Patterns and factors associated with environmental health practices in households of rural Mozambique

Analytical quantitative studies focusing on health-related behaviours as the final outcomes are scarce, especially in the field of Environmental Health. They have mostly focused on behaviours as risk factors for disease and have rarely dealt with determinants of such behaviours. This study examines the relationship between socio-economic, psycho-social, demographic, and environmental factors and Environmental Health practices at the household level. It further explores, qualitatively, lay perceptions of such practices and illnesses associated with them. An analytical cross-sectional study, complemented by a qualitative study, was the approach chosen for this purpose. Fieldwork took place in Manhiqa, a rural district in Southern Mozambique, from October 2002 to November 2003. The cross-sectional study comprised the following data collection methods: a socio-economic and demographic questionnaire, spot-check observations, and a questionnaire on women's autonomy covering 405 households, and structured observations covering 102 households. The qualitative study comprised 12 focus group discussions (involving 134 people in total) namely with mothers, grandmothers and fathers of children under 5, and 25 semi-structured interviews with caretakers of children under 5. Using factor analysis, three dimensions of wealth (characterising households) and five autonomy constructs (characterising caretakers of children under-5) served as the main predicting factors that the study sought to explore in relation to Household Environmental Health (HHEH) practices. Other predicting factors of interest were type and domain of water source, child's age, and caretaker's age. Prevalence of latrine ownership was high (95%), and so was soap availability (86%). Sixty-two percent of households had access to water from taps (either private or public). However, hand-washing with soap was observed on 6% of occasions after potential faecal contact, and children's stools were disposed of in the latrine on 6% of occasions after open defecation events. In terms of access to hygiene and sanitation hardware, only caretaker's education predicted latrine ownership, and access to soap was associated with caretaker's education, caretaker's exposure to information and socio-economic status of the head of household. With regards to hygiene and sanitation practices, there was no strong evidence for the influence of any of the predicted factors on hand-washing. Socio-economic status of the head of household and type of water source were the only variables significantly associated with safe disposal of stools. Infants under 1 and children between 2 and 5 years of age were the most likely to contaminate the household environment with faeces. Regarding mosquito deterrence practices, it was found that the likelihood that children under 5 were protected by any deterrence method increased with increased caretaker's education and with caretakers decreased proximity to maiden family. Use of traditional fumigation in the child's bedroom was associated with decreased accumulation of modern assets, increased accumulation of traditional assets, and increased caretaker's age. Protecting children under 5 with commercially available products other than bednets was associated with caretaker's education and her financial independence. Bednet use by children was predicted by increased head of household socio-economic status, accumulation of modern assets, and decreased proximity of caretaker to her maiden family. It was also found that certain hygiene and sanitation practices are highly clustered and that there are greater psychosocial connotations carried by sanitation practices than by mosquito deterrence practices. The qualitative study revealed that, from the study participants' perspective, HHEH practices, in particular latrine possession status were associated with the following factors: authority, social commitment, value for self, self-reliance, self-organisation, and completeness. Good fortune was particularly related to bednet possession. Lack of initiative and modernism were personal attributes viewed to be associated with both not having bednets and not having latrines. Through its detailed examination of the associations between individual and household characteristics and behaviour outcomes this study makes an original contribution to our understandiing of how risk and protective practices are produced at household level. This is of interest to those who seek to understand human behaviour from an academic perspective and to those who seek to influence it in order to improve health outcomes. For example, the study adds a contribution to HHEH behaviour change initiatives, especially those that require criteria in order to carry out selective targeting of households according to their social, economic, demographic, or environmental characteristics.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Economic and cost-effectiveness analysis of the community-level interventions for pre-eclampsia (CLIP) trials in India, Pakistan and Mozambique

Background: The Community-Level Interventions for Pre-eclampsia (CLIP) trials (NCT01911494) in India, Pakistan and Mozambique (February 2014-2017) involved community engagement and task sharing with community health workers for triage and initial treatment of pregnancy hypertension. Maternal and perinatal mortality was less frequent among women who received ≥8 CLIP contacts. The aim of this analysis was to assess the incremental costs and cost-effectiveness of the CLIP intervention overall in comparison to standard of care, and by PIERS (Pre-eclampsia Integrated Estimate of RiSk) On the Move (POM) mobile health application visit frequency.Methods: Included were all women enrolled in the three CLIP trials who had delivered with known outcomes by trial end. According to the number of POM-guided home contacts received (0, 1-3, 4-7, ≥8), costs were collected from annual budgets and spending receipts, with inclusion of family opportunity costs in Pakistan. A decision tree model was built to determine the cost-effectiveness of the intervention (vs usual care), based on the primary clinical endpoint of years of life lost (YLL) for mothers and infants. A probabilistic sensitivity analysis was used to assess uncertainty in the cost and clinical outcomes.Results: The incremental per pregnancy cost of the intervention was US$12.66 (India), US$11.51 (Pakistan) and US$13.26 (Mozambique). As implemented, the intervention was not cost-effective due largely to minimal differences in YLL between arms. However, among women who received ≥8 CLIP contacts (four in Pakistan), the probability of health system and family (Pakistan) cost-effectiveness was ≥80% (all countries).Conclusion: The intervention was likely to be cost-effective for women receiving ≥8 contacts in Mozambique and India, and ≥4 in Pakistan, supporting WHO guidance on antenatal contact frequency.Trial registration number: NCT01911494

Tipping the balance towards long-term retention in the HIV care cascade: A mixed methods study in southern Mozambique

BACKGROUND: The implementation of quality HIV control programs is crucial for the achievement of the UNAIDS 90-90-90 targets and to motivate people living with HIV (PLWHIV) to link and remain in HIV-care. The aim of this mixed method cross-sectional study was to estimate the linkage and long-term retention in care of PLWHIV and to identify factors potentially interfering along the HIV-care continuum in southern Mozambique. METHODS: A home-based semi-structured interview was conducted in 2015 to explore barriers and facilitators to the HIV-care cascade among individuals that had been newly HIV-diagnosed in community testing campaigns in 2010 or 2012. Linkage and long-term retention were estimated retrospectively through client self-reports and clinical records. Cohen's Kappa coefficient was calculated to measure the agreement between participant self-reported and documented cascade outcomes. RESULTS: Among the 112 interviewed participants, 24 (21.4%) did not disclose their HIV-positive serostatus to the interviewer. While 84 (75.0%) self-reported having enrolled in care, only 69 (61.6%) reported still being in-care 3-5 years after diagnosis of which 17.4% reported having disengaged and re-engaged. An important factor affecting optimal continuum in HIV-care was the impact of the fear-based authoritarian relationship between the health system and the patient that could act as both driver and barrier. CONCLUSION: Special attention should be given to quantify and understand repeated cycles of patient disengagement and re-engagement in HIV-care. Strategies to improve the relationship between the health system and patients are still needed in order to optimally engage PLWHIV for long-term periods.The author(s) received no specific funding for this work.S

Conceptual frameworks for understanding the acceptability and feasibility of the minimally invasive autopsy to determine cause of death: Findings from the CADMIA Study in western Kenya

Establishing the cause of death (CoD) is critical to better understanding health and prioritizing health investments, however the use of full post-mortem examination is rare in most low and middle-income counties for multiple reasons. The use of minimally invasive autopsy (MIA) approaches, such as needle biopsies, presents an alternate means to assess CoD. In order to understand the feasibility and acceptability of MIA among communities in western Kenya, we conducted focus groups and in-depth interviews with next-of-kin of recently deceased persons, community leaders and health care workers in Siaya and Kisumu counties. Results suggest two conceptual framework can be drawn, one with facilitating factors for acceptance of MIA due to the ability to satisfy immediate needs related to interest in learning CoD or protecting social status and honoring the deceased), and one framework covering barriers to acceptance of MIA, for reasons relating to the failure to serve an existing need, and/or the exacerbation of an already difficult time

Causes and circumstances of maternal death:a secondary analysis of the Community-Level Interventions for (CLIP) trials cohort

BACKGROUND: Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. METHODS: The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12–49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. FINDINGS: Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193–268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0·56 [95% CI 0·43–0·66]) or InterVA-5 (κ=0·44 [0·30–0·57]), and InterVA-4 and InterVA-5 (κ=0·72 [0·60–0·84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0·48 [0·38–0·58]), poor for physician review versus InterVA-5 (κ=0·36 [0·27–0·46]), and good for InterVA-4 versus InterVA-5 (κ=0·69 [0·59–0·79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0·04 [0·00–0·15]). INTERPRETATION: Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. FUNDING: University of British Columbia (grantee of the Bill & Melinda Gates Foundation)

Maternal Carriage of Group B Streptococcus and Escherichia coli in a District Hospital in Mozambique.

BACKGROUND: In low-income countries, data on prevalence and effects of group B Streptococcus (GBS) and Escherichia coli (E. coli) colonization among pregnant women are scarce, but necessary to formulate prevention strategies. We assessed prevalence of GBS and E. coli colonization and factors associated among pregnant women, its effect in newborns and acceptability regarding the utilized sampling methods in a semirural Mozambican hospital. METHODS: Pregnant women were recruited from June 2014 to January 2015, during routine antenatal clinics at gestational age ≥ 34 weeks (n = 200); or upon delivery (n = 120). Maternal risk factors were collected. Vaginal and vagino-rectal samples for GBS and E. coli determination were obtained and characterized in terms of antimicrobial resistance and serotype. Anti-GBS antibodies were also determined. Neonatal follow-up was performed in the first 3 months after birth. Semistructured interviews were performed to investigate acceptability of sample collection methods. RESULTS: In total, 21.3% of women recruited were GBS carriers, while 16.3% were positive for E. coli. Prevalence of HIV was 36.6%. No association was found between being colonized by GBS and E. coli and maternal risk factors. GBS isolates were fully susceptible to penicillin and ampicillin. Serotypes V (32.4%), Ia (14.7%) and III (10.3%) were the most commonly found and 69.2% of the women tested had immunoglobuline G antibodies against GBS. E. coli isolates showed resistance to ampicillin in 28.9% and trimethoprim/sulfamethoxazole in 61.3% of the cases. CONCLUSION: Prevalence of GBS and/or E. coli colonization among pregnant women is high in this semirural community and comparable with those reported in similar settings. Four serotypes accounted for nearly 70% of all isolates of GBS. Population-based data on infant GBS infections would enable the design of prevention strategies for GBS disease in Mozambique

Patterns and factors associated with environmental health practices in households of rural Mozambique

Analytical quantitative studies focusing on health-related behaviours as the final outcomes are scarce, especially in the field of Environmental Health. They have mostly focused on behaviours as risk factors for disease and have rarely dealt with determinants of such behaviours. This study examines the relationship between socio-economic, psycho-social, demographic, and environmental factors and Environmental Health practices at the household level. It further explores, qualitatively, lay perceptions of such practices and illnesses associated with them. An analytical cross-sectional study, complemented by a qualitative study, was the approach chosen for this purpose. Fieldwork took place in Manhiqa, a rural district in Southern Mozambique, from October 2002 to November 2003. The cross-sectional study comprised the following data collection methods: a socio-economic and demographic questionnaire, spot-check observations, and a questionnaire on women's autonomy covering 405 households, and structured observations covering 102 households. The qualitative study comprised 12 focus group discussions (involving 134 people in total) namely with mothers, grandmothers and fathers of children under 5, and 25 semi-structured interviews with caretakers of children under 5. Using factor analysis, three dimensions of wealth (characterising households) and five autonomy constructs (characterising caretakers of children under-5) served as the main predicting factors that the study sought to explore in relation to Household Environmental Health (HHEH) practices. Other predicting factors of interest were type and domain of water source, child's age, and caretaker's age. Prevalence of latrine ownership was high (95%), and so was soap availability (86%). Sixty-two percent of households had access to water from taps (either private or public). However, hand-washing with soap was observed on 6% of occasions after potential faecal contact, and children's stools were disposed of in the latrine on 6% of occasions after open defecation events. In terms of access to hygiene and sanitation hardware, only caretaker's education predicted latrine ownership, and access to soap was associated with caretaker's education, caretaker's exposure to information and socio-economic status of the head of household. With regards to hygiene and sanitation practices, there was no strong evidence for the influence of any of the predicted factors on hand-washing. Socio-economic status of the head of household and type of water source were the only variables significantly associated with safe disposal of stools. Infants under 1 and children between 2 and 5 years of age were the most likely to contaminate the household environment with faeces. Regarding mosquito deterrence practices, it was found that the likelihood that children under 5 were protected by any deterrence method increased with increased caretaker's education and with caretakers decreased proximity to maiden family. Use of traditional fumigation in the child's bedroom was associated with decreased accumulation of modern assets, increased accumulation of traditional assets, and increased caretaker's age. Protecting children under 5 with commercially available products other than bednets was associated with caretaker's education and her financial independence. Bednet use by children was predicted by increased head of household socio-economic status, accumulation of modern assets, and decreased proximity of caretaker to her maiden family. It was also found that certain hygiene and sanitation practices are highly clustered and that there are greater psychosocial connotations carried by sanitation practices than by mosquito deterrence practices. The qualitative study revealed that, from the study participants' perspective, HHEH practices, in particular latrine possession status were associated with the following factors: authority, social commitment, value for self, self-reliance, self-organisation, and completeness. Good fortune was particularly related to bednet possession. Lack of initiative and modernism were personal attributes viewed to be associated with both not having bednets and not having latrines. Through its detailed examination of the associations between individual and household characteristics and behaviour outcomes this study makes an original contribution to our understandiing of how risk and protective practices are produced at household level. This is of interest to those who seek to understand human behaviour from an academic perspective and to those who seek to influence it in order to improve health outcomes. For example, the study adds a contribution to HHEH behaviour change initiatives, especially those that require criteria in order to carry out selective targeting of households according to their social, economic, demographic, or environmental characteristics

High HIV prevalence and incidence among women in Southern Mozambique: Evidence from the MDP microbicide feasibility study.

BackgroundThe study aimed to assess the feasibility of conducting large scale HIV prevention clinical trials in Mozambique by measuring HIV prevalence and incidence among women of reproductive age. This paper describes the baseline socio-demographic characteristics of the Mozambique Microbicides Development Programme (MDP) feasibility cohort, baseline prevalence of HIV and other STIs, and HIV incidence.MethodsThe Mozambique MDP feasibility study was conducted from September 2007 to August 2009 in urban Mavalane and rural Manhiça, in Southern Mozambique. Sexually active, HIV negative women aged 18 years and above were recruited to attend the study clinic every 4 weeks for a total of 40 weeks. At baseline, we collected demographic and sexual behaviour data, samples to test for sexually transmitted infections (STI) and conducted HIV rapid testing. STI and HIV testing were repeated at clinical follow-up visits. We describe HIV prevalence of women at screening, the demographic, behavioural and clinical characteristics of women at enrolment, and HIV incidence during follow-up.ResultsWe screened 793 women (369 at Mavalane and 424 at Manhiça) and enrolled 505 eligible women (254 at Mavalane and 251 at Manhiça). Overall HIV prevalence at screening was 17%; 10% at Mavalane and 22% at Manhiça. Women screened at Manhiça were twice as likely as women screened at Mavalane to be HIV positive and HIV positive status was associated with younger age (18-34), lower educational level, not using a reliable method of contraception and being Zionist compared to other Christian religions. At enrolment contraceptive use was low in both clinics at 19% in Mavalane and 21% in Manhiça, as was reported condom use at last sex act at 48% in Mavalane and 25% in Manhiça. At enrolment, 8% of women tested positive for Trichomonas vaginalis, 2% for Neisseria gonorrhoeae, 4% for Chlamydia trachomatis and 46% for bacterial vaginosis. In Manhiça, 8% of women had active syphilis at screening. HIV incidence was 4.3 per 100 person years at Mavalane and 9.2 per 100 person years at Manhiça.ConclusionsWe demonstrated the ability to recruit a cohort of women at risk of HIV who were willing to participate in clinical research. The high HIV incidence necessitates additional action around HIV prevention for women and offers opportunities to evaluate the impact of available prevention options, such as treatment as prevention and oral PrEP. The high HIV incidence and STI prevalence also offers opportunities to evaluate the added benefit of potential prevention options such as new formulations of oral PrEP, vaginal microbicides (also called topical PrEP), vaccines, and multi-purpose technologies for HIV, STIs and contraception