The impact of a hybrid social marketing intervention on inequities in access, ownership and use of insecticide-treated nets

BACKGROUND: An ITN intervention was initiated in three predominantly rural districts of Eastern Province, Zambia, that lacked commercial distribution and communication infrastructures. Social marketing techniques were used for product and message development. Public sector clinics and village-based volunteers promoted and distributed subsidized ITNs priced at $2.5 per net. A study was conducted to assess the effects of the intervention on inequities in knowledge, access, ownership and use of ITNs. METHODS: A post-test only quasi-experimental study design was used to compare intervention and comparison districts. A total of 2,986 respondents were interviewed. Survey respondents were grouped into four socio-economic (SES) categories: low, medium-low, medium and high. Knowledge, access, ownership and use indicators are compared. Concentration index scores are calculated. Interactions between intervention status and SES help determine how different SES groups benefited from the intervention. RESULTS: Although overall use of nets remained relatively low, post-test data show that knowledge, access, ownership and use of mosquito nets was higher in intervention districts. A decline in SES inequity in access to nets occurred in intervention districts, resulting from a disproportionately greater increase in access among the low SES group. Declines in SES inequities in net ownership and use of nets were associated with the intervention. The largest increases in net ownership and use occurred among medium and high SES categories. CONCLUSION: Increasing access to nets among the poorest respondents in rural areas may not lead to increases in net use unless the price of nets is no longer a barrier to their purchase

Determinants for HIV testing and counselling in Nairobi urban informal settlements

BACKGROUND: Counselling and testing is important in HIV prevention and care. Majority of people in sub-Saharan Africa do not know their HIV status and are therefore unable to take steps to prevent infection or take up life prolonging anti-retroviral drugs in time if infected. This study aimed at exploring determinants of HIV testing and counselling in two Nairobi informal settlements. METHODS: Data are derived from a cross-sectional survey nested in an ongoing demographic surveillance system. A total of 3,162 individuals responded to the interview and out of these, 82% provided a blood sample which was tested using rapid test kits. The outcome of interest in this paper was HIV testing status in the past categorised as "never tested"; "client-initiated testing and counselling (CITC)" and provider-initiated testing and counselling (PITC). Multinomial logistic regression was used to identify determinants of HIV testing. RESULTS: Approximately 31% of all respondents had ever been tested for HIV through CITC, 22% through PITC and 42% had never been tested but indicated willingness to test. Overall, 62% of females and 38% of males had ever been tested for HIV. Males were less likely to have had CITC (OR = 0.47; p value < 0.001) and also less likely to have had PITC (OR = 0.16; p value < 0.001) compared to females. Individuals aged 20-24 years were more likely to have had either CITC or PITC compared to the other age groups. The divorced/separated/widowed were more likely (OR = 1.65; p value < 0.01) to have had CITC than their married counterparts, while the never married were less likely to have had either CITC or PITC. HIV positive individuals (OR = 1.60; p value < 0.01) and those who refused testing in the survey (OR = 1.39; p value < 0.05) were more likely to have had CITC compared to their HIV negative counterparts. CONCLUSION: Although the proportion of individuals ever tested in the informal settlements is similar to the national average, it remains low compared to that of Nairobi province especially among men. Key determinants of HIV testing and counselling include; gender, age, education level, HIV status and marital status. These factors need to be considered in efforts aimed at increasing participation in HIV testing

Social disorganization and history of child sexual abuse against girls in sub-Saharan Africa : a multilevel analysis

Background: Child sexual abuse (CSA) is a considerable public health problem. Less focus has been paid to the role of community level factors associated with CSA. The aim of this study was to examine the association between neighbourhood-level measures of social disorganization and CSA. Methods: We applied multiple multilevel logistic regression analysis on Demographic and Health Survey data for 6,351 adolescents from six countries in sub-Saharan Africa between 2006 and 2008. Results: The percentage of adolescents that had experienced CSA ranged from 1.04% to 5.84%. There was a significant variation in the odds of reporting CSA across the communities, suggesting 18% of the variation in CSA could be attributed to community level factors. Respondents currently employed were more likely to have reported CSA than those who were unemployed (odds ratio [OR] = 2.05, 95% confidence interval [CI] 1.48 to 2.83). Respondents from communities with a high family disruption rate were 57% more likely to have reported CSA (OR=1.57, 95% CI 1.14 to 2.16). Conclusion: We found that exposure to CSA was associated with high community level of family disruption, thus suggesting that neighbourhoods may indeed have significant important effects on exposure to CSA. Further studies are needed to explore pathways that connect the individual and neighbourhood levels, that is, means through which deleterious neighbourhood effects are transmitted to individuals

Married women's decision making power on modern contraceptive use in urban and rural southern Ethiopia

<p>Abstract</p> <p>Background</p> <p>Women in developing countries are either under collective decision making with their partners or completely rely on the male partner's decision on issues that affect their reproductive live. Identifying the major barriers of married women's decision making power on contraceptive use has significant relevance for planning contextually appropriate family planning interventions. The objective of this study was to determine current modern contraceptive practices and decision making power among married women in Tercha Town and surrounding rural areas of Dawro zone, Southern Ethiopia.</p> <p>Methods</p> <p>Community based comparative cross-sectional design with both quantitative and Qualitative study has been employed in March and April 2010. The respondents were 699 married women of child bearing age from urban and rural parts of Dawro zone. After conducting census, we took the sample using simple random sampling technique.</p> <p>Results</p> <p>Current modern contraceptive use among married women in the urban was 293 (87.5%) and 243 (72.8%) in rural. Married women who reside in urban area were more likely to decide on the use of modern contraceptive method than rural women. Having better knowledge about modern contraceptive methods, gender equitable attitude, better involvement in decisions related to children, socio-cultural and family relations were statistically significant factors for decision making power of women on the use of modern contraceptive methods in the urban setting. Better knowledge, fear of partner's opposition or negligence, involvement in decisions about child and economic affairs were statistically significant factors for better decision making power of women on the use of modern contraceptive methods in the rural part.</p> <p>Conclusions</p> <p>High level of current modern contraceptive practice with reduced urban-rural difference was found as compared to regional and national figures. Urban women had better power to make decisions on modern contraceptive than rural women. Modern family planning interventions in the area should be promoted by considering empowering of women on modern contraceptive use decision making.</p

Are Tanzanian patients attending public facilities or private retailers more likely to adhere to artemisinin-based combination therapy?

BACKGROUND: Artemisinin combination therapy (ACT) is first-line treatment for malaria in most endemic countries and is increasingly available in the private sector. Most studies on ACT adherence have been conducted in the public sector, with minimal data from private retailers. METHODS: Parallel studies were conducted in Tanzania, in which patients obtaining artemether-lumefantrine (AL) at 40 randomly selected public health facilities and 37 accredited drug dispensing outlets (ADDOs) were visited at home and questioned about doses taken. The effect of sector on adherence, controlling for potential confounders was assessed using logistic regression with a random effect for outlet. RESULTS: Of 572 health facility patients and 450 ADDO patients, 74.5% (95% CI: 69.8, 78.8) and 69.8% (95% CI: 64.6, 74.5), respectively, completed treatment and 46.0% (95% CI: 40.9, 51.2) and 34.8% (95% CI: 30.1, 39.8) took each dose at the correct time ('timely completion'). ADDO patients were wealthier, more educated, older, sought care later in the day, and were less likely to test positive for malaria than health facility patients. Controlling for patient characteristics, the adjusted odds of completed treatment and of timely completion for ADDO patients were 0.65 (95% CI: 0.43, 1.00) and 0.69 (95% CI: 0.47, 1.01) times that of health facility patients. Higher socio-economic status was associated with both adherence measures. Higher education was associated with completed treatment (adjusted OR = 1.68, 95% CI: 1.20, 2.36); obtaining AL in the evening was associated with timely completion (adjusted OR = 0.35, 95% CI: 0.19, 0.64). Factors associated with adherence in each sector were examined separately. In both sectors, recalling correct instructions was positively associated with both adherence measures. In health facility patients, but not ADDO patients, taking the first dose of AL at the outlet was associated with timely completion (adjusted OR = 2.11, 95% CI: 1.46, 3.04). CONCLUSION: When controlling for patient characteristics, there was some evidence that the adjusted odds of adherence for ADDO patients was lower than that for public health facility patients. Better understanding is needed of which patient care aspects are most important for adherence, including the role of effective provision of advice

Analysing and Recommending Options for Maintaining Universal Coverage with Long-Lasting Insecticidal Nets: The Case of Tanzania in 2011.

Tanzania achieved universal coverage with long-lasting insecticidal nets (LLINs) in October 2011, after three years of free mass net distribution campaigns and is now faced with the challenge of maintaining high coverage as nets wear out and the population grows. A process of exploring options for a continuous or "Keep-Up" distribution system was initiated in early 2011. This paper presents for the first time a comprehensive national process to review the major considerations, findings and recommendations for the implementation of a new strategy. Stakeholder meetings and site visits were conducted in five locations in Tanzania to garner stakeholder input on the proposed distribution systems. Coverage levels for LLINs and their decline over time were modelled using NetCALC software, taking realistic net decay rates, current demographic profiles and other relevant parameters into consideration. Costs of the different distribution systems were estimated using local data. LLIN delivery was considered via mass campaigns, Antenatal Care-Expanded Programme on Immunization (ANC/EPI), community-based distribution, schools, the commercial sector and different combinations of the above. Most approaches appeared unlikely to maintain universal coverage when used alone. Mass campaigns, even when combined with a continuation of the Tanzania National Voucher Scheme (TNVS), would produce large temporal fluctuations in coverage levels; over 10 years this strategy would require 63.3 million LLINs and a total cost of $444 million USD. Community mechanisms, while able to deliver the required numbers of LLINs, would require a massive scale-up in monitoring, evaluation and supervision systems to ensure accurate application of identification criteria at the community level. School-based approaches combined with the existing TNVS would reach most Tanzanian households and deliver 65.4 million LLINs over 10 years at a total cost of$449 million USD and ensure continuous coverage. The cost of each strategy was largely driven by the number of LLINs delivered. The most cost-efficient strategy to maintain universal coverage is one that best optimizes the numbers of LLINs needed over time. A school-based approach using vouchers targeting all students in Standards 1, 3, 5, 7 and Forms 1 and 2 in combination with the TNVS appears to meet best the criteria of effectiveness, equity and efficiency

Breadwinners and Homemakers: Migration and Changing Conjugal Expectations in Rural Bangladesh

The literature on marriage norms and aspirations across societies largely sees the institution as static – a tool for the assertion of masculinities and subordination of women. The changing meanings of marriage and conjugality in the contemporary context of globalisation have received scant attention. Based on research in rural Bangladesh, this article questions the usefulness of notions of autonomy and dependence in understanding conjugal relations and expectations in a context of widespread migration for extended periods, especially to overseas destinations, where mutuality is crucial for social reproduction, though in clearly genderdemarcated domains

Examining equity in access to long-lasting insecticide nets and artemisinin-based combination therapy in Anambra state, Nigeria

<p>Abstract</p> <p>Background</p> <p>In order to achieve universal health coverage, the government of Anambra State, southeast Nigeria has distributed free Long-lasting Insecticide treated Nets (LLINs) to the general population and delivered free Artemisinin-based Combination Therapy (ACT) to pregnant women and children less than 5 years. However, the levels of coverage with LLINS and ACTs is not clear, especially coverage of different socio-economic status (SES) population groups. This study was carried out to determine the level of coverage and access to LLINs and ACTs amongst different SES groups.</p> <p>Methods</p> <p>A questionnaire was used to collect data from randomly selected households in 19 local government areas of the State. Selected households had a pregnant woman and/or a child less than 5 years. The lot quality assurance sampling (LQAS) methodology was used in sampling. The questionnaire explored the availability and utilization of LLINs and ACTs from 2394 households. An asset-based SES index was used to examine the level of access of LLINS and ACTs to different SES quintiles.</p> <p>Results</p> <p>It was found that 80.5 % of the households had an LLIN and 64.4 % of the households stated that they actually used the nets the previous night. The findings showed that 42.3 % of pregnant women who had fever within the past month received ACTs, while 37.5 % of children ≪5 years old who had malaria in the past month had received ACTs. There was equity in ownership of nets for the range 1–5 nets per household. No significant SES difference was found in use of ACTs for treatment of malaria in children under five years old and in pregnant women.</p> <p>Conclusions</p> <p>The free distribution of LLINs and ACTs increased household coverage of both malaria control interventions and bridged the equity gap in access to them among the most vulnerable groups.</p

Ultra-High Energy Neutrino Fluxes: New Constraints and Implications

We apply new upper limits on neutrino fluxes and the diffuse extragalactic component of the GeV gamma-ray flux to various scenarios for ultra high energy cosmic rays and neutrinos. As a result we find that extra-galactic top-down sources can not contribute significantly to the observed flux of highest energy cosmic rays. The Z-burst mechanism where ultra-high energy neutrinos produce cosmic rays via interactions with relic neutrinos is practically ruled out if cosmological limits on neutrino mass and clustering apply.Comment: 10 revtex pages, 9 postscript figure