HMP Shunt Pathway
HMP Shunt Pathway, also known as Pentose Phosphate Pathway, is an alternative pathway for glucose oxidation, more anabolic in nature. It plays a crucial role in the biosynthesis of NADPH and pentoses, with enzymes located in the cytosol of various active tissues like liver, adipose tissue, and erythrocytes. This unique and multifunctional pathway involves both oxidative and non-oxidative phases, facilitating the interconversion of important metabolic substances.
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Nigeria HPN Multi-Activity Evaluation Zamfara Results Review Meeting September 30, 2022
Meeting objectives 01 Share highlights from the Zamfara state findingsof the Nigeria health, population, and nutrition (HPN) multi-activity evaluation. 02 Facilitate use of findings for state annual operational planning processes and for the annual Activity work planning process. 03 Increase awareness of how to access detailed results of the evaluation for ongoing program decision-making.
Agenda Use of health services, health facility readiness, and provider knowledge, attitudes and practice: Zamfara baseline findings. 10:05 10:45 am Sustainability of HPN activities: Zamfara baseline findings 10:45 11:20 am Coordination and collaboration: Zamfara 11:20 11:45 am Wrap up and closing 11.45 12.00 pm
Use of health services, health facility readiness, and provider knowledge, attitudes and practice Zamfara baseline quantitative findings
Assessing the effectiveness of HPN Activities on the use of health services Preliminary DHIS2 analysis
Data Source and Sample Health facility-level data from Nigeria District Health Information Software 2 (DHIS2) Monthly data from January 2017 March 2022 (63 time periods) Exclusion criteria for preliminary analysis: hospital or private in facility name Preliminary analytical sample: 691 Zamfara facilities
Initial service delivery outcomes of interest Malaria (under 5 years) Persons presenting with fever & tested by RDT Persons with confirmed uncomplicated malaria Persons with confirmed uncomplicated malaria treated with ACT Descriptive comparison of trends over time Antenatal Care 1st ANC visit IPTp1 Family Planning New acceptors (female)
Preliminary Analytical Approach DHIS2 data review: High rates of missing data at the facility-month level led to decision to analyze mean cases per month per facility at the state level as the main outcome. Question Indicator Example calculation # Zamfara facilities reporting # persons presenting with fever and tested by RDT in October 2021 Total # Zamfara facilities % of facilities reporting service delivery indicator by month How does facility-level reporting of health service delivery change over time? Total # persons presenting with fever and tested by RDT in October 2021 across all Zamfara facilities # Zamfara facilities that reported # persons presenting with fever and tested by RDT in October 2021 State-level average number of cases or clients per facility by month How do state-level service delivery volumes change over time?
DHIS2 under-5 malaria reporting Facility reporting rates have slightly increased over time for all malaria indicators. % Facilities reporting malaria indicators by month, Zamfara Fever tested by RDT Confirmed uncomplicated malaria Confirmed uncomplicated malaria treated with ACT
Under-5 malaria service utilization Case loads have experienced fluctuations due to seasonality. Nearly all confirmed malaria cases are treated with ACT. State-level average number of cases per facility by month, Zamfara Fever tested by RDT Confirmed uncomplicated malaria Confirmed uncomplicated malaria treated with ACT
DHIS2 ANC and FP reporting Reporting rates for the first ANC visit and FP acceptor have remained stable over time under 40%. IPTp1 reporting rates have slightly decreased. % Facilities reporting ANC and FP indicators by month, Zamfara 1st ANC visit IPTp1 New FP acceptors
ANC and FP service utilization ANC1 and IPTp1 client loads are relatively stable over time with some observed seasonality. New FP acceptor client loads have increased over the study period. State-level average number of clients per facility by month, Zamfara 1st ANC visit IPTp1 New FP acceptors
Next steps for DHIS2 analysis Exclusion of facilities not providing services of interest True zero values vs. missing data Examination of outliers Further data quality review Malaria service cascade Expanded indicator list Triangulation with population-based data Classification of facilities by intervention intensity Modelling Additional analyses Periodic result updates Refreshing DHIS2 data every 6 months
Assessing the effectiveness of HPN activities on health facility readiness Evaluation baseline health facility assessment (HFA) results
Data Source and Sample HFA data were collected by D4I at health facilities between July 5 August 12, 2021 Evaluation analytical sample: 120 facilities o 86% primary health centers o 88% rural settings
HFA results: A. General service readiness
General Service Readiness 33% of facilities have all essential medicines available. The mean percentage of essential medicines available at a facility is 66%. Percentage of Zamfara health facilities that have essential medicines available (N=120) Hormonal contraceptives (oral, injectable and/or implants) Hormonal contraceptives (oral, injectable, and/or 81% implants) Paracetamol tab/cap 68% Paracetamol tab/cap Artemisinin-based combination therapy (ACT) Artemisinin-based combination therapy (ACT) 65% Folic acid tab/cap 55% Folic acid tab/cap 0 50 100
General Service Readiness 33% of facilities have all basic consumables available. The mean percentage of basic consumables available at a facility is 75%. Percentage of Zamfara health facilities that have basic consumables available (N=120) Male condoms Male condoms 47.5 Sterile gauze swabs Sterile gauze swabs 79.2 Alcohol swabs 82.5 Alcohol swabs Examination gloves, latex, single use Examination gloves, latex, 80.0 single use Single use syringes Single use syringes 90.0 0 50 100
HFA results: B. Malaria service availability and readiness
Malaria Service Availability 100% of facilities offer malaria diagnostic and treatment services, and 88% provide IPTp. Percentage of Zamfara health facilities that offer specific malaria services (N=120) 100 Malaria diagnosis Malaria diagnosis 100 Malaria treatment Malaria treatment IPTp 88 IPTp 0 50 100
Malaria Service Availability 99% of facilities provide malaria diagnosis by testing: 98% offer RDT, 23% clinical diagnosis, and 8% microscopy Percentage of Zamfara health facilities that offer specific malaria diagnostic services (N=120) Malaria diagnosis by 99 Malaria diagnosis by RDT testing Malaria diagnosis by testing Malaria diagnosis by 98 RDT Malaria diagnosis by clinical symptoms and 23 Malaria diagnosis by clinical signs Malaria diagnosis by microscopy Malaria diagnosis by microscopy 8 0 50 100
Malaria Service Readiness 100% offacilities have staff trained to diagnosis and treat malaria. 90% of facilities had malaria diagnostic testing capacity. Percentage of Zamfara health facilities that are ready to provide Malaria services today (among facilities providing malaria services) (N=120) Staff trained in malaria diagnosis and 100 Staff trained in malaria diagnosis and treatment treatment Guidelines for diagnosis and treatment 93 Guidelines for diagnosis and treatment of malaria of malaria Malaria diagnostic testing capacity 90 Malaria diagnostic testing capacity 0 50 100
Malaria Service Readiness Facilities in Zamfara on average have 98% of malaria diagnostic items available but only 46% of malaria medicines and commodities available. Mean percentage of items available to provide malaria services today (among Zamfara facilities providing malaria services) (N=120) Mean % of malaria diagnostics items at facilities 98 Mean % of malaria staff and guidelines items at facilities 91 Mean % of malaria medicines and commodities items at facilities 46 Mean % of all malaria items at facilities 72 0 50 100
Service Readiness IPTp in ANC 81% Zamfara facilities provide any ANC serves and 55% of Zamfara offer intermittent preventative treatment in pregnancy (IPTp) in ANC Percentage of Zamfara health facilities ready to provide IPTp care (among facilities providing ANC) (N=97) IPT medicine 43.3 Facility has staff trained in IPTp 100.0 Facility has national guidelines/checklists on IPTp 90.7 0 50 100
Malaria Service Readiness- Stockouts 36% of Zamfara facilities experienced RDT stock outs in the past 4 weeks 43% of Zamfara facilities experienced 1st line anti-malarial stock outs in the past 4 weeks Percentage of Zamfara health facilities that experience stock outs by type and length RDTs 5.8 11.7 15.8 1st Line Anti-Malarials 5.8 12.5 24.2 0 5 10 15 20 25 30 35 40 45 Less than 7 days 7-14 days More than 14 days
HFA results: C. Antenatal care and family planning service availability and readiness
Antenatal Care Service Availability 81% of facilities in Zamfara offer antenatal care services. IPTp and routine checks for urine protein are the least commonly offered ANC services. Percentage of Zamfara health facilities that offer specific ANC service (N=120) Antenatal care services 80.8 Tetanus toxoid vaccination 78.3 Monitoring for hypertensive disorder of pregnancy 73.3 Folic acid supplementation 66.7 Iron supplementation 66.7 Intermittent preventive treatment in pregnancy for malaria (IPTp) 55.0 Routine checks for urine protein 52.5 0 50 100
Antenatal Care Service Readiness On average, ANC facilities in Zamfara have 65% of all ANC items available. No ANC facilities had all ANC items available. Mean percentage of items available to provide ANC services today (among Zamfara facilities providing ANC services) (N=97) Mean percentage of all ANC items at facilities 65 Mean percentage of ANC diagnostics items at facilities 31 Mean percentage of ANC medicines and commodities items at facilities 54 Mean percentage of ANC equipment items at facilities 80 Mean percentage of ANC staff and guidelines items at facilities 75 0 50 100
Family Planning Service Readiness 83% of facilities in Zamfara offer family planning services. Mean percentage of all family planning items at Zamfara facilities: 78.4% Percentage of Zamfara health facilities with the capacity to provide family planning services on the day of assessment (N=99) Staff trained in family planning 96 Blood pressure apparatus 84 Any modern methods available 92 3 or more modern methods available 60 Facility has all family planning items 38 0 50 100
Assessing the effectiveness of HPN activities on providers knowledge, attitudes, and practices Evaluation baseline provider survey results
Data Source and Sample 4 modules: Background, Training, Clinical Vignettes, and Provider Attitudes and Norms Up to 5 providers/facility interviewed. Eligibility criteria included: Present at facility on day of survey Provide out-patient services See sick children, ANC, and/or family planning patients Fieldwork: July 1 August 12, 2021 Zamfara provider survey sample size: 345 providers from 120 PHCs
Provider survey results: A. Provider Background
Provider Demographics, Experience, and Tenure The average provider in Zamfara. . . Female (34%) 40 years of age 15 years of education Received technical qualifications/basic training 13 years ago About 4% were professional health workers Has worked at current facility for 11+ years (39%), with an average of 10 years 2% seconded
Services Provided Most clinicians provide malaria, and child health services. Services health worker personally provides in current position at facility (N = 345) Malaria % 87 Child health services % 71 % Antenatal care 32 Family planning services % 41 0 50 100
Provider survey results: B. Training
General Training 88% of health workers reported receiving training in any of the specified general topics. Percent of health workers who received training on general topics (N = 345) Approximately 3 out of 4 providers reported receiving training on safe injection practices, standard precautions, and HMIS/reporting Roughly 1 in 3 providers reported receiving training on GBV In general half of the training received within past 2 years Safe injection practices 37 44 % % Standard precautions 29 46 % % HMIS/reporting 35 36 % % GBV 17 18 % % 0 50 100 Past 24 mo 2+ yr
Malaria 87% of respondents personally diagnose and/or treat malaria. 95% of these health workers reported receiving training in any of the specified malaria topics. Percent of malaria providers who received training on malaria topics (N = 301) Malaria training levels higher than child health, family planning (FP), and antenatal care (ANC) service trainings mRDT performance % 45 45 % Diagnosing malaria in children 40 42 % % Case mgmt/tx of malaria during pregnancy 41 36 % % IPT of malaria in pregnancy 38 37 % % 0 50 100 Past 24 mo 2+ yr
Antenatal Care 32% of respondents provide ANC services. 93% of these health workers reported receiving training in any of the specified ANC topics. Percent of ANC providers who received training on ANC topics (N = 112) Male engagement and partner communication training low in Zamfara IPT of malaria during pregnancy Counseling for ANC Pregnancy comp. and mgmt. ANC screening Nutritional assessment of preg. women Male engagement in ANC Partner communication in birth planning 0 20 40 60 80 100 Past 24 mo 2+ yr
Family Planning 41% of respondents provide FP services. 81% of these health workers reported receiving training in any of the specified FP topics. Percent of FP providers who received training on FP topics (N = 141) IUCD insertion/removal, male engagement and partner communication training low in Zamfara General counseling for FP Implant insertion/removal Clinical mgmt of FP methods Post-partum FP IUCD insertion/removal Male engagement in FP Partner communication for FP 0 20 40 60 80 100 Past 24 mo 2+ yr
Provider survey results: C. Attitudes and Norms
Provider Attitudes and Norms Are provider attitudes different from perceived professional community norms among other providers in LGA? Topic 1. Malaria, ANC, and FP attitudes, practices, and norms Topic 2. Gender attitudes and gender-sensitive quality of care norms
Key findings: Provider attitudes and LGA norms Malaria case management attitudes and norms are generally positive at Evaluation baseline and align with corresponding community norms ANC provider attitudes are universally positive at evaluation baseline LGA norms slightly more positive than provider norms on ANC Exception: LGA norms around mosquito net provision are less positive than corresponding provider norms There is more variation in provider attitudes and LGA norms on family planning than on malaria case management and ANC Provider attitudes on family planning are more progressive than LGA norms around offering contraceptives to women under 18, but less progressive around requiring partner consent for contraceptives
Key findings: Provider gender attitudes and LGA norms Gender norms among providers and LGA norms are less gender equitable in Zamfara than in other states in the Evaluation Almost all providers agreed or strongly agreed with statements expressing supportive LGA norms on couples communication and individual agency in family planning service provision 52% providers agreed or strongly agreed with the statement the clinicians in this LGA believe that men s only role in family planning should be to help select methods used by their female partner
Provider survey results: D. Clinical Vignettes
Child Health Vignette Case: uncomplicated malaria in child age 5 years. Child health: Domain and weighted total scores Key findings 99% of providers would perform mRDT 100% of providers would treat with ACT 42% of providers in Zamfara would provide an antibiotic Only 6% of providers mentioned disclosing the diagnosis during counseling 33% of providers would counsel on completing medication to avoid drug resistance Zamfara (N=240) P-value 50.6 0.000 Weighted total Notes: *** p<0.001
ANC: Malaria in Pregnancy Vignette ANC-MIP: Domain and weighted total scores Key findings Vignette focuses on treatment of a woman presenting with malaria in pregnancy Nearly universal malaria testing (94%) and treatment with ACT (94%) Zamfara (N=107) P-value 72.9 0.910 Weighted total Notes: *** p<0.001
Family Planning (Implant) Side Effects Vignette Key findings 40% of providers would not offer counseling on another FP method o Most common reason is that side effects are normal Among providers who would offer another method: 25% would counsel on all methods available from any source 23% would counsel on methods available at the facility today 66% of providers would refer the client to another clinic if her preferred method is unavailable FP-SE: Domain and weighted total scores Zamfara (N=107) P-value 37.2 0.000 Weighted total Notes: * p<0.05; *** p<0.001
Post-partum Family Planning Vignette PPFP: Domain and weighted total scores Key findings 94% of providers would counsel the client in choosing a post-partum contraceptive method 48% of providers would counsel on FP methods that can be used during breastfeeding 30% of providers would counsel on birth planning to get FP at time of delivery 44% of providers said that the earliest time to get PPFP is at the time of delivery; 31% said at 6-week post-natal check up. Zamfara (N=107) P-value 53.4 0.003 Weighted total Notes: * p<0.05; ** p<0.01
Male Engagement in FP Vignette Content MEFP: Domain and weighted total scores Key findings Scores on male engagement in family planning items are generally low 33% of providers offered joint couple counseling on PPFP if the woman wanted it 29% of providers asked the woman about joint discussion/decision-making about FP in PPFP vignette Zamfara (N=107) P-value 11.4 0.035 Weighted total Notes: * p<0.05; *** p<0.001
Gender-Based Violence Vignette Content GBV: Domain and weighted total scores GBV embedded in an ANC vignette Key findings 37% of providers would implement GBV screening 2% of providers mentioned looking for signs of physical violence in the physical exam No providers in Zamfara diagnosed explicit GBV risk Low in all states but Ebonyi and Kebbi providers performed better than Zamfara Zamfara (N=107) P-value 14.9 0.044 Weighted total Notes: * p<0.05; *** p<0.001
