SARS-CoV-2 incidence monitoring and statistical estimation of the basic and time-varying reproduction number at the early onset of the pandemic in 45 sub-Saharan African countries.

The world battled to defeat a novel coronavirus 2019 (SARS-CoV-2 or COVID-19), a respiratory illness that is transmitted from person to person through contacts with droplets from infected persons. Despite efforts to disseminate preventable messages and adoption of mitigation strategies by governments and the World Health Organization (WHO), transmission spread globally. An accurate assessment of the transmissibility of the coronavirus remained a public health priority for many countries across the world to fight this pandemic, especially at the early onset. In this paper, we estimated the transmission potential of COVID-19 across 45 countries in sub-Saharan Africa using three approaches, namely, [Formula: see text] based on (i) an exponential growth model (ii) maximum likelihood (ML) estimation and (iii) a time-varying basic reproduction number at the early onset of the pandemic. Using data from March 14, 2020, to May 10, 2020, sub-Saharan African countries were still grappling with COVID-19 at that point in the pandemic. The region's basic reproduction number ([Formula: see text]) was 1.89 (95% CI: 1.767 to 2.026) using the growth model and 1.513 (95% CI: 1.491 to 1.535) with the maximum likelihood method, indicating that, on average, infected individuals transmitted the virus to less than two secondary persons. Several countries, including Sudan ([Formula: see text]: 2.03), Ghana ([Formula: see text]: 1.87), and Somalia ([Formula: see text]: 1.85), exhibited high transmission rates. These findings highlighted the need for continued vigilance and the implementation of effective control measures to combat the pandemic in the region. It is anticipated that the findings in this study would not only function as a historical record of reproduction numbers during the COVID-19 pandemic in African countries, but can serve as a blueprint for addressing future pandemics of a similar nature.

Understating the barriers to achievement of the UNAIDS 90-90-90 goal in Tanzania using a population-based HIV impact assessment survey 2016-2017.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners launched the 90-90-90 targets. We used Tanzania HIV Impact Survey (THIS) data in 2017 to study the barriers to achieve 90-90-90 targets. THIS was a population-based survey with a stratified multistage stage sampling design. We used weighted logistic regression to associate three targets with socio-demographics, HIV-related discrimination, fear and shame. We defined HIV awareness by a combination of self-reported of HIV status positive and detected antiretroviral (ARV) in blood among PLWH. On ARV was defined as those who self-reported among awareness. Viral load suppression was defined as 400 copies/ml or less in the blood sample. The three targets were estimated at 61-90-85 in Tanzania from the weighted analysis. The first target was far from being achieved. The weighted regression showed that being female, having attained higher education, married, having insurance, and living in urban areas were associated with a high likelihood of having ever tested for HIV. The results indicated that intervention programmes in Tanzania should focus on the first target. Intervention programmes should be designed for each target separately. Integrated strategies in the context of low and middle-income countries are needed to achieve these targets.

Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study.

BACKGROUND: An estimated 40% of pregnancies globally are unintended. Measurement of pregnancy intention in low- and middle-income countries relies heavily on surveys, notably Demographic and Health Surveys (DHS), yet few studies have evaluated survey questions. We examined questions for measuring pregnancy intention, which are already in the DHS, and additional questions and investigated associations with maternity care utilisation and adverse pregnancy outcomes. METHODS: The EN-INDEPTH study surveyed 69,176 women of reproductive age in five Health and Demographic Surveillance System sites in Ghana, Guinea-Bissau, Ethiopia, Uganda and Bangladesh (2017-2018). We investigated responses to survey questions regarding pregnancy intention in two ways: (i) pregnancy-specific intention and (ii) desired-versus-actual family size. We assessed data completeness for each and level of agreement between the two questions, and with future fertility desire. We analysed associations between pregnancy intention and number and timing of antenatal care visits, place of delivery, and stillbirth, neonatal death and low birthweight. RESULTS: Missing data were <2% in all questions. Responses to pregnancy-specific questions were more consistent with future fertility desire than desired-versus-actual family size responses. Using the pregnancy-specific questions, 7.4% of women who reported their last pregnancy as unwanted reported wanting more children in the future, compared with 45.1% of women in the corresponding desired family size category. Women reporting unintended pregnancies were less likely to attend 4+ antenatal care visits (aOR 0.73, 95% CI 0.64-0.83), have their first visit during the first trimester (aOR 0.71, 95% CI 0.63-0.79), and report stillbirths (aOR 0.57, 95% CI 0.44-0.73) or neonatal deaths (aOR 0.79, 95% CI 0.64-0.96), compared with women reporting intended pregnancies. We found no associations for desired-versus-actual family size intention. CONCLUSIONS: We found the pregnancy-specific intention questions to be a much more reliable assessment of pregnancy intention than the desired-versus-actual family size questions, despite a reluctance to report pregnancies as unwanted rather than mistimed. The additional questions were useful and may complement current DHS questions, although these are not the only possibilities. As women with unintended pregnancies were more likely to miss timely and frequent antenatal care, implementation research is required to improve coverage and quality of care for those women.

Retention of knowledge and clinical competence among Ugandan mid-level health providers 1 year after intensive clinical mentorship in TB and HIV management.

INTRODUCTION: Clinical mentorship is effective in improving knowledge and competence of health providers and may be a useful task sharing approach for improving antiretroviral therapy. However, the endurance of the effect of clinical mentorship is uncertain. METHODS: The midlevel health providers who participated in a cluster-randomized trial of one-on-one, on-site, clinical mentorship in tuberculosis and HIV for 8 h a week, every 6 weeks over 9 months were followed to determine if the gains in knowledge and competence that occurred after the intervention were sustained 6- and 12-months post-intervention. In December 2014 and June 2015, their knowledge and clinical competence were respectively assessed using vignettes and a clinical observation tool of patient care. Multilevel mixed effects regression analysis was used to compare the differences in mean scores for knowledge and clinical competence between times 0, 1, 2, and 3 by arm. RESULTS: At the end of the intervention phase of the trial, the mean gain in knowledge scores and clinical competence scores in the intervention arm was 13.4% (95% confidence interval ([CI]: 7.2, 19.6), and 27.8% (95% CI: 21.1, 34.5) respectively, with no changes seen in the control arm. Following the end of the intervention; knowledge mean scores in the intervention arm did not significantly decrease at 6 months (0.6% [95% CI - 1.4, 2.6]) or 12 months (- 2.8% [95% CI: - 5.9, 0.3]) while scores in the control arm significantly increased at 6 months (6.6% [95% CI: 4.4, 8.9]) and 12 months (7.9% [95% CI: 5.4, 10.5]). Also, no significant decrease in clinical competence mean scores for intervention arm was seen at 6 month (2.8% [95% CI: - 1.8, 7.5] and 12 months (3.7% [95% CI: - 2.4, 9.8]) while in the control arm, a significant increase was seen at 6 months (5.8% [95% CI: 1.2, 10.3] and 12 months (11.5% [95% CI: 7.6, 15.5]). CONCLUSIONS: Mentees sustained the competence and knowledge gained after the intervention for a period of one year. Although, there was an increase in knowledge in the control group over the follow-up period, MLP in the intervention arm experienced earlier and sustained gains. One-on-one clinical mentorship should be scaled-up as a task-sharing approach to improve clinical care. Trial Registration The study received ethics approvals from 3 institutions-the US Centers for Disease Control and Prevention Institutional Review Board (USA), the Institutional Review Board "JCRC's HIV/AIDS Research Committee" IRB#1-IRB00001515 with Federal Wide Assurance number (FWA00009772) based in Kampala and the Uganda National Council of Science and Technology (Uganda) which approves all scientific protocols to be implemented in Uganda.

Social intolerance, risky sexual behaviors and their association with HIV knowledge among Ugandan adults: results from a national survey.

Understanding the link between HIV knowledge, risky sexual behaviors, and social intolerance such as stigma and discrimination is important for HIV prevention and treatment program planning. We investigated whether intolerant attitudes and practices among Ugandan adults were associated with HIV-transmission knowledge. We analyzed data from a nationally representative population-based household survey, the 2011 Uganda AIDS Indicator Survey. A total of 15,526 participants who responded to questions on HIV knowledge, social intolerance and risky sexual behavior were included in this analysis. Results show that 34.8% of respondents reported having fear of casual contact with people living with HIV (PLWA), 21% blame PLWAs for their disease, 62% would not want HIV infection in their family disclosed, while 25% reported engaging in risky sexual behaviors. After adjusting for age, sex, residence, and level of education, people with low HIV-transmission knowledge had almost three-fold higher odds of fear of casual contact with a PLWA (aOR = 2.70, 95%CI = 2.33-3.13), and had 30% higher odds of HIV-related stigmatizing attitudes (aOR = 1.29, 95%CI = 1.07-1.54). Further, they had 47% higher odds of having sex under the influence of alcohol (aOR = 1.47, 95%CI = 1.25-1.73) and 40% higher odds of having unprotected sex with any of their last three sex partners (aOR = 1.39, 95%CI = 1.06-1.89). Our findings show that intolerant attitudes such as stigma still persist, particularly among people with low HIV-transmission knowledge. Improving knowledge about HIV/AIDS can foster positive attitudes and building safe practices among populations, and is critical for improving prevention and treatment programs.

Prevalence of depressive symptoms and associated factors among adolescents living with HIV/AIDS in South Western Uganda.

Adolescents living with HIV (ALHIV) are prone to depression, which can have detrimental effects including disease progression, poor treatment adherence and mortality. We aimed to determine the prevalence of depressive symptoms and their associated factors among ALHIV in Uganda. We conducted a cross-sectional survey among ALHIV (10-19 years) attending urban and rural clinics in Mbarara, Uganda between March and May 2017. Presence of depressive symptoms was assessed using the Centre for Epidemiological Studies' Depression scale. We interviewed 336 adolescents with a median age of 13 years, 62% of whom were female. A third (37%) had disclosed their HIV/AIDS status and 13% were sexually active. Overall, 154 (∼46%, [95% CI: 40.5-51.2]) had depressive symptoms. On bivariate analysis, the odds of having depressive symptoms were higher among adolescents who were ≥ 15 years, had disclosed HIV status, traveled >30 min for routine care and had risky sexual practices. On multiple variable analysis, only travel time to the clinic of >30 min was independently associated with depressive symptoms (AOR = 1.6 [95% CI: 1.02-2.7]). With the high prevalence of depressive symptoms among ALHIV in Uganda, screening and prompt treatment of depression should be incorporated within their routine care.

The knowledge-risk-behaviour continuum among young Ugandans: what it tells us about SRH/HIV integration.

BACKGROUND: With a human immunodeficiency virus (HIV) prevalence of 2.1% among 15-24 year olds, opportunities for further integration of sexual and reproductive health (SRH) and HIV prevention services for young people in Uganda exist. We examine a range of factors that contribute to variance in risky sexual behaviour among young Ugandans. METHODS: A cross-sectional, nationally representative household survey was conducted between February and March 2016. The questionnaire used assessed knowledge, attitudes and practices related to SRH among young people aged 10-24 years. A composite indicator was constructed to assess risky sexual behaviour, defined as being involved in sexual relations under the influence of alcohol or drugs, engaging in sexual activities without a condom, and having multiple sexual partners in the 6 months preceding the survey. Exploratory analysis was conducted to provide descriptive statistics. Logistic regression was conducted to determine the factors associated with risky sexual behaviour. This analysis focuses on the sub-category aged 15-24 years, comprised of 2725 respondents. RESULTS: Knowledge levels of family planning (FP), sexually transmitted infections (STIs) and HIV across all respondents were high (above 82%). Self-reported perceived risk of STIs and pregnancy was consistently higher among 20-24 year old respondents, with 61.5% feeling at risk of STIs compared to 46.2% of 15-19 year olds. A total of 22.7% of respondents reported having been involved in risky sexual behaviour. Factors associated with risky sexual behaviour among the 15-19 years group included gender, single orphanhood, casual work, schooling status, FP knowledge and self-perceived risk of STIs/HIV. For the 20-24 year old respondents, significantly associated factors included gender, educational level, relationship to head of household, place of residence, and self-perceived risk of pregnancy. CONCLUSIONS: Despite high general SRH/HIV knowledge and perceived risk of pregnancy and HIV, risky sexual behaviour among young Ugandans remains high. Effectiveness gaps in the integrated SRH/HIV response for young people should be addressed and targeted interventions focused on holistic prevention at individual level through information, risk awareness, and skill development should be combined with interventions targeting social structures affecting individual behaviour.

Effectiveness of Potential Interventions to Change Gendered Social Norms on Prevalence of Intimate Partner Violence in Uganda: a Causal Inference Approach.

Evidence of the effectiveness of programs to change gendered social norms related to intimate partner violence (IPV) is growing, but their potential to significantly impact actual occurrence of IPV at population level is lacking. We study whether modest changes in gendered social norms related to wife-beating can result in significant changes in the incidence of emotional, physical, and sexual IPV among ever married women in Uganda. We employ an imputation-based causal inference approach, based on nationally representative Demographic Health Survey data. The steps are (1) model the association between adjusted neighborhood norms and experiences of IPV using a random effects logistic regression model, (2) impute unobserved counterfactual probabilities of experiencing IPV for each woman while manipulating her neighborhood norms by setting it to different values, (3) average the probabilities across the population, and (4) bootstrap confidence intervals. Results show that statistically significant inverse associations between more prohibitive neighborhood IPV norms and women's experiences of different forms of IPV at the population level exist. The effect is however small, that even if an entire community disapproves of wife-beating, incidence of IPV falls by about 10 percentage points to 48.5% (95% CI 46.0%-50.9%) from the observed value of 57.6% (95% CI 55.2%-59.9%). Furthermore, changes in neighborhood social norms are found to have no statistical significant effect on the incidence of sexual violence. In conclusion, changing gendered social norms related to wife-beating will not result in significant reductions in different forms for IPV at the population level.

A generalized longitudinal mixture IRT model for measuring differential growth in learning environments.

This article describes a generalized longitudinal mixture item response theory (IRT) model that allows for detecting latent group differences in item response data obtained from electronic learning (e-learning) environments or other learning environments that result in large numbers of items. The described model can be viewed as a combination of a longitudinal Rasch model, a mixture Rasch model, and a random-item IRT model, and it includes some features of the explanatory IRT modeling framework. The model assumes the possible presence of latent classes in item response patterns, due to initial person-level differences before learning takes place, to latent class-specific learning trajectories, or to a combination of both. Moreover, it allows for differential item functioning over the classes. A Bayesian model estimation procedure is described, and the results of a simulation study are presented that indicate that the parameters are recovered well, particularly for conditions with large item sample sizes. The model is also illustrated with an empirical sample data set from a Web-based e-learning environment.

A call-to-action: integrate a learning health system framework into longitudinal population studies to improve health response in Africa.

Longitudinal population studies (LPSs) in Africa have the potential to become powerful engines of change by adopting a learning health system (LHS) framework. This is a call-to-action opinion and highlights the importance of integrating an LHS approach into LPSs, emphasizing their transformative potential to improve population health response, drive evidence-based decision making, and enhance community well-being. Operators of LPS platforms, community members, government officials, and funding agencies have a role to contribute to this transformative journey of driving evidence-based interventions, promoting health equity, and fostering long-term public health solutions for African communities.

Utilizing a multi-stage transition model for analysing child stunting in two urban slum settlements of Nairobi: A longitudinal analysis, 2011-2014.

INTRODUCTION: Stunting is common among children in many low and middle income countries, particularly in rural and urban slum settings. Few studies have described child stunting transitions and the associated factors in urban slum settlements. We describe transitions between stunting states and associated factors among children living in Nairobi slum settlements. METHODS: This study used data collected between 2010 and 2014 from the Nairobi Urban and Demographic Surveillance System (NUHDSS) and a vaccination study nested within the surveillance system. A subset of 692 children aged 0 to 3 years, with complete anthropometric data, and household socio-demographic data was used for the analysis. Height-for-age Z-scores (HAZ) was used to define stunting: normal (HAZ ≥ 1), marginally stunted (-2 ≤ HAZ < -1), moderately stunted (-3 ≤ HAZ < -2), and severely stunted (HAZ < -3). Transitions from one stunting level to another and in the reverse direction were computed. The associations between explanatory factors and the transitions between four child stunting states were modeled using a continuous-time multi-state model. RESULTS: We observed that 48%, 39%, 41%, and 52% of children remained in the normal, marginally stunted, moderately stunted, and severely stunted states, respectively. About 29% transitioned from normal to marginally stunted state, 15% to the moderately stunted state, and 8% to the severely stunted state. Also, 8%, 12%, and 29% back transitioned from severely stunted, moderately stunted, and marginally stunted states, to the normal state, respectively. The shared common factors associated with all transitions to a more severe state include: male gender, ethnicity (only for mild and severe transition states), child's age, and household food insecurity. In Korogocho, children whose parents were married and those whose mothers had attained primary or post-primary education were associated with a transition from a mild state into a moderately stunted state. Children who were breastfed exclusively were less likely to transition from moderate to severe stunting state. CONCLUSION: These findings reveal a high burden of stunting and transitions in urban slums. Context-specific interventions targeting the groups of children identified by the socio-demographic factors are needed. Improving food security and exclusive breastfeeding could potentially reduce stunting in the slums.

INSPIRE datahub: a pan-African integrated suite of services for harmonising longitudinal population health data using OHDSI tools.

Introduction: Population health data integration remains a critical challenge in low- and middle-income countries (LMIC), hindering the generation of actionable insights to inform policy and decision-making. This paper proposes a pan-African, Findable, Accessible, Interoperable, and Reusable (FAIR) research architecture and infrastructure named the INSPIRE datahub. This cloud-based Platform-as-a-Service (PaaS) and on-premises setup aims to enhance the discovery, integration, and analysis of clinical, population-based surveys, and other health data sources. Methods: The INSPIRE datahub, part of the Implementation Network for Sharing Population Information from Research Entities (INSPIRE), employs the Observational Health Data Sciences and Informatics (OHDSI) open-source stack of tools and the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) to harmonise data from African longitudinal population studies. Operating on Microsoft Azure and Amazon Web Services cloud platforms, and on on-premises servers, the architecture offers adaptability and scalability for other cloud providers and technology infrastructure. The OHDSI-based tools enable a comprehensive suite of services for data pipeline development, profiling, mapping, extraction, transformation, loading, documentation, anonymization, and analysis. Results: The INSPIRE datahub's "On-ramp" services facilitate the integration of data and metadata from diverse sources into the OMOP CDM. The datahub supports the implementation of OMOP CDM across data producers, harmonizing source data semantically with standard vocabularies and structurally conforming to OMOP table structures. Leveraging OHDSI tools, the datahub performs quality assessment and analysis of the transformed data. It ensures FAIR data by establishing metadata flows, capturing provenance throughout the ETL processes, and providing accessible metadata for potential users. The ETL provenance is documented in a machine- and human-readable Implementation Guide (IG), enhancing transparency and usability. Conclusion: The pan-African INSPIRE datahub presents a scalable and systematic solution for integrating health data in LMICs. By adhering to FAIR principles and leveraging established standards like OMOP CDM, this architecture addresses the current gap in generating evidence to support policy and decision-making for improving the well-being of LMIC populations. The federated research network provisions allow data producers to maintain control over their data, fostering collaboration while respecting data privacy and security concerns. A use-case demonstrated the pipeline using OHDSI and other open-source tools.

Experiences of mothers and health workers with MomCare and SafeCare bundles in Kenya and Tanzania: A qualitative evaluation.

Between 2019 and 2022, the digital dividend project (DDP), a technology-based intervention that combined care (MomCare) and quality improvement (SafeCare) bundles to empower mothers to access quality care during pregnancy, labor, and delivery, and postnatally, was implemented in Kenya and Tanzania aiming to improve maternal and newborn health outcomes. We describe the experiences of the mothers in accessing and utilizing health services under the bundles, and the experiences of the health workers in providing the services. Between November and December 2022, we conducted a qualitative evaluation across health facilities in Kenya and Tanzania. We held Interviews with mothers (pregnant and postpartum women who had benefited from the care bundles) and health workers (physicians, nurses, and midwives who provided the care bundles, including health facility In-Charges) at the antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) service delivery points. We performed content analysis. Findings are reported using themes and quotes from the participants. We included 127 mothers (Kenya = 76, Tanzania = 51) and 119 health workers. Findings revealed that among mothers, the care bundles eased access to health services, ensured easy access and optimal ANC use, provision of respectful care, removed financial constraints, and led to the receipt of sufficient health education. Health workers reported that the care bundles offered them a new opportunity to provide quality maternal and newborn care and to adhere to the standard of care besides experiencing a positive and fulfilling practice. Health systems improvements included prompt emergency response and continual care, infrastructural developments, medical supplies and logistics, staffing, and increased documentation. Overall, the care bundles led to the strengthening of the healthcare system (staffing, service delivery, financing, supplies/logistics, and information management) in order to deliver quality maternal and child health services. The bundles should be replicated in settings with similar maternal and child health challenges.

Performance of a Finnish Diabetes Risk Score in detecting undiagnosed diabetes among Kenyans aged 18-69 years.

BACKGROUND: The application of risk scores has often effectively predicted undiagnosed type 2 diabetes in a non-invasive way to guide early clinical management. The capacity for diagnosing diabetes in developing countries including Kenya is limited. Screening tools to identify those at risk and thus target the use of limited resources could be helpful, but these are not validated for use in these settings. We, therefore, aimed to measure the performance of the Finnish diabetes risk score (FINDRISC) as a screening tool to detect undiagnosed diabetes among Kenyan adults. METHODS: A nationwide cross-sectional survey on non-communicable disease risk factors was conducted among Kenyan adults between April and June 2015. Diabetes mellitus was defined as fasting capillary whole blood ≥ 7.0mmol/l. The performance of the original, modified, and simplified FINDRISC tools in predicting undiagnosed diabetes was assessed using the area under the receiver operating curve (AU-ROC). Non-parametric analyses of the AU-ROC, Sensitivity (Se), and Specificity (Sp) of FINDRISC tools were determined. RESULTS: A total of 4,027 data observations of individuals aged 18-69 years were analyzed. The proportion/prevalence of undiagnosed diabetes and prediabetes was 1.8% [1.3-2.6], and 2.6% [1.9-3.4] respectively. The AU-ROC of the modified FINDRISC and simplified FINDRISC in detecting undiagnosed diabetes were 0.7481 and 0.7486 respectively, with no statistically significant difference (p = 0.912). With an optimal cut-off ≥ 7, the simplified FINDRISC had a higher positive predictive value (PPV) (7.9%) and diagnostic odds (OR:6.65, 95%CI: 4.43-9.96) of detecting undiagnosed diabetes than the modified FINDRISC. CONCLUSION: The simple, non-invasive modified, and simplified FINDRISC tools performed well in detecting undiagnosed diabetes and may be useful in the Kenyan population and other similar population settings. For resource-constrained settings like the Kenyan settings, the simplified FINDRISC is preferred.

Effect of justification of wife-beating on experiences of intimate partner violence among men and women in Uganda: A propensity-score matched analysis of the 2016 Demographic Health Survey data.

INTRODUCTION: In some communities, rationalization of men's controlling attitudes is associated with the justification of gender norms such as wife-beating as a method of correcting spouse behaviour. In this quasi-experimental study, we investigate the causal effects of the acceptability of gender norms justifying wife-beating on experiences of sexual, emotional, and physical intimate partner violence (IPV) among Ugandan men and women. METHODS AND MATERIALS: We analysed the 2016 Uganda Demographic and Health Survey data using propensity-score matching. The exposure variable is the acceptability of gender norms justifying wife-beating measured on a binary scale and the outcomes are the respondent's lifetime experiences of sexual, physical, and emotional IPV. We matched respondents who accepted gender norms justifying wife-beating with those that never through a 1:1 nearest-neighbour matching with a caliper to achieve comparability on selected covariates. We then estimated the causal effects of acceptability of gender norms justifying wife-beating on the study outcomes using a logistic regression model. RESULTS: Results showed that a total of 4,821 (46.5%) out of 10,394 respondents reported that a husband is justified in beating his wife for specific reasons. Among these, the majority (3,774; 78.3%) were women compared to men (1,047; 21.7%). Overall, we found that men and women who accept gender norms justifying wife-beating are more likely to experience all three forms of IPV. In the sub-group analysis, men who justify wife-beating were more likely to experience emotional and physical IPV but not sexual IPV. However, women who justify wife-beating were more likely to experience all three forms of IPV. CONCLUSIONS: In conclusion, the acceptability of gender norms justifying wife-beating has a positive effect on experiences of different forms of IPV by men and women in Uganda. There is, therefore, a need for more research to study drivers for acceptance of gender norms justifying wife-beating to enable appropriate government agencies to put in place mechanisms to address the acceptability of gender norms justifying wife-beating at the societal level.

Effect of high-risk versus low-risk pregnancy at the first antenatal care visit on the occurrence of complication during pregnancy and labour or delivery in Kenya: a double-robust estimation.

OBJECTIVES: We evaluated the causal effects of high-risk versus low-risk pregnancy at the first antenatal care (ANC) visit on the occurrence of complications during pregnancy and labour or delivery among women in Kenya. METHODS: We designed a quasi-experimental study using observational data from a large mobile health wallet programme, with the exposure as pregnancy risk at the first ANC visit, measured on a binary scale (low vs high). Complications during pregnancy and at labour or delivery were the study outcomes on a binary scale (yes vs no). Causal effects of the exposure were examined using a double-robust estimation, reported as an OR with a 95% CI. RESULTS: We studied 4419 women aged 10-49 years (mean, 25.6±6.27 years), with the majority aged 20-29 years (53.4%) and rural residents (87.4%). Of 3271 women with low-risk pregnancy at the first ANC visit, 833 (25.5%) had complications during pregnancy while 1074 (32.8%) had complications at labour/delivery. Conversely, of 1148 women with high-risk pregnancy at the first ANC visit, 343 (29.9%) had complication during pregnancy while 488 (42.5%) had complications at labour delivery. Multivariable adjusted analysis showed that women with high-risk pregnancy at the time of first ANC attendance had a higher occurrence of pregnancy during pregnancy (adjusted OR (aOR) 1.22, 95% CI 1.02 to 1.46) and labour or delivery (aOR 1.20, 95% CI 1.03 to 1.41). In the double-robust estimation, a high-risk pregnancy at first ANC visit increased the occurrence of complications during pregnancy (OR 1.23, 95% CI 1.04 to 1.46) and labour or delivery (OR 1.24, 95% CI 1.07 to 1.45). CONCLUSION: Women with a high-risk pregnancy at the first ANC visit have an increased occurrence of complications during pregnancy and labour or delivery. These women should be identified early for close and appropriate obstetric and intrapartum monitoring and care to ensure maternal and neonatal survival.

Factors associated with viral load suppression among orphans and vulnerable children and adolescents living with HIV in Kenya.

While tremendous progress has been made on attaining HIV treatment goals (95-95-95), children's viral load suppression remains a challenge particularly among the orphans and vulnerable groups. In Sub Saharan Africa, there is limited evidence of specific interventions in orphans and vulnerable children (OVC) programs to support children and adolescents living with HIV (CALHIV) to attain durable viral load suppression. Through a large OVC cohort, the study sought to identify correlates of optimal viral load suppression among CALHIV in the Kenya OVC program. This cross-sectional study utilized data on CALHIV below the age of 18 years who were enrolled in the OVC program and actively receiving HIV care and treatment services from ART clinics across Kenya and with documented VL results between October 2019 and September 2020. To obtain a nationally representative sample, data was retrieved from USAID implementing partners' databases across the country. Association between selected variables and VL suppression (outcome of interest) were assessed using a multivariate mixed effect logistic regression model, using glmer function in the LME4 package in R. Factors associated with VL suppression included child's education status (aOR = 1.33; 95% CI: 1.07, 1.65), membership of a psychosocial support group (aOR = 1.258; 95% CI: 1.15, 1.38), and membership of a voluntary savings and lending association (VSLA) (aOR = 1.226; 95% CI: 1.129, 1.33). In addition, child's sex (aOR = 0.88; 95% CI: 0.83, 0.94), caregiver sex (aOR = 0.909; 95% CI: 0.839, 0.997) and "high" status for caregiver household vulnerability (aOR = 0.81; 95% CI: 0.71, 0.924), had an inverse relationship with VL suppression. CALHIV characteristics including child's sex, child's education status (whether currently active in school or inactive) and child's membership in a psychosocial support group were key determinants of VL suppression. Similarly, caregiver sex and membership in a voluntary savings and lending association also influence VL suppression.

Simple imputation methods versus direct likelihood analysis for missing item scores in multilevel educational data.

Missing data, such as item responses in multilevel data, are ubiquitous in educational research settings. Researchers in the item response theory (IRT) context have shown that ignoring such missing data can create problems in the estimation of the IRT model parameters. Consequently, several imputation methods for dealing with missing item data have been proposed and shown to be effective when applied with traditional IRT models. Additionally, a nonimputation direct likelihood analysis has been shown to be an effective tool for handling missing observations in clustered data settings. This study investigates the performance of six simple imputation methods, which have been found to be useful in other IRT contexts, versus a direct likelihood analysis, in multilevel data from educational settings. Multilevel item response data were simulated on the basis of two empirical data sets, and some of the item scores were deleted, such that they were missing either completely at random or simply at random. An explanatory IRT model was used for modeling the complete, incomplete, and imputed data sets. We showed that direct likelihood analysis of the incomplete data sets produced unbiased parameter estimates that were comparable to those from a complete data analysis. Multiple-imputation approaches of the two-way mean and corrected item mean substitution methods displayed varying degrees of effectiveness in imputing data that in turn could produce unbiased parameter estimates. The simple random imputation, adjusted random imputation, item means substitution, and regression imputation methods seemed to be less effective in imputing missing item scores in multilevel data settings.

Effect of comprehensive knowledge of HIV on risky sexual behaviours associated with HIV transmission among adult Ugandans: a propensity score-matched analysis.

OBJECTIVE: To evaluate the effect of comprehensive knowledge of HIV on extramarital sexual relationships and consistent condom use. DESIGN: Quasi-experimental study. SETTING: 20 880 households, Uganda. PARTICIPANTS: Married/cohabiting men and women, aged 15-54 years. METHODS: We applied propensity score-matched analysis and defined comprehensive knowledge of HIV as knowing that consistent use of condoms during sexual intercourse and having just one faithful partner without HIV reduces the chance of getting HIV, knowing that a healthy-looking person can have HIV and rejecting two local misconceptions (HIV can be transmitted by mosquito bites and by sharing food with a person who has HIV). The primary outcome was extramarital sexual relationship defined as involvement in a sexual relationship with a partner other than a spouse or cohabiting partner, within 12 months preceding the survey. The secondary outcome was consistent condom use, defined as using a condom at every sexual intercourse with any non-spouse/non-cohabiting partner over the past 12 months. RESULTS: Among 18 504 participants matched in a 1:1 ratio, comprehensive knowledge of HIV showed no effect on extramarital sexual relationships (OR 1.03, 95% CI 0.96 to 1.11) but improved consistent condom use among married/cohabiting couples in extramarital sexual relationships (OR 1.18, 95% CI 1.02 to 1.37). Among married/cohabiting men, comprehensive knowledge of HIV had no effect on extramarital sexual relationships (OR 0.95, 95% CI 0.83 to 1.08) but improved consistent use of condoms in extramarital sexual relationships (OR 1.31, 95% CI 1.04 to 1.66). However, among married/cohabiting females, there was no effect on both outcomes. CONCLUSIONS: Comprehensive knowledge of HIV has no effect on extramarital sexual relationships but increases consistent condom use among those in extramarital sexual relationships. There is a need to consistently provide correct HIV prevention messages among sexually active married/cohabiting couples in Uganda.

Prevalence and Risk Factors for Women's Reports of Past-Year Intimate Partner Violence: A Comparative Analysis of Six East African National Surveys.

Violence against women, in all its forms, has been acknowledged as a violation of basic human rights and research evidence shows that it could lead to adverse health consequences. In this study we aimed to determine the prevalence and coexistence of different forms of IPV as well as examine individual-level factors associated with ever experiencing any form of IPV in the 12 months preceding the survey using the most recent Demographic Health Survey data from six East African countries. Results show that the prevalence ranged between 16.5% (Burundi) and 29.3% (Uganda) for emotional, 16.8% (Ethiopia) and 26.6% (Tanzania) for physical, and 8.3% (Rwanda and Ethiopia) and 18.4% (Burundi) for sexual IPV. The prevalence of any IPV ranged from 26.7% to 39.3%. In terms of coexistence, 15.6% to 19.0% of women reported experiencing all the three forms of IPV, with higher proportions reporting experiencing two of the three forms of IPV. The prevalence of both physical and emotional IPV was highest in Tanzania (49.1%), both emotional and sexual IPV in Uganda (28.0%), and both physical and sexual IPV in Burundi (26.2%). A partner's use of alcohol and a woman's justification of wife beating were both statistically significant common risk factors for IPV across the six countries. Women whose partners got drunk often were found to be up to nine times more likely to experience IPV compared to those whose partners did not drink. Younger women and those with larger families were at an increased risk of experiencing IPV, while other significant factors were country specific. In conclusion, our findings highlight the need for integrated and context-specific approaches that deconstruct gendered norms related to power dynamics and patriarchal nuances at household and community level in order to holistically address different forms of IPV.