Estimating vaccine coverage in conflict settings using geospatial methods: a case study in Borno state, Nigeria.

Reliable estimates of subnational vaccination coverage are critical to track progress towards global immunisation targets and ensure equitable health outcomes for all children. However, conflict can limit the reliability of coverage estimates from traditional household-based surveys due to an inability to sample in unsafe and insecure areas and increased uncertainty in underlying population estimates. In these situations, model-based geostatistical (MBG) approaches offer alternative coverage estimates for administrative units affected by conflict. We estimated first- and third-dose diphtheria-tetanus-pertussis vaccine coverage in Borno state, Nigeria, using a spatiotemporal MBG modelling approach, then compared these to estimates from recent conflict-affected, household-based surveys. We compared sampling cluster locations from recent household-based surveys to geolocated data on conflict locations and modelled spatial coverage estimates, while also investigating the importance of reliable population estimates when assessing coverage in conflict settings. These results demonstrate that geospatially-modelled coverage estimates can be a valuable additional tool to understand coverage in locations where conflict prevents representative sampling.

Factors associated with suboptimal complementary feeding practices among mothers of infants and young children in India.

Objectives: To examine the current complementary feeding practices among infants and young children aged 6 to 23 months in India, and factors influencing these practices at child, parental, household and community levels. Material and methods: Data on 74,095 last-born children aged 6 to 23 months used in this study were obtained from the 2015 India Demographic and Health Survey (IDHS). Complementary feeding indicators (timely introduction of complementary foods to infants aged 6 to 8 months old, minimum meal frequency, minimum dietary diversity, and minimum acceptable diets) were estimated, and their associated factors were identified using descriptive and multivariate (logistic regression) analyses. Results: The prevalence of the timely introduction of complementary foods to infants aged 6 to 8 months was 45.1%. The proportion of children between ages 6 to 23 months who received the minimum meal frequency, minimum dietary diversity and minimum acceptable diets were 36%, 21% and 9.1%, respectively. Findings from the multivariate analyses revealed that mothers of infants delivered at home, mothers who had no antenatal check-up, mothers who are Hindus, mothers living in rural areas or those from the Western/Northern geographical regions of India were at higher risk of suboptimal complementary feeding practices.Conclusions. Our findings indicate that, among other factors, achieving the recommended four or more antenatal visits was consistently associated with improved complementary feeding practices. Thus, policies that ensure increased coverage and quality of antenatal check-up could improve complementary feeding practices of mothers in India, and help towards achieving sustainable development goal 2, targeted at eradicating hunger and malnutrition.

Temporal trends in stillbirth over eight decades in England and Wales: A longitudinal analysis of over 56 million births and lives saved by improvements in maternity care.

Background: Considering the public health importance of stillbirth, this study quantified the trends in stillbirths over eight decades in England and Wales. Methods: This longitudinal study utilized the publicly available aggregated data from the Office for National Statistics that captured maternity information for babies delivered in England and Wales from 1940 to 2019. We computed the trends in stillbirth with the associated incidence risk difference, incidence risk ratio, and extra lives saved per decade. Results: From 1940-2019, 56 906 273 births were reported. The stillbirth rate declined (85%) drastically up to the early 1980s. In the initial five decades, the estimated number of deaths per decade further decreased by 67 765 (9.49/1000 births) in 1940-1949, 2569 (0.08/1000 births) in 1950-1959, 9121 (3.50/1000 births) in 1960-1969, 15 262 (2.31/1000 births) in 1970-1979, and 10 284 (1.57/1000 births) in 1980-1989. However, the stillbirth rate increased by an additional 3850 (0.58/1000 births) stillbirths in 1990-1999 and 693 (0.11/1000 births) stillbirths in 2000-2009. The stillbirth rate declined again during 2010-2019, with 3714 fewer stillbirths (0.54/1000 births). The incidence of maternal age <20 years reduced over time, but pregnancy among older women (>35 years) increased. Conclusions: The stillbirth rate declined drastically, but the rate of decline slowed in the last three decades. Though teenage pregnancy (<20 years) had reduced, the prevalence of women with a higher risk of stillbirth may have risen due to an increase in advanced maternal age. Improved, more personalised care is required to reduce the stillbirth rate further.

Impact of pre-exposure and post-exposure prophylaxes prevention programme on HIV burden and services in a low-resource setting: a simulation modelling approach.

INTRODUCTION: sub-Saharan African countries contribute substantially to the global HIV disease burden. Despite this burden, and the promises that prevention could deliver, the implementation and uptake of HIV prevention programmes are still low. The study used the decision support system model to explore the potential impacts of prevention implementation on HIV burden (incidence) and service delivery. METHODS: an operational research technique known as discrete event simulation model was used to capture an individual patient´s pathways through the HIV care process from diagnosis to treatment and monitoring. The regular monitoring, over a 5-year period, including all the activities and resources utilized at each stage of the pathway were analysed, and the impact of increasing prevention measures for an HIV treatment service in a treatment centre in Nigeria was tested using the simulation model. RESULTS: forty-three patients currently access the Pre-Exposure Prophylaxis (PrEP) and Post Exposure Prophylaxis (PEP) annually, with a 20% and 80% split in the number of patients offered PrEP and PEP, respectively. Scenarios-based on increasing the number of people offered PrEP and PEP from 43 to 250 with a 50/50 split were tested. The outputs revealed improved preventive care by averting new HIV cases, reduction in service demand and utilization, but an increase in the required human resource as well as financial burden. In the next 5 years, the cumulative averted HIV cases are expected to increase from 2 and 5 people (baseline) to 24 and 20 people for PrEP and PEP, respectively. The potentially averted 2 cases per infected persons based on the basic reproductive number of HIV. CONCLUSION: the effective implementation of PrEP/PEP programme offers an additional safety measure to prevent HIV transmission in at-risk individuals and possibility of ending HIV epidemic.

Adherence to Guidelines in Postpartum Management of Hypertensive Disorders in Pregnancy in Tertiary Health Facilities in Nigeria: A Multi-centre Study.

Hypertensive disorders in pregnancy (HDPs) are a leading cause of maternal morbidity and mortality. Available guidelines for their postpartum management are expected to be optimally utilized. This study aimed to determine adherence to guidelines in selected Nigerian tertiary hospitals. It was nested in a cohort of women with HDPs who delivered in eight facilities between October 2017 and June 2018. Nine weeks after delivery, their cases were evaluated on prespecified indicators and supplemented with interviews. The level of adherence to the guidelines was determined using descriptive analyses, including frequencies, percentages, means, and standard deviations, as well as charts. Of the 366 participants, 33 (9%), 75 (20%), 200 (55%), and 58 (16%) had chronic hypertension, gestational hypertension, preeclampsia, and eclampsia, respectively. Only about a third had their blood pressure measured between postpartum days three and five. Similarly, a third of those with persistent hypertension (≥140/90 mmHg) were not on antihypertensive medications within the first week postpartum. In addition, 37% and 42% of participants were not counseled on contraceptives and early subsequent antenatal visits, respectively. Among those with preeclampsia/eclampsia, 93% were not offered postpartum screening for thromboprophylaxis. Although all women with preeclampsia/eclampsia remained hypertensive two weeks after discharge, only 24% had medical reviews. Overall, only 58% and 44% of indicators were adhered to among all HDPs and preeclampsia/eclampsia-specific indicators, respectively. Level of adherence to guidelines on postpartum management of HDPs in Nigerian tertiary hospitals is poor. It is recommended that institutionalization of guidelines be prioritized and linked to the entire continuum from preconception through longer term postpartum care.

HIV-MSS: A user-friendly management support system for better planning of HIV care services.

The advent of antiretroviral therapy (ART) has transformed HIV infection from a deadly disease to a manageable chronic condition. The life expectancy of people living with HIV has been prolonged dramatically. Therefore, health systems are now confronted with new challenges, with ever-increasing number of newly diagnosed cases, fuelling the pool of existing patients, with many comorbidities and requiring hospital admissions. Are health systems prepared to handle large and increasing numbers of people with HIV? We developed a HIV-Management Support System (MSS) to support service evaluation and management using simulation by capturing individual patient's pathways within HIV services in the United Kingdom. Two scenarios were tested: (1) the impact of increasing the number of diagnosed cases in steps of 5% on human resources and (2) the impact of treating all patients with ART on hospital admissions. A 5% increase in newly diagnosed HIV cases increases human resource requirements between 4% and 8%, whereas the impact of treating all HIV patients with ART on hospital admissions is far greater. HIV services are under intense pressure and managing patient and service needs are far more important than ever, hence the development of our HIV MSS is timely, to support better planning of services. Note that the HIV simulation model presented in this study is the first of its kind.

Prevalence and determinants of chronic kidney disease in women with hypertensive disorders in pregnancy in Nigeria: a cohort study.

BACKGROUND: Worldwide, hypertensive disorders in pregnancy (HDPs) complicate between 5 and 10% of pregnancies. Sub-Saharan Africa (SSA) is disproportionately affected by a high burden of HDPs and chronic kidney disease (CKD). Despite mounting evidence associating HDPs with the development of CKD, data from SSA are scarce. METHODS: Women with HDPs (n = 410) and normotensive women (n = 78) were recruited at delivery and prospectively followed-up at 9 weeks, 6 months and 1 year postpartum. Serum creatinine was measured at all time points and the estimated glomerular filtration rates (eGFR) using CKD-Epidemiology equation determined. CKD was defined as decreased eGFR< 60 mL/min/1.73m2 lasting for ≥ 3 months. Prevalence of CKD at 6 months and 1 year after delivery was estimated. Logistic regression analyses were conducted to evaluate risk factors for CKD at 6 months and 1 year postpartum. RESULTS: Within 24 h of delivery, 9 weeks, and 6 months postpartum, women with HDPs were more likely to have a decreased eGFR compared to normotensive women (12, 5.7, 4.3% versus 0, 2 and 2.4%, respectively). The prevalence of CKD in HDPs at 6 months and 1 year postpartum was 6.1 and 7.6%, respectively, as opposed to zero prevalence in the normotensive women for the corresponding periods. Proportions of decreased eGFR varied with HDP sub-types and intervening postpartum time since delivery, with pre-eclampsia/eclampsia showing higher prevalence than chronic and gestational hypertension. Only maternal age was independently shown to be a risk factor for decreased eGFR at 6 months postpartum (aOR = 1.18/year; 95%CI 1.04-1.34). CONCLUSION: Prior HDP was associated with risk of future CKD, with prior HDPs being more likely to experience evidence of CKD over periods of postpartum follow-up. Routine screening of women following HDP-complicated pregnancies should be part of a postpartum monitoring program to identify women at higher risk. Future research should report on both the eGFR and total urinary albumin excretion to enable detection of women at risk of future deterioration of renal function.

Effect of community antiretroviral therapy on treatment outcomes among stable antiretroviral therapy patients in Nigeria: A quasi experimental study.

OBJECTIVES: This study evaluates the effect of Community Anti-retroviral Groups on Immunologic, Virologic and clinical outcomes of stable Antiretroviral Therapy patients in Nigeria. METHOD: A cohort of 251 eligible adults (≥18 years) on first-line ART for at least 6 months with CD4 counts >200 cells/mm3 and viral load <1000 c/ml were devolved from 10 healthcare facilities to 51 community antiretroviral therapy groups. Baseline immunologic, virologic and clinical parameters were collected and community antiretroviral therapy group patients were followed up for a year after which Human Immunodeficiency Virus treatment outcomes at the baseline and a year after follow-up were compared using paired sample t-test. All the analyses were performed in STATA version 14. RESULT: Out of the 251 stable antiretroviral therapy adults enrolled, 186 (75.3%) were female, 52 (22.7%) had attained post-secondary education and the mean age of participants was 38 years (SD: 9.5). Also, 66 (27.9%) were employed while 125 (52.7%) were self-employed and 46(19.41%) unemployed. 246 (98.0%) of the participants were retained in care. While there was no statistically significant change in the CD4 counts (456cells/mm3 vs 481cells/mm3 P-0.489) and Log10 viral load (3.54c/ml vs 3.69c/ml P-0.359) after one year of devolvement into the community, we observed a significant increase in body weight (60.8 vs 65, P-0.01). CONCLUSION: This study demonstrates that community antiretroviral therapy has a potential of maintaining optimum treatment outcomes while improving adherence and retention, and reducing the burden of HIV treatment on the health facility. This study provides baseline information for further research and vital information for HIV program implementers planning to decentralize the management of stable antiretroviral therapy clients.

Prevalence and risk factors for obesity among elderly patients living with HIV/AIDS in a low-resource setting.

ABSTRACT: Obesity is associated with detrimental changes in cardiovascular and metabolic parameters, including blood pressure, dyslipidemia, markers of systemic inflammation, and insulin resistance. In the elderly living with the human immunodeficiency virus (EPLHIV), and being treated with antiretroviral medications, the obesity complications escalate and expose the elderly to the risk of noncommunicable diseases. Given that over 3 million EPLHIV in sub-Sahara Africa, we assessed the prevalence of obesity and its associated factors among EPLHIV in a low-resource setting.This was a cross sectional study of EPLHIV aged 50 years and older, being treated with antiretroviral medications from 2004 to 2018. HIV treatment data collected from multiple treatment sites were analyzed. Baseline characteristics of the participants were described, and multivariable relative risk model was applied to assess the associations between obesity (body mass index [BMI] ≥30 kg/m2) and the prespecified potential risk factors.Of the 134,652 in HIV cohort, 19,566 (14.5%) were EPLHIV: 12,967 (66.3%) were normal weight (18.5 ≤ BMI < 25), 4548 (23.2%) were overweight (25 ≤ BMI < 30), while 2,051 (10.5%) were obese (BMI ≥30). The average age the normal weight (57.1; standard deviation 6.6) and the obese (56.5; standard deviation 5.5) was similar. We observed that being an employed (relative risk [RR] 1.71; 95% confidence interval [CI] 1.48-2.00; P < .001), educated (RR 1.93; 95% CI 1.54-2.41; P < .001), and presence of hypertension (RR 1.78; 95% CI 1.44-2.20; P < .001), increased the risk of obesity. Also, being male (RR 0.38; 95% CI 0.33-0.44; P < .001), stages III/IV of the World Health Organization clinical stages of HIV (RR 0.58; 95% CI 0.50-0.68; P < .001), tenofovir-based regimen (RR 0.84; 95% CI 0.73-0.96, P < .001), and low CD4 count (RR 0.56; 95% CI 0.44-0.71; P < .001) were inversely associated with obesity.This study demonstrates that multiple factors are driving obesity prevalence in EPLHIV. The study provides vital information for policy-makers and HIV program implementers in implementing targeted-interventions to address obesity in EPLHIV. Its findings would assist in the implementation of a one-stop-shop model for the management of HIV and other comorbid medical conditions in EPLHIV.

Can an mhealth clinical decision-making support system improve adherence to neonatal healthcare protocols in a low-resource setting?

BACKGROUND: This study assessed health workers' adherence to neonatal health protocols before and during the implementation of a mobile health (mHealth) clinical decision-making support system (mCDMSS) that sought to bridge access to neonatal health protocol gap in a low-resource setting. METHODS: We performed a cross-sectional document review within two purposively selected clusters (one poorly-resourced and one well-resourced), from each arm of a cluster-randomized trial at two different time points: before and during the trial. The total trial consisted of 16 clusters randomized into 8 intervention and 8 control clusters to assess the impact of an mCDMSS on neonatal mortality in Ghana. We evaluated health workers' adherence (expressed as percentages) to birth asphyxia, neonatal jaundice and cord sepsis protocols by reviewing medical records of neonatal in-patients using a checklist. Differences in adherence to neonatal health protocols within and between the study arms were assessed using Wilcoxon rank-sum and permutation tests for each morbidity type. In addition, we tracked concurrent neonatal health improvement activities in the clusters during the 18-month intervention period. RESULTS: In the intervention arm, mean adherence was 35.2% (SD = 5.8%) and 43.6% (SD = 27.5%) for asphyxia; 25.0% (SD = 14.8%) and 39.3% (SD = 27.7%) for jaundice; 52.0% (SD = 11.0%) and 75.0% (SD = 21.2%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. In the control arm, mean adherence was 52.9% (SD = 16.4%) and 74.5% (SD = 14.7%) for asphyxia; 45.1% (SD = 12.8%) and 64.6% (SD = 8.2%) for jaundice; 53.8% (SD = 16.0%) and 60.8% (SD = 11.7%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. We observed nonsignificant improvement in protocol adherence in the intervention clusters but significant improvement in protocol adherence in the control clusters. There were 2 concurrent neonatal health improvement activities in the intervention clusters and over 12 in the control clusters during the intervention period. CONCLUSION: Whether mHealth interventions can improve adherence to neonatal health protocols in low-resource settings cannot be ascertained by this study. Neonatal health improvement activities are however likely to improve protocol adherence. Future mHealth evaluations of protocol adherence must account for other concurrent interventions in study contexts.

Cohort profile: the Nigerian HIV geriatric cohort study.

BACKGROUND: The Nigerian HIV Geriatric Cohort (NHGC) is a longitudinal cohort setup to learn how elderly people living with HIV (EPLHIV) in Nigeria fare, despite not being prioritized by the national treatment program, and to deepen knowledge for their differentiated care and achieve better outcomes. In this paper, we describe data collected on sociodemographic and clinical data from EPLHIV from the inception of Nigeria's national HIV program to 2018. METHODS: Patient-level data spanning the period 2004 to 2018, obtained from comprehensive HIV treatment hospitals, that are supported by four major PEPFAR-implementing partners in Nigeria were used. These 4 entities collaborated as member organizations of the Nigeria Implementation Science Alliance. We defined elderly as those aged 50 years and above. From deidentified treatment records, demographic and clinical data of EPLHIV ≥50-year-old at ART initiation during the review period was extracted, merged into a single REDcap® database, and described using STATA 13. RESULTS: A total of 101,652 EPLHIV were analysed. Women accounted for 53,608 (53%), 51,037 (71%) of EPLHIV identified as married and 33,446 (51%) unemployed. Median age was 57.1 years (IQR 52-60 years) with a median duration on ART treatment of 4.1 years (IQR 1.7-7.1 years). ART profile showed that 97,586 (96%) were on 1st-line and 66,125 (65%) were on TDF-based regimens. Median body mass index (BMI) was 22.2 kg/m2 (IQR 19.5-25.4 kg/m2) with 43,012 (55%), 15,081 (19%) and 6803 (9%) showing normal (BMI 18.5 - < 25 kg/m2), overweight (BMI 25 - < 30 kg/m2) and obese (BMI ≥30 kg/m2) ranges respectively. Prevalence of hypertension (systolic-BP > 140 mmHg or diastolic-BP > 90 mmHg) was 16,201 (21%). EPLHIV median CD4 count was 381 cells/µL (IQR 212-577 cells/µL) and 26,687 (82%) had a viral load result showing < 1000copies/ml within one year of their last visit. As for outcomes at their last visit, 62,821 (62%) were on active-in-treatment, 28,463 (28%) were lost-to-follow-up, 6912 (7%) died and 2456 (3%) had stopped or transferred out. Poor population death records and aversion to autopsies makes it almost impossible to estimate AIDS-related deaths. CONCLUSIONS: This cohort describes the clinical and non-clinical profile of EPLHIV in Nigeria. We are following up the cohort to design and implement intervention programs, develop prognostic models to achieve better care outcomes for EPLHIV. This cohort would provide vital information for stakeholders in HIV prevention, care and treatment to understand the characteristics of EPLHIV.

Prognostic models for adverse pregnancy outcomes in low-income and middle-income countries: a systematic review.

INTRODUCTION: Ninety-nine per cent of all maternal and neonatal deaths occur in low-income and middle-income countries (LMIC). Prognostic models can provide standardised risk assessment to guide clinical management and can be vital to reduce and prevent maternal and perinatal mortality and morbidity. This review provides a comprehensive summary of prognostic models for adverse maternal and perinatal outcomes developed and/or validated in LMIC. METHODS: A systematic search in four databases (PubMed/Medline, EMBASE, Global Health Library and The Cochrane Library) was conducted from inception (1970) up to 2 May 2018. Risk of bias was assessed with the PROBAST tool and narratively summarised. RESULTS: 1741 articles were screened and 21 prognostic models identified. Seventeen models focused on maternal outcomes and four on perinatal outcomes, of which hypertensive disorders of pregnancy (n=9) and perinatal death including stillbirth (n=4) was most reported. Only one model was externally validated. Thirty different predictors were used to develop the models. Risk of bias varied across studies, with the item 'quality of analysis' performing the least. CONCLUSION: Prognostic models can be easy to use, informative and low cost with great potential to improve maternal and neonatal health in LMIC settings. However, the number of prognostic models developed or validated in LMIC settings is low and mirrors the 10/90 gap in which only 10% of resources are dedicated to 90% of the global disease burden. External validation of existing models developed in both LMIC and high-income countries instead of developing new models should be encouraged. PROSPERO REGISTRATION NUMBER: CRD42017058044.

Effect of community treatment initiative on antiretroviral therapy uptake among linkage-resistant people living with HIV in Northern Nigeria.

BACKGROUND: Community Treatment Initiative (CTI) was developed in northern Nigeria as an intervention to link a cohort of people living with HIV (PLHIV) who refused antiretroviral treatment through a conventional linkage method to care and treatment. The CTI attempted to take treatment to PLHIV in the community. METHODS: This was a non-control interventional study that evaluated the proportion of linkage-resistant PLHIV linked to treatment through the CTI in nine geographical areas. Data were collected between October and December 2015. Linkage-resistant PLHIV were identified and linked to treatment using the CTI. Data were analyzed using Excel and IBM SPSS version 20.0. The simple proportion was used to estimate the linkage-resistant PLHIV who were eventually linked and retained in care and who ultimately achieved virological suppression (viral load <1000 copies/ml). The Chi-square test was used and the level of significance set at a p-value of <0.05. RESULTS: An estimated 541 (20%) PLHIV (239 (44.2%) male, 302 (55.8%) female) seen from October to December 2015 refused linkage to treatment. This was statistically significant at a p-value of <0.0001. Three hundred and seventy-seven (69.7%) of the PLHIV who refused linkage to treatment eventually accepted treatment using an alternative community treatment method; this was significant (p<0.0001). The 6-month retention rate for PLHIV who accepted the alternative treatment method was 88.1% (n=332); this was significant (p<0.0001). Seventy-eight percent of those retained in care attained virological suppression. CONCLUSIONS: The CTI improved linkage to care and treatment for a cohort of linkage-resistant PLHIV. Focus on this cohort of linkage-resistant positive clients is required to achieve HIV epidemic control.

The effect of an mHealth clinical decision-making support system on neonatal mortality in a low resource setting: A cluster-randomized controlled trial.

BACKGROUND: MHealth interventions promise to bridge gaps in clinical care but documentation of their effectiveness is limited. We evaluated the utilization and effect of an mhealth clinical decision-making support intervention that aimed to improve neonatal mortality in Ghana by providing access to emergency neonatal protocols for frontline health workers. METHODS: In the Eastern Region of Ghana, sixteen districts were randomized into two study arms (8 intervention and 8 control clusters) in a cluster-randomized controlled trial. Institutional neonatal mortality data were extracted from the District Health Information System-2 during an 18-month intervention period. We performed an intention-to-treat analysis and estimated the effect of the intervention on institutional neonatal mortality (primary outcome measure) using grouped binomial logistic regression with a random intercept per cluster. This trial is registered at ClinicalTrials.gov (NCT02468310 ) and Pan African Clinical Trials Registry (PACTR20151200109073). FINDINGS: There were 65,831 institutional deliveries and 348 institutional neonatal deaths during the study period. Overall, 47 âˆ™ 3% of deliveries and 56 âˆ™ 9% of neonatal deaths occurred in the intervention arm. During the intervention period, neonatal deaths increased from 4 âˆ™ 5 to 6 âˆ™ 4 deaths and, from 3 âˆ™ 9 to 4 âˆ™ 3 deaths per 1000 deliveries in the intervention arm and control arm respectively. The odds of neonatal death was 2⋅09 (95% CI (1 âˆ™ 00;4 âˆ™ 38); p = 0 âˆ™ 051) times higher in the intervention arm compared to the control arm (adjusted odds ratio). The correlation between the number of protocol requests and the number of deliveries per intervention cluster was 0 âˆ™ 71 (p = 0 âˆ™ 05). INTERPRETATION: The higher risk of institutional neonatal death observed in intervention clusters may be due to problems with birth and death registration, unmeasured and unadjusted confounding, and unintended use of the intervention. The findings underpin the need for careful and rigorous evaluation of mHealth intervention implementation and effects. FUNDING: Netherlands Foundation for Scientific Research - WOTRO, Science for Global Development; Utrecht University.

Using Mobile Health to Support Clinical Decision-Making to Improve Maternal and Neonatal Health Outcomes in Ghana: Insights of Frontline Health Worker Information Needs.

BACKGROUND: Developing and maintaining resilient health systems in low-resource settings like Ghana requires innovative approaches that adapt technology to context to improve health outcomes. One such innovation was a mobile health (mHealth) clinical decision-making support system (mCDMSS) that utilized text messaging (short message service, SMS) of standard emergency maternal and neonatal protocols via an unstructured supplementary service data (USSD) on request of the health care providers. This mCDMSS was implemented in a cluster randomized controlled trial (CRCT) in the Eastern Region of Ghana. OBJECTIVE: This study aimed to analyze the pattern of requests made to the USSD by health workers (HWs). We assessed the relationship between requests made to the USSD and types of maternal and neonatal morbidities reported in health facilities (HFs). METHODS: For clusters in the intervention arm of the CRCT, all requests to the USSD during the 18-month intervention period were extracted from a remote server, and maternal and neonatal health outcomes of interest were obtained from the District Health Information System of Ghana. Chi-square and Fisher exact tests were used to compare the proportion and type of requests made to the USSD by cluster, facility type, and location; whether phones accessing the intervention were shared facility phones or individual-use phones (type-of-phone); or whether protocols were accessed during the day or at night (time-of-day). Trends in requests made were analyzed over 3 6-month periods. The relationship between requests made and the number of cases reported in HFs was assessed using Spearman correlation. RESULTS: In total, 5329 requests from 72 (97%) participating HFs were made to the intervention. The average number of requests made per cluster was 667. Requests declined from the first to the third 6-month period (44.96% [2396/5329], 39.82% [2122/5329], and 15.22% [811/5329], respectively). Maternal conditions accounted for the majority of requests made (66.35% [3536/5329]). The most frequently accessed maternal conditions were postpartum hemorrhage (25.23% [892/3536]), other conditions (17.82% [630/3536]), and hypertension (16.49% [583/3536]), whereas the most frequently accessed neonatal conditions were prematurity (20.08% [360/1793]), sepsis (15.45% [277/1793]), and resuscitation (13.78% [247/1793]). Requests made to the mCDMSS varied significantly by cluster, type of request (maternal or neonatal), facility type and its location, type-of-phone, and time-of-day at 6-month interval (P<.001 for each variable). Trends in maternal and neonatal requests showed varying significance over each 6-month interval. Only asphyxia and sepsis cases showed significant correlations with the number of requests made (r=0.44 and r=0.79; P<.001 and P=.03, respectively). CONCLUSIONS: There were variations in the pattern of requests made to the mCDMSS over time. Detailed information regarding the use of the mCDMSS provides insight into the information needs of HWs for decision-making and an opportunity to focus support for HW training and ultimately improved maternal and neonatal health.

Prevalence of hypertension among patients aged 50 and older living with human immunodeficiency virus.

BACKGROUND: Hypertension is one of the common medical conditions observed among patients aged 50 years and elder living with HIV (EPLWH) and to date no systematic review has estimated its global prevalence. PURPOSE: To conduct a systematic review to estimate the global prevalence of hypertension among EPLWH. DATA SOURCES: PubMed/MEDLINE, Embase, the Cochrane Library, and Global Health databases for relevant publications up till May 25, 2018. STUDY SELECTION: Observational studies (cohort or cross-sectional studies) that estimated the prevalence of hypertension among EPLWH. DATA EXTRACTION: Required data were extracted independently by three reviewers and the main outcome was hypertension prevalence among EPLWH. DATA SYNTHESIS: The 24 (n = 29,987) eligible studies included were conducted in North America, Europe, Africa, and Asia. A low level bias threat to the estimated hypertension prevalence rates was observed. The global prevalence of hypertension among EPLWH was estimated at 42.0% (95% CI 29.6%-55.4%), I = 100%. The subgroup analysis showed that North America has the highest prevalence of hypertension 50.2% (95% CI 29.2% -71.2%) followed by Europe 37.8% (95% CI 30.7%-45.7%) sub-Saharan Africa 31.9% (95% CI 18.5% -49.2%) and Asia 31.0% (95% CI 26.1%-36.3%). We found the mean age of the participants explaining a considerable part of variation in hypertension prevalence. CONCLUSION: This study demonstrated that two out of five EPLWH are hypertensive. North America appears to have the highest prevalence of hypertension followed by Europe, sub-Saharan Africa (SSA) and Asia respectively. Findings from this study can be utilized to integrate hypertension management to HIV management package. (Registration number: CRD42018103069).

Country Characteristics and Variation in Diabetes Prevalence among Asian Countries - an Ecological Study.

OBJECTIVES: To determine the variation in diabetes prevalence across Asian countries and its relationship with the quality of health system and socioeconomic characteristics of the country. METHODOLOGY: An ecological analysis was conducted using publicly available data from the World Bank, the World Health Organization and the International Diabetes Federation. Geographical variation in diabetes prevalence across countries was examined using control charts while the relationships between country-level determinants and diabetes prevalence were investigated using linear regression analysis. RESULTS: The control chart shows special-cause variation in diabetes prevalence in 21 (58%) of the Asian countries; nine countries were below the 99.8% control limits while twelve were above it.Fifteen (42%) countries suggest common-cause variation. Three country characteristics independently associated with diabetes prevalence were hypertension prevalence (OR 0.39, 95% CI 0.22 to 0.55; p-value<0.001), obesity prevalence (OR 0.15, 95% CI 0.13 to 0.18; p-value<0.001), and quality of health care governance (OR 0.18, 95% CI 0.04 to 0.34; p-value=0.02). CONCLUSIONS: There is a considerable geographical variation in diabetes prevalence across Asian countries. A substantial part of this variation could be explained by differences in the quality of health care governance, hypertension prevalence and obesity prevalence.

Addressing the under-reporting of adverse drug reactions in public health programs controlling HIV/AIDS, Tuberculosis and Malaria: A prospective cohort study.

BACKGROUND: Adverse Drug Reactions (ADRs) are a major clinical and public health problem world-wide. The prompt reporting of suspected ADRs to regulatory authorities to activate drug safety surveillance and regulation appears to be the most pragmatic measure for addressing the problem. This paper evaluated a pharmacovigilance (PV) training model that was designed to improve the reporting of ADRs in public health programs treating the Human Immunodeficiency Virus (HIV), Tuberculosis (TB) and Malaria. METHODS: A Structured Pharmacovigilance and Training Initiative (SPHAR-TI) model based on the World Health Organization accredited Structured Operational Research and Training Initiative (SOR-IT) model was designed and implemented over a period of 12 months. A prospective cohort design was deployed to evaluate the outcomes of the model. The primary outcomes were knowledge gained and Individual Case Safety Reports (ICSR) (completed adverse drug reactions monitoring forms) submitted, while the secondary outcomes were facility based Pharmacovigilance Committees activated and health facility healthcare workers trained by the participants. RESULTS: Fifty-five (98%) participants were trained and followed up for 12 months. More than three quarter of the participants have never received training on pharmacovigilance prior to the course. Yet, a significant gain in knowledge was observed after the participants completed a comprehensive training for six days. In only seven months, 3000 ICSRs (with 100% completeness) were submitted, 2,937 facility based healthcare workers trained and 46 Pharmacovigilance Committees activated by the participants. Overall, a 273% increase in ICSRs submission to the National Agency for Food and Drug Administration and Control (NAFDAC) was observed. CONCLUSION: Participants gained knowledge, which tended to increase the reporting of ADRs. The SPHAR-TI model could be an option for strengthening the continuous reporting of ADRs in public health programs in resource limited settings.

Effect of clients Strategic Index Case Testing on community-based detection of HIV infections (STRICT study).

BACKGROUND: Strategic Index Case Testing (STRICT), a form of partner notification service, was initiated to track, identify and notify sexual partners of people living with HIV (Index clients) with the sole aim of testing them to determine their HIV status and linking clients who are positive to Anti-Retroviral Therapy (ART). This research analyzed the HIV sero-prevalence among sexual partners of HIV positive clients using STRICT and determines the role of STRICT in HIV epidemic control. METHODS: This is a non-control Interventional study that determined the impact of Strategic Index Case Testing (STRICT) on detecting previously undiagnosed HIV infections among sexual partners of positive index clients. This study was conducted in seven Local Government Areas (LGAs) of Karu, Nasarawa, Lafia, Doma, AMAC, Bwari, and Ushongo. These LGAs were selected for HIV epidemic control due to projected high prevalence of HIV from previous program level data. HTS was offered to sexual partners of index PLHIV from facility and community within the LGAs. Index clients were PLHIV diagnosed from outreaches, hot spots set up in strategic places and Provider Initiated Testing and Counseling (PITC) in comprehensive and primary health care facilities. Newly diagnosed PLHIV and those already enrolled and commenced on ART from October 2015 to July 2016 were identified from source registers. These index clients were counseled on how to notify their sexual partners about their HIV status and on bringing them for HIV Testing and Counseling (HTS). Those unable to do so after a given period of time were assisted by health workers in informing their various sexual partners based on the confidential agreement and informed consent signed by the Index clients. FINDINGS: A total of 1277 index cases were counseled and interviewed with 879 index clients agreeing to disclosure, giving a disclosure rate of 68.3%. We identified 888 sexual partners from the interviews and traced 870 (97.9%) sexual contacts. A total of 741 (85.2%) of 870 sexual contacts traced were tested for HIV, out of which 378 (51%) tested positive using an HIV rapid test kit, and this was statistically significant at P Value=0.0254. A total of 348 (92.1%) out of 378 HIV positive sexual partners were immediately commenced on ART using the recommended UNAIDS Test and Treat approach to HIV epidemic control. INTERPRETATION: STRICT identifies the need for reaching out to sexual partners of index clients and providing them with HIV Testing Services (HTS) as they belong to a high risk priority population and also linking them to care and treatment. This group of people must be reached with HTS strategies in order to end the HIV epidemic as evidenced by high sero-prevalence of 51% among them.