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Background: Unintended pregnancies can pose significant public health concerns for both maternal and child health because of their associated risks and implications. Experience of unintended pregnancies may lead to delay in seeking antenatal care, thus leading to increased risk of complications during pregnancy and childbirth. Globally, the prevalence of unintended pregnancies has declined. However, the problem remains acute in sub-Saharan Africa. This study was conducted to examine the factors associated with an experience of unintended pregnancy among women of reproductive ages in Zambia., Methods: This study used secondary data from the Zambia Demographic and Health Surveys (ZDHSs) which were conducted between 2001 and 2018. A pooled weighted sample of 4,090 pregnant women of reproductive age 15-49 years at the time of the survey was included in the analysis. Multivariable binary logistic regression model was employed to examine the association between independent correlates and experience of unintended pregnancy. All statistical analyses were conducted using Stata software., Results: Findings show that the proportion of women of reproductive age who experienced unintended pregnancy in Zambia declined from 50.4% (95% CI: 47.1, 53.8) in 2001 to 45.2% (95% CI: 40.5, 49.9) in 2018. The decline in the prevalence of unintended pregnancy is more pronounced among women age groups 25-29 years and 30-34 years. Increasing age was associated with an increased risk of experiencing unintended pregnancies. On the other hand, women who were living in rural areas (aOR = 0.76; 95% CI: 0.58, 1.00) and those with tertiary education (aOR = 0.46; 95% CI: 0.26, 0.80) were less likely to experience an unintended pregnancy. Women who desired a large family (aOR = 0.45; 95% CI: 0.24, 0.85) and those who watched television (aOR = 0.75; 95% CI: 0.59, 0.94) had lower odds of experiencing unintended pregnancies., Conclusions: The study has established that the prevalence of unintended pregnancy is still high in Zambia. Women's age, place of residence, level of education, desired family size and exposure to media were associated with the risk of experiencing an unintended pregnancy. Enhancing access to family planning services and commodities targeting women with low education levels will be key to further reduce unintended pregnancies., (© 2024. The Author(s).)

Background: Low birthweight (LBW) infants are at increased risk of morbidity and mortality. Exclusive breastfeeding up to six months is recommended to help them thrive through infection prevention, growth improvements, and enhancements in neurodevelopment. However, limited data exist on the feeding experiences of LBW infants, their caregivers and key community influencers. The qualitative component of the Low Birthweight Infant Feeding Exploration (LIFE) study aimed to understand practices, facilitators, and barriers to optimal feeding options in the first six months for LBW infants in low-resource settings., Methods: This study was conducted in four sites in India, Malawi, and Tanzania from July 2019 to August 2020. We conducted 37 focus group discussions with mothers and family members of LBW infants and community leaders and 142 in-depth interviews with healthcare providers, government officials, and supply chain and donor human milk (DHM) experts. Data were analyzed using a framework approach., Results: All participants believed that mother's own milk was best for LBW infants. Direct breastfeeding was predominant and feeding expressed breast milk and infant formula were rare. DHM was a new concept for most. Adequate maternal nutrition, lactation support, and privacy in the facility aided breastfeeding and expression, but perceived insufficient milk, limited feeding counseling, and infant immaturity were common barriers. Most believed that DHM uptake could be enabled through community awareness by overcoming misconceptions, safety concerns, and perceived family resistance., Conclusion: This study fills an evidence gap in LBW infant feeding practices and their facilitators and barriers in resource-limited settings. LBW infants face unique feeding challenges such as poor latching and tiring at the breast. Similarly, their mothers are faced with numerous difficulties, including attainment of adequate milk supply, breast pain and emotional stress. Lactation support and feeding counseling could address obstacles faced by mothers and infants by providing psychosocial, verbal and physical support to empower mothers with skills, knowledge and confidence and facilitate earlier, more and better breast milk feeding. Findings on DHM are critical to the future development of human milk banks and highlight the need to solicit partnership from stakeholders in the community and health system., (© 2023. The Author(s).)

Background: Even though evidence shows that fertility transition has begun almost everywhere in sub-Saharan Africa (SSA), the decline has been slower than in other parts of the world. Research shows that there is a positive relationship between fertility levels and fertility preference. Therefore, many countries in the region are implementing family planning education campaigns targeting at influencing reproductive behavior of women. Thus, this study aimed to examine the extent to which exposure to family planning communication influences fertility preferences of adolescent girls in SSA., Methods: This study used data extracted from the most recent Demographic and Health Survey datasets for 28 countries in SSA. Analyses were conducted on a pooled sample of 87,950 female adolescents' aged 15-19 years who were captured in respective country's survey. Multivariable binary logistic regression model was fitted in Stata version 17 software to examine the association between exposure to family planning communication and fertility preference among adolescent girls in SSA., Results: The average fertility preference among adolescent girls in SSA was 4.6 children (95% CI: 4.5, 4.7). Findings show that regardless of the country, adolescents who had exposure to family planning messages [aOR = 0.76, 95% CI = 0.72-0.80] were less likely to prefer 4 or more children. On average, fertility preference among adolescents who had exposure to family planning communication was (3.8 children compared to 4.5 children; p < 0.001) among those with no exposure. Furthermore, results show that married adolescents in SSA who had exposure to family planning message had a higher average preferred family size compared to those who were not married (4.8 versus 3.8; p < 0.001)., Conclusion: Exposure to family planning communication has shown the potential to influence adolescents' fertility preference in sub-Saharan Africa. Adolescents with exposure to family planning messages preferred a small family size. Therefore, there is a need to scale-up family planning education programmes in order to reduce fertility further in SSA., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Early childbearing remains a public health concern in sub-Saharan Africa (SSA) because it has substantial implications for women's and children's health and population control. However, little is known about recent changes in early childbearing in the region following the implementation of the Family Planning 2020 initiative (FP2020) national-level interventions. Thus, this study examined factors associated with early childbearing among women in SSA., Methods: The study used data from the most recent Demographic and Health Surveys conducted in 31 countries in sub-Saharan Africa between 2010 and 2021. The analysis included a pooled sample of 54,671 parous young women aged 20-24 years. A multivariable binary logistic regression model was used to examine the association between early childbearing and individual and household-level factors. All analyses were weighted to account for complex survey design., Results: The study shows that the mean prevalence of early childbearing was high in SSA at 39% (95% CI: 35, 43). Chad had the highest prevalence of early childbearing, 62% (95% CI: 60, 64) while Rwanda had the lowest prevalence of 13% (95% CI: 11, 15). Completing secondary school (aOR = 0.57; 95% CI: 0.52, 0.62) or attaining tertiary level education (aOR = 0.32; 95% CI: 0.22, 0.45), first sexual debut in the age range 15-24 years (aOR = 0.15; 95% CI: 0.14, 0.16) and desire for a small family size (aOR = 0.63; 95% CI: 0.58, 0.69) were associated with reduced odds of early childbearing among young women in SSA., Conclusion: The study has established that the prevalence of early childbearing is high in SSA. Level of education, age at first sexual debut, household size, and desired family size are associated with early childbearing in SSA. Governments of SSA countries should enhance sexual and reproductive health interventions to change reproductive behaviour, particularly in adolescents and young women., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Globally, millions of adolescent girls and young women (AGYW) who menstruate have limited access to appropriate and comfortable products to manage their menstruation. Yathu Yathu was a cluster randomised trial (CRT) that estimated the impact of community-based, peer-led sexual and reproductive health (SRH) services on knowledge of HIV status among adolescents and young people aged 15-24 (AYP). Among the services offered through Yathu Yathu were free disposable pads and menstrual cups. This study aimed to investigate whether the availability of free menstrual products through Yathu Yathu increased AGYW's use of an appropriate menstrual product at their last menstruation and explored the characteristics of AGYW who accessed menstrual products through Yathu Yathu., Methods: Yathu Yathu was conducted between 2019 and 2021 in 20 zones across two urban communities of Lusaka, Zambia. Zones were randomly allocated to the intervention or standard-of-care arm. In intervention zones, a community-based hub, staffed by peers, was established to provide SRH services. In 2019, a census was conducted in all zones; all consenting AYP aged 15-24 were given a Yathu Yathu Prevention Points Card, which allowed AYP to accrue points for accessing services at the hub and health facility (intervention arm), or the health facility only (control arm). Points could be exchanged for rewards, thus acting as an incentive in both arms. We conducted a cross-sectional survey in 2021 to estimate the impact of Yathu Yathu on the primary outcome (knowledge of HIV status) and secondary outcomes. Sampling was stratified by sex and age group; we analysed data from AGYW only to estimate the impact of Yathu Yathu on use of an appropriate menstrual product (disposable or reusable pad, cup, tampon) at last menstruation. We analysed data at zone-level using a two-stage process recommended for CRTs with < 15 clusters/arm., Results: Among 985 AGYW participating in the survey who had experienced menarche, the most commonly used products were disposable pads (88.8%; n = 875/985). At their last menstruation, 93.3% (n = 459/492) of AGYW in the intervention arm used an appropriate menstrual product compared to 85.7% (n = 420/490) in the control arm (adjPR = 1.09 95%CI 1.02, 1.17; p = 0.02). There was no evidence for interaction by age (p = 0.20), but use of appropriate products was higher among adolescents in the intervention arm relative to control (95.5% vs 84.5%, adjPR = 1.14 95%CI 1.04, 1.25; p = 0.006) with no evidence for a difference among young women (91.1% vs 87.0%, adjPR = 1.06 95%CI 0.96, 1.16, p = 0.22)., Conclusions: Delivering community-based peer-led SRH services increased the use of appropriate menstrual products among adolescent girls aged 15-19 at the start of the Yathu Yathu study. With less economic independence, the free provision of appropriate menstrual products is critical for adolescent girls to access materials that allow them to effectively manage their menstruation., (© 2023. The Author(s).)

Background: Violence against women and girls is a major public health issue, a violation of human rights, and is linked to a number of harmful effects on one's physical, mental, sexual, and reproductive health. Studies conducted in other parts of sub-Saharan Africa (SSA) suggest that there is an association between contextual factors and experience of intimate partner violence. However, in Zambia, this association is not well documented. Thus, this study was conducted to examine how individual and community-level characteristics influence spousal violence against women in Zambia., Methods: Data from the most recent Zambia Demographic and Health Survey conducted in 2018 was used. A sample of 7,358 ever-married women aged 15-49 years was used in the analysis. Two level multilevel binary logistic regression models were employed to examine the association between individual and contextual-level factors and experience of spousal violence., Results: The prevalence of spousal physical violence against women in Zambia was 21.1% [95% CI, 19.8, 22.5]. Women aged 15-19 [aOR = 2.36, 95% CI = 1.34-4.14] and 20-24 [aOR = 2.11, 95% CI = 1.38-3.22], who did not own mobile phone [aOR = 1.36, 95% CI = 1.10-1.69], and had low decision making autonomy [aOR = 1.24, 95% CI = 1.01-1.54] were more likely experience spousal physical violence. Furthermore, communities which had a low proportion of women with decision making power [aOR = 1.66, 95% CI = 1.26-2.19] were more likely experience spousal physical violence. Additionally, women whose partners' drank alcohol [aOR = 2.81, 95% CI = 2.30-3.45] and those whose partners exhibited jealous behaviour [aOR = 2.38, 95% CI = 1.88-3.21] were more likely to experience spousal physical violence., Conclusion: Both individual and community-level factors influenced spousal physical violence in Zambia. Integrating community level factors when designing interventions to address gender-based would be key to reduce women's vulnerability to gender based violence in the country. There is need to re-evaluate and re-strategize current strategies being implemented to address gender based violence in the country to make them context specific., (© 2023. The Author(s).)

Background: Teenage pregnancy remains a major social and public health challenge in developing countries especially sub-Saharan Africa (SSA) where prevalence rates are still increasing. Even if considerable effort has been made over the years to study determining factors of teenage pregnancy in SSA, few studies have looked at the trends and associated factors over a longer period. Furthermore, no known study has focussed on both individual and contextual factors influencing teenage pregnancy in Zambia. This study, thus sought to fill this gap in knowledge by simultaneously investigating trends of teenage pregnancy as well as its individual and contextual determining factors., Methods: A total pooled weighted sample of 10,010 teenagers (in the age group 15-19) from four waves of the Zambia Demographic and Health Surveys were extracted. Using bivariate analysis, we investigated the trends of teenage pregnancy between 2001 and 2018. Separate multilevel logistic regression models were fitted on pooled teenage pregnancy data in relation to several individual and contextual level factors. Both fixed and random effects were produced. Bayesian parameter estimates were produced using lme4 package in R statistical programming environment., Results: Results of the trends of teenage pregnancy in Zambia have shown an overall decrease of 2% between 2001 and 2018. Almost all the socioeconomic and demographic variables were consistently associated with teenage pregnancy (p < 0.001) in a bivariate analysis across the four survey. In multilevel analysis, the odds of being pregnant were higher for teenagers who were employed (aOR = 1.21, 95% CI: 1.02-1.42), married (aOR = 7.71, 95% CI: 6.31-9.52) and those with knowledge of ovulation period (aOR = 1.58, 95% CI: 1.34-1.90). On the other hand, belonging to households in high wealth quintiles, being literate, exposure to mass-media family planning messages and delayed sexual debut were associated with decreased odds of teenage pregnancy., Conclusion: The study shows that teenage pregnancy remains a social and public health challenge in Zambia as the country has seen little decrease in the prevalence over the years under consideration. Factors associated with teenage pregnancy include marital status, and employment, knowledge of ovulation period, wealth quintile, sexual debut and exposure to mass-media family planning messaging. Concerted effort must be made to improve literacy levels, reduce poverty and enhance sexual health promotion through the mass media in view of cultural norms, which may prevent parents and children from discussion sexual education topics thus exacerbate the vice., (© 2023. The Author(s).)

Background: Child marriage has long been a public health concern around the world, because it has the potential to deprive adolescent girls of their sexual reproductive health rights and limits their ability to reach their full potential in life. The prevalence of child marriage has been consistently higher in sub-Saharan Africa than elsewhere. However, fewer studies have explored the influence of both individual and community-level influences on early marriage in sub-Saharan Africa. This study, therefore, examined individual and community-level factors associated with child marriages in Zambia., Methods: Data came from the Zambia Demographic and Health Surveys (ZDHS) conducted in 2007, 2013-14 and 2018. A pooled weighted sample of 9990 women aged 20-29 years was used in the analysis. Stata software version 17 was used to perform statistical analysis, taking into account complex survey design. The association between individual- and community- level factors and early marital behavior was assessed using multilevel logistic regression models., Results: The prevalence of child marriage among women aged 20-29 was 44.4 percent (95% CI: 42.1, 46.7) in 2018, declining from 51.5 percent (95% CI: 48.9, 54.0) in 2007. Women with secondary or higher level of education [aOR = 0.36, 95% CI = 0.26-0.49] and [aOR = 0.07, 95% CI = 0.03-0.18] and those whose age at first birth was (15-19 year) or (20-29 years) were associated with less likelihood of experiencing child marriage. Communities with a high percentage of women who gave birth at a young age [aOR = 1.36, 95% CI = 1.15-1.62] were more likely to experience child marriage. Individual and community-level characteristics accounted for 35% of the overall variations in communities' likelihood of experiencing early marriage. Even after controlling for both individual and community-level influences, the intra-class correlation revealed that around 4.5 percent of the overall variations remained unexplained., Conclusion: Prevalence of child marriage has reduced over the years but is still high in Zambia. Both individual and community- level factors influenced child marriage in Zambia. There is a need to strengthen strategies that keep girls in school to delay their exposure to early sexual debut and child marriage. Designing of reproductive health interventions in the country should consider integration of community factors such as economic insecurity and access to reproductive health information., (© 2023. The Author(s).)

Background: Closing the gap of unmet needs for family planning (FP) in sub-Saharan Africa remains critical in improving maternal and child health outcomes. Determining the prevalence of unmet needs for family planning among married women in the reproductive age is vital for designing effective sexual reproductive health interventions and programmes. Here, we use nationally representative data drawn from sub-Saharan countries to estimate and examine heterogeneity of unmet needs for family planning among currently married women of reproductive age., Methods: This study used secondary data from Demographic and Health Surveys (DHS) conducted between January 1, 1995 to December 31, 2020 from 37 countries in sub-Saharan African. An Inverse Heterogeneity model (IVhet) in MetaXL application was used to estimate country and sub-regional level pooled estimates and confidence intervals of unmet needs for FP in SSA., Results: The overall prevalence of unmet need for family planning among married women of reproductive age in the sub-region for the period under study was 22.9% (95% CI: 20.9-25.0). The prevalence varied across countries from 10% (95% CI: 10-11%) in Zimbabwe to 38% (95% CI: 35-40) and 38 (95% CI: 37-39) (I2 = 99.8% and p-value < 0.0001) in Sao Tome and Principe and Angola, respectively. Unmet needs due to limiting ranged from 6%; (95% CI: 3-9) in Central Africa to 9%; (95% CI: 8-11) in East Africa. On the other hand, the prevalence of unmet needs due to spacing was highest in Central Africa (Prev: 18; 95% CI: 16-21) and lowest in Southern Africa (Prev: 12%; 95% CI: 8-16). Our study indicates that there was no publication bias because the Luis Furuya-Kanamori index (0.79) was within the symmetry range of -1 and + 1., Conclusion: The prevalence of unmet need for FP remains high in sub-Saharan Africa suggesting the need for health policymakers to consider re-evaluating the current SRH policies and programmes with the view of redesigning the present successful strategies to address the problem., (© 2023. The Author(s).)

Background: The attainment of targets set for modern contraceptive use remains a challenge in sub-Saharan Africa. Rwanda, in its new Family Planning and Adolescent Sexual Reproductive Health/Family Planning (FP/ASRH) Strategic Plan 2018-2024 has set the attainment of a contraceptive prevalence rate (CPR) of 60% by 2024. To achieve this, identifying factors that enhance modern contraceptive use among sexually active women is critical., Methods: We used three Rwanda Demographic Health Surveys (RDHS) datasets collected in 2010, 2015, and 2019/2020 in a multivariable decomposition analysis technique to describe trends and identify factors influencing change in modern contraceptive use among sexually active women aged 15-49 years. Results presented as coefficients and percentages took into consideration the complex survey design weighted using StataSE 17., Results: Modern contraceptive use increased from 40% in 2010 to 52.4% in 2020 among sexually active women. About 23.7% of the overall percentage change in modern contraceptive use was attributable to women's characteristics which included women's education levels, number of living children, and being told about family planning at health facilities. Coefficients contributed 76.26% to the change in modern contraceptive use. This change was attributed to modern contraceptive use among young women between the age of 20-24 years, women's education level, the number of living children, changes in family size, and being visited by community health workers., Conclusion: Rwanda remains on course to archive its 2024 family planning targets. However, there is a need to enhance programs that target sexually active adolescents and young adults, and women from rural areas to sustain the gains made. Furthermore, continuous support of community health workers will be key in exceeding the set targets of modern contraceptive use among sexually active women in Rwanda., (© 2022. The Author(s).)

Background: Unmet need for family planning among married women is still a public health concern in sub-Saharan Africa. In Zambia, one in every five married women had an unmet need for family planning in 2018. Unmet need for family planning has the potential to increase the number of unintended pregnancies and unsafe abortions. These factors can increase the proportion of women of child bearing age, who are at high risk of birth complications. This study was therefore conducted to understand the determinants of unmet need for family planning among married women in Zambia based on recent cross-sectional data., Methods: The study analysed data extracted from the Zambia Demographic and Health Survey, which was a representative cross-sectional survey conducted in 2018. The analysis was done on a sample of 7598 currently married women aged 15-49 years. Multivariate logistic regression was used to examine determinants of unmet need for family planning in Zambia. The analyses was weighted to account for complex sample design., Results: Prevalence of unmet need for family planning is still high in Zambia at 20%. Women in the age groups 25-34 and 35-49 were less likely to have total unmet need for family planning (AOR = 0.61; 95% CI 0.47, 0.78) and (AOR = 0.63; 95% CI 0.45, 0.86) respectively, compared with those aged 15-24 years. Age of a woman, parity, household wealth and exposure to media-based family planning messages were found to be significantly associated with unmet need for family planning among married women., Conclusion: There were significant differences in unmet need for family planning based on a woman's age, number of children ever born, wealth level, and exposure to media-based family planning messaging. Improving access to family planning messages and addressing underlying structural factors that improve the wealth status, particularly among young women, may help to reduce unmet need for family planning in Zambia., (© 2022. The Author(s).)

Background: Pneumonia is the leading infectious cause of death in children aged under 5 years in low- and middle-income countries (LMICs). World Health Organization (WHO) pneumonia diagnosis guidelines rely on non-specific clinical features. We explore chest radiography (CXR) findings among select children in the Innovative Treatments in Pneumonia (ITIP) project in Malawi in relation to clinical outcomes., Methods: When clinically indicated, CXRs were obtained from ITIP-enrolled children aged 2 to 59 months with community-acquired pneumonia hospitalized with treatment failure or relapse. ITIP1 (fast-breathing pneumonia) and ITIP2 (chest-indrawing pneumonia) trials enrolled children with non-severe pneumonia while ITIP3 enrolled children excluded from ITIP1 and ITIP2 with severe pneumonia and/or selected comorbidities. A panel of trained pediatricians classified the CXRs using the standardized WHO CXR research methodology. We analyzed the relationship between CXR classifications, enrollee characteristics, and outcomes., Results: Between March 2016 and June 2018, of 114 CXRs obtained, 83 met analysis criteria with 62.7% (52/83) classified as having significant pathology per WHO standardized interpretation. ITIP3 (92.3%; 12/13) children had a higher proportion of CXRs with significant pathology compared to ITIP1 (57.1%, 12/21) and ITIP2 (57.1%, 28/49) (p-value = 0.008). The predominant pathological CXR reading was "other infiltrates only" in ITIP1 (83.3%, 10/12) and ITIP2 (71.4%, 20/28), while in ITIP3 it was "primary endpoint pneumonia"(66.7%, 8/12,; p-value = 0.008). The percent of CXRs with significant pathology among children clinically cured (60.6%, 40/66) vs those not clinically cured (70.6%, 12/17) at Day 14 was not significantly different (p-value = 0.58)., Conclusions: In this secondary analysis we observed that ITIP3 children with severe pneumonia and/or selected comorbidities had a higher frequency of CXRs with significant pathology, although these radiographic findings had limited relationship to Day 14 outcomes. The proportion of CXRs with "primary endpoint pneumonia" was low. These findings add to existing data that additional diagnostics and prognostics are important for improving the care of children with pneumonia in LMICs., Trial Registration: ITIP1, ITIP2, and ITIP3 were registered with ClinicalTrials.gov ( NCT02760420 , NCT02678195 , and NCT02960919 , respectively)., (© 2022. The Author(s).)

Background: Mobile phone-based interventions have been demonstrated in different settings to overcome barriers to accessing critical psychosocial support. In this study, we aimed to assess the acceptability and feasibility of a phone-based, peer-to-peer support group intervention for adolescent pregnant women aged 15-24 years living with HIV in Zambia., Methods: Sixty-one consenting participants were recruited from Antenatal Clinics of two large urban communities in Lusaka. They were invited to participate in the mobile phone-based intervention that allowed them to anonymously communicate in a small group led by a facilitator for 4 months. A mixed methods approach was used to assess acceptability and feasibility, including a focus group discussion, pre- and post-intervention interview and analysis of the content of the text message data generated., Results: Participants reported finding the platform "not hard to use" and enjoyed the anonymity of the groups. Seventy-one percent of participants (n = 43) participated in the groups, meaning they sent text messages to their groups. Approximately 12,000 text messages were sent by participants (an average of 169 messages/user and 6 mentors in 6 groups. Topics discussed were related to social support and relationships, stigma, HIV knowledge and medication adherence., Conclusion: The study showed that the intervention was acceptable and feasible, and highlighted the potential of the model for overcoming existing barriers to provision of psychosocial support to this population., (© 2021. The Author(s).)

Background: Meeting the sexual and reproductive health (SRH) needs of adolescents and young people (AYP) requires their meaningful engagement in intervention design. We describe an iterative process of engaging AYP to finalise the design of a community-based, peer-led and incentivised SRH intervention for AYP aged 15-24 in Lusaka and the lessons learnt., Methods: Between November 2018 and March 2019, 18 focus group discussions, eight in-depth interviews and six observations were conducted to assess AYP's knowledge of HIV/SRH services, factors influencing AYP's sexual behaviour and elicit views on core elements of a proposed intervention, including: community-based spaces (hubs) for service delivery, type of service providers and incentivising service use through prevention points cards (PPC; "loyalty" cards to gain points for accessing services and redeem these for rewards). A total of 230 AYP (15 participated twice in different research activities) and 21 adults (only participated in the community mapping discussions) participated in the research. Participants were purposively selected based on age, sex, where they lived and their roles in the study communities. Data were analysed thematically., Results: Alcohol and drug abuse, peer pressure, poverty, unemployment and limited recreation facilities influenced AYP's sexual behaviours. Adolescent boys and young men lacked knowledge of contraceptive services and all AYP of pre and post exposure prophylaxis for HIV prevention. AYP stated a preference for accessing services at "hubs" located in the community rather than the health facility. AYP considered the age, sex and training of the providers when choosing whom they were comfortable accessing services from. PPCs were acceptable among AYP despite the loyalty card concept being new to them. AYP suggested financial and school support, electronic devices, clothing and food supplies as rewards., Conclusions: Engaging AYP in the design of an SRH intervention was feasible, informative and considered responsive to their needs. Although AYP's suggestions were diverse, the iterative process of AYP engagement facilitated the design of an intervention that is informed by AYP and implementable., Trial Registration: This formative study informed the design of this trial: ClinicalTrials.gov, NCT04060420. Registered 19 August, 2019., (© 2021. The Author(s).)

Background: Provision of high-quality family planning (FP) services improves access to contraceptives. Negative experiences in maternal health have been documented worldwide and likely occur in other services including FP. This study aims to quantify disrespectful care for adult and adolescent women accessing FP in Malawi., Methods: We used simulated clients (SCs) to measure disrespectful care in a census of public facilities in six districts of Malawi in 2018. SCs visited one provider in each of the 112 facilities: two SCs visits (one adult and one adolescent case scenario) or 224 SC visits total. We measured disrespectful care using a quantitative tool and field notes and report the prevalence and 95% confidence intervals for the indicators and by SC case scenarios contextualized with quotes from the field notes., Results: Some SCs (12%) were refused care mostly because they did not agree to receive a HIV test or vaccination, or less commonly because the clinic was closed during operating hours. Over half (59%) of the visits did not have privacy. The SCs were not asked their contraceptive preference in 57% of the visits, 28% reported they were not greeted respectfully, and 20% reported interruptions. In 18% of the visits the SCs reported humiliation such as verbal abuse. Adults SCs received poorer counseling compared to the adolescent SCs with no other differences found., Conclusions: We documented instances of refusal of care, lack of privacy, poor client centered care and humiliating treatment by providers. We recommend continued effort to improve quality of care with an emphasis on client treatment, regular quality assessments that include measurement of disrespectful care, and more research on practices to reduce it.

Background: Despite the aging HIV epidemic, increasing age can be associated with hesitancy to test. Addressing this gap is a critical policy concern and highlights the urgent need to identify the underlying factors, to improve knowledge of HIV-related risks as well as uptake of HIV testing and prevention services, in midlife-older adults., Methods: We conducted five focus group discussions and 12 in-depth interviews between April 2013 and November 2016 among rural and urban Malawian midlife-older (≥30 years) men and women. Using a life-course theoretical framework we explored how age is enacted socially and its implications on HIV testing and sexual risk behaviours. We also explore the potential for HIV self-testing (HIVST) to be part of a broader strategy for engaging midlife-older adults in HIV testing, prevention and care. Thematic analysis was used to identify recurrent themes and variations., Results: Midlife-older adults (30-74 years of age) associated their age with respectability and identified HIV as "a disease of youth" that would not affect them, with age protecting them against infidelity and sexual risk-taking. HIV testing was felt to be stigmatizing, challenging age norms, threatening social status, and implying "lack of wisdom". These norms drove self-testing preferences at home or other locations deemed age and gender appropriate. Awareness of the potential for long-standing undiagnosed HIV to be carried forward from past relationships was minimal, as was understanding of treatment-as-prevention. These norms led to HIV testing being perceived as a threat to status by older adults, contributing to low levels of recent HIV testing compared to younger adults., Conclusions: Characteristics associated with age-gender norms and social position encourage self-testing but drive poor HIV-risk perception and unacceptability of conventional HIV testing in midlife-older adults. There is an urgent need to provide targeted messages and services more appropriate to midlife-older adults in sub-Saharan Africa. HIVST which has often been highlighted as a tool for reaching young people, may be a valuable tool for engaging midlife-older age groups who may not otherwise test.

Background: Due to high risk of mortality, children with comorbidities are typically excluded from trials evaluating pneumonia treatment. Understanding heterogeneity of outcomes among children with pneumonia and comorbidities is critical to ensuring appropriate treatment., Methods: We explored whether the percentage of children with fast-breathing pneumonia cured at Day 14 was lower among those with selected comorbidities enrolled in a prospective observational study than among those enrolled in a concurrent randomized controlled trial evaluating treatment with amoxicillin in Lilongwe, Malawi., Results: Among 79 children with fast-breathing pneumonia in the prospective observational cohort, 57 (72.2%) had HIV infection/exposure, 20 (25.3%) had malaria, 2 (2.5%) had severe acute malnutrition, and 17 (21.5%) had anemia. Treatment failure rate was slightly (not significantly) lower in children with comorbidities (4.1%, 3/73) compared to those without comorbidities (4.5%, 25/552) similarly treated. There was no significant difference in clinical cure rates by Day 14 (95.8% with vs 96.7% without comorbidity)., Conclusions: Children with fast-breathing pneumonia excluded from a concurrent clinical trial due to comorbidities did not fare worse. Children at higher risk whose caregivers seek care early and who receive appropriate risk assessment (e.g., pulse oximetry, hemoglobin, HIV/malaria testing) and treatment, can achieve clinical cure by Day 14., Trial Registration: ClinicalTrials.gov NCT02960919 ; registered November 8, 2016.

Background: Door-to-door distribution of HIV self-testing kits (HIVST) has the potential to increase uptake of HIV testing services (HTS). However, very few studies have explored the social response to and implications of door-to-door including secondary distribution of HIVST on household relations and the ability of individuals to self-test with or without supervision within households., Methods: A CRT of HIVST distribution was nested within the HPTN 071 (PopART) trial, in four Zambian communities randomised to receive the PopART intervention. The nested HIVST trial aimed to increase knowledge of HIV status at population level. Between February 1 and April 30, 2017, 66 zones (clusters) within these four communities were randomly allocated to either the PopART standard of care door-to-door HTS (33 clusters) or PopART standard of care door-to-door HTS plus oral HIVST (33 clusters). In clusters randomised to HIVST, trained Community HIV care provider (CHiPs) visited households and offered individuals aged ≥ 16 and eligible for an offer of HTS the choice of HIV testing using HIVST or routine door-to-door HTS (finger-prick RDT). To document participants' experiences with HIVST, Interviews (n = 40), observations (n = 22) and group discussions (n = 91) with household members and CHiPs were conducted. Data were coded using Atlas.ti 7 and analysed thematically., Results: The usage and storage of HIVST kits was facilitated by familiarity with and trust in CHiPs, the novelty of HIVST, and demonstrations and supervision provided by CHiPs. Door-to-door distribution of HIVST kits was appreciated for being novel, convenient, private, empowering, autonomous and easy-to-use. Literacy and age influenced accurate usage of HIVST kits. The novelty of using oral fluids to test for HIV raised questions, some anxiety and doubts about the accuracy of HIVST. Although HIVST protected participants from experiencing clinic-based stigma, it did not address self-stigma. Within households, HIVST usually strengthened relationships but, amongst couples, there were a few reports of social harms., Conclusion: Door-to-door distribution of HIVST as a choice for how to HIV test is appreciated at community level and provides an important testing option in the sub-Saharan context. However, it should be accompanied by counselling to manage social harms and by supporting those testing HIV-positive to link to care.

Background: Patients being treated for recurrent or multidrug-resistant tuberculosis (TB) require long courses of injectable anti-tuberculous agents. In order to maintain strong TB control programmes, it is vital that the experiences of people who receive long-term injectables for TB are well understood. To investigate the feasibility of a novel model of care delivery, a clinical trial (The TB-RROC Study) was conducted at two central hospitals in Malawi. Hospital-based care was compared to a community-based approach for patients on TB retreatment in which 'guardians' (patient-nominated lay people) were trained to deliver injections to patients at home. This study is the qualitative evaluation of the TB-RROC trial. It examines the experiences of people receiving injectables as part of TB treatment delivered in hospital and community-based settings., Methods: A qualitative evaluation of the TB-RROC intervention was conducted using phenomenographic methods. Trial participants were purposively sampled, and in-depth interviews were conducted with patients and guardians in both arms of the trial. Key informant interviews and observations in the wards and community were performed. Thematic content analysis was used to derive analytical themes., Results: Fourteen patients, 12 guardians and 9 key informants were interviewed. Three key themes relating to TB retreatment emerged: medical experiences (including symptoms, treatment, and HIV); the effects of the physical environment (conditions on the ward, disruption to daily routines and livelihoods); and trust (in other people, the community and in the health system). Experiences were affected by the nature of a person's prior role in their community and resulted in a range of emotional responses. Patients and guardians in the community benefited from better environment, social interactions and financial stability. Concerns were expressed about the potential for patients' health or relationships to be adversely affected in the community. These potential concerns were rarely realised., Conclusions: Guardian administered intramuscular injections were safe and well received. Community-based care offered many advantages over hospital-based care for patients receiving long-term injectable treatment for TB and their families.

We aimed to identify effective behaviour change techniques to increase modern contraceptive use in low and middle income countries (LMICs). Literature was identified in Global Health, Web of Science, MEDLINE, PsycINFO and Popline, as well as peer reviewed journals. Articles were included if they were written in English, had an outcome evaluation of contraceptive use, modern contraceptive use, contraceptive initiation/uptake, contraceptive adherence or continuation of contraception, were a systematic review or randomised controlled trial, and were conducted in a low or middle income country. We assessed the behaviour change techniques used in each intervention and included a new category of male partner involvement. We identified six studies meeting the inclusion criteria. The most effective interventions were those that involve male partner involvement in the decision to initiate contraceptive use. The findings also suggest that providing access to contraceptives in the community promotes their use. The interventions that had positive effects on contraceptive use used a combination of behaviour change techniques. Performance techniques were not used in any of the interventions. The use of social support techniques, which are meant to improve wider social acceptability, did not appear except in two of the interventions. Our findings suggest that when information and contraceptives are provided, contraceptive use improves. Recommendations include reporting of behaviour change studies to include more details of the intervention and techniques employed. There is also a need for further research to understand which techniques are especially effective.

Background: Because of a physician shortage in many low-income countries, the use of nonphysicians to classify perinatal mortality (stillbirth and early neonatal death) using verbal autopsy could be useful., Objective: To determine the extent to which underlying perinatal causes of deaths assigned by nonphysicians in Guatemala, Pakistan, Zambia, and the Democratic Republic of the Congo using a verbal autopsy method are concordant with underlying perinatal cause of death assigned by physician panels., Methods: Using a train-the-trainer model, 13 physicians and 40 nonphysicians were trained to determine cause of death using a standardized verbal autopsy training program. Subsequently, panels of two physicians and individual nonphysicians from this trained cohort independently reviewed verbal autopsy data from a sample of 118 early neonatal deaths and 134 stillbirths. With the cause of death assigned by the physician panel as the reference standard, sensitivity, specificity, positive and negative predictive values, and cause-specific mortality fractions were calculated to assess nonphysicians' coding responses. Robustness criteria to assess how well nonphysicians performed were used., Results: Causes of early neonatal death and stillbirth assigned by nonphysicians were concordant with physician-assigned causes 47% and 57% of the time, respectively. Tetanus filled robustness criteria for early neonatal death, and cord prolapse filled robustness criteria for stillbirth., Conclusions: There are significant differences in underlying cause of death as determined by physicians and nonphysicians even when they receive similar training in cause of death determination. Currently, it does not appear that nonphysicians can be used reliably to assign underlying cause of perinatal death using verbal autopsy.