Mosquito control by abatement programmes in the United States: perspectives and lessons for countries in sub-Saharan Africa.

Africa and the United States are both large, heterogeneous geographies with a diverse range of ecologies, climates and mosquito species diversity which contribute to disease transmission and nuisance biting. In the United States, mosquito control is nationally, and regionally coordinated and in so much as the Centers for Disease Control (CDC) provides guidance, the Environmental Protection Agency (EPA) provides pesticide registration, and the states provide legal authority and oversight, the implementation is usually decentralized to the state, county, or city level. Mosquito control operations are organized, in most instances, into fully independent mosquito abatement districts, public works departments, local health departments. In some cases, municipalities engage independent private contractors to undertake mosquito control within their jurisdictions. In sub-Saharan Africa (SSA), where most vector-borne disease endemic countries lie, mosquito control is organized centrally at the national level. In this model, the disease control programmes (national malaria control programmes or national malaria elimination programmes (NMCP/NMEP)) are embedded within the central governments' ministries of health (MoHs) and drive vector control policy development and implementation. Because of the high disease burden and limited resources, the primary endpoint of mosquito control in these settings is reduction of mosquito borne diseases, primarily, malaria. In the United States, however, the endpoint is mosquito control, therefore, significant (or even greater) emphasis is laid on nuisance mosquitoes as much as disease vectors. The authors detail experiences and learnings gathered by the delegation of African vector control professionals that participated in a formal exchange programme initiated by the Pan-African Mosquito Control Association (PAMCA), the University of Notre Dame, and members of the American Mosquito Control Association (AMCA), in the United States between the year 2021 and 2022. The authors highlight the key components of mosquito control operations in the United States and compare them to mosquito control programmes in SSA countries endemic for vector-borne diseases, deriving important lessons that could be useful for vector control in SSA.

Understanding the Effect of a Healthcare Provider-Led Family Planning Support Intervention on Contraception use and Pregnancy Desires among Postpartum Women Living with HIV in Southwestern Uganda.

Modern contraceptive prevalence among women living with HIV (WLWH) in Uganda is still low at 45%, and up to a third of women are likely to discontinue the method within the first year of initiation. This increases risks of unplanned pregnancies, perinatal HIV transmission and pregnancy complications. We aim to explore and explain the mechanism of effect of a family planning support intervention investigated in a randomized controlled trial conducted between October 2016 and June 2018 among 320 postpartum WLWH at a referral hospital in Southwestern Uganda that led to improved uptake, decreased contraception discontinuation and lowered pregnancy rates. Thirty WLWH and 10 of their primary sexual partners who participated in this trial were purposively selected and interviewed in the local language; interviews were digitally recorded. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive descriptive categories using an inductive content analytic approach. Up to 83% of women wanted to avoid pregnancy within the first year postpartum. Qualitative data showed that contraception uptake and use were influenced by: 1) Participant awareness and understanding of different methods available; 2) Participant perception of offered health services; 3) Healthcare provider (HCP) socio-cultural sensitivity to individual experiences and (mis)conceptions surrounding contraception; 4) Having tactile engagement, follow-up reminders and a reference to prompt action or discussions with partners. Supportive and culturally sensitive HCPs and systems facilitated information sharing leading to increased patient awareness and understanding of the contraceptive methods, and improved health user experience, care engagement, confidence and willingness to take up and continue using modern contraceptive methods.

Structured and sustained family planning support facilitates effective use of postpartum contraception amongst women living with HIV in South Western Uganda: A randomized controlled trial.

BACKGROUND: Despite low pregnancy intentions, many women accessing contraception discontinue use, increasing the risk of unwanted pregnancies among women living with HIV (WLWH). We evaluate whether a family planning support intervention, inclusive of structured immediate one-on-one postpartum counseling, and a follow-up mechanism through additional health information and SMS reminders affects continuous contraceptive use and pregnancy incidence among recently postpartum WLWH. METHODS: We performed a randomized controlled trial between October 2016 and June 2018 at a referral hospital in southwestern Uganda. We included adult WLWH randomized and enrolled in a 1:1 ratio to receive family planning support or standard of care (control) and completed an interviewer-administered questionnaire at enrolment, 6 and 12 months postpartum. Our two primary outcomes of interest were; continuous use of contraception, and incidence of pregnancy. Secondary outcomes included contraception uptake, method change, discontinuation and pregnancy intentions. The trial was registered with clinicaltrials.gov (NCT02964169). RESULTS: A total of 317(99%) completed all study procedures. Mean age was 29.6 (SD = 6.0) vs 30.0 (SD = 5.9) years for the intervention vs control groups respectively. All women were enrolled on ART. Total women using contraception continuously were 126 (79.8%) in the intervention compared to 110 (69.2%) in control group (odds ratio (OR) = 1.75; confidence interval (CI) = 1.24-2.75, P = 0.003). Pregnancy rates were 2% (N = 3) in the intervention vs 9% (N = 14) in the control group (OR = 0.20, 95% CI = 0.05-0.62, P = 0.006). Pregnancy intention was lower in the intervention vs control group (OR = 0.23, 95% CI = 0.08-0.64, P = 0.002). Women actively enrolled on contraception reduced more in the control compared to the intervention group (OR = 3.92, 95% CI = 1.66-9.77, P = 0.001). Women enrolled on each contraceptive method did not differ by group except for implants. More women initiating contraception use within three months postpartum had better continued use for either intervention (N = 123, 97.6% vs N = 3,2.4%) or control group (N = 86,78.2% vs N = 24,21.8%). Method-related side effects were less reported in the intervention group (OR = 0.25, 95% CI = 0.10-0.60, P = 0.001). CONCLUSION: We found that sustained and structured family planning support facilitates continuous use of contraception and lowers rates of pregnancy amongst postpartum WLWH in rural southwestern Uganda. Women who initiated contraception within three months postpartum were more likely to maintain continuous use of contraception than those initiating later. Further evaluation of actual and perceived facilitators to the continuous contraception use by this support intervention will help replication in similar settings. TRIAL REGISTRATION: NCT02964169.

Patterns and Practices of Self-Medication Among Students Enrolled at Mbarara University of Science and Technology in Uganda.

PURPOSE: Self-medication is drug use without advice from a medical professional. Proper self-medication can reduce health expenses and physician waiting time. However, prescription or over-the-counter drugs are considered unsafe when used irrationally. Presumably, university students can make informed decisions regarding their lives. However, there are limited studies documenting self-medication in Ugandan universities. This study sought to document the prevalence, patterns and factors associated with self-medication among students enrolled at Mbarara University of Science and Technology (MUST). PATIENTS AND METHODS: A descriptive cross-sectional study was done on 385 medical and non-medical students. Data were collected by interviewer-led semi-structured questionnaires and analyzed using the Statistical Package for Social Sciences (SPSS) version 20. The statistical significance was considered as p < 0.05 for both univariate and multivariate analyses. RESULTS: This study showed a 63.5% prevalence of self-medication. Self-medication reasons were classifying illnesses as minor (33%), time-saving (15%), having old prescriptions (11%) and high consultation fees (9%). Not self-medicating reasons included risk of using wrong drugs (19%), insufficient knowledge (17%), fear of side effects (15%), wrong drug use (15%) and misdiagnosis (14%). Respondents accessed drugs from pharmacies (56%), friends/family (17%) or private clinics (15%). Headache relievers, pain relievers and antibiotics were most commonly self-medicated. In adjusted analysis, being female, existing allergies, and being in advanced years of study were associated with increased odds of self-medication. No statistically significant difference existed between medical and non-medical students regarding self-medication. Self-medication likelihood increased with a lack of access to medical services. CONCLUSION: There is a high rate of self-medication amongst female students, those in advanced years of study and those with existing allergies. Medical services access significantly reduced the chances of self-medication. Vital medical services need to be extended to the university students to receive information on medicines, diagnosis, prescription and treatment. More studies should evaluate the impact of a high rate of self-medication among these students.

Provision of family planning vouchers and early initiation of postpartum contraceptive use among women living with HIV in southwestern Uganda: A randomized controlled trial.

BACKGROUND: Unwanted pregnancies remain a burden for women living with HIV (WLWH). Family planning prevents unplanned pregnancies while promoting longer birth intervals, key strategies to eliminate perinatal transmission of HIV and promote maternal and child health. We evaluated the effect of a family planning voucher, inclusive of immediate postpartum counseling, on uptake, early initiation, and continuation of modern contraceptive methods among recently postpartum WLWH delivering at a publicly funded regional referral hospital in rural, southwestern Uganda. METHODS AND FINDINGS: We performed a randomized controlled trial between October, 2016 and June, 2018 at a referral hospital in southwestern Uganda. This interim analysis includes adult WLWH randomized and enrolled equally to receive a family planning voucher or standard of care (control). Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrollment and 6 months postpartum. Our primary outcome of interest for this analysis is initiation of a modern family planning method within 8 weeks postpartum. Secondary outcomes included family planning initiation at 12, 14, 16, and 20 weeks postpartum, family planning discontinuation and/or change, pregnancy incidence, and mean time without contraception. The trial was registered with clinicaltrials.gov (NCT02964169). At enrollment, half of the women in both the voucher (N = 87, 55%) and control (N = 86, 54%) groups wanted to have a child in 2 years postpartum. Over 80% of referent pregnancies in the voucher (N = 136, 86%) and control (N = 128, 81%) groups were planned. All women were accessing ART. The mean CD4 count was 396 cells/mm3 (SD = 61) for those enrolled in the control group versus 393 cells/mm3 (SD = 64) in the family planning voucher group. By 8 weeks postpartum, family planning was initiated in 144 (91%) participants in the voucher group and 83 (52%) participants in the control group (odds ratio [OR] 9.42; CI 4.67-13.97, P < 0.001). We also found high family planning uptake rates for both groups, with higher rates among the intervention group at 12 weeks (OR 5.66; CI 2.65-12.12, P < 0.001), 14 weeks (OR 2.51; CI 1.31-4.79, P < 0.001), 16 weeks (OR 4.02; CI 1.66-9.77, P = 0.001), and 20 weeks (OR 3.65; CI 1.40-9.47, P = 0.004) postpartum. The average time to family planning initiation was reduced to 5.9 weeks (SD = 2.4) for those in the voucher group compared to 9.3 weeks (SD = 5) in the control (P < 0.001). One pregnancy was recorded in the group receiving standard of care; none were reported in the voucher group. Method mix did not differ by group: injectables were selected by most women (N = 150, 50%), and 52% of this proportion were in the experimental arm, with <10% in each arm selecting condoms, oral contraception, or intrauterine devices (IUDs). Similar proportions of women changed contraceptive methods over the 6-month follow-up in the voucher and control groups (N = 8, 5% versus N = 5, 4%; P = 0.467). More women in the control group discontinued contraception for 1 to 2 weeks (N = 19, 13% versus N = 7, 5%; P = 0.008) or more than 4 weeks (N = 15, 10% versus N = 3, 2%; P = 0.002) compared to those given a family planning voucher. The main limitation of this study is that its findings may not be generalized to settings without improved availability of contraceptives in publicly funded facilities. CONCLUSION: These findings indicate that a well-structured, time-bound family planning voucher program appeared to increase early postpartum contraceptive uptake and continuation in a setting in which users are faced with financial, knowledge, and structural barriers to contraceptive services. Further work should clarify the role of vouchers in empowering WLWH to avoid unintended pregnancies over time. TRIAL REGISTRATION: ClinicalTrials.gov NCT02964169.