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ObjectiveThe aim of this study was to investigate if attitudes or behavioral beliefs about antiretroviral therapy (ART) influence ART adherence intention among pregnant and breastfeeding women in Zambia.MethodsWe recruited 150 HIV-positive women receiving ART in urban (Lusaka) and rural (Sinazongwe) districts of Zambia. Generalized modified Poisson regression models were used to assess the extent to which adherence intention was influenced by attitude toward ART or behavioral beliefs about ART.ResultsIntention to adhere to ART differed significantly by income, knowledge about HIV transmission, attitudes, and behavioral beliefs (all Ps

Abstract Background Improving the coverage of antenatal care is regarded as an important strategy to reduce the risks of maternal and child mortality in low income settings like Gambia. Nonetheless, a large number of countries in Africa, including Gambia, are struggling to attain an optimum level of healthcare utilization among pregnant women. The role of socioeconomic inequalities in maternal healthcare uptake has received little attention in Gambia. To address this evidence gap, the present study analyses nationally representative data to explore the socioeconomic inequalities in the use of maternal healthcare. Methods Data on women aged 15–49 years (n = 5351) were extracted from the latest round of Gambia Demographic and Health Survey in 2013 for this study. The outcome measures were early and adequate antenatal visit and HIV tests during the last pregnancy. Data were analyzed using descriptive and multivariate regression methods. Socioeconomic status was assessed through the women’s education, type of employment, and household wealth quintile. Results From the total of 5351 participants included in the study, 38.7 and 78.8% of the women had early and adequate ANC visits respectively with a 65.4% HIV test coverage during ANC visits. The odds of early [OR = 1.30, 95% confidence interval (CI) =1.06, 1.59] and adequate [OR = 1.45, 95%CI = 1.15, 1.82] ANC visits were higher in the rural areas compared with urban. Women with secondary [OR = 1.24, 95%CI = 1.04, 1.48] and higher education [OR = 1.80, 95%CI = 1.20, 2.70] had higher odds of making early ANC visits. Women from richest wealth quintile households had significantly higher odds of having early [OR = 1.49, 95%CI = 1.14, 1.95] and adequate ANC visits [OR = 2.06, 95%CI = 1.48, 2.87], but not of having HIV tests. Having access to electronic media showed a positive association with adequate ANC visits [OR = 1.32, 95%CI = 1.08, 1.62] and with taking HIV test during ANC [OR = 1.48, 95%CI = 1.21, 1.80]. A fewer odds of having unintended child was associated with early ANC visit [OR = 0.70, 95%CI = 0.59, 0.84], but positively associated with taking HIV test [OR = 1.75, 95%CI = 1.42, 2.15]. Conclusion A large proportion of women in Gambia were not using antenatal care and HIV tests during pregnancy. There are important sociodemographic differences in using maternal healthcare services such as HIV testing during pregnancy. This calls for strategic direction to promote the utilization of these services.

Abstract Objective The aim of this study was to investigate if attitudes or behavioral beliefs about antiretroviral therapy (ART) influence ART adherence intention among pregnant and breastfeeding women in Zambia. Methods We recruited 150 HIV-positive women receiving ART in urban (Lusaka) and rural (Sinazongwe) districts of Zambia. Generalized modified Poisson regression models were used to assess the extent to which adherence intention was influenced by attitude toward ART or behavioral beliefs about ART. Results Intention to adhere to ART differed significantly by income, knowledge about HIV transmission, attitudes, and behavioral beliefs (all Ps

Abstract Background The increasing burden of non-communicable diseases (NCDs) in sub-Saharan Africa is causing further burden to the health care systems that are least equipped to deal with the challenge. Countries are developing policies to address major NCD risk factors including tobacco use, unhealthy diets, harmful alcohol consumption and physical inactivity. This paper describes NCD prevention policy development process in five African countries (Kenya, South Africa, Cameroon, Nigeria, Malawi), including the extent to which WHO “best buy” interventions for NCD prevention have been implemented. Methods The study applied a multiple case study design, with each country as a separate case study. Data were collected through document reviews and key informant interviews with national-level decision-makers in various sectors. Data were coded and analyzed thematically, guided by Walt and Gilson policy analysis framework that examines the context, content, processes and actors in policy development. Results Country-level policy process has been relatively slow and uneven. Policy process for tobacco has moved faster, especially in South Africa but was delayed in others. Alcohol policy process has been slow in Nigeria and Malawi. Existing tobacco and alcohol policies address the WHO “best buy” interventions to some extent. Food-security and nutrition policies exist in almost all the countries, but the “best buy” interventions for unhealthy diet have not received adequate attention in all countries except South Africa. Physical activity policies are not well developed in any study countries. All have recently developed NCD strategic plans consistent with WHO global NCD Action Plan but these policies have not been adequately implemented due to inadequate political commitment, inadequate resources and technical capacity as well as industry influence. Conclusion NCD prevention policy process in many African countries has been influenced both by global and local factors. Countries have the will to develop NCD prevention policies but they face implementation gaps and need enhanced country-level commitment to support policy NCD prevention policy development for all risk factors and establish mechanisms to attain better policy outcomes while considering other local contextual factors that may influence policy implementation such as political support, resource allocation and availability of local data for monitoring impacts.

Abstract Background Malaria case management remains a vital component of malaria control strategies. Despite the introduction of national malaria treatment guidelines and scale-up of malaria control interventions in Nigeria, anecdotal evidence shows some deviations from the guidelines in malaria case management. This study assessed factors influencing adherence to malaria diagnosis and treatment guidelines among healthcare workers in public and private sectors in Ogun State, Nigeria. Methods A comparative cross-sectional study was carried out among 432 (216 public and 216 private) healthcare workers selected from nine Local Government Areas using a multistage sampling technique. A pre-tested interviewer administered questionnaire was used to collect information on availability and use of malaria Rapid Diagnostic Test (mRDT) and artemisinin combination therapy (ACT), for management of uncomplicated malaria. Adherence was defined as when choice of antimalarials for parasitological confirmed malaria cases was restricted to recommended antimalarial medicines. Association between adherence and independent variables were tested using Chi-square at 5 % level of significance. Results Malaria RDT was available in 81.9 % of the public health facilities and 19.4 % of the private health facilities (p = 0.001). Its use was higher among public healthcare workers (85.2 %) compared to 32.9 % in private facilities (p = 0.000). Presumptive diagnosis of malaria was higher among private healthcare workers (94.9 %) compared to 22.7 % public facilities (p =

Abstract Background Young people are becoming increasingly exposed to the risk of HIV infection. According to the 2008 HIV/Syphilis sentinel survey in Nigeria, 3.3% of young people aged 15-19 years are infected. Primary prevention especially abstinence, remains one of the most realistic interventions for reducing further spread of the virus. However, the adoption of sexual abstinence as a prevention strategy among adolescents remains low and factors influencing its practice among urban young people in Nigeria are relatively unknown. The aim of the study was to document the sexual abstinence behaviour of in-school adolescents, the factors influencing or obstructing abstinence, and knowledge of HIV and AIDS in Ibadan, South-West Nigeria. Methods The study was a descriptive cross-sectional survey of students in Ibadan South-West Local Government Area. A total of 420 respondents (52% males and 48% females), selected through a multistage sampling technique, completed a semi-structured questionnaire. This was supplemented with eight focus group discussions (FGDs) which had an average of 9 respondents within the 10 and 19 years age group. The data from the FGDs were transcribed and summarized manually while the quantitative data was analyzed using the Statistical Package for the Social Sciences to generate frequencies, cross tabulations of variables and logistic regression analysis. Results Twelve percent of the entire sample had ever had sex. Overall, knowledge of HIV transmission and prevention was high and most respondents favoured the promotion of abstinence as an HIV prevention strategy. A smaller proportion of male respondents (79%) abstained compared with the females (98%). Major predictors of sexual abstinence were being a female, not having a boyfriend or girl friend, not using alcohol and having a positive attitude towards abstinence (P < 0.05). Sexual abstinence was also significantly associated with perceived self efficacy to refuse sex and negative perception of peers who engage in sexual behaviours (P < 0.05). Majority of the FGD discussants suggested the involvement of parents, media, schools, faith-based institutions and non governmental organizations in promoting the adoption of abstinence. Conclusions The sexual abstinence behaviour of young persons is influenced by multiple factors and should be considered in determining the effectiveness of interventions targeting this behaviour. Coherent sexuality education interventions to promote the adoption of abstinence among young people are urgently needed.

Background: Young people are becoming increasingly exposed to the risk of HIV infection. According to the 2008 HIV/Syphilis sentinel survey in Nigeria, 3.3% of young people aged 15-19 years are infected. Primary prevention especially abstinence, remains one of the most realistic interventions for reducing further spread of the virus. However, the adoption of sexual abstinence as a prevention strategy among adolescents remains low and factors influencing its practice among urban young people in Nigeria are relatively unknown. The aim of the study was to document the sexual abstinence behaviour of in-school adolescents, the factors influencing or obstructing abstinence, and knowledge of HIV and AIDS in Ibadan, South-West Nigeria. Methods: The study was a descriptive cross-sectional survey of students in Ibadan South-West Local Government Area. A total of 420 respondents (52% males and 48% females), selected through a multistage sampling technique, completed a semi-structured questionnaire. This was supplemented with eight focus group discussions (FGDs) which had an average of 9 respondents within the 10 and 19 years age group. The data from the FGDs were transcribed and summarized manually while the quantitative data was analyzed using the Statistical Package for the Social Sciences to generate frequencies, cross tabulations of variables and logistic regression analysis. Results: Twelve percent of the entire sample had ever had sex. Overall, knowledge of HIV transmission and prevention was high and most respondents favoured the promotion of abstinence as an HIV prevention strategy. A smaller proportion of male respondents (79%) abstained compared with the females (98%). Major predictors of sexual abstinence were being a female, not having a boyfriend or girl friend, not using alcohol and having a positive attitude towards abstinence (P < 0.05). Sexual abstinence was also significantly associated with perceived self efficacy to refuse sex and negative perception of peers who engage in sexual behaviours (P < 0.05). Majority of the FGD discussants suggested the involvement of parents, media, schools, faith-based institutions and non governmental organizations in promoting the adoption of abstinence. Conclusions: The sexual abstinence behaviour of young persons is influenced by multiple factors and should be considered in determining the effectiveness of interventions targeting this behaviour. Coherent sexuality education interventions to promote the adoption of abstinence among young people are urgently needed. [ABSTRACT FROM AUTHOR]

Abstract Background Insufficient physical activity (PA) is a growing public health challenge among Nigerian adolescents. Significant information gap exists on the school-related factors which influence the participation of adolescents in school-based physical activity programmes in Nigeria. This study was conducted to document the qualitative views of school principals and teachers on the barriers and opportunities for promoting the physical activity behaviours of adolescents within the school settings in light of the socio-ecological model. Methods This was a qualitative study conducted in 12 public and private schools in two local government areas of Oyo state, Nigeria. Two key sources and data collection methods (i.e key informant interviews and focus group discussions) were used. Six key informant interviews were held with school principals and six focus group discussions with classroom teachers using pre-tested guides. Data was analysed using thematic analysis. Results Fourteen sub-themes were identified as barriers to PA and linked to different levels of the socio-ecological model. Three themes were categorised as parental factors, three themes as socio-cultural and religious factors while the school-related factors had eight sub-themes. Specifically, the school-related barriers were the declining number of trained physical health education teachers, limited opportunities for continuing education and low prioritisation of physical health education. Other school-related factors such as increasing demand for classroom academic time, negative attitudinal dispositions of other teachers and inadequate funding for schools which hampered the provision of facilities and equipment were identified as factors that limit the effective implementation of policies and programmes for physical activity in schools. Opportunities to promote PA within the school settings during assemblies, breaktime, after-school and inter-house sports competition exist. However, these opportunities are hampered by competing academic time, security threats, fear of causalities to students due to poor supervision after school, poor funding and brawling associated with competitive school-based sporting events. Conclusions Factors that contribute to insufficient physical activity among in-school adolescents in the school settings are multi-factorial. Implementation of holistic, multi-component interventions which address the social-cultural and school-level factors and enhance students’ opportunities for physical activity in schools are recommended.

Abstract Background Drug-resistant TB (DR-TB) remains a public health concern due to the high morbidity and mortality rates from the disease. The DR-TB is a multifaceted illness with expensive treatment regimens, toxic medications and most often the long duration of treatment constitutes a substantial financial burden on both infected patients and the health system. Despite significant research advances in the diagnosis and treatment, there is a paucity of synthesized evidence on how socio-economic factors are associated with DR-TB. This review aims to address this gap by synthesizing available evidence and data on the common socio-economic drivers of DR-TB infection in Africa. Methods A systematic search was conducted on PUBMED and Google Scholar databases from January 2011 to January 2020 using Joanna Briggs Institute’s scoping review approach. An updated search was conducted on 21 September 2020. The eligibility criteria only included systematic reviews and studies with quantitative research methods (cross-sectional, case-control, cohort, and randomized-control trials). Studies conducted in Africa and focusing on socio-economic factors influencing DR-TB burden in African countries were also considered. Data was extracted from all the studies that met the eligibility criteria based on the study’s objectives. Results Out of the 154 articles that were retrieved for review, 20 abstracts of these articles met all the eligibility criteria. Of the 20 articles, 17 quantitative and 3 reviews. Two additional articles were found eligible, following the updated search. The following themes were identified as major findings: Social and economic drivers associated with DR-TB. Substance abuse of which, stigma and discrimination were the prominent social drivers. Economic drivers included poverty, financial constraints because of job loss, loss of productive time during hospital admission and treatment costs. Conclusion This review has highlighted which socio-economic factors contribute to DR- TB This is relevant to assist DR-TB management program and TB stakeholders in different settings to address identified socio-economic gaps and to reduce its negative impact on the programmatic management of DR TB. Therefore, redirecting strategies with more focus on socio-economic empowerment of DR-TB patients could be one of the innovative solutions to reduce the spread and eliminate DR-TB in Africa.

Abstract Background Few studies have characterized the epidemiology and management of hypertension across several communities with comparable methodologies in sub-Saharan Africa. We assessed prevalence, awareness, treatment, and control of hypertension and predicted 10-year cardiovascular disease risk across seven sites in East and West Africa. Methods Between June and August 2018, we conducted household surveys among adults aged 18 years and above in 7 communities in Kenya, Nigeria, Tanzania, and Uganda. Following a standardized protocol, we collected data on socio-demographics, health insurance, and healthcare utilization; and measured blood pressure using digital blood pressure monitors. We estimated the 10-year cardiovascular disease (CVD) risk using a country-specific risk score and fitted hierarchical models to identify determinants of hypertension prevalence, awareness, and treatment. Results We analyzed data of 3549 participants. The mean age was 39·7 years (SD 15·4), 60·5% of whom were women, 9·6% had ever smoked cigarettes, and 32·7% were overweight/obese. A quarter of the participants (25·4%) had hypertension, more than a half of whom (57·2%) were aware that they had diagnosed hypertension. Among those diagnosed, 50·5% were taking medication, and among those taking medication 47·3% had controlled blood pressure. After adjusting for other determinants, older age was associated with increased hypertension prevalence, awareness, and treatment whereas primary education was associated with lower hypertension prevalence. Health insurance was associated with lower hypertension prevalence and higher chances of treatment. Median predicted 10-yr CVD risk across sites was 4·9% (Interquartile range (IQR), 2·4%, 10·3%) and 13·2% had predicted 10-year CVD risk of 20% or greater while 7·1% had predicted 10-year CVD risk of > 30%. Conclusion In seven communities in east and west Africa, a quarter of participants had hypertension, about 40% were unaware, half of those aware were treated, and half of those treated had controlled blood pressure. The 10-year predicted CVD risk was low across sites. Access to health insurance is needed to improve awareness, treatment, and control of hypertension in sub-Saharan Africa.

Abstract Background In African countries, including Angola, antenatal care (ANC) coverage is suboptimal and maternal mortality is still high due to pregnancy and childbirth-related complications. There is evidence of disparities in the uptake of ANC services, however, little is known about both the socio-economic and geographic-based disparity in the use of ANC services in Angola. The aim of this study was to assess the extent of socio-economic, urban-rural and subnational inequality in ANC coverage in Angola. Methods We analyzed data from the 2015 Angola Demographic and Health Survey (ADHS) using the World Health Organization (WHO) Health Equity Assessment Toolkit (HEAT) software. The analysis consisted of disaggregated ANC coverage rates using four equity stratifiers (economic status, education, residence, and region) and four summary measures (Difference, Population Attributable Risk, Ratio and Population Attributable Fraction). To measure statistical significance, an uncertainty interval (UI) of 95% was constructed around point estimates. Results The study showed both absolute and relative inequalities in coverage of ANC services in Angola. More specifically, inequality favored women who were rich (D = 54.2, 95% UI; 49.59, 58.70, PAF = 43.5, 95% UI; 40.12, 46.92), educated (PAR = 19.9, 95% UI; 18.14, 21.64, R = 2.14, 95% UI; 1.96, 2.32), living in regions such as Luanda (D = 51.7, 95% UI; 43.56, 59.85, R = 2.64, 95% UI; 2.01, 3.26) and residing in urban dwellings (PAF = 20, 95% UI; 17.70, 22.38, PAR = 12.3, 95% UI; 10.88, 13.75). Conclusion The uptake of ANC services were lower among poor, uneducated, and rural residents as well as women from the Cuanza Sul region. Government policy makers must consider vulnerable subpopulations when designing needed interventions to improve ANC coverage in Angola to achieve the 2030 Sustainable Development Goal of reducing global maternal mortality ratio to 70 deaths per 100,000 live births.

Abstract Background Harmful alcohol use is a modifiable risk factor contributing to the increasing burden of non-communicable diseases and deaths and the implementation of policies focused on primary prevention is pivotal to address this challenge. Policies with actions targeting the harmful use of alcohol have been developed in Nigeria. This study is an in-depth analysis of alcohol-related policies in Nigeria and the utilization of WHO Best Buy interventions (BBIs) and multi-sectoral action (MSA) in the formulation of these policies. Methods A descriptive case study design and the Walt and Gilson framework of policy analysis was utilized for the research. Components of the study included a scoping review consisting of electronic search of Google and three online databases (Google Scholar, Science Direct and PubMed) to identify articles and policy documents with no language and date restrictions. Government institution provided documents which were not online. Thirteen policy documents, reports or articles relevant to the policy formulation process were identified. Other components of the study included interviews with 44 key informants (Bureaucrats and Policy Makers) using a pretested guide. The qualitative data were coded and analyzed using thematic analysis. Results Findings revealed that policy actions to address harmful alcohol use are proposed in the 2007 Federal Road Safety Act, the Non-communicable Diseases Prevention and Control Policy and the Strategic Plan of Action. Only one of the best buy interventions, (restricted access to alcohol) is proposed in these policies. Multi-sectoral action for the formulation of alcohol-related policy was low and several relevant sectors with critical roles in policy implementation were not involved in the formulation process. Overall, alcohol currently has no holistic, health-sector led policy document to regulate the marketing, promotion of alcohol and accessibility. A major barrier is the low government budgetary allocation to support the process. Conclusions Nigeria has few alcohol-related policies with weak multi-sectoral action. Funding constraint remains a major threat to the implementation and enforcement of proposed policy actions.

Abstract Background Tobacco use is a major risk factor for non-communicable diseases and policy formulation on tobacco is expected to engrain international guidelines. This paper describes the historical development of tobacco control policies in Nigeria, the use of multi-sectoral action in their formulation and extent to which they align with the World Health Organisation “best buy” interventions. Methods We adopted a descriptive case study methodology guided by the Walt and Gilson Policy Analysis Framework. Data collection comprised of document review (N = 18) identified through search of government websites and electronic databases with no date restriction and key informant interviews (N = 44) with stakeholders in public and private sectors. Data was integrated and analyzed using content analysis. Ethical approval was granted by the University of Ibadan and University College Hospital Ethics Review Committee. Results Although the agenda for development of a national tobacco control policy dates back to the 1950s, a comprehensive Framework Convention for Tobacco Control (FCTC) compliant policy was only developed in 2015, 10 years after Nigeria signed the FCTC. Lack of funding and conflict of interest (of protecting citizens from harmful effect of tobacco viz. a viz. the economic gains from the industry) are the major barriers that slowed the policy process. Current tobacco –related policies developed by the Federal Ministry of Health were formulated through strong multi-sectoral engagement and covering all the four WHO “best buy” interventions. Other policies had limited multi-sectoral engagement and “best buy” strategies. The tobacco industry was involved in the development of the Standards for Tobacco Control of 2014 contrary to the long-standing WHO guideline against engagement of the industry in policy formulation. Conclusions Nigeria has a comprehensive national policy for tobacco control which was formulated a decade after ratification of the FCTC due to constraints of funding and conflict of interest. Not all the tobacco control policies in Nigeria engrain the principles of multisectorality and best buy strategies in their formulation. There is an urgent need to address these neglected areas that may hamper tobacco control efforts in Nigeria.

Abstract Background The World Health Organization’s Framework Convention on Tobacco Control, enforced in 2005, was a watershed international treaty that stipulated requirements for signatories to govern the production, sale, distribution, advertisement, and taxation of tobacco to reduce its impact on health. This paper describes the timelines, context, key actors, and strategies in the development and implementation of the treaty and describes how six sub-Saharan countries responded to its call for action on tobacco control. Methods A multi-country policy review using case study design was conducted in Cameroon, Kenya, Nigeria, Malawi, South Africa, and Togo. All documents related to the WHO Framework Convention on Tobacco Control and individual country implementation of tobacco policies were reviewed, and key informant interviews related to the countries’ development and implementation of tobacco policies were conducted. Results Multiple stakeholders, including academics and activists, led a concerted effort for more than 10 years to push the WHO treaty forward despite counter-marketing from the tobacco industry. Once the treaty was enacted, Cameroon, Kenya, Nigeria, Malawi, South Africa, and Togo responded in unique ways to implement tobacco policies, with differences associated with the country’s socio-economic context, priorities of country leaders, industry presence, and choice of strategies. All the study countries except Malawi have acceded to and ratified the WHO tobacco treaty and implemented tobacco control policy. Conclusions The WHO Framework Convention on Tobacco Control provided an unprecedented opportunity for global action against the public health effects of tobacco including non-communicable diseases. Reviewing how six sub-Saharan countries responded to the treaty to mobilize resources and implement tobacco control policies has provided insight for how to utilise international regulations and commitments to accelerate policy impact on the prevention of non-communicable diseases.

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Abstract Background Cardiovascular diseases (CVD) are a leading contributor to the burden of disease in low- and middle-income countries. Guidelines for CVD prevention care in low resource settings have been developed but little information is available on strategies to implement this care. A community health insurance program might be used to improve patients' access to care. The operational research project "QUality Improvement Cardiovascular care Kwara - I (QUICK-I)" aims to assess the feasibility of CVD prevention care in rural Nigeria, according to international guidelines, in the context of a community based health insurance scheme. Methods/Design Design: prospective observational hospital based cohort study. Setting: a primary health care centre in rural Nigeria. Study population: 300 patients at risk for development of CVD (patients with hypertension, diabetes, renal disease or established CVD) who are enrolled in the Hygeia Community Health Plan. Measurements: demographic and socio- economic data, physical and laboratory examination, CVD risk profile including screening for target organ damage. Measurements will be done at 3 month intervals during 1 year. Direct and indirect costs of CVD prevention care will be estimated. Outcomes: 1) The adjusted cardiovascular quality of care indicator scores based on the "United Kingdom National Health Services Quality and Outcome Framework". 2) The average costs of CVD prevention and treatment per patient per year for patients, the clinic and the insurance company. 3) The estimated net health care costs of standard CVD prevention care per quality-adjusted life year gained. Analysis: The primary outcomes, the score on CVD quality indicators and cost data will be descriptive. The quality scores and cost data will be used to describe the feasibility of CVD prevention care according to international guidelines. A cost-effectiveness analysis will be done using a Markov model. Discussion Results of QUICK-I can be used by policy makers and professionals who aim to implement CVD prevention programs in settings with limited resources. The context of the insurance program will provide insight in the opportunities community health insurance may offer to attain sustainable chronic disease management programs in low resource settings. Trial registration This protocol has been registered at ISRCTN, ID number: ISRCTN47894401.