BACKGROUND: Malaria prevalence in Kenya is 6%, with a three-fold higher prevalence in western Kenya. Adherence to malaria treatment guidelines improves care for suspected malaria cases and can reduce unnecessary anti-malarial use. Data on adherence to guidelines in retail drug outlets (DOs) is limited, yet approximately 50% of people with fever access treatment first in these outlets. This study assessed adherence to the national malaria treatment guidelines among DOs in a high transmission area of Western Kenya.
METHODS: In a cross-sectional survey of DOs in Kisumu Central and Seme sub-counties in 2021, DO staff were interviewed using structured questionnaires to assess outlet characteristics (location, testing services), staff demographics (age, sex, training), and health system context (supervision, inspection). Mystery shoppers (research assistants disguised as clients) observed malaria management practices and recorded observations on a standardized tool. Adherence was defined as dispensing artemether-lumefantrine (AL) to patients with a confirmed positive test, accompanied by appropriate medication counseling. Logistic regression was used to test for association between adherence to guidelines and DO-related factors.
RESULTS: None of the 70 DOs assessed had a copy of the guidelines, and 60 (85.7%) were in an urban setting. Staff adhered to the guidelines in 14 (20%) outlets. The odds of adherence were higher among staff who had a bachelor\'s degree {odds ratio (OR) 6.0, 95% confidence interval (95% CI) 1.66-21.74}, those trained on malaria rapid diagnostic test (RDT) {OR 4.4, 95% CI 1.29-15.04}, and those who asked about patient\'s symptoms {OR 3.6, 95% CI 1.08-12.25}. DOs that had higher odds of adherence included those with functional thermometers {OR 5.3, 95% CI 1.46-19.14}, those recently inspected (within three months) by Pharmacy and Poisons Board (PPB) {OR 9.4, 95% CI 2.55-34.67}, and those with all basic infrastructure {OR 3.9, 95% CI 1.01-15.00}. On logistic regression analysis, recent PPB inspection {adjusted OR (AOR) 4.6, 95% CI 1.03-20.77} and malaria RDT-trained staff (aOR 4.5, 95% CI 1.02-19.84) were independently associated with adherence.
CONCLUSIONS: Most outlets didn\'t adhere to malaria guidelines. Regular interaction with regulatory bodies could improve adherence. Ministry of Health should enhance private sector engagement and train DOs on RDT use.

South Africa (SA) has the largest antiretroviral therapy programme in the world. While the majority of the country accesses healthcare in the public sector, 15.2% access private healthcare. In 2019, dolutegravir was introduced as first-line treatment for HIV. Dolutegravir has clinically significant interactions with numerous commonly used medicines, e.g. rifampicin and cation-containing medicines such as calcium and iron. They require dosage adjustments, detailed in public and private HIV guidelines.
To describe SA healthcare workers\' guideline access, training and knowledge of dolutegravir\'s interactions, focusing on differences between the public and private sectors.
A cross-sectional, descriptive study was done using an online survey of healthcare workers in the field of HIV in SA, conducted by the National HIV and TB Healthcare Worker Hotline. Convenience sampling was used, with electronic dissemination to users of the hotline and by relevant HIV-focused organisations. Simple descriptive statistics and statistical analyses were used.
A total of 1 939 surveys were analysed, with 22% from the private sector. Training on the dolutegravir guidelines was received by significantly fewer healthcare workers in the private sector v. the public sector: 42.4% (95% confidence interval (CI) 37 - 48) v. 67.5% (95% CI I 65 - 70), respectively. Significantly fewer healthcare workers in the private sector had access to the guidelines (63.8%; 95% CI 59 - 69 v. 78.8%; 95% CI 77 - 81). When asked if they were aware that dolutegravir has interactions, just over half (56.9%) of healthcare workers in the private sector responded \'yes\', 24.6% responded \'no\' and 18.5% did not answer. Of those who were aware that dolutegravir has interactions, 48.9% knew that dolutegravir interacts with calcium, 44.6% with iron and 82.0% with rifampicin. Private sector knowledge of dosing changes was lower for all interacting drugs, with the difference only significant for calcium and iron. Private sector healthcare workers reported significantly lower levels of counselling on dolutegravir use in all appropriate situations.
Private sector healthcare worker access to HIV training and guidelines requires attention. In a high-burden HIV setting such as SA, it is vital that healthcare workers across all professions, in both the public and private sector, know how to adjust antiretroviral dosing due to clinically significant interactions. Without these adjustments, there is a risk of treatment failure, increased mother-to-child transmission and morbidity and mortality.

BACKGROUND: Malaria is an infectious disease which has been globally targeted for elimination in at least 35 of 90 endemic countries by 2030. Most successful malaria elimination country programmes have engaged the private health sector in an effort to identify, document, investigate, provide effective treatment, and follow-up cases. However, there has been limited rigorous research showing evidence of adherence among healthcare providers of the formal private health sector to national malaria diagnosis and treatment guidelines in Ethiopia, starting from malaria control to elimination phases. The aims of this study were to investigate and explain the level of adherence to malaria diagnosis and treatment guidelines among healthcare providers working in formal private health facilities in north-western Ethiopia.
METHODS: An explanatory sequential mixed method design was conducted in the West Gojjam Zone of Ethiopia. Quantitative data were extracted from 1650 medical records of adult uncomplicated malaria outpatients served in 11 private-for-profit health facilities. In addition, using a qualitative approach, 33 in-depth interviews (IDIs) with healthcare providers were conducted. All interviews were audio-recorded, transcribed verbatim, and analysed using eight steps.
RESULTS: Of 1650 suspected malaria cases in adult outpatients, 80.6% (1330/1650) were screen tested using microscopy and the remainder 19.4% (320/1650) were tested using multispecies rapid diagnosis tests (RDTs). Hence, the results revealed that private healthcare providers universally adhered to diagnosis guidelines. In addition, after following-up and excluding other causes of fever, 4.1% (56/1376) patients were clinically diagnosed with uncomplicated malaria. Despite this, the proportion of private healthcare provider adherence with confirmed malaria case treatment guidelines was 20.9% (69/330). In addition, 1320 (95.9%) of adult outpatients with negative laboratory results were not treated. Some of the identified determinant factors for sub-optimal adherence of healthcare providers to malaria guidelines were interruptions in supply and lack of availability of recommended anti-malarial drugs, lack of availability of quality assured laboratory supplies, and poor knowledge of the recommendations of the national standards.
CONCLUSIONS: Private healthcare providers adhered to universal parasitological diagnosis, providing comprehensive counseling, and linking patients with community health workers. In addition, almost all laboratory negative patients were not treated with anti-malarial drugs. However, only one-fifth of confirmed patients were treated in line with national guideline recommendations. Malaria control and elimination efforts across Ethiopia could be improved through establishing a collaborative function of a win-win public private mix partnership model. In addition, including the data of the private health sector in the health information system could show real malaria burden and use the information to improve the adherence to malaria diagnosis, treatment, and reporting standards within the targeted era of elimination. Therefore, building the capacity of private healthcare providers and ensuring the availability of all nationally recommended drugs and supplies in private health sector facilities is recommended to improve the quality of services.

Health services respond to myriad practice standards and guidelines that regulate, monitor, and improve the safety and quality of healthcare. Although important, information overload and compliance fatigue for accreditation can be burdensome for service managers and clinicians. To address this, and ultimately improve the safety and quality of care, this case study demonstrates how a mapping exercise was completed to synthesise seven practice standards and guidelines relevant to palliative care; and develop an online resource to aid accreditation efforts and improve palliative care. A working group, comprised of service managers, clinicians, and academics, mapped a state-wide blueprint to improve palliative care against seven unique practice standards and guidelines, most of which were national in scope. This project culminated with a freely available online resource to translate the standards and guidelines for accreditation - a resource that supports service managers and clinicians across public and private health sectors to readily determine whether and how they demonstrated safety and quality in the context of palliative care and pursue accreditation. By developing one matrix, there is opportunity to alleviate information overload and compliance fatigue for service managers and clinicians. Despite its focus on palliative care, this case study demonstrates how to collaboratively map distinct practice standards and guidelines and form a resource to aid accreditation efforts to improve healthcare.

In the Democratic Republic of the Congo, the first recourse in case of suspected malaria in the health system is the private pharmacy sector. This study was therefore designed to assess private provider adherence to national case management guidelines in Kimpese, a rural area of Central Kongo province. A descriptive cross-sectional survey of 103 pharmacies took place in March 2016. The study included 97 pharmacies. The artemether-lumefantrine combination recommended as the first-line treatment for uncomplicated P. falciparum malaria was available in 100% of pharmacies but only 3% stocked quality-assured medicines. The sulfadoxine-pyrimethamine recommended for intermittent preventive treatment of malaria in pregnant women and quinine, which is no longer part of national policy, were widely available (>97.0% of pharmacies). Among providers, fewer than 20% were aware of the national malaria treatment guidelines. The main reasons for non-adherence to national guidelines among private dispensers was the high cost (up to 10 times more expensive than sulfadoxine-pyrimethamine treatment) and adverse effects of artemisinin-based combination therapies. Governmental interventions to improve private sector engagement in implementation of the national guidelines and to prevent the spread of ineffective and non-quality assured antimalarial medicines must be intensified.

BACKGROUND: There is increased international focus on improving the rigour of clinical practice guideline (CPG) development practices. However, few empirical studies on CPG development have been conducted in low- and middle-income countries. This paper explores national stakeholders\' perceptions of processes informing CPG development for primary healthcare in South Africa, focusing on both their aspirations and views of what is actually occurring.
METHODS: A qualitative study design was employed including individual interviews with 37 South African primary care CPG development role-players. Participants represented various disciplines, sectors and provinces. The data were analysed through thematic analysis and an interpretivist conceptual framework.
RESULTS: Strongly reflecting current international standards, participants identified six \'aspirational\' processes that they thought should inform South African CPG development, as follows: (1) evidence; (2) stakeholder consultation; (3) transparency; (4) management of interests; (5) communication/co-ordination between CPG development groups; and (6) fit-for-context. While perceptions of a transition towards more robust processes was common, CPG development was seen to face ongoing challenges with regards to all six aspirational processes. Many challenges were attributed to inadequate financial and human resources, which were perceived to hinder capacity to undertake the necessary methodological work, respond to stakeholders\' feedback, and document and share decision-making processes. Challenges were also linked to a complex web of politics, power and interests. The CPG development arena was described as saturated with personal and financial interests, groups competing for authority over specific territories and unequal power dynamics which favour those with the time, resources and authority to make contributions. These were all perceived to affect efforts for transparency, collaboration and inclusivity in CPG development.
CONCLUSIONS: While there is strong commitment amongst national stakeholders to advance CPG development processes, a mix of values, politics, power and capacity constraints pose significant challenges. Contrasting perspectives regarding managing interests and how best to adapt to within-country contexts requires further exploration. Dedicated resources for CPG development, standardised systems for managing conflicting interests, and the development of a political environment that fosters collaboration and more equitable inclusion within and between CPG development groups are needed. These initiatives may enhance CPG quality and acceptability, with associated positive impact on patient care.

Although there are over 26,000 private schools in the United States, little is known about the relationship of their characteristics to mandated and recommended time allocations for physical education (PE).
Private secondary schools (N = 450; grades 6-12) in California completed a 15-item questionnaire related to school characteristics and PE policies and practices. Using correlational analysis and predictive modeling, we assessed the associations and influences of various factors relative to the schools meeting state (California) and national professional time targets for PE.
Whereas most schools fell short of meeting PE weekly time recommendations, 5 of 10 tested variables were significantly associated with schools meeting PE minutes/week targets: school enrollment, school level, having a fitness testing policy, PE class size, and not permitting exemptions for PE. Large schools and those serving high school students provided more PE and were more likely to meet PE time allocation standards. Having policies for PE minutes/week and no exemptions for PE were significantly associated with a school having all its PE classes taught by a specialist.
Private secondary schools should consider the adoption of professional guidelines related to PE time allocations, class size, conducting physical fitness testing, employing PE specialists, and not permitting exemptions for PE.

Prompt diagnosis and effective treatment of acute malaria in pregnancy (MiP) is important for the mother and fetus; data on health-care provider adherence to diagnostic guidelines in pregnancy are limited. From September to November 2013, a cross-sectional survey was conducted in 51 health facilities and 39 drug outlets in Western Kenya. Provider knowledge of national diagnostic guidelines for uncomplicated MiP were assessed using standardized questionnaires. The use of parasitologic testing was assessed in health facilities via exit interviews with febrile women of childbearing age and in drug outlets via simulated-client scenarios, posing as pregnant women or their spouses. Overall, 93% of providers tested for malaria or accurately described signs and symptoms consistent with clinical malaria. Malaria was parasitologically confirmed in 77% of all patients presenting with febrile illness at health facilities and 5% of simulated clients at drug outlets. Parasitological testing was available in 80% of health facilities; 92% of patients evaluated at these facilities were tested. Only 23% of drug outlets had malaria rapid diagnostic tests (RDTs); at these outlets, RDTs were offered in 17% of client simulations. No differences were observed in testing rates by pregnancy trimester. The study highlights gaps among health providers in diagnostic knowledge and practice related to MiP, and the lack of malaria diagnostic capacity, particularly in drug outlets. The most important factor associated with malaria testing of pregnant women was the availability of diagnostics at the point of service. Interventions that increase the availability of malaria diagnostic services might improve malaria case management in pregnant women.

UNASSIGNED: Hypertension is the most prevalent cardiovascular disease in Zimbabwe. The prevalence of Hypertension in the country is above 30% regardless of the cut off used. Currently, majority of patients in Zimbabwe seek health care from the private sector due to limited government funding for the public health sector. However, Standard treatment guidelines for hypertension are only available in the public sector and are optional in the private sector. This study assesses compliance of private sector prescribing to Standard Treatment guidelines for hypertension.
UNASSIGNED: We reviewed hypertension prescription claims to a private health insurance company in Zimbabwe for the period Jan 1-Dec 31 2015. We used the last prescription claimed in the year on the assumption that it represented the patient\'s current treatment. Prescription data was analyzed by comparing medicines prescribed to those recommended in the Zimbabwe 7th Essential Medicines List and Standard Treatment Guidelines 2015. We used Microsoft Excel© 2010 to conduct the analysis.
UNASSIGNED: A total of 1019 prescriptions were reviewed. Most patients were either on mono or dual therapy (76%). The mostly prescribed class of antihypertensive as first line were Angiotensin Converting Enzyme Inhibitors /Angiotensin Receptor Blockers. Regardless of whether they were being used as first, second or third line this class of antihypertensives emerged as the most prescribed (639 times). Only 358 (35%) prescriptions were compliant with standard treatment guidelines; the rest (661) did not meet several criteria. Areas of non-compliance included use of second line medicines as first line, failure to consider patient characteristics when prescribing, use of contraindicated medicines for certain patients, clinically significant interactions among prescribed medicines and illogical combinations that predispose patients to toxicity.
UNASSIGNED: The poor compliance to standard treatment guidelines observed in our study indicates need to improve prescription practices for Hypertension in the private sector in Zimbabwe for its cost-effective management among the covered patients. However, further investigation is needed to understand the drivers of the prescribing habits and the non-compliance to the Essential Medicines List and Standard Treatment guidelines observed. This will enable design of appropriate educational, managerial and economic interventions to improve compliance.

Foot and mouth disease (FMD) is an important transboundary disease in South-East Asia. Its control has been a priority in the region for at least 20 years, with extensive institutional support and capacity-building being provided by the international community through the World Organisation for Animal Health. This paper describes the FMD control and eradication programme in the Mekong region (Myanmar, Thailand, the Lao People\'s Democratic Republic, Cambodia and Vietnam) of South-East Asia and evaluates the FMD control programme in one of the region\'s countries, namely Cambodia. Significant progress has been made, and the strategy for eradication is now both clearly understood and feasible in the Mekong. However, FMD control in this region requires more than just an effective vaccination strategy and regulatory support. Success will also depend on obtaining consensus and buy-in at all levels of the value chain, from input suppliers to consumers. Culturally and economically acceptable incentives must be in place to ensure that control measures are implemented, and those stakeholders who are expected to bear the risk and costs of control programmes must also be the main beneficiaries. The present institutional environment in the Mekong, and in particular in Cambodia, makes control and eradication of transboundary diseases difficult. Further work is required to ensure that control strategies are aligned with stakeholder needs and priorities, and actively improve smallholder welfare. Cattle producers and traders are crucial to the control of FMD in Cambodia. Economic incentives and education as well as regulation are required to ensure these stakeholders participate in this important transboundary disease eradication programme.
La fièvre aphteuse est une maladie animale transfrontalière majeure en Asie du Sud-Est. La lutte contre cette maladie est une priorité depuis au moins deux décennies dans la région et fait l’objet d’un soutien institutionnel important et d’activités de renforcement des capacités de la part de la communauté internationale par le biais de l’Organisation mondiale de la santé animale. Des progrès significatifs ont été accomplis, de sorte que la stratégie d’éradication est désormais bien comprise et constitue un objectif atteignable dans la région du Mékong. Néanmoins, la lutte contre la fièvre aphteuse dans cette région exige davantage qu’une simple stratégie de vaccination assortie d’un soutien réglementaire. Le succès dépendra également du consensus mis en place et de l’adhésion des acteurs de chaque échelon de la chaîne de valeur, depuis les fournisseurs d’intrants jusqu’aux consommateurs. Des mesures incitatives acceptables au plan culturel et économique doivent être proposées afin de garantir la mise en oeuvre des mesures de lutte, en faisant en sorte que les parties prenantes qui supportent les risques et les coûts des programmes de lutte en soient également les principaux bénéficiaires. Le contexte institutionnel actuel ne facilite pas le contrôle et l’éradication des maladies transfrontalières dans la région du Mékong, notamment au Cambodge. Des efforts supplémentaires seront nécessaires pour s’assurer que les stratégies de lutte sont adaptées aux besoins et aux priorités des parties prenantes et qu’elles améliorent efficacement les conditions de vie des petits éleveurs. La participation des éleveurs et des négociants de bovins dans la lutte contre la fièvre aphteuse au Cambodge est déterminante. La mise en place d’incitations économiques et des efforts en matière d’éducation et de législation sont indispensables pour que ces parties prenantes jouent un rôle plus actif dans le programme d’éradication de cette maladie transfrontalière majeure.
La fiebre aftosa es una importante enfermedad transfronteriza que asola el Sudeste asiático. Hace 20 años que la lucha contra ella es una de las prioridades de la región, que para ello ha contado con servicios de capacitación y un vasto apoyo institucional por parte de la comunidad internacional a través de la Organización Mundial de Sanidad Animal. Se han logrado avances sustanciales, y ahora hay una estrategia para erradicarla que todas las partes entienden claramente y resulta viable en la región del Mekong. Sin embargo, la lucha contra la enfermedad en esta región requiere algo más que una estrategia eficaz de vacunaciones y apoyo reglamentario. Para tener éxito en la empresa también hay que suscitar consenso y adhesión en todos los niveles de la cadena de valor, desde los proveedores de insumos hasta los consumidores. Para asegurar una aplicación efectiva de las medidas de control es preciso que existan incentivos cultural y económicamente aceptables, y aquellos interlocutores que en principio deban asumir los riesgos y costos de los programas de lucha deben ser también sus principales beneficiarios. La arquitectura institucional presente actualmente en la zona del Mekong, especialmente en Camboya, dificulta el control y la erradicación de enfermedades transfronterizas. Aún queda trabajo por delante para lograr que las estrategias de lucha respondan a las necesidades y prioridades de los interesados y para mejorar activamente el nivel de bienestar de los pequeños ganaderos. Para lograr que los productores y tratantes de ganado, que son un eslabón esencial de la lucha contra la fiebre aftosa en Camboya, participen en este importante programa de erradicación de una enfermedad transfronteriza se requieren a la vez incentivos económicos y una labor pedagógica.