Hypertension and Obesity in Adults Living in a High HIV Prevalence Rural Area in South Africa

Hypertension and excess body weight are major risk factors of cardiovascular morbidity and mortality in developing countries. In countries with a high HIV prevalence, it is unknown how increased antiretroviral treatment and care (ART) coverage has affected the prevalence of overweight, obesity, and hypertension. We conducted a health survey in 2010 based on the WHO STEPwise approach in 14,198 adult resident participants of a demographic surveillance area in rural South Africa to investigate factors associated with hypertension and excess weight including HIV infection and ART status. Women had a significantly higher median body mass index (BMI) than men (26.4 vs. 21.2 kg/$m^2$, p<0.001). The prevalence of obesity (BMI≥30 kg/$m^2$) in women (31.3%, 95% confidence interval (CI) 30.2–32.4) was 6.5 times higher than in men (4.9%, 95% CI 4.1–5.7), whereas prevalence of hypertension (systolic or diastolic blood pressure≥140 or 90 mm Hg, respectively) was 1.4 times higher in women than in men (28.5% vs 20.8%, p<0.001). In multivariable regression analysis, both hypertension and obesity were significantly associated with sex, age, HIV and ART status. The BMI of women and men on ART was on average 3.8 (95% CI 3.2–3.8) and 1.7 (95% CI 0.9–2.5) kg/$m^2$ lower than of HIV-negative women and men, respectively. The BMI of HIV-infected women and men not on ART was on average 1.2 (95% CI 0.8–1.6) and 0.4 (95% CI -0.1–0.9) kg/m2 lower than of HIV-negative women and men, respectively. Obesity was a bigger risk factor for hypertension in men (adjusted odds ratio (aOR) 2.99, 95% CI 2.00–4.48) than in women (aOR 1.64, 95% CI 1.39–1.92) and overweight (25≤BMI<30) was a significant risk factor for men only (aOR 1.53 95% CI 1.14–2.06). Our study suggests that, cardiovascular risk factors of hypertension and obesity differ substantially between women and men in rural South Africa

Health Worker Preferences for Community-Based Health Insurance Payment Mechanisms: A Discrete Choice Experiment

Background: In 2004, a community-based health insurance scheme (CBI) was introduced in Nouna health district, Burkina Faso. Since its inception, coverage has remained low and dropout rates high. One important reason for low coverage and high dropout is that health workers do not support the CBI scheme because they are dissatisfied with the provider payment mechanism of the CBI. Methods: A discrete choice experiment (DCE) was used to examine CBI provider payment attributes that influence health workers’ stated preferences for payment mechanisms. The DCE was conducted among 176 health workers employed at one of the 34 primary care facilities or the district hospital in Nouna health district. Conditional logit models with main effects and interactions terms were used for analysis. Results: Reimbursement of service fees (adjusted odds ratio (aOR) 1.49, p < 0.001) and CBI contributions for medical supplies and equipment (aOR 1.47, p < 0.001) had the strongest effect on whether the health workers chose a given provider payment mechanism. The odds of selecting a payment mechanism decreased significantly if the mechanism included (i) results-based financing (RBF) payments made through the local health management team (instead of directly to the health workers (aOR 0.86, p < 0.001)) or (ii) RBF payments based on CBI coverage achieved in the health worker’s facility relative to the coverage achieved at other facilities (instead of payments based on the numbers of individuals or households enrolled at the health worker’s facility (aOR 0.86, p < 0.001)). Conclusions: Provider payment mechanisms can crucially determine CBI performance. Based on the results from this DCE, revised CBI payment mechanisms were introduced in Nouna health district in January 2011, taking into consideration health worker preferences on how they are paid

Expansion of HIV testing in Eswatini: stakeholder perspectives on reaching the first 90

Achieving the United Nations' 90-90-90 goals has proven challenging in most settings and the ambitious 95-95-95 goals seem even more elusive. However, in Eswatini - a lower-middle-income country in sub-Saharan Africa with the highest HIV prevalence in the world - an estimated 92% of people living with HIV know their status. We conducted 26 in-depth interviews with stakeholders from policy, implementation, donor, local advocacy and academic sectors to elicit the facilitators and inhibitors to HIV testing uptake in Eswatini. Background data and related reports and policy documents (n = 57) were also reviewed. Essential facilitators included good governance via institutional and national budgetary commitments, which often led to swift adoption of globally recommended programs and standards. The integration of HIV testing into all points of care fostered a sense that testing was part of routine care, which reduced stigma. Challenges, however, centred on social norms that disadvantage certain groups with high ongoing HIV risk (such as key populations, adolescent girls and young women), a heavy reliance on external donor funding, and stigma that had subsided but nevertheless persisted. Amid concerns about whether the 90-90-90 targets could be achieved by 2020, the experience of Eswatini provides tangible insights into factors that have successfully influenced HIV testing uptake and may thus prove informative for other countries

Correlates of internalizing and externalizing problems among school-going young adolescents in Sub-Saharan Africa.

Mental health in adolescence is important for health and well-being throughout the life course, but evidence from Sub-Saharan Africa is sparse. This study aimed to assess the correlates of internalizing, externalizing and cumulative problems among early adolescents. This study used cross-sectional survey data from 3516 school-going adolescents in Ouagadougou, Burkina Faso; Addis Ababa, Ethiopia and Dar es Salaam, Tanzania. We used a 25-item Strengths and Difficulties Questionnaire to measure internalizing, externalizing and cumulative problems. We carried out multi-variable linear regression analyses with the estimation of adjusted mean differences and 95% confidence intervals, to determine the factors associated with internalizing, externalizing and cumulative problems. Overall, 1 in 8 adolescents had internalizing problems, while 1 in 10 had externalizing problems. In two sites, having friends was related to lower internalizing problems, while repeating a grade, physical fights and household food insecurity were related to greater internalizing problems. Household food insecurity and involvement in physical fights were associated with greater externalizing problems across sites, while repeating a grade was linked with greater externalizing problems in two sites. Having a caring adult in school was associated with fewer externalizing problems across sites, while having friends was associated with fewer externalizing problems in two sites. Overall, having friends was related to fewer cumulative problems, while physical fights and household food insecurity were related to higher cumulative problems. School-based mental health and food programs may be useful in addressing social-emotional problems among school-aged adolescents in Burkina Faso, Ethiopia and Tanzania

Early access to antiretroviral therapy versus standard of care among HIV-positive participants in Eswatini in the public health sector : the MaxART stepped-wedge randomized controlled trial

Introduction The WHO recommends antiretroviral treatment (ART) for all HIV-positive patients regardless of CD4 count or disease stage, referred to as "Early Access to ART for All" (EAAA). The health systems effects of EAAA implementation are unknown. This trial was implemented in a government-managed public health system with the aim to examine the "real world" impact of EAAA on care retention and viral suppression. Methods In this stepped-wedge randomized controlled trial, 14 public sector health facilities in Eswatini were paired and randomly assigned to stepwise transition from standard of care (SoC) to EAAA. ART-naive participants >= 18 years who were not pregnant or breastfeeding were eligible for enrolment. We used Cox proportional hazard models with censoring at clinic transition to estimate the effects of EAAA on retention in care and retention and viral suppression combined. Results Between September 2014 and August 2017, 3405 participants were enrolled. In SoC and EAAA respectively, 12-month HIV care retention rates were 80% (95% CI: 77 to 83) and 86% (95% CI: 83 to 88). The 12-month combined retention and viral suppression endpoint rates were 44% (95% CI: 40 to 48) under SoC compared to 80% (95% CI: 77 to 83) under EAAA. EAAA increased both retention (HR: 1 center dot 60, 95% CI: 1 center dot 15 to 2 center dot 21,p = 0.005) and retention and viral suppression combined (HR: 4.88, 95% CI: 2.96 to 8.05,p < 0.001). We also identified significant gaps in current health systems ability to provide viral load (VL) monitoring with 80% participants in SoC and 66% in EAAA having a missing VL at last contact. Conclusions The observed improvement in retention in care and on the combined retention and viral suppression provides an important co-benefit of EAAA to HIV-positive adults themselves, at least in the short term. Our results from this "real world" health systems trial strongly support EAAA for Eswatini and countries with similar HIV epidemics and health systems. VL monitoring needs to be scaled up for appropriate care management

Dietary intake and quality for young adolescents in sub‐Saharan Africa: Status and influencing factors

Adolescents face the risk of the triple burden of malnutrition—the co‐existence of micronutrient deficiencies, underweight and overweight and obesity and related non-communicable diseases. Poor‐quality diets are a modifiable risk factor for all forms of malnutrition in adolescents. However, there is limited knowledge about diet quality for African adolescents. We analyzed data from 4609 school‐going adolescents aged 10–15 years in Burkina Faso, Ethiopia, Sudan and Tanzania. Dietary intake was assessed using food frequency questionnaires, and diet quality computed using the Global Diet Quality Score (GDQS). Generalized estimating equations linear regression models were used to evaluate factors associated with adolescent diet quality. Mean adolescent age was 12.4 (±1.4) years and 54% of adolescents were female. Adolescents reported physical activity on 1.5 (±1.7) days/week. The mean GDQS (±SD) was 20.6 (±4.0) (maximum 40). Adolescent consumption of vegetables, fruit, nuts and seeds, eggs, fish and poultry was low, and refined grain consumption was relatively high. Boys consumed unhealthy foods less frequently but consumed fewer cruciferous vegetables and deep orange tubers. Older adolescents had higher fish and lower red meat consumption. Having an unemployed mother versus farmer (estimate−2.60, 95% confidence interval [CI]:−4.81,−0.39), and having 3–4 days of physical activity per week versus none(estimate 0.64, 95% CI: 0.11, 1.17) were associated with GDQS. We found evidence of poor‐quality adolescent diets and gender and age differences in the consumption of healthy diets. Programs to address poor‐quality diets should consider tailoring interventions for adolescent girls and boys of different ages and also consider the role of physical activity in these contexts

Burden and determinants of anaemia among in-school young adolescents in Ethiopia, Sudan and Tanzania.

Anaemia among adolescents is a global health problem. However, evidence regarding its burden and risk factors, particularly for younger adolescents and in sub-Saharan Africa (SSA), remains scarce. We aimed to assess the prevalence and potential determinants of anaemia among urban and semi-urban in-school young adolescents in Ethiopia, Sudan and Tanzania. We conducted a school-based survey among 3558 adolescents aged 10-14 years. A capillary blood sample was used to assess haemoglobin concentration. We assessed anaemia prevalence and examined associations between measures at the individual, household and school levels and anaemia using Poisson regression models adjusted for school and country-level clustering. The prevalence of anaemia was 32.0% overall, and 10.8% in Ethiopia, 25.0% in Sudan and 58.3% in Tanzania. Being a boy [adjusted risk ratio (RR): 1.11, 95% confidence interval (CI): 1.08-1.15, p < 0.001], poorer diet quality (RR: 1.12, 95% CI: 1.02-1.23 p = 0.015), no school handwashing stations (RR: 1.26, 95% CI: 1.20-1.32, p < 0.001) and food insecurity (RR for moderate/severe anaemia: 1.06, 95% CI: 1.02-1.10, p = 0.002) were associated with increased anaemia risk. Younger age (RR: 0.91, 95% CI: 0.86-0.96, p < 0.001) and increasing height-for-age z-score (RR: 0.93, 95% CI: 0.91-0.95, p < 0.001) were associated with decreased anaemia risk. Associations were consistent for moderate or severe anaemia. There was no evidence of effect modification by sex. This study highlights anaemia as a public health problem and identified nutritional, dietary and hygiene measures as key risk factors of anaemia among young adolescents in SSA. School-based interventions addressing these factors could reduce the burden of anaemia in adolescence

Adolescent health and well-being in sub-Saharan Africa: Strengthening knowledge base and research capacity through a collaborative multi-country school-based study.

In Sub-Saharan Africa (SSA), adolescents make up around one-quarter of the population who are growing up in a rapidly urbanizing environment, with its associated risks and benefits, including impacts on health, psychosocial development, nutrition, and education. However, research on adolescents' health and well-being in SSA is limited. The ARISE (African Research, Implementation Science and Education) Network's Adolescent Health and Nutrition Study is an exploratory, school-based study of 4988 urban adolescents from five countries: Burkina Faso, Ethiopia, South Africa, Sudan, and Tanzania. A multistage random sampling strategy was used to select the schools and adolescents. Adolescent boys and girls aged 10-15 years were interviewed using a standardized questionnaire by trained enumerators. The questionnaire covered multiple domains including demographic and socioeconomic characteristics, water, sanitation and hygiene practices, antimicrobial resistance, physical activity, dietary behaviours, socioemotional development, educational outcomes, media use, mental health, and menstrual hygiene (only for girls). Additionally, a desk review of health and school meal policies and programs and a qualitative investigation into health and food environments in schools were conducted with students, administrators, and food vendors. In this paper, we describe the study design and questionnaire, present profiles of young adolescents who participated in the study, and share field experiences and lessons learned for future studies. We expect that this study along with other ARISE Network projects will be a first step toward understanding young people's health risks and disease burdens, identifying opportunities for interventions and improving policies, as well as developing potential research capacities on adolescent health and well-being in the SSA region

Every drop matters: combining population-based and satellite data to investigate the link between lifetime rainfall exposure and chronic undernutrition in children under five years in rural Burkina Faso.

Climate change is projected to induce extreme and irregular rainfall patterns in the West African Sahel region, affecting household food security and income. Children are among the worst affected population groups. Previous studies focusing on rainfall irregularities in specified periods have revealed how child health and nutritional status are impacted, especially in rural settings. However, the aggregated effect of rainfall over a lifetime on chronic child undernutrition remains poorly understood. We conducted a multilevel regression using a 2017 household survey from rural Burkina Faso containing 12 919 under-five-year-old children and their corresponding household rainfall data. The rainfall data originated from the Climate Hazards Infrared Precipitation with Stations monthly dataset with a native resolution of 4.8 km (0.05°). We show that an increase in rainfall below 75 mm monthly average tends to produce poor nutritional outcomes (regression coefficient = −0.11***; 95% CI = −0.13, −0.10; p < 0.001) in rural Burkina Faso children. We found a consistent negative relationship between different sex and household wealth groups, but not age groups. Vulnerable younger children were more affected by the adverse effects of increased rainfall, while older children seemed to handle it better. Our methodological approach tracing the impact of rainfall over children’s lifetimes makes a meaningful contribution to the portfolio of tools for studying the complex relationship between climate change and health outcomes. Our work confirms that rainfall is a risk factor for chronic child undernutrition, highlighting the need for adaptation strategies that boost household and community resilience to counteract the harmful impacts of climate change on child nutritional status

COVID-19 Knowledge, Perception, Preventive Measures, Stigma, and Mental Health Among Healthcare Workers in Three Sub-Saharan African Countries: A Phone Survey.

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented public health crisis globally. Understanding healthcare providers' (HCPs') knowledge and perceptions of COVID-19 is crucial to identifying effective strategies to improve their ability to respond to the pandemic in sub-Saharan Africa. A phone-based survey of 900 HCPs in Burkina Faso, Ethiopia, and Nigeria (300 per country) was conducted to assess knowledge, perceptions, COVID-19 prevention measures, stigma, and mental health of HCPs. Modified Poisson regression models were used to evaluate predictors of knowledge, perceptions, and prevention measures; adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) were calculated. Three-fourths of the HCPs had adequate knowledge, and over half had correct perceptions of risk and high levels of self-reported prevention measures. The majority of the HCPs (73.7%) reported self-perceived social stigma. There was relatively low prevalence of depression (6.6%), anxiety (6.6%), or psychological distress (18%). Compared with doctors, being a nurse was associated with lower levels of knowledge (ARR: 0.83; 95% CI: 0.77-0.90) and was also negatively associated with having correct perceptions toward COVID-19 (AOR: 0.82; 95% CI: 0.73-0.92). HCPs treating COVID-19 patients had higher likelihood of having high levels of prevention measures (AOR: 1.37; 95% CI: 1.23-1.53). Despite high levels of knowledge among HCPs in sub-Saharan Africa, there is a need to improve COVID-19 perceptions and compliance with prevention measures as well as address social stigma toward HCPs to better ensure their safety and prepare them to deliver health services