LLIN evaluation in Uganda project (LLINEUP2): association between housing construction and malaria burden in 32 districts.

BACKGROUND: Well-built housing limits mosquito entry and can reduce malaria transmission. The association between community-level housing and malaria burden in Uganda was assessed using data from randomly selected households near 64 health facilities in 32 districts. METHODS: Houses were classified as 'improved' (synthetic walls and roofs, eaves closed or absent) or 'less-improved' (all other construction). Associations between housing and parasitaemia were made using mixed effects logistic regression (individual-level) and multivariable fractional response logistic regression (community-level), and between housing and malaria incidence using multivariable Poisson regression. RESULTS: Between November 2021 and March 2022, 4.893 children aged 2-10 years were enrolled from 3.518 houses; of these, 1.389 (39.5%) were classified as improved. Children living in improved houses had 58% lower odds (adjusted odds ratio = 0.42, 95% CI 0.33-0.53, p < 0.0001) of parasitaemia than children living in less-improved houses. Communities with > 67% of houses improved had a 63% lower parasite prevalence (adjusted prevalence ratio 0.37, 95% CI 0.19-0.70, p < 0.0021) and 60% lower malaria incidence (adjusted incidence rate ratio 0.40, 95% CI 0.36-0.44, p < 0.0001) compared to communities with < 39% of houses improved. CONCLUSIONS: Improved housing was strongly associated with lower malaria burden across a range of settings in Uganda and should be utilized for malaria control.

Drought, HIV Testing, and HIV Transmission Risk Behaviors: A Population-Based Study in 10 High HIV Prevalence Countries in Sub-Saharan Africa.

Droughts are associated with poor health outcomes and disruption of public health programming. Data on the association between drought and HIV testing and transmission risk behaviors are limited. We combined data from Demographic and Health Surveys from 10 high HIV prevalence sub-Saharan African countries with a high-resolution measure of drought. We estimated the association between drought and recent HIV testing, report of condomless sex, and number of sexual partners in the last year. Respondents exposed to drought were less likely to have an HIV test and more likely to have condomless sex, although effect sizes were small. We found evidence for effect modification by sex and age for the association between drought and HIV testing, such that the negative association between drought and HIV testing was strongest among men (marginal risk ratio [mRR] 0.92, 95% CI 0.89-0.95) and adolescents (mRR 0.90, 95% CI 0.86-0.93). Drought may hinder HIV testing programs in countries with high HIV prevalence.

Do precipitation anomalies influence short-term mobility in sub-saharan Africa? An observational study from 23 countries.

BACKGROUND: Precipitation anomalies are associated with a number of poor health outcomes. One potential consequence of precipitation extremes is human geographic mobility. We evaluated the associations between precipitation anomalies (droughts and heavy rains) and short-term mobility in 23 sub-Saharan African countries by linking satellite data on precipitation to cross-sectional representative surveys. METHODS: Using data from 23 Demographic and Health Surveys from 2011 to 2017, we estimated the associations between deviations in long-term rainfall trends and short-term mobility among 294,539 women and 136,415 men over 15 years of age. We fit multivariable logistic regression models to assess potential non-linear relationships between rainfall deviations and short-term mobility, adjusting for survey month and socio-demographic covariates, and stratified by participant gender. Furthermore, we assessed whether these associations differed by marital status. RESULTS: Rainfall deviations were associated with short-term mobility among women, but not men. The relationship between rainfall deviations and mobility among women was U-shaped, such that women had increased marginal probabilities of mobility in instances of both lower and heavier precipitation. Differences between married and unmarried women were also revealed: among married women, we found positive associations between both rainfall deviation extremes (drought and heavy rains) and mobility; however, among unmarried women, there was only a positive association for heavy rains. CONCLUSION: Precipitation anomalies were associated with short-term mobility among women, which may be in turn associated with poor health outcomes. More research with longitudinal data is needed to elaborate the associations between weather shocks, mobility, and downstream health impacts.

Gender difference in the incidence of malaria diagnosed at public health facilities in Uganda.

BACKGROUND: Routine malaria surveillance data in Africa primarily come from public health facilities reporting to national health management information systems. Although information on gender is routinely collected from patients presenting to these health facilities, stratification of malaria surveillance data by gender is rarely done. This study evaluated gender difference among patients diagnosed with parasitological confirmed malaria at public health facilities in Uganda. METHODS: This study utilized individual level patient data collected from January 2020 through April 2021 at 12 public health facilities in Uganda and cross-sectional surveys conducted in target areas around these facilities in April 2021. Associations between gender and the incidence of malaria and non-malarial visits captured at the health facilities from patients residing within the target areas were estimated using poisson regression models controlling for seasonality. Associations between gender and data on health-seeking behaviour from the cross-sectional surveys were estimated using poisson regression models controlling for seasonality. RESULTS: Overall, incidence of malaria diagnosed per 1000 person years was 735 among females and 449 among males (IRR = 1.72, 95% CI 1.68-1.77, p < 0.001), with larger differences among those 15-39 years (IRR = 2.46, 95% CI 2.34-2.58, p < 0.001) and over 39 years (IRR = 2.26, 95% CI 2.05-2.50, p < 0.001) compared to those under 15 years (IRR = 1.46, 95% CI 1.41-1.50, p < 0.001). Female gender was also associated with a higher incidence of visits where malaria was not suspected (IRR = 1.77, 95% CI 1.71-1.83, p < 0.001), with a similar pattern across age strata. These associations were consistent across the 12 individual health centres. From the cross-sectional surveys, females were more likely than males to report fever in the past 2 weeks and seek care at the local health centre (7.5% vs. 4.7%, p = 0.001) with these associations significant for those 15-39 years (RR = 2.49, 95% CI 1.17-5.31, p = 0.018) and over 39 years (RR = 2.56, 95% CI 1.00-6.54, p = 0.049). CONCLUSIONS: Females disproportionately contribute to the burden of malaria diagnosed at public health facilities in Uganda, especially once they reach childbearing age. Contributing factors included more frequent visits to these facilities independent of malaria and a higher reported risk of seeking care at these facilities for febrile illnesses.

Drought and migration: An analysis of the effects of drought on temporary labor and return migration from a migrant-sending area in Nepal.

Although the relationship between drought - a dimension of climate change - and migration has been explored in a number of settings, prior research has largely focused on out-migration and has not considered climate factors at the migrant destination. However, drought may impact not only out-migration, but also return migration, particularly in settings where temporary labor migration and agricultural reliance are common. Thus, considering drought conditions at origin and destinations is necessary to specify the effects of climate on migrant-sending populations. Using detailed data from the Chitwan Valley Family Study, a household panel study in a migrant-sending area in Nepal, we analyze the effect of drought at the neighborhood level on individual-level out-migration and drought at the origin district on return migration among adults from 2011 to 2017, assessing these associations among males and females separately. In mixed-effect discrete-time regressions, we find that neighborhood drought is positively associated with out-migration and return migration, both internally and internationally among males. Among females, drought is positively associated with internal out-migration and return migration, but not international migrations. We did not find an association between drought at the origin and return migration independent of drought status at the destination. Taken together, these findings contribute to our understanding of the complexity of the impacts of precipitation anomalies on population movement over time.

Drought and child vaccination coverage in 22 countries in sub-Saharan Africa: A retrospective analysis of national survey data from 2011 to 2019.

BACKGROUND: 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.

Relationships between test positivity rate, total laboratory confirmed cases of malaria, and malaria incidence in high burden settings of Uganda: an ecological analysis.

BACKGROUND: Malaria surveillance is critical for monitoring changes in malaria morbidity over time. National Malaria Control Programmes often rely on surrogate measures of malaria incidence, including the test positivity rate (TPR) and total laboratory confirmed cases of malaria (TCM), to monitor trends in malaria morbidity. However, there are limited data on the accuracy of TPR and TCM for predicting temporal changes in malaria incidence, especially in high burden settings. METHODS: This study leveraged data from 5 malaria reference centres (MRCs) located in high burden settings over a 15-month period from November 2018 through January 2020 as part of an enhanced health facility-based surveillance system established in Uganda. Individual level data were collected from all outpatients including demographics, laboratory test results, and village of residence. Estimates of malaria incidence were derived from catchment areas around the MRCs. Temporal relationships between monthly aggregate measures of TPR and TCM relative to estimates of malaria incidence were examined using linear and exponential regression models. RESULTS: A total of 149,739 outpatient visits to the 5 MRCs were recorded. Overall, malaria was suspected in 73.4% of visits, 99.1% of patients with suspected malaria received a diagnostic test, and 69.7% of those tested for malaria were positive. Temporal correlations between monthly measures of TPR and malaria incidence using linear and exponential regression models were relatively poor, with small changes in TPR frequently associated with large changes in malaria incidence. Linear regression models of temporal changes in TCM provided the most parsimonious and accurate predictor of changes in malaria incidence, with adjusted R2 values ranging from 0.81 to 0.98 across the 5 MRCs. However, the slope of the regression lines indicating the change in malaria incidence per unit change in TCM varied from 0.57 to 2.13 across the 5 MRCs, and when combining data across all 5 sites, the R2 value reduced to 0.38. CONCLUSIONS: In high malaria burden areas of Uganda, site-specific temporal changes in TCM had a strong linear relationship with malaria incidence and were a more useful metric than TPR. However, caution should be taken when comparing changes in TCM across sites.

Associations between environmental covariates and temporal changes in malaria incidence in high transmission settings of Uganda: a distributed lag nonlinear analysis.

BACKGROUND: Environmental factors such as temperature, rainfall, and vegetation cover play a critical role in malaria transmission. However, quantifying the relationships between environmental factors and measures of disease burden relevant for public health can be complex as effects are often non-linear and subject to temporal lags between when changes in environmental factors lead to changes in malaria incidence. The study investigated the effect of environmental covariates on malaria incidence in high transmission settings of Uganda. METHODS: This study leveraged data from seven malaria reference centres (MRCs) located in high transmission settings of Uganda over a 24-month period. Estimates of monthly malaria incidence (MI) were derived from MRCs' catchment areas. Environmental data including monthly temperature, rainfall, and normalized difference vegetation index (NDVI) were obtained from remote sensing sources. A distributed lag nonlinear model was used to investigate the effect of environmental covariates on malaria incidence. RESULTS: Overall, the median (range) monthly temperature was 30 °C (26-47), rainfall 133.0 mm (3.0-247), NDVI 0.66 (0.24-0.80) and MI was 790 per 1000 person-years (73-3973). Temperature of 35 °C was significantly associated with malaria incidence compared to the median observed temperature (30 °C) at month lag 2 (IRR: 2.00, 95% CI: 1.42-2.83) and the increased cumulative IRR of malaria at month lags 1-4, with the highest cumulative IRR of 8.16 (95% CI: 3.41-20.26) at lag-month 4. Rainfall of 200 mm significantly increased IRR of malaria compared to the median observed rainfall (133 mm) at lag-month 0 (IRR: 1.24, 95% CI: 1.01-1.52) and the increased cumulative IRR of malaria at month lags 1-4, with the highest cumulative IRR of 1.99(95% CI: 1.22-2.27) at lag-month 4. Average NVDI of 0.72 significantly increased the cumulative IRR of malaria compared to the median observed NDVI (0.66) at month lags 2-4, with the highest cumulative IRR of 1.57(95% CI: 1.09-2.25) at lag-month 4. CONCLUSIONS: In high-malaria transmission settings, high values of environmental covariates were associated with increased cumulative IRR of malaria, with IRR peaks at variable lag times. The complex associations identified are valuable for designing strategies for early warning, prevention, and control of seasonal malaria surges and epidemics.

What is the impact of removing performance-based financial incentives on community health worker motivation? A qualitative study from an infant and young child feeding program in Bangladesh.

BACKGROUND: Community health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Financial and non-financial motivators may influence CHW behavior through two dimensions of motivation: desire to perform and effort expended. The aim of this study was to explore how the removal of performance-based financial incentives impacted CHW motivation after formal funding ceased for Alive and Thrive (A&T), an infant and young child feeding (IYCF) program in Bangladesh. METHODS: This qualitative study included seven focus groups (n = 43 respondents) with paid supervisors of volunteer CHWs tasked with delivering interpersonal IYCF counseling services. Data were transcribed, translated into English, and then analyzed using both a priori themes and a grounded theory approach. RESULTS: Results suggest the removal of financial incentives was perceived to have negatively impacted CHWs' desire to perform in three primary ways: 1) a decreased desire to work without financial compensation, 2) changes in pre- and post-intervention motivation, and 3) household income challenges due to dependence on incentives. Removal of financial incentives was perceived to have negatively impacted CHWs' level of effort expended in four primary ways: 1) a reduction in CHW visits, 2) a reduction in quality of care, 3) CHW attrition, and 4) substitution of other income-generating activities. CONCLUSIONS: This study provides new evidence regarding how removing performance-based financial incentives from a CHW program can negatively impact CHW motivation. The findings suggest that program decision makers should consider how to construct community health work programs such that CHWs may continue to receive performance-based compensation after the original funding ceases.

Drought and intimate partner violence towards women in 19 countries in sub-Saharan Africa during 2011-2018: A population-based study.

BACKGROUND: Drought has many known deleterious impacts on human health, but little is known about the relationship between drought and intimate partner violence (IPV). We aimed to evaluate this relationship and to assess effect heterogeneity between population subgroups among women in 19 sub-Saharan African countries. METHODS AND FINDINGS: We used data from 19 Demographic and Health Surveys from 2011 to 2018 including 83,990 partnered women aged 15-49 years. Deviations in rainfall in the year before the survey date were measured relative to the 29 previous years using Climate Hazards Group InfraRed Precipitation with Station data, with recent drought classified as ordinal categorical variable (severe: ≤10th percentile; mild/moderate: >10th percentile to ≤30th percentile; none: >30th percentile). We considered 4 IPV-related outcomes: reporting a controlling partner (a risk factor for IPV) and experiencing emotional violence, physical violence, or sexual violence in the 12 months prior to survey. Logistic regression was used to estimate marginal risk differences (RDs). We evaluated the presence of effect heterogeneity by age group and employment status. Of the 83,990 women included in the analytic sample, 10.7% (9,019) experienced severe drought and 23.4% (19,639) experienced mild/moderate drought in the year prior to the survey, with substantial heterogeneity across countries. The mean age of respondents was 30.8 years (standard deviation 8.2). The majority of women lived in rural areas (66.3%) and were married (73.3%), while less than half (42.6%) were literate. Women living in severe drought had higher risk of reporting a controlling partner (marginal RD in percentage points = 3.0, 95% CI 1.3, 4.6; p < 0.001), experiencing physical violence (marginal RD = 0.8, 95% CI 0.1, 1.5; p = 0.019), and experiencing sexual violence (marginal RD = 1.2, 95% CI 0.4, 2.0; p = 0.001) compared with women not experiencing drought. Women living in mild/moderate drought had higher risk of reporting physical (marginal RD = 0.7, 95% CI 0.2, 1.1; p = 0.003) and sexual violence (marginal RD = 0.7, 95% CI 0.3, 1.2; p = 0.001) compared with those not living in drought. We did not find evidence for an association between drought and emotional violence. In analyses stratified by country, we found 3 settings where drought was protective for at least 1 measure of IPV: Namibia, Tanzania, and Uganda. We found evidence for effect heterogeneity (additive interaction) for the association between drought and younger age and between drought and employment status, with stronger associations between drought and IPV among adolescent girls and unemployed women. This study is limited by its lack of measured hypothesized mediating variables linking drought and IPV, prohibiting a formal mediation analysis. Additional limitations include the potential for bias due to residual confounding and potential non-differential misclassification of the outcome measures leading to an attenuation of observed associations. CONCLUSIONS: Our findings indicate that drought was associated with measures of IPV towards women, with larger positive associations among adolescent girls and unemployed women. There was heterogeneity in these associations across countries. Weather shocks may exacerbate vulnerabilities among women in sub-Saharan Africa. Future work should further evaluate potential mechanisms driving these relationships.

Estimating malaria incidence from routine health facility-based surveillance data in Uganda.

BACKGROUND: Accurate measures of malaria incidence are essential to track progress and target high-risk populations. While health management information system (HMIS) data provide counts of malaria cases, quantifying the denominator for incidence using these data is challenging because catchment areas and care-seeking behaviours are not well defined. This study's aim was to estimate malaria incidence using HMIS data by adjusting the population denominator accounting for travel time to the health facility. METHODS: Outpatient data from two public health facilities in Uganda (Kihihi and Nagongera) over a 3-year period (2011-2014) were used to model the relationship between travel time from patient village of residence (available for each individual) to the facility and the relative probability of attendance using Poisson generalized additive models. Outputs from the model were used to generate a weighted population denominator for each health facility and estimate malaria incidence. Among children aged 6 months to 11 years, monthly HMIS-derived incidence estimates, with and without population denominators weighted by probability of attendance, were compared with gold standard measures of malaria incidence measured in prospective cohorts. RESULTS: A total of 48,898 outpatient visits were recorded across the two sites over the study period. HMIS incidence correlated with cohort incidence over time at both study sites (correlation in Kihihi = 0.64, p < 0.001; correlation in Nagongera = 0.34, p = 0.045). HMIS incidence measures with denominators unweighted by probability of attendance underestimated cohort incidence aggregated over the 3 years in Kihihi (0.5 cases per person-year (PPY) vs 1.7 cases PPY) and Nagongera (0.3 cases PPY vs 3.0 cases PPY). HMIS incidence measures with denominators weighted by probability of attendance were closer to cohort incidence, but remained underestimates (1.1 cases PPY in Kihihi and 1.4 cases PPY in Nagongera). CONCLUSIONS: Although malaria incidence measured using HMIS underestimated incidence measured in cohorts, even when adjusting for probability of attendance, HMIS surveillance data are a promising and scalable source for tracking relative changes in malaria incidence over time, particularly when the population denominator can be estimated by incorporating information on village of residence.

Association between recent overnight travel and use of long-lasting insecticidal nets in rural Uganda: a prospective cohort study in Tororo.

BACKGROUND: The burden of malaria in Uganda remains high, but has become increasingly heterogenous following intensified malaria control. Travel within Uganda is recognized as a risk factor for malaria, but behaviours associated with travel are not well-understood. To address this knowledge gap, malaria-relevant behaviours of cohort participants were assessed during travel and at home in Uganda. METHODS: Residents from 80 randomly selected households in Nagongera sub-county, Tororo district were enrolled into a cohort to study malaria in rural Uganda. All participants were given long-lasting insecticidal nets (LLINs) at enrolment and were evaluated every 4 weeks at the study clinic. Participants were asked if they had travelled overnight from their home, and if so, a questionnaire was administered to capture information on travel details and behaviours. Behaviour while travelling was assessed within 4 weeks following travel during the study clinic visit. Behaviour while at home was assessed using a similar questionnaire during two-weekly home visits. Behaviours while travelling vs at home were compared using log binomial regression models with generalized estimating equations adjusting for repeated measures in the same individual. Analysis of factors associated with LLIN adherence, such as destination and duration of travel, time to bed during travel, gender and age at time of travel, were assessed using log binomial regression models with generalized estimating equations adjusting for repeated measures in the same individual. RESULTS: Between October 2017 and October 2019, 527 participants were enrolled and assessed for travel. Of these, 123 (23.2%) reported taking 211 overnight trips; 149 (70.6%) trips were within Tororo. Participants were less likely to use LLINs when travelling than when at home (41.0% vs. 56.2%, relative risk [RR] 0.73, 95% CI 0.60-0.89, p = 0.002); this difference was noted for women (38.8% vs 59.2%, RR 0.66, 95% CI 0.52-0.83, p = 0.001) but not men (48.3% vs 46.6%, RR 0.96, 95% CI 0.67-1.40, p = 0.85). In an adjusted analysis, factors associated with LLIN use when travelling included destination (travelling to districts not receiving indoor residual spraying [IRS] 65.8% vs Tororo district 32.2%, RR 1.80, 95% CI 1.31-2.46, p < 0.001) and duration of travel (> 7 nights 60.3% vs one night 24.4%, RR 1.97, 95% CI 1.07-3.64, p = 0.03). CONCLUSIONS: Travellers, particularly women, were less likely to use LLINs when travelling than when at home. LLIN adherence was higher among those who travelled to non-IRS districts and for more than 1 week, suggesting that perceived malaria risk influences LLIN use. Strategies are needed to raise awareness of the importance of using LLINs while travelling.

Rapid shifts in the age-specific burden of malaria following successful control interventions in four regions of Uganda.

BACKGROUND: Malaria control using long-lasting insecticidal nets (LLINs) and indoor residual spraying of insecticide (IRS) has been associated with reduced transmission throughout Africa. However, the impact of transmission reduction on the age distribution of malaria cases remains unclear. METHODS: Over a 10-year period (January 2009 to July 2018), outpatient surveillance data from four health facilities in Uganda were used to estimate the impact of control interventions on temporal changes in the age distribution of malaria cases using multinomial regression. Interventions included mass distribution of LLINs at all sites and IRS at two sites. RESULTS: Overall, 896,550 patient visits were included in the study; 211,632 aged < 5 years, 171,166 aged 5-15 years and 513,752 > 15 years. Over time, the age distribution of patients not suspected of malaria and those malaria negative either declined or remained the same across all sites. In contrast, the age distribution of suspected and confirmed malaria cases increased across all four sites. In the two LLINs-only sites, the proportion of malaria cases in < 5 years decreased from 31 to 16% and 35 to 25%, respectively. In the two sites receiving LLINs plus IRS, these proportions decreased from 58 to 30% and 64 to 47%, respectively. Similarly, in the LLINs-only sites, the proportion of malaria cases > 15 years increased from 40 to 61% and 29 to 39%, respectively. In the sites receiving LLINs plus IRS, these proportions increased from 19 to 44% and 18 to 31%, respectively. CONCLUSIONS: These findings demonstrate a shift in the burden of malaria from younger to older individuals following implementation of successful control interventions, which has important implications for malaria prevention, surveillance, case management and control strategies.

Can complex programs be sustained? A mixed methods sustainability evaluation of a national infant and young child feeding program in Bangladesh and Vietnam.

BACKGROUND: Poor early-life nutrition is a major barrier to good health and cognitive development, and is a global health priority. Alive & Thrive (A&T) was a multi-pronged initiative to improve infant and young child feeding behaviors. It aimed to achieve at-scale child health and nutrition improvements via a comprehensive approach that included nutrition counseling by health workers, policy change, social mobilization and mass media activities. This study evaluated the sustainability of activities introduced during A&T implementation (2009-2014) in Bangladesh and Vietnam. METHODS: This was a mixed methods study that used a quasi-experimental design. Quantitative data (surveys with 668 health workers, and 269 service observations) were collected in 2017; and analysis compared outcomes (primarily dose and fidelity of activities, and capacity) in former A&T intervention areas versus areas that did not receive the full A&T intervention. Additionally, we conducted interviews and focus groups with 218 stakeholders to explore their impressions about the determinants of sustainability, based on a multi-level conceptual framework. RESULTS: After program conclusion, stakeholders perceive declines in mass media campaigns, policy and advocacy activities, and social mobilization activities - but counseling activities were institutionalized and continued in both countries. Quantitative data show a persisting modest intervention effect: health workers in intervention areas had significantly higher child feeding knowledge, and in Bangladesh greater self-efficacy and job satisfaction, compared to their counterparts who did not receive the full package of A&T activities. While elements of the program were integrated into routine services, stakeholders noted dilution of the program focus due to competing priorities. Qualitative data suggest that some elements, such as training, monitoring, and evaluation, which were seen as essential to A&T's success, have declined in frequency, quality, coverage, or were eliminated altogether. CONCLUSIONS: The inclusion of multiple activities in A&T and efforts to integrate the program into existing institutions were seen as crucial to its success but also made it difficult to sustain, particularly given unstable financial support and human resource constraints. Future complex programs should carefully plan for institutionalization in advance of the program by cultivating champions across the health system, and designing unique and complementary roles for all stakeholders including donors.

Do Deviations From Historical Precipitation Trends Influence Child Nutrition? An Analysis From Uganda.

Changes in precipitation patterns might have deleterious effects on population health. We used data from the Uganda National Panel Survey from 2009 to 2012 (n = 3,223 children contributing 5,013 assessments) to evaluate the link between rainfall and undernutrition in children under age 5 years. We considered 3 outcomes (underweight, wasting, and stunting) and measured precipitation using household-reported drought and deviations from long-term precipitation trends measured by satellite. We specified multilevel logistic regression models with random effects for the community, village, and individual. Underweight (13%), wasting (4%), and stunting (33%) were common. Reported drought was associated with underweight (marginal risk ratio (RR) = 1.18, 95% confidence interval (CI): 1.04, 1.35) in adjusted analyses. Positive annual deviations (greater rainfall) from long-term precipitation trends were protective against underweight (marginal RR per 50-mm increase = 0.94, 95% CI: 0.92, 0.97) and wasting (marginal RR per 50-mm increase = 0.93, 95% CI: 0.87, 0.98) but not stunting (marginal RR per 50-mm increase = 1.00, 95% CI: 0.98, 1.01). Precipitation was associated with measures of acute but not chronic malnutrition using both objective and subjective measures of exposure. Sudden reductions in rainfall are likely to have acute adverse effects on child nutritional status.

Does health worker performance affect clients' health behaviors? A multilevel analysis from Bangladesh.

BACKGROUND: Suboptimal healthcare quality may be a barrier to achieving child health improvements, yet little is known about the relationship between provider compliance with evidence-based practices and client behavior change. We assess provider compliance in the context of infant and young child feeding (IYCF) counseling, its relationship with client IYCF behaviors in Bangladesh, and explore its potential determinants. METHODS: We use data from a 2017 evaluation of an IYCF program that includes a health worker survey (n = 74), caregiver survey (n = 232), and direct service observation checklists of counseling sessions (n = 232 observations of 74 health workers). We assess the relationship between provider compliance with recommended IYCF counseling topics and behaviors (standardized to a 100-point scale) and three reported IYCF behaviors among clients using multi-level models with random effects at the health worker and sub-district (sampling) levels. We also evaluate whether health worker self-efficacy, satisfaction, and technical knowledge are associated with provider compliance. RESULTS: Health worker compliance was significantly associated with reported exclusive breastfeeding for children under 6 months of age (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.06, 95% CI 1.01, 1.12) and marginally associated with minimum dietary diversity (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.05, 95% CI 1.00, 1.11). Counseling compliance was significantly and positively associated with both health worker self-efficacy and technical knowledge. CONCLUSIONS: We find evidence for an association between health worker compliance and client health behaviors; however, small effect sizes suggest that behavior change is multifactorial and affected by factors beyond care quality. Improvements to technical quality of care may contribute to desired health outcomes; but policies and programs seeking to change health behaviors through counseling may also wish to target upstream factors such as self-efficacy, alongside technical skill-building and knowledge, for maximum impact.

Spatiotemporal distribution and bionomics of Anopheles stephensi in different eco-epidemiological settings in Ethiopia.

BACKGROUND: Malaria is a major public health concern in Ethiopia, and its incidence could worsen with the spread of the invasive mosquito species Anopheles stephensi in the country. This study aimed to provide updates on the distribution of An. stephensi and likely household exposure in Ethiopia. METHODS: Entomological surveillance was performed in 26 urban settings in Ethiopia from 2021 to 2023. A kilometer-by-kilometer quadrant was established per town, and approximately 20 structures per quadrant were surveyed every 3 months. Additional extensive sampling was conducted in 50 randomly selected structures in four urban centers in 2022 and 2023 to assess households' exposure to An. stephensi. Prokopack aspirators and CDC light traps were used to collect adult mosquitoes, and standard dippers were used to collect immature stages. The collected mosquitoes were identified to species level by morphological keys and molecular methods. PCR assays were used to assess Plasmodium infection and mosquito blood meal source. RESULTS: Catches of adult An. stephensi were generally low (mean: 0.15 per trap), with eight positive sites among the 26 surveyed. This mosquito species was reported for the first time in Assosa, western Ethiopia. Anopheles stephensi was the predominant species in four of the eight positive sites, accounting for 75-100% relative abundance of the adult Anopheles catches. Household-level exposure, defined as the percentage of households with a peridomestic presence of An. stephensi, ranged from 18% in Metehara to 30% in Danan. Anopheles arabiensis was the predominant species in 20 of the 26 sites, accounting for 42.9-100% of the Anopheles catches. Bovine blood index, ovine blood index and human blood index values were 69.2%, 32.3% and 24.6%, respectively, for An. stephensi, and 65.4%, 46.7% and 35.8%, respectively, for An. arabiensis. None of the 197 An. stephensi mosquitoes assayed tested positive for Plasmodium sporozoite, while of the 1434 An. arabiensis mosquitoes assayed, 62 were positive for Plasmodium (10 for P. falciparum and 52 for P. vivax). CONCLUSIONS: This study shows that the geographical range of An. stephensi has expanded to western Ethiopia. Strongly zoophagic behavior coupled with low adult catches might explain the absence of Plasmodium infection. The level of household exposure to An. stephensi in this study varied across positive sites. Further research is needed to better understand the bionomics and contribution of An. stephensi to malaria transmission.

The association between timing in pregnancy of drought and excess rainfall, infant sex, and birthweight: Evidence from Nepal.

Background: Past research on the impact of climatic events, such as drought, on birth outcomes has primarily been focused in Africa, with less research in South Asia, including Nepal. Existing evidence has generally found that drought impacts birthweight and infant sex, with differences by trimester. Additionally, less research has looked at the impact of excess rain on birth outcomes or focused on the impact of rainfall extremes in the preconception period. Using data from a large demographic surveillance system in Nepal, combined with a novel measure of drought/excess rainfall, we explore the impact of these on birthweight by time in pregnancy. Methods: Using survey data from the 2016 to 2019 Chitwan Valley Study in rural Nepal combined with data from Climate Hazards InfraRed Precipitation with Station, we explored the association between excess rainfall and drought and birthweight, looking at exposure in the preconception period, and by trimester of pregnancy. We also explore the impact of excess rainfall and drought on infant sex and delivery with a skilled birth attendant. We used multilevel regressions and explored for effect modification by maternal age. Results: Drought in the first trimester is associated with lower birthweight (ß = -82.9 g; 95% confidence interval [CI] = 164.7, -1.2) and drought in the preconception period with a high likelihood of having a male (odds ratio [OR] = 1.41; 95% CI = 1.01, 2.01). Excess rainfall in the first trimester is associated with high birthweight (ß = 111.6 g; 95% CI = 20.5, 202.7) and higher odds of having a male (OR = 1.48; 95% CI = 1.02, 2.16), and in the third trimester with higher odds of low birth weight (OR = 2.50; 95% CI = 1.40, 4.45). Conclusions: Increasing rainfall extremes will likely impact birth outcomes and could have implications for sex ratios at birth.

Mapping malaria incidence using routine health facility surveillance data in Uganda.

INTRODUCTION: Maps of malaria risk are important tools for allocating resources and tracking progress. Most maps rely on cross-sectional surveys of parasite prevalence, but health facilities represent an underused and powerful data source. We aimed to model and map malaria incidence using health facility data in Uganda. METHODS: Using 24 months (2019-2020) of individual-level outpatient data collected from 74 surveillance health facilities located in 41 districts across Uganda (n=445 648 laboratory-confirmed cases), we estimated monthly malaria incidence for parishes within facility catchment areas (n=310) by estimating care-seeking population denominators. We fit spatio-temporal models to the incidence estimates to predict incidence rates for the rest of Uganda, informed by environmental, sociodemographic and intervention variables. We mapped estimated malaria incidence and its uncertainty at the parish level and compared estimates to other metrics of malaria. To quantify the impact that indoor residual spraying (IRS) may have had, we modelled counterfactual scenarios of malaria incidence in the absence of IRS. RESULTS: Over 4567 parish-months, malaria incidence averaged 705 cases per 1000 person-years. Maps indicated high burden in the north and northeast of Uganda, with lower incidence in the districts receiving IRS. District-level estimates of cases correlated with cases reported by the Ministry of Health (Spearman's r=0.68, p<0.0001), but were considerably higher (40 166 418 cases estimated compared with 27 707 794 cases reported), indicating the potential for underreporting by the routine surveillance system. Modelling of counterfactual scenarios suggest that approximately 6.2 million cases were averted due to IRS across the study period in the 14 districts receiving IRS (estimated population 8 381 223). CONCLUSION: Outpatient information routinely collected by health systems can be a valuable source of data for mapping malaria burden. National Malaria Control Programmes may consider investing in robust surveillance systems within public health facilities as a low-cost, high benefit tool to identify vulnerable regions and track the impact of interventions.

Characterizing pyrethroid resistance and mechanisms in Anopheles gambiae (s.s.) and Anopheles arabiensis from 11 districts in Uganda.

Insecticide resistance threatens recent progress on malaria control in Africa. To characterize pyrethroid resistance in Uganda, Anopheles gambiae (s.s.) and Anopheles arabiensis were analyzed from 11 sites with varied vector control strategies. Mosquito larvae were collected between May 2018 and December 2020. Sites were categorized as receiving no indoor-residual spraying ('no IRS', n â€‹= â€‹3); where IRS was delivered from 2009 to 2014 and in 2017 and then discontinued ('IRS stopped', n â€‹= â€‹4); and where IRS had been sustained since 2014 ('IRS active', n â€‹= â€‹4). IRS included bendiocarb, pirimiphos methyl and clothianidin. All sites received long-lasting insecticidal nets (LLINs) in 2017. Adult mosquitoes were exposed to pyrethroids; with or without piperonyl butoxide (PBO). Anopheles gambiae (s.s.) and An. arabiensis were identified using PCR. Anopheles gambiae (s.s.) were genotyped for Vgsc-995S/F, Cyp6aa1, Cyp6p4-I236M, ZZB-TE, Cyp4j5-L43F and Coeae1d, while An. arabiensis were examined for Vgsc-1014S/F. Overall, 2753 An. gambiae (s.l.), including 1105 An. gambiae (s.s.) and 1648 An. arabiensis were evaluated. Species composition varied by site; only nine An. gambiae (s.s.) were collected from 'IRS active' sites, precluding species-specific comparisons. Overall, mortality following exposure to permethrin and deltamethrin was 18.8% (148/788) in An. gambiae (s.s.) and 74.6% (912/1222) in An. arabiensis. Mortality was significantly lower in An. gambiae (s.s.) than in An. arabiensis in 'no IRS' sites (permethrin: 16.1 vs 67.7%, P â€‹< â€‹0.001; deltamethrin: 24.6 vs 83.7%, P â€‹< â€‹0.001) and in 'IRS stopped' sites (permethrin: 11.3 vs 63.6%, P â€‹< â€‹0.001; deltamethrin: 25.6 vs 88.9%, P â€‹< â€‹0.001). When PBO was added, mortality increased for An. gambiae (s.s.) and An. arabiensis. Most An. gambiae (s.s.) had the Vgsc-995S/F mutation (95% frequency) and the Cyp6p4-I236M resistance allele (87%), while the frequency of Cyp4j5 and Coeae1d were lower (52% and 55%, respectively). Resistance to pyrethroids was widespread and higher in An. gambiae (s.s.). Where IRS was active, An. arabiensis dominated. Addition of PBO to pyrethroids increased mortality, supporting deployment of PBO LLINs. Further surveillance of insecticide resistance and assessment of associations between genotypic markers and phenotypic outcomes are needed to better understand mechanisms of pyrethroid resistance and to guide vector control.