Historical Perspective of Arboviruses in Mozambique and Its Implication for Current and Future Epidemics.

Mozambique is a tropical country situated in the Southern part of Africa, a region where data on the burden and epidemiology of arbovirus is presently quite scarce although the frequency of outbreaks caused by arboviruses is rapidly increasing. Outbreaks of dengue fever have been reported in Mozambique, Angola and Tanzania and a recent unprecedented outbreak of Yellow fever has been recorded in Angola. These new outbreaks collectively suggest that arboviruses, and specifically flavivirus infections, are endemic in Mozambique.Although recent data on arbovirus activity is scarce, the work of Kokernot et al. [R.H. Kokernot, K.C. Smithburn, A.F. Gandara, B.M. Mc'Intosh and C.S. Heymann Anais Inst Med Trop (1960), 17:201-230] describes seroepidemiological and entomological studies carried out in several parts of Mozambique during the 1950s. Complementary seroepidemiological investigations on arboviruses that were conducted in the early 1980s also found serological evidence of several arboviruses which included Dengue, Chikungunya, Zika, Rift Valey Fever, Sinbdis virus, Wesselsbron, Bunyamwera, Pongola and Bawamba Fever and Yellow Fever.Notably the first description of Chikungunya virus in 1952-1953 in Tanzania also included reported cases in northern Mozambique. Furthermore, DENV serotype 3 was for the first time described in northern Mozambique in 1984 and 1985. Since several arboviral infections result in acute self limiting fever they have remained unsuspected for several decades. However, it is well known that during the 1980's intensive malaria control initiatives which included massive distribution of bed nets, community education and indoor and outdoor spraying campaigns were implemented. It is possible that these measures may have influenced the epidemiology of arboviruses. However, the impact of these interventions in controlling the spread of arboviruses is not known.In conclusion, the old literature on arboviruses in Mozambique is relevant for assessing the gaps and current risk of occurrence of these pathogens at the region, particularly in a time in which they are spreading worldwide.

The comprehensive 'Communicate to Vaccinate' taxonomy of communication interventions for childhood vaccination in routine and campaign contexts.

BACKGROUND: Communication can be used to generate demand for vaccination or address vaccine hesitancy, and is crucial to successful childhood vaccination programmes. Research efforts have primarily focused on communication for routine vaccination. However, vaccination campaigns, particularly in low- or middle-income countries (LMICs), also use communication in diverse ways. Without a comprehensive framework integrating communication interventions from routine and campaign contexts, it is not possible to conceptualise the full range of possible vaccination communication interventions. Therefore, vaccine programme managers may be unaware of potential communication options and researchers may not focus on building evidence for interventions used in practice. In this paper, we broaden the scope of our existing taxonomy of communication interventions for routine vaccination to include communication used in campaigns, and integrate these into a comprehensive taxonomy of vaccination communication interventions. METHODS: Building on our taxonomy of communication for routine vaccination, we identified communication interventions used in vaccination campaigns through a targeted literature search; observation of vaccination activities in Cameroon, Mozambique and Nigeria; and stakeholder consultations. We added these interventions to descriptions of routine vaccination communication and categorised the interventions according to their intended purposes, building from an earlier taxonomy of communication related to routine vaccination. RESULTS: The comprehensive taxonomy groups communication used in campaigns and routine childhood vaccination into seven purpose categories: 'Inform or Educate'; 'Remind or Recall'; 'Enhance Community Ownership'; 'Teach Skills'; 'Provide Support'; 'Facilitate Decision Making' and 'Enable Communication'. Consultations with LMIC stakeholders and experts informed the taxonomy's definitions and structure and established its potential uses. CONCLUSIONS: This taxonomy provides a standardised way to think and speak about vaccination communication. It is categorised by purpose to help conceptualise communication interventions as potential solutions to address needs or problems. It can be utilised by programme planners, implementers, researchers and funders to see the range of communication interventions used in practice, facilitate evidence synthesis and identify evidence gaps.

Factors affecting the implementation of childhood vaccination communication strategies in Nigeria: a qualitative study.

BACKGROUND: The role of health communication in vaccination programmes cannot be overemphasized: it has contributed significantly to creating and sustaining demand for vaccination services and improving vaccination coverage. In Nigeria, numerous communication approaches have been deployed but these interventions are not without challenges. We therefore aimed to explore factors affecting the delivery of vaccination communication in Nigeria. METHODS: We used a qualitative approach and conducted the study in two states: Bauchi and Cross River States in northern and southern Nigeria respectively. We identified factors affecting the implementation of communication interventions through interviews with relevant stakeholders involved in vaccination communication in the health services. We also reviewed relevant documents. Data generated were transcribed verbatim and analysed using thematic analysis. RESULTS: We used the SURE framework to organise the identified factors (barriers and facilitators) affecting vaccination communication delivery. We then grouped these into health systems and community level factors. Some of the commonly reported health system barriers amongst stakeholders interviewed included: funding constraints, human resource factors (health worker shortages, training deficiencies, poor attitude of health workers and vaccination teams), inadequate infrastructure and equipment and weak political will. Community level factors included the attitudes of community stakeholders and of parents and caregivers. We also identified factors that appeared to facilitate communication activities. These included political support, engagement of traditional and religious institutions and the use of organised communication committees. CONCLUSIONS: Communication activities are a crucial element of immunization programmes. It is therefore important for policy makers and programme managers to understand the barriers and facilitators affecting the delivery of vaccination communication so as to be able to implement communication interventions more effectively.

Adherence in a pragmatic randomized controlled trial on prophylactic iron supplementation during pregnancy in Maputo, Mozambique.

OBJECTIVE: Assessing the level of adherence and its determinants is important in appraising the overall effectiveness of trials. The present study aimed to evaluate the extent of adherence and its determinants in a pragmatic randomized controlled trial of Fe prophylaxis during pregnancy in Maputo, Mozambique. DESIGN: A pragmatic randomized controlled trial. SETTING: Two health centres (1° de Maio and Machava) in Maputo, Mozambique. SUBJECTS: Pregnant women (≥12 weeks' gestation, ≥18 years old, non-high-risk pregnancy; n 4326) attending prenatal care consultations at two health centres were randomized to receive routine Fe (n 2184; 60 mg ferrous sulfate plus 400 µg folic acid daily throughout pregnancy) or selective Fe (n 2142; screening and treatment for anaemia and daily intake of 1 mg folic acid). RESULTS: The level of adherence was 79% for having two or more visits, 53% for adequate prenatal care and 67% for complete intake of Fe/folic acid tablets during the trial. The correlation between the adherence measures ranged between 0·151 and 0·739. Adherence did not differ by trial arm, but there were centre differences in adequate prenatal visits and intake of tablets. Older women (>20 years) and those with a history of abortion were more likely to achieve greater adherence, whereas an increased number of previous births decreased the likelihood of adherence. HIV positivity decreased the likelihood of adherence in one trial centre and increased it in the other. CONCLUSIONS: The variation in adherence by trial centre, women's characteristics and outcome measures suggests that adherence in trials fully depends on participants' behaviour and can be increased by paying attention to contextual factors.

Mapping how information about childhood vaccination is communicated in two regions of Cameroon: What is done and where are the gaps?

BACKGROUND: The 'Communicate to vaccinate' (COMMVAC) project builds research evidence for improving communication with parents and communities about childhood vaccinations in low- and middle-income countries. Understanding and mapping the range of vaccination communication strategies used in different settings is an important component of this work. In this part of the COMMVAC project, our objectives were: (1) to identify the vaccination communication interventions used in two regions of Cameroon; (2) to apply the COMMVAC taxonomy, a global taxonomy of vaccination communication interventions, to these communication interventions to help us classify these interventions, including their purposes and target audiences; and identify whether gaps in purpose or target audiences exist; (3) to assess the COMMVAC taxonomy as a research tool for data collection and analysis. METHODS: We used the following qualitative methods to identify communication strategies in the Central and North West Regions of Cameroon in the first half of 2014: interviews with program managers, non-governmental organizations, vaccinators, parents and community members; observations and informal conversations during routine immunization clinics and three rounds of the National Polio Immunization Campaign; and document analysis of reports and mass media communications about vaccination. A survey of parents and caregivers was also done. We organised the strategies using the COMMVAC taxonomy and produced a map of Cameroon-specific interventions, which we presented to local stakeholders for feedback. RESULTS: Our map of the interventions used in Cameroon suggests that most childhood vaccination communication interventions focus on national campaigns against polio rather than routine immunisation. The map also indicates that most communication interventions target communities more broadly, rather than parents, and that very few interventions target health workers. The majority of the communication interventions aimed to inform or educate or remind or recall members of the community about vaccination. The COMMVAC taxonomy provided a useful framework for quickly and simply mapping existing vaccination communication strategies. CONCLUSIONS: By identifying the interventions used in Cameroon and developing an intervention map, we allowed stakeholders to see where they were concentrating their communication efforts and where gaps exist, allowing them to reflect on whether changes are needed to the communication strategies they are using.

A pragmatic randomised controlled trial on routine iron prophylaxis during pregnancy in Maputo, Mozambique (PROFEG): rationale, design, and success.

The effects of prophylactic iron during pregnancy on maternal and child health in developing settings with endemic malaria and high prevalence of HIV remain unclear. This paper describes the rationale, implementation and success of a pragmatic randomised controlled trial comparing routine iron supplementation vs. screening and treatment for anaemia during pregnancy. The setting was two health centres in Maputo, Mozambique. Pregnant women (≥ 12-week gestation; ≥ 18 years old; and not with a high-risk pregnancy, n=4326) were recruited. The main outcomes are preterm delivery and low birthweight. The women were randomly assigned to one of two iron administration policies: a routine iron group (n=2184) received 60 mg of ferrous sulphate plus 400 µg of folic acid daily while a selective iron group (n=2142) had screening and treatment for anaemia and a daily intake of 1 mg of folic acid. The recruitment, follow-up, and collection of follow-up data were successful; both groups were similar to each other in all the trial stages. Collection of delivery data was challenging and data on about 40% of births is missing. These are currently being traced through different hospitals and health centres. The compliance of the study personnel and the women with regard to regular measurement of haemoglobin and intake of the iron and folic acid tablets was high and similar in both trial arms. Taking into account the various constraints encountered, the stages of the present trial prior to delivery were carried out well.

Policy challenges facing integrated community case management in Sub-Saharan Africa.

OBJECTIVE: To report an in-depth analysis of policy change for integrated community case management of childhood illness (iCCM) in six sub-Saharan African countries. We analysed how iCCM policies developed and the barriers and facilitators to policy change. METHODS: Qualitative retrospective case studies drawing from document reviews, semi-structured interviews and in-country validation workshops were conducted in Burkina Faso, Kenya, Malawi, Mali, Mozambique and Niger. These countries were selected to maximise variation in iCCM policy status, community health worker (CHW) models and different African regions. RESULTS: Country iCCM policies evolved in an ad hoc fashion, but were substantially influenced by the history of primary health care and the nature of CHW programmes. Technical officers within Ministries of Health led iCCM policy change with support from international donors, but neither communities nor political leadership was mobilised. Concerns about achieving the Millennium Development Goals, together with recognition of the shortcomings of existing child health programmes, led to the adoption of iCCM policies. Availability of external financing played a critical role in facilitating policy change. CONCLUSIONS: iCCM policy change has been promoted by international agencies, but national governments have struggled to align iCCM with country health systems. Greater investment is needed in tailoring global policy initiatives to match country needs. High-level, political ownership of iCCM policies could facilitate policy change, as could clearer strategies for ensuring the long-term sustainability of such policies.

Cassava.

Gleadow et al. introduce the food crop cassava.

Lay health worker attrition: important but often ignored.

Lay health workers are key to achieving universal health-care coverage, therefore measuring worker attrition and identifying its determinants should be an integral part of any lay health worker programme. Both published and unpublished research on lay health workers has largely focused on the types of interventions they can deliver effectively. This is an imperative since the main objective of these programmes is to improve health outcomes. However, high attrition rates can undermine the effectiveness of these programmes. There is a lack of research on lay health worker attrition. Research that aims to answer the following three key questions would help address this knowledge gap: what is the magnitude of attrition in programmes? What are the determinants of attrition? What are the most successful ways of reducing attrition? With community-based interventions and task shifting high on the United Nations Millennium Development Goals' policy agenda, research on lay health worker attrition and its determinants requires urgent attention.

Konzo risk factors, determinants and etiopathogenesis: What is new? A systematic review.

Konzo is a toxico-nutritional upper motor neuron disease causing a spastic paraparesis in schoolchildren and childbearing women in some African countries. Almost a century since the first description of konzo, its underlying etiopathogenic mechanisms and causative agent remain unknown. This paper aims at refreshing the current knowledge of konzo determinants and pathogenesis in order to enlighten potential new research and management perspectives. Literature research was performed in PubMed and Web of Science databases according to the PRISMA methodology. Available data show that cassava-derived cyanide poisoning and protein malnutrition constitute two well-documented risk factors of konzo. However, observational studies have failed to demonstrate the causal relationship between konzo and cyanide poisoning. Thiocyanate, the current marker of choice of cyanide exposure, may underestimate the actual level of cyanide poisoning in konzo patients as a larger amount of cyanide is detoxified via other unusual pathways in the context of protein malnutrition characterizing these patients. Furthermore, the appearance of konzo may be the consequence of the interplay of several factors including cyanide metabolites, nutritional deficiencies, psycho-emotional and geo-environmental factors, resulting in pathophysiologic phenomena such as excitotoxicity or oxidative stress, responsible for neuronal damage that takes place at sparse cellular and/or subcellular levels.

Translating research into policy: lessons learned from eclampsia treatment and malaria control in three southern African countries.

BACKGROUND: Little is known about the process of knowledge translation in low- and middle-income countries. We studied policymaking processes in Mozambique, South Africa and Zimbabwe to understand the factors affecting the use of research evidence in national policy development, with a particular focus on the findings from randomized control trials (RCTs). We examined two cases: the use of magnesium sulphate (MgSO(4)) in the treatment of eclampsia in pregnancy (a clinical case); and the use of insecticide treated bed nets and indoor residual household spraying for malaria vector control (a public health case). METHODS: We used a qualitative case-study methodology to explore the policy making process. We carried out key informants interviews with a range of research and policy stakeholders in each country, reviewed documents and developed timelines of key events. Using an iterative approach, we undertook a thematic analysis of the data. FINDINGS: Prior experience of particular interventions, local champions, stakeholders and international networks, and the involvement of researchers in policy development were important in knowledge translation for both case studies. Key differences across the two case studies included the nature of the evidence, with clear evidence of efficacy for MgSO(4 )and ongoing debate regarding the efficacy of bed nets compared with spraying; local researcher involvement in international evidence production, which was stronger for MgSO(4 )than for malaria vector control; and a long-standing culture of evidence-based health care within obstetrics. Other differences were the importance of bureaucratic processes for clinical regulatory approval of MgSO(4), and regional networks and political interests for malaria control. In contrast to treatment policies for eclampsia, a diverse group of stakeholders with varied interests, differing in their use and interpretation of evidence, was involved in malaria policy decisions in the three countries. CONCLUSION: Translating research knowledge into policy is a complex and context sensitive process. Researchers aiming to enhance knowledge translation need to be aware of factors influencing the demand for different types of research; interact and work closely with key policy stakeholders, networks and local champions; and acknowledge the roles of important interest groups.

Knowledge, attitudes and practices regarding antibiotic use in Maputo City, Mozambique.

BACKGROUND: Irrational use of antibiotics is a major driver of antimicrobial resistance (AMR) worldwide. Sub-Saharan Africa, where the risk of spread of AMR is highest, lacks data on the knowledge, attitudes and practices regarding antibiotic prescription and use. This is the first study in Mozambique to address this gap. METHODS: A cross-sectional study was conducted in 2016 in 1091 adults (age ≥18 years) living in five districts in peri-urban areas of Maputo City. Three stage cluster sampling was used to select the households. A semi-structured questionnaire was used to collect information on the knowledge, attitudes and practices regarding antibiotics and their use and socio-demographic data. RESULTS: Of the 1091 participants, 20.9% (228/1091) had used non-prescribed antibiotics. Most of the non-prescribed antibiotics were purchased in pharmacies (199/228; 87.3%). The proportion of use of non-prescribed antibiotics was higher in those who purchased from informal markets (82.6%; 14/17) and home stores (66.7%; 12/18), compared to pharmacies (24.6%; 199/810) (p = 0.000). Variables significantly associated with use of non-prescribed antibiotics were male gender (p = 0.004), living in the Central A (p<0.001), Aeroporto B (p<0.001) or 25 de Junho (p<0.001) neighborhoods, purchase of antibiotics in informal markets (p<0.002) or obtaining from home stores (p = 0.026), not completing the course (p<0.001) and having poor knowledge on the use of antibiotics (p<0.001). Main reasons for use of non-prescribed antibiotics were a perception that there was no need to attend a health facility (26.8%), followed by someone else's advice (7.7%), symptoms similar to a previous episode (6.2%) and poor quality of care in health facilities (6.7%). CONCLUSIONS: Our study shows for the first time that knowledge regarding antibiotics is poor in Maputo City. Purchase of non-prescribed antibiotics is a common practice and most are sold in pharmacies, indicating deficient inspection. Interventions to reinforce adherence by pharmacies to current legislation for dispensing antibiotics, combined with community education are urgently needed.

Identification of preliminary core outcome domains for communication about childhood vaccination: An online Delphi survey.

BACKGROUND: Communication interventions for childhood vaccination are promising strategies to address vaccine hesitancy, but current research is limited by the outcomes measured. Most studies measure only vaccination-related outcomes, with minimal consideration of vaccine hesitancy-relevant intermediate outcomes. This impedes understanding of which interventions or elements are effective. It is also unknown which outcomes are important to the range of stakeholders affected by vaccine hesitancy. Outcome selection shapes the evidence base, informing future interventions and trials, and should reflect stakeholder priorities. Therefore, our aim was to identify which outcome domains (i.e. broad outcome categories) are most important to different stakeholders, identifying preliminary core outcome domains to inform evaluation of three common vaccination communication types: (i) communication to inform or educate, (ii) remind or recall, and (iii) enhance community ownership. METHODS: We conducted a two-stage online Delphi survey, involving four stakeholder groups: parents or community members, healthcare providers, researchers, and government or non-governmental organisation representatives. Participants rated the importance of eight outcome domains for each of the three communication types. They also rated specific outcomes within one domain ("attitudes or beliefs") and provided feedback about the survey. RESULTS: Collectively, stakeholder groups prioritised outcome domains differently when considering the effects of different communication types. For communication that aims to (i) inform or educate, the most important outcome domain is "knowledge or understanding"; for (ii) reminder communication, "vaccination status and behaviours"; and for (iii) community engagement communication, "community participation". All stakeholder groups rated most outcome domains as very important or critical. The highest rated specific outcome within the "attitudes or beliefs" domain was "trust". CONCLUSION: This Delphi survey expands the field of core outcomes research and identifies preliminary core outcome domains for measuring the effects of communication about childhood vaccination. The findings support the argument that vaccination communication is not a single homogenous intervention - it has a range of purposes, and vaccination communication evaluators should select outcomes accordingly.

Epidemiology, clinical features and risk factors for human rabies and animal bites during an outbreak of rabies in Maputo and Matola cities, Mozambique, 2014: Implications for public health interventions for rabies control.

BACKGROUND: In Mozambique, the majority of rabies outbreaks are unreported and data on the epidemiological features of human rabies and animal bites are scarce. An outbreak of human rabies in adjacent Maputo and Matola cities in 2014 prompted us to investigate the epidemiology, clinical features and risk factors of human rabies and animal bites in the two cities. METHODOLOGY/PRINCIPAL FINDINGS: We reviewed cases of human rabies and animal bites from April to July 2014, and carried out a community investigation in July and August in the neighborhoods where cases of human rabies resided. This investigation included collection of clinical, demographic and epidemiological information and a case control study to investigate the risk factors associated with human rabies. Fourteen cases of human rabies were detected in Maputo (n = 10) and Matola (n = 3) cities and neighbouring Boane district (n = 1) between April and August 2014, all of whom had been admitted to hospital. All had a recent history of dog bite. Of the 14 rabid dogs, only one had been immunized. 819 cases of animal bites were registered, of which 64.6% (529/819) were from Maputo City. Dogs were responsible for 97.8% (801/819) of all animal bites, but only 27.0% (126/467) were immunized. Factors significantly associated with human rabies were: age <15 years (p = 0.05), bite by stray dog (p = 0.002), deep wound (p = 0.02), bite in the head (p = 0.001), bite by unimmunized dog (p = 0.01), no use of soap and water (p = 0.001), and no post-exposure prophylaxis (p = 0.01). CONCLUSIONS/SIGNIFICANCE: Implementation of control measures for rabies is poor in Maputo and Matola cities, where cases of human rabies were strongly associated with bites by stray and unvaccinated dogs and irregular implementation of post-exposure measures.

Causes of death among women aged 17-49 years between 2007 and 2010 in Maputo, Mozambique.

OBJECTIVES: To describe causes of death among young women and estimate the role of HIV/AIDS as a cause in Maputo City, based on the civil death register. METHODS: Death data of 17-49 year-old women were abstracted from January 2007-March 2010 from the civil death register in Maputo City, registering overall about 15 000 deaths per-year. Causes of death in the register were either based on physicians' diagnoses on death certificates or determined by asking questions to deceased relatives. Causes of death were written in Portuguese; we translated them into English and classified them into 106 codes using ICD-9; these codes were then categorized into 10 groups. Estimated populations from the 2007 census were used to calculate annual mortality rates. An earlier study was used to compare deaths in 2001. FINDINGS: A total of 9640 deaths (6510 for residents of Maputo City) were registered and 77% had a specified cause of death reported. HIV-deaths represented 36% of all deaths and 40% among 25-39 year-olds. The death rate did not increase linearly by age, as there was a peak among women aged 30-34 years. The overall annual death rate was 6.7 deaths per 1000 population, with a notable decline by year. Death rates for HIV slightly declined by year. HIV-deaths explained most of the peak in death rate among 30-34-year-olds. The share of HIV-deaths among all deaths increased from 18% in 2001 to 35% in 2007-2010. Sixty-eight percent of all and 92% of HIV-related deaths occurred in hospital, with no increase over time. CONCLUSIONS: Routine death register was useful to study death rates, distribution of deaths, and change over time in the urban setting of Maputo during late 2000s. Over time, the death rate among 17-49 years old women seemed to have declined, but the relative contribution of HIV increased.

An epidemic of spastic paraparesis of unknown aetiology in Northern Mozambique.

This case study is based on a real-life outbreak investigation undertaken in Mozambique in 1981. This case study describes and promotes one particular approach to unknown disease outbreak investigation. Investigational procedures, however, may vary depending on location and outbreak. It is anticipated that the epidemiologist investigating an unknown disease outbreak will work within the framework of a "multidisciplinary investigation team". It is through the collaborative efforts of this team, with each member playing a critical role, that outbreak investigations are successfully completed. Some aspects of the original outbreak and investigation have, however, been altered to assist in meeting the desired teaching objectives and to allow completion of the case study in less than 3 hours.

Severe Chikungunya infection in Northern Mozambique: a case report.

BACKGROUND: Although Chikungunya virus has rapidly expanded to several countries in sub-Saharan Africa, little attention has been paid to its control and management. Until recently, Chikungunya has been regarded as a benign and self-limiting disease. In this report we describe the first case of severe Chikungunya disease in an adult patient in Pemba, Mozambique. CASE PRESENTATION: A previously healthy 40 year old male of Makonde ethnicity with no known past medical history and resident in Pemba for the past 11 years presented with a severe febrile illness. Despite administration of broad spectrum intravenous antibiotics the patient rapidly deteriorated and became comatose while developing anaemia, thrombocytopenia and later, melaena. Laboratory testing revealed IgM antibodies against Chikungunya virus. Malaria tests were consistently negative. CONCLUSIONS: This report suggests that Chikungunya might cause unsuspected severe disease in febrile patients in Mozambique and provides insights for the improvement of national protocols for management of febrile patients in Mozambique. We recommend that clinicians should consider Chikungunya in the differential diagnosis of febrile illness in locations where Aedes aegypti mosquitos are abundant.

Using the COMMVAC taxonomy to map vaccination communication interventions in Mozambique.

BACKGROUND: Improved communication about childhood vaccination is fundamental to increasing vaccine uptake in low-income countries. Mozambique, with 64% of children fully vaccinated, uses a range of communication interventions to promote uptake of childhood immunisation. OBJECTIVES: Using a taxonomy developed by the 'Communicate to Vaccinate' (COMMVAC) project, the study aims to identify and classify the existing communication interventions for vaccination in Mozambique and to find the gaps. METHODS: We used a qualitative research approach to identify the range of communication interventions used in Mozambique. In-depth semi-structured interviews were carried out with key purposively selected personnel at national level and relevant documents were collected and analysed. These data were complemented with observations of communication during routine vaccination and campaigns in Nampula province. We used the COMMVAC taxonomy, which organises vaccination communication intervention according to its intended purpose and the population targeted, to map both routine and campaign interventions. RESULTS: We identified interventions used in campaign and routine vaccination, or in both, fitting five of the seven taxonomy purposes, with informing or educating community members predominating. We did not identify any interventions that aimed to provide support or facilitate decision-making. There were interventions for all main target groups, although fewer for health providers. Overlap occurred: for example, interventions often targeted both parents and community members. CONCLUSIONS: We consider that the predominant focus on informing and educating community members is appropriate in the Mozambican context, where there is a high level of illiteracy and poor knowledge of the reasons for vaccination. We recommend increasing interventions for health providers, in particular training them in better communication for vaccination. The taxonomy was useful for identifying gaps, but needs to be more user-friendly if it is to be employed as a tool by health service managers.

Stakeholder perceptions of communication about vaccination in two regions of Cameroon: A qualitative case study.

BACKGROUND: Understanding stakeholders' (parents', communities' and health workers') perspectives of communication about childhood vaccination, including their preferences for its format, delivery and content, is an important step towards designing better communication strategies and ensuring more informed parents. Our objectives were to explore stakeholders' views, experiences and preferences for childhood vaccination communication in Cameroon. METHODS: In 2014, in the Central and North West Regions of Cameron, we gathered qualitative data for our case study using the following methods: semi structured interviews; observations and informal conversations during routine immunization clinics and three rounds of the National Polio Immunization Campaign; document analysis of reports and mass media communications about vaccination; and a survey of parents. We conducted a thematic analysis of the qualitative data to identify themes relating to views, experiences and perceptions of vaccination information and its delivery. Survey data were analysed using simple descriptive statistics. RESULTS: All of the parents interviewed felt that vaccinating their child was important, and trusted the information provided by health workers. However, many parents wanted more information. Parents did not always feel that they could ask questions during vaccination appointments. All participants felt that health workers and vaccination clinics were important sources of information. Social mobilisation activities such as door-to-door visits and announcements during religious services were important and accepted ways of communicating information, especially during vaccination campaigns. Information communicated through mass media and text messages was also seen as important. In general, stakeholders believed that more consistent messaging about routine vaccination through community channels would be helpful to remind parents of the importance of routine vaccination during ongoing rounds of vaccination campaigns against polio. CONCLUSIONS: This study confirms that parents regard information about childhood vaccination as important, but that health services need to be organized in ways that prioritize and facilitate communication, particularly about routine vaccination.

Childhood vaccination communication outcomes unpacked and organized in a taxonomy to facilitate core outcome establishment.

OBJECTIVES: We present a comprehensive taxonomy of outcomes for childhood vaccination communication interventions. Adding to our earlier map of trial outcomes, we aimed to (1) identify relevant outcomes not measured in trials, (2) identify outcomes from stakeholder focus groups, and (3) organize outcomes into a taxonomy. STUDY DESIGN AND SETTING: We identified additional outcomes from nonvaccination health communication literature and through parent and health care professional focus groups. We organized outcomes into the taxonomy through iterative discussion and informed by organizational principles established by leaders in core outcome research. RESULTS: The taxonomy includes three overarching core areas, divided into eight domains and then into outcomes. Core area one is psychosocial impact, including the domains "knowledge or understanding," "attitudes or beliefs," and "decision-making." Core area two is health impact, covering "vaccination status and behaviors" and "health status and well-being." Core area three is community, social, or health system impact, containing "intervention design and implementation," "community participation," and "resource use." CONCLUSION: To our knowledge, this taxonomy is the first attempt to conceptualize the range of potential outcomes for vaccination communication. It can be used by researchers selecting outcomes for complex communication interventions. We will also present the taxonomy to stakeholders to establish core outcome domains.