Childhood immunization during the COVID-19 pandemic: experiences in Haiti, Lesotho, Liberia and Malawi.

OBJECTIVE: To examine changes in vaccination of children younger than 1 year during the coronavirus disease 2019 (COVID-19) pandemic (March 2020-August 2021) in Haiti, Lesotho, Liberia and Malawi. METHODS: We used data from health management information systems on vaccination of children aged 12 months or younger in districts supported by Partners In Health. We used data from January 2016 to February 2020 and a linear model with negative binomial distribution to estimate the expected immunization counts for March 2020-August 2021 with 95% prediction intervals, assuming no pandemic. We compared these expected levels with observed values and estimated the immunization deficits or excesses during the pandemic months. FINDINGS: Baseline vaccination counts varied substantially by country, with Lesotho having the lowest count and Haiti the highest. We observed declines in vaccination administration early in the COVID-19 pandemic in Haiti, Lesotho and Liberia. Continued declines largely corresponded to high rates of COVID-19 infection and discrete stock-outs. By August 2021, vaccination levels had returned to close to or above expected levels in Haiti, Liberia and Lesotho; in Malawi levels remained below expected. CONCLUSION: Patterns of childhood immunization coverage varied by country over the course of the pandemic, with significantly lower than expected vaccination levels seen in one country during subsequent COVID-19 waves. Governments and health-care stakeholders should monitor vaccine coverage closely and consider interventions, such as community outreach, to avoid or combat the disruptions in childhood vaccination.

Trends of cervical cancer at global, regional, and national level: data from the Global Burden of Disease study 2019.

BACKGROUND: Cervical cancer is an important global health problem. In this study we aimed to analyze trends in cervical cancer at the global, regional, and national levels from 1990 to 2019, to inform health service decision-making. METHODS: Data on cervical cancer was extracted from the Global Burden of Disease study, 2019. Trends in cervical cancer burden were assessed based on estimated annual percentage change (EAPC) and age-standardized rate (ASR). RESULTS: Globally, decreasing trends were observed in incidence, death, and disability adjusted life years (DALYs) of cervical cancer from 1990 to 2019, with respective EAPCs of - 0.38 (95% confidence interval [CI]: - 0.41 to - 0.34), - 0.93 (95%CI: - 0.98 to - 0.88), and - 0.95 (95 CI%: - 1.00 to - 0.90). Meanwhile, decreasing trends were detected in most sociodemographic index (SDI) areas and geographic regions, particularly death and DALYs in Central Latin America, with respective EAPCs of - 2.61 (95% CI: - 2.76 to - 2.46) and - 2.48 (95% CI: - 2.63 to - 2.32); hhowever, a pronounced increasing trend in incidence occurred in East Asia (EAPC = 1.33; 95% CI: 1.12 to 1.55). At the national level, decreasing trends in cervical cancer were observed in most countries/territories, particularly DALYs in the Maldives (EAPC = - 5.06; 95% CI: - 5.40 to - 4.72), Whereas increasing trends were detected in Lesotho, Zimbabwe, and Bulgaria. CONCLUSIONS: Slowly decreasing trends in cervical cancer were detected worldwide from 1990 to 2019. Cervical cancer remains a substantial health problem for women globally, requiring more effective prevention and control strategies.

Global and country-level estimates of human population at high altitude.

Estimates of the global population of humans living at high altitude vary widely, and such data at the country level are unavailable. Herein, we use a geographic information system (GIS)-based approach to quantify human population at 500-m elevation intervals for each country. Based on georeferenced data for population (LandScan Global 2019) and elevation (Global Multiresolution Terrain Elevation Data), 500.3 million humans live at ≥1,500 m, 81.6 million at ≥2,500 m, and 14.4 million at ≥3,500 m. Ethiopia has the largest absolute population at ≥1,500 m and ≥2,500 m, while China has the greatest at ≥3,500 m. Lesotho has the greatest percentage of its population above 1,500 m, while Bolivia has the greatest at ≥2,500 m and ≥3,500 m. High altitude presents a myriad of environmental stresses that provoke physiological responses and adaptation, and consequently impact disease prevalence and severity. While the majority of high-altitude physiology research is based upon lowlanders from western, educated, industrialized, rich, and democratic countries ascending to high altitude, the global population distribution of high-altitude residents encourages an increased emphasis on understanding high-altitude physiology, adaptation, epidemiology, and public health in the ∼500 million permanent high-altitude residents.

Use of Point-of-Care Nucleic Acid Tests Beyond Early Infant Diagnosis of HIV: A Retrospective Case Review in Lesotho.

BACKGROUND: Rapid diagnostic tests (RDTs) for HIV antibodies remain the primary method of diagnosis of HIV in individuals over age 18 months in Lesotho. Although antibody tests have high sensitivity and specificity, up to 2.3% of serial two-test algorithms can have discrepant results between RDTs. In the case of inconclusive RDT results, Lesotho guidelines at the time of this study recommended either repeat testing with the same RDT algorithm after 14 days or immediately collect a blood sample to be sent for laboratory-based polymerase chain reaction testing. Point-of-care qualitative nucleic acid tests (POC qual NAT) may have benefits in rapidly resolving these inconclusive results, particularly when compared with repeating RDTs later or conventional polymerase chain reaction testing at the National Reference Laboratory. SETTING: Hospitals and clinics at 29 locations throughout Lesotho that had access to point-of-care nucleic acid testing. METHODS: Retrospective case review. RESULTS: We identified 100 testing records where POC qual NAT was used to resolve inconclusive RDTs per Lesotho guidelines. Eighty-nine percent of patients received their results in a median of one day from their inconclusive RDT result (interquartile range 0-7 days). Sixty-eight patients (68%) were determined to be HIV positive based on POC nucleic acid tests (NATs), of which 54 (79%) were started on antiretroviral therapy (ART). Median time from inconclusive RDT result to initiation of ART therapy was 2 days (interquartile range 0-14 days). Three patients in this review were pregnant at the time of testing; one was HIV positive by POC qual NAT and was started on ART therapy the same day. CONCLUSION: As the availability of POC qual NAT platforms increases, they may serve as feasible options for rapid resolution of inconclusive results and initiation of ART, particularly in populations with high risk of imminent transmission.

Lessons learned from stakeholder-driven sustainability analysis of six national HIV programmes.

BACKGROUND: In light of the decline in donor HIV funding, HIV programmes increasingly need to assess their available and potential resources and maximize their utilization. This article presents lessons learned related to how countries have addressed the sustainability of HIV programmes in a stakeholder-driven sustainability analysis. METHODOLOGY: During HIV/AIDS Programme Sustainability Analysis Tool (HAPSAT) applications in six countries (Benin, Guyana, Kenya, Lesotho, Sierra Leone and South Sudan), stakeholders identified key sustainability challenges for their HIV responses. Possible policy approaches were prepared, and those related to prioritization and resource mobilization are analysed in this article. RESULTS: The need to prioritize evidence-based interventions and apply efficiency measures is being accepted by countries. Five of the six countries in this study requested that the HAPSAT team prepare 'prioritization' strategies. Countries recognize the need to prepare for an alternative to 'universal access by 2015', acknowledging that their capacity might be insufficient to reach such high-coverage levels by then. There is further acceptance of the importance of reaching the most-at-risk, marginalized populations, as seen, for example, in South Sudan and Sierra Leone. However, the pace at which resources are shifting towards these populations is slow. Finally, only two of the six countries, Kenya and Benin, chose to examine options for generating additional financial resources beyond donor funding. In Kenya, three non-donor sources were recommended, yet even if all were to be implemented, it would cover only 25% of the funding needed. CONCLUSIONS: Countries are increasingly willing to address the challenges of HIV programme sustainability, yet in different ways and with varying urgency. To secure achievements made to date and maximize future impact, countries would benefit from strengthening their strategic plans, operational plans and funding proposals with concrete timelines and responsibilities for addressing sustainability issues.

Health governance: principal-agent linkages and health system strengthening.

Governance is increasingly recognized as an important factor in health system performance, yet conceptually and practically it remains poorly understood and subject to often vague and competing notions of both what its role is and how to address its weaknesses. This overview article for the symposium on health governance presents a model of health governance that focuses on the multiplicity of societal actors in health systems, the distribution of roles and responsibilities among them and their ability and willingness to fulfil these roles and responsibilities. This focus highlights the principal-agent linkages among actors and the resulting incentives for good governance and health system performance. The discussion identifies three disconnects that constitute challenges for health system strengthening interventions that target improving governance: (1) the gap between the good governance agenda and existing capacities, (2) the discrepancy between formal and informal governance and (3) the inattention to sociopolitical power dynamics. The article summarizes the three country cases in the symposium and highlights their governance findings: health sector reform in China, financial management of health resources in Brazilian municipalities and budget reform in hospitals in Lesotho. The concluding sections clarify how the three cases apply the model's principal-agent linkages and highlight the importance of filling the gaps remaining between problem diagnosis and the development of practical guidance that supports 'best fit' solutions and accommodates political realities in health systems strengthening.

Strong association between the prevalence of bacterial vaginosis and male point-concurrency.

OBJECTIVE: The prevalence of bacterial vaginosis (BV) differs considerably between different populations, and individual-level risk factors such as number of sex partners seem unable to explain these differences. The effect of network-level factors, such as the prevalence of partner concurrency (the proportion of sexual partnerships that overlap in time as opposed to running sequentially) on BV prevalence has not hitherto been investigated. STUDY DESIGN: We performed linear regression to assess the relationship between the prevalence of male concurrency and prevalence of BV in each of 11 countries for which we could obtain comparable data. The data for concurrency prevalence were taken from the WHO/Global Programme on AIDS (GPA) sexual behavioural surveys. BV prevalence rates were obtained from a systematic review of the global patterning of BV. RESULTS: We found a strong relationship between the prevalence of male concurrency and BV prevalence (Pearson's R(2)=0.57; P=0.007). CONCLUSIONS: The findings of a strong ecological-level association between BV and partner concurrency need to be replicated and augmented with different types of studies such as multilevel prospective studies tracking the incidence of BV and associated individual, partner and network level risk factors.

Assessment of eight HPV vaccination programs implemented in lowest income countries.

BACKGROUND: Cervix cancer, preventable, continues to be the third most common cancer in women worldwide, especially in lowest income countries. Prophylactic HPV vaccination should help to reduce the morbidity and mortality associated with cervical cancer. The purpose of the study was to describe the results of and key concerns in eight HPV vaccination programs conducted in seven lowest income countries through the Gardasil Access Program (GAP). METHODS: The GAP provides free HPV vaccine to organizations and institutions in lowest income countries. The HPV vaccination programs were entirely developed, implemented and managed by local institutions. Institutions submitted application forms with institution characteristics, target population, communication delivery strategies. After completion of the vaccination campaign (3 doses), institutions provided a final project report with data on doses administered and vaccination models. Two indicators were calculated, the program vaccination coverage and adherence. Qualitative data were also collected in the following areas: government and community involvement; communication, and sensitization; training and logistics resources, and challenges. RESULTS: A total of eight programs were implemented in seven countries. The eight programs initially targeted a total of 87,580 girls, of which 76,983 received the full 3-dose vaccine course, with mean program vaccination coverage of 87.8%; the mean adherence between the first and third doses of vaccine was 90.9%. Three programs used school-based delivery models, 2 used health facility-based models, and 3 used mixed models that included schools and health facilities. Models that included school-based vaccination were most effective at reaching girls aged 9-13 years. Mixed models comprising school and health facility-based vaccination had better overall performance compared with models using just one of the methods. Increased rates of program coverage and adherence were positively correlated with the number of vaccination sites. Qualitative key insights from the school models showed a high level of coordination and logistics to facilitate vaccination administration, a lower risk of girls being lost to follow-up and vaccinations conducted within the academic year limit the number of girls lost to follow-up. CONCLUSION: Mixed models that incorporate both schools and health facilities appear to be the most effective at delivering HPV vaccine. This study provides lessons for development of public health programs and policies as countries go forward in national decision-making for HPV vaccination.

Programmatic management of multidrug-resistant tuberculosis: models from three countries.

BACKGROUND: Although multidrug-resistant tuberculosis (MDR-TB) is a major global health problem, there is a gap in programmatic treatment implementation. METHODS: This study describes MDR-TB treatment models in three countries--Peru, Russia and Lesotho-- using qualitative data collected over a 13-year period. RESULTS: A program analysis is presented for each country focusing on baseline medical care, initial implementation and program evolution. A pattern analysis revealed six overarching themes common to all three programs: 1) importance of baseline assessments, 2) early identification of key collaborators, 3) identification of initial locus of care, 4) minimization of patient-incurred costs, 5) targeted interventions for vulnerable populations and 6) importance of technical assistance and funding. Site commonalities and differences in each of these areas were analyzed. CONCLUSIONS: It is recommended that all programs providing MDR-TB treatment address these six areas during program development and implementation.

South-south collaboration in scale-up of HIV care: building human capacity for care.

OBJECTIVES: South-south collaborations in building human resource capacity have been inadequately emphasized globally despite the growing experience among resource-poor countries in scaling up HIV care and the funding to implement programmes. This paper aims to describe one such successful collaboration, in which a model of HIV care was developed in Haiti, adapted and expanded to Lesotho, and allowed the effective scale-up of HIV and other treatment services in a rural African setting. METHODS: Institutional experiences and lessons learned over a 10-year period in Haiti and a 3-year period in Lesotho are discussed. RESULTS: The Haiti-Lesotho collaborative model shows that human resource capacity can be built using creative partnerships and exchanges between developing countries, particularly with financial support from the north. The collaboration allows for the sharing of experiences and solutions through perspectives and experiences that are unique to developing countries. Healthcare workers in Haiti and Lesotho have established meaningful and fruitful cross-country working relationships, job satisfaction and retention has been improved and a sense of solidarity developed. The model of care developed in Haiti was successfully adapted, replicated and implemented in Lesotho. CONCLUSION: South-south collaborations are an important way for countries with established experience managing HIV in resource-poor settings to share their skills in a collaborative fashion with other nations facing similar disease problems and infrastructural challenges. This model for scaling up effective practice should be encouraged and supported by programme funders.

Expanding global HIV treatment: case studies from the field.

In the last 25 years, human immunodeficiency virus (HIV) has become the leading infectious killer of adults globally, with an estimated 44 million people infected with the virus worldwide. Most of these individuals live in poor regions of the world, particularly sub-Saharan Africa. Although a great deal of work has been done in identifying and treating individuals with the disease, there has been little action to date to address the complex socioeconomic factors that lie at the heart of this global pandemic. Understanding and responding to such factors is of paramount importance if HIV infection is to be managed in a meaningful way. This article explores the social context of people living with HIV in three different geographic and epidemiologic settings and highlights the social factors that shape and define an individual's risk of acquiring HIV. It also discusses unique programs aimed at addressing the complex realities of the world in which HIV thrives. These programs can act as models of HIV prevention and treatment.

Assessment of knowledge and attitudes about HIV/AIDS among inmates of Quthing Prison, Lesotho.

OBJECTIVE: To assess the knowledge of and attitudes towards HIV/AIDS among the inmates in Quthing Prison, Lesotho. METHOD: A semi-structured questionnaire was used to interview the prisoners. Of the 138 prisoners, 123 inmates were successfully interviewed The data were collated and analyzed quantitatively using the SPSS computer software programme. RESULTS: Ninety-two per cent of the respondents were in the age group 20-44 years, while 57. 7% were single and had never married. Knowledge about HIV/AIDS was found to be high, as 95.5% of the inmates knew the cause of the disease and over 70% of the inmates knew how it could be transmitted or prevented A majority of the respondents (68.1%) agreed that people with the disease should be isolated (evidence of unfavourable attitudes); 31.2% believed that there were holes and worms in the condoms (misconception) and 41.5% would not use condom (prevent full sexual enjoyment) despite the risk associated with non-use. CONCLUSION: Knowledge about HIV/AIDS was found to be high and prisoners had misconceptions about HIV/AIDS and use of condoms.

Assessment of knowledge and attitudes about HIV/AIDS among inmates of Quthing Prison, Lesotho / Evaluación del conocimiento y la actitud hacia el vih/sida entre los reclusos de la prisión de quthing, en lesotho

OBJECTIVE: To assess the knowledge of and attitudes towards HIV/AIDS among the inmates in Quthing Prison, Lesotho. METHOD: A semi-structured questionnaire was used to interview the prisoners. Of the 138 prisoners, 123 inmates were successfully interviewed The data were collated and analyzed quantitatively using the SPSS computer software programme. RESULTS: Ninety-two per cent of the respondents were in the age group 20-44 years, while 57. 7were single and had never married. Knowledge about HIV/AIDS was found to be high, as 95.5of the inmates knew the cause of the disease and over 70of the inmates knew how it could be transmitted or prevented A majority of the respondents (68.1) agreed that people with the disease should be isolated (evidence of unfavourable attitudes); 31.2believed that there were holes and worms in the condoms (misconception) and 41.5would not use condom (prevent full sexual enjoyment) despite the risk associated with non-use. CONCLUSION: Knowledge about HIV/AIDS was found to be high and prisoners had misconceptions about HIV/AIDS and use of condoms.

Objetivo. Evaluar el conocimiento y actitud hacia el VIH/SIDA entre los reclusos de la prisión de Quthing, en Lesotho. Método. Se aplicó un cuestionario semiestructurado para entrevistar a los prisioneros. De los 138 prisioneros, 123 fueron entrevistados con éxito. Los datos fueron recopilados y analizados cuantitativamente usando el programa SPSS. Resultados. Noventa y dos de los encuestados estaban en el grupo etario de 20 a 44 años, mientras que el 57.7% eran solteros y no habían estado casados nunca. Se halló que el conocimiento sobre el VIH/SIDA era alto, ya que 95.5% de los reclusos conocía la causa de la enfermedad, y más del 70% de ellos sabía como podía trasmitirse y prevenirse. Una mayoría de encuestados (68.1%) estuvo de acuerdo en que las personas con esa enfermedad debían ser aisladas (evidencia de actitudes desfavorables); el 31.2% creia que habían huecos y gusanos en los condones (concepción errónea); y 41.5% no usaría condones (alegando que impiden el pleno goce sexual), a pesar del riesgo asociado con el abandono de su uso. Conclusión. Se hallo que el; conocimiento sobre el VIH/SIDA era alto, y que los prisioneras tenían concepciones erróneas sobre el VIH/SIDA, y el uso de los condones

Growth charts only marginally improved maternal learning from nutrition education and growth monitoring in Lesotho.

A study done in Lesotho in 1985-1986 assessed whether growth charts increased the impact of nutrition education and growth monitoring on maternal learning about weaning practices and diarrhea. Seven hundred and seventy six mothers were given three monthly sessions of group nutrition education along with growth monitoring of children and individual counseling. Growth charts, which were taught to one of two groups, fostered learning but only on issues related to diarrhea and only among new clinic attendants, mothers with less than secondary schooling and mothers of malnourished children. These benefits, however, were small (differences less than 10%) compared with the overall impact of the nutrition education and growth monitoring intervention (increases between baseline and post-intervention were greater than 50% for some questions). Our findings suggest that well-designed clinic-based nutrition education and growth monitoring can have a significant impact on maternal nutrition knowledge. Teaching growth charts to mothers may not be necessary for obtaining such results in programs conducted under ideal conditions. More research is needed to determine under what circumstances, for what purposes and for whom growth charts may be beneficial.

PIP: Between December 1985 and November 1986, before and after 3 monthly sessions of group nutrition counseling and individual counseling about weaning and diarrhea management at 9 primary health clinics in Lesotho, researchers compared data on 575 mothers who received a growth chart to monitor their 2-year old children's growth with data on 201 mothers of 2-year old children who did not receive a growth chart. They wanted to learn whether growth charts promoted maternal learning and whether the growth charts better served some mothers than other mothers. Growth monitoring intervention improved knowledge of diarrhea management but not weaning practices. This improvement in learning about diarrhea management was limited to new clinic attendants, mothers with less than high school education, and mothers with malnourished children, however. Yet the differences in benefits between these 2 groups were 10% and insignificant. Nutrition education interventions had significantly improved knowledge of weaning practices and diarrhea management for both groups of mothers (range of improvement 3-119.2%; p.05). The greatest improvements occurred in correct responses to continuous feeding of solid foods during diarrhea (119.2% for mothers who did not receive charts and 85.2% for those who did) and to introduction of protein rich vegetables to children's diet (42.6% and 58.9%, respectively). Thus use of growth charts contributed only slightly to increased effectiveness of nutrition education. It appeared that the quality and specificity of educational projects and proper use of weight information during individual counseling contributed the most to improved maternal learning. Nevertheless further research is warranted to learn the circumstances, purposes, and target audience under which use of growth charts would bring the most benefits.

The mediating effect of maternal nutrition knowledge on the association between maternal schooling and child nutritional status in Lesotho.

The present study tested whether maternal nutrition knowledge was a mediating factor in the association between maternal schooling and child nutritional status, and whether the mechanism involved differed according to socioeconomic status. The data were collected in Lesotho on 921 mother-child pairs and included scores from a nutrition knowledge test, socioeconomic and demographic information, and the child's anthropometric data. A wealth factor derived from a factor analysis was used to stratify the sample into two socioeconomic groups. Two-stage least-squares estimation was used to test the mediating role of nutrition knowledge between maternal schooling and child weight-for-age. Results showed that both the importance of maternal schooling and the mechanism by which it affects the child's weight-for-age are contingent upon the family's socioeconomic status. While maternal schooling was positively associated with weight-for-age for both wealthier and poorer households, the size of the effect was much larger for the latter group. The effect of maternal schooling on weight-for-age was mediated by the mother's nutrition knowledge only among wealthier households. These results imply that, in Lesotho, nutrition education for mothers could contribute to improving children's growth, but only in households that have access to a minimum level of resources. For poorer households, nutrition education would not be sufficient.

Impact of a clinic-based growth monitoring programme on maternal nutrition knowledge in Lesotho.

An evaluation of the impact of a nationwide clinic-based growth monitoring (GM) programme was done in Lesotho to determine if clinic attendance was associated with improved maternal knowledge of weaning practices and diarrhoea. A total of 907 mothers from eight clinics were included in the study. Our results showed that mothers who had attended the clinics knew more about the appropriate timing for introducing animal protein-rich foods in the child's diet and about the use of oral rehydration salts for diarrhoea, than those who had not. The difference in knowledge between previous clinic attendants and new attendants was particularly marked among mothers with less than secondary schooling and mothers with young babies (less than 6 months). From observation in the clinics, we believe that group nutrition education, although it was not integrated with growth monitoring, was probably responsible for the positive association between clinic attendance and maternal knowledge. Prior clinic attendance was not specifically associated with improved knowledge about feeding during diarrhoea or the need to stop breastfeeding gradually. These need to be better incorporated into present clinic nutrition education. Whether improvements in growth monitoring would further significantly improve nutrition education remains to be seen.

PIP: Between December 1985-November 1986, survey data from 907 mothers of 2-year-old children in 8 Catholic Relief Services (CRS) clinics in Mahale's Hoek and Mafeteng districts in Lesotho were analyzed to determine if attendance at a typical nationwide clinic-based growth monitoring program improved maternal knowledge of weaning practices and diarrhea management. 85% of the mothers were Basotho women. At the clinics, the mothers did not undergo individual counseling or receive training in growth charts. Group nutrition education efforts did occur, however, but separately from the program. Mothers who attended a clinic had a significantly higher increased knowledge of the appropriate timing for introducing animal protein rich foods and about the use of oral rehydration salts than those who did not attend (p.05). This association was especially significant for mothers with only primary education and those with infants 6 months old. The mothers reported breast feeding a mean of 2 years. 85% knew to introduce cereals and liquids between 4-6 months old. Yet few mothers knew how to appropriately stop breast feeding. For example, 50% believed it should stop in 1 day. The researchers believed that the separate group nutrition activities contributed to the positive effect of clinic attendance on maternal knowledge of nutrition and diarrhea management. Other research needs to be done to determine if teaching of growth charts and individual counseling would significantly improve maternal knowledge. Clinic staff delivering improved educational messages could have a significant positive effect on the growth and health of Basotho children who are undergoing weaning.

Comparison of two growth charts in Lesotho: health workers' ability to understand and use them for action.

BACKGROUND: Two growth monitoring charts widely used for growth monitoring in Africa (the Road-to-Health (RTH) and the Growth Surveillance (GS] were compared in order to assist the Government of Lesotho to decide on an appropriate national growth chart. METHODS: Thirty-four health workers were taught and tested on the RTH during a first week of training and on the GS during a second week (the RTH-GS group), while the order was reversed for another 25 trainees (the GS-RTH group). The health workers were trained and tested on their ability not only to use and interpret the two charts, but also to make the right decisions about specific actions to be taken when growth faltering occurs. RESULTS: There was no difference between scores to the RTH and GS charts after one week of training. After the second week of training, the scores to the RTH chart improved and became better than those to the GS chart. The scores to the GS test did not increase with previous knowledge of the RTH chart. CONCLUSIONS: For this reason and others discussed in the paper, the RTH chart was recommended for nationwide use in Lesotho. The adoption of this recommendation was facilitated by the close involvement in this research of public and private agencies responsible for growth monitoring in Lesotho.

Collaboration within the United Nations system: liberation struggle in Southern Africa: assistance to the front-line States, Lesotho and Swaziland

World Health Assembly, 43. World Health Organization; 7-17 May 1990

Collaboration within the United Nations System : Liberation struggle in Southern Africa : Assistance to the front-line states, Lesotho and Swaziland; and to Namibia and National Liberation movements in South Africa : Report by the Director-General / Collaboration a línterieur du Systeme des Nations Unies: Lutte de liberation en Afrique Australe - Assistance aux etats de premiere ligne, au Lesotho et au Swaziland, ainsi quá a la Namibie et aux mouvements de liberation nationales en Afrique du Sud. Rapport to Directeur General

World Health Assembly, 41. World Health Organization; 4-15 May 1988

Liberation struggle in Southern Africa : Assistance to the front-line states; Lesotho and Swaziland

World Health Assembly, 40. World Health Organization; 4-15 May 1987