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Transformative learning occurs when a person, group, or larger social unit encounters ideas that are at odds with their prevailing perspective. This discrepant perspective can lead to an examination of previously held beliefs, values, and assumptions. The Consortium for Advanced Research Training in Africa (CARTA) has since 2011 been training and supporting faculty from different African universities, to become more reflective and productive researchers, research leaders, educators, and change agents who will drive institutional changes in their institutions. As part of a mid-term evaluation of CARTA, an open-ended question was posed to the CARTA fellows asking them to describe any changes they had experienced in their professional lives as a result of the CARTA Programme. The 135 responses were inductively coded and analysed using qualitative thematic analysis. These themes were subsequently mapped onto Hoggan's typology of transformative learning outcomes. CARTA fellows reported shifts in their sense of self; worldviews; beliefs about the definition of knowledge, how it is constructed and evaluated; and changes in behaviour/practices and capacities. This paper argues that the changes described by the CARTA fellows reflect transformative learning that is embedded in CARTA's Theory of Change. The reported transformation was enabled by a curriculum intentionally designed to facilitate critical reflection, further exploration, and questioning, both formally and informally during the fellows' PhD journey with the support of CARTA facilitators. Documenting and disseminating these lessons provide a guide for future practice, and educators wishing to revitalise their PhD training may find it useful to review the CARTA PhD curriculum. [ABSTRACT FROM AUTHOR]

There have been increasing calls for collaboration between Indigenous health practitioners (IHPs) and allopathic health practitioners (AHPs) in Africa. Despite this, very few successful systems exist to facilitate formal collaboration. Direct relationships between providers, and at a health systems level are crucial to successful collaboration, but the nature and extent of these relationships have yet to be adequately explored. To explore the relationship between IHPs and AHPs in Africa, and to discuss the implications of this for future collaboration. An interpretive qualitative synthesis approach, combining elements of thematic analysis, meta-ethnography, and grounded theory, was used to systematically bring together findings of qualitative studies addressing the topic of collaboration between Indigenous and allopathic health practitioners in Africa. A total of 1,765 papers were initially identified, 1,748 were excluded after abstract, full text and duplicate screening. Five additional studies were identified through references. Thus, 22 papers were included in the final analysis. We found that the relationship between Indigenous and allopathic health practitioners is defined by a power struggle which gives rise to lack of mutual understanding, rivalry, distrust, and disrespect. The power struggle which defines the relationship between IHPs and AHPs in Africa is a hindrance to their collaboration and as such could partly account for the limited success of efforts to foster collaboration to date. Future efforts to foster collaboration between IHPs and AHPs in Africa must aim to balance the power disparity between them if collaboration is to be successful. Since this would be a novel approach, decision-makers and organisations who trial this power balancing approach to facilitate collaboration should evaluate resultant policies and interventions to ascertain their feasibility and efficacy in fostering collaboration, and the lessons learnt should be shared. [ABSTRACT FROM AUTHOR]

In 2008 nine African Universities and four African research institutions, in partnership with non-African institutions started the Consortium for Advanced Research Training in Africa (CARTA) to strengthen doctoral training and research capacity on health in Africa. This study describes particular aspects of the CARTA program that promotes collaboration between the PhD fellows in the program, and determines the patterns of collaborative publications that resulted from the intervention. We reviewed program monitoring and evaluation documents and conducted a bibliometric analysis of 806 peer-reviewed publications by CARTA fellows published between 2011 and 2018. Results indicate that recruiting multidisciplinary fellows from various institutions, encouraging registration of doctoral-level fellows outside home institutions, and organizing joint research seminars stimulated collaborative research on health-related topics. Fellows collaborated among themselves and with non-CARTA researchers. Fellows co-authored 75 papers (10%) between themselves, of which 53 (71%) and 42 (56%) included fellows of different cohorts and different disciplines respectively, and 19 (25%) involved fellows of different institutions. CARTA graduates continued to publish with each other after graduating – 11% of the collaborative publications occurred post-graduation – indicating that the collaborative approach was maintained after exiting from the program. However, not all fellows contributed to publishing collaborative papers. The study recommends concerted effort towards enhancing collaborative publications among the CARTA fellows, both doctoral and post-doctoral, which can include holding research exchange forums and collaborative grant-writing workshops. [ABSTRACT FROM AUTHOR]

Changed health behaviours can contribute significantly to improved health. Consequently, significant investments have been channelled towards health behaviour change initiatives in Africa. Health behaviour change initiatives that address social, economic and environmental levers for behaviour change can create more sustained impact. Through a scoping study of the literature, we explored the literature on behaviour change initiatives in Africa, to assess their typologies. We explored whether the availability of initiatives reflected country demographic characteristics, namely life expectancy, gross domestic product (GDP), and population sizes. Finally, we assessed topical themes of interventions relative to frequent causes of mortality. We used the Behaviour Change Wheel intervention categories to categorise each paper into a typology of initiatives. Using Pearson's correlation coefficient, we explored whether there was a correlation between the number of initiatives implemented in a country in the specified period, and socio-demographic indicators, namely, GDP per capita, total GDP, population size, and life expectancy. Almost 64% of African countries were represented in the identified initiatives. One in five initiatives was implemented in South Africa, while there was a dearth of literature from Central Africa and western parts of North Africa. There was a positive correlation between the number of initiatives and GDP per capita. Most initiatives focused on addressing sexually transmitted infections and were short-term trials and/or pilots. Most initiatives were downstream focused e.g. with education and training components, while upstream intervention types such as the use of incentives were under-explored. We call for more emphasis on initiatives that address contextual facilitators and barriers, integrate considerations for sustainable development, and consider intra-regional deprivation. [ABSTRACT FROM AUTHOR]

This paper reports on the design of a study to generate a quality of care index for countries in the World Health Organization Africa Region. Quality of care, for all people at all times, remains pivotal to the advancement of the 2030 agenda and the attainment of Universal Health Coverage. We present a study protocol for deriving a quality of care index, hinged on indicators and data elements currently monitored through routine information systems and institutionalized facility assessments in the World Health Organization Africa Region. This paper seeks to offer more insight into options in the Region for strengthening monitoring processes of quality of care, as a step towards generating empirical evidence which can galvanize action towards an improved care process. The methodology proposed in this study design has broad implications for policymaking and priority setting for countries, emphasizing the need for robust empirical measures to understand the functionality of health systems for the delivery of quality essential services. Application of this protocol will guide policymaking, as countries work to increasingly improve quality of care and adopt policies that will best facilitate their advancement towards Universal Health Coverage. [ABSTRACT FROM AUTHOR]

Background: Because most deaths in Africa and Asia are not well documented, estimates of mortality are often made using scanty data. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering all deaths over time and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available. Objective: To build a large standardised mortality database from African and Asian sites, detailing the relevant methods, and use it to describe cause-specific mortality patterns. Design: Individual demographic and verbal autopsy (VA) data from 22 INDEPTH sites were collated into a standardised database. The INDEPTH 2013 population was used for standardisation. The WHO 2012 VA standard and the InterVA-4 model were used for assigning cause of death. Results: A total of 111,910 deaths occurring over 12,204,043 person-years (accumulated between 1992 and 2012) were registered across the 22 sites, and for 98,429 of these deaths (88.0%) verbal autopsies were successfully completed. There was considerable variation in all-cause mortality between sites, with most of the differences being accounted for by variations in infectious causes as a proportion of all deaths. Conclusions: This dataset documents individual deaths across Africa and Asia in a standardised way, and on an unprecedented scale. While INDEPTH sites are not constructed to constitute a representative sample, and VA may not be the ideal method of determining cause of death, nevertheless these findings represent detailed mortality patterns for parts of the world that are severely under-served in terms of measuring mortality. Further papers explore details of mortality patterns among children and specifically for NCDs, external causes, pregnancy-related mortality, malaria, and HIV/AIDS. Comparisons will also be made where possible with other findings on mortality in the same regions. Findings presented here and in accompanying papers support the need for continued work towards much wider implementation of universal civil registration of deaths by cause on a worldwide basis. [ABSTRACT FROM AUTHOR]

Background: Research capacity enhancement is needed in low- and middle-income countries (LMICs) for improved health, wellbeing, and health systems' development. In this article, we discuss two capacity-building projects, the African/Asian Regional Capacity Development (ARCADE) in Health Systems and Services Research (HSSR) and Research on Social Determinants of Health (RSDH), implemented from 2011 to 2015. The two projects focussed on providing courses in HSSR and social determinants of health research, and on developing collaborations between universities, along with capacity in LMIC universities to manage research grant submissions, financing, and reporting. Both face-to-face and sustainable online teaching and learning resources were used in training at higher postgraduate levels (Masters and Doctoral level). Design: We collated project meeting and discussion minutes along with project periodic reports and deliverables. We extracted key outcomes from these, reflected on these in discussions, and summarised them for this paper. Results: Nearly 55 courses and modules were developed that were delivered to over 920 postgraduate students in Africa, Asia, and Europe. Junior researchers were mentored in presenting, developing, and delivering courses, and in preparing research proposals. In total, 60 collaborative funding proposals were prepared. The consortia also developed institutional capacity in research dissemination and grants management through webinars and workshops. Discussion: ARCADE HSSR and ARCADE RSDH were comprehensive programmes, focussing on developing the research skills, knowledge, and capabilities of junior researchers. One of the main strengths of these programmes was the focus on network building amongst the partner institutions, where each partner brought skills, expertise, and diverse work cultures into the consortium. Through these efforts, the projects improved both the capacity of junior researchers and the research environment in Africa, Asia, and Europe. [ABSTRACT FROM AUTHOR]

Background: The importance of tackling economic, social and health-related inequities is increasingly accepted as a core concern for the post-Millennium Development Goal framework. However, there is a global dearth of high-quality, policy-relevant and actionable data on inequities within populations, which means that development solutions seldom focus on the people who need them most. INTREC (INDEPTH Training and Research Centres of Excellence) was established with this concern in mind. It aims to provide training for researchers from the INDEPTH network on associations between health inequities, the social determinants of health (SDH), and health outcomes, and on presenting their findings in a usable form to policy makers. Objective: As part of a baseline situation analysis for INTREC, this paper assesses the current status of SDH training in three of the African INTREC countries--Ghana, Tanzania, and South Africa--as well as the gaps, barriers, and opportunities for training. Methods: SDH-related courses from the three countries were identified through personal knowledge of the researchers, supplemented by snowballing and online searches. Interviews were also conducted with, among others, academics engaged in SDH and public health training in order to provide context and complementary material. Information regarding access to the Internet, as a possible INTREC teaching medium, was gathered in each country through online searches. Results: SDH-relevant training is available, but 1) the number of places available for students is limited; 2) the training tends to be public-health-oriented rather than inclusive of the broader, multi-sectoral issues associated with SDH; and 3) insufficient funding places limitations on both students and on the training institutions themselves, thereby affecting participation and quality. We also identified rapidly expanding Internet connectivity in all three countries, which opens up opportunities for e-learning on SDH, though the current quality of the Internet services remains mixed. Conclusions: SDH training is currently in short supply, and there is a clear role for INTREC to contribute to the training of a critical mass of African researchers on the topic. This work will be accomplished most effectively by building on pre-existing networks, institutions, and methods. [ABSTRACT FROM AUTHOR]

Background: Growing demand for Global Health (GH) training and the internationalisation of education requires innovative approaches to training. Blended learning (BL, a form of e-learning combining face-to-face or real-time interaction with computer-assisted learning) is a promising approach for increasing GH research capacity in low- to middle-income countries. Implementing BL, however, requires additional skills and efforts from lecturers. This paper explores lecturers' views and experiences of delivering BL courses within the context of two north-south collaborative research capacity building projects, ARCADE HSSR and ARCADE RSDH. Design: We used a qualitative approach to explore the experiences and perceptions of 11 lecturers involved in designing and delivering BL courses collaboratively across university campuses in four countries (South Africa, Uganda, India and Sweden). Data were collected using interviews in person or via Skype. Inductive qualitative content analysis was used. Results: Participants reported that they felt BL increased access to learning opportunities and made training more flexible and convenient for adult learners, which were major motivations to engage in BL. However, despite eagerness to implement and experiment with BL courses, they lacked capacity and support, and found the task time consuming. They needed to make compromises between course objectives and available technological tools, in the context of poor Internet infrastructure. Conclusions: BL courses have the potential to build bridges between low- and middle-income contexts and between lecturers and students to meet the demand for GH training. Lecturers were very motivated to try these approaches but encountered obstacles in implementing BL courses. Considerable investments are needed to implement BL and support lecturers in delivering courses. [ABSTRACT FROM AUTHOR]

Background: Promoting national health research agendas in low- and middle-income countries (LMICs) requires adequate numbers of individuals with skills to initiate and conduct research. Recently, non-governmental organizations (NGOs) have joined research capacity building efforts to increase research leadership by LMIC nationals. Partners In Health, an international NGO operating in Rwanda, implemented its first Intermediate Operational Research Training (IORT) course to cultivate Rwandan research talent and generate evidence to improve health care delivery. Objective: This paper describes the implementation of IORT to share experiences with other organizations interested in developing similar training programmes. Methods: The Intermediate Operational Research Training utilized a deliverable-driven training model, using learning-by-doing pedagogy with intensive hands-on mentorship to build research skills from protocol development to scientific publication. The course had short (two-day) but frequent training sessions (seven sessions over eight months). Trainees were clinical and programme staff working at the district level who were paired to jointly lead a research project. Results: Of 10 trainees admitted to the course from a pool of 24 applicants, nine trainees completed the course with five research projects published in peer-reviewed journals. Strengths of the course included supportive national and institutional research capacity guidelines, building from a successful training model, and trainee commitment. Challenges included delays in ethical review, high mentorship workload of up to 250 hours of practicum mentorship, lack of access to literature in subscription journals and high costs of open access publication. Conclusions: The IORT course was an effective way to support the district-based government and NGO staff in gaining research skills, as well as answering research questions relevant to health service delivery at district hospitals. Other NGOs should build on successful programmes while adapting course elements to address context-specific challenges. Mentorship for LMIC trainees is critical for effectiveness of research capacity building initiatives. [ABSTRACT FROM PUBLISHER]

Background: Evidence-based antenatal care is one cornerstone in Safe Motherhood and educated and confident midwives remain to be optimal caregivers in Africa. Confidence in antenatal midwifery skills is important and could differ depending on the provision of education among the training institutions across Africa. Objective: The aim of the study was to describe and compare midwifery students' confidence in basic antenatal skills, in relation to age, sex, program type and level of program. Methods: A survey in seven sub-Saharan African countries was conducted. Enrolled midwifery students from selected midwifery institutions in each country presented selfreported data on confidence to provide antenatal care. Data were collected using a selfadministered questionnaire. The questionnaire consisted of 22 antenatal skills based on the competency framework from the International Confederation of Midwives. The skills were grouped into three domains; Identify fetal and maternal risk factors and educate parents; Manage and document emergent complications and Physical assessment and nutrition. Results: In total, 1407 midwifery students from seven Sub-Saharan countries responded. Almost one third (25-32%) of the students reported high levels of confidence in all three domains. Direct entry programs were associated with higher levels of confidence in all three domains, compared to post-nursing and double degree programs. Students enrolled at education with diploma level presented with high levels of confidence in two out of three domains. Conclusions: A significant proportion of student midwives rated themselves low on confidence to provide ANC. Midwifery students enrolled in direct entry programs reported higher levels of confidence in all domains. It is important that local governments develop education standards, based on recommendations from the International Confederation of midwives. Further research is needed for the evaluation of actual competence. [ABSTRACT FROM AUTHOR]

Background: Worldwide, nearly 570,000 women are diagnosed with cervical cancer each year, with 85% of new cases in low- and middle-income countries. The African continent is home to 35 of 40 countries with the highest cervical cancer mortality rates. In 2014, a partnership involving a rural region of Senegal, West Africa, was facing cervical cancer screening service sustainability barriers and began adapting regional-level policy to address implementation challenges. Objective: This manuscript reports the findings of a systematic literature review describing the implementation of decentralized cervical cancer prevention services in Africa, relevant in context to the Senegal partnership. We report barriers and policy-relevant recommendations through Levesque's Patient-Centered Access to Healthcare Framework and discuss the impact of this information on the partnership's approach to shaping Senegal's regional cervical cancer screening policy. Methods: The systematic review search strategy comprised two complementary sub-searches. We conducted an initial search identifying 4272 articles, then applied inclusion criteria, and ultimately 19 studies were included. Data abstraction focused on implementation barriers categorized with the Levesque framework and by policy relevance. Results: Our findings identified specific demand-side (clients and community) and supply-side (health service-level) barriers to implementation of cervical cancer screening services. We identify the most commonly reported demand- and supply-side barriers and summarize salient policy recommendations discussed within the reviewed literature. Conclusions: Overall, there is a paucity of published literature regarding barriers to and best practices in implementation of cervical cancer screening services in rural Africa. Many articles in this literature review did describe findings with notable policy implications. The Senegal partnership has consulted this literature when faced with various similar barriers and has developed two principal initiatives to address contextual challenges. Other initiatives implementing cervical cancer visual screening services in decentralized areas may find this contextual reporting of a literature review helpful as a construct for identifying evidence for the purpose of guiding ongoing health service policy adaptation. [ABSTRACT FROM AUTHOR]

There is an alarming tide of cardiovascular and metabolic disease (CMD) sweeping across Africa. This may be a result of an increasingly urbanized lifestyle characterized by the growing consumption of processed and calorie-dense food, combined with physical inactivity and more sedentary behaviour. While the link between lifestyle and public health has been extensively studied in Caucasian and African American populations, few studies have been conducted in Africa. This paper describes the detailed methods for Phase 1 of the AWI-Gen study that were used to capture phenotype data and assess the associated risk factors and end points for CMD in persons over the age of 40 years in sub-Saharan Africa (SSA). We developed a population-based cross-sectional study of disease burden and phenotype in Africans, across six centres in SSA. These centres are in West Africa (Nanoro, Burkina Faso, and Navrongo, Ghana), in East Africa (Nairobi, Kenya) and in South Africa (Agincourt, Dikgale and Soweto). A total of 10,702 individuals between the ages of 40 and 60 years were recruited into the study across the six centres, plus an additional 1021 participants over the age of 60 years from the Agincourt centre. We collected socio-demographic, anthropometric, medical history, diet, physical activity, fat distribution and alcohol/tobacco consumption data from participants. Blood samples were collected for disease-related biomarker assays, and genomic DNA extraction for genome-wide association studies. Urine samples were collected to assess kidney function. The study provides base-line data for the development of a series of cohorts with a second wave of data collection in Phase 2 of the study. These data will provide valuable insights into the genetic and environmental influences on CMD on the African continent. [ABSTRACT FROM AUTHOR]

Data from many high- and low- or middle-income countries have linked exposures during key developmental periods (in particular pregnancy and infancy) to later health and disease. Africa faces substantial challenges with persisting infectious disease and now burgeoning non-communicable disease.This paper opens the debate to the value of strengthening the developmental origins of health and disease (DOHaD) research focus in Africa to tackle critical public health challenges across the life-course. We argue that the application of DOHaD science in Africa to advance life-course prevention programmes can aid the achievement of the Sustainable Development Goals, and assist in improving health across generations. To increase DOHaD research and its application in Africa, we need to mobilise multisectoral partners, utilise existing data and expertise on the continent, and foster a new generation of young African scientists engrossed in DOHaD. [ABSTRACT FROM PUBLISHER]

Background: Several research capacity strengthening (RCS) initiatives have been established in Africa over the past decade. One such initiative is the Consortium for Advanced Research Training in Africa (CARTA) that has gained traction over the years and has been proven as an effective multidisciplinary approach to strengthen research capacity to address public and population health in Africa. Objectives: In this article, we document the experiences and management-related interventions that cushioned the CARTA programme and enabled it to remain resilient during the COVID pandemic. We further make recommendations on the enablers of resilience and optimal performance of such RCS initiatives during crises and beyond. Methods: We used routine information gathered by the CARTA secretariat from consortium correspondence, meeting minutes, reports and other related documents produced in the year 2020 in order to consolidate the experiences and interventions taken by the programme at programmatic, institutional and fellowship levels. Results: We identified a series of management-related cyclic phases that CARTA went through during the pandemic period, which included immobilisation, reflection, brainstorming, decision-making, intervening and recovery. We further identified strategic management-related interventions that contributed to the resilience of the programme during the pandemic including assessment and monitoring, communication management, policy and resource management, making investments and execution. Moreover, we observed that the strength of the leadership and management of CARTA, coupled with the consortium´s culture of collaboration, mutual trust, respect, openness, transparency, equitability, ownership, commitment and accountability, all contributed to its success during the pandemic period. Conclusion: We conclude that RCS initiatives undergo a series of phases during crises and that they need to promptly adopt and adapt appropriate management-related strategic interventions in order to remain resilient during such periods. This can be significantly realised if RCS initiatives build a culture of trust, commitment and joint ownership, and if they invest in strong management capacity. [ABSTRACT FROM AUTHOR]

Undernutrition remains a major public health issue in low- and middle-income countries. Objective Our aim for this study was to identify the factors contributing to undernutrition in children under five years old in North Africa. We searched five electronic bibliographic databases (Ovid MEDLINE, Web of Science, Embase (Ovid), ProQuest, and CINAHL) for eligible observational studies published after 2006. STATA version 17 software was used to calculate the odds ratios between associated factors and indicators of undernutrition, with 95% confidence intervals. For each factor, the overall odds were pooled using a forest plot. Due to the significant heterogeneity among the studies (I2 > 50%), a random-effects model was used, and sensitivity analysis was conducted to examine the effect of outliers. Out of 1093 initially identified studies, 14 met the selection criteria. Our meta-analysis revealed that uneducated mothers were the most common factor associated with undernutrition in North African children. Children aged 0–23 months were significantly associated with stunting (odds ratios (OR) = 1.27; 95% CI: 1.18; 1.37) and wasting (OR = 1.68; 95% CI: 1.42; 1.99). Children living in rural areas were also at higher odds of being stunted (OR = 1.74; 95% CI: 1.64; 1.84) and underweight (OR = 1.59; 95% CI: 1.35; 1.88). These analyses also indicated that a lower wealth index, mothers' nutritional health, uneducated fathers, and low birth weight were other factors significantly associated with stunting. Addressing undernutrition in Northern Africa requires a multidisciplinary approach prioritising mothers and young children, especially families in underprivileged areas. [ABSTRACT FROM AUTHOR]

Lifestyle Africa is an adapted version of the Diabetes Prevention Program designed for delivery by community health workers to socioeconomically disadvantaged populations in low- and middle-income countries (LMICs). Results from the Lifestyle Africa trial conducted in an under-resourced community in South Africa indicated that the programme had a significant effect on reducing haemoglobin A1c (HbA1c). To estimate the cost of implementation and the cost-effectiveness (in cost per point reduction in HbA1c) of the Lifestyle Africa programme to inform decision-makers of the resources required and the value of this intervention. Interviews were held with project administrators to identify the activities and resources required to implement the intervention. A direct-measure micro-costing approach was used to determine the number of units and unit cost for each resource. The incremental cost per one point improvement in HbA1c was calculated. The intervention equated to 71 United States dollars (USD) in implementation costs per participant and a 0.26 improvement in HbA1c per participant. Lifestyle Africa reduced HbA1c for relatively little cost and holds promise for addressing chronic disease in LMIC. Decision-makers should consider the comparative clinical effectiveness and cost-effectiveness of this intervention when making resource allocation decisions. Trial registration is at ClinicalTrials.gov (NCT03342274). [ABSTRACT FROM AUTHOR]

Advocacy is one of the core functions of public health and is a key tool for achieving Sustainable Development Goals. Public health associations play a key role in advocating for the development and implementation of strategies to prevent diseases and promote health and well-being. This study aims to map out the focus of public health advocacy carried out by selected national public health associations over 4 years, between 2018 and 2021, in order to identify gaps and strengths and support associations and professionals in their advocacy efforts. Twelve national public health associations participated in the study. Official policy documents produced between 2018 and 2021 were collected and analysed. The title and summary of the policy documents were examined line by line and coded into the main subject categories and themes. A qualitative thematic analysis was conducted. Policies were assessed from global and regional perspectives. A total of 220 policy documents were analysed. Overall, the largest number of policy documents came from high-income countries and dealt with environmental health and communicable diseases, including COVID-19, with, however, important differences among regions. In the African region, public health advocacy focused mainly on strengthening health systems; Europe and South America were mostly concerned with communicable diseases and pandemic management; and North America and the Western Pacific regions focused primarily on climate change. Limited attention was paid to international health and health as a human right in all regions. Our study showed that, especially in high-income countries, public health associations actively engage in advocacy; however, more effort needs to be devoted to implementing a more international and intersectoral approach at the global level, anchored in health as a human right and aligned with the Sustainable Development Goals. [ABSTRACT FROM AUTHOR]

Colorectal cancer (CRC) is the third most common cancer worldwide. The incidence of CRC is rising in low- and middle-income countries but decreasing in high-income countries due to the widespread use of surveillance colonoscopy. In Africa, the implementation of screening programs remains a challenge, even in countries, such as Ghana that have established CRC screening guidelines. The purpose of this review was to identify the barriers and recommend strategies for implementing CRC screening in African countries. A literature search using PubMed was conducted with the following search terms: colorectal neoplasm, early detection of cancer, mass screening, colonoscopy, faecal occult blood test, faecal immunochemical test (FIT) and Africa. After inclusion and exclusion criteria were applied, a total of 13 articles were reviewed. The most common barriers reported were limited endoscopic capacity, poor knowledge of CRC and CRC screening, health care factors, cultural factors and sociodemographic factors. Recommendations to increase the availability of CRC screening tests were to include the use of FITs, to provide more training for health care providers, and to expand educational programs for patients, physicians, and religious/community leaders. The primary barrier to screening for CRC in Africa is the limited endoscopic capacity, specifically the lack of infrastructure and trained personnel, which requires systematic changes by governing bodies. In addition, health care professionals should be involved in educating patients about CRC and CRC screening. Further research is needed to clarify the factors related to subtypes of CRC and to explore the feasibility of using FITs in Africa. [ABSTRACT FROM AUTHOR]

Diabetes is one of the non-communicable diseases (NCDs) which is rising significantly across sub-Saharan African (SSA) countries and posing a threat to the social, economic, and cultural fabric of the SSA population. The inclusion of NCDs into the post-2015 development agenda along with the global monitoring framework provides an opportunity to monitor progress of development programmes in developing countries. This paper examines challenges associated with dealing with diabetes within the development agenda in SSA and explores some policy options. This conceptual review draws from a range of works published in Medline and the grey literature to advance the understanding of the post-2015 development agenda and how it relates to NCDs. The paper begins with the burden of diabetes in sub-Sahara Africa and then moves on to examine challenges associated with diabetes prevention, treatment, and management in Africa. It finishes by exploring policy implications. With regards to development programmes on NCDs in the SSA sub-continent, several challenges exist: 1) poor documentation of risk factors, 2) demographic transitions (rapid urbanisation and ageing), 3) the complementary role of traditional healers, 4) tuberculosis and the treatment of the acquired immunodeficiency syndrome as risk factors for diabetes, 5) diabetes in complex emergencies, 6) diabetes as an international development priority and not a policy agenda for many SSA countries, and 7) poorly regulated food and beverage industry. For the post-2015 development agenda for NCDs to have an impact, sufficient investments will be needed to address legislative, technical, human, and fiscal resource constraints through advocacy, accountability, political leadership, and effective public–private partnership. Striking the right balance between competing demands and priorities, policies, and implementation strategies hold the key to an effective response to diabetes in SSA countries. [ABSTRACT FROM AUTHOR]

Migrant health workers fill care gaps in their destination countries, but they also actively engage in improving living conditions for people of their countries of origin through expatriate professional networks. This paper aims to explore the professional links that migrant health workers from sub-Saharan African countries living in five African and European destinations (Botswana, South Africa, Belgium, Austria, and the United Kingdom) have to their countries of origin. Qualitative interviews were conducted with migrant doctors, nurses, and midwives from sub-Saharan Africa (N=66). A qualitative content analysis of the material was performed using the software ATLAS.ti. Almost all migrant health workers have professional ties with their countries of origin supporting health, education, and social structures. They work with non-governmental organizations, universities, or hospitals and travel back and forth between their destination country and country of origin. For a few respondents, professional engagement or even maintaining private contacts in their country of origin is difficult due to the political situation at home. The results show that African migrant health workers are actively engaged in improving living conditions not only for their family members but also for the population in general in their countries of origin. Our respondents are mediators and active networkers in a globalized and transnationally connected world. The research suggests that the governments of these countries of origin could strategically use their migrant health workforce for improving education and population health in sub-Saharan Africa. Destination countries should be reminded of their need to comply with the WHO Global Code of Practice for the international recruitment of health professionals. [ABSTRACT FROM AUTHOR]

Background: Mortality from non-communicable diseases (NCDs) is a major global issue, as other categories of mortality have diminished and life expectancy has increased. TheWorld Health Organization's Member States have called for a 25% reduction in prematureNCDmortality by 2025,which can only be achieved by substantial reductions in risk factors and improvements in the management of chronic conditions. A high burden of NCD mortality among much older people, who have survived other hazards, is inevitable. The INDEPTH Network collects detailed individual data within defined Health and Demographic Surveillance sites. By registering deaths and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available. Objective: To describe patterns of adult NCD mortality from INDEPTH Network sites across Africa and Asia, according to the WHO 2012 verbal autopsy (VA) cause categories, with separate consideration of premature (15-64 years) and older (65- years) NCD mortality. Design: All adult deaths at INDEPTH sites are routinely registered and followed up with VA interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provide person-time denominators for mortality rates. Results: A total of 80,726 adult (over 15 years) deaths were documented over 7,423,497 person-years of observation. NCDs were attributed as the cause for 35.6% of these deaths. Slightly less than half of adult NCD deaths occurred in the 15-64 age group. Detailed results are presented by age and sex for leading causes ofNCD mortality. Per-site rates ofNCDmortalitywere significantly correlated with rates ofHIV/AIDS-relatedmortality. Conclusions: These findings present important evidence on the distribution of NCD mortality across a wide range of African and Asian settings. This comes against a background of global concern about the burden of NCD mortality, especially among adults aged under 70, and provides an important baseline for future work. [ABSTRACT FROM AUTHOR]

Background: Despite indications that infection-related mortality in sub-Saharan Africa may be decreasing and the burden of non-communicable diseases increasing, the overwhelming reality is that health information systems across most of sub-Saharan Africa remain too weak to track epidemiological transition in a meaningful and effective way. Proposals: We propose a minimum dataset as the basis of a functional health information system in countries where health information is lacking. This would involve continuous monitoring of cause-specific mortality through routine civil registration, regular documentation of exposure to leading risk factors, and monitoring effective coverage of key preventive and curative interventions in the health sector. Consideration must be given as to how these minimum data requirements can be effectively integrated within national health information systems, what methods and tools are needed, and ensuring that ethical and political issues are addressed. A more strategic approach to health information systems in sub-Saharan African countries, along these lines, is essential if epidemiological changes are to be tracked effectively for the benefit of local health planners and policy makers. Conclusion: African countries have a unique opportunity to capitalize on modern information and communications technology in order to achieve this. Methodological standards need to be established and political momentum fostered so that the African continent's health status can be reliably tracked. This will greatly strengthen the evidence base for health policies and facilitate the effective delivery of services. [ABSTRACT FROM AUTHOR]

With the evolving epidemiological parameters of COVID-19 in Africa, the response actions and lessons learnt during the pandemic's past two years, SARS-COV 2 will certainly continue to circulate in African countries in 2022 and beyond. As countries in the African continent need to be more prepared and plan to 'live with the virus' for the upcoming two years and after and at the same time mitigate risks by protecting the future most vulnerable and those responsible for maintaining essential services, WHO AFRO is anticipating four interim scenarios of the evolution of the pandemic in 2022 and beyond in the region. In preparation for the rollout of response actions given the predicted scenarios, WHO AFRO has identified ten strategic orientations and areas of focus for supporting member states and partners in responding to the COVID-19 pandemic in Africa in 2022 and beyond. WHO analysed trends of the transmissions since the first case in the African continent and reviewed lessons learnt over the past months. Establishing a core and agile team solely dedicated to the COVID-19 response at the WHO AFRO, the emergency hubs, and WCOs will improve the effectiveness of the response and address identified challenges. The team will collaborate with the various clusters of the regional office, and other units and subunits in the WCOs supported with good epidemics intelligence. COVID-19 pandemic has afflicted global humanity at unprecedented levels. Two years later and while starting the third year of the COVID-19 response, we now need to change and adapt our strategies, tools and approaches in responding timely and effectively to the pandemic in Africa and save more lives. [ABSTRACT FROM AUTHOR]

Community health volunteers are considered a vital part of the community health structure in Africa. Despite this vital role in African health systems, very little is known about the community health volunteers' day-to-day lived experiences providing services in communities and supporting other health workers. This scoping review aims to advance understanding of the day-to-day experiences of community health volunteers in Africa. In doing so, this review draws attention to these under-considered actors in African health systems and identifies critical factors and conditions that represent challenges to community health volunteers' work in this context. Ultimately, our goal is to provide a synthesis of key challenges and considerations that can inform efforts to reduce attrition and improve the sustainability of community health volunteers in Africa. This scoping review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews checklist to achieve the objectives. A comprehensive search of six databases returned 2140 sources. After screening, 31 peer-reviewed studies were selected for final review. Analytical themes were generated based on the reviewers' extraction of article data into descriptive themes using an inductive approach. In reviewing community health volunteers' accounts of providing health services, five key challenges become apparent. These are: (1) challenges balancing work responsibilities with family obligations; (2) resource limitations; (3) exposure to stigma and harassment; (4) gendered benefits and risks; and (5) health-system level challenges. This scoping review highlights the extent of challenges community health volunteers must navigate to provide services in communities. Sustained commitment at the national and international level to understand the lived experiences of community health volunteers and mitigate common stressors these health actors face could improve their performance and inform future programs. [ABSTRACT FROM AUTHOR]

The global community has committed to achieving universal access to sexual and reproductive health and rights (SRHR) services, but how to do it remains a challenge in many low-income countries. Capacity development is listed as a means of implementation for Agenda 2030. Although it has been a major element in international development cooperation, including SRHR, its effectiveness and circumstances under which it succeeds or fails have limited evidence. The study sought to examine whether improvement in team capacity of SRHR practitioners resulted in improved organisational effectiveness and/or improved SRHR outcomes in low-income countries. The study involved 99 SRHR interventions implemented in 13 countries from Africa and Asia. Self-reported evaluation data from healthcare practitioners who participated in a capacity development international training programme in SRHR was used. The training was conducted by Lund University in Sweden between 2015 and 2019. Logistic regression models were used to examine the association between improved team capacity, improved organizational effectiveness and improved SRHR outcomes, for all the 99 interventions. Adoption of new SRHR approaches (guidelines and policies), media engagement, support from partner organisations and involvement of stakeholders were assessed as possible confounders. Improved team capacity, support from partner organisations and media engagement were positively associated with improved organisational effectiveness. Improved team capacity was the strongest predictor of organisational effectiveness even after controlling for other covariates at multivariate analysis. However, adopting new SRHR approaches significantly reduced organisational effectiveness. Furthermore, support from partner organisations was positively associated with increased awareness of and demand for SRHR services. Successful implementation of capacity development interventions requires an enabling environment. In this study, an SRHR training programme aiming at improving team capacity resulted in an improvement in organisational effectiveness. Support from partner organisations and media engagement were key enablers of organisational effectiveness. [ABSTRACT FROM AUTHOR]

The Ebola virus is known as one of the deadliest pathogens to infect humans. Children represent a minority of Ebola Virus Disease cases globally. Yet, the different Ebola outbreaks in Africa had a wide impact on children's lives and children' rights. Review the published literature to date on Children's rights during Ebola outbreaks. Outcomes shall contribute to get a better understanding of the main limitations or violations of children's rights, identify potential gaps in the literature and support the promotion and protection of children's rights for current and future health crisis. A scoping review from PubMed, Medline, Cochrane Library and Web of Science was performed using PRISMA-ScR guidelines. Articles, reports and editorial, published on Ebola Outbreaks between 1976 and 2020 were retrieved. The UNCRC clusters of rights and treaty specific guidelines were used as a framework. Documents were found through a targeted search of websites from international or regional organisations involved in Ebola crises and children's protection. 48 articles and reports were reviewed. Few documents focused solely on children's rights. Several articles covered the topic of children and Ebola outbreaks. Most of the data are linked to basic health, education, discrimination of orphans and survivors. 31% of the reviewed articles underline the violence against the children (rape, abuse, Female genital mutilations), while 21% focus on the right to education. 23% cover the topic of orphans. Impact on mental health and SRH were amongst the other covered topics. A lack of data on children's rights and their violations during epidemics is observed. Regional and international collaboration is needed to document the situation of children in health emergencies. Health measures and strategies based on children's opinions and raising awareness of their crucial role in society is key. Child-centred guidelines should be developed based on these elements. [ABSTRACT FROM AUTHOR]

Science education and research have the potential to drive profound change in low- and middle-income countries (LMICs) through encouraging innovation, attracting industry, and creating job opportunities. However, in LMICs, research capacity is often limited, and acquisition of funding and access to state-of-the-art technologies is challenging. The Alliance for Global Health and Science (the Alliance) was founded as a partnership between the University of California, Berkeley (USA) and Makerere University (Uganda), with the goal of strengthening Makerere University's capacity for bioscience research. The flagship program of the Alliance partnership is the MU/UCB Biosciences Training Program, an in-country, hands-on workshop model that trains a large number of students from Makerere University in infectious disease and molecular biology research. This approach nucleates training of larger and more diverse groups of students, development of mentoring and bi-directional research partnerships, and support of the local economy. Here, we describe the project, its conception, implementation, challenges, and outcomes of bioscience research workshops. We aim to provide a blueprint for workshop implementation, and create a valuable resource for bioscience research capacity strengthening in LMICs. [ABSTRACT FROM AUTHOR]

Background: A multi-sectoral response is advocated by international organisations as a good strategy to address the multiple drivers and impact of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and was historically mandated as a condition of funding. In March 2017, the South African National AIDS Council (SANAC) launched the latest 5 year National Strategic Plan (NSP) to address HIV, sexually transmitted infections and tuberculosis. As with previous iterations, the NSP calls for multi-sectoral action (MSA) and mandates AIDS councils (ACs) at different levels to coordinate its implementation. Efforts have been made to advocate for the adoption of MSA in South Africa, yet evaluation of these efforts is currently limited. Objective: This paper assesses the implementation of a multi-sectoral response to HIV in South Africa, through a case study of the Mpumalanga Province. Methods: We identified and reviewed key policy documents, conducted 12 interviews and held six focus group discussions. We also drew on our involvement, through participant observation, in the development of NSPs and in AC meetings. Results: SANAC is struggling to provide much-needed support to provincial, district and local ACs. Therefore, most ACs are generally weak and failing to implement MSA. Membership is voluntary, there is a lack of sustained commitment and they do not include representatives from all sectors. There is little capacity to undertake the activities necessary for coordinating the implementation of MSA, and unclear roles and responsibilities within ACs result in divisions and tension between sectors. There is inadequate senior political leadership and funding to facilitate effective implementation of MSA. Conclusion: We identified three interventions that we argue are required to support the effective implementation of MSA: strengthening and stabilising the SANAC structure; building capacity of ACs; and creating an enabling environment for effective implementation of MSA through political leadership, support and resourcing of the HIV response. [ABSTRACT FROM PUBLISHER]

Background: Antimicrobial resistance (AMR) is a growing public health threat in Africa. AMR prevention and control requires coordination across multiple sectors of government and civil society partners. Objectives: To assess the current role, needs, and capacities of CSOs working in AMR in Africa. Methods: We conducted an online survey of 35 CSOs working in 37 countries across Africa. The survey asked about priorities for AMR, current AMR-specific activities, monitoring practices, training needs, and preferences for sharing information on AMR. Further data were gathered on the main roles of the organisations, the length of time engaged in and budget spent on AMR-related activities, and their involvement in the development and implementation of National Action Plans (NAPs). Results were assessed against The Africa Centres for Disease Control and Prevention (Africa CDC) Framework for Antimicrobial Resistance (2018–2023). Results: CSOs with AMR-related activities are working in all four areas of Africa CDC's Framework: improving surveillance, delaying emergence, limiting transmission, and mitigating harm from infections caused by AMR microorganisms. Engagement with the four objectives is mainly through advocacy, followed by accountability and service delivery. There were limited monitoring activities reported by CSOs, with only seven (20%) providing an example metric used to monitor their activities related to AMR, and 27 (80%) CSOs reporting having no AMR-related strategy. Half the CSOs reported engaging with the development and implementation of NAPs; however, only three CSOs are aligning their work with these national strategies. Conclusion: CSOs across Africa are supporting AMR prevention and control, however, there is potential for more engagement. Africa CDC and other government agencies should support the training of CSOs in strategies to control AMR. Tailored training programmes can build knowledge of AMR, capacity for monitoring processes, and facilitate further identification of CSOs' contribution to the AMR Framework and alignment with NAPs and regional strategies. [ABSTRACT FROM AUTHOR]

Background: A number of countries have adopted sugar-sweetened beverage taxes to prevent non-communicable diseases but there is variance in the structures and rates of the taxes. As interventions, sugar-sweetened beverage taxes could be cost-effective but must be compliant with existing legal and taxation systems. Objectives: To assess the legal feasibility of introducing or strengthening taxation laws related to sugar-sweetened beverages, for prevention of non-communicable diseases in seven countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda and Zambia. Methods: We assessed the legal feasibility of adopting four types of sugar-sweetened beverage tax formulations in each of the seven countries, using the novel FELIP framework. We conducted a desk-based review of the legal system related to sugar-sweetened beverage taxation and assessed the barriers to, and facilitators and legal feasibility of, introducing each of the selected formulations by considering the existing laws, laws related to impacted sectors, legal infrastructure, and processes involved in adopting laws. Results: Six countries had legal mandates to prevent non-communicable diseases and protect the health of citizens. As of 2019, all countries had excise tax legislation. Five countries levied excise taxes on all soft drinks, but most did not exclusively target sugar-sweetened beverages, and taxation rates were well below the World Health Organization's recommended 20%. In Uganda and Kenya, agricultural or HIV-related levies offered alternative mechanisms to disincentivise consumption of sugar-sweetened beverages without the introduction of new taxes. Nutrition-labelling laws in all countries made it feasible to adopt taxes linked to the sugar content of beverages, but there were lacunas in existing infrastructure for more sophisticated taxation structures. Conclusion: Sugar-sweetened beverage taxes are legally feasible in all seven countries Existing laws provide a means to implement taxes as a public health intervention. [ABSTRACT FROM AUTHOR]

The WHO developed a generic 'TB patient cost survey' tool and a standardized approach to assess the direct and indirect costs of TB incurred by patients and their households, estimate the proportion of patients experiencing catastrophic costs, and measure the impact of interventions to reduce patient costs. While the generic tool is a facility-based cross-sectional survey, this standardized approach needs to be adapted for longitudinal studies. A longitudinal approach may overcome some of the limitations of a cross-sectional design and estimate the economic burden of TB more precisely. We describe the process of creating a longitudinal instrument and its application to the TB Sequel study, an ongoing multi-country, multi-center observational cohort study. We adapted the cross-sectional WHO generic TB patient cost survey instrument for the longitudinal study design of TB Sequel and the local context in each study country (South Africa, Mozambique, Tanzania, and The Gambia). The generic instrument was adapted for use at enrollment (start of TB treatment; Day 0) and at 2, 6, 12 and 24 months after enrollment, time points intended to capture costs incurred for diagnosis, during treatment, at the end of treatment, and during long-term follow-up once treatment has been completed. These time points make the adapted version suitable for use in patients with either drug-sensitive or drug-resistant TB. Using the adapted tool provides the opportunity to repeat measures and make comparisons over time, describe changes that extend beyond treatment completion, and link cost survey data to treatment outcomes and post-TB sequelae. Trial registration: ClinicalTrials.gov: NCT032516 August 1196, 2017. Abbreviations: DOTS: Directly observed treatment, short-course; DR-TB: Drug-resistant tuberculosis; MDR-TB: Multi-drug resistant tuberculosis; NTP: National Tuberculosis Programme; TB: Tuberculosis; USD: United States Dollar; WHO: World Health Organization. [ABSTRACT FROM AUTHOR]

Understanding the prevalence and types of antibiotics used in a given human and/or animal population is important for informing stewardship strategies. Methods used to capture such data often rely on verbal elicitation of reported use that tend to assume shared medical terminology. Studies have shown the category 'antibiotic' does not translate well linguistically or conceptually, which limits the accuracy of these reports. This article presents a 'Drug Bag' method to study antibiotic use (ABU) in households and on farms, which involves using physical samples of all the antibiotics available within a given study site. We present the conceptual underpinnings of the method, and our experiences of using this method to produce data about antibiotic recognition, use and accessibility in the context of anthropological research in Africa and South-East Asia. We illustrate the kinds of qualitative and quantitative data the method can produce, comparing and contrasting our experiences in different settings. The Drug Bag method can produce accurate antibiotic use data as well as provide a talking point for participants to discuss antibiotic experiences. We propose it can help improve our understanding of antibiotic use in peoples' everyday lives across different contexts, and our reflections add to a growing conversation around methods to study ABU beyond prescriber settings, where data gaps are currently substantial. [ABSTRACT FROM AUTHOR]

Background: Efforts to improve national civil registration and vital statistics (CRVS) systems are focusing on transforming traditionally passive systems into active systems that have the ability to reach the household level. While community health agents remain at the core of many birth and death reporting efforts, previous literature has not explored elements for their successful integration into CRVS efforts. Objective: To inform future efforts to improve CRVS systems, we conducted a systematic review of literature to understand and describe the design features, resulting data quality, and factors impacting the performance of community health agents involved in tracking vital events. Methods: We reviewed 393 articles; reviewers extracted key information from 58 articles meeting the eligibility criteria: collection of birth and/or death information outside of a clinic environment by a community agent. Reviewers recorded information in an Excel database on various program aspects, and results were summarized into key themes and topic areas. Results: The majority of articles described work in rural areas of Africa or South-East Asia. Nearly all articles (86%) cited some form of household visitation by community health agents. Only one article described a process in which vital events tracking activities were linked to official vital events registers. Other factors commonly described included program costs, relationship of community agents to community, and use of mobile devices. About 1/3 of articles reported quantitative information on performance and quality of vital events data tracked; various methods were described for measuring completeness of reporting, which varied greatly across articles. Conclusions: The multitude of articles on this topic attests to the availability of community health agents to track vital events. Creating a programmatic norm of integrating with CRVS systems the vital events information collected from existing community health programs has the potential to provide governments with information essential for public health decision-making. [ABSTRACT FROM AUTHOR]

Background: The global focus on promoting Universal Health Coverage has drawn attention to the need to increase public domestic funding for health care in low- and middle-income countries. Objectives: This article examines whether increased tax revenue in the three territories of Kenya, Lagos State (Nigeria) and South Africa was accompanied by improved resource allocation to their public health sectors, and explores the reasons underlying the observed trends. Methods: Three case studies were conducted by different research teams using a common mixed methods approach. Quantitative data were extracted from official government financial reports and used to describe trends in general tax revenue, total government expenditure and government spending on the health sector and other sectors in the first decade of this century. Twenty-seven key informant interviews with officials in Ministries of Health and Finance were used to explore the contextual factors, actors and processes accounting for the observed trends. A thematic content analysis allowed this qualitative information to be compared and contrasted between territories. Findings: Increased tax revenue led to absolute increases in public health spending in all three territories, but not necessarily in real per capita terms. However, in each of the territories, the percentage of the government budget allocated to health declined for much of the period under review. Factors contributing to this trend include: inter-sectoral competition in priority setting; the extent of fiscal federalism; the Ministry of Finance's perception of the health sector's absorptive capacity; weak investment cases made by the Ministry of Health; and weak parliamentary and civil society involvement. Conclusion: Despite dramatic improvements in tax revenue collection, fiscal space for health in the three territories did not improve. Ministries of Health must strengthen their ability to motivate for larger allocations from government revenue through demonstrating improved performance and the relative benefits of health investments. [ABSTRACT FROM AUTHOR]

Background: Despite the importance of inclusive employment, described in Goal 8 of the Sustainable Development Goals (SDGs), employment of persons with psychiatric disabilities in Africa is lower than among the general population. Objective: The aim of this scoping review is to explore evidence related to the barriers to and facilitators of employment of persons with psychiatric disabilities in Africa. Methods: A literature search was conducted using six relevant electronic databases of articles published between 1990 and 2017. Results: Eight studies were identified and analysed regarding barriers and facilitators of employment of persons with psychiatric disabilities. The dynamic adaptation of the bio-psycho-social model was used as an analytical framework. Identified barriers include ill health, (anticipated) psychiatric illness, social stigma and discrimination, negative attitudes among employers and the lack of social support and government welfare. Facilitators of employment include stability of mental illness, heightened self-esteem, a personal decision to work despite stigma, competitive and supported employment, reduction in social barriers/stigma and workplace accommodations. Conclusion: Employment of persons with psychiatric disabilities is essential, yet there is dearth of scientific evidence to identify contextual models that might be useful in African countries and other low-and middle countries (LMICs). This gap in information would benefit from further research to improve the employment rates of persons with psychiatric disabilities in Africa. [ABSTRACT FROM AUTHOR]

Background: Suicide ideation is a health issue affecting adolescents worldwide. There are significant variations in suicide ideation between countries and genders, which have not been fully explained. Research is especially lacking in countries outside Europe and North America. Gender equality has been shown to matter in other aspects of adolescent mental health, such as life satisfaction, but has not been researched in relation to suicide ideation at national level. Objective: To investigate how national gender inequality is related to self-reported suicide ideation among adolescents, and whether this association differs between boys and girls. Methods: This is a cross-national, cross-sectional study using individual survey data from the Global School-based Student Health Survey, a survey in Africa, Asia, Latin America and the South Pacific, developed and supported by among others the WHO and the CDC; connecting this to national data: the gender inequality index from the UNDP; controlling for GDP per capita and secondary school enrolment. The data was analysed using a multilevel logistic regression method and included 149,306 students from 37 countries. Results: Higher national gender inequality, as measured by the gender inequality index, was significantly associated with a higher likelihood of suicide ideation in both girls and boys (odds ratio: 1.38 p-value: 0.015), but for girls and both sexes this was only after adjusting for selection bias due to secondary school enrolment (as well as GDP/capita). Interaction models showed that this association was stronger in boys than in girls. Conclusions: National gender inequality seems to be associated with higher levels of suicide ideation among adolescents in mainly low- and middle-income countries, especially among boys. [ABSTRACT FROM AUTHOR]

Introduction: Increasing efforts are being made globally on capacity building. North-south research partnerships have contributed significantly to enhancing the research capacity in low- and middle-income countries (LMICs) over the past few decades; however, a lack of skilled researchers to inform health policy development persists, particularly in LMICs. TheEUFP7 fundedAfrican/AsianRegional CapacityDevelopment (ARCADE) projects were multi-partner consortia aimed to develop a new generation of highly trained researchers from universities across the globe, focusing on global health-related subjects: health systems and services research and research on social determinants of health. This article aims to outline the successes, challenges and lessons learned from the life course of the projects, focusing on the key outputs and experiences of developing and implementing these two projects together with sub-Saharan African, Asian and European institution partners. Design: Sixteen participants from 12 partner institutions were interviewed. The data were analysed using thematic content analysis, which resulted in four themes and three sub-categories. These data were complemented by a review of project reports. Results: The results indicated that the ARCADE projects have been successful in developing and delivering courses, and have reached over 920 postgraduate students. Some partners thought the north-south and south-south partnerships that evolved during the project were the main achievement. However, others found there to be a 'north-south divide' in certain aspects. Challenges included technical constraints and quality assurance. Additionally, adapting new teaching and learning methods into current university systems was challenging, combined with not being able to award students with credits for their degrees. Conclusion: The ARCADE projects were introduced as an innovative and ambitious project idea, although not designed appropriately for all partner institutions. Some challenges were underestimated from the beginning, and for such future projects, a more structured approach needs to be adopted. ARCADE partners learned that integrating courses into current university systems and awarding students credits are essential. [ABSTRACT FROM AUTHOR]

Background: As blended learning (BL; a combination of face-to-face and e-learning methods) becomes more commonplace, it is important to assess whether students find it useful for their studies. ARCADE HSSR and ARCADE RSDH (African Regional Capacity Development for Health Systems and Services Research; Asian Regional Capacity Development for Research on Social Determinants of Health) were unique capacity-building projects, focusing on developing BL in Africa and Asia on issues related to global health. Objective: We aimed to evaluate the student experience of participating in any of five ARCADE BL courses implemented collaboratively at institutions from Africa, Asia, and Europe. Design: A post-course student survey with 118 students was conducted. The data were collected using email or through an e-learning platform. Data were analysed with SAS, using bivariate and multiple logistic regression. We focused on the associations between various demographic and experience variables and student-reported overall perceptions of the courses. Results: In total, 82 students responded to the survey. In bivariate logistic regression, the course a student took [p=0.0067, odds ratio (OR)=0.192; 95% confidence interval (CI): 0.058-0.633], male gender of student (p=0.0474, OR=0.255; 95% CI: 0.066-0.985), not experiencing technical problems (p<0.001, OR=17.286; 95%CI: 4.629-64.554), and reporting the discussion forum as adequate for student needs (p=0.0036,OR=0.165; 95%CI: 0.049-0.555) were found to be associated with a more positive perception of BL, as measured by student rating of the overall helpfulness of the e-learning component to their studies. In contrast, perceiving the assessment as adequate was associated with a worse perception of overall usefulness. In a multiple regression, the course, experiencing no technical problems, and perceiving the discussion as adequate remained significantly associated with a more positively rated perception of the usefulness of the online component of the blended courses. Discussion: The results suggest that lack of technical problems and functioning discussion forums are of importance during BL courses focusing on global health-related topics. Through paying attention to these aspects, global health education could be provided using BL approaches to student satisfaction. [ABSTRACT FROM AUTHOR]

Background: The association of early maternal birthing age with smaller children has been widely observed. However, it is unclear if this is due to confounding by factors such as socioeconomic status, or the age at which child growth restriction first occurs. Objective: To examine the effect of early maternal birthing age on the first-born child's height-for-age in a sample of developing countries in Africa, Asia, and Latin America. Design: Cross-sectional data from Demographic Health Surveys from 18 countries were used, to select the first-born child of mothers aged 15-24 years and a range of potential confounding factors, including maternal height. Child length/height-for-age z-scores (HAZs) was estimated in age bands of 0-11, 12-23, 24-35, 36-47, and 48-59 months; HAZ was first compared between maternal age groups of 15-17, 18-19, and 20-24 years. Results: 1) There were significant bivariate associations between low child HAZ and young maternal age (71 of 180 possible cases; at p <0.10), but the majority of these did not persist when controlling for confounders (41 cases, 23% of the 180). 2) For children < 12 months, when controlling for confounders, three out of seven Asian countries showed a significant association between lower infant HAZ and low maternal age, as did six out of nine African countries (15-17 or 15-19 years vs. the older group). 3) The association (adjusted) continued after 24 months in 12 of the 18 countries, in Africa, Asia, and Latin America. 4) The stunting differences for children between maternal age groups were around 9 percentage points (ppts) in Asia, 14 ppts in Africa, and 10 ppts in Latin America. These data do not show whether this is due to, for example, socioeconomic factors that were not included, an emerging effect of intrauterine growth restriction, or the child feeding or caring behaviors of young mothers. The latter is considered to be the most likely. Conclusions: The effect of low maternal age on child height restriction from 0 to 11 months occurred in half the countries studied after adjusting for confounders. Poorer growth continuing after 24 months in children of younger mothers was observed in all regions, but needs further research to determine the causes. The effects were about double (in stunting prevalence terms) in Africa, where there was an increase in 10 ppts in stunting for children of young mothers. [ABSTRACT FROM AUTHOR]

Background: About 80% of deaths from non-communicable diseases (NCDs) occur in developing countries such as Kenya. However, not much is known about the burden of NCDs in slums, which account for about 60% of the residences of the urban population in Kenya. This study examines trends in NCD mortality from two slum settings in Nairobi. Design:We use verbal autopsy data on 1954 deaths among adults aged 35 years and older who were registered in the Nairobi Urban Health and Demographic Surveillance System between 2003 and 2011. InterVA-4, a computer-based program, was used to assign causes of death for each case. Results are presented as annualized cause-specific mortality rates (CSMRs) and cause-specific mortality fractions (CSMFs) by sex. Results: The CSMRs for NCDs did not appear to change significantly over time for both males and females. Among males, cardiovascular diseases (CVDs) and neoplasms were the leading NCDs -- contributing CSMFs of 8 and 5%, respectively, on average over time. Among females, CVDs contributed a CSMF of 14% on average over time, while neoplasms contributed 8%. Communicable diseases and related conditions remained the leading causes of death, contributing a CSMF of over 50% on average in males and females over time. Conclusions: Our findings are consistent with the Global Burden of Disease 2010 study which shows that communicable diseases remain the dominant cause of death in Africa, although NCDs were still significant contributors to mortality. We recommend an integrated approach towards disease prevention that focuses on health systems strengthening in resource-limited settings such as slums. [ABSTRACT FROM AUTHOR]

Background: Mortality from external causes, of all kinds, is an important component of overall mortality on a global basis. However, these deaths, like others in Africa and Asia, are often not counted or documented on an individual basis. Overviews of the state of external cause mortality in Africa and Asia are therefore based on uncertain information. The INDEPTH Network maintains longitudinal surveillance, including cause of death, at population sites across Africa and Asia, which offers important opportunities to document external cause mortality at the population level across a range of settings. Objective: To describe patterns of mortality from external causes at INDEPTH Network sites across Africa and Asia, according to the WHO 2012 verbal autopsy (VA) cause categories. Design: All deaths at INDEPTH sites are routinely registered and followed up with VA interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provide person-time denominators for mortality rates. Results: A total of 5,884 deaths due to external causes were documented over 11,828,253 person-years. Approximately one-quarter of those deaths were to children younger than 15 years. Causes of death were dominated by childhood drowning in Bangladesh, and by transport-related deaths and intentional injuries elsewhere. Detailed mortality rates are presented by cause of death, age group, and sex. Conclusions: The patterns of external cause mortality found here generally corresponded with expectations and other sources of information, but they fill some important gaps in population-based mortality data. They provide an important source of information to inform potentially preventive intervention designs. [ABSTRACT FROM AUTHOR]

Background: As the HIV/AIDS pandemic has evolved over recent decades, Africa has been the most affected region, even though a large proportion of HIV/AIDS deaths have not been documented at the individual level. Systematic application of verbal autopsy (VA) methods in defined populations provides an opportunity to assess the mortality burden of the pandemic from individual data. Objective: To present standardised comparisons of HIV/AIDS-related mortality at sites across Africa and Asia, including closely related causes of death such as pulmonary tuberculosis (PTB) and pneumonia. Design: Deaths related to HIV/AIDS were extracted from individual demographic and VA data from 22 INDEPTH sites across Africa and Asia. VA data were standardised to WHO 2012 standard causes of death assigned using the InterVA-4 model. Between-site comparisons of mortality rates were standardised using the INDEPTH 2013 standard population. Results: The dataset covered a total of 10,773 deaths attributed to HIV/AIDS, observed over 12,204,043 person-years. HIV/AIDS-related mortality fractions and mortality rates varied widely across Africa and Asia, with highest burdens in eastern and southern Africa, and lowest burdens in Asia. There was evidence of rapidly declining rates at the sites with the heaviest burdens. HIV/AIDS mortality was also strongly related to PTB mortality. On a country basis, there were strong similarities between HIV/AIDS mortality rates at INDEPTH sites and those derived from modelled estimates. Conclusions: Measuring HIV/AIDS-related mortality continues to be a challenging issue, all the more so as anti-retroviral treatment programmes alleviate mortality risks. The congruence between these results and other estimates adds plausibility to both approaches. These data, covering some of the highest mortality observed during the pandemic, will be an important baseline for understanding the future decline of HIV/AIDS. [ABSTRACT FROM AUTHOR]

Background: Malaria continues to be a major cause of infectious disease mortality in tropical regions. However, deaths from malaria are most often not individually documented, and as a result overall understanding of malaria epidemiology is inadequate. INDEPTH Network members maintain population surveillance in Health and Demographic Surveillance System sites across Africa and Asia, in which individual deaths are followed up with verbal autopsies. Objective: To present patterns of malaria mortality determined by verbal autopsy from INDEPTH sites across Africa and Asia, comparing these findings with other relevant information on malaria in the same regions. Design: From a database covering 111,910 deaths over 12,204,043 person-years in 22 sites, in which verbal autopsy data were handled according to the WHO 2012 standard and processed using the InterVA-4 model, over 6,000 deaths were attributed to malaria. The overall period covered was 1992-2012, but two-thirds of the observations related to 2006-2012. These deaths were analysed by site, time period, age group and sex to investigate epidemiological differences in malaria mortality. Results: Rates of malaria mortality varied by 1:10,000 across the sites, with generally low rates in Asia (one site recording no malaria deaths over 0.5 million person-years) and some of the highest rates in West Africa (Nouna, Burkina Faso: 2.47 per 1,000 person-years). Childhood malaria mortality rates were strongly correlated with Malaria Atlas Project estimates of Plasmodium falciparum parasite rates for the same locations. Adult malaria mortality rates, while lower than corresponding childhood rates, were strongly correlated with childhood rates at the site level. Conclusions: The wide variations observed in malaria mortality, which were nevertheless consistent with various other estimates, suggest that population-based registration of deaths using verbal autopsy is a useful approach to understanding the details of malaria epidemiology. [ABSTRACT FROM AUTHOR]

Background: The probable coexistence of two or more epidemiological profiles in urban Africa is poorly documented. In particular, very few studies have focused on the comparison of cause-specific mortality between two types of neighborhoods that characterize contemporary southern cities: formal neighborhoods, that is, structured or delineated settlements (planned estates) that have full access to public utilities (electricity and water services), and the informal neighborhoods, that is, spontaneous and unplanned peri-urban settlements where people live in slum-like conditions, often with little or no access to public utilities. Objective: To compare the causes of death between the formal and informal neighborhoods covered by the Ouagadougou Health and Demographic Surveillance Systems (HDSS). Design: The data used come from the INDEPTH pooled dataset which includes the contribution of Ouagadougou HDSS and are compiled for the INDEPTH Network Data repository. The data were collected between 2009 and 2011 using verbal autopsy (VA) questionnaires completed by four fieldworkers well trained in the conduction of VAs. The VA data were then interpreted using the InterVA-4 program (version 4.02) to arrive at the causes of death. Results: Communicable diseases are the leading cause of death among children (aged between 29 days and 14 years) in both formal and informal neighborhoods, contributing more than 75% to the mortality rate. Mortality rates from non-communicable diseases (NCDs) are very low before age 15 but are the leading causes from age 50, especially in formal neighborhoods. Mortality from injuries is very low, with no significant difference between the two neighborhoods. Conclusions: The fact that mortality from NCDs is higher among adults in formal neighborhoods seems consistent with the idea of a correlation between modern life and epidemiological transition. However, NCDs do affect informal neighborhoods as well. They consist mainly of cardiovascular diseases and neoplasms most of which are preventable and/or manageable through a change in lifestyle. A prevention program would certainly reduce the burden of these chronic diseases among adults and the elderly with a significant economic impact for families. [ABSTRACT FROM AUTHOR]

This synthesis brings together findings on cause-specific mortality documented by means of verbal autopsies applied to over 110,000 deaths across Africa and Asia, within INDEPTH Network sites. Methods: Developments in computerised methods to assign causes of death on the basis of data from verbal autopsy (VA) interviews have made possible these standardised analyses of over 110,000 deaths from 22 African and Asian Health and Demographic Surveillance System sites in the INDEPTH Network. In addition to previous validations of the InterVA-4 probabilistic model, these wide-ranging analyses provide further evidence of the applicability of this approach to assigning the cause of death. Plausible comparisons with existing knowledge of disease patterns, as well as substantial correlations with out-of-model parameters such as time period, country, and other independent data sources were observed. Findings: Substantial variations in mortality between sites, and in some cases within countries, were observed. A number of the mortality burdens revealed clearly constitute grounds for public health actions. At an overall level, these included high maternal and neonatal mortality rates. More specific examples were childhood drowning in Bangladesh and homicide among adult males in eastern and southern Africa. Mortality from non-communicable diseases, particularly in younger adulthood, is an emerging cause for concern. INDEPTH's approach of documenting all deaths in particular populations, and successfully assigning causes to the majority, is important for formulating health policies. Future directions: The pooled dataset underlying these analyses is available at the INDEPTH Data Repository for further analysis. INDEPTH will continue to fill cause-specific mortality knowledge gaps across Africa and Asia, which will also serve as a baseline for post-2015 development goals. The more widespread use of similar VA methods within routine civil registration systems is likely to become an important medium-term strategy in many countries. Keywords: mortality; cause of death; Africa; Asia; verbal autopsy; INDEPTH [ABSTRACT FROM AUTHOR]

Background: Studies of trends in population changes and epidemiological profiles in the developing world have overwhelmingly relied upon the concepts of demographic, epidemiological, and health transitions, even though their usefulness in describing and understanding population and health trends in developing countries has been repeatedly called into question. The issue is particularly relevant for the study of population health patterns in Africa and sub-Saharan Africa, as the history and experience there differs substantially from that of Western Europe and North America, for which these concepts were originally developed. Objective: The aim of this study is two-fold: to review and clarify any distinction between the concepts of demographic transition, epidemiological transition and health transition and to identify summary indicators of population health to test how well these concepts apply in Africa. Results: Notwithstanding the characteristically diverse African context, Africa is a continent of uncertainties and emergencies where discontinuities and interruptions of health, disease, and mortality trends reflect the enduring fragility and instability of countries and the vulnerabilities of individuals and populations in the continent. Africa as a whole remains the furthest behind the world's regions in terms of health improvements and longevity, as do its sub-Saharan African regions and societies specifically. This study documents: 1) theoretically and empirically the similarities and differences between the demographic transition, epidemiological transition, and health transition; 2) simple summary indicators that can be used to evaluate their descriptive and predictive features; 3) marked disparities in the onset and pace of variations and divergent trends in health, disease, and mortality patterns as well as fertility and life expectancy trajectories among African countries and regions over the past 60 years; 4) the rapid decline in infant mortality and gains in life expectancy from the 1950s through the 1990s in a context of preponderant communicable diseases in all African countries; 5) the salient role of adult mortality, mostly ascribed to HIV/AIDS and co-morbidities, since the 1990s in reversing trends in mortality decline, its interruption of life expectancy improvements, and its reversal of gender differences in life expectancies disadvantaging women in several countries with the highest prevalence of HIV/AIDS; 6) the huge impact of wars in reversing the trends in under-five mortality decline in sub-Saharan countries in the 1990s and beyond. These assessments of these transition frameworks and these phenomena were not well documented to date for all five regions and 57 countries of Africa. Conclusion: Prevailing frameworks of demographic, epidemiological, and health transitions as descriptive and predictive models are incomplete or irrelevant for charting the population and health experiences and prospects of national populations in the African context. [ABSTRACT FROM AUTHOR]