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Background: While school-aged children in low- and middle-income countries remain highly exposed to acute infections, programs targeting this age group remain limited in scale and scope. In this paper, we evaluate the impact of a new and comprehensive primary school-based health intervention program on student-reported morbidity and anthropometric outcomes in Lusaka, Zambia. Methods: A prospective matched control study identified 12 classes in 7 schools for the intervention and 12 classes in 7 matched schools as controls. Teachers in intervention schools were trained to deliver health lessons and to refer sick students to care. In addition, vitamin A and deworming medication were biannually administered to intervention students. The primary study outcome was student-reported morbidity. Secondary outcomes were weight, height, health knowledge, and absenteeism. Multivariable linear and logistic regression models were used to estimate program impact. Results: 380 students ages 4–16 were enrolled in the study in 2015, and 97% were followed up at endline in 2016. The intervention decreased the adjusted odds of self-reported acute illnesses by 38% (95% CI: 0.48, 0.77) and the adjusted odds of stunting by 52% (95% CI: 0.26, 0.87). It also increased health knowledge by 0.53 standard deviations (95% CI: 0.24, 0.81). No impact was found on weight (adjusted mean difference β = 0.17, 95% CI: - 1.11, 1.44) and student absenteeism (adjusted odds ratio (aOR) = 0.89, 95% CI: 0.60, 1.33). Conclusion: The results presented in this paper suggest that comprehensive school-based health programs may offer a highly effective way to improve students’ health knowledge as well as their health status. Given their low cost, a more general adoption and implementation of such programs seems recommendable. Trial registration: ClinicalTrials.gov Identifier: . [ABSTRACT FROM AUTHOR]

Background: A community’s cultural beliefs, attitudes and discourse can affect their responses in surveys. Knowledge of these cultural factors and how to comply with them or adjust for them during data collection can improve data quality. Objective: This study describes implications of features of Gambian culture related to women’s reproductive health, and mortality, when collecting data in surveys. Methods: 13 in-depth interviews of female interviewers and a focus group discussion among male interviewers were conducted in two rural health and demographic surveillance systems as well as three key informant interviews in three regions in The Gambia. Results: From the fieldworker’s viewpoint, questions relating to reproduction were best asked by women as culturally pregnancies should be concealed, and menstruation is considered a sensitive topic. Gambians were reluctant to speak about decedents and the Fula did not like to be counted, potentially affecting estimation of mortality. Asking about siblings proved problematic among the Fula and Serahule communities. Proposals made to overcome these challenges were that culturally-appropriate metaphors and symbols should be used to discuss sensitive matters and to enumerating births/deaths singly instead of collecting summary totals, which had threatening connotations. This was as opposed to training interviewers to ask standardised and precise verbatim questions. Contribution: This paper presents indigenous Gambian solutions by fieldworkers to culturally sensitive topics when collecting pregnancy outcomes and mortality data in demographic and health surveys. For researchers collecting maternal mortality data, it highlights the potential shortcomings of the sibling history methodology. [ABSTRACT FROM AUTHOR]

Purpose: The overall goal of the Saleema Initiative in Sudan is to promote long-term abandonment of female genital mutilation and cutting (FGM) through a contribution to changing social norms, attitudes, and intentions related to the practice. The initiative aims to create positive cultural associations with a girl remaining uncut, a new social norm. Saleema hypothesizes that branding the alternative to FGM (abandonment) will promote social norms change. In 2014, the lead author designed a monitoring and evaluation framework for Saleema in partnership with UNICEF, the National Council for Child Welfare (NCCW), and local organizations. Methods: The Saleema evaluation aimed to evaluate the effectiveness of the campaign in reducing pro-FGM social norms. A quasi-experimental design controlled for dosage of campaign messages delivered across the 18 states in Sudan to measure a dose-response effect. We operationalized social norms through a 4-item scale validated in previous research. Results: This paper reports on quantitative evaluation findings based on data gathered in from 2015–2017 and focuses on the dose-response relationship between Saleema exposure and changes in FGM social norms. We found that self-reported exposure was associated with reduced pro-FGM social norms (coeff. = -0.329, p < .001). Additionally, higher doses of Saleema, measured through an exogenous measure of campaign event exposure from an independent monitoring system was associated with reduced pro-FGM social norms (coeff. = -0.146, p < .001). Conclusions: Saleema was effective in reducing pro-FGM social norms. It is a promising strategy and findings contribute to the growing literature on social norms approaches to behavior change. [ABSTRACT FROM AUTHOR]

Background: Crime and violence causes massive disruptions to the health, survival and development of populations. In South Africa, incredibly high rates of crime and violence are noted. The country also has a very large youth population whose health, survival and development are key to economic growth. Among other efforts to encourage healthy youth development and the promotion of social activities such as sports, youth groups, choirs and so forth. This study examines the relationship between perceived community safety and the uptake of social activities among youth in South Africa. Data and methods: This paper uses data from the National Youth Lifestyle Survey (2008) with an unweighted sample of 4,391 youth (age12-22 years old). Using chi-square and logistic regression analysis the association between perceived community safety and social activity participation are tested. Findings: The results indicate that youth participation in social activities in South Africa is high (55% of males and 45% of females). Among males, the most prominent activity is sports (51.8%), while for females there is high participation in choir and singing groups (55.68%). More than 50% of males perceive their communities as risky while less than half of females feel the same. Male youth are more likely to participate in social activities if they perceive their communities as risky (OR = 1.04). Females (OR = 0.83), youth have a negative view of their future (OR = 0.43) are less likely to participate in social activities. Conclusions: There exists an association between youth’s perception of community safety and their participation in social activities. Whether sports and groups are protective or enabling environments for youth from unsafe communities is moot. More in-depth research is needed on why youth participate in these clubs and groups to truly understand the role of social activities in South African societies. [ABSTRACT FROM AUTHOR]

Introduction and method: Africa is currently host to a number of international genomics research and biobanking consortia, each with a mandate to advance genomics research and biobanking in Africa. Whilst most of these consortia promise to transform the way international health research is done in Africa, few have articulated exactly how they propose to go about this. In this paper, we report on a qualitative interviewing study in which we involved 17 genomics researchers in Africa. We describe their perceptions and expectations of international genomics research and biobanking initiatives in Africa. Results: All interviewees were of the view that externally funded genomics research and biobanking initiatives in Africa, have played a critical role in building capacity for genomics research and biobanking in Africa and in providing an opportunity for researchers in Africa to collaborate and network with other researchers. Whilst the opportunity to collaborate was seen as a benefit, some interviewees stressed the importance of recognizing that these collaborations carry mutual benefits for all partners, including their collaborators in HICs. They also voiced two major concerns of being part of these collaborative initiatives: the possibility of exploitation of African researchers and the non-sustainability of research capacity building efforts. As a way of minimising exploitation, researchers in Africa recommended that genuine efforts be made to create transparent and equitable international health research partnerships. They suggested that this could be achieved through,: having rules of engagement, enabling African researchers to contribute to the design and conduct of international health projects in Africa, and mutual and respectful exchange of experience and capacity between research collaborators. These were identified as hallmarks to equitable international health research collaborations in Africa. Conclusion: Genomics research and biobanking initiatives in Africa such as H3Africa have gone some way in defining aspects of fair and equitable research collaborations in Africa. However, they will need to strive at achieving equitable health research collaborations if they truly aim at setting a gold standard for how international health research should be conducted in Africa. [ABSTRACT FROM AUTHOR]

Background: The population of Ghana is increasingly becoming urbanized with about 70% of the estimated 27 million people living in urban and peri-urban areas. Nonetheless, eight out of the ten regions in Ghana remain predominantly rural where only 32% of the national health sector workforce works. Moreover, the rural-urban disparities in the density of health tutors (staff responsible for pre-service training of health professionals) are enormous. This paper explores perceived needs of health tutors in rural and urban health training institutions in Ghana. Methods: This is a descriptive qualitative study conducted in the Greater Accra and Northern regions of Ghana. The Study used the deductive thematic and sub-thematic analysis approaches. Five health training institutions were randomly sampled, and 72 tutors engaged in separate focus group discussions with an average size of 14 participants per group in each training institution. Results: Perceived rural-urban disparities among health tutors were found in the payment of extra duty allowances; school infrastructure including libraries and internet connectivity; staff accommodation; and opportunities for scholarships and higher education. Health tutors in rural areas generally expressed more frustration with these work conditions than those in urban areas. Conclusions: There is the need to initiate and sustain work incentives that promote motivation of rural health tutors to control ongoing rural-urban migration of qualified staff. It is recommended the following incentives be prioritized to promote retention of qualified health tutors in rural health training schools: payment of research, book and rural allowances; early promotion of rural staff; prioritizing rural tutors for scholarships, and introduction of national best health tutor awards. [ABSTRACT FROM AUTHOR]

We propose a novel laboratory experiment to document the pressure to share income within social networks in Africa. We find that the redistributive pressure exerted via the possibility of receiving a claim increases altruism, while the possibility of hiding from such claim reduces it. Our results indicate that sharing norms are crucial drivers of giving to other members of the network. We also find that pressure to share has a detrimental effect on the undertaking of profitable but risky investments. [ABSTRACT FROM AUTHOR]

Background: The underutilization of formal, evidence-based maternal health services continues to contribute to poor maternal outcomes among women living in rural Africa. Women’s choice of the type of maternal care they receive strongly influences their utilization of maternal health services. There is therefore a need to understand rural women’s preferred choices to help set priorities for initiatives attempting to make formal maternal care more responsive to women’s needs. The aim of this review was to explore and identify women’s preferences for different sources of childbirth and postnatal care and the factors that contribute to these preferences. Methods: A systematic literature search was conducted using the Ovid Medline, Embase, CINAHL, and Global Health databases. Thirty-seven studies that elicited women’s preferences for childbirth and postnatal care using qualitative methods were included in the review. A narrative synthesis was conducted to collate study findings and to report on patterns identified across findings. Results: During the intrapartum period, preferences varied across communities, with some studies reporting preferences for traditional childbirth with traditional care-takers, and others reporting preferences for a formal facility-based childbirth with health professionals. During the postpartum period, the majority of relevant studies reported a preference for traditional postnatal services involving traditional rituals and customs. The factors that influenced the reported preferences were related to the perceived need for formal or traditional care providers, accessibility to maternal care, and cultural and religious norms. Conclusion: Review findings identified a variety of preferences for sources of maternal care from intrapartum to postpartum. Future interventions aiming to improve access and utilization of evidence-based maternal healthcare services across rural Africa should first identify major challenges and priority needs of target populations and communities through formative research. Evidence-based services that meet rural women’s specific needs and expectations will increase the utilization of formal care and ultimately improve maternal outcomes across rural Africa. [ABSTRACT FROM AUTHOR]

Gender diversity is known to have a positive effect on innovation in developed countries. However, it is unclear whether the benefits of gender diversity for innovation also apply to the particular context of developing countries, which is characterized by diverse and lower levels of gender equality. We propose that gender diversity positively impacts innovation in the developing countries participating in our study. In addition, we expect that this effect is moderated by country-specific levels of gender equality. In a cross-country study covering 18,547 firms in 15 developing countries, we find that gender diversity among a firm’s owners and workforce as well as having a female top manager benefit innovation in developing countries. Yet, contradictory to our expectations, gender equality does not significantly moderate this relationship. As such, our results underline the importance of enabling and fostering gender diversity and have critical implications for firms and policy makers alike. [ABSTRACT FROM AUTHOR]

Background: Achieving Universal Health Coverage (UHC) by improving financial protection and effective service coverage is target 3.8 of the Sustainable Development Goals. Little is known, however, about the extent to which paying bribes within healthcare acts as a financial barrier to access and, thus, UHC. Methods: Using survey data in adults from 32 sub-Saharan African countries in 2014–2015, we constructed a multilevel model to evaluate the relationship between paying bribes and reported difficulties of obtaining medical care. We controlled for individual-, region-, and country-level variables. Results: Having paid bribes for medical care significantly increased the odds of reporting difficulties in obtaining care by 4.11 (CI: 3.70–4.57) compared to those who never paid bribes, and more than doubled for those who paid bribes often (OR = 9.52; 95% CI: 7.77–11.67). Respondents with higher levels of education and more lived poverty also had increased odds. Those who lived in rural areas or within walking distance to a health clinic had reduced odds of reporting difficulties. Sex, age, living in a capital region, healthcare expenditures per capita, and country Corruption Perception Index were not significant predictors. Conclusions: We found that bribery in healthcare is a significant barrier to healthcare access, negatively affecting the potential of African countries to make progress toward UHC. Future increases in health expenditures—which are needed in many countries to achieve UHC—should be accompanied by greater efforts to fight corruption in order to avoid wasting money. Measuring and tracking health sector-specific corruption is critical for progress toward UHC. [ABSTRACT FROM AUTHOR]

Introduction: Some studies in developing countries have shown that infant mortality is highly associated with maternal education, implying that maternal education might play an important role in the reduction of infant mortality. However, other research has shown that lower levels of maternal education does not have any significant contribution to infant survival. In this systematic review, we focus on the effect of different levels of maternal education on infant mortality in Ethiopia. Methods: MEDLINE, EMBASE, CINAHL, Scopus, and Maternity and Infant Care databases were searched between November 15, 2017 and February 20, 2018. All articles published until February 20, 2018 were included in the study. The data extraction was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA 2009) guidelines. An I2 test was used to assess heterogeneity and a funnel plot was used to check publication bias. Findings: We retrieved 441 records after removing duplications. During screening, 31 articles were fully accessed for data extraction. Finally, five articles were included for analysis. The overall pooled estimate indicated that attending primary education was associated with a 28% reduction in the odds of infant mortality compared to those infants born to mothers who were illiterate, OR: 0.72 (95% CI = 0.66, 0.78). Another pooled estimate indicated that attending secondary education and above was associated with a 45% reduction in the odds of infant mortality compared to those infants born to mothers who were illiterate, OR: 0.55 (95% CI = 0.47, 0.64). Conclusion: From this study, understanding the long-term impact of maternal education may contribute to reduce infant mortality. Therefore, policy makers should give more attention in promoting the role of women through removing institutional and cultural barriers, which hinder women from access to education in order to reduce infant mortality in Ethiopia. [ABSTRACT FROM AUTHOR]

How pervasive is labor market discrimination against immigrants and what options do policymakers and migrants have to reduce it? To answer these questions, we conducted a field experiment on employer discrimination in Sweden. Going beyond existing work, we test for a large range of applicant characteristics using a factorial design. We examine whether migrants can affect their employment chances—by adopting citizenship, acquiring work experience, or signaling religious practice—or whether fixed traits such as country of birth or gender are more consequential. We find little systematic evidence that immigrants can do much to reduce discrimination. Rather, ethnic hierarchies are critical: callback rates decline precipitously with the degree of ethno-cultural distance, leaving Iraqis and Somalis, especially if they are male, with much reduced employment chances. These findings highlight that immigrants have few tools at their disposal to escape ethnic penalties and that efforts to reduce discrimination must address employer prejudice. [ABSTRACT FROM AUTHOR]

Background: In 2016 the first African emergency care clinical practice guideline (CPG) was developed for national uptake in the prehospital sector in South Africa, with implementation starting in 2018. Comprehensive uptake of CPGs post development is not a given, as this requires effective and efficient dissemination and implementation strategies that take into account the perceptions, barriers and facilitators of the local end-users. This study aimed to identify prehospital end-users’ perceptions of the emergency care guidelines, including barriers and facilitators for national decision makers, to strengthen CPG uptake in South Africa. Methods: Our study employed a descriptive qualitative research design, including nine focus groups with 56 operational emergency care providers across four major provinces in South Africa. Data was analysed using thematic analysis in ATLAS.ti. Ethics approval was provided by Stellenbosch University. Results: Themes related to provider perceptions, expectations and guideline uptake emerging from the data was unofficial and unclear communication, broadening versus limiting guideline expectations, conflicted personal reactions and spreading the word. Challenges to dissemination and implementation included poor communication, changes to scope of practice, and limited capacity to upskill existing providers. Facilitators included using technology for end-user documents, local champions to support change, establishing online and modular training, and implementation by independent decision makers. Conclusion: This study provides an overview of the perceptions of operational emergency care providers and how their experiences of hearing about and engaging with the guidelines, in their industry, can contribute to the dissemination, implementation and uptake of emergency care guidelines. In order to disseminate and implement an emergency care CPG, decision makers must take into account the perceptions, barriers, and facilitators of local end-users. [ABSTRACT FROM AUTHOR]

Background: Research on contraceptive behaviour changes over time in Uganda is scarce, yet it has among the highest fertility and maternal mortality rates of any country in the East African region. Understanding temporal patterns of contraceptive use for both women and men is vital in evaluating the effectiveness of family planning interventions and strategies, and identifying those with the most unmet need. Using repeated nationally representative cross-sectional samples, this study charts the changes in Uganda’s population-based contraceptive use over recent years. Methods: Five Demographic and Health Survey datasets for Uganda over 21 years, from 1995 to 2016, were sourced and interrogated. Eligible participants included all women aged 15–49 years and men aged 15–54 years. Responses to questions on modern and any (modern or traditional) contraceptive use were analysed. Stratified by gender, weighted regression analyses were employed to detect change over time. The patterns associated with key demographic variables were also investigated. Results: Overall, 50,027 women and 14,092 men were included within the study. In 2016, 30.3% of women and 39.9% of men were using any contraceptive method, a significant non-linear increase from 13.4% of women and 20.3% of men in 1995. Furthermore, 27.3% of women and 35.9% of men were using modern contraceptive methods in 2016, an increase from 7.4% of women and 10.4% of men in 1995. All considered demographic variables were significantly associated with contraceptive use for both women and men (all P<0.001); and for women, all variables differentially changed over time (all P<0.001). Conclusion: This study showed a significant increase and dynamism across key demographic variables in contraceptive uptake by both women and men. Sustained family planning programs and interventions have successfully resulted in behaviour change across the Ugandan population. However, continued efforts are needed to further reduce Uganda’s relatively high fertility and associated maternal mortality rates. [ABSTRACT FROM AUTHOR]

Background: The gap between fertility outcomes and fertility ideals is notably higher in sub-Saharan Africa (SSA) than elsewhere, relating to both under- and overachievement of fertility ideals. We consider the extent to which the relationship between fertility ideals and fertility outcomes is related to educational achievement. Further, we consider if these educational differentials are the same or different in SSA, and thereby consider the extent to which increasing levels of education in SSA may decrease fertility. Data and methods: We use 227 Demographic and Health Surveys (DHSs) from 58 countries worldwide to look at population- level measures of the mismatch between fertility ideals and fertility outcomes. Population level measures are used to assess whether the correspondence between fertility intentions and achievements differ by level of education. We then look at the individual-level determinants of both under- and overachieving fertility intentions. Data from the most recent DHS in 54 of the original countries is used for the individual level analysis, with five countries excluded due to the most recent available survey being out of date. Results: An average of 40% of women in SSA underachieve their stated fertility intentions compared to 26% in non-SSA countries. Furthermore, compared to other LMICs, higher levels of education are not related to better correspondence between fertility intentions and outcomes in SSA. In Middle/Western Africa countries, on average, 48% of women with secondary or higher education have fewer children than their ideal, compared to just 24% who have more children than their ideal. Conclusion: We argue that the phenomenon of underachieving fertility ideals (or unrealized fertility) may be of particular importance for the ongoing fertility transition throughout SSA, especially as more highly educated groups do not appear to be following the patterns observed elsewhere. [ABSTRACT FROM AUTHOR]

Evidence suggests that people with disabilities are the most marginalised and vulnerable group within any population. However, little is known about the extent of inequality between people with and without disabilities in contexts where the majority of persons experience extreme poverty and hardship. This includes in Liberia, where very little is understood about the lives of disabled people in general. This study uses a multidimensional wellbeing framework to understand perceived relative inequality associated with disability by assessing several facets of wellbeing across and within households containing disabled members (N = 485) or households with no disabled members (N = 538) in Liberian communities (Total individuals surveyed, N = 2020). Statistical comparisons (adjusted for age, sex, education and wealth differences and clustered at the household, village and county level) reveal that disabled Liberians are managing similarly to non-disabled Liberians in terms of income and education, but experience many perceived relative inequalities including in life satisfaction, transport access, political participation and social inclusion. Our results further suggest that disability may lead to perceived relative inequality at the household level in terms of trust held in neighbours. However, they also show that being the head of a household may protect against perceived relative inequality in certain dimensions (e.g. healthcare and transport access, political participation) irrespective of disability status. Results are discussed in terms of practical implications for development efforts in Liberia and for disabled people in other low- and middle-income settings. [ABSTRACT FROM AUTHOR]

Poor reproductive health among youth and adolescents threatens their future health and economic wellbeing in Zimbabwe amidst a high HIV/AIDS prevalence. This study evaluates the impact of a multi-pronged adolescent sexual and reproductive health (ASRH) strategy implemented by government of Zimbabwe between 2010 and 2015 to improve ASRH in terms of the uptake of condoms and HIV testing as well as outcomes in terms of sexually transmitted infection (STI) prevalence and HIV prevalence. We combine the difference in difference and propensity score matching methods to analyse repeated Zimbabwe demographic health survey cross-sectional datasets. Young people aged 15–19 years at baseline in 2010, who were exposed for the entire five-year strategy are designated as the treatment group and young adults aged 25–29 at baseline as the control. We find that the ASRH strategy increased HIV testing amongst youth by 36.6 percent, whilst treatment of STIs also increased by 30.4 percent. We also find that the HIV prevalence trajectory was reduced by 0.7 percent. We do not find evidence of impact on condom use and STI prevalence. The findings also suggest that although HIV testing increased for all socio-economic groups that were investigated, the effect was not the same. Lastly, we do not find evidence supporting that more resources translate to better ASRH outcomes. We recommend designing future ASRH strategies in a way that differentiates service delivery for youths in HIV hotspots, rural areas and out of school. We also recommend improving the strategy’s coordination and monitoring, as well as aligning and enforcing government policies that promote sexual and reproductive health rights. [ABSTRACT FROM AUTHOR]

Background: Medicines regulatory harmonization has been recommended as one way to improve access to quality-assured medicines in low- and middle-income countries. The rationale is that by lowering barriers to entry more manufacturers will be enticed to enter the market, while the capacity at the national medicines regulatory authorities is strengthened. The African Medicines Regulatory Harmonization Initiative, agreed in 2009, is developing regional platforms with harmonized regulatory procedures for the registration of medicines. The first region to implement medicines regulatory harmonization was the East African Community (EAC). The harmonization was based on the existing EAC Free Trade Agreement, which officially launched the free movement of goods and services in 2010. Methods and findings: In this study we conducted semi-structured interviews and performed document reviews. The main target group for our interviews was pharmaceutical companies. We interviewed 18 companies, including 64% of the total companies who had experienced the EAC joint product assessment procedure, and two EAC-based national medicines regulatory authorities. We found that generally pharmaceutical companies are supportive of the African-based MRH efforts and appreciative of the progress being achieved. However, many companies are now hesitant to use the joint product assessment procedure until efficiency improvements are made. Common frustrations were the length of time to receive the actual marketing authorization; unexpectedly higher quality standards than national procedures; and challenges in getting all EAC countries to recognize EAC approvals. Smaller, less attractive markets have not yet become more attractive from a corporate perspective, and there is no free trade of pharmaceuticals in the EAC region. Conclusions: Pharmaceutical companies agree that medicines regulatory harmonization is the way forward. However, regulatory medicines harmonization must actually result in quicker access to the harmonized markets for quality-assured medicines. At this time, improvements are required to the current EAC processes to meet the vision of harmonization. [ABSTRACT FROM AUTHOR]

Purpose: This study was conducted to explore the perceptions of perinatal women and key maternal care health workers about perinatal depression and the health service needs required to inform development of a culturally sensitive and acceptable psychosocial intervention. Methods: This qualitative study used a descriptive exploratory design; it is the first phase of a larger mixed methods study aimed at adapting a psychosocial intervention for perinatal depression. We conducted in-depth interviews with 22 women who screened positive for depression using a locally validated Chichewa version of the Edinburgh Postnatal Depression Scale at antenatal and postnatal clinics in 1 rural and 1 urban health care setting in Lilongwe District, Malawi. We also conducted 10 key informant interviews with maternal care health workers. Informed consent was obtained from all participants. An interview guide was used to guide enquiry about perceptions of perinatal depression and health service needs. Interviews were transcribed, translated and analysed using content analysis approach. Results: Perinatal depression was recognized as a common mental health problem that affected self-care activities and functioning of women in the perinatal period. Financial difficulties, relationship problems (polygamy, lack of support, neglect, and infidelity), traumatic events (intimate partner violence and loss) and fear of birth outcomes were identified as causes of depression. All study participants acknowledged the need for support and an intervention that will address the identified challenges. Additionally, they viewed strengthening the health delivery system as crucial to effectively address their needs and gaps identified in the system. Conclusion: The results of this study support plans to develop a family focused intervention for perinatal depression in Malawi addressing relationship, psychosocial and economic issues. It also highlights the importance of strengthening the health delivery system especially at primary care level where the majority of women access care in Malawi and across Sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

The distribution of silent comic illustrations can facilitate the communication and transfer of scientific recommendations about sustainable land management (SLM) to local communities in countries where many people are illiterate. However, since there are cross-cultural differences in "visual languages", visualization styles need to be carefully selected as well as locals' comprehension of the illustrated recommendation evaluated systematically. Three agricultural recommendations were chosen for comic-style illustrations, distributed to six communities in the Mahafaly region of southwestern Madagascar and evaluated using a three-step, interdependent approach. The silent comics illustrated (i) composting of manure and its application to improve soil fertility; (ii) cautious utilization of succulent silver thicket as supplementary forage; and (iii) sustainable harvesting practices of wild yam. Results revealed that general understandability strongly depended on the community that was surveyed and on the environmental subject that was illustrated. We found a strong relationship between the general understandability of comics and the divergence that exist in communities' socio-economic structure. Education level was an important factor that explained a better understanding of respondents for the comic illustrating compost production, but not for comics that illustrated sustainable usage of silver thicket and wild yam harvest. Willingness to follow the recommended practice was impaired when respondents valued no change to the improved technique compared to the common one. Effects of respondents' socio-economic characteristics on the implementation of the recommended practice could not be clarified within this study due to the small subset of data. Based on the evaluation of recurring comments made by respondents and interviewers, we conclude that comics can be a useful communication tool to increase locals' awareness and comprehension for SLM practices. This, however, requires that drawing details used to facilitate farmers' ability to adopt a point-of-view inside the comic story are used thoughtfully as they might interfere with the central message. [ABSTRACT FROM AUTHOR]

South Africa ranks third among 22 high burden countries in the world. TB which remains a leading cause of death causes one in five adult deaths in South Africa. An in-depth understanding of knowledge, attitudes and practices of young people towards TB is required to implement meaningful interventions. We analysed young men and women (18–24 years)'s TB knowledge including TB/HIV coinfections, testing rates and factors associated with them. A cross sectional cluster-based household survey was conducted in two provinces. Participants completed computer-assisted self-interviews on TB knowledge, testing history and TB/HIV coinfections. A participant was regarded as knowledgeable of TB if s/he correctly answered the WHO-adopted TB knowledge questions. We built three multivariate regression models in Stata 13.0 to assess factors associated with knowing TB alone, testing alone and both knowing and testing for TB. 1955 participants were interviewed (89.9% response rate). Their median age was 20 years (IQR19-22). Sixteen percent (16.2%) of the participants were social grant recipients, 55% were enrolled in a school/college and 5% lived in substandard houses. A total of 72% had knowledge of TB, 21% underwent screening tests for TB and 14.7% knew and tested for TB. Factors associated with TB knowledge were being female, younger, a student, social grant recipient, not transacting sex and having positive attitudes towards people living with HIV (PLWH). Factors associated with TB testing were being a student, receiving a social grant, living in OR Tambo district, HIV knowledge and having a family member with TB history. Factors associated with both TB knowledge and testing were being female, a student, using the print media, living in OR Tambo district and having a family member with a TB history. The study demonstrates the importance of demographic factors (gender, economic status, family TB history, and location) and HIV factors in explaining TB knowledge and testing. We recommend extending community TB testing services to increase testing. [ABSTRACT FROM AUTHOR]

Background: Method-specific contraceptive prevalence varies widely globally, as huge variations exist in the use of different types of contraception, with short-term methods being the most common methods in sub-Saharan Africa (SSA). Evidence is scanty on the trends, patterns and determinants of long-acting reversible contraceptive (LARC) methods in SSA. This study aimed to address this knowledge gap. Methods: Using a pseudo longitudinal research design and descriptive and inferential statistics, we analysed Demographic and Health Survey data of eight countries selected on the basis of contraceptive prevalence rates across SSA. Multinomial logistic regression modelling was used to tease out the predictors of the uptake of LARC methods in the selected countries. Results: Findings exhibit a steady but slow upward trend in LARC methods across selected countries, as a marginal increase was recorded in LARC uptake over a 10-year period in many of the selected countries. Results established significant predictors of LARC methods uptake, including fertility-related characteristics, age, level of education, work status, wealth index and exposure to mass media. This study underscored the need to address various barriers to the uptake of LARC methods in SSA. It is recommended that governments at different levels undertake to cover the costs of LARC methods in order to increase access and uptake. [ABSTRACT FROM AUTHOR]

Iodine deficiency (ID) during pregnancy results in pregnancy losses, intrauterine growth retardation, and lower IQ in the offspring. Even after two decades of universal salt iodization (USI) implementation, the efficacy of USI has not been reported in high risk groups in vulnerable regions in Ghana. We aimed to assess and improve ID status in childbearing age women (all lactating women) and their toddlers in northern Ghana, a geographically and socioeconomically vulnerable region. We provided weekly supply of household iodized salt and community-based feeding of native Hibiscus Sabdariffaa leaves meal (HSM) prepared with iodized salt to women and their toddlers in intervention (n = 60) vs. control group (n = 60). At baseline, ID was prevalent in women (36%) and their toddlers (29%). For women, both median UIC values for intervention (57.4 ug/l) and control group (65.1 ug/l) were below the recommended UIC value of 100 ug/l with no significant differences between the two groups (p = 0.2778). At the endpoint, median UIC for the intervention group (123.6 ug/l) was significantly higher (p = 0.008) than the control group (59.7 ug/l). Our results suggest that weekly supply of iodized salt along with the feeding HSM is an effective channel for improving iodine status of economically disadvantaged groups in communities remote from coastal lands. Furthermore, our results suggest that decreased median UIC among lactating mothers does not necessarily imply lower iodine status for their breastfed toddlers. And finally, the observed median UIC<100 ug/l may point to a non-improvement in iodine status for the past decade for Ghana. There is a need to revisit, assess, and ascertain the challenges in preventing populations from attaining the intended benefits of the USI policy in Ghana. [ABSTRACT FROM AUTHOR]

Background: Patients experiencing adverse drug events (ADE) in many developing countries are in the best position to report these events to the authorities but need to be empowered to do so. Systematic evaluation of community engagement and patient support especially in rural areas would provide evidence for a program to monitor potential harm from medicines. The aim of this study was to assess the effects of a community dialogue and sensitization (CDS) program on the knowledge, attitude and practises of community members for reporting ADE. Methods: This an uncontrolled before-after study was conducted in two eastern Ugandan districts between September 2016 and August 2017 Results: After implementation of the community dialogue and sensitization (CDS) program, there was an overall 20% (95% CI:16% to 25%) increase in knowledge about ADE in the community compared to before the program began. Awareness levels increased by 50% (95% CI: 37% to 63%) among those with little or no education and by41% (95% CI: 31% to 52%) among young people (15–24 years). Furthermore, 5% (95% CI: 3% to 7%) more respondents recognized the need for reporting ADEs compared to before the program. Finally, there was a significant increase of 115% (95% CI:137% to 217%) in respondent recognition and reporting of ADEs compared to the beginning of the CDS program. Overall, this community found the CDS program acceptable and proposed aspects that could be improved for future use. Conclusion: Our evaluation showed that the CDS program increased knowledge and improved attitudes by catalyzing discussions among community members and healthcare professionals on health issues and monitoring safety of medicines compared to before the program. Successful implementation of the program depends on holistic health systems strengthening and adaptation to the community’s way of life. [ABSTRACT FROM AUTHOR]

Objective: We assessed feasibility of an HIV-combination-prevention trial among fishing communities in Uganda. Design: Cluster randomised trial in four fishing communities on Lake Victoria, Uganda. Two intervention communities received a combination-prevention-package (behaviour change communication, condom promotion, HIV testing, voluntary male medical circumcision and referral for anti-retroviral therapy if HIV-positive). All four communities received routine government HIV care services. Methods: Using household census data we randomly selected a cohort of consenting residents aged ≥18 years. A baseline sero-survey in July 2014 was followed by two repeat surveys in March and December 2015. We measured uptake of HIV prevention methods, loss-to-follow-up and HIV incidence, accounting for multistage survey design. Results: A total of 862 participants were enrolled and followed for 15 months. Participation was 62% and 74% in the control and intervention arms respectively; Overall loss to follow up (LTFU) was 21.6% and was similar by arm. Self-reported abstinence/faithfulness increased between baseline and endline in both arms from 53% to 73% in the control arm, and 55% to 67% in the intervention arm. Reported condom use throughout the study period was 36% in the intervention arm vs 28% in the control arm; number of male participants reporting circumsicion in both arms from 58% to 79% in the intervention arm, and 39% to 46% in the control arm. Independent baseline predictors of loss-to-follow-up were: being HIV positive, residence in the community for <1 year, younger age, living in an urban area, and being away from the area for >1 month/year Conclusions: Recruitment and retention of participants in longitudinal trials in highly mobile HIV fishing communities is challenging. Future research should investigate modes for locating and retaining participants, and delivery of HIV-combination prevention. [ABSTRACT FROM AUTHOR]

While access to safe sanitation is a global issue, there are large disparities in access. Women living in informal settlements, in particular, are disproportionately affected by lack of access to sanitation. Without adequate sanitation, these women may resort to unsafe strategies to manage their sanitation needs, but limited research has focused specifically on this issue. Qualitative and quantitative data were collected from women in the Mathare informal settlement in Nairobi, Kenya in 2016. A latent class analysis (LCA) using the quantitative data yielded five distinct sanitation profiles (SP) among women in Mathare. In-depth interviews and sanitation walks with women added further detail about the characteristics of and motivations underlying each profile. Women's sanitation profiles in these settlements are complex. A majority of women in this study utilized an unsafe method of disposal at least once in a 24-hour period that increased their risk of direct exposure to waste and harmful pathogens. [ABSTRACT FROM AUTHOR]

In 1994, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) included “culture-bound syndromes” in its classification of psychiatric disorders and associated them with disease processes that manifest in behavioural or thought disorders that develop within a given cultural context. This study examines the definitions, explanatory models, signs and symptoms, and healthcare-seeking behaviours common to Fang culture-bound syndromes (i.e., kong, eluma, witchcraft, mibili, mikug, and nsamadalu). The Fang ethnic group is the majority ethnic group in Equatorial Guinea. From September 2012 to January 2013, 45 key Fang informants were selected, including community leaders, tribal elders, healthcare workers, traditional healers, and non-Catholic pastors in 39 of 724 Fang tribal villages in 6 of 13 districts in the mainland region of Equatorial Guinea. An ethnographic approach with an emic-etic perspective was employed. Data were collected using semi-structured interviews, participant observation and a questionnaire that included DHS6 key indicators. Interviews were designed based on the Cultural Formulation form in the DSM-5 and explored the definition of Fang cultural syndromes, symptoms, cultural perceptions of cause, and current help-seeking. Participants defined “Fang culture-bound syndromes" as those diseases that cannot be cured, treated, or diagnosed by science. Such syndromes present with the same signs and symptoms as diseases identified by Western medicine. However, they arise because of the actions of enemies, because of the actions of spirits or ancestors, as punishments for disregarding the law of God, because of the violation of sexual or dietary taboos, or because of the violation of a Fang rite of passage, the dzas, which is celebrated at birth. Six Fang culture-bound syndromes were included in the study: 1) Eluma, a disease that is targeted at the victim out of envy and starts out with sharp, intense, focussed pain and aggressiveness; 2) Witchcraft, characterized by isolation from the outside, socially maladaptive behaviour, and the use of hallucinogenic substances; 3) Kong, which is common among the wealthy class and manifests as a disconnection from the environment and a lack of vital energy; 4) Mibili, a possession by evil spirits that manifests through visual and auditory hallucinations; 5) Mikug, which appears after a person has had contact with human bones in a ritual; and 6) Nsamadalu, which emerges after a traumatic process caused by violating traditions through having sexual relations with one’s sister or brother. The therapeutic resources of choice for addressing Fang culture-bound syndromes were traditional Fang medicine and the religious practices of the Bethany and Pentecostal churches, among others. Among African ethnic groups, symbolism, the weight of tradition, and the principle of chance in health and disease are underlying factors in the presentation of certain diseases, which in ethno-psychiatry are now referred to as culture-bound syndromes. In this study, traditional healers, elders, healthcare professionals, religious figures, and leaders of the Fang community in Equatorial Guinea referred to six such cultural syndromes: eluma, witchcraft, kong, mibili, mikug, and nsamadalu. In the absence of a multidisciplinary approach to mental illness in the country, the Fang ethnic group seeks healthcare for culture-bound syndromes from traditional healing and religious rites in the Evangelical faiths. [ABSTRACT FROM AUTHOR]

Introduction: Interventions to keep adolescent girls and young women in school, or support their return to school, are hypothesised to also reduce HIV risk. Such interventions are included in the DREAMS combination package of evidence-based interventions. Although there is evidence of reduced risky sexual behaviours, the impact on HIV incidence is unclear. We used nationally representative surveys to investigate the association between being in school and HIV prevalence. Methods: We analysed Demographic and Health Survey data from nine DREAMS countries in sub-Saharan Africa restricted to young women aged 15–19 (n = 20,429 in total). We used logistic regression to assess cross-sectional associations between being in school and HIV status and present odds ratios adjusted for age, socio-economic status, residence, marital status, educational attainment and birth history (aOR). We investigated whether associations seen differed across countries and by age. Results: HIV prevalence (1.0%–9.8%), being currently in school (50.0%-72.6%) and the strength of association between the two, varied between countries. We found strong evidence that being currently in school was associated with a reduced odds of being HIV positive in Lesotho (aOR: 0.37; 95%CI: 0.17–0.79), Swaziland (aOR: 0.32; 95%CI: 0.17–0.59), and Uganda (aOR: 0.48: 95%CI: 0.29–0.80) and no statistically significant evidence for this in Kenya, Malawi, Mozambique, Tanzania, Zambia or Zimbabwe. Conclusions: Although the relationship is not uniform across countries or over time, these data are supportive of the hypothesis that young women in school are at lower risk of being HIV positive than those who leave school in some sub-Saharan African settings. There is a possibility of reverse causality, with pre-existing HIV infection leading to school drop-out. Further investigation of the contextual factors behind this variation will be important in interpreting the results of HIV prevention interventions promoting retention in school. [ABSTRACT FROM AUTHOR]

Childhood traumas, in the form of physical, sexual, and emotional abuse and neglect, are globally widespread and highly prevalent, and associated with a range of subsequent poor health outcomes. This study sought to understand the relationship between physical, sexual and emotional childhood abuse and subsequent HIV-risk behaviours amongst young people (18–30) living in urban informal settlements in Durban, South Africa. Data came from self-completed questionnaires amongst 680 women and 677 men comprising the baseline of the Stepping Stones and Creating Futures intervention trial. Men and women were analysed separately. Logistic regression models assessed the relationship between six HIV-risk behaviours and four measures of trauma: the form of trauma, the severity of each trauma, the range of traumas, and overall severity of childhood trauma. Childhood traumas were incredibly prevalent in this population. All childhood traumas were associated with a range of HIV-risk behaviours. This was for the ever/never trauma, as well as the severity of each type of trauma, the range of trauma, and overall severity of childhood trauma. Despite the wider harsh contexts of urban informal settlements, childhood traumas still play a significant role in shaping subsequent HIV-risk behaviours amongst young people. Interventions to reduce childhood traumas for populations in informal settlements need to be developed. In addition, trauma focused therapies need to be considered as part of wider HIV-prevention interventions for young adults. Trial registration: ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

Background: Congenital talipes equino-varus (CTEV), also known as clubfoot, is one of the most common congenital musculoskeletal malformations. Despite this, considerable variation exists in the measurement of deformity correction and outcome evaluation. This study aims to determine the criteria for successful clubfoot correction using the Ponseti technique in low resource settings through Africa. Methods: Using the Delphi method, 18 experienced clubfoot practitioners and trainers from ten countries in Africa ranked the importance of 22 criteria to define an ‘acceptable or good clubfoot correction’ at the end of bracing with the Ponseti technique. A 10cm visual analogue scale was used. They repeated the rating with the results of the mean scores and standard deviation of the first test provided. The consistency among trainers was determined with the intra-class correlation coefficient (ICC). From the original 22 criteria, ten criteria with a mean score >7 and SD <2 were identified and were rated through a second Delphi round by 17 different clubfoot treatment trainers from 11 countries in Africa. The final definition consisted of all statements that achieved strong agreement, a mean score of >9 and SD<1.5. Results: The consensus definition of a successfully treated clubfoot includes: (1) a plantigrade foot, (2) the ability to wear a normal shoe, (3) no pain, and (4) the parent is satisfied. Participants demonstrated good consistency in rating these final criteria (ICC 0.88; 0.74,0.97). Conclusions: The consistency of Ponseti technique trainers from Africa in rating criteria for a successful outcome of clubfoot management was good. The consensus definition includes basic physical assessment, footwear use, pain and parent satisfaction. [ABSTRACT FROM AUTHOR]

Schistosomiasis is one of the major Neglected Tropical Diseases (NTDs) in sub-Saharan Africa. In sub-Saharan Africa, two major human schistosome species namely Schistosoma mansoni and S. haematobium often occur sympatrically largely affecting children. Recognizing the public health impact of Schistosomiasis, the World Health Organization (WHO) is urging member states to regularly treat at least 75% and up to 100%, of all school-aged children at risk of morbidity. For control strategies based on targeted mass drug administration (MDA) to succeed it is essential to have a simple and sensitive test for monitoring the success of these interventions. Current available diagnostic tests, such as egg detection in stool by Kato-Katz (KK) for S. mansoni and detection of eggs or blood (hematuria) in urine for S. haematobium have reduced sensitivity in low intensity settings. The objective of the study was to evaluate active single or duo schistosome infections in school children following MDA using molecular diagnostics (PCR) on filtered urine samples and comparing that against traditional diagnostic tests. This cross-sectional study was conducted among 111 school children aged 7–15 years in Chongwe and Siavonga Districts in Zambia. Species-specific cell-free repeat DNA fragment were amplified from 111 filtered urine samples. Our approach detected eight times more positive cases (total 77) than by KK (9) for S. mansoni and six times more (total 72) than by hematuria (11) for S. haematobium and even more against urine filtration (77 compared to only 6). The same pattern was observed when stratified for age group and sex specific analysis with 100% sensitivity and specificity devoid of any cross amplification. In addition, 69 individuals (62%) were co-infected by both parasites. We have demonstrated a significantly higher prevalence of both species than indicated by the traditional tests and the persistent maintenance of reservoir of infection after MDA. Our approach is an effective means of detecting low intensity infection, which will enhance the effectiveness of surveillance and assess the impact of MDA control programs against schistosomiasis. [ABSTRACT FROM AUTHOR]

The Ugandan government is committed to scaling-up proven HIV prevention strategies including safe male circumcision, and innovative strategies are needed to increase circumcision uptake. The aim of this study was to assess the acceptability and feasibility of implementing a soccer-based intervention (“Make The Cut”) among schoolboys in a peri-urban district of Uganda. The intervention was led by trained, recently circumcised “coaches” who facilitated a 60-minute session delivered in schools, including an interactive penalty shoot-out game using metaphors for HIV prevention, sharing of the coaches’ circumcision story, group discussion and ongoing engagement from the coach to facilitate linkage to male circumcision. The study took place in four secondary schools in Entebbe sub-district, Uganda. Acceptability of safe male circumcision was assessed through a cross-sectional quantitative survey. The feasibility of implementing the intervention was assessed by piloting the intervention in one school, modifying it, and implementing the modified version in a second school. Perceptions of the intervention were assessed with in-depth interviews with participants. Of the 210 boys in the cross-sectional survey, 59% reported being circumcised. Findings showed high levels of knowledge and generally favourable perceptions of circumcision. The initial implementation of Make The Cut resulted in 6/58 uncircumcised boys (10.3%) becoming circumcised. Changes made included increasing engagement with parents and improved liaison with schools regarding the timing of the intervention. Following this, uptake improved to 18/69 (26.1%) in the second school. In-depth interviews highlighted the important role of family and peer support and the coach in facilitating the decision to circumcise. This study showed that the modified Make The Cut intervention may be effective to increase uptake of safe male circumcision in this population. However, the intervention is time-intensive, and further work is needed to assess the cost-effectiveness of the intervention conducted at scale. [ABSTRACT FROM AUTHOR]

The factors that trigger sudden, seasonal movements of elephants are uncertain. We hypothesized that savannah elephant movements at the end of the dry season may be a response to their detection of distant thunderstorms. Nine elephants carrying Global Positioning System (GPS) receivers were tracked over seven years in the extremely dry and rugged region of northwestern Namibia. The transition date from dry to wet season conditions was determined annually from surface- and satellite-derived rainfall. The distance, location, and timing of rain events relative to the elephants were determined using the Tropical Rainfall Measurement Mission (TRMM) satellite precipitation observations. Behavioral Change Point Analysis (BCPA) was applied to four of these seven years demonstrating a response in movement of these elephants to intra- and inter-seasonal occurrences of rainfall. Statistically significant changes in movement were found prior to or near the time of onset of the wet season and before the occurrence of wet episodes within the dry season, although the characteristics of the movement changes are not consistent between elephants and years. Elephants in overlapping ranges, but following separate tracks, exhibited statistically valid non-random near-simultaneous changes in movements when rainfall was occurring more than 100 km from their location. While the environmental trigger that causes these excursions remains uncertain, rain-system generated infrasound, which can travel such distances and be detected by elephants, is a possible trigger for such changes in movement. [ABSTRACT FROM AUTHOR]