Protective efficacy of the oral vaccine Tc24:Co1 produced in Schizochytrium sp. against Trypanosoma cruzi infection in a mouse model.

Trypanosoma cruzi parasite - causal Chagas disease agent - affects about 7 million people; no vaccine is available, and current medications have not been entirely effective. Multidisciplinary efforts are necessary for developing clinical vaccine prototypes. Thus, this research study aims to assess the expressed and whole-cell administration protection of the oral vaccine prototype Tc24:Co1 using Schizochytrium sp. microalga. High recombinant protein expression yields (675 µg/L) of algal culture were obtained. Additionally, Schizochytrium sp.-Tc24:Co1 resulted stable at 4 °C for up to six months and at 25 °C for three months. After receiving four oral doses of the vaccine, the mice showed a significant humoral immune response and a parasitemia reduction associated with a lack of heart inflammatory damage compared with the unvaccinated controls. The Schizochytrium sp.-Tc24:Co1 vaccine demonstrates to be promising as a prototype for further development showing protective effects against a T. cruzi challenge in a mouse model.

Assessment of the quality of the vital registration system for under-5 mortality in Yucatan, Mexico.

INTRODUCTION: Vital registration is an important element in health information systems which can inform policy and strengthen health systems. Mexico has a well-functioning vital registration system; however, there is still room for improvement, especially for deaths of children under 5. This study assesses the quality of the vital registration system in capturing deaths and evaluates the quality of cause of death certification in under-5 deaths in Yucatan, Mexico. METHODS: We collected information on under-5 deaths that occurred in 2015 and 2016 in Yucatan, Mexico. We calculated the Vital Statistics Performance Index (VSPI) to have a general assessment of the vital registration performance. We examined the agreement between vital registration records and medical records at the individual and population levels using the chance-corrected concordance (CCC) and cause-specific mortality fraction (CSMF) accuracy as quality metrics. RESULTS: We identified 966 records from the vital registry for all under-5 deaths, and 390 were linked to medical records of deaths occurring at public hospitals. The Yucatan vital registration system captured 94.8% of the expected under-5 deaths, with an overall VSPI score of 87.2%. Concordance between underlying cause of death listed in the vital registry and the cause determined by the medical record review varied substantially across causes, with a mean overall chance-corrected concordance across causes of 6.9% for neonates and 46.9% for children. Children had the highest concordance for digestive diseases, and neonates had the highest concordance for meningitis/sepsis. At the population level, the CSMF accuracy for identifying the underlying cause listed was 35.3% for neonates and 67.7% for children. CONCLUSIONS: Although the vital registration system has overall good performance, there are still problems in information about causes of death for children under 5 that are related mostly to certification of the causes of death. The accuracy of information can vary substantially across age groups and causes, with causes reported for neonates being generally less reliable than those for older children. Results highlight the need to implement strategies to improve the certification of causes of death in this population.

Impact of the Salud Mesoamerica Initiative on delivery care choices in Guatemala, Honduras, and Nicaragua.

BACKGROUND: The Salud Mesoamérica Initiative (SMI) is a public-private collaboration aimed to improve maternal and child health conditions in the poorest populations of Mesoamerica through a results-based aid mechanism. We assess the impact of SMI on the staffing and availability of equipment and supplies for delivery care, the proportion of institutional deliveries, and the proportion of women who choose a facility other than the one closest to their locality of residence for delivery. METHODS: We used a quasi-experimental design, including baseline and follow-up measurements between 2013 and 2018 in intervention and comparison areas of Guatemala, Nicaragua, and Honduras. We collected information on 8754 births linked to the health facility closest to the mother's locality of residence and the facility where the delivery took place (if attended in a health facility). We fit difference-in-difference models, adjusting for women's characteristics (age, parity, education), household characteristics, exposure to health promotion interventions, health facility level, and country. RESULTS: Equipment, inputs, and staffing of facilities improved after the Initiative in both intervention and comparison areas. After adjustment for covariates, institutional delivery increased between baseline and follow-up by 3.1 percentage points (ß = 0.031, 95% CI -0.03, 0.09) more in intervention areas than in comparison areas. The proportion of women in intervention areas who chose a facility other than their closest one to attend the delivery decreased between baseline and follow-up by 13 percentage points (ß = - 0.130, 95% CI -0.23, - 0.03) more than in the comparison group. CONCLUSIONS: Results indicate that women in intervention areas of SMI are more likely to go to their closest facility to attend delivery after the Initiative has improved facilities' capacity, suggesting that results-based aid initiatives targeting poor populations, like SMI, can increase the use of facilities closest to the place of residence for delivery care services. This should be considered in the design of interventions after the COVID-19 pandemic may have changed health and social conditions.

Performance of passive case detection for malaria surveillance: results from nine countries in Mesoamerica and the Dominican Republic.

BACKGROUND: In malaria elimination settings, available metrics for malaria surveillance have been insufficient to measure the performance of passive case detection adequately. An indicator for malaria suspected cases with malaria test (MSCT) is proposed to measure the rate of testing on persons presenting to health facilities who satisfy the definition of a suspected malaria case. This metric does not rely on prior knowledge of fever prevalence, seasonality, or external denominators, and can be used to compare detection rates in suspected cases within and between countries, including across settings with different levels of transmission. METHODS: To compute the MSCT, an operational definition for suspected malaria cases was established, including clinical and epidemiological criteria. In general, suspected cases included: (1) persons with fever detected in areas with active malaria transmission; (2) persons with fever identified in areas with no active transmission and travel history to, or residence in areas with active transmission (either national or international); and (3) persons presenting with fever, chills and sweating from any area. Data was collected from 9 countries: Belize, Colombia (in areas with active transmission), Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Panama (September-March 2020). A sample of eligible medical records for 2018 was selected from a sample of health facilities in each country. An algorithm was constructed to assess if a malaria test was ordered or performed for cases that met the suspected case definition. RESULTS: A sample of 5873 suspected malaria cases was obtained from 239 health facilities. Except for Nicaragua and Colombia, malaria tests were requested in less than 10% of all cases. More cases were tested in areas with active transmission than areas without cases. Travel history was not systematically recorded in any country. CONCLUSIONS: A statistically comparable, replicable, and standardized metric was proposed to measure suspected malaria cases with a test (microscopy or rapid diagnostic test) that enables assessing the performance of passive case detection. Cross-country findings have important implications for malaria and infectious disease surveillance, which should be promptly addressed as countries progress towards malaria elimination. Local and easy-to-implement tools could be implemented to assess and improve passive case detection.

Two strains of a novel begomovirus encoding Rep proteins with identical ß1 strands but different ß5 strands are not compatible in replication.

Geminiviruses have genomes composed of single-stranded DNA molecules and encode a rolling-circle replication (RCR) initiation protein ("Rep"), which has multiple functions. Rep binds to specific repeated DNA motifs ("iterons"), which are major determinants of virus-specific replication. The particular amino acid (aa) residues that determine the preference of a geminivirus Rep for specific iterons (i.e., the trans-acting replication "specificity determinants", or SPDs) are largely unknown, but diverse lines of evidence indicate that most of them are closely associated with the so-called RCR motif I (FLTYP), located in the first 12-19 aa residues of the protein. In this work, we characterized two strains of a novel begomovirus, rhynchosia golden mosaic Sinaloa virus (RhGMSV), that were incompatible in replication in pseudorecombination experiments. Systematic comparisons of the Rep proteins of both RhGMSV strains in the DNA-binding domain allowed the aa residues at positions 71 and 74 to be identified as the residues most likely to be responsible for differences in replication specificity. Residue 71 is part of the ß-5 strand structural element, which was predicted in previous studies to contain Rep SPDs. Since the Rep proteins encoded by both RhGMSV strains are identical in their first 24 aa residues, where other studies have mapped potential SPDs, this is the first study lending direct support to the notion that geminivirus Rep proteins contain separate SPDs in their N-terminal domain.

Tackling equitable coverage and quality of care for neonates in hospitals: a pre-post assessment on asphyxia interventions in Mesoamerica.

BACKGROUND: Intrapartum-related hypoxic events, or birth asphyxia, causes one-fourth of neonatal deaths globally and in Mesoamerica. Multidimensional care for asphyxia must be implemented to ensure timely and effective care of newborns. Salud Mesoamérica Initiative (SMI) is a performance-based program seeking to improve maternal and child health for low-income areas of Central America. Our objective was to assess the impact of SMI on neonatal asphyxia care in health centers and hospitals in the region. METHODS: A pre-post design. Two hundred forty-eight cases of asphyxia were randomly selected from medical records at baseline (2011-2013) and at second-phase follow-up (2017-2018) in Mexico (state of Chiapas), Honduras, Nicaragua, and Guatemala as part of the SMI Initiative evaluation. A facility survey was conducted to assess quality of health care and the management of asphyxia. The primary outcome was coverage of multidimensional care for the management of asphyxia, consisting of a skilled provider presence at birth, immediate assessment, initial stabilization, and appropriate resuscitation measures of the newborn. Data were analyzed using multivariable logistic regression. RESULTS: Management of asphyxia improved significantly after SMI. Proper care of asphyxia in intervention areas was better (OR = 2.4; 95% CI = 1.3-4.6) compared to baseline. Additionally, multidimensional care was significantly higher in Honduras (OR = 4.0; 95% CI = 1.4-12.0) than in Mexico. Of the four multidimensional care components, resuscitation showed the greatest progress by follow-up (65.7%) compared to baseline (38.7%). CONCLUSION: SMI improved the care for neonatal asphyxia management across all levels of health care in all countries. Our findings show that proper training and adequate supplies can improve health outcomes in low-income communities. SMI provides a model for improving health care in other settings.

Increased removal of cadmium by Chlamydomonas reinhardtii modified with a synthetic gene for γ-glutamylcysteine synthetase.

Bioremediation with genetically modified microalgae is becoming an alternative to remove metalloids and metals such as cadmium, a contaminant produced in industrial processes and found in domestic waste. Its removal is important in several countries including Mexico, where the San Luis Potosi region has elevated levels of it. We generated a construct with a synthetic gene for γ-glutamylcysteine synthetase and employed it in the chloroplast transformation of Chlamydomonas reinhardtii. In dose-response kinetics with media containing from 1 to 20 mg/L of cadmium, both the transplastomic clone and the wild-type strain grew similarly, but the former removed up to 32% more cadmium. While the growth of both decreased with higher concentrations of cadmium, the transplastomic clone removed 20 ± 9% more than the wild-type strain. Compared to the wild-type strain, in the transplastomic clone the activity of glutathione S-transferase and the intracellular glutathione increased up to 2.1 and 1.9 times, respectively, in media with 2.5 and 10 mg/mL of cadmium. While 20 mg/L of cadmium inhibited the growth of both, the transplastomic clone gradually duplicated. These results confirm the expression of the synthetic gene gshA in the transformed strain as revealed in its increased removal uptake and metabolic response.

Antenatal care as a means to increase participation in the continuum of maternal and child healthcare: an analysis of the poorest regions of four Mesoamérican countries.

BACKGROUND: Antenatal care (ANC) is a means to identify high-risk pregnancies and educate women so that they might experience a healthier delivery and outcome. There is a lack of evidence about whether receipt of ANC is an effective strategy for keeping women in the system so they partake in other maternal and child interventions, particularly for poor women. The present analysis examines whether ANC uptake is associated with other maternal and child health behaviors in poor mothers in Guatemala, Honduras, Nicaragua, and Mexico (Chiapas). METHODS: We conducted a cross-sectional survey of women regarding their uptake of ANC for their most recent delivery in the last two years and their uptake of selected services and healthy behaviors along a continuity of maternal and child healthcare. We conducted logistic regressions on a sample of 4844 births, controlling for demographic, household, and maternal characteristics to understand the relationship between uptake of ANC and later participation in the continuum of care. RESULTS: Uptake of four ANC visits varied by country from 17.0% uptake in Guatemala to 81.4% in Nicaragua. In all countries but Nicaragua, ANC was significantly associated with in-facility delivery (IFD) (Guatemala odds ratio [OR] = 5.28 [95% confidence interval [CI] 3.62-7.69]; Mexico OR = 5.00 [95% CI: 3.41-7.32]; Honduras OR = 2.60 [95% CI: 1.42-4.78]) and postnatal care (Guatemala OR = 4.82 [95% CI: 3.21-7.23]; Mexico OR = 4.02 [95% CI: 2.77-5.82]; Honduras OR = 2.14 [95% CI: 1.26-3.64]), but did not appear to have any positive relationship with exclusive breastfeeding habits or family planning methods, which may be more strongly determined by cultural influences. CONCLUSIONS: Our results demonstrate that uptake of the WHO-recommended four ANC visits has limited effectiveness on uptake of services in some poor populations in Mesoamérica. Our study highlights the need for continued and varied efforts in these populations to increase both the uptake and the effectiveness of ANC in encouraging positive and lasting effects on women's uptake of health care services.

Methods to measure quality of care and quality indicators through health facility surveys in low- and middle-income countries.

OBJECTIVE: Present methods to measure standardized, replicable and comparable metrics to measure quality of medical care in low- and middle-income countries. DESIGN: We constructed quality indicators for maternal, neonatal and child care. To minimize reviewer judgment, we transformed criteria from check-lists into data points and decisions into conditional algorithms. Distinct criteria were established for each facility level and type of care. Indicators were linked to discharge diagnoses. We designed electronic abstraction tools using computer-assisted personal interviewing software. SETTING: We present results for data collected in the poorest areas of Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the state of Chiapas in Mexico (January-October 2014). RESULTS: We collected data from 12 662 medical records. Indicators show variations of quality of care between and within countries. Routine interventions, such as quality antenatal care (ANC), immediate neonatal care and postpartum contraception, had low levels of compliance. Records that complied with quality ANC ranged from 68.8% [confidence interval (CI):64.5-72.9] in Costa Rica to 5.7% [CI:4.0-8.0] in Guatemala. Less than 25% of obstetric and neonatal complications were managed according to standards in all countries. CONCLUSIONS: Our study underscores that, with adequate resources and technical expertise, collecting data for quality indicators at scale in low- and middle-income countries is possible. Our indicators offer a comparable, replicable and standardized framework to identify variations on quality of care. The indicators and methods described are highly transferable and could be used to measure quality of care in other countries.

Arsenic removal using Chlamydomonas reinhardtii modified with the gene acr3 and enhancement of its performance by decreasing phosphate in the growing media.

Arsenic contamination of groundwater is a significant problem in countries like Mexico, where San Luis Potosi is among the regions registering severe levels of it. Bioremediation with microalgae capable to absorb and metabolize metals or metalloids like arsenic reduces their toxicity and is a cost-effective approach compared to physical-chemical processes. We evaluated the capability of Chlamydomonas reinhardtii to remove arsenate and compared it with an acr3-modified recombinant strain, which we produced by transforming the wild-type strain with Agrobacterium tumefaciens using the construct pARR1 including a synthetic, optimized acr3 gene from Pteris vittata, a hyper-accumulator of arsenic. We monitored the growth of both strains in media with arsenate, containing a standard or a 10-fold decreased amount of phosphate. Comparing both strains in media initially with 0.5, 1, and 1.5 mg/L of arsenate, the acr3-modified strain removed 1.5 to 3 times more arsenic than the wild-type strain. Moreover, the arsenic uptake rate increased 1.2 to 2.3 times when growing the acr3-modified strain in media with decreased phosphate, while the uptake rate for the wild-type strain scarcely changed under the same conditions. These results confirm the expression of the acr3 gene in C. reinhardtii and its potential application to remove arsenic.

Health system strategies to increase HIV screening among pregnant women in Mesoamerica.

BACKGROUND: To propose health system strategies to meeting the World Health Organization (WHO) recommendations on HIV screening through antenatal care (ANC) services, we assessed predictors of HIV screening, and simulated the impact of changes in these predictors on the probability of HIV screening in Guatemala, Honduras, Mexico (State of Chiapas), Nicaragua, Panama, and El Salvador. METHODS: We interviewed a representative sample of women of reproductive age from the poorest Mesoamerican areas on ANC services, including HIV screening. We used a multivariate logistic regression model to examine correlates of HIV screening. First differences in expected probabilities of HIV screening were simulated for health system correlates that were associated with HIV screening. RESULTS: Overall, 40.7% of women were screened for HIV during their last pregnancy through ANC. This rate was highest in El Salvador and lowest in Guatemala. The probability of HIV screening increased with education, household expenditure, the number of ANC visits, and the type of health care attendant of ANC visits. If all women were to be attended by a nurse, or a physician, and were to receive at least four ANC visits, the probability of HIV screening would increase by 12.5% to reach 45.8%. CONCLUSIONS: To meet WHO's recommendations for HIV screening, special attention should be given to the poorest and least educated women to ensure health equity and progress toward an HIV-free generation. In parallel, health systems should be strengthened in terms of testing and human resources to ensure that every pregnant woman gets screened for HIV. A 12.5% increase in HIV screening would require a minimum of four ANC visits and an appropriate professional attendance of these visits.

Collecting verbal autopsies: improving and streamlining data collection processes using electronic tablets.

BACKGROUND: There is increasing interest in using verbal autopsy to produce nationally representative population-level estimates of causes of death. However, the burden of processing a large quantity of surveys collected with paper and pencil has been a barrier to scaling up verbal autopsy surveillance. Direct electronic data capture has been used in other large-scale surveys and can be used in verbal autopsy as well, to reduce time and cost of going from collected data to actionable information. METHODS: We collected verbal autopsy interviews using paper and pencil and using electronic tablets at two sites, and measured the cost and time required to process the surveys for analysis. From these cost and time data, we extrapolated costs associated with conducting large-scale surveillance with verbal autopsy. RESULTS: We found that the median time between data collection and data entry for surveys collected on paper and pencil was approximately 3 months. For surveys collected on electronic tablets, this was less than 2 days. For small-scale surveys, we found that the upfront costs of purchasing electronic tablets was the primary cost and resulted in a higher total cost. For large-scale surveys, the costs associated with data entry exceeded the cost of the tablets, so electronic data capture provides both a quicker and cheaper method of data collection. CONCLUSIONS: As countries increase verbal autopsy surveillance, it is important to consider the best way to design sustainable systems for data collection. Electronic data capture has the potential to greatly reduce the time and costs associated with data collection. For long-term, large-scale surveillance required by national vital statistical systems, electronic data capture reduces costs and allows data to be available sooner.

Results-based aid with lasting effects: sustainability in the Salud Mesoamérica Initiative.

BACKGROUND: The Salud Mesoamérica Initiative is a public-private partnership aimed at reducing maternal and child morbidity and mortality for the poorest populations in Central America and the southernmost state of Mexico. Currently at the midpoint of implementation and with external funding expected to phase out by 2020, SMI's sustainability warrants evaluation. In this study, we examine if the major SMI components fit into the Dynamic Sustainability Framework to predict whether SMI benefits could be sustainable beyond the external funding and to identify threats to sustainability. METHODS: Through the 2016 Salud Mesoamérica Initiative Process Evaluation, we applied qualitative methods including document review, key informant interviews, focus group discussions, and a social network analysis to address our objective. RESULTS: SMI's design continuously evolves and aligns with national needs and objectives. Partnerships, the regional approach, and the results-based aid model create a culture that prioritizes health care. SMI's sector-wide approach and knowledge-sharing framework strengthen health systems. Evidence-based practice promotes policy dialogue and scale-up of interventions. CONCLUSION: Most SMI elements fit within the Dynamic Sustainability Framework, suggesting a likelihood of sustainability after external funding ceases, and subsequent application of lessons learned by the global community. This includes a flexible design, partnerships and a culture of prioritizing healthcare, health systems strengthening mechanisms, policy changes, and scale-ups of interventions. However, threats to sustainability, including possible transient culture of prioritizing health care, dissipation of reputational risk and financial partnerships, and personnel turnover, need to be addressed.

Corn-based vaccines: current status and prospects.

MAIN CONCLUSION: Corn is an attractive host for vaccine production and oral delivery. The present review provides the current outlook and perspectives for this field. Among seed-crops, corn represents a key source of biomass for food, fuel production, and other applications. Since the beginning of the development of plant-based vaccines, corn was explored for the production and delivery of vaccines. About a dozen of pathogens have been studied under this technology with distinct degrees of development. A vaccine prototype against enterotoxigenic Escherichia coli was evaluated in a phase I clinical trial and several candidates targeting bacterial and viral diseases are under preclinical evaluation. The present review provides an updated outlook on this topic highlighting the employed expression strategies; perspectives for the field are also provided.

Expression of the VP40 antigen from the Zaire ebolavirus in tobacco plants.

MAIN CONCLUSION: The plant cell is able to produce the VP40 antigen from the Zaire ebolavirus , retaining the antigenicity and the ability to induce immune responses in BALB/c mice. The recent Ebola outbreak evidenced the need for having vaccines approved for human use. Herein we report the expression of the VP40 antigen from the Ebola virus as an initial effort in the development of a plant-made vaccine that could offer the advantages of being cheap and scalable, which is proposed to overcome the rapid need for having vaccines to deal with future outbreaks. Tobacco plants were transformed by stable DNA integration into the nuclear genome using the CaMV35S promoter and a signal peptide to access the endoplasmic reticulum, reaching accumulation levels up to 2.6 µg g-1 FW leaf tissues. The antigenicity of the plant-made VP40 antigen was evidenced by Western blot and an initial immunogenicity assessment in test animals that revealed the induction of immune responses in BALB/c mice following three weekly oral or subcutaneous immunizations at very low doses (125 and 25 ng, respectively) without accessory adjuvants. Therefore, this plant-based vaccination prototype is proposed as an attractive platform for the production of vaccines in the fight against Ebola virus disease outbreaks.

Perceived neighborhood environmental attributes associated with leisure-time and transport physical activity in Mexican adults.

Environmental factors have been associated with specific physical activity domains, including leisure-time and transport physical activity, in some high income countries. Few studies have examined the environmental correlates for domain-specific physical activity in low-and middle-income countries, and results are inconsistent. We aimed to estimate the associations between perceived environment and self-reported leisure-time walking, moderate-to-vigorous leisure-time physical activity and transport physical activity among adults living in Cuernavaca, Mexico. A population-based study of adults 20 to 64years old was conducted in Cuernavaca, Mexico in 2011 (n=677). Leisure and transport physical activity was measured using the International Physical Activity Questionnaire - Long Form. Perceptions of neighborhood environment were obtained by questionnaire. Hurdle regression models estimated the association between environmental perceptions and participation and time spent in each physical activity domain. High perceived aesthetics were positively correlated with participation and time spent in leisure-time walking and moderate-to-vigorous physical activity. SES differences existed for aesthetics in relation to participation in leisure-time walking. Participation in transport physical activity was positively associated with easy access to large parks, while closer distance to large parks was a negative correlate for participation and time-spent in this physical activity domain. Results suggest that perceived environmental characteristics related with physical activity are domain specific. High perceived aesthetics were an important correlate for leisure-time activities among Mexican adults, suggesting that policy strategies aimed at improving this environmental perception may be warranted. Patterns of associations between environmental correlates and transport physical activity differed from those reported in commonly studied high income countries.

Increases in Caesarean Delivery Rates and Change of Perinatal Outcomes in Low- and Middle-Income Countries: A Hospital-Level Analysis of Two WHO Surveys.

BACKGROUND: Maternal and neonatal outcomes have improved substantially. During the same period, the caesarean delivery rate soared. The aim of this analysis was to determine whether an increase in caesarean rate was associated with an improvement in perinatal outcome at an institutional level in low- and middle-income countries. METHODS: The WHO Global Survey on Maternal and Perinatal Health (WHOGS) and the WHO Multi-Country Survey on Maternal and Newborn Health (WHOMCS) were two multi-country, facility-based, cross-sectional surveys conducted in 2004-08 and 2010-11, respectively. The increase in caesarean rate and the change of prevalence of adverse perinatal outcomes were calculated using a two-point estimator of percent change annualized (PCA) method. Maternal, perinatal, and neonatal composite indexes were used as the outcomes. A linear mixed model was used to assess the association between the change of caesarean rate and the change of perinatal outcome. RESULTS: A total of 259 facilities in 20 countries participated in both surveys, with 217 844 women in WHOGS and 227 734 women in WHOMCS. The caesarean rate in these facilities increased, on average, by 4.0% annually, while the prevalence of adverse perinatal outcomes decreased by 4.6% annually. However, after adjustments for potential confounders, no association was found between the increase in caesarean rate and the change of adverse outcome indexes, regardless of whether starting caesarean rates were already high (above 10%) or not. CONCLUSIONS: In low- and middle-income countries, the increases in caesarean rates were not associated with improved perinatal outcomes regardless of whether the starting caesarean rate was already high or not.

Perceptions of and barriers to family planning services in the poorest regions of Chiapas, Mexico: a qualitative study of men, women, and adolescents.

BACKGROUND: In the poorest regions of Chiapas, Mexico, 50.2% of women in need of contraceptives do not use any modern method. A qualitative study was needed to design effective and culturally appropriate interventions. METHODS: We used purposive maximum-variation sampling to select eight municipalities with a high proportion of residents in the poorest wealth quintile, including urban, rural, indigenous, and non-indigenous communities. We conducted 44 focus group discussions with 292 women, adolescent women, and men using semi-structured topic guides. We analyzed the data through recursive abstraction. RESULTS: There were intergenerational and cultural gaps in the acceptability of family planning, and in some communities family planning use was greatly limited by gender roles and religious objections to contraception. Men strongly influenced family planning choices in many households, but were largely unreached by outreach and education programs due to their work hours. Respondents were aware of many modern methods but often lacked deeper knowledge and held misconceptions about long-term fertility risks posed by some hormonal methods. Acute physical side effects also dissuaded use. The implant was a new and highly acceptable method due to ease of use, low upkeep, and minimal side effects; however, it was perceived as subject to stock-outs. Adolescent women reported being refused services at health facilities and requested more reproductive health information from their parents and schools. Mass and social media are growing sources of reproductive health information. CONCLUSIONS: Our study identifies a number of barriers to family planning that have yet to be adequately addressed by existing programs in Chiapas' poorest regions, and calls for reinvigorated efforts to provide effective, acceptable, and culturally appropriate interventions for these communities.

What is the optimal recall period for verbal autopsies? Validation study based on repeat interviews in three populations.

BACKGROUND: One key contextual feature in Verbal Autopsy (VA) is the time between death and survey administration, or recall period. This study quantified the effect of recall period on VA performance by using a paired dataset in which two VAs were administered for a single decedent. METHODS: This study used information from the Population Health Metrics Research Consortium (PHMRC) Study, which collected VAs for "gold standard" cases where cause of death (COD) was supported by clinical criteria. This study repeated VA interviews within 3-52 months of death in PHMRC study sites in Andhra Pradesh, India, and Bohol and Manila, Philippines. The final dataset included 2113 deaths interviewed twice and with recall periods ranging from 0 to 52 months. COD was assigned by the Tariff method and its accuracy determined by comparison with the gold standard COD. RESULTS: The probability of a correct diagnosis of COD decreased by 0.55 % per month in the period after death. Site of data collection and survey module also affected the probability of Tariff Method correctly assigning a COD. The probability of a correct diagnosis in VAs collected 3-11 months after death will, on average, be 95.9 % of that in VAs collected within 3 months of death. CONCLUSIONS: These findings suggest that collecting VAs within 3 months of death may improve the quality of the information collected, taking the need for a period of mourning into account. This study substantiates the WHO recommendation that it is reasonable to collect VAs up to 1 year after death providing it is accepted that probability of a correct diagnosis is likely to decline month by month during this period.

The paradox of verbal autopsy in cause of death assignment: symptom question unreliability but predictive accuracy.

BACKGROUND: We believe that it is important that governments understand the reliability of the mortality data which they have at their disposable to guide policy debates. In many instances, verbal autopsy (VA) will be the only source of mortality data for populations, yet little is known about how the accuracy of VA diagnoses is affected by the reliability of the symptom responses. We previously described the effect of the duration of time between death and VA administration on VA validity. In this paper, using the same dataset, we assess the relationship between the reliability and completeness of symptom responses and the reliability and accuracy of cause of death (COD) prediction. METHODS: The study was based on VAs in the Population Health Metrics Research Consortium (PHMRC) VA Validation Dataset from study sites in Bohol and Manila, Philippines and Andhra Pradesh, India. The initial interview was repeated within 3-52 months of death. Question responses were assessed for reliability and completeness between the two survey rounds. COD was predicted by Tariff Method. RESULTS: A sample of 4226 VAs was collected for 2113 decedents, including 1394 adults, 349 children, and 370 neonates. Mean question reliability was unexpectedly low (kappa = 0.447): 42.5 % of responses positive at the first interview were negative at the second, and 47.9 % of responses positive at the second had been negative at the first. Question reliability was greater for the short form of the PHMRC instrument (kappa = 0.497) and when analyzed at the level of the individual decedent (kappa = 0.610). Reliability at the level of the individual decedent was associated with COD predictive reliability and predictive accuracy. CONCLUSIONS: Families give coherent accounts of events leading to death but the details vary from interview to interview for the same case. Accounts are accurate but inconsistent; different subsets of symptoms are identified on each occasion. However, there are sufficient accurate and consistent subsets of symptoms to enable the Tariff Method to assign a COD. Questions which contributed most to COD prediction were also the most reliable and consistent across repeat interviews; these have been included in the short form VA questionnaire. Accuracy and reliability of diagnosis for an individual death depend on the quality of interview. This has considerable implications for the progressive roll out of VAs into civil registration and vital statistics (CRVS) systems.