1,721,332 research outputs found
The impact of underuse of modern methods of contraception among adolescents with unintended pregnancies in 12 low- and middle-income countries
Get PDFBackground In spite of the last decade increase in availability of contraception, around half of the annual 21 million pregnancies notified in
low- and middle-income countries in individuals aged 15-19 years are
unintended. We sought to explore the contribution of the underuse of
modern methods of contraception (MMC) to the annual incidence of unintended pregnancies among adolescent women.
Methods We used Demographic and Health Survey (DHS) data from 12
low- and middle-income countries. The pooled analysis exploring the
risk of unintended pregnancy included 7268 adolescent women with
a current unintended pregnancy and 121894 currently not pregnant
15- to 19-year-old sexually active women who did not desire pregnancy. For each country and the pooled analysis, the odds ratio of unintended pregnancy was calculated in relation to the type of contraception
(MMC, Traditional Methods, and No Contraception). Expected unintended pregnancies and population attributable fraction (PAF) of unintended pregnancies attributable to not using MMC were calculated for
each country.
Results The use of traditional methods was associated with a 3.4 (95%
confidence interval (CI)=2.1-4.7) time increased odds of having an undesired pregnancy compared with the use of MMC of contraception while
not using any method of contraception was associated with a 4.6 (95%
CI=2.6-6.6) times increased odds. The population attributable fraction
(PAF) of not using MMC accounted for 86.8% of the estimated unintended pregnancies (9464654 in total in the 12 countries) in the pooled
analysis. PAF ranged from 65.8% (1022154) for Bangladesh to 95.1%
(540176) for Niger and the estimated number of unintended pregnancies because of the use of traditional methods or non-use of contraception ranged from 18638 in Namibia to 4303872 in India.
Conclusions Eight million out of 9.5 million unintended pregnancies
occurring annually in twelve countries could have been prevented with
the optimal use of MMC of contraception. MMC need to be further supported in order to further prevent unintended pregnancies globally
Evaluation of a community-based mobile video breastfeeding intervention in Khayelitsha, South Africa: The Philani MOVIE cluster-randomized controlled trial
Get PDFBackground: In South Africa, breastfeeding promotion is a national health priority. Regular perinatal home visits by community health workers (CHWs) have helped promote exclusive breastfeeding (EBF) in underresourced settings. Innovative, digital approaches including mobile video content have also shown promise, especially as access to mobile technology increases among CHWs. We measured the effects of an animated, mobile video series, the Philani MObile Video Intervention for Exclusive breastfeeding (MOVIE), delivered by a cadre of CHWs (“mentor mothers”). Methods and findings: We conducted a stratified, cluster-randomized controlled trial from November 2018 to March 2020 in Khayelitsha, South Africa. The trial was conducted in collaboration with the Philani Maternal Child Health and Nutrition Trust, a nongovernmental community health organization. We quantified the effect of the MOVIE intervention on EBF at 1 and 5 months (primary outcomes), and on other infant feeding practices and maternal knowledge (secondary outcomes). We randomized 1,502 pregnant women in 84 clusters 1:1 to 2 study arms. Participants’ median age was 26 years, 36.9% had completed secondary school, and 18.3% were employed. Mentor mothers in the video intervention arm provided standard-of-care counseling plus the MOVIE intervention; mentor mothers in the control arm provided standard of care only. Within the causal impact evaluation, we nested a mixed-methods performance evaluation measuring mentor mothers’ time use and eliciting their subjective experiences through in-depth interviews. At both points of follow-up, we observed no statistically significant differences between the video intervention and the control arm with regard to EBF rates and other infant feeding practices [EBF in the last 24 hours at 1 month: RR 0.93 (95% CI 0.86 to 1.01, P = 0.091); EBF in the last 24 hours at 5 months: RR 0.90 (95% CI 0.77 to 1.04, P = 0.152)]. We observed a small, but significant improvement in maternal knowledge at the 1-month follow-up, but not at the 5-month follow-up. The interpretation of the results from this causal impact evaluation changes when we consider the results of the nested mixed-methods performance evaluation. The mean time spent per home visit was similar across study arms, but the intervention group spent approximately 40% of their visit time viewing videos. The absence of difference in effects on primary and secondary endpoints implies that, for the same time investment, the video intervention was as effective as face-to-face counseling with a mentor mother. The videos were also highly valued by mentor mothers and participants. Study limitations include a high loss to follow-up at 5 months after premature termination of the trial due to the COVID-19 pandemic and changes in mentor mother service demarcations. Conclusions: This trial measured the effect of a video-based, mobile health (mHealth) intervention, delivered by CHWs during home visits in an underresourced setting. The videos replaced about two-fifths of CHWs’ direct engagement time with participants in the intervention arm. The similar outcomes in the 2 study arms thus suggest that the videos were as effective as face-to-face counselling, when CHWs used them to replace a portion of that counselling. Where CHWs are scarce, mHealth video interventions could be a feasible and practical solution, supporting the delivery and scaling of community health promotion services
Predictive value of pulse oximetry for mortality in infants and children presenting to primary care with clinical pneumonia in rural Malawi: A data linkage study
Get PDFBACKGROUND: The mortality impact of pulse oximetry use during infant and childhood pneumonia management at the primary healthcare level in low-income countries is unknown. We sought to determine mortality outcomes of infants and children diagnosed and referred using clinical guidelines with or without pulse oximetry in Malawi. METHODS AND FINDINGS: We conducted a data linkage study of prospective health facility and community case and mortality data. We matched prospectively collected community health worker (CHW) and health centre (HC) outpatient data to prospectively collected hospital and community-based mortality surveillance outcome data, including episodes followed up to and deaths within 30 days of pneumonia diagnosis amongst children 0-59 months old. All data were collected in Lilongwe and Mchinji districts, Malawi, from January 2012 to June 2014. We determined differences in mortality rates using <90% and <93% oxygen saturation (SpO2) thresholds and World Health Organization (WHO) and Malawi clinical guidelines for referral. We used unadjusted and adjusted (for age, sex, respiratory rate, and, in analyses of HC data only, Weight for Age Z-score [WAZ]) regression to account for interaction between SpO2 threshold (pulse oximetry) and clinical guidelines, clustering by child, and CHW or HC catchment area. We matched CHW and HC outpatient data to hospital inpatient records to explore roles of pulse oximetry and clinical guidelines on hospital attendance after referral. From 7,358 CHW and 6,546 HC pneumonia episodes, we linked 417 CHW and 695 HC pneumonia episodes to 30-day mortality outcomes: 16 (3.8%) CHW and 13 (1.9%) HC patients died. SpO2 thresholds of <90% and <93% identified 1 (6%) of the 16 CHW deaths that were unidentified by integrated community case management (iCCM) WHO referral protocol and 3 (23%) and 4 (31%) of the 13 HC deaths, respectively, that were unidentified by the integrated management of childhood illness (IMCI) WHO protocol. Malawi IMCI referral protocol, which differs from WHO protocol at the HC level and includes chest indrawing, identified all but one of these deaths. SpO2 < 90% predicted death independently of WHO danger signs compared with SpO2 ≥ 90%: HC Risk Ratio (RR), 9.37 (95% CI: 2.17-40.4, p = 0.003); CHW RR, 6.85 (1.15-40.9, p = 0.035). SpO2 < 93% was also predictive versus SpO2 ≥ 93% at HC level: RR, 6.68 (1.52-29.4, p = 0.012). Hospital referrals and outpatient episodes with referral decision indications were associated with mortality. A substantial proportion of those referred were not found admitted in the inpatients within 7 days of referral advice. All 12 deaths in 73 hospitalised children occurred within 24 hours of arrival in the hospital, which highlights delay in appropriate care seeking. The main limitation of our study was our ability to only match 6% of CHW episodes and 11% of HC episodes to mortality outcome data. CONCLUSIONS: Pulse oximetry identified fatal pneumonia episodes at HCs in Malawi that would otherwise have been missed by WHO referral guidelines alone. Our findings suggest that pulse oximetry could be beneficial in supplementing clinical signs to identify children with pneumonia at high risk of mortality in the outpatient setting in health centres for referral to a hospital for appropriate management
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Drought and child vaccination coverage in 22 countries in sub-Saharan Africa: A retrospective analysis of national survey data from 2011 to 2019
Get PDFBACKGROUND: Extreme weather events, including droughts, are expected to increase in parts of sub-Saharan Africa and are associated with a number of poor health outcomes; however, to the best of our knowledge, the link between drought and childhood vaccination remains unknown. The objective of this study was to evaluate the relationship between drought and vaccination coverage.
METHODS AND FINDINGS: We investigated the association between drought and vaccination coverage using a retrospective analysis of Demographic and Health Surveys data in 22 sub-Saharan African countries among 137,379 children (50.4% male) born from 2011 to 2019. Drought was defined as an established binary variable of annual rainfall less than or equal to the 15th percentile relative to the 29 previous years, using data from Climate Hazards Group InfraRed Precipitation with Station (CHIRPS) data. We evaluated the association between drought at the date of birth and receipt of bacillus Calmette-Guérin (BCG), diphtheria-pertussis-tetanus (DPT), and polio vaccinations, and the association between drought at 12 months of age and receipt of measles vaccination. We specified logistic regression models with survey fixed effects and standard errors clustered at the enumeration area level, adjusting for child-, mother-, and household-level covariates and estimated marginal risk differences (RDs). The prevalence of drought at date of birth in the sample was 11.8%. Vaccination rates for each vaccination ranged from 70.6% (for 3 doses of the polio vaccine) to 86.0% (for BCG vaccination); however, only 57.6% of children 12 months and older received all recommended doses of BCG, DPT, polio, and measles vaccinations. In adjusted models, drought at date of birth was negatively associated with BCG vaccination (marginal RD = -1.5; 95% CI -2.2, -0.9), DPT vaccination (marginal RD = -1.4; 95% CI -2.2, -0.5), and polio vaccination (marginal RD = -1.3; 95% CI -2.3, -0.3). Drought at 12 months was negatively associated with measles vaccination (marginal RD = -1.9; 95% CI -2.8, -0.9). We found a dose-response relationship between drought and DPT and polio vaccinations, with the strongest associations closest to the timing of drought. Limitations include some heterogeneity in findings across countries.
CONCLUSIONS: In this study, we observed that drought was associated with lower odds of completion of childhood BCG, DPT, and polio vaccinations. These findings indicate that drought may hinder vaccination coverage, one of the most important interventions to prevent infections among children. This work adds to a growing body of literature suggesting that health programs should consider impacts of severe weather in their programming
Management of severe malaria: challenges and lessons learned with the introduction of pre-referral Rectal Artesunate in the Democratic Republic of the Congo
Get PDFMalaria causes over 240 million cases and over 600,000 deaths annually, mostly among children under the age of five years. The Democratic Republic of the Congo (DRC) has the second highest malaria mortality in the world, accounting for 12% of the global burden of malaria. Despite substantial improvements in prevention and treatment during the past 10 years, malaria remains the principal cause of morbidity and mortality, accounting for 44% of all deaths among outpatient visits in children, and 22% of all in-patient deaths. One of the major challenges in severe malaria case management remains the limited access to higher-level health facilities where a full treatment can be provided. This is especially an issue for populations living in remote areas, resulting in treatment delays of several hours or even days. In such situations, the World Health Organization (WHO) recommends pre-referral treatment, either with a single dose of a parenteral anti-malarial, or with a single dose of rectal artesunate (RAS). The Congolese National Malaria Control Programme (NMCP) is committed to reducing the high number of malaria-related deaths through proven interventions such as pre-referral RAS. The aim of this thesis was to identify challenges and draw lessons learned from the implementation of pre-referral RAS in DRC, in view of supporting its responsible introduction into the national health system. The present work was entirely conducted in the frame of the multi-country Community Access to Rectal Artesunate for Malaria (CARAMAL) project.
In DRC, we setup a patient surveillance system (PSS) in three Health Zones to determine the distribution of dangers signs for severe malaria and assess their impact on RAS use, referral completion, injectable treatment and ACT provision, and health outcomes including death. To contextualize the data gathered through the PSS, we also conducted cross-sectional household surveys in the same locations to assess treatment seeking predictors and the prevalence of malaria.
Findings showed a high prevalence of malaria (45.1%, 95% CI 39.8–50.4) and anaemia (79.5%, 95% CI 77.1–81.7) in these communities. The presence of danger signs was not optimal but still increased the likelihood of seeking treatment (aOR=2.12, 95% CI 1.03–4.38). Unfortunately, still many children with danger signs were not brought to health facilities, or were brought late. Importantly, danger signs were well recognized by health provider at the primary care level, and RAS is acceptable and can be given without problem by low-level health care workers.
Referral Health Facilities (RHF) are the subsequent point of contact for severely ill children, after they successfully complete their referral.
According to the current treatment recommendations, the post-referral treatment of severe malaria comprises the provision of parenteral artesunate for at least 24 hours, followed by a full course of an Artemisinin Combination Therapy (ACT) once the patient can tolerate oral medication. In the RHFs, our aim was to assess the compliance of health care workers with the recommended treatment in children under 5 years. While only half of children were given parenteral antimalarial treatment (50.3%, 2,117/4,208), inpatient ACT administration was more common (78.7%, 1,314/1,669). The overall poor quality of severe malaria case management at higher-level facilities is an important health system issue and it is probably the reasons why the introduction of RAS did not have an impact on the Case Facility Rate of the pediatric patients. In addition, parenteral artesunate not followed up with oral ACT constitutes an artemisinin monotherapy and may favor the selection of resistant parasites. Stricter compliance with the WHO severe malaria treatment guidelines is critical to effectively manage this disease and further reduce child mortality.
Finally, we assessed the health system costs and constraints to the successful implementation of pre-referral RAS at community level. We did so to inform operational guidance and financial planning for the scale-up of RAS as pre-referral treatment for severe malaria. The equivalent annual costs of preparing the health system for managing severe malaria with RAS was 464 per child treated. Strengthening essential routine health system components accounted for the majority of these costs (76.4%).
In conclusion, introducing pre-referral RAS as a single intervention seemed not to add value in terms of reducing child mortality. Deploying successful pre-referral RAS at large scale requires preceding investments to strengthen the health system along the entire cascade of care. Only then can the potential of RAS as a pre-referral treatment be realized
Neurocognitive outcomes in Malawian children exposed to malaria during pregnancy: An observational birth cohort study.
Get PDFBACKGROUND: Annually 125 million pregnancies are at risk of malaria infection. However, the impact of exposure to malaria in pregnancy on neurodevelopment in children is not well understood. We hypothesized that malaria in pregnancy and associated maternal immune activation result in neurodevelopmental delay in exposed offspring. METHODS AND FINDINGS: Between April 2014 and April 2015, we followed 421 Malawian mother-baby dyads (median [IQR] maternal age: 21 [19, 28] years) who were previously enrolled (median [IQR] gestational age at enrollment: 19.7 [17.9, 22.1] weeks) in a randomized controlled malaria prevention trial with 5 or 6 scheduled assessments of antenatal malaria infection by PCR. Children were evaluated at 12, 18, and/or 24 months of age with cognitive tests previously validated in Malawi: the Malawi Developmental Assessment Tool (MDAT) and the MacArthur-Bates Communicative Development Inventories (MCAB-CDI). We assessed the impact of antenatal malaria (n [%] positive: 240 [57.3]), placental malaria (n [%] positive: 112 [29.6]), and maternal immune activation on neurocognitive development in children. Linear mixed-effects analysis showed that children exposed to antenatal malaria between 33 and 37 weeks gestation had delayed language development across the 2-year follow-up, as measured by MCAB-CDI (adjusted beta estimate [95% CI], -7.53 [-13.04, -2.02], p = 0.008). Maternal immune activation, characterized by increased maternal sTNFRII concentration, between 33 and 37 weeks was associated with lower MCAB-CDI language score (adjusted beta estimate [95% CI], -8.57 [-13.09, -4.06], p < 0.001). Main limitations of this study include a relatively short length of follow-up and a potential for residual confounding that is characteristic of observational studies. CONCLUSIONS: This mother-baby cohort presents evidence of a relationship between malaria in pregnancy and neurodevelopmental delay in offspring. Malaria in pregnancy may be a modifiable risk factor for neurodevelopmental injury independent of birth weight or prematurity. Successful interventions to prevent malaria during pregnancy may reduce the risk of neurocognitive delay in children
Challenges and key research questions for yaws eradication
No full textWellcome Trust Clinical Research FellowshipMiguel Servet of the ISCII
Going Beyond Counting First Authors in Author Co-citation Analysis
Get PDFThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
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