Predictors of tuberculosis treatment outcomes in Antananarivo: a retrospective cohort study.

Introduction: Tuberculosis (TB) is a global public health issue, affecting Africa and Madagascar. Adverse outcomes following ineffective treatment are common. Previous studies conducted in similar settings have not adequately accounted for confounding factors. The objective of this study is to identify predictive factors that are associated with tuberculosis treatment outcomes in Madagascar. Methods: a retrospective cohort study was conducted using registries of 628 outpatients with tuberculosis at the Analakely Hospital (CHUSSPA) in 2019. Univariate and multivariate logistic regression analyses were performed. Results: the study included 628 patients with a mean age of 37.19 ± 15.86 years and a sex ratio of 1.57. These patients were followed up for a total of 2886 person-months. Out of the 628, 517 achieved treatment success, while 31 patients died and 31 discontinued their treatment. The rates of treatment success, death, failure, and default were 82.3%, 4.9%, 0.2%, and 8.3% respectively. Female gender was found to be a predictor of treatment success area of responsibility adjusted odds ratio(AOR 1.67 [1.07-2.66]; p=0.026). Smear-negative pulmonary tuberculosis (SNPTB) was associated with a lower likelihood of treatment success (AOR 0.38 [0.23-0.65]; p<0.001) and was a common factor for default (AOR 3.17 [1.60-6.21]; p=0.001) and death (AOR=8.03 [3.01-23.72; p<0.001]). Extra-pulmonary TB was identified as a predictor of death (AOR 5.15 [1.99-14.95]; p=0.001). Conclusion: the tuberculosis treatment indicators in this center have not yet met national and global targets. It is necessary to focus on early diagnosis, improving education, and implementing rigorous follow-up procedures for patients at high risk of adverse outcomes (SNPTB and extra-pulmonary tuberculosis(EPTB).

Beyond abortion: impacts of the expanded global gag rule in Kenya, Madagascar and Nepal.

Since 1984, Republican administrations in the US have enacted the global gag rule (GGR), which prohibits non-US-based non-governmental organisations (NGOs) from providing, referring for, or counselling on abortion as a method of family planning, or advocating for the liberalisation of abortion laws, as a condition for receiving certain categories of US Global Health Assistance. Versions of the GGR implemented before 2017 applied to US Family Planning Assistance only, but the Trump administration expanded the policy's reach by applying it to nearly all types of Global Health Assistance. Documentation of the policy's harms in the peer-reviewed and grey literature has grown considerably in recent years, however few cross-country analyses exist. This paper presents a qualitative analysis of the GGR's impacts across three countries with distinct abortion laws: Kenya, Madagascar and Nepal. We conducted 479 in-depth qualitative interviews between August 2018 and March 2020. Participants included representatives of Ministries of Health and NGOs that did and did not certify the GGR, providers of sexual and reproductive health (SRH) services at public and private facilities, community health workers, and contraceptive clients. We observed greater breakdown of NGO coordination and chilling effects in countries where abortion is legal and there is a sizeable community of non-US-based NGOs working on SRH. However, we found that the GGR fractured SRH service delivery in all countries, irrespective of the legal status of abortion. Contraceptive service availability, accessibility and training for providers were particularly damaged. Further, this analysis makes clear that the GGR has substantial and deleterious effects on public sector infrastructure for SRH in addition to NGOs.

[Knowledge and perception of malnutrition among the rural population in the Central Highlands, Madagascar]. / Connaissances et perceptions de la malnutrition par la population rurale des Hautes Terres Centrales, Madagascar.

INTRODUCTION: malnutrition due to inadequate food supply is a major challenge in low- and middle-income countries. The purpose of this study is to identify the sociocultural drivers of malnutrition. METHODS: we conducted a qualitative study in the Amoron´I Mania region, Madagascar. The study involved pregnant women, mothers and fathers, grandmothers and health actors such as "matrones", community workers and health workers. A total of 24 semi-structured individual interviews and 6 focus groups were used to collect data. Thematic analysis was used. RESULTS: malnutrition refers to a lack of food and undernourishment. It revolves around the amount of rice consumption, socio-cultural factors and insufficient financial resources. Vulnerable groups were mainly composed of children and pregnant women. Severe malnutrition including signs was reported, but there was evidence for local adaptation. Thus, families were trying by different means to fight against malnutrition. CONCLUSION: the socio-cultural context modulates knowledge and perception of the causes, the manifestations and the vulnerability or non-vulnerability of an individual as well as the severity of malnutrition.

Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar.

Madagascar's health system is highly dependent on donor funding, especially from the United States (US), and relies on a few nongovernmental organisations (NGOs) to provide contraceptive services in remote areas of the country. The Trump administration reinstated and expanded the Global Gag Rule (GGR) in 2017; this policy requires non-US NGOs receiving US global health funding to certify that neither they nor their sub-grantees will provide, counsel or refer for abortion as a method of family planning. Evidence of the impact of the GGR in a country with restrictive abortion laws, like Madagascar - which has no explicit exception to save the woman's life - is limited. Researchers conducted semi-structured interviews with 259 representatives of the Ministry of Health and NGOs, public and private health providers, community health workers and contraceptive clients in Antananarivo and eight districts between May 2019 and March 2020. Interviews highlighted the impact of the GGR on NGOs that did not certify the policy and lost their US funding. This reduction in funding led to fewer contraceptive service delivery points, including mobile outreach services, a critical component of care in rural areas. Public and private health providers reported increased contraceptive stockouts and fees charged to clients. Although the GGR is ostensibly about abortion, it has reduced access to contraception for the Malagasy population. This is one of few studies to directly document the impact on women who themselves described their increased difficulties obtaining contraception ultimately resulting in discontinuation of contraceptive use, unintended pregnancies and unsafe abortions.

Appréciation des interventions de lutte contre la malnutrition maternelle par la population à Madagascar.

INTRODUCTION: Madagascar has adopted strategies to fight against maternal malnutrition, but the evaluation of their implementation is not effective.Purpose of research: The present study aims to describe beneficiary appreciation of interventions to fight maternal malnutrition and to identify their expectations. METHOD: A qualitative study was conducted in the Amoron’i Mania region, Madagascar. The study included mothers of children under 5, pregnant women, and other family members and community members (fathers, grandmothers, matrons and community workers). Six focus groups and 16 individual interviews were conducted to collect the data. The thematic analysis was used. RESULTS: Food supplementation, improved production of agriculture and livestock, and nutrition education, operated by NGOs, are the best-known interventions. The health centers were not mentioned as interveners and their interventions were ignored. The effectiveness of the intervention is generally judged on the benefits perceived by the beneficiaries. Interveners working on a project basis were assessed as unsustainable. Two main problems were mentioned: first, the insufficiency of agricultural production resulting in the inaccessibility of the ingredients required for the nutrition education, and second the low coverage of the interventions. The improvement of agricultural production is the main suggestion mentioned to fight against maternal undernutrition. CONCLUSIONS: Beneficiaries thought that existing interventions in the region are insufficient to address the problem of malnutrition among mothers.

Nutritional status of female prisoners in Antanimora prison, Madagascar.

INTRODUCTION: The prison population in low-income countries is a group vulnerable to undernutrition, particularly incarcerated women. The aim of the study is to assess the nutritional status of women in prison and to determine the social profile and prison conditions related to undernutrition. METHODS: A cross-sectional study was conducted among 125 women prisoners in Antanimora prison located in the city of Antananarivo, Madagascar. All women detained for 3 months or more at the time of the survey were included in the study. Data collection was conducted in May and June 2013. A survey of women and anthropometric measurements were carried out to collect the data. RESULTS: The proportion of undernourished female prisoners is 38.4%. Five percent of pregnant and lactating women and 44.3% of non-lactating and non-pregnant women are undernourished. The factors related to undernutrition of women prisoners are: taking two meals a day instead of three meals (p = 0.003), insufficient energy intake (p < 0.001), incarceration duration of more than 10 months (p < 0.001), absence of family visits (p = 0.013) and lack of financial assistance from family (p = 0.013). CONCLUSION: Improving the prisoners' diets and assistance from family both help to fight against prisoner undernutrition in prisons.

Food consumption and undernutrition variations among mothers during the post-harvest and lean seasons in Amoron'i Mania Region, Madagascar.

BACKGROUND: Seasonal variation affects nutrition particularly in contexts where people's food consumption depends on their production of food. Assessing the effect of the season on nutrition status can help us to identify strategies to address undernutrition. This study aims to measure the variations in food consumption and the incidence of undernutrition according to season, and to identify the factors associated with the incidence of undernutrition. METHODS: A cohort study was conducted among 608 mothers aged between 18 and 45 years living in the Amoron'i Mania Region of Madagascar. Inclusion in the study occurred during the post-harvest season, and mothers were followed until the end of the next lean period (7 months). A dichotomous variable of the frequency of consumption of various foods was used to establish variation in food consumption. Body Mass Index < 18.5 kg/m2 and Middle Upper Arm Circumference < 220 mm were used to measure incidence of undernutrition. A generalized linear model was used to identify factors associated with the incidence of undernutrition and to derive relative risks. RESULTS: During the lean season, the frequency of consumption of leafy green vegetables, peanuts, fish, and eggs decreased significantly. In contrast, the frequency of fruit, legumes, and non-leafy green vegetables consumption increased significantly. The prevalence of undernutrition (based on the BMI and/or MUAC) among mothers increased from 19.6% in the post-harvest period to 27.1% in the lean period (p < 0.001). The incidence of undernutrition (based on the BMI and/or MUAC) during the follow-up was 12.2%. The factors related to undernutrition were low and medium score of movable property possession (Adjusted RR = 3.26 [1.33-7.94] and Adjusted RR = 2.48 [1.01-6.10]), no toilet (Adjusted RR = 1.76 [1.07-2.91]), and pregnancy (Adjusted RR = 2.92 [1.42-6.04]) (based on the MUAC only for pregnancy). CONCLUSION: This study highlights the variation in the frequency and type of food consumption and subsequent deterioration in mothers' nutritional status during the lean season. Economic, hygiene, and reproductive factors were associated with undernutrition. Analyzing the existing interventions to fight maternal undernutrition is necessary to determine whether or not seasonality is considered and addressed.

Mothers' dietary practices in the Amoron'i Mania region Madagascar.

INTRODUCTION: Madagascar has one of the highest prevalence's of malnutrition worldwide. Dietary practice is an important element to consider in the fight against malnutrition. This study aims to describe mothers' dietary patterns and dietary diversity and to identify characteristics associated with this dietary diversity. METHODS: A cross sectional study was carried-out among 670 non-pregnant mothers aged 18 to 45, who had delivered more than 6 months earlier and were living in the Amoron'i Mania region of Madagascar. The study was conducted during the post-harvest period. A food frequency questionnaire were used to assess the dietary pattern and the women's dietary diversity score was established from the 24-hour recall data. RESULTS: Almost all (99%) of mothers ate rice every day and 59% ate green leaves. Fifty three percent of mothers had consumed fruit less than once per week, 55% for legumes, 67% for vegetables and 91% for meat. Dietary diversity score ranged from 1 to 7 and 88% of mothers had a low dietary diversity score (<5). On multivariate analysis, factors significantly associated with low dietary diversity were: low education level (AOR=3.80 [1.58-9.02], p=0.003), parity higher than 3 (AOR=2.09 [1.22-3.56], p=0.007), birth interval ≥ 24 months (AOR=4.01 [2.08-7.74], p<0.001), rice production availability ≤ 6 months (AOR=2.33 [1.30-4.17], p=0.013), low attendance at market (AOR=4.20 [1.63-10.83], p<0.001) and low movable property possession score (AOR=4.87 [2.15-11.04], p<0.001). CONCLUSION: Mother's experience poor diet diversity. Unfavorable socioeconomic conditions are associated with this poor food diversification.

[Women's dietary habits during pregnancy and breastfeeding in Amoron'i Mania region, Madagascar: a qualitative study]. / Habitude alimentaire des mères pendant la grossesse et l'allaitement, région Amoron'i Mania Madagascar: étude qualitative.

INTRODUCTION: Women's dietary habits are very important due to the specific nutritional requirements for reproduction. This study aimed to describe women's dietary habits during pregnancy and breastfeeding and to identify factors influencing these habits. METHODS: We conducted a qualitative study of pregnant and breastfeeding women living in Amoron'i Mania region, Madagascar. Eight focus groups (6-10 women per group) and 23 individual interviews were carried out to collect data. Thematic analysis was used and focused on the description of women's dietary habits on the basis of dietary behaviours as well as of sociocultural and economic determinants of the described habits. RESULTS: During pregnancy and breastfeeding, women's dietary habits did not vary considerably except at the very beginning of breastfeeding. They had a little diversified and monotonous diet, poor in fruit and vegetables and poor in proteins. At the very beginning of breastfeeding, during the practice of "mifana " tradition, women had a diet more rich than usual. These dietary habits were influenced by the type of agricultural products in the region and by their availability during the year (self-consumption)as well as by purchasing power (in case of shortage) and tradition. CONCLUSION: Mothers' dietary habits appear to be inadequate. This study highlights the importance of improving knowledge of the determinants of mothers' dietary behaviours.

Socioeconomic determinants of malnutrition among mothers in the Amoron'i Mania region of Madagascar: a cross-sectional study.

BACKGROUND: Maternal malnutrition, which has been a problem in Madagascar for several years, has been rising despite interventions to improve the situation. This study aims to identify the socioeconomic determinants of malnutrition among mothers who are one of the most vulnerable groups. METHODS: A cross sectional study was carried out among 670 mothers aged 18 to 45 living in the Amoron'i Mania region of Madagascar. The study was conducted during the post-harvest period. The nutritional status of mothers was assessed by anthropometry. A Body Mass Index (BMI) lower than 18.5 kg/m2 or an arm circumference lower than 220 mm were used to define malnutrition. Data on the characteristics of the mothers and their households were also collected. Multiple logistic regression was used to identify factors associated with maternal malnutrition. RESULTS: The prevalence of maternal undernutrition is estimated at 17% (95% CI: 14­20) according to BMI and 9% (95% CI: 7­11) for Mid Upper Arm Circumference (MUAC). In the multivariate analysis, using BMI, the factors significantly associated with malnutrition were: the household size equal to or greater than 6 (AOR = 1.59 [1.04­3.42], p = 0.029) and use of unsafe water source (AOR = 1.99 [1.02­3.85], p = 0.030). For the MUAC, the factors associated are: use of unsafe water source (AOR = 2.82 [1.01­7.97], p = 0.041) and increased number of children under five years old (AOR = 1.38 [1.02­1.89], p = 0.025). CONCLUSION: This study confirmed the importance of mothers' malnutrition in the study area. Fight against maternal malnutrition needs interventions to improve access to safe drinking water and to promote family planning.

[Factors associated with tuberculosis treatment non-compliance in Antananarivo city, Madagascar]. / Facteurs associés à l'abandon du traitement anti-tuberculeux dans la ville d'Antananarivo, Madagascar.

A retrospective epidemiological study of patients' medical records (n = 442) was conducted in one of the tuberculosis (TB) treatment centers in the city of Antananarivo, to identify risk factors of treatment default. Results show that males give up treatment more than women (OR=1,81 [1,13; 3,03]). Among those living farthest away from the center, patients younger than 30 years old tend to be more irregular in the follow-up of their treatment (OR=3,43 [1,16; 10,15]). There is no statistically significant relationship between TB treatment default and the patient's age, the clinical form, the therapeutic regime or the place of residence. Managers of treatment centers should be more aware and vigilant regarding male and young TB patients presenting these characteristics and should adapt methods and means for follow-up according to these risk factors.