Outreach Training and Supportive Supervision for Quality Malaria Service Delivery: A Qualitative Evaluation in 11 Sub-Saharan African Countries.

Quality improvement of malaria services aims to ensure that more patients receive accurate diagnosis, appropriate treatment, and referral. The Outreach Training and Supportive Supervision Plus (OTSS+) approach seeks to improve health facility readiness and provider competency through onsite supportive supervision, troubleshooting, and on-the-job training. As part of a multicomponent evaluation, qualitative research was conducted to understand the value of the OTSS+ approach for malaria quality improvement. Semistructured key informant interviews, focus group discussions, and structured health facility-based interviews were used to gather stakeholder perspectives at subnational, national, and global levels. Data were collected globally and in 11 countries implementing OTSS+; in-depth data collection was done in four: Cameroon, Ghana, Niger, and Zambia. Study sites and participants were selected purposively. Verbatim transcripts were analyzed thematically, following the Framework approach. A total of 262 participants were included in the analysis; 98 (37.4%) were supervisees, 99 (37.8%) were supervisors, and 65 (24.8%) were other stakeholders. The OTSS+ approach was perceived to improve provider knowledge and skills in malaria service delivery and to improve data and supply management indirectly. Improvements were attributed to a combination of factors. Participants valued the relevance, adaptation, and digitization of supervision checklists; the quality and amount of contact with problem-solving supervisors; and the joint identification of problems and solutions, and development of action plans. Opportunities for improvement were digitized checklist refinement, assurance of a sufficient pool of supervisors, prioritization of health facilities, action plan dissemination and follow-up, and data review and use. The OTSS+ approach was perceived to be a useful quality improvement approach for malaria services.

Can Outreach Training and Supportive Supervision Improve Competency in Malaria Service Delivery? An Evaluation in Cameroon, Ghana, Niger, and Zambia.

Outreach Training and Supportive Supervision (OTSS) of malaria services at health facilities has been adopted by numerous malaria-endemic countries. The OTSS model is characterized by a hands-on method to enhance national guidelines and supervision tools, train supervisors, and perform supervision visits. An independent evaluation was conducted to evaluate the effectiveness of OTSS on health worker competence in the clinical management of malaria, parasitological diagnosis, and prevention of malaria in pregnancy. From 2018 to 2021, health facilities in Cameroon, Ghana, Niger, and Zambia received OTSS visits during which health workers were observed directly during patient consultations, and supervisors completed standardized checklists to assess their performance. Mixed-effects logistic regression models were developed to assess the impact of increasing OTSS visit number on a set of eight program-generated outcome indicators, including overall competency and requesting a confirmatory malaria test appropriately. Seven of eight outcome indicators showed evidence of beneficial effects of increased OTSS visits. Odds of health workers reaching competency thresholds for the malaria-in-pregnancy checklist increased by more than four times for each additional OTSS visit (odds ratio [OR], 4.62; 95% CI, 3.62-5.88). Each additional OTSS visit was associated with almost four times the odds of the health worker foregoing antimalarial prescriptions for patients who tested negative for malaria (OR, 3.80; 95% CI, 2.35-6.16). This evaluation provides evidence that successive OTSS visits result in meaningful improvements in indicators linked to quality case management of patients attending facilities for malaria diagnosis and treatment, as well as quality malaria prevention services received by women attending antenatal services.

Highlighting a population-based re-emergence of Syphilis infection and assessing associated risk factors among pregnant women in Cameroon: Evidence from the 2009, 2012 and 2017 national sentinel surveillance surveys of HIV and syphilis.

BACKGROUND: Syphilis and HIV can be transmitted from pregnant women to their children and they remain a public health problem in Africa. Our study aimed to determine the trends of seroprevalence of HIV/syphilis co-infection and syphilis infection overtime through the national surveillance system in Cameroon and to explore associated risk factors. METHODS: We conducted cross-sectional studies of HIV and syphilis, targeting each year 7000 first antenatal care (ANC-1) attendees at the same sites during the 2009, 2012 and 2017 sentinel surveillance surveys. Pregnant women were enrolled at their ANC-1, sociodemographic and clinical information were collected. HIV and Syphilis test were performed by serial algorithm as per the national guidelines. Trends were assessed for HIV, syphilis and HIV/syphilis by estimating seroprevalence from cross-sectional studies. Associated risk factors were explored using multinomial logistic regression with 4 outcomes: HIV/syphilis co-infection, HIV infection only, syphilis infection only and no infection. RESULTS: Overall, 6 632, 6 521 and 6 859 pregnant women were enrolled in 2009, 2012 and 2017 respectively. In 2017, a total of 3 901 pregnant women enrolled were tested for syphilis. Almost half of them (47.9%) were living in urban area and were aged less than 25 years (44.7%). While HIV epidemic was on a decline (from 7.6% (95% CI: 6.99-8.28) in 2009 to 5.7% (95% CI: 4.93-6.4) in 2017), a huge significant increase of syphilis prevalence was observed (from 0.6% (95% CI:0.40-0.80) in 2009 to 5.7% (95% CI:4.93-6.40) in 2017). Pregnant women residing in rural areas were more likely to be infected with syphilis than those living in the urban area (aOR = 1.8 [95% CI: 1.3-2.4]). Unmarried pregnant women were three time more likely to be infected by HIV/Syphilis Co-infection than married, cohabiting, widow or divorced pregnant women (aOR = 2.8 [95% CI: 1.3-2.4]). Furthermore; living in Northern region was associated with a lower risk of being infected with HIV (aOR = 0.6 [95% CI: 0.5-0.9]) and Syphilis infection (aOR = 0.6 [95% CI: 0.4-0.9]). CONCLUSION: The epidemiological dynamics of syphilis suggests a growing burden of syphilis infection in the general population of Cameroon. Our findings support the fact that while emphasizing strategies to fight HIV, huge efforts should also be made for strategies to prevent and fight syphilis infection especially among HIV positive women, in rural area, and southern regions.

On estimating the number of people with known HIV positive status.

OBJECTIVE: In 2014, the Joint United Nations Program on HIV and AIDS (UNAIDS) and partners set the '90-90-90 targets'. Many countries are facing the challenge of estimating the first 90. Our objective was to propose an alternative modelling procedure, and to discuss its usefulness for taking into account duplication. RESULTS: For deduplication, we identified two important ingredients: the probability for an HIV+ person of being re-tested during the period and average number of HIV+ tests. Other adjusted factors included: the false positive probability; the death and emigration probabilities. The uncertainty of the adjusted estimate was assessed using the plausibility bounds and sensitivity analysis. The proposed method was applied to Cameroon for the period 1987-2016. Of the 560,000 people living with HIV estimated from UNAIDS in 2016; 504,000 out to know their status. The model estimates that 380,464 [379,257, 381,674] know their status (75.5%); thus 179,536 who do not know their status should be sought through the intensification of testing. These results were subsequently used for constructing the full 2016 Cameroon HIV cascade for identifying programmatic gap, prioritizing the resources, and guiding the strategies of the 2018-2022 National Strategy Plan and funding request.