General publics' perception toward COVID-19 vaccines in Afghanistan, 2021.

As of August 2021, less than 5% of the total population in Afghanistan has been fully vaccinated against COVID-19. Concerns remain regarding low uptake of the vaccine due to several factors. This study was conducted to understand the perception of the public on COVID-19 and its vaccines in Afghanistan. This was a formative study using qualitative method that included FGDs with vaccination target groups and KIIs, using interview guides in local languages in 12 provinces with 300 participants during May-June 2021. Verbatim transcripts were created, and a deductive thematic analysis was conducted with transcripts after the key themes and sub-themes were developed and reviewed. Totally 24 FGDs with male and female COVID-19 high-risk groups, 12 KIIs with EPI managers, and 12 KIIs with prison heads were conducted. Key themes included awareness and perception about COVID-19, its vaccination, motivators for getting vaccinated, barriers for not getting vaccinated, and sources of information. Awareness about the COVID-19 was high in urban areas compared to rural areas. Almost 60% of the participants considered the COVID-19 vaccine effective. However, participants expressed their concerns regarding rumors and misconceptions on content, source, effectiveness, and side effects of the vaccine in their communities. Based on the study results, many participants expressed accurate knowledge about the COVID-19 disease and its vaccines. Significant barriers including misinformation, conspiracy theories, and fear of side effects persist. Collaboration between stakeholders and increasing awareness and engagement of communities about the benefits and effectiveness of the vaccines should be considered crucial.

Multisector nutrition gains amidst evidence scarcity: scoping review of policies, data and interventions to reduce child stunting in Afghanistan.

BACKGROUND: Child health indicators have substantially improved across the last decade, yet Afghanistan has among the highest child stunting and malnutrition rates in Asia. Multisectoral approaches were recently introduced but evidence for this approach to improve support for and implementation of child nutrition programmes is limited compared to other countries. METHODS: We reviewed policy and programme data to identify best practices and gaps surrounding child malnutrition in Afghanistan. We conducted a scoping review using broad search categories and approaches, including database and website searches, reference hand-searches, purposive policy and programme document request, and key informant interviews. Inclusion and exclusion criteria were developed iteratively, with abstracts and documents assessed against the final criteria. We abstracted documents systematically and summarised and synthesised content to generate the main findings. RESULTS: We included 18 policies and strategies, 45 data sources and reports, and 20 intervention evaluations. Movement towards multisectoral efforts to address malnutrition at the policy level has started; however, integrated nutrition-specific and nutrition-sensitive interventions are not yet uniformly delivered at the community level. Many data sources capturing nutrition, food security and WASH (water, sanitation and hygiene) indicators are available but indicator definitions are not standardised and there are few longitudinal nutrition surveys. Political will to improve household nutrition status has shown increased government and donor investments in nutrition-sensitive and nutrition-specific programmes through combined small- and large-scale interventions between 2004 and 2013; however, evidence for interventions that effectively decrease stunting prevalence is limited. CONCLUSIONS: This review shows a breadth of nutrition programme, policy and data in Afghanistan. Multisector approaches faced challenges of reaching sufficient coverage as they often included a package of food security, livelihoods and health interventions but were each implemented independently. Further implementation evidence is needed to aid policy and programmes on effective integration of nutrition, food security and WASH in Afghanistan.

Review of policies, data, and interventions to improve maternal nutrition in Afghanistan.

Malnutrition contributes to direct and indirect causes of maternal mortality, which is particularly high in Afghanistan. Women's nutritional status before, during, and after pregnancy affects their own well-being and mortality risk and their children's health outcomes. Though maternal nutrition interventions have documented positive impact on select child health outcomes, there are limited data regarding the effects of maternal nutrition interventions on maternal health outcomes globally. This scoping review maps policies, data, and interventions aiming to address poor maternal nutrition outcomes in Afghanistan. We used broad search categories and approaches including database and website searches, hand searches of reference lists from relevant articles, policy and programme document requests, and key informant interviews. Inclusion and exclusion criteria were developed by type of source document, such as studies with measures related to maternal nutrition, relevant policies and strategies, and programmatic research or evaluation by a third party with explicit interventions targeting maternal nutrition. We abstracted documents systematically, summarized content, and synthesized data. We included 20 policies and strategies, 29 data reports, and nine intervention evaluations. The availability of maternal nutrition intervention data and the inclusion of nutrition indicators, such as minimum dietary diversity, have increased substantially since 2013, yet few nutrition evaluations and population surveys include maternal outcomes as primary or even secondary outcomes. There is little evidence on the effectiveness of interventions that target maternal nutrition in Afghanistan. Policies and strategies more recently have shifted towards multisectoral efforts and specifically target nutrition needs of adolescent girls and women of reproductive age. This scoping review presents evidence from more than 10 years of efforts to improve the maternal nutrition status of Afghan women. We recommend a combination of investments in measuring maternal nutrition indicators and improving maternal nutrition knowledge and behaviours.

Quality of child healthcare at primary healthcare facilities: a national assessment of the Integrated Management of Childhood Illnesses in Afghanistan.

OBJECTIVE: To assess quality of the national Integrated Management of Childhood Illness (IMCI) program services provided for sick children at primary health facilities in Afghanistan. DESIGN: Mixed methods including cross-sectional study. SETTING: Thirteen (of thirty-four) provinces in Afghanistan. PARTICIPANTS: Observation of case management and re-examination of 177 sick children, exit interviews with caretakers and review of equipment/supplies at 44 health facilities. INTERVENTION: Introduction and scale up of Integrated Management of Childhood Illnesses at primary health care facilities. MAIN OUTCOME MEASURES: Care of sick children according to IMCI guidelines, health worker skills and essential health system elements. RESULTS: Thirty-two (71%) of the health workers were trained in IMCI and five (11%) received supervision in clinical case management during the past 6 months. On average, 5.4 out of 10 main assessment tasks were performed during cases observed, the index being higher in children seen by trained providers than untrained (6.3 vs 3.5, 95% CI 5.8-6.8 vs 2.9-4.1). In all, 74% of the 104 children who needed oral antibiotics received prescriptions, while 30% received complete and correct advice and 30% were overprescribed, and more so by untrained providers. Home care counseling was associated with provider training status (41.3% by trained and 24.5% by untrained). Essential oral and pre-referral injectable medicine and equipment/supplies were available in 66%, 23%, and 45% of health facilities, respectively. CONCLUSION: IMCI training improved assessment, rational use of antibiotics and counseling; further investment in IMCI in Afghanistan, continuing provider capacity building and supportive supervision for improved quality of care and counseling for sick children is needed, especially given high burden treatable childhood illness.

Prevalence of Zoonotic and Vector-Borne Infections Among Afghan National Army Recruits in Afghanistan.

OBJECTIVE: To measure prevalence of prior/current Plasmodium vivax and Plasmodium falciparum (PV and PF), Brucella spp. (BR), dengue virus (DENV), Leishmania donovani (visceral leishmaniasis; VL), and Crimean-Congo hemorrhagic fever (CCHF) virus exposure among Afghan National Army (ANA) recruits. METHODS: Randomly chosen, nationally representative serum samples from consenting men aged 18-40 years and who were screened between February 2010 and January 2011 were tested, with ∼25 samples/province. Samples were screened for PV and PF antigens and VL antibody with rapid diagnostic tests. Reactive malaria screening results were confirmed with polymerase chain reaction assay. Enzyme-linked immunosorbent assays were used to screen for CCHF and DENV antibodies; reactive DENV samples were confirmed with the plaque-reduction neutralization test. BR screening and confirmatory testing was performed with slide and tube agglutination, respectively. Correlates of BR titres >1:80 were analyzed using logistic regression. RESULTS: Of 809 participants contributing specimens, 62% had previously lived outside Afghanistan, predominantly in Pakistan and Iran. CCHF (4.1%, n = 33), DENV (2.1%, n = 17), and VL (1.0%, n = 8) antibody prevalence was low. For PV and PF, only 7 out of 56 reactive samples had detectable nucleic acid. For BR, 8.0% (n = 65) of samples had screening titers >1:40, of which 83.1% had confirmatory titers >1:80. Participants from Kabul and surrounding provinces had lower odds (OR = 0.19, 95% CI: 0.04-1.00) of BR antibody compared with other regions. CONCLUSIONS: BR exposure was relatively common with a nearly national distribution, whereas geographic distribution for other pathogens aligned roughly with the expected vector distribution. Public health protection measures should include vector control, food safety, and enhanced diagnostics for acute febrile illness.

A case-control study of correlates of severe acute maternal morbidity in Kabul, Afghanistan.

OBJECTIVE: To identify correlates of severe acute maternal morbidity (SAMM) in Kabul, Afghanistan. METHODS: The present case-control study enrolled postpartum couples at four public maternity hospitals between September 2007 and December 2009. Eligibility was determined by: spousal consent; SAMM criteria from chart review for cases; and matching by age, parity, and time since previous delivery for controls (uncomplicated deliveries). Staff administered questionnaires to women and their husbands separately. SAMM correlates were analyzed with conditional logistic regression in models including (proximate) and excluding (distal) care factors. RESULTS: Among 285 case and 285 control couples, the most frequent SAMM diagnoses were obstructed labor (104 [36.5%]) and hemorrhage requiring transfusion (102 [35.8%]). In both models, SAMM was associated with the husband having more than one wife (distal: adjusted odds ratio [aOR] 48.6, 95% CI 5.4-436.5; proximate: 141.8, 3.5-5819.0), prior stillbirth(s) (distal: 16.2, 6.1-42.9; proximate: 8.0, 2.9-22.4), and complications in a prior pregnancy (distal: 5.4, 95% CI 2.5-12.1; proximate: 7.1, 2.5-20.4). In the proximate model, SAMM was associated with visiting another facility before hospitalization (aOR 7.5, 95% CI 3.1-17.9), male-reported planned home delivery (5.5, 1.5-20.0), and provider-determined care-seeking (4.8, 1.6-14.9). CONCLUSION: Planned home delivery and referral to multiple facilities or by providers are factors associated with SAMM that are potentially amenable to intervention in Afghanistan.

The final push for polio eradication: addressing the challenge of violence in Afghanistan, Pakistan, and Nigeria.

Seye Abimbola and colleagues provide a view from Nigeria, Pakistan, and Afghanistan on global efforts to eradicate polio in those countries. Please see later in the article for the Editors' Summary.

Midwifery training in post-conflict Afghanistan: tensions between educational standards and rural community needs.

OBJECTIVE: To compare the performance of students selected for midwifery education by three methods: community mobilization in rural Afghanistan, a regional examination by the Institute of Health Sciences (IHS), and the National University Entrance Examination (NUEE). METHODS: A retrospective survey was conducted in January 2009 on academic records of 178 midwives trained at the IHS in Herat, including 147 graduates from 2003-08 and the cohort of 31 final-semester students graduating in March 2009. An interview survey of the 31 final semester students was also conducted. Outcome variables included knowledge, skills and employment status, stratified by method of selection. Individual attributes including completion of high school, marital status, age and urban/rural residence were also assessed. Data analysis used STATA version 2009. Significance was measured by appropriate statistical tests. Findings were verified by key informant interviews. RESULTS: Ninety-six per cent of midwifery graduates selected by communities were employed, compared with 74% chosen by the IHS and 82% by the NUEE. Sixty-three per cent of community-selected graduates were working in rural locations, compared with 43% recruited by IHS and 9% by the NUEE. While fewer midwifery graduates selected by communities had completed high school and their academic performance was slightly lower during training, there was no difference in their pass rates and acquisition of practical skills. CONCLUSIONS: Community mobilization for local selection of trainees achieved significantly higher employment levels of trained midwives in high-risk rural communities than usual selection methods, without compromising quality of skills.