Countdown to 2015: Tracking Maternal and Child Health Intervention Targets Using Lot Quality Assurance Sampling in Bauchi State Nigeria

Background

Improving maternal and child health remains a top priority in Nigeria’s Bauchi State in the northeastern region where the maternal mortality ratio (MMR) and infant mortality rate (IMR) are as high as 1540 per 100,000 live births and 78 per 1,000 live births respectively. In this study, we used the framework of the continuum of maternal and child care to evaluate the impact of interventions in Bauchi State focused on improved maternal and child health, and to ascertain progress towards the achievement of Millennium Development Goals (MDGs) 4 and 5.

Methods

At baseline (2012) and then at follow-up (2013), we randomly sampled 340 households from 19 random locations in each of the 20 Local Government Areas (LGA) of Bauchi State in Northern Nigeria, using the Lot Quality Assurance Sampling (LQAS) technique. Women residents in the households were interviewed about their own health and that of their children. Estimated LGA coverage of maternal and child health indicators were aggregated across the State. These values were then compared to the national figures, and the differences from 2012 to 2014 were calculated.

Results

For several of the indicators, a modest improvement from baseline was found. However, the indicators in the continuum of care neither reached the national average nor attained the 90% globally recommended coverage level. The majority of the LGA surveyed were classifiable as high priority, thus requiring intensified efforts and programmatic scale up.

Conclusions

Intensive scale-up of programs and interventions is needed in Bauchi State, Northern Nigeria, to accelerate, consolidate and sustain the modest but significant achievements in the continuum of care, if MDGs 4 and 5 are to be achieved by the end of 2015. The intentional focus of LGAs as the unit of intervention ought to be considered a condition precedent for future investments. Priority should be given to the re-allocating resources to program areas and regions where coverage has been low. Finally, systematic considerations need to be given to the design of strategies that address the demand for health services.     

Determination of mechanical stiffness of bone by pQCT measurements: correlation with non-destructive mechanical four-point bending test data

Mechanical tests of bone provide valuable information about material and structural properties important for understanding bone pathology in both clinical and research settings, but no previous studies have produced applicable non-invasive, quantitative estimates of bending stiffness. The goal of this study was to evaluate the effectiveness of using peripheral quantitative computed tomography (pQCT) data to accurately compute the bending stiffness of bone. Normal rabbit humeri (N=8) were scanned at their mid-diaphyses using pQCT. The average bone mineral densities and the cross-sectional moments of inertia were computed from the pQCT cross-sections. Bending stiffness was determined as a function of the elastic modulus of compact bone (based on the local bone mineral density), cross-sectional moment of inertia, and simulated quasistatic strain rate. The actual bending stiffness of the bones was determined using four-point bending tests. Comparison of the bending stiffness estimated from the pQCT data and the mechanical bending stiffness revealed excellent correlation (R2=0.96). The bending stiffness from the pQCT data was on average 103% of that obtained from the four-point bending tests. The results indicate that pQCT data can be used to accurately determine the bending stiffness of normal bone. Possible applications include temporal quantification of fracture healing and risk management of osteoporosis or other bone pathologies.     

In-vitro head and neck response to impact

Two unembalmed and one embalmed human cadaveric head-neck systems were instrumented and subjected to central forehead impact of ballistically suspended 3.07-kg aluminum shell at velocities ranging from 50 to 345 cm/s. Occipital skull accelerations and disk pressures were measured by transducers, while the deformation of the system was determined by framing camera data. The results were found to be in accord with those from corresponding tests in artificial head-neck replica. Initial and terminal X-ray examination of the structure revealed no evidence of either skull or vertebral fractures.     

Evaluation of a Well-Established Task-Shifting Initiative: The Lay Counselor Cadre in Botswana

Background

Evidence supports the implementation of task shifting to address health worker shortages that are common in resource-limited settings. However, there is need to learn from established programs to identify ways to achieve the strongest, most sustainable impact. This study examined the Botswana lay counselor cadre, a task shifting initiative, to explore effectiveness and contribution to the health workforce.

Methods

This evaluation used multiple methods, including a desk review, a national lay counselor survey (n = 385; response = 94%), in-depth interviews (n = 79), lay counselors focus group discussions (n = 7), lay counselors observations (n = 25), and client exit interviews (n = 47).

Results

Interview and focus group data indicate that lay counselors contribute to essentially all HIV-related programs in Botswana and they conduct the majority of HIV tests and related counseling at public health facilities throughout the country. Interviews showed that the lay counselor cadre is making the workload of more skilled health workers more manageable and increasing HIV acceptance in communities. The average score on a work-related knowledge test was 74.5%. However for 3 questions, less than half answered correctly. During observations, lay counselors demonstrated average competence for most skills assessed and clients (97.9%) were satisfied with services received. From the survey, lay counselors generally reported being comfortable with their duties; however, some reported clinical duties that extended beyond their training and mandate. Multiple factors affecting the performance of the lay counselors were identified, including insufficient resources, such as private counseling space and HIV test kits; and technical, administrative, and supervisory support.

Conclusion

Lay counselors are fulfilling an important role in Botswana''s healthcare system, serving as the entry point into HIV care, support, and treatment services.

Recommendation

For this and other similar task shifting initiatives, it is important that lay counselors'' responsibilities are clear and that training and support are adequate to optimize their effectiveness.     

Hysteretic pinching of human secondary osteons subjected to torsion

The mechanical behavior of bone tissue's ultra- and micro- structure is fundamental to assessment of macroscopic bone mechanics. This paper explores the ultra-structural characteristics of human femoral tissue responsible for energy absorption of secondary osteons under mechanical loading. A novel mathematical interpretation of single osteon mechanics elucidates the behavior of the collagen-apatite interface. Fully calcified single osteon specimens were mechanically tested quasi-statically under cyclic torsional loading about their longitudinal axis. On each hysteretic diagram, all cycles after the initial monotonic cycle appear pinched and share two points. Stiffness degradation and pinching degradation were investigated on the torque versus deflection-angle-per-unit-length diagrams as the number of cycles increases, in relation to the appearance of osteons in cross-section under circularly polarized light microscopy. Material science's Bauschinger effect, originally defined for metals and later extended to structures reinforced with metal bars, is adapted to describe pinching. Material science's prying effect, defined as amplification of eccentric tensile load through lever action, is employed to explain pinching. The presence of the two points shared by all complete cycles is analyzed in terms of the mathematical fixed point theorem. The results allow formulation of the following conjectures: (1) the prying of carbonated apatite crystallites at the interface with the 40 nm long bands of non-calcified collagen fibrils causes pinching; (2) the prying effect increases with the increasing percentage of collagen-apatite elements that form a larger angle with the osteon axis; and (3) micro-cracks increase more in number than in length as the number of cycles increases.