Sexual health knowledge acquisition processes among very young adolescent girls in rural Malawi: Implications for sexual and reproductive health programs.

Early adolescence is a period characterized by enormous biological, cognitive, sexual, emotional, and social changes. Sexual curiosity and the desire to acquire sexual health (SH) information are part of these developments. Understanding the SH knowledge acquisition process is critical for designing interventions that can best support very young adolescents (VYAs). This study explored the SH knowledge acquisition processes among VYA girls aged 10 to 14 years who attended the DREAMs Girl Only Clubs (GOCs) and those who did not. The GOCs were a part of a larger comprehensive HIV prevention project called DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) which provided an evidence-based core package of interventions to VYAs to prevent HIV. In-depth interviews were conducted with 43 VYA girls aged 10-14 years in two rural southern districts of Zomba and Machinga in Malawi. Twenty-three VYA girls were GOC participants and 20 VYAs were not. Guided by the Social Ecological Model, a thematic analysis approach was used to analyze the data with the assistance of Nvivo 12 software. The SH knowledge acquisition processes were the interaction of various factors at the microsystem (self-efficacy, attitudes, trust and the beginning of menstruation), mesosystem (communication of SH issues between VYAs and their immediate family and peers), and exosystem levels (availability of life skills programs and mother-groups in schools and availability of GOCs). Compared to Non-GOC participants, GOC participants demonstrated an in-depth knowledge of SH issues and positive sexual behaviors such as HIV testing. Limitations to SH knowledge acquisition were adult messages' focus on sexual relationship avoidance and on girls who have started menstruation; the perception of adults not being knowledgeable about SH and school teachers hiding some SH information. VYAs' SH interventions that provide VYAs with accurate, consistent, and age-appropriate SH information such as the GOCs have the potential to address the limitations that other sources have in reaching VYAs. Integrating such interventions with programs that empower parents, other adults, and teachers with comprehensive SH information and with skills on how to deliver SH information to VYAs can enhance VYAs' SH knowledge acquisition and influence positive behavior change.

Social support and very young adolescent girl's knowledge on sexual relationships: A comparative qualitative study of Girl Only Clubs' participants and non-participants in rural Malawi.

Early sexual relationships are associated with an increased risk of acquiring sexually transmitted diseases including HIV/AIDs, teenage pregnancies, and unsafe abortions among other negative health outcomes. Understanding sexual relationships among very young adolescents (VYAs) is important to equip them to protect themselves from negative sexual health (SH) outcomes. DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) is an HIV prevention initiative that provided an evidence-based core package of interventions to VYAs to prevent HIV acquisition in 15 countries in sub-Saharan Africa. The Girl Only Club (GOC) was the primary context for the interventions. Our objective in this study was to explore if there was any difference in social support (SS) received concerning sexual relationships between the VYA girls who attended GOCs and those who did not. In-depth interviews were conducted with 43 VYA girls, aged 10-14 years, in two rural southern districts, Zomba and Machinga, in Malawi. Twenty-three VYA girls were participants in GOCs and 20 VYA girls did not participate. A thematic, descriptive approach that involved a constant comparative analysis guided the data analysis, and Nvivo 12 software was used. In both study sites available SS concerning sexual relationships is informational support including information from parents, older relatives, and friends. However, club participants differed from non-club participants in sexual and reproductive health (SRH) knowledge and use. Club participants reported consulting others on decision-making and information on sexual relationships; receiving detailed SH information from clubs; condom use due to education received from the clubs; quitting sexual relationships; and correcting misinformation with club information. GOC participants received more SS which made them more knowledgeable and better at handling sexual relationship issues than those not in clubs. Interventions that integrate SS including social asset building and safe spaces are critical for VYA SRH programming.

Adolescent sexual health interventions that include very young adolescents in sub-Saharan Africa: a scoping review protocol.

INTRODUCTION: Targeting very young adolescents (VYAs) with sexual health (SH) interventions is increasingly being recognised as one of the strategies for addressing SH challenges in late adolescence. However, there is a dearth of literature regarding SH interventions implemented specifically for VYAs in sub-Saharan Africa (SSA). This scoping review aims to provide a summary of documented evidence on SH interventions that include VYAs in SSA, identify gaps in existing interventions and provide recommendations for further programmatic work on SH for VYAs. METHODS AND ANALYSIS: The methods for this scoping review will be guided by the framework proposed by Arksey and O'Malley and further enhanced by Levac et al and the Joanna Briggs Institute. We will search electronic databases: Popline, EMBASE, PubMed, CINAHL, Dimensions, African Journals Online (AJOL) and specific summon country-specific search. We will include published studies from SSA and only adolescent SH interventions published from the year 2003-2022. Furthermore, we will include programmatic and intervention literature that has not been published in peer-reviewed articles. The data will be charted using the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review. The data will then be collated and summarised. ETHICS AND DISSEMINATION: The scoping review methodology involves putting together information from articles or grey literature that is either publicly available or shared by the authors, this study does not require ethical approval. Findings of this scoping review will be published in a scientific journal and presented at relevant scientific fora and conferences. This scoping review will provide a comprehensive overview of the evidence base of adolescent SH interventions for VYAs in SSA and will highlight critical gaps in the existing interventions and areas where further programmatic work is needed for VYAs in SSA. REGISTRATION: https://archive.org/details/osf-registrations-gn538-v1.

Spatial disparities in impoverishing effects of out-of-pocket health payments in Malawi.

BACKGROUND: Out-of-pocket health payments as a means of financing health services are a cause of concern among households in low and middle-income countries. They prevent households from accessing health care services, can disrupt households' living standards by reducing consumption of other basic needs and push households into poverty. Previous studies have reported geographical variations in impoverishing effects of out-of-pocket health payments. Yet, we know relatively little about spatial effects on impoverishing effects of health payments. OBJECTIVE: This paper assesses the factors associated with impoverishing effects of health payments and quantifies the role of districts spatial effects on impoverishment in Malawi. METHODS: The paper uses a cross sectional integrated household survey data collected from April 2016 to April 2017 among 12447 households in Malawi. Impoverishing effect of out-of-pocket health payments was calculated as the difference between poverty head count ratio before and after subtracting health payments from total household consumption expenditures. We assessed the factors associated with impoverishment and quantified the role of spatial effects using a spatial multilevel model. RESULTS: About 1.6% and 1.2% of the Malawian population were pushed below the national and international poverty line of US$1.90 respectively due health payments. We found significant spatial variations in impoverishment across districts with higher spatial residual effects clustering in central region districts. Higher socio-economic status (AOR=0.34, 95% CI=0.22-0.52) decreased the risk of impoverishment whereas hospitalizations (AOR=3.63, 95% CI 2.54-5.15), chronic illness (AOR=1.56, 95% CI=1.10-1.22), residency in rural area (AOR=2.03, 95% CI=1.07-4.26) increased the risk of impoverishment. CONCLUSIONS: Our study suggests the need to plan financial protection programs according to district specific needs and target the poor, residents of rural areas and those with chronic illnesses. Policy makers need to pay attention to the importance of spatial and neighborhood effects when designing financial protection programs and policies.

Decomposing socio-economic inequality in catastrophic out-of-pocket health expenditures in Malawi.

Reducing health inequalities and inequities is one of the key goals that health systems aspire to achieve as it ensures improvement in health outcomes among all population groups. Addressing the factors contributing to inequality in catastrophic health expenditures is important to reducing inequality in the burden of health expenditures. However, there are limited studies to explain the factors contributing to inequalities in catastrophic health expenditures. The study aimed to measure and decompose socio-economic inequality in catastrophic health into its determinants. Data for the analysis come from the fourth integrated household survey. Data for 12447 households in Malawi were collected from April 2016 to April 2017 by the National Statistical Office. The secondary analysis was conducted from June 2021 to October 2021. Catastrophic health expenditure was estimated as a proportion of households whose out-of-pocket health expenditures as a ratio of non-food consumption expenditures exceeds 40% threshold level. We estimated the magnitude of socio-economic inequality using the Erreygers corrected concentration index and used decomposition analysis to assess the contribution of inequality in each determinant of catastrophic health expenditure to the overall socio-economic inequality. The magnitude of the Erreygers corrected concentration index of catastrophic health expenditure (CI = 0.004) is small and positive which indicates that inequality is concentrated among the better-off. Inequality in catastrophic health expenditure is largely due to inequalities in rural residency (127%), socio-economic status (-40%), household size (14%), presence of a child under five years old (10%) and region of the household (10%). The findings indicate that socio-economic inequality in catastrophic health expenditures is concentrated among the better-off in Malawi. The results imply that policies that aim to reduce inequalities in catastrophic health expenditures should simultaneously address urban-rural and income inequalities.

Correction: Examining the incidence of catastrophic health expenditures and its determinants using multilevel logistic regression in Malawi.

[This corrects the article DOI: 10.1371/journal.pone.0248752.].

Girl-only clubs' influence on SRH knowledge, HIV risk reduction, and negative SRH outcomes among very young adolescent girls in rural Malawi.

BACKGROUND: Early adolescence is an important period to lay the foundation for positive sexual health development that can overcome sexual and reproductive health (SRH) challenges faced by very young adolescents (VYAs) as they reach puberty and sexual debut. In this study, we explored the following questions: first, what are the experiences of VYA girls on DREAMS' Go Girl club participation? Second, how does club participation influence the VYAs SRH knowledge to reduce their risk for HIV and negative sexual health outcomes? METHODS: This was a qualitative study in which twenty-three in-depth interviews were conducted with VYA girls aged 12-14 years. These girls were enrolled in girl-only clubs in two rural southern districts in Malawi. The clubs were a part of larger comprehensive HIV prevention project called DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) which provided an evidence-based core package of interventions to VYAs to prevent HIV. Interventions included improved access to key health services, education support, social skills, asset building, and economic strengthening. Narrative inquiry was used to generate first-hand accounts of the girls' experiences with club participation. Thematic analysis was used to generate themes from the transcribed stories. RESULTS: Six main themes were generated: 1) reasons for joining the clubs with desire to learn about SRH as a motivation for joining the clubs.; 2) influence on gender norms and roles whereby participants described a change of gender roles and norms at home; 3) influence on child abuse practices whereby participants reported a decline in child abusive practices at home;4) influence on life skills and social networks whereby participants described learning about networking; 5) support to go back to school whereby out-of-school girls described how economic empowerment of their guardians facilitated their return to school; and 6) influence of clubs on SRH knowledge acquisition and behaviours whereby participants described acquiring knowledge on sexual health issues. CONCLUSION: Girls-only HIV and SRH programs coupled with economic empowerment for their families can be effective in keeping VYA girls in school and improving SRH knowledge and health seeking behavior.

Examining the incidence of catastrophic health expenditures and its determinants using multilevel logistic regression in Malawi.

BACKGROUND: Despite a free access to public health services policy in most sub-Saharan African countries, households still contribute to total health expenditures through out-of-pocket expenditures. This reliance on out-of-pocket expenditures places households at a risk of catastrophic health expenditures and impoverishment. This study examined the incidence of catastrophic health expenditures, impoverishing effects of out-of-pocket expenditures on households and factors associated with catastrophic expenditures in Malawi. METHODS: We conducted a secondary analysis of the most recent nationally representative integrated household survey conducted by the National Statistical Office between April 2016 to 2017 in Malawi with a sample size of 12447 households. Catastrophic health expenditures were estimated based on household annual nonfood expenditures and total household annual expenditures. We estimated incidence of catastrophic health expenditures as the proportion of households whose out-of-pocket expenditures exceed 40% threshold level of non-food expenditures and 10% of total annual expenditures. Impoverishing effect of out-of-pocket health expenditures on households was estimated as the difference between poverty head count before and after accounting for household health payments. We used a multilevel binary logistic regression model to assess factors associated with catastrophic health expenditures. RESULTS: A total of 167 households (1.37%) incurred catastrophic health expenditures. These households on average spend over 52% of household nonfood expenditures on health care. 1.6% of Malawians are impoverished due to out-of-pocket health expenditures. Visiting a religious health facility (AOR = 2.27,95% CI:1.24-4.15), hospitalization (AOR = 6.03,95% CI:4.08-8.90), larger household size (AOR = 1.20,95% CI:1.24-1.34), higher socioeconomic status (AOR = 2.94,95% CI:1.39-6.19), living in central region (AOR = 3.54,95% CI:1.79-6.97) and rural areas (AOR = 5.13,95% CI:2.14-12.29) increased the odds of incurring catastrophic expenditures. CONCLUSION: The risk of catastrophic health expenditures and impoverishment persists in Malawi. This calls for government to improve the challenges faced by the free public health services and design better prepayment mechanisms to protect more vulnerable groups of the population from the burden of out-of-pocket payments.

Household knowledge, perceptions and practices of mosquito larval source management for malaria prevention and control in Mwanza district, Malawi: a cross-sectional study.

BACKGROUND: Mosquito larval source management (LSM) is a key outdoor malaria vector control strategy in rural communities in sub-Saharan Africa. Knowledge of this strategy is important for optimal design and implementation of effective malaria control interventions in this region. This study assessed household knowledge, perceptions and practices of mosquito LSM methods (draining stagnant water, larviciding, clearing grass/bushes and clean environment). METHODS: A cross-sectional design was used whereby 479 households were selected using two-stage sampling in Mwanza district, Malawi. A household questionnaire was administered to an adult member of the house. Respondents were asked questions on knowledge, perceptions and practices of mosquito LSM methods. Multivariable logistic regression model was used to identify factors associated with high-level knowledge of mosquito LSM methods. RESULTS: Majority of the respondents (64.5%) had high-level knowledge of mosquito LSM methods. Specifically, 63.7% (200/314) had positive perceptions about draining stagnant water, whereas 95.3% (223/234) practiced clean environment for malaria control and 5.2% had knowledge about larviciding. Compared to respondents with primary education, those with secondary education were more likely, whereas those without education were less likely, to have high-level knowledge of mosquito LSM methods (AOR = 3.54, 95% CI 1.45-8.63 and AOR = 0.38, 95% CI 0.23-0.64, respectively). Compared to respondents engaged in crop farming, those engaged in mixed farming (including pastoralists) and the self-employed (including business persons) were more likely to have high-level knowledge of mosquito LSM methods (AOR = 6.95, 95% CI 3.39-14.23 and AOR = 3.61, 95% CI 1.47-8.86, respectively). Respondents living in mud-walled households were less likely to have high-knowledge of mosquito LSM methods than those living in brick-walled households (AOR = 0.50, 95% CI 0.30-0.86). CONCLUSIONS: A high-level knowledge of mosquito LSM methods was established. However, when designing and implementing this strategy, specific attention should be paid to the uneducated, crop farmers and those living in poor households.

Family group decision-making for children at risk of abuse or neglect: A systematic review.

Background: Capturing the scale of child maltreatment is difficult, but few would argue that it is anything less than a global problem which can affect victims' health and well-being throughout their life. Systems of detection, investigation and intervention for maltreated children are the subject of continued review and debate. Objectives: To assess the effectiveness of the formal use of family group decision-making (FGDM) in terms of child safety, permanence (of child's living situation), child and family well-being, and client satisfaction with the decision-making process. Search Methods: Both published and unpublished manuscripts were considered eligible for this review. Library staff from Scholarly Information (Brownless Biomedical Library) University of Melbourne, conducted 14 systematic bibliographic searches. Reviewers also checked the reference lists of all relevant articles obtained, and reference lists from previously published reviews. Researchers also hand-searched 10 relevant journals. Selection Criteria: Study samples of children and young people, aged 0-18 years, who have been the subject of a child maltreatment investigation, were eligible for this review. Studies had to have used random assignment to create treatment and control groups; or, parallel cohorts in which groups were assessed at the same point in time. Any form of FGDM, used in the course of a child maltreatment investigation or service, was considered an eligible intervention if it involved: a concerted effort to convene family, extended family, and community members; and professionals; and involved a planned meeting with the intention of working collaboratively to develop a plan for the safety well-being of children; with a focus on family-centred decision-making. Data Collection and Analysis: Two review authors independently extracted the necessary data from each study report, using the software application Covidence. Covidence highlighted discrepancies between data extracted by separate reviewers, further analysis was conducted until a consensus was reached on what data were to be included in the review. Two authors also independently conducted analyses of study bias. Main Results: Eighteen eligible study reports were found, providing findings from 15 studies, involving 18 study samples. Four were randomised controlled trials (RCTs; N = 941) the remainder employed quasi-experimental designs with parallel cohorts. Three of the quasi-experimental studies used prospective evaluations of nonrandomly assigned comparison groups (N = 4,368); the rest analysed pre-existing survey data, child protection case files or court data (N = 91,786). The total number of children studied was 97,095. The longest postintervention follow-up period was 3 years. Only four studies were conducted outside the United States; two in Canada and one in Sweden and one in the Netherlands. The review authors judged there to be a moderate or high risk of bias, in most of the bias categories considered. Only one study referenced a study protocol. Eleven of the fifteen studies were found to have a high likelihood of selection bias (73%). Baseline imbalance bias was deemed to be unlikely in just two studies, and highly likely in nine (60%). Confounding variables were judged to be highly likely in four studies (27%), and contamination bias was judged highly likely in five studies (33%). Researcher allegiance was rated as a high risk in three studies (20%) where the authors argued for the benefits of FGDM within the article, but without supporting references to an appropriate evidence base. Bias from differential diagnostic activity, and funding source bias, were less evident across the evidence reviewed. This review combines findings for eight FGDM outcome measures. Findings from RCTs were available for four outcomes, but none of these, combined in meta-analysis or otherwise, were statistically significant. Combining findings from the quasi-experimental studies provided one statistically significant finding, for the reunification of families, favouring FGDM. Ten effect sizes, from nine quasi-experimental studies, were synthesised to examine effects on the reunification of children with their family or the effect on maintaining in-home care; in short, the effect FGDM has on keeping families together. There was a high level of heterogeneity between the studies (I 2 = 92%). The overall effect, based on the combination of these studies was positive, small, but statistically significant: odds ratio (OR), 1.69 (confidence interval [CI], 1.03, 2.78). Holinshead's (2017) RCT also measured the maintenance on in-home care and reported a similar result: OR, 1.54 (CI, -0.19, 0.66) not statistically significant. The overall effect for continued maltreatment from meta-analysis of five quasi-experimental studies, favoured the FGDM group, but was not statistically significant: OR, 0.73 (CI, 0.48, 1.11). The overall combined effect for continued maltreatment, reported in RCTs, favoured the control group. But it was not statistically significant: OR, 1.29 (CI, 0.85, 1.98). Five effect sizes, from nonrandomised studies, were synthesised to examine the effect of FGDM on the number of kinship placements. The overall positive effect based on the combination of these studies was negligible: OR, 1.31 (CI, 0.94, 1.82). Meta-analysis was not possible with other outcomes. FGDM's role in expediting case processing and case closures was investigated in six studies, three of which reported findings favouring FGDM, and three which favoured the comparison group. Children's placement stability was reported in two studies: an RCT's findings favoured the control, while a quasi-experimental study's findings favoured FGDM. Three studies reported findings for service user satisfaction: one had only 30 participants, one reported a statistically significant positive effect for FGDM, the other found no difference between FGDM and a control. Engagement with support services was reported in two studies; neither reported statistically significant findings. Authors' Conclusions: The current evidence base, in this field, is insufficient to draw conclusions about the effectiveness of FGDM. These models of child protection decision-making may help bring about better outcomes for children at risk, or they may increase the risk of further maltreatment. Further research of rigour, designed to avoid the potential biases of previous evaluations, is needed.

Exploring The Migration Profiles of Primary Healthcare Users in South Africa.

South Africa's public healthcare system responses seldom engage with migration. Our exploratory study investigates migration profiles and experiences of primary healthcare (PHC) users. A cross-sectional survey involving non-probability sampling was conducted with 229 PHC users at six purposively selected PHC clinics in three districts of SA. The survey captured socio-demographic information, migration histories, and PHC experiences. Chi square and Fischer's exact tests were used to compare categorical variables, whilst Mann-Whitney U tests compared continuous variables between groups. Most PHC users were migrants (22% internal South African; 45% cross-border) who generally move for reasons other than healthcare seeking. Length of time accessing services at a specific clinic was shown to be key in describing experiences of PHC use. Understanding population movement is central to PHC strengthening in SA and requires improved understanding of mobility dynamics in regard to not just nationality, but also internal mobility and length of stay.

Using surrogate vaccines to assess feasibility and acceptability of future HIV vaccine trials in men: a randomised trial in inner-city Johannesburg, South Africa.

BACKGROUND: Developing an effective HIV vaccine is the overriding priority for HIV prevention research. Enrolling and maintaining cohorts of men into HIV vaccine efficacy trials is a necessary prerequisite for the development and licensure of a safe and efficacious vaccine. METHODS: One hundred-fifty consenting HIV-negative men were enrolled into a pilot 1:1 randomised controlled trial of immediate vaccination with a three-dose hepatitis B vaccine compared to deferred vaccination (at 12 months) to investigate feasibility and acceptability of a future HIV vaccine trial in this population. Adverse events, changes in risk behaviour, acceptability of trial procedures and motivations for participation in future trials were assessed. RESULTS: Men were a median 25 years old (inter-quartile range = 23-29), 53% were employed, 90% secondary school educated and 67% uncircumcised. Of the 900 scheduled study visits, 90% were completed in the immediate vaccination arm (405/450) and 88% (396/450) in the delayed arm (P = 0.338). Acceptability of trial procedures and services was very high overall. However, only 65% of the deferred group strongly liked being randomised compared to 90% in the immediate group (P = 0.001). Informed consent processes were viewed favourably by 92% of the delayed and 82% of the immediate group (P = 0.080). Good quality health services, especially if provided by a male nurse, were rated highly. Even though almost all participants had some concern about the safety of a future HIV vaccine (98%), the majority were willing to participate in a future trial. Future trial participation would be motivated mainly by the potential for accessing an effective vaccine (81%) and altruism (75%), rather than by reimbursement incentives (2%). CONCLUSIONS: Recruitment and retention of men into vaccine trials is feasible and acceptable in our setting. Findings from this surrogate vaccine trial show a high willingness to participate in future HIV vaccine trials. While access to potentially effective vaccines is important, quality health services are an equally compelling incentive for enrolment.

Intersections between polyvictimisation and mental health among adolescents in five urban disadvantaged settings: the role of gender.

BACKGROUND: Polyvictimisation (PV) - exposure to violence across multiple contexts - causes considerable morbidity and mortality among adolescents. Despite high levels of violence in urban disadvantaged settings, gender differences in associations between PV and mental health have not been well established. METHODS: We analysed data from a survey with 2393 adolescents aged 15-19 years, recruited using respondent-driven sampling from urban disadvantaged settings in Baltimore (USA), Delhi (India), Ibadan (Nigeria), Johannesburg (South Africa) and Shanghai (China). PV was defined as exposure to two or more types of violence in the past 12 months with family, peers, in the community, or from intimate partners and non-partner sexual violence. Weighted logistic regression models are presented by gender to evaluate whether PV is associated with posttraumatic stress, depression, suicidal thoughts and perceived health status. RESULTS: PV was extremely common overall, but ranged widely, from 74.5% of boys and 82.0% of girls in Johannesburg, to 25.8 and 23.9% respectively in Shanghai. Community violence was the predominant violence type, affecting 72.8-93.7% across the sites. More than half of girls (53.7%) and 45.9% of boys had at least one adverse mental health outcome. Compared to those that did not report violence, boys exposed to PV had 11.4 higher odds of having a negative perception of health (95%CI adjusted OR = 2.45-53.2), whilst this figure was 2.58 times in girls (95%CI = 1.62-4.12). Among girls, PV was associated with suicidal thoughts (adjusted OR = 4.68; 95%CI = 2.29-9.54), posttraumatic stress (aOR = 4.53; 95%CI = 2.44-8.41) and depression (aOR = 2.65; 95%CI = 1.25-5.63). Among boys, an association was only detected between PV and depression (aOR = 1.82; 95%CI = 1.00-3.33). CONCLUSION: The findings demonstrate that PV is common among both sexes in urban disadvantaged settings across the world, and that it is associated with poor mental health outcomes in girls, and with poor health status in both girls and boys. Clearly, prevention interventions are failing to address violence exposure across multiple contexts, but especially within community settings and in Johannesburg. Interventions are needed to identify adolescents exposed to PV and link them to care, with services targeting a range of mental health conditions among girls and perhaps focusing on depression among boys.

Hierarchical spatial modelling of pneumonia prevalence when response outcome has misclassification error: Applications to household data from Malawi.

Pneumonia remains a major cause of child mortality in less developed countries. However, the accuracy of its prevalence and burden remains a challenge because disease data is often based on self-reports, resulting in measurement error in a form of under- and over-reporting. We propose hierarchical disease mapping approaches that permit measurement error, through different prior distributions of sensitivity and specificity. Proposed models were used to evaluate spatial variation of risk of pneumonia in children in Malawi. Results show that the true prevalence was 0.50 (95 CI: 0.4-0.66), however, estimates were dependent on sensitivity and specificity parameters. The estimated sensitivity was 0.76 (95% CI: 0.68-0.95), whereas specificity was 0.84 (95% CI: 0.72-0.93). A lower specificity underestimated the true prevalence, while sensitivity and specificity of greater or equal to 0.75 provided reliable and stable prevalence estimates. The spatial variation in disease risk changed little; however, misclassification of areas as high risk was visible.

The role of material deprivation and consumerism in the decisions to engage in transactional sex among young people in the urban slums of Blantyre, Malawi.

Transactional sex has been associated with a high risk of HIV acquisition and unintended pregnancy among young women in urban slums in sub-Saharan Africa. However, few studies have explored the structural drivers of transactional sex from the perspective of both genders in these settings. This paper explores how young men and women understand the factors that lead to transactional sex among their peers, and how deprivation of material resources (housing, food and health care access) and consumerism (a desire for fashionable goods) may instigate transactional sex in the urban slums of Blantyre, Malawi. Data from 5 focus group discussions and 12 in-depth interviews undertaken with a total of 60 young men and women aged 18-23 years old, conducted between December 2012 and May 2013, were analysed using anticipated and grounded codes. Housing and food deprivation influenced decisions to engage in transactional sex for both young men and women. Poor health care access and a desire for fashionable goods (such as the latest hair or clothing styles and cellular phones) influenced the decisions of young women that led to transactional sex. Interventions that engage with deprivations and consumerism are essential to reducing sexual and reproductive health risks in urban slums.

Material deprivation and unemployment affect coercive sex among young people in the urban slums of Blantyre, Malawi: A multi-level approach.

We explore relations among material deprivation (measured by insufficient housing, food insecurity and poor healthcare access), socio-economic status (employment, income and education) and coercive sex. A binary logistic multi-level model is used in the estimation of data from a survey of 1071 young people aged 18-23 years, undertaken between June and July 2013, in the urban slums of Blantyre, Malawi. For young men, unemployment was associated with coercive sex (odds ratio [OR]=1.77, 95% confidence interval [CI]: 1.09-3.21) while material deprivation (OR=1.34, 95% CI: 0.75-2.39) was not. Young women in materially deprived households were more likely to report coercive sex (OR=1.37, 95% CI: 1.07-2.22) than in non-materially deprived households. Analysis of local indicators of deprivation is critical to inform the development of effective strategies to reduce coercive sex in urban slums in Malawi.

Sharing perspectives and experiences of doctoral fellows in the first cohort of Consortium for Advanced Research Training in Africa: 2011-2014.

BACKGROUND: Resolution of public health problems in Africa remains a challenge because of insufficient skilled human resource capacity. The Consortium for Advanced Research Training in Africa (CARTA) was established to enhance capacity in multi-disciplinary health research that will make a positive impact on population health in Africa. OBJECTIVE: The first cohort of the CARTA program describes their perspectives and experiences during the 4 years of fellowship and puts forward suggestions for future progress and direction of research in Africa. CONCLUSIONS: The model of training as shown by the CARTA program is an effective model of research capacity building in African academic institutions. An expansion of the program is therefore warranted to reach out to more African academics in search of advanced research training.

Material deprivation affects high sexual risk behavior among young people in urban slums, South Africa.

Young people in urban slums adopt HIV risk behaviors influenced by their neighborhood factors. Three critical factors in urban slums of Southern and Eastern Africa--the region most affected by the HIV epidemic in the world--are unmet needs of housing, food, and health care, which are associated with HIV sexual risks. Yet, there has been limited attention on how the combination of unmet needs of housing, food, and health care--i.e., material deprivation-relates to sexual risk behavior among young people in urban slums. Cross-sectional data were extracted from the LoveLife survey in South African four provinces--KwaZulu Natal, Mpumalanga, Eastern Cape, and Gauteng, to examine the association between material deprivation and sexual risk behavior among young people aged 18-23 years (263 males, 267 females) in urban slums. Adjusted logistic regression models showed that material deprivation was significantly associated with increased odds of high sexual risk taking for young men (adjusted OR = 1.20; 95 % CI = 1.10, 5.58) and young women (adjusted OR = 1.43; 95 % CI = 1.35, 3.28). Financial difficulty--a proxy for other deprivations--was the most salient influence on young women's high sexual risk taking (adjusted OR = 2.11; 95 % CI = 1.66, 2.70). Localized behavioral HIV prevention interventions should target young people in deprived households.