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Abstract Background Between 2000–2015, many low- and middle-income countries (LMICs) implemented evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M). Even among LMICs successful in reducing U5M, this drop was unequal subnationally, with varying success in EBI implementation. Building on mixed methods multi-case studies of six LMICs (Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal) leading in U5M reduction, we describe geographic and wealth-based equity in facility-based delivery (FBD), a critical EBI to reduce neonatal mortality which requires a trusted and functional health system, and compare the implementation strategies and contextual factors which influenced success or challenges within and across the countries. Methods To obtain equity gaps in FBD coverage and changes in absolute geographic and wealth-based equity between 2000–2015, we calculated the difference between the highest and lowest FBD coverage across subnational regions and in the FBD coverage between the richest and poorest wealth quintiles. We extracted and compared contextual factors and implementation strategies associated with reduced or remaining inequities from the country case studies. Results The absolute geographic and wealth-based equity gaps decreased in three countries, with greatest drops in Rwanda – decreasing from 50 to 5% across subnational regions and from 43 to 13% across wealth quintiles. The largest increases were seen in Bangladesh – from 10 to 32% across geography – and in Ethiopia – from 22 to 58% across wealth quintiles. Facilitators to reducing equity gaps across the six countries included leadership commitment and culture of data use; in some countries, community or maternal and child health insurance was also an important factor (Rwanda and Peru). Barriers across all the countries included geography, while country-specific barriers included low female empowerment subnationally (Bangladesh) and cultural beliefs (Ethiopia). Successful strategies included building on community health worker (CHW) programs, with country-specific adaptation of pre-existing CHW programs (Rwanda, Ethiopia, and Senegal) and cultural adaptation of delivery protocols (Peru). Reducing delivery costs was successful in Senegal, and partially successful in Nepal and Ethiopia. Conclusion Variable success in reducing inequity in FBD coverage among countries successful in reducing U5M underscores the importance of measuring not just coverage but also equity. Learning from FBD interventions shows the need to prioritize equity in access and uptake of EBIs for the poor and in remote areas by adapting the strategies to local context.

Abstract Background The Ethiopian government implemented a national community health program, the Health Extension Program (HEP), to provide community-based health services to address persisting access-related barriers to care using health extension workers (HEWs). We used implementation research to understand how Ethiopia leveraged the HEP to widely implement evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M) and address health inequities. Methods This study was part of a six-country case study series using implementation research to understand how countries implemented EBIs between 2000–2015. Our mixed-methods research was informed by a hybrid implementation science framework using desk review of published and gray literature, analysis of existing data sources, and 11 key informant interviews. We used implementation of pneumococcal conjugate vaccine (PCV-10) and integrated community case management (iCCM) to illustrate Ethiopia’s ability to rapidly integrate interventions into existing systems at a national level through leveraging the HEP and other implementation strategies and contextual factors which influenced implementation outcomes. Results Ethiopia implemented numerous EBIs known to address leading causes of U5M, leveraging the HEP as a platform for delivery to successfully introduce and scale new EBIs nationally. By 2014/15, estimated coverage of three doses of PCV-10 was at 76%, with high acceptability (nearly 100%) of vaccines in the community. Between 2000 and 2015, we found evidence of improved care-seeking; coverage of oral rehydration solution for treatment of diarrhea, a service included in iCCM, doubled over this period. HEWs made health services more accessible to rural and pastoralist communities, which account for over 80% of the population, with previously low access, a contextual factor that had been a barrier to high coverage of interventions. Conclusions Leveraging the HEP as a platform for service delivery allowed Ethiopia to successfully introduce and scale existing and new EBIs nationally, improving feasibility and reach of introduction and scale-up of interventions. Additional efforts are required to reduce the equity gap in coverage of EBIs including PCV-10 and iCCM among pastoralist and rural communities. As other countries continue to work towards reducing U5M, Ethiopia’s experience provides important lessons in effectively delivering key EBIs in the presence of challenging contextual factors.

Background: The COVID-19 pandemic resulted in drops in access to and availability of a number of evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M) across a wide range of countries, including Rwanda. We aimed to understand the strategies and contextual factors associated with preventing or mitigating drops nationally and subnationally, and the extent to which previous efforts to reduce U5M supported the maintenance of healthcare delivery. Methods: We used a convergent mixed methods implementation science approach, guided by hybrid implementation research and resiliency frameworks. We triangulated data from three sources: desk review of available documents, existing routine data from the health management information system, and key informant interviews (KIIs). We analyzed quantitative data through scatter plots using interrupted time series analysis to describe changes in EBI access, uptake, and delivery. We used a Poisson regression model to estimate the impact of COVID-19 on health management information system indicators, adjusting for seasonality. We used thematic analysis of coded interviews to identify emerging patterns and themes. Results: We found moderate 4% (IRR = 0.96; 95%CI: 0.93, 1.00) and 5% (IRR = 0.95; 95%CI: 0.92, 0.99) drops in pentavalent and rotavirus 2 doses vaccines administered, respectively. Nationally, there was a 5% drop in facility-based delivery (IRR = 0.95; 95%CI: 0.92, 0.99). Lockdown and movement restrictions and community and health-worker fear of COVID-19 were barriers to service delivery early in the pandemic. Key implementation strategies to prevent or respond to EBI drops included leveraging community-based healthcare delivery, data use for decision-making, mentorship and supervision, and use of digital platform. Conclusions: While Rwanda had drops in some EBIs early in the pandemic, especially during the initial lockdown, this was rapidly identified, and response implemented. The resiliency of the health system was associated with the Rwandan health system’s ability to learn and adapt, encouraging a flexible response to fit the situation.

Samuel Debas Bayable,1 Netsanet Temesgen Ayenew,1 Abebaw Misganaw,1 Melaku Bantie Fetene,2 Wubet Dessie Amberbir3 1Department of Anesthesia, College of Medicine and Health Science, Debre Markos University, Debre Markos, Ethiopia; 2Department of Anesthesia, College of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia; 3Department of Anesthesia, Menelik II Health Science College, Addis Ababa, EthiopiaCorrespondence: Samuel Debas Bayable, Tel +251 911437507, Email Samuel_debas@dmu.edu.et; samueldebas88@yahoo.comBackground: The incidence and severity of succinylcholine-induced fasciculation and postoperative myalgia have been shown to decrease when vecuronium bromide or preservative-free 2% plain lignocaine hydrochloride is administered before induction. The aim of this study is to examine the effectiveness of defasciculation dosages of vecuronium bromide and 2% preservative-free plain lignocaine hydrochloride in decreasing succinylcholine-induced fasciculation and postoperative myalgia in patients undergoing elective surgery.Methods: A total of 110 participants were included in a prospective observational cohort study that was located in an institution. Patients were randomly assigned to (Group L) and (Group V) based on the prophylactic measures they received from the responsible anesthetist utilizing preservative-free 2% plain lignocaine and defasciculation dose of vecuronium bromide, respectively. We recorded, socio-demographic variables, fasciculation, postoperative myalgia, total number of analgesics administered following surgery in 48hrs, and kind of procedure. The descriptive data were compiled using descriptive statistics. Categorical and continuous data were evaluated, respectively, using chi-square statistics and the independent sample t-test. To compare the prevalence of fasciculation and myalgia across the various groups, the Fischer exact test was performed. A 0.05 p-value was deemed statistically significant.Results: This study found that the incidence of fasciculation in the groups receiving the defasciculation doses of vecuronium bromide and preservative-free 2% plain lignocaine hydrochloride was 14.6% and 20% (p-value 0.007), respectively. The rate of mild-to-moderate postoperative myalgia in the vecuronium bromide group was 23.7%, 30.9%, and 16.4% in the first, 24th, and 48th hours, respectively (p-value 0.001), as opposed to 0%, 37.3%, and 9.1%, respectively (p-value 0.008) in the group receiving preservative-free 2% plain lignocaine hydrochloride.Conclusion: Pretreatment with 2% plain lignocaine that is preservative-free is more efficient than vecuronium bromide at reducing the frequency and intensity of postoperative succinylcholine-induced myalgia, whereas defasciculation dose of vecuronium was more effective prevention of succinylcholine-induced fasciculation.Keywords: fasciculation, muscle pain, postoperative myalgia, succinylcholine, vecuronium

The growing burden of asthma in low- and middle-income countries has been linked to urbanisation and lifestyle changes. However, this burden has not been well characterised in adults. Therefore, we investigated the prevalence of self-reported diagnosed asthma and associated factors in urban and rural adults in Malawi, Southern Africa. Within a cross-sectional population-based survey to determine the burden and risk factors for non-communicable diseases (NCDs) in the city of Lilongwe and rural Karonga district, we collected information on self-reported previously diagnosed asthma and asthma-related symptoms using an interviewer-led questionnaire. Other data collected included: demographic characteristics, socioeconomic status indicators, NCD comorbidities, environmental exposures, and anthropometric measurements. We used multivariable logistic regression models to explore factors associated with self-reported asthma adjusting for variables associated with the outcome in univariable analysis. Findings were corrected for multiple comparisons using the Bonferroni method. We analysed data from 30,483 adult participants (54.6% urban,45.4% rural and 61.9% female). A prior asthma diagnosis was reported in 5.1% of urban and 4.5% of rural participants. In urban females, being obese (>30 kg/m2) compared to normal weight (18.5-24.9 kg/m2) was associated with greater odds of asthma (OR = 1.59, 95% CI [1.26-2.01], p

AbstractResistance spot welding (RSW) is one of the welding technologies that uses the force and heat generated by resistance to the flow of electricity to join metal surfaces. The goal of this research is to investigate the mechanical behavior of RSW,the welding parameters of sheet metal-covered aluminum spot-welded junctions, and finally to verify the micro-hardness of the weld structure. RSW process is a complicated operation that combines electrical, thermal, and mechanical processes. Moreover, serious complications are observed when the weld material is aluminum, because it is a very soft metal and difficult to weld as compared to other metals, Hence, we used mild steel as a cover on both sides and easily did the RSW. Aluminum (Al) thickness, cover sheet metal thickness, and overall welding time achieved relative impacts of 3.890%, 3.250%, and 84.390%, respectively. The percentage impacts of aluminum (Al) thickness, weld cover sheet metal thickness, and welding time in the deformation scenario are 1.171%, 8.731%, and 80.881%, respectively. The percentage impacts of aluminum thickness, cover sheet metal thickness, and welding time duration on temperature are 9.960%, 87.820%, and 1.660%, respectively. The thickness of the cover mild steel sheet is the second-most important factor, next to welding time. Validation results of the two critical weld constraints (welding temperature and welding time) agrees with the experimental results. In addition, the welding temperature response has a percent error of 10.620% due to materials characteristics and the impact of additional welding process constraints.

Background: Mathematical modeling of infectious diseases is an important decision-making tool for outbreak control. However, in Africa, limited expertise reduces the use and impact of these tools on policy. Therefore, there is a need to build capacity in Africa for the use of mathematical modeling to inform policy. Here we describe our experience implementing a mathematical modeling training program for public health professionals in East Africa. Methods: We used a deliverable-driven and learning-by-doing model to introduce trainees to the mathematical modeling of infectious diseases. The training comprised two two-week in-person sessions and a practicum where trainees received intensive mentorship. Trainees evaluated the content and structure of the course at the end of each week, and this feedback informed the strategy for subsequent weeks. Findings: Out of 875 applications from 38 countries, we selected ten trainees from three countries – Rwanda (6), Kenya (2), and Uganda (2) – with guidance from an advisory committee. Nine trainees were based at government institutions and one at an academic organization. Participants gained skills in developing models to answer questions of interest and critically appraising modeling studies. At the end of the training, trainees prepared policy briefs summarizing their modeling study findings. These were presented at a dissemination event to policymakers, researchers, and program managers. All trainees indicated they would recommend the course to colleagues and rated the quality of the training with a median score of 9/10. Conclusions: Mathematical modeling training programs for public health professionals in Africa can be an effective tool for research capacity building and policy support to mitigate infectious disease burden and forecast resources. Overall, the course was successful, owing to a combination of factors, including institutional support, trainees’ commitment, intensive mentorship, a diverse trainee pool, and regular evaluations.

Abstract The recent 78th United Natiions General Assembly (UNGA) declaration relaunched a new health priority and political commitment in accelerating Universal Health Coverage (UHC), adopted by the United Nations (UN) in 2015 and are intended to be met by 2030. At mid-way point of UHC implementation, we advocate for the much needed programmatic implementation research, evidence-based interventions (EBIs) policies and strategies leadership and management capacity building to enable robust, resilient and sustainable multi-sectoral partnerships, integrated coordination and governance mechanisms capabilities in accelerating UHC package mainly infectious diseases of poverty elimination and eradication agenda. Graphical Abstract

Abstract Childhood stunting in its moderate and severe forms is a major global problem and an important indicator of child health. Rwanda has made progress in reducing the prevalence of stunting. However, the burden of stunting and its geographical disparities have precipitated the need to investigate its spatial clusters and attributable factors. Here, we assessed the determinants of under‐5 stunting and mapped its prevalence to identify areas where interventions can be directed. Using three combined rounds of the nationally representative Rwanda Demographic and Health Surveys of 2010, 2015 and 2020, we employed the Blinder‐Oaxaca decomposition analysis and the hotspot and cluster analyses to quantify the contributions of key determinants of stunting. Overall, there was a 7.9% and 10.3% points reduction in moderate stunting among urban and rural areas, respectively, and a 2.8% and 8.3% points reduction in severe stunting in urban and rural areas, respectively. Child age, wealth index, maternal education and the number of antenatal care visits were key determinants for the reduction of moderate and severe stunting. Over time, persistent statistically significant hotspots for moderate and severe stunting were observed in Northern and Western parts of the country. There is a need for an adaptive scaling approach when implementing national nutritional interventions by targeting high‐burden regions. Stunting hotspots in Western and Northern provinces underscore the need for coordinated subnational initiatives and strategies such as empowering the rural poor, enhancing antenatal health care, and improving maternal health and education levels to sustain the gains made in reducing childhood stunting.

This research explored the impact of air gap on torque and eddy current behavior of a magnet-north-pole rotating axial disk-type magnetic coupler using the magnetic equivalent circuit method. A magnetic equivalent circuit (MEC) model was developed to analyze the torque and induced eddy current behavior for the magnetic N-pole rotation angle 0° to 30° axial disk type magnetic coupler (MC). Torque equations were derived by combining Kirchhoff's law and the integral method, whereas induced eddy current equations were derived using Ampere's law. Flux leakage reluctance equations were obtained using an integral method. Furthermore, the study conducted 2D finite element simulations, and the results were validated against experimental data to ensure the accuracy and reliability of the proposed MEC model. Finally, the research findings suggested that an air gap length of 4 mm was an optimum length to obtain maximum torque and minimum magnetic saturation effects for a proposed MEC model of N-pole rotating axial disk type MC. [ABSTRACT FROM AUTHOR]

Objective To determine how often men in Malawi attend health facilities and if testing for human immunodeficiency virus (HIV) is offered during facility visits. Methods We conducted a cross-sectional, community-representative survey of men (15-64 years) from 36 villages in Malawi. We excluded men who ever tested HIV-positive. Primary outcomes were: health facility visits in the past 12 months (for their own health (client visit) or to support the health services of others (guardian visit)); being offered HIV testing during facility visits; and being tested that same day. We disaggregated all results by HIV testing history: tested [less than or equal to] 12 months ago, or in need of testing (never tested or tested > 12 months before) Findings We included 1116 men in the analysis. Mean age was 34 years (standard deviation: 13.2) and 55% (617/1116) of men needed HIV testing. Regarding facility visits, 82% (920/1116) of all men and 70% (429/617) of men in need of testing made at least one facility vise in the past 12 months. Men made a total of 1973 visits (mean two visits): 39% (765/1973) were as guardians and 84% (1657/1973) were to outpatient departments. Among men needing HIV testing, only 7% (30/429) were offered testing during any visit. The most common reason for not testing was not being offered services (37%; 179/487). Conclusion Men in Malawi attend health facilities regularly, but few of those in need of HIV testing are offered testing services. Health screening services should capitalize on men's routine visits to outpatient departments as clients and guardians. Objectif Determiner la frequence a laquelle les hommes se rendent dans des etablissements de soins au Malawi, et savoir si un depistage du virus de l'immunodeficience humaine (VIH) est propose lors de ces visites. Methodes Nous avons mene une enquete transversale representative de la communaute aupres d'hommes (15-64 ans) residant dans 36 villages malawites. Nous n'y avons pas inclus les hommes testes positifs au VIH. Les criteres primaires etaient les suivants: visites dans des etablissements de soins au cours des 12 derniers mois pour leur propre sante (visite en qualite de patient) ou pour la sante d'autrui (visite en qualite de tuteur); proposition de depistage du VIH lors de ces visites; et enfin, test effectue le jour meme. Nous avons ensuite ventile l'ensemble des resultats en fonction des antecedents de depistage du VIH: test realise [less than or equal to] 12 mois auparavant, ou test necessaire (car jamais realise ou realise > 12 mois auparavant). Resultats Notre analyse s'est interessee a 1116 hommes Ages de 34 ans en moyenne (ecart type: 13,2), dont 55% (617/1116) avaient besoin d'un depistage du VIH. Concernant les visites dans des etablissements de soins, 82% (920/1116) des hommes dans leur globalite et 70% (429/617) des hommes ayant besoin d'un depistage ont effectue au moins une visite au cours des 12 derniers mois. Le groupe etudie s'est rendu 1973 fois dans de tels etablissements (ce qui equivaut a deux visites en moyenne): 39% (765/1973) sont venus en qualite de tuteur, et 84% (1657/1973) se sont adresses a des services de consultation externes. Parmi ceux qui avaient besoin d'un depistage du VIH, seulement 7% (30/429) se sont vu proposer un test lors de l'une de leurs visites. Cette absence de test est principalement due a l'indisponibilite du service (37%; 179/487). Conclusion Au Malawi, les hommes se rendent regulierement dans des etablissements de soins, mais rares sont ceux qui se voient proposer un test VIH malgre le besoin. Les services de depistage devraient miser sur ces visites de routine dans des cliniques externes, que les hommes soient tuteurs ou patients. Objetivo Determinar la frecuencia con la que los hombres de Malawi acuden a los centros de salud y si se ofrecen pruebas del virus de la inmunodeficiencia humana (VIH) durante las visitas a dichos centros. Metodos Se realizo una encuesta transversal, representativa de la comunidad, de hombres (de 15 a 64 anos) de 36 pueblos de Malawi. Se excluyeron los hombres que alguna vez dieron positivo en la prueba del VIH. Los resultados primarios fueron: visitas a centros de salud en los ultimos 12 meses (para su propia salud [visita del paciente] o para apoyar los servicios de salud de otros [visita de cuidador]); que se les ofreciera la prueba del VIH durante las visitas a los centros; y que se les hiciera la prueba ese mismo dia. Desglosamos todos los resultados segun el historial de pruebas del VIH: se hicieron la prueba hace 12 meses antes). Resultados Se incluyeron 1116 hombres en el analisis. La edad media fue de 34 anos (desviacion estandar: 13,2) y el 55 % (617/1116) de los hombres necesitaban la prueba del VIH. En cuanto a las visitas a los centros, el 82 % (920/1116) de todos los hombres y el 70 % (429/617) de los hombres que necesitaban la prueba realizaron al menos una visita a un centro en los ultimos 12 meses. Hubo un total de 1973 visitas (con una media de dos visitas): el 39 % (765/1973) fueron como cuidadores y el 84 % (1657/1973) fueron a departamentos ambulatorios. Entre los hombres que necesitaban someterse a la prueba del VIH, solo al 7% (30/429) se les ofrecio la prueba durante cualquier visita. La razon mas comun para no hacerse la prueba fue que no se les ofrecieron servicios (un 37 %; 179/487). Conclusion Los hombres de Malawi acuden a los centros de salud con regularidad, pero a pocos de los que necesitan someterse a la prueba del VIH se les ofrecen los servicios. Los servicios de deteccion sanitaria deberian aprovechar las visitas rutinarias de los hombres a los departamentos ambulatorios como pacientes y cuidadores., Introduction Men throughout sub-Saharan Africa have a lower life expectancy than women. (1) One contributing factor is men's underrepresentation in early disease detection, for example, timely diagnosis of life-threatening conditions [...]

Abstract Background The prevalence of Human Immunodeficiency Virus (HIV) among prisoners remains high in many countries, especially in Africa, despite a global decrease in HIV incidence. Programs to reach incarcerated populations with HIV services have been implemented in Malawi, but the success of these initiatives is uncertain. We explored which challenges prisoners face in receiving essential HIV services and whether HIV risk behavior is prevalent in prisons. Methods We conducted a mixed-methods (qualitative and quantitative), cross-sectional study in 2018 in six prisons in Southern Malawi, two large central prisons with on-site, non-governmental organization (NGO) supported clinics and 4 smaller rural prisons. Four hundred twelve prisoners were randomly selected and completed a structured questionnaire. We conducted in-depth interviews with 39 prisoners living with HIV, which we recorded, transcribed and translated. We used descriptive statistics and logistic regression to analyze quantitative data and content analysis for qualitative data. Results The majority of prisoners (93.2%) were male, 61.4% were married and 63.1% were incarcerated for 1–5 years. Comprehensive services were reported to be available in the two large, urban prisons. Female prisoners reported having less access to general medical services than males. HIV risk behavior was reported infrequently and was associated with incarceration in urban prisons (adjusted odds ratio [aOR] 18.43; 95% confidence interval [95%-CI] 7.59–44.74; p =

BackgroundThe Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context.MethodsWe used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors-the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI).FindingsBetween 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6-58·8) of global deaths and 41·2% (39·8-42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa.InterpretationDeclines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden.FundingBill & Melinda Gates Foundation.

Abstract Background The prevalence of excess adiposity, as measured by elevated body mass index (BMI) and waist-hip ratio (WHR), is increasing in sub-Saharan African (SSA) populations. This could add a considerable burden of cardiovascular and metabolic diseases for which these populations are currently ill-prepared. Evidence from white, European origin populations shows that higher adiposity leads to an adverse lipid profile; whether these associations are similar in all SSA populations requires further exploration. This study compared the association of BMI and WHR with lipid profile in urban Malawi with a contemporary cohort with contrasting socioeconomic, demographic, and ethnic characteristics in the United Kingdom (UK). Methods We used data from 1248 adolescents (mean 18.7 years) and 2277 Malawian adults (mean 49.8 years), all urban-dwelling, and from 3201 adolescents (mean 17.8 years) and 6323 adults (mean 49.7 years) resident in the UK. Adiposity measures and fasting lipids were assessed in both settings, and the associations of BMI and WHR with total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) were assessed by sex and age groups in both studies. Results Malawian female adults were more adipose and had more adverse lipid profiles than their UK counterparts. In contrast, Malawian adolescent and adult males were leaner and had more favourable lipid profiles than in the UK. Higher BMI and WHR were associated with increased TC, LDL-C and TG and reduced HDL-C in both settings. The magnitude of the associations of BMI and WHR with lipids was mostly similar or slightly weaker in the Malawian compared with the UK cohort in both adolescents and adults. One exception was the stronger association between increasing adiposity and elevated TC and LDL-C in Malawian compared to UK men. Conclusions Malawian adult women have greater adiposity and more adverse lipid profiles compared with their UK counterparts. Similar associations of adiposity with adverse lipid profiles were observed for Malawian and UK adults in most age and sex groups studied. Sustained efforts are urgently needed to address the excess adiposity and adverse lipid profiles in Malawi to mitigate a future epidemic of cardio-metabolic disease among the poorest populations.

Abstract Background Mental health (MH) disorders in low and middle-income countries (LMICs) account for a large proportion of disease burden. While efficacious treatments exist, only 10% of those in need are able to access care. This treatment gap is fueled by structural determinants including inadequate resource allocation and prioritization, both rooted in a lack of research and policy capacity. The goal of the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building (SHARP), based in Malawi and Tanzania, is to address those research and policy-based determinants. Methods SHARP aims to (1) build implementation science skills and expertise among Malawian and Tanzanian researchers in the area of mental health; (2) ensure that Malawian and Tanzanian policymakers and providers have the knowledge and skills to effectively apply research findings on evidence-based mental health programs to routine practice; and (3) strengthen dialogue between researchers, policymakers, and providers leading to efficient and sustainable scale-up of mental health services in Malawi and Tanzania. SHARP comprises five capacity building components: introductory and advanced short courses, a multifaceted dialogue, on-the-job training, pilot grants, and “mentor the mentors” courses. Discussion Program evaluation includes measuring dose delivered and received, participant knowledge and satisfaction, as well as academic output (e.g., conference posters or presentations, manuscript submissions, grant applications). The SHARP Capacity Building Program aims to make a meaningful contribution in pursuit of a model of capacity building that could be replicated in other LMICs. If impactful, the SHARP Capacity Building Program could increase the knowledge, skills, and mentorship capabilities of researchers, policymakers, and providers regarding effective scale up of evidence-based MH treatment.

Introduction: Since June 2016, the national HIV programme in Malawi has adopted Universal Test and Treat (UTT) guidelines requiring that all persons who test HIV positive will be referred to start antiretroviral therapy (ART). Although there is strong evidence from clinical trials that early initiation of ART leads to reduced morbidity and mortality, the impact of UTT on retention on ART in real-life programmatic settings in Africa is not yet known. Methods: We conducted a retrospective cohort study in Zomba district, Malawi to compare ART outcomes of patients who initiated ART under 2016 UTT guidelines and those who started ART prior to rollout of UTT (pre-UTT). We analysed data from 32 rural and urban health facilities of various sizes. Cox proportional hazards modelling was used to determine the independent risk factors of attrition from ART at 12 months. All analyses were adjusted for clustering by health facility using a robust standard errors approach. Results: Among 1492 patients (mean age 34.4 years, 933 (63%) female) who initiated ART during the study period, 501 were enrolled in the pre-UTT cohort and 911 during UTT. At 12 months, retention on ART in the UTT cohort was higher than in the pre-UTT cohort 83.0% (95% confidence interval (CI): 81.0% to 85.0%) versus 76.2% (95% CI 73.9% to 78.5%). Adolescents, aged 10 to 19 years (adjusted hazard ratio (aHR) 1.53; 95% CI 1.01 to 2.32), and women who were pregnant or breastfeeding at ART initiation (aHR 1.87; 95% CI 1.30 to 2.38) were at higher risk of attrition in the combined pre-UTT and UTT cohort. Conclusions: Retention on ART was nearly 6% higher after UTT introduction. Young adults and women who were pregnant or breastfeeding at the start of ART were at increased risk of attrition, emphasizing the need for targeted interventions for these groups to achieve the 90-90-90 UNAIDS targets in the UTT era. Keywords: Africa; Malawi; antiretroviral therapy; HIV; retention in care; Universal Test and Treat, 1 | INTRODUCTION Malawi's adult HIV prevalence of 10.6% is one of the highest in the world [1]. The HIV burden varies widely across the country and is greatest in [...]

Abstract Background Drug therapy problem is any undesirable event experienced by a patient during drug therapy that interferes with achieving the desired goals of therapy. Drug therapy problems are common causes of patient morbidity and mortality. There was no study that has been done on drug therapy problems in the study area, Dessie referral hospital, northeast Ethiopia. Method A prospective observational study was conducted among hospitalized patients in the medical ward of Dessie referral hospital from March 01 to May 31, 2014. Ethical approval was obtained and informed consent was signed by each study participant before the commencement of the study. All patients admitted to the ward during the study period were included in the study. Data regarding each patient’s demographics, medical condition, drug therapy and patient compliance to the drug therapy were collected using pretested checklists, and drug therapy problems were determined based on the standard practice and textbooks. Descriptive statistical analysis was done using SPSS Version 20 Software. Result A total of 147 patients were included, 75.51% of whom experienced at least one drug therapy problem. During the 3 month period a total of 159 drug therapy problems were identified of which needs additional drug therapy (35.85%) was the most common followed by unnecessary drug therapy (30.19%) and dosage too low (13.2%). Antibiotics, 75 (40.32%) was the most frequent drug class involved in drug therapy problems followed by cardiovascular drugs, 69 (37.1%) and nonsteroidal anti-inflammatory drugs, 9 (4.84%). Ceftriaxone (25.81%) was the most frequent specific drug prone to the drug therapy problems followed by spiranolactone (14.52%), enalapril (6.45%) and furosemide (6.45%). Conclusions Three out of four patients experienced at least one drug therapy problem during their hospital stay in the medical ward, with the most commonly observed DTP being no drug therapy prescribed for a condition requiring drug treatment.

Abstract Background In Ethiopia there is no complete registration system to measure disease burden and risk factors accurately. In this study, the 2015 global burden of diseases, injuries and risk factors (GBD) data were used to analyse the incidence, prevalence and mortality rates of malaria in Ethiopia over the last 25 years. Methods GBD 2015 used verbal autopsy surveys, reports, and published scientific articles to estimate the burden of malaria in Ethiopia. Age and gender-specific causes of death for malaria were estimated using cause of death ensemble modelling. Results The number of new cases of malaria declined from 2.8 million [95% uncertainty interval (UI) 1.4–4.5 million] in 1990 to 621,345 (95% UI 462,230–797,442) in 2015. Malaria caused an estimated 30,323 deaths (95% UI 11,533.3–61,215.3) in 1990 and 1561 deaths (95% UI 752.8–2660.5) in 2015, a 94.8% reduction over the 25 years. Age-standardized mortality rate of malaria has declined by 96.5% between 1990 and 2015 with an annual rate of change of 13.4%. Age-standardized malaria incidence rate among all ages and gender declined by 88.7% between 1990 and 2015. The number of disability-adjusted life years lost (DALY) due to malaria decreased from 2.2 million (95% UI 0.76–4.7 million) in 1990 to 0.18 million (95% UI 0.12–0.26 million) in 2015, with a total reduction 91.7%. Similarly, age-standardized DALY rate declined by 94.8% during the same period. Conclusions Ethiopia has achieved a 50% reduction target of malaria of the millennium development goals. The country should strengthen its malaria control and treatment strategies to achieve the sustainable development goals.

Abstract Background Currently available diagnostic techniques of Plasmodium falciparum infection are not optimal for non-invasive, population-based screening for malaria. It was hypothesized that a mass spectrometry-based metabolomics approach could identify urinary biomarkers of falciparum malaria. Methods The study used a case–control design, with cases consisting of 21 adults in central Ethiopia with a diagnosis of P. falciparum infection confirmed with microscopy, and 25 controls of adults with negative blood smears for malaria matched on age and sex. Urinary samples were collected from these individuals during presentation at the clinic, and a second sample was collected from both cases and controls 4 weeks later, after the cases had received anti-malarial medication. The urine samples were screened for small molecule urinary biomarkers, using mass spectrometry-based metabolomics analyses followed by multivariate analysis using principal component analysis and orthogonal partial least square-discriminant analysis. The chemical identity of statistically significant malaria biomarkers was confirmed using tandem mass spectrometry. Results The urinary metabolic profiles of cases with P. falciparum infection were distinct from healthy controls. After treatment with anti-malarial medication, the metabolomic profile of cases resembled that of healthy controls. Significantly altered levels of 29 urinary metabolites were found. Elevated levels of urinary pipecolic acid, taurine, N-acetylspermidine, N-acetylputrescine and 1,3-diacetylpropane were identified as potential biomarkers of falciparum malaria. Conclusion The urinary biomarkers of malaria identified have potential for the development of non-invasive and rapid diagnostic test of P. falciparum infection.

Abstract Background The global burden of anemia is large especially in sub-Saharan Africa, where HIV is common and lifestyles are changing rapidly with urbanization. The effects of these changes are unknown. Studies of anemia usually focus on pregnant women or children, among whom the burden is greatest. We describe prevalence and risk factors for anemia among rural and urban men and women of all ages in Malawi. Methods We analyzed data from a population-wide cross-sectional survey of adults conducted in two sites, Karonga (rural) and Lilongwe (urban), commencing in May 2013. We used multinomial logistic regression models, stratified by sex to identify risk factors for mild and moderate-to-severe anemia. Results Anemia prevalence was assessed among 8,926 men (age range 18–100 years) and 14,978 women (age range: 18–103 years). Weighted prevalence levels for all, mild, and moderate-to-severe anemia were 8.2, 6.7 and 1.2% in rural men; 19.4, 12.0 and 7.4% in rural women; 5.9, 5.1 and 0.8% in urban men; and 23.4, 13.6 and 10.1% in urban women. Among women, the odds of anemia were higher among urban residents and those with higher socioeconomic status. Increasing age was associated with higher anemia prevalence in men. Among both men and women, HIV infection was a consistent risk factor for severity of anemia, though its relative effect was stronger on moderate-to-severe anemia. Conclusions The drivers of anemia in this population are complex, include both socioeconomic and biological factors and are affecting men and women differently. The associations with urban lifestyle and HIV indicate opportunities for targeted intervention.

Abstract Background Hypertension and diabetes prevalence is high in Africans. Data from HIV infected populations are limited, especially from Malawi. Integrating care for chronic non-communicable co-morbidities in well-established HIV services may provide benefit for patients by preventing multiple hospital visits but will increase the burden of care for busy HIV clinics. Methods Cross-sectional study of adults (≥18 years) at an urban and a rural HIV clinic in Zomba district, Malawi, during 2014. Hypertension and diabetes were diagnosed according to stringent criteria. Proteinuria, non-fasting lipids and cardio/cerebro-vascular disease (CVD) risk scores (Framingham and World Health Organization/International Society for Hypertension) were determined. The association of patient characteristics with diagnoses of hypertension and diabetes was studied using multivariable analyses. We explored the additional burden of care for integrated drug treatment of hypertension and diabetes in HIV clinics. We defined that burden as patients with diabetes and/or stage II and III hypertension, but not with stage I hypertension unless they had proteinuria, previous stroke or high Framingham CVD risk. Results Nine hundred fifty-two patients were enrolled, 71.7% female, median age 43.0 years, 95.9% on antiretroviral therapy (ART), median duration 47.7 months. Rural and urban patients’ characteristics differed substantially. Hypertension prevalence was 23.7% (95%-confidence interval 21.1–26.6; rural 21.0% vs. urban 26.5%; p = 0.047), of whom 59.9% had stage I (mild) hypertension. Diabetes prevalence was 4.1% (95%-confidence interval 3.0–5.6) without significant difference between rural and urban settings. Prevalence of proteinuria, elevated total/high-density lipoprotein-cholesterol ratio and high CVD risk score was low. Hypertension diagnosis was associated with increasing age, higher body mass index, presence of proteinuria, being on regimen zidovudine/lamivudine/nevirapine and inversely with World Health Organization clinical stage at ART initiation. Diabetes diagnosis was associated with higher age and being on non-standard first-line or second-line ART regimens. Conclusion Among patients in HIV care 26.6% had hypertension and/or diabetes. Close to two-thirds of hypertension diagnoses was stage I and of those few had an indication for antihypertensive pharmacotherapy. According to our criteria, 13.0% of HIV patients in care required drug treatment for hypertension and/or diabetes.