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The combination of low uptake of modern contraceptives, high rates of unintended pregnancies, and the pervasive HIV epidemic in Sub-Saharan Africa (SSA) poses a threat to maternal, newborn, and child health in the region. This study examined the prevalence, need, and demand satisfied by modern contraceptive methods for women who tested positive for HIV (both unmarried and married) in 10 countries in SSA. We used the Family Planning Estimation Tool (FPET) to generate national-level trends and projections from 1983 through 2030. Individual-level data from 30 DHS surveys conducted between 2004 and 2018 in 10 sub-Saharan Africa (SSA) countries were used to produce projections for 1) all women and 2) unmarried and married women who tested positive for HIV. Throughout the period, Ethiopian and Guinean women who tested positive for HIV had a higher %mCPR (utilization of modern family planning methods) vis-à-vis all women. Among women who tested positive for HIV, the highest percentage of family planning demand satisfied by modern methods was observed in Zimbabwe (85.27, CI: 76.32-91.69), Lesotho (82.75, CI: 71.80-89.86), Rwanda (80.17, CI: 70.01-87.62), Malawi (73.11, CI: 61.50-82.63), and Zambia (72.63, CI: 64.49-80.09). The highest unmet need for modern contraceptives was found in Senegal (25.38, CI:18.36-33.72), followed by Cameroon (23.59, CI:19.30-28.59) and Sierra Leone (23.16, CI:16.64-32.05). Zimbabwe had the lowest unmet need (10.61, CI:6.36-16.13) and achieved the highest change in %mCPR (49.28, SE:6.80). Among married women who tested positive for HIV, their unmet need for modern contraception will remain higher in 2030. Continuing existing policies until 2030 would result in significant coverage gain among married vis-à-vis unmarried women who tested positive for HIV. Our projections emphasize the importance of country-specific strengthening initiatives, programs, and services targeting unmarried women., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Ambade et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Though women in sub-Saharan Africa have increased risk of intimate sexual violence, research on the association between sexual autonomy and intimate partner violence among this population has not received the requisite attention. Consequently, we investigated if sexual autonomy is a protective factor against intimate partner violence among women in sub-Saharan Africa., Methods: Secondary data analysis was conducted based on the Demographic and Health Surveys (DHSs) of 27 sub-Saharan African countries from 2008 to 2021. A total of 104,523 married or cohabitating women were included in the study. We applied a multilevel Poisson regression model with robust variance to identify associated factors. Variables with a p-value<0.2 in the bi-variable multilevel Poisson regression analysis were considered for the multivariable analysis. The Adjusted Prevalence Ratio (APR) with its 95% confidence interval (CI) was reported, and variables with a p-value <0.05 were included in the multivariable analysis., Results: The prevalence of intimate partner violence and sexual autonomy among women in SSA were 32.96% [95% CI: 32.68%, 33.25%] and 88.79% [95% CI: 88.59%, 88.97%], respectively. Women in Sierra Leone had the highest prevalence of IPV (52.71%) while Comoros had the lowest prevalence of IPV (8.09%). The prevalence of sexual autonomy was highest in Namibia (99.22%) and lowest in Mali (61.83%). The MOR value in the null model was 1.26. We found that women who had sexual autonomy are 1.28 times [APR = 1.28, 95% CI: 1.17, 1.40] more likely to experience IPV than women who had no sexual autonomy., Conclusion: This study has demonstrated that sexual autonomy is significantly associated with intimate partner violence, however, it does not necessarily act as a protective factor. The study suggests the need for more education on intimate partner violence targeting women's partners. This can help secure the commitment of the perpetrators to rather become proponents of anti-intimate partner violence and further offer women the necessary support for them to attain their full fundamental rights in all spheres of life., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Tesema et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Child abuse is a dominant public health concern that permeates race, varied social contexts and culture. Child abuse comprises any act of omission or commission perpetrated by a child's parent, caregiver, or other adult leading to harm, potential for, or any threat of harm to a child (below age 18), either intentional or unintentional. This subject has usually been explored by focusing on men. This study investigated the prevalence and social correlates of child abuse across seven countries in sub-Saharan Africa., Methods and Materials: Data was obtained from Demographic and Health Surveys (DHS) conducted in seven countries in sub-Saharan Africa between 2013 and 2020. The outcome variable employed for this study was acts of child abuse (including shouting, striking, and slapping). Descriptive and inferential analyses were carried out. The descriptive analysis focused on the bivariate analysis between the country variable and the outcome variables. Multivariate analysis was, however, utilized to determine the relationship between the outcome variables and the respondents' explanatory variables, using a binary logistic regression model. The adjusted odds ratios for each variable were calculated using a 95% confidence range., Results: The proportion of women shouting at children was 72 percent. This ranged from 49.2 percent in Chad to 84.2 percent in Benin. The proportion of women striking children was 52.5 percent and this ranged from 37.1 percent in Chad to 63.8 percent in Benin. The odds of women striking their children was higher for those with children aged 10-14 (aOR = 1.18, CI = 1.03, 1.34), women with primary education (aOR = 1.25, CI = 1.17, 1.33), cohabiting women (aOR = 1.17, CI = 1.10, 1.25) and women who had experienced intimate partner violence (aOR = 1.06, CI = 1.00, 1.12). The odds of women shouting at their children was higher for those aged 30-34 years (aOR = 1.31, CI = 1.11, 1.55) and for working women (aOR = 1.43, 1.33, 1.56). The odds of women slapping their children was higher for those who justify wife-beating (aOR = 1.10, CI = 1.03, 1.16) and for women with richest wealth status (aOR = 1.25, CI = 1.17, 1.33)., Conclusions: The findings show that it is imperative for the governments of the countries studied, especially those with high prevalence like Benin, to consider parent-friendly and culturally acceptable non-formal educational initiatives that will dissuade parents and guardians from abusing children. Possibly, legal reforms that sanction harsher punishments to perpetrators of child abuse may help make child abuse less attractive to parents and guardians., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Dickson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

This study assessed Africa's child survival gains and prospects for attaining Sustainable Development Goals (SDG) target 3.2. We analysed multiple country-level secondary datasets of 54 African countries and presented spatial analysis. Results showed that only 8 out of the 54 African countries have achieved substantial reductions in under-5 mortality with an under-five mortality rate (U5MR) of 25 deaths per 1,000 live births or less. Many countries are far from achieving this target. Results of the predictions using supervised machine learning on the Bayesian network reveal that the probability of achieving the SDG target 3.2 (i.e., having U5MR of 25 deaths per 1000 live births or less) increases (from 21.6% to 100%) when the contraceptive prevalence increases from 49.8% to 78.5%; and the use of skilled birth attendants increases from 44.8% to 86.3%; and percentage of secondary school completion of female increases from 42.5 to 74.0%. Our results from Local indicator of spatial autocorrelation (LISA) cluster maps show that 7 countries (mainly in West/Central Africa) formed the high-high clusters (hotspots for U5M) and may not achieve the SDG target 3.2 unless urgent and appropriate investments are deployed. As 2030 approaches, there is a need to address the problem of limited access to quality health care, female illiteracy, limited access to safe water, and poor access to quality family planning services, particularly across many sub-Saharan African countries., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Adedini et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Several youth staying at emergency youth shelters (EYSs) in Toronto experience poorly coordinated care for their health needs, as both the EYS and health systems operate largely in silos when coordinating care for this population. Understanding how each system is structurally and functionally bound in their healthcare coordination roles for youth experiencing homelessness (YEH) is a preliminary step to identify how healthcare coordination can be strengthened using a system thinking lens, particularly through the framework for transformative system change., Methods: Forty-six documents, and twenty-four semi-structured interviews were analyzed to explore how the EYS and health systems are bound in their healthcare coordination roles. We continuously compared data collected from documents and interviews using constant comparative analysis to build a comprehensive understanding of each system's layers, and the niches (i.e., programs and activities), organizations and actors within these layers that contribute to the provision and coordination of healthcare for YEH, within and between these two systems., Results: The EYS and health systems are governed by different ministries, have separate mandates, and therefore have distinct layers, niches, and organizations respective to coordinating healthcare for YEH. While neither system takes sole responsibility for this task, several government, research, and community-based efforts exist to strengthen healthcare coordination for this population, with some overlap between systems. Several organizations and actors within each system are collaborating to develop relevant frameworks, policies, and programs to strengthen healthcare coordination for YEH. Findings indicate that EYS staff play a more active role in coordinating care for YEH than health system staff., Conclusion: A vast network of organizations and actors within each system layer, work both in silos and collaboratively to coordinate health services for YEH. Efforts are being made to bridge the gap between systems to improve healthcare coordination, and thereby youths' health outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Hudani et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Postpartum contraception is essential to sexual and reproductive health (SRH) care because it encourages healthy spacing between births, helps women avoid unwanted pregnancies, and lessens the risks of health problems for mothers and babies. Sub-Saharan African immigrant and refugee populations are rapidly increasing in the United States, and they come from a wide range of cultural, linguistic, religious, and social origins, which may pose challenges in timely access to culturally acceptable SRH care, for preventing mistimed or unwanted childbearing. The objective of this scoping review is to assess the extent of the available literature on postpartum contraception among sub-Saharan African immigrant and refugee women living in the United States., Methods: We developed preliminary search terms with the help of an expert librarian, consisting of keywords including birth intervals, birth spacing, contraception, postpartum contraception or family planning, and USA or America, and sub-Saharan African immigrants, or emigrants. The study will include the following electronic databases: PubMed/MEDLINE, PsycINFO, CINAHL, EMBASE, and the Global Health Database. The sources will include studies on postpartum care and contraceptive access and utilization among sub-Saharan African immigrants living in the US. Citations, abstracts, and full texts will be independently screened by two reviewers. We will use narrative synthesis to analyze the data using quantitative and qualitative methods. Factors associated with postpartum contraception will be organized using the domains and constructs of the PEN-3 Model as a guiding framework., Conclusion: This scoping review will map the research on postpartum contraception among sub-Saharan African immigrant and refugee women living in the US. We expect to identify knowledge gaps, and barriers and facilitators of postpartum contraception in this population. Based on the findings of the review, recommendations will be made for advocacy and program and policy development toward optimizing interpregnancy intervals in sub-Saharan African immigrants living in the US., Trial Registration: Review registration Open Science Framework: https://osf.io/s385j., Competing Interests: None, (Copyright: © 2024 Olorunsaiye et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The practice of female genital mutilation is associated with harmful social norms promoting violence against girls and women. Various studies have been conducted to examine the prevalence of female genital mutilation and its associated factors. However, there has been limited studies conducted to assess the association between female genital mutilation and markers of women's autonomy, such as their ability to negotiate for safer sex. In this study, we examined the association between female genital mutilation and women's ability to negotiate for safer sex in sub-Saharan Africa (SSA)., Methods: We pooled data from the most recent Demographic and Health Surveys (DHS) conducted from 2010 to 2020. Data from a sample of 50,337 currently married and cohabiting women from eleven sub-Saharan African countries were included in the study. A multilevel binary logistic regression analysis was used to examine the association between female genital mutilation and women's ability to refuse sex and ask their partners to use condom. Adjusted odds ratios (aORs) with a 95% confidence interval (CI) were used to present the findings of the logistic regression analysis. Statistical significance was set at p<0.05., Results: Female genital mutilation was performed on 56.1% of women included in our study. The highest and lowest prevalence of female genital mutilation were found among women from Guinea (96.3%) and Togo (6.9%), respectively. We found that women who had undergone female genital mutilation were less likely to refuse sex from their partners (aOR = 0.91, 95% CI = 0.86, 0.96) and ask their partners to use condoms (aOR = 0.82, 95% CI = 0.78, 0.86) compared to those who had not undergone female genital mutilation., Conclusion: Female genital mutilation hinders women's ability to negotiate for safer sex. It is necessary to implement health education and promotion interventions (e.g., decision making skills) that assist women who have experienced female genital mutilation to negotiate for safer sex. These interventions are crucial to enhance sexual health outcomes for these women. Further, strict enforcement of policies and laws aimed at eradicating the practice of female genital mutilation are encouraged to help contribute to the improvement of women's reproductive health., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Aboagye et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The early gut microbiota composition is fundamentally important for piglet health, affecting long-term microbiome development and immunity. In this study, the gut microbiota of postparturient dams was compared with that of their offspring in three Finnish pig farms at three growth phases. The differences in fecal microbiota of three study development groups (Good, Poorly, and PrematureDeath) were analyzed at birth (initial exposure phase), weaning (transitional phase), and before slaughter (stable phase). Dam Lactobacillaceae abundance was lower than in piglets at birth. Limosilactobacillus reuteri and Lactobacillus amylovorus were dominantly expressed in dams and their offspring. Altogether 17 piglets (68%) were identified with Lactobacillaceae at the initial exposure phase, divided unevenly among the development groups: 85% of Good, 37.5% of Poorly, and 75% of PrematureDeath pigs. The development group Good was identified with the highest microbial diversity, whereas the development group PrematureDeath had the lowest diversity. After weaning, the abundance and versatility of Lactobacillaceae in piglets diminished, shifting towards the microbiome of the dam. In conclusion, the fecal microbiota of pigs tends to develop towards a similar alpha and beta diversity despite development group and rearing environment., Competing Interests: Vetcare Ltd. (Grant number: 031019; https://www.vetcare.fi/), and A-Farmers Ltd. (Grant number: 281019; https://www.atriatuottajat.fi/) funded the research project of M.H., including this study. Further, at the time this study was conducted, S.B. was an employee of Vetcare Ltd. (Grant number: 031019; https://www.vetcare.fi/). This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare., (Copyright: © 2024 König et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Diarrhea is the second leading cause of under-five deaths claiming half a million children every year. Most of these deaths occurred in sub-Saharan Africa and South Asia. Oral rehydration solution (ORS) has been described as the most effective treatment of diarrhea. However, only 36% of children with diarrhea received ORS in sub-Saharan Africa. This study examined the factors associated with ORS use for children with diarrhea in the sub-region., Methods: Demographic and Health Surveys (DHS) data sets of 31 countries in sub-Saharan Africa were used in this study. The data involved 30,102 under-five children with diarrhea. The multivariable analysis involved binary logistic regression., Results: Prevalence of ORS use was 38% in sub-Saharan Africa with countries such as Namibia (71.8%), Zambia (66.4%) and Malawi (63.8%) having the highest rates. Use of ORS was most common among children whose mothers had secondary or higher education (45%), were exposed to media (41%) and attended antenatal care (41%). ORS use was significantly associated with secondary or higher education (OR = 1.63; 95%CI: [1.47-1.81]; p<0.001), exposure to media (OR = 1.17; 95%CI: [1.07-1.27]; p<0.001), antenatal care attendance (OR = 2.33; 95%CI: [1.08-1.27]; p<0.001), child's age (OR = 1.46; 95%CI: [1.35-1.59]; p<0.001), child's size at birth (OR = 1.08; 95%CI: [1.00-1.17]; p<0.05), household size (OR = 1.28; 95%CI:[1.06-1.54]; p<0.05) and source of drinking water (OR = 1.18; 95%CI: [1.09-1.29]; p<0.001)., Conclusion: This study revealed a 38% prevalence of ORS use during diarrhea episodes in sub-Saharan Africa. This is low as it is less than the 44% recorded for developing countries as a whole. While this study emphasises the need for a further study on effects of severity of diarrhea on ORS use and factors determining differences in ORS use among countries, it also calls for interventions that will increase use of ORS is sub-Saharan Africa. Such interventions should include increase in literacy rate among girls and women, increase in the proportion of women with access to media, involvement of health workers in programmes that would promote antenatal care utilization among women at community level and provision of social amenities like pipe-borne water., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Adedokun, Yaya. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Intimate partner violence (IPV) is a major public health concern that mostly impacts women's health and social well-being. This study explored how the various types of IPV (physical, sexual, and emotional) including women's experience of childhood violence influence their help-seeking behavior in sub-Saharan Africa (SSA)., Methods: We analyzed data from the most recent Demographic and Health Surveys (DHS), carried out between 2018 and 2021. The outcome variable was help-seeking behavior. Descriptive and inferential analyses were carried out. The descriptive analysis looked at the bivariate analysis between the country and outcome variables. Using a binary logistic regression model, a multivariate analysis was utilized to determine the association between the outcome variable and the explanatory variables. Binary logistic regression modelling was used based on the dichotomous nature of the outcome variable. The results were sample-weighted to account for any under- or over-sampling in the sample., Results: The proportion of women who sought help for intimate partner violence was 36.1 percent. This ranged from 19.2 percent in Mali to 49.6 percent in Rwanda. Women who experienced violence in childhood (OR = 0.75, CI = 0.69, 0.82) have a lower likelihood of seeking help compared to those who did not experience violence in their childhood. Women who had experienced emotional violence (OR = 1.94, CI = 1.80, 2.08), and physical violence (OR = 1.37, CI = 1.26, 1.48) have a higher likelihood of seeking help compared to those who have not. Women with secondary educational levels (aOR = 1.13, CI = = 1.02, 1.24) have a higher likelihood of seeking help compared to those with no education. Cohabiting women have a higher likelihood (aOR = 1.22, CI = 1.10, 1.35) of seeking help compared to married women., Conclusion: The study highlights the importance of early identification of IPV and fit-for-purpose interventions to demystify IPV normalization to enhance women's willingness to seek help. The study's findings suggest that education is crucial for increasing women's awareness of the legalities surrounding IPV and available structures and institutions for seeking help., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Ayebeng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: There has been significant progress in maternal health outcomes in the sub-Saharan African region since the early 1990s, in part due to digital and mobile health interventions. However, critical gaps and disparities remain. Mobile phones in particular have potential to reach underserved, hard-to-reach populations with underdeveloped infrastructure. In spite of the opportunities for mobile phones to address maternal mortality in the region, there is no extensive mapping of the available literature on mobile phone interventions that aim to improve access of maternal care in sub-Saharan Africa. The proposed scoping review aims to map literature on the nature and extent of mobile phones interventions designed to improve maternal care health services in the region., Methods: Conduct of this scoping review will be guided by the Joanna Briggs Institute approach. Literature searches will be conducted in multiple electronic databases, including MEDLINE, Embase, CINAHL, APA PsycInfo, Cochrane Central Register of Controlled Trials, Global Health, African Index Medicus, Web of Science, and Applied Social Sciences Index & Abstracts. Grey literature will also be identified. Keyword searches will be used to identify articles. Two reviewers will independently screen eligible titles, abstracts and full articles with a third reviewer to help resolve any disputes. We will extract data on general study characteristics, population characteristics, concept, context, intervention details, study results, gaps and recommendations., Discussion: Understanding use of mobile phones among underserved, hard-to-reach populations with underdeveloped infrastructure to address maternal mortality in developing countries is very critical to informing health systems on potential effective strategies. This review will complement the evidence base on utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Constantine et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Universal Health Coverage (UHC) will not be achieved if health care worker shortages, estimated to increase to 18 million by 2030, are not addressed rapidly. Community-based health systems, which pivot to effective engagement of community health workers (CHW), may have an essential role in linking communities with health care facilities and reducing unmet health services needs caused by these shortages. The Canadian Red Cross (CRC) has partnered with different National Red Cross/Red Crescent Societies and Ministries of Health in Africa in the implementation of programs where CHWs contributed to the provision of various health services. This study reports on key findings (i.e., beneficiaries reached, CHWs engaged, programs implemented, intervention outcomes) and lessons learned from CRC supported CHW programs in Africa over the last 15 years (2007-2022). Qualitative methodology was employed to conduct document analysis on 17 sets of reports from each CRC-supported community health worker project in Africa over the past 15 years. Focus was on identifying challenges, facilitators, and lessons learned. CRC supported projects have trained over 9000 CHWs, benefiting nearly 7.5 million people across Africa. Key success factors include adaptability and agility in programming and project management, and considering contextual factors (political, social, and cultural systems). Investing in essential training for CHWs, staff, and volunteers is crucial, alongside employing an evidence-based approach to inform all aspects of programming and implementation. Additionally, projects prioritizing protection, gender and inclusion (PGI) while leveraging existing community structures and partnerships important for successful implementation. Despite challenges (i.e., weak health systems, lack of political commitment, insufficient funding, inadequate training) CHWs are recognized as crucial in promoting community-based health, improving access to care, addressing disparities, and contributing to achieving (UHC). Their unique position within communities enables them to provide culturally appropriate and localized primary health care- particularly in remote, resource limited and poverty-stricken regions., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Idriss-Wheeler et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Tramadol is a widely prescribed painkiller around the world. As a synthetic opioid, it offers a valuable substitute for morphine and its derivatives in African countries. However, the adverse health effects of tramadol use resulting from illicit trafficking, like those caused by fentanyl and methadone in North America, have not been well-documented in Africa. This scoping review aims to shed light on the nature and scope of the nonmedical use (NMU) of tramadol in Africa and its associated health consequences. To carry out our scoping review, we used Arksey and O'Malley's (2005) five-step approach for exploratory analysis and followed Joanna Briggs Institute guidelines for scoping reviews to ensure systematic and replicable studies. We then searched six databases: Medline, Global Health (EBSCO), Scopus, Web of Science, the African Journals online database, and for grey literature via Google Scholar without any time restriction. The articles were imported into Covidence and reviewed by two independent researchers. Eighty-three studies on NMU of tramadol's prevalence or health consequences were selected from 532 titles/abstracts screened, including 60 cross-sectional and six qualitative studies from 10 African countries. Findings from the included studies highlighted five distinct groups significantly affected by the NMU of tramadol. These groups include: 1) young adults/active populations with varying degrees of prevalence ranging from 1.9% to 77.04%, 2) professionals, where drivers exhibit a relatively high prevalence of tramadol NMU, ranging from 7.2% to 35.1%, and commercial motorcyclists, with a prevalence of 76%, 3) patients, who have a high rate of tramadol NMUs, with prevalence rates ranging from 77.1% to 92%, 4) academics, with a considerable rate of tramadol misuse among substance-using undergraduates (74.2%) and substance-using high school students (83.3%), and 5) other individuals impacted in various ways. The health consequences are classified into four distinct types: intoxication, dependence syndrome, withdrawal syndrome and other symptoms. Despite providing a comprehensive global overview of the phenomenon described in the African literature, this systematic scoping review's main limitations stem from the relatively limited exploration of various consequences of the NMU of tramadol, notably those of a social and economic nature. Our review shows that tramadol misuse affects diverse populations in Africa. The prevalence of misuse varies within sub-populations, indicating the complexity of the issue. Professional and academic groups have different rates of misuse across regions. This highlights the need for targeted interventions to address unique challenges contributing to tramadol misuse. Future studies should focus on the social and economic costs of abuse on households to better understand the impact on well-being. Systematic review registration: Open Science Framework: https://osf.io/ykt25/., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Boun et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The HIV/AIDS pandemic remains a significant public health issue, with sub-Saharan Africa (SSA) at its epicentre. Although antiretroviral therapy (ART) has been introduced to decrease new infections and deaths, SSA reports the highest incidence of HIV/AIDS, constituting two-thirds of the global new infections. This review aimed to elucidate the predominant barriers and facilitators influencing ART adherence and to identify effective strategies to enhance ART adherence across SSA., Methods: A comprehensive review was conducted on studies examining barriers to ART adherence and interventions to boost adherence among HIV-positive adults aged 15 and above in SSA, published from January 2010 onwards. The research utilized databases like Medline Ovid, CINAHL, Embase, and Scopus. Included were experimental and quasi-experimental studies, randomized and non-randomized controlled trials, comparative before and after studies, and observational studies such as cross-sectional, cohort, prospective and retrospective studies. Two independent reviewers screened the articles, extracted pertinent data, and evaluated the studies' methodological integrity using Joanna Briggs Institute's standardized appraisal tools. The compiled data underwent both meta-analysis and narrative synthesis., Results: From an initial pool of 12,538 papers, 45 were selected (30 for narrative synthesis and 15 for meta-analysis). The identified barriers and facilitators to ART adherence were categorized into seven principal factors: patient-related, health system-related, medication-related, stigma, poor mental health, socioeconomic and socio-cultural-related factors. Noteworthy interventions enhancing ART adherence encompassed counselling, incentives, mobile phone short message service (SMS), peer delivered behavioural intervention, community ART delivery intervention, electronic adherence service monitoring device, lay health worker lead group intervention and food assistance. The meta-analysis revealed a statistically significant difference in ART adherence between the intervention and control groups (pooled OR = 1.56, 95%CI:1.35-1.80, p = <0.01), with evidence of low none statistically significant heterogeneity between studies (I2 = 0%, p = 0.49)., Conclusion: ART adherence in SSA is influenced by seven key factors. Multiple interventions, either standalone or combined, have shown effectiveness in enhancing ART adherence. To optimize ART's impact and mitigate HIV's prevalence in SSA, stakeholders must consider these barriers, facilitators, and interventions when formulating policies or treatment modalities. For sustained positive ART outcomes, future research should target specific underrepresented groups like HIV-infected children, adolescents, and pregnant women in SSA to further delve into the barriers, facilitators and interventions promoting ART adherence., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Buh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Despite many interventions, Togo continues to have one of the highest rates of poverty and food insecurity in the sub-Saharan African region. Currently there is no systematic analysis of the factors associated with household food-insecurity in this country. This study aimed at exploring the factors associated with food insecurity in Togo., Methods: This was a cross-sectional study that used data from five waves (2014 to 2018) of the Gallup World Poll (GWP) for Togo. Sample size included 4754 participants, aged 15 and above. Food insecurity was measured using the Food Insecurity Experience Scale (FIES) questionnaire as per the Food and Agricultural Organization (FAO) guidelines. Our outcome variable was food insecurity, categorized as: 1) food secure (FIES score = 0-3), moderately food insecure (FIES score = 4-6), and severely food insecure (FIES score = 7-8). We did descriptive and multinomial regressions to analyze data using Stata version 16., Results: Between 2014 and 2018, the percentage of severe food insecurity fluctuated-42.81% in 2014, 37.79% in 2015, 38.98% in 2016, 45.41% in 2017, and 33.84% in 2018. Whereas that of moderate food insecurity increased from 23.55% to 27.33% except for 2016 and 2017 where the percentage increased to 32.33% and 27.46% respectively. In the logistic regression analysis, we found that respondents with lower than elementary education had a higher relative risk ratio of moderate (RRR = 1.45,95%CI = 1.22-1.72) and severe (RRR = 1.72, 95%CI = 1.46-2.02) food insecurity compared to those with secondary and higher education. Rural respondents had higher RRR of severe food insecurity (RRR = 1.37, 95%CI = 1.16-1.62) compared to those who lived in the urban areas. Compared with those in the richest wealth quintile, respondents in the poorest wealth quintile had 2.21 times higher RRR of moderate (RRR = 2.21, 95%CI = 1.69-2.87) and 3.58 times higher RRR of severe (RRR = 3.58, 95%CI = 2.81-4.55) food insecurity., Conclusion: About two-thirds of participants experienced some level of food insecurity in 2018. Lower levels of education, rural residency and poorer household wealth index areas were associated with a higher risk of food insecurity. National food security programs should focus on promoting education and improving socioeconomic condition of people especially in rural areas., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Kota et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Marital dissolution, which refers to being divorced or separated, is considered one of the most dramatic demographic events that significantly disrupt families. Unearthing the factors predicting marital dissolution would support actions to reduce the incidence of this phenomenon. The present study sought to examine the association between sex preference for children and marital dissolution segregated by place of residence., Methods: Data for the study were extracted from the most recent Demographic and Health Surveys (DHS) of 25 countries in sub-Saharan Africa. Percentages were used to summarise the proportion of marital dissolution among women in sub-Saharan Africa. Binary logistic regression models were fitted to examine the association between sex preference for children and marital dissolution per place of residence. Results of the regression analysis were presented using adjusted odds ratios (aOR) with their respective 95% confidence interval (CI)., Results: The overall prevalence of marital dissolution was 5.92% (95% CI: 5.83-6.00), and this ranged from 1.63% (95% CI: 1.41-1.85) in Burkina Faso to 15.62% (95% CI: 14.70-16.54) in Mozambique. In urban sub-Saharan Africa, the overall prevalence of marital dissolution was 8.88% (95% CI:8.78-8.99), with the lowest prevalence in Mali (3.30%; 95% CI: 2.91-3.69) and the highest in Uganda (18.60%; 95% CI: 17.95-19.25). For rural sub-Saharan Africa, the pooled prevalence was 4.11% (95% CI: 4.03-4.18), with the lowest (0.80%; 95% CI: 0.65-0.95) and highest (14.40%; 95% CI: 13.51-15.29) prevalences in Burkina Faso and Mozambique, respectively. Compared to women with no sex preference, the preference for boys was less likely to result in marital dissolution (aOR = 0.87; 95%CI = 0.83-0.90) in both urban and rural areas, whereas the preference for girls was more likely to result in marital dissolution (aOR = 1.06; 95%CI = 1.02-1.10). When the results were disaggregated by place of residence, in both urban (aOR = 0.87; 95%CI = 0.80-0.95) and rural areas (aOR = 0.87; 95%CI = 0.82-0.92), women who preferred boys were less likely to experience marital dissolution compared to those who had no preference. However, the preference for girls showed no statistically significant association with marital dissolution., Conclusion: Our study has shown that sex preference for children has a significant association with marital dissolution in both rural and urban areas in sub-Saharan Africa. Whereas the preference for male children serves as a protective factor against marital dissolution, the preferences for females was found to increase the likelihood of marital dissolution. Thus, underscoring a need for anti-marital dissolution campaigns and initiatives to prioritise the sensitisation of society about the value of female children. Religious groups and leaders can leverage their platform to quell sex preferences and dissuade marital dissolution. Policies and programmes aimed at reducing the risk of marital dissolution in sub-Saharan Africa must also focus on enlightening the population on intimate partner violence prevention., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Okyere et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: In Ethiopia, country-wide community-based primary health programs have been in effect for about two decades. Despite the program's significant contribution to advancing Maternal Newborn and Child Health (MNCH), Ethiopia's maternal and child mortality is still one of the highest in the world. The aim of this manuscript is to critically examine the multifaceted fragmentation challenges of Ethiopia's Community Health Workers (CHWs) program to deliver optimum MNCH and build a resilient community health system., Methods: We conducted a qualitative case study in West Shewa Zone, rural Ethiopia. A purposive sampling technique was used to recruit participants. Data sources were two focus group discussions with sixteen CHWs, twelve key informant interviews with multilevel public health policy actors, and a policy document review related to the CHW program to triangulate the findings. Thematic analysis of the qualitative data was conducted. The World Health Organization's health systems framework and socio-ecological model guided the data collection, analysis, and interpretation., Results: The CHWs program has been an extended arm of Ethiopia's primary health system and has contributed to improved health outcomes. However, the program has been facing unique systemic challenges that stem from the fragmentation of health finance; medical and equipment supply; working and living infrastructures; CHWs empowerment and motivation, monitoring, supervision, and information; coordination and governance; and community and stakeholder engagement. The ongoing COVID-19 and volatile political and security issues are exacerbating these fragmentation challenges., Conclusion: This study emphasized the gap between the macro (national) level policy and the challenge during implementation at the micro (district)level. Fragmentation is a blind spot for the community-based health system in rural Ethiopia. We argue that the fragmentation challenges of the community health program are exacerbating the fragility of the health system and fragmentation of MNCH health outcomes. This is a threat to sustain the MNCH outcome gains, the realization of national health goals, and the resilience of the primary health system in rural Ethiopia. We recommend that beyond the current business-as-usual approach, it is important to emphasize an evidence-based and systemic fragmentation monitoring and responsive approach and to better understand the complexity of the community-based health system fragmentation challenges to sustain and achieve better health outcomes. The challenges can be addressed through the adoption of transformative and innovative approaches including capitalizing on multi-stakeholder engagement and health in all policies in the framework of co-production., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Gebremeskel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Understanding the factors associated with women's autonomy to refuse risky sex is imperative to inform the development of policies and interventions to reduce the risk of unintended pregnancies, sexually transmitted infections, unsafe abortion, and maternal mortality. This study sought to examine the prevalence and factors associated with women's autonomy to refuse risky sex in sub-Saharan Africa (SSA). Data for the study were extracted from the most recent Demographic and Health Surveys (DHS) of thirty countries in SSA conducted from 2010 to 2020. We included a weighted sample of 260,025 women who were married or cohabiting in the final analysis. Percentages were used to present the results of the prevalence of women's ability to refuse risky sex. We used a multilevel logistic regression analysis to examine the factors associated with women's ability to refuse risky sex. Stata software version 16.0 was used for the analysis. We found that 61.69% (95% confidence interval [CI]: 56.22-67.15) of the women were autonomous to refuse sex if their partners have other women, and this was highest in Namibia (91.44% [95% CI: 90.77-92.18]) and lowest in Mali (22.25% [95% CI: 21.24-23.26]). The odds of autonomy in refusing risky sex was higher among women with higher education (adjusted odds ratio [aOR] = 1.88; 95% CI = 1.78-1.46) compared to those with no formal education. Employment status was also a significant predictor, with working women having higher odds of sex refusal compared to non-working women (aOR = 1.16; 95% CI = 1.13-1.18). Advocacy to improve women's autonomy to refuse risky sex must leverage the mass media as it emerged as a significant factor. Policies and intervention to enhance women's autonomy must also target high-risk sub-populations which constitutes adolescent girls, those with no formal education, and those without employment., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Budu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Antiretroviral therapy (ART) needs to be taken for life with near perfect levels of adherence for it to be effective. Nonetheless, ART non-adherence is still observed in sub-Saharan African (SSA) countries such as Cameroon. The objective of this study was to assess the factors influencing non-adherence and or adherence among people living with HIV (PLWH) who have experienced non-adherence to ART in Cameroon., Methods: A descriptive qualitative study of PLWH who have experienced non-adherence with ART in Cameroon was conducted. Data were collected using in-depth interviews. Collected data were analyzed using the NVIVO 12 software., Results: In total, 43 participants participated in this study. The Southwest and Littoral regions each contributed 15 (34.88%) of participants, participants' mean age was 37.1 years (SD: 9.81) and majority 34 (82.93%) were females. ART adherence barriers include those related to patient (forgetfulness, business with other things, unwillingness to swallow drugs daily), medication (side effects), health service (arrogance of caregivers, occasional drug shortages at treatment centre, poor counseling of patient), stigma (fear of status disclosure), use of alternative treatment (traditional medicine, prayers and deliverance), resource limitation (limited food, limited finances), environmental/social (limited or no home support), and political instability (disruption of free circulation by ghost towns, roadblocks and gunshots in some regions). ART adherence facilitators include social support (family and peer support), aligning treatment with patient's daily routines (align ART with schedule of family members), use of reminders (phone alarm, sound of church bell), health sector/caregiver support (messages to patient, financial support, proper counseling), and patient's awareness of HIV status/ART knowledge (awareness of HIV positive status, Knowledge of ART benefits)., Conclusion: ART adherence barriers in Cameroon include those related to patient, medication, health service, stigma, use of alternative treatment, resource limitation, environmental/social, and political instability. ART adherence facilitators include social support, aligning treatment with patient's daily routines, use of reminders, health sector/caregiver support, and patient's awareness of HIV status/ART knowledge. Given these barriers and facilitators, continuous information provision and consistent support both from patients' families and caregivers are needed to improve adherence among patients. Further studies including many regions and larger samples using both in-depth and focused group discussions as well as quantitative approaches are required to uncover the burden related to ART non-adherence., Competing Interests: The authors declare that they have no competing interests., (Copyright: © 2023 Buh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: The study applies the principal-agent approach to explore providers' experiences before and after the introduction of performance-based financing (PBF) in Cameroon, challenges and facilitators in the implementation process, and mechanisms in place to ensure sustainability., Methods: The study was an in-depth qualitative study whose goal was to provide multiple descriptions of experiences and insights from a principal-agent analysis perspective. Purposive sampling was used to identify the key characteristics of the participants relevant to the study. A snowballing technique was used to further identify eligible participants. Only healthcare providers who were exposed to the previous system and could reflect on and provide meaningful data that captured the everyday experiences before and after the implementation of PBF were included. Data were collected from three districts in the Southwest region of Cameroon from May 2021 to August 2021. Data were transcribed and analyzed using MaxQDA., Results: A total of 17 interviews and 3 focus group discussions (24 participants) were conducted with healthcare providers and key stakeholders involved in PBF. The respondents described a range of changes that they had experienced since the introduction of PBF. Each of these changes was categorized as either positive or negative. Positive changes were framed into 14 dominant categories: motivation, negotiations, innovation, resource allocation, autonomy, decentralization, transparency, improved quality of care, separation of function, performance, equity considerations, opportunity to recruit, participation in decision-making, and improved access to and utilization of maternal health services. The main challenges (negative experiences) reported were framed into nine categories: management of change, retention issues, conflict of interest, poor understanding of the PBF concept, resistance to change, verification challenges, delays in payment of PBF incentives, data entry and documentation, and challenges in meeting the equity considerations of the poor and vulnerable. Despite the challenges, providers preferred the decentralized approach to the centralized system., Conclusion: PBF is a national strategy for achieving universal health coverage in Cameroon, and the experiences of providers provide a vital guide to refine national policy. The introduction of PBF has provided positive changes to providers' quality of care when compared to the previous system. Addressing the delays in PBF payments will help to overcome the challenges to implementation and provide opportunities for health facilities to be more efficient and improve their performance. Despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal)., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Nkangu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Immigrant students face various challenges in high-income countries that can contribute to the decline of their mental well-being upon arrival in their host country. Despite the growing population of these students in several high-income countries, there is inadequate attention given to their mental health needs and their access to mental health services. Thus, this systematic scoping review aimed to identify gaps in existing research relating to the barriers and facilitators associated with access to and use of mental health services in high-income countries., Methods: Following the PRISMA-ScR checklist as guidance we systematically searched Ovid Medline, APA PsycInfo, Education Source, CINAHL, Web of Science databases for peer reviewed articles related to barriers and facilitators of mental health service use among immigrant students. We conducted a narrative evidence synthesis to highlight barriers and facilitators to the use of mental health services., Results: Out of the 2407 articles initially found, 47 studies met the inclusion criteria and were considered for this review. The increasing attention towards the mental health concerns of immigrant students and their access to mental health services is evident. However, various barriers like stigma, insufficient knowledge, or adherence to traditional gender roles (such as masculinity) hinder their utilization of these services. On the other hand, factors such as being a woman, having a strong sense of cultural adaptation, or possessing adequate mental health literacy serve as facilitators for accessing mental health services., Conclusion: These students have unique experiences, and their needs are often unmet. To improve their mental health and use of mental health services, it is important to consider the barriers they face and their unique experience in their specific life context and to develop tailored prevention and intervention programs., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Dombou et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Anaemia among women has been reported to be a significant contributor to hemorrhage, exacerbated risk of stillbirths, miscarriages, and maternal mortalities. Hence, understanding the factors associated with anaemia is imperative to develop preventive strategies. We examined the association between history of hormonal contraceptive use and risk of anaemia among women in sub-Saharan Africa., Methods: We analyzed data from the recent Demographic and Health Surveys (DHS) of sixteen countries in sub-Saharan Africa. Countries with recent DHSs conducted from 2015 to 2020 were included in the study. A total of 88,474 women of reproductive age were included. We used percentages to summarize the prevalence of hormonal contraceptives and anaemia among women of reproductive age. We used multilevel binary logistic regression analysis to examine the association between hormonal contraceptives and anaemia. We presented the results using crude odds ratio (cOR) and adjusted odds ratios (aOR), with their respective 95 percent confidence intervals (95% CIs)., Results: On the average, 16.2% of women are using hormonal contraceptives and this ranged from 7.2% in Burundi to 37.7% in Zimbabwe. The pooled prevalence of anaemia was 41%, ranging from 13.5% in Rwanda to 58.0% in Benin. Women who used hormonal contraceptives were less likely to be anaemic compared to those who were not using hormonal contraceptives (aOR = 0.56; 95%CI = 0.53, 0.59). At the country-level, hormonal contraceptive use was associated with a reduced likelihood of anaemia in 14 countries, except for Cameroon and Guinea., Conclusion: The study underscores the importance of promoting the use of hormonal contraceptives in communities and regions that have a high burden of anaemia among women. Specifically, health promotion interventions aimed at promoting the use of hormonal contraceptives among women must be tailored to meet the needs of adolescents, multiparous women, those in the poorest wealth index, and women in union as these sub-populations were at significantly higher risk of anaemia in sub-Saharan Africa., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Aboagye et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: During the COVID-19 pandemic, growing evidence from the United States, the United Kingdom, and China has demonstrated the unequal social and economic burden of this health crisis. Yet, in Canada, studies assessing the socioeconomic and demographic determinants of COVID-19, and how these determinants vary by gender and ethnic minority status, remain scarce. As new strains of COVID-19 emerge, it is important to understand the disparities to be able to initiate policies and interventions that target and prioritise the most at-risk sub-populations., Aim: The objective of this study is to assess the socioeconomic and demographic factors associated with COVID-19-related symptoms in Canada, and how these determinants vary by identity factors including gender and visible minority status., Methods: We implemented an online survey and collected a nationally representative sample of 2,829 individual responses. The original data collected via the SurveyMonkey platform were analysed using a cross-sectional study. The outcome variables were COVID-19-related symptoms among respondents and their household members. The exposure variables were socioeconomic and demographic factors including gender and ethnicity as well as age, province, minority status, level of education, total annual income in 2019, and number of household members. Descriptive statistics, chi-square tests, and multivariable logistic regression analyses were performed to test the associations. The results were presented as adjusted odds ratios (aORs) at p < 0.05 and a 95% confidence interval., Results: We found that the odds of having COVID-19-related symptoms were higher among respondents who belong to mixed race [aOR = 2.77; CI = 1.18-6.48] and among those who lived in provinces other than Ontario and Quebec [aOR = 1.88; CI = 1.08-3.28]. There were no significant differences in COVID-19 symptoms between males and females, however, we did find a significant association between the province, ethnicity, and reported COVID-19 symptoms for female respondents but not for males. The likelihood of having COVID-19-related symptoms was also lower among respondents whose total income was $100,000 or more in 2019 [aOR = 0.18; CI = 0.07-0.45], and among those aged 45-64 [aOR = 0.63; CI = 0.41-0.98] and 65-84 [aOR = 0.42; CI = 0.28-0.64]. These latter associations were stronger among non-visible minorities. Among visible minorities, being black or of the mixed race and living in Alberta were associated with higher odds of COVID-19-related symptoms., Conclusion: We conclude that ethnicity, age, total income in 2019, and province were significantly associated with experiencing COVID-19 symptoms in Canada. The significance of these determinants varied by gender and minority status. Considering our findings, it will be prudent to have COVID-19 mitigation strategies including screening, testing, and other prevention policies targeted toward the vulnerable populations. These strategies should also be designed to be specific to each gender category and ethnic group, and to account for minority status., Competing Interests: The authors have declared that no competing interests exist. The work was not undertaken under the auspices of PHAC as part of employment responsibilities. It was conducted under the author’s other affiliation and any views expressed therein are personal opinions and not those of PHAC., (Copyright: © 2023 Pongou et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Tramadol is one of the most prescribed painkillers in the world. It is a synthetic opioid that is an excellent alternative to morphine and its derivatives in African countries. It is an essential drug due to its low cost and constant availability. However, the health consequences of tramadol use due to illicit trafficking, like those caused by fentanyl and methadone in North America, are poorly documented. This scoping review aims to understand the nature and extent of the use and health consequences of the Non-Medical Use (NMU) of tramadol in Africa to guide future research., Methods: Due to the perceived lack of African literature on the subject, our search strategy is based on the simultaneous use of the keywords "tramadol" and Medical Subject Heading (MeSH), such as "Drug abuse," "illicit drugs," or "Prescription Drug Misuse," combined with the term "Africa" and Boolean operators (and, or not) to form our search equations. Two researchers will independently select studies from literature searched in several databases such as Medline, Embase, the Scopus database, Web of Science, the African Journals online database, and for grey literature Google Scholar without any time restriction. All research, in various formats, conducted in Africa, will be included in our study on the prevalence of use in different African population groups or on evidence of addiction, intoxication, seizures and mortality related to NMU of tramadol., Results: Through this study, we aim to map consumers and identify risk factors, health consequences, and prevalence of the NMU of tramadol in African countries., Discussion: We are conducting the first scoping review study to investigate the prevalence and consequences of NMU of tramadol in Africa. Upon completion, our findings will be published in a peer-reviewed journal and presented at relevant conferences and workshops. However, since health is not limited to the lack of disease, our study is likely incomplete without incorporating the studies of the social impact of NMU of tramadol., Systematic Review Registration: Open Science Framework: https://osf.io/ykt25/., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Sabi Boun et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In Cameroon, HIV care decentralization is enforced as a national policy, but follow-up of people living with HIV (PLWH) is provider-driven, with little patient education and limited patient participation in clinical surveillance. These types of services can result in low antiretroviral therapy (ART) adherence. The objective of this study was to assess the prevalence and predictors of ART non-adherence among PLWH in Cameroon., Methods: A cross-sectional descriptive study of PLWH in HIV treatment centres in Cameroon was conducted. Only PLWH, receiving treatment in a treatment centre within the country, who had been on treatment for at least six months and who were at least 21 years old were included in the study. Individuals were interviewed about their demographics and ART experiences. Data were collected using a structured interviewer-administered questionnaire and analyzed using STATA version 14., Results: A total of 451 participants participated in this study, 33.48% were from the country's Southwest region. Their mean age was 43.42 years (SD: 10.42), majority (68.89%) were females. Overall proportion of ART non-adherence among participants was 37.78%, 35.88% missed taking ART twice in the last month. Reasons for missing ART include forgetfulness, business and traveling without drugs. Over half of participants (54.67%) know ART is life-long, 53.88% have missed ART service appointments, 7.32% disbelieve in ART benefits, 28.60% think taking ART gives unwanted HIV Status reminder and 2.00% experienced discrimination seeking ART services. In the multivariate analysis, odds of ART non-adherence in participants aged 41 and above was 0.35 times (95%CI: 0.14, 0.85) that in participants aged 21-30 years, odds of ART non-adherence comparing participants who attained only primary education to those who attained higher than secondary education was 0.57 times (95%CI: 0.33, 0.97) and the odds of ART non-adherence in participants who are nonalcohol consumers was 0.62 times (95%CI: 0.39, 0.98) that in alcohol consumers., Conclusion: High proportion of participants are ART non-adherent, and the factors significantly associated with ART non-adherence include age, education and alcohol consumption. However, some reasons for missing ART are masked in participants' limited knowledge in taking ART, disbelief in ART benefits, feelings that ART gives unwanted HIV status reminder and experiencing discrimination when seeking ART services. These underscores need to improve staff (health personnel) attitudes, staff-patient-communication, and proper ART prior initiation counselling of patients. Future studies need to focus on assessing long-term ART non-adherence trends and predictors using larger samples in many treatment centres and regions., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Buh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Women, gender minorities and their children are at heightened risk of intimate partner violence (IPV) following stressful life events (SLE). The increase in IPV during the global pandemic of the Novel Coronavirus (COVID-19) is recent evidence. Studies have linked IPV to poor health, resulting in lower mental, physical, sexual, and reproductive health outcomes. IPV has also been shown as a barrier to labour force participation, leading to negative socioeconomic outcomes (i.e., low or no employment). Formal and informal supports help individuals who experience IPV, but it is unclear if and how these are being accessed during SLEs such as environmental disasters, pandemics, and economic recessions. Accessibility to programs is an issue in normal times because of stigma, social norms, and lack of knowledge; this has been further amplified by situations where individuals who experience violence are isolated physically and emotionally, as well as face controlling behaviours by their perpetrators of violence. This scoping review will be used to conduct a comprehensive review of literature and address the research question: What is known in published literature about access to services by individuals who experience IPV during stressful life events in high-income countries?, Methods: The following electronic databases will be searched for relevant publications: MEDILINE (OVID), Embase (OVID), PsychINfo (OVID), CINAHL (EBSCO), Global Health (EBSCO), Gender Watch (ProQuest), Web of Science and Applied Social Sciences Index & Abstracts (ProQuest). Key terms and medical subject headings (MeSH) will be based on previous literature and consult with an expert librarian. The major concepts include 'stressful life events' AND intimate partner violence' AND 'access to services'. Google, Google Scholar, and the WHO website will be used to search for grey literature, books/chapters, and programme reports as well as references of relevant reviews. Studies will be screened and extracted by two reviewers and conflicts resolved through discussion or a third reviewer. Both quantitative and qualitative analysis of relevant data will outline key findings., Discussion: The scoping review will provide synthesized and summarized findings on literature regarding access to informal and formal social supports by victims of IPV during SLEs (i.e., pandemics and natural/environmental disasters/emergencies, economic recessions) where possible, highlighting key barriers, facilitators and lessons learned. Findings have potential to inform programs, policies, and interventions on accessibility to necessary support and health services during disasters., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Idriss-Wheeler et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: During major pandemics such as COVID-19, the fear of being infected, uncertain prognoses, and the imposition of restrictions may result in greater odds of emotional and psychological distress. Hence, the present study examines the predictors of psychological distress during the COVID-19 pandemic in Canada, and how they differ by gender., Methods: Data of 2,756 adults aged 18 years and above from a cross-sectional online survey conducted between July and October 2020 was used for this study. A multivariable logistic regression analysis was carried out. The results were presented as adjusted odds ratio (aOR) with their respective confidence interval (CI)., Results: Lower odds of psychological distress were found among males compared to females and among individuals aged 45-64 or 65-84 years compared to those aged 18-44. The odds of psychological distress decreased with a rise in income, with individuals whose annual income was greater than or equal to $100,000 being less likely to experience psychological distress compared to those whose income was less than $20,000. The odds of psychological distress were higher among residents of Ontario compared to residents of Quebec. Similarly, the odds of psychological distress were higher among individuals who reported experiencing COVID-19 symptoms compared to those who did not report any COVID-19 symptoms. The disaggregated results by gender showed that age, province, and self-reported COVID-19 symptoms had significant associations with psychological distress in both males and females, but these effects were more pronounced among females compared to males. In addition, income was negatively associated with psychological distress for both males and females, with this effect being stronger among males., Conclusion: Five exposure variables (gender, age, province, experiencing COVID-19 symptoms, and total annual income in 2019) significantly predicted the likelihood of reporting psychological distress during the COVID-19 pandemic in Canada. Clearly, there is an imminent need to provide mental health support services to vulnerable groups. Additionally, interventions and policies aimed at combating psychological distress during pandemics such as COVID-19 should be gender specific., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Pongou et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Despite the evidence-based effectiveness of diarrhoea treatment in preventing diarrhoea-related child mortality, the accessibility and utilization of diarrhoea treatments remain low in sub-Saharan Africa, even though these treatments are available. Therefore, this study aimed to assess the prevalence and predictors of diarrhoea treatment among under-five children in sub-Saharan Africa., Methods: This study involved cross-sectional analyses of secondary data from the most recent Demographic and Health Surveys of 30 countries in sub-Saharan Africa. Percentages with their respective 95% confidence intervals (CI) were used to summarise the prevalence of diarrhoea treatment. A multivariable multilevel binary logistic regression analysis was employed to examine the predictors of diarrhoea treatment among children under five years in sub-Saharan Africa. The regression results were presented using adjusted odds ratio with their accompanying 95% confidence intervals. Statistical significance was set at p<0.05. Stata software version 16.0 was used for the analyses., Results: The overall prevalence of diarrhoea treatment among under-five children in sub-Saharan Africa was 49.07% (95% CI = 44.50-53.64). The prevalence of diarrhoea treatment ranged from 23.93% (95% CI = 20.92-26.94) in Zimbabwe to 66.32% (95% CI = 61.67-70.97) in Liberia. Children aged 1 to 4 years, those whose mothers had at least primary education, those whose mothers had postnatal care visits, those whose mothers believed that permission to go and get medical help for self was a big problem, and those whose mothers' partners had at least primary education were more likely to undergo diarrhoea treatment as compared to their counterparts. The odds of diarrhoea treatment increased with increasing wealth index with the highest odds among those in the richest quintile. Also, the odds of diarrhoea treatment was higher in the Central, Eastern, and Western geographical subregions compared to those in the Southern geographical subregion. However, children whose mothers were cohabiting, those whose mothers were exposed to watching television, and those living in female-headed households were less likely to undergo diarrhoea treatment., Conclusion: The study found that the prevalence of diarrhoea treatment among children in sub-Saharan Africa was relatively low and varied across countries. The sub-regional estimates of diarrhoea treatment and identified associated factors can support country-specific needs assessments targeted at improving policy makers' understanding of within-country disparities in diarrhoea treatment. Planned interventions (e.g., provision of quality and affordable supply of oral rehydration salts and zinc) should seek to scale up diarrhoea treatment uptake among under-five children in sub-Saharan Africa with much focus on the factors identified in this study., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Awareness creation through mass media has the potential to promoted positive behaviors and discourage negative health-related behaviors through direct and indirect pathways. In this study, we examined the association between exposure to mass media and maternal health care services utilization among women in sub-Saharan Africa., Methods: We used data from the recent Demographic and Health Surveys (DHS) conducted between 2010 and 2020. A total of 28 countries with a survey dataset within 2010-2020 were included in our study. We included 199,146 women who had ever had a pregnancy in the last five years preceding the survey. Weighting was applied. Multilevel mixed-effect models were considered to account for cluster-level variations and correct inferences. Fixed and random effects estimates were reported. Adjusted odds ratio (aOR) with their 95% confidence intervals (CIs) were used to present the results. Also, we presented the random intercept variations, intraclass correlation coefficient, and model fitness., Results: Women who listened to radio at least once every week (aOR = 1.11, 95% CI = 1.07,1.15) were more likely to attend ANC as against those who did not listen to radio at all. Also, women who watched television at least once a week (aOR = 1.39, 95% CI = 1.33,1.46) were more likely to attend ANC compared to those who did not watch television at all. Women who read newspaper/magazine at least once a week (aOR = 1.27, 95% CI = 1.14,1.41); listened to radio at least once a week (aOR = 1.12, 95% CI = 1.07,1.17); and watched television at least once a week (aOR = 1.32, 95% CI = 1.24,1.40), were more likely to utilize SBA than those who did not read newspaper/magazine; listen to radio; and watch television at all. Women who read newspaper/magazine at least once a week (aOR = 1.35, 95% CI = 1.27,1.45); listened to radio at least once a week (aOR = 1.37, 95% CI = 1.32,1.42); and watched television at least once a week (aOR = 1.39, 95% CI = 1.32,1.47) were more likely to utilize PNC compared to those who did not., Conclusions: The study identified a strong positive relationship between mass media exposure and maternal health care services utilization. Specifically, exposure to radio and television were positively associated with ANC visitations. Moreover, exposure to mass media (newspaper/magazine, radio and television) were positively associated with SBA and PNC utilization. Policymakers and other non-governmental organizations should continuously invest resources in the design and implementation of maternal health service utilization educational programs through all the mass media channels to scale up women's maternal health service services utilization uptake in sub-Saharan Africa., Competing Interests: The authors have declared that no competing interests exist.

Background: Although intrahousehold transmission is a key source of Coronavirus Disease 2019 (COVID-19) infections, studies to date have not analysed socioeconomic risk factors on the household level or household clustering of severe COVID-19. We quantify household income differences and household clustering of COVID-19 incidence and severity., Methods and Findings: We used register-based cohort data with individual-level linkage across various administrative registers for the total Finnish population living in working-age private households (N = 4,315,342). Incident COVID-19 cases (N = 38,467) were identified from the National Infectious Diseases Register from 1 July 2020 to 22 February 2021. Severe cases (N = 625) were defined as having at least 3 consecutive days of inpatient care with a COVID-19 diagnosis and identified from the Care Register for Health Care between 1 July 2020 and 31 December 2020. We used 2-level logistic regression with individuals nested within households to estimate COVID-19 incidence and case severity among those infected. Adjusted for age, sex, and regional characteristics, the incidence of COVID-19 was higher (odds ratio [OR] 1.67, 95% CI 1.58 to 1.77, p < 0.001, 28.4% of infections) among individuals in the lowest household income quintile than among those in the highest quintile (18.9%). The difference attenuated (OR 1.23, 1.16 to 1.30, p < 0.001) when controlling for foreign background but not when controlling for other household-level risk factors. In fact, we found a clear income gradient in incidence only among people with foreign background but none among those with native background. The odds of severe illness among those infected were also higher in the lowest income quintile (OR 1.97, 1.52 to 2.56, p < 0.001, 28.0% versus 21.6% in the highest quintile), but this difference was fully attenuated (OR 1.08, 0.77 to 1.52, p = 0.64) when controlling for other individual-level risk factors-comorbidities, occupational status, and foreign background. Both incidence and severity were strongly clustered within households: Around 77% of the variation in incidence and 20% in severity were attributable to differences between households. The main limitation of our study was that the test uptake for COVID-19 may have differed between population subgroups., Conclusions: Low household income appears to be a strong risk factor for both COVID-19 incidence and case severity, but the income differences are largely driven by having foreign background. The strong household clustering of incidence and severity highlights the importance of household context in the prevention and mitigation of COVID-19 outcomes., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Existing studies have acknowledged the underutilization of skilled maternal healthcare services among women in rural Nigeria. Consequently, women in rural areas face a disproportionate risk of poor health outcomes including maternal morbidity and mortality. Addressing the challenge of non-use of skilled maternal healthcare in rural areas necessitates the involvement of multi-stakeholders across different sectors who have vital roles to play in improving maternal health. This study explores the factors contributing to the non-use of maternal healthcare services in rural areas of Edo, Nigeria from the perspectives of community elders and policymakers., Methods: In this qualitative study, data were collected through 10 community conversations (group discussions) with community elders each consisting of 12 to 21 participants, and six key informant interviews with policymakers in rural areas of Edo State, Nigeria. Participants were purposefully selected. Conversations and interviews occurred in English, Pidgin English and the local language; lasted for an average of 9 minutes; were audio-recorded and transcribed to English. Data were manually coded, and data analysis followed the analytical strategies for qualitative description including an iterative process of inductive and deductive approaches., Results: Policymakers and community elders attributed the non-use of maternal health services to poor quality of care. Notions of poor quality of care included shortages in skilled healthcare workers, apathy and abusive behaviours from healthcare providers, lack of life-saving equipment, and lack of safe skilled pregnancy care. Non-use was also attributed to women's complex utilization patterns which involved a combination of different types of healthcare services, including traditional care. Participants also identified affordability and accessibility factors as deterrents to women's use of skilled maternal healthcare., Conclusion: The emerging findings on pregnant women's combined use of different types of care highlight the need to improve the quality, availability, accessibility, and affordability of skilled maternal care for rural women in Nigeria., Competing Interests: The authors have declared that no competing interests exist.

Background: Intimate partner violence (IPV) against women and poor nutritional status are growing health problems in low and middle-income countries (LMICs). Moreover, violence against women has been shown to be associated with poor nutrition. This study investigated the relationship between IPV and nutritional status (i.e., underweight, overweight, and obesity) among women of reproductive age (15-49 years) in Zimbabwe., Methods: Pooled data from the 2005/2006, 2010/2011, and 2015 Zimbabwe Demographic Health Surveys (ZDHS) on 13,008 married/cohabiting women were analysed. Multinomial logistic regression models were used to examine the associations between the various forms of IPV and the nutritional status of women. We further estimated the prevalence of BMI ≥ 25.0 kg/m2 (overweight and obesity) by intimate partner violence type., Results: The mean BMI of women was 24.3 kg/m2, more than one-fifth (24%) were overweight and about 12% were obese. Forty-three percent (43%) of women reported to have ever experienced at least one form of intimate partner violence. More than one-third (35%) of women who reported to have ever experienced at least one form of intimate partner violence had a BMI ≥ 25.0 kg/m2 (p< 0.01). Relative to normal weight, women who had ever experienced at least one form of IPV (i.e., physical, emotional, or sexual) were more likely to be obese (aOR = 2.59; 95% CI = 1.05-6.39). Women's exposure to any form of intimate partner violence was not significantly associated with the likelihood of being underweight or overweight relative to normal weight., Conclusions: The study findings show that women of reproductive age in Zimbabwe are at high risk of both IPV and excess weight. Moreover, we found a positive relationship between exposure to at least one form IPV and obesity. Public health interventions that target the well-being, empowerment and development of women are needed to address the complex issue of IPV and adverse health outcomes, including obesity., Competing Interests: The authors have declared that no competing interests exist.

Background: Countries in sub-Sahara African continue to have the highest maternal and under- five child death occurrences in the world and this has become a key health challenge in the region and persists as global public health agenda. Although Community Health Workers (CHWs) are increasingly being acknowledged as crucial members of the healthcare workforce in reducing health disparity, evidence is limited on perspective of community health workers. The objective of this protocol is to outline the methodological process of a systematic review that will gather qualitative data to examine determinants of community health workers effectiveness for delivery of maternal and child health in Sub Saharan Africa. Synthesizing the perspectives of community health workers' perceived experience is crucial to inform decision makers, policy makers, and practitioners to address barriers to and scaleup facilitators of CHWs program to ensure maternal and child health equity and a resilience community health system., Methods: The protocol has been registered in the PROSPERO (CRD42020206874). We will systematically conduct a literature search from inception in MEDLINE complete, EMBASE, CINAHL complete and Global Health for relevant studies. Eligible studies will be reports of original research, peer reviewed articles having a qualitative component (i.e., qualitative, mixed, or multi-method studies) on empowerment of CHWs associated with maternal and child health in the sub-Saharan Africa. Eligibility will be restricted to studies published in English. Two reviewers will independently screen all included abstracts and full-text articles. The primary outcome will be CHWs' perceived barriers to and facilitators of effectiveness of community health workers in maternal and child health in sub-Saharan Africa. Study methodological quality (or bias) will be appraised using appropriate tools. Narrative analysis will be conducted, and narrative summary of findings will be presented. We will use the 'best fit' framework method as a systematic approach to analyzing the qualitative data., Discussion: This study will systematically and comprehensively search literature and integrate evidence on perceived barriers to and facilitators of effectiveness of community health workers led maternal and child health program in sub-Saharan Africa. Our findings will inform policy and practice on maternal and child health equity and a resilient communities health system. The resulting manuscript will be disseminated in a peer-reviewed journal and at international and national conferences., Competing Interests: The authors have declared that no competing interests exist.

Background: The HIV/AIDS pandemic continues to be a major public health concern, particularly in Sub-Saharan Africa (SSA). Despite efforts to reduce new infections and deaths with the use of antiretroviral therapy (ART), SSA countries continue to bear the heaviest burden of HIV/AIDS globally, accounting for two-thirds of global new infections. The goal of this review is to identify common barriers to ART adherence as well as common effective interventions that can be implemented across SSA countries to improve ART adherence., Methods: A systematic review of published studies on adult HIV-positive patients aged 15 or above, that have assessed the barriers to ART adherence and interventions improving patients' adherence to ART in SSA countries shall be conducted. We will conduct electronic searches for articles that have been published starting from January 2010 onwards. The databases that shall be searched will include Medline Ovid, CINAHL, Embase, and Scopus. The review will include experimental and quasi-experimental studies such as randomized and non-randomized controlled trials as well as comparative before and after studies, and observational studies-cross-sectional studies, cohort studies, prospective and retrospective studies. Two independent reviewers will screen all identified studies, extract data and appraise the methodological quality of the studies using standard critical appraisal tools from the Joanna Briggs Institute. The extracted data will be subjected to a meta-analysis and narrative synthesis., Discussion: This review will synthesize existing evidence on ART adherence barriers and strategies for improving patient adherence to ART in SSA countries. It will identify common barriers to adherence and common interventions proven to improve adherence across SSA. We anticipate that the findings of this review will provide information policy makers and stakeholders involved in the fight against HIV, will find useful in deriving better ways of not only retaining patients on treatment but having them adhere to their treatment., Review Registration: This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO); registration number CRD42021262256., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Over the past three decades, undernutrition has become a major cause of morbidity and mortality among children under five years globally. Low birth weight has been identified as a risk factor for child morbidity and mortality, especially among children under five years in sub-Saharan Africa. There is, however, a paucity of empirical literature establishing the association between low birth weight and undernutrition in sub-Saharan Africa. We examined the association between birth weight and nutritional status of children under five in sub-Saharan Africa., Methods: Our analyses were performed on a weighted sample of 110,497 children under five years from 32 countries in sub-Saharan Africa. Data were obtained from the Demographic and Health Surveys conducted from 2010 to 2019. We reported the prevalence of low birth weight and nutritional status (stunting, wasting, and underweight) for all the 32 countries using percentages. We used multilevel binary logistic regression to examine the association between birth weight and nutritional status (stunting, wasting, and underweight) of the children, controlling for covariates. The results of the regression analyses were presented using adjusted odds ratios (aOR) with 95% confidence intervals. Statistical significance was set at p<0.05., Results: The prevalence of low birth weight was 5.4%, with the highest (13.1%) and lowest (0.9%) reportedin South Africa and Chad, respectively. The pooled prevalence of wasting, underweight, and stunting were 8.1%, 17.0%, and 31.3%, respectively. Niger had the highest prevalence of wasting (21.5%) and underweight (37.1%), whereas Burundi had the highest prevalence of stunting (51.7%). We found that children with low birth weight were more likely to be stunted [aOR = 1.68, 95% CI = 1.58-1.78], underweight [aOR = 1.82, 95% CI = 1.70-1.94], and wasted [aOR = 1.35, 95% CI = 1.20-1.38] after controlling for covariates., Conclusion: Our study has demonstrated that low birth weight is a key determinant of undernutrition among children under five in sub-Saharan Africa. Policymakers need to give special attention to improving the nutritional status of children under-five years in sub-Saharan Africa by implementing measures aimed at enhancing the weight of children. To accelerate progress towards the achievement of the Sustainable Development Goal 3.2 target of ending preventable deaths of newborns and under-five by 2030, it is imperative for countries in sub-Saharan Africa to intensify interventions aimed at improving maternal and child nutrition. Specific nutrition interventions such as dietary modification counselling should prioritized., Competing Interests: The authors have declared that no competing interests exist.

Background: The Sustainable Development Goal (SDG) 3 aims at reducing neonatal and under-5 mortality to below 12 per 1000 and 25 per 1000 live births, respectively, globally by 2030. Studies have found that initiation of breastfeeding within one hour of birth and continuous breastfeeding for over 12 months can positively impact neonatal and infant health. However, there is evidence that the sex of a child may influence the breastfeeding practices of a mother. Thus, we examined sex inequality in early breastfeeding initiation in sub-Saharan Africa., Materials and Methods: Data from Demographic and Health Surveys conducted in 24 sub-Saharan African countries between January 2010 and December 2019 were pooled and analysed. A total of 137,677 women of reproductive age (15-49 years) were considered in this study. Bivariate and multivariable regression analyses were performed, and the results were presented using crude odds ratio (cOR) and adjusted odds ratio (aOR) with statistical significance at a p-value less than 0.05., Results: The highest inequality in early initiation of breastfeeding was reported in Togo with a difference of 5.21% between the female and male children, while the lowest inequality was reported in Guinea with 0.48% difference between the female and male children. A higher odds of breastfeeding within 1 hour was observed among female children [cOR = 1.05; 95%(CI = 1.02-1.09)] compared to male children, and this persisted after controlling for the confounders included in this study [aOR = 1.05; 95%(CI = 1.02-1.08)]., Conclusion: We found higher odds for early breastfeeding initiation of female children compared to male children in sub-Saharan Africa. To reduce breastfeeding initiation inequalities, programmes that educate and encourage early initiation of breastfeeding irrespective of the child sex should be promoted among mothers., Competing Interests: The author(s) have declared no competing interest.

Background: The death of children under-five years is one of the critical issues in public health and improving child survival continues to be a matter of urgent concern. In this paper, we assessed the proximate and socio-economics determinants of child mortality in Guinea., Methods: Using the 2018 Guinea Demographic and Health Survey (GDHS), we extracted demographic and mortality data of 4,400 children under-five years. Both descriptive and multivariable logistic regression analyses were conducted., Results: Under-five mortality was 111 deaths per 1,000 live births in Guinea. The likelihood of death was higher among children born to mothers who belong to other religions compared to Christians (aOR = 2.86, 95% CI: 1.10-7.41), smaller than average children compared to larger than average children (aOR = 1.97, 95% CI: 1.28-3.04) and those whose mothers had no postnatal check-up visits after delivery (aOR = 1.72, 95% CI: 1.13-2.63). Conversely, the odds of death in children with 2-3 birth rank & >2 years of birth interval compared to ≥4 birth rank and ≤2 years of birth interval were low (aOR = 0.53, 95% CI: 0.34-0.83)., Conclusion: We found that household/individual-level socioeconomic and proximate factors predict under-five mortality in Guinea. With just about a decade left to the 2030 deadline of the Sustainable Development Goals (SDGs), concerted efforts across all key stakeholders, including government and development partners, need to be geared towards implementing interventions that target these predictors., Competing Interests: The authors have declared that no competing interests exist.

Background: In 2016, WHO launched the Global Health Sector Strategy on STIs, 2016-2021 (GHSS) to provide guidance and benchmarks for country achievement by 2020 and four global targets for achievement by 2030., Methods: A country survey jointly developed by experienced technical personnel at WHO Headquarters (HQ) and WHO regional offices was reviewed and distributed by WHO regional advisors to 194 WHO Member States in September-March 2020. The survey sought to assess implementation and prioritization of STI policy, surveillance, service delivery, commodity availability, and surveillance based on targets of the GHSS., Results: A majority (58%, 112/194) of countries returned a completed survey reflecting current (2019) STI activities. The regions with the highest survey completion rates were South-East Asia Region (91%, 10/11), Region of the Americas (71%, 25/35) and Western Pacific Region (67%, 18/27). Having a national STI strategy was reported by 64% (72/112) and performing STI surveillance activities by 88% (97/110) of reporting countries. Availability of STI services within primary health clinics was reported by 88% of countries (99/112); within HIV clinics by 92% (103/112), and within reproductive health services by 85% (95/112). Existence of a national strategy to eliminate mother-to-child transmission of HIV and syphilis (EMTCT) was reported by 70% of countries (78/112). Antimicrobial resistance (AMR) monitoring for gonococcal infection (gonorrhoea) was reported by 64% (57/89) of reporting countries with this laboratory capacity. Inclusion of HPV vaccine for young women in the national immunization schedule was reported by 59% (65/110) and availability of cervical cancer screening was reported by 91% (95/104). Stockouts of STI medicines, primarily benzathine penicillin, within the prior four years were reported by 34% (37/110) of countries., Conclusions: Mechanisms to support improvements to STI service delivery through national-level policy, commitment, programming and surveillance are needed to operationalize, accelerate and monitor progress towards achievement of the 2030 global STI strategy targets., Competing Interests: The authors have declared that no competing interests exist.

Background: The most commonly diagnosed cancers among women are breast and cervical cancers, with cervical cancer being a relatively bigger problem in low and middle income countries (LMICs) than breast cancer., Methods: The main aim of this study was to asses factors associated with and socioeconomic inequalities in breast and cervical cancer screening among women aged 15-64 years in Botswana. This study is part of the broad study on Chronic Non-Communicable Diseases in Botswana conducted (NCD survey) in 2016. The NCD survey was conducted across 3 cities and towns, 15 urban villages and 15 rural areas of Botswana. The survey collected information on several NCDs and risk factors including cervical and breast cancer screening. The survey adopted a multistage sampling design and a sample of 1178 participants (males and females) aged 15 years and above was selected in both urban and rural areas of Botswana. For this study, a sub-sample of 813 women aged 15-64 years was selected and included in the analysis. The inequality analysis was conducted using decomposition analysis using ADePT software version 6. Logistic regression models were used to show the association between socioeconomic variables and cervical and breast cancer screening using SPSS version 25. All comparisons were considered statistically significant at 5%., Results: Overall, 6% and 62% of women reported that they were screened for breast and cervical cancer, respectively. Women in the poorest (AOR = 0.16, 95% CI = 0.06-0.45) and poorer (AOR = 0.37, 95% CI = 0.14-0.96) wealth quintiles were less likely to report cervical cancer screening compared to women in the richest wealth quintile. Similarly, for breast cancer, the odds of screening were found to be low among women in the poorest (AOR = 0.39, 95% CI = 0.06-0.68) and the poorer (AOR = 0.45, 95% CI = 0.13-0.81)) wealth quintiles. Concentration indices (CI) showed that cervical (CI = 0.2443) and breast cancer (CI = 0.3975) screening were more concentrated among women with high SES than women with low SES. Wealth status was observed to be the leading contributor to socioeconomic inequality observed for both cervical and breast cancer screening., Conclusions: Findings in this study indicate the need for concerted efforts to address the health care needs of the poor in order to reduce cervical and breast cancer screening inequalities., Competing Interests: The authors have declared that no competing interests exist.

Recent evidence suggests that, in some foci, elimination of onchocerciasis from Africa may be feasible with mass drug administration (MDA) of ivermectin. To achieve continental elimination of transmission, mapping surveys will need to be conducted across all implementation units (IUs) for which endemicity status is currently unknown. Using boosted regression tree models with optimised hyperparameter selection, we estimated environmental suitability for onchocerciasis at the 5 × 5-km resolution across Africa. In order to classify IUs that include locations that are environmentally suitable, we used receiver operating characteristic (ROC) analysis to identify an optimal threshold for suitability concordant with locations where onchocerciasis has been previously detected. This threshold value was then used to classify IUs (more suitable or less suitable) based on the location within the IU with the largest mean prediction. Mean estimates of environmental suitability suggest large areas across West and Central Africa, as well as focal areas of East Africa, are suitable for onchocerciasis transmission, consistent with the presence of current control and elimination of transmission efforts. The ROC analysis identified a mean environmental suitability index of 0·71 as a threshold to classify based on the location with the largest mean prediction within the IU. Of the IUs considered for mapping surveys, 50·2% exceed this threshold for suitability in at least one 5 × 5-km location. The formidable scale of data collection required to map onchocerciasis endemicity across the African continent presents an opportunity to use spatial data to identify areas likely to be suitable for onchocerciasis transmission. National onchocerciasis elimination programmes may wish to consider prioritising these IUs for mapping surveys as human resources, laboratory capacity, and programmatic schedules may constrain survey implementation, and possibly delaying MDA initiation in areas that would ultimately qualify., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: WM is Program Analyst in Population and Development at the United Nations Population Fund-UNFPA Country Office in Peru, institution which not necessarily endorses this study. JAS reports personal fees from Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, Practice Point communications, the National Institutes of Health, the American College of Rheumatology, Simply Speaking. JAS reports other contributions from Amarin, Viking, Moderana and Vaxart pharmaceuticals. JAS reports non-financial support from the FDA Arthritis Advisory Committee, the Steering committee of OMERACT, an international organization that develops measures for clinical trials and receives arms length funding from 12 pharmaceutical companies, the Veterans Affairs Rheumatology Field Advisory Committee, and the Editor and the Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis.

Introduction: The success of current policies and interventions on providing effective access to treatment for childhood illnesses hinges on families' decisions relating to healthcare access. In sub-Saharan Africa (SSA), there is an uneven distribution of child healthcare services. We investigated the role played by barriers to healthcare accessibility in healthcare seeking for childhood illnesses among childbearing women in SSA., Materials and Methods: Data on 223,184 children under five were extracted from Demographic and Health Surveys of 29 sub-Saharan African countries, conducted between 2010 and 2018. The outcome variable for the study was healthcare seeking for childhood illnesses. The data were analyzed using Stata version 14.2 for windows. Chi-square test of independence and a two-level multivariable multilevel modelling were carried out to generate the results. Statistical significance was pegged at p<0.05. We relied on 'Strengthening the Reporting of Observational Studies in Epidemiology' (STROBE) statement in writing the manuscript., Results: Eighty-five percent (85.5%) of women in SSA sought healthcare for childhood illnesses, with the highest and lowest prevalence in Gabon (75.0%) and Zambia (92.6%) respectively. In terms of the barriers to healthcare access, we found that women who perceived getting money for medical care for self as a big problem [AOR = 0.81 CI = 0.78-0.83] and considered going for medical care alone as a big problem [AOR = 0.94, CI = 0.91-0.97] had lower odds of seeking healthcare for their children, compared to those who considered these as not a big problem. Other factors that predicted healthcare seeking for childhood illnesses were size of the child at birth, birth order, age, level of community literacy, community socio-economic status, place of residence, household head, and decision-maker for healthcare., Conclusion: The study revealed a relationship between barriers to healthcare access and healthcare seeking for childhood illnesses in sub-Saharan Africa. Other individual and community level factors also predicted healthcare seeking for childhood illnesses in sub-Saharan Africa. This suggests that interventions aimed at improving child healthcare in sub-Saharan Africa need to focus on these factors., Competing Interests: The authors have declared that no competing interests exist.

Background: The Lagos State Tuberculosis, Buruli Ulcer, and Leprosy Control Program (LSTBLCP) started engaging private hospitals under the Public-Private Mix (PPM) Program in 2008. The study aimed to evaluate the trend and predictors of successful Tuberculosis (TB) treatment outcomes of patients managed across these private health facilities between 2010-2016 in Lagos, Nigeria., Methods: Retrospective review of TB treatment register and treatment cards of patients commenced on TB treatment between January 2010 and December 2016 in 36 private health facilities engaged by the LSTBLCP. Between December 2016 and February 2017, data were collected and entered into Microsoft Excel by trained data entry clerks. The analysis was done using SPSS software. Independent predictors of successful treatment outcomes were determined using multivariate analysis at the statistical significance of p<0.05 and 95% confidence interval., Results: A total of 1660 records of TB patients were reviewed. 1535 (92.47%) commenced treatment, while 1337 (87.10%) of all records had documented treatment outcomes. Of the 1337 patients with outcomes, 1044 (78.09%) had a successful treatment outcome, and 293 (21.91%) had an unsuccessful outcome. Majority were male, 980 (59.04%), Human Immunodeficiency Virus (HIV) negative status, 1295 (80.24%), diagnosed with smear, 1141 (73.14%), treated in private not-for-profit (PNFP) hospital, 1097 (66.08%), treated for TB between 2014-2016 (18.96%-19.52%). In multivariate analysis, age>20years (aOR = 0.26, p = 0.001), receiving TB treatment in 2013 (aOR = 0.39, p = 0.001), having genexpert for TB diagnosis (aOR = 0.26, p = 0.031) and being HIV positive (aOR = 0.37, p = 0.001) significantly reduced likelihood of successful treatment outcome. The site of TB, being on ART or CPT, were confounding determinants of successful treatment outcomes as they became non-significant at the multivariate analysis level., Conclusion: Treatment outcome among Lagos private hospitals was low compared with NTBLCP and World Health Organization (WHO) target. We urge the government and TB stakeholders to strengthen the PPM interventions to improve adherence, particularly among People Living with HIV (PLHIV) and older TB patients. Hence, promotion of early care-seeking, improving diagnostic and case holding efficiencies of health facilities, and TB/HIV collaborative interventions can reduce the risk of an unsuccessful outcome., Competing Interests: The authors have declared that no competing interests exist.

Many native populations in South America have been severely impacted by two relatively recent historical events, the Inca and the Spanish conquest. However decisive these disruptive events may have been, the populations and their gene pools have been shaped markedly also by the history prior to the conquests. This study focuses mainly on the Chachapoya peoples that inhabit the montane forests on the eastern slopes of the northern Peruvian Andes, but also includes three distinct neighboring populations (the Jívaro, the Huancas and the Cajamarca). By assessing mitochondrial, Y-chromosomal and autosomal diversity in the region, we explore questions that have emerged from archaeological and historical studies of the regional culture (s). These studies have shown, among others, that Chachapoyas was a crossroads for Coast-Andes-Amazon interactions since very early times. In this study, we examine the following questions: 1) was there pre-Hispanic genetic population substructure in the Chachapoyas sample? 2) did the Spanish conquest cause a more severe population decline on Chachapoyan males than on females? 3) can we detect different patterns of European gene flow in the Chachapoyas region? and, 4) did the demographic history in the Chachapoyas resemble the one from the Andean area? Despite cultural differences within the Chachapoyas region as shown by archaeological and ethnohistorical research, genetic markers show no significant evidence for past or current population substructure, although an Amazonian gene flow dynamic in the northern part of this territory is suggested. The data also indicates a bottleneck c. 25 generations ago that was more severe among males than females, as well as divergent population histories for populations in the Andean and Amazonian regions. In line with previous studies, we observe high genetic diversity in the Chachapoyas, despite the documented dramatic population declines. The diverse topography and great biodiversity of the northeastern Peruvian montane forests are potential contributing agents in shaping and maintaining the high genetic diversity in the Chachapoyas region., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Contraception plays a significant role in fertility regulation and determines the reproductive health rights of women. Studies in other parts of the world have found that sexual violence has negative effects on unmet need for contraception. There has not been any study on the association between these two phenomena in sub-Saharan Africa using current nationally-representative survey data. We investigated the association between sexual violence and unmet need for contraception among married and cohabiting women in sub-Saharan Africa., Materials and Methods: This study was based on secondary datasets from 26 sub-Saharan African countries' Demographic and Health Surveys conducted between 2010 and 2018. A sample of 101,968 women in sexual unions (married and cohabiting) with complete information on sexual violence and all the variables of interest were included in the analyses. Both bivariate and multilevel logistic regression analyses were carried out to examine the association between sexual violence and unmet need for contraception. Other individual and contextual level socio-economic and demographic variables were considered as covariates. Crude odds ratios [cOR] and adjusted odds ratios [aOR] with their corresponding 95% confidence intervals [CI], signifying precision, were presented. Level of statistical significance was declared at p<0.05., Results: The overall prevalence of sexual violence and unmet need for contraception in the 26 sub-Saharan African countries were 8.7% and 28.7% respectively. Experience of sexual violence within the last 12 months resulted in 10% increase in unmet need for contraception [OR = 1.10, CI = 1.03-1.14] and 5% increase in unmet need for contraception after controlling for individual and contextual level factors [aOR = 1.05, CI = 1.01-1.11]. With the individual level factors, women with 4 or more births [aOR = 4.85, CI = 4.41-5.33], those cohabiting [aOR = 1.43, CI = 1.37-1.47], those in female headed households [aOR = 1.22, CI = 1.18-1.27] and those who watched television at least once a week [aOR = 1.12, CI = 1.07-1.16] had higher odds of unmet need for family planning. However, those aged 30-34 [aOR = 0.56, CI = 0.52-0.61], those with secondary/higher level of education [AOR = 0.80, CI = 0.77-0.84], those who read newspaper less than once a week [aOR = 0.75, CI = 0.71-0.79] and those who listened to radio at least once a week [aOR = 0.94, CI = 0.90-0.97] had lower odds of unmet need for contraception. In terms of the contextual factors, women in rural areas [aOR = 0.87, CI = 0.84-0.91] and those in the richest wealth quintile households [aOR = 0.80, CI = 0.75-0.85] had lower odds of unmet need for contraception., Conclusion: Our study has shown an association between sexual violence and unmet need for contraception in sub-Saharan Africa. Experiencing sexual violence increases the likelihood of unmet need for contraception in sub-Saharan Africa. It is also worthy to note that having four or more children, cohabiting with a male partner, and living in female-headed households are some of the key variables associated with unmet need for contraception in sub-Saharan Africa. Our study recommends that, successful contraceptive initiatives should focus on reducing sexual violence, while taking into consideration other significant factors that increase unmet need for contraception. Meanwhile, in doing this, contextual factors ought to be prioritised., Competing Interests: The authors have declared that no competing interests exist.

Background: Paying for sex has often been associated with risky sexual behavior among heterosexual men, and men who pay for sex are considered as a bridging population for sexually transmitted infections. Consistent condom use during paid sex is essential for reducing sexually transmitted infections, including HIV/AIDS. In this study, we assessed the prevalence and predictors of consistent condom use among men who pay for sex in sub-Saharan Africa., Materials and Methods: We pooled data from 29 sub-Saharan African countries' Demographic and Health Surveys. A total of 3,353 men in sub-Saharan Africa who had paid for sex in the last 12 months preceding the surveys and had complete information on all the variables of interest were used in this study. The outcome variable for the study was consistent condom use for every paid sex in the last 12 months. Both bivariate and multivariable logistic regression analyses were carried out. Results were presented as adjusted odds ratios with their corresponding 95% confidence intervals. Statistical significance was declared at p< 0.05., Results: Overall, the prevalence of consistent condom use during paid sex in sub-Saharan Africa was 83.96% (CI = 80.35-87.56), ranging from 48.70% in Benin to 98% in Burkina Faso. Men aged 35-44 [AOR, 1.39 CI = 1.04-1.49], men in the richest wealth quintile [AOR, 1.96 CI = 1.30-3.00], men with secondary level of education [AOR, 1.69 CI = 1.17-2.44], and men in Burkina Faso [AOR = 67.59, CI = 8.72-523.9] had higher odds of consistent condom use during paid sex, compared to men aged 15-19, those in the poorest wealth quintile, those with no formal education, and men in Benin respectively. Conversely, Muslim men had lower odds [AOR = 0.71, CI = 0.53-0.95] of using condom consistently during paid sex, compared to Christian men., Conclusion: Empirical evidence from this study suggests that consistent condom use during paid sex encompasses complex social and demographic characteristics. The study also revealed that demographic characteristics such as age, wealth quintile, education, and religion were independently related to consistent condom use for paid sex among men. With sub-Saharan Africa having the highest sexual and reproductive health burden in the world, continuous application of evidence-based interventions (e.g., educational and entrepreneurial training) that account for behavioural and social vulnerabilities are required., Competing Interests: The authors have declared that no competing interests exist.

Background: Substantial inequality in neonatal mortality rates (NMR) remains in low- and middle-income countries to the detriment of disadvantaged subpopulations. In Ethiopia, there is a dearth of evidence on the extent and trends of disparity in NMR. This study assessed the socioeconomic, residence and sex-based inequalities in NMR, as well as examined its change over a sixteen year period in Ethiopia., Methods: Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the Ethiopia Demographic and Health Surveys (EDHS) were analyzed between 2000 and 2016. NMR was disaggregated by four equity stratifiers: education, wealth, residence and sex. In addition, absolute and relative inequality measures, namely Difference, Population Attributable Risk (PAR), Ratio, Relative Concentration Index (RCI) and Slope Index of Inequality (SII) were calculated to understand inequalities from different perspectives. Corresponding 95% Uncertainty Intervals (UIs) were computed to measure statistical significance., Findings: Large educational inequalities in NMR were found in 2000, 2005, and 2011, while wealth-driven inequality occurred in 2011. Sex disparity was noted in all the surveys, and urban-rural differentials remained in all the surveys except in 2016. While socioeconomic and area-related inequalities decreased over time, sex related inequality did not change during the period of study., Conclusions: NMR appeared to be concentrated among male newborns, neonates born to illiterate and poor women and those living in rural settings. However, the inequality narrowed over time. Interventions appropriate for different subpopulations need to be designed., Competing Interests: The authors have declared that no competing interests exist

Background: The underutilization of formal, evidence-based maternal health services continues to contribute to poor maternal outcomes among women living in rural Africa. Women's choice of the type of maternal care they receive strongly influences their utilization of maternal health services. There is therefore a need to understand rural women's preferred choices to help set priorities for initiatives attempting to make formal maternal care more responsive to women's needs. The aim of this review was to explore and identify women's preferences for different sources of childbirth and postnatal care and the factors that contribute to these preferences., Methods: A systematic literature search was conducted using the Ovid Medline, Embase, CINAHL, and Global Health databases. Thirty-seven studies that elicited women's preferences for childbirth and postnatal care using qualitative methods were included in the review. A narrative synthesis was conducted to collate study findings and to report on patterns identified across findings., Results: During the intrapartum period, preferences varied across communities, with some studies reporting preferences for traditional childbirth with traditional care-takers, and others reporting preferences for a formal facility-based childbirth with health professionals. During the postpartum period, the majority of relevant studies reported a preference for traditional postnatal services involving traditional rituals and customs. The factors that influenced the reported preferences were related to the perceived need for formal or traditional care providers, accessibility to maternal care, and cultural and religious norms., Conclusion: Review findings identified a variety of preferences for sources of maternal care from intrapartum to postpartum. Future interventions aiming to improve access and utilization of evidence-based maternal healthcare services across rural Africa should first identify major challenges and priority needs of target populations and communities through formative research. Evidence-based services that meet rural women's specific needs and expectations will increase the utilization of formal care and ultimately improve maternal outcomes across rural Africa., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Previous studies have attempted to assess the role of health insurance on health care utilization in African settings. However, there is limited evidence on the effects of health insurance on use of maternal health care. In the present study our objective was to measure the prevalence of insurance ownership, types of services covered by the insurance and the association of insurance ownership with the utilization of respective maternal health services in Ghana., Methods: This study was based on nationally representative Demographic and Health Survey in Ghana (GDHS 2014) encompassing 4,293 mothers aged 15-49 years. Outcome variables were use of early antenatal care (ANC), facility delivery, and postnatal care (PNC) for mothers and children, and the explanatory variables were insurance coverage for these services. Associations were analysed using logistic regression models whilst controlling for potentially confounding variables., Results: Prevalence of health insurance ownership was 66.8% (95%CI = 64.5-68.9) with significant socioeconomic disparities. The prevalence was higher particularly among women who were urban residents, had higher educational and wealth status. In general, insurance coverage for services such as ANC, childbirth and postnatal care was higher in rural areas, but that of cash benefit was higher in urban areas. Findings of multivariate analysis indicated that women who had their ANC services covered had significantly higher odds of attending at least one and four ANC visits, as well as receiving PNC for child. Insurance coverage for childbirth services showed significant association with the PNC for child, not with choice of health facility delivery. Women who had cash benefit were twice as likely to use early ANC visit (OR = 2.046, p<0.05), facility delivery (OR = 1.449, p<0.05), and PNC for mother (OR = 1.290, p<0.05)., Conclusion: Overall prevalence of health insurance coverage has increased since 2008, with significant disparities across demographic and socioeconomic groups. Insurance ownership for different types of maternal health services showed positive association with service uptake, with exceptions for place of delivery, indicating that insurance coverage alone may not be able to promote facility delivery. More studies are required to measure the progress in maternal healthcare utilisation through the insurance programmes., Competing Interests: The authors have declared that no competing interests exist.

Background: Unmet need for contraception and unwanted pregnancy are recognised as significant barriers to promoting women's reproductive health and well-being. Currently there is no research evidence on these two crucial indicators of reproductive care in Angola. Therefore, we conducted this study with the objectives of exploring the current prevalence of unmet need for contraception and unintended pregnancy as well as their relationship among married women in Angola., Methods: This study was based on cross-sectional data from Angola Demographic and Health Survey (DHS) conducted in 2015-16. Participants were 7,808 married women aged 15-49 years. Unwanted pregnancy was measured in terms of the mistimed and unintended conception for the last-born child. Unmet need for contraception included those who reported unmet need for spacing and limiting. Data were analysed using bivariate and multivariable techniques., Results: The combined prevalence of mistimed and unwanted pregnancy was 38.3% (95%CI = 35.9-40.7), and that of unmet need for contraception for spacing and limiting was 51.7% (49.9-53.5). Among the 18 regions, Luanda had the highest prevalence of unmet need for contraception and of unwanted pregnancy with the prevalence being higher than more than one-third of the women. Multivariable analysis significantly revealed a significantly positive association between unmet need and unwanted pregnancy. In all the models, the odds of unwanted pregnancy were found to be as high as four times among women with unmet need compared with those had no unmet need. Compared to women who had no unmet need, those who had unmet need had respectively four (OR = 4.380; 95%CI = 3.690-5.198) and seven (OR = 6.951; 95%CI = 4.642-10.410) times higher odds of experiencing unwanted pregnancy., Conclusion: This study concludes that the prevalence of unmet need for contraception and unwanted pregnancy are high with significant disparities across the regions. Women in the capital city had the highest prevalence of both unmet need for contraception and unwanted pregnancy. Although the data were cross-sectional and do not indicate causal relationships, the findings showed a strong positive association between unmet need for contraception and unwanted pregnancy. However, it is recommended to conduct further studies to replicate the findings and to explore the influence behavioural and cultural practices on unwanted pregnancy., Competing Interests: The authors have declared that no competing interests exist.

Background: Under-5 mortality rate in the sub-Saharan region has remained unabated. Worse still, information on the regional trend and associated determinants are not readily available. Knowledge of the trend and determinants of under-5 mortality are essential for effective design of intervention programmes that will enhance their survival. We aimed to examine the mortality patterns in under-5 children and maternal factors associated with under-5 deaths., Methods: Demographic and Health Survey (DHS) data from five sub-Sahara Africa countries; Chad, Democratic Republic of Congo, Mali, Niger and Zimbabwe were used in this study. The sample size consisted of 68,085 women aged 15-49 years with at least one history of childbirth. The outcome variable was under-five mortality rate. Relevant information on maternal factors were extracted for analysis. Multivariable Cox proportional hazards regression was used to model maternal factors associated with under-five mortality., Results: The current under-5 mortality rate (per 1,000 live births) was; 133 in Republic of Chad, 104 in Democratic Republic of Congo, 95 in Mali, 127 in Niger, and 69 in Zimbabwe. Several maternal and child level factors were found to be significantly associated with under-five mortality. Lack of spousal support (not currently married) resulted to increase in under-five mortality (Chad- Hazard Ratio [HR] = 1.11, 95%CI = 0.97-1.25; DR Congo- HR = 1.24, 95%CI = 1.11-1.40; Mali- HR = 2.43, 95%CI = 1.63-3.64; Niger- HR = 1.59, 95%CI = 1.24-2.03; Zimbabwe- HR = 1.33, 95%CI = 1.06-1.67). Delivery by caesarean section was significantly associated with under-five mortality (Chad- HR = 1.32, 95%CI = 1.00-1.77; DR Congo- HR = 1.20, 95%CI = 1.01-1.43; Mali- HR = 1.42, 95%CI = 1.08-1.85; Niger- HR = 1.43, 95%CI = 1.06-1.92; Zimbabwe- HR = 1.49, 95%CI = 1.03-2.15)., Conclusion: Despite concerted effort by government and several stakeholders in health to improve childhood survival, the rate of under-5 mortality is still high. Our findings provided evidence on the contribution of maternal age, place of residence, household wealth index, level of education, employment, marital status, religious background, birth type, birth order and interval, sex and size of child, place and mode of delivery, to Under-5 mortality rate in SSA. The position of prominent risk factors for under-five mortality should be addressed through effective design of timely and efficient intervention aimed at reducing childhood mortality., Competing Interests: The authors have declared that no competing interests exist.