR by Qure.ai, an AI-based screening tool used in diagnostic centers, CXR films are interpreted. Confirmation of TB is completed using portable battery-operated micro PCR machine TrueLab.

*Figure 1. Project workflow with private- and public-sector components.*

### Acknowledgements

Nagpur Municipal Corporation , Disha Foundation, Chest X-Ray laboratories, Qure.ai and Stop TB Partnership.

### Project impact


### Closing remarks


### TB REACH intervention highlights


ACCELERATING ACCESS TO QUALITY CARE FOR PRESUMPTIVE PAEDIATRIC TUBERCULOSIS PATIENTS THROUGH IMPROVED DIAGNOSTIC STRATEGIES IN INDIA Accelerating Access to Rapid and High-Quality Diagnostic Services for Diagnosis of Pediatric TB - Experience From India

### Authors

Aakshi Kalra1, Rajashree Sen1, Debadutta Parija1, Sarabjit Singh Chadha1, Sanjay Sarin1and Catharina Boehme2

<sup>1</sup> Foundation For Innovative New Diagnostics, New Delhi Delhi, India

<sup>2</sup> Foundation For Innovative New Diagnostics, Geneva, Switzerland

### Introduction

The Sustainable Development Goals (SDGs) prioritise well-being of vulnerable populations including children in the 2030 agenda. The goal 3 promotes universal health coverage and specifically targets reduction in tuberculosis (TB) incidence among all populations including children. However, in the current scenario, diagnosis of TB in children remains a challenge since signs and symptoms of TB are non-specific, significant proportion of extrapulmonary TB cases, difficulty in obtaining samples and poor sensitivity of the available diagnostic with the exception of more sensitive molecular diagnostic tests. This results in underdiagnosis of TB in children.

*Figure 4. Uniqueness of the project.*

To overcome these challenges, a large-scale project was implemented in 10 major cities across India (in a phased manner) under which upfront rapid and highly sensitive molecular TB test (Xpert MTB/RIF) was offered free of cost for early and improved diagnosis of TB among children from April 2014 to March 2018.

### Methods

Several low-cost outreach and education interventions were undertaken to increase diagnostic uptake by providers catering to paediatric population. A high throughput lab was established in each of the project cities and linked to various providers in the public and private sector, through rapid specimen transportation and electronic reporting. In addition to contined medical education (CMEs) sessions, trainings were organized for the providers on extra pulmonary sample collection.

*Figure 1. Map showing the geographies under the paediatric project (red flags show initial 4 project cities; blue flags show the cities where the project was extended in 2016-2017.*

> First initiative with upfront access to GeneXpert testing exclusively for paediatric population in India

Focused on Public Private Mix (PPM) activities

For the first time, large volumes of non-sputum specimens tested

Largest cohort of paediatric patients evaluated in India

Facilitated policy decision by NTP mandating upfront GeneXpert testing for TB diagnosis in children

### Conclusion

This project, which was one of the largest initiatives globally among paediatric population, demonstrated the feasibility of providing and sustaining upfront access to rapid and more sensitive TB diagnostics. Introducing innovative technology and rethinking the TB diagnostic process in India has enabled three times as many children to be diagnosed with TB than using the available tests. The initial findings from the project facilitated a policy decision by India's National TB Programme mandating the use of GeneXpert as a primary diagnostic tool for TB in children.

*Figure 2. Project model.*

### Results


*Figure 3. Provider engagement classified by type of providers/facilities engaged; The graph reflects data as follows: from Q2 14 to Q1 16- from 4 project cities; Q2 16 onwards -from 7 project cities; from Q3 16 - from 9 project cities ; from Q3 17' onwards - from 6 cities (post transition of first 4 sites to the National TB Programme and addition of 10th site to project).* 

#### Author contacts/current affiliation

Lucy Kaluvu Guest junior researcher Julius Center for Primary Care and Health Sciences UMC Utrecht, The Netherlands Email address: L.M.Kaluvu@umcutrecht.nl

### ELIMINATION OF BOTTLENECKS IN HIV PREVENTION,CARE AND TREATMENT: THE MOBILE HEALTH OPPORTUNITY IN KENYA

### A Literature Review

### Authors

Lucy Kaluvu Supervisor: Hermen Ormel KIT Royal Tropical Institute

### Introduction

HIV/AIDS is a leading cause of death and disability in Kenya. Almost 2 million Kenyans are living with HIV. Nearly 100,000 AIDS-related deaths occur annually. To reduce the HIV burden, access to good quality services is paramount. With increasing mobile phone penetration in remote areas and near-100% penetration elsewhere, mobile health (mhealth) opportunities offer promise in addressing challenges in access and utilization. Mhealth is the application of medical and public health through mobile communication devices. Mobile phones are portable, with ease of access and sharing capabilities, and hence can reach more people.

*Figure 3: Mhealth and ICT framework, Labrique et al.*

Kenya has a generalized HIV epidemic with concentrated epidemics among key populations (KPs). Young adults (15-24 years) have a higher risk of acquiring HIV. KPs constitute female sex workers (FSW), men having sex with men (MSM), people who inject drugs (PWID) and male sex workers (MSW). Reports show that the likelihood of contracting HIV is more than twenty times higher among PWIDs and MSMs when compared to the general population. Moreover, the risk of contracting HIV for FSWs is ten times higher than the general population.


 The World Health Organization(WHO) Digital Health Intervention Guidelines 2019 report was instrumental in classifying evidence and study quality evaluation.

*Figure 1: HIV and HIV testing among young people (15-24 years), Kenya 2017.* 

### Methodology

 The Levesque model of access to health services was applied to identify the barriers and facilitators to access of HIV services.

### Findings

The main demand barriers to the access of HIV services identified were:


The main supply side barriers identified were:


### Recommendations


Guidelines. This will ensure prioritization of studies whose evidence is high.

*Figure 2: The Levesque model of access to health services, Levesque et al.*

*"*Health applications can play a vital role in health systems strengthening. They can be applied in client behavior change communication, provider communication, education and training and to promote supply chain transparency. To ensure proper scale up of mhealth interventions, proper implementation, monitoring and evaluation, is key in addressing 'mhealth pilotitis"

### Closing remarks

*"I look forward to engaging with you all. Working at the interface of digital and global health, I truly believe that digital health is the FUTURE of healthcare delivery"*

## DEVELOPMENT OF HEALTH INFORMATICS WORKFORCE MODEL FOR NAMIBIAN PUBLIC HEALTH SECTOR

### Author

Etuna Kamati

### Introduction

Health is a crucial element of human life and global concern.

Access to public health services is a basic right of every Namibian citizen.

Health care provision is knowledge intensive and requires adequate human capital development, modern technology adoption and implementation for efficient and effective services delivery.

Lack of operational knowledge of these modern technologies may render any huge investment within the sector useless.

Proper implementation of Information Technology in the health sector has a powerful potential to enhance organisational efficiency.

Health informatics focuses on how data are created/gathered, processed, stored, communicated and analysed using ICT systems to provide knowledge for planning and decision making in the health sector. The introduction of health informatics has enabled sustainable qualitative data gathering and processing for healthcare knowledge discovery, sharing and decision making.

However, the lack of an ICT and Informatics skilled health workforce has remained a major setback in developing countries including the Namibian health care sector in harnessing the opportunities provided through health informatics for effective and efficient healthcare services delivery

### Research Objectives

The purpose of this study is to assess the skills of health informatics workers in the Namibian health sector, so as to establish what skills are available and in what quantities.

The study also aims to identify the types of technical skills needed and how they can be developed.



### Theoretical Framework


### Research Methodology and Design

The interpretivist approach/paradigm will be applied to this study.

The research will be conducted using the case study research design which falls under qualitative research methods.

### Data Collection Techniques

	- semi-structured interviews,
	- observations,
	- documents analysis,
	- and questionnaires.

### Sampling Method


### Study Participants

The suggested participants from which data will be collected are those who are involved in the creation, gathering, analysis, processing, communication and storage of data in the public health care sector.

Those who use information and knowledge that is derived from health informatics data for the purposes of decision making will also be investigated.

The focus will be on:


*Figure 2: Cultural Historical Activity Theory (Source: www.researchgate.net).*

### References

Coiera, E. (2015). *Guide to Health Informatics 3rd Edition.* New York: CRC Press. DePoy, E., & Gitlin, L. N. (2005). *Introduction to Research Understanding and Applying Multiple Strategies.* Philadelphia: Elsevier Mosby. Dwivedi, Y. K., Lal, B., Williams, M. D., Schenerberger, S. L., & Wade, M. (2009). *Handbook of Research on Contemporary Theoretical Models in Information Systems.*

Hershey, United States of America: Information Science Reference.

Hersh William, M. A. (2010). Building a Health Informatics Workforce in Developing Countries. *Health Affairs*, 275 - 278.

Ouma Stella, H. M. (2008). E-Health in Rural Areas: Case of Developing Countries. *World Academy of Science, Engineering and Technology*.



### Conclusion

This research aims to produce a model for health informatics workforce (HIW) skills that can be used to provide appropriate training that will equip HIW for effective service delivery in the health sector. The next

*Figure 1: Careers in Health Informatics (Source: www.stoodnt.com).*

## THE RELATIONSHIP BETWEEN CHANGES IN PREGNANCY-RELATED ANXIETY AND DEPRESSION AND PRETERM BIRTH

### Authors

Sharifa Lalani, Aliyah Dosani, Ntonghanwah Forcheh, Shahirose Sadrudin Premji, Sana Siddiqui, Kiran Shaikh, Ayesha Mian and Ilona S. Yim

Aga Khan University, Mount Royal University, York University, University of California, Irvine

### What is Already Known About the Topic


### Research Questions

1. Do changes in pregnancy-related anxiety and antenatal depressive symptoms during pregnancy in the Pakistani context influence the risk of having a preterm birth?

2. What is the relationship between the various components of the pregnancy-related anxiety scale and preterm birth?

### Method Participants

300 low risk pregnant women were recruited from four centers of Aga Khan Hospital for Women and Children in Pakistan including Hyderabad 70 (23%), Garden 111 (37%), Kharadar 44 (15%) , and Karimabad 75 (25%).

> *Table 1:Predictive model for preterm birth given changes in pregnancy-related anxiety and antenatal depressive symptoms during pregnancy adjusted for perceived stress.*

*Table 2: Predictive model for preterm birth given changes in dimensions of pregnancy-related anxiety and depressive symptoms during pregnancy adjusted for perceived stress and covariates.*

### Acknowledgements

Maternal Infant Global Health Team (MiGHT) Collaborators in Research members. We wish to express our sincere appreciation to the entire team

### Conclusion

Women's anxiety about fetal heath was a significant predictor of PTB, along with changes in EPDS. Health care providers need to reorganize their care practices to address maternal concerns about fetal health early in pregnancy and monitor changes in depression during pregnancy to identify women at risk of PTB.

### Results Descriptive data

Of the 249 women, 24 gave birth preterm (9.6%). In terms of age, 2.3% were under 20 years old, while 30.1%, 41.0%, and 26.1% of the women were aged 20-24, 25-29 and 30+ years, respectively. The largest ethnic group was the Muhajirs (30.5%), followed by Sindhi (19.7%) and Memon (14.1%).

### Measures


### Design

• Prospective cohort design recruited at 12-19 weeks and at 22-29 weeks gestation.

### Data Analysis


• Process analysis

#### References Hanif et al. (2017) Purisch & Gyamfi-Bannerman(2017) Quinn et al. (2016)

### Correspondence

Sharifa Lalani sharifa.lalani@aku.edu AKU-SONAM


The above table shows mother's concerns/worries about fetal health', emerged as a significant predictor of preterm birth.

The above table shows change in perceived stress has protective influence on the relationship between change in depressive symptoms and preterm birth but not on effect of change in pregnancy-related anxiety.



Time 1


### PATIENTS PROFILE, OUTCOMES AND RISK FACTORS FOR MORTALITY IN CRITICALLY–ILL WOMEN ADMITTED TO AN OBSTETRIC HIGH DEPENDENCY UNIT IN A LOW RESOURCE SETTING

### Authors

Claudia Marotta1,2, Luigi Pisani2, Francesco Cavallin2, Francesco Di Gennaro2, Enzo Pisani2, Michael M. Koroma2, Walter Mazzucco1,2 and Giovanni Putoto2

1 Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) Department, University of Palermo. Italy 2 Doctor With Africa Cuamm, Freetown, Sierra Leone

### Introduction

Sierra Leone faces the highest maternal mortality in the world. Despite this high burden, the potential role of obstetric critical care and high dependency units (HDUs) in low–resource settings remains scarcely explored.

This study aimed to investigate the patient profile, clinical outcomes and risk factors for mortality of parturients admitted to an obstetric HDU in low-resource setting.

*Figure 1. Simplification of a PCMH HDU bed.* 

### Methods

A retrospective cohort study including all consecutive obstetric critically–ill patients admitted to the HDU of Princess Christian Maternity Hospital in Freetown, Sierra Leone, from 02/10/2017 to 02/10/2018, was conducted. Primary outcome was mortality during HDU stay. Univariate and multivariable analyses were performed using logistic regression models.

*Figure 3. Main obstetric diagnosis in patients admitted in HDU by number of admissions (n, showed in grey bars) and specific fatality rate (%, showed in blue). Distribution of the number of patients (n, showed in grey bars) and mortality (%, showed in red) by reason for referral to HDU.* 

### Doctors with Africa CUAMM

c.marotta@cuamm.org https://doctorswithafrica.org/

The primary epidemiological findings are summarised as follows: (1) 1 HDU admission per 14 deliveries, with a crude mortality rate of 10.5%;

(2) independent predictors of mortality were poor neurological and respiratory status at admission, while a red code at OEWS was not a predictor of mortality;

(3) the use of antibiotics during stay and higher SpO2 on admission were positive modifiable factors for survival.

Results

523 patients (median age 25 years, IQR 21-30) were admitted to HDU, 65.1% of them was referred in red Early Warning Score (EWS). Mortality was 10.5%.


*Figure 4. Analysis of risk factors associated to mortality among women admitted to the HDU of PCMH in Freetown (Sierra Leone) from 2nd October 2017 to 2nd October 2018.* 

*Figure 5. A CUAMM doctor performing obstetric ultrasound in HDU.*

### Closing remarks

Our data can contribute to tackle the scarcity of data on in-hospital obstetric critical illness that jeopardize the adoption of solutions along the whole spectrum of care. Critically-ill parturients admitted to a HDU in Sierra Leone are generally young and referred in red EWS code. One in ten admitted patients died in HDU. Main risk factors for HDU mortality were poor neurological and respiratory status at admission.

At multivariable analysis, being referred from the ward rather than the operating room (OR 6.10, 95%CI 2.39-16.30), being responsive to pain on AVPU scale (OR 5.13, 95%CI 1.68-15.17) or unresponsive (OR 4.97, 95%CI 2.14-11.94) at admission, receiving oxygen (OR 2.66, 95%CI 1.19-5.98) or vasopressors (OR 3.88, 95%CI 1.73-8.67) during the stay were risk factors for mortality, while higher SpO2 (OR 0.95, 95%CI 0.91-0.99) and receiving antibiotics (OR 0.31, 95%CI 0.09-0.91) were associated with lower risk.

*Figure 2. Characteristics at admission to the HDU of PCMH of the 523 patients in study.* 

### BREAKING STEREOTYPES AND REMODELLING THE CONCEPT OF SEXUAL VIOLENCE PREVENTION BY BUILDING RESILIENCY AND DEFENSE SKILLS AMONG VULNERABLE WOMEN IN UGANDA

### A Realistic Approach on the Fieldwork 2020

### Author

Numa Memisevic

### Research Background

Recent population derived data from Uganda indicate that 51% of women aged 15-49 have experienced physical violence at some point in their lives, and 22% of women in the same age group have experienced a sexual assault [1]. An empowerment approach to self-defense training contributes to the antiviolence movement in multiple ways: providing a pathway to increase womens' and girls' safety and their potential for becoming effective social change agents,providing an informed and embodied understanding of violence, and offering comprehensive options to recognize, prevent, and interrupt violence [2]. *Figure 3 The ratio between the participants being sexually assaulted and the participants without* 

*experience of sexual assault.*

### Aim and Methodology

The aim of the research was to test a novel empowerment-based sexual assault prevention training initiative targeting women at high risk for sexual violence in Uganda.

This intervention focused on both non-physical and physical measures. The research has been conducted in a period of September 2020. The self-defense training program lasted 2 weeks.

We employed a cluster-randomized trial design in order to ascertain the training's effectiveness in improving self-efficacy, deployment readiness, self-esteem andmitigation of sexual assault.

We conducted 60 in-depth interviews and 24 self-defense trainings. The interviews were recorded and safeguarded unter the code so enabled the

confidentiality of data.

The participants were selected based on previously established eligibility criteria. Hospitals in the Kimombasa region, the Butabika Psychiatric Hospital in Nakawa region as well Makarere University Hospital in central area of Kampala in Uganda served as site clusters.


*Figure 1. Number of participants, hospitals and their distribution represented in a form of site clusters.*

#### Women 's view on self-defense training and their view of being a woman as a social actor in defending themselves against the perpetrator

90% of interviewed participants responded that because they are women they are at higher risk to be sexually assaulted

However, half of the women who answered that they are at higher risk to be assaulted believed that with the learned skills they can defend themselves

85% of rapes were reported to authorities and out of 85% of the committed rapes only 10 % were been processed and 3% of the sexual assaults were convicted

60% of participants were familiar with the term of female empowerment and the meaning of self-defense training

*Figure 2. Display of how many times the participants who had experience of sexual assault were assaulted in their lifetime.*

Author: Numa Memisevic, Institute of Global Health, University of Heidelberg Adress: Im Neuheimer Feld 365, 69120 Heidelberg Contact Number: +4915167403226

### RESULTS

The participants who were included in the in-depth interviews were 60 ( n=60). Out of 60 interviewed participants 60% of them had experience of sexual assault int their lives. Only 21.6% of participants had no experience of sexual assault in their lifetime. Out of 60% of participants who had a history of being sexually assaulted 66% of the participants were one time assaulted, 13.8% were sexually assaulted twice, 8.3% of participants were sexually assaulted 3 times and only 5.5% percent were assaulted more than 4 times.

The identified risk factors which made the participants more at risk of being sexually assaulted were the following: the fact that they have been working as sexual workers, less educated ( most of the women finished only primary school), their poor economical status , being single or single parents as well on some occasion alcohol consume. Also more than 80 % of women thought they are at higher risk to of being assaulted because they are women meaning weaker sexual actors and so being unable to

*Figure 4.Overview of the view 's of women on their seld-confidence, self-worth before and after intervention. Displayed other information on reported crimes.*

## DELAYED AND IRREGULAR PRENATAL CARE *PREGNANCY OUTCOMES AMONG UNDOCUMENTED MIGRANTS IN GENEVA*

### Author

Caterina Montagnoli

MSc in Global Health, Midwife Co-president of Global Health Young Professionals Initiative Assistante HEdS, caterina.montagnoli@hesge.ch

### Migrant Maternal Health

Migration is a global phenomenon that concerns not only people on the move, but also residents of the receiving countries. The health of migrants is determined by a varying and complex set of factors. Generally speaking, maternal outcomes in migrants are poorer than those of locals. Yet, in the canton of Geneva, Switzerland, maternal health and antenatal care outcomes have been proven to not be worse than those of the general population. The aim of this scoping review is to provide a social, anthropological and healthcare overview to justify differentiated patterns of health service utilization during the prenatal period and explain maternal health physiological outcomes among irregular migrant women resettled in Geneva.

2019.

### Medicalizing pregnancy

Considering that:


However, this may not be the case for countries where migrant mothers might come from. In an effort to understand migrant women's low antenatal care attendance in Geneva, the provision of healthcare might culturally differ from women's beliefs and practices. In every society, new generations of parents are expected to follow a set of cultural practices that replicate basic values that are widely approved. While in Geneva—and in most western countries—this cultural model might be identified with the technocratic biomedical one, different cultural models might be embodied in other countries.

The paradox: access to healthcare and pregnancy outcomes

Access to Heath care Impact upon pregnancy outcomes Geneva (Wolff et al. 2008) Irregular no Canada (Khanlou et al, 2017) Irregular No when ethnic specific curves are used USA (Galvez 2011) Irregular (Mexican migrants) No, described as the "birthweight paradox"

#### References

Gálvez, Alyshia 2011 Patient Citizens, Immigrant Mothers: Mexican Women, Public Prenatal Care, and the Birth Weight Paradox. Rutgers University Press De Loache, Judy S., and Alma Gottlieb. 2016 A world of babies: Imagined childcare guides for eight societies. Cambridge University Press. Huschke, Susann 2014 Performing deservingness. Humanitarian health care provision for migrants in Germany. Social Science & Medicine, Volume 120: 352-359. doi:

10.1016/j.socscimed.2014.04.046. Khanlou, N., N. Haque, A. Skinner, A. Mantini, and C. Kurtz Landy 2017 Scoping Review on Maternal Health among Immigrant and Refugee Women in Canada: Prenatal, Intrapartum, and Postnatal Care. Journal of Pregnancy 2017: 1–14.

#### Materials and Methods Relevant literature was searched in PubMed, SCIELO and Web of Science between October 2018 and April Search terms "Illegal" OR "irregular" OR" undocumented" AND "migrant" AND "antenatal care" OR "prenatal care" OR "medicalized care" OR "medicalised childbirth" OR "medicalised delivery" OR "natural pregnancy" OR "physiological pregnancy" OR "pathologic pregnancy" OR "technocratic model of birth" OR "habitus" OR "individual and self" OR "biomedical model" "Illegal" OR "irregular" OR "undocumented" AND "migrant" AND "antenatal care" OR "prenatal care" OR "medicalised childbirth" OR "medicalised delivery" OR "natural pregnancy" OR "physiological pregnancy" OR "pathologic pregnancy" OR "pregnancy outcomes" OR "Maternal outcomes" OR " New-born outcomes"

Smith-Oka, Vania 2012 Bodies of risk: Constructing motherhood in a Mexican public hospital. Social Science & Medicine. 75(12): 2275–2282. Doi:10.1016/j.socscimed.2012.08.029. Wolff, Hans, Manuella Epiney, Ana P. Lourenco, Michael C. Costanza, Jacqueline Delieutraz-Marchand, Nicole Andreoli, Jean-Bernard Dubuisson, Jean-Michel Gaspoz, and Olivier Irion. 2008 Undocumented migrants lack access to pregnancy care and prevention. BMC Public Health 8: 93. doi: 10.1186/1471-2458-8-93.

### **Conversely, physiological pregnancy outcomes are not**

#### **directly corresponding to more assiduous access to antenatal care**

*Figure 4. Worldwide migrant effect paradox.*

### Locating the pregnant body: socio-economic and legal context

Socio-economic disparities during pregnancy by means of


may reduce and worsen the situation.

The searches identified 4156 studies. After screening titles and abstracts, 157 studies were full text analyzed, out of which 70 met the inclusion criteria. Thirty-eight more studies were identified through bibliographic cross-referencing and added to the remaining 54. Ninety-two studies were finally included in the literature review.

### Conclusion

Further quality assessment included the appraisal of the description of the methodology used to conduct the study.

Further data come from the author's role as a research assistant at a local healthcare ambulatory clinic dedicated to people without healthcare insurance and originate from semi-structured interviews with medical personnel, nurses, midwives and undocumented migrants.

### Results

While entitlement is provided to citizens by the law, in Geneva, access to free of cost antenatal care is assigned by the protocol-based human evaluation of affordability and psychosomatic evidence. To meet the expectations and respond to their needs, migrants are forced to set up a "performative expression of suffering" to present themselves as deserving of free medical attention (Huschke 2014).

### "Access to pregnancy care: the cultural self and the pregnant body

Reproduction involves physical and behavioral changes. A person, by reproducing, never produces an exact copy of the self, but rather a new human being. In parallel to the socio-economic and medically described maternal and fetal physical changes, the attitude of the birthing women towards pregnancy and its management changes with time.

### *"Many valid models of childbearing and many solid practices of living the moment of pregnancy exists, but every such model is shaped by a combination of deeply held values and widely varying social, political and economic context"*

(Gottlieb and DeLoache, 2016).

To properly describe this interior phenomenon, Smith-Oka et al. (2012) developed a new concept of "habitus". The "reproductive habitus" are the "modes of living the reproductive body, bodily practices, and the creation of new subjects through interactions between people and structures" (Smith-Oka, 2012: 2276). Personal and cultural behavioral approaches might be good substitutes of the biomedical schema in addressing minor pregnancy-related conditions.

### Discussion

Standardized models of care, including antenatal care, are lifesaving and work exceptionally well when biological equivalents in medicine are needed. Yet, when it comes down to

reproductive physiological care, current models need to be "personalized" or progressively adapted to the mother-infant's physical and biological wellbeing and to her social and cultural beliefs

*Figure 5. PRISMA Flow Chart.*

Gaining a better understanding of the reality of migrants' mothers' health with a quality study could help society define the balance between excessive medicalization and complete lack of access to medical healthcare. In order to achieve this, a clearer insight of migrants' cultural practices could be extremely beneficial for integrating the current biomedical healthcare system in the light of World Health Organization Agenda 2030. This may advance local government commitment to understanding and recognizing migrants as a specific vulnerable group and illegality as a real health risk.

### Authors

Daniel Cobos, Carmen Sant Fruchtman, Laura Monzon Llamas and Don de Savigny

Swiss Tropical and Public Health Institute, Basel

### Introduction

All countries need timely and complete national vital statistics, the cornerstone for population and socioeconomic policies. For the health sector in particular, reliable data on causes of is fundamental to decision making, health systems planning and resource allocation.

Verbal autopsy (VA) is an indirect method of estimating causes of death from information on signs, symptoms and circumstances preceding death. Although an imperfect tool, VA is still the best alternative in the absence of medical practitioners. There is growing interest on using VA as an integral part of countries mortality surveillance systems.

However, there is limited information on the costs of implementing such intervention. *Figure1. Front screen of the costing section of the Costing & Budgeting Tool.*


### Conclusion

Countries will need to decide which interventions they will implement to get reliable, representative, and accurate cause of death statistics. In addition, donors face the challenge of being exposed to multiple funding priorities and pressure to show an impact on the investments made. The VA costing & budgeting tool could inform decision-making processes by providing an accurate and reliable estimate of the resources needed to implement VA.

### Further information

Daniel.cobos@swisstph.ch

Socinstrasse 57, P.O. BOX, 4002 Basel, Switzerland

+41(0)61 284 81 11, www.swisstph.ch

#### *Figure 2 Summary of cost of VA implementation activity group in 4 countries (US\$2015).*

*Figure 3 Relationship between the cost per VA in US\$ 2017 and the total number of VAs conducted in each sub-national area.*

## THE COST OF VERBAL AUTOPSY DEVELOPMENT OF A COSTING AND BUDGETING TOOL

### Aim

To understand the resource implications and cost of implementing VA integrated in mortality systems, and to develop a tool to assist countries with their estimation. Surveillance.


### Methods

The tool is based on Microsoft Excel® and uses standard costing methodology to produce estimates on the incremental cost of VA implementation as well as unit cost per population covered. The tool provides a stepwise process to define costing assumptions, to collect data and, finally, to produce the results of the analysis in different formats. Agilelementation. The tool also highlighted that VA is a human resource intensive activity with a high number of staff involved in the different VA activities but only using a small fraction of their time.

### IMPROVING HEALTH OUTCOMES IN YOUNG PEOPLE INFECTED WITH HIV THROUGH MOBILE HEALTH INTERVENTIONS, IN A RURAL DISTRICT, IN UGANDA A Qualitative Study

### Authors

Agnes Bwanika Naggirinya1,2, Joshua Beinomugisha1, Suzan Nakazzi1, George Eram1, Winnie Aziku1, Peter Waiswa3, David Meya2, Joseph Rujumba4, Rosalind Parkes-Ratanshi1,5

<sup>1</sup> Infectious Diseases Institute, College of Health Sciences, Makerere University, Uganda, 2 College of Health Sciences, School of Medicine, Department of Internal Medicine, Makerere University; 3 College of Health Sciences, School of Public Health, Makerere University, 4 College of Health Sciences, School of Medicine, Department of Child Health & Development, Makerere University; 5 Institute of Public Health, University of Cambridge, UK

### Introduction

About 80% of youth infected with HIV live in sub-Saharan Africa1. 53,000 new HIV infections occurred among youth in 2018, accounting for 26% of HIV incidence in Uganda.2

Adherence to ART is the principal for achieving viral suppression3.

In Uganda, youth are performing poorly in attaining viral suppression per 90:90:90 target.4

Involvement of end user prior to implementation of intervention yields effective user-friendly and acceptable interventions.5,6

Objectives: Assess barriers to adherence among youth infected with HIV in rural settings.

Assess acceptability of mHealth for HIV adherence support among youths prior to implementing mHealth intervention.

*Figure1. Focus group discussion with a group less experienced on ART ( less than 3 months on ART).*

### Methods

A qualitative study was conducted in mid-Western Uganda in June 2020, after research approval. Purposive selection was done for youth registered at ART clinic.

Data were collected through two focus group discussions and 3 in-depth interviews (initiated on ART for less than 3 months and established on ART for more than 3 months), with a predesigned guide with seven themes. Audio recordings of interviews were transcribed and typed verbatim. Data coding and analysis performed using NVivo 12.0 Themes and sub-themes were identified following the interview guide and transcripts. Quotes have been used to highlight the key findings in this study

### Results

Purposive selection of 15 youths (16–24 years) infected with HIV, male and female, newly initiated ART (<3 months on ART) and those established on ART (>3 months on ART) consented/assented and participated in the study. Two focus group discussions for youth 18–24 years experienced on ART; youth newly initiated on ART and three in-depth interviews for youth below 18 years (one newly initiated on ART, two were experienced on ART).

#### References

1.UNAIDS,Report 2018b 2..Avert.Org, Report 2019 3. Mujugira, A., et ai,2016 4. Pérez-Sánchez, I.N., M. Candela Iglesias, and E. Rodriguez-Estrada,,2018 5. Riordan, F., et al, 2020 6. Gahan, L., et al, 2019

Credits go to: The patients and staff of the IDI and Kiryandongo ART Clinics.

This study and the Academy are initially funded by Janssen, the Pharmaceutical Companies of Johnson & Johnson as part of its commitment to global public health through collaboration with the Johnson & Johnson Corporate Citizenship Trust

*Table 1. Demographic characteristics of focus group interview* participants.




### Accepting mHealth Support for ART Adherence:

Challenges with ART adherence, missing drugs, or even taking drugs beyond stipulated time because of forgetfulness and busy work schedules has affected many youths. Pill reminder was seen as promoting adherence through real-time pill reminder for both AR- experienced and those newly initiated on ART.

*"I accept because sometimes, like me, it is very easy to forget. So, sometimes I may be very busy and come back home when am very tired and sometimes I forget and <sup>I</sup> use only the alarm. Sometimes, I do not set the alarm and my timing will not be correct. So, it can remind me so that I do the right thing. FGD, Female, ART duration <3 months*

*"For me, I forget easily, I sleep at 10:00 p.m. but sometimes I skip taking drugs (they laugh it off). Therefore, it is going to be very helpful because I oversleep. Even yesterday, it rained and I put my baby to sleep, but I also slept until morning (the rest laughed off). It is really going to help me so much." FGD, Female, ART experienced*

### Remote Health Education Tips:

Health messages were seen as a motivation. Information will make them feel valued and not left alone, and advice will help them live a healthy life.

*"We need it because it helps to educate you how to take your drugs well, they educate you more and you stay well." FGD,ART experienced "Yes, I would like to listen to the health tips" FGD, ART-naïve* 

Participants selected days preferred to listen to health tips, and after mid-day was the best time for the majority.

### Remote Symptom Reporting:

Participants argued that symptom reporting would enable sharing and report their challenges/health problems. Transport costs to and from health facilities will decrease in case of remote consultation.

"*It will also help because previously I used to fall sick very often when I had just started those drugs; sometimes I would find I had to bus to Kiryandongo. When at work, I leave when already late, without having* time *to go the hospital. So, it will be of great help, depending on how I will be handling it." FGD, ART experienced*

*"It will help me in discussing my problems." IDI- ART experienced youth*

*"Because I stay in the village, sometimes it is hard to come, when the child is*  Conclusion *not well and mum is well, so it will help me." FGD, ART experienced*

Baseline findings suggest mHealth is acceptable and will conveniently reach out to the youth struggling with ART adherence, to optimise viral suppression thus improving health outcomes. Youths ˂ 19 years expressed more need for support on ART adherence

## IMPACT OF WATER SALINITY ON MATERNAL AND NEONATAL HEALTH

### An Assessment in South 24 Parganas District of West Bengal, India

### Authors

Runa Nath and Kallol Mukherji

Tdh India Delegation

### Introduction

Terre des hommes Foundation is currently implementing an integrated Health and WASH project in the coastal area Canning II block of South 24 Parganas district in West Bengal, India. Water salinity in the area is a significant challenge; and has serious implications on water quality for human needs. Canning II is a coastal area; and the objective of this study was to evaluate the potential impact of water salinity in the health of pregnant women and children in the area.

*Figure 1. Interaction with a Nurse Midwife in a health facility.*

### Methods

Health Management Information System (HMIS) data from South 24 Parganas district in 2010 -2016 and government data from Canning II block of the same district in 2018-2019 were collected and analyzed to estimate the prevalence of diseases during pregnancy and at birth.

*Figure 2. A Mother with her Low Birth Weight newborn.*

### **Literature review of several studies in Bangladesh revealed that**


### South 24 Parganas District HMIS Data Analysis


### Results

HMIS data show that more than 20% of the deaths among 6 years old and above; more than 30% of maternal deaths were due to hypertension related reasons; and more than 50% of neonatal deaths were due to low birth weight. Government data show that 10% of the pregnant women in Canning II are hypertensive and 16% of the children are born with low birth weight.

Contact Information

Runa Nath

Mother and Child Health & Nutrition Programme Manager Terre des hommes Foundation, India Email: runa.nath@tdh.ch

Salinity of water sample from the area tested in the recent monsoon season was found to be 830 mg/L; but this salt concentration increases during the dry summer season.

*Figure 3. Data Analysis from 2010-2016.*

## YOUNG CHILD FEEDING PRACTICES DURING CHILDHOOD ILLNESS

A Population Survey in Patharpratima Block of South 24 Parganas District of West Bengal, India

### Introduction

Terre des hommes Foundation has implemented a Health and Nutrition project from 2011 to 2018 in Patharpratima block of South 24 Parganas district of West Bengal in India. The primary objective of the project was to address acute malnutrition among U5 children. A community mobilisation approach was also designed and implemented to improve Infant and Young Child Feeding (IYCF) and treatment seeking practices during childhood illnesses.

*Figure 2. A community level worker disseminating messages on Infant and Young Child Feeding (IYCF).*

### Methods

A population survey with questions to mothers and other child caregivers was conducted mid-2018. Information about recent illnesses among U5 children, and health seeking and IYCF practices during illnesses was collected and analyzed.

*Figure 1. Growth Monitoring session for U5 children.*

### Results

Questions were responded by 1242 people in the surveyed population. Data analysis revealed that whereas feeding practices among U5 children improved significantly during usual times, more than 70% of the mothers have gone to rural health practitioners for treatment during child illness; and more than 80% of the children were fed less than usual during diarrhoea, fever and cough episodes. Changes on feeding practices during child illness were justified by 65.7% of participants as being part of the recommendations provided by rural practitioners.

Contact Information Runa Nath Mother and Child Health & Nutrition Programme Manager Terre des hommes Foundation, India Email: runa.nath@tdh.ch

*Figure 5. Distribution of feeding practices during Fever.* 

### Authors

Runa Nath

Tdh India Delegation


*Figure 3. Distribution of respondents by source of seeking advice about treatment of any of these illness survey 2018.*


#### More than usual 8 2.2


*Figure 6. Distribution of feeding practices during Cough.*

*Figure 4. A community meeting using Participatory Learning and Action (PLA) Approach.*

## FROM BIOMEDICAL IMAGE SEGMENTATION TO FLOOD MAPPING AT UNOSAT

### Transfer Knowledge from Biomedical to Humanitarian Application

### Authors

Edoardo Nemni1, Joseph Bullock2, Samir Belabbes1, Sami Tabbara1, Sofia Vallecorsa3 , Miguel Luengo-Oroz2 and Lars Bromley1

### Introduction

Flood Rapid response to natural hazards, such as floods, is essential to mitigate loss of life and the reduction of suffering. For emergency response teams, access to timely and accurate data is essential. Satellite imagery offers a rich source of information that can be analyzed to help determine regions affected by a disaster. Much remote sensing flood analysis is semi-automated, with time consuming manual components requiring hours to complete. In [3], we present a fully automated approach to the rapid flood mapping currently carried out by many non-governmental, national and international organizations. We design a Convolutional Neural Network (CNN) based method which isolates the flooded pixels in freely available Copernicus Sentinel-1 Synthetic Aperture Radar (SAR) imagery, requiring minimal pre-processing.

> *Figure 5. From left to right: raw SAR tiles displayed using the viridis colormap followed by tiles of the ground truth and neural network predictions. The background is displayed in purple and water in yellow.*

### Methods

Dataset:


### Neural Architectures

U-Net [1] was originally introduced for segmentation of neuronal structures in electron microscopic stacks. XNet [2] was developed as X-Ray Image Segmentation CNN. In [3], both architectures were used in the disaster response context for flood segmentation.

*Figure 2. The U-Net [1] with input images of size 256x256 pixels producing a segmentation mask of the same size.*

### Bibliography


3. Nemni, E.; Bullock, J.; Belabbes, S.; Bromley, L. Fully Convolutional Neural Network for Rapid Flood Segmentation in Synthetic Aperture Radar Imagery. Remote Sens. 2020, 12, 2532.

### Results

The best output of the networks studied in [3] achieved an overall accuracy of 97% with precision of 91% and recall of 92%. This methodology also reduces the time required to develop a flood map by 80%, while achieving strong performance over a wide range of locations and environmental conditions.

<sup>1</sup> United Nations Institute of Training and Research Operational Satellite Application Programme (UNITAR-UNOSAT) <sup>2</sup> UN Global Pulse

<sup>3</sup> CERN

Neural Architectures:


*Figure 4. Precision-recall curves of the best XNet, U-Net and U-Net+ResNet models after hyperparameter tuning.*

*Figure 3 The Xnet [2] with input images of size 256x256 pixels producing a segmentation mask of the same size.*

*Figure 1. The analysis of Vietnam on the 6th September 2019 with the corresponding flood annotation. The left image displays the satellite imagery using the greyscale colormap. The image on the right shows the water label in yellow using the viridis colormap.*

### Conclusion

The ability to perform rapid mapping in disaster situations is essential to assisting national and local governments. UNOSAT, UN Global Pulse, and CERN transferred the knowledge from medical segmentation models to humanitarian application for flood segmentation in radar satellite imagery. By enabling flood mapping to be completed automatically in a fraction of the time, teams on the ground are able to respond more quickly to disaster situations. Given the outstanding results and the open-source data, this methodology can also be integrated into end-to-end pipelines for more timely and continuous flood monitoring.

### Background

Uganda has one of the highest refugee per capita in the world.1

Nutrition indicators among under-fives assess and monitor general well-being of populations.2,3

Malnutrition is a public health concern in refugee hosting districts4 which are rural with generally poor social services. Refugee influxes strain local resources increasing vulnerabilities of surrounding communities. These districts receive support to strengthen social service sectors and build resilience. In practice, implementation is meagre5. Nevertheless, nearby communities may benefit more than communities away, therefore differences in general wellbeing including nutritional status among under-fives

### IS THE 'HOST COMMUNITY' APPLICABLE TO ENTIRE DISTRICT POPULATIONS? A COMPARATIVE ASSESSMENT OF NUTRITIONAL STATUS AMONG UNDER-FIVES

### Results

The mean z-scores of outcomes among study population;


### References


*in Refugee Settlements for Host community.*


Acknowledgements

The support from Isingiro district local government and Makerere University Email: apiobenardate@gmail.com

### Authors

Apio Benardate Okiria, John Isunju Bosco and Henry Wamani

*Figure.3. Map showing refugee settlement boundary and administrative units* 

### Closing remarks

The host community's general wellbeing may be the most compromised.

Access to social services including health and nutrition is key to protect against under nutrition. Address livelihoods to ensure food security Streamline gender messaging to educate communities in sharing of household responsibilities

### Methods

A comparative cross-sectional study of a quantitative methods approach was conducted in Isingiro district surrounding Nakivale refugee settlement.

A random sample of 556 children, 278 in either community were assessed for under-nutrition and their caretakers interviewed using a semi structured questionnaire. Summary statistics, chi-squares and odds ratios were computed.

### Objectives

This study compared nutrition status and associated factors among children aged 6-59 months from the host community and non-host community of Isingiro district.

**Communities closest to refugee settlements suffer the severest burden of under nutrition in Uganda's oldest refugee hosting district** 

*Classification of severity of malnutrition in either community by prevalence of stunting, wasting and underweight for children under 5 years of age*

**Males participating in household chores is protective against child under nutrition**

### **Food secure households are protective against stunting**

**Children aged 18-29 months are likely to be stunted**

*Figure 2: Prevalence of outcomes among children aged 6-59 months in the host and non-host community*

Comparison of nutrition status

Stunting and underweight were

statistically significantly different

(χ

2=7.5, p-value 0.006;

χ

2=8.4, p-

value 0.004).

Factors associated to under nutrition

• In either community, older children

#### were more likely to be stunted (18-29 months). • In the non-host community, food secure households were protective against stunting (Adjusted PR: 0.59; CI: 0.35-


**Underweight Poor** Acceptable

**Wasting** Acceptable Acceptable

## GENEVA TRENDS OF OVERWEIGHT AND OBESITY AMONG 5-6-YEAR-OLD SCHOOLCHILDREN FROM 2003 TO 2018

### Authors

Narvaez Luisaa, Mahler Perb, Thadikkaran-Salomon Lynnec, Jeannot Emiliend

<sup>a</sup> Institute of Global Health, Faculty of Medicine, University of Geneva, Switzerland

<sup>b</sup> Service de santé de la jeunesse, Département de l'instruction publique, Geneva, Switzerland

<sup>c</sup> Cantonal Health Service, General Directorate for Health, Geneva, Switzerland <sup>d</sup> Addiction medicine, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland

### Introduction

Overweight and obesity in children and the harmful health consequences of these conditions throughout the course of their lives is a growing, worldwide public health problem.

Excessive fat accumulation has been attributed to an imbalance between energy intake and expenditure, which has a multifactorial origin. Hereditary, environmental and socioeconomic factors play a role in the predisposition to and development of overweight and obesity.

*Figure 1. Trends in the prevalence of overweight among Geneva children aged 5–6 years between 2003–04 and 2017–18 by gender*

### Objective

The aim of the present study is to estimate the prevalence of overweight and obesity and their time trends among 5-to 6-year-old schoolchildren in Geneva over a 15-year period starting in 2003–2004, and to compare it with results from other areas of Switzerland.

### Methods

A cross-sectional study at nine points in time, conducted in public schools from

2003–2004 to 2017–2018. During a systematic health check at school, data on the height and body weight of 5- to 6-year-old children attending public schools in the canton of Geneva were obtained. 12,918 girls and 13,395 boys were recruited for the study. Cole's references were used to classify the body mass index.

Data was obtained during a systematic health check at school, the children's weight and height measurements were carried out by the school nurses, BMI was calculated and compared to international norms and then was anonymously transferred to a database where depending on their weight status, each child was allocated to one of 3 groups: normal (including underweight), overweight and obese.

### Correspondence

Dr Emilien Jeannot, MD, Institute of Global Health, Chemin de Mines 9, 1202 Geneva, Faculty of Medicine, University of Geneva, Switzerland. Emilien.Jeannot@unige.ch

### A further decrease in overweight and obesity becomes an objective, more aggressive approaches might be necessary

The prevalence of obesity has increased by 0.7 points since 2003–04, but this increase is not statistically significant.

A relatively marked and statistically significant increase in the prevalence of obesity (1.9 points, p = 0.0130) since 2010 was observed for both sexes in this age group.

For girls, the prevalence of obesity has shown a non-significant increase (0.7 points) since 2003–04, but this rise has become more important since 2010–11, with an increase of 2.0 points.

The prevalence of obesity among boys has increased by 0.7 points since 2003– 04. However, the prevalence changed from 2.6% in 2010–11 to 4.2% in 2017–18, an increase of 1.6 points.

### Results


*Figure 2. Trends in the prevalence of obesity among Geneva children aged 5–6 years between 2003–04 and 2017–18 by gender.*

### Discussion

A stabilization and, to some extent, a decrease in overweight and obesity rates seem to be continuing, which is consistent with results from other Swiss cities, as well as other countries worldwide.

We identified an important difference between girls and boys due to a statistically significant increase in the prevalence of overweight in girls from 2010–11 onwards, and a continuous decline in the prevalence of overweight in boys from the same age group.

This study also shows a non-significant increase in the general prevalence of

obesity during the same period.

There has been a relatively marked and significant increase in obesity for both boys and girls since 2010–11.

We observed a relative increase in the percentage of obese children compared to all overweight children, which is a more recent phenomenon.

The best way to further reduce the problem is to continue monitoring BMI and to implement proven prevention strategies that influence energy intake and expenditure.

The prevalence of overweight children has remained stable at around 10.3% since 2003–04; it has increased slightly (0.7 points) since 2013–14, but this increase is not significant.

There is an increase of 2.5 points (p = 0.14) in the prevalence of overweight among girls since the 2003–04 school year. The increase has not been steady, but the increase since 2010–11 is statistically significant (an increase of 3.3 points).

Among boys, after an initial decline followed by an increase, overweight has now decreased by 2.7 points (p = 0.06) since 2003–04. However, only the decrease since 2008–09 is significant (3.5 points, p = 0.0287).

*Table 1: Prevalence (95% confidence intervals) of overweight and obesity in Geneva children aged 5- 6 years over nine school years between 2003–04 and 2017–18 using Cole's reference.*


## DEMOCRATISING PROSTHETIC AND DIABETIC CARE

### A Resilient Model for Healthcare Delivery

### Authors

Francesca Riccio-Ackerman1, Lindsay Aranoff2 and Giovanni Porcellana2

1 Biomechatronics Group, MIT Media Lab; 2 Sapientia

### Abstract

We are developing a healthcare delivery model for people with diabetes and limb loss in medically underserved communities to offer convenient, high quality care for a fraction of the cost.

Satellite mobile health clinics increase the capacity and geographical range of medical services, and are operated by local clinicians, allowing the community to support its own members. We reduce the burden of treatment while sharing the cost of technology and high quality services across a larger community. Onboard, patients with amputations can obtain prosthetic care, and treatment for diabetes prevents future cases of amputation and other complications of unmanaged diabetes. An epidemiological heat map strategically guides our intervention to where services and resources are most needed to address health disparities.

Health outcomes, economic evidence and our impact on health access will support the sustainability and scalability of this model to additional locations.

### The Challenge

Of the 900,000 amputees in Mexico, more than 85% were due to a lack of diabetic care, tracking, and management. Diabetic amputations have been ranked as the most preventable surgery. For diabetic patients who consistently struggle to control their blood glucose, the risk of amputation skyrockets by up to 30 times. Because health access is so influential on diabetic management, regular haemoglobin A1c testing has been associated with a 39% decrease in amputation risk.

### The Mobile Clinic Design

An innovative design is proposed for the Mobile Clinic, with foldable side panels that allow the interior area to triple when stationary, thus also becoming fully accessible for patients on wheelchairs. In this way, the inconvenience for the patients is reduced as well as the need for staff for assisting wheelchairs transfers.

As visible in Figure 3, there would be three main areas:


*Figure 4. A few of the data layers incorporated into our algorithm for identifying locations in need of expanded services.*

For more information, or to get in contact, refer to our website: https://www.media.mit.edu/projects/resilient-prosthetic-and-diabeticcare/overview/

### Closing remarks

This project started from the passion and commitment of the authors and their colleagues for democratising access to healthcare in underserved areas. Every further support, advise, partnership is welcome, please refer to the below website.

### Health Outcomes

The medical results of more convenient, frequent and accessible healthcare can be measured in a number of ways, including clinical outcomes, impact on health access, and economic impact.

Since 2005, the cost of diabetic complications in Mexico has increased more than 500%.

We aspire to lower the rate of amputations and gather evidence of better diabetic management, thereby lowering this economic cost.

*Figure 3. Floor plan of clinic with side panels fully extended for operation.*

### Health Disparities Heat Map

A fundamental aspect of the project is the development of a data-driven system for aggregating information and building an agile and impactful method of delivering healthcare. A mapping tool is in development to collect available data from open repositories, and analysing them with algorithms for specific markers and indicators.

Extensive evidence shows that social determinants of health contribute to higher rates of the disease in specific geographical areas. Specifically, unmanaged diabetes and amputation cases demonstrate geospatial clustering. By knowing these factors, one can predict which areas would be mostly affected, even when direct prevalence rate data are not available.

Moreover, by training the model in well-known data-rich areas (like some states in the US), the same approach could be applied in data deserts.00

*Figure 1. A homemade prosthesis made by a patient without access to proper care (photo taken in Nogales, Mexico).*

*Figure 2. One method of measuring our influence on components of health access.*

Diabetic Services Area

With regard to both diabetic and postamputation care, patients continually experience difficulties in reaching clinics, obtaining proper equipment, and maintaining their limbs. While the number of amputees and diabetic patients grows exponentially, the infrastructure that provides their medical services remains stagnant. Only 3% of the 900,000 amputees in Mexico have a functional prosthesis, and there are less than 50 prosthetic clinics in Mexico.

### INEQUALITY IN UTILIZATION OF HEALTHCARE SERVICES AMONG ADOLESCENT GIRLS IN URBAN SLUMS

### Findings From a Study in Slums of Jaipur City

### Authors

Rajnish Ranjan Prasad

### Introduction

a. In India, evidence shows that there is inequity in the utilization of health services by adolescent girls.

b. However, adolescent girls are not a homogeneous group, and depending on socioeconomic and demographic factors, some girls are more disadvantaged in the utilization of health services than others.

c. Hence, this study was undertaken to understand inequality in utilization of health services among adolescent girls.

### Methodology

a. The study was done using mixed methods in the urban slums of Jaipur (capital city of Rajasthan, India).

b. The sample size for the study with a 95% confidence level, 5% error margin, and 10% non- response rate was 295 adolescent girls.

c. A total of 281 girls responded to the interview, and 3 FGDs (10 girls in each FGD) were conducted with the adolescent girls to collect in-depth qualitative information.

### Findings


### PhD Fellow, IIHMR Univeristy

*Figure 2. Association among different variables and health service utilization.*

### Results


*Figure 3. Strength of Association-Odds ratio.* 

### Conclusion

a. The findings from the study highlight significant inequities among adolescent girls in urban slums, depending on their socioeconomic and demographic background.



*Figure 1. Type of treatment availed.*


### LAUNCHING EHEALTH TO IMPROVE UHC IN UKRAINE AS A PART OF 2017–2019 HEALTH FINANCING REFORM

### A Case Study

### Authors

Nataliia Riabtseva, Oleg Petrenko, Tetiana Stepurko and Dmytro Chernysh

### Background

Since gaining independence in 1991, Ukraine has not succeeded in reforming its healthcare system for decades. Ukraine's health financing reform was launched in Fall 2017 through a Law that aimed to protect citizens from catastrophic expenditures and introduce the concept of universal health coverage (UHC) by establishing national strategic purchaser, health benefit package, and new payment mechanisms.The principal decision of the Government was that every stage of reform be equipped with essential eHealth functionalities to ensure transparent, reliable, and timely data.

At the beginning, the reform initiated the changes at the primary healthcare (PHC) level that had been neglected in the country for many years. In 2018, new regulations and payment mechanisms were introduced for PHC providers through the national strategic purchaser National Health Service Ukraine (NHSU). One year later, the governmental program for the reimbursement of medicines for the most common NCDs was transferred to NHSU, and new payment mechanisms for the hospitals were piloted in one of the regions.

*Figure 2. Distance correlation among PHC providers and the nearest pharmacies contracted, Volyn region (6.95 km is the mean of distance, 5.11 km is the median of the distance).*

### Study design

The objective of the study is to understand the potential of eHealth launch for UHC enhancement in Ukraine.

This study is based on a case study methodology that includes participatory observation, review of documents, and analysis of publicly available data. Participatory observation includes practical field work in the health financing reform team at the Ministry of Health and National Health Service of Ukraine. The document review comprises legislation and related normative and methodological publications. Public data are mainly accessible through the website of National Health Service Ukraine, www.nszu.gov.ua.

### Implementation results

The implementation of eHealth functionalities has contributed to the UHC in Ukraine in the following ways:



### Contact details

Nataliia Riabtseva, NHSU, natalia.riabtseva@nszu.gov.ua Tetiana Stepurko, MED Project, tetiana.stepurko@mededu.org.ua

Within health financing reform, the Government has selected a hybrid model of eHealth when the State is responsible for the central component and data base (standards, architecture, security, and interoperability), whereas IT businesses provide competitive solutions for users.

### Conclusions

Whereas introduction of eHealth is always a challenging task, the hybrid model has allowed to mitigate number of related risks and introduce each essential functionality for a whole country at once. In practical terms, such «eHealth coverage» has contributed to the UHC as it reduces the barriers for the patients and stimulates the development of PHC.

In parallel, eHealth enhances the transparency of data both for the citizens and for the policy makers, giving reliable, timely, and structured data. It also allows operating big data, so NHSU could see the gaps in service provision and react.

The next reform stage takes place in April 2020, when all other types of healthcare will move to new financing model. This stage is also accompanied with eHealth functionalities, including the patient health records, referrals, contracting and reporting.

### Implementation process

Essential eHealth functionalities were introduced one by one according to the reform stages for the whole country at once.

For PHC, eHealth has provided the following functionalities:





The introduction of all these functionalities—patient–doctor declarations, contracting of PHC facilities and pharmacies, e-prescription—took half a year in total. All the developments were done according to international standards as well as HL7 FHIR medical data requirements. Each functionality was developed in two steps—at the central data base and afterwards with the help of IT businesses for the ultimate users.

Contrary to usual practice, but considering the country context, the patient health records at PHC level were launched after e-prescription, in September 2019.

### Acknowledgement

The development and provision of this poster at GHF-2020 was possible due to the support of Swiss Development Cooperation through the Swiss-Ukrainian Medical Education Reform project.

*Figure 1. Example of the dashboard available at the NHSU web-site: mapping PHC providers.*

### In Ukraine, eHealth has directly contributed to UHC by helping to reduce the barriers for the patients and enhance

the role of PHC in the country.

*Figure 3. Dynamic of enrolment of new patients to reimbursement program.*

Dynamic of new patients' enrollment to the medicine reimbursement program "Affordable medicine"

### Influenza-like illness


#### breath)

Active User: at least one weekly questionnaire completed within the previous 14 days OR any user who reported an ILI

#### Data collection



#### Participant Recruitment



### Key points on Influenza


network of 150 to 250 physicians Objective to evaluate Grippenet's performance between 2016 and 2019 in monitoring influenzalike illnesses (ILI) in Switzerland, identify risk factors associated with contracting an ILI and investigate medical-care seeking behaviors

### Grippenet.ch


### GRIPPENET: A NEW TOOL FOR THE MONITORING, RISK-FACTOR AND VACCINATION COVERAGE ANALYSIS OF INFLUENZA-LIKE ILLNESS IN SWITZERLAND

#### Population description

1247 participants (total users) included between 7 November 2016 and 28 April 2019. Not representative of the Swiss population:


### Methods

### Results

Geographic distribution: Blue: areas with at least one active user; red: areas with at least one influenza-like illness (ILI) case.

Participants were mostly located in the Frenchspeaking part of Switzerland.

#### ILI risk factors


### Background

Definitions

#### ILI incidence comparison for season 2018-2019 Blue: Grippenet incidence Orange: Sentinella incidence

#### User participation rate

#### Vaccination rates within risk categories (2018–2019 season)

Medical care-seeking behavior Percentage of users reporting one or more ILIs who did not consult a medical doctor



### Conclusion

A participatory monitoring system such as Grippenet can help monitor ILI cases in a fast and flexible way, identify ILI risk factors and gaps in the influenza vaccination coverage, and analyze medical care-seeking behaviors. It has the potential to enhance traditional surveillance systems by collecting information in real time from a different population profile, including people who do not seek medical help.

Increase in participation rate at the beginning of influenza season, which declines after ILI peak.

### Authors

Aude Richard1, Laura Müller1, Ania Wisniak1, Amaury Thiabaud1, Thibaut Merle1, Damien Dietrich1,2, Daniela Paolotti3, Emilien Jeannot1,4 and Antoine Flahault1

<sup>1</sup> Institute of Global Health, Faculty of Medicine, University of Geneva, 1202 Geneva, Switzerland;

<sup>2</sup> Luxembourg Institute of Health, Strassen 1445, Luxemburg;

3 Institute for Scientific Interchange Foundation, 10126 Torino, Italy;

<sup>4</sup> Addiction Medicine, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, 1004 Lausanne, Switzerland

\* Correspondence: aude.richard@unige.ch

### BUILDING HEALTH PLANNING CAPACITY TO ENSURE EVIDENCE-BASED INTERVENTIONS AND FOSTER PARTICIPATION AND ACCOUNTABILITY IN MOLDOVA

Results of Health Profiles Development and Roll-out for Health Planning in Ten Districts of Rural Moldova

### Authors

Constantin Rimis1, Florence Sécula2, Diana Berari1Laura Aaben4, Ion Salaru5, Helen Prytherch2,3 and Ala Curteanu1

### Introduction

The WHO Health Profile concept provides an assessment of the health status and determinants of health, including risk factors in a given administrative-territorial unit. In Moldova, the Health Profile tool was endorsed in 2014, building on results of the WHO-led initiative. However, little progress has been made with the implementation, especially for health planning and integration of health profiles in local and regional development plans and in health promotion.

SDC's *Healthy Life: Reducing the burden of non-communicable diseases (NCDs)* project is working to improve healthcare-seeking behaviors and reduce NCD risk behavior among the rural population, while also strengthening the quality of NCD prevention, treatment, and management. To advance the policy frame and facilitate greater approval of healthy behaviors, the project has introduced a "health in all policies" approach. This includes supporting the National Agency for Public Heath (NAPH) to advance evidence-based, intersectoral, health promotion interventions through the use of local Health Profiles.

*Figure1. Training of multidisciplinary teams on Health Profiles, 2018.*

### Methods

The Health Profile covers seven areas: 1) population and demography; 2) the health status of the population; 3) economy, labor force and social welfare; 4) children's health and wellbeing; 5) health literacy and behavior; 6) the living environment and 7) the health system infrastructure. The Healthy Life Project facilitated the simplification of the Health Profile tool from 95 originally proposed indicators to 42 NCD-related indicators.

### Results

The NAPH has introduced evidence-based health planning at both central and decentralized levels, and the development of Health Profiles in 10 pilot districts. The whole data management process (collection, analysis, interpretation, gap identification and feedback, and dissemination) was clarified, and data to furnish health profiles indicators for the period of 2013-2018 were collected. In tandem, training was provided to local public health experts to analyze and interpret the Health Profile indicators. Additionally, workshops were organized on "How to plan successfully" for teams of District Public Health Councils composed by representatives from Local Public Authorities (LPAs), social, education, health care and other sectors as a members of multisectoral local teams.

*Figure 2. Health Profile from Briceni district. Figure 4. Asset mapping meeting, 2019.*

### Conclusions

The Health Profile data were largely disseminated at all levels, and their use for health planning and intervention design was systematically integrated in the health promotion work with district and community partners. The process of building capacity to prepare and use Health Profiles created common community values and empowered citizens to identify their needs for health. This process improved the link between LPAs, institutions, and services and motivated inter-institutional and intersectoral cooperation for more efficient planning using limited resources.

1 Swiss Agency for Development and Cooperation (SDC) Healthy Life Project, Chisinau, Moldova <sup>2</sup> Swiss Tropical and Public Health Institute, P.O. Box, CH-4002 Basel, Switzerland <sup>3</sup> University of Basel, P.O. Box, CH-4003 Basel, Switzerland <sup>4</sup> Ministry of Interior, Tallinn, Estonia <sup>5</sup> National Agency for Public Health, Chisinau, Moldova www.viatasan.md www.facebook.com/viatasan.md

As a result, 10 small grant proposals, based on the Health Profiles indicators, were developed and implemented in 2019, increasing intersectoral collaboration and the local capacity on health promotion interventions, addressing the issues of hypertension, type 2 diabetes, obesity, and promoting physical activities and healthy nutrition. Further, health profile data were used by district LPAs for strategic evidence-based health planning and development of intersectoral action plans being in the process of implementation.

Being a critical component of health planning – indicating locally relevant health priorities- the resulting Health Profiles for 10 pilot districts were used at village level to raise awareness of LPAs and local stakeholders (health, social, and education sectors, as well as the police force and church) and stimulating them to actions for health promotion and NCD prevention and control. Thus, the Health Profiles were disseminated at village level to help to close the information gap on evidence-based health issues and priorities by bringing the data to the lowest level of action for health promotion (communities).

Based on districts Health Profile results and participatory asset mapping of the village resources for health performed by local group members in 20 pilot localities, community coalitions for Health Promotion were built to foster not only collaboration but also greater accountability to tackle health issues at community level.

#### *Figure 3. Health Profile from Briceni district.*

## IMPLEMENTING WITHOUT GUIDELINES: LEARNING AT THE COALFACE

A Case Study of Health Promoters in an Era of Community Health Workers

### Authors

Teurai Rwafa-Ponela, John Eyles, Nicola Christofides and Jane Goudge DOI: https://doi.org/10.1186/s12961-020-00561-5

### Introduction


*Figure 3. Lewin's three-step change model.*

### Study Aim

The study examined the tension between two cadres (health promoters and CHWs) in two South African provinces in an era of a primary health reform.

*Figure 1. Ward-based outreach teams (WBOTs).*

### Findings

The introduction of CHWs triggered anxiety and uncertainty among some health promoters due to considerable role overlap between the two cadres.

	- Providing up-to-date health information;
	- Jointly discussing how to assist with community health problems;
	- Providing advice;
	- Household-visit support.

### Discussion

### Methods

#### Study Design: A qualitative case study.

#### *Table 1: Introduction of policy*


### Corresponding Author Teurai Rwafa-Ponela

Postal Address: 3rd Floor, The Centre for Health Policy, School of Public Health Building, Faculty of Health Science, University of the Witwatersrand, 27 St. Andrews Road, Parktown , JHB, South Africa Telephone No.: (+27) 74 963 7019 Email address: rwafateurai@gmail.com

*Table 2. Organizational change in this study using Lewin's three-stage model.*


### Conclusion


*Figure 2. Sampling, data collection and analysis.*

### Acknowledgements

### Policy Recommendations

 Policy makers and HP managers (at the top) can learn from innovation within facilities (at the bottom) and develop formalised operational guidelines and direction for HPPs' routine practices, particularly within the PHC reform.

### References


### Introduction of policy

## HEALTH PROMOTION CAPACITY AND INSTITUTIONAL SYSTEMS

A Three-Level Assessment of the South African Department of Health

### Authors

Teurai Rwafa-Ponela, Nicola Christofides, John Eyles and Jane Goudge DOI: https://doi.org/10.1093/heapro/daaa098

### Introduction


*Table 1. Organizational capacity scores to implement health promotion.*


### Study Aim

The aim of this study was to assess organizational capacity and institutional systems to implement HP across three levels of the South African Department of Health (DoH).

*Figure 1. Health promotion capacity assessment tool.*

### Key Results

	- This was compounded by serious structural disconnects between national and provincial levels.
	- Limited priority setting, monitoring and evaluation of the HP programme occurred.
	- The district health information system does not collect any HP specific indicators.
	- No external coordination role, or internal within the DoH.
	- Lack of HP specific training among designated HP staff was emphasized.
	- Budgetary and resource constraints emerged as a major challenge, with participants reporting limited resources to conduct activities at any level.
	- Institutional constraints highlighted in the findings reduce the full potential of HP capacity in the

### Capacity Domains: Qualitative Results

### Methods

### Design and data collection


### Study sites and sample


*Figure 2. Sample for the health promotion capacity assessment workshops, (n=28).*

### Corresponding Author Teurai Rwafa-Ponela

Postal Address: 3rd Floor, The Centre for Health Policy, School of Public Health Building, Faculty of Health Science, University of the Witwatersrand, 27 St. Andrews Road, Parktown , JHB, South Africa Telephone No.: (+27) 74 963 7019 Email address: rwafateurai@gmail.com

### Capacity Domains: Quantitative Results

*Figure 3. Themes and quotes from the workshop discussions on the four capacity domains.*

### References

1. RWAFA-PONELA, T., CHRISTOFIDES, N., EYLES, J. & GOUGDE, J. (2020). Health promotion capacity and institutional systems: An assessment of the South African Department of Health. Health Promotion International.

DOI: https://doi.org/10.1093/heapro/daaa098


### Data analysis


*\*Key for the presence or absence of function and or system Stage 1 ≥1.00-1.49= absent/not present; Stage 2 ≥1.50-2.49= present, limited capacity; Stage 3 ≥2.50-3.49= present, regular capacity; Stage 4 ≥3.50-4.00=present, full capacity.*

### Acknowledgements


### Conclusions and Policy recommendations


### Study limitations


60

### PROTECTIVE AND RISK FACTORS FOR MENTAL HEALTH OF CHILDREN OF ASYLUM-SEEKERS AND REFUGES

### A Cross-Sectional Study at the Pediatric Migrant Health Clinic of Geneva

### Introduction

Recent migratory and sanitary crises across the globe have drawn unprecedented attention to the complexity of migration and its impact on health. Children of refugees constitute a vulnerable group as circumstances during forced migration may compromise their basic rights, development and wellbeing. They are at increased risk of developing mental health and psychosocial problems. Factors related to all three phases of migration (predeparture, travel and settlement) may have a protective or detrimental effect on mental health. Improving our understanding of these factors will allow recognition of vulnerable children and implementation of psychosocial interventions tailored to their needs. An explorative study was carried out at the Geneva University Hospitals (GUH) to provide a snapshot view of the psychological vulnerability of children of asylumseekers and refugees in the canton of Geneva.

### Objective

Explore protective and risk factors for mental health of child refugees\* in Geneva from chronological and socioecological perspectives.

\* For simplicity purposes, "child refugees" refer to children of asylum-seekers and refugees

### Methods

This cross-sectional study was conducted at the Pediatric Migrant Health Clinic of the GUH.

Study populations included:


Data collection:


Statistical analysis: Comparison achieved by independent *t*-test (or Wilcoxon rank sum) and Chi-square test (or Fisher's exact test); *p* < 0.05

### Affiliations

<sup>1</sup> Department of Pediatrics, Sainte-Justine Hospital, Montreal 2 Global Health Institute, University of Geneva

<sup>3</sup> Pediatric Infectious Diseases Division, Geneva University Hospitals <sup>4</sup> International Centre for Migration Health and Development, Geneva <sup>5</sup> Child & Adolescent Psychiatry Division, Geneva University Hospitals

### Conclusion

Identification of protective and risk factors for mental health outcomes in children of asylum-seekers and refugees is crucial. It allows proper assessment of their individual vulnerability and resilience capacity as well as their specific needs. Finally, gaps in mental healthcare and psychosocial support provision exist particularly regarding vulnerable children who appear asymptomatic. Preventive care provision in mental health should also become a priority of first-line health workers and health promoters to enable refugee children to thrive and develop to their full potential in host countries.

### Results

30 children (2-14 years old) were included in sample 1 "without identified psychological dysfunction" and in sample 2 "with identified psychological dysfunction". Children in sample 2 were older (8 vs 6 years old) and had been residing in Switzerland for longer time (23 vs 14 months). There were more boys (63%) than girls (37%) in sample 2 whereas gender was more balanced in sample 1.

*Figure 1 The three phases of migration.*

Children without psychological dysfunction (N=30) Children with psychological dysfunction (N = 30)

*Figure 2. Exposure to protective/risk factors related to premigratory phase.*

*Figure 3. Exposure to protective/risk factors related to travel phase.*

*Figure 4. Exposure to protective/risk factors related to settlement.*

*Figure 2. Country of origin in both samples.*

Most children in sample 1 (47%) held a residence permit with refugee status whereas most subjects in sample 2 (43%) held a provisional admission permit.

Protective and risk factors from all three migratory phases are associated with children's psychological state. Children's exposure to trauma in any phase of migration is associated with psychological dysfunction. Parental psychological status is also associated with worst mental health outcomes in children possibly due to abnormal or ineffective parent-child interactions.

Overall, the median duration of migratory trajectories was 90 days and median stay in temporary refugee settlements for those exposed was 70 days. There was no difference between samples.

Mean duration stay in temporary accommodations "foyers" was significantly different: 12.4 months (sample 1) compared to 18.8 months (sample 2), *p*=0.022. However, there was no difference noted regarding mean time for asylum claim processing.

### Vulnerability/Resilience Assessment

Surprisingly, 30% and 37% of children in sample 1 were perceived, respectively, at high and moderate vulnerability. These children were not benefitting from any specific psychosocial support.

Focused interventions made readily available could benefit vulnerable children with the aim of preventing occurrence of psychological symptoms and dysfunction by strengthening their coping strategies and resilience.


*Figure 5. Vulnerability and resilience scores of subjects.*

### Authors

Sima Saleh1,2, Noémie Wagner3, Manuel Carballo4, Beat Stoll1 and Saskia von Overbeck5

### ETHNIC DISPARITY AND EXPOSURE TO SUPPLEMENTS RATHER THAN ADVERSE CHILDHOOD EXPERIENCES LINKED TO PRETERM BIRTH IN PAKISTANI WOMEN

### Authors

Kiran Shaikh,a<sup>ǂ</sup> Shahirose Sadrudin Premji,bǂ§ Sharifa Lalani,a<sup>ǂ</sup> Forcheh Ntonghanwahb,ǂ, Aliyah Dosani,c Ilona S Yim,d Pauline Samia,e Christopher Naugler,f Nicole Letourneau,g and the Maternal Infant Global Health Team (MiGHT) Collaborators in Research

### Introduction


### Objective

To examine the impact of adverse childhood experience on prenatal mental health and preterm birth among women residing in Pakistan

### Method

### *Study Design*


#### *Instruments*


### *Statistical Methods*

A predictive multiple logistic regression model for preterm birth (PTB; i.e., < 37 weeks' gestation) was developed from variables significantly (P < 0.05) or marginally (P < 0.10) associated with PTB in the bivariate analyses..

### Results:


*PTB and socio-demographic/psychosocial factors*

Mother's education level (*P* = 0.011), mother's ethnicity (*P* = 0.010), taking medications during pregnancy (*P* = 0.006) were associated.

References Acknowledgement Afflication Correspondence

1.Feiliittii et al., (1988;2018b) Research Participant aAga Khan University, Karachi, PAKISTAN Kiran shaikh 2.World Health Organization (2018) Funded by University Research Couni, bYork University, Toronto, CANADA Kiran.shaid@aku.edu Aga Khan University, Karachi, Pakistant cMount Royal University, Calgary, CANADA AKUSONAM dUniversity of California, Irvine, California, USA eAga Khan University Hospital, Nairobi, KENYA f Alberta Public Laboratories, Alberta, CANADA gUniversity of Calgary, Calgary, CANADA ǂ Equal authorship

### Discussion and Conclusions


Age at birth of first child or current age if primiparous (*P* = 0.049) and age at marriage (*P* = 0.0918) emerged as significant in bivariate analyses

### Parsimonious predictive model for PTB




*Table 5: Odds ratios and confidence intervals in parsimonious predictive model for preterm birth.*


*PTB=preterm birth; SD=standard deviation*

*Table 4a: Categorical demographic and other variables: relationship to PTB.*

### DIVERSIFIED USE OF DIGITAL TECHNOLOGY TO NUDGE SOCIAL AND BEHAVIOR CHANGE FOR IMPROVING HEALTH OF THE POPULATION IN INDIA

### Introduction

Digital technology has the ability to promote behavior change by providing tailored support to individuals across different geographies and socioeconomic statuses. It overcomes mobility barriers and increases socialconnectedness. The present endeavor aimed to highlight the diversified use of digital technology in social and behavior change communication.

### Methods

Project JAGRITI Phase-I, a communitybased intervention, was implemented across 15 districts (2016−2018), and Phase-II currently is being implemented in 11 districts of India to bring healthrelated behavior change among women, adolescents, and children using different approaches, including digital technology. We use multiple digital approaches to transform health-related practices in the society, such as contraceptive uptake, exclusive and early breastfeeding, nutrition of adolescents, quality of antenatal and postnatal care, etc. The multiple digital approaches used to reach different segments of populations have been shown in Figure 1. The success of the intervention was assessed by comparing the change in the twelve outcome indicators at end line over baseline. We used quantitative research methods and a cross-sectional study design during both surveys.

### Digital approaches

1. Mobile Application: The JAGRITI mobile app was developed for adolescents to educate them about health and nutrition through games and quizzes. The app has features such as a Body Mass Index calculator for tracking malnutrition and a scribble pad to write down one's thoughts and ideas when in a low mood.

2. Facebook learning: Over 90 Facebook posts were shared to information to adults, adolescents, and

#### parents of adolescents.

3. Jagriti Virtual Conference: A 3-day virtual conference was organized for the staff to share their learnings from the field and learn new issues related to nutrition and COVID-19. 4. WhatsApp: WhatsApp groups were formed with young men to share information about family planning and other health-related issues. 5. SMS (Sandesh Campaign): Short messages on breastfeeding, family planning, hygiene, and maternal

nutrition were sent to beneficiaries. We

have sent over 70000 messages so far. 6. ODK tool: The open data kit (ODK) tool was used for data collection from the beneficiaries during surveys. We have filled over 14000 data collection forms using ODK.

7. SKEE (Skill and Knowledge Evaluation Exam): The knowledge and skills of outreach program staff were evaluated through online exams (based on pre-fixed criteria) on a periodic basis. 8. Online Management Information System (MIS): We created an online MIS that contains socio-demographic and health-related data from over 2 million people.

### Results

A total of 1,642,342 people, including pregnant women, lactating mothers, adolescents, and young couples, were reached through community-based actions. The target populations were provided with structured education sessions, besides being engaged through events and village-level meetings. There was a significant improvement in the health-related behavior of the beneficiaries postintervention, as shown in Figure 2.

### Conclusion

Digital technology is a promising approach to reach the last mile and tailor health messages for the target populations. It can act as a catalyst in transforming primary health care.

*Figure 1. Different digital approaches used to reach communities with health messages and capture their data.*

*Figure 2. Percent distribution of 12 key outcome indicators among participants\* at baseline and end line. \*Adolescents (n=1166a, n=1358b), Pregnant (n=1591a; n=1242b), Lactatinga (n=1673a, n=1261b), and Married Young Women (n=1657a; n=1342b)*

*aBaseline; bEnd line*

For further information, contact: shantanusharma@mamtahimc.org

### Authors

Shantanu Sharma1,2, Faiyaz Akhtar2, Rajesh Kumar Singh2 and Sunil Mehra2

1 Researcher, Lund University, Malmö, Sweden 2 MAMTA Health Institute for Mother and Child, New Delhi, India

### DECISION-MAKING PROCESS AT THE WHO, AND THE INTERNATIONAL RESPONSE TO THE OUTBREAK OF ZIKA VIRUS AND NEUROLOGICAL CONGENITAL DISORDERS

### A Critical Security Studies Perspective

### Authors

Leandro Viegas and Deisy de Freitas LimaVentura

### The 2015 ZikaOutbreak

In July 2015, the Brazilian Government informed the Pan-American Health Organization (PAHO) on an outbreak of an unidentified disease with unknown etiology in the northeastern states of Brazil.

(AGÊNCIA BRASIL, 2015). PAHO's Director decided to inform Member States on the outbreak in Brazil and to recommend the adoption of precautionary measures to prevent the spread of the disease (PAHO, 2015a,b,c). Over that year, Brazilian authorities expressed their concern on the unprecedented numbers of cases of newborns with microcephaly in the same region as the one in which the unknown disease was spreading. A steep increase in the number of cases of Guillaume-Barré Syndrome (GBS) was also reported, indicating that the disease could be related to the Zikavirus.

Health experts in Brazil and abroad started analyzing the etiology of the disease, and established a link between the mothers' infection by the Zika virus and the development of newborns with microcephaly and other neurological conditions (DINIZ,2016).

The outbreak rapidly affected other countries in the Americas, and called on the attention of global experts and authorities, particularly when Brazil declared a public health emergency of national concern in November, 2015 (BRASIL, 2015). The escalation of global cases pushed Dr. Margaret Chan, Director-General (DG) of the World Health Organization (WHO) to convene an Emergency Committee (EC)on the Zika virus and microcephaly that recommended the declaration of a Public Health Emergency of International Concern (PHEIC) on 1 February 2016 (WHO, 2016ª). A few weeks later, Dr. Chan paid a visit to Brazil, in which she expressed her satisfaction on how the government of Brazil was handling the crisis and controlling the spread of the virus and of its vector, the Aedes aegypti mosquito (G1,2016).

The EC met four other times over the course of that year, but for the purposes of that work, the meeting of outmost importance was the third, held a few weeks before the beginning of the Olympic and Paralympic Games in Brazil. During that meeting, the EC acknowledged that Brazil was taking all necessary steps to curb the spread of the virus (WHO, 2016b; 2016c), and stated that the risk of contamination was considered low, since the Games would be held in the usually dry winter times in Brazil (when it is harder for mosquito larvae to thrive). The EC met two other times after the Games and, on its last meeting, it recommended the suspension of the PHEIC since the knowledge on the dynamics of the disease had reached a relatively safe point, and Zika had become an endemic disease needing regular monitoring by the WHO and member states (WHO, 2016d). On the basis of the EC's recommendations, the DG lifted the PHEIC in November 2016. In Brazil, the emergency was only lifted in May 2017.

### Why was Zika considered a PHEIC?

The main objective of this work is to understand both internal and external mechanisms of the WHO that lead to the declaration of a PHEIC for some diseases and not to others. The main question is why the WHO convened an EC for Zika if the same mosquito was capable of also transmitting dengue, chikungunya, and other infectious diseases that were never the object of a PHEIC, but are highly prevalent in the global population. In order to investigate how and why a PHEIC is declared, the first thing to do is to try and understand what a PHEIC really means (Ventura, D., 2016; Heymann D. et

### The Global Health Vigilance Apparatus

The current surveillance system of infectious diseases has its origins in the 19th century, during which a series of international sanitary conferences were held to try and establish widely accepted protocols for the control of infections. Before, some well-knownmeasures had already been used by national governments, such as quarantines, curfews, and the infamous "lazaretti". The 9th International Sanitary Conference held in Paris in 1894 mainly focused on how to avoid the spread of diseases so as to not disturb the flow of international trade and travel. These outcomes represent the "classical regime of governance of infectious diseases" (Fidler,2005). The technical and scientific advancements of the 20th century with the establishment of international organizations such as the WHO in the 1940s synthetized those measures into the InternationalSanitary Regulations (ISR) in 1951, which focused only on six infectious diseases (cholera, plague, yellow fever, smallpox, typhus, and relapsingfever). The ISR (1951) were revised in 1969 to shorten the list of diseases to only three, but over the 1970s and 1980s, it started to show its limitations (Weir, L. and Mykhalovskiy,2010). First, differently from what was believed until then, there was a growing perception that the world was not free from communicable diseases, old and new (emergent and re-emergent). Second, there was a growing perception that national governments were not transparent on the circulation of pathogens. They seemed to be afraid of being "named and shamed"for having a disease in their territories, which could lead to impediments to the circulation of people andmerchandise. Third, in spite of the resistance of national governments to provide reliable epidemiological information, global experts established information networks of epidemiological information, including experts from the WHO's Secretariat. These networks provided regular and timely information on current outbreaks. There was clearly a need for the revision of the system of disease surveillance based on the classical regime.

Most importantly, there was growing concern about the use of biological agents as weapons, such as the sarin gas attacks in Tokyo in 1995 or the attacks by anthrax to US senators in 2001. Technological developments on the use of biological pathogens were also a source of fear to the authorities and the public. Some argued that the end of the Cold War demanded that states try and find a new focus for their security concerns, which included the transposition of soft-power topics such as HIV/AIDS, to the traditional arenas of hard-power debates such as the UN General Assembly (Waever, 1995; Elbe, 2008; Davies, 2008; McInnes and Lee, 2012; Nunes,2018). These all led to pressure from developed countries, mainly the United States and European powers to the WHO to revise the IHR (1969), which was finally taken into consideration in 1995, when the World Health Assembly (WHA) approved a resolution (WHO, 1995) to begin the negotiations for new IHR. These took an entire decade and were only unlocked when the outbreak of SARS exposed the fragilities of the classical regime (Davies, Kamradt-Scott, and Rushton,2015).

The IHR approved in 2005 included a new perspective on disease surveillance that focused on public-health events on real time, which set the stage for the Global Health Vigilance Apparatus (Weir and Mikhalovskiy, 2010).

The most important tool of such an apparatus is the Public Health Emergency of International Concern (PHEIC), which can only be declared by the WHO's DG on the basis of EC recommendations. The conception of a PHEIC is not based on the prevalence of a disease, but on symbolic representations of a threat, which maybe the reason why the 2016 PHEIC was not declared on the Zika disease itself, but on the "threat" of newborns with malformations and neurological conditions (Nunes and Pimenta, 2016; Lakoff, 2017; Wenham and Farias, 2019).

BRASIL (2015). PORTARIA Nº 1.813, DE 11 DE NOVEMBRO DE 2015. Declara Emergência em Saúde Pública de Importância Nacional (ESPIN) por alteração do padrão de ocorrência de microcefalias no Brasil. Diário Oficial da União Nº 216, 12 de novembro de 2015, p.51.

DAVIES, Sara E. 2008. 'Securitizing Infectious Disease. 'International Affairs84 (2): 295–313. doi:10.1111 /j.1468-2346.2008.00704.

de-zika-virus-na-bahia-e-no-rio-grande-do-norte>. AGÊNCIA BRASIL (2015). Ministério confirma 16 casos de zika vírus na Bahia e no Rio Grande do Norte. LAKOFF, Andrew. "Unprepared: global health in a time of emergency". Oakland, California: University of EBC Notícias. 14 de maio. Disponível em <http://www.ebc.com.br/noticias/2015/05/ministerio-confirma-16-casos- California Press, [2017].

FIDLER, David P. 2005. 'From International Sanitary Conventions to Global Heatlh Security:The New International Health Regulations.' Chinese Journal of International Law4 (2):325–392. doi:10.1093/chinesejil/jmi029. G1 (2016). "Brasil 'tem sido transparente', diz diretora da OMS sobre dados do zika". Matéria de jornal. HEYMANN, David L, ABRAHAM Hodgson, Amadou Alpha SALL, David O. FREEMAN, J. Erin STAPLES, Fernando ALTHAPE, et al. 2016. 'Zika virus and microcephaly: why is this situation a PHEIC?' The Lancet 387 (10020): 719–721. doi:10.1016/S0140-6736(16)00320-2.

ELBE, Stefan. 2008. 'Risking Lives: AIDS, Security and Three Concepts of Risk.' SecurityDialogue 39 (2–3): 177–198. doi:10.1177/0967010608088774. DINIZ, D (20161). Zika: do sertão nordestino à ameaça global. 1ª ed. Rio de Janeiro: Civilização Brasileira. 191p. OPAS (2015a). Epidemiological Alert: Zika virus infection. 7 maio de 2015.

MCINNESS, Colin, and LEE, Kelley, 2012. Global Health and International Relations. Cambridge, UK: Polity Press.

NUNES, Joao. 2018. Critical Security Studies and Global Health. The Oxford Handbook of Global Health Politics. DOI: 10.1093/oxfordhb/9780190456818.013.11.

NUNES, João; PIMENTA, Denise N. (2016). A Epidemia de Zika e os Limites da Saúde Global. Lua Nova, São Paulo, n. 98, p. 21-46.

(2015b). Epidemiological Update: Zika virus infection. 16 de outubro de 2015.

(2015c). Epidemiological alert: Increase of microcephaly in the Northeast of Brazil. VENTURA, Deisy (2016). Do Ebola ao Zika: as emergências internacionais e a securitização da saúde global. Cadernos de Saúde Pública. Rio de Janeiro, 32(4):e00033316. WAEVER, Ole. 1995. 'Securitisation and Desecuritisation.' In On Security, edited by RonnieLipschtz, 46–86. New York: Columbia University Press. WEIR, Lorna, MYKHALOVSKIY, Eric, 2010. Global Public Health Vigilance: Creating

aWorld on Alert. Abing-don, UK: Routledge.

WENHAM, Claire; FARIAS, Deborah F L (2019). Securitizing Zika: the Case of Brazil. Security Dialogue, 1-18.

WHO (2016a). WHO statement on the first meeting of the International Health Regulations (2005) (IHR 2005) Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malformations.

1 february. Disponível em <http://www.who.int/mediacentre/news/ statements/2016/1st-emergency-committee-zika/en/>.

(2016b). WHO statement on the third meeting of the International Health Regulations (2005) (IHR(2005)) Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malforma-tions. 14 June. Disponível em

<http://www.who.int/mediacentre/news/statements/2016/ zika-third-ec/en />.

(2016c). WHO public health advice regarding the Olympics and Zika virus. 28 May. Disponível em <http://www.who.int/mediacentre/news/releases/2016/zika- health-advice-olympics/en/ >

(2016d). Fifth meeting of the Emergency Committee under the International Health Regulations (2005) regarding microcephaly, other neurological disorders

#### References


### Authors

Akosua Agyeman Wamba, Noah F. Takah and Cathy Johnman

Korle-Bu Teaching Hospital, London School of Hygiene and Tropical Medicine, University of Glasgow

### Results


### Background

Africa has the highest prevalence of hypertension globally. 46% of adults aged 25 and above in Sub-Saharan Africa (SSA) are hypertensive as opposed to 45% in America. Persistently high blood pressure is a major risk factor for strokes, cardiovascular and ischaemic heart disease, and a preventable cause of death. There is sparse evidence on the interventions employed in hypertension prevention in (SSA). It is imperative that this growing global epidemic is addressed promptly.

### Research Questions


### Methods


### Prisma study selection flow diagram


### Systolic and Diastolic blood pressure forest plots



Studies included in quantitative synthesis (meta-analysis) (n = 6)

### Conclusion


effectiveness of the interventions we described and to better inform public health policy and practice.

• Also, study outcomes need to be reported in formats that can easily be extracted for meta-analyses.

*A Ghanaian nurse screens a patient for hypertension during an outreach activity. Richard Ofori-Asenso, Irina Ofei, https://degrees.fhi360.org/2015/05/in-ghana-a-louderapproach-to-a-silent-killer-hypertension, Accessed 14/10/2020.*

### Correspondence to

Akosua Agyeman Wamba, kossywamba@gmail.com.

### THE IMPACT OF INTERVENTIONS FOR THE PRIMARY PREVENTION OF HYPERTENSION IN SUB-SAHARAN AFRICA

### A Systematic Review and Meta-Analysis

## HEALTH FACILITIES CAPACITY FOR DIAGNOSIS AND TREATMENT OF TUBERCULOSIS IN ETHIOPIA

### Authors

Girum Taye\*, Tigist Shumet, Theodros Getachew, Tefera Tadele, Atkure Defar, Misrak Getnet, Geremew Gonfa, Habtamu Teklie, Ambaye Tadese, Gebeyaw Mola and Abebe Bekele

### Background

Tuberculosis is one of the major public health challenges in Ethiopia. There are limited information on health facilities capacity to offer Tuberculosis services at national level. The purpose of the study is to evaluate the capacity of health facilities to provide Tuberculosis service and, its variations by type of health facilities and regions in Ethiopia.

### Methods

Data from the 2018 Ethiopian Service Availability and Readiness Assessment (SARA) survey were used. The data were collected from all regions of the country. The overall Tuberculosis service readiness score was calculated by considering twelve Tuberculosis tracer items. Mean availability was considered for measuring health facilities overall capacity to provide Tuberculosis service. Multiple linear regression was done to assess the association of selected health facilities characteristics with overall readiness score.

*Figure 1. Distribution of health facilities by type, Ethiopia Service Availability and Readiness Assessment 2018.*

*Table 1. TB diagnosis and treatment services by health facility characteristics.*

### Conclusion

Hospitals and health centers in Ethiopia had good capacity to provide Tuberculosis service, however low capacity was observed in clinics. There was a significant

regional heterogeneity on the capacity of health facilities for Tuberculosis service diagnosis and treatment in Ethiopia. This is also detected by facility type and facility setting. Tuberculosis service improvement interventions should focus on the clinics and the regions whose readiness score is low to ensure equity and its capacity.

Result

A total of 632 health facilities were included in the analysis. Twenty-six percent of the clinics provided Tuberculosis diagnosis, treatment prescription, or treatment follow-up; 18% had national diagnosis and treatment of Tuberculosis guideline; and 16% Tuberculosis smear microscopy diagnostic mechanism. Hospitals had better capacity score (76%) than health centers (69%) and clinics (13%). The overall Tuberculosis service capacity score for urban facilities (60%) was higher than that of the rural (49%) health facilities (β=-0.13, 95% C.I: -0.18,-0.08 ), Clinics (β=-0.59, 95% C.I: -0.67,-0.52) had lower capacity score than hospitals. Facilities in Afar (β=-0.13, 95% C.I: -0.23,-0.02), Amhara (β=- 0.12 95% C.I: -0.19,-0.04), Oromiya (β=-0.12, 95% C.I: -0.20,-0.04) and Somali (β=-0.13, 95% C.I: -0.23,-0.03 ) regions had lower capacity score than facilities in Tigray.

*Table 2. Determinants of TB Serviice readiness score.*

\* Correspondence: girumt2000@yahoo.com

Health system and Reproductive health Research Directorate, Ethiopian Public Health Institute,


### **Rural** 94 (68) 90 (65) 91 (66) 91 (66)


## AVAILABILITY AND DISTRIBUTION OF HUMAN RESOURCES FOR EMERGENCY OBSTETRIC CARE SERVICES IN ETHIOPIA

### Authors

Girum Taye\*, Ana Lorena Ruano, Patricia E Bailey, Tefera Tadele, Wasihun Andualem, Aster Berhe and Abebe Bekele

### Background

Being able to provide emergency obstetric and newborn care requires a frontline team of skilled personnel that includes physicians, surgeons, anesthetists, nurses, midwives and other cadres. Meeting in-country and international standards for the development and distribution of human resources is a key component of a system-wide strategy to lower maternal and newborn death rates. This study uses the findings from the national Ethiopian Emergency Obstetric and Newborn Care Assessment to provide an overview of the status of human resources for health in the country and the availability, distribution and status of in-service training for EmONC.

*Figure 2. Plot of means for general practitioners , midwives, nurses, and health officers by region.*

### Methods

We used a secondary data analysis technique of the 2016 Ethiopia Emergency Obstetric and Newborn Care Assessment that included 3804 facilities providing childbirth services. Using the data on overall staffing, we calculated the number of midwives, nurses, physicians, general surgeons, neonatologists, emergency surgical, officers and anesthesiologists in order to make comparisons with national and international benchmarks.


*Figure 1. Comparison between FMHACA human resource minimum requirement and the observed number of human resources in facilities, Ethiopia, EmONC 2016.*

\* Correspondence: girumt2000@yahoo.com

Health system and Reproductive health Research Directorate, Ethiopian Public Health Institute

*Table 1. This is an example of a simple table. Not much going on here, move along.*

### Conclusion

This study suggests that national numerical standards are being met but key international standards are not, especially for physicians, nurses and midwives. Although a large proportion of higher-level cadres had training on Emergency Obstetric and Newborn Care, the mid-level health workers who attend most births

had much lower levels of specialized training. Policies aimed at keeping health workers in the public sector must be implemented in order to prevent more health professionals from clustering in big cities and private facilities.

### Results

Ethiopia met national standards of health facility staffing much more often than

international ones. There is a relatively equitable distribution of health worker cadres across regions, location and managing authorities. Despite policies to accelerate the training of midwives, nurses and health officers in the country, large proportion of these professionals had not received in-service training in either basic or comprehensive emergency obstetric and newborn care services, or on neonatal intensive care, which are critical to saving lives when a woman or her newborn develops or is born with severe complications.

MDPI

St. Alban -Anlage 6 4052 Basel Switzerland Tel. +41 61 683 77 34 Fax +41 61302 89 18 www.mdpi.com

### MDPI

St. Alban-Anlage 66 4052 Basel Switzerland

### Tel: +41 61 683 77 34 Fax: +41 61 302 89 18

www.mdpi.com