Implementation of the vaccination program in Guinea-Bissau: Coverage and missed opportunities for BCG at birth.

BACKGROUND: The Bacillus Calmette-Guérin (BCG) vaccine is recommended at birth in Guinea-Bissau but often given with delay. Delays are not evident in routine coverage estimates since coverage is measured by 12 months of age. Studies show that BCG protects against other infections than tuberculosis and lowers neonatal mortality. Hence, the timing of BCG is important since the children should benefit from these non-specific effects as early as possible. METHODS: Using data from a nationally representative health and demographic surveillance system in Guinea-Bissau, we assessed BCG coverage at birth (within the first 3 days of life), 1 month, and 12 months for children born in 2013-19. We measured the proportion of children who had a documented health system contact within the first 3 days of life, thus an opportunity for BCG at birth, and whether the opportunities were utilized. In binomial regression models, we investigated factors associated with missed opportunities for vaccination. RESULTS: Among the 22,178 children only 19 % were vaccinated at birth. By 1 month and 12 months, BCG coverages were 64 % and 93 %. The timeliness of BCG improved over time, with coverage at birth increasing from 16 % in 2013 to 25 % in 2019 and 1-month coverage from 63 % in 2013 to 75 % in 2019. If all vaccination opportunities had been utilized, the BCG coverage at birth could have reached 45 % (in the 1-month cohort) instead of the actual coverage of 19 %, as only 40 % of the vaccination opportunities were utilized. Region of residence was associated with having a missed opportunity for vaccination. CONCLUSION: The high coverage estimates at 12 months falsely imply that the vaccine is being administered according to the recommended schedule. Our findings suggest that early coverage could be markedly improved by ensuring that children are vaccinated at their first contact with the health system.

Informal caregiving among people supporting a person with type 2 diabetes in rural communities of Northern Vietnam: A cross-sectional study of caregiver burdens.

OBJECTIVE: The prevalence of type 2 diabetes mellitus (T2DM) in Vietnam has doubled from 3% to 6% over the last decades, with potential consequences for persons with diabetes and their caregivers. This study aimed to assess caregiver burdens and factors associated with caregiver burden. METHOD: A cross-sectional study was conducted in 2019, using data from 1,241 informal caregivers (ICGs). Caregiver burden was scored from 0-32 using 8 questions from the Zarit Burden Interview (ZBI). Quantile regression analysis was used to identify factors associated with caregiver burden. RESULTS: The median score of the ZBI was 7.0 (Q1-Q3: 2.0-10.0), indicating that the burden among caregiver of persons with T2DM is not high. Quantile regression showed that the higher the monthly income, the lower the burden among caregivers (50% quantile and 75% quantile of burden: -0.004). Lower educational level (25%Q: 4.0, 50%Q; 3.0, 75%Q: 2.16), being a farmer (25%Q: 2.0) and providing care to other people besides the person with T2DM (25%Q: 2.0, 50%Q; 2.54, 75%Q: 1.66) were associated with higher burden on caregivers. CONCLUSION: The study found that caregivers facing additional life stressors, such as low income or other caregiving responsibilities, reported higher levels of burden. These findings could inform the development of interventions targeted at supporting informal caregivers in rural areas in low- and middle-income countries.

Incidence and determinants of perinatal mortality in five urban hospitals in Dar es Salaam, Tanzania: a cohort study with an embedded case-control analysis.

INTRODUCTION: Tanzania has one of the highest burdens of perinatal mortality, with a higher risk among urban versus rural women. To understand the characteristics of perinatal mortality in urban health facilities, study objectives were: I. To assess the incidence of perinatal deaths in public health facilities in Dar es Salaam and classify these into a) pre-facility stillbirths (absence of fetal heart tones on admission to the study health facilities) and b) intra-facility perinatal deaths before discharge; and II. To identify determinants of perinatal deaths by comparing each of the two groups of perinatal deaths with healthy newborns. METHODS: This was a retrospective cohort study among women who gave birth in five urban, public health facilities in Dar es Salaam. I. Incidence of perinatal death in the year 2020 was calculated based on routinely collected health facility records and the Perinatal Problem Identification Database. II. An embedded case-control study was conducted within a sub-population of singletons with birthweight ≥ 2000 g (excluding newborns with congenital malformations); pre-facility stillbirths and intra-facility perinatal deaths were compared with 'healthy newborns' (Apgar score ≥ 8 at one and ≥ 9 at five minutes and discharged home alive). Descriptive and logistic regression analyses were performed to explore the determinants of deaths. RESULTS: A total of 37,787 births were recorded in 2020. The pre-discharge perinatal death rate was 38.3 per 1,000 total births: a stillbirth rate of 27.7 per 1,000 total births and an intra-facility neonatal death rate of 10.9 per 1,000 live births. Pre-facility stillbirths accounted for 88.4% of the stillbirths. The case-control study included 2,224 women (452 pre-facility stillbirths; 287 intra-facility perinatal deaths and 1,485 controls), 99% of whom attended antenatal clinic (75% with more than three visits). Pre-facility stillbirths were associated with low birth weight (cOR 4.40; (95% CI: 3.13-6.18) and with maternal hypertension (cOR 4.72; 95% CI: 3.30-6.76). Intra-facility perinatal deaths were associated with breech presentation (aOR 40.3; 95% CI: 8.75-185.61), complications in the second stage (aOR 20.04; 95% CI: 12.02-33.41), low birth weight (aOR 5.57; 95% CI: 2.62-11.84), cervical dilation crossing the partograph's action line (aOR 4.16; 95% CI:2.29-7.56), and hypertension during intrapartum care (aOR 2.9; 95% CI 1.03-8.14), among other factors.  CONCLUSION: The perinatal death rate in the five urban hospitals was linked to gaps in the quality of antenatal and intrapartum care, in the study health facilities and in lower-level referral clinics. Urgent action is required to implement context-specific interventions and conduct implementation research to strengthen the urban referral system across the entire continuum of care from pregnancy onset to postpartum. The role of hypertensive disorders in pregnancy as a crucial determinant of perinatal deaths emphasizes the complexities of maternal-perinatal health within urban settings.

Ethical dilemmas in conducting qualitative, public health research on social media: using a study on Facebook as a case.

AIM: Platforms on social media are increasingly used for public health research. While social media provides an exceptional opportunity to explore communication about public health topics, this practice is not without ethical dilemmas. Our aim was to identify and unfold some of these dilemmas and to suggest possible solutions and ways forward for future research. METHODS: Using our own research within a closed forum for people experiencing suicidal thoughts as a case, we explored certain dilemmas and possible answers relating to whether what is to be researched falls under a public or private social media domain; we investigated avenues for obtaining access to participants in an evolving online environment; how to secure informed consent from participants; and ways of ensuring anonymity. RESULTS: We provide recommendations and reflections that we hope will offer inspiration for researchers embarking on similar social media public health research within and beyond suicide research. CONCLUSIONS: The ethical framework commonly referred to in health research, based on confidentiality, anonymity, informed consent and doing no harm must be adjusted to be relevant for a social media context where technologies and regulations are constantly being altered.

Pre-/-post-analyses of a feasibility study of a peer-based club intervention among people living with type 2 diabetes in Vietnam's rural communities.

OBJECTIVES: Insufficient self-management is a significant barrier for people with type 2 diabetes (T2D) to achieve glycemic control and consequently reduce the risk of acute and long-term diabetes complications, negatively affecting their quality of life and increasing their risk of diabetes-related death. This pre-post study aimed to evaluate whether a peer-based club intervention might reduce glycated hemoglobin from baseline to post-intervention and enhance self-management among people living with T2D in two rural communities in Vietnam. METHODS: A pre-post study was implemented with 222 adults with T2D residing in two rural communities in Vietnam. We used a structured questionnaire, clinical examination, and glycated hemoglobin to evaluate the possible effects of a diabetes club intervention by comparing Glycated Hemoglobin (HbA1c), Body Mass Index (BMI), Blood Pressure (BP), and diabetes-related self-management behaviors at baseline and post-intervention. The data were analyzed using SPSS 20, applying two related sample tests (Wilcoxon and McNemar test) and a paired-sample t-test at a significance level of less than 0.05. RESULTS: The findings indicated that after implementation of the intervention, there were no significant statistical differences when comparing pre-and post-intervention levels of the primary outcome HbA1c, but some components of diabetes self-management showed statistically significant improvement. CONCLUSIONS: After the peer support intervention in a Vietnamese rural community, there was no significant reduction in the primary outcome proportion of patients having an HbA1c less than 7%, but foot care knowledge and practice had improved. TRIAL REGISTRATION: ClinicalTrials.gov NCT05602441.

Awareness of and participation in mass drug administration programs used for onchocerciasis control in the Atwima Nwabiagya North District, Ghana.

BACKGROUND: Studies on Mass drug administration (MDA) in Ghana targeting various diseases, have mostly focused on factors that affect coverage and compliance to MDA with limited focus on evidence regarding awareness and community perception of the program. Therefore, this study sought to provide empirical evidence on the knowledge of onchocerciasis, and awareness of and participation in the MDA among community members. METHODS: A community-based cross-sectional survey was conducted from August to October 2019 in communities within the Atwima Nwabiagya North District, Ghana. Data was collected from 2,008 respondents. Bivariate and multivariate logistic regression analyses were performed to measure the associations between socio-demographics, having heard of onchocerciasis and its prevention, and levels of awareness of the MDA program. RESULTS: A total of 1268 respondents (63.2%) were aware of the MDA program. The majority ofMost respondents (74.4%) were of the view that the information given about the program was not enough and 45.4% of the respondents had no idea about the relevance of the MDA program. Respondents who had ever heard about onchocerciasis prevention and persons who had previously participated in the MDA program were more likely to be aware of the MDA program during implementation (AOR = 2.32; 95% CI 1.79-3.01 and AOR = 9.31; 95% CI 7.06-12.26, respectively). CONCLUSIONS: We observed a significant association between being aware of MDA campaigns and knowledge of onchocerciasis and its preventive methods, and participation in previous MDA campaigns. We recommend intensification and improvement of prevention campaigns regarding the onchocerciasis MDA program as key to ensuring increased MDA program participation.

Factors associated with continuity of care in hypertension and type 2 diabetes among forcibly displaced persons in the Bidibidi refugee settlement in Uganda: Protocol for a cross-sectional, mixed-methods study.

BACKGROUND: Non-communicable diseases in humanitarian settings are generally under-researched, particularly in Africa and have been called a neglected crisis. Little is known about factors affecting access to and (dis)continuity of care for chronic conditions, such as hypertension (HTN) and type 2 diabetes among forcibly displaced persons (FDPs) in Uganda. AIM: To investigate factors affecting access to and (dis)continuity of HTN and/or type 2 diabetes care among FDPs in the Bidibidi refugee settlement, Uganda. METHODS: A sequential explanatory mixed-methods design incorporating methodological and investigator triangulation will be conducted. The study aims to employ a community-based participatory research approach to equitably engage community members, researchers, and other stakeholders in the research process, recognising and maximising their diverse contributions. In phase 1, the quantitative arm of the study, 960 FDPs with HTN and/or type 2 diabetes will be interviewed about their sociodemographic characteristics, health status, migration experiences, social capital, and awareness, treatment, and control of these diseases. Participants will be purposively recruited from phase 1 as well as village health teams, healthcare providers, and policymakers to participate in phase 2, the qualitative study, in order to gain more insight into how mobility and social factors affect (dis)continuity of care among FDPs with HTN and/or type 2 diabetes. DISCUSSION: The findings from phase 1 and phase 2 of the study will be integrated through a triangulation process to provide a more holistic and comprehensive insight into the factors affecting access to and (dis)continuity for HTN and/or type 2 diabetes care among FDPs. Understanding these factors is expected to pave the way for conceptualizing health-enabling environments and strengthening health systems for FDPs with chronic conditions. It is anticipated that the study will generate baseline evidence that might be beneficial in developing and implementing HTN and diabetes care models for FDPs in the region.

Risk of stillbirth and preterm birth among undocumented pregnant migrant women in Denmark: A retrospective case-control study.

AIMS: To examine the associations between undocumented pregnant migrant women and the risk of experiencing stillbirth or preterm birth. METHODS: A retrospective case-control study based on nationwide registers from Statistics Denmark and hospital journals from the seven largest hospital wards in Denmark from 1 January 2011 to 31 December 2018. A total of 882 undocumented pregnant migrant women and 3528 matched controls (both documented migrant and non-migrant women) were included. Logistic regression models were used to estimate the risk of undocumented pregnant migrant women experiencing (a) stillbirth and (b) preterm birth compared with the control group. RESULTS: Of the undocumented pregnant migrant women, 33.3% were EU citizens, 16.2% were applicants for residence and 50.5% had an unknown basis for residence. The mean age of the undocumented pregnant migrant women was 28.4 years, whereas the mean age of women in the control group was 30.9 years. Higher adjusted odds of experiencing stillbirth (aOR 3.50; 95% CI 1.31-9.38) and preterm birth (aOR 1.41; 95% CI 1.04-1.93) were observed among the undocumented pregnant migrant women compared with the control group. The basis of residence was not associated with higher odds of experiencing stillbirth or preterm birth. CONCLUSIONS: We found a higher risk of stillbirth and preterm birth among the undocumented pregnant migrant women than in the control group. Our findings suggest a need to increase the focus on providing access to antenatal care among those women currently excluded from this care.

Unmet needs for informal care among people with type 2 diabetes in rural communities in Vietnam.

Objectives: The objective of this study was to identify determinants associated with unmet needs for informal support among people with type-2 diabetes in rural communities of Vietnam in order to inform development of effective interventions aimed at bridging the gap between community members and resource constrained health systems. Study design: A cross-sectional survey was conducted from December 2018 to February 2019 in a rural area of northern Vietnam. Methods: From 2 districts in northern Vietnam, 806 people with type-2 diabetes participated in a survey to assess who were their most important informal caregivers (ICGs) and to measure the association between demographic and socio-economic predictors and unmet needs of informal support of relevance for diabetes self-care using bivariate and multivariate analyses. Results: The spouse was reported as the most important ICG (62.9%) followed by a daughter or son (28.4%). 32.0% reported at least one type of unmet need for informal support. The most commonly reported unmet needs of informal care were: transport to health facilities and company when seeking formal care (20.5%), financial support related to costs of diabetes self-management (18.5%), and reminders to engage in physical exercise (14.5%). People living alone reported the highest odds ratio (OR) for unmet need of informal care (OR = 4.41; CI95%: 2.19-8.88), followed by those being poor (OR = 3.79; CI95%: 1.25-11.52) and those being unemployed (OR = 2.85; CI95%: 1.61-5.05). Conclusions: Almost one-third of people with type-2 diabetes reported at least one type of unmet need for informal care. These findings provide a basis for development of new modalities for strengthening support provided by ICGs in rural communities in Vietnam and in other low- and middle-income countries.

Making Sense or Non-Sense? Communicating COVID-19 Guidelines to Young Adults at Danish Folk High Schools.

Little is known about young people's behaviors and responses under outbreaks of infectious diseases such as the COVID-19 pandemic, especially in institutional settings. This research investigated the reactions of young adults residing at Danish folk high schools (FHSs) towards COVID-19 guidelines and the communicative styles used to enforce COVID-19 guidelines. The qualitative data consists of focus group discussions (FGDs) with students, interviews with staff, and participant observations, as well as survey data from 1800 students. This study showed that young adults reacted negatively when first faced with the new reality of COVID-19 restrictions. They expressed distress over the loss of meaning (non-sense), loss of sense of community, as well as uncertainty. Hygiene guidelines, however, made immediate sense and were socially well accepted. Most FHSs actively involved students in risk communication and creative examples of community-building communication were identified. This study demonstrates that successful risk communication at educational institutions must take into consideration how young adults make sense of and cope with the uncertainties of life during crisis situations including epidemics.

HIV testing and associated factors among female sex workers in Tanzania: approaching the first 90% target?

Use of HIV testing services among FSW in sub-Saharan Africa (SSA) is below the desired UNAIDS target of 90%. We estimated the prevalence and factors associated with HIV testing among FSW in Dar es Salaam, Tanzania. A respondent-driven sampling method was used to recruit FSW aged 18. Modified Poisson regression models were used to determine factors associated with recent HIV testing. Of 958 surveyed FSW (median age 26 years), 85.4% (95% CI: 82.3, 88.1) reported to have ever been tested for HIV and 65.3% (95% CI: 61.2, 69.3) tested in the past 12 months. Condom use on the last day worked (prevalence ratio (PR) = 1.17; 95% CI: 0.99, 1.38), no or low self-perceived risk of HIV acquisition (PR = 1.16; 95% CI: 1.02, 1.32), having never felt stigmatized as a sex worker (PR = 1.18; 95% CI: 1.04, 1.33), and having been in contact with a peer educator (PR = 1.33; 95% CI: 1.18, 1.49) during the past year preceding the survey were associated with recent HIV testing. Interventions aiming to mitigate stigma due to sex work, improve health education to address risk perception as a barrier to HIV testing, and scaling up peer educator's engagement should be given priority.

Labor augmentation with oxytocin in low- and lower-middle-income countries: a systematic review and meta-analysis.

OBJECTIVE: Despite its worldwide use, reviews of oxytocin for labor augmentation include mainly studies from high-income countries. Meanwhile, oxytocin is a potentially harmful medication and risks may be higher in low-resource settings. We conducted a systematic review and meta-analysis of practices, benefits, and risks of oxytocin for labor augmentation in low- and lower-middle-income countries. DATA SOURCES: PubMed, Embase, PsycINFO, Index Medicus, Cochrane, and Google Scholar were searched for publications until January 1, 2022. STUDY ELIGIBILITY CRITERIA: All studies evaluating oxytocin augmentation rates were included. To investigate benefits and risks, randomized and quasi-randomized trials comparing oxytocin augmentation with placebo or no oxytocin were included. To explore risks more broadly, cohort and case-control studies were also included. METHODS: Data were extracted and quality-assessed by 2 researchers using a modified Newcastle-Ottawa scale. Generic inverse variance outcome and a random-effects model were used. Adjusted or crude effect measures with 95% confidence intervals were used. RESULTS: In total, 42 studies were included, presenting data from 885 health facilities in 25 low- and lower-middle-income countries (124,643 women). Rates of oxytocin for labor augmentation varied from 0.7% to 97.0%, exceeding 30% in 14 countries. Four studies investigated timing of oxytocin for augmentation and found that 89.5% (2745) of labors augmented with oxytocin did not cross the partograph's action line. Four cohort and 7 case-control studies assessed perinatal outcomes. Meta-analysis revealed that oxytocin was associated with: stillbirth and day-1 neonatal mortality (relative risk, 1.45; 95% confidence interval, 1.02-2.06; N=84,077; 6 studies); low Apgar score (relative risk, 1.54; 95% confidence interval, 1.21-1.96; N=80,157; 4 studies); neonatal resuscitation (relative risk, 2.69; 95% confidence interval, 1.87-3.88; N=86,750; 3 studies); and neonatal encephalopathy (relative risk, 2.90; 95% confidence interval, 1.87-4.49; N=1383; 2 studies). No studies assessed effects on cesarean birth rate and uterine rupture. CONCLUSION: This review discloses a concerning level of oxytocin use, including in labors that often did not fulfill criteria for dystocia. Although this finding is limited by confounding by indication, oxytocin seems associated with increased perinatal risks, which are likely mediated by inadequate fetal monitoring. We call for cautious use on clear indications and robust implementation research to support evidence-based guidelines for labor augmentation, particularly in low-resource settings.

Testing for Drug-Related Infectious Diseases and Determinants among People Who Use Drugs in a Low-Resource Setting: A Respondent-Driven Cross-Sectional Survey.

(1) Background: There is a dearth of data on the levels and determinants of testing for drug-related infectious diseases among people who use drugs (PWUD). We assessed the proportions and determinants of testing for drug-related infectious diseases to inform ongoing interventions for PWUD. (2) Methods: A cross-sectional study involving 599 PWUD was conducted in Dar es Salaam and Tanga between January and February 2019. Data were collected through a researcher-administered questionnaire using handheld tablets. Logistic regression models were used to identify independent testing determinants for drug-related infectious diseases. (3) Results: A majority (98.0%) of participants were males, with a mean age of 36.8 (SD = 7.8) years. 75.0%, 40.6%, 38.6%, and 8.2% reported having ever tested for HIV, tuberculosis (TB), sexually transmitted infections (STIs), and viral hepatitis, respectively. The likelihood of HIV testing was higher among those living with someone (AOR = 2.18, 95% CI: 1.09-4.68) compared with those who were homeless and perceived treatment was appropriate (AOR = 2.18, 95% CI: 1.05-4.46), but was lower among those who experienced mild to moderate (AOR = 0.44, 95% CI: 0.21-0.95) and severe internalized stigma (AOR = 0.44, 95% CI: 0.22-0.94) compared with those reporting no internalized stigma, and among those who experienced financial difficulties resulting from spending on health care services (AOR = 0.60, 95% CI: 0.40-0.89). Perception of treatment appropriateness (AOR = 2.29, 96% CI: 1.10-5.06) and severe enacted stigma (AOR = 1.90, 95% CI: 1.06-3.42) were associated with increased odds of TB testing. The odds of STIs testing increased among those who were married (AOR = 2.31, 95% CI: 1.45-3.72) compared with those who were single and those who had experienced mild (AOR = 2.39, 95% CI: 1.28-4.53) or severe (AOR = 6.20, 95% CI: 1.99-23.83) sexual violence, compared with those who had not experienced sexual violence. However, the odds decreased among those who had been remanded in the past month (AOR = 0.64, 95% CI: 0.43-0.95) compared with those who were not remanded and among those who had financial difficulties resulting from spending on health care services (AOR = 0.66, 95% CI: 0.47-0.94). The likelihood of testing for viral hepatitis testing increased among those who had heard about the comprehensive HIV intervention package (CHIP) (AOR = 2.59, 95% CI: 1.40-4.94); however, it decreased among those who had financial difficulties resulting from spending on health care services (AOR = 0.48, 95% CI: 0.24-0.92). (4) Conclusions: Except for HIV, PWUD had undergone limited testing for drug-related infectious diseases. The study findings highlight some factors influencing testing for the selected infectious diseases investigated, which should be targeted for tailored interventions to improve diagnosis and treatment.

Not a Problem at All or Excluded by Oneself, Doctors and the Law? Healthcare Workers' Perspectives on Access to HIV-Related Healthcare among Same-Sex Attracted Men in Tanzania.

Background: An increasing body of literature focuses on access to healthcare services for men who engage in sex with other men in Africa, but how healthcare workers conceive of this topic of healthcare workers' views on men's care has not been much studied. Drawing on qualitative research, this article explores healthcare providers' perspectives on access to HIV-related healthcare services among gender and sexuality diverse men in Tanzania. Methods: A qualitative study was conducted among healthcare workers in Dar es Salaam and Tanga, Tanzania in 2018/2019. Data collection entailed qualitative interviewing, focus group discussions and participant observation. A purposive sampling strategy was used to select study participants who varied with respect to age, education level, work experience, and the type and location of the facilities they worked in. A total of 88 participants took part in the study. Results: This paper describes four different discourses that were identified among healthcare workers with respect to their perception of access to healthcare services for men who have sex with men. One held that access to healthcare was not a major problem, another that some same-sex attracted men did not utilize healthcare services although they were available to them, a third that some healthcare workers prevented these men from gaining access to healthcare and a fourth that healthcare for gender and sexual minority persons was made difficult by structural barriers. Conclusion: Although these are four rather different takes on the prevailing circumstances with respect to healthcare access for same-sex attracted men (SSAM), we suggest that they may all be "true" in the sense that they grasp and highlight different aspects of the same realities. More education is needed to healthcare providers to enable them accept SSAM who seek healthcare services and hence improve access to healthcare.

Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study).

While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained.Trial registration number: NCT04685668.

Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study.

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study's programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen - safe and respectful clinical childbirth care - is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants' motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.

Mass drug administration targeting Onchocerca volvulus in Owabi catchment area in Ashanti Region, Ghana: Determinants of drug coverage and drug uptake.

INTRODUCTION: Achieving high Mass Drug Administration (MDA) coverage and drug uptake are pivotal in the efforts to eradicate onchocerciasis. The present study investigated the extent and predictors of ivermectin MDA coverage and uptake from the individual and healthcare providers' perspectives. The extent of ivermectin distribution and uptake, and the predictors of distribution and uptake were investigated in endemic communities in the Ashanti Region of Ghana. METHODS: A cross-sectional survey was conducted from August to October 2019 in communities within the Atwima Nwabiagya North District. A total of 2008 respondents were interviewed. Data was collected with REDCap mobile App which had an electronic version of the structured questionnaire. Descriptive data was presented in frequency tables, and bivariate and multivariate logistics regression analysis were performed to measure the associations between exposure variables and outcome variables which were received and uptake of MDA drugs. RESULTS: A total of 1284 (63.9%) respondents did not receive ivermectin during the 2019 MDA programme and more than half of them were not aware of the drug distribution (53.3%). The most common reasons for not ingesting the drug were fear of side effects (47.7%) and not trusting the drug distributors (20.0%). Respondents in the age group 48-57 years (AOR = 1.37; 95%CI: 1.01-2.67), Persons in the high wealth index (AOR = 1.40; 95%CI: 1.11-1.77), Being aware of the MDA programme (AOR = 6.67: 95%CI: 4.76-9.35), MDA being beneficial (AOR = 2.12; 95%CI: 1.54-2.92) participating in previous MDA (AOR = 5.44; 95%CI: 4.25-6.98) and having stayed in the communities for 10 years and above significantly increased the odds of receiving MDA drugs. Previous uptake of MDA drugs (AOR = 10.58; 95%CI: 5.78-19.38) and perception of the MDA drug as beneficial (AOR = 5.25; 95%CI: 2.55-10.82) increased the likelihood of ingesting drugs when received. CONCLUSION: The main health system challenge was limited awareness creation regarding MDA. This seems to affect the optimal utilization of the ivermectin MDA intervention. MDA programmes against onchocerciasis eradication should be designed taking into account specific contextual factors to improve implementation outcomes.

Socio-cognitive factors influencing access to HIV prevention services among people who inject drugs in Dar es Salaam, Tanzania: An integrated bio-behavioural survey.

INTRODUCTION: People who inject drugs (PWID) in Sub-Saharan Africa have limited access to comprehensive HIV services. While it is important to inform programming, knowledge about factors influencing access to comprehensive HIV services is scarce. We assessed the proportions of PWID with access to HIV prevention services and associated socio-cognitive factors in Tanzania. METHODS: A cross-sectional survey was conducted among PWID between October and December 2017 in Dar es Salaam, Tanzania. Data on access to HIV prevention services, demographics and selected socio-cognitive factors were collected through structured face-to-face interviews. Weighted descriptive and forward selection multivariable logistics regression analyses were done to assess independent associations between HIV prevention services and predictors of interest. The results were two tailed and a p-value of less than 0.05 was considered statistically significant. RESULTS: The study included 611 PWID (males: 94.4%) with a median age of 34 years (Interquartile Range (IQR), 29-38). A large majority of participants reported to have access to condoms (87.8%), sterile needles/syringes (72.8%) and ever tested for HIV (66.0%). About half (52.0%) reported to have used condoms in the past one month and about a third (28.5%) accessed a peer educator. The odds of testing for HIV decreased among participants who perceived their HIV risk to be high (aOR = 0.29; 95%CI: 0.17-0.49) and those experienced sexual violence (aOR = 0.60; 95%CI 0.37-0.98). However, the odds of testing for HIV increased among participants with secondary level of education (aOR = 2.16; 95%CI: 1.06-5.55), and those who reported having correct comprehensive HIV knowledge (CCHK) (aOR = 1.63; 95%CI 1.12-2.41). The odds of access to condoms increased among females (aOR = 2.23; 95%CI: 1.04-5.02) but decreased among participants with secondary level of education (aOR = 0.41; 95%CI: 0.19-0.84), an income of >TZS 200,000 (aOR = 0.39; 95%CI: 0.23-0.66) and those who perceived their HIV risk to be high (aOR = 0.13; 95%CI: 0.03-0.36). The odds of access to peer educators was higher among participants with primary (aOR = 1.61; 95%CI: 1.01-2.26), and secondary (aOR = 2.71; 95%CI: 1.39-5.33) levels of education. The odds of access to sterile needle and syringe decreased among participants who perceived their HIV risk to be high (aOR = 0.11;95%CI 0.05-0.22), and low-medium (aOR = 0.25;95%CI 0.11-0.52) but increased among those with primary level of education (aOR = 1.72;95%CI 1.06-2.78). CONCLUSION: Access to condom, HIV testing, sterile needles and syringes were relatively high among PWID. However, condom use and access to peer educators was relatively low. HIV knowledge and risk perception, gender, education, and sexual violence influenced access to HIV prevention services. There is an urgent need to address the identified socio-cognitive factors and scale up all aspects of HIV prevention services to fast-track attainment of the 2025 UNAIDS goals and ending the HIV epidemic.