Contextual factors associated with contraceptive utilization and unmet need among sexually active unmarried women in Kenya: A multilevel regression analysis.

BACKGROUND: Unmarried women who report less recent sexual intercourse (>30 days from survey enumeration) are largely excluded from global health monitoring and evaluation efforts. This study investigated level and contextual factors in modern contraceptive utilization and unmet need within this overlooked female subpopulation in Kenya from 2014 to 2019. METHODS: This study analyzed data from the Performance Monitoring and Accountability (PMA) survey in Kenya, a nationally representative survey of female respondents, to understand the level and contextual factors for family planning utilization and unmet need within female subgroups including married, unmarried sexually active (defined as sexual intercourse within 30 days of survey enumeration), and unmarried with less recent sexual intercourse (defined as sexual intercourse 1-12 months prior to survey enumeration). The analysis included multilevel regression modeling to assess correlates on outcomes of modern contraceptive prevalence rate (mCPR), unmet need, and recent emergency contractive pill (ECP) use, which is a unique PMA question: "Have you used emergency contraception at any time in the last 12 months?". RESULTS: Cumulatively, the surveys enumerated 19,161 women and this weighted analysis included 12,574 women aged 15-49 from three female subgroups: 9,860 married women (78.4%), 1,020 unmarried sexually active women (8.1%), and 1,694 unmarried women with less recent sexual intercourse (13.5%). In 2019, while controlling for covariates, unmarried women with less recent sexual intercourse exhibited statistically significant differences (p-value<0.02) in current mCPR, mCPR at last sexual intercourse, unmet need for modern contraceptives, and recent ECP use. As compared to an unmarried woman with less recent sexual intercourse (i.e., reported sex 1-12 months prior to survey), the odds of an unmarried sexually active woman (i.e., reported sex within last 30 days of survey) currently using modern contraceptives was 2.28 (95% CI: 1.64, 3.18), using modern contraceptives at last sexual intercourse was 1.44 (95% CI: 1.06, 1.95), and having an unmet need for modern contraceptives was 2.01 (95% CI: 1.29, 3.13) while controlling for covariates. The odds of a married woman using ECP during the last 12 months was 0.60 (95% CI: 0.44, 0.82) as compared to an unmarried woman with less recent sexual intercourse. In 2019, unmarried women with less recent sexual intercourse reported the highest rate of ECP use during the last 12 months at 13.5%, which was similar for unmarried sexually active women at 13.3%. Since 2014, summary measures of unmet need and total demand for modern contraceptives increased for unmarried women with less recent sexual intercourse, but declined for the other female subgroups. CONCLUSION: In Kenya, unmarried women with less recent sexual intercourse exhibited significantly different contraceptive utilization, unmet need, and recent emergency contraceptive use. Moreover, changes over time in key family planning indicators were asymmetrical by female subgroup. This study identifies an important monitoring gap regarding unmarried women with less recent sexual intercourse. Evidence dissemination by the global measurement community for these unmarried women is exceedingly scarce; therefore, developing an inclusive research agenda and actionable information about these marginalized women is needed to enable targeted planning and equitable service delivery.

Recent Progress in Lyme Disease and Remaining Challenges.

Lyme disease (also known as Lyme borreliosis) is the most common vector-borne disease in the United States with an estimated 476,000 cases per year. While historically, the long-term impact of Lyme disease on patients has been controversial, mounting evidence supports the idea that a substantial number of patients experience persistent symptoms following treatment. The research community has largely lacked the necessary funding to properly advance the scientific and clinical understanding of the disease, or to develop and evaluate innovative approaches for prevention, diagnosis, and treatment. Given the many outstanding questions raised into the diagnosis, clinical presentation and treatment of Lyme disease, and the underlying molecular mechanisms that trigger persistent disease, there is an urgent need for more support. This review article summarizes progress over the past 5 years in our understanding of Lyme and tick-borne diseases in the United States and highlights remaining challenges.

Effectiveness of SMS Technology on Timely Community Health Worker Follow-Up for Childhood Malnutrition: A Retrospective Cohort Study in sub-Saharan Africa.

BACKGROUND: The Millennium Villages Project facilitated technology-based health interventions in rural under-resourced areas of sub-Saharan Africa. Our study examined whether data entry using SMS compared with paper forms by community health workers (CHWs) led to higher proportion of timely follow-up visits for malnutrition screening in under-5 children in Ghana, Rwanda, Senegal, and Uganda. METHODS: Children under 5 years were screened for malnutrition every 90 days by CHWs using mid-upper arm circumference (MUAC) readings. CHWs used either SMS texts or paper forms to enter MUAC data. Reminder texts were sent at 15 days before follow-up was needed. Chi-square tests assessed proportion of timely follow-up visits within 90 days between SMS and paper groups. Logistic regression analysis was conducted in a step-wise multivariate model. Post-hoc power calculations were conducted to verify strength of associations. RESULTS: SMS data entry was associated with a higher proportion of timely malnutrition follow-up visits compared with paper forms across all sites. The association was strongest with consistent SMS use over consecutive visits. SMS use at the first of 2 consecutive visits was most effective, highlighting the importance of SMS reminder alerts. CONCLUSIONS: SMS technology with reminders increased timely CHW malnutrition screening visits for under-5 children in Ghana, Rwanda, Senegal, and Uganda, highlighting the importance of such technology for improving health worker behavior in low-resource settings.

Data-informed decision-making for life-saving commodities investments in Malawi: A qualitative case study.

Background: During the last 15 years, Malawi has made remarkable progress in reducing child mortality. However, maternal and newborn mortality remains persistently high. To help address these entrenched challenges, the Reproductive, Maternal, Newborn and Child Health (RMNCH) Trust Fund provided short-term catalytic financing of $11.5 million (2013-2016) to support country plans to advance the RMNCH and commodity agenda. Objectives: (1) To document how Malawi (ministries, partners, working groups) used evidence to inform decision-making and RMNCH investments, (2) To identify barriers to utilizing information and evidence in the planning and prioritization process at national and sub-national levels, and (3) To assess the utility of the RMNCH Landscape Synthesis, which uses existing information to review life-saving RMNCH commodities and services. Methods: This was a qualitative case study utilizing a Rapid Appraisal (RA) approach, where semi-structured interviews were conducted with staff members from UN agencies, development partners and the Ministry of Health (MoH) at national and district level. The analysis enlists a framework approach for manual qualitative content analysis. Results: Led by the MoH, the RMNCH Trust Fund grant proposal utilized an evidence-based and equity-focused process for prioritization of investments. Data-informed decision-making permeates similar commodity-focused working groups. However, common health information system (HIS) weaknesses, such as data quality and collection burden, persist and are more prevalent at district-level. The collation of evidence in the RMNCH Landscape Synthesis was a useful and sustainable tool to support planning. Conclusions: The evidence-based, equity-focused decision-making process for the RMNCH Trust Fund proposal provides an effective model for inter-agency investment prioritization. Strengthening data-informed decision-making will require financial and political commitments to HIS and capacity building for data use, particularly at the district-level. New initiatives (e.g. Health Data Collaborative and QED Network to Improve Quality of Care) provide opportunities to further improve evidence-informed decision-making.

The UN Commission on Life Saving Commodities 3 years on: global progress update and results of a multicountry assessment.

BACKGROUND: In September, 2012, the UN Commission on Life Saving Commodities (UNCoLSC) outlined a plan to expand availability and access to 13 life saving commodities. We profile global and country progress against these recommendations between 2012 and 2015. METHODS: For 12 countries in sub-Saharan Africa that were off-track to achieve the Millennium Development Goals for maternal and child survival, we reviewed key documents and reference data, and conducted interviews with ministry staff and partners to assess the status of the UNCoLSC recommendations. The RMNCH fund provided short-term catalytic financing to support country plans to advance the commodity agenda, with activities coded by UNCoLSC recommendation. Our network of technical resource teams identified, addressed, and monitored progress against cross-cutting commodity-related challenges that needed coordinated global action. FINDINGS: In 2014 and 2015, child and maternal health commodities had fewer bottlenecks than reproductive and neonatal commodities. Common bottlenecks included regulatory challenges (ten of 12 countries); poor quality assurance (11 of 12 countries); insufficient staff training (more than half of facilities on average); and weak supply chains systems (11 of 12 countries), with stock-outs of priority commodities in about 40% of facilities on average. The RMNCH fund committed US$175·7 million to 19 countries to support strategies addressing crucial gaps. $68·2 million (39·0%) of the funds supported systems-strengthening interventions with the remainder split across reproductive, maternal, newborn, and child health. Health worker training ($88·6 million, 50·4%), supply chain ($53·3 million, 30·0%), and demand generation ($21·1 million, 12·0%) were the major topics of focus. All priority commodities are now listed in the WHO Essential Medicines List; appropriate price reductions were secured; quality manufacturing was improved; a fast-track registration mechanism for prequalified products was established; and methods were developed for advocacy, quantification, demand generation, supply chain, and provider training. Slower progress was evident around regulatory harmonisation and quality assurance. INTERPRETATION: Much work is needed to achieve full implementation of the UNCoLSC recommendations. Coordinated efforts to secure price reductions beyond the 13 commodities and improve regulatory efficiency, quality, and supply chains are still needed alongside broader dissemination of work products. FUNDING: Governments of Norway (NORAD) and the UK (DFID).

Capitalizing on the characteristics of mHealth to evaluate its impact.

The field of mHealth has made significant advances in a short period of time, demanding a more thorough and scientific approach to understanding and evaluating its progress. A recent review of mHealth literature identified two primary research needs in order for mHealth to strengthen health systems and promote healthy behaviors, namely health outcomes and cost-benefits (Mechael et al., 2010 ). In direct response to the gaps identified in mHealth research, the aim of this paper is to present the study design and highlight key observations and next steps from an evaluation of the mHealth activities within the electronic health (eHealth) architecture implemented by the Millennium Villages Project (MVP) by leveraging data generated through mobile technology itself alongside complementary qualitative research and costing assessments. The study, funded by the International Development and Research Centre (IDRC) as part of the Open Architecture Standards and Information Systems research project (OASIS II) (Sinha, 2009 ), is being implemented on data generated by 14 MVP sites in 10 Sub-Saharan African countries including more in-depth research in Ghana, Rwanda, Tanzania, and Uganda. Specific components of the study include rigorous quantitative case-control analyses and other epidemiological approaches (such as survival analysis) supplemented by in-depth qualitative interviews spread out over 18 months, as well as a costing study to assess the impact of mHealth on health outcomes, service delivery, and efficiency.

HIV attitudes, awareness and testing among older adults in Africa.

In Africa, older adults aged 50 and older are still sexually active and play a critical role as caregivers, yet little is known about their attitudes towards HIV and awareness of services. In this study, surveys were conducted in nine African sites. A multilevel model was fitted to evaluate the relationship between age and outcome variables. The study reveals that people aged 50 years and older have lower levels of HIV-related knowledge and awareness than those aged 25-49. Older adults were less likely to have been tested for HIV and women aged 50 and older showed particularly low levels of awareness.

Multisector intervention to accelerate reductions in child stunting: an observational study from 9 sub-Saharan African countries.

BACKGROUND: In sub-Saharan Africa, ~ 40% of children <5 y old are stunted, with levels that have remained largely unchanged over the past 2 decades. Although the complex determinants of undernutrition are well recognized, few studies have evaluated strategies that combine nutrition-specific, health-based approaches with food system- and livelihood-based interventions. OBJECTIVE: We examined changes in childhood stunting and its determinants after 3 y of exposure to an integrated, multisector intervention and compared these changes with national trends. DESIGN: A prospective observational trial was conducted across rural sites in 9 sub-Saharan African countries with baseline levels of childhood stunting >20%. A stratified random sample of households and resident children <2 y old from villages exposed to the program were enrolled in the study. Main outcome measures included principal determinants of undernutrition and childhood stunting, which was defined as a height-for-age z score less than -2. National trends in stunting were generated from demographic and health surveys. RESULTS: Three years after the start of the program in 2005-2006, consistent improvements were observed in household food security and diet diversity, whereas coverage with child care and disease-control interventions improved for most outcomes. The prevalence of stunting in children <2 y old at year 3 of the program (2008-2009) was 43% lower (adjusted OR: 0.57; 95% CI: 0.38, 0.83) than at baseline. The average national stunting prevalence for the countries included in the study had remained largely unchanged over the past 2 decades. CONCLUSION: These findings provide encouraging evidence that a package of multisector interventions has the potential to produce reductions in childhood stunting.

Combining vital events registration, verbal autopsy and electronic medical records in rural Ghana for improved health services delivery.

This paper describes the process of implementing a low-cost 'real-time' vital registration and verbal autopsy system integrated within an electronic medical record within the Millennium Village cluster in rural Ghana. Using MGV-Net, an open source health information architecture built around the OpenMRS platform, a total of 2378 births were registered between January 2007 and June 2009. The percentage of births registered in the health facility under supervision of a skilled attendant increased substantially over the course of the project from median of 35% in 2007 to 64% in 2008 and 85% midway through 2009. Building additional clinics to reduce distance to facility and using the CHEWs to refer women for delivery in the clinics are possible explanations for the success in the vital registration. The integration of vital registration and verbal autopsies with the MGV-Net information system makes it possible for rapid assessment of effectiveness and provides important feedback to local providers and the Millennium Villages Project.

Underreported threat of multidrug-resistant tuberculosis in Africa.

Multidrug-resistant tuberculosis (MDR TB) in Africa may be more prevalent than previously appreciated. Factors leading to development of drug resistance need to be understood to develop appropriate control strategies for national programs. We gathered estimates of MDR TB rates for 39 of 46 countries in Africa. The relationship between MDR TB rates and independent factors was analyzed by using correlation and linear regression models. Our findings indicate that drug resistance surveys in Africa are critically needed. MDR TB rates must be assessed in countries without these surveys. In countries that have conducted a drug resistance survey, a new survey will determine evolution of drug resistance rates. We found no correlation between high MDR rates and TB incidence, HIV/TB co-infection rates, or year of introduction of rifampin. Results show that the retreatment failure rate was the most predictive indicator for MDR TB. Current category II drug regimens may increase MDR TB.