Settings In sub-Saharan Africa Research Articles

Abstract 38: Setting up a Cancer Clinic in a Low-and-Middle-Income Country (LMIC) in Sub-Saharan Africa: A Case of Taita Taveta County in Kenya.

Abstract Purpose: Quality Cancer treatment is expensive and not accessible to all in LMIC settings in sub-Saharan Africa including Kenya. Despite having a cancer diagnosis, patients and their families not living in major towns and cities, have to travel far to seek treatment incurring cost in transport, upkeep during treatment and out of pocket expenditure to access care. Methods: International Cancer Institute in Eldoret-Kenya, partnered with Taita Taveta County to implement a cancer and other non-communicable disease (NCD) project in August 2020. Taita Taveta County established a technical working group (TWG) in September 2020 to oversee the project activities and identified space and staff to set up a new cancer clinic. ICI provided technical support in project planning, budgeting, capacity/needs assessment, training and mentorship of healthcare providers; and running joint cancer clinics. Results: Periodic review meetings between ICI and Taita Taveta County TWG identified lack of: qualified staff to provide cancer care; cancer screening supplies; and drug stock-outs. In September 2020, ICI and its strategic partners supported Taita Taveta County to launch a Cancer Clinic to provide basic Cancer care. ICI offered trainings and continuous medical education on cancer for 91 healthcare providers both online (26) and on-site (65); ICI provided cervical, breast and prostate cancer screening supplies; established a revolving fund pharmacy as a stop gap measure to drug stock-outs; and held joint cancer clinics twice a month where mentorship and skills training for county staff paired with ICI staff across various disciplines was achieved resulting in the first patient receiving chemotherapy in November 2020; histopathology support was provided for 151 samples. Conclusion: The process of setting up a cancer clinic in a low resource setting requires a systematic needs assessment approach; identifying a core team early that outlines output measures of interest; and having strategic partnership guiding step-by-step developments. Citation Format: Gloria Kitur, Emmah Achieng, Rebecca Mwakichako, Felix Kimotho, Chite Asirwa. Setting up a Cancer Clinic in a Low-and-Middle-Income Country (LMIC) in Sub-Saharan Africa: A Case of Taita Taveta County in Kenya. [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 38.

Abstract 75: Cost-effectiveness Analysis of CHOP and R-CHOP Treatment of Diffuse Large B-cell Lymphoma in Malawi

Abstract Purpose: Cost-effectiveness data for cancer treatment are needed from sub-Saharan Africa (SSA), where diffuse large B-cell lymphoma (DLBCL) is a common, curable cancer. In high-income countries, the standard of care for DLBCL is R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemoimmunotherapy. Rituximab is often not available in SSA due to cost, and treatment with CHOP is common. Methods: We evaluated the cost-effectiveness of DLBCL treatment using Malawi-specific data. Clinical data were from a prospective observational cohort treated with CHOP, as well as a clinical trial of R-CHOP. We used a decision-tree model to calculate costs per disability adjusted life year (DALY) averted from the health system perspective and estimated a willingness to pay (WTP) threshold of three times GDP per capita. Results: On a per-patient level, compared to no chemotherapy, CHOP is estimated to avert 7·9 DALYS, at an incremental cost of $1,500, for an incremental cost-effectiveness ratio (ICER) of $194 per DALY averted, which is well below WTP. In probabilistic sensitivity analysis, CHOP was cost-effective for DLBCL in >99% of simulations. Compared to CHOP, R-CHOP is estimated to avert 2·9 DALYs, at an incremental cost of $3,198 and ICER of $1,104 per DALY averted, which is at the WTP threshold and was below WTP in 45% of simulations. Conclusion: CHOP is cost-effective for DLBCL in Malawi, and the addition of rituximab may be cost-effective. Future studies in SSA and other LMIC settings should include rigorous economic evaluation to promote continued cancer treatment investments and prioritization. Citation Format: Matthew Painschab, Racquel Kohler, Stephen Kimani, Stephanie Wheeler, Satish Gopal. Cost-effectiveness Analysis of CHOP and R-CHOP Treatment of Diffuse Large B-cell Lymphoma in Malawi [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 75.

Steering Sustainable Economic Growth: Entrepreneurial Ecosystem Approach

The importance of entrepreneurship in steering sustained economic growth and improved well-being has been re-echoed over the past decade. Regrettably, the sub-Saharan Africa setting lags behind from the point of harnessing the economic development impact of entrepreneurship, and the obvious implication is ever increasing unemployment and poverty. Utilising a systematic review approach, this article draws from the body of knowledge to shed light on critical strategies towards achieving productive entrepreneurship. Specifically, we forward an entrepreneurial ecosystem framework that underlines the importance of institutional level and enterprise level attributes in achieving effective entrepreneurial ecosystem and maximising economic growth gains. We highlight strategic and pro-active initiatives for ensuring active and ambitious entrepreneurial orientation that will contribute to economic growth and create employment. Towards achieving these targets, we also flag critical policy guides, drawing attention to the facilitating role that governments can play in ensuring an effective and economic growth impacting entrepreneurial ecosystem. Directions for future research have been flagged.

Puberty- and Menstruation-Related Stressors Are Associated with Depression, Anxiety, and Reproductive Tract Infection Symptoms Among Adolescent Girls in Tanzania.

Puberty and menstruation are significant stressors for adolescent girls and young women in low-resource settings in sub-Saharan Africa. However, little is known about the impact of these stressors on girls' mental health and reproductive health. In 2018, a cross-sectional self-report survey was conducted with 581 adolescent girls and young women between 13 to 21years old who had reached menarche and were attending secondary school in Moshi, Tanzania. Structural equation modeling was used to examine the relationships of puberty-related stressors and menstruation-related stressors (menstrual deficits, movement/activity difficulties, and menstrual symptoms) to depression, anxiety, and the likelihood of reporting reproductive tract infection (RTI) symptoms. Puberty-specific stressors, menstrual symptoms, and menstrual deficits were associated with depression and anxiety. Movement/activity difficulties were associated with anxiety. Increases in menstrual symptoms, menstrual deficits, puberty stressors, and depression were associated with an increased likelihood of reporting a lifetime RTI. However, the relationship of puberty stressors and depression with RTIs was no longer significant in two of three models after correcting for Type I error. Overall, puberty- and menstruation-related stressors were associated with mental health and symptoms of reproductive tract infections. This suggests there is an important relationship between stressors specific to adolescent girls and young women during puberty, mental health, and reproductive health. There is a need for adolescent-tailored interventions to reduce the negative impact of stressors among girls transitioning through puberty in sub-Saharan Africa.

Maternal and perinatal outcomes in women with eclampsia by mode of delivery at Riley mother baby hospital: a longitudinal case-series study

BackgroundEclampsia, considered as serious complication of preeclampsia, remains a life-threatening condition among pregnant women. It accounts for 12% of maternal deaths and 16–31% of perinatal deaths worldwide. Most deaths from eclampsia occurred in resource-limited settings of sub-Saharan Africa. This study was performed to determine the optimum mode of delivery, as well as factors associated with the mode of delivery, in women admitted with eclampsia at Riley Mother and Baby Hospital.MethodsThis was a hospital-based longitudinal case-series study conducted at the largest and busiest obstetric unit of the tertiary hospital of western Kenya. Maternal and perinatal variables, such as age, parity, medications, initiation of labour, mode of delivery, admission to the intensive care unit, admission to the newborn care unit, organ injuries, and mortality, were analysed using the Statistical Package for the Social Sciences software version 20.0. Quantitative data were described using frequencies and percentages. The significance of the obtained results was judged at the 5% level. The chi-square test was used for categorical variables, and Fisher’s exact test or the Monte Carlo correction was used for correction of the chi-square test when more than 20% of the cells had an expected count of less than 5.ResultsDuring the study period, 53 patients diagnosed with eclampsia were treated and followed up to 6 weeks postpartum. There was zero maternal mortality; however, perinatal mortality was reported in 9.4%. Parity was statistically associated with an increased odds of adverse perinatal outcomes (p = 0.004, OR = 9.1, 95% CI = 2.0–40.8) and caesarean delivery (p = 0.020, OR = 4.7, 95% CI = 1.3–17.1). In addition, the induction of labour decreased the risk of adverse outcomes (p = 0.232, OR = 0.3, 95% CI = 0.1–2.0).ConclusionThere is no benefit of emergency caesarean section for women with eclampsia. This study showed that induction of labour and vaginal delivery can be successfully achieved in pregnant women with eclampsia. Maternal and perinatal mortality from eclampsia can be prevented through prompt and effective care.

Pratique de l’automesure tensionnelle dans une population d’hypertendus en Afrique subsharienne

AimTo investigate home blood pressure monitoring (HBPM) practice among treated hypertensive patients in a subsaharan Africa setting. Patients and methodsCross-sectional observational study over a five-month period from April 30 to September 30, 2019. The survey was carried out among treated hypertensive patients aged at least 18-years-old, received in outpatient consultations department at the Abidjan Heart Institute during the study period. We assessed the rate of patients performing HBPM, and compared characteristics and rate of blood pressure control between patients according to the realization of HBPM. ResultsThree hundred hypertensive patients (mean age 59.2±12.0 years, sex ratio 1.4) were included. Of these, 68.3% reported to have information about HBPM. In 42.3% of cases, patients had an electronic blood pressure device at home, the majority of which were devices with arm cuffs (65.3%). The study showed that 40.3% of the patients had received education on hBPSM, most commonly provided by practitioners (71.9%). Among our population study, 36.3% performed HBPM, of whom only 13.8% according to the 3-day standardised protocol. In multivariate analysis, HBPM appeared to be an independent factor associated with better blood pressure control. ConclusionHBPM is rarely used by patients with hypertension in our practice. Most of the patients do not receive education about HBPM and adequate training in order to perform it routinely.

Recognition and Management of Pediatric Sepsis in a Resource-Limited Emergency Department in Mwanza, Tanzania: A Qualitative Study.

The World Health Organization aims to reduce worldwide under-five mortality rates (U5MR), with a focus on resource-limited settings (RLS). Tanzania reports a mean U5MR of 54 per 1000 live births, largely due to treatable infectious diseases that may lead to sepsis, accounting for 40% of the under-five deaths. Bugando Medical Centre in Mwanza, Tanzania represents a resource-limited setting in Sub-Saharan Africa and estimates a 14% pediatric mortality rate. We sought to better understand provider experience in recognizing and managing pediatric sepsis in the emergency department (ED) at Bugando Medical Centre in Mwanza, Tanzania. We conducted a qualitative study with a purposive sampling of 14 Bugando Medical Centre ED providers from January to February 2019, via minimally structured interviews, to identify factors influencing the recognition and management of children presenting to the ED with concern for sepsis. Interviews were conducted in English, audio recorded, and transcribed. Data saturation determined the sample size. Three primary coders independently coded all transcripts and developed an initial coding list. Consensus among all authors generated a final coding scheme. A grounded theory approach guided data analysis. We achieved thematic saturation after 13 interviews. Responses identified patient-, provider-, and health care system-related factors influencing sepsis recognition and management in children presenting to the ED. Patient-related factors include the use of traditional healers, limited parent health literacy, and geographic factors impacting access to medical care. Provider-related factors include limited knowledge of pediatric sepsis, lack of a standard communication process among providers, and insufficient experience with procedural skills on children. Health care system-related factors include limited personnel and resources, delayed transfers from referral hospitals, and lack of standard antibiotic-use guidelines. This qualitative study identified patient, provider, and health care system-related factors that influence the emergency care of children with suspected sepsis in a quaternary hospital in Mwanza, Tanzania. These factors may serve as a framework for educational opportunities to improve the early recognition and management of pediatric sepsis in a resource-limited setting.

A land use regression model using machine learning and locally developed low cost particulate matter sensors in Uganda

The application of land use regression (LUR) modeling for estimating air pollution exposure has been used only rarely in sub-Saharan Africa (SSA). This is generally due to a lack of air quality monitoring networks in the region. Low cost air quality sensors developed locally in sub-Saharan Africa presents a sustainable operating mechanism that may help generate the air monitoring data needed for exposure estimation of air pollution with LUR models. The primary objective of our study is to investigate whether a network of locally developed low-cost air quality sensors can be used in LUR modeling for accurately predicting monthly ambient fine particulate matter (PM2.5) air pollution in urban areas of central and eastern Uganda. Secondarily, we aimed to explore whether the application of machine learning (ML) can improve LUR predictions compared to ordinary least squares (OLS) regression. We used data for the entire year of 2020 from a network of 23 PM2.5 low-cost sensors located in urban municipalities of eastern and central Uganda. Between January 1, 2020 and December 31, 2020, these sensors collected highly time-resolved measurement data of PM2.5 air concentrations. We used monthly-averaged PM2.5 concentration data for LUR prediction modeling of monthly PM2.5 concentrations. We used eight different ML base-learner algorithms as well as ensemble modeling. We applied 5-fold cross validation (80% training/20% test random splits) to evaluate the models with resampling and Root mean squared error (RMSE). The relative explanatory power and accuracy of the ML algorithms were evaluated by comparing coefficient of determination (R2) and RMSE, using OLS as the reference approach. The overall average PM2.5 concentration during the study period was 52.22 μg/m3 (IQR: 38.11, 62.84 μg/m3)—well above World Health Organization PM2.5 ambient air guidelines. From the base-learner and ensemble models, RMSE and R2 values ranged between 7.65 μg/m3 – 16.85 μg/m3 and 0.24–0.84, respectively. Extreme gradient boosting (xgbTree) performed best out of the base learner algorithms (R2 = 0.84; RMSE = 7.65 μg/m3). Model performance from ensemble modeling with Lasso and Elastic-Net Regularized Generalized Linear Models (glmnet) did not outperform xgbTree, but prediction performance was comparable to that of xgbTree. The most important temporal and spatial predictors of monthly PM2.5 levels were monthly precipitation, percent of the population using solid fuels for cooking, distance to Lake Victoria, and greenspace (NDVI) within a 500-m buffer of air monitors. In conclusion, data from locally developed low-cost PM sensors provide evidence that they can be used for spatio-temporal prediction modeling of air pollution exposures in Uganda. Moreover, the non-parametric ML and ensemble approaches to LUR modeling clearly outperformed OLS regression algorithm for the prediction of monthly PM2.5 concentrations. Deploying low-cost air quality sensors in concert with implementation of data quality control measures, can help address the critical need for expanding and improving air quality monitoring in resource-constrained settings of sub-Saharan Africa. These low-cost sensors, in conjunction with non-parametric ML algorithms, may provide a rapid path forward for PM2.5 exposure assessment and to spur air pollution epidemiology research in the region.

Water and health in mining settings in sub-Saharan Africa: A mixed methods geospatial visualization.

Industrial mining transforms local landscapes, including important health determinants like clean water and sanitation. In this paper, we combined macro-level quantitative and micro-level qualitative data to show how mining projects affect water infrastructures and ultimately the health of affected communities. Although we observed a positive trend of water infrastructure in mining settings, surrounding communities are also characterized by water scarcity and degradation of water quality. The video at the core of this publication showcases inter-linkages of the findings obtained at both the macro- and the micro-levels, embedding our results in a geospatial context. While mining projects can have positive impacts on the development of local water infrastructure, improved management of negative impacts of mining projects is needed for promoting 'Good health and well-being' and 'Clean water and sanitation' as promulgated by the Sustainable Development Goals of the 2030 Agenda.

Implementing newborn screening for sickle cell disease in Korle Bu Teaching Hospital, Accra: Results and lessons learned.

Early diagnosis of sickle cell disease (SCD) through newborn screening (NBS) is a cost-effective intervention, which reduces morbidity and mortality. In sub-Saharan Africa (SSA) where disease burden is greatest, there are no universal NBS programs and few institutions have the capacity to conduct NBS. We determined the feasibility and challenges of implementing NBS for SCD in Ghana's largest public hospital. The SCD NBS program at Korle Bu Teaching Hospital (KBTH) is a multiyear partnership between the hospital and the SickKids Center for Global Child Health, Toronto, being implemented in phases. The 13-month demonstration phase (June 2017-July 2018) and phase one (November 2018-December 2019) focused on staff training and the feasibility of universal screening of babies born in KBTH. During the demonstration phase, 115 public health nurses and midwives acquired competency in heel stick for dried blood spot sampling. Out of 9990 newborns, 4427 babies (44.3%) were screened, of which 79 (1.8%) were identified with presumptive SCD (P-SCD). Major challenges identified included inadequate nursing staff to perform screening, shortage of screening supplies, and delays in receiving screening results. Strategies to overcome some of the challenges were incorporated into phase one, resulting in increased screening coverage to 83.7%. Implementing NBS for SCD in KBTH presented challenges with implications on achieving and sustaining universal NBS in KBTH and other settings in SSA. Specific steps addressing these challenges comprehensively will help build on the modest initial gains, moving closer toward a sustainable national NBS program.

PrEP reminds me that I am the one to take responsibility of my life: a qualitative study exploring experiences of and attitudes towards pre-exposure prophylaxis use by women in Eswatini

BackgroundPre-exposure-prophylaxis (PrEP) has been heralded for its potential to put women in control of preventing HIV infection, but uptake and continuation rates have been disappointing in high-incidence settings in sub-Saharan Africa. We explored structural and social factors that influenced PrEP use among young women and pregnant or breastfeeding women in rural Eswatini.MethodsWe conducted two in-depth interviews with ten women on PrEP, and one-time in-depth interviews with fourteen women who declined or discontinued PrEP. Interviews covered decision-making processes around PrEP initiation and experiences with pill-taking. In-depth interviews were conducted with nine health workers, covering experiences in delivering PrEP services, and two focus group discussions were held with men to elicit their perceptions of PrEP. Interviews and discussions were audio-recorded, translated, transcribed and analysed thematically, using an inductive approach.ResultsPrEP initiation and use were experienced by many women as empowering them to take control of their health and well-being, and stay HIV free, facilitating them to realise their aspirations relating to motherhood and educational attainment. However, the social norms that defined relationship dynamics with partners or family members either undermined or promoted this empowerment potential. In particular, young women were rarely supported by family members to take PrEP unless it was perceived to be for protecting an unborn child. Stigmatisation of pill-taking through its associations with HIV and the burden of daily pill-taking also contributed to PrEP discontinuation.ConclusionsUnlike many prevention tools, PrEP enabled women to achieve a sense of control over their lives. Nevertheless, women’s agency to continue and adhere to PrEP was influenced by social and structural factors including gender norms, family expectations of young women, relationship dynamics and stigma related to HIV. Future interventions should address these barriers to promote PrEP use among sexually-active women.

The potential role of long-acting injectable cabotegravir–rilpivirine in the treatment of HIV in sub-Saharan Africa: a modelling analysis

SummaryBackgroundThe use of a combination of the integrase inhibitor, cabotegravir, and the non-nucleoside reverse transcriptase inhibitor, rilpivirine, in a long-acting injectable form is being considered as an antiretroviral treatment option for people with HIV in sub-Saharan Africa. We aimed to model the effects of injectable cabotegravir–rilpivirine to help to inform its potential effectiveness and cost-effectiveness under different possible policies for its introduction.MethodsWe used an existing individual-based model of HIV to predict the effects of introducing monthly injections of cabotegravir–rilpivirine for people with HIV in low-income settings in sub-Saharan Africa. We evaluated policies in the context of 1000 setting scenarios that reflected characteristics of HIV epidemics and programmes in sub-Saharan Africa. We compared three policies for introduction of injectable cabotegravir–rilpivirine with continued use of dolutegravir-based oral regimens for: all individuals on antiretroviral therapy (ART); individuals with a recently measured viral load of more than 1000 copies per mL (signifying poor adherence to oral drugs, and often associated with drug resistance); and individuals with a recently measured viral load of less than 1000 copies per mL (a group with a lower prevalence of pre-existing drug resistance). We also did cost-effectiveness analysis, taking a health system perspective over a 10 year period, with 3% discounting of disability-adjusted life-years (DALYs) and costs. A cost-effectiveness threshold of US$500 per DALY averted was used to establish if a policy was cost-effective.FindingsIn our model, all policies involving the introduction of injectable cabotegravir–rilpivirine were predicted to lead to an increased proportion of people with HIV on ART, increased viral load suppression, and decreased AIDS-related mortality, with lesser benefits in people with a recently measured viral load of less than 1000 copies per mL. Its introduction is also predicted to lead to increases in resistance to integrase inhibitors and non-nucleoside reverse transcriptase inhibitors if introduced in all people with HIV on ART or in those with a recently measured viral load of less than 1000 copies per mL, but to a lesser extent if introduced in people with more than 1000 copies per mL due to concentration of its use in people less adherent to oral therapy. Consistent with the effect on AIDS-related mortality, all approaches to the introduction of injectable cabotegravir–rilpivirine are predicted to avert DALYs. Assuming a cost of $120 per person per year, use of this regimen in people with a recently measured viral load of more than 1000 copies per mL was borderline cost-effective (median cost per DALY averted across setting scenarios $404). The other approaches considered for its use are unlikely to be cost-effective unless the cost per year of injectable cabotegravir–rilpivirine is considerably reduced.InterpretationOur modelling suggests that injectable cabotegravir–rilpivirine offers potential benefits; however, to be a cost-effective option, its introduction might need to be carefully targeted to individuals with HIV who might otherwise have suboptimal adherence to ART. As data accumulate from trials and implementation studies, such findings can be incorporated into the model to better inform on the full consequences of policy alternatives.FundingBill & Melinda Gates Foundation, including through the HIV Modelling Consortium (OPP1191655).

Barriers to access and utilization of healthcare by children with neurological impairments and disability in low-and middle-income countries: a systematic review

Background: Neurological impairments (NI) and disability are common among survivors of childhood mortality in low-and middle-income countries (LMICs). We conducted a systematic review to examine the barriers limiting access and utilization of biomedical care by children and adolescents with NI in LMICs. Methods: We searched PubMed, Latin America and Caribbean Health Sciences Literature, Global Index Medicus, and Google Scholar for studies published between 01/01/1990 and 14/11/2019 to identify relevant studies. We included all reports on barriers limiting access and utilization of preventive, curative, and rehabilitative care for children aged 0-19 years with NI in five domains: epilepsy, and cognitive, auditory, visual, and motor function impairment. Data from primary studies were synthesized using both qualitative and quantitative approaches, and we report a synthesized analysis of the barriers identified in the primary studies. Results: Our literature searches identified 3,074 reports of which 16 were included in the final analysis. Fourteen studies (87.5%) originated from rural settings in sub-Saharan Africa (SSA). Factors limiting access and utilization of healthcare services in >50% of the studies were: financial constraints (N=15, 93.8%), geographical inaccessibility (N=11, 68.8%), inadequate healthcare resources (N=11, 68.8%), inadequate education/awareness (N=9, 56.3%), and prohibitive culture/beliefs (N=9, 56.3%). Factors reported in <50% of the studies related to the attitude of the patient, health worker, or society (N=7, 43.8%), poor doctor-patient communication (N=5, 31.3%), physical inaccessibility (N=3, 18.8%), and a lack of confidentiality for personal information (N=2, 12.5%). Very few reports were identified from outside Africa preventing a statistical analysis by continent and economic level. Conclusions: Financial constraints, geographic inaccessibility, and inadequate healthcare resources were the most common barriers limiting access and utilization of healthcare services by children with NI in LMICs. PROSPERO registration: CRD42020165296 (28/04/2020)

Towards poverty alleviation in developing countries: An empirical study of the impact of land tenure reforms in Kati, Mali.

Post-colonial land tenure reforms in emerging countries have partly aimed at poverty reduction through equitable land access. However, the poverty rate keeps rising in rural and peri-urban settings in Sub-Saharan Africa dominated by agricultural activities. This article reviews land tenure reforms in Mali, from the year 2000 to 2017 regarding poverty alleviation and evaluates their impacts on indigenous smallholder farmers, using multiple linear and logistic regression models and local experts’ elicitations. The results indicate that the advent of land titles as the only definitive evidence of land ownership, following the reforms, has generally weakened customary land management. Smallholder farmers face several barriers to obtaining land titles, limiting equity in land access and security. This has paved way for land markets marred by irregularities and resulted in colossal loss of agricultural lands, which are the main source of rural livelihood. Thus, the reforms have not yielded the intended poverty reduction outcomes. The study recommends that land transfers must be authorised by a single institution, represented at the various administrative levels, which issues an authentic and incorruptible document using appropriate technology. Moreover, since pro-poor provisions in the reforms usually lack implementing decrees in Mali, political will is key to achieving equitable land access and security.

Akwenda intervention programme for children and youth with cerebral palsy in a low-resource setting in sub-Saharan Africa: protocol for a quasi-randomised controlled study

IntroductionCerebral palsy (CP) is the most common childhood-onset motor disorder accompanied by associated impairments, placing a heavy burden on families and health systems. Most children with CP live in low/middle-income...

Community-driven citizen science approach to explore cardiovascular disease risk perception, and develop prevention advocacy strategies in sub-Saharan Africa: a programme protocol

BackgroundIn sub-Saharan Africa (SSA), which experiences a disproportionately high cardiovascular disease (CVD) burden, population-based screening and prevention measures are hampered by low levels of knowledge about CVD and associated risk factors, and inaccurate perceptions of severity of risk.MethodsThis protocol describes the planned processes for implementing community-driven participatory research, using a citizen science method to explore CVD risk perceptions and to develop community-specific advocacy and prevention strategies in the rural and urban SSA settings. Multi-disciplinary research teams in four selected African countries will engage with and train community members living in rural and urban communities as citizen scientists to facilitate conceptualization, co-designing of research, data gathering, and co-creation of knowledge that can lead to a shared agenda to support collaborative participation in community-engaged science. The emphasis is on robust community engagement, using mobile technology to support data gathering, participatory learning, and co-creation of knowledge and disease prevention advocacy.DiscussionContextual processes applied and lessons learned in specific settings will support redefining or disassembling boundaries in participatory science to foster effective implementation of sustainable prevention intervention programmes in Low- and Middle-income countries.

Intimate Partners Violence in Sub-Saharan Africa: Review of Risk Factors and Impacts

Background: Intimate Partner Violence (IPV) against women is one of the most known public health concerns. The depth of the problem varies across regions and different settings. The purpose of this scooping review is to assess the overall prevalence and risk factors of IPV in the context of Sub-Saharan Africa (SSA).
 Methods: The review was conducted based on 24 articles selected from PubMed and google search. The selection considered only those conducted in SSA based on a representative sample size of women of reproductive age (15-49), published in peer-reviewed journals in the last ten years, and those having resemblance in study design and conceptualization of IPV.
 Results: While slight methodological variations exist among the individual studies, nearly all the reported prevalence of IPV were unacceptably high. The lifetime experience of IPV ranged from about 20% in some societies to more than 75% in other settings. Physical and emotional violence were the most frequently reported type of IPV. One common feature of all studies reviewed is that they all recognized the important role of women’s attitude (acceptance) towards their experience of IPV. Good proportion (ranging between 33-57%) of women justified IPV more often than men do. The studies further documented a wide range of risk factors associated with IPV, more importantly, low maternal and paternal education, partner's alcohol drinking behavior, childhood experience of domestic violence, and certain household and community/cultural factors.
 Conclusion: Given considerable proportion of women experienced one or more forms of IPV in most settings in SSA, national and local governments have a long way to go in preventing or reducing its occurrence in their geographic areas if they must meet SDG 3 (i.e., better health of children and women). Since IPV is embedded in most cultures; concerned authorities should establish appropriate norms, enhance women's status, and ensure proper implementation of policies and laws on abuse. Community reflections, mass education/ behavioral change communications are essential in this endeavor.

Relevance of Antibiotic Prophylaxis in Non-Mesh Inguinal Hernia Repair in Remote and Poor Medical Settings in Sub-Saharan Africa

Background: Because of the poor local medical conditions, and because the surgical site infection (SSI) rate after hernia repair in sub-Saharan Africa is higher than in developed countries, deployed surgeons within Role 2 usually perform non-mesh inguinal herniorrhaphy. Regarding antimicrobial prophylaxis, the latter currently is not recommended in non-mesh inguinal hernia repairs. Our study aimed at assessing the relevance of antibiotic prophylaxis in non-mesh inguinal hernia repair within a Role 2 surgical structure deployed in sub-Saharan Africa. Methods: From January 1 to December 31, 2019, we conducted a non-randomized prospective study in a French Role 2 military surgical structure deployed to Abidjan, Republic of Côte d'Ivoire. We included all patients presenting with uncomplicated inguinal hernia. All subjects underwent open herniorrhaphy through a groin incision. The primary endpoint was the occurrence of an SSI. Results: We recorded 120 open hernia repairs. Antimicrobial prophylaxis was administered in 70 interventions (60%). An SSI was reported in 13 cases (11%). Multivariable logistic regression analysis of SSI occurrence, according to the administration of intra-operative antimicrobial prophylaxis, showed a 0.219 odds ratio with a 95% confidence interval of 0.05-0.84 and p = 0.028. This finding was in favor of its significant protective effect on the risk of SSI after open non-mesh inguinal hernia repair, taking into account the American Society of Anesthesiologists score, Body Mass Index, and recurrence status. Conclusion: Administration of intra-operative antimicrobial prophylaxis in open non-mesh inguinal hernia repair in remote and poor medical settings, for example during deployment conditions as in our study, was associated with a reduction of the SSI rate.

"I Just Decided to Stop:" Understanding PrEP Discontinuation Among Individuals Initiating PrEP in HIV Care Centers in Kenya.

Preexposure prophylaxis (PrEP) discontinuation rates in clinical trials and demonstration projects have been well characterized; however, little is known about discontinuation in routine public health settings in sub-Saharan Africa. Understanding discontinuation in nonstudy settings is important for establishing expectations for PrEP continuation in national programs and for facilitating effective PrEP scale-up. We conducted in-depth interviews with 46 individuals who had initiated PrEP at 25 HIV comprehensive care clinics (CCCs) in central and western Kenya and whose clinic records indicated they had discontinued. Many of our study participants discontinued PrEP when their perceived risk decreased (eg, hiatus or end of a sexual relationship or partner known to be living with HIV became virally suppressed). Others reported discontinuation due to side effects, daily pill burden, preference for condoms, or their partner's insistence. Participant narratives frequently described facility level factors such as stigma-related discomforts with accessing PrEP at CCCs, inconvenient clinic location or operating hours, long wait times, and short refill dates as discouraging factors, suggesting actionable areas for improving PrEP access and continuation. Clients frequently make intentional decisions to discontinue PrEP as they weigh different prevention options within the context of complex lives. Many clients will decide to discontinue PrEP when perceiving themselves to be at reduced risk and PrEP counseling must include provisions for addressing seasons of risk. PrEP will not be the right prevention method for everyone, or forever. Expanding PrEP access points and increasing sex-positive messaging may facilitate PrEP being a better option for many.

National standard treatment guidelines: their impact on medicine use indicators in a resource-limited setting

Abstract Objectives Standard treatment guidelines improve patient care outcomes. Few studies assess the impact of standard treatment guidelines on population-level medicine use indicators in resource limited settings in sub-Saharan Africa, where the burden of disease is greatest. The objective of this study was to determine the immediate and long-term impact of the national standard treatment guidelines on medicine use indicators at the population-level in Namibia. Methods An interrupted time-series modeling of the impact of national standard treatment guidelines implemented in Namibia in 2011, on population-level medicine use indicators. Antibiotic, generic and polypharmacy prescribing indicators were abstracted from the national Pharmaceutical Information System, over an eight-year period, 2007– 2015. This generated 15-quarterly time points. The impact was estimated by changes in trends of the indicators, immediately and after the intervention using R-software. The immediate impact was reflected by level change while long term impact was determined by trends/quarterly change after standard treatment guideline implementation. Key findings Data points from 522 Pharmaceutical Information System reports from 38 health facilities were included. The eight-year period estimates were, 2.9 ± 0.1 medicines prescribed per outpatient, 48.1 ± 2.5% of prescriptions had an antibiotic and 74.0 ± 4.2% of medicines were prescribed by generic name. Of the 13 regions, 61.3% and 53.8% had a decline in the average medicines per prescription and prescriptions with antibiotics respectively, as well as 53.8% of the regions had an increase in prescribing of generic medicines immediately after implementation of the standard treatment guidelines. Thereafter, quarterly trends in the three indicators did not significantly improve after the intervention at national and in all regions, except for generic prescribing in Oshikoto region, 4.5% (95% CI: 2.6 – 6.3%, P < 0.001). Conclusion Whilst national standard treatment guidelines immediately improved medicine use indicators, it is discouraging that the improvement over time was marginal across regions and was not sustained at the national level. Robust point of care interventions is needed for sustained and effective implementation of standard treatment guidelines.