Antibiotic prescribing practices for acute respiratory illness in children less than 24 months of age in Kenema, Sierra Leone: is it time to move beyond algorithm driven decision making?

BACKGROUND: Lower respiratory tract infections are the leading cause of mortality in young children globally. In many resource-limited settings clinicians rely on guidelines such as IMCI or ETAT + that promote empiric antibiotic utilization for management of acute respiratory illness (ARI). Numerous evaluations of both guidelines have shown an overall positive response however, several challenges have also been reported, including the potential for over-prescribing of unnecessary antibiotics. The aims of this study were to describe the antibiotic prescribing practices for children less than 24 months of age with symptoms of ARI, that were admitted to Kenema Government Hospital (KGH) in the Eastern Province of Sierra Leone, and to identify the number of children empirically prescribed antibiotics who were admitted to hospital with ARI, as well as their clinical signs, symptoms, and outcomes. METHODS: We conducted a prospective study of children < 24 months of age admitted to the KGH pediatric ward with respiratory symptoms between October 1, 2020 and May 31, 2022. Study nurses collected data on demographic information, medical and medication history, and information on clinical course while hospitalized. RESULTS: A total of 777 children were enrolled. Prior to arrival at the hospital, 224 children (28.8%) reported taking an antibiotic for this illness without improvement. Only 15 (1.9%) children received a chest radiograph to aid in diagnosis and 100% of patients were placed on antibiotics during their hospital stay. CONCLUSIONS: Despite the lives saved, reliance on clinical decision-support tools such as IMCI and ETAT + for pediatric ARI, is resulting in the likely over-prescribing of antibiotics. Greater uptake of implementation research is needed to develop strategies and tools designed to optimize antibiotic use for ARI in LMIC settings. Additionally, much greater priority needs to be given to ensuring clinicians have the basic tools for clinical diagnosis, as well as greater investments in essential laboratory and radiographic diagnostics that help LMIC clinicians move beyond the sole reliance on algorithm based clinical decision making.

'I married when I was 16 due to poverty, I had no other way': multi-level factors influencing HIV-related sexual risk behaviours among adolescent girls in Zambézia, Mozambique.

This paper explores individual, interpersonal- and household-level factors influencing HIV-related sexual risk behaviour among adolescent girls who participated in an intervention to reduce HIV risk in a rural setting in Mozambique. Twenty-eight adolescent girls ages 13-19, 30 heads of household, and 53 influential men participated in in-depth interviews at two time points. Comparative analysis compared girls who reported reducing risk behaviours over time to girls who did not and identified factors that respondents described as influential to behaviour change. Among the twenty girls self-reporting sexual risk at the first time point, half had reduced these behaviours one year later. Changes in girls' behaviours were contingent upon household- and interpersonal-level factors, particularly households' economic stability and family members' financial support. Future interventions with adolescents in similar settings should evaluate and leverage household and family support to achieve sexual risk reduction.

Multiple Concurrent Illnesses Associated with Anemia in HIV-Infected and HIV-Exposed Uninfected Children Aged 6-59 Months, Hospitalized in Mozambique.

Anemia is an increasingly recognized problem in sub-Saharan Africa. To determine the magnitude, severity, and associated factors of anemia among hospitalized children aged 6-59 months, HIV-infected and HIV-exposed uninfected children (a child born to a known HIV-infected mother) with a documented fever or history of fever within the prior 24 hours of hospital admission (N = 413) were included in this analysis. Of 413 children enrolled, 364 (88%) were anemic, with 53% classified as mild anemia (hemoglobin [Hb] 7-9.9 g/dL). The most common diagnoses associated with hospital admission included acute respiratory illness (51%), malnutrition (47%), gastroenteritis/diarrhea (25%), malaria (17%), and bacteremia (13%). A diagnosis of malaria was associated with a decrease in Hb by 1.54 g/dL (P < 0.001). In HIV-infected patients, malaria was associated with a similar decrease in Hb (1.47 g/dL), whereas a dual diagnosis of bacteremia and malaria was associated with a decrease in Hb of 4.12 g/dL (P < 0.001). No difference was seen in Hb for patients on antiretroviral therapy versus those who were not. A diagnosis of bacteremia had a roughly 4-fold increased relative odds of death during hospitalization (adjusted odds ratio = 3.97; 95% CI: 1.61, 9.78; P = 0.003). The etiology of anemia in high-burden malaria, HIV, tuberculosis, and poor nutrition countries is multifactorial, and multiple etiologies may be contributing to one's anemia at any given time. Algorithms used by physician and nonphysician clinicians in Mozambique should incorporate integrated and non-disease specific approaches to pediatric anemia management and should include improved access to blood culture.

Monitoring Pharmacy and Test Kit Stocks in Rural Mozambique: U.S. President's Emergency Plan for AIDS Relief Surveillance to Help Prevent Ministry of Health Shortages.

Support of human immunodeficiency virus (HIV) and tuberculosis (TB) testing and treatment supported by President's Emergency Plan for AIDS Relief (PEPFAR) in Africa requires immense quantities of tests and medications. We sought to use central pharmacy supply data of Mozambique's rural Zambézia Province (2017 population ≈5.11 million persons; ≈12.6% adult HIV prevalence in 2016) to examine shortages, stockouts, and trends in availability. Using stock surveillance for 60 weeks in 2014-2015, we assessed availability of 36 medications [4 classes: adult antiretroviral (ARV) medications, pediatric ARVs, anti-TB medications, and antibiotics] and diagnostic test kits (2 rapid tests for HIV; 1 each for malaria and syphilis). We contrasted these to 2018-2019 data. We modeled pharmacy data using ordinal logistic regression, characterizing weekly product availability in four categories: good, adequate, shortage, or complete stockout. We found 166 (7.7%) stockouts and 150 (6.9%) shortages among 2,160 weekly records. Earlier calendar time was associated with reduced medication supplies (p < .001). Certain medication/test kit classes were associated with reduced supply (p < .001). We found an interaction between time and medication class on the odds of reduced supply (p < .001). Pediatric ARVs had a 17.4 (95% confidence interval: 8.8-34.4) times higher odds of reduced medication supply compared with adult ARVs at study midpoint. Trends comparing the first and last weeks showed adult ARVs having 67% and pediatric having 71% lower odds of reduced supplies. Only adult ARV shortages improved amid growing demand. Data from 2018 to 2019 suggest continuing inventory management challenges. Monitoring of drug (especially pediatric) and test kit shortages is vital to ensure quality improvement to guarantee adequate supplies to enable patients and care providers to achieve sustained viral suppression. A central Mozambican drug repository in the nation's second largest Province continues to experience drug and rapid test kit stockouts.

Immunodeficiency at Antiretroviral Therapy Start: Five-Year Adult Data (2012-2017) Based on Evolving National Policies in Rural Mozambique.

Before the 2015 implementation of "Test and Start," the initiation of combination antiretroviral therapy (ART) was guided by specific CD4 cell count thresholds. As scale-up efforts progress, the prevalence of advanced HIV disease at ART initiation is expected to decline. We analyzed the temporal trends in the median CD4 cell counts among adults initiating ART and described factors associated with initiating ART with severe immunodeficiency in Zambézia Province, Mozambique. We included all HIV-positive, treatment-naive adults (age ≥ 15 years) who initiated ART at a Friends in Global Health (FGH)-supported health facility between September 2012 and September 2017. Quantile regression and multivariable logistic regression models were applied to ascertain the median change in CD4 cell count and odds of initiating ART with severe immunodeficiency, respectively. A total of 68,332 patients were included in the analyses. The median change in CD4 cell count under "Test and Start" was higher at +68 cells/mm3 (95% CI: 57.5-78.4) compared with older policies. Younger age and female sex (particularly those pregnant/lactating) were associated with higher median CD4 cell counts at ART initiation. Male sex, advanced age, WHO Stage 4 disease, and referrals to the health facility through inpatient provider-initiated testing and counseling (PITC) were associated with higher odds of initiating ART with severe immunodeficiency. Although there were reassuring trends in increasing median CD4 cell counts with ART initiation, ongoing efforts are needed that target universal HIV testing to ensure the early initiation of ART in men and older patients.

A longitudinal qualitative evaluation of an economic and social empowerment intervention to reduce girls' vulnerability to HIV in rural Mozambique.

PURPOSE: An intervention including business training and health education was implemented in Mozambique, where girls are at elevated risk for acquiring HIV. As part of a mixed-methods evaluation, we describe perceived effects of the intervention on girls' sexual behavior and school attendance. METHODS: We conducted 49 in-depth interviews (IDIs) with girl intervention participants (ages 13-19), 24 IDIs with heads of girls' households, 36 IDIs with influential males identified by girls, and 12 focus group discussions with community members after the intervention ended and one year later. RESULTS: Informants said the primary intervention benefit was realized when girls had money to stay in or return to school and/or to buy necessities for themselves and their households-reducing their need for transactional or intergenerational sex. However, some girls did not make a profit and some businesses were not sustainable. Sometimes the intervention appeared to be implemented in a way to reinforce inequitable gender norms resulting in some girls feeling shame when they reengaged in risky sex after their businesses failed. CONCLUSIONS: Earning money enabled girls to potentially reduce their vulnerability to HIV. We offer recommendations for future multi-sector interventions, including the need to address potential harms in programs serving vulnerable girls.

HIV Rapid Diagnostic Test Inventories in Zambézia Province, Mozambique: A Tale of 2 Test Kits.

BACKGROUND: The first pillar of the UNAIDS 90-90-90 goal seeks to accurately identify persons living with HIV (PLHIV), a process that is predicated on facilities having the necessary HIV tests available to perform the task. In many rural settings, the identification of PLHIV is accomplished through a two-step process involving the sequential use of 2 separate rapid diagnostic tests (RDTs). Inadequate inventory of either test has ramifications for the success of HIV-related programs. The purpose of this study was to evaluate the inventory levels of HIV RDT kits at specific healthcare facilities in Zambézia province, Mozambique. METHODS: Using facility-level pharmacy stock surveillance data from October 2015 through September 2016, we assessed the inventory levels of HIV RDTs at 75 health facilities in 8 districts within Zambézia province, Mozambique. Using programmatically established categories (good, sufficient, threatened, or stockout), defined in conjunction with the provincial health authorities, descriptive statistics were performed to determine inventory control of HIV RDTs at the district and health facility levels. Monthly proportions of adequate (good + sufficient) inventory were calculated for each district to identify inventory trends over the evaluation period. To assess whether the proportion of inadequate stocks differed between RDT, a mixed-effects logistic regression was conducted, with inadequate inventory status as the outcome of interest. RESULTS: When viewed as a whole, the inventory of each test kit was reported as being at adequate levels more than 89% of the time across the 75 facilities. However, disaggregated analysis revealed significant variability in the inventory levels of HIV RDTs at the district level. Specifically, the districts of Inhassunge, Namacurra, and Pebane reported inadequate inventory levels (threatened + stockout), of one or both test kits, for more than 10% of the study period. In addition, a disparity between inventory levels of each test kit was identified, with the odds of reporting inadequate inventory levels of the confirmatory test (Uni-Gold™) being approximately 1.8-fold greater than the initial test (Determine™) (odds ratio: 1.82, 95% CI: 1.40-2.38). CONCLUSION: As Test and Treat programs evolve, a significant emphasis should be placed on the "test" component of the strategy, beginning with assurances that health facilities have the adequate inventory of RDT necessary to meet the needs of their community. As national policy-makers rely predominantly on data from the upstream arm of the supply chain, it is unlikely the disparity between inventory levels of HIV RDTs identified at individual districts and specific health facilities would have been recognized. Moving forward, our findings point to a need for (1) renewed efforts reinforcing appropriate downstream forecasting of essential medicines and diagnostic tests in general and for Uni-Gold™ test kits specifically, and (2) simple metrics that may be routinely collected at all health facilities and which may then easily and quickly flow upstream so that policy-makers may optimally allocate resources.

Exploring intersections of localised gender norms and unanticipated effects of a sexual and reproductive health intervention: implications of respect and being a "good girl" in Zambézia Province, Mozambique.

Women First was a combined economic and social empowerment intervention implemented between 2010 and 2015 in Zambézia Province, Mozambique. The intervention was designed to reduce adolescent girls' risk of HIV and gender-based violence, improve school attendance and empower girls. However, perceptions of girls' improved respectfulness also emerged as an unanticipated effect during the programme evaluation. In this paper, we explore emic definitions of respect and girls' good behaviour and perceptions of how the intervention caused improvements in behaviour from the perspective of intervention participants, their heads of household, influential men in their lives, and community members. In depth interviews and focus group discussions were conducted at two time points in 12 rural communities where the intervention was implemented. Respondents described "good girls" as deferential and obedient; productive and willing to serve their families and communities; and sexually chaste and modestly dressed. Respondents believed the intervention had reinforced or taught these behaviours, although they were generally aligned with gender norms that were not part of the formal intervention content and sometimes contrary to the intervention's primary goals. Implications for future sexual and reproductive health programmes are discussed.

Hazardous alcohol use among female heads-of-household in rural Mozambique.

Hazardous drinking places individuals at risk for adverse health events, resulting in a major public health burden globally. Patterns of alcohol consumption among women in Africa remain poorly understood. We aimed to describe alcohol consumption in a representative sample of female heads-of-household in Mozambique. A 2014 population-based cross-sectional study of 3892 heads-of-household was conducted in Zambézia Province. Data on alcohol use were collected using the Alcohol Use Disorders Identification Test (AUDIT). Sociodemographic characteristics were summarized by alcohol use. A multivariable proportional odds model adjusted for age, education, Portuguese fluency, marital status, income, social support, depression, food insecurity, currently pregnant, and child mortality was used for the ordinal AUDIT scale as outcomes with robust covariance to account for clustering of respondents. The overall prevalence of current alcohol consumption among female heads-of-household was 15%. The mean PHQ-8 score was 2.7 (SD 4.7). The prevalence of women considered "hazardous drinkers" (score >4) was 8%. In bivariate analyses, depression, marital status, currently being pregnant, food insecurity, and death of a child were associated with higher risk of hazardous drinking. After adjusting for multiple characteristics, depression (aOR: 2.20 [1.28, 3.76] p = 0.004), death of a child (aOR: 2.44 [1.46, 4.07] p = 0.001), and being currently pregnant (aOR: 1.83 [0.99, 3.39] p = 0.002) were associated with hazardous drinking behavior. Being single (aOR: 0.48 [0.29, 0.80], p = 0.017) and food insecure (aOR: 0.96 [0.92, 1.00], p = 0.050) showed a protective effect on hazardous drinking behavior. The percentage of female heads-of-household in north-central Mozambique that regularly drink alcohol was lower than expected. This may be due to the unique characteristics of female heads-of-household and the extreme poverty pervasive in Zambézia.

Depression among female heads-of-household in rural Mozambique: A cross-sectional population-based survey.

BACKGROUND: An estimated 350 million people live with depression worldwide. In Mozambique, there are no national data quantifying the burden of mental illnesses. With the sixth highest suicide rate in the world, there is strong evidence of an unmet mental health need. We conducted a survey to measure the prevalence of depression among female heads of household and assess individual, social, and cultural risk factors associated with a positive depression screening. METHODS: This survey was conducted across 14 rural districts in central Mozambique in 2014. We gathered information from 3543 female heads of household (100% response rate) on > 500 variables, including a depression screening tool (PHQ-8). Weighted percentages of survey responses are reported. RESULTS: Among female heads of household, 14% screened positive for depression (PHQ-8 score ≥ 10). Our adjusted models show increased odds of depression per additional year of age (aOR: 1.02 [1.01, 1.04]; p = 0.002), additional year of education (aOR: 1.06 [1.02, 1.11]; p = 0.006), and additional kilometer from the nearest clinic (aOR: 1.05 [1.02, 1.07]; p = < 0.001). Experiencing food insecurity (aOR: 1.05 [1.02, 1.08]; p = 0.003) was associated with increased odds of depression. Being single (aOR: 0.42 [0.29, 0.60]) or divorced/widowed/separated (aOR: 0.57 [0.34, 0.98]; p < 0.001) vs. married was protective against depression, as was a perceived "sufficient" household income (aOR: 0.37 [0.19, 0.69]; p = 0.008). LIMITATIONS: Social desirability bias may have led women to underreport feelings of depression. CONCLUSIONS: The association of more education and marriage with increased odds of depression may reflect a frustration with limited opportunity for success experienced by some women in rural Mozambique.

Determinants of full vaccination status in children aged 12-23 months in Gurùé and Milange districts, Mozambique: results of a population-based cross-sectional survey.

Background: In 2011, 64% of children in Mozambique, ages 12-23 months, were fully immunized. Large provincial differences in vaccine uptake exist. Methods: We conducted a survey of 1650 females with children aged 12-23 months in the districts of Gurùé and Milange. Implementation occurred from November to December 2014. Descriptive statistics and logistic regression using R-software 3.0.2 were used to examine factors associated with full vaccination status. ArcGIS version 10.3.1 (ESRI, Redlands, CA, USA) was used to map spatial patterns of vaccine uptake. Results: Full vaccination was roughly 48%. Identifying 'hospital' as a location to get vaccinated was associated with having a fully vaccinated child (OR=1.87, 95% CI=1.02, 3.41, p=0.043). Households where health decisions are made solely by the male or the female had 38% (95% CI=0.32, 1.21) and 55% (95% CI=0.29, 0.69) lower odds, respectively, of their child being fully immunized. For every 10 km increase from the nearest health facility there was a 36% lower odds of the child being fully immunized (OR=0.64, 95% CI=0.44, 0.93, p<0.001). Conclusion: Zambézia Province, as a whole and the districts of Gurùé and Milange specifically, is falling short of vaccination targets. Intensified efforts focused on the least educated, most distant and which take a more family-centered approach are needed to improve vaccine uptake.

Prevalence and determinants of malaria among children in Zambézia Province, Mozambique.

BACKGROUND: Malaria is the leading cause of death among children in Mozambique. Prevalence and factors associated with malaria are not well studied among children in rural Zambézia Province. Whether prevalence of malaria varies across diverse districts within the province is unknown. METHODS: A cross-sectional survey of female heads of household was conducted during April and May 2014, a period of peak malaria transmission. Data were collected on up to two randomly selected children aged 6-59 months per household. The outcome of interest was self-report of symptomatic malaria confirmed by diagnostic test in the past 30 days. Analyses accounted for the two-stage cluster sample design. Prevalence of symptomatic malaria was calculated for the province and three over-sampled focus districts-Alto Molócuè, Morrumbala, and Namacurra. Multivariable logistic regression of symptomatic malaria diagnosis included: district, age, sex, education, bed net use, urban setting, distance to health facility, income, roofing material, and pig farming. RESULTS: Data were collected on 2540 children. Fifty percent were female, and the median age was 24 months. Sixty percent of children slept under bed nets the night prior to the survey, but utilization varied between districts (range 49-89%; p < 0.001). Forty-three percent of children reported fever in the past 30 days, 91% of those sought care at a health facility, 67% of those had either a malaria rapid diagnostic test or blood smear, and 67% of those had a positive test result and therefore met our case definition of self-reported symptomatic malaria. There were significant differences in prevalence of fever (p < 0.001), health-seeking (p < 0.001), and diagnostic testing (p = 0.003) between focus districts. Province-wide prevalence of symptomatic malaria was 13% and among focus districts ranged from 14% in Morrumbala to 17% in Namacurra (p < 0.001). Higher female caregiver education (OR 1.88; 95% CI 1.31-2.70), having fewer young children in the household (OR 1.25; 95% CI 1.01-1.56), and higher income (OR 1.56; 95% CI 1.11-2.22) were independently associated with having a child with symptomatic malaria. CONCLUSIONS: Self-reported symptomatic malaria is highly prevalent among children in Zambézia Province, Mozambique and varies significantly between diverse districts. Factors facilitating access to health services are associated with symptomatic malaria diagnosis. These findings should inform resource allocation in the fight against malaria in Mozambique.

Understanding intra-vaginal and labia minora elongation practices among women heads-of-households in Zambézia Province, Mozambique.

Intra-vaginal drying and tightening and labia minora elongation are commonly practised in some parts of southern Africa. We sought to capture data on these practices among women living in Zambézia province, Mozambique. Information was gathered from 3543 female heads of household on > 500 variables, including vaginal practices, in 2014. Women who planned to use intra-vaginal tightening substances had 1.84 times higher odds of ever receiving an HIV test (p < 0.001) and 1.40 times higher odds of at least one antenatal care visit attended during last pregnancy (p = 0.015). Women who had or planned to undergo labia minora elongation had 2.61 times higher odds of receiving an HIV test in the past (p < 0.001) and 1.60 times higher odds of attending at least one antenatal care visit during their last pregnancy (p < 0.001). There was little evidence for a relationship between self-reported HIV status and anticipated use of intra-vaginal tightening substances (p = 0.21). Current or anticipated participation in labia elongation showed a protective effect on HIV infection (p = 0.028). Given documented associations between intra-vaginal substance use, vaginal infections and HIV acquisition, understanding the prevalence of vaginal practices is an essential component to addressing the epidemic.

Predictors of Health-Care Utilization Among Children 6-59 Months of Age in Zambézia Province, Mozambique.

Globally, approximately 5.9 million children under 5 years of age died in 2015, a reduction of over 50% since 1990. Millennium Development Goal 4 established the goal of reducing child mortality by two-thirds by 2015. Multiple countries have surpassed this goal; however, regional and within-country inequities exist. We sought to study determinants of health-care utilization among children 6-59 months of age with fever, diarrhea, and respiratory symptoms in Zambézia Province, Mozambique. We conducted a population-based cross-sectional survey of female heads of household between April and May 2014. Mobile teams conducted interviews in 262 enumeration areas, with three distinct districts being oversampled for improved precision. Descriptive statistics and logistic regression using Stata 13.1 and R 3.2.2 were used to examine factors associated with health-care utilization. A total of 2,317 children were evaluated in this study. Mothers' median age was 26 years, whereas child median age was 24 months. The proportion of children reporting fever, diarrhea, or respiratory illness in the prior 30 days was 44%, 22%, and 22%, respectively. Health-care utilization varied with 65% seeking health care for fever, compared with 57% for diarrhea and 25% for respiratory illness. In multivariable logistic regression, the characteristics most associated with health-care utilization across illnesses were delivery of last child at a facility, higher maternal education, and household ownership of a radio. The decision or ability to use health care is a multifaceted behavior swayed by societal norms, values, socioeconomics, and perceived need. Recognizing the predictors of a particular population may offer useful information to increase uptake in health-care services.

Prevalence and determinants of malaria among children in Zambézia Province, Mozambique

Background: Malaria is the leading cause of death among children in Mozambique. Prevalence and factors associated with malaria are not well studied among children in rural Zambézia Province. Whether prevalence of malaria varies across diverse districts within the province is unknown. Methods: A cross­sectional survey of female heads of household was conducted during April and May 2014, a period of peak malaria transmission. Data were collected on up to two randomly selected children aged 6­59 months per household. The outcome of interest was self­report of symptomatic malaria confirmed by diagnostic test in the past 30 days. Analyses accounted for the two­stage cluster sample design. Prevalence of symptomatic malaria was calculated for the province and three over­sampled focus districts­Alto Molócuè, Morrumbala, and Namacurra. Multivariable logistic regression of symptomatic malaria diagnosis included: district, age, sex, education, bed net use, urban setting, distance to health facility, income, roofing material, and pig farming. Results: Data were collected on 2540 children. Fifty percent were female, and the median age was 24 months. Sixty percent of children slept under bed nets the night prior to the survey, but utilization varied between districts (range 49­89%; p < 0.001). Forty­three percent of children reported fever in the past 30 days, 91% of those sought care at a health facility, 67% of those had either a malaria rapid diagnostic test or blood smear, and 67% of those had a positive test result and therefore met our case definition of self­reported symptomatic malaria. There were significant differences in prevalence of fever (p < 0.001), health­seeking (p < 0.001), and diagnostic testing (p = 0.003) between focus districts. Province­wide prevalence of symptomatic malaria was 13% and among focus districts ranged from 14% in Morrumbala to 17% in Namacurra (p < 0.001). Higher female caregiver education (OR 1.88; 95% CI 1.31­2.70), having fewer young children in the household (OR 1.25; 95% CI 1.01­1.56), and higher income (OR 1.56; 95% CI 1.11­2.22) were independently associated with having a child with symptomatic malaria. Conclusions: Self­reported symptomatic malaria is highly prevalent among children in Zambézia Province, Mozambique and varies significantly between diverse districts. Factors facilitating access to health services are associated with symptomatic malaria diagnosis. These findings should inform resource allocation in the fight against malaria in Mozambique.

Predictors of Health-Care Utilization Among Children 6-59 Months of Age in Zambézia Province, Mozambique

Abstract. Globally, approximately 5.9 million children under 5 years of age died in 2015, a reduction of over 50% since 1990. Millennium Development Goal 4 established the goal of reducing child mortality by two-thirds by 2015. Multiple countries have surpassed this goal; however, regional and within-country inequities exist. We sought to study determinants of health-care utilization among children 6­59 months of age with fever, diarrhea, and respiratory symptoms in Zambézia Province, Mozambique. We conducted a population-based cross-sectional survey of female heads of household between April and May 2014. Mobile teams conducted interviews in 262 enumeration areas, with three distinct districts being oversampled for improved precision. Descriptive statistics and logistic regression using Stata 13.1 and R 3.2.2 were used to examine factors associated with health-care utilization. A total of 2,317 children were evaluated in this study. Mothers' median age was 26 years, whereas child median age was 24 months. The proportion of children reporting fever, diarrhea, or respiratory illness in the prior 30 days was 44%, 22%, and 22%, respectively. Health-care utilization varied with 65% seeking health care for fever, compared with 57% for diarrhea and 25% for respiratory illness. In multivariable logistic regression, the characteristics most associated with health-care utilization across illnesses were delivery of last child at a facility, higher maternal education, and household ownership of a radio. The decision or ability to use health care is a multifaceted behavior swayed by societal norms, values, socioeconomics, and perceived need. Recognizing the predictors of a particular population may offer useful information to increase uptake in health-care services.

Factors associated with the use of mosquito bed nets: results from two cross-sectional household surveys in Zambézia Province, Mozambique.

BACKGROUND: Malaria remains a major threat to some 3.2 billion persons globally. Malaria contributes heavily to the overall disease burden in Mozambique and is considered endemic. A cornerstone of Mozambique's vector control strategy has been to strive for universal coverage of insecticide-treated nets (ITN). METHODS: The study is a population-based cross-sectional survey of female heads-of-household in Zambézia Province, Mozambique conducted during August-September, 2010 and April-May, 2014. Analyses accounted for a stratified two-stage cluster sample design. Outcomes of interest included sleeping under a mosquito net during the previous night. Descriptive statistics were calculated for three oversampled districts and for the entire province. Multivariable logistic regression analysis was used to estimate factors associated with both changes over time and increased mosquito bed net usage. RESULTS: Of the 3916 households interviewed in 2010 and 3906 households in 2014, 64.3% were in possession of at least one mosquito bed net. A higher proportion of households in Namacurra (90%) reported possession of a mosquito net, compared to Alto Molócuè (77%) and Morrumbala (34%), respectively in 2014. Of pregnant respondents, 58.6% reported sleeping under a mosquito net the previous night in 2010 compared to 68.4% in 2014. Fifty percent of children 0-59 months slept under a mosquito net the previous night in 2010 compared to 60% in 2014. Factors associated with use of a mosquito net for female head-of-household respondents were higher education, understanding Portuguese, larger household size, having electricity in the household, and larger household monthly income. As travel time to a health facility increased (per 1 h), respondents had 13% lower odds of sleeping under a mosquito net (OR 0.87; 95% CI 0.74-1.01, p = 0.07). Pregnant women in 2014 had a 2.4 times higher odds of sleeping under a bed net if they lived in Namacurra compared to Alto Molócuè (95% CI 0.91-6.32, p = 0.002 for district). Higher maternal education, living in Namacurra, and acquisition of mosquito bed nets were associated with a child 0-59 months reporting sleeping under the net in the previous night in 2014. CONCLUSIONS: Intensified focus on the poorest, least educated, and most distant from health services is needed to improve equity of ITN availability and usage. Additionally, while some districts have already surpassed goals in terms of coverage and utilization of ITN, renewed emphasis should be placed on bringing all geographic regions of the province closer to meeting these targets.

Determinants of undernutrition among children aged 6 to 59 months in rural Zambézia Province, Mozambique: Results of two population-based serial cross-sectional surveys.

BACKGROUND: While many countries are transitioning from epidemics of undernutrition to overnutrition, Mozambique's very high 44% prevalence of stunting in children under age 5 years is cause for serious concern. METHODS: We conducted two population-based cross-sectional surveys of ~4000 female heads of households each in Zambézia Province, Mozambique from August-September 2010 (Baseline) and April-May 2014 (Endline) as part of the USAID funded Strengthening Communities through Integrated Programs (SCIP) grant. Anthropometric measurements were collected on 560 children aged 6-59 months at Baseline and 912 children at Endline and classified as: "stunted," a height-for-age z-score less than -2; "wasted," weight-for-height z-score less than -2; and "underweight," weight-for-age z-score less than -2. Descriptive statistics and logistic regression using Stata 13.1 were used to examine factors associated with undernutrition. RESULTS: Of children under age five years, 43% were undernourished in 2010 and 55% in 2014. The most common form of undernutrition was stunting (39% in 2010, 51% in 2014), followed by underweight (13% in both 2010 and 2014), and wasting (7% in 2010, 5% in 2014). Child's age was found to have a non-linear association with stunting. Vitamin A supplementation was associated with a 31% (p=0.04) decreased odds of stunting. Children who were exclusively breastfed for at least six months had an 80% (p=0.02) lower odds of wasting in 2014 and 57% (p=0.05) decreased odds of being underweight in 2014. Introducing other foods after age six months was associated with a five-fold increased odds of wasting in 2014 (p=0.02); household food insecurity was associated with wasting (OR=2.08; p=0.03) and underweight in 2010 (OR=2.31; p=0.05). Children whose mother washed her hands with a cleaning agent had a 40% (p=0.05) decreased odds of being underweight. Surprisingly, per point increase in household dietary diversity score, children had 12% greater odds of being stunted in 2010 (p=0.01) but 9% decreased odds of being underweight in 2014 (p=0.02). CONCLUSIONS: A combination of household and individual level factors was associated with undernutrition. As such, employment of multidimensional interventions should be considered to decrease undernutrition in children under five years old.

Antiretroviral therapy program expansion in Zambézia Province, Mozambique: geospatial mapping of community-based and health facility data for integrated health planning.

OBJECTIVE: To generate maps reflecting the intersection of community-based Voluntary Counseling and Testing (VCT) delivery points with facility-based HIV program demographic information collected at the district level in three districts (Ile, Maganja da Costa and Chinde) of Zambézia Province, Mozambique; in order to guide planning decisions about antiretroviral therapy (ART) program expansion. METHODS: Program information was harvested from two separate open source databases maintained for community-based VCT and facility-based HIV care and treatment monitoring from October 2011 to September 2012. Maps were created using ArcGIS 10.1. Travel distance by foot within a 10 km radius is generally considered a tolerable distance in Mozambique for purposes of adherence and retention planning. RESULTS: Community-based VCT activities in each of three districts were clustered within geographic proximity to clinics providing ART, within communities with easier transportation access, and/or near the homes of VCT volunteers. Community HIV testing results yielded HIV seropositivity rates in some regions that were incongruent with the Ministry of Health's estimates for the entire district (2-13% vs. 2% in Ile, 2-54% vs. 11.5% in Maganja da Costa, and 23-43% vs. 14.4% in Chinde). All 3 districts revealed gaps in regional disbursement of community-based VCT activities as well as access to clinics offering ART. CONCLUSIONS: Use of geospatial mapping in the context of program planning and monitoring allowed for characterizing the location and size of each district's HIV population. In extremely resource limited and logistically challenging settings, maps are valuable tools for informing evidence-based decisions in planning program expansion, including ART.

Multidimensional poverty in rural Mozambique: a new metric for evaluating public health interventions.

BACKGROUND: Poverty is a multidimensional phenomenon and unidimensional measurements have proven inadequate to the challenge of assessing its dynamics. Dynamics between poverty and public health intervention is among the most difficult yet important problems faced in development. We sought to demonstrate how multidimensional poverty measures can be utilized in the evaluation of public health interventions; and to create geospatial maps of poverty deprivation to aid implementers in prioritizing program planning. METHODS: Survey teams interviewed a representative sample of 3,749 female heads of household in 259 enumeration areas across Zambézia in August-September 2010. We estimated a multidimensional poverty index, which can be disaggregated into context-specific indicators. We produced an MPI comprised of 3 dimensions and 11 weighted indicators selected from the survey. Households were identified as "poor" if were deprived in >33% of indicators. Our MPI is an adjusted headcount, calculated by multiplying the proportion identified as poor (headcount) and the poverty gap (average deprivation). Geospatial visualizations of poverty deprivation were created as a contextual baseline for future evaluation. RESULTS: In our rural (96%) and urban (4%) interviewees, the 33% deprivation cut-off suggested 58.2% of households were poor (29.3% of urban vs. 59.5% of rural). Among the poor, households experienced an average deprivation of 46%; thus the MPI/adjusted headcount is 0.27 ( = 0.58×0.46). Of households where a local language was the primary language, 58.6% were considered poor versus Portuguese-speaking households where 73.5% were considered non-poor. Living standard is the dominant deprivation, followed by health, and then education. CONCLUSIONS: Multidimensional poverty measurement can be integrated into program design for public health interventions, and geospatial visualization helps examine the impact of intervention deployment within the context of distinct poverty conditions. Both permit program implementers to focus resources and critically explore linkages between poverty and its social determinants, thus deriving useful findings for evidence-based planning.