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BACKGROUND: Childhood stunting is a major indicator of child malnutrition and a focus area of Global Nutrition Targets for 2025 and Sustainable Development Goals. Risk factors for childhood stunting are well studied and well known and could be used in a risk prediction model for assessing whether a child is stunted or not. However, the selection of child stunting predictor variables is a critical step in the development and performance of any such prediction model. This paper compares the performance of child stunting diagnostic predictive models based on predictor variables selected using a set of variable selection methods. METHODS: Firstly, we conducted a subjective review of the literature to identify determinants of child stunting in Sub-Saharan Africa. Secondly, a multivariate logistic regression model of child stunting was fitted using the identified predictors on stunting data among children aged 0-59 months in the Malawi Demographic Health Survey (MDHS 2015-16) data. Thirdly, several reduced multivariable logistic regression models were fitted depending on the predictor variables selected using seven variable selection algorithms, namely backward, forward, stepwise, random forest, Least Absolute Shrinkage and Selection Operator (LASSO), and judgmental. Lastly, for each reduced model, a diagnostic predictive model for the childhood stunting risk score, defined as the child propensity score based on derived coefficients, was calculated for each child. The prediction risk models were assessed using discrimination measures, including area under-receiver operator curve (AUROC), sensitivity and specificity. RESULTS: The review identified 68 predictor variables of child stunting, of which 27 were available in the MDHS 2016-16 data. The common risk factors selected by all the variable selection models include household wealth index, age of the child, household size, type of birth (singleton/multiple births), and birth weight. The best cut-off point on the child stunting risk prediction model was 0.37 based on risk factors determined by the judgmental variable selection method. The model's accuracy was estimated with an AUROC value of 64% (95% CI: 60%-67%) in the test data. For children residing in urban areas, the corresponding AUROC was AUC = 67% (95% CI: 58-76%), as opposed to those in rural areas, AUC = 63% (95% CI: 59-67%). CONCLUSION: The derived child stunting diagnostic prediction model could be useful as a first screening tool to identify children more likely to be stunted. The identified children could then receive necessary nutritional interventions.
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Transtornos do Crescimento , Humanos , Malaui/epidemiologia , Transtornos do Crescimento/epidemiologia , Transtornos do Crescimento/diagnóstico , Lactente , Pré-Escolar , Feminino , Masculino , Modelos Logísticos , Fatores de Risco , Recém-Nascido , Algoritmos , Transtornos da Nutrição Infantil/diagnóstico , Transtornos da Nutrição Infantil/epidemiologiaRESUMO
INTRODUCTION: Consumption of unhealthy foods in children contributes to high levels of childhood obesity globally. In developing countries there is paucity of empirical studies on the association. This study employed propensity-score methods to evaluate the effect of unhealthy foods on overweight among children in Malawi using observational data. METHODS: Data on 4625 children aged 6 to 59 months from the 2015-16 Malawi Demographic and Health Survey (MDHS) were analyzed. A multivariable logistic regression model of unhealthy foods (yes or no) on purported confounders of childhood overweight was used to obtain a child's unhealthy food propensity score. The propensity scores were then used to form matched sets of healthy and unhealthy fed children. The association between unhealthy foods and childhood overweight was assessed using the conditional logistic regression model. RESULTS: The prevalence of overweight (body mass index (BMI) z-score > 2 standard deviations) was estimated at 4.5% (3.8%, 5.3%). The proportion of children who consumed unhealthy foods was estimated at 14.6% (95% CI: 13.1%, 16.2%). Our propensity score matching achieved a balance in the distribution of the confounders between children in the healthy and unhealthy food groups. Children fed unhealthy foods were significantly more likely to be overweight than those fed healthy foods (OR = 2.5, 95% CI: (1.2, 5.2)). CONCLUSION: The findings suggest the adverse effects of unhealthy foods on childhood overweight in Malawi. Thus, efforts to reduce unhealthy food consumption among children should be implemented and supported to address the problem of childhood overweight in Malawi and the sub-Saharan African region.
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Obesidade Infantil , Criança , Humanos , Obesidade Infantil/epidemiologia , Obesidade Infantil/etiologia , Sobrepeso/epidemiologia , Malaui/epidemiologia , Índice de Massa Corporal , AlimentosRESUMO
OBJECTIVES: South Africa has made remarkable progress in increasing the coverage of antiretroviral therapy (ART) among pregnant women; however, viral suppression among pregnant women receiving ART is reported to be low. Access to routine viral load testing is crucial to identify women with unsuppressed viral load early in pregnancy and to provide timely intervention to improve viral suppression. This study aimed to determine the coverage of maternal viral load monitoring nationally, focusing on viral load testing, documentation of viral load test results, and viral suppression (viral load < 50 copies/mL). At the time of this study, the first-line regimen for women initiating ART during pregnancy was non-nucleoside reverse transcriptase (NNRTI)-based regimen. METHODS: Between 1 October and 15 November 2019, a cross-sectional survey was conducted among 15- to 49-year-old pregnant women attending antenatal care in 1589 nationally representative public health facilities. Data on ART status, viral load testing and viral load test results were extracted from medical records. Logistic regression was used to examine factors associated with coverage of viral load testing. RESULTS: Of 8112 participants eligible for viral load testing, 81.7% received viral load testing, and 94.1% of the viral load test results were documented in the medical records. Of those who had viral load test results documented, 74.1% were virally suppressed. Women initiated on ART during pregnancy and who received ART for three months had lower coverage of viral load testing (73%) and viral suppression (56.8%) compared with women initiated on ART before pregnancy (82.8% and 76.1%, respectively). Initiating ART during pregnancy rather than before pregnancy was associated with a lower likelihood of receiving a viral load test during pregnancy (adjusted odds ratio = 1.6, 95% confidence interval: 1.4-1.8). CONCLUSIONS: Viral load result documentation was high; viral load testing could be improved especially among women initiating ART during pregnancy. The low viral suppression among women who initiated ART during pregnancy despite receiving ART for three months highlights the importance of enhanced adherence counselling during pregnancy. Our finding supports the WHO recommendation that a Dolutegravir-containing regimen be the preferred regimen for women who are newly initiating ART during pregnancy for more rapid viral suppression.
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Fármacos Anti-HIV , Infecções por HIV , Complicações Infecciosas na Gravidez , Adolescente , Adulto , Fármacos Anti-HIV/uso terapêutico , Estudos Transversais , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Humanos , Pessoa de Meia-Idade , Gravidez , Complicações Infecciosas na Gravidez/tratamento farmacológico , África do Sul , Carga Viral , Adulto JovemRESUMO
BACKGROUND: Multilevel logistic regression models are widely used in health sciences research to account for clustering in multilevel data when estimating effects on subject binary outcomes of individual-level and cluster-level covariates. Several measures for quantifying between-cluster heterogeneity have been proposed. This study compared the performance of between-cluster variance based heterogeneity measures (the Intra-class Correlation Coefficient (ICC) and the Median Odds Ratio (MOR)), and cluster-level covariate based heterogeneity measures (the 80% Interval Odds Ratio (IOR-80) and the Sorting Out Index (SOI)). METHODS: We used several simulation datasets of a two-level logistic regression model to assess the performance of the four clustering measures for a multilevel logistic regression model. We also empirically compared the four measures of cluster variation with an analysis of childhood anemia to investigate the importance of unexplained heterogeneity between communities and community geographic type (rural vs urban) effect in Malawi. RESULTS: Our findings showed that the estimates of SOI and ICC were generally unbiased with at least 10 clusters and a cluster size of at least 20. On the other hand, estimates of MOR and IOR-80 were less accurate with 50 or fewer clusters regardless of the cluster size. The performance of the four clustering measures improved with increased clusters and cluster size at all cluster variances. In the analysis of childhood anemia, the estimate of the between-community variance was 0.455, and the effect of community geographic type (rural vs urban) had an odds ratio (OR)=1.21 (95% CI: 0.97, 1.52). The resulting estimates of ICC, MOR, IOR-80 and SOI were 0.122 (indicative of low homogeneity of childhood anemia in the same community); 1.898 (indicative of large unexplained heterogeneity); 0.345-3.978 and 56.7% (implying that the between community heterogeneity was more significant in explaining the variations in childhood anemia than the estimated effect of community geographic type (rural vs urban)), respectively. CONCLUSION: At least 300 clusters with sizes of at least 50 would be adequate to estimate the strength of clustering in multilevel logistic regression with negligible bias. We recommend using the SOI to assess unexplained heterogeneity between clusters when the interest also involves the effect of cluster-level covariates, otherwise, the usual intra-cluster correlation coefficient would suffice in multilevel logistic regression analyses.
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Modelos Logísticos , Análise por Conglomerados , Simulação por Computador , Humanos , Análise Multinível , Razão de ChancesRESUMO
BACKGROUND: The rising burden of the ongoing COVID-19 epidemic in South Africa has motivated the application of modeling strategies to predict the COVID-19 cases and deaths. Reliable and accurate short and long-term forecasts of COVID-19 cases and deaths, both at the national and provincial level, are a key aspect of the strategy to handle the COVID-19 epidemic in the country. METHODS: In this paper we apply the previously validated approach of phenomenological models, fitting several non-linear growth curves (Richards, 3 and 4 parameter logistic, Weibull and Gompertz), to produce short term forecasts of COVID-19 cases and deaths at the national level as well as the provincial level. Using publicly available daily reported cumulative case and death data up until 22 June 2020, we report 5, 10, 15, 20, 25 and 30-day ahead forecasts of cumulative cases and deaths. All predictions are compared to the actual observed values in the forecasting period. RESULTS: We observed that all models for cases provided accurate and similar short-term forecasts for a period of 5 days ahead at the national level, and that the three and four parameter logistic growth models provided more accurate forecasts than that obtained from the Richards model 10 days ahead. However, beyond 10 days all models underestimated the cumulative cases. Our forecasts across the models predict an additional 23,551-26,702 cases in 5 days and an additional 47,449-57,358 cases in 10 days. While the three parameter logistic growth model provided the most accurate forecasts of cumulative deaths within the 10 day period, the Gompertz model was able to better capture the changes in cumulative deaths beyond this period. Our forecasts across the models predict an additional 145-437 COVID-19 deaths in 5 days and an additional 243-947 deaths in 10 days. CONCLUSIONS: By comparing both the predictions of deaths and cases to the observed data in the forecasting period, we found that this modeling approach provides reliable and accurate forecasts for a maximum period of 10 days ahead.
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COVID-19/epidemiologia , SARS-CoV-2 , COVID-19/mortalidade , Humanos , Modelos Logísticos , Modelos Estatísticos , África do Sul/epidemiologiaRESUMO
BACKGROUND: The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012). OBJECTIVES: To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies. SELECTION CRITERIA: Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries. DATA COLLECTION AND ANALYSIS: At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison. AUTHORS' CONCLUSIONS: iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.
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Administração de Caso/organização & administração , Serviços de Saúde da Criança/organização & administração , Agentes Comunitários de Saúde , Países em Desenvolvimento , África Subsaariana , Ásia , Viés , Pré-Escolar , Agentes Comunitários de Saúde/economia , Agentes Comunitários de Saúde/educação , Agentes Comunitários de Saúde/organização & administração , Estudos Controlados Antes e Depois , Diarreia/terapia , Febre/terapia , Humanos , Lactente , Mortalidade Infantil , Transtornos da Nutrição do Lactente/terapia , Recém-Nascido , Malária/terapia , Sepse Neonatal/terapia , Pneumonia/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto , Salários e Benefícios , Nações UnidasRESUMO
BACKGROUND: Intimate Partner Violence (IPV) against women is a major public health and human rights problem worldwide. Sub-Saharan Africa (SSA) has one of the highest prevalence of IPV against women in the world. This study used meta-analysis to obtain pooled rural-urban and education attainment differences in the prevalence of IPV among ever-partnered women in SSA, and assessed whether the differences in IPV depended on the SSA region or period or women's age. METHODS: We analysed IPV data on 233,585 ever-partnered women aged 15-49 years from 44 demographic and health surveys conducted between 2000 and 2018 in 29 SSA countries. Random-effects meta-analyses were used to estimate overall rural-urban residence and educational differences in IPV rates among the women in SSA. Subgroup analyses were also done to investigate the sources of heterogeneity in the overall meta-analysis findings. RESULTS: The pooled prevalence of intimate partner violence was estimated to be 41.3% (37.4-45.2%). Regionally, the highest prevalence of IPV was in Middle Africa (49. 3%; 40.32-58.45), followed by East Africa (44.13%; 36.62-51.67), Southern Africa (39.36%; 34.23-44.49), and West Africa (34.30%; 27.38-41.22). The risks of experiencing IPV were significantly higher if the women had less than secondary education (RR = 1.12; 95% CI 1.07-1.22) compared to those with at least a secondary education. Generally, women who resided in a rural area had their risks of experiencing IPV increased (RR = 1.02; CI 0.96-1.06) compared to those who resided in urban areas, but the IPV increases were only significant in East Africa (RR = 1.13; CI 1.07-1.22). CONCLUSION: In sub-Saharan Africa, intimate partner violence against women is widespread, but the levels are much higher among women with lower levels of education and residing in rural areas. Our findings have provided additional support to policies aimed at achieving SDG goals on the elimination of all forms of violence against women and girls in sub-Saharan Africa. For example, policies that advocate improved educational attainment, especially among women and communities in rural areas.
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Violência por Parceiro Íntimo , África Subsaariana/epidemiologia , África Oriental , Estudos Transversais , Feminino , Inquéritos Epidemiológicos , Humanos , Prevalência , Fatores de RiscoRESUMO
OBJECTIVE: To profile the prevalence of the three body mass index (BMI) categories by sociodemographic characteristics, and to calculate the percentage transitioning (or not) from one BMI category to another, to inform South African health policy for the control of obesity and noncommunicable diseases. METHODS: We used data from the National Income Dynamics Study, including sociodemographic characteristics and BMI measurements collected in 2008, 2010, 2012, 2014 and 2017. For each data collection wave and each population group, we calculated mean BMI and prevalence by category. We also calculated the percentage making an upwards transition (e.g. from overweight to obese), a downwards transition or remaining within a particular category. We used a multinomial logistic regression model to estimate transition likelihood. FINDINGS: Between 2008 and 2017, mean BMI increased by 2.3 kg/m2. We calculated an increased prevalence of obesity from 19.7% (3686/18 679) to 23.6% (3412/14 463), with the largest increases in prevalence for those aged 19-24 years and those with at least high school education. The percentages of upwards transitions to overweight or obese categories increased sharply between the ages of 19 and 50 years. Once overweight or obese, the likelihood of transitioning to a normal BMI is low, particularly for women, those of higher age groups, and those with a higher income and a higher level of education. CONCLUSION: In the development of national strategies to control obesity and noncommunicable diseases, our results will allow limited public health resources to be focused on the relevant population groups.
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Obesidade , Sobrepeso , Adulto , Índice de Massa Corporal , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade , Obesidade/epidemiologia , Sobrepeso/epidemiologia , Prevalência , África do Sul/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Several studies have shown that maternal HIV infection is associated with adverse pregnancy outcomes such as low birth weight and perinatal mortality. However, the association is conflicted with the effect of antiretroviral therapy (ART) on the pregnancy outcomes and it remains unexamined. If the association is confirmed then it would guide policy makers towards more effective prevention of mother to child HIV transmission interventions. Using methods for matching possible confounders, the objectives of the study were to assess the effect of maternal HIV infection on birth weight and perinatal mortality and to investigate the effect of ART on these two pregnancy outcomes in HIV-infected women. METHODS: Data on 4111 and 4759 children, born within five years of the 2010 and 2015-16 Malawi Demographic and Health Surveys (MDHS) respectively, whose mothers had an HIV test result, were analysed. A best balancing method was chosen from a set of covariate balance methods namely, the 1:1 nearest neighbour (NN) matching, matching on the propensity score (PS) and inverse weighting on the PS. HIV and ART data were only available in the MDHS 2010, permitting an assessment of the moderating effect of ART on the association between maternal HIV infection and birth weight and perinatal mortality. RESULTS: The overall average birth weight was 3227.9g (95% CI: 3206.4, 3249.5) in 2010 and 3226.4g (95%: 3205.6, 3247.2) in 2015-16 and perinatal mortality was 3.8% (95%: 3.2, 4.3) in 2010 and 3.5% (95%: 2.8, 3.8) in 2015-16. The prevalence of HIV among the mothers was 11.1% (95%: 10.1, 12.0) and 9.2% (95% CI: 8.4, 10.1) in 2010 and 2015-16, respectively. In 2010, maternal HIV infection was negatively associated with birth weight (mean= -25.3g, 95% CI:(-95.5, -7.4)) and in 2015-16 it was positively associated with birth weight (mean= 116.3g, 95% CI:(27.8, 204.7)). Perinatal mortality was higher in infants of HIV-infected mothers compared to infants of HIV-uninfected mothers (OR = 1.5, 95% CI:(1.1 - 3.1)) in 2010, while there was no difference in the rate in 2015-16 (OR = 1.0, 95% CI:(0.4, 1.6)). ART was not associated with birth weight, however, it was associated with perinatal mortality (OR=3.9, 95% CI:(1.1, 14.8)). CONCLUSION: The study has found that maternal HIV infection had an adverse effect on birth weight and perinatal mortality in 2010. Birth weight was not dependent on ART uptake but perinatal mortality was higher among infants of HIV-infected mothers who were not on ART. The higher birth weight among HIV-infected mothers and similarity in perinatal mortality with HIV-uninfected mothers in 2015-16 may be indicative of successes of interventions within the PMTCT program in Malawi.
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Antirretrovirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Mortalidade Perinatal/tendências , Complicações Infecciosas na Gravidez/epidemiologia , Resultado da Gravidez/epidemiologia , Adolescente , Adulto , Antirretrovirais/administração & dosagem , Peso ao Nascer , Estudos Transversais , Feminino , Infecções por HIV/prevenção & controle , Humanos , Recém-Nascido , Transmissão Vertical de Doenças Infecciosas/prevenção & controle , Malaui/epidemiologia , Gravidez , Fatores Socioeconômicos , Adulto JovemRESUMO
BACKGROUND: Noncommunicable diseases (NCDs) including cardiovascular diseases (CVDs), diabetes, cancer and chronic lung disease are increasingly emerging as major contributors to morbidity and mortality in developing countries. For example, in South Africa, 195 people died per day between 1997 and 2004 from CVDs related causes. Access to efficient and effective health facility and care is an important contributing factor to overall population health and addressing prognosis, care and management CVD disease burden. This study aimed to spatially evaluate geographic health care access of people diagnosed with CVD to health facilities and to evaluate the density of the existing health facility network in South Africa. METHODS: Data was obtained from the National Income Dynamics Study (NIDS) conducted in 4 waves (phases) between 2008 and 2014. The participants who responded as having heart problems that were diagnosed by a health practitioner were extracted for use in this study. Network analyst in ArcGIS ® was used to generate a least-cost path, which refers to the best path that one can travel. The residential locations of participants diagnosed with heart problems were put into the network analysis model as origins and the location of health facilities were destinations. District averages were used to protect the identity of studied participants. RESULTS: There were a total of 51, 42, 43, 43 health districts out the 52 that had recorded subjects with a heart condition in the 2008, 2010-2011, 2012 and 2014-2015 waves, respectively. The mean distance from a case household to a health facility per wave was 2, 2.3, 2.1 and 2.1 km in 2008, 2010-2011 and 2014-2015 respectively. The maximum individual distances travelled per wave were 41.4 km, 40,5 km, 44,2 km and 39.6 km for the 2008, 2010-2011, 2012 and 2014-2015 waves respectively. For district level analysis, participants with CVD residing in the districts found to be among the poorest in the country travelled the longest distances. These were located in the provinces of Limpopo and KwaZulu Natal. It was also found that districts with large proportions of their population living in rural settings had among the lowest densities of health facilities. Significant percentages of study participants were exposed to numerous CVD risk factors, the commonly reported one being high blood pressure. A lack of regular exercise was also commonly reported in each of the waves. CONCLUSION: A lack of accessible healthcare in already impoverished municipalities could result in an increase lack of timely diagnosis, CVD case management. This could result in increased CVD-related morbidity and mortality. GIS methods have the potential to assist national health programs to develop policies that target issues such as areas or populations being underserved by health facilities and populations that must travel long distances to receive healthcare. These policies will be key in preventing and controlling the emerging CVD burden through an accessible primary healthcare system for early detection and case management.
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Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/terapia , Instalações de Saúde/provisão & distribuição , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Adolescente , Adulto , Feminino , Geografia , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Áreas de Pobreza , População Rural/estatística & dados numéricos , África do Sul/epidemiologia , Viagem/estatística & dados numéricos , Adulto JovemRESUMO
The aim of this study was to assess spatial co-occurrence of acute respiratory infections (ARI), diarrhoea and stunting among children of the age between 6 and 59 months in Somalia. Data were obtained from routine biannual nutrition surveys conducted by the Food and Agriculture Organization 2007-2010. A Bayesian hierarchical geostatistical shared component model was fitted to the residual spatial components of the three health conditions. Risk maps of the common spatial effects at 1×1 km resolution were derived. The empirical correlations of the enumeration area proportion were 0.37, 0.63 and 0.66 for ARI and stunting, diarrhoea and stunting and ARI and diarrhoea, respectively. Spatially, the posterior residual effects ranged 0.03-20.98, 0.16-6.37 and 0.08-9.66 for shared component between ARI and stunting, diarrhoea and stunting and ARI and diarrhoea, respectively. The analysis showed clearly that the spatial shared component between ARI, diarrhoea and stunting was higher in the southern part of the country. Interventions aimed at controlling and mitigating the adverse effects of these three childhood health conditions should focus on their common putative risk factors, particularly in the South in Somalia.
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Land management decisions have extensively modified land use and land cover in the Zambezi Region. These decisions are influenced by land tenure classifications, legislation, and livelihoods. Land use and land cover change is an important indicator for quantifying the effectiveness of different land management strategies. However, there has been no evidence on whether protected or communal land tenure is more affected by land use and land cover changes in southern Africa and particularly Namibia. Our study attempted to fill this gap by analyzing the relationship between land use and land cover change and land tenure regimes stratified according to protected and communal area in the Zambezi Region. Multi-temporal Landsat TM and ETM+ imagery were used to determine the temporal dynamics of land use and land cover change from 1984 to 2010. The landscape showed distinctive modifications over the study period; broad trends include the increase in forest land after 1991. However, changes were not uniform across the study areas. Two landscape development stages were deduced: (1) 1984-1991 represented high deforestation and gradual increase in shrub land; (2) 1991-2000 and 2000-2010 represented lower deforestation and slower agropastoral expansion. The results further show clear patterns of the dynamics, magnitude, and direction of land use and land cover change by tenure regime. The study concluded that land tenure has a direct impact on land use and land cover, since it may restrict some activities carried out on the land in the Zambezi Region.
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Conservação dos Recursos Naturais/métodos , Monitoramento Ambiental , Florestas , NamíbiaRESUMO
The objective of the study was to determine predictors of survival among HIV-positive children (<15 years) in Swaziland. A retrospective cohort analysis of medical records for 4 167 children living with HIV who were initiated on antiretroviral therapy (ART) between 2004 and 2008, and followed up until 2014 was conducted in clinical settings at 36 health facilities. The Kaplan Meier Estimator, signed-ranks test, and the Cox proportional hazards regression model were applied to determine survival probabilities, significant difference among stratified survival functions and adjusted hazard ratios respectively. The results reveal that the median survival time for children was 78 months (95% CI: 77-79). Children who were initiated early on ART had higher survival probability over time (HR: 0.35 [95% CI: 0.21-0.57], p < 0.001) compared to those whose ART initiation was delayed. Children within the age group of <1 years had higher hazard (HR = 1.55 [95% CI: 1.16-2.08], p < 0.001) of death than children within the age group of 1-14 years. Children who were nourished had 88% lower hazard of death (HR: 0.12 [95% CI: 0.07-0.19], p < 0.001) than severely malnourished children. The study demonstrates that ART paediatric services are effective in increasing survival among HIV infected children and early initiated children have high survival probability. Active tuberculosis (TB), malnutrition, and delayed ART initiation remain predictors of poor survival among children living with HIV.
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Antirretrovirais/administração & dosagem , Infecções por HIV/tratamento farmacológico , Infecções por HIV/mortalidade , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Essuatíni/epidemiologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Sound public health policy on HIV/AIDS depends on accurate prevalence and incidence statistics for the epidemic at both local and national levels. However, HIV statistics derived from epidemiological extrapolation models and data sources have a number of limitations that may lead to under- or overestimation of the epidemic. Thus, adjustment techniques need to be employed to correctly estimate the size of the HIV burden. METHODS: A multi-stage methodological approach is proposed to obtain HIV statistics at subnational levels by combining nationally population-based and antenatal clinic HIV data. The stages range from computing inverse probability weighting (IPW) for consenting to HIV testing, to HIV status prediction modelling, to the recently developed Bayesian multivariate spatial models to jointly model and map multiple HIV risks. The 2010 Malawi Demographic and Health Survey (MDHS 2010) and the 2010 Malawi Antenatal Clinic (ANC 2010) Sentinel HIV data were used for analyses. Gender, residence, employment, marital status, ethnicity, condom use, and multiple sex partners were considered when estimating HIV prevalence. RESULTS: The observed MDHS 2010 HIV prevalence among people aged 15-49 years was 10.15 %, with 95 % confidence interval (CI) of (9.66, 10.67 %). The ANC 2010 site HIV prevalence had a median of 10.63 %, with 95 % CI ranging from 1.85-24.09 %. The MDHS 2010 prevalence was 10.61 % (9.9, 11.33 %) and 10.19 % (9.69, 10.71 %) using the HIV weight and IPW, respectively. After predicting the HIV status for the non-tested subjects, the overall MDHS 2010 HIV prevalence was 11.05 % (10.80, 11.30 %). Higher HIV prevalence rates were observed in the mostly Southern districts, where poverty and population density levels are also comparatively high. The excess risk attributable to ANC HIV was much larger in the central-eastern and northern parts of the country. CONCLUSIONS: Inverse Probability Weighting combined with an appropriate HIV prediction model can be a useful tool to correct for non-response to HIV testing, especially if the number of tested individuals is very minimal at subnational levels. In populations where most know their HIV status, population-based HIV prevalence estimates can be heavily biased. High-coverage antenatal clinics' surveillance HIV data would then be the only important HIV data information sources.
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BACKGROUND: Antiretroviral treatment (ART) has been effective in reducing HIV/AIDS related morbidity and mortality. However, the use and uptake of ART has resulted in adverse reactions, due mainly to the medicine's toxicity and interactions with other medicines. The timing of adverse drug reactions (ADRs) among these patients is a critical public health issue for antiretroviral (ARV) treatment adherence and retention. Reliable monitoring of HIV patients on ART is through a structured pharmacovigilance surveillance system. However, recurrent nature of these data pose challenges in their analyses. This study aimed at modelling the timing of ADR events in HIV patients on ART using correlated time-to-event models. METHODS: The data concern 590 HIV patients registered onto the Medunsa National ARV Pharmacovigilance Surveillance System within 6 months of ART initiation between February 2007 and July 2011. Recurrent times of ADRs and baseline characteristics: patient gender, and age, ART regimen, clinic and initiation period were extracted from the data. The recurrent ADR events data were modelled using both shared frailty and marginal models on the five patients' characteristics as covariates. RESULTS: Out of 590 patients, 67% were female, 68% started on regimen: Stavudine, Lamivudine and Efavirenz; 37% had experienced at least one ADR and 67% started ART in 2009-2011. Age (p-value = 0.0210), clinic (p-value < 0.0001) and period of ART initiation (p-value = 0.0002) were significantly associated with timing of first ADR. There was a significantly higher rates of ADR recurrences in patients aged 38-44 years [HR = 2.45; 95% CI = (1.47; 4.10)] vs. 30 years and less, patients taking regimen: Zidovudine, Lamivudine and Nevarapine) vs. regimen: Stavudine, Lamivudine and Efavirenz [HR = 2.09; 95% CI = (1.35; 3.22)], while the rate was lower among those who started ART in 2009-2011 vs. those who initiated in 2007-2008 [HR = 0.55; 95% CI = (0.40; 0.76)]. CONCLUSION: More realistic time-to-event models for recurrent events data have been used to analyse timing of ADR events in HIV patients taking ARV treatment. Age, antiretroviral regimen type and period of initiation of ART were associated with the timing of HIV/AIDS drug related adverse reactions regardless of the analysis model used. This study has public health policy implications in addressing the added morbidity among HIV patients taking ARV treatment in the context of universal scaling up of ARV treatment.
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BACKGROUND: The number of Human Immunodeficiency Virus (HIV) infected people eligible for initiation on antiretroviral Therapy (ART) is increasing. ART programmatic success requires that patients who are taking ART remain on treatment and are followed up regularly. This study investigated factors associated with being lost to follow-up, in a cohort of patients enrolled in a pharmacovigilance study in South Africa. METHODS: This was a retrospective observational cohort study performed at one of the Medunsa National Pharmacovigilance Centre's (MNPC) ART sentinel surveillance sites. Loss to Follow-up (LTFU) was defined as "a patient who had been followed up at the sentinel site, who had not had contact with the health facility for 180 days or more since their last recorded expected date of return or if there were 180 days or more between the expected date of return and the next clinic visit". RESULTS: Out of 595 patients, 65.5% (n = 390) were female and 23.4% (n = 139) were LTFU. The median time on ART before LTFU was 21.5 months (interquartile range: 12.9 - 34.7 months). The incidence rate of LTFU was 103 per 1000 person-years in the first year on ART and increased to 405 per 1000 person-years in the eighth year of taking ART. Factors associated with becoming LTFU included not having a committed partner (Adjusted Hazard Ratio (aHR): 2.9, 95% Confidence Interval (CI):1.19-6.97, p = 0.019), being self-employed (aHR: 13.9, 95% CI:2.81 - 69.06, p = 0.001), baseline CD4 count > 200 cells/ml (aHR: 3.8, 95% CI: 1.85-7.85, p < 0.001), detectable last known Viral Load (VL) (aHR: 3.6, 95% CI:1.98-6.52, p < 0.001) and a last known World Health Organisation clinical stage three or four (aHR: 2.0, 95% CI:1.22-3.27, p = 0.006). Patients that previously had an ART adverse event had a lower risk (aHR: 0.6, 95% CI: 0.38 - 0.99, p = 0.044) of becoming LTFU than those that had not. CONCLUSION: The incidence rate of LTFU increases with additional years on ART. Intensified measures to improve patient retention on ART must be prioritised with increasing patient time on ART and in patients that are at increased risk of becoming lost to follow-up.
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Antirretrovirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , Perda de Seguimento , Adulto , Contagem de Linfócito CD4 , Feminino , Infecções por HIV/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Farmacovigilância , Estudos Retrospectivos , Parceiros Sexuais , África do Sul/epidemiologia , Carga Viral , Organização Mundial da SaúdeRESUMO
BACKGROUND: Little research has examined whether alcohol reduction interventions improve antiretroviral therapy (ART) adherence and HIV treatment outcomes. This study assesses the efficacy of an intervention for reducing alcohol use among HIV patients on ART who are hazardous/harmful drinkers. Specific aims include adapting a blended Motivational Interviewing (MI) and Problem Solving Therapy (PST) intervention for use with HIV patients; evaluating the efficacy of the intervention for reducing alcohol consumption; and assessing counsellors' and participants' perceptions of the intervention. METHODS/DESIGN: A randomised controlled trial will evaluate the intervention among ART patients in public hospital-based HIV clinics in Tshwane, South Africa. We will recruit patients who are HIV-positive, on ART for at least 3 months, and classified as harmful/hazardous drinkers using the AUDIT-3. Eligible patients will be randomly assigned to one of three conditions. Patients in the experimental group will receive the MI-PST intervention to reduce harmful/hazardous alcohol use. Patients in the equal-attention wellness intervention group will receive an intervention focused on addressing health risk behaviours. Patients in the control condition will receive treatment as usual. Participants will complete an interviewer-administered questionnaire at baseline and 3, 6 and 12 months post-randomisation to assess alcohol consumption, ART adherence, physical and mental health. We will also collect biological specimens to test for recent alcohol consumption, CD4 counts and HIV RNA viral loads. The primary outcome will be reduction in the volume of alcohol consumed. Secondary outcomes include reduction in harmful/hazardous use of alcohol, reduction in biological markers of drinking, increase in adherence rates, reductions in viral loads, and increases in CD4 T-cell counts. A process evaluation will ascertain counsellors' and participants' perceptions of the acceptability and effectiveness of the interventions. DISCUSSION: We have obtained ethical approval and approval from the study sites and regional and provincial health departments. The study has implications for clinicians, researchers and policy makers as it will provide efficacy data on how to reduce harmful/hazardous alcohol consumption among HIV patients and will shed light on whether reducing alcohol consumption impacts on HIV treatment adherence and other outcomes. TRIAL REGISTRATION: Pan African Clinical Trials Register Number: PACTR201405000815100.
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Consumo de Bebidas Alcoólicas/psicologia , Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Adesão à Medicação , Adulto , Consumo de Bebidas Alcoólicas/efeitos adversos , Contagem de Linfócito CD4 , Protocolos Clínicos , Feminino , Infecções por HIV/imunologia , Infecções por HIV/psicologia , Humanos , Masculino , África do Sul , Adulto JovemRESUMO
BACKGROUND: Computer-aided detection (CAD) can help identify people with active tuberculosis left undetected. However, few studies have compared the performance of commercially available CAD products for screening in high tuberculosis and high HIV settings, and there is poor understanding of threshold selection across products in different populations. We aimed to compare CAD products' performance, with further analyses on subgroup performance and threshold selection. METHODS: We evaluated 12 CAD products on a case-control sample of participants from a South African tuberculosis prevalence survey. Only those with microbiological test results were eligible. The primary outcome was comparing products' accuracy using the area under the receiver operating characteristic curve (AUC) against microbiological evidence. Threshold analyses were performed based on pre-defined criteria and across all thresholds. We conducted subgroup analyses including age, gender, HIV status, previous tuberculosis history, symptoms presence, and current smoking status. FINDINGS: Of the 774 people included, 516 were bacteriologically negative and 258 were bacteriologically positive. Diverse accuracy was noted: Lunit and Nexus had AUCs near 0·9, followed by qXR, JF CXR-2, InferRead, Xvision, and ChestEye (AUCs 0·8-0·9). XrayAME, RADIFY, and TiSepX-TB had AUC under 0·8. Thresholds varied notably across these products and different versions of the same products. Certain products (Lunit, Nexus, JF CXR-2, and qXR) maintained high sensitivity (>90%) across a wide threshold range while reducing the number of individuals requiring confirmatory diagnostic testing. All products generally performed worst in older individuals, people with previous tuberculosis, and people with HIV. Variations in thresholds, sensitivity, and specificity existed across groups and settings. INTERPRETATION: Several previously unevaluated products performed similarly to those evaluated by WHO. Thresholds differed across products and demographic subgroups. The rapid emergence of products and versions necessitates a global strategy to validate new versions and software to support CAD product and threshold selections. FUNDING: Government of Canada.
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Inteligência Artificial , Humanos , África do Sul/epidemiologia , Feminino , Masculino , Adulto , Pessoa de Meia-Idade , Prevalência , Estudos de Casos e Controles , Software , Radiografia Torácica/métodos , Diagnóstico por Computador/métodos , Tuberculose Pulmonar/diagnóstico por imagem , Tuberculose Pulmonar/epidemiologia , Tuberculose Pulmonar/diagnóstico , Adulto Jovem , Tuberculose/diagnóstico , Tuberculose/epidemiologia , Infecções por HIV/epidemiologia , Sensibilidade e Especificidade , Programas de Rastreamento/métodosRESUMO
Introduction: The identification of classes of nutritionally similar food items is important for creating food exchange lists to meet health requirements and for informing nutrition guidelines and campaigns. Cluster analysis methods can assign food items into classes based on the similarity in their nutrient contents. Finite mixture models use probabilistic classification with the advantage of taking into account the uncertainty of class thresholds. Methods: This paper uses univariate Gaussian mixture models to determine the probabilistic classification of food items in the South African Food Composition Database (SAFCDB) based on nutrient content. Results: Classifying food items by animal protein, fatty acid, available carbohydrate, total fibre, sodium, iron, vitamin A, thiamin and riboflavin contents produced data-driven classes with differing means and estimates of variability and could be clearly ranked on a low to high nutrient contents scale. Classifying food items by their sodium content resulted in five classes with the class means ranging from 1.57 to 706.27 mg per 100 g. Four classes were identified based on available carbohydrate content with the highest carbohydrate class having a mean content of 59.15 g per 100 g. Food items clustered into two classes when examining their fatty acid content. Foods with a high iron content had a mean of 1.46 mg per 100 g and was one of three classes identified for iron. Classes containing nutrient-rich food items that exhibited extreme nutrient values were also identified for several vitamins and minerals. Discussion: The overlap between classes was evident and supports the use of probabilistic classification methods. Food items in each of the identified classes were comparable to allowed food lists developed for therapeutic diets. This data-driven ranking of nutritionally similar classes could be considered for diet planning for medical conditions and individuals with dietary restrictions.