Rachelle E. Desrochers

In order to inform large scale supplementation programme design, we review and summarize the barriers and enablers for improved coverage and utilization of iron and folic acid (IFA) supplements by pregnant women in 7 countries in Africa and Asia. Mixed methods were used to analyse IFA supplementation programmes in Afghanistan, Bangladesh, Indonesia, Ethiopia, Kenya, Nigeria, and Senegal based on formative research conducted in 2012–2013. Qualitative data from focus‐group discussions and interviews with women and service providers were used for content analysis to elicit common themes on barriers and enablers at internal, external, and relational levels. Anaemia symptoms in pregnancy are well known among women and health care providers in all countries, yet many women do not feel personally at risk. Broad awareness and increased coverage of facility‐based antenatal care (ANC) make it an efficient delivery channel for IFA; however, first trimester access to IFA is hindered by beliefs about when to first attend ANC and preferences for disclosing pregnancy status. Variable access and poor quality ANC services, including insufficient IFA supplies and inadequate counselling to encourage consumption, are barriers to both coverage and adherence. Community‐based delivery of IFA and referral to ANC provides earlier and more frequent access and opportunities for follow‐up. Improving ANC access and quality is needed to facilitate IFA supplementation during pregnancy. Community‐based delivery and counselling can address problems of timely and continuous access to supplements. Renewed investment in training for service providers and effective behaviour change designs are urgently needed to achieve the desired impact.

Objective: To investigate knowledge and prevention practices regarding dengue and chikungunya amongst community members, as well as knowledge, treatment and diagnostic practices among healthcare workers.Method: We conducted a cross‐sectional survey with 125 community members and 125 healthcare workers from 13 health facilities in six villages in the Hai district of Tanzania. A knowledge score was generated based on participant responses to a structured questionnaire, with a score of 40 or higher (of 80 and 50 total scores for community members and healthcare workers, respectively) indicating good knowledge. We conducted qualitative survey (n = 40) to further assess knowledge and practice regarding dengue and chikungunya fever.Results: 15.2% (n = 19) of community members had good knowledge regarding dengue, whereas 53.6%, (n = 67) of healthcare workers did. 20.3% (n = 16) of participants from lowland areas and 6.5% (n = 3) from highland areas had good knowledge of dengue (χ² = 4.25, P = 0.03). Only 2.4% (n = 3) of all participants had a good knowledge score for chikungunya. In the qualitative study, community members expressed uncertainty about dengue and chikungunya. Some healthcare workers thought that they were new diseases.Conclusion: There is insufficient knowledge regarding dengue and chikungunya fever among community members and healthcare workers. Health promotion activities on these diseases based on Ecological Health Mode components to increase knowledge and improve preventive practices should be developed.

Introduction: Malaria prevalence has declined in the Kilimanjaro Region of Tanzania over the past 10 years, particularly at lower altitudes. While this decline has been related to the scale up of long-lasting insecticidal nets to achieve universal coverage targets, it has also been attributed to changes in environmental factors that are important for enabling and sustaining malaria transmission. Objectives: Herein we apply spatial analytical approaches to investigate the impact of environmental and demographic changes, including changes in temperature, precipitation, land cover and population density, on the range of the major malaria vector species Anopheles arabiensis in two districts of Tanzania, situated on the southern slope of Mount Kilimanjaro. These models are used to identify environmental changes that have occurred over a ten-year period and highlight the implications for malaria transmission in this highland region. Methods: Entomological data were collected from the Hai and Lower Moshi districts of Tanzania in 2001-2004 and 2014-2015. Vector occurrence data were applied alongside satellite remote sensing indices of climate and land cover, and gridded population data, to develop species distribution models for An. arabiensis for the 2004 and 2014 periods using Maxent. Models were compared to assess the relative contribution of different environmental and demographic factors to observed trends in vector species distribution in lowland and highland areas. Results: Changes in land cover were observed in addition to increased population densities, increased warm season temperature and decreased wetness at low altitudes. The predicted area and extent of suitable habitat for An. arabiensis declined across the study area over the ten-year period, with notable contraction at lower altitudes, while species range in higher altitude zones expanded. Importantly, deforestation and warmer temperatures at higher altitudes may have created stable areas of suitable vector habitat in the highlands capable of sustaining malaria transmission. Conclusions: We show that environmental changes have had an important influence on the distribution of malaria vector species in a highland area of northern Tanzania. Highland areas may be at continued risk for sporadic malaria outbreaks despite the overall range contraction of principal vector species at lower altitudes, where malaria transmission remains at low intensity.

Aim: It has been found that species richness can be a peaked function of natural area, meaning that conversion of natural cover can increase species numbers. Here, we test whether regional richness–environment relationships can predict local change in species richness.Location: The greater park ecosystem of Thousand Islands National Park (TINPecosystem), Ontario, Canada.Methods: We evaluated change in bird richness in 85 100‐km²sites, censused from 1981 to 1985 and from 2001 to 2005. We related change in richness over 20 years to change in natural land cover for sites having initially less or greater than half natural area to determine whether richness changes in the direction predicted. We also assessed the extent to which local effects (site‐level extinction and colonization based on species‐specific habitat amount and neighbourhood occupancy by conspecifics) affected the predictability of species richness response to environmental change.Results: Local effects predicted bird richness changes through time far better than natural area change (adjustedr² = 0.56 vs. adjustedr² = 0.13). Species richness did not consistently respond to change in natural area in the directions predicted by the broader spatial richness–environment relationship, tending to increase with decrease in natural area regardless of the initial amount of natural area. The observed natural area changes (+0.7 km²to −4.4 km²) were small relative to the changes in richness (+60 species to −37 species), likely impacting our ability to detect a response.Main conclusions: The importance of local effects observed here in determining site‐level species presence and consequently species richness has implications for species monitoring and the use of species richness as a measure of the avian response to land cover modification in Ontario. Detecting richness responses to environmental changes may often be challenged by low ‘signal‐to‐noise’ ratios and highlights the benefits of long‐term species monitoring.

Objectives: To identify existing barriers and potential enabling opportunities for the revitalization of iron and folic acid (IFA) supplementation to reduce anemia in pregnant women. Methods: A synthesis of formative research results from eight countries (Afghanistan, Bangladesh, Ethiopia, Indonesia, Kenya, Nepal, Nigeria, Senegal) was conducted to understand current antenatal care-seeking practices and identify relevant barriers and enablers associated with improved coverage and adherence to prenatal IFA supplementation. Results: Anemia in pregnancy is a well-known health concern by women, family decision-makers and health care providers in all countries studied. Widely varying views on when to start IFA supplementation, the dosage and the duration were expressed by women, family members and health care providers. Broad awareness of and modest attendance at facility-based ANC by pregnant women support this delivery channel for IFA, yet timely access is hindered by conflicting beliefs about the value of early initiation of ANC and the importance of prenatal IFA without anemia symptoms. Variable access and poor quality ANC services, specifically inadequate counseling on managing side effects and insufficient number of tablets given, are barriers to improving IFA coverage and ensuring adherence (≥90 tablets). In some cases, community-based delivery of ANC and IFA provided greater accessibility and follow-up for pregnant women. Conclusions: Improved ANC access and quality is needed to facilitate IFA supplementation. There is potential for community-based delivery and counseling to address concerns with IFA supplement supply and adherence. Renewed investment in IFA programs with strong behaviour change designs is urgently needed to achieve reductions in anemia.

Objectives: Treatment of diarrhea with zinc and ORS has both life-saving potential and diarrhea prevention benefits, yet here we explore the barriers as to why coverage and adherence remain low. Methods: A synthesis of formative research results from nine countries (Afghanistan, Bangladesh, Ethiopia, India, Indonesia, Kenya, Nepal, Nigeria, Senegal) was conducted to understand child diarrhea treatment practices and identify the barriers and enablers associated with ORS and zinc use. Results: In all countries, caregivers felt that diarrhea can be adequately cared for at home with local foods and drinks, traditional remedies and herbal medicine, tailored to the type of diarrhea. Perceived causes of diarrhea and advice from senior family members directly influenced treatment seeking. ORS was widely known for preventing dehydration in children with diarrhea, but was perceived as ineffective in stopping diarrhea. Caregivers and some health workers preferred antibiotics and anti-diarrheal medicines to “stop” diarrhea promptly. Outreach activities and free treatment for child diarrhea motivated caregivers to seek facility-based treatment. Barriers to ORS and zinc use include low awareness of zinc at multiple levels, frequent supply stock-outs and poor prescribing practices of health workers. Barriers to adherence to the full course of zinc include the common practice of stopping treatment when diarrhea stops and a lack of caregiver awareness of the benefits of zinc for prevention of diarrhea. Conclusions: Addressing context-specific beliefs about diarrhea causes and the effectiveness of home-remedies is essential to improve care-seeking behaviours. Maintaining adequate supplies and promoting the benefits of zinc will help to improve coverage and adherence.

It is well established that insecticide-treated bed nets (ITNs), in particular long-lasting, insecticidal nets (LLINs), can be used as one of the primary interventions for effective malaria control. A consistent gap between net ownership and use has been observed, indicating that factors exist that prevent an owned mosquito net from being used. One approach used in the context of LLIN campaigns is a post-distribution, door-to-door visit of households with educational messages and to physically assist with hang-up of nets.

Objective  To evaluate the effect of integrating ITN distribution on measles vaccination campaign coverage in Madagascar.Methods  Nationwide cross‐sectional survey to estimate measles vaccination coverage, nationally, and in districts with and without ITN integration. To evaluate the effect of ITN integration, propensity score matching was used to create comparable samples in ITN and non‐ITN districts. Relative risks (RR) and 95% confidence intervals (CI) were estimated via log‐binomial models. Equity ratios, defined as the coverage ratio between the lowest and highest household wealth quintile (Q), were used to assess equity in measles vaccination coverage.Results  National measles vaccination coverage during the campaign was 66.9% (95% CI 63.0–70.7). Among the propensity score subset, vaccination campaign coverage was higher in ITN districts (70.8%) than non‐ITN districts (59.1%) (RR = 1.3, 95% CI 1.1–1.6). Among children in the poorest wealth quintile, vaccination coverage was higher in ITN than in non‐ITN districts (Q1; RR = 2.4, 95% CI 1.2–4.8) and equity for measles vaccination was greater in ITN districts (equity ratio = 1.0, 95% CI 0.8–1.3) than in non‐ITN districts (equity ratio = 0.4, 95% CI 0.2–0.8).Conclusion  Integration of ITN distribution with a vaccination campaign might improve measles vaccination coverage among the poor, thus providing protection for the most vulnerable and difficult to reach children.