The Development of an Electronic Clinical Decision and Support System to Improve the Quality of Antenatal Care in Rural Tanzania: Lessons Learned Using Intervention Mapping.

It is widely recognised that high quality antenatal care is a key element in maternal healthcare. Tanzania has a very high maternal mortality ratio of 524 maternal deaths per 100,000 live births. Most maternal deaths are due to preventable causes that can be detected during pregnancy, and antenatal care therefore plays an important role in reducing maternal morbidity and mortality. Unfortunately, quality of antenatal care in Tanzania is low: Research has shown that healthcare workers show poor adherence to antenatal care guidelines, and the majority of pregnant women miss essential services. Digital health tools might improve the performance of healthcare workers and contribute to improving the quality of antenatal care. To this end, an electronic clinical decision and support system (the Nurse Assistant App) was developed and implemented in Tanzania in 2016 to provide digital assistance during antenatal care consultations to healthcare workers. The current study systematically evaluated the development and implementation process of the Nurse Assistant App in Magu District, Tanzania, with the aim of informing future programme planners about relevant steps in the development of a digital health intervention. Desk research was combined with semi-structured interviews to appraise the development process of the digital health tool. We employed the criteria stipulated by Godin et al., which are based on the six steps of Intervention Mapping [IM; Bartholomew Eldredge et al.]. Findings indicated that five of the six steps of IM were completed during the development and implementation of the Nurse Assistant App. Tasks related to community engagement, adjustment to local context, implementation in the practical context in collaboration with local partners, and rigorous evaluation were accomplished. However, tasks related to identifying theory-based behaviour change methods were not accomplished. Based on the lessons learned during the process of developing and implementing the Nurse Assistant App, we conclude that programme developers are recommended to (1) engage the community and listen to their insights, (2), focus on clear programme goals and the desired change, (3), consult or involve a behaviour change specialist, and (4), anticipate potential problems in unexpected circumstances.

Antenatal care and opportunities for quality improvement of service provision in resource limited settings: A mixed methods study.

Antenatal care is essential to improve maternal and newborn health and wellbeing. The majority of pregnant women in Tanzania attend at least one visit. Since implementation of the focused antenatal care model, quality of care assessments have mostly focused on utilization and coverage of routine interventions for antenatal care. This study aims to assess the quality of antenatal care provision from a holistic perspective in a rural district in Tanzania. Structure, process and outcome components of quality are explored. This paper reports on data collected over several periods from 2012 to 2015 through facility audits of supplies and services, ANC observations and exit interviews with pregnant women. Additional qualitative methods were used such as interviews, focus group observations and participant observations. Findings indicate variable performance of routine ANC services, partly explained by insufficient resources. Poor performance was also observed for appropriate history taking, attention for client's wellbeing, basic physical examination and adequate counseling and education. Achieving quality improvement for ANC requires increased attention for the process of care provision beyond coverage, including attention for response-based services, which should be assessed based on locally determined criteria.

Sexual behaviour of women in rural South Africa: a descriptive study.

BACKGROUND: Sexual behaviour is a core determinant of the HIV and sexually transmitted infection (STI) epidemics in women living in rural South Africa. Knowledge of sexual behaviour in these areas is limited, but constitutes essential information for a combination prevention approach of behavioural change and biomedical interventions. METHODS: This descriptive study was conducted in rural Mopani District, South Africa, as part of a larger study on STI. Women of reproductive age (18-49 years) who reported sexual activity were included regardless of the reason for visiting the facility. Questionnaires were administered to 570 women. We report sexual behaviour by age group, ethnic group and self-reported HIV status. RESULTS: Young women (<25 years) were more likely to visit bars, practice fellatio, have concurrent sexual partners and report a circumcised partner than older women (>34 years); there was no difference for condom use during last sex act (36 % overall). Sotho women were more likely to report concurrent sexual partners whereas Shangaan women reported more frequent intravaginal cleansing and vaginal scarring practice in our analysis. HIV-infected women were older, had a higher number of lifetime sexual partners, reported more frequent condom use during the last sex act and were more likely to have a known HIV-infected partner than women without HIV infection; hormonal contraceptive use, fellatio, and a circumcised partner were less often reported. CONCLUSIONS: This study provides insight into women's sexual behaviour in a rural South African region. There are important differences in sexual behaviour by age group and ethnicity and HIV status; these should be taken into account when designing tailor-made prevention packages.

Evaluation of syndromic management guidelines for treatment of sexually transmitted infections in South African women.

OBJECTIVE: To evaluate the performance of three different guidelines for the management of vaginal discharge syndrome (VDS) for women living in a rural setting in South Africa. METHODS: We conducted a secondary analysis of data from a cross-sectional study in Mopani District, South Africa. The 2015 and 2008 guidelines of the South African Department of Health (DoH) and the most recent WHO guidelines were evaluated for adequate treatment of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and Trichomonas vaginalis infection. RESULTS: Of the 489 women included in this analysis, 35% presented with VDS according to the DoH and 30% per WHO definition of VDS. Fifty-six per cent of the women with VDS would be treated adequately for these STI when using the 2015 DoH guideline, whereas 76% (P = 0.01) and 64% (P = 0.35) would receive adequate treatment with the 2008 DoH and WHO guidelines, respectively. Of the symptomatic women who tested negative for all four STI, STI treatment would have been indicated for 36% as per 2015 DoH guideline vs. 69% (P < 0.001) per 2008 DoH and 67% (P < 0.001) per WHO guidelines. CONCLUSION: A considerable proportion of symptomatic women infected with these common curable STI would receive adequate treatment when using a syndromic management approach, and significant differences exist between the three guidelines. Many symptomatic women without these STI receive broad-spectrum antibiotics, so new approaches are needed to improve syndromic STI control.

Microbiological Characteristics of Chlamydia trachomatis and Neisseria gonorrhoeae Infections in South African Women.

We analyzed data of 263 women with at least one genital or anorectal sexually transmitted infection from a cross-sectional study conducted in rural South Africa. We provide new insights concerning the concurrence of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis infections as well as the characteristics of bacterial loads.

Prevalence and macrolide resistance of Mycoplasma genitalium in South African women.

Remnant specimens from 601 women obtained in a cross-sectional study from rural South Africa were tested for Mycoplasma genitalium. Overall, 10.8% of women were infected with M. genitalium either in the vagina or in the rectum. Macrolide resistance, although of low prevalence, in M. genitalium is described for the first time in Sub-Saharan Africa.

Cross-sectional study of genital, rectal, and pharyngeal Chlamydia and gonorrhea in women in rural South Africa.

BACKGROUND: Epidemiological data of genital chlamydia and gonorrhea, required to inform design and implementation of control programs, are limited for rural Africa. There are no data on the prevalence of rectal or pharyngeal infections among African women. METHODS: A cross-sectional study of 604 adult women visiting 25 primary health care facilities in rural South Africa was conducted. Vaginal, anorectal, and oropharyngeal swabs were tested for Chlamydia trachomatis and Neisseria gonorrhoeae. RESULTS: Prevalence of genital chlamydia was 16% and that of gonorrhea was 10%; rectal chlamydial infection was diagnosed in 7.1% and gonococcal in 2.5% of women. One woman had pharyngeal chlamydia. Most women with genital chlamydia (61%) and gonorrhea (57%) were asymptomatic. Independent risk factors for genital chlamydia were younger age (adjusted odds ratio [aOR], 0.96 per year; 95% confidence interval [CI], 0.93-0.98), hormonal contraceptive use (aOR, 2.2; 95% CI, 1.3-3.7), pregnancy (aOR, 2.4; 95% CI, 1.3-4.4), and intravaginal cleansing (aOR, 1.7; 95% CI, 1.04-2.8). Intravaginal cleansing was associated with genital gonorrhea (aOR, 1.9; 95% CI, 1.1-3.3). CONCLUSIONS: Genital and rectal, but not pharyngeal, chlamydia and gonorrhea are highly prevalent and frequently asymptomatic in women in rural South Africa. Young women attending health care facilities for antenatal care or family planning should be prioritized in control efforts.

Faecal immunochemical test accuracy in patients referred for surveillance colonoscopy: a multi-centre cohort study.

BACKGROUND: Given the increasing burden on colonoscopy capacity, it has been suggested that faecal immunochemical test (FIT) results could guide surveillance colonoscopy intervals. Against this background, we have evaluated the test accuracy of single and double FIT sampling to detect colorectal cancer (CRC) and/or advanced adenomas in an asymptomatic colonoscopy-controlled high-risk population. METHODS: Cohort study of asymptomatic high-risk patients (personal history of adenomas/CRC or family history of CRC), who provided one or two FITs before elective colonoscopy. Test accuracy of FIT for detection of CRC and advanced adenomas was determined (cut-off level 50 ng/ml). RESULTS: 1,041 patients provided a FIT (516 personal history of adenomas, 172 personal history of CRC and 353 family history of CRC). Five CRCs (0.5%) and 101 advanced adenomas (9.7%) were detected by colonoscopy. Single FIT sampling resulted in a sensitivity, specificity, PPV and NPV for CRC of 80%, 89%, 3% and 99.9%, respectively, and for advanced adenoma of 28%, 91%, 24% and 92%, respectively. Double FIT sampling did not result in a significantly higher sensitivity for advanced neoplasia. Simulation of multiple screening rounds indicated that sensitivity of FIT for advanced adenoma could reach 81% after 5 screening rounds. CONCLUSIONS: In once-only FIT sampling before surveillance colonoscopy, 70% of advanced neoplasia were missed. A simulation approach indicates that multiple screening rounds may be more promising in detecting advanced neoplasia and could potentially alleviate endoscopic burden.