Implementation of the vaccination program in Guinea-Bissau: Coverage and missed opportunities for BCG at birth.

BACKGROUND: The Bacillus Calmette-Guérin (BCG) vaccine is recommended at birth in Guinea-Bissau but often given with delay. Delays are not evident in routine coverage estimates since coverage is measured by 12 months of age. Studies show that BCG protects against other infections than tuberculosis and lowers neonatal mortality. Hence, the timing of BCG is important since the children should benefit from these non-specific effects as early as possible. METHODS: Using data from a nationally representative health and demographic surveillance system in Guinea-Bissau, we assessed BCG coverage at birth (within the first 3 days of life), 1 month, and 12 months for children born in 2013-19. We measured the proportion of children who had a documented health system contact within the first 3 days of life, thus an opportunity for BCG at birth, and whether the opportunities were utilized. In binomial regression models, we investigated factors associated with missed opportunities for vaccination. RESULTS: Among the 22,178 children only 19 % were vaccinated at birth. By 1 month and 12 months, BCG coverages were 64 % and 93 %. The timeliness of BCG improved over time, with coverage at birth increasing from 16 % in 2013 to 25 % in 2019 and 1-month coverage from 63 % in 2013 to 75 % in 2019. If all vaccination opportunities had been utilized, the BCG coverage at birth could have reached 45 % (in the 1-month cohort) instead of the actual coverage of 19 %, as only 40 % of the vaccination opportunities were utilized. Region of residence was associated with having a missed opportunity for vaccination. CONCLUSION: The high coverage estimates at 12 months falsely imply that the vaccine is being administered according to the recommended schedule. Our findings suggest that early coverage could be markedly improved by ensuring that children are vaccinated at their first contact with the health system.

HIV testing and associated factors among female sex workers in Tanzania: approaching the first 90% target?

Use of HIV testing services among FSW in sub-Saharan Africa (SSA) is below the desired UNAIDS target of 90%. We estimated the prevalence and factors associated with HIV testing among FSW in Dar es Salaam, Tanzania. A respondent-driven sampling method was used to recruit FSW aged 18. Modified Poisson regression models were used to determine factors associated with recent HIV testing. Of 958 surveyed FSW (median age 26 years), 85.4% (95% CI: 82.3, 88.1) reported to have ever been tested for HIV and 65.3% (95% CI: 61.2, 69.3) tested in the past 12 months. Condom use on the last day worked (prevalence ratio (PR) = 1.17; 95% CI: 0.99, 1.38), no or low self-perceived risk of HIV acquisition (PR = 1.16; 95% CI: 1.02, 1.32), having never felt stigmatized as a sex worker (PR = 1.18; 95% CI: 1.04, 1.33), and having been in contact with a peer educator (PR = 1.33; 95% CI: 1.18, 1.49) during the past year preceding the survey were associated with recent HIV testing. Interventions aiming to mitigate stigma due to sex work, improve health education to address risk perception as a barrier to HIV testing, and scaling up peer educator's engagement should be given priority.

Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study).

While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained.Trial registration number: NCT04685668.

Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study.

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study's programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen - safe and respectful clinical childbirth care - is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants' motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.

Building Strong Primary Health Care to Tackle the Growing Burden of Non-Communicable Diseases in Nepal.

Nepal is currently facing a double burden of non-communicable diseases (NCDs) and communicable diseases, with rising trends of NCDs. This situation will add great pressure to already fragile health systems and pose a major challenge to the country's development unless urgent action is taken. While the primary health care approach offers a common platform to effectively address NCDs through preventive and curative interventions, yet its potential is not fully tapped in Nepal. In line with the Alma Ata and Astana Declarations, we propose an integrated approach for Nepal, and other low-and middle-income countries, including six key reforms to enhance the primary care response to the increasing burdens of NCDs.

Intimate partner violence during pregnancy in Vietnam: prevalence, risk factors and the role of social support.

Background: Violence against women is a global public health problem. A better understanding of risk factors for intimate partner violence (IPV) exposure during pregnancy is important to develop interventions for supporting women being exposed to IPV. Objective: The purpose of this study was to measure the prevalence of IPV during pregnancy and analyse how social support and various risk factors are associated with IPV. Methods: A cross-sectional study conducted among 1309 pregnant women in Dong Anh district, Vietnam. Information about socio-economic conditions and previous exposure to IPV was collected when women attended antenatal care before the 24th gestational week. Information about social support information and exposure to IPV during pregnancy was collected in the 30th-34th gestational week. Multivariable regression was used to identify associations between IPV, social support and other potential risk factors. Results: The prevalence of IPV exposure during pregnancy was 35.2% (Emotional violence: 32.2%; physical violence: 3.5% and sexual violence: 9.9%). There was a statistically significant association between previous IPV exposure, lack of social support and IPV exposure during pregnancy. After adjustment for socioeconomic characteristics, pregnant women who had previously been exposed to IPV were more likely to be exposed IPV at least one time (AOR = 6.3; 95% CI: 4.9-8.2) as well as multiple times (AOR = 6.0; 95% CI: 4.5-8.0). Similarly, pregnant women having a lack of social support had a higher likelihood of being exposed to IPV at least one time (AOR = 3.1; 95% CI: 2.4-3.9) or multiple times (AOR = 2.9; 95% CI: 2.2-3.8). Conclusion: IPV is relatively high during pregnancy in Vietnam. Previous exposure to IPV and lack of social support is associated with increased risk of violence exposure among pregnant women in Vietnam.

'It brought joy in my home as in the area of my wife.' How recently circumcised adult men ascribe value to and make sense of male circumcision.

The present study used a phenomenological approach to explore the everyday-life experiences of male circumcision (MC) and to learn how recently circumcised men ascribe value to and make sense of MC. Thirteen recently circumcised Zambian men were identified through the snowball technique and interviewed using a semi-structured interviewer's guide. Findings indicate that the post-operational experience of adult MC smoothly fits into the everyday-life experience of the men interviewed and is perceived and experienced as a broader social health issue, which largely transcends both the personal HIV risk of the individual male and the private sphere. The study provides three important lessons for MC programmes: (1) the broad social aspects of MC put forward by the interviewees suggest the potential for a popular intervention and, consequently, a large uptake of MC; (2) findings suggest that in addition to emphasising the HIV protective effect of MC, MC promotion should also highlight the social, sexual and romantic values perceived and experienced by the interviewees of this study; (3) the analysis reveals potentially harmful misconceptions about the health benefits of MC, demonstrating the importance of proper pre- and post-circumcision counselling as well as public health messages related to MC.