Analysing the association between perceived knowledge, and attitudes on Lassa Fever infections and mortality risk factors in lower Bambara Chiefdom.

BACKGROUND: Lassa fever (LF) presents significant public health challenges in Sierra Leone, particularly in the Lower Bambara Chiefdom. This study aims to deeply understand how knowledge and attitudes towards LF correlate with community-driven prevention and control measures. METHODS: A descriptive cross-sectional quantitative approach was used to conduct the research. Data from 2167 participants were collected using an Android-based survey from 1st February 2022 to 14th February 2022. Respondents' knowledge of LF causes, risk factors, transmission modes, and preventive measures were evaluated through a multiple-choice questionnaire, and attitudes toward prevention and control were measured on a 5-point Likert scale. Quantitative data were analyzed using SPSS version 26.0 and frequencies were presented in count, percentage, and table. Chi-square statistics were used to test for associations. RESULTS: Among the 2167 participants, over half were males (1184, 54.60%), farmers (1406, 64.90%), married (monogamous) (1428, 65.90%), and had never attended school (1336, 61.70%). Respondents demonstrated high knowledge levels of LF across socio-demographic groups (33% to 100%) and shared a positive attitude towards prevention and control (mean score of 26.77 on a 5-40 scale). Educational level, religious beliefs, and occupational status significantly influenced LF knowledge (p < 0.05). Specifically, illiterates had a high knowledge score of 48.24%, while those with tertiary education had the highest score at 83.33%. Additionally, a Pearson correlation analysis revealed a positive linear relationship between the degree of knowledge and positive attitude towards LF infection and mortality risk factors (r = 0.090, p = 0.02). CONCLUSION: High LF knowledge in Lower Bambara Chiefdom positively influences prevention attitudes. Education, religion, and occupation are key factors. Tailored interventions enhance public health efforts.

PREvalence Study on Surgical COnditions (PRESSCO) 2020: A Population-Based Cross-Sectional Countrywide Survey on Surgical Conditions in Post-Ebola Outbreak Sierra Leone.

BACKGROUND: Understanding the burden of diseases requiring surgical care at national levels is essential to advance universal health coverage. The PREvalence Study on Surgical COnditions (PRESSCO) 2020 is a cross-sectional household survey to estimate the prevalence of physical conditions needing surgical consultation, to investigate healthcare-seeking behavior, and to assess changes from before the West African Ebola epidemic. METHODS: This study (ISRCTN: 12353489) was built upon the Surgeons Overseas Surgical Needs Assessment (SOSAS) tool, including expansions. Seventy-five enumeration areas from 9671 nationwide clusters were sampled proportional to population size. In each cluster, 25 households were randomly assigned and visited. Need for surgical consultations was based on verbal responses and physical examination of selected household members. RESULTS: A total of 3,618 individuals from 1,854 households were surveyed. Compared to 2012, the prevalence of individuals reporting one or more relevant physical conditions was reduced from 25 to 6.2% (95% CI 5.4-7.0%) of the population. One-in-five conditions rendered respondents unemployed, disabled, or stigmatized. Adult males were predominantly prone to untreated surgical conditions (9.7 vs. 5.9% women; p < 0.001). Financial constraints were the predominant reason for not seeking care. Among those seeking professional health care, 86.7% underwent surgery. CONCLUSION: PRESSCO 2020 is the first surgical needs household survey which compares against earlier study data. Despite the 2013-2016 Ebola outbreak, which profoundly disrupted the national healthcare system, a substantial reduction in reported surgical conditions was observed. Compared to one-time measurements, repeated household surveys yield finer granular data on the characteristics and situations of populations in need of surgical treatment.

Evaluating the cascade of care for hypertension in Sierra Leone.

OBJECTIVE: To assess the care for hypertension in Sierra Leone, by the use of a cascade-of-care approach, to identify where the need for healthcare system interventions is greatest. METHODS: Using data from a nationwide household survey on surgical conditions undertaken in 1956 participants ≥18 years from October 2019 to March 2020, a cascade of care for hypertension consisting of four categories - hypertensive population, those diagnosed, those treated and those controlled - was constructed. Hypertension was defined as having a blood pressure ≥140/90 mmHg, or self-reported use of antihypertensive medication. Logistic regression analysis was used to investigate factors associated with undiagnosed hypertension. RESULTS: The prevalence of hypertension was 22%. Among those with hypertension, 23% were diagnosed, 11% were treated and 5% had controlled blood pressure. The largest loss to care (77%) was between being hypertensive and receiving a diagnosis. Male sex, age and living in a rural location, were significantly associated with the odds of undiagnosed hypertension. There was no significant difference between men and women in the number of patients with controlled blood pressure. Adults aged 40 or older were observed to be better retained in care compared with those younger than 40 years of age. CONCLUSION: There is a significant loss to care in the care cascade for hypertension in Sierra Leone. Our results suggest that increasing awareness of cardiovascular risk and risk factor screening for early diagnosis might have a large impact on hypertension care.

Public health-relevant consequences of the COVID-19 pandemic on malaria in sub-Saharan Africa: a scoping review.

BACKGROUND: The COVID-19 pandemic has resulted in unprecedented challenges to health systems worldwide, including the control of non-COVID-19 diseases. Malaria cases and deaths may increase due to the direct and indirect effects of the pandemic in malaria-endemic countries, particularly in sub-Saharan Africa (SSA). This scoping review aims to summarize information on public health-relevant effects of the COVID-19 pandemic on the malaria situation in SSA. METHODS: Review of publications and manuscripts on preprint servers, in peer-reviewed journals and in grey literature documents from 1 December, 2019 to 9 June, 2021. A structured search was conducted on different databases using predefined eligibility criteria for the selection of articles. RESULTS: A total of 51 papers have been included in the analysis. Modelling papers have predicted a significant increase in malaria cases and malaria deaths in SSA due to the effects of the COVID-19 pandemic. Many papers provided potential explanations for expected COVID-19 effects on the malaria burden; these ranged from relevant diagnostical and clinical aspects to reduced access to health care services, impaired availability of curative and preventive commodities and medications, and effects on malaria prevention campaigns. Compared to previous years, fewer country reports provided data on the actual number of malaria cases and deaths in 2020, with mixed results. While highly endemic countries reported evidence of decreased malaria cases in health facilities, low endemic countries reported overall higher numbers of malaria cases and deaths in 2020. CONCLUSIONS: The findings from this review provide evidence for a significant but diverse impact of the COVID-19 pandemic on malaria in SSA. There is the need to further investigate the public health consequences of the COVID-19 pandemic on the malaria burden. Protocol registered on Open Science Framework: https://doi.org/10.17605/OSF.IO/STQ9D.

Measuring coverage of maternal and child health services using routine health facility data: a Sierra Leone case study.

BACKGROUND: There are limited existing approaches to generate estimates from Routine Health Information Systems (RHIS) data, despite the growing interest to these data. We calculated and assessed the consistency of maternal and child health service coverage estimates from RHIS data, using census-based and health service-based denominators in Sierra Leone. METHODS: We used Sierra Leone 2016 RHIS data to calculate coverage of first antenatal care contact (ANC1), institutional delivery and diphtheria-pertussis-tetanus 3 (DPT3) immunization service provision. For each indicator, national and district level coverages were calculated using denominators derived from two census-based and three health service-based methods. We compared the coverage estimates from RHIS data to estimates from MICS 2017. We considered the agreement adequate when estimates from RHIS fell within the 95% confidence interval of the survey estimate. RESULTS: We found an overall poor consistency of the coverage estimates calculated from the census-based methods. ANC1 and institutional delivery coverage estimates from these methods were greater than 100% in about half of the fourteen districts, and only 3 of the 14 districts had estimates consistent with the survey data. Health service-based methods generated better estimates. For institutional delivery coverage, five districts met the agreement criteria using BCG service-based method. We found better agreement for DPT3 coverage estimates using DPT1 service-based method as national coverage was close to survey data, and estimates were consistent for 8 out of 14 districts. DPT3 estimates were consistent in almost half of the districts (6/14) using ANC1 service-based method. CONCLUSION: The study highlighted the challenge in determining an appropriate denominator for RHIS-based coverage estimates. Systematic and transparent data quality check and correction, as well as rigorous approaches to determining denominators are key considerations to generate accurate coverage statistics using RHIS data.

Oral rehydration therapies in Senegal, Mali, and Sierra Leone: a spatial analysis of changes over time and implications for policy.

BACKGROUND: Oral rehydration solution (ORS) is a simple intervention that can prevent childhood deaths from severe diarrhea and dehydration. In a previous study, we mapped the use of ORS treatment subnationally and found that ORS coverage increased over time, while the use of home-made alternatives or recommended home fluids (RHF) decreased, in many countries. These patterns were particularly striking within Senegal, Mali, and Sierra Leone. It was unclear, however, whether ORS replaced RHF in these locations or if children were left untreated, and if these patterns were associated with health policy changes. METHODS: We used a Bayesian geostatistical model and data from household surveys to map the percentage of children with diarrhea that received (1) any ORS, (2) only RHF, or (3) no oral rehydration treatment between 2000 and 2018. This approach allowed examination of whether RHF was replaced with ORS before and after interventions, policies, and external events that may have impacted healthcare access. RESULTS: We found that RHF was replaced with ORS in most Sierra Leone districts, except those most impacted by the Ebola outbreak. In addition, RHF was replaced in northern but not in southern Mali, and RHF was not replaced anywhere in Senegal. In Senegal, there was no statistical evidence that a national policy promoting ORS use was associated with increases in coverage. In Sierra Leone, ORS coverage increased following a national policy change that abolished health costs for children. CONCLUSIONS: Children in parts of Mali and Senegal have been left behind during ORS scale-up. Improved messaging on effective diarrhea treatment and/or increased ORS access such as through reducing treatment costs may be needed to prevent child deaths in these areas.

The state of enrollment on the National Health Insurance Scheme in rural Ghana after eight years of implementation.

BACKGROUND: In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations. METHODS: A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES. RESULTS: Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme. CONCLUSIONS: Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.

The global distribution and burden of dengue.

Dengue is a systemic viral infection transmitted between humans by Aedes mosquitoes. For some patients, dengue is a life-threatening illness. There are currently no licensed vaccines or specific therapeutics, and substantial vector control efforts have not stopped its rapid emergence and global spread. The contemporary worldwide distribution of the risk of dengue virus infection and its public health burden are poorly known. Here we undertake an exhaustive assembly of known records of dengue occurrence worldwide, and use a formal modelling framework to map the global distribution of dengue risk. We then pair the resulting risk map with detailed longitudinal information from dengue cohort studies and population surfaces to infer the public health burden of dengue in 2010. We predict dengue to be ubiquitous throughout the tropics, with local spatial variations in risk influenced strongly by rainfall, temperature and the degree of urbanization. Using cartographic approaches, we estimate there to be 390 million (95% credible interval 284-528) dengue infections per year, of which 96 million (67-136) manifest apparently (any level of disease severity). This infection total is more than three times the dengue burden estimate of the World Health Organization. Stratification of our estimates by country allows comparison with national dengue reporting, after taking into account the probability of an apparent infection being formally reported. The most notable differences are discussed. These new risk maps and infection estimates provide novel insights into the global, regional and national public health burden imposed by dengue. We anticipate that they will provide a starting point for a wider discussion about the global impact of this disease and will help to guide improvements in disease control strategies using vaccine, drug and vector control methods, and in their economic evaluation.

A Two-Center Randomized Trial of an Additional Early Dose of Measles Vaccine: Effects on Mortality and Measles Antibody Levels.

Background: In addition to protecting against measles, measles vaccine (MV) may have beneficial nonspecific effects. We tested the effect of an additional early MV on mortality and measles antibody levels. Methods: Children aged 4-7 months at rural health and demographic surveillance sites in Burkina Faso and Guinea-Bissau were randomized 1:1 to an extra early standard dose of MV (Edmonston-Zagreb strain) or no extra MV 4 weeks after the third diphtheria-tetanus-pertussis-hepatitis B-Haemophilus influenzae type b vaccine. All children received routine MV at 9 months. We assessed mortality through home visits and compared mortality from enrollment to age 3 years using Cox proportional hazards models, censoring for subsequent nontrial MV. Subgroups of participants had blood sampled to assess measles antibody levels. Results: Among 8309 children enrolled from 18 July 2012 to 3 December 2015, we registered 145 deaths (mortality rate: 16/1000 person-years). The mortality was lower than anticipated and did not differ by randomization group (hazard ratio, 1.05; 95% confidence interval, 0.75-1.46). At enrollment, 4% (16/447) of children in Burkina Faso and 21% (90/422) in Guinea-Bissau had protective measles antibody levels. By age 9 months, no measles-unvaccinated/-unexposed child had protective levels, while 92% (306/333) of early MV recipients had protective levels. At final follow-up, 98% (186/189) in the early MV group and 97% (196/202) in the control group had protective levels. Conclusions: Early MV did not reduce all-cause mortality. Most children were susceptible to measles infection at age 4-7 months and responded with high antibody levels to early MV. Clinical Trials Registration: NCT01644721.

Local, national, and regional viral haemorrhagic fever pandemic potential in Africa: a multistage analysis.

BACKGROUND: Predicting when and where pathogens will emerge is difficult, yet, as shown by the recent Ebola and Zika epidemics, effective and timely responses are key. It is therefore crucial to transition from reactive to proactive responses for these pathogens. To better identify priorities for outbreak mitigation and prevention, we developed a cohesive framework combining disparate methods and data sources, and assessed subnational pandemic potential for four viral haemorrhagic fevers in Africa, Crimean-Congo haemorrhagic fever, Ebola virus disease, Lassa fever, and Marburg virus disease. METHODS: In this multistage analysis, we quantified three stages underlying the potential of widespread viral haemorrhagic fever epidemics. Environmental suitability maps were used to define stage 1, index-case potential, which assesses populations at risk of infection due to spillover from zoonotic hosts or vectors, identifying where index cases could present. Stage 2, outbreak potential, iterates upon an existing framework, the Index for Risk Management, to measure potential for secondary spread in people within specific communities. For stage 3, epidemic potential, we combined local and international scale connectivity assessments with stage 2 to evaluate possible spread of local outbreaks nationally, regionally, and internationally. FINDINGS: We found epidemic potential to vary within Africa, with regions where viral haemorrhagic fever outbreaks have previously occurred (eg, western Africa) and areas currently considered non-endemic (eg, Cameroon and Ethiopia) both ranking highly. Tracking transitions between stages showed how an index case can escalate into a widespread epidemic in the absence of intervention (eg, Nigeria and Guinea). Our analysis showed Chad, Somalia, and South Sudan to be highly susceptible to any outbreak at subnational levels. INTERPRETATION: Our analysis provides a unified assessment of potential epidemic trajectories, with the aim of allowing national and international agencies to pre-emptively evaluate needs and target resources. Within each country, our framework identifies at-risk subnational locations in which to improve surveillance, diagnostic capabilities, and health systems in parallel with the design of policies for optimal responses at each stage. In conjunction with pandemic preparedness activities, assessments such as ours can identify regions where needs and provisions do not align, and thus should be targeted for future strengthening and support. FUNDING: Paul G Allen Family Foundation, Bill & Melinda Gates Foundation, Wellcome Trust, UK Department for International Development.

Good collaborative practice: reforming capacity building governance of international health research partnerships.

In line with the policy objectives of the United Nations Sustainable Development Goals, this commentary seeks to examine the extent to which provisions of international health research guidance promote capacity building and equitable partnerships in global health research. Our evaluation finds that governance of collaborative research partnerships, and in particular capacity building, in resource-constrained settings is limited but has improved with the implementation guidance of the International Ethical Guidelines for Health-related Research Involving Humans by The Council for International Organizations of Medical Sciences (CIOMS) (2016). However, more clarity is needed in national legislation, industry and ethics guidelines, and regulatory provisions to address the structural inequities and power imbalances inherent in international health research partnerships. Most notably, ethical partnership governance is not supported by the principal industry ethics guidelines - the International Conference on Harmonization Technical Requirements for Registration of Pharmaceutical for Human Use (ICH) Good Clinical Practice (ICH-GCP). Given the strategic value of ICH-GCP guidelines in defining the role and responsibility of global health research partners, we conclude that such governance should stipulate the minimal requirements for creating an equitable environment of inclusion, mutual learning, transparency and accountability. Procedurally, this can be supported by i) shared research agenda setting with local leadership, ii) capacity assessments, and iii) construction of a memorandum of understanding (MoU). Moreover, the requirement of capacity building needs to be coordinated amongst partners to support good collaborative practice and deliver on the public health goals of the research enterprise; improving local conditions of health and reducing global health inequality. In this respect, and in order to develop consistency between sources of research governance, ICH-GCP should reference CIOMS ethical guidelines as the established standard for collaborative partnership. Moreover, greater commitment and support should be given to co-ordinate, strengthen and enforce local laws requiring equitable research partnerships and health system strengthening.

Informal workers' access to health care services: findings from a qualitative study in the Kassena-Nankana districts of Northern Ghana.

BACKGROUND: Over the past two decades, employment in the informal sector has grown rapidly in all regions including low and middle-income countries. In the developing countries, between 50 and 75% of workers are employed in the informal sector. In Ghana, more than 80% of the total working population is working in the informal sector. They are largely self-employed persons such as farmers, traders, food processors, artisans, craft-workers among others. The persistent problem in advancing efforts to address health vulnerabilities of informal workers is lack of systematic data. Therefore, this study explored factors affecting informal workers access to health care services in Northern Ghana. METHOD: The study used qualitative methodology where focus group discussions and in-depth interviews were conducted. Purposive sampling technique was used to select participants for the interviews. The interviews were transcribed and coded into emergent themes using Nvivo 10 software before thematic content analysis. RESULTS: Study participants held the view that factors such as poverty, time spent at the health facility seeking for health care, unpleasant attitude of health providers towards clients affected their access to health care services. They perceived that poor organization and operations of the current health system and poor health care services provided under the national health insurance scheme affected access to health care services according to study participants. However, sale of assets, family support, borrowed money from friends and occasional employer support were the copying strategies used by informal workers to finance their health care needs. CONCLUSION: Most of the population in Ghana are engaged in informal employment hence their contribution to the economy is very important. Therefore, efforts needed to be made by all stakeholders to address these challenges in order to help improve on access to health care services to all patients particularly the most vulnerable groups in society.

Defining Health Research for Development: The perspective of stakeholders from an international health research partnership in Ghana and Tanzania.

OBJECTIVES: The study uses a qualitative empirical method to define Health Research for Development. This project explores the perspectives of stakeholders in an international health research partnership operating in Ghana and Tanzania. METHODS: We conducted 52 key informant interviews with major stakeholders in an international multicenter partnership between GlaxoSmithKline (GSK, Vaccine Developer) and the global health nonprofit organisation PATH and its Malaria Vaccine Initiative program (PATH/MVI, Funder-Development Partner), (RTS, S) (NCT00866619). The respondents included teams from four clinical research centres (two centres in Ghana and two in Tanzania) and various collaborating partners. This paper analyses responses to the question: What is Health Research for Development? RESULTS: Based on the stakeholders' experience the respondents offered many ways of defining Health Research for Development. The responses fell into four broad themes: i) Equitable Partnerships; ii) System Sustainability; iii) Addressing Local Health Targets, and iv) Regional Commitment to Benefit Sharing. CONCLUSION: Through defining Health Research for Development six key learning points were generated from the four result themes: 1) Ensure there is local research leadership working with the collaborative partnership, and local healthcare system, to align the project agenda and activities with local research and health priorities; 2) Know the country-specific context - map the social, health, legislative and political setting; 3) Define an explicit development component and plan of action in a research project; 4) Address the barriers and opportunities to sustain system capacity. 5) Support decentralised health system decision-making to facilitate the translation pathway; 6) Govern, monitor and evaluate the development components of health research partnerships. Overall, equity and unity between partners are required to deliver health research for development.

Application of Ethical Principles to Research using Public Health Data in The Global South: Perspectives from Africa.

Existing ethics guidelines, influential literature and policies on ethical research generally focus on real-time data collection from humans. They enforce individual rights and liberties, thereby lowering need for aggregate protections. Although dependable, emerging public health research paradigms like research using public health data (RUPD) raise new challenges to their application. Unlike traditional research, RUPD is population-based, aligned to public health activities, and often reliant on pre-collected longitudinal data. These characteristics, when considered in relation to the generally lower protective ethico-legal frameworks of the Global South, including Africa, highlight ethical gaps. Health and demographic surveillance systems are examples of public health programs that accommodate RUPD in these contexts. We set out to explore the perspectives of professionals with a working knowledge of these systems to determine practical ways of appropriating the foundational principles of health research to advance the ever growing opportunities in RUPD. We present their perspectives and in relation to the literature and our ethical analysis, make context relevant recommendations. We further argue for the development of a framework founded on the discussions and recommendations as a minimum base for achieving optimal ethics for optimal RUPD in the Global South.

"You cannot collect data using your own resources and put It on open access": Perspectives from Africa about public health data-sharing.

Data-sharing is a desired default in the field of public health and a source of much ethical deliberation. Sharing data potentially contributes the largest, most efficient source of scientific data, but is fraught with contextual challenges which make stakeholders, particularly those in under-resourced contexts hesitant or slow to share. Relatively little empirical research has engaged stakeholders in discussing the issue. This study sought to explore relevant experiences, contextual, and subjective explanations around the topic to provide a rich and detailed presentation of what it means to different stakeholders and contexts to share data and how that can guide practice and ethical guidance. A qualitative design involving interviews was undertaken with professionals working in public health institutions endowed with data (HDSS), ethics committees, and advisory agencies which help shape health research in Africa. A descriptive form of thematic analysis was used to summarize results into six key themes: (1) The role of HDSSs in research using public health data and data-sharing; (2) Ownership and funding are critical factors influencing data-sharing; (3) Other factors discourage data-sharing; (4) Promoting and sustaining data-sharing; (5) Ethical guidance structures; and (6) Establishing effective guidance. The themes reveal factors regarding the willingness or not to share and an intricate ethical system that current discourse could reflect. Many of the concerns resonate with the literature, but a whole other gamut of people and process issues; commitments, investments, careers, and the right ethical guidance are needed to realize a sustainable goal of reaching 'share' as a default.

A systematic review and synthesis of the strengths and limitations of measuring malaria mortality through verbal autopsy.

BACKGROUND: Lack of valid and reliable data on malaria deaths continues to be a problem that plagues the global health community. To address this gap, the verbal autopsy (VA) method was developed to ascertain cause of death at the population level. Despite the adoption and wide use of VA, there are many recognized limitations of VA tools and methods, especially for measuring malaria mortality. This study synthesizes the strengths and limitations of existing VA tools and methods for measuring malaria mortality (MM) in low- and middle-income countries through a systematic literature review. METHODS: The authors searched PubMed, Cochrane Library, Popline, WHOLIS, Google Scholar, and INDEPTH Network Health and Demographic Surveillance System sites' websites from 1 January 1990 to 15 January 2016 for articles and reports on MM measurement through VA. INCLUSION CRITERIA: article presented results from a VA study where malaria was a cause of death; article discussed limitations/challenges related to measurement of MM through VA. Two authors independently searched the databases and websites and conducted a synthesis of articles using a standard matrix. RESULTS: The authors identified 828 publications; 88 were included in the final review. Most publications were VA studies; others were systematic reviews discussing VA tools or methods; editorials or commentaries; and studies using VA data to develop MM estimates. The main limitation were low sensitivity and specificity of VA tools for measuring MM. Other limitations included lack of standardized VA tools and methods, lack of a 'true' gold standard to assess accuracy of VA malaria mortality. CONCLUSIONS: Existing VA tools and methods for measuring MM have limitations. Given the need for data to measure progress toward the World Health Organization's Global Technical Strategy for Malaria 2016-2030 goals, the malaria community should define strategies for improving MM estimates, including exploring whether VA tools and methods could be further improved. Longer term strategies should focus on improving countries' vital registration systems for more robust and timely cause of death data.

Strengthening capacity to research the social determinants of health in low- and middle-income countries: lessons from the INTREC programme.

BACKGROUND: The INDEPTH Training & Research Centres of Excellence (INTREC) collaboration developed a training programme to strengthen social determinants of health (SDH) research in low- and middle-income countries (LMICs). It was piloted among health- and demographic researchers from 9 countries in Africa and Asia. The programme followed a blended learning approach and was split into three consecutive teaching blocks over a 12-month period: 1) an online course of 7 video lectures and assignments on the theory of SDH research; 2) a 2-week qualitative and quantitative methods workshop; and 3) a 1-week data analysis workshop. This report aims to summarise the student evaluations of the pilot and to suggest key lessons for future approaches to strengthen SDH research capacity in LMICs. METHODS: Semi-structured interviews and questionnaires with 24 students from 9 countries in Africa and Asia were used to evaluate each teaching block. Information was collected about the students' motivation and interest in studying SDH, any challenges they faced during the consecutive teaching blocks, and suggestions they had for future courses on SDH. RESULTS: Of the 24 students who began the programme, 13 (54%) completed all training activities. The students recognised the need for such a course and its potential to improve their skills as health researchers. The main challenges with the online course were time management, prior knowledge and skills required to participate in the course, and the need to get feedback from teaching staff throughout the learning process. All students found the face-to-face workshops to be of high quality and value for their work, because they offered an opportunity to clarify SDH concepts taught during the online course and to gain practical research skills. After the final teaching block, students felt they had improved their data analysis skills and were better able to develop research proposals, scientific manuscripts, and policy briefs. CONCLUSIONS: The INTREC programme has trained a promising cadre of health researchers who live and work in LMICs, which is an essential component of efforts to identify and reduce national and local level health inequities. Time management and technological issues were the greatest challenges, which can inform future attempts to strengthen research capacity on SDH.

Assessing the impoverishment effects of out-of-pocket healthcare payments prior to the uptake of the national health insurance scheme in Ghana.

BACKGROUND: There is a global concern regarding how households could be protected from relatively large healthcare payments which are a major limitation to accessing healthcare. Such payments also endanger the welfare of households with the potential of moving households into extreme impoverishment. This paper examines the impoverishing effects of out-of-pocket (OOP) healthcare payments in Ghana prior to the introduction of Ghana's national health insurance scheme. METHODS: Data come from the Ghana Living Standard Survey 5 (2005/2006). Two poverty lines ($1.25 and $2.50 per capita per day at the 2005 purchasing power parity) are used in assessing the impoverishing effects of OOP healthcare payments. We computed the poverty headcount, poverty gap, normalized poverty gap and normalized mean poverty gap indices using both poverty lines. We examine these indicators at a national level and disaggregated by urban/rural locations, across the three geographical zones, and across the ten administrative regions in Ghana. Also the Pen's parade of "dwarfs and a few giants" is used to illustrate the decreasing welfare effects of OOP healthcare payments in Ghana. RESULTS: There was a high incidence and intensity of impoverishment due to OOP healthcare payments in Ghana. These payments contributed to a relative increase in poverty headcount by 9.4 and 3.8% using the $1.25/day and $2.5/day poverty lines, respectively. The relative poverty gap index was estimated at 42.7 and 10.5% respectively for the lower and upper poverty lines. Relative normalized mean poverty gap was estimated at 30.5 and 6.4%, respectively, for the lower and upper poverty lines. The percentage increase in poverty associated with OOP healthcare payments in Ghana is highest among households in the middle zone with an absolute increase estimated at 2.3% compared to the coastal and northern zones. CONCLUSION: It is clear from the findings that without financial risk protection, households can be pushed into poverty due to OOP healthcare payments. Even relatively richer households are impoverished by OOP healthcare payments. This paper presents baseline indicators for evaluating the impact of Ghana's national health insurance scheme on impoverishment due to OOP healthcare payments.

Decreasing child mortality, spatial clustering and decreasing disparity in North-Western Burkina Faso.

Within relatively small areas, there exist high spatial variations of mortality between villages. In rural Burkina Faso, with data from 1993 to 1998, clusters of particularly high child mortality were identified in the population of the Nouna Health and Demographic Surveillance System (HDSS), a member of the INDEPTH Network. In this paper, we report child mortality with respect to temporal trends, spatial clustering and disparity in this HDSS from 1993 to 2012. Poisson regression was used to describe village-specific child mortality rates and time trends in mortality. The spatial scan statistic was used to identify villages or village clusters with higher child mortality. Clustering of mortality in the area is still present, but not as strong as before. The disparity of child mortality between villages has decreased. The decrease occurred in the context of an overall halving of child mortality in the rural area of Nouna HDSS between 1993 and 2012. Extrapolated to the Millennium Development Goals target period 1990-2015, this yields an estimated reduction of 54%, which is not too far off the aim of a two-thirds reduction.

Ethical issues in genomic research on the African continent: experiences and challenges to ethics review committees.

This is a report on a workshop titled 'Ethics for genomic research across five African countries: Guidelines, experiences and challenges', University of the Witwatersrand, Johannesburg, South Africa, 10 and 11 December 2012. The workshop was hosted by the Wits-INDEPTH partnership, AWI-Gen, as part of the H3Africa Consortium.