Distinguishing multicystic from focal encephalomalacia on delayed MRI in children with term hypoxic ischemic injury.

BACKGROUND AND PURPOSE: To define cystic patterns resulting from term hypoxic ischemic injury (HII) on delayed Magnetic Resonance Imaging (MRI) and determine associated HII patterns and lesions that reflect the severity of injury, from a database of African children with cerebral palsy. METHODS: Retrospective review of 1175 children with cerebral palsy due to term HII diagnosed on late MRI, identifying those with cystic changes. These were classified as multicystic or (multi-) focal-cystic, and were evaluated for associated injuries-thalami, basal ganglia, hippocampi, cerebellum, and presence of ulegyria. RESULTS: Three hundred and eighty-eight of 1175 (33%) children had cystic encephalomalacia. Two hundred and seven of 388 (53.3%) had focal-cystic and 181/388 (46.6%) had multicystic injury. The focal-cystic group comprised 87.9% (182/207) with thalamic injury, 25.6% (53/207) with basal ganglia injury, and 15% (31/207) with cerebellar involvement. Basal-ganglia-thalamus (BGT) pattern was present in 43.9% (91/207) and ulegyria in 69.6% (144/207). In the multicystic group, 88.9% (161/181) had thalamic injury, 30.9% (56/181) had basal ganglia injury, and 21% (38/181) had cerebellar involvement. BGT pattern was observed in 29.8% (54/181) and ulegyria in 28.7%. (52/181). Significant associations (p<.05) were found between multicystic injury and caudate/globus pallidus involvement, and between focal-cystic pattern of injury and ulegyria. CONCLUSIONS: Cystic encephalomalacia was seen in almost one-third of patients with term HII imaged with delayed MRI, with a similar prevalence of focal-cystic and multicystic injury. Multicystic injury was associated with caudate and globus pallidi involvement, typical of the BGT pattern of HII, whereas the focal-cystic pattern was associated with ulegyria, typical of watershed injury.

Understanding factors influencing linkage to HIV care in a rural setting, Mbeya, Tanzania: qualitative findings of a mixed methods study.

BACKGROUND: In remote rural Tanzania, the rate of linkage into HIV care was estimated at 28% in 2014. This study explored facilitators and barriers to linkage to HIV care at individual/patient, health care provider, health system, and contextual levels to inform eventual design of interventions to improve linkage to HIV care. METHODS: We conducted a descriptive qualitative study nested in a cohort study of 1012 newly diagnosed HIV-positive individuals in Mbeya region between August 2014 and July 2015. We conducted 8 focus group discussions and 10 in-depth interviews with recently diagnosed HIV-positive individuals and 20 individual interviews with healthcare providers. Transcripts were analyzed inductively using thematic content analysis. The emergent themes were then deductively fitted into the four level ecological model. RESULTS: We identified multiple factors influencing linkage to care. HIV status disclosure, support from family/relatives and having symptoms of disease were reported to facilitate linkage at the individual level. Fear of stigma, lack of disclosure, denial and being asymptomatic, belief in witchcraft and spiritual beliefs were barriers identified at individual's level. At providers' level; support and good patient-staff relationship facilitated linkage, while negative attitudes and abusive language were reported barriers to successful linkage. Clear referral procedures and well-organized clinic procedures were system-level facilitators, whereas poorly organized clinic procedures and visit schedules, overcrowding, long waiting times and lack of resources were reported barriers. Distance and transport costs to HIV care centers were important contextual factors influencing linkage to care. CONCLUSION: Linkage to HIV care is an important step towards proper management of HIV. We found that access and linkage to care are influenced positively and negatively at all levels, however, the individual-level and health system-level factors were most prominent in this setting. Interventions must address issues around stigma, denial and inadequate awareness of the value of early linkage to care, and improve the capacity of HIV treatment/care clinics to implement quality care, particularly in light of adopting the 'Test and Treat' model of HIV treatment and care recommended by the World Health Organization.

Sexting and high sexual risk-taking behaviours among school youth in northern Ethiopia: estimating using prevalence ratio.

BACKGROUND: Increasing access to digital technology to young people in low-income settings has greatly influenced their porngraphy viewing and sexting, receiving and/or sending of sexual explicit materials via electronic devices. These change the sexual communication and behaviour of the young population. However, evidence to attest this change is not available in our setting. Thus, this study examined the relationship of high sexual risk-taking behaviour with sexting and pornography viewing among school youth in Ethiopia. METHODS: A cross-sectional study was conducted from March to April 2015 by selecting school youth using a multistage sampling procedure. Data were collected using a pre-validated anonymous facilitator-guided self-administered questionnaire. Poisson regression was run to calculate adjusted prevalence ratio with its 95% confidence intervals. All differences were considered as significant for p values ≤0.05. RESULTS: In total, 5924 questionnaires were distributed, and 5306 (89.57%) school youth responded in full to questions related to outcome variables. Of these respondents, 1220 (22.99%; 95% CI 19.45 to 26.96) were involved in high sexual risk-taking behaviour; 1769 (33.37%; 95% CI 30.52 to 36.35) had experienced sexting and 2679 (50.26%; 95% CI 46.92 to 53.61) were viewing pornography. The proportion of high sexual risk-taking behaviour was three-fold among pornography viewers (adjusted prevalence ratio (APR) 95% CI 3.02 (2.52 to 3.62)) and two-fold among sexters (APR 95% CI 2.48 (1.88 to 3.27)) as compared with their counterparts. CONCLUSIONS: Exposure to sexually explicit materials via communication technology is associated with increased high sexual risk-taking behaviour among school youth in northern Ethiopia. Considering these emerged predictors of sexual behaviours in our sexual education programmes, further research in this area is essential.

Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study.

BACKGROUND: Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. METHODS: An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). RESULTS: More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). CONCLUSIONS: Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less "linkage-ready". Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.

Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.

OBJECTIVE: Linkage to care is the bridge between HIV testing and HIV treatment, care and support. In Tanzania, mobile testing aims to address historically low testing rates. Linkage to care was reported at 14% in 2009 and 28% in 2014. The study compares linkage to care of HIV-positive individuals tested at mobile/outreach versus public health facility-based services within the first 6 months of HIV diagnosis. SETTING: Rural communities in four districts of Mbeya Region, Tanzania. PARTICIPANTS: A total of 1012 newly diagnosed HIV-positive adults from 16 testing facilities were enrolled into a two-armed cohort and followed for 6 months between August 2014 and July 2015. 840 (83%) participants completed the study. MAIN OUTCOME MEASURES: We compared the ratios and time variance in linkage to care using the Kaplan-Meier estimator and Log rank tests. Cox proportional hazards regression models to evaluate factors associated with time variance in linkage. RESULTS: At the end of 6 months, 78% of all respondents had linked into care, with differences across testing models. 84% (CI 81% to 87%, n=512) of individuals tested at facility-based site were linked to care compared to 69% (CI 65% to 74%, n=281) of individuals tested at mobile/outreach. The median time to linkage was 1 day (IQR: 1-7.5) for facility-based site and 6 days (IQR: 3-11) for mobile/outreach sites. Participants tested at facility-based site were 78% more likely to link than those tested at mobile/outreach when other variables were controlled (AHR=1.78; 95% CI 1.52 to 2.07). HIV status disclosure to family/relatives was significantly associated with linkage to care (AHR=2.64; 95% CI 2.05 to 3.39). CONCLUSIONS: Linkage to care after testing HIV positive in rural Tanzania has increased markedly since 2014, across testing models. Individuals tested at facility-based sites linked in significantly higher proportion and modestly sooner than mobile/outreach tested individuals. Mobile/outreach testing models bring HIV testing services closer to people. Strategies to improve linkage from mobile/outreach models are needed.

Validity and reliability of the South African health promoting schools monitoring questionnaire.

Health promoting schools, as conceptualised by the World Health Organisation, have been developed in many countries to facilitate the health-education link. In 1994, the concept of health promoting schools was introduced in South Africa. In the process of becoming a health promoting school, it is important for schools to monitor and evaluate changes and developments taking place. The Health Promoting Schools (HPS) Monitoring Questionnaire was developed to obtain opinions of students about their school as a health promoting school. It comprises 138 questions in seven sections: socio-demographic information; General health promotion programmes; health related Skills and knowledge; Policies; Environment; Community-school links; and support Services. This paper reports on the reliability and face validity of the HPS Monitoring Questionnaire. Seven experts reviewed the questionnaire and agreed that it has satisfactory face validity. A test-retest reliability study was conducted with 83 students in three high schools in Cape Town, South Africa. The kappa-coefficients demonstrate mostly fair (κ-scores between 0.21 and 0.4) to moderate (κ-scores between 0.41 and 0.6) agreement between test-retest General and Environment items; poor (κ-scores up to 0.2) agreement between Skills and Community test-retest items, fair agreement between Policies items, and for most of the questions focussing on Services a fair agreement was found. The study is a first effort at providing a tool that may be used to monitor and evaluate students' opinions about changes in health promoting schools. Although the HPS Monitoring Questionnaire has face validity, the results of the reliability testing were inconclusive. Further research is warranted.

Pre-term and post-term births: predictors and implications on neonatal mortality in Northern Ethiopia.

BACKGROUND: Pre-term and post-term births are major determinants of neonatal mortality, including short- and long-term morbidity. In developing countries, where pre-term and post-term births are disproportionately common, the magnitude and underlying causes are not well understood, and evidence is required to design appropriate interventions. This study measured the incidence and identified risk factors of pre-term birth and post-term births in Ethiopia. In addition, it examined the effects of pre-term and post-term birth on neonatal mortality. METHOD: This study is a portion of prospective cohort study conducted on 1152 live births born between April and July 2014 in seven hospitals in Tigray region, Northern Ethiopia. Neonatal mortality and birth outcomes were considered as dependent variables. Data were collected using a structured questionnaire and weekly neonatal follow up directed at midwives. Data were described using frequency, percentage, ratio of relative risk (RRR), and 95 % confidence interval (CI). We used multinomial and binary logistic regression to identify independent predictors of birth outcome and neonatal mortality respectively. RESULT: The prevalence of pre-term and post term births was 8.1 % and 6.0 % respectively. Underweight maternal body mass index (RRR: 0.47, CI: 0.22-0.99), medium reported income (RRR: 0.26, CI: 0.12-0.5), length of neonate (RRR: 0.05, CI: 0.01-0.41), and multiple births (RRR: 2.86, CI: 1.4-5.650) were associated with pre-term birth. Predictors for post-term birth were overweight maternal body mass index (RRR: 3.88, CI: 1.01-15.05), high reported income mothers (RRR: 2.17, CI:1.1-4.3), as well as unmarried, widowed and divorced marital status (RRR:2.43, CI:1.02-5.80). With regards to binary logistic regression, pre-term birth (RR: 2.45, CI: 1.45-4.04) was an independent predictor for neonatal mortality, but this was not true for post-term births (RR: 0.45, CI: 0.07-2.96). CONCLUSION: Socioeconomic and proximate factors are important predictors for pre-term and post-term births. Empowering women in terms of income status and controlling body mass index within the normal range are recommended. In addition, early detection and close antenatal follow-ups for mothers, who are at risk before and during pregnancy, are necessary to prevent both pre-term and post-term births.

Survival of neonates and predictors of their mortality in Tigray region, Northern Ethiopia: prospective cohort study.

BACKGROUND: Neonatal mortality accounts for an estimated 2.8 million deaths worldwide, which constitutes 44 % of under-5-mortality and 60 % of infant mortality. Neonatal mortality predictors vary by country with the availability and quality of health care. Therefore, aim of this study was to estimate survival time and identify predictors of neonatal mortality in Tigray region, northern Ethiopia. METHOD: A prospective cohort study design was carried out among a cohort of neonates delivered in seven hospitals of Tigray from April to July, 2014 and followed up for a total of 28 days. Data were collected by interviewing mothers using structured questionnaires and assessments of the neonate and mothers by midwives. Kaplan-Meier, Log rank test and Cox-proportional hazard regressions were used. STATA V-11 program was used for data entry, cleaning and analysis. RESULTS: From 1152 neonates, 68 died (neonatal mortality rate 62.5/1000 live births), 73.52 % of the neonates died within 7 days, 60 were lost to follow-up and the percentage of survival at 28 days was 93.96 % (95 % CI: 92.4, 95.2 %). Predictors of neonatal mortality were: normal birth weight (AHR: 0.45, 95 % CI: 0.24, 0.84), not initiating exclusive breastfeeding (AHR: 7.5, 95 % CI: 3.77, 15.05), neonatal complications (AHR: 0.14, 95 % CI 0.07, 0.29), maternal complications (AHR: 0.37, 95 % CI: 0.22, 0.63) and proximity (AHR: 2.5, 95 % CI: 1.29, 4.91). CONCLUSION: Neonatal mortality is unacceptably very high. Managing complications and low birth weight, initiating exclusive breast feeding, improving quality of services and ensuring a continuum of care are recommended to increase survival of neonates.

Multilevel analysis of individual and community level factors associated with institutional delivery in Ethiopia.

BACKGROUND: Improving maternal health is one of the eight millennium development goals to reduce maternal mortality (MM) by three quarters between 1990 and 2015. Institutional delivery is considered to be the most critical intervention in reducing MM and ensuring safe motherhood. However, the level of maternal morbidity and mortality in Ethiopia are among the highest in the world and the proportion of births occurring at health facilities is very low. This study examined the individual and community level factors associated with institutional delivery in Ethiopia. METHODS: Data from the 2011 Ethiopian demographic and health survey were used to identify individual and community level factors associated with institutional delivery among women who had a live birth during the 5 years preceding the survey. Taking into account the nested structure of the data, multilevel logistic regression analysis has been employed to a nationally representative sample of 7757 women nested with in 595 communities. RESULTS: At the individual level; higher educational level of the women (AOR = 3.60; 95% CI 2.491-5.214), women from richest households (AOR = 1.74; 95% CI 1.143-2.648) and increased ante natal care attendance (AOR = 4.43; 95% CI 3.405-5.751) were associated with institutional delivery. Additionally, at the community level; urban residence (AOR = 4.74; 95% CI 3.196-7.039), residing in communities with high proportion of educated women (AOR = 1.71; 95% CI 1.256-2.319) and residing in communities with high ANC utilization rate (AOR = 1.55; 95% CI 1.132-2.127) had a significant effect on institutional delivery. Also region and distance to health facility showed significant association with institutional delivery. The random effects showed that the variation in institutional delivery service utilization between communities was statistically significant. CONCLUSION: Both individual and community level factors are associated with institutional delivery service uptake. As a result, further research is needed to better understand why these factors may affect institutional delivery.

The effect of isoniazid preventive therapy on incidence of tuberculosis among HIV-infected clients under pre-ART care, Jimma, Ethiopia: a retrospective cohort study.

BACKGROUND: Tuberculosis (TB) is a major public health problem that accounts for almost half a million human immunodeficiency virus (HIV) associated deaths. Provision of isoniazid preventive therapy (IPT) is one of the public health interventions for the prevention of TB in HIV infected individuals. However, in Ethiopia, the coverage and implementation of IPT is limited. The objective of this study is to compare the incidence rate of TB, TB-free survival time and identify factors associated with development TB among HIV-infected individuals on pre-ART follow up. METHODS: A retrospective cohort study was conducted from January, 2008 to February 31, 2012 in Jimma hospital. Kaplan-Meier survival plots were used to calculate the crude effect in both groups on TB-free survival probabilities and compared using the log rank test. A Cox proportional hazard model was used to identify predictors of TB. RESULT: A total of 588 patients on pre-ART care (294 IPT and 294 non-IPT group) were followed retrospectively for a median duration of 24.1 months. The median CD4 (+) cell count was 422 cells/µl (IQR 344-589). During the follow up period, 49 individuals were diagnosed with tuberculosis, giving an overall incidence of 3.78 cases per 100 person year (PY). The incidence rate of TB was 5.06 per 100 PY in non-IPT group and 2.22 per 100 PY in IPT user group. Predictors of higher TB risk were: being on clinical WHO stage III/IV (adjusted hazard ratio (AHR = 3.05, 95% confidence interval (CI): 1.61, 5.81); non-IPT user (AHR = 2.02, 95% CI: 1.04, 3.92); having CD4 (+) cell count less than 350 cells/µl (AHR = 3.16, 95% CI: 1.04, 3.92) and between 350-499 cells/µl, (AHR = 2.87; 95% CI: 1.37-6.03) and having episode of opportunistic infection (OI) in the past (AHR = 2.41, 95% CI: 1.33-4.34). CONCLUSION: IPT use was associated with fifty percent reduction in new cases of tuberculosis and probability of developing TB was higher in non-IPT group. Implementing the widespread use of IPT has the potential to reduce TB rates substantially among HIV-infected individuals in addition to other tuberculosis prevention and control effort in resource limited settings.

Identifying factors associated with the uptake of prevention of mother to child HIV transmission programme in Tigray region, Ethiopia: a multilevel modeling approach.

BACKGROUND: Prevention of mother to child HIV transmission (PMTCT) remains a challenge in low and middle-income countries. Determinants of utilization occur--and often interact--at both individual and community levels, but most studies do not address how determinants interact across levels. Multilevel models allow for the importance of both groups and individuals in understanding health outcomes and provide one way to link the traditionally distinct ecological- and individual-level studies. This study examined individual and community level determinants of mother and child receiving PMTCT services in Tigray region, Ethiopia. METHODS: A multistage probability sampling method was used for this 2011 cross-sectional study of 220 HIV positive post-partum women attending child immunization services at 50 health facilities in 46 districts. In view of the nested nature of the data, we used multilevel modeling methods and assessed macro level random effects. RESULTS: Seventy nine percent of mothers and 55.7% of their children had received PMTCT services. Multivariate multilevel modeling found that mothers who delivered at a health facility were 18 times (AOR = 18.21; 95% CI 4.37,75.91) and children born at a health facility were 5 times (AOR = 4.77; 95% CI 1.21,18.83) more likely to receive PMTCT services, compared to mothers delivering at home. For every addition of one nurse per 1500 people, the likelihood of getting PMTCT services for a mother increases by 7.22 fold (AOR = 7.22; 95% CI 1.02,51.26), when other individual and community level factors were controlled simultaneously. In addition, district-level variation was low for mothers receiving PMTCT services (0.6% between districts) but higher for children (27.2% variation between districts). CONCLUSIONS: This study, using a multilevel modeling approach, was able to identify factors operating at both individual and community levels that affect mothers and children getting PMTCT services. This may allow differentiating and accentuating approaches for different settings in Ethiopia. Increasing health facility delivery and HCT coverage could increase mother-child pairs who are getting PMTCT. Reducing the distance to health facility and increasing the number of nurses and laboratory technicians are also important variables to be considered by the government.