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Background: Antiphospholipid syndrome (APS) is an autoimmune multisystem disorder. There has been a limited number of reported cases from Nigeria. Objectives: To determine the awareness and frequency of encounters with APS cases by medical practitioners in health institutions in South East Nigeria. Materials and Methods: It was a descriptive cross-sectional study. All medical doctors met in the clinics who were willing to participate in the study were recruited during the period of the study. Statistical Package for Social Sciences was used for data entry, validation, and analysis. Results: A total of 581 study questionnaires were distributed to medical doctors met at the clinics and clinical meetings of five hospitals in Southeast Nigeria however, 581 were approximately filled and retrieved, giving an response rate of 94.84%. Males were 383 (69.5%) and females were 168 (30.5%). A total of 445 (80.8%) were unaware of the autoimmune multisystemic nature of APS. Of the 551 respondents, 348 (63.2%) were aware that Rheumatologist is the primary care physician for APS, 290 (52.6%) reported rarity of APS, and 366 (66.4%) had up to 50% overall knowledge of APS. Respondents’ encounters with unexplained thrombotic events and unexplained stroke in the young were limited. A total of 62 (11.3%) were aware of the international classification criteria for APS. Conclusion: The authors conclude that APS awareness among medical practitioners in South East Nigeria is suboptimal.

Antibiotic-resistant Staphylococcus aureus (S. aureus) in retail meat poses a public health threat requiring continuous surveillance. This study investigated the frequency of isolation, toxin genes, and antibiotic resistance profile of S. aureus recovered from retail poultry meat samples and presented results beneficial to public health interventions. Of 200 samples collected, 16% (32/200) tested positive for S. aureus, and these were recovered from thigh 37.5% (12/32), wing 34.4% (11/32), gizzard (15.6% (5/32), and liver 12.5% (4/32) samples. Findings of spa typing analysis revealed that 68.8% (22/32), 18.8% (6/32), 9.4% (3/32), and 3.0% (1/32) of the isolates belonged to the spa types t267, t160, t548, and t008, respectively. For antibiotic susceptibility testing, 12.5% (4/32) of the isolates were resistant to only penicillin, but one isolate (1/32; 3%) showed resistance to the antibiotics penicillin, erythromycin, ampicillin, and oxacillin. PCR analysis revealed that 9.4% (3/32) of the isolates carried the mecA gene associated with methicillin-resistant Staphylococcus aureus (MRSA) isolates. One MRSA isolate was identified as a t008 spa type, and harbored a 26,974 bp-sized plasmid, which was the source of its resistance to penicillin, ampicillin, erythromycin, and oxacillin. The staphylococcal enterotoxin (SE) genes seg, sei, sek, seb, selm, and seln were also identified among the isolates, and mostly the antimicrobial and enterotoxin genes were carried on plasmids of the isolates. This study raises awareness on the continuous circulation of pathogenic microbes like S. aureus in retail poultry meat.

Achieving carbon neutrality by 2050 remains fundamental to limiting global warming to 1.5 °C this century and mitigating the catastrophic effects of climate change. Policymakers have indicated that the transition towards a renewable energy economy is the catalyst for achieving this. Transitioning towards a renewable energy economy requires substantial investment in renewable energy technologies. While most empirical studies have explored the linkage between investment in research and development (R&D) and carbon emissions, not much is known empirically about the effect of energy innovation R&D on renewable energy generation. This study, therefore, contributes to the literature by investigating the impact of energy innovation R&D on renewable energy generation using a comprehensive panel dataset of 26 OECD countries from 1974 to 2020. Using a battery of robust alternative estimation methods, the results indicate that energy innovation R&D generally does not increase total renewable energy generation in the panel of OECD countries. The results further show that energy innovation R&D has a heterogeneous effect on disaggregated renewable energy sources such as solar energy, wind energy, nuclear energy, and hydro energy generation.

In Ghana, little is known about the drivers of inequities of basic water, sanitation, and hygiene (WASH) services in healthcare facilities (HCFs). We aim to examine the status and factors driving access to basic WASH services in Ghana. This survey involved an analysis of routine health service data submitted to the District Information Management System 2 (DHIMS 2). Complete data were available for 1,646 HCFs across Ghana for analysis. Coverage of basic Water, Sanitation and hygiene services was 69, 58, and 64%, respectively. About 50% had a WASH-IPC action plan, and 67% had a WASH-IPC manager who is responsible for the day-to-day WASH management. Regional inequities in access to basic WASH services exist, with the newly established regions and those in Northern Ghana being disadvantaged. Significant drivers of basic WASH services were the location of HCF, the level of service delivery, and availability of a trained facility-based assistant WASH manager. WASH services in Ghanaian HCFs have improved, but it is still not up to the standards set by the Sustainable Development Goals for WASH. Universal access to basic WASH services can be attained by mounting targeted WASH interventions and appointing WASH-IPC managers at all levels of the health system. HIGHLIGHTS Little is known about the status and drivers of inequities in the provision of basic WASH services in Ghana.; More than half of the HCFs in Ghana have access to basic WASH services.; Health system factors and the geographic location of the facilities are related to basic WASH services.; Urgent targeted WASH actions are required at all levels to bridge the inequity gaps in the provision of WASH services towards UHC attainment.;

Abstract Purpose Knowledge, positive attitude and good preventive practices are keys to successful myopia control, but information on these is lacking in Africa. This study determined the KAP on myopia in Ghana. Methods This was a population-based cross-sectional survey conducted among adults (aged 18 years and older) living across 16 regions of Ghana between May and October 2021. Data on socio-demographic factors (sex, age, gender, level of education, working status, type of employment, monthly income, and region of residence), respondents’ awareness, and knowledge, attitude and preventive practices (KAP) about myopia were collected. Composite and mean scores were calculated from eleven knowledge (total score = 61), eight attitude (48), and nine preventive practice items (33). Differences in mean scores were assessed using one-way analysis of variance (ANOVA) and standardized coefficients (β) with 95% confidence intervals (CI), using multiple linear regression to determine the associations between the dependent (KAP) and demographic variables. Results Of the 1,919 participants, mean age was 37.4 ± 13.4 years, 42.3% were aged 18–30 years, 52.6% were men, 55.8% had completed tertiary education, and 49.2% had either heard about myopia, or accurately defined myopia as short sightedness. The mean KAP scores were 22.9 ± 23.7, 33.9 ± 5.4, and 22.3 ± 2.8, respectively and varied significantly with many of the demographic variables particularly with age group, region, marital status, and type of employment. Multiple linear regression analyses revealed significant associations between region of residence and knowledge (β =—0.54, 95%CI:-0.87, -0.23, p

Abstract Background Ghana and Nigeria are the two countries in Africa that currently run the Doctor of Optometry (OD) program in sub-Saharan Africa (SSA). Optometrists in these countries are licensed to provide glaucoma care. Despite the clinically relevant practice guidelines for glaucoma, there is no data on the practice patterns for glaucoma eye care in SSA, a region with the highest prevalence of glaucoma. This study aimed to profile glaucoma diagnosis adherence to practice guidelines among optometrists in two neighbouring anglophone countries (Nigeria and Ghana). Methods A web-based cross-sectional survey of practising optometrists was conducted in both countries. Each country data was weighted to reflect the total number of licensed and practising optometrists at the time of this survey. Descriptive analyses were performed against demography and practice factors using survey commands to adjust for sampling weights when estimating confidence intervals (CI) around prevalence estimates. Simple and multiple logistic regression analyses were performed to identify factors associated with glaucoma diagnosis. Results A total of 493 optometrists (238, 48.3% and 255, 51.7%) from Ghana and Nigeria respectively, responded to the survey-the first to document and compare the glaucoma diagnostic criteria between optometrists in Ghana and Nigeria. More Ghanaian than Nigerian optometrists diagnosed glaucoma and over 90% in both countries reported that they frequently performed either tonometry, visual field testing, or fundus examination during glaucoma diagnosis. Ghanaian optometrists were significantly more likely to diagnose glaucoma than Nigerian optometrists (adjusted odd ratio, AOR = 6.15, 95%CI:1.63–23.15, P = .007). Optometrists who have practiced for more than 10 years (AOR = 7.04; 95%CI:1.74–28.47, P = .006) and private practice optometrists (AOR = 3.33; 95%CI:1.13–9.83, P = .03) were more likely to diagnose glaucoma. Conclusions The study provides information for evaluating glaucoma assessment for optometrists in both countries. Optometrists in both countries are reasonably well-equipped to diagnose glaucoma and are practicing at an adequate level, but with room for improvement.

Tariff reforms in electricity markets is becoming an area of active evaluation as efforts intensify to decarbonize electricity generation, stabilize the power grid, and maximize the welfare of electricity producers and consumers. Peaks in load profiles occur when demand is not regulated, requiring huge capacity additions, which are not utilized during off-peak periods thus undermining system efficiency. With dynamic pricing of electricity, opportunities can arise to shift demand from peak to off-peak periods and this can help to reduce the need for huge capacity additions. This paper conducts a systematic review of dynamic electricity pricing literature in order to understand the evolution of research in this growing field. 218 relevant journal papers published between 1949 and 2020 are identified from which thematic maps and ontological tables are drawn to understand key subject areas that have emerged over the years and their interlinkages. Six major thematic areas of dynamic electricity pricing research are reported including 1) pricing scheme and modeling, 2) pricing impacts, 3) user demand response, 4) consumption scheduling, 5) load scheduling technologies, and 6) cybersecurity threats and fairness issues. These six major thematic areas are then broken down into twenty second-order themes and fifty eight first-order themes. The review provides an overview of the development of the field while providing insights on its future development. It concludes that, despite coherent themes, the research on dynamic electricity pricing has enormous potential for follow-up work and theory development.

BackgroundNumerous studies have established a correlation between Food Insecurity (FI) and diminished physical and psychological well-being. However, there is a lack of knowledge regarding this association among migrant and refugee populations. Migrants and refugees face difficulties, such as a lack of legal clarity and employment opportunities, which can exacerbate FI and psychological well-being issues. Therefore, the main goal of this study is to conduct a systematic review of the existing body of literature, followed by a meta-analysis of the results, where appropriate, to examine how common food insecurity is among migrants and refugees living in high-income countries and whether it might be linked to mental distress.MethodsThe inclusion of studies will be contingent upon providing quantitative data on migrants and refugees in developed countries. This criterion encompasses all pertinent observational study designs and has been published in English. The review will specifically include cross-sectional, case-control, and cohort studies that utilize standardized and validated measurement tools for food insecurity (e.g., Food Insecurity Experience Scale) and psychological stress (e.g., 21-item Depression Anxiety and Stress Scale (DASS-21)), excluding non-standard or non-validated measures. A systematic search will be conducted across electronic databases such as Ovid Medline, Embase, SCOPUS, and Web of Science, containing peer-reviewed journal papers in health, psychology, and social sciences from January 1, 2008, to the present for relevant studies. Prevalence estimates will be generated using meta-analysis with a 95% CI, 95% prediction intervals, and I2 statistics for heterogeneity. The studies incorporated in the review will be analysed using meta-analysis, as deemed suitable for the characteristics of the data obtained.DiscussionThis study has practical implications for policies and interventions, offering insights for evidence-based initiatives targeting food security and mental health among migrants and refugees, thus improving resource allocation. PROSPERO registration number: CRD42024525690.

BackgroundThe human hand has constant contact with the environment, hence requires regular hand hygiene. Hand hygiene has gained recognition because of the COVID-19 pandemic and is a largely effective, affordable preventive measure against infectious diseases. This study used both national and sub-national analyses to evaluate the effect of COVID-19 handwashing guidelines on instances of diarrhea in Ghana.MethodsData on diarrhea cases spanning February 2018 and March 2022 were retrieved from the District Health Information Management System (DHIMS 2) using a data extraction guide. The data were summarized using descriptive statistics. The difference in diarrhea cases between the pre-COVID-19 and COVID-19 periods was measured using a two-sample t-test across Ghana's 16 administrative areas. Causal Impact package in R statistical software was employed to determine the impact of the introduction of COVID-19 hand hygiene protocols on diarrheal disease.ResultsA total of 5,645,533 diarrheal cases reported between February 2018 and March 2022 through the routine MIS (DHIMS2) were examined. Fifty-three percent of the cases occurred before the introduction of the hand hygiene protocol. Descriptive statistics indicated a statistically significant decrease in average diarrheal cases during the hand hygiene implementation era (13,463 cases reduction, pConclusionThis study underscores the effectiveness of COVID-19 hand hygiene protocols in reducing diarrheal morbidity in Ghana, with varying regional impacts. These findings advocate for the sustenance of investments and commitments made at the COVID hand hygiene protocols, particularly in this era where the pandemic appears controlled.

Abstract Background Research suggests that rates of mental illness are similar in rural and urban Australia, although there are significant workforce shortages in rural regions along with higher rates of chronic disease and obesity and lower levels of socioeconomic status. However, there are variations across rural Australia and limited local data on mental health prevalence, risk, service use and protective factors. This study describes the prevalence of self-reported mental health problems of psychological distress and depression, in a rural region in Australia and aims to identify the factors associated with these problems. Methods The Crossroads II study was a large-scale cross-sectional study undertaken in the Goulburn Valley region of Victoria, Australia in 2016–18. Data were collected from randomly selected households across four rural and regional towns and then screening clinics from individuals from these households. The main outcome measures were self-reported mental health problems of psychological distress assessed by the Kessler 10 and depression assessed by Patient Health Questionnaire-9. Unadjusted odd ratios and 95% confidence intervals of factors associated with the two mental health problems were calculated using simple logistic regression with multiple logistic regression using hierarchical modelling to adjust for the potential confounders. Results Of the 741 adult participants (55.6% females), 67.4% were aged ≥ 55 years. Based on the questionnaires, 16.2% and 13.6% had threshold-level psychological distress and depression, respectively. Of those with threshold-level K-10 scores, 19.0% and 10.5% had seen a psychologist or a psychiatrist respectively while 24.2% and 9.5% of those experiencing depression had seen a psychologist or a psychiatrist, respectively in the past year. Factors such as being unmarried, current smoker, obesity, were significantly associated with a higher prevalence of mental health problems whereas physical activity, and community participation reduced the risk of mental health problems. Compared to rural towns, the regional town had higher risk of depression which was non-significant after adjusting for community participation and health conditions. Conclusions The high prevalence of psychological distress and depression in this rural population was consistent with other rural studies. Personal and lifestyle factors were more relevant to mental health problems than degree of rurality in Victoria. Targeted lifestyle interventions could assist in reducing mental illness risk and preventing further distress.

Abstract Background Failure to use antenatal care (ANC) and inadequate receipt of components of ANC pose a significant risk for the pregnant woman and the baby. This study aimed to examine a regional analysis of factors associated with receiving no ANC and inadequate receipt of components of ANC services among Indian women. Method Information from 173,970 women of reproductive age 15–49 years from the 2019–21 India National Family Health Survey (NFSH-5) was analysed. Logistic regression analyses that adjusted for cluster and survey weights were conducted to assess the socio-demographic and other factors associated with receiving non-use of ANC and inadequate receipt of components of ANC, respectively, in the six regions and 28 states, and 8 union territories in India. Results Across regions in India, 7% of women reported no ANC, and the prevalence of inadequate and adequate receipt of components of ANC in all six regions ranged from 67 to 89% and 8% to 24%, respectively. Of all the 36 federated entities, the prevalence of inadequate receipt of ANC components was less than two-thirds in Tamil Nadu, Puducherry, Andaman and the Nicobar Islands, Odisha, and Gujarat. Our analyses revealed that associated factors vary by region, state, and union territories. Women from poor households reported increased odds of receiving no ANC in North, East and North-eastern regions. Women who reported no schooling in South, East and Central regions were associated with increased odds of receiving no ANC. Women from poor households in Himachal Pradesh, Bihar, Uttar Pradesh, Nagaland, Manipur, Uttar Pradesh, and Madhya Pradesh states reported significantly higher odds of inadequate components ANC than women from rich households. The receipt of inadequate components of ANC was significantly higher among women who never read magazines in Delhi, Ladakh, Karnataka, Telangana, Jharkhand, Maharashtra, Uttar Pradesh, Chhattisgarh, Arunachal Pradesh, Manipur, and Mizoram states in India. Conclusion A better understanding of the factors associated with and incorporating them into the short- and long-term intervention strategies, including free financial support from the Indian government to encourage pregnant women from lower socioeconomic groups to use health services across all regions, states and union territories.

Abstract Background Vaccination remains the most powerful weapon against the emergence of new variants of coronavirus (COVID-19). However, false information about COVID-19 vaccines through various platforms including social media remains a major threat to global public health. This study examined the impact of information sources on COVID-19 vaccine hesitancy and resistance in sub-Saharan Africa (SSA). Methods A validated web-based cross-sectional study was conducted from 14 March to 16 May 2021, and was administered in both French and English to 2572 participants aged 18 years and over. Data on sociodemographic characteristics, medical and vaccination history, and the information sources (mainstream media and social media) used by the participants during the pandemic were obtained. There were three main outcomes: The vaccinated group were those who responded in the affirmation (Yes) to the question of whether they have been vaccinated against COVID-19. Those who responded ‘not sure’ or ‘no’ to the question were then asked if they were willing to be vaccinated when the vaccine became available in their home countries. The responses to this follow-up question were used to derive the second and third outcome variables of ‘vaccine hesitancy’ and ‘vaccine resistance’, respectively. A series of logistic regression analyses were used to examine the impact of information sources on the three main outcomes. Results The prevalence of COVID-19 vaccine hesitancy among the participants was lowest among newspaper readers (42%) and highest among TV (72%) and social media users (73%). The prevalence of COVID-19 vaccine-resistance was also lowest among newspaper readers (37%) but highest among social media users (87%). Multivariate analyses revealed that compared to those who did not use these information sources, SSA participants who relied on the radio (aOR 0.83, 95%CI = 0.70, 0.99), TV (aOR 0.80, 95%CI = 0.65, 0.97) and social media (aOR 0.79, 95%CI = 0.65, 0.97) for information during the pandemic were less likely to be hesitant towards taking the vaccines. However, social media users (aOR 2.13, 95%CI = 1.62, 2.80), those who watched TV (aOR 1.40, 95%CI =1.08, 1.80), relied on healthcare workers (HCWs: aOR 1.32, 95%CI = 1.07, 1.63) and families/friends (aOR 1.31, 95%CI = 1.06, 1.61) for COVID-19 related information during the pandemic were more likely to resist taking the COVID vaccines in this study. Participants who relied on the newspaper for information during the pandemic were less likely to resist the vaccines (aOR 0.77, 95%CI = 0.62, 0.95) compared to non-readers of a newspaper. Conclusion We found that all six information sources except radio were strong predictors of the resistance towards COVID-19 vaccination. Further research on how these channels can be used to improve the availability of reliable healthcare information is needed. Investments in these resources will protect people and empower them to make appropriate choices about their health.

Abstract Background The COVID-19 vaccines are being rolled out across all the sub-Saharan Africa (SSA) countries, with countries setting targets for achieving full vaccination rates. The aim of this study was to compare the uptake of, resistance and hesitancy to the COVID-19 vaccine between SSA locally residents and in the diasporan dwellers. Methods This was a cross-sectional study conducted using a web and paper-based questionnaire to obtain relevant information on COVID-19 vaccine acceptance. The survey items included questions on demography, uptake and planned acceptance or non-acceptance of the COVID-19 vaccines among SSAs. Multinomial logistic regression was used to determine probabilities of outcomes for factors associated with COVID-19 vaccination resistance and hesitancy among SSA respondents residing within and outside Africa. Results Uptake of COVID-19 vaccines varied among the local (14.2%) and diasporan (25.3%) dwellers. There were more locals (68.1%) who were resistant to COVID-19 vaccine. Participants’ sex [adjusted relative risk (ARR) = 0.73, 95% CI: 0.58 – 0.93], education [primary/less: ARR = 0.22, CI:0.12 – 0.40, and bachelor’s degree: ARR = 0.58, CI: 0.43 – 0.77]), occupation [ARR = 0.32, CI: 0.25—0.40] and working status [ARR = 1.40, CI: 1.06—1.84] were associated with COVID-19 vaccine resistance among locals. Similar proportion of local and diasporan dwellers (~ 18% each) were hesitant to COVID-19 vaccine, and this was higher among health care workers [ARR = 0.25, CI: 0.10 – 0.62 and ARR = 0.24, CI:0.18—0.32, diaspora and locals respectively]. After adjusting for the potential confounders, local residents aged 29–38 years [ARR = 1.89, CI: 1.26—2.84] and lived in East Africa [ARR = 4.64, CI: 1.84—11.70] were more likely to report vaccine hesitancy. Knowledge of COVID vaccines was associated with hesitancy among local and diasporan dwellers, but perception was associated with vaccine resistance [ARR = 0.86,CI: 0.82 – 0.90] and hesitancy [ARR = 0.85, CI: 0.80 – 0.90], only among the local residents. Conclusions Differences exist in the factors that influence COVID-19 vaccine acceptance between local SSA residents and thediasporan dwellers. Knowledge about COVID-19 vaccines affects the uptake, resistance, and hesitancy to the COVID-19 vaccine. Information campaigns focusing on the efficacy and safety of vaccines could lead to improved acceptance of COVID-19 vaccines.

The fight against malaria is a continuum as the epidemic is not abating. For proper deployment of tools in the fight against malaria, an assessment of the situation is necessary. This work assessed the level of antimalarial drug treatment failure in Ebonyi State, Nigeria. Both survey and in vitro analyses were adopted. The survey was used to obtain qualitative information from both the malaria subjects and the pharmacies where antimalarial drugs are sourced. The results from the survey were complemented by an in vitro assay of the level of active pharmaceutical ingredients (APIs) in the commonly used artemisinin combination in Nigeria; artemether/lumefantrine. Results from the survey revealed that artemisinin combination therapies (ACTs) remain the mainstay in the treatment of malaria, even though other non-artemisinin drugs are still used. It also revealed that many patients still self-medicate, although, this may not be connected to the treatment failure seen among some malaria subjects. The in vitro assay showed that ACT contains the right quantity of APIs. Further surveillance is, therefore, necessary to understand the real cause of treatment failure among malaria subjects in Nigeria.

Background Undernutrition remains a major public health issue in low- and middle-income countries. Objective Our aim for this study was to identify the factors contributing to undernutrition in children under five years old in North Africa. Methods We searched five electronic bibliographic databases (Ovid MEDLINE, Web of Science, Embase (Ovid), ProQuest, and CINAHL) for eligible observational studies published after 2006. STATA version 17 software was used to calculate the odds ratios between associated factors and indicators of undernutrition, with 95% confidence intervals. For each factor, the overall odds were pooled using a forest plot. Due to the significant heterogeneity among the studies (I2 > 50%), a random-effects model was used, and sensitivity analysis was conducted to examine the effect of outliers. Results Out of 1093 initially identified studies, 14 met the selection criteria. Our meta-analysis revealed that uneducated mothers were the most common factor associated with undernutrition in North African children. Children aged 0–23 months were significantly associated with stunting (odds ratios (OR) = 1.27; 95% CI: 1.18; 1.37) and wasting (OR = 1.68; 95% CI: 1.42; 1.99). Children living in rural areas were also at higher odds of being stunted (OR = 1.74; 95% CI: 1.64; 1.84) and underweight (OR = 1.59; 95% CI: 1.35; 1.88). These analyses also indicated that a lower wealth index, mothers’ nutritional health, uneducated fathers, and low birth weight were other factors significantly associated with stunting. Conclusion Addressing undernutrition in Northern Africa requires a multidisciplinary approach prioritising mothers and young children, especially families in underprivileged areas.

Background: The coronavirus disease (COVID-19) outbreak has caused a universal health crisis resulting in significant morbidities and mortalities particularly among high-risk groups. This study sought to determine regional factors associated with knowledge and attitude towards COVID-19 mitigation practices and risk perception of contracting the disease in Sub-Saharan African (SSA) countries. Methods: A cross-sectional anonymous online study was conducted among 1970 participants between April and May 2020, during the lockdown in many SSA countries. Recruitment of participants was via WhatsApp, Facebook and emails using authors’ networks. The outcome variables were KAP (knowledge, attitudes and practice) of COVID-19 and analysis of variance (ANOVA) with post hoc test was run to assess the level of KAP by four regions in SSA. Simple and multiple linear regression (MLR) analyses were performed to examine factors associated with the outcome measures in the four SSA regions. Results: Mean knowledge (P=0.707) and risk perception (P=0.904) scores by four regions in SSA did not differ significantly. However, the mean attitude score was higher among West Africans compared with Southern (P=0.019) and Central Africans (P=0.003). MLR analysis revealed that among those living in West (adjusted coefficient β=-0.83 95% CI: -1.19, -0.48) and Southern Africa (β=-0.91 95% CI: -1.42, -0.40), having a primary or secondary education was associated with a decrease in knowledge scores while not being worried about COVID-19 decreased risk perception scores across the four SSA regions(West [β=-6.57, 95% CI: -7.53, -5.62], East [β=-6.24: 95% CI: -8.34,-4.15], Central [β=-6.51, 95% CI: -8.70, -4.31], and Southern Africa [β=-6.06: 95% CI: -7.51, -4.60]). Except among Southern Africans, participants who practiced self-isolation had positive attitude towards COVID-19. Conclusion: Future research on health education regarding COVID-19 or a future related pandemic in SSA should target people with lower education, those who do not self-isolate, those living in Southern and Western Africa and not worried about contracting COVID-19.

Objective: To investigate the experiences and perceptions of postnatal mothers with quality of healthcare including WASH amenities among postnatal mothers in Ghana during the COVID-19 outbreak. Study design: The study was an institutional cross-sectional. Methods: The survey was conducted in six (6) regions across the northern, middle, and coastal belts of Ghana among postnatal mothers (n = 424). Eligible respondents accessed antenatal care (ANC) in 12 healthcare facilities (primary level and secondary level) during the outbreak of COVID-19 pandemic. Univariate ordered logistic regression analysis was conducted to predict determinants of overall perceived quality of healthcare and experiences with WASH amenities in healthcare facilities visited. Findings: Privacy and confidentiality (mean score = 3.07) were the most highly rated quality indicator while the least rated indicator was dignity and respect of clients (mean score = 2.13). Approximately 50% of postnatal mothers reported paying out-of-pocket for essential ANC medications. Perceived quality of healthcare was positive among those who accessed care at a district/municipal hospital (Coef. = 1.29; 95%CI 0.45, 2.13, p = 0.003); co-habiting with a partner (Coef. = 1.64; 95%CI 0.64, 2.65, p = 0.001), and resident in an urban location (Coef. = 2.30; 95%CI 0.30, 3.30, p = 0.001). Mothers who accessed care at a district or municipal hospital (Coef. = 1.81; 95%CI 0.83, 2.78, p = 0.001); were co-habiting with a partner (Coef. = 1.92; 95%CI 0.76, 3.07, p = 0.001), and had a private health insurance cover (Coef. = 3.18; 95%CI 0.69, 5.67, p = 0.012) were more likely to rank WASH amenities better than their comparators. Conclusion: Overall perception of postnatal mothers of healthcare quality including WASH amenities after outbreak of COVID-19 was good, but with significant concerns about dignity and respect accorded them during care and having to pay out-of-pocket for some ANC medications. Relevant managers, service providers and regulatory institutions are encouraged to initiate and sustain policy dialogues and stakeholder consultations on the healthcare quality care gaps established in this study. There is the need for more investments in WASH amenities in the health sector as a quality assurance strategy, especially for maternal and child health services.

Abstract Concurrent wasting and stunting (WaSt) is a condition where both wasting and stunting exist in a child at the same time. This study aimed to assess the prevalence of WaSt and to identify potential associated factors in Ethiopia. A total of 33,650 children aged between 0 and 59 months were included in the analysis from the four waves of the Ethiopian Demographic and Health Survey. A mixed‐effects logistic regression model was used to identify the determinants of WaSt. The prevalence of WaSt was found to be 4.7% (95% confidence interval [CI]: (4.5–4.9)), with respectively 2.5% (95% CI: 2.1–3.1) and 4.9% (95% CI: 4.7–5.2) among children in urban and rural settings. Children: (i) in the age group 12–23 months (adjusted odds ratio [AOR]: 4.16, 95% CI: (3.20–5.42)) and 24–59 months (AOR: 3.08, 95% CI: (2.28–4.17)); (ii) who were perceived by their mothers to be smaller than normal at birth (AOR: 1.98, 95% CI: (1.57–2.50)); (iii) had diarrhoea (AOR: 1.38, 95% CI: (1.11–1.71)); and (iv) fever in the past 2 weeks (AOR: 1.38, 95% CI: (1.10–1.71)) reported higher odds of WaSt. Being a female child (AOR: 0.57, 95% CI: (0.48–0.69)), having received measles vaccination (AOR: 0.71, 95% CI: (0.55–0.89)), having a mother with a normal body mass index (18.5–24.9 kg/m2) (AOR: 0.57, 95% CI: (0.48–0.68)), having a wealthier household (AOR: 0.67, 95% CI: (0.50–0.90)), and living in rural setting (AOR: 0.49, 95% CI: (0.32–0.74)) were associated with reduced odds of WaSt. The prevalence of WaSt was high, with approximately 1 in 20 Ethiopian children suffering from the condition and needing a prompt response to minimize the poor health and developmental outcomes. Children perceived by their mother to be smaller than normal at birth, older children, and babies with diarrhoea and fever had higher odds of WaSt.

Abstract Background Long stay in intensive care unit (ICU) is associated with poor outcomes, particularly in people with diabetes. It increases the financial burden of care and this is a challenge to the South Western Sydney region, which is already a hotspot for diabetes in Australia. This study compared ICU admission characteristics of people with and without diabetes and the factors associated with long ICU stay among patients admitted to public hospitals in this metropolitan health district from 2014 to 2017. Methods Cross-sectional datasets on 187,660, including all ICU admissions in the New South Wales Admitted Patient Data Collection (APDC) from June 2014 – July 2017 in public hospital were extracted. Data on demographic and health insurance status, primary admission diagnosis using ICD-10, comorbidities including death among hospital inpatients aged ≥18 years residing in SWS were analysed. The ICU length of stay was the outcome variable and were classified into short stay (≤48 h) and long stay (> 48 h), and were examined against potential confounding factors using bivariate and multiple logistic regression analyses. Results Our results showed higher ICU admissions in patients with diabetes than in those without diabetes (5% vs. 3.3%, P

Undernutrition (stunting, wasting and underweight) among children remains a public health concern in North Africa, especially following recent conflicts in the region. Therefore, this paper systematically reviews and meta-analyses the prevalence of undernutrition among children under five in North Africa to determine whether efforts to reduce undernutrition are on track to achieving the Sustainable Development Goals (SDGs) by 2030. Eligible studies published between 1st January 2006 and 10th April 2022 were searched for, using five electronic bibliographic databases (Ovid MEDLINE, Web of Science, Embase (Ovid), ProQuest and CINAHL). The JBI critical appraisal tool was used, and a meta-analysis was conducted using the ‘metaprop’ command in STATA, to estimate the prevalence of each undernutrition indicator in the seven North African countries (Egypt, Sudan, Libya, Algeria, Tunisia, Morocco, and Western Sahara). Due to the significant heterogeneity among studies (I2 >50%), a random effect model and sensitivity analysis were conducted to examine the effect of outliers. Out of 1592 initially identified, 27 met the selection criteria. The prevalence of stunting, wasting and being underweight were 23.5%, 7.9% and 12.9%, respectively. Significant variations between the countries with the highest rates of stunting and wasting were reported in Sudan (36%, 14.1%), Egypt (23.7%, 7.5%), Libya (23.1%, 5.9%), and Morocco (19.9%, 5.1%). Sudan also had the highest prevalence of underweight (24.6%), followed by Egypt (7%), Morocco (6.1%), and Libya (4.3%) with more than one in ten children in Algeria and Tunisia having stunted growth. In conclusion, undernutrition is widespread in the North African region, particularly in Sudan, Egypt, Libya, and Morocco, making it challenging to meet the SDGs by 2030. Nutrition monitoring and evaluation in these countries is highly recommended.

BackgroundBreast and cervical cancers remain the most common cancers and the leading cause of cancer deaths in Ghana. Non-communicable diseases such as cancers, have been associated with psychological burdens such as anxiety and depression disorders as well as severe mental disorders such as bipolar disorder. As such the World Health Organisation has noted that mental health and well-being are crucial in reducing the NCD burden.MethodsA convergent mixed method approach was used to ascertain the psychosocial burden of breast and cervical cancer patients who sought treatment in three major cancer hospitals in Ghana. Primary data were collected using a questionnaire and an interview guide from 298 breast and cervical cancer patients seeking treatment at the Korle-Bu and Komfo Anokye Teaching Hospitals as well as the Sweden Ghana Medical Centre. Qualitative analysis was done using thematic content analysis while quantitative analysis was done using logistic regression.ResultsThe findings of the study showed that patients not only battled with psychological burdens such as anxiety, depression, pain, stigma, fear of death and loss of spouses but also struggled with physical, social, and dietary restrictions. Patients with low educational levels and income status, retired or unemployed, and/or had larger household sizes suffered more psychosocial burdens.ConclusionThere is a need for liaison psychiatrists and health psychologists to assist oncologists to provide psychological support such as free and routine counselling services for cancer patients and their caregivers. Educational campaigns on mainstream and social media need to be intensified to demystify the stigma surrounding cancers in Ghana.

Abstract Background Diabetes is a major public health problem affecting about 1.4 million Australians, especially in South Western Sydney, a hotspot of diabetes with higher than average rates for hospitalisations. The current understanding of the international burden of diabetes and related complications is poor and data on hospital outcomes and/or what common factors influence mortality rate in people with and without diabetes in Australia using a representative sample is lacking. This study determined in-hospital mortality rate and the factors associated among people with and without diabetes. Methods Retrospective data for 554,421 adult inpatients was extracted from the population-based New South Wales (NSW) Admitted Patient Data over 3 financial years (from 1 July 2014–30 June 2015 to 1 July 2016–30 June 2017). The in-hospital mortality per 1000 admitted persons, standardised mortality ratios (SMR) were calculated. Binary logistic regression was performed, adjusting for potential covariates and co-morbidities for people with and without diabetes over three years. Results Over three years, 8.7% (48,038 people) of admissions involved people with diabetes. This increased from 8.4% in 2014–15 to 8.9% in 2016–17 (p = 0.007). Across all age groups, in-hospital mortality rate was significantly greater in people with diabetes (20.6, 95% Confidence intervals CI 19.3–21.9 per 1000 persons) than those without diabetes (11.8, 95%CI 11.5–12.1) and more in men than women (23.1, 95%CI 21.2–25.0 vs 17.9, 95%CI 16.2–19.8) with diabetes. The SMR for those with and without diabetes were 3.13 (95%CI 1.78–4.48) and 1.79 (95%CI 0.77–2.82), respectively. There were similarities in the factors associated with in hospital mortality in both groups including: older age (> 54 years), male sex, marital status (divorced/widowed), length of stay in hospital (staying longer than 4 days), receiving intensive care in admission and being admitted due to primary respiratory and cardiovascular diagnoses. The odds of death in admission was increased in polymorbid patients without diabetes (28.68, 95%CI 23.49–35.02) but not in those with diabetes. Conclusions In-patients with diabetes continue to have higher mortality rates than those without diabetes and the Australian population. Overall, similar factors influenced mortality rate in people with and without diabetes, but significantly more people with diabetes had two or more co-morbidities, suggesting that hospital mortality may be driven by those with pre-existing health/comorbidities. Urgent measures in primary care to prevent admissions among people with multiple co-morbidities are needed.

Background Safety is one of the dimensions of healthcare quality and is core to achieving universal health coverage and healthcare delivery worldwide. In Ghana, the status of patient safety in the last 7 years has remained unknown. Therefore, this study aims to assess the patient safety status in selected hospitals in Ghana.Methods Using the WHO Patient Safety Long Form, a mixed methodology was used to assess the patient safety status in 27 hospitals in Ghana. Data were analysed using descriptive statistics and axial codes for thematic analysis.Results The average national patient safety score was high (85%). However, there were variations in the performance of the hospitals across the WHO patient safety action areas. Knowledge and learning in patient safety (97%) was the highest-rated patient safety action area. Patient safety surveillance, patient safety funding, patient safety partnerships and national patient safety policy had mean scores lower than the national average score (85%). Less than half (42%) of the hospitals had a dedicated budget for patient safety activities. The means of continuous education for health professionals include clinical sessions, and in-service training, while the system of clinical audits in the hospitals were maternal mortality, perinatal mortality, stillbirth and general mortality audits. The hospitals use posters, leaflets, public address systems and health education sessions to inform patients about their rights. Patient safety issues are reported through suggestion boxes, designated desks and the use of contacts of core management staff.Conclusion The current patient safety status in the hospitals was generally good, with the highest score in the knowledge and learning in the patient safety domain. Patient safety surveillance was identified as the weakest action area. The findings of this study will form the scientific basis for initiating the development of a national patient safety policy in Ghana. This is crucial for ensuring resilient and sustainable health systems that guarantee safer care to all patients in Ghana.

Access to improved water, sanitation and hygiene (WASH) is essential for the delivery of high-quality care in healthcare facilities and the prevention of hospital-acquired infections such as the transmission of the SARS-CoV-2. In addition, unimpeded access to WASH facilities in coronavirus disease 2019 (COVID-19) treatment centres (TCs) is central in facilitating compliance with infection prevention and control protocols. However, data for the WASH status of COVID-19 TCs in Ghana are limited. We evaluated the WASH status of seven COVID-19 TCs in Ghana using the WHO/UNICEF water and sanitation for health facility improvement tool (WASH FIT). The water domain had the highest number of indicators meeting standards with an average percentage score of 90.5% (range: 66.7–100%) across the seven TCs, followed by management (66.9%) and hygiene (58.7%). The TCs performed poorly in the sanitation and healthcare waste domain, with an average percentage score of 44.6% (range: 22.2–75%). These findings highlight the challenges being faced by COVID-19 TCs in implementing WASH services. Specific WASH interventions are urgently required to strengthen WASH services in the COVID-19 TCs. This should precede the prioritisation of resources to WASH infrastructure in the treatment facilities coupled with actions that involve all stakeholders. HIGHLIGHTS Water, sanitation and hygiene (WASH) in healthcare facilities is crucial in preventing the transmission of highly infectious diseases.; We used the WHO/UNICEF water and sanitation for health facility improvement tool (WASH FIT) to evaluate the WASH status of COVID-19 treatment centres (TCs).; There were gaps in the performance of the TCs across the four WASH domains.; We call for the prioritisation of resources to WASH infrastructure in the TCs.; This is crucial in building a resilient WASH system in the treatment facilities.;

There are over 17,000 residential fire incidents in Australia annually, of which 6,500 occur in New South Wales (NSW). The number of state-provided accommodations for those on low incomes (social housing), is over 437,000 in Australia of which 34% are located in NSW. This study compared causes, characteristics and consequences of residential fires in social and non-social housing in NSW, Australia.This population-based study used linked fire brigade and health service data to identify those who experienced a residential fire incident from 2005 to 2014. Over the study period, 43,707 residential fires were reported, of which 5,073 (11.6%) occurred in social housing properties.Fires in social housing were more likely to occur in apartments (RR 1.85, 95%CI 1.75–1.96), caused by matches and lighters (RR 1.62, 95%CI 1.51–1.74) and smokers’ materials (RR 1.51, 95%CI 1.34 – 1.71). The risk of health service utilisation or hospital admission was 16% (RR 1.16, 95%CI 1.04–1.28) and 25% (RR 1.25, 95%CI 1.02–1.51) higher in social housing respectively. Those aged 25–65 were at 40% (RR 1.40, 95%CI 1.14 – 1.73) higher risk of using residential fire-related health services. Almost 88% of social housing properties did not have a functioning fire detector of any type, and 1.2% were equipped with sprinklers.Overall, the risk of residential fire incidents and associated injuries was higher for residents in social housing. Risk mitigation strategies beyond the current provision of smoke alarms are required to reduce the impact of residential fires in social and non-social housing.

This paper discusses multidisciplinary international research collaboration team formation during the COVID-19 pandemic, challenges faced, strategies adopted, achievements and dynamics in the implementation of research on Coronavirus disease-2019 (COVID-19), by the African Translational Research Group (ATReG). The paper also discusses the lessons learnt and future opportunities for global collaborative research. In-depth virtual interviews were conducted with consenting members of ATReG. Questions were designed to provide rich, deep, and insightful opinions, lived experiences and perspectives of ATReG group members on group formation, challenges, strategies and achievements. Interview data was transcribed and analysed thematically, and the results were presented with important quotations presented. The ATReG consisted of English ( n = 13) and French ( n = 1) speaking sub-Saharan African (SSA) researchers who specialise in public health, epidemiology, optometry, information technology, supply chain management, psychiatry, community health, general medical practice, nutrition and biostatistics. Most members of the group reported an informal but well-coordinated structure of the group. Formed during the pandemic, all group meetings were held online, and many members are yet to meet each other in person. The group collected data from Africans and published 10 peer reviewed journal articles on COVID-19 within two years. It presented in international conferences, engaged with the media and the public and was awarded a national competitive funding in Nigeria all of which which contributed to career progression and academic promotion of some members. There have been challenges in sustaining the research collaboration and maintaining productivity. Challenges include difficulties meeting deadlines and obtaining funding for research activities. However, these challenges have been addressed through a collaborative problem-solving approach. The study found the need for operational and methodological flexibility, centralised coordination, and established funding sources as being essential for long term sustainability and performance of the group. The ATReG’s objective of providing useful data on COVID-19 and generating useful knowledge about COVID-19 in SSA has been achieved. In such a multi-disciplinary international collaborative team relaiant on the online medium to operate, the experiences and challenges can be a model for learning for researchers intending to form international multidisciplinary collaborative groups. Nonetheless, there are still many important areas of research which ATReG will continue to pursue.

A numerical model for simulating and predicting blood flow dynamics in diseased arterial vessels has been developed. The time-dependent one-dimensional hyperbolic system of quasilinear partial differential equations which incorporates a diagnostic disease descriptor (kD) was used to simulate transient flow distribution for idealized healthy and diseased states. Blood flow simulations in the iliac arteries over about 125% of a cardiac cycle were generated and calibrated using the kD values from 0 to 3 representing hypothetical diseased states. Early results indicate that disease conditions induce abnormal flow in the artery, generating disorder and increased amplitude of blood pressure, flow and distensibility with increasing numerical values of the disease factor kD. More so, the prospective use of the kD-approach with documentation of in vivo adverse flow visualizations for diagnostic purposes was decisively discussed.

Background: The Nigeria Demographic and Health Survey (NDHS) revealed that the under-five mortality rate (U5MR) in the northwest geopolitical zone (NWGZ), Nigeria, increased by 1.1% from 185 to 187 deaths per 1,000 live births between 2013 and 2018, indicating a setback to the previously reported modest improvement in U5MR. Objectives: This study sought to examine trends and factors related to under-5 mortality (U5M) in NWGZ from 2008 to 2018. Methods: A combined NWGZ dataset extracted from the 2008, 2013 and 2018 NDHSs, with a sample of 32,015 singleton live births, including 3,745 under-5 deaths, was used. The U5MRs for each survey year and potential independent factors were obtained using the STATA “syncrmrates” command, and then the trends were examined. A logistic regression generalised linear latent and mixed model was used to explore the potential factors associated with U5M in NWGZ. Findings: In NWGZ, the U5MR declined by only 8.2% (from 195 to 179 per 1,000 live births between 2008 and 2018, respectively), with a similar trend observed among its seven states. Multivariable analyses indicated that maternal education (no formal or primary education), maternal non-use of contraception, a mother’s perception of the baby being small or very small, birth order (second to fourth or higher) with a shorter birth interval (≤2 years), younger or older maternal age (

Background The increase in online learning during the pandemic has been linked to various ocular complaints. This study determined the prevalence and factors associated with ocular complaints among schoolchildren aged 12–19 years during the COVID-19 lockdown in Trinidad and Tobago (T&T). Methods A cross-sectional study was conducted between January and May 2021, during the COVID-19 lockdown in T&T among secondary school students studying remotely. A two-stage cluster sampling method was employed. A modified web-based Computer Vision Syndrome questionnaire was administered to students. Data on demography, duration of digital device use, and ocular complaints were collected, and multilevel logistic regression was used to determine factors associated with ocular complaints among school children, 12–19 years of age in T&T. Results A total of 435 schoolchildren (mean age, standard deviation, 15.2 ± 1.9 years range 12–19 years) responded to the questionnaire. The prevalence of self-reported symptoms of headache, blurred vision, dry eyes, itchy eyes, and double vision were 75.0%, 65.1%; 56.8%; 46.4%; and 33.5%, respectively. Schoolchildren aged 18–19 years, those that used spectacles for correction of their refractive errors, and spent more than 6 h on average on digital devices, reported a high prevalence of any ocular complaints. Analysis also revealed that age (14–15 years) was associated with dry eyes, blurred vision, and headaches, while gender (more prevalently females) was associated with blurred vision and headache. Those that had an eye examination in the last year and schoolchildren that took action to resolve ocular complaints were more likely to experience nearly all ocular complaints. Conclusions During the COVID-19 lockdown, over three in four students in T&T reported ocular complaints from digital devices for online learning. Tailored interventional messages to reduce all forms of ocular complaints should target older students, particularly females, those who laid down when learning online via their devices and people who regularly examine their eyes.

BackgroundHijras in Bangladesh face considerable discrimination, stigma, and violence despite the 2013 legislation that recognized Hijras as a third gender. There is a dearth of published literature describing the extent of human rights violations among this population and their associated factors.MethodsA questionnaire was administered to 346 study participants aged 15 years and older, living in five urban cities of Bangladesh who self-identified as Hijra, in 2019. The six human rights violation indicators (Economic, Employment, Health, Education, Social and Civic and Political Right) assessed were categorized as binary. Associations between sociodemographic characteristics and the six human rights violations were tested using univariate and multivariate logistic regression.ResultsHuman right violations including economic, educational, political, employment, health and social/civil right violations were reported in 73.3%, 59.3%, 58.5%, 46.4%, 42.7%, and 34.4% of the participants, respectively. Economic rights violations were associated with bisexuality (Adjusted odds ratios [AOR] 3.60, 95%CI: 1.57, 8.26) and not living with family (AOR 2.71, 95%CI: 1.21, 6.09), while Hijras who earned more than 10,000 Bangladesh Taka experienced higher odds of educational (AOR 2.77, 95%CI: 1.06, 7.19) and political rights violations (AOR 4.30, 95%CI: 1.06, 7.44). Living in Dhaka city was associated with a reduced odds for economic and political rights violation while experiencing violations of one human right could lead to violation of another in the Hijra community.ConclusionHuman rights violations were common in Bangladesh Hijras, particularly the Bisexual Hijras. Media and educational awareness campaigns are needed to address the underlying roots of a violation. Programs focused on the families, young people and high-income earners of this community are needed in Bangladesh.

Iron deficiency anaemia remains a public health problem, particularly in children aged 6–59 months. This study assessed factors associated with iron deficiency anaemia among children aged 6–23 months, 24–59 months and 6–59 months in Tanzania. Data for this cross-sectional study were extracted from the 2015–16 Tanzania Demographic and Health Survey and Malaria Indicator Survey (2015–16 TDHS-MIS). The study covered 8014 children aged 6–59 months and their mothers. Iron deficiency anaemia was defined (haemoglobin < 11g/dL). Univariable and multivariable logistic regression analyses that adjust for clustering and sampling weights were conducted to describe the associations between anaemia and potential confounding variables. The prevalence of iron deficiency anaemia among children aged 6–23 months, 24–59 months and 6–59 months were 76%, 49% and 59%, respectively. Factors associated with increased odds of iron deficiency anaemia among children aged 6–23 months included a mother being employed, being a male child, child perceived to small size at birth by mothers, a mother being anaemic and children belonging to the poorest socio-economic quintile. In addition, being a mother with no schooling, children not being dewormed, a mother being anaemic, delivering a baby at home, child fever and stunting, were factors associated with increased odds of iron deficiency anaemia among children aged 24–59 months. Factors associated with increased odds of iron deficiency anaemia among children aged 6–59 months were: a mother being employed, being a mother with no schooling, being a male child, belonging to the 6–59 months age bracket, a mother having a BMI of between 19 and 25 kg/m2, a mother being anaemic, having a baby at home, children belonging to bigger households, child fever and stunting. Interventions to minimise the burden of iron deficiency anaemia in children should target employed and/or anaemic mothers, poor and rich households, as well as male children.

This study aims to evaluate the acceptance and risk perception of pregnant and non pregnant women towards COVID-19 vaccines using a cross-sectional matched-sample study approach. A web-based questionnaire with closed- and open-ended questions was administered to adults older than 18 years in the sub–Saharan African (SSA) region. Respondents (n = 131) were grouped based on their pregnancy status (54 pregnant and 77 non pregnant women) and matched for comparison by age. The matched groups were compared using the chi-square test and the t-test where appropriate. Compared to non pregnant women, pregnant women reported significantly lower risk perception scores of COVID-19 infection (3.74 vs. 5.78, p < 0.001) and were less likely to take the COVID-19 vaccine (odds ratio = 0.12, 95% confidence interval (CI) 0.06–0.27, p < 0.001). A similar proportion of pregnant and non pregnant women believed in false information about the COVID-19 vaccine, and 40% of unvaccinated pregnant women (n = 40) were concerned about the safety of the vaccine. After adjustment, women’s education, marital status, belief in misconceptions and risk perception were associated with non-vaccination among pregnant women. The content analysis revealed that pregnant women refused the vaccine due to mistrust of their countries’ health systems, concerns about the country where the vaccines were manufactured and a lack of confidence in the production process of the vaccines. This study shows the poor acceptance of COVID-19 vaccines among pregnant women in SSA, who perceived a lower risk of COVID-19 infection. Understanding the reasons for non-acceptance and the motivation to accept the COVID-19 vaccine could guide the development of health education and promotion programmes, and aid governments and policymakers in implementing targeted policy changes.

Abstract Background Inappropriate complementary feeding practices significantly contribute to undernutrition among children under 2 years of age in India. However, there is limited up-to-date evidence on the prevalence and factors associated with complementary feeding practices to guide policy actions at the subnational level in India. We investigated the regional prevalence and factors associated with complementary feeding practices in India. Methods This study used a sample of 69,464 maternal responses from the 2015–16 National Family Health Survey in India. The prevalence of complementary feeding indicators was estimated using data for each administrative region, namely: North (n = 8469), South (n = 12,828), East (n = 18,141), West (n = 8940), North-East (n = 2422) and Central (n = 18,664). Factors associated with complementary feeding by region in India were investigated using logistic regression Generalized Linear Latent and Mixed Models (GLLAMM) with a logit link and binomial family that adjusted for clustering and sampling weights. Results The study showed a wide variation in the prevalence of introduction of solid, semi-solid or soft foods (complementary foods) among infants aged 6–8 months in regional India; highest in the South (61%) and lowest in the Central and Northern regions (38%). Similarly, minimum dietary diversity (MDD) was highest in the South (33%) and lowest in the Central region (12%). Both minimum meal frequency (MMF) and minimum acceptable diet (MAD) varied substantially across the regions. The factors associated with complementary feeding practices also differed across Indian regions. Significant modifiable factors associated with complementary feeding practices included higher household wealth index for the introduction of complementary foods in the North and Eastern India; higher maternal education for MMF and MDD in the North and Central regions; and frequent antenatal care visits (≥4 visits) for all indicators but for different regions. Conclusion Our study indicates that there are wide differences in regional prevalence and factors associated with complementary feeding practices in India. The improvement of complementary feeding practices in India would require national and sub-national efforts that target vulnerable mothers, including those with no education and limited health service contacts.

Abstract Background The perinatal mortality rate (PMR) in Nigeria rose by approximately 5% from 39 to 41 deaths per 1000 total births between 2008 and 2013, indicating a reversal in earlier gains. This study sought to identify factors associated with increased PMR. Methods Nationally representative data including 31,121 pregnancies of 7 months or longer obtained from the 2013 Nigeria Demographic and Health Survey were used to investigate the community-, socio-economic-, proximate- and environmental-level factors related to perinatal mortality (PM). Generalized linear latent and mixed models with the logit link and binomial family that adjusted for clustering and sampling weights was employed for the analyses. Results Babies born to obese women (adjusted odds ratio [aOR] = 1.46, 95% confidence interval [CI]: 1.13–1.89) and babies whose mothers perceived their body size after birth to be smaller than the average size (aOR = 1.92, 95% CI: 1.61–2.30) showed greater odds of PM. Babies delivered through caesarean section were more likely to die (aOR = 2.85, 95% CI: 2.02–4.02) than those born through vaginal delivery. Other factors that significantly increased PM included age of the women (≥40 years), living in rural areas, gender (being male) and a fourth or higher birth order with a birth interval ≤ 2 years. Conclusions Newborn and maternal care interventions are needed, especially for rural communities, that aim at counselling women that are obese. Promoting well-timed caesarean delivery, Kangaroo mother care of small-for-gestational-age babies, child spacing, timely referral for ailing babies and adequate medical check-up for older pregnant women may substantially reduce PM in Nigeria.

Abstract Background Exclusive breastfeeding (EBF) has important benefits for both the mother and child. In India, no nationwide studies have examined patterns of EBF in the past decade to inform national and subnational breastfeeding programmes. The present study aimed to investigate the regional prevalence and determinants of EBF in India. Methods This study used a total weighted sample of 21,352 from the 2015–2016 India National Family Health Survey. EBF was measured as the proportion of infants 0–5 months of age who received breast milk as the only source of nourishment, based on mother’s recall on feeds given to the infant 24 h before the survey. The prevalence of EBF and other breastfeeding patterns were estimated by region, and multivariable logistic regression that adjusted for clustering and sampling weights was used to investigate the association between the study factors (child, maternal, household, health service and community factors) and EBF by regional areas in India. Results This study indicated that wide differences in the prevalence of EBF and other childhood feeding practices exist across regions of India, where Southern India had the highest EBF prevalence (79.2%) and the North-East reported the lowest (68.0%). EBF prevalence decreased with infant age, dropping faster in the South (43.7% at 5 months) compared to the North-East region (54.0% at 5 months). Similarly, substantial variations in key determinants of EBF were evident by region, where higher birth order was the only common factor associated with non-EBF across all regions. Key modifiable determinants of non-EBF included higher maternal education in the South and belonging to rich households in Central India, while those for EBF were higher maternal education in the Central region and frequent antenatal care (≥ 4) visits in Northern India. Conclusion This study demonstrates wide variations in regional prevalence and determinants of EBF in India. Improving EBF participation in India would require multifaceted national and subnational efforts that include dedicated funds and the establishment of appropriate policy and interventions that are consistently monitored and evaluated.

Abstract Background Undernutrition is an important public health indicator for monitoring nutritional status and survival. In spite of its importance, undernutrition is a significant problem health problem in many East African communities. The aim of this study was to identify factors associated with childhood undernutrition in three disadvantaged East African Districts. Methods We examined data for 9270 children aged 0–59 months using cross-sectional survey from Gicumbi District in Rwanda, Kitgum District in Uganda and Kilindi District in Tanzania. We considered the level of undernutrition (stunting, wasting and underweight) as the outcome variables with four ordinal categories (severely undernourished, moderately undernourished, mildly undernourished, and nourished). Generalized linear latent and mixed models (GLLAMM) with the mlogit link and binomial family that adjusted for clustering and sampling weights were used to identify factors associated with undernutrition among children aged 0–59 months in three disadvantaged East African Districts. Results After adjusting for potential confounding factors, the odds of a child being stunted were higher in Gicumbi District in Rwanda while the odds of a child being wasted and underweight were higher in Kitgum District in Uganda. Having diarrhoea two weeks prior to the survey was significantly associated with severe undernutrition. Wealth index (least poor household), increasing child’s age, sex of the child (male) and unavailability of water all year were reported to be associated with moderate or severe stunting/wasting. Children of women who did not attend monthly child growth monitoring sessions and children who had Acute Respiratory Infection (ARI) symptoms were significantly associated with moderate or severe underweight. Conclusions Findings from our study indicated that having diarrhoea, having ARI, not having water availability all year and not attending monthly child growth monitoring sessions were associated with undernutrition among children aged 0–59 months. Interventions aimed at improving undernutrition in these disadvantaged communities should target all children especially those children from households with poor sanitation practices.

Objective In Ethiopia, despite the implementation of several interventions to improve infant and young child feeding (IYCF) practices, no published studies have highlighted the most effective IYCF interventions in the country. This systematic review investigated the impacts of various interventions on IYCF in Ethiopia.Source of information A systematic search was conducted on seven computerised bibliographic databases (Embase, ProQuest Central, Scopus, PsycINFO, Web of Science, MEDLINE/PubMed and CINAHL) to locate experimental or quasi-experimental studies published between the year 2000 and May 2021.Study eligibility criteria Interventional studies that measured IYCF indicators (early initiation of breast feeding (EIBF), exclusive breast feeding (EBF), the introduction of complementary foods, minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet) as outcome variables were included.Study appraisal and synthesis All included studies were examined for biases related to interventional studies (ie, selection bias, performance bias, attrition bias, detection bias and reporting bias). Author reports of effect size measures were used to narratively report the findings of each study.Results Of the 23 eligible studies, 14 studies were quasi-experimental and 9 studies were cluster randomised trials (CRTs). Eight quasi-experimental studies had a serious risk of bias, while two CRTs had a high risk of bias. Four studies for EBF and six studies for EIBF showed significant impacts of policy advocacy, health service strengthening, interpersonal communication, community mobilisation and mass media campaigns. Six studies for MDD and three studies for MMF indicated significant effects of community-level and health facility complementary feeding promotions on infants and young children. Interventions that delivered in combination increased the impacts in improving EIBF, MDD and MMF compared with a single intervention.Conclusion Our review showed that 12 out of 21 eligible studies that implemented in the form of community-level and health facility interventions improved EIBF, EBF, and/or MDD in Ethiopia.Protocol registration number PROSPERO, CRD42020155519.

Background: As the search for effective treatment of coronavirus disease 2019 (COVID-19) infection continues, the public opinion around the potential use of chloroquine (CQ) in treating COVID-19 remains mixed. Aim: To examine opinion and uptake of CQ for treating COVID-19 in the sub-Saharan African (SSA) region. Setting: This study was conducted through an online survey software titled SurveyMonkey. Methods: Anonymous online survey of 1829 SSA countries was conducted during the lockdown period using Facebook, WhatsApp and authors’ networks. Opinion and uptake of CQ for COVID-19 treatment were assessed using multivariate analyses. Results: About 14% of respondents believed that CQ could treat COVID-19 and of which, 3.2% took CQ for COVID-19 treatment. Multivariate analyses revealed that respondents from Central (adjusted odds ratios [aOR]: 2.54, 95% confidence interval [CI] 1.43, 4.43) and West Africa (aOR: 1.79, 95% CI 1.15, 2.88) had higher odds of believing that CQ could treat COVID-19. Respondents from East Africa reported higher odds for uptake of CQ for COVID-19 than Central, Western and Southern Africans. Knowledge of the disease and compliance with the public health advice were associated with both belief and uptake of CQ for COVID-19 treatment. Conclusion: Central and West African respondents were more likely to believe in CQ as a treatment for COVID-19 whilst the uptake of the medication during the pandemic was higher amongst East Africans. Future intervention discouraging the unsupervised use of CQ should target respondents from Central, West and East African regions.

Background: Feelings of isolation, insecurity, and instability triggered by COVID-19 could have a long-term impact on the mental health status of individuals. Objectives: The aim of this study was to examine the prevalence of mental health symptoms (anxiety, depression, and stress) in Bangladesh and the factors associated with these symptoms during the COVID-19 pandemic. Methods: From 1 to 30 April 2020, we used a validated self-administered questionnaire to conduct a cross-sectional study on 10,609 participants through an online survey platform. We assessed mental health status using the Depression, Anxiety, and Stress Scale (DASS-21). The total depression, anxiety, and stress subscale scores were divided into normal, mild, moderate, severe, and multinomial logistic regression was used to examine associated factors. Findings: The prevalence of depressive symptoms was 15%, 34%, and 15% for mild, moderate, and severe depressive symptoms, respectively. The prevalence of anxiety symptoms was 59% for severe anxiety symptoms, 14% for moderate anxiety symptoms, and 14% for mild anxiety symptoms, while the prevalence for stress levels were 16% for severe stress level, 22% for moderate stress level, and 13% for mild stress level. Multivariate analyses revealed that the most consistent factors associated with mild, moderate, and severe of the three mental health subscales (depression, anxiety, and stress) were respondents who lived in Dhaka and Rangpur division, females, those who self-quarantined in the previous seven days before the survey, and those respondents who experienced chills, breathing difficulty, dizziness, and sore throat. Conclusion: Our results showed that about 64%, 87%, and 61% of the respondents in Bangladesh reported high levels of depression, anxiety, and stress, respectively. There is a need for mental health support targeting women and those who self-quarantined or lived in Dhaka and Rangpur during the pandemic.

BackgroundThere is suboptimal early initiation of breastfeeding (EIBF) with widespread prelacteal feeding in Ghana. However, studies exploring the determinants of EIBF and prelacteal feeding are limited in Ghana. The study was conducted to assess the prevalence and determinants of EIBF and prelacteal feeding in Northern Ghana.MethodsThis cross-sectional study was conducted among 508 mothers with infants aged 0-24 months in the Sagnarigu Municipality of Northern Ghana. The quantitative data were collected using a structured questionnaire adapted from Ghana's demographic and health survey. Multivariate logistic regression was used to identify the independent determinants of EIBF and prelacteal feeding.ResultsThe prevalence of EIBF and prelacteal feeding was 72% and 21%, respectively. The independent positive determinants of EIBF were partner support to breastfeed [adjusted Odds ratio (AOR): 1.86, 95% Confidence interval (CI): 1.09-3.17] and exposure to breastfeeding information during pregnancy (AOR = 1.63 (95% CI: 1.01-2.64). Lower odds of EIBF were observed among mothers from extended family (AOR = 0.62, 95% CI: 0.41-0.95). Regarding prelacteal feeding, negative determinants were having a normal weight baby (AOR: 0.50, 95% CI: 0.27-0.90), exposure to breastfeeding information during pregnancy (AOR: 0.54, 95% CI: 0.31-0.92), while experiencing delayed onset of lactation was a risk factor for prelacteal feeding practice (AOR: 2.35, 95% CI: 1.41-3.94).ConclusionIn this study, EIBF was slightly higher than the 2030 global target on EIBF with widespread prelacteal feeding practice. Health programs aimed at improving EIBF should focus on the women partners, nutrition counselling, and support to mothers from the extended family. In the same vein, programs aimed at discouraging prelacteal feeding practice should also target women at risk, such as those with low birthweight babies and women experiencing delayed lactation onset.

Background Recent data indicated that approximately four in every ten newborns in Pakistan do not receive postnatal care (PNC) services in the first 48 hours after delivery. Objectives This study aimed to identify factors associated with the non-utilization of PNC for newborns in Pakistan using the 2017–18 Pakistan Demographic and Health Survey (PDHS). Methods This was a cross-sectional analytical study utilizing data from 3887 live-born newborns recorded in the 2017–18 PDHS. Non-utilization of PNC was assessed against a set of independent factors using multilevel logistic regression analysis, and the population attributable risk estimates of factors associated with non-utilization of PNC were also calculated. Results There were 1443 newborns (37%) in Pakistan whose mothers did not utilize PNC check-ups in the first 2 days after delivery. The non-utilization of PNC was largely attributable to newborns delivered at non-health facilities 53% (47% to 59%) and those born to uneducated women 27% (13% to 38%). Adjusted analyses indicated that newborns with higher birth order and with a birth interval of more than 2 years, women who perceived their baby to be small at birth, women with no formal education and those living in regional areas of Khyber Pakhtunkhwa and Federally Administered Tribal Areas were significantly associated with non-utilization of PNC services. Conclusions Tailored health messages by community health workers, including door-to-door visits on utilizing health facilities through pregnancy to the postnatal periods, are needed and should target places of low socioeconomic status, including educationally disadvantaged women from regional areas of Pakistan.

Dengue, the most important mosquito-borne viral disease of humans is a recurring global health problem. In Bangladesh, dengue outbreaks are on the increase despite the efforts of government and it is not clear what the understanding of the general Dhaka population towards dengue fever is. Knowledge, attitude and practice (KAP) studies are essential guides in public health interventions. Hence, using KAP, this study aims to assess patient-perspectives with regards to factors associated with dengue, as well as investigate the associated factors between the two corporations in Dhaka. A Hospital-based cross-sectional study of 242 fever patients from two city-corporations in Dhaka (Dhaka North City Corporations, DNCC (n = 91, 37.6%) and Dhaka South City Corporation, DSCC (n = 151, 62.4%) was conducted using pre-tested KAP items. Wilcoxon's Rank Sum was used to determine the KAP by DNCC, DSCC and both corporations and multivariate Poisson regression analyses. The two corporations were analysed separately due to the differences in income distribution, concentration of slums, hospitals and clinics. The study found that more than half of the study population were knowledgeable about dengue (mean percentage scores was 52%), possess an appropriate and acceptable attitude towards the disease (69.2%), and about two thirds of the respondents (71.4%) engaged in practices towards its prevention. After adjusting for the potential cofounders, the factors associated with KAP about dengue fever varied between DNCC and DSCC; with duration of residency and use of mosquito nets were associated with knowledge in the north while income class and age were associated with knowledge and attitude in the south. In the pooled analysis (combining both corporations), knowledge of dengue was associated with good practice towards dengue fever among the respondents. The duration of residence in Dhaka (10+ years), not using mosquito nets and length of time spent in the hospital (7+ days) due to dengue, and decreased knowledge (Adjusted coefficient (β) = -0.01, 95%CI: -0.02, -0.01) were associated with attitude towards dengue in DNCC. On the other hand, middle-high income class, age (40+ years) and increased knowledge were associated with practice towards dengue in DSCC (β = 0.02, 95%CI: 0.01, 0.03). Efforts to increase knowledge about dengue fever through education by the administrations of both corporations would benefit from targeting these high-risk groups for a more sustainable outcome.

Introduction: Food handlers’ hands serve as a vehicle for potential foodborne pathogenic contamination which constitutes a public health risk. In Ghana, there are always constant reports of outbreaks of foodborne diseases in schools. However, determinants of hand hygiene practice among educational institutions food handlers are little known. The study, therefore, aimed to assess the determinants of hand hygiene practice at critical times among educational institutions’ food handlers in the Sagnarigu Municipality of Ghana. Methods: This was a cross-sectional survey among educational institutions food handlers in the Sagnarigu Municipality. Two hundred and six food handlers were selected through convenience sampling in the educational institutions. At the same time, structured questions that were developed from previous studies were used to assess food handlers’ hand hygiene practice at critical times. Data were analyzed using descriptive statistics, bivariate and multivariate logistic regression models. All variables with their respective confidence intervals (95%) and adjusted odds ratios were declared significant at P -values less than .05. Results: Hand hygiene practice at critical times among the food handlers were relatively good at a rating of 66.0% (95% CI: 59.1, 72.5%). Good hand hygiene practice at critical times was less likely among food handlers with no food safety training (AOR 0.04; 95% CI: 0.00, 0.41) and food handlers who had insufficient knowledge of hand hygiene (AOR 0.06; 95% CI 0.01, 0.25). Good hygiene practice at critical times was 99% lower in food handlers with a negative attitude as compared to food handlers with positive attitudes towards hand hygiene at critical times (AOR 0.01; 95% CI 0.00, 0.07). Only 17.0% of the food handlers demonstrated proper handwashing techniques, whereas a good number (85.4%) of the food handlers did not wash their hands after touching money. Conclusion: Good hand hygiene practice at critical times was relatively good. Food safety training, knowledge of hand hygiene and attitudes towards hand hygiene were independent predictors of hand hygiene practice at critical times. Concerned stakeholders and organizations should focus on WASH interventions that seek to improve educational institutions food handlers’ knowledge and attitudes towards hand hygiene, coupled with training on food safety.

Abstract Background Perinatal mortality is a devastating pregnancy outcome affecting millions of families in many low and middle-income countries including Nepal. This paper examined the more distant factors associated with perinatal mortality in Nepal. Methods A sample of 23,335 pregnancies > 28 weeks’ gestation from the Nepal Demographic and Health Survey datasets for the period (2001–2016) was analysed. Perinatal Mortality (PM) is defined as the sum of stillbirth (fetal deaths in pregnancies > 28 weeks’ gestation) and early neonatal mortality (deaths within the first week of life), while Extended Perinatal Mortality (EPM) is denoted as the sum of stillbirth and neonatal mortality (deaths within the first 28 days of life). Rates of PM and EPM were calculated. Logistic regression generalized linear latent and mixed models (GLLAMM) that adjusted for clustering and sampling weight was used to examine the factor associated with perinatal mortality. Results Over the study period, the PMR was 42 [95% Confidence Interval (CI): 39, 44] per 1000 births for the five-year before each survey; while corresponding EPMR was 49 (95% CI, 46, 51) per 1000 births. Multivariable analyses revealed that women residing in the mountains, who did not use contraceptives, women aged 15–18 years or 19–24 years, and women having no education were associated with increased PM and EPM. The study also identified households using biomass as cooking fuel, and households who reported unimproved sanitation or open defecation were significantly more likely to experience PM and EPM. Conclusions Interventions aimed to improve use of contraceptives, and reduce biomass as a source of cooking fuel are needed to achieve the recommended target of

Abstract Background Non-exclusive breastfeeding (non-EBF) is a risk factor for many of the 2300 under-five deaths occurring daily in Nigeria – a developing country with approximately 40 million children. This study aimed to quantify and compare the attributable burden of key modifiable risk factors associated with non-EBF in Nigeria to inform strategic policy responses and initiatives. Methods Relative risk and exposure prevalence for selected modifiable risk factors were used to calculate population attributable fractions based on Nigeria Demographic and Health Surveys data for the period (1999–2013). Scenarios based on feasible impact of community-based interventions in reducing exposure prevalence were also considered to calculate comparative potential impact fractions. Results In Nigeria, an estimated 22.8% (95% Confidence Interval, CI: 9.2–37.0%) of non-EBF was attributable to primary and no maternal education; 24.7% (95% CI: 9.5–39.5%) to middle and poor household wealth, 9.7% (1.7–18.1%) to lower number (1–3) and no antenatal care visits; 18.8% (95% CI: 6.9–30.8%) to home delivery and 16.6% (95% CI: 3.0–31.3%) to delivery assisted by a non-health professional. In combination, more than half of all cases of non-EBF (64.5%; 95% CI: 50.0–76.4%) could be attributed to those modifiable risk factors. Scenarios based on feasible impacts of community-based approaches to improve health service access and human capacity suggest that an avoidable burden of non-EBF practice of approximately 11% (95% CI: -5.4; 24.7) is achievable. Conclusion Key modifiable risk factors contribute significantly to non-EBF in Nigerian women. Community-based initiatives and appropriate socio-economic government policies that specifically consider those modifiable risk factors could substantially reduce non-EBF practice in Nigeria.

Abstract Background Depression is a leading source of morbidity and health loss in Australian women. This study investigates the determinants of antenatal depressive symptoms and postnatal depressive symptoms in an Australian population, including people from culturally and linguistically diverse (CALD) backgrounds. Method The study used a retrospective cohort of mothers of all live births in public health facilities in 2014 (N = 17,564) within South Western Sydney Local Health District and Sydney Local Health District in New South Wales, Australia. Prevalence of antenatal and postnatal depressive symptoms were estimated for the cohort. Multivariate logistic regression models were conducted to investigate the sociodemographic, psychological and health service determinants of antenatal and postnatal depressive symptoms, measured using the Edinburgh Postnatal Depression Scale (EPDS). Results The prevalence of antenatal and postnatal depressive symptoms was 6.2% and 3.3% of the cohort, respectively. Significant risk factors for maternal depressive symptoms during pregnancy were, a lack of partner support, history of intimate partner violence, being from the CALD population and low socioeconomic status. Self-reported antenatal depressive symptoms were strongly associated with postnatal depressive symptoms. Risk factors for postnatal depressive symptoms were similar to those for antenatal depressive symptoms, as well as assisted delivery. Conclusion Factors relating to demographic and psychosocial disadvantage were associated with subsequent antenatal and postnatal depressive symptoms in New South Wales, Australia. Our study suggests that screening for probable depression and timely referral for expert assessment of at-risk mothers may be an effective strategy to improve maternal mental health outcomes.

Abstract Background Diarrhoea is a leading cause of child mortality in Tanzania. The association between optimal infant feeding practices and diarrhoea has been reported elsewhere, but the evidence has been limited to promote and advocate for strategic interventions in Tanzania. This study examined the association between infant and young child feeding (IYCF) practices and diarrhoea in Tanzanian children under 24 months. Methods The study used the Tanzania Demographic and Health Survey data to estimate the prevalence of diarrhoea stratified by IYCF practices. Using multivariable logistic regression modelling that adjusted for confounding factors and cluster variability, the association between IYCF practices and diarrhoea among Tanzanian children was investigated. Results Diarrhoea prevalence was lower in infants aged 0–5 months whose mothers engaged in exclusive breastfeeding (EBF) and predominant breastfeeding (PBF) compared to those who were not exclusively and predominantly breastfed. Infants aged 6–8 months who were introduced to complementary foods had a higher prevalence of diarrhoea compared to those who received no complementary foods, that is, infants who were exclusively breastfed at 6–8 months. Infants who were exclusively and predominantly breastfed were less likely to experience diarrhoea compared to those who were not exclusively and predominantly breastfed [adjusted odds ratio (AOR) 0.31, 95% confidence interval (CI) 0.16–0.59, P

This study examines the impact of the determinants of new firm formation in New England at the county level from 1999 to 2009. Based on the Spatial Durbin panel model that accounts for spillover effects, it is found that population density and human capital positively affect single-unit firm births within a county and its neighbors. Population growth rate also exerts a significant positive impact on new firm formation, but most of the effect is from spatial spillovers. On the contrary, the ratio of large to small firm in terms of employment size and unemployment rate negatively influence single-unit firm births both within counties and among neighbors. However, there is no significant impact of local financial capital and personal income growth on new firm formation.