Determinants of pregnant women's satisfaction with interactions with health providers at antenatal consultation in primary health care in Southern Mozambique in 2021: a cross-sectional study.

BACKGROUND: The Ministry of Health of Mozambique (MISAU) and the World Health Organization (WHO) recommend enhancing pregnant women's satisfaction with health care services in order to advance maternal and child health. This study aims to assess the levels and determinants of pregnant women's satisfaction regarding their interactions with antenatal care (ANC) providers, the services of which were provided at the primary health care level in southern Mozambique. METHODOLOGY: We conducted an observational, quantitative, and cross-sectional study from November 4 to December 10, 2021. A structured questionnaire was administered to pregnant women who attended ANC during that period. The characteristics of the participants were illustrated using descriptive statistics; to analyse pregnant women's satisfaction determinants, we estimated crude and adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) using logistic regression models. All analyses were performed in SPSS version 24 using a 5% significance level. RESULTS: We selected 951 pregnant women with a mean age of 25 years old; 14% attained a secondary educational level, 36% were married or living in a marital relationship, and 85.9% reported being satisfied with their current ANC. Factors that reduced the odds of being satisfied were the following: an "insufficient" ANC duration (AOR = 0.173; 95% CI: 0.079, 0.381); inadequate ANC waiting area (AOR = 0.479; 95% CI: 0.265, 0.863); women's perception about the existing norm of nonattendance in case of late arrival to the ANC (AOR = 0.528; 95% CI 0.292, 0.954); the perception of the existing norm that women are obliged to give birth in same health facility where ANC occurred (AOR = 0.481; 95% CI: 0.273, 0.846); and the perception that delivered ANC is not important for foetal health (AOR = 0.030; 95% CI:0.014, 0.066). CONCLUSIONS: Most of the pregnant women mentioned being satisfied with the ANC they received. The perception of short consultation duration, inadequate waiting spaces, strict linkage rules to specific health facilities and ANC norms, the perception that the received ANC is not relevant for foetal well-being are determinants of not being satisfied with ANC, and these determinants can be addressed by reorganizing ANC and, indeed, are modifiable by the improved paced implementation of the MISAU strategies for quality maternal and child health care.

Caregivers' psychosocial assessment for identifying HIV-infected infants at risk of poor treatment adherence: an exploratory study in southern Mozambique.

Psychosocial support (PSS) to caregivers of HIV-infected infants on antiretroviral treatment (ART) is crucial to ensure ART adherence and sustained long-term viral suppression in children. A specific approach including tools to monitor and understand adherence behavior and risk factors that prevent optimal treatment compliance are urgently needed. This qualitative exploratory study, conducted in southern Mozambique, monitored the infants' viral response trajectories during 18 months follow-up, as a measure of adherence, reviewed the caregiver's PSS session notes and the answers to a study questionnaire, to analyze whether the standard PSS checklist applied to infants' caregivers can identify barriers influencing their adherence. Only 9 of 31 infants had sustained virologic response. Reported factors affecting adherence were: difficulties in drugs administration, shared responsibility to administer treatment; disclosure of child's HIV status to family members but lack of engagement; mother's ART interruption and poor viral response. In conclusion, we found that the standard PSS approach alone, applied to caregivers, was lacking focus on many relevant matters that were identified by the study questionnaire. A comprehensive patient-centered PSS package of care, including an adherence risk factor monitoring tool, tailored to caregivers and their children must be developed.

The impact of performance-based financing within local health systems: Evidence from Mozambique.

Most evidence on Performance Based Financing (PBF) in low-income settings has focused on services delivered by providers in targeted health administrations, with limited understanding of how effects on health and care vary within them. We evaluated the population effects of a program implemented in two provinces in Mozambique, focusing on child, maternal and HIV/AIDS care and knowledge. We used a difference-in-difference estimation strategy applied to data on mothers from the Demographic Health Surveys, linked to information on their closest health facility. The impact of PBF was limited. HIV testing during antenatal care increased, particularly for women who were wealthier, more educated, or residing in Gaza Province. Knowledge about transmission of HIV from mother-to-child, and its prevention, increased, particularly for women who were less wealthy, less educated, or residing in Nampula Province. Exploiting the roll-out by facility, we found that the effects were concentrated on less wealthy and less educated women, whose closest facility was in the referral network of a PBF facility. Results suggest that HIV testing and knowledge promotion increased in the whole district, as a strategy to boost referral for highly incentivized HIV services delivered in PBF facilities. However, demand-side constraints may prevent the use of those services.

Factors associated with malaria care seeking among children under 5 years of age in Mozambique: a secondary analysis of the 2018 Malaria Indicator Survey.

BACKGROUND: Mozambique is ranked fourth in a list of the 29 countries that accounted for 95% of all malaria cases globally in 2019. The aim of this study was to identify factors associated with care seeking for fever, to determine the association between knowledge about malaria and care seeking and to describe the main reasons for not seeking care among children under five years of age in Mozambique. METHODS: This is a quantitative, observational study based on a secondary data analysis of the 2018 Malaria Indicator Survey. This weighted analysis was based on data reported by surveyed mothers or caregivers of children aged 0-59 months who had fever in the two weeks prior to the survey. RESULTS: Care was reportedly sought for 69.1% [95% CI 63.5-74.2] of children aged 0-59 months old with fever. Care-seeking was significantly higher among younger children, < 6 months old (AOR = 2.47 [95% CI 1.14-5.31]), 6-11 months old (AOR = 1.75 [95% CI 1.01-3.04]) and 12-23 months old (AOR = 1.85 [95% CI 1.19-2.89]), as compared with older children (48-59 months old). In adjusted analysis, mothers from the middle (AOR = 1.66 [95% CI 0.18-3.37]) and richest (AOR = 3.46 [95% CI 1.26-9.49]) wealth quintiles were more likely to report having sought care for their febrile children than mothers from the poorest wealth quintile. Additionally, mothers with secondary or higher education level were more likely to seek care (AOR = 2.16 [95% CI 1.19-3.93]) than mothers with no education. There was no association between maternal malaria knowledge or reported exposure to malaria messages and care-seeking behaviours. The main reasons reported for not seeking care included distance to health facility (46.3% of respondents), the perception that the fever was not severe (22.4%) and the perception that treatment was not available at the health facility (15%). CONCLUSION: Health facility access and socioeconomic barriers continue to be important constraints to malaria service utilization in Mozambique.

How prepared is Mozambique to treat COVID-19 patients? A new approach for estimating oxygen service availability, oxygen treatment capacity, and population access to oxygen-ready treatment facilities.

BACKGROUND: This study aims to assess the COVID-19 response preparedness of the Mozambican health system by 1) determining the location of oxygen-ready public health facilities, 2) estimating the oxygen treatment capacity, and 3) determining the population coverage of oxygen-ready health facilities in Mozambique. METHODS: This analysis utilizes information on the availability of oxygen sources and delivery apparatuses to determine if a health facility is ready to deliver oxygen therapy to patients in need, and estimates how many patients can be treated with continuous oxygen flow for a 7-day period based on the available oxygen equipment at health facilities. Using GIS mapping software, the study team modeled varying travel times to oxygen-ready facilities to estimate the proportion of the population with access to care. RESULTS: 0.4% of all health facilities in Mozambique are prepared to deliver oxygen therapy to patients, for a cumulative total of 283.9 to 406.0 patients-weeks given the existing national capacity, under varying assumptions including ability to divert oxygen from a single source to multiple patients. 35% of the population in Mozambique has adequate access within one-hour driving time of an oxygen-ready health facility. This varies widely by region; 89.1% of the population of Maputo City was captured by the one-hour driving time network, as compared ot 4.4% of the population of Niassa province. CONCLUSIONS: The Mozambican health system faces the dual challenges of under-resourced health facilities and low geographic accessibility to healthcare as it prepares to confront the COVID-19 pandemic. This analysis also illustrates the disparity between provinces in preparedness to deliver oxygen therapy to patient, with Cabo Delgado and Nampula being particularly under-resourced.

Community knowledge and acceptance of indoor residual spraying for malaria prevention in Mozambique: a qualitative study.

BACKGROUND: Malaria control remains a leading health challenge in Mozambique. Indoor residual spraying (IRS) is an effective strategy to control malaria transmission, but there are often barriers to reaching the coverage necessary for attaining maximum community protective effect of IRS. Mozambique recorded a high number of household refusals during the 2016 IRS campaign. This study sought to evaluate household and community factors related to the acceptability of IRS to inform strategies for future campaigns in Mozambique and the region. METHODS: A cross-sectional, qualitative study was conducted in eight urban and rural communities in two high malaria burden provinces in Mozambique. Data were collected through in-depth interviews with community members, leaders, sprayers, and representatives of district health directorates; focus group discussions with community members who accepted and who refused IRS during the 2016 campaign; systematic field observations; and informal conversations. Data were systematically coded and analysed using NVIVO-11®. RESULTS: A total of 61 interviews and 12 discussions were conducted. Community participants predominantly described IRS as safe, but many felt that it had limited efficacy. The main factors that participants mentioned as having influenced their IRS acceptance or refusal were: understanding of IRS; community leader level of support; characteristics of IRS programmatic implementation; environmental, political and historical factors. Specifically, IRS acceptance was higher when there was perceived community solidarity through IRS acceptance, desire to reduce the insect population in homes, trust in government and community satisfaction with past IRS campaign effectiveness. Participants who refused were mainly from urban districts and were more educated. The main barriers to acceptance were associated with selection and performance of spray operators, negative experiences from previous campaigns, political-partisan conflicts, difficulty in removing heavy or numerous household assets, and preference for insecticide-treated nets over IRS. CONCLUSIONS: Acceptance of IRS was influenced by diverse operational and contextual factors. As such, future IRS communications in targeted communities should emphasize the importance of high IRS coverage for promoting both familial and community health. Additionally, clear communications and engagement with community leaders during spray operator selection and spray implementation may help reduce barriers to IRS acceptance.

Health equity monitoring is essential in public health: lessons from Mozambique.

BACKGROUND: Countries must be able to describe and monitor their populations health and well-being needs in an attempt to understand and address them. The Sustainable Development Goals (SDGs) have re-emphasized the need to invest in comprehensive health information systems to monitor progress towards health equity; however, knowledge on the capacity of health information systems to be able do this, particularly in low-income countries, remains very limited. As a case study, we aimed to evaluate the current capacity of the national health information systems in Mozambique, and the available indicators to monitor health inequalities, in line with SDG 3 (Good Health and Well Being for All at All Ages). METHODS: A data source mapping of the health information system in Mozambique was conducted. We followed the World Health Organization's methodology of assessing data sources to evaluate the information available for every equity stratifier using a three-point scale: 1 - information is available, 2 - need for more information, and 3 - an information gap. Also, for each indicator we estimated the national average inequality score. RESULTS: Eight data sources contain health information to measure and monitor progress towards health equity in line with the 27 SDG3 indicators. Seven indicators bear information with nationally funded data sources, ten with data sources externally funded, and ten indicators either lack information or it does not applicable for the matter of the study. None of the 27 indicators associated with SDG3 can be fully disaggregated by equity stratifiers; they either lack some information (15 indicators) or do not have information at all (nine indicators). The indicators that contain more information are related to maternal and child health. CONCLUSIONS: There are important information gaps in Mozambique's current national health information system which prevents it from being able to comprehensively measure and monitor health equity. Comprehensive national health information systems are an essential public health need. Significant policy and political challenges must also be addressed to ensure effective interventions and action towards health equity in the country.

Client experiences with antenatal care waiting times in southern Mozambique.

BACKGROUND: Antenatal care (ANC) provides a range of critical health services during pregnancy that can improve maternal and neonatal health outcomes. In Mozambique, only half of women receive four or more ANC visits, which are provided for free at public health centers by maternal and child health (MCH) nurses. Waiting time has been shown to contribute to negative client experiences, which may be a driver of low maternity care utilization. A recent pilot study of a program to schedule ANC visits demonstrated that scheduling care reduces waiting time and results in higher rates of complete ANC. This study aims to explore client experiences with waiting time for ANC in standard practice and care and after the introduction of appointment scheduling. METHODS: This study uses a series of qualitative interviews to unpack client experiences with ANC waiting time with and without scheduled care, in order to better understand the impact of waiting time on client experiences. Thirty-eight interviews were collected in May to June 2017 at three pilot study clinics in southern Mozambique, with a focus on two paired intervention and comparison facilities sharing similar facility characteristics. Data were analyzed using inductive thematic analysis methods using NVivo software. RESULTS: Clients described strong motivations to seek ANC, pointing to the need to address convenience of care, and highlighted direct and indirect costs of seeking care that were exacerbated by long waiting times. Direct costs include time and transport costs of going to the clinic, while indirect costs include being unable to fulfill household and work obligations. Other barriers to complete ANC utilization of four or more visits include transport costs, negative provider experiences, and delayed ANC initiation, which limit the potential number of clinic contacts. CONCLUSIONS: Findings demonstrate that the scheduling intervention improves the client experience of seeking care by allowing women to both seek ANC and fulfill other productive obligations. Innovation in healthcare delivery should consider adapting models that minimize waiting times.

Inequalities in the access to and quality of healthcare in Mozambique: evidence from the household budget survey.

OBJECTIVES: To assess the inequalities in the access to and quality of care and its related direct payments. DESIGN: Secondary analysis of the cross-sectional Mozambican Household Budget Survey (HBS). SETTING: Nationally-representative sample of households in Mozambique. PARTICIPANTS: 11 480 households (58 118 individuals) interviewed during HBS 2014/15. INTERVENTION: None. MAIN OUTCOME MEASURES: Equity, utilization of healthcare, access to quality care and direct payments. RESULTS: About 12.2% of women and 10.1% of men of the survey report a perceive health need. About 72.1% of women and 72.9% men use healthcare. Population in a disadvantaged position living in rural areas have less probabilities of using healthcare for equal health compared to the individuals of a wealthier position and living in urban settings. With regard to quality care, 47.7% women and 46.8% men do not report quality problems. No differences for women's wealth. Men in a disadvantaged position report less chances of accessing quality care compared to men of advantaged position. Also, women and men living in rural areas have less probabilities of accessing quality care. Finally, the majority of people who access healthcare paid 1 Mt during their visit. CONCLUSIONS: This study tackles a fundamental policy concern for health systems of Sub-Saharan Africa and points to areas that urge action to address the existent of socioeconomic and geographical inequalities in the access to and quality of care for women and men, including the strengthening of health facilities in rural and deprived areas to ensure that access to adequate care of acceptable quality is distributed according to need.

'Good health' as a barrier and facilitator to ART initiation: a qualitative study in the era of test-and-treat in Mozambique.

HIV test-and-treat programmes are being implemented throughout sub-Saharan Africa, enrolling HIV-positive clients into antiretroviral treatment (ART) immediately after diagnosis, regardless of clinical stage or CD4 count. This study conducted in Mozambique examined what influenced clients who tested HIV-positive in the context of test-and-treat to make ART initiation decisions. Eighty in-depth interviews with HIV-positive clients and nine focus group discussions with health care workers were completed across 10 health facilities. 'Good health' acted simultaneously as a barrier and facilitator; clients in good health often found a positive HIV diagnosis hard to cope with since HIV was traditionally associated with ill health. Concerns about ART side effects, fear of inadvertent HIV status disclosure and discrimination, limited privacy at health facilities and long waiting times were also barriers to initiation. In contrast, being in good health also acted as a motivator to start treatment so as to remain healthy, maintain responsibilities such as work and caring for dependents and avoid unwanted disclosure. Study findings offer an in-depth understanding of the complex dynamics between individual perceptions of 'being healthy' and its influence on ART initiation within the context of test-and-treat programme implementation.

Development and Usefulness of a District Health Systems Tool for Performance Improvement in Essential Public Health Functions in Botswana and Mozambique.

INTRODUCTION: This study describes the development of a self-audit tool for public health and the associated methodology for implementing a district health system self-audit tool that can provide quantitative data on how district governments perceive their performance of the essential public health functions. METHODS: Development began with a consensus-building process to engage Ministry of Health and provincial health officers in Mozambique and Botswana. We then worked with lists of relevant public health functions as determined by these stakeholders to adapt a self-audit tool describing essential public health functions to each country's health system. We then piloted the tool across districts in both countries and conducted interviews with district health personnel to determine health workers' perception of the usefulness of the approach. RESULTS: Country stakeholders were able to develop consensus around 11 essential public health functions that were relevant in each country. Pilots of the self-audit tool enabled the tool to be effectively shortened. Pilots also disclosed a tendency to upcode during self-audits that was checked by group deliberation. Convening sessions at the district enabled better attendance and representative deliberation. Instant feedback from the audit was a feature that 100% of pilot respondents found most useful. CONCLUSION: The development of metrics that provide feedback on public health performance can be used as an aid in the self-assessment of health system performance at the district level. Measurements of practice can open the door to future applications for practice improvement and research into the determinants and consequences of better public health practice. The current tool can be assessed for its usefulness to district health managers in improving their public health practice. The tool can also be used by the Ministry of Health or external donors in the African region for monitoring the district-level performance of the essential public health functions.

The effect of pre-service training on post-graduation skill and knowledge retention among mid-level healthcare providers in Mozambique.

BACKGROUND: Mozambique suffers from critical shortages of healthcare workers including non-physician clinicians, Tecnicos de Medicina Geral (TMGs), who are often senior clinicians in rural health centres. The Mozambique Ministry of Health and the International Training and Education Center for Health, University of Washington, Seattle, revised the national curriculum to improve TMG clinical knowledge and skills. To evaluate the effort, data was collected at graduation and 10 months later from pre-revision (initial) and revised curriculum TMGs to determine the following: (1) Did cohorts trained in the revised curriculum score higher on measurements of clinical knowledge, physical exam procedures, and solving clinical case scenarios than those trained in the initial curriculum; (2) Did TMGs in both curricula retain their knowledge over time (from baseline to follow-up); and (3) Did skills and knowledge retention differ over time by curricula? Post-graduation and over time results are presented. METHODS: t-tests examine differences in scores between curriculum groups. Univariate and multivariate linear regression models assess curriculum-related, demographic, and workplace factors associated with scores on each of three evaluation methods at the p < 0.05 level. Paired t-tests examine within-group changes over time. ANOVA models explore differences between Health Training Institutes (HTIs). Generalized estimating equations determine whether change in scores over time differed by curricula. RESULTS: Mean scores of initial curriculum TMGs at follow-up were 52.7%, 62.6%, and 40.0% on the clinical cases, knowledge test, and physical exam, respectively. Averages were significantly higher among the revised group for clinical cases (60.2%; p < 0.001) and physical exam (47.6%; p < 0.001). HTI was influential on clinical case and physical exam scores. Between graduation and follow-up, clinical case and physical exam scores decreased significantly for initial curriculum students; clinical case scores increased significantly among revised curriculum TMGs. CONCLUSIONS: Although curriculum revision had limited effect, marginal improvements in the revised group show promise that these TMGs may have increased ability to synthesize clinical information. Weaknesses in curriculum and practicum implementation likely compromised the effect of curriculum revision. An improvement strategy that includes strengthened TMG training, greater attention to pre-service clinical practice, and post-graduation mentoring may be more advantageous than curriculum revision, alone, to improve care provided by TMGs.

Why did I participate in an HIV vaccine study? Experiences of participation in the first phase II HIV vaccine trial in Mozambique: An ancillary study using a mixed-method approach.

Introduction: This study recognized the lack of information regarding recruitment and retention factors associated with implementing HIV vaccine trials from the perspective of de facto participants. It aimed to describe the motives and experiences of 31 young adults who participated in a phase II HIV vaccine clinical trial conducted in Maputo, Mozambique. Methods: This was an ancillary study with a mixed-method approach that employed a convergent design, combining both quantitative and qualitative methodologies. Data collection involved questionnaire surveys, in-depth interviews, and focus group discussions. Participants were assessed before and after learning whether they received the experimental vaccine or placebo. Thematic analysis was used for qualitative data, while descriptive analysis and statistical tests such as Fischer's test and McNemar's exact test were applied to quantitative data. The study also utilized the Health Belief Model to understand the decision-making process of participating in an HIV vaccine study. Results: Most of our participants were young females, single, with limited financial resources. Participants joined the trial with the belief that they had a unique opportunity to help the fight against HIV and contribute to the research for the discovery of an HIV vaccine. Positive experiences related to trial participation include gaining knowledge about HIV and personal health and receiving risk reduction counseling. Participants reported blood collection as a negative experience and that they suffered social harm because of trial participation. Participants felt abandoned after the trial ended. Conclusion: Preventive HIV vaccine trials should integrate a social-behavioral component to assess reasons for participation and refusal in real-time. Providing ongoing personal attention is crucial for young individuals who have committed 1-2 years to trial participation, extending beyond the trial period. Implementing tailored strategies for HIV risk assessment and reduction during and after the trial is essential. Addressing these factors can enhance preventive HIV vaccine trial implementation.

Estimating the cost for obstetric fistula repair in hospitals of Mozambique: a low-income country.

BACKGROUND: Obstetric fistula is incident and prevalent in low-income countries. Globally, about 100,000 women develop fistula annually. In Mozambique, more than 2,000 fistulas are reported annually. A national strategy to combat obstetric fistula has been implemented in Mozambique from 2012-2020. This strategy is under review, making it opportune to generate evidence that reflects the course of the strategy implemented to subsidize/optimize the definition of priorities of the new strategy to achieve universal health coverage. In Mozambique, information on the costs incurred to treat fistula is scarce. This study aims to estimate the mean unit cost of repair/treatment of simple and complex obstetric fistula in Mozambique. METHODS: We carried out a retrospective evaluation, from the provider's perspective, using the Ingredient and Stepdown approaches. The mean unit cost was obtained by the sum of individual and shared ingredients to treat fistula. Cost dimensions included Direct Medical Costs (personnel, drugs, and supplies), Overhead and Capital Costs (administration and capital assets' costs, respectively). The average exchange rate was USD 1 = MZN 61.47. Data were collected in secondary, tertiary, and quaternary hospitals of Zambézia and Nampula provinces in 2021. Costs borne by patients and their families and loss of productivity were not included. RESULTS: The mean cost for Simple Obstetric Fistula repair was MZN 14,937.21 (USD 243) and Complex Obstetric Fistula was MZN 21,145.68 (USD 344) per person operated. Regardless of the type of fistula, the repair cost was MZN 18,072.18 (USD 294). CONCLUSION: Without neglecting that prevention is better than plasty, the results show feasible levels of fistula repair costs for mobilization of funds. For the estimated 2,000 fistulas reported annually, the government needs an average MZN 36,144,360 (USD 588,000).

Cost-Effectiveness and Budget Impact Analysis of the Implementation of Differentiated Service Delivery Models for HIV Treatment in Mozambique: a Modelling Study.

INTRODUCTION: In 2018, the Mozambique Ministry of Health launched guidelines for implementing differentiated service delivery models (DSDMs) to optimize HIV service delivery, improve retention in care, and ultimately reduce HIV-associated mortality. The models were fast-track, 3-month antiretrovirals dispensing, community antiretroviral therapy groups, adherence clubs, family approach and three one-stop shop models: adolescent-friendly health services, maternal and child health, and tuberculosis. We conducted a cost-effectiveness analysis and budget impact analysis to compare these models to conventional services. METHODS: We constructed a decision tree model based on the percentage of enrolment in each model and the probability of the outcome (12-month retention in treatment) for each year of the study period-three for the cost-effectiveness analysis (2019-2021) and three for the budget impact analysis (2022-2024). Costs for these analyses were primarily estimated per client-year from the health system perspective. A secondary cost-effectiveness analysis was conducted from the societal perspective. Budget impact analysis costs included antiretrovirals, laboratory tests and service provision interactions. Cost-effectiveness analysis additionally included start-up, training and clients' opportunity costs. Effectiveness was estimated using an uncontrolled interrupted time series analysis comparing the outcome before and after the implementation of the differentiated models. A one-way sensitivity analysis was conducted to identify drivers of uncertainty. RESULTS: After implementation of the DSDMs, there was a mean increase of 14.9 percentage points (95% CI: 12.2, 17.8) in 12-month retention, from 47.6% (95% CI, 44.9-50.2) to 62.5% (95% CI, 60.9-64.1). The mean cost difference comparing DSDMs and conventional care was US$ -6 million (173,391,277 vs. 179,461,668) and -32.5 million (394,705,618 vs. 433,232,289) from the health system and the societal perspective, respectively. Therefore, DSDMs dominated conventional care. Results were most sensitive to conventional care interaction costs in the one-way sensitivity analysis. For a population of 1.5 million, the base-case 3-year financial costs associated with the DSDMs was US$550 million, compared with US$564 million for conventional care. CONCLUSIONS: DSDMs were less expensive and more effective in retaining clients 12 months after antiretroviral therapy initiation and were estimated to save approximately US$14 million for the health system from 2022 to 2024.

Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial.

BACKGROUND: Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique. METHODS: This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective. DISCUSSION: SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning. TRIAL REGISTRATION: ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

Quality of routine data for monitoring nutrition and diarrhoea indicators of children under 5 in Mozambique: an ecological study over a 5-year period.

BACKGROUND: Undernutrition and diarrhoea have a high burden in children under 5 in low/middle-income countries. Having data-driven quality health services for these two diseases is key in order to address the high burden of diseases; therefore, health systems must provide data to monitor, manage, plan and decide on policies at all levels of health services. OBJECTIVE: We aimed to assess the quality of nutrition and diarrhoea routine data on children under 5 in Mozambique. DESIGN: A longitudinal ecological study was implemented. Secondary data were used to assess the quality of moderate acute malnutrition (MAM), deworming and rotavirus vaccine indicators based on the data's completeness, presence of outliers and consistency, and seasonality analysis in the form of time series analysis was performed. SETTING: We used monthly district-level count data from 2017 to 2021, from all health facilities, from the Mozambican health information system (Sistema de Informação de Saúde para Monitoria e Avaliação, or District Health Information System version 2). RESULTS: The rotavirus vaccine indicators presented better completeness when compared with other indicators under analysis. Extreme outliers were observed for deworming and rotavirus vaccines, with a higher number of outliers in the Zambezia and Nampula Provinces. Better consistency over time was observed when analysing the period before the COVID-19 pandemic, for all of the indicators and across provinces. Indicators of MAM and MAM-recovered showed more consistency issues over time in both periods of 2017-2019 and 2018-2021. In terms of seasonality analysis, for the MAM and MAM-recovered indicators, lower variation was observed, and heterogeneous patterns were seen across provinces for the rotavirus vaccine, which had the most pronounced negative seasonality components in Maputo City. CONCLUSION: Major deficits regarding the analysed quality indicators were observed for Cabo Delgado, Nampula, Zambezia, Tete, Manica, and Maputo City and Province.

Regional Differences in Intestinal Parasitic Infections among Army Recruits in a Southern Mozambique Training Center: A Cross-Sectional Study.

Due to the high prevalence and diversity of clinical manifestations, intestinal parasitic infections (IPIs) represent a public health problem. The objective of the work was to determine the prevalence of IPIs among army recruits at a practice and training center in southern Mozambique. Sociodemographic information was obtained through semi-structured interviews. Single urine and stool samples were collected from 362 recruits. Parasite diagnosis was made by filtration, formaldehyde-ether and Kato-Katz techniques. Positive individuals underwent abdominal ultrasound. Then, descriptive statistics and cross-tabulations were performed, and p-values < 0.05 were considered significant. The prevalence of infection with at least one parasite was 25.1% (95% CI: 20.5-29.6; n = 91). The most common parasites were Entamoeba coli (10.7%; 95% CI: 7.4-13.7; n = 37) and Trichuris trichiura (6.1%; 95% CI: 4.6-9.9; n = 25). Parasitic infection was associated with the origin of the participant (p-value < 0.001), and the province of Sofala had the highest prevalence among the provinces studied (70.6%; 95% CI: 47.0-87.8; 12/17). Since oral fecal transmission occurs for several parasites, routine screening and deworming prior to enrollment at the army training center is recommended to reduce transmission of intestinal parasites among recruits.

Perceptions on use of insecticide-treated bed nets to prevent malaria: a qualitative assessment in two rural districts of Zambézia province in Mozambique.

Background: Malaria prevention in Africa merits particular attention as the world strives toward a better life for the poorest. The insecticide-treated bed nets (ITNs) are one of the malaria control strategies that, due to their cost effectiveness, are largely used in the country. Data on the actual coverage and usage of bed nets is unreliable, as it is based only on administrative data from distributed ITNs. Objective: This study assesses knowledge about malaria and bed net use in two areas of high malaria transmission. Methods: A qualitative study was conducted in 6 (six) rural communities in two malaria high-burden districts in Zambézia province. About 96 adults were recruited from the communities and enrolled to participate in focus group discussions. Data were transcribed verbatim, coded, and thematically analyzed using Nvivo11.0. Results: Participants mentioned the mosquito as the only cause of malaria and that the use of bed nets was highlighted as the most proficient protection against mosquito bites and malaria. Children and pregnant women were described as being the priority groups to sleep under a bed net protection in the household. The use of bed nets was common among households, although not sufficient for the number of household members. In addition, the preservation of the nets was considered inadequate. Conclusions: The findings of this study highlight the need to increase public knowledge about malaria and nets and to strengthen the communication and logistics component of the net distribution campaign to ensure that households have enough nets for their members and use them appropriately.

Determinants of COVID-19 vaccine acceptance in Mozambique: The role of institutional trust.

BACKGROUND: Vaccination plays an imperative role in protecting public health and preventing avoidable mortality. Yet, the reasons for vaccine hesitancy in African countries are not well understood. This study investigates the factors associated with the acceptance of COVID-19 vaccine in Mozambique, with a focus on the role of institutional trust. METHODS: The data came from the three waves of the COVID-19 Knowledge, Attitudes and Practices (KAP) survey which followed a cohort of 1,371 adults in Mozambique over six months (N = 3809). We examined vaccine acceptance based on three measurements: willingness to take vaccine, perceived vaccine efficacy, and perceived vaccine safety. We conducted multilevel regression analysis to investigate the trajectories of, and the association between institutional trust and vaccine acceptance. RESULTS: One third of the survey participants (37%) would definitely take the vaccine. Meanwhile, 31% believed the vaccine would prevent the COVID-19 infection, and 27% believed the vaccine would be safe. There was a significant decrease in COVID-19 vaccine acceptance between waves 1 and 3 of the survey. Institutional trust was consistently and strongly correlated with different measures of vaccine acceptance. There was a greater decline in vaccine acceptance in people with lower institutional trust. The positive correlation between institutional trust and vaccine acceptance was stronger in younger than older adults. Vaccine acceptance also varied by gender and marital status. CONCLUSIONS: Vaccine acceptance can be volatile even over short periods of time. Institutional trust is a central driver of vaccine acceptance and contributes to the resilience of the health system. Our study highlights the importance of health communication and building a trustful relationship between the general public and the institutions in the context of a global pandemic.