A multilevel analysis of the predictors of diarrhea among children under 5 years of age in Eswatini.

Diarrhea remains a public health challenge and persistently affect children under 5 years of age, primarily in developing countries. The aim of the study was to investigate the effects of individual, household and community level factors on child diarrhea. Using combined data 2010 and 2014 Eswatini Multiple Indicator Cluster surveys, data for 4,363 under five children was analysed. Univariable, bivariable and multivariable multilevel logistic regression models were used for data analysis. We found that the prevalence of diarrhea was 16.2%, (95% confidence interval (CI): 15.3-18.1). Higher odds of diarrhea were observed among children aged 6-11 months (AOR: 2.67, 95% CI: 1.93, 3.71) and 12-23 months (AOR=2.12, 95% CI: 1.56, 2.87) compared to those aged less than 6 months. However, lower odds of diarrhea were observed among children aged 36-47 months (AOR=0.68, 95% CI: 0.48, 0.97) and 48-59 months (AOR=0.39, 95% CI: 0.26, 0.58), compared to children aged less than 6 months. Children born to mothers aged 35-39 years had lower odds of having diarrhea, (AOR=0.48, 95%CI: 0.30, 0.79) compared to those born to mothers aged 15-19 years. Higher odds of having diarrhea were observed among children from communities with a low proportion of households with improved toilet facility (AOR=1.29, 95% CI: 1.01, 1.66) compared to those from communities with a high proportion of households with improved toilet facility. We found that individual- and community-level factors were associated with child diarrhea in Eswatini. Programmes and policies that aim to mitigate child morbidity due to diarrhea should pay attention to the individual and community factors.

Knowledge, attitude and practice of female university students regarding human papillomavirus and self-sampling in KwaZulu-Natal, South Africa: a cross-sectional survey.

BACKGROUND: Human papillomavirus (HPV) infection remains a major cause of cervical cancer. Screening practice in South Africa has remained persistently low, with the invasiveness of pelvic examination as a major barrier to screening. This occasions the need to assess women's knowledge, attitude, and practice regarding HPV testing and self-sampling. METHOD: This is a cross-sectional quantitative study which enrolled 386 female students between the ages of 18 and 65 years at the University of KwaZulu-Natal, South Africa. Data was collected through a self-administered structured questionnaire, from February to March 2020. Data on participants' socio-demographic characteristics, knowledge, attitudes and practices regarding HPV, HPV testing and self-sampling were obtained. RESULTS: Out of the 386 respondents, 30.6% were unaware that HPV can be transmitted through unprotected sex, only 25.1% knew about the availability of HPV vaccines in South Africa, 16.1% knew that the vaccines are accessible for free, while 79.0% were oblivious to the asymptomatic nature of HPV infection. Furthermore, a vast majority (95.8%) had never heard about self-sampling while only 1.0% had undergone HPV testing prior to this study. Although 52.9% knew that HPV testing could prevent cervical cancer, it did not positively impact screening practice. However, 57.7% of participants were willing to undergo future screening if allowed to self-sample. CONCLUSION: Self-sampling is a more acceptable means of sample collection compared to pelvic examination. Therefore, encouraging self-sampling and providing self-sampling kits will aid increased screening participation and address certain barriers associated with HPV testing. Awareness and educational campaigns about HPV and its causative relationship with cervical cancer will occasion better attitude towards screening participation.

Individual and community-level factors associated with lifetime number of sexual partners among women aged 15-49 in Eswatini.

INTRODUCTION: Understanding the risk factors for behavioral patterns in sexual relationships play a significant role in the reduction of the transmission of HIV/AIDS and other sexually transmitted infections. OBJECTIVE: To investigate individual and community level factors on the lifetime number of sexual partners of women in Eswatini. MATERIAL AND METHODS: The study was a secondary cross-sectional analysis of the 2014 Eswatini Multiple Indicator Cluster Survey (MICS). A total of 2,832 women aged 15-49 years were asked in total, how many different people have you had sexual intercourse in your lifetime. The multilevel negative binomial regression model was used to analyze the data. RESULTS: The overall mean number of lifetime sexual partners was 2.78 (95% CI: 2.66, 2.91) in 2014. Compared to women aged 15-19, those aged 20 years and older, formerly married or never married reported more lifetime sexual partners compared to currently married women. Those that were aged 15 years and older at sexual debut reported fewer lifetime sexual partners compared to those that were aged less than 15 years. Compared to women that used a condom at last sexual intercourse, those that did not use a condom at last sexual encounter reported fewer lifetime sexual partners. Relative to women that lived with their sons and daughters, those that did not live with their sons and daughters reported more lifetime sexual partners. Women that lived in the Shiselweni and Lubombo regions reported fewer lifetime sexual partners compared to those residents in the Hhohho region. CONCLUSION: Overall, lifetime sexual partners in Eswatini was significantly associated with individual characteristics and is unique across regions. Programs that aim to elucidate the factors associated with incident HIV infections among women in Eswatini should focus on individual and community-level factors that are associated with multiple sexual partnerships, which in turn might increase the risk of HIV exposure.

Exploring the Influences of Hegemonic and Complicit Masculinity on Lifestyle Risk Factors for Noncommunicable Diseases Among Adult Men in Maseru, Lesotho.

Masculinity is an important health determinant and has been studied as a risk factor for communicable diseases in the African context. This paper explores how hegemonic and complicit masculinities influence the lifestyle risk factors for noncommunicable diseases among men. A qualitative research method was used, where eight focus group discussions were conducted among adult men in Maseru, Lesotho. The data were analyzed using a thematic analysis approach. Although the participants typically described taking responsibility as a key feature of what it meant to be a man in Lesotho, their reported behaviors and rationales indicated that men commonly abdicated responsibility for their health to women. Participants were aware of the negative effects of smoking on health and acknowledged the difficulty to stop smoking due to the addictive nature of the habit. The initiation of smoking was linked by participants to the need to be seen as a man, and then maintained as a way of distinguishing themselves from the feminine. Regarding harmful alcohol consumption, participants reported that stress, particularly in their relationships with women, were linked to the need to drink, as they reported limited outlets for emotional expression for men in Lesotho. On the subject of poor diet, the study found that most men were aware of the importance of vegetable consumption; the perceived lengthy preparation process meant they typically depended on women for such healthy food preparation. Almost all participants were aware of the increased susceptibility to diverse negative health effects from physical inactivity, but because of the physical nature of the work, those engaged in traditionally masculine occupations did not exercise. In the context of lifestyle risk factors for noncommunicable diseases, masculinity has positive and negative impacts. It is important to design health education programs targeting men to successfully mitigate the negative health impacts of masculinity.

Elimination of paediatric HIV in KwaZulu-Natal, South Africa: large-scale assessment of interventions for the prevention of mother-to-child transmission.

OBJECTIVE: To report the rates of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV), and the coverage of interventions designed to prevent such transmission, in KwaZulu-Natal. METHODS: Mothers with infants aged ≤ 16 weeks and fathers or legal guardians with infants aged 4-8 weeks who, between May 2008 and April 2009, attended immunization clinics in six districts of KwaZulu-Natal were included. The mothers' uptake of interventions for the prevention of MTCT was explored. Blood samples from infants aged 4-8 weeks were tested for anti-HIV antibodies and, if antibody-positive, for HIV desoxyribonucleic acid (DNA). FINDINGS: Of the 19,494 mothers investigated, 89·9% reported having had an HIV test in their recent pregnancy. Of the 19,138 mothers who reported ever having had an HIV test, 34.4% reported that they had been found HIV-positive and, of these, 13.7% had started lifelong antiretroviral treatment and 67.2% had received zidovudine and nevirapine. Overall, 40.4% of the 7981 infants tested were found positive for anti-HIV antibodies, indicating HIV exposure. Just 7.1% of the infants checked for HIV DNA (equating to 2.8% of the infants tested for anti-HIV antibodies) were found positive. CONCLUSION: The low levels of MTCT observed among the infants indicate the rapid, successful implementation of interventions for the prevention of such transmission. Sampling at immunization clinics appears to offer a robust method of estimating the impact of interventions designed to reduce such transmission. Large-scale elimination of paediatric HIV infections appears feasible, although this goal has not yet been fully achieved in KwaZulu-Natal.

Disease profile of children under 5 years attending primary health care clinics in a high HIV prevalence setting in South Africa.

OBJECTIVE: To describe the presenting complaints and disease profile of children attending primary health care (PHC) clinics in two provinces of South Africa. METHODS: Participants were sick children 2-59 months old presenting for care at PHC clinics in KwaZulu-Natal (KZN) and Limpopo provinces from 2006-2007. Children were assessed by an expert Integrated Management of Childhood Illnesses (IMCI) practitioner. Children for whom parental/guardian consent was obtained were tested for HIV. RESULTS: A total of 1357 children attending one of 74 clinics were assessed. HIV seroprevalence overall was 7.1%, but was significantly higher in KZN than Limpopo (7.5 vs. 2.4%; OR = 3.3, 95%CI 1.9-5.8%). Commonest presenting complaints were cough (72%), skin conditions (22%) and diarrhoea (19%). Of 1349 children, 120 (8.9%) had a weight below the third percentile; 108/1357 (8.0%) children required urgent referral, most commonly for severe pneumonia (53.7%) and severe malnutrition (16.7%). In multivariate analyses, severe pneumonia, growth faltering and urgent referral were independently associated with younger age, residence in KZN and HIV infection (P < 0.05). CONCLUSIONS: Many children with severe illnesses and undiagnosed HIV infection present to PHC facilities. PHC staff require skills to correctly manage these conditions and undertake HIV testing. Although IMCI provides evidence-based guidelines, implementation must be improved to achieve adequate coverage of life-saving interventions.

Routine checks for HIV in children attending primary health care facilities in South Africa: attitudes of nurses and child caregivers.

Management of HIV-infected and exposed children is challenging for health workers in primary care settings. Integrated management of childhood illness (IMCI) is a WHO/UNICEF strategy for improving morbidity and mortality in under 5 children attending first level facilities in developing countries. In high HIV-prevalence settings, IMCI includes an HIV component for identification and management of HIV-infected and exposed children, which requires health workers to ask all mothers about their HIV status and check all children for signs of HIV. Effective implementation of the HIV component depends on the ability and willingness of health workers to take every opportunity to identify HIV-infected children during routine care, and implementation in South Africa is poor. In 2006, we conducted 10 focus groups in two provinces in South Africa with IMCI-trained nurses, and with mothers attending first level facilities, to determine their attitudes towards, and experiences of, routine checks for HIV during consultations with sick children. Nurses were frequently unwilling to check for HIV in all children, believing it was unnecessary, unacceptable to mothers, and that they lack skills to implement HIV care. Nurses feared mothers would become upset or make a complaint. Mothers consistently recognised the importance of checking children for HIV and supported implementation of routine checks, although the attitude of the nurse was important in determining the acceptability of HIV-related questions. Mothers expressed fears about lack of confidentiality from nurses, and that receiving HIV-related services could lead to unintentional disclosure of their HIV status. Nurses lack the skills in HIV management and communication skills to implement the HIV component of IMCI. We identify issues relate to improved training, clear policies on record keeping, and organization of health services to respect privacy and confidentiality, to improve the willingness of health workers to provide HIV care and mothers to accept it.

Experiences of training and implementation of integrated management of childhood illness (IMCI) in South Africa: a qualitative evaluation of the IMCI case management training course.

BACKGROUND: Integrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under-5 years by improving management of common illnesses at primary level. IMCI has been shown to improve health worker performance, but constraints have been identified in achieving sufficient coverage to improve child survival, and implementation remains sub-optimal. At the core of the IMCI strategy is a clinical guideline whereby health workers use a series of algorithms to assess and manage a sick child, and give counselling to carers. IMCI is taught using a structured 11-day training course that combines classroom work with clinical practise; a variety of training techniques are used, supported by comprehensive training materials and detailed instructions for facilitators. METHODS: We conducted focus group discussions with IMCI trained health workers to explore their experiences of the methodology and content of the IMCI training course, whether they thought they gained the skills required for implementation, and their experiences of follow-up visits. RESULTS: Health workers found the training interesting, informative and empowering, and there was consensus that it improved their skills in managing sick children. They appreciated the variety of learning methods employed, and felt that repetition was important to reinforce knowledge and skills. Facilitators were rated highly for their knowledge and commitment, as well as their ability to identify problems and help participants as required. However, health workers felt strongly that the training time was too short to acquire skills in all areas of IMCI. Their increased confidence in managing sick children was identified by health workers as an enabling factor for IMCI implementation in the workplace, but additional time required for IMCI consultations was expressed as a major barrier. Although follow-up visits were described as very helpful, these were often delayed and there was no ongoing clinical supervision. CONCLUSION: The IMCI training course was reported to be an effective method of acquiring skills, but more time is required, either during the course, or with follow-up, to improve IMCI implementation. Innovative solutions may be required to ensure that adequate skills are acquired and maintained.

Paediatric HIV management at primary care level: an evaluation of the integrated management of childhood illness (IMCI) guidelines for HIV.

BACKGROUND: Integrated Management of Childhood Illness (IMCI) is a WHO/UNICEF strategy to improve child survival in resource poor settings. South Africa adopted IMCI in 1997, and IMCI guidelines were adapted to include identification and management of HIV infected and exposed children. This study describes the validity of the IMCI/HIV algorithm when used by IMCI experts, the use of IMCI/HIV guidelines by IMCI trained health workers in routine clinical practice, and the burden of HIV among children under 5 years attending first level health facilities. METHODS: Seventy seven randomly selected IMCI trained health workers were observed in 74 health facilities in two provinces of South Africa. Consultations were observed with 1357 sick children; each child was reassessed by an IMCI expert to confirm the correct findings. Consent was requested for HIV testing of all children who attended with a parent or legal guardian. Positive rapid HIV tests were confirmed with HIV PCR in children aged less than 18 months. HIV positive children had a CD4 count and HIV clinical staging done. RESULTS: Of 1064 children with HIV results available, 76 (7.1% CI: 5.7% - 8.9%) children were confirmed HIV positive. IMCI experts using the HIV algorithm classified 54/76 (71.1% CI: 59.5%-80.9%) HIV positive children as suspected symptomatic HIV, and 15/22 remaining HIV positive children were identified as HIV exposed. Therefore, 69/76 (90.8% CI: 81.9-96.2) HIV infected children were identified by IMCI experts. No classification was made for HIV by observed health workers in 899/1357(66.2%) children.906/1243(72.9%) mothers had been tested previously for HIV, of whom 221(24.4%) reported testing positive. Of 221 children therefore identified as HIV exposed, only 78(35.3%) had been tested for HIV within routine services. CONCLUSION: The HIV algorithm is a valid tool for identifying HIV infected and exposed children when correctly and comprehensively implemented. However, it is not being used by IMCI trained health workers in routine practise, leading to a failure to implement life saving interventions.

An evaluation of the quality of IMCI assessments among IMCI trained health workers in South Africa.

BACKGROUND: Integrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under 5 years by improving case management of common and serious illnesses at primary health care level, and was adopted in South Africa in 1997. We report an evaluation of IMCI implementation in two provinces of South Africa. METHODOLOGY/PRINCIPAL FINDINGS: Seventy-seven IMCI trained health workers were randomly selected and observed in 74 health facilities; 1357 consultations were observed between May 2006 and January 2007. Each health worker was observed for up to 20 consultations with sick children presenting consecutively to the facility, each child was then reassessed by an IMCI expert to determine the correct findings. Observed health workers had been trained in IMCI for an average of 32.2 months, and were observed for a mean of 17.7 consultations; 50/77(65%) HW's had received a follow up visit after training. In most cases health workers used IMCI to assess presenting symptoms but did not implement IMCI comprehensively. All but one health worker referred to IMCI guidelines during the period of observation. 9(12%) observed health workers checked general danger signs in every child, and 14(18%) assessed all the main symptoms in every child. 51/109(46.8%) children with severe classifications were correctly identified. Nutritional status was not classified in 567/1357(47.5%) children. CONCLUSION/SIGNIFICANCE: Health workers are implementing IMCI, but assessments were frequently incomplete, and children requiring urgent referral were missed. If coverage of key child survival interventions is to be improved, interventions are required to ensure competency in identifying specific signs and to encourage comprehensive assessments of children by IMCI practitioners. The role of supervision in maintaining health worker skills needs further investigation.

A community-based study to examine the effect of a youth HIV prevention intervention on young people aged 15-24 in South Africa: results of the baseline survey.

OBJECTIVES: To determine whether South African youths living in communities that had either of two youth human immunodeficiency virus (HIV) prevention interventions [(a) loveLife Youth Centre or (b) loveLife National Adolescent Friendly Clinic Initiative] would have a lower prevalence of HIV, sexually transmitted infections (STIs), and high risk sexual behaviours than communities without either of these interventions. METHODS: In 2002 the baseline survey of a quasi-experimental, community-based study was conducted in South Africa. In total 33 communities were included in three study arms (11 communities per study arm). The final sample included 8735 youths aged 15-24 years. All participants took part in a behavioural interview and were tested for HIV, gonorrhoea (Neisseria gonorrhoeae) and Chlamydia (Chlamydia trachomatis). RESULTS: HIV prevalence was 20.0% among females and 7.5% among males (OR 3.93 95% CI 2.51-6.15). There were no significant differences between study arms for HIV, NG or CT prevalence at baseline. In multiple regression analyses, HIV was significantly associated with NG infection (OR 1.96 95% CI 1.24-3.12) but not with CT infection. Youths who reported >1 lifetime partner were also significantly more likely to be infected with HIV (OR 1.98 95% CI 1.55-2.52), as were those who reported ever having engaged in transactional sex (OR 1.86 P = 0.02) or having had genital ulcers in the past 12 months (OR 1.71 P < or = 0.001). CONCLUSIONS: HIV prevention programmes must ensure that gender inequities that place young women at greater risk for HIV infection are urgently addressed and they must continue to emphasize the importance of reducing the number of sexual partners and STI treatment.

Young people's sexual health in South Africa: HIV prevalence and sexual behaviors from a nationally representative household survey.

OBJECTIVES: To determine the prevalence of HIV infection, HIV risk factors, and exposure to national HIV prevention programs, and to identify factors associated with HIV infection among South African youth, aged 15-24 years. DESIGN: A cross-sectional, nationally representative, household survey. METHODS: From March to August 2003 we conducted a national survey of HIV prevalence and sexual behavior among 11 904 15-24 year olds. Multivariable models for HIV infection were restricted to sexually experienced youth. RESULTS: Young women were significantly more likely to be infected with HIV in comparison with young men (15.5 versus 4.8%). Among men, a history of genital ulcers in the past 12 months was associated with HIV infection [adjusted odds ratio (AOR), 1.91; 95% confidence interval (CI), 1.04-3.49) whereas among women a history of unusual vaginal discharge in the past 12 months was associated with HIV infection (AOR, 1.75; 95% CI, 1.26-2.44). Young women with older partners were also at increased risk of HIV infection. Among both men and women, increasing partner numbers and inconsistent condom use were significantly associated with HIV infection. Males and females who reported participation in at least one loveLife program were less likely to be infected with HIV (AOR, 0.60; 95% CI, 0.40-0.89; AOR, 0.61; 95% CI, 0.43-0.85, respectively). CONCLUSION: This survey confirms the high HIV prevalence among young people in South Africa and, in particular, young women's disproportionate risk. Programs for youth must continue to promote partner reduction, consistent condom use and prompt treatment for sexually transmitted infections while also addressing contextual factors that make it difficult for them to implement behavior change.