Search

Objectives: The objective was to identify antimicrobial resistance related knowledge, attitudes and practice gaps of general practitioners, patients and farmers. Methods: Cross-sectional, mixed-mode (in-person and distance) survey conducted out among the key antimicrobial prescribers and consumers in Uzbekistan, from March to October 2020. We calculated knowledge and attitude scores and applied multivariable adaptive linear regression. Results: Data were collected from 718 adults (236 - GPs, 251 - patients and 231 - farmers) aged 18 years and older. 66.5 % (n = 157) of general practitioners didn't base their antimicrobials prescription on guidelines. A third were not familiar with the delayed antibiotic prescriptions strategy. Most general practitioners prescribe antibiotics on patients' request; one third if patients have fever, almost 60 % (n = 142) if patients have cough with sputum.Majority of patients believed that antibiotics can cure influenza and cold. Every third farmer thought that antibiotics is an antiviral and every fifth a tool to increase productivity. Almost two third of them used antibiotics to protect livestock/poultry/fish from disease.For all three groups, the strongest predictor for the right attitude was the knowledge level. Conclusions: All three groups had knowledge gaps in the form of misconception and problem underestimation which manifests itself as a wrong practice. Interventions are needed at the national, institutional and individual levels, in particular in the trainings of general practitioners and farmers.

Background: Non-communicable diseases (NCDs) are the leading cause of mortality worldwide, and increasingly so in low- and middle-income countries. Afghanistan is dealing with a double burden of diseases, yet there has been no evidence synthesis on the prevalence of major NCDs and their risk factors. Objective: This study aims to provide a comprehensive synthesis of the existing data on the prevalence of major NCDs and the common related risk factors in Afghanistan. Method: We systematically reviewed scientific articles from 2000 to 2022 that reported the prevalence of diabetes, chronic respiratory diseases (CRDs), cardiovascular diseases (CVDs) or cancer, and their risk factors in Afghanistan. Four online databases (PubMed, Web of Science, Cochrane and Google Scholar) and two local journals in Afghanistan (not indexed online) were systematically searched and screened. Two reviewers independently screened and appraised the quality of the articles. Data extraction and synthesis were performed using tabulated sheets. Results: Among 51 eligible articles, 10 (19.6%) focused on cancer, 10 (19.6%) on diabetes, 4 (7.8%) on CVDs, 4 (7.8%) on CRDs and 23 (45.1%) on risk factors as the primary outcome. Few articles addressed major NCD prevalence; no evidence of CVDs, cancer was 0.15%, asthma ranged between 0.3% and 17.3%, and diabetes was 12%. Pooled prevalence of hypertension and overweight were 31% and 35%, respectively. Central obesity was twice as prevalent in females (76% versus 40%). Similarly, gender differences were observed in smoking and snuff use with prevalence rates of 14% and 25% among males and 2% and 3% among females, respectively. A total of 14% of the population engaged in vigorous activity. Pooled prevalence for physical inactivity, general obesity, fruit and vegetable consumption, dyslipidaemia and alcohol consumption couldn’t be calculated due to the heterogeneity of articles. Conclusion: Only little evidence is available on the prevalence of major NCDs in Afghanistan; however, the NCD risk factors are prevalent across the country. The quality of the available data, especially those of the local resources, is poor; therefore, further research should generate reliable evidence in order to inform policymakers on prioritizing interventions for controlling and managing NCDs.

BackgroundThis scoping review is a further step to build up the Mental Health Surveillance System for Germany. It summarizes and analyzes indicators used or described in Organization for Economic Co-operation and Development (OECD) countries for public mental health monitoring in children and adolescents aged 0–18 years.MethodsWe searched PubMed-MEDLINE, PsycINFO, Cochrane Databases, and Google Scholar from 2000 to September 2022. The search used five general keyword categories: 1) “indicators/monitoring/surveillance” at the population level, 2) “mental/psychological,” 3) “health/disorders,” 4) “children and adolescents,” and 5) 38 OECD countries. The search was complemented with an extensive grey literature search, including OECD public health institutions and an internet search using Google. A predefined set of inclusion and exclusion criteria was applied.ResultsOver 15,500 articles and documents were screened (scientific search N = 10,539, grey literature search more than 5,000). More than 700 articles and documents have been full-text assessed, with 382 being ultimately included. Out of 7,477 indicators extracted, an initial set of 6,426 indicators met our inclusion criteria for indicators. After consolidating duplicates and similar content, this initial set was categorized into 19 topics, resulting in a final set of 210 different indicators. The analysis highlighted an increasing interest in the topic since 2008, but indicators for the younger age, particularly those aged 0 to 2 years, were less readily available.ConclusionOur research provides a comprehensive understanding of the current state of mental health indicators for children and adolescents, identifying both (1) indicators of public mental health noted in a previous scoping review on adults and (2) new indicators specific to this age group. These findings contribute to the development of effective public health surveillance strategies for children and adolescents and inform future research in this field.

Abstract Cervical cancer is a significant disease burden in Ethiopia. Mathematical models and computer simulations on disease dynamics can support effective resource allocation. The objectives of this work are (i) to explore the perspectives of health decision-makers on computer-aided predictions supporting cervical cancer interventions, (ii) to identify their information needs from these predictions, and (iii) their willingness to apply the results in their work. We conducted deliberative interviews with 15 health decision-makers and advisors in Ethiopia in autumn 2019. We analyze the data using a five steps framework approach drawing on thematic analysis and find that Ethiopian health decision-makers are willing to use computer-aided predictions in their decisions. Data on HPV prevalence and the cervical cancer burden are scarce but valued highly and decision-makers are particularly interested in the identification of local HPV hotspots. Data-driven mathematical models and computer simulations may increasingly influence health decision-making in Ethiopia.

BackgroundAfter the unprecedented Zika virus (ZIKV) outbreak in the western hemisphere from 2015-2018, Aedes aegypti and Ae. albopictus are now well established primary and secondary ZIKV vectors, respectively. Consensus about identification and importance of other secondary ZIKV vectors remain. This systematic review aims to provide a list of vector species capable of transmitting ZIKV by reviewing evidence from laboratory vector competence (VC) studies and to identify key knowledge gaps and issues within the ZIKV VC literature.MethodsA search was performed until 15th March 2022 on the Cochrane Library, Lilacs, PubMed, Web of Science, WHOLIS and Google Scholar. The search strings included three general categories: 1) "ZIKA"; 2) "vector"; 3) "competence", "transmission", "isolation", or "feeding behavior" and their combinations. Inclusion and exclusion criteria has been predefined and quality of included articles was assessed by STROBE and STROME-ID criteria.FindingsFrom 8,986 articles retrieved, 2,349 non-duplicates were screened by title and abstracts,103 evaluated using the full text, and 45 included in this analysis. Main findings are 1) secondary vectors of interest include Ae. japonicus, Ae. detritus, and Ae. vexans at higher temperature 2) Culex quinquefasciatus was not found to be a competent vector of ZIKV, 3) considerable heterogeneity in VC, depending on the local mosquito strain and virus used in testing was observed. Critical issues or gaps identified included 1) inconsistent definitions of VC parameters across the literature; 2) equivalency of using different mosquito body parts to evaluate VC parameters for infection (mosquito bodies versus midguts), dissemination (heads, legs or wings versus salivary glands), and transmission (detection or virus amplification in saliva, FTA cards, transmission to neonatal mice); 3) articles that fail to use infectious virus assays to confirm the presence of live virus; 4) need for more studies using murine models with immunocompromised mice to infect mosquitoes.ConclusionRecent, large collaborative multi-country projects to conduct large scale evaluations of specific mosquito species represent the most appropriate approach to establish VC of mosquito species.

BackgroundThe COVID-19 pandemic is characterized by rapid increases in infection burden owing to the emergence of new variants with higher transmissibility and immune escape. To date, monitoring the COVID-19 pandemic has mainly relied on passive surveillance, yielding biased epidemiological measures owing to the disproportionate number of undetected asymptomatic cases. Active surveillance could provide accurate estimates of the true prevalence to forecast the evolution of the pandemic, enabling evidence-based decision-making. ObjectiveThis study compared 4 different approaches of active SARS-CoV-2 surveillance focusing on feasibility and epidemiological outcomes. MethodsA 2-factor factorial randomized controlled trial was conducted in 2020 in a German district with 700,000 inhabitants. The epidemiological outcome comprised SARS-CoV-2 prevalence and its precision. The 4 study arms combined 2 factors: individuals versus households and direct testing versus testing conditioned on symptom prescreening. Individuals aged ≥7 years were eligible. Altogether, 27,908 addresses from 51 municipalities were randomly allocated to the arms and 15 consecutive recruitment weekdays. Data collection and logistics were highly digitized, and a website in 5 languages enabled low-barrier registration and tracking of results. Gargle sample collection kits were sent by post. Participants collected a gargle sample at home and mailed it to the laboratory. Samples were analyzed with reverse transcription loop-mediated isothermal amplification (RT-LAMP); positive and weak results were confirmed with real-time reverse transcription–polymerase chain reaction (RT-PCR). ResultsRecruitment was conducted between November 18 and December 11, 2020. The response rates in the 4 arms varied between 34.31% (2340/6821) and 41.17% (2043/4962). The prescreening classified 16.61% (1207/7266) of the patients as COVID-19 symptomatic. Altogether, 4232 persons without prescreening and 7623 participating in the prescreening provided 5351 gargle samples, of which 5319 (99.4%) could be analyzed. This yielded 17 confirmed SARS-CoV-2 infections and a combined prevalence of 0.36% (95% CI 0.14%-0.59%) in the arms without prescreening and 0.05% (95% CI 0.00%-0.108%) in the arms with prescreening (initial contacts only). Specifically, we found a prevalence of 0.31% (95% CI 0.06%-0.58%) for individuals and 0.35% (95% CI 0.09%-0.61%) for households, and lower estimates with prescreening (0.07%, 95% CI 0.0%-0.15% for individuals and 0.02%, 95% CI 0.0%-0.06% for households). Asymptomatic infections occurred in 27% (3/11) of the positive cases with symptom data. The 2 arms without prescreening performed the best regarding effectiveness and accuracy. ConclusionsThis study showed that postal mailing of gargle sample kits and returning home-based self-collected liquid gargle samples followed by high-sensitivity RT-LAMP analysis is a feasible way to conduct active SARS-CoV-2 population surveillance without burdening routine diagnostic testing. Efforts to improve participation rates and integration into the public health system may increase the potential to monitor the course of the pandemic. Trial RegistrationDeutsches Register Klinischer Studien (DRKS) DRKS00023271; https://tinyurl.com/3xenz68a International Registered Report Identifier (IRRID)RR2-10.1186/s13063-021-05619-5

Objectives: We analyze whether the prevalence of depressive symptoms differs among various migrant and non-migrant populations in Germany and to what extent these differences can be attributed to socioeconomic position (SEP) and social relations.Methods: The German National Cohort health study (NAKO) is a prospective multicenter cohort study (N = 204,878). Migration background (assessed based on citizenship and country of birth of both participant and parents) was used as independent variable, age, sex, Social Network Index, the availability of emotional support, SEP (relative income position and educational status) and employment status were introduced as covariates and depressive symptoms (PHQ-9) as dependent variable in logistic regression models.Results: Increased odds ratios of depressive symptoms were found in all migrant subgroups compared to non-migrants and varied regarding regions of origins. Elevated odds ratios decreased when SEP and social relations were included. Attenuations varied across migrant subgroups.Conclusion: The gap in depressive symptoms can partly be attributed to SEP and social relations, with variations between migrant subgroups. The integration paradox is likely to contribute to the explanation of the results. Future studies need to consider heterogeneity among migrant subgroups whenever possible.

BackgroundEvidence suggests that healthcare utilization among tribal communities in isolated regions can be influenced by social determinants of health, particularly cultural and geographical factors. The true mortality and morbidity due to these factors in remote tribal communities are often underestimated due to facility-dependent reporting systems often difficult to access. We studied the utilization of health services for maternal and newborn care and explored how cultural beliefs, perceptions, and practices influence the health-seeking behavior (HSB) of an indigenous tribal community in Northeast India.MethodsWithin a concurrent triangulation design, the combined results from 7 focus group discussions and 19 in-depth interviews, and the 109 interviews of mothers from a community-based survey were interpreted in a complementary manner. The qualitative data were analyzed using a conceptual framework adapted from the socio-ecological and three-delays model, using a priori thematic coding. Multivariable logistic regression was carried out to identify factors associated with home delivery.ResultsOnly 3.7% of the interviewed mothers received the four recommended antenatal check-ups in health centers, and 40.1% delivered at home. Mothers residing in the villages without a health center or one that was not operational were more likely to deliver at home. HSB was influenced significantly by available finances, the mother’s education, low self-esteem, and a strong belief in traditional medicine favored by its availability and religious affiliation. The community sought health services in facilities only in emergency situations, determined primarily by the tribe’s poor perception of the quality of health services provided in the irregularly open centers, locally available traditional medicine practitioners, and challenges in geographical access. National schemes intended to incentivize access to facilities failed to impact this community due to flawed program implementation that did not consider this region’s cultural, social, and geographical differences.ConclusionThe health-seeking behavior of the tribe is a complex, interrelated, and interdependent process framed in a medical pluralistic context. The utilization of health centers and HSBs of indigenous communities may improve when policymakers adopt a “bottom-up approach,” addressing structural barriers, tailoring programs to be culturally appropriate, and guaranteeing that the perceived needs of indigenous communities are met before national objectives.

OBJECTIVE: The aim of this study was to identify the occupational risk for a SARS-CoV-2 infection in a nationwide sample of German workers during the first wave of the COVID-19 pandemic (1 February–31 August 2020). METHODS: We used the data of 108 960 workers who participated in a COVID follow-up survey of the German National Cohort (NAKO). Occupational characteristics were derived from the German Classification of Occupations 2010 (Klassifikation der Berufe 2010). PCR-confirmed SARS-CoV-2 infections were assessed from self-reports. Incidence rates (IR) and incidence rate ratios (IRR) were estimated using robust Poisson regression, adjusted for person-time at risk, age, sex, migration background, study center, working hours, and employment relationship. RESULTS: The IR was 3.7 infections per 1000 workers [95% confidence interval (CI) 3.3–4.1]. IR differed by occupational sector, with the highest rates observed in personal (IR 4.8, 95% CI 4.0–5.6) and business administration (IR 3.4, 95% CI 2.8–3.9) services and the lowest rates in occupations related to the production of goods (IR 2.0, 95% CI 1.5–2.6). Infections were more frequent among essential workers compared with workers in non-essential occupations (IRR 1.95, 95% CI 1.59–2.40) and among highly skilled compared with skilled professions (IRR 1.36, 95% CI 1.07–1.72). CONCLUSIONS: The results emphasize higher infection risks in essential occupations and personal-related services, especially in the healthcare sector. Additionally, we found evidence that infections were more common in higher occupational status positions at the beginning of the pandemic.

IntroductionStrong and efficient institutions are vital to the development of well-functioning governments and strong societies. The term “institution building” encompasses the creation, support, development, and strengthening of organizations and institutions. Still, there is little aggregated evidence on “institution building” considering a wider system-thinking approach, best practices, or development cooperation specifically in the field of public health. In 2007, the International Association of National Public Health Institutes (IANPHI) created a guiding Framework that countries may use for developing National Public Health Institutes (NPHIs). This Framework is currently being revised.MethodsIn this context, we conducted a systematic review to facilitate this revision with recent evidence on institution building and its potential contribution to NPHI. We followed the PRISMA guidelines for systematic reviews, searching for relevant publications in seven scientific databases (Pubmed, VHL/LILACS, EconLit, Google Scholar, Web of Science, World Affairs Online, ECONBIZ) and four libraries (World Bank; European Health for All database of the World Health Organization European Region, WHO; Organization for Economic Cooperation and Development, OECD; and the African Union Common Repository). The search was carried out in October 2021. We used the “framework analysis” tool for systematically processing documents according to key themes.ResultsAs a result, we identified 3,015 records, of which we included 62 documents in the final review. This systematic review fills a major gap of aggregated information on institution building in the field of public health and National Public Health Institutes. It is to our knowledge the first systematic review of this kind. The overriding result is the identification and definition of six domains of institution building in the health sector: “governance,” “knowledge and innovation,” “inter-institutional cooperation,” “monitoring and control,” “participation,” and “sustainability and context-specific adaptability.”DiscussionOur results show that the described domains are highly relevant to the public health sector, and that managers and the scientific community recognize their importance. Still, they are often not applied consistently when creating or developing NPHIs. We conclude that organizations engaged in institution building of NPHIs, including IANPHI, may greatly benefit from state-of-the-art research on institution building as presented in this study.

We thank van Tongeren et al for responding to our study on occupational disparities in SARS-CoV-2 infection risks during the first pandemic wave in Germany (1). The authors address the potential for bias resulting from differential testing between occupational groups and propose an alternative analytical strategy for dealing with selective testing. In the following, we want to discuss two aspects of this issue, namely (i) the extent and reasons of differential testing in our cohort and (ii) the advantages and disadvantages of different analytical approaches to study risk factors for SARS-CoV-2 infection. Our study relied on nationwide prospective cohort data including more than 100 000 workers in order to compare the incidence of infections between different occupations and occupational status positions. We found elevated infection risks in personal services and business administration, in essential occupations (including health care) and among people in higher occupational status positions (ie, managers and highly skilled workers) during the first pandemic wave in Germany (2). Van Tongeren’s et al main concern is that the correlations found could be affected by a systematic bias because people in healthcare professions get tested more often than employees in other professions. A second argument is that better-off people could be more likely to use testing as they are less affected by direct costs (prices for testing) and the economic hardship associated with a positive test result (eg, loss of earnings in the event of sick leave). We share the authors’ view that differential testing must be considered when analysing and interpreting the data. Thus, in our study, we examined the proportion of tests conducted in each occupational group as part of the sensitivity analyses (see supplementary figure S1, accessible at www.sjweh.fi/article/4037). As expected, testing proportions were exceptionally high in medical occupations (due to employer requirements). However, we did not observe systematic differences among non-medical occupations or when categorising by skill-level or managerial responsibility. This might be explained by several reasons. First, SARS-CoV-2 testing was free of charge during the first pandemic wave in Germany, but reporting a risk contact or having symptoms was a necessary condition for testing ( https://www.bundesgesundheitsministerium.de/coronavirus/chronik-coronavirus.html (accessed 5 September 2022). The newspaper article cited by van Tongeren et al is misleading as it refers to a calendar date after our study period. Second, different motivation for testing due to economic hardship in case of a positive test result is an unlikely explanation, because Germany has a universal healthcare system, including paid sick leave and sickness benefits for all workers (3). Self-employed people carry greater financial risks in case of sickness. We therefore included self-employment in the multivariable analyses to address this potential source of bias. While the observed inverse social gradient may be surprising, it actually matches with findings of ecological studies from Germany (4, 5), the United States (6, 7) as well as Spain, Portugal, Sweden, The Netherlands, Israel, and Hong Kong (8), all of which observed higher infection rates in wealthier neighbourhoods during the initial outbreak phase of the pandemic. One possible explanation is the higher mobility of managers and better educated workers, who are more likely to participate in meetings and engage in business travel and holiday trips like skiing. Given the increasing number of studies providing evidence for this hypothesis, we conclude that the inverse social gradient in our study likely reflects different exposure probabilities and is not a result of systematic bias. This also holds true for the elevated infection risks in essential workers, which is actually corroborated by a large body of research (9–11). Regarding differential likelihood of testing, van Tongeren et al state that “[i]t is relatively simple to address this problem by using a test-negative design” (1). As van Tongeren et al describe, this is a case–control approach only including individuals who were tested (without considering those who were not tested). However, the proposed analytical strategy can lead to another (more serious) selection bias if testing proportions and/or testing criteria differ between groups (12). This can be easily illustrated when comparing the results based on a time-incidence design with those obtained by a test-negative design as shown in table 1 (see PDF). Both approaches show similar results in terms of vertical occupational differences. Infection was more common if individuals had a high skill level or had a managerial position, but associations were stronger in the time-incidence design and did not reach statistical significance in the test-negative design (as indicated by the confidence intervals overlapping “1”). Unfortunately, the test-negative approach relies on a strongly reduced sample size and thus results in greater statistical uncertainty and loss of statistical power (13). In contrast, the test-negative design yields a different picture when estimating the association between essential occupation and infection risk: In this analysis, essential workers did not differ from non-essential workers in their chance of being infected with SARS-CoV-2 (the test-negative design even exhibits a lower chance for essential workers). This is rather counter-intuitive and is not in accordance with what we know about the occupational hazards of healthcare workers during the pandemic (14). The main problem is that proportions of positive tests are highly unreliable when testing proportions and/or testing criteria differ between groups. As essential workers were tested more often without being symptomatic (due to employer requirements), a lower proportion of positive tests in this group does not necessarily correspond to a lower risk of infection. Consequently, we are not convinced that the test-negative design should be the ‘gold standard’ for studying risk factors for SARS-CoV-2 infections (15). Especially problematic is the loss of statistical power (increasing the probability of a type II error) and the low validity of the test-positivity when test criteria and/or test proportions differ between groups. References 1. van Tongeren M, Rhodes S, Pearce N. Occupation and SARS-CoV-2 infection risk among workers during the first pandemic wave in Germany: potential for bias. Scand J Work Environ Health 2022;48(7):586-587. https://doi.org/10.5271/sjweh.4052. 2. Reuter M, Rigó M, Formazin M, Liebers F, Latza U, Castell S, et al. Occupation and SARS-CoV-2 infection risk among 108 960 workers during the first pandemic wave in Germany. Scand J Work Environ Health 2022;48:446–56. https://doi.org/10.5271/sjweh.4037. 3. Busse R, Blümel M, Knieps F, Bärnighausen T. Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition. Lancet 2017;390:882–97. https://doi.org/10.1016/S0140-6736(17)31280-1. 4. Wachtler B, Michalski N, Nowossadeck E, Diercke M, Wahrendorf M, Santos-Hövener C, et al. Socioeconomic inequalities in the risk of SARS-CoV-2 infection – First results from an analysis of surveillance data from Germany. J Heal Monit 2020;5:18–29. https://doi.org/10.25646/7057. 5. Plümper T, Neumayer E. The pandemic predominantly hits poor neighbourhoods? SARS-CoV-2 infections and COVID-19 fatalities in German districts. Eur J Public Health 2020;30:1176–80. https://doi.org/10.1093/eurpub/ckaa168. 6. Abedi V, Olulana O, Avula V, Chaudhary D, Khan A, Shahjouei S, et al. Racial, Economic, and Health Inequality and COVID-19 Infection in the United States. J Racial Ethn Heal Disparities 2021;8:732–42. https://doi.org/10.1007/s40615-020-00833-4. 7. Mukherji N. The Social and Economic Factors Underlying the Incidence of COVID-19 Cases and Deaths in US Counties During the Initial Outbreak Phase. Rev Reg Stud 2022;52. https://doi.org/10.52324/001c.35255. 8. Beese F, Waldhauer J, Wollgast L, Pförtner T, Wahrendorf M, Haller S, et al. Temporal Dynamics of Socioeconomic Inequalities in COVID-19 Outcomes Over the Course of the Pandemic—A Scoping Review. Int J Public Health 2022;67:1–14. https://doi.org/10.3389/ijph.2022.1605128. 9. Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo C-G, Ma W, et al. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Heal 2020;5:e475–83. https://doi.org/10.1016/S2468-2667(20)30164-X. 10. Chou R, Dana T, Buckley DI, Selph S, Fu R, Totten AM. Epidemiology of and Risk Factors for Coronavirus Infection in Health Care Workers. Ann Intern Med 2020;173:120–36. https://doi.org/10.7326/M20-1632. 11. Stringhini S, Zaballa M-E, Pullen N, de Mestral C, Perez-Saez J, Dumont R, et al. Large variation in anti-SARS-CoV-2 antibody prevalence among essential workers in Geneva, Switzerland. Nat Commun 2021;12:3455. https://doi.org/10.1038/s41467-021-23796-4. 12. Accorsi EK, Qiu X, Rumpler E, Kennedy-Shaffer L, Kahn R, Joshi K, et al. How to detect and reduce potential sources of biases in studies of SARS-CoV-2 and COVID-19. Eur J Epidemiol 2021;36:179–96. https://doi.org/10.1007/s10654-021-00727-7. 13. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd Editio. New York: Routledge; 2013. https://doi.org/10.4324/9780203771587. 14. The Lancet. The plight of essential workers during the COVID-19 pandemic. Lancet 2020;395:1587. https://doi.org/10.1016/S0140-6736(20)31200-9. 15. Vandenbroucke JP, Brickley EB, Pearce N, Vandenbroucke-Grauls CMJE. The Evolving Usefulness of the Test-negative Design in Studying Risk Factors for COVID-19. Epidemiology 2022;33:e7–8. https://doi.org/10.1097/EDE.0000000000001438.

Abstract The aim of this study is to assess factors that influence the uptake of short-term contraceptives among married women aged between 15 and 49 years in Afghanistan. The cross-sectional Afghanistan 2015 Demographic and Health Survey provided the dataset for this analysis. We included 22,974 women and applied multivariable logistic regression to investigate the influencing factors for the uptake of short-term contraceptives. 92% of Afghan women knew at least one type of short-term contraception but only 17% were using short term contraceptives. Short term contraceptive use was most prevalent among women in the age group between 30 and 40 who were educated, employed, and rich. Most of the users were living in the western parts of Afghanistan and women from the Balooch and Pashtun ethnic groups were most likely to use short-term contraceptives. Media exposure and women empowerment were also positively associated with the use of short-term contraceptives. We did not find an association with living in urban or rural settings. Contraception promotion in Afghanistan requires multisectoral efforts, tailored to the needs of women from low and middle socioeconomic strata. Health promotion activities, empowering women, strengthening education, and training of service providers on effective counseling are options that should be considered to improve the current situation.

BackgroundDespite the important role of testing as a measure against the COVID-19 pandemic, user perspectives on SARS-CoV-2 tests remain scarce, inhibiting an improvement of testing approaches. As the world enters the third year of the pandemic, more nuanced perspectives of testing, and opportunities to expand testing in a feasible and affordable manner merit consideration.MethodsConducted amid the second pandemic wave (late 2020–early 2021) during and after a multi-arm trial evaluating SARS-CoV-2 surveillance strategies in the federal state Baden-Württemberg, Germany, this qualitative sub-study aimed to gain a deeper understanding of how test users and test rejectors perceived mail-in SARS-CoV-2 gargle tests. We conducted 67 semi-structured in-depth interviews (mean duration: 60 min) via telephone or video call. Interviews were audio-recorded, transcribed verbatim and analyzed inductively using thematic analysis. The Consolidated Framework for Implementation Research guided the findings' presentation.ResultsRespondents generally described gargle sampling as simple and comfortable. However, individual perceptions of the testing method and its feasibility varied widely from disgusting and complicated to simple and brilliant. Self-sampling was appreciated for lowering infection risks during testing, but also considered more complex. Gargle-sampling increased participants' self-efficacy to sample correctly. Communication (first contact, quantity and content of information, reminders, support system) and trust (in the study, its institutional affiliation and test method) decisively influenced the intervention's acceptability.ConclusionUser-driven insights on how to streamline testing include: consider communication, first impressions of tests and information as key for successful mail-in testing; pay attention to the role of mutual trust between those taking and administering tests; implement gargle self-sampling as a pleasant alternative to swab testing; offer multiple test methods to increase test up-take.

ABSTRACT OBJECTIVE: To describe the prevalence pattern of anemia among Indigenous children in Latin America. METHODS: PRISMA guidelines were followed. Records were identified from the databases PubMed, Google Scholar, and Lilacs by two independent researchers between May and June 2021. Studies were included if the following criteria were met: a) studied Indigenous people b) was about children (from 0 to 12 years old); c) reported a prevalence estimate of anemia; d) had been conducted in any of the countries of Latin America; e) was published either in English, Portuguese, or Spanish; f) is a peer-reviewed article; and g) was published at any date. RESULTS: Out of 2,401 unique records retrieved, 42 articles met the inclusion criteria. A total of 39 different Indigenous communities were analyzed in the articles, and in 21 of them (54.0%) child anemia was a severe public health problem (prevalence ≥ 40%). Those communities were the Aymara (Bolivia); Aruak, Guaraní, Kamaiurá, Karapotó, Karibe, Kaxinanuá, Ma-cro-Jê, Suruí, Terena, Xavante (Brazil); Cabécar (Costa Rica), Achuar, Aguaruna, Awajún, Urarina, Yomybato (Peru); Piaroa and Yucpa (Venezuela); and Quechua (Peru and Bolivia). Children below two years had the highest prevalence of anemia (between 16.2% and 86.1%). Among Indigenous people, risk factors for anemia include nutrition, poor living conditions, access to health services, racism, and discrimination. Bolivia and Guatemala are scarcely studied, despite having the highest proportion of Indigenous communities in Latin America. CONCLUSIONS: Anemia constitutes a poorly documented public health problem among Indigenous children in 21 Indigenous communities in Bolivia, Brazil, Colombia, Costa Rica, Ecuador, Guatemala, Mexico, and Peru. In all Indigenous communities included in this study child anemia was an issue, especially in younger children.

Although a majority of SARS-COV-2 diagnosis are asymptomatic, presymptimatic or minimally symptomatic, little has been described and understood about the illness careers of these individuals. This study explored the lived experience of a SARS-COV-2 diagnosis and subsequent quarantine among individuals in Germany who were diagnosed with SARS-COV-2 during the second wave of the pandemic (late 2020-early 2021), but whose diagnosis was unexpected due to a lack of a known contact, or the asymptomatic nature of their case at the time of diagnosis. In-depth interviews (n ​= ​22) were conducted by phone or video call, audio-recorded, and transcribed verbatim. Routine debriefings guided data collection and facilitated analysis, which followed a framework approach. Regardless of age, gender or socioeconomic status, data consistently demonstrated a diagnosis and quarantine career marked by five emotional phases: overconfidence, shock and denial, coming to grips and asking questions, enduring, and cautious optimism as quarantine ended. These experiences suggest that providing trustworthy, easily accessible information regarding certain key aspects of the post diagnosis and quarantine period could benefit patients in terms of reducing stress, understanding the consequences of a diagnosis and mitigating foreseeable challenges in terms of personal, logistical and emotional issues. Follow-up research with providers and public health bureaus could inform how to best tailor such messaging for clients who experience an unexpected diagnosis.

Abstract Background To achieve higher effectiveness in population-based SARS-CoV-2 surveillance and to reliably predict the course of an outbreak, screening, and monitoring of infected individuals without major symptoms (about 40% of the population) will be necessary. While current testing capacities are also used to identify such asymptomatic cases, this rather passive approach is not suitable in generating reliable population-based estimates of the prevalence of asymptomatic carriers to allow any dependable predictions on the course of the pandemic. Methods This trial implements a two-factorial, randomized, controlled, multi-arm, prospective, interventional, single-blinded design with cluster sampling and four study arms, each representing a different SARS-CoV-2 testing and surveillance strategy based on individuals’ self-collection of saliva samples which are then sent to and analyzed by a laboratory. The targeted sample size for the trial is 10,000 saliva samples equally allocated to the four study arms (2500 participants per arm). Strategies differ with respect to tested population groups (individuals vs. all household members) and testing approach (without vs. with pre-screening survey). The trial is complemented by an economic evaluation and qualitative assessment of user experiences. Primary outcomes include costs per completely screened person, costs per positive case, positive detection rate, and precision of positive detection rate. Discussion Systems for active surveillance of the general population will gain more importance in the context of pandemics and related disease prevention efforts. The pandemic parameters derived from such active surveillance with routine population monitoring therefore not only enable a prospective assessment of the short-term course of a pandemic, but also a more targeted and thus more effective use of local and short-term countermeasures. Trial registration ClinicalTrials.gov DRKS00023271 . Registered November 30, 2020, with the German Clinical Trials Register (Deutsches Register Klinischer Studien)

Abstract Background In recent years, there has been greater recognition of the important role of community health volunteers in many countries and their important role informs many health programs. This include health education, provision of services such as screening, monitoring and referral to health facilities. Their roles are better understood in the areas of communicable diseases like HIV infection, Tuberculosis and Malaria however little is known about their role in non-communicable diseases. This study seeks to explore perception of CHVs’ functions, tasks, and their fulfilment in identifying people with elevated blood pressure for diagnosis and monitoring of hypertension in Lilongwe, Malawi. Methods This was a qualitative naturalistic research design utilizing observation and semi-structured interviews with community health volunteers working in Lilongwe, Malawi. Interviews were carried out with the researcher. Participants were recruited from the ZaMaC project. An interview guide was developed with a category-guided deductive approach. The interviews were recorded through note taking. Data analysis was performed using content analysis approach. Results Community health volunteers have multiple roles in prevention and monitoring of hypertension. They act as health educators and provide lifestyle counselling. They screened for hypertension and monitored blood pressure and assisted community members to navigate the health system such as linkage to health facilities. These roles were shaped in response to community needs. Conclusion This study indicates the complexities of the roles of community health volunteer in identifying people with elevated BP for diagnosis and monitoring of hypertension. Understanding community health volunteers’ roles provides insight into their required competencies in provision of their daily activities as well as required training to fill in their knowledge gaps.

Abstract Objectives In this cluster-randomised controlled study (CoV-Surv Study), four different “active” SARS-CoV-2 testing strategies for general population surveillance are evaluated for their effectiveness in determining and predicting the prevalence of SARS-CoV-2 infections in a given population. In addition, the costs and cost-effectiveness of the four surveillance strategies will be assessed. Further, this trial is supplemented by a qualitative component to determine the acceptability of each strategy. Findings will inform the choice of the most effective, acceptable and affordable strategy for SARS-CoV-2 surveillance, with the most effective and cost-effective strategy becoming part of the local public health department’s current routine health surveillance activities. Investigating its everyday performance will allow us to examine the strategy’s applicability to real time prevalence prediction and the usefulness of the resulting information for local policy makers to implement countermeasures that effectively prevent future nationwide lockdowns. The authors would like to emphasize the importance and relevance of this study and its expected findings in the context of population-based disease surveillance, especially in respect to the current SARS-CoV-2 pandemic. In Germany, but also in many other countries, COVID-19 surveillance has so far largely relied on passive surveillance strategies that identify individuals with clinical symptoms, monitor those cases who then tested positive for the virus, followed by tracing of individuals in close contact to those positive cases. To achieve higher effectiveness in population surveillance and to reliably predict the course of an outbreak, screening and monitoring of infected individuals without major symptoms (about 40% of the population) will be necessary. While current testing capacities are also used to identify such asymptomatic cases, this rather passive approach is not suitable in generating reliable population-based estimates of the prevalence of asymptomatic carriers to allow any dependable predictions on the course of the pandemic. To better control and manage the SARS-CoV-2 pandemic, current strategies therefore need to be complemented by an active surveillance of the wider population, i.e. routinely conducted testing and monitoring activities to identify and isolate infected individuals regardless of their clinical symptoms. Such active surveillance strategies will enable more effective prevention of the spread of the virus as they can generate more precise population-based parameters during a pandemic. This essential information will be required in order to determine the best strategic and targeted short-term countermeasures to limit infection spread locally. Trial design This trial implements a cluster-randomised, two-factorial controlled, prospective, interventional, single-blinded design with four study arms, each representing a different SARS-CoV-2 testing and surveillance strategy. Participants Eligible are individuals age 7 years or older living in Germany’s Rhein-Neckar Region who consent to provide a saliva sample (all four arms) after completion of a brief questionnaire (two arms only). For the qualitative component, different samples of study participants and non-participants (i.e. eligible for study, but refuse to participate) will be identified for additional interviews. For these interviews, only individuals age 18 years or older are eligible. Intervention and comparator Of the four surveillance strategies to be assessed and compared, Strategy A1 is considered the gold standard for prevalence estimation and used to determine bias in other arms. To determine the cost-effectiveness, each strategy is compared to status quo, defined as the currently practiced passive surveillance approach. Strategy A1: Individuals (one per household) receive information and study material by mail with instructions on how to produce a saliva sample and how to return the sample by mail. Once received by the laboratory, the sample is tested for SARS-CoV-2 using Reverse Transcription Loop-mediated Isothermal Amplification (RT-LAMP). Strategy A2: Individuals (one per household) receive information and study material by mail with instructions on how to produce their own as well as saliva samples from each household member and how to return these samples by mail. Once received by the laboratory, the samples are tested for SARS-CoV-2 using RT-LAMP. Strategy B1: Individuals (one per household) receive information by mail on how to complete a brief pre-screening questionnaire which asks about COVID-19 related clinical symptoms and risk exposures. Only individuals whose pre-screening score crosses a defined threshold, will then receive additional study material by mail with instructions on how to produce a saliva sample and how to return the sample by mail. Once received by the laboratory, the saliva sample is tested for SARS-CoV-2 using RT-LAMP. Strategy B2: Individuals (one per household) receive information by mail on how to complete a brief pre-screening questionnaire which asks about COVID-19 related clinical symptoms. Only individuals whose pre-screening score crosses a defined threshold, will then receive additional study material by mail with instructions how to produce their own as well as saliva samples from each household member and how to return these samples by mail. Once received by the laboratory, the samples are tested for SARS-CoV-2 using RT-LAMP. In each strategy, RT-LAMP positive samples are additionally analyzed with qPCR in order to minimize the number of false positives. Main outcomes The identification of the one best strategy will be determined by a set of parameters. Primary outcomes include costs per correctly screened person, costs per positive case, positive detection rate, and precision of positive detection rate. Secondary outcomes include participation rate, costs per asymptomatic case, prevalence estimates, number of asymptomatic cases per study arm, ratio of symptomatic to asymptomatic cases per study arm, participant satisfaction. Additional study components (not part of the trial) include cost effectiveness of each of the four surveillance strategies compared to passive monitoring (i.e. status quo), development of a prognostic model to predict hospital utilization caused by SARS-CoV-2, time from test shipment to test application and time from test shipment to test result, and perception and preferences of the persons to be tested with regard to test strategies. Randomisation Samples are drawn in three batches of three continuous weeks. Randomisation follows a two-stage process. First, a total of 220 sampling points have been allocated to the three different batches. To obtain an integer solution, the Cox-algorithm for controlled rounding has been used. Afterwards, sample points have been drawn separately per batch, following a probability proportional to size (PPS) random sample. Second, for each cluster the same number of residential addresses is randomly sampled from the municipal registries (self-weighted sample of individuals). The 28,125 addresses drawn per municipality are then randomly allocated to the four study arms A1, A2, B1, and B2 in the ratio 5 to 2.5 to 14 to 7 based on the expected response rates in each arm and the sensitivity and specificity of the pre-screening tool as applied in strategy B1 and B2. Based on the assumptions, this allocation should yield 2500 saliva samples in each strategy. Although a municipality can be sampled by multiple batches and the overall number of addresses per municipality might vary, the number of addresses contacted in each arm is kept constant. Blinding (masking) The design is single-blinded, meaning the staff conducting the SARS-CoV-2 tests are unaware of the study arm assignment of each single participant and test sample. Sample sizes Total sample size for the trial is 10,000 saliva samples equally allocated to the four study arms (i.e. 2,500 participants per arm). For the qualitative component, up to 60 in-depth interviews will be conducted with about 30 study participants (up to 15 in each arm A and B) and 30 participation refusers (up to 15 in each arm A and B) purposefully selected from the quantitative study sample to represent a variety of gender and ages to explore experiences with admission or rejection of study participation. Up to 25 asymptomatic SARS-CoV-2 positive study participants will be purposefully selected to explore the way in which asymptomatic men and women diagnosed with SARS-CoV-2 give meaning to their diagnosis and to the dialectic between feeling concurrently healthy and yet also being at risk for transmitting COVID-19. In addition, 100 randomly selected study participants will be included to explore participants’ perspective on testing processes and implementation. Trial Status Final protocol version is “Surveillance_Studienprotokoll_03Nov2020_v1_2” from November 3, 2020. Recruitment started November 18, 2020 and is expected to end by or before December 31, 2020. Trial registration The trial is currently being registered with the German Clinical Trials Register (Deutsches Register Klinischer Studien), DRKS00023271 ( https://www.drks.de/drks_web/navigate.do?navigationId=trial . HTML&TRIAL_ID=DRKS00023271). Retrospectively registered 30 November 2020. Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Abstract Background There has been a significant reduction of abortion rates in high-income countries, while the rates remain unchanged in low- and middle-income countries. In Ethiopia, for example, the number of women of reproductive age seeking an induced abortion is increasing. However, there is limited information concerning the reasons why the occurrence of this procedure is increasing. Thus, this study aimed to identify factors associated with having induced abortion in Addis Ababa, Ethiopia. Methods An unmatched case-control study was conducted using a semi-structured, interviewer-administered questionnaire from October to December 2017. The cases were 147 women of reproductive age who underwent abortion in a health facility or presented with complications due to induced abortion conducted outside the health facility. The controls were 295 women who came for antenatal care and who reported never having had an induced abortion. The cases were selected by consecutive sampling from nine health facilities, whereas the controls were selected by systematic sampling from the same health facilities. Bivariate and multivariate logistic regression models were employed using STATA version 14 to identify factors associated with induced abortion. Results The mean age of cases was 26.5 ± 5.7 years, while for the controls it was 28.1 ± 4.8 years. Being unmarried (AOR = 9.6; 95% CI: 1.5–61.7), having primary (AOR = 5.3; 95% CI: 1.5–18.3) and tertiary (AOR = 5.7; 95% CI: 1.6–21.1) education, earning monthly income 100–300 USD (AOR = 0.2; 95% CI: 0.1–0.4) and > 300 USD (AOR = 0.1; 95% CI: 0.0–0.2), initiating first intercourse between ages of 15 and 19 (AOR = 4.7; 95% CI: 1.4–15.6), marrying before the age of 18 (AOR = 2.9; 95% CI: 1.3–6.7), and having two children (AOR = 4.7; 95% CI: 1.8–12.7) were independent predictors of induced abortion. Conclusion Family planning programs hoping to reduce the occurrence of induced abortion should specifically target unmarried women, low income, and those who have two children. The government should also work on preventing early marriage and providing sexual and reproductive health education to help adolescents delay age at first sexual experience.

Objectives To examine the knowledge, attitudes and practices (KAP) of COVID-19 of rural and urban residents in Liberia to inform the development of local social and behaviour change communication strategies.Design Cross-sectional, mixed-mode (online and telephone) survey using non-probability sampling.Setting All 15 counties in Liberia with a focus on Maryland County.Participants From 28 May to 28 June 2020, data were collected from a total of 431 adults aged 18 years and older (telephone 288 (66.8%); online 143 (33.2%)) out of a total of 741 contacts.Main outcome measures KAP scores. Frequencies and proportions were calculated, followed by univariate and multivariable analyses to examine the association between KAP scores and the sociodemographic variables.Results Around 69% of the online survey respondents were younger than 35 years of age, compared with 56% in the telephone interviews. The majority (87%) of online respondents had completed tertiary education, compared with 77% of the telephone respondents. Male participants, on average, achieved higher knowledge (52%) and attitude scores (72%), in contrast to females (49% and 67%, respectively). Radio (71%) was the most cited source for COVID-19 information, followed by social media (63%). After controlling for sociodemographic variables, adaptive regression modelling revealed that survey mode achieved 100% importance for predicting knowledge and practice levels with regard to COVID-19.Conclusions The survey population demonstrated moderate COVID-19 knowledge, with significant differences between survey mode and educational level. Correct knowledge of COVID-19 was associated with appropriate practices in Maryland County. Generalisation of survey findings must be drawn carefully owing to the limitations of the sampling methods. Yet, given the differences in knowledge gaps between survey modes, sex, education, occupation and place of residence, it is recommended that information is tailored to different audiences.

(1) Background: Thailand is a major migrant receiving country and pioneer of migrant health policy in the ASEAN region. However, on the ground, coverage of migrants is faced with multiple barriers. (2) Objectives: We aim to scope and analyse the types of available evidence on migrant health coverage in Thailand and identify knowledge gaps. Specifically, we characterise the literature along year of publication, migrant subpopulation, health domain, scope of coverage, methods, study design, objectives and results. (3) Methods: We searched PubMed, Web of Science, Google Scholar, Cochrane Database, Worldwide Science and the Asian Citation Index for peer-reviewed and grey literature in October 2021 for studies analysing original data on health coverage of migrants in Thailand. To conceptualise health coverage, we used the three dimensions availability, accessibility and acceptability. (4) Results: 101 articles were included in the final analysis. Sixty-three were published after 2016, 39 focused on migrant workers and 18 on migrants in general. Forty-two concentrated on health in broader terms, followed by reproductive and maternal health (n = 31). Thirty-eight assessed coverage of specific services and 36 health coverage in general. Migrants themselves and key informants were the main data sources in 80 and 43 of the articles, respectively. Forty publications were qualitative, while 38 applied quantitative methods (22% descriptive; 7% analytical). Among the health coverage components, 79 articles included aspects of accessibility, followed by acceptability (n = 59) and availability (n = 30). (5) Conclusions: While there is a high number and broad range of studies on migrant health coverage in Thailand, we found that research on migrant subgroups, such as victims of trafficking and migrant children, as well as on the health domains, non-communicable diseases and occupational and mental health is neglected.

Zika virus (ZIKV) emerged in Brazil during 2013-2014 causing an epidemic of previously unknown congenital abnormalities. The frequency of severe congenital abnormalities after maternal ZIKV infection revealed an unexplained geographic variability, especially between the Northeast and the rest of Brazil. Several reasons for this variability have been discussed. Prior immunity against Dengue virus (DENV) affecting ZIKV seems to be the most likely explanation. Here we summarise the current evidence regarding this prominent co-factor to potentially explain the geographic variability. This systematic review followed the PRISMA guidelines. The search was conducted up to May 15th, 2020, focussing on immunological interactions from Zika virus with previous Dengue virus infections as potential teratogenic effect for the foetus. Eight out of 339 screened studies reported on the association between ZIKV, prior DENV infection and microcephaly, mostly focusing on antibody-dependent enhancement (ADE) as potential pathomechanism. Prior DENV infection was associated with enhancement for ZIKV infection and increased neurovirulence in one included in vitro study only. Interestingly, the seven in vivo studies exhibited a heterogeneous picture with three studies showing a protective effect of prior DENV infections and others no effect at all. According to several studies, socio-economic factors are associated with increased risk for microcephaly. Very few studies addressed the question of unexplained variability of infection-related microcephaly. Many studies focussed on ADE as mechanism without measuring microcephaly as endpoint. Interestingly, three of the included studies reported a protective effect of prior DENV infection against microcephaly. This systematic review strengthens the hypothesis that immune priming after recent DENV infection is the crucial factor for determining protection or enhancement activity. It is of high importance that the currently ongoing prospective studies include a harmonised assessment of the potential candidate co-factors.

ObjectiveWe undertook a systematic review of the literature to explore the prevalence of post-traumatic stress disorder (PTSD) in Palestinian children and adolescents exposed to political violence. This is the first systematic review and meta-analysis of the prevalence of PTSD in this population.MethodsPubMed, Embase, PsycInfo, Google Scholar and Cochrane library were searched until June 2020. To estimate the prevalence of PTSD, sub-group and meta-analysis were conducted.ResultsThe search resulted in 2786 studies, of which 28 articles representing 32 samples with a total of 15,121 participants from Gaza Strip and West Bank met either the DSM-4 or DSM-5 criteria and were included. The pooled prevalence of PTSD was 36% (95% CI 30-41%; I2 98.6%) and ranged from 6% to 70%. Sub-group analysis showed that the PTSD prevalence did not differ according to region (West Bank, Gaza Strip) and tended to decrease after including only studies using a representative sample (pConclusionWe identified high prevalence of PTSD among Palestinian children and adolescents exposed to political violence. However, the pooled results should be interpreted with caution, due to the high heterogeneity and risk of bias in the included studies. These limitations also reflect the challenge in conceptualizing and measuring PTSD in the Palestinian context with a background of continuous and cumulative trauma. Understanding the contextual factors and developing locally adapted survey measures are of relevance to future research, public health planning, and the provision of mental healthcare in Palestine.

ObjectiveTo explore the barriers to successful home-based human papillomavirus (HPV) self-sampling in North Gondar, Ethiopia.MethodsThe study participants were women who had previously participated in a community-wide home-based HPV self-sampling pilot study, community health workers, women's development army leaders, and the sample collectors of the home-based HPV self-sampling pilot study. A community based qualitative descriptive study was conducted. We applied purposive and convenience sampling. In total, 47 women participated in the study (in-depth interviews n = 22, four focus group discussions n = 25, 6-7 participants each). The study employed thematic analysis for clustering the emerged themes.ResultsHusband disapproval was identified as the main barrier to the acceptance of home-based HPV self-sampling. Social influence, lack of knowledge about cervical cancer and screening, lack of health education on cervical cancer and HPV-based screening, feeling healthy, and religious influence were identified as additional barriers. Fear of using Evalyn brush® for self-sampling was found to be the main barrier to the provision of a quality sample. The inability of the sample collectors to check the proper utilization of Evalyn brush® and the difficulty in understanding the instructions did also contribute to the low-quality. Providing health education concerning cervical cancer and HPV self-sapling to women, male involvement in the screening program, and linking the screening service to existing local health facilities were suggested to guarantee the success of home-based HPV self-sampling.ConclusionsEducating women regarding cervical cancer and HPV testing, providing clear instructions on how to collect self-sample, and male involvement in the screening program are prerequisites for a successful implementation of home-based HPV testing. Women empowerment should also be focused to overcome the identified sociocultural barriers. Furthermore, the screening program should guarantee the timely provision of the test results and offering women follow-up examinations and treatment for abnormal findings.

Background: The 2011 UN declaration on non-communicable diseases (NCDs) recognized their importance as a global health issue, particularly for low- and middle-income countries. The extent to which these countries address policy implementation gaps in the face of resource limitations and competing priorities remains largely unexplored. Objective: This qualitative study presents Kenya’s experience of translating the UN declaration to national policies for diabetes prevention and control. Methods: Policy documents published between 2006 and 2016 were analyzed. Thirty-two documents were included in the analysis. Interviews with six purposively selected policy stakeholders at multiple levels of decision-making were conducted. Emerging themes were deconstructed into a policy analysis triangle. Results: Diabetes-specific policies already existed in Kenya before 2011, suggesting successful advocacy work by diabetes interest groups. The 2011 UN declaration subsequently coincided with a period of political transition in Kenya, opening policy windows that the diabetes community leveraged to trigger political drive against prevailing challenges. The post-declaration period reflected a transition from diabetes-specific policies to a wider NCD agenda. Most of the documents and national strategies aligned strongly with international documents, however, were based on scant local evidence. The implementation process was largely health-sector driven. The non-health sector remained largely uninvolved, contrary to global recommendations. This, in addition to fragmented health governance and weak monitoring systems, continues to undermine existing gains and efforts to fight diabetes and NCDs on a wider scale. Conclusions: In Kenya, a major gap remains between how diabetes is addressed within the NCD policy agenda and tackling diabetes in reality, with respect to local implementation processes. More emphasis on population-wide prevention and inclusion of the non-health sector could help to cascade national efforts to the grassroots level. A concerted effort from the highest political level is needed to address overarching NCD drivers while maintaining health system improvement strategies.

Abstract Background Mortality statistics are used to compare health status of populations; optimally, they base on individual death certificates. However, determining cause of death is error-prone. E.g. cardiovascular disease (CVD) death determination is characterized by sensitivity (SE) and specificity (SP) lower than 85 %. Furthermore, differential misclassification may be present in case of homogenous target populations. We investigate the bias of standardized mortality ratios (SMR), based on real-world data. Methods CVD mortality of 6378 ethnic German repatriates was assessed and the SMR calculated. Non-differential age-dependent misclassification was introduced into data by scenarios of equal SE and SP in a range of 0.7 to 0.85. The bias between originally reported and actual SMR was calculated for each pair of values. Additionally, four differential misclassification scenarios were simulated, reflecting two extreme scenarios of both quality criteria varied in the cohort but fixed to either higher or lower in the reference, and two scenarios of crossed criteria values. Results In case of non-differential misclassification the bias is always towards the null-hypothesis. The lowest bias was 13.5 % (SE, SP = 0.85 constantly), the maximum bias was 40 % (SP = 0.7). However, in case of differential misclassification the observed SMR can be on the wrong track. If SP is high but SE low in the cohort, negative bias up to −10 % can occur. In case SE is low but SP is high in the reference, the bias remains always positive. In the opposite case plus SP is high in the cohort, the bias can reach −30 %. Conclusion SMR values are always biased due to the diagnostic test character of death determination. In majority of epidemiological studies the bias should be towards the null-hypothesis (non-differential misclassification). However, caution is needed in case of differential misclassification, possibly experienced in studies on homogenous subgroups, and in large prospective cohorts with specifically trained personnel.

Data on renal impairment in sub-Saharan Africa (SSA) remains scarce, determination of renal function is not part of routine assessments. We evaluated renal function and blood pressure in a cohort of people living with HIV (PLWH) on antiretroviral treatment (ART) in the Renal Care Zambia project (ReCaZa).Using routine data from an HIV outpatient clinic from 2011-2013, we retrospectively estimated the glomerular filtration rate (eGFR, CKD-Epi formula) of PLWH on ART in Lusaka, Zambia. Data were included if adults had had at least one serum creatinine recorded and had been on ART for a minimum of three months. We investigated the differences in eGFR between ART subgroups with and without tenofovir disproxil fumarate (TDF), and applied multivariable linear models to associate ART and eGFR, adjusted for eGFR before ART initiation.Among 1118 PLWH (63,3% female, mean age 41.8 years, 83% ever on TDF; median duration 1461 [range 98 to 4342] days) on ART, 28.3% had an eGFR

Chronic kidney disease (CKD) is a probably underrated public health problem in Sub-Saharan-Africa, in particular in combination with HIV-infection. Knowledge about the CKD prevalence is scarce and in the available literature different methods to classify CKD are used impeding comparison and general prevalence estimates.This study assessed different serum-creatinine based equations for glomerular filtration rates (eGFR) and compared them to a cystatin C based equation. The study was conducted in Lilongwe, Malawi enrolling a population of 363 adults of which 32% were HIV-positive.Comparison of formulae based on Bland-Altman-plots and accuracy revealed best performance for the CKD-EPI equation without the correction factor for black Americans. Analyzing the differences between HIV-positive and -negative individuals CKD-EPI systematically overestimated eGFR in comparison to cystatin C and therefore lead to underestimation of CKD in HIV-positives.Our findings underline the importance for standardization of eGFR calculation in a Sub-Saharan African setting, to further investigate the differences with regard to HIV status and to develop potential correction factors as established for age and sex.