The Human Resources for Health Effort Index: a tool to assess and inform Strategic Health Workforce Investments.

BACKGROUND: Despite its importance, the field of human resources for health (HRH) has lagged in developing methods to measure its status and progress in low- and middle-income countries suffering a workforce crisis. Measures of professional health worker densities and distribution are purely numerical, unreliable, and do not represent the full spectrum of workers providing health services. To provide more information on the multi-dimensional characteristics of human resources for health, in 2013-2014, the global USAID-funded CapacityPlus project, led by IntraHealth International, developed and tested a 79-item HRH Effort Index modeled after the widely used Family Planning Effort Index. METHODS: The index includes seven recognized HRH dimensions: Leadership and Advocacy; Policy and Governance; Finance; Education and Training; Recruitment, Distribution, and Retention; Human Resources Management; and Monitoring, Evaluation, and Information Systems. Each item is scored from 1 to 10 and scores are averaged with equal weights for each dimension and overall. The questionnaire is applied to knowledgeable informants from public, nongovernmental organization, and private sectors in each country. A pilot test among 49 respondents in Kenya and Nigeria provided useful information to improve, combine, and streamline questions. CapacityPlus applied the revised 50-item questionnaire in 2015 in Burkina Faso, Dominican Republic, Ghana, and Mali, among 92 respondents. Additionally, the index was applied subnationally in the Dominican Republic (16 respondents) and in a consensus-building meeting in Mali (43 respondents) after the national application. RESULTS: The results revealed a range of scores between 3.7 and 6.2 across dimensions, for overall scores between 4.8 and 5.5. Dimensions with lower scores included Recruitment, Distribution, and Retention, while Leadership and Advocacy had higher scores. CONCLUSIONS: The tool proved to be well understood and provided key qualitative information on the health workforce to assist in health systems strengthening. It is expected that subsequent applications should provide more information for comparison purposes, to refine aspects of the questionnaire and to correlate scores with measures of service outputs and outcomes.

Successful mLearning Pilot in Senegal: Delivering Family Planning Refresher Training Using Interactive Voice Response and SMS.

BACKGROUND: In-service training of health workers plays a pivotal role in improving service quality. However, it is often expensive and requires providers to leave their posts. We developed and assessed a prototype mLearning system that used interactive voice response (IVR) and text messaging on simple mobile phones to provide in-service training without interrupting health services. IVR allows trainees to respond to audio recordings using their telephone keypad. METHODS: In 2013, the CapacityPlus project tested the mobile delivery of an 8-week refresher training course on management of contraceptive side effects and misconceptions to 20 public-sector nurses and midwives working in Mékhé and Tivaouane districts in the Thiès region of Senegal. The course used a spaced-education approach in which questions and detailed explanations are spaced and repeated over time. We assessed the feasibility through the system's administrative data, examined participants' experiences using an endline survey, and employed a pre- and post-test survey to assess changes in provider knowledge. RESULTS: All participants completed the course within 9 weeks. The majority of participant prompts to interact with the mobile course were made outside normal working hours (median time, 5:16 pm); average call duration was about 13 minutes. Participants reported positive experiences: 60% liked the ability to determine the pace of the course and 55% liked the convenience. The largest criticism (35% of participants) was poor network reception, and 30% reported dropped IVR calls. Most (90%) participants thought they learned the same or more compared with a conventional course. Knowledge of contraceptive side effects increased significantly, from an average of 12.6/20 questions correct before training to 16.0/20 after, and remained significantly higher 10 months after the end of training than at baseline, at 14.8/20, without any further reinforcement. CONCLUSIONS: The mLearning system proved appropriate, feasible, and acceptable to trainees, and it was associated with sustained knowledge gains. IVR mLearning has potential to improve quality of care without disrupting routine service delivery. Monitoring and evaluation of larger-scale implementation could provide evidence of system effectiveness at scale.

Can the Perinatal Information System in Peru be used to measure the proportion of adverse birth outcomes attributable to maternal syphilis infection?

OBJECTIVE: To describe the capacity of Peru's Perinatal Information System (Sistema Informático Perinatal, SIP) to provide estimates for monitoring the proportion of stillbirths and other adverse birth outcomes attributable to maternal syphilis. METHODS: A descriptive study was conducted to assess the quality and completeness of SIP data from six Peruvian public hospitals that used the SIP continuously from 2000 - 2010 and had maternal syphilis prevalence of at least 0.5% during that period. In-depth interviews were conducted with Peruvian stakeholders about their experiences using the SIP. RESULTS: Information was found on 123 575 births from 2000 - 2010 and syphilis test results were available for 99 840 births. Among those 99 840 births, there were 1 075 maternal syphilis infections (1.1%) and 619 stillbirths (0.62%). Among women with syphilis infection in pregnancy, 1.7% had a stillbirth, compared to 0.6% of women without syphilis infection. Much of the information needed to estimate the proportion of stillbirths attributable to maternal syphilis was available in the SIP, with the exception of syphilis treatment information, which was not collected. However, SIP data collection is complex and time-consuming for clinicians. Data were unlinked across hospitals and not routinely used or quality-checked. Despite these limitations, the SIP data examined were complete and valid; in 98% of records, information on whether or not the infant was stillborn was the same in both the SIP and clinical charts. Nearly 89% of women had the same syphilis test result in clinical charts and the SIP. CONCLUSIONS: The large number of syphilis infections reported in Peru's SIP and the ability to link maternal characteristics to newborn outcomes make the system potentially useful for monitoring the proportion of stillbirths attributable to congenital syphilis in Peru. To ensure good data quality and sustainability of Peru's SIP, data collection should be simplified and information should be continually quality-checked and used for the benefit of participating facilities.

Can the Perinatal Information System in Peru be used to measure the proportion of adverse birth outcomes attributable to maternal syphilis infection? / ¿Se puede utilizar el Sistema Informático Perinatal del Perú para medir la proporción de resultados adversos del nacimiento atribuibles a sífilis materna?

OBJECTIVE: To describe the capacity of Peru's Perinatal Information System (Sistema Informático Perinatal, SIP) to provide estimates for monitoring the proportion of stillbirths and other adverse birth outcomes attributable to maternal syphilis. METHODS: A descriptive study was conducted to assess the quality and completeness of SIP data from six Peruvian public hospitals that used the SIP continuously from 2000 - 2010 and had maternal syphilis prevalence of at least 0.5% during that period. In-depth interviews were conducted with Peruvian stakeholders about their experiences using the SIP. RESULTS: Information was found on 123 575 births from 2000 - 2010 and syphilis test results were available for 99 840 births. Among those 99 840 births, there were 1 075 maternal syphilis infections (1.1%) and 619 stillbirths (0.62%). Among women with syphilis infection in pregnancy, 1.7% had a stillbirth, compared to 0.6% of women without syphilis infection. Much of the information needed to estimate the proportion of stillbirths attributable to maternal syphilis was available in the SIP, with the exception of syphilis treatment information, which was not collected. However, SIP data collection is complex and time-consuming for clinicians. Data were unlinked across hospitals and not routinely used or quality-checked. Despite these limitations, the SIP data examined were complete and valid; in 98% of records, information on whether or not the infant was stillborn was the same in both the SIP and clinical charts. Nearly 89% of women had the same syphilis test result in clinical charts and the SIP. CONCLUSIONS: The large number of syphilis infections reported in Peru's SIP and the ability to link maternal characteristics to newborn outcomes make the system potentially useful for monitoring the proportion of stillbirths attributable to congenital syphilis in Peru. To ensure good data quality and sustainability of Peru's SIP, data collection should be simplified and information should be continually quality-checked and used for the benefit of participating facilities.

OBJETIVO: Describir la capacidad del Sistema Informático Perinatal (SIP) del Perú para proporcionar estimaciones que permitan vigilar la proporción de mortinatos y otros resultados adversos del nacimiento atribuibles a sífilis materna. MÉTODOS: Se llevó a cabo un estudio descriptivo para evaluar la calidad y la integridad de los datos del SIP correspondientes a seis hospitales públicos peruanos que utilizaron el SIP de forma continuada del 2000 al 2010, y presentaron una prevalencia de sífilis materna de como mínimo 0,5% durante ese período. Se realizaron entrevistas exhaustivas con interesados directos de Perú acerca de sus experiencias con el uso del SIP. RESULTADOS: Se obtuvo información sobre 123 575 nacimientos ocurridos del 2000 al 2010 y se dispuso de resultados de pruebas serológicas de sífilis correspondientes a 99 840 nacimientos. Se produjeron 1 075 casos de sífilis materna (1,1%) y 619 mortinatos (0,62%). El 1,7% de las mujeres con sífilis gestacional tuvieron un mortinato, en comparación con el 0,6% de las mujeres sin infección sifilítica. En el SIP se disponía de gran parte de la información necesaria para calcular la proporción de mortinatos atribuibles a sífilis materna, a excepción de la información sobre el tratamiento de la sífilis, que no se recopiló. Sin embargo, la recopilación de datos del SIP es compleja y exige a los médicos clínicos dedicar tiempo. Los datos de los diferentes hospitales no estaban vinculados, no se utilizaban habitualmente ni se sometían a controles de calidad. A pesar de estas limitaciones, los datos del SIP analizados estaban completos y eran válidos; en 98% de los registros, la información sobre si se trataba o no de un mortinato coincidía entre el SIP y las historias clínicas. En casi 89% de las mujeres los resultados de las pruebas serológicas de sífilis eran los mismos en las historias clínicas y el SIP. CONCLUSIONES: El gran número de infecciones sifilíticas notificadas en el SIP del Perú y la capacidad de vincular las características maternas con los resultados de los recién nacidos hacen que el sistema sea potencialmente útil para vigilar la proporción de mortinatos atribuibles a sífilis congénita en Perú. Con objeto de garantizar la buena calidad de los datos y la sostenibilidad del SIP en Perú, es preciso simplificar la recopilación de datos y mantener un control permanente de la calidad de la información, que debe utilizarse en beneficio de los establecimientos participantes.

Pregnancy outcomes associated with Cesarean deliveries in Peruvian public health facilities.

A continuous rise in the rate of cesarean deliveries has been reported in many countries over recent decades. This trend has prompted the emergence of a debate on the risks and benefits associated with cesarean section. The present study was designed to estimate cesarean section rates over time during the period between 2000 and 2010 in Peru and to present outcomes for each mode of delivery. This is a secondary analysis of a large database obtained from the Perinatal Information System, which includes 570,997 pregnant women and their babies from 43 Peruvian public health facilities in three geographical regions: coast, highlands, and jungle. Over 10 years, 558,901 women delivered 563,668 infants weighing at least 500 g. The cesarean section rate increased from 25.5% in 2000 to 29.9% in 2010 (26.9% average; P < 0.01). The rate of stillbirths was lower with cesarean than vaginal deliveries (P < 0.01). On the other hand, and as expected, the rates for preterm births, twin pregnancies, and preeclampsia were higher in women who delivered by cesarean section (P < 0.01). More importantly, the rate of maternal mortality was 5.5 times higher in the cesarean section group than in the vaginal delivery group. Data suggest that cesarean sections are associated with adverse pregnancy outcomes.

Coverage of post-partum and post-natal care in Egypt in 2005-2008 and Bangladesh in 2004-2007: levels, trends and unmet need.

Maternal and neonatal mortality in the post-partum period remain high in many countries because of the limited provision of care. This study uses demographic & health survey data for Egypt in 2005 and 2008 and Bangladesh in 2004 and 2007 to analyse levels and trends in post-partum and post-natal care by place of delivery. Improvements were found in levels and timing of post-partum care following institutional deliveries in both countries, especially within 24 hours post-partum. In Egypt, post-partum care within 24 hours rose from 86% to 93% between the two surveys, and in Bangladesh from 46% to 67% (data for home deliveries only). In contrast, although most first neonatal care was within 24 hours, few improvements were seen in the proportion of infants receiving early care after institutional or home deliveries. If the first hour after delivery were excluded from our analysis, more than 40% and 78%, respectively, of the level of institution-based post-partum care in Egypt in 2008 and Bangladesh in 2007 would be excluded, implying that post-partum coverage may be far worse than DHS data indicate. This study shows that post-partum and post-natal care--like skilled attendance and emergency obstetric care--continue to be grossly neglected and lag far behind the high and rising levels of antenatal care in a growing number of countries.

Maternal and perinatal outcomes in second hemoglobin measurement in nonanemic women at first booking: effect of altitude of residence in peru.

Objective. To determine changes in hemoglobin concentration at second measurements after a normal hemoglobin concentration was detected at first booking during pregnancy at low and at high altitudes. Methods. This is a secondary analysis of a large database obtained from the Perinatal Information System in Peru which includes 379,816 pregnant women and their babies from 43 maternity units in Peru. Results. Most women remained with normal hemoglobin values at second measurement (75.1%). However, 21.4% of women became anemic at the second measurement. In all, 2.8% resulted with moderate/severe anemia and 3.5% with erythrocytosis (Hb>14.5 g/dL). In all cases Hb was higher as altitude increased. Risk for moderate/severe anemia increased associated with higher gestational age at second measurement of hemoglobin, BMI <19.9 kg/m(2), living without partner, <5 antenatal care visits, first parity, multiparity, and preeclampsia. Lower risk for moderate/severe anemia was observed with normal high Hb level at first booking living at moderate and high altitude, and high BMI. Conclusion. Prevalence of anemia increases as pregnancy progress, and that a normal value at first booking may not be considered sufficient as Hb values should be observed throughout pregnancy. BMI was a risk for anemia in a second measurement.

Association of hemoglobin values at booking with adverse maternal outcomes among Peruvian populations living at different altitudes.

OBJECTIVE: To determine hemoglobin values associated with adverse maternal outcomes among Peruvian populations at different altitudes. METHODS: A retrospective cohort study was conducted using data from the Perinatal Information System. Adverse maternal outcomes were assessed. RESULTS: Risk of pre-eclampsia increased at maternal hemoglobin levels above 14.5 g/dL (OR 1.27; 95% CI, 1.18-1.36) or below 7.0 g/dL (OR 1.52; CI 95%, 1.08-2.14). Altitude above 2000 m reduced risk (OR 0.65; 95% CI 0.62-0.68). Risk of postpartum hemorrhage (PPH) increased with moderate/severe anemia (OR 6.15; 95% CI, 3.86-9.78) and at moderate altitudes (OR 1.26; 95% CI, 1.12-1.43). Mild anemia at any altitude was associated with reduced risk of pre-eclampsia (OR 0.85, 95% CI, 0.81-0.89) and PPH (OR 1.01; 95% CI, 0.88-1.15). Risk of premature rupture of membranes was reduced at high hemoglobin values. Maternal mortality increased at hemoglobin levels below 9.0 g/dL (OR 5.68; 95% CI, 2.97-10.80) and above 14.5 g/dL (OR 2.18; 95% CI, 1.22-3.91). Maternal mortality increased at moderate altitudes (OR 29.2; 95% CI, 2.62-324.60) and high altitudes (OR 66.4; 95% CI, 6.65-780.30) when hemoglobin levels were below 9.0 g/dL. CONCLUSION: Elevated altitude and hemoglobin levels influence maternal outcomes.

In vitro motility of liver connexin vesicles along microtubules utilizes kinesin motors.

Trafficking of the proteins that form gap junctions (connexins) from the site of synthesis to the junctional domain appears to require cytoskeletal delivery mechanisms. Although many cell types exhibit specific delivery of connexins to polarized cell sites, such as connexin32 (Cx32) gap junctions specifically localized to basolateral membrane domains of hepatocytes, the precise roles of actin- and tubulin-based systems remain unclear. We have observed fluorescently tagged Cx32 trafficking linearly at speeds averaging 0.25 µm/s in a polarized hepatocyte cell line (WIF-B9), which is abolished by 50 µM of the microtubule-disrupting agent nocodazole. To explore the involvement of cytoskeletal components in the delivery of connexins, we have used a preparation of isolated Cx32-containing vesicles from rat hepatocytes and assayed their ATP-driven motility along stabilized rhodamine-labeled microtubules in vitro. These assays revealed the presence of Cx32 and kinesin motor proteins in the same vesicles. The addition of 50 µM ATP stimulated vesicle motility along linear microtubule tracks with velocities of 0.4-0.5 µm/s, which was inhibited with 1 mM of the kinesin inhibitor AMP-PNP (adenylyl-imidodiphosphate) and by anti-kinesin antibody but only minimally affected by 5 µM vanadate, a dynein inhibitor, or by anti-dynein antibody. These studies provide evidence that Cx32 can be transported intracellularly along microtubules and presumably to junctional domains in cells and highlight an important role of kinesin motor proteins in microtubule-dependent motility of Cx32.

Trifluoroethanol reveals helical propensity at analogous positions in cytoplasmic domains of three connexins.

Cytoplasmic domains of gap junction proteins (connexins) are involved in channel gating, voltage and pH sensitivity, and contain binding sites for partner proteins. However, their secondary structure is incompletely characterized and comparisons among the connexins is totally lacking. Circular dichroism (CD) was used to study the conformational properties of synthetic peptides corresponding to the highly divergent amino acid sequences of cytoplasmic domains of connexin (Cx)32, Cx36, and Cx43. We report that whereas peptides were largely unstructured in aqueous buffer, certain peptides in 30% trifluoroethanol (TFE) showed considerable helical content. These structured peptides correspond to analogous regions in each of the three connexin cytoplasmic domains. This first comparative study of conformational properties of connexin cytoplasmic domains reveals protein domains that may play similar roles in channel function and protein-protein interactions.

The neuronal connexin36 interacts with and is phosphorylated by CaMKII in a way similar to CaMKII interaction with glutamate receptors.

Electrical synapses can undergo activity-dependent plasticity. The calcium/calmodulin-dependent kinase II (CaMKII) appears to play a critical role in this phenomenon, but the underlying mechanisms of how CaMKII affects the neuronal gap junction protein connexin36 (Cx36) are unknown. Here we demonstrate effective binding of (35)S-labeled CaMKII to 2 juxtamembrane cytoplasmic domains of Cx36 and in vitro phosphorylation of this protein by the kinase. Both domains reveal striking similarities with segments of the regulatory subunit of CaMKII, which include the pseudosubstrate and pseudotarget sites of the kinase. Similar to the NR2B subunit of the NMDA receptor both Cx36 binding sites exhibit phosphorylation-dependent interaction and autonomous activation of CaMKII. CaMKII and Cx36 were shown to be significantly colocalized in the inferior olive, a brainstem nucleus highly enriched in electrical synapses, indicating physical proximity of these proteins. In analogy to the current notion of NR2B interaction with CaMKII, we propose a model that provides a mechanistic framework for CaMKII and Cx36 interaction at electrical synapses.

Cardiac connexins: genes to nexus.

Gap junctions are formed of at least 20 connexin proteins in mammals and possibly pannexins as well. Of the connexins, at least 5 (Cx30.2, Cx37, Cx40, Cx43 and Cx45) are prominently expressed in the heart and each shows regional and cell type specific expression. Contributions of each of these connexins to heart function has been in many cases illuminated by connexin null mice. The cardiac connexin genes whose genomic organization and transcriptional controls have been studied most thoroughly indicate more complex possibilities for alternate promoter usage than originally thought as well a multiple transcription factor binding sites; presumably, such complexity governs developmental timing and regional connexin expression patterns. The structure of cardiac connexin proteins indicate four primarily alpha-helical transmembrane domains, cytoplasmic amino and carboxyl termini and a cytoplasmic loop, all of which contain some regions of alpha-helix, and extracellular loops that are primarily Beta-structure. A number of proteins that bind to cardiac connexins are known, and more are certain to be discovered, linking the connexin into an intercellular signaling complex, the nexus. Binding sites may either correspond to structured regions within the connexin molecules or be unstructured, leading to presumably low-affinity and dynamic interactions.

Transfection of mammalian cells with connexins and measurement of voltage sensitivity of their gap junctions.

Vertebrate gap junction channels are formed by a family of more than 20 connexin proteins. These gap junction proteins are expressed with overlapping cellular and tissue specificity, and coding region mutations can cause human hereditary diseases. Here we present a summary of what has been learned from voltage clamp studies performed on cell pairs either endogenously expressing gap junctions or in which connexins are exogenously expressed. General protocols presented here are currently used to transfect mammalian cells with connexins and to study the biophysical properties of the heterologously expressed connexin channels. Transient transfection is accomplished overnight with maximal expression occurring at about 36 h; stable transfectants normally can be generated within three or four weeks through colony selection. Electrophysiological protocols are presented for analysis of voltage dependence and single-channel conductance of gap junction channels as well as for studies of chemical gating of these channels.

Factors affecting the performance of maternal health care providers in Armenia.

BACKGROUND: Over the last five years, international development organizations began to modify and adapt the conventional Performance Improvement Model for use in low-resource settings. This model outlines the five key factors believed to influence performance outcomes: job expectations, performance feedback, environment and tools, motivation and incentives, and knowledge and skills. Each of these factors should be supplied by the organization in which the provider works, and thus, organizational support is considered as an overarching element for analysis. Little research, domestically or internationally, has been conducted on the actual effects of each of the factors on performance outcomes and most PI practitioners assume that all the factors are needed in order for performance to improve. This study presents a unique exploration of how the factors, individually as well as in combination, affect the performance of primary reproductive health providers (nurse-midwives) in two regions of Armenia. METHODS: Two hundred and eighty-five nurses and midwives were observed conducting real or simulated antenatal and postpartum/neonatal care services and interviewed about the presence or absence of the performance factors within their work environment. Results were analyzed to compare average performance with the existence or absence of the factors; then, multiple regression analysis was conducted with the merged datasets to obtain the best models of "predictors" of performance within each clinical service. RESULTS: Baseline results revealed that performance was sub-standard in several areas and several performance factors were deficient or nonexistent. The multivariate analysis showed that (a) training in the use of the clinic tools; and (b) receiving recognition from the employer or the client/community, are factors strongly associated with performance, followed by (c) receiving performance feedback in postpartum care. Other - extraneous - variables such as the facility type (antenatal care) and whether observation was on simulated vs. real patients (postpartum care) also had a role in observed performance. CONCLUSION: This study concludes that the antenatal and postpartum care performance of health providers in Armenia is strongly associated with having the practical knowledge and skills to use everyday tools of the trade and with receiving recognition for their work, as well as having performance feedback. The paper recognized several limitations and expects further studies will illuminate this important topic further.

A case/comparison study in the Eastern Region of Ghana on the effects of incorporating selected reproductive health services on family planning services.

OBJECTIVE: to assess the impact on the provision of family planning (FP) services when FP providers were also trained to provide additional, selected, reproductive health services. DESIGN: case/comparison study. PARTICIPANTS AND SETTINGS: twenty-four FP service delivery points in which training in sexually transmitted infection prevention and control services or post-abortion care services had been initiated (case facilities), were compared to 19 control facilities in which similar provider training had not yet been targeted. All settings were located in the Eastern Region of Ghana. MEASUREMENTS: service statistics for three study years (1996-1998) were reviewed. Structured interviews with providers, managers and clients provided qualitative data concerning impact and satisfaction. FINDINGS: case facilities which had integrated these additional reproductive health (RH) services experienced consistently higher numbers of clients and the total number of clients receiving FP services increased over time. There was also a statistically significant increase in continuing FP clients within case facilities. In contrast, the number of FP clients serviced in the comparison area remained basically unchanged over time. KEY CONCLUSIONS: interviews conducted with providers and managers in both types of settings indicated strong support for receipt of training to provide these integrated services and a request for additional training in an even broader array of RH and adult/child services. Clients also perceived the benefit of additional RH services and perceived these services to be of high quality. IMPLICATIONS FOR PRACTICE: expanding the repertoire of clinical skills of FP providers, enabling these practitioners to render RH services that augment basic FP services, has the potential to increase the number of new and continuing FP clients, and increases the satisfaction of both providers and consumers with respect to these services.