The Likoma Network Study: Context, data collection and initial results

The extent and structure of sexual networks have important consequences for the spread of sexually transmitted diseases such as HIV. However, very few datasets currently exist that allow a detailed investigation of sexual networks in sub-Saharan African settings where HIV epidemics have become generalized. In this paper, we describe the context and methods of the Likoma Network Study (LNS), one of the few studies that have collected extensive information on sexual networks in sub-Saharan Africa. We start by reviewing theoretical arguments and empirical studies emphasizing the importance of network structures in the epidemiology of HIV and other sexually transmitted infections (STI). The island setting of this study is described, and we argue that the choice of an island as a research site limited potential biases that may make the collection of sexual network data difficult. We then document our empirical strategy for the collection of sexual network data and the subsequent identification of sexual network partners. A description of the protocol for the collection of biomarker data (HIV infection) is provided. Finally, we present initial results relating to the socioeconomic context of the island, the size and composition of sexual networks, the quality of the sexual network data, the determinants of successful contact tracing during the LNS, and the prevalence of HIV in the study population.HIV risk factors, HIV transmission, Malawi, sexual behavior, sexual networks

Sexual behavior and STI/HIV status among adolescents in rural Malawi: An evaluation of the effect of interview mode on reporting

This paper presents the results from an interview-mode experiment conducted by the Population Council with unmarried young women in rural southern Malawi. To collect data on sexual behavior and the dynamics of HIV transmission, respondents were randomly assigned to either an audio computer-assisted self-interview (ACASI) or a conventional face-to-face (FTF) interview. Clear evidence indicates that the mode of interviewing and probing concerning various sexual partnerships affects respondents’ reporting of their sexual activity, yet the results are not always in accordance with expectations. Reporting for “ever had sex” and “sex with a boyfriend” is higher in the FTF mode, whereas, when we ask about other partners as well as multiple lifetime partners, the reporting is consistently higher with ACASI, in many cases significantly so. The interview-administered mode produced more consistent reporting of sexual activity between the main interview and a subsequent interview. Finally, the association between infection status and reporting of sexual behavior is stronger in the FTF mode, although in both modes, some young women who denied ever having had sex tested positive for STIs/HIV

The Likoma Network Study: Context, Data Collection and Initial Results

The sexual networks connecting members of a population have important consequences for the spread of sexually transmitted diseases including HIV. However, very few datasets currently exist that allow an investigation of the structure of sexual networks, particularly in sub-Saharan Africa where HIV epidemics have become generalized. In this paper, we describe the context and methods of the Likoma Network Study (LNS), a survey of complete sexual networks we conducted in Likoma island (Malawi) between October 2005 and March 2006. We start by reviewing theoretical arguments and empirical studies emphasizing the importance of network structures for the epidemiology of sexually and transmitted diseases. We describe the island setting of this study, and argue that the choice of an island as research site addresses the possible sources of bias in the collection of complete network data. We then describe in detail our empirical strategy for the identification of sexual networks, as well as for the collection of biomarker data (HIV infection). Finally, we provide initial results relating to the socioeconomic context of the island, the size and composition of sexual networks, the prevalence of HIV in the study population, the quality of the sexual network data, the determinants of successful contact tracing during the LNS, and basic measures of network connectivity

Northern Nigeria Maternal, Newborn and Child Health Programme: Selected Analyses from Population-Based Baseline Survey

Maternal mortality in Northern Nigeria is among the highest in the world. To guide programme planning we interviewed 7,442 women in April and May 2009 in three northern states (Katsina, Yobe, and Zamfara) to understand patterns of antenatal care and delivery. Here, we present findings from a population-based survey conducted under the PRRINN-MNCH Programme to provide evidence-base programmatic interventions aimed at improving maternal and child health indicators. In the paper, we outline the health challenges facing northern Nigeria, describe the PRRINN-MNCH Programme, describe the baseline survey design, implementation, and subsequent data. We provide a series of maternal and child health indicators in order to address two key important policy issues: (1) the importance of visits to health care facilities to enable women get proper maternal care, and (2) the importance of having access to skilled personnel at birth. We further describe how these data can be used to develop appropriate strategies for integrated programmes to increase awareness of pregnancy and delivery complications and to reduce the barriers to assessing risk and accessing the facilities in a timely manner. Appropriate strategies and interventions are necessary to address the existing health challenges. To a large extent, these data also provide an opportunity to measure the impact of the programme in assisting Nigeria attain the health Millennium Development Goals of maternal and child health

Trends in socioeconomic disparities in a rapid under-five mortality transition: a longitudinal study in United Republic of Tanzania

Abstract: Objective To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of United Republic of Tanzania between 2000 and 2011. Methods: We used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. We estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models. Findings: The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births (95% confidence interval, CI: 119.3–147.4) in 2000 to 66.2 (95%CI: 59.0–74.3) in 2011 and in Rufiji from 118.4 deaths per 1000 live births (95% CI: 107.1– 130.7) in 2000 to 76.2 (95% CI: 66.7–86.9) in 2011. Combining both sites, in 2000– 2001, the risk of dying for children of uneducated mothers was 1.44 (95% CI: 1.08– 1.92) higher than for children of mothers who had received education beyond primary school. In 2010–2011, the HR was 1.18 (95% CI: 0.90–1.55). In contrast mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 (95% CI: 0.99–1.47) in 2000–2001 to 1.48 (95% CI: 1.15–1.89) in 2010–2011, while in Ifakara, disparities narrowed from 1.30 (95% CI: 1.09–1.55) to 1.15 (95% CI: 0.95–1.39) in the same period. Conclusion: While childhood survival has improved, mortality disparities still persist, suggesting a need for policies and programmes that both reduce child mortality and address socioeconomic disparities

Knowledge, risk perceptions, and behaviors related to the COVID-19 pandemic in Malawi

BACKGROUND Behavioral changes are needed to limit the spread and mitigate the impact of the COVID-19 pandemic. OBJECTIVE We measured knowledge and behaviors related to COVID-19 during the early stages of the pandemic in Malawi (Southeast Africa). METHODS Using lists of phone numbers collected prior to the COVID-19 pandemic, we contacted a sample of adults by mobile phone in the six weeks after the first confirmed cases of COVID-19 were recorded in the country. We interviewed 619 respondents (79.5% response rate). RESULTS Approximately half of respondents perceived no risk or only limited risk that they would become infected with the novel coronavirus. Contrary to projections from epidemiological models, a large percentage of respondents (72.2%) expected to be severely ill if they became infected. Increased hand washing and avoiding crowds were the most frequently reported strategies used to prevent spreading SARS-CoV-2. The adoption of other protective behaviors (e.g., face masks) was limited. Respondents in urban areas had more accurate knowledge of disease patterns and had adopted more protective behaviors than rural respondents. CONCLUSIONS In the first weeks of the pandemic, the adoption of preventive behaviors remained limited in Malawi, possibly due to low perceived risk of infection among a large fraction of the population. Additional information campaigns are needed to address misperceptions about the risk of infection with SARS-CoV-2 and the likelihood of severe illness due to COVID-19. CONTRIBUTION This study provides early data on behavioral responses to the COVID-19 pandemic in a low-income country

Does Proximity to Health Facilities Improve Child Survival? New Evidence from a Longitudinal Study in Rural Tanzania

Distance to health facilities is often cited as a major barrier limiting access to care in sub-Saharan and other developing countries. There are however limited data on the causal effects of distance to facilities on child survival. Existing estimates may be biased because 1) most existing data are on distance to health care facilities are cross-sectional, and 2) existing analyses do not account for the endogeneity of residential choices and health services location. This paper uses unique longitudinal data collected in a rural district of Tanzania to test whether enhanced proximity to health services arising from investment in dispensaries contributed to the rapid decline in underfive mortality recently observed in Tanzania. Data on births, deaths, household socioeconomic characteristics and migrations have been recorded every 120 days since 1999 (n≈85,000). Geographic data on the precise location of households and health facilities have also been collected over time. We use multivariate analysis 1) to measure the causal effects of distance to health facilities on child survival and 2) to test for possible interactions between distance to health facilities and socioeconomic characteristics of households (e.g., educational attainment, wealth). Initial results indicate that, from 2000 to 2010, child mortality declined close to 40% (from 110 to 70 per 1000). The distance to the closest health facility remained a strong determinant of child survival, even after adjusting for endogeneity biases. The development of community-based primary health care in rural communities by posting community health assistants, and conducting regular household visits, can improve health outcomes. It can also increase equity by offsetting the detrimental effects of low maternal education, householdpoverty and distance to health facilities

Supplementary polio immunization activities and prior use of routine immunization services in non-polio-endemic sub-Saharan Africa

OBJECTIVE: To determine participation in polio supplementary immunization activities (SIAs) in sub-Saharan Africa among users and non-users of routine immunization services and among users who were compliant or non-compliant with the routine oral poliovirus vaccine (OPV) immunization schedule. METHODS: Data were obtained from household-based surveys in non-polio-endemic sub-Saharan African countries. Routine immunization service users were children (aged < 5 years) who had ever had a health card containing their vaccination history; non-users were children who had never had a health card. Users were considered compliant with the OPV routine immunization schedule if, by the SIA date, their health card reflected receipt of required OPV doses. Logistic regression measured associations between SIA participation and use of both routine immunization services and compliance with routine OPV among users. FINDINGS: Data from 21 SIAs conducted between 1999 and 2010 in 15 different countries met inclusion criteria. Overall SIA participation ranged from 70.2% to 96.1%. It was consistently lower among infants than among children aged 1–4 years. In adjusted analyses, participation among routine immunization services users was > 85% in 12 SIAs but non-user participation was > 85% in only 5 SIAs. In 18 SIAs, participation was greater among users (P < 0.01 in 16, 0.05 in 1 and < 0.10 in 1) than non-users. In 14 SIAs, adjusted analyses revealed lower participation among non-compliant users than among compliant users (P < 0.01 in 10, < 0.05 in 2 and < 0.10 in 2). CONCLUSION: Large percentages of children participated in SIAs. Prior use of routine immunization services and compliance with the routine OPV schedule showed a strong positive association with SIA participation

The Tanzania Connect Project: a cluster-randomized trial of the child survival impact of adding paid community health workers to an existing facility-focused health system

Background: Tanzania has been a pioneer in establishing community-level services, yet challenges remain in sustaining these systems and ensuring adequate human resource strategies. In particular, the added value of a cadre of professional community health workers is under debate. While Tanzania has the highest density of primary health care facilities in Africa, equitable access and quality of care remain a challenge. Utilization for many services proven to reduce child and maternal mortality is unacceptably low. Tanzanian policy initiatives have sought to address these problems by proposing expansion of community-based providers, but the Ministry of Health and Social Welfare (MoHSW ) lacks evidence that this merits national implementation. The Tanzania Connect Project is a randomized cluster trial located in three rural districts with a population of roughly 360,000 ( Kilombero, Rufiji, and Ulanga). Description of intervention: Connect aims to test whether introducing a community health worker into a general program of health systems strengthening and referral improvement will reduce child mortality, improve access to services, expand utilization, and alter reproductive, maternal, newborn and child health seeking behavior; thereby accelerating progress towards Millennium Development Goals 4 and 5. Connect has introduced a new cadre — Community Health Agents (CHA) — who were recruited from and work in their communities. To support the CHA, Connect developed supervisory systems, launched information and monitoring operations, and implemented logistics support for integration with existing district and village operations. In addition, Connect’s district-wide emergency referral strengthening intervention includes clinical and operational improvements. Evaluation design: Designed as a community-based cluster-randomized trial, CHA were randomly assigned to 50 of the 101 villages within the Health and Demographic Surveillance System (HDSS) in the three study districts. To garner detailed information on household characteristics, behaviors, and service exposure, a random sub-sample survey of 3,300 women of reproductive age will be conducted at the baseline and endline. The referral system intervention will use baseline, midline, and endline facility-based data to assess systemic changes. Implementation and impact research of Connect will assess whether and how the presence of the CHA at village level provides added life-saving value to the health system. Discussion: Global commitment to launching community-based primary health care has accelerated in recent years, with much of the implementation focused on Africa. Despite extensive investment, no program has been guided by a truly experimental study. Connect will not only address Tanzania’s need for policy and operational research, it will bridge a critical international knowledge gap concerning the added value of salaried professional community health workers in the context of a high density of fixed facilities. Trial registration: ISRCTN9681984