Communicating coverage data with non-literate communities: beans, sticks or pie charts?

A study was undertaken by staff of a health project in Malawito identify the optimum strategy for reporting information tobeneficiary communities regarding project coverage and effectiveness.Three candidate methods for presentation of coverage data tothis non-literate or semi-literate population were selected,based on preliminary qualitative research: (1) a two-colourrotating pie chart; (2) a set of sticks cut in varying lengthsrelative to a ‘full length’ (100%) standard stickand; (3) measures of beans, with ten measures representing afull (100%) measure of beans. Data were presented to 60 individual participants, using twoexamples for each of the three methods. Questions requiringinterpretation of the data were then asked of each of 60 individualparticipants, using two examples for each of the three methods.Questions requiring interpretation of the data were then askedof each of 60 participants and responses recorded as corrector incorrect. All three methods were more than 80% effectivein communicating concepts of proportion, as measured by thepercentage of correct responses. The 'pie chart' method appearedleast effective, and the ‘beans method’ most effectivein presentation of the information. The effectiveness of the‘beans method’ was significantly greater than thatof the ‘pie chart’ method (P=0.02). This study providesinformation which may be of use to programme managers in selectingstrategies for communication of health service data to the communitiesin which they work. It also demonstrates a simple methodologyfor identifying and assessing the relative effectiveness ofpresentation methods.     

四川省实施卫生部/全球疫苗免疫联盟乙型肝炎疫苗合作项目评价

目的评价四川省实施卫生部/全球疫苗免疫联盟乙型肝炎(乙肝)疫苗(HepB)合作项目(GAVI项目)情况。方法从全省20个市(州,下同)随机抽取20个县(区,下同)、40个乡(镇,下同)开展HepB纳入免疫规划工作调查,抽取324份<3岁儿童血标本进行乙肝病毒(HBV)血清标志物检测。结果四川省自2003年开始实施GAVI项目以来,新生儿HepB全程(HepB3)接种率、首针(HepB1)及时接种率不断提高,分别为90.82%、74.73%;<3岁儿童乙肝病毒表面抗原(HBsAg)携带率为0.63%,比GAVI项目实施前的2002年下降了79.74%;县、乡两级医院住院分娩儿童HepB1及时接种率≥95%;通过项目的实施,提高了乡村医生和儿童监护人对乙肝预防知识的认知度,促进了预防接种安全注射的开展。结论四川省GAVI项目效果显著,以省为单位新生儿HepB3接种率、HepB1及时接种率和<3岁儿童HBsAg携带率已达到项目既定目标。今后的重点应在少数民族地区和边远山区,加强培训和宣传教育,提高住院和在家分娩儿童HepB1及时接种率。     

Catalyzing the scale‐up of community‐based primary healthcare in a rural impoverished region of northern Ghana

Ghana's Community‐based Health Planning and Services (CHPS) initiative develops accessible healthcare with participatory community support, using strategies developed and tested by a project of the Navrongo Health Research Centre. In 1996, the project was expanded to a district‐wide four‐celled trial. In response to evidence that strategies could reduce fertility and childhood mortality, a replication project was launched to develop methods for scale‐up. Based on experience gained, CHPS scale‐up was launched in 2000. Although CHPS now reaches all of Ghana's districts, the pace of scale‐up within districts has been slow. In response, the Ministry of Health conducted a review of factors that constrain CHPS scale‐up and problems that detract from its original evidence‐based design. To resolve problems that were identified, a project was launched in 2010 to test means of accelerating CHPS scale‐up and expand its range of care. Known as the Ghana Essential Health Interventions Program (GEHIP), the project provided catalytic revenue to four treatment district managers for 3 years, in conjunction with implementation of strategies for comprehensive leadership development and community partnership. Monitoring systems were developed to gauge CHPS coverage time trends in all nine study districts. GEHIP successfully accelerated CHPS implementation, producing 100% of its targeted community coverage within 5 years of implementation. Coverage in comparison districts also improved. However, the rate of coverage and per cent of the population reached by CHPS in comparison districts was only half that of GEHIP districts. GEHIP success in completing CHPS coverage represents the initial stage of a national program for strengthening community health systems in Ghana. Copyright © 2015 John Wiley & Sons, Ltd.     

Positive Impact of a Shelter-based Hepatitis B Vaccine Program in Homeless Baltimore Children and Adolescents

Homeless youth are at increased risk for hepatitis B virus (HBV) infection and HBV vaccine coverage is poor in this group. The purpose of our study was to determine if a shelter-based HBV vaccine program in children and adolescents 2–18 years of age with a randomized controlled trial using a culturally appropriate HBV video could increase HBV vaccine coverage rates. Subjects were randomized to an 8 min HBV video or a control, smoking prevention video. Before exposure to the videos, HBV knowledge, and demographics were assessed in caregivers and adolescents. HBV vaccine no. 1 was offered to all subjects who did not produce a vaccine record; subsequently, an accurate HBV vaccine history was obtained from medical providers. Subjects were asked to return 1 and 3 months after visit 1, HBV vaccine was offered to all with incomplete coverage, and HBV knowledge was reassessed. There were 328 children and adolescents cared for by 170 caregivers enrolled in the study. One hundred and four had incomplete HBV vaccine coverage. Data are reported for all family units with at least one subject needing vaccine. There were 53 children and adolescents randomized to the HBV video vs. 51 to the smoking video. HBV knowledge scores of caregivers improved at Visit no. 2 vs. no. 1 in the HBV video group (p = 0.01) but not in the smoking group (p = 0.82). Similar results were observed for adolescents in the HBV video group (p = 0.05) but not in the smoking group (p = 0.40). Exposure to the HBV video vs the smoking video had a significant effect on return rates for vaccine at Visit no. 2 (59 vs. 31%; p = 0.05) but not at Visit no. 3 (47 vs. 18%, p = 0.06). The shelter-based vaccine program was very effective in increasing HBV coverage rates in the entire group of 328 children and adolescents enrolled in the study, from 68% coverage at baseline to 85% at the conclusion of the study. We conclude that shelter-based HBV vaccine programs can be highly effective in increasing vaccine coverage rates in older children and adolescents. A brief exposure to a culturally appropriate HBV video improves HBV knowledge and may improve return rates for vaccine.     

Improving hepatitis B birth dose coverage through village health volunteer training and pregnant women education

Hepatitis B is highly endemic in the Republic of Kiribati, while the coverage of timely birth dose vaccination, the primary method shown to prevent mother-to-child transmission of hepatitis B virus, was only 66% in 2014. Children born at home are especially at high risk, as they have limited access to timely birth dose (i.e. within 24 h) vaccination. To improve birth dose coverage, a project to improve linkages between village health volunteers and health workers and educate pregnant women on hepatitis B vaccination was carried out in 16 communities with low birth dose coverage in Kiribati from November 2014 to May 2015. After project completion, the coverage of timely birth dose administration increased significantly both in the densely populated capital region of South Tarawa (from 89% to 95%, p = 0.001) and the Outer Islands (from 57% to 83%, p < 0.001). The coverage of timely birth dose administration among infants born at home increased significantly from 70% to 84% in South Tarawa (p = 0.001) and from 49% to 75% in the Outer Islands (p < 0.001). Timely birth dose was associated with being born in a hospital, being born during the study period and caregivers having developed an antenatal birth dose plan. The project demonstrates a successful model for improving hepatitis B vaccine birth dose coverage that could be adopted in other areas in Kiribati as well as other similar settings.     

High and equitable tuberculosis awareness coverage in the community-driven Axshya TB control project in India

Data from surveys on knowledge, attitudes and practice (KAP) on tuberculosis (TB) conducted under the Axshya project at two time points (baseline 2010–2011 and mid-line 2012–2013) were analysed for changes in coverage and equity of TB awareness after project interventions. Overall coverage increased from 84% at baseline to 88% at midline (5% increase, P < 0.05). In comparison to baseline results, coverage at the midline survey had significantly increased, from 81% to 87% among the rural population, from 81% to 86% among women, from 73% to 85% in the ⩾55 years age group, from 71% to 80% among illiterates and from 73% to 81% in the south zone (P < 0.05). The equity gap among the different study groups (settlement, sex, age, education and zones) decreased from 6–23% at baseline to 3–11% during the midline survey. The maximum decline was observed for type of settlement (rural vs. urban), from 10% to 3% (P < 0.05). This community-driven TB control project has achieved high and equitable coverage of TB awareness, offering valuable lessons for the global community.     

Employer choices of family premium sharing

In 1997, nearly two-thirds of married couples with children under age 18 were dual-earner couples. Such families may have a variety of insurance options available to them. If so, declining a high employee premium contribution may be a mechanism for one spouse to take money wages in lieu of coverage while the other spouse takes coverage rather than high wages. Employers may use these preferences and the size of premium contributions to encourage workers to obtain family coverage through their spouse. The purpose of this paper is to explore the effects of labor force composition, particularly the proportion of dual-earner couples in the labor market, on the marginal employee premium contribution (marginal EPC) for family coverage. We analyze data from the 1997–2001 Medical Expenditure Panel Survey— Insurance Component (MEPS-IC) List Sample of private establishments. We find strong evidence that the marginal EPC for family coverage is higher when there is a larger concentration of women in the workforce, but only in markets with a higher proportion of dual-earner households. JEL Code I11 - Analysis of Health Care Markets This study was funded by the Employee Benefits Security Administration of the U.S. Department of Labor and was prepared for the conference “Employee Benefits and Two-Earner Households,” May 8, 2004, Washington, D.C. Jessica Vistnes received no funding for her participation in the project.The research in this paper was conducted while Jessica Vistnes was also a Census Bureau research associate at the Center for Economic Studies. Research results and conclusions expressed are those of the authors and do not necessarily indicate concurrence by the Bureau of the Census, the Department of Health and Human Services or the Agency for Healthcare Research and Quality. This paper has been screened to insure that no confidential information has been revealed.     

Changes in Childhood Immunization Disparities between Central Cities and Their Respective States, 2000 versus 2006

Central cities have lower childhood immunization coverage rates than states in which they are located. We conducted a secondary analysis of the National Immunization Survey (NIS) 2000 and 2006 of children 19–35 months old for 26 NIS-defined central cities and the rest of their respective states in order to examine patterns in early childhood immunization disparities between central cities and their respective states and the contextual factors associated with these disparities. We examined three measures of immunization disparities (absolute, difference, and ratio of change) and the patterns of disparity change with regard to selected contextual factors derived from the census. In 2000, immunization coverage in central cities was 68.3% and 74.7% in the rest of their states, a 6.4% disparity (t = 3.82, p < 0.000). Between 2000 and 2006, the overall city/state disparity narrowed to 3.5%, with the central city coverage up to 78.7% vs. 82.5% for the rest of state (t = 2.48, p = 0.017). However, changes in immunization disparities were not uniform: six cities narrowed, 14 had minimal change, and six widened. Central cities with a larger share of Hispanics experienced less reduction in disparities than other cities (beta = −4.2, t = −2.11, p = 0.047). Despite overall progress in childhood immunization coverage, most central cities still show significant disparities with respect to the rest of their states. Cities with larger Hispanic populations may need extra help in narrowing their disparities.     

中国乙型肝炎疫苗纳入儿童免疫规划实施情况调查分析

目的了解乙型肝炎(乙肝)疫苗(HepB)纳入儿童免疫规划后现状,发现存在的问题。方法从卫生部与全球疫苗免疫联盟/儿童疫苗基金合作项目的22个省(自治区、直辖市,下同)中,抽取10个省开展HepB纳入儿童免疫规划后经费支持、接种工作实施、安全注射、接种率及HepB使用与管理等情况调查。结果大部分省都能及时提供项目所需的配套经费和工作经费,以省为单位HepB报告接种率已经达到项目既定的目标,但估算和调查HepB首针及时接种率仍未达到项目目标。结论尽管各省实际HepB接种率没有报告接种率那么高,但HepB3全程接种率和HepB1及时接种率在HepB纳入儿童免疫规划后已经取得巨大成绩。为了达到项目目标,工作的重点应该是提高在家分娩儿童的HepB1及时接种率。     

Accelerating measles elimination and strengthening routine immunization services in Guizhou Province,China, 2003–2009

BackgroundTo develop a successful model for accelerating measles elimination in poor areas of China, we initiated a seven-year project in Guizhou, one of the poorest provinces, with reported highest measles incidence of 360 per million population in 2002.MethodsProject strategies consisted of strengthening routine immunization services, enforcement of school entry immunization requirements at kindergarten and school, conducting supplemental measles immunization activities (SIAs), and enhancing measles surveillance. We measured coverage of measles containing vaccines (MCV) by administrative reporting and population-based sample surveys, systematic random sampling surveys, and convenience sampling surveys for routine immunization services, school entry immunization, and SIAs respectively. We measured impact using surveillance based measles incidence.ResultsRoutine immunization coverage of the 1st dose of MCV (MCV1) increased from 82% to 93%, while 2nd dose of MCV (MCV2) coverage increased from 78% to 91%. Enforcement of school entry immunization requirements led to an increase in MCV2 coverage from 36% on primary school entry in 2004 to 93% in 2009. Province-wide SIAs achieved coverage greater than 90%. The reported annual incidence of measles dropped from 200 to 300 per million in 2003 to 6 per million in 2009, and sustained at 0.9–2.2 per million in 2010–2013.ConclusionsThis project found that a package of strategies including periodic SIAs, strengthened routine immunization, and enforcing school entry immunization requirements, was an effective approach toward achieving and sustaining measles elimination in less-developed area of China.     

深圳市结核病控制项目实施效果及可持续性发展初探

目的：深圳市实施世界银行贷款结核病控制项目的效果及项目取得的成效。方法：收集项目运行期间全市有关的各种统计报表及有关资料进行分析。结果：从1993年至2001年项目实施期间，病人发现率逐年增加，治疗覆盖率达100%，完成治疗率达98%，督导化疗管理率达100%。新发涂阳痰菌阴转率达88%，复治涂阳达85%，新发涂阳治愈率达97%，复治达91%。结论：深圳市自实施世行贷款结核病控制项目以来，政府重视，配套经费落实，归口管治工作卓有成效。三级防痨网络牢固建立，项目的各项指标完成良好，达到和超过了项目的指标，有效地降低了结核病的疫情。     

健康教育对提高农牧区新生儿乙型肝炎疫苗首针及时接种率的效果分析

目的探讨在农牧区开展健康教育推动新生儿乙型肝炎(乙肝)疫苗首针(HepB1)及时接种。方法开发宣传品、培训专业人员、动员当地知名人士开展宣传和健康教育活动。结果居民知晓率、新生儿HepB1及时接种率分别由项目前的48.84%、42.61%上升到项目后的91.27%、75.02%,差异均有非常显著的统计学意义(χ2=57.13,χ2=838.16;P均<0.001)。结论在农牧区开展乙肝预防控制健康教育,可促进新生儿HepB1及时接种率的提高。     

Lessons learnt from implementing community engagement interventions in mobile hard-to-reach (HTR) projects in Nigeria, 2014–2015

Background

The year 2014 was a turning point for polio eradication in Nigeria. Confronted with the challenges of increased numbers of polio cases detected in rural, hard-to-reach (HTR), and security-compromised areas of northern Nigeria, the Nigeria polio program introduced the HTR project in four northern states to provide immunization and maternal and child health services in these communities. The project was set up to improve population immunity, increase oral polio vaccine (OPV) and other immunization uptake, and to support Nigeria’s efforts to interrupt polio transmission by 2015. Furthermore, the project also aimed to create demand for these services which were often unavailable in the HTR areas. To this end, the program developed a community engagement (CE) strategy to create awareness about the services being provided by the project. The term HTR is operationally defined as geographically difficult terrain, with any of the following criteria: having inter-ward/inter-Local Government Area/interstate borders, scattered households, nomadic population, or waterlogged/riverine area, with no easy to access to healthcare facilities and insecurity.

Methods

We evaluated the outcome of CE activities in Kano, Bauchi, Borno, and Yobe states to examine the methods and processes that helped to increase OPV and third pentavalent (penta3) immunization coverage in areas of implementation. We also assessed the number of community engagers who mobilized caregivers to vaccination posts and the service satisfaction for the performance of the community engagers.

Results

Penta3 coverage was at 22% in the first quarter of project implementation and increased to 62% by the fourth quarter of project implementation. OPV coverage also increased from 54% in the first quarter to 76% in the last quarter of the 1-year project implementation.

Conclusions

The systematic implementation of a CE strategy that focused on planning and working with community structures and community engagers in immunization activities assisted in increasing OPV and penta3 immunization coverage.

     

Evaluation of factors influencing vaccine uptake in Mozambique

A pulse immunization project was started in Mozambique to compensate for the decrease in routine immunization caused by destabilization. A study was conducted to evaluate the project and identify determinants of vaccination in urban and rural areas of Mozambique. Vaccine coverage based on a documented record, the 'Road to Health' card, was 53% in urban and 60% in rural project areas, and 12% higher if a verbal history of vaccination was considered. A further 17% of children would have received effective vaccination if the correct schedule had been followed for all vaccines given and all preventive health services contacts had been used for vaccination. Factors relating to the individual mother and child and factors relating to the clusters were investigated for their association with vaccine uptake. Those which showed a strong negative association included vaccination on offer at the nearest vaccination post for only a small number of days per week; cancellation of an outreach session; knowing a child with a post-vaccination abscess; child born at home; at least five children in the family; mother's inability to speak Portuguese and her inability to name at least two target diseases. Improving the supervision of health services and immunizing at least three days per week at permanent immunization clinic sites may be the most important measures to improve coverage further.     

世界银行贷款疾病预防项目计划免疫子项目实施不同阶段疫苗接种率及影响因素调查分析

目的评价世界银行贷款疾病预防项目计划免疫子项目实施不同阶段,计划免疫服务提供与工作管理质量。方法在实施的初期(1996年)、中期(1999年)、终期(2003年)分别采用分层多阶段组群随机抽样方法,对卡介苗(BCG)、口服脊髓灰质炎疫苗(OPV)、麻疹疫苗(MV)、百白破联合疫苗(DPT)、乙型肝炎疫苗(HepB)接种率及其影响因素进行了调查,分别以河北、山西、河南、湖北、广西、贵州、云南、陕西、甘肃、新疆10个项目省(自治区,下同)1993、1997、2001年出生的儿童为调查对象,调查该年度出生儿童12月龄内5种疫苗的接种情况,并比较项目实施不同阶段的接种率。结果项目实施终期10个项目省的BCG、OPV3、DPT3、MV接种率和四苗全程免疫覆盖率分别为96.8%、89.4%、89.4%、89.8%和79.5%。2003年终期调查时HepB3接种率及HepB1及时接种率分别为71.79%、48.45%,显著高于初期和中期调查时的接种率水平。结论项目的实施对项目省保持较高的计划免疫疫苗接种率有明显的作用,但不同省、地区间的接种率水平仍存在着较大差异,农村地区及城市地区的流动人口仍为计划免疫工作的薄弱环节。     

Managing externally financed projects: the Integrated Primary Health Care Project in Bolivia.

Bolivia is one of the poorest countries in Latin America. Health indicators are very poor, communicable diseases are prevalent and, coupled with malnutrition, remain the major killers of children under 5 years old. The Integrated Primary Health Care Project (PROISS) was a US$39 million project executed by the Ministry of Health (MOH), 50% financed by the World Bank and aimed at improving primary health care in the four largest Bolivian municipalities. The implementation of the project started in 1990 and ended in 1997. During implementation it went through three distinct phases: Phase 1 (1990-94) was a period characterized by conflict and confusion; Phase 2 (1995-mid-1996) documented major improvements in coverage and service quality; and Phase 3 (mid-1996-97) witnessed the decline of the project. This paper explores the factors that contributed to the success and the decline of the project, draws lessons for project managers and international agencies involved in the definition and implementation of social sector projects, and discusses the unlikelihood that externally financed projects can have a sustainable impact on the development of the health sector of recipient countries.     

Evaluation of storing hepatitis B vaccine outside the cold chain in the Solomon Islands: Identifying opportunities and barriers to implementation

Monovalent Hepatitis B vaccine (HepB) is heat stable, making it suitable for storage outside cold chain (OCC) at 37 °C for 1 month. We conducted an OCC project in the Solomon Islands to determine the feasibility of and barriers to national implementation and to evaluate impact on coverage. Healthcare workers at 13 facilities maintained monovalent HepB birth dose (HepB-BD) OCC for up to 28 days over 7 months. Vaccination data were recorded for children born during the project and those born during 7 months before the project. Timely HepB-BD coverage among facility and home births increased from 30% to 68% and from 4% to 24%, respectively. Temperature excursions above 37 °C were rare, but vaccine wastage was high and shortages common. Storing HepB OCC can increase HepB-BD coverage in countries with insufficient cold chain capacity or numerous home births. High vaccine wastage and unreliable vaccine supply must be addressed for successful implementation.     

农村乙型肝炎防治健康教育效果分析

目的探讨在农村通过健康教育推动乙型肝炎(乙肝)疫苗(HepB)接种。方法2001年12月~2003年12月中国肝炎防治基金会与美国百时美施贵宝基金会合作,在陕西省的岐山、洛川、华县和甘肃省的会宁、古浪、康乐县实施“乙肝防治健康教育项目”。结果项目完成后儿童监护人预防乙肝知识知晓率从项目实施前的25%提高到项目实施后的87.80%,基层医生的相关知识知晓率从72.57%提高到97.10%,1岁内儿童HepB全程接种率从项目前的45%提高到项目实施后的90.6%,乙肝病毒表面抗原携带率从1.66%下降到0.17%。结论在农村开展乙肝防治健康教育,可有力地促进HepB接种率的提高。     

Generational Status,Health Insurance,and Public Benefit Participation Among Low-Income Latino Children

The objectives of this study were to (1) measure health insurance coverage and continuity across generational subgroups of Latino children, and (2) determine if participation in public benefit programs is associated with increased health insurance coverage and continuity. We analyzed data on 25,388 children income-eligible for public insurance from the 2003 to 2004 National Survey of Children’s Health and stratified Latinos by generational status. First- and second-generation Latino children were more likely to be uninsured (58 and 19%, respectively) than third-generation children (9.5%). Second-generation Latino children were similarly likely to be currently insured by public insurance as third-generation children (61 and 62%, respectively), but less likely to have private insurance (19 and 29%, respectively). Second-generation Latino children were slightly more likely than third-generation children to have discontinuous insurance during the year (19 and 15%, respectively). Compared with children in families where English was the primary home language, children in families where English was not the primary home language had higher odds of being uninsured versus having continuous insurance coverage (OR: 2.19; 95% CI [1.33–3.62]). Among second-generation Latino children, participation in the Food Stamp (OR 0.26; 95% CI [0.14–0.48]) or Women, Infants, and Children (OR 0.40; 95% CI [0.25–0.66]) programs was associated with reduced odds of being uninsured. Insurance disparities are concentrated among first- and second-generation Latino children. For second-generation Latino children, connection to other public benefit programs may promote enrollment in public insurance.