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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]

Ghana has made significant stride towards universal health coverage (UHC) by implementing the National Health Insurance Scheme (NHIS) in 2003. This paper investigates the progress of UHC indicators in Ghana from 1995 to 2015 and makes future predictions up to 2030 to assess the probability of achieving UHC targets. National representative surveys of Ghana were used to assess health service coverage and financial risk protection. The analyses estimated the coverage of 13 prevention and four treatment service indicators at the national level and across wealth quintiles. In addition, we calculated catastrophic health payments and impoverishment to assess financial hardship and used a Bayesian regression model to estimate trends and future projections as well as the probabilities of achieving UHC targets by 2030. Wealth-based inequalities and regional disparities were also assessed. At the national level, 14 out of the 17 health service indicators are projected to reach the target of 80% coverage by 2030. Across wealth quintiles, inequalities were observed amongst most indicators with richer groups obtaining more coverage than their poorer counterparts. Subnational analysis revealed while all regions will achieve the 80% coverage target with high probabilities for the prevention services, the same cannot be applied to the treatment services. In 2015, the proportion of households that suffered catastrophic health payments and impoverishment at a threshold of 25% non-food expenditure were 1.9% (95%CrI: 0.9–3.5) and 0.4% (95%CrI: 0.2–0.8), respectively. These are projected to reduce to 0.4% (95% CrI: 0.1–1.3) and 0.2% (0.0–0.5) respectively by 2030. Inequality measures and subnational assessment revealed that catastrophic expenditure experienced by wealth quintiles and regions are not equal. Significant improvements were seen in both health service coverage and financial risk protection over the years. However, inequalities across wealth quintiles and regions continue to be cause of concerns. Further efforts are needed to narrow these gaps. [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]

Background: Modeling contributes to health program planning by allowing users to estimate future outcomes that are otherwise difficult to evaluate. However, modeling results are often not easily translated into practical policies. This paper examines the barriers and enabling factors that can allow models to better inform health decision-making. Description: The Decision Makers’ Program Planning Tool (DMPPT) and its successor, DMPPT 2, are illustrative examples of modeling tools that have been used to inform health policy. Their use underpinned Voluntary Medical Male Circumcision (VMMC) scale-up for HIV prevention in southern and eastern Africa. Both examine the impact and cost-effectiveness of VMMC scale-up, with DMPPT used initially in global advocacy and DMPPT 2 then providing VMMC coverage estimates by client age and subnational region for use in country-specific program planning. Their application involved three essential steps: identifying and engaging a wide array of stakeholders from the outset, reaching consensus on key assumptions and analysis plans, and convening data validation meetings with critical stakeholders. The subsequent DMPPT 2 Online is a user-friendly tool for in-country modeling analyses and continuous program planning and monitoring. Lessons learned: Through three iterations of the DMPPT applied to VMMC, a comprehensive framework with six steps was identified: (1) identify a champion, (2) engage stakeholders early and often, (3) encourage consensus, (4) customize analyses, (5), build capacity, and (6) establish a plan for sustainability. This framework could be successfully adapted to other HIV prevention programs to translate modeling results to policy and programming. Conclusions: Models can be used to mobilize support, strategically plan, and monitor key programmatic elements, but they can also help inform policy environments in which programs are conceptualized and implemented to achieve results. The ways in which modeling has informed VMMC programs and policy may be applicable to an array of other health interventions. [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]

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]

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]

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]

In December 2016, the Nigerian Federal Ministry of Health updated its HIV guidelines to a Treat All approach, expanding antiretroviral therapy (ART) eligibility to all individuals with HIV infection, regardless of CD4+ cell count, and recommending ART be initiated within two weeks of HIV diagnosis (i.e., the Test and Treat strategy). The Test and Treat policy was first piloted in 32 local government areas (LGAs). The primary objective of this study was to evaluate the clinical outcomes of adult patients initiated on ART within two weeks of HIV diagnosis during this pilot. We conducted a retrospective cohort analysis of patients who initiated ART within two weeks of new HIV diagnosis between October 2015 and September 2016 in eight randomly selected LGAs participating in the Test and Treat pilot study. 2,652 adults were newly diagnosed and initiated on ART within two weeks of HIV diagnosis. Of these patients, 8% had documentation of a 12-month viral load measurement, and 13% had documentation of a six-month viral load measurement. Among Test and Treat patients with a documented viral load, 79% were suppressed (≤400 copies/ml) at six months and 78% were suppressed at 12 months. By 12 months post-ART initiation, 34% of the patients who initiated ART under the Test and Treat strategy were lost to follow-up. The median CD4 cell count among patients initiating ART within two weeks of HIV diagnosis was 323 cells/mm3 (interquartile range, 161–518). While randomized controlled trials have demonstrated that Test and Treat strategies can improve patient retention and increase viral suppression compared to standard of care, these findings indicate that the effectiveness of Test and Treat in some settings may be far lower than the efficacy demonstrated in randomized controlled trials. Significant attention to the way Test and Treat strategies are implemented, monitored, and improved particularly related to early retention, can help expand access to ART for all patients. [ABSTRACT FROM AUTHOR]

Background: Strong primary health care (PHC) is essential for achieving universal health coverage, but in many low- and middle-income countries (LMICs) PHC services are of poor quality. Facility management is hypothesized to be critical for improving PHC performance, but evidence about management performance and its associations with PHC in LMICs remains limited. Methods: We quantified management performance of PHC facilities in Ghana and assessed the experiences of women who sought care at sampled facilities. Using multi-level models, we examined associations of facility management with five process outcomes and eight experiential outcomes. Findings: On a scale of 0 to 1, the average overall management score in Ghana was 0·76 (IQR = 0·68–0·85). Facility management was significantly associated with one process outcome and three experiential outcomes. Controlling for facility characteristics, facilities with management scores at the 90th percentile (management score = 0·90) had 22% more essential drugs compared to facilities with management scores at the 10th percentile (0·60) (p = 0·002). Positive statistically non-significant associations were also seen with three additional process outcomes—integration of family planning services (p = 0·054), family planning types provided (p = 0·067), and essential equipment availability (p = 0·104). Compared to women who sought care at facilities with management scores at the 10th percentile, women who sought care at facilities at the 90th percentile reported 8% higher ratings of trust in providers (p = 0·028), 15% higher ratings of ease of following provider’s advice (p = 0·030), and 16% higher quality rating (p = 0·020). However, women who sought care in the 90th percentile facilities rated their waiting times as worse (22% lower, p = 0·039). Interpretation: Higher management scores were associated with higher scores for some process and experiential outcomes. Large variations in management performance indicate the need to strengthen management practices to help realize the full potential of PHC in improving health outcomes. [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: TB persists despite being relatively easy to detect and cure because the journey from the onset of symptoms to cure involves a series of steps, with patients being lost to follow-up at each stage and delays occurring among patients not lost to follow-up. One cause of drop-off and delay occurs when patients delay or avoid returning to clinic to get their test results and start treatment. Methods: We fielded two SMS interventions in three Cape Town clinics to see their effects on whether people returned to clinic, and how quickly. One was a simple reminder; the other aimed to overcome “optimism bias” by reminding people TB is curable and many millions die unnecessarily from it. Recruits were randomly assigned at the clinic level to a control group or one of the two SMS groups (1:2:2). In addition to estimating effects on the full sample, we also estimated effects on HIV-positive patients. Results: SMS recipients were more likely to return to clinic in the requested two days than the control group. The effect was smaller in the intent-to-treat analysis (52/101 or 51.5% vs. 251/405 or 62.0%, p = 0.05) than in the per-protocol analysis (50/97 or 51.5% vs. 204/318 or 64.2%, p = 0.03). The effect was larger among HIV-positives (10/35 or 28.6% vs. 97/149 or 65.1%, p<0.01). The effects of SMS messages diminished as the interval increased: significant effects at the 5% level were found at five and 10 days only among HIV-positives. The second SMS message had larger effects, albeit not significantly larger, likely due in part to lack of statistical power. Conclusions: At 2 U.S. cents per message, SMS reminders are an inexpensive option to encourage TB testers to return to clinic, especially when worded to counter optimism bias. [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]

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]

We propose a method for analyzing repeated residential movements based on graphical loglinear models. This method allows an explicit representation of residential presence and absence patterns from several areas without defining mobility measures. We make use of our method to analyze data from one of the most comprehensive demographic surveillance sites in Africa that is characterized by high adult HIV prevalence, high levels of poverty and unemployment and frequent residential changes. Between 2004 and 2016, residential changes were recorded for 8,857 men over 35,500.01 person-years, and for 12,158 women over 57,945.35 person-years. These individuals were HIV negative at baseline. Over the study duration, there were a total of 806 HIV seroconversions in men, and 2,458 HIV seroconversions in women. Our method indicates that establishing a residence outside the rural study area is a strong predictor of HIV seroconversion in men (OR = 2.003, 95% CI = [1.718,2.332]), but not in women. Residing inside the rural study area in a single or in multiple locations is a less significant risk factor for HIV acquisition in both men and women compared to moving outside the rural study area. [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]

Despite the high success rates of preformed metal crowns (PMCs) in children no randomized clinical trials compare methods of placement and none describe its use in Africa. Our aim was to compare survival and cost-effectiveness of PMCs placed by conventional techniques (CT) and biological Hall techniques (HT) using a prospective randomized control trial in a general dental practice from Khartoum. One hundred and nine and 103 PMCs were placed in randomly selected children (5-8years) with 1–2 carious primary molars using HT and CT respectively and followed for 2 years. Socioeconomic status, periodontal health, occlusion, anxiety, and procedure time were compared using student t-test. Kaplan–Meier survival rates and incremental cost effectiveness ratio (ICER) were compared between CT and HT. CT and HT groups were similar for age, gender, socio-economic status. Survival rates were high (over 90%) for both study arms and not statistically different (p>0.05). Anxiety scores were significantly higher in CT arm after 12 months compared to HT (p<0.001). Clinically, gingival and plaque indices were similar between groups (p>0.05) but occlusions were raised in nearly all subjects in the HT arm (p<0.05). Periodontal health improved, and occlusions adjusted over time in both arms. There were 3 (2.7%) and 6 (5.8%) minor failures, 7 (6.4%) and 6 (5.8%) major failures in HT and CT arms respectively. Mean procedure time was lower in HT (9.1 min) than CT (33.9 min); p<0.001. Mean PMC cost was US$2.45 and US$7.81 for HT and CT respectively. The ICER was US$136.56 more for each PMC placed by CT per life year. We show that PMCs have high survival outcomes in disadvantaged populations similar to results from developed countries. As HT can be carried out by less experienced dental operators and therapists, this biological approach provides a promising cost-effective option to manage caries in developing countries with limited resources. Trial registration: The trial is registered at clinicaltrials.gov. ClinicalTrial.gov Trial Registration: [ABSTRACT FROM AUTHOR]

Background: Fisherfolk are a most-at-risk population for HIV being prioritized for the scale up of HIV treatment in Uganda. Heavy alcohol use and potential drug use may be a major barrier to treatment adherence for men in this setting. Objective: This study examines the prevalence of substance use, and its influence on antiretroviral treatment (ART) adherence, among male fisherfolk on ART in Wakiso District, Uganda. Methods: This cross-sectional study included structured questionnaires (N = 300) with men attending HIV clinics near Lake Victoria. Using generalized logistic modeling analyses with a binomial distribution and logit link, we conducted multivariate models to test the association between each alcohol variable (quantity and frequency index, hazardous drinking) and missed pills, adjusting for covariates, and tested for interactions between number of pills prescribed and alcohol variables. Results: Thirty-one percent of men reported sub-optimal adherence. Half (46.7%) reported drinking, of which 64.8% met criteria for hazardous drinking. Illicit drug use was low (6%). In the multivariate model, men with greater scores on the alcohol frequency and quantity index were more likely to report missed pills compared to those reporting no drinking (AOR: 1.60, 95% CI: 1.29–1.97). Hazardous drinking had a greater effect on missed ARV doses among men taking twice daily regimens compared to once daily (AOR: 4.91, 95% CI: 1.68–14.37). Conclusions: Our findings highlight the need for targeted alcohol-reduction interventions for male fisherfolk on ART who drink at high quantities to improve ART adherence and to prevent the known negative health effects of alcohol for HIV-infected individuals. [ABSTRACT FROM AUTHOR]

To accelerate malaria elimination in areas where core interventions such as insecticide-treated nets (ITNs) are already widely used, it is crucial to consider additional factors associated with persistent transmission. Qualitative data on human behaviours and perceptions regarding malaria risk was triangulated with quantitative data on Anopheles mosquito bites occurring indoors and outdoors in south-eastern Tanzania communities where ITNS are already used but lower level malaria transmission persists. Each night (18:00h-07:00h), trained residents recorded human activities indoors, in peri-domestic outdoor areas, and in communal gatherings. Host-seeking mosquitoes were repeatedly collected indoors and outdoors hourly, using miniaturized exposure-free double net traps (DN-Mini) occupied by volunteers. In-depth interviews were conducted with household representatives to explore perceptions on persistent malaria and its control. Higher proportions of people stayed outdoors than indoors in early-evening and early-morning hours, resulting in higher exposures outdoors than indoors during these times. However, exposure during late-night hours (22:00h–05:00h) occurred mostly indoors. Some of the popular activities that kept people outdoors included cooking, eating, relaxing and playing. All households had at least one bed net, and 83.9% of people had access to ITNs. Average ITN use was 96.3%, preventing most indoor exposure. Participants recorgnized the importance of ITNs but also noted that the nets were not perfect. No complementary interventions were reported being used widely. Most people believed transmission happens after midnight. We conclude that insecticide-treated nets, where properly used, can still prevent most indoor exposures, but significant risk continues unabated before bedtime, outdoors and at communal gatherings. Such exposure is greatest for rural and low-income households. There is therefore an urgent need for complementary interventions, particularly those targeting outdoor-biting and are applicable for all people including the marginalised populations such as migratory farmers and fishermen. Besides, the differences in community understanding of ongoing transmission, and feedback on imperfections of ITNs should be considered when updating malaria-related communication and interventions. [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]

Introduction: In 2016, for the very first time, the Ministry of Health in Zambia implemented a reactive outbreak response to control the spread of cholera and vaccinated at-risk populations with a single dose of Shancol—an oral cholera vaccine (OCV). This study aimed to assess the costs of cholera illness and determine the cost-effectiveness of the 2016 vaccination campaign. Methodology: From April to June 2017, we conducted a retrospective cost and cost-effectiveness analysis in three peri-urban areas of Lusaka. To estimate costs of illness from a household perspective, a systematic random sample of 189 in-patients confirmed with V. cholera were identified from Cholera Treatment Centre registers and interviewed for out-of-pocket costs. Vaccine delivery and health systems costs were extracted from financial records at the District Health Office and health facilities. The cost of cholera treatment was derived by multiplying the subsidized cost of drugs by the quantity administered to patients during hospitalisation. The cost-effectiveness analysis measured incremental cost-effectiveness ratio—cost per case averted, cost per life saved and cost per DALY averted—for a single dose OCV. Results: The mean cost per administered vaccine was US$1.72. Treatment costs per hospitalized episode were US$14.49–US$18.03 for patients ≤15 years old and US$17.66–US$35.16 for older patients. Whereas households incurred costs on non-medical items such as communication, beverages, food and transport during illness, a large proportion of medical costs were borne by the health system. Assuming vaccine effectiveness of 88.9% and 63%, a life expectancy of 62 years and Gross Domestic Product (GDP) per capita of US$1,500, the costs per case averted were estimated US$369–US$532. Costs per life year saved ranged from US$18,515–US$27,976. The total cost per DALY averted was estimated between US$698–US$1,006 for patients ≤15 years old and US$666–US$1,000 for older patients. Conclusion: Our study determined that reactive vaccination campaign with a single dose of Shancol for cholera control in densely populated areas of Lusaka was cost-effective. [ABSTRACT FROM AUTHOR]

Commercial captive breeding and trade in body parts of threatened wild carnivores is an issue of significant concern to conservation scientists and policy-makers. Following a 2016 decision by Parties to the Convention on International Trade in Endangered Species of Wild Fauna and Flora, South Africa must establish an annual export quota for lion skeletons from captive sources, such that threats to wild lions are mitigated. As input to the quota-setting process, South Africa’s Scientific Authority initiated interdisciplinary collaborative research on the captive lion industry and its potential links to wild lion conservation. A National Captive Lion Survey was conducted as one of the inputs to this research; the survey was launched in August 2017 and completed in May 2018. The structured semi-quantitative questionnaire elicited 117 usable responses, representing a substantial proportion of the industry. The survey results clearly illustrate the impact of a USA suspension on trophy imports from captive-bred South African lions, which affected 82% of respondents and economically destabilised the industry. Respondents are adapting in various ways, with many euthanizing lions and becoming increasingly reliant on income from skeleton export sales. With rising consumer demand for lion body parts, notably skulls, the export quota presents a further challenge to the industry, regulators and conservationists alike, with 52% of respondents indicating they would adapt by seeking ‘alternative markets’ for lion bones if the export quota allocation restricted their business. Recognizing that trade policy toward large carnivores represents a ‘wicked problem’, we anticipate that these results will inform future deliberations, which must nonetheless also be informed by challenging inclusive engagements with all relevant stakeholders. [ABSTRACT FROM AUTHOR]

Introduction: Despite the government’s efforts to decentralize and expand health institutions to promote facility-based child delivery, home delivery and maternal mortality are still widespread problems in Ethiopia. Most mothers continue to give birth at home. This study aims at identifying the socio-cultural practices, perceived benefit or need, and accessibility factors influencing women’s choice of health facilities for delivery services in Gida Ayana Woreda, western Ethiopia. Methods: We conducted a cross-sectional survey to assess women’s use of delivery care services in Gida Ayana Woreda, from November 2016 to January 2017; 459 women who were selected randomly participated in the study. We evaluated the socio-cultural, perceived benefit or need, and economic and physical accessibility factors in women’s choice of delivery care and used adjusted logistic regression analysis to examine significant predictors of delivery site use decisions. Results: Over half (56.6%) of the women self-reported using institutional delivery care; 80.9% gave birth at a health center. A socio-cultural variable, maternal education, significantly influenced women’s choice of health facility for delivery care services (AOR 3.4; 95% CI 2.0–5.9). Mothers’ knowledge level of obstetric complications and experience of complications during the last birth were the two perceived benefits or need factors associated with higher odds of receiving delivery care from decentralized local facilities. Utilization of health centers for maternal delivery care was significantly higher than of health posts (AOR 5.0; 95% CI 2.4–10.2). Availability of motorized transportation during labor to nearby delivery site was a significant predictor of institutional delivery. Conclusion: This study demonstrates the under-utilization of decentralized health facilities for maternal delivery care services in Gida Ayana Woreda, which was significantly influenced by socio-cultural, perceived need, and accessibility factors of women during childbirth. This suggests the need for tailored intervention to improve childbirth services use for mothers in this kind of rural settings. [ABSTRACT FROM AUTHOR]

Background: Community-based health insurance (CBHI) scheme is an emerging strategy for providing financial protection against health-related poverty. It is being piloted in the Sheko district, but community satisfaction with the scheme has not yet studied. Therefore, this study aimed to assess the level of household’s satisfaction to CBHI scheme and associated factors in a piloted Sheko district; southwest Ethiopia. Methods: A community-based cross-sectional study was conducted in Sheko district from March to April 2018. Data was collected on 528 households by using simple random sampling method. Trained data collectors gathered the data using a pre-tested and structured questionnaire. Descriptive statistics, bivariate and multivariable logistic regression analyses were performed. To determine the independent predictors of household’s satisfaction to CBHI, a cut point of p values < 0.05 were used. Results: This study showed that more than half (54.7%) of the households were satisfied with the CBHI scheme. Satisfaction to CBHI was positively associated with adequate knowledge of CBHI benefit packages (AOR = 2.29, 95% CI = 1.55–3.38), type of health facility visit (AOR = 1.93, 95% CI = 1.09–3.39), laboratory service provision (AOR = 2.07, 95% CI = 1.15–373) and length of enrollment (AOR = 1.53, 95% CI = 1.01–2.32). Conclusions: Household’s satisfaction to CBHI scheme was moderate. Modifiable factors, including adequate knowledge of CBHI benefit packages, type of health facility visit, laboratory service provision, and length of enrollment were independent determinants of satisfaction. In order to augment enrollee’s satisfaction to CBHI, efforts should be given to improving their knowledge of CBHI benefit packages through education and information campaigns. Furthermore, due consideration should also be given to improving the quality of health services. [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]

Background: The Maternal Mortality Ratio in Mozambique has stagnated at 405 deaths per 100,000 live births with virtually no progress over the last 15 years. Low Institutional Birth Rates (IBRs) levelling around 50% in many rural areas constitute one of the contributing reasons. Demand-side financing has successfully increased usage of maternal health services in other countries, but little information exists on in-kind incentives in rural Africa. The objective was to test the impact on Institutional Birth Rates of giving a USD 5.50 baby package incentive to every woman who came to give birth in a health centre in a rural, poor district of Cabo Delgado, Mozambique. Methods and findings: The intervention was implemented in one district in 2010 with the remaining 15 districts serving as controls. The total population in the 16 districts in 2006 was just under 1.5 million people. IBRs were observed from 2006 to 2013 (53 months before and 55 months after the intervention began). The non-intervention districts showed a slight increase, from a mean IBR of 0.39 (SD = 0.10) in 2006 to 0.67 (SD = 0.13) in 2014. The intervention district had a dramatic increase in IBRs within six months of the start of the intervention in 2010, which was sustained until the end of the study. Adjusting for the background increase and for confounders, including health facilities and health personnel per district, and taking clustering in districts into account, the estimated rate ratio of institutional births in the intervention district was 1.80 (95% CI 1.72, 1.89 p<0.001). Conclusion: Women were almost twice as likely to have an institutional birth following the introduction of the baby package. [ABSTRACT FROM AUTHOR]

Increasing modern contraceptive use is important for improving maternal and child health and achieving economic growth and development goals. However, pervasive high unmet need for modern contraceptives in sub-Saharan Africa warrants new understandings of the drivers of modern contraceptive use. A deviance approach (i.e., examining how women’s experiences/characteristics differ from other women in their community) provides an innovative framework for capturing heterogeneity among women in a community. This framework can inform public health programming by both exploring how women avoid adverse health outcomes and understanding the needs of harder-to-reach populations who may experience health risks, despite living in communities where others do not experience vulnerability. Using data from Demographic and Health Surveys from 29 sub-Saharan African countries, we examine how a woman’s deviation from community norms around socioeconomic characteristics and gender and fertility norms and behaviors is associated with modern contraceptive use. Random-effects logistic regression models were fitted for each country to examine relationships between modern contraceptive use and deviance. Some deviance factors were associated with modern contraceptive use in only a few countries, while others were significant across many countries. Cross-country consistency in the direction of the relationship between deviance and modern contraceptive use varied by the specific deviance factor, with some relationships being consistent across countries, and other relationships being more varied. For example, having more education than the community norm was associated with increased modern contraceptive use across countries; however, marrying older than other women in the community was associated with an increase in modern contraceptive use in some countries and a decrease in others. More work is needed to understand the role of deviance on modern contraceptive use; however, this study suggests that using context-specific deviance approaches may be important for further elucidating experiences of modern contraceptive use. [ABSTRACT FROM AUTHOR]

Acute gastrointestinal illness (AGI) is a global public health priority that often disproportionately effects Indigenous populations. While previous research examines the association between meteorological conditions and AGI, little is known about how socio-cultural factors may modify this relationship. This present study seeks to address this research gap by comparing AGI prevalence and determinants between an Indigenous and non-Indigenous population in Uganda. We estimate the 14-day self-reported prevalence of AGI among adults in an Indigenous Batwa population and their non-Indigenous neighbours using cross-sectional panel data collected over four periods spanning typically rainy and dry seasons (January 2013 to April 2014). The independent associations between Indigenous status, precipitation, and AGI are examined with multivariable multi-level logistic regression models, controlling for relative wealth status and clustering at the community level. Estimated prevalence of AGI among the Indigenous Batwa was greater than among the non-Indigenous Bakiga. Our models indicate that both Indigenous identity and decreased levels of precipitation in the weeks preceding the survey period were significantly associated with increased AGI, after adjusting for confounders. Multivariable models stratified by Indigenous identity suggest that Indigenous identity may not modify the association between precipitation and AGI in this context. Our results suggest that short-term changes in precipitation affect both Indigenous and non-Indigenous populations similarly, though from different baseline AGI prevalences, maintaining rather than exacerbating this socially patterned health disparity. In the context of climate change, these results may challenge the assumption that changing weather patterns will necessarily exacerbate existing socially patterned health disparities. [ABSTRACT FROM AUTHOR]

Background: Mobile Health or mHealth interventions, including Short Message Service (SMS), can help increase access to care, enhance the efficiency of health service delivery and improve diagnosis and treatment for HIV. Text messaging, or SMS, allows for the low cost transmission of information, and has been used to send appointment reminders, information about HIV counselling and treatment, messages to encourage adherence and information on nutrition and side-effects. HIV Viral Load (VL) monitoring is recommended by the WHO and has been progressively adopted in many settings. In Zimbabwe, implementation of VL is routine and has been rolled out with support of Médecins Sans Frontières (MSF) since 2012. An SMS intervention to assist with the management of VL results was introduced in two rural districts of Zimbabwe. After completion of the HIV VL testing at the National Microbiology Reference Laboratory in Harare, results were sent to health facilities via SMS. Consenting patients were also sent an SMS informing them that their viral load results were ready for collection at their nearest health facilities. No actual VL results were sent to patients. Methods: A qualitative study was conducted in seven health-care facilities using in-depth interviews (n = 32) and focus group discussions (n = 5) to explore patient and health-care worker experiences of the SMS intervention. Purposive sampling was used to select participants to ensure that male and female patients, as well as those with differing VL results and who lived differing distances from the clinics were included. Data were transcribed, translated from Shona into English, coded and thematically analysed using NVivo software. Results: The VL SMS intervention was considered acceptable to patients and health-care workers despite some challenges in implementation. The intervention was perceived by health-care workers as improving adherence and well-being of patients as well as improving the management of VL results at health facilities. However, there were some concerns from participants about the intervention, including challenges in understanding the purpose and language of the messages and patients coming to their health facility unnecessarily. Health-care workers were more concerned than patients about unintentional HIV disclosure relating to the content of the messages or phone-sharing. Conclusion: This was an innovative intervention in Zimbabwe, in which SMS was used to send VL results to health-care facilities, and notifications of the availability of VL results to patients. Interventions such as this have the potential to reduce unnecessary clinic visits and ensure patients with high VL results receive timely support, but they need to be properly explained, alongside routine counselling, for patients to fully benefit. The findings of this study also have potential policy implications, as if implemented well, such an SMS intervention has the potential to help patients adopt a more active role in the self-management of their HIV disease, become more aware of the importance of adherence and VL monitoring and seek follow-up at clinics when results are high. [ABSTRACT FROM AUTHOR]

Despite the removal of user fees on public primary healthcare in Zambia, prior studies suggest that out-of-pocket payments are still significant. However, we have little understanding of the extent to which out-of-pocket payments lead patients to hardship methods of financing out-of-pocket costs. This study analyses the prevalence and determinants of hardship financing arising from out-of-pocket payments in healthcare, using data from a nationally-representative household health expenditure survey conducted in 2014. We employ a sequential logistic regression model to examine the factors associated with the risk of hardship financing conditional on reporting an illness and an out-of-pocket expenditure. The results show that up to 11% of households who reported an illness had borrowed money, or sold items or asked a friend for help, or displaced other household consumption in order to pay for health care. The risk of hardship financing was higher among the poorest households, female headed-households and households who reside further from health facilities. Improvements in physical access and quality of public health services have the potential to reduce the incidence of hardship financing especially among the poorest. [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]

Background: There is no available training programme with standard elements for health workers treating clubfoot in Africa. Standardised training with continued mentorship has the potential to improve management of clubfoot. We aimed to evaluate the feasibility of such a training programme among clubfoot providers in Africa, and assess implications for training effectiveness and scale up. Method: We used participatory research with trainers from 18 countries in Africa over two years to devise, pilot and refine a 2-day basic and a 2-day advanced clubfoot treatment course. (The Africa Clubfoot Training or ‘ACT’ Course.) The pilots involved training 113 participants. Mixed methods (both qualitative and quantitative) were used for evaluation. We describe and synthesise the results using the eight elements proposed by Bowen et al (2010) to assess feasibility. All participants completed feedback questionnaires, and interviews were conducted with a subset of participants. We undertook a narrative description of themes raised in the participant questionnaires and interviews. Descriptive statistics were used to compare pre- and post-course scores for confidence and knowledge. Results: 113 participants completed pre and post-course measures (response rate = 100%). Mean participant confidence increased from 64% (95%CI: 59–69%) to 88% (95%CI: 86–91%) post course. Mean participant knowledge increased from 55% (95%CI: 51–60%) to 78% (95%CI: 76–81%) post course. No difference was found in mean for either subscale of cadre or sex. The qualitative analysis generated themes under four domains: ‘practical learning in groups’, ‘interactive learning’, ‘relationship with the trainer’ and ‘ongoing supervision and mentorship’ Conclusion: The Africa Clubfoot Training package to teach health care workers to manage clubfoot is likely to be feasible in Africa. Future work should evaluate its impact on short and long term treatment outcomes and a process evaluation of implementation is required. [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 provision of healthcare in rural African communities is a highly complex and largely unsolved problem. Two main difficulties are the identification of individuals that are most likely affected by disease and the prediction of responses to health interventions. Social networks have been shown to capture health outcomes in a variety of contexts. Yet, it is an open question as to what extent social network analysis can identify and distinguish among households that are most likely to report poor health and those most likely to respond to positive behavioural influences. We use data from seven highly remote, post-conflict villages in Liberia and compare two prominent network measures: in-degree and betweenness. We define in-degree as the frequency in which members from one household are named by another household as a friends. Betweenness is defined as the proportion of shortest friendship paths between any two households in a network that traverses a particular household. We find that in-degree explains the number of ill family members, whereas betweenness explains engagement in preventative health. In-degree and betweenness independently explained self-reported health and behaviour, respectively. Further, we find that betweenness predicts susceptibility to, instead of influence over, good health behaviours. The results suggest that targeting households based on network measures rather than health status may be effective for promoting the uptake of health interventions in rural poor villages. [ABSTRACT FROM AUTHOR]