Impact of biomass fuel smoke on respiratory health of children under 15 years old in Madagascar.

BACKGROUND: Children exposed to biomass used in households are at risk to develop diseases or respiratory symptoms. In Madagascar more than 95% of households use it daily. The main objective is to study the impact of chronic exposure to biomass on respiratory health of children under 15 years old in Madagascar. METHODS: Descriptive cross-sectional study conducted with questionnaires among urban and rural population of Antananarivo and Mahajanga provinces between 2016 and 2017. Variables were collected: number of hours spent in kitchen per day, respiratory symptoms and spirometric data. Categorized symptoms score and exposure index expressing chronic exposure to biomass were analyzed with multinomial logistic regression models. RESULTS: Of the 661 children included in the analysis, 27.7% had 1 respiratory symptom and 29.3% had 2 or more respiratory symptoms. Moderate exposure index (aOR=1.57; CI95%=[1.30-1.89]; p<0.001) and high exposure index (aOR=1.76; CI95%=[1.39-2.24]; p<0.001) were significantly associated with 1 respiratory symptom, adjusted with provinces, household members and visitors smoking, perceived discomfort related to air pollution and birthweight. Exposure index was not significantly associated with an increased risk of having 2 or more respiratory symptoms (p = 0.754). CONCLUSION: Respiratory symptoms were associated with exposure to biomass, living in coastal areas, birthweight, tobacco and perceived discomfort related to air pollution. Recommendations and actions must be implemented in order to improve respiratory health related to biomass among children.

[Knowledge and perception of malnutrition among the rural population in the Central Highlands, Madagascar]. / Connaissances et perceptions de la malnutrition par la population rurale des Hautes Terres Centrales, Madagascar.

INTRODUCTION: malnutrition due to inadequate food supply is a major challenge in low- and middle-income countries. The purpose of this study is to identify the sociocultural drivers of malnutrition. METHODS: we conducted a qualitative study in the Amoron´I Mania region, Madagascar. The study involved pregnant women, mothers and fathers, grandmothers and health actors such as "matrones", community workers and health workers. A total of 24 semi-structured individual interviews and 6 focus groups were used to collect data. Thematic analysis was used. RESULTS: malnutrition refers to a lack of food and undernourishment. It revolves around the amount of rice consumption, socio-cultural factors and insufficient financial resources. Vulnerable groups were mainly composed of children and pregnant women. Severe malnutrition including signs was reported, but there was evidence for local adaptation. Thus, families were trying by different means to fight against malnutrition. CONCLUSION: the socio-cultural context modulates knowledge and perception of the causes, the manifestations and the vulnerability or non-vulnerability of an individual as well as the severity of malnutrition.

Appréciation des interventions de lutte contre la malnutrition maternelle par la population à Madagascar.

INTRODUCTION: Madagascar has adopted strategies to fight against maternal malnutrition, but the evaluation of their implementation is not effective.Purpose of research: The present study aims to describe beneficiary appreciation of interventions to fight maternal malnutrition and to identify their expectations. METHOD: A qualitative study was conducted in the Amoron’i Mania region, Madagascar. The study included mothers of children under 5, pregnant women, and other family members and community members (fathers, grandmothers, matrons and community workers). Six focus groups and 16 individual interviews were conducted to collect the data. The thematic analysis was used. RESULTS: Food supplementation, improved production of agriculture and livestock, and nutrition education, operated by NGOs, are the best-known interventions. The health centers were not mentioned as interveners and their interventions were ignored. The effectiveness of the intervention is generally judged on the benefits perceived by the beneficiaries. Interveners working on a project basis were assessed as unsustainable. Two main problems were mentioned: first, the insufficiency of agricultural production resulting in the inaccessibility of the ingredients required for the nutrition education, and second the low coverage of the interventions. The improvement of agricultural production is the main suggestion mentioned to fight against maternal undernutrition. CONCLUSIONS: Beneficiaries thought that existing interventions in the region are insufficient to address the problem of malnutrition among mothers.

Nutritional status of female prisoners in Antanimora prison, Madagascar.

INTRODUCTION: The prison population in low-income countries is a group vulnerable to undernutrition, particularly incarcerated women. The aim of the study is to assess the nutritional status of women in prison and to determine the social profile and prison conditions related to undernutrition. METHODS: A cross-sectional study was conducted among 125 women prisoners in Antanimora prison located in the city of Antananarivo, Madagascar. All women detained for 3 months or more at the time of the survey were included in the study. Data collection was conducted in May and June 2013. A survey of women and anthropometric measurements were carried out to collect the data. RESULTS: The proportion of undernourished female prisoners is 38.4%. Five percent of pregnant and lactating women and 44.3% of non-lactating and non-pregnant women are undernourished. The factors related to undernutrition of women prisoners are: taking two meals a day instead of three meals (p = 0.003), insufficient energy intake (p < 0.001), incarceration duration of more than 10 months (p < 0.001), absence of family visits (p = 0.013) and lack of financial assistance from family (p = 0.013). CONCLUSION: Improving the prisoners' diets and assistance from family both help to fight against prisoner undernutrition in prisons.

[Adherence of private sector providers to uncomplicated malaria management policy in Madagascar]. / Adhérence des prestataires du secteur privé à la politique de prise en charge des cas de paludisme simple à Madagascar.

INTRODUCTION: This study aims to assess the adherence of private health providers to the use of malaria rapid diagnostic tests (RDTs) and to the prescription of artemisinin-containing combinations (ACT) in patients with uncomplicated malaria. METHODS: We conducted an analytical, retrospective and cross-sectional study in 11 Madagascar's health districts divided into four epidemiological strata in September and in October 2015. A total of 43 health providers from 39 private health care facilities (PHF) were interviewed and visited. RESULTS: Health providers declared having read the malaria management manual in 16.3% of cases (4/43). Only one quarter (25.6%) of health providers had RDTs in their office. ACT was reported as "first-line drug" for the treatment of uncomplicated malaria by 83.7% of health providers. In practice, 55.6% of health providers had doubts about the results of the RDTs. The use of antimalarial drugs, despite having had negative RDTs results (38.2%), was more frequent among those who had raised doubts (p = 0.03). Conversely, despite having had positive RDTs results, half of the health providers did not prescribe ACT (50%). The decision to not participate in periodic reviews by the Health District (p = 0.05) negatively influenced the adherence to the policies. CONCLUSION: The low adherence of private health providers to the national guidelines for the management of uncomplicated malaria raises questions about the importance of exercising more control over health providers activities.

Mothers' dietary practices in the Amoron'i Mania region Madagascar.

INTRODUCTION: Madagascar has one of the highest prevalence's of malnutrition worldwide. Dietary practice is an important element to consider in the fight against malnutrition. This study aims to describe mothers' dietary patterns and dietary diversity and to identify characteristics associated with this dietary diversity. METHODS: A cross sectional study was carried-out among 670 non-pregnant mothers aged 18 to 45, who had delivered more than 6 months earlier and were living in the Amoron'i Mania region of Madagascar. The study was conducted during the post-harvest period. A food frequency questionnaire were used to assess the dietary pattern and the women's dietary diversity score was established from the 24-hour recall data. RESULTS: Almost all (99%) of mothers ate rice every day and 59% ate green leaves. Fifty three percent of mothers had consumed fruit less than once per week, 55% for legumes, 67% for vegetables and 91% for meat. Dietary diversity score ranged from 1 to 7 and 88% of mothers had a low dietary diversity score (<5). On multivariate analysis, factors significantly associated with low dietary diversity were: low education level (AOR=3.80 [1.58-9.02], p=0.003), parity higher than 3 (AOR=2.09 [1.22-3.56], p=0.007), birth interval ≥ 24 months (AOR=4.01 [2.08-7.74], p<0.001), rice production availability ≤ 6 months (AOR=2.33 [1.30-4.17], p=0.013), low attendance at market (AOR=4.20 [1.63-10.83], p<0.001) and low movable property possession score (AOR=4.87 [2.15-11.04], p<0.001). CONCLUSION: Mother's experience poor diet diversity. Unfavorable socioeconomic conditions are associated with this poor food diversification.

[Women's dietary habits during pregnancy and breastfeeding in Amoron'i Mania region, Madagascar: a qualitative study]. / Habitude alimentaire des mères pendant la grossesse et l'allaitement, région Amoron'i Mania Madagascar: étude qualitative.

INTRODUCTION: Women's dietary habits are very important due to the specific nutritional requirements for reproduction. This study aimed to describe women's dietary habits during pregnancy and breastfeeding and to identify factors influencing these habits. METHODS: We conducted a qualitative study of pregnant and breastfeeding women living in Amoron'i Mania region, Madagascar. Eight focus groups (6-10 women per group) and 23 individual interviews were carried out to collect data. Thematic analysis was used and focused on the description of women's dietary habits on the basis of dietary behaviours as well as of sociocultural and economic determinants of the described habits. RESULTS: During pregnancy and breastfeeding, women's dietary habits did not vary considerably except at the very beginning of breastfeeding. They had a little diversified and monotonous diet, poor in fruit and vegetables and poor in proteins. At the very beginning of breastfeeding, during the practice of "mifana " tradition, women had a diet more rich than usual. These dietary habits were influenced by the type of agricultural products in the region and by their availability during the year (self-consumption)as well as by purchasing power (in case of shortage) and tradition. CONCLUSION: Mothers' dietary habits appear to be inadequate. This study highlights the importance of improving knowledge of the determinants of mothers' dietary behaviours.

Socioeconomic determinants of malnutrition among mothers in the Amoron'i Mania region of Madagascar: a cross-sectional study.

BACKGROUND: Maternal malnutrition, which has been a problem in Madagascar for several years, has been rising despite interventions to improve the situation. This study aims to identify the socioeconomic determinants of malnutrition among mothers who are one of the most vulnerable groups. METHODS: A cross sectional study was carried out among 670 mothers aged 18 to 45 living in the Amoron'i Mania region of Madagascar. The study was conducted during the post-harvest period. The nutritional status of mothers was assessed by anthropometry. A Body Mass Index (BMI) lower than 18.5 kg/m2 or an arm circumference lower than 220 mm were used to define malnutrition. Data on the characteristics of the mothers and their households were also collected. Multiple logistic regression was used to identify factors associated with maternal malnutrition. RESULTS: The prevalence of maternal undernutrition is estimated at 17% (95% CI: 14­20) according to BMI and 9% (95% CI: 7­11) for Mid Upper Arm Circumference (MUAC). In the multivariate analysis, using BMI, the factors significantly associated with malnutrition were: the household size equal to or greater than 6 (AOR = 1.59 [1.04­3.42], p = 0.029) and use of unsafe water source (AOR = 1.99 [1.02­3.85], p = 0.030). For the MUAC, the factors associated are: use of unsafe water source (AOR = 2.82 [1.01­7.97], p = 0.041) and increased number of children under five years old (AOR = 1.38 [1.02­1.89], p = 0.025). CONCLUSION: This study confirmed the importance of mothers' malnutrition in the study area. Fight against maternal malnutrition needs interventions to improve access to safe drinking water and to promote family planning.

Management of uncomplicated malaria in febrile under five-year-old children by community health workers in Madagascar: reliability of malaria rapid diagnostic tests.

BACKGROUND: Early diagnosis, as well as prompt and effective treatment of uncomplicated malaria, are essential components of the anti-malaria strategy in Madagascar to prevent severe malaria, reduce mortality and limit malaria transmission. The purpose of this study was to assess the performance of the malaria rapid diagnostic tests (RDTs) used by community health workers (CHWs) by comparing RDT results with two reference methods (microscopy and Polymerase Chain Reaction, PCR). METHODS: Eight CHWs in two districts, each with a different level of endemic malaria transmission, were trained to use RDTs in the management of febrile children under five years of age. RDTs were performed by CHWs in all febrile children who consulted for fever. In parallel, retrospective parasitological diagnoses were made by microscopy and PCR. The results of these different diagnostic methods were analysed to evaluate the diagnostic performance of the RDTs administered by the CHWs. The stability of the RDTs stored by CHWs was also evaluated. RESULTS: Among 190 febrile children with suspected malaria who visited CHWs between February 2009 and February 2010, 89.5% were found to be positive for malaria parasites by PCR, 51.6% were positive by microscopy and 55.8% were positive by RDT. The performance accuracy of the RDTs used by CHWs in terms of sensitivity, specificity, positive and negative predictive values was greater than 85%. Concordance between microscopy and RDT, estimated by the Kappa value was 0.83 (95% CI: 0.75-0.91). RDTs stored by CHWs for 24 months were capable of detecting Plasmodium falciparum in blood at a level of 200 parasites/µl. CONCLUSION: Introduction of easy-to-use diagnostic tools, such as RDTs, at the community level appears to be an effective strategy for improving febrile patient management and for reducing excessive use of anti-malarial drugs.

Compliance, safety, and effectiveness of fixed-dose artesunate-amodiaquine for presumptive treatment of non-severe malaria in the context of home management of malaria in Madagascar.

Home management of malaria is recommended for prompt, effective antimalarial treatment in children less than five years of age. Compliance, safety, and effectiveness of the new fixed-dose artesunate-amodiaquine regimen used to treat suspected malaria were assessed in febrile children enrolled in a 24-month cohort study in two settings in Madagascar. Children with fever were asked to visit community health workers. Presumptive antimalarial treatment was given and further visits were scheduled for follow-up. The primary endpoint was the risk of clinical/parasitologic treatment failure. Secondary outcomes included fever/parasite clearance, change in hemoglobin levels, and frequency of adverse events. The global clinical cure rate was 98.4% by day 28 and 97.9% by day 42. Reported compliance was 83.4%. No severe adverse effects were observed. This study provides comprehensive data concerning the clinical cure rate obtained with artesunate-amodiaquine and evidence supporting the scaling up of home management of malaria.

[Factors associated with tuberculosis treatment non-compliance in Antananarivo city, Madagascar]. / Facteurs associés à l'abandon du traitement anti-tuberculeux dans la ville d'Antananarivo, Madagascar.

A retrospective epidemiological study of patients' medical records (n = 442) was conducted in one of the tuberculosis (TB) treatment centers in the city of Antananarivo, to identify risk factors of treatment default. Results show that males give up treatment more than women (OR=1,81 [1,13; 3,03]). Among those living farthest away from the center, patients younger than 30 years old tend to be more irregular in the follow-up of their treatment (OR=3,43 [1,16; 10,15]). There is no statistically significant relationship between TB treatment default and the patient's age, the clinical form, the therapeutic regime or the place of residence. Managers of treatment centers should be more aware and vigilant regarding male and young TB patients presenting these characteristics and should adapt methods and means for follow-up according to these risk factors.