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Chronic conditions are an increasing problem in Low- and Middle-Income Countries (LMICs) yet, the challenges faced by low-income populations with these conditions in such countries are not well understood. Based on in-depth interviews with people affected by chronic conditions and their family members, this paper describes the experience of patients suffering from diabetes or hypertension in rural communities of Mozambique, Nepal, and Peru. We analysed our data using the concepts of disruption and adaptive strategies, finding that despite being very different countries, the implications in daily lives, interpersonal relationships, and family dynamics are similar, and that oftentimes such impact is defined along gender lines. We show that adjustments to living with a chronic disease are not always easy, particularly when they imply changes and reconfiguration of roles and responsibilities for which neither the individual nor their families are prepared. The study adds to the literature on the disruptive effects of chronic conditions and stresses the importance of contextualising disruptive experiences among disadvantaged populations within weak health systems. Our findings highlight the relevance of understanding the challenges of developing adaptive solutions to chronic care in resource-scarce contexts.

IntroductionFront-line health workers in remote health facilities are the first contact of the formal health sector and are confronted with life-saving decisions. Health information systems (HIS) support the collection and use of health related data. However, HIS focus on reporting and are unfit to support decisions. Since data tools are paper-based in most primary healthcare settings, we have produced an innovative Paper-based Health Information System in Comprehensive Care (PHISICC) using a human-centred design approach. We are carrying out a cluster randomised controlled trial in three African countries to assess the effects of PHISICC compared with the current systems.Methods and analysisStudy areas are in rural zones of Côte d’Ivoire, Mozambique and Nigeria. Seventy health facilities in each country have been randomly allocated to using PHISICC tools or to continuing to use the regular HIS tools. We have randomly selected households in the catchment areas of each health facility to collect outcomes’ data (household surveys have been carried out in two of the three countries and the end-line data collection is planned for mid-2021). Primary outcomes include data quality and use, coverage of health services and health workers satisfaction; secondary outcomes are additional data quality and use parameters, childhood mortality and additional health workers and clients experience with the system. Just prior to the implementation of the trial, we had to relocate the study site in Mozambique due to unforeseen logistical issues. The effects of the intervention will be estimated using regression models and accounting for clustering using random effects.Ethics and disseminationEthics committees in Côte d’Ivoire, Mozambique and Nigeria approved the trials. We plan to disseminate our findings, data and research materials among researchers and policy-makers. We aim at having our findings included in systematic reviews on health systems interventions and future guidance development on HIS.Trial registration numberPACTR201904664660639; Pre-results.

BackgroundFrontline health workers in remote, rural health facilities are the first contact of the formal health sector and are confronted with the need to make life-saving clinical and public health decisions. Appropriate health information systems (HIS) provide data to support the collection and use of data, thus facilitating decision-making. However, HIS focus on reporting and are unfit to support critical decisions at the peripheral level. Since data tools are paper-based in most primary health care settings, we have produced an innovative paper-based HIS (PHISICC), embracing all health care areas in primary health care, using a Human Centred Design, co-creation approach. The PHISICC tools aid decision-making, include recording and reporting and substitute the regular HIS tools. We are carrying out a cluster-randomised controlled trial in three African countries to assess the effects of PHISICC compared with the current systems, on data use and quality, quality of health care and health worker perceptions, in remote, rural settings.MethodsWe have selected study areas in rural zones of Côte d’Ivoire, Mozambique and Nigeria. Seventy health facilities in each country have been randomly allocated to using PHISICC tools or to continuing to use the regular HIS tools (35 per arm). We have selected three villages in the catchment area of each health facility to carry out surveys in 10 households each. Outcomes of interest include data quality and use, coverage of health services, health workers perceptions and other process and explanatory variables. DiscussionWe strive to contribute to producing robust evidence on health systems interventions, affecting people in remote, rural settings where the most vulnerable live. The PHISICC tools focus on decision-making rather than data and are meant to support health workers decisions as well as reporting to the higher levels of the system. Robust evidence on HIS can better find its way to high quality systematic reviews and guidance development to inform policy and practice.Trial registration: Pan African Clinical Trials Registry - PACTR201904664660639. Registered 01/04/2019, https://pactr.samrc.ac.za/Search.aspx.

Background Noncommunicable diseases (NCD) are the leading cause of morbidity and mortality worldwide with a disproportionate burden affecting low- and middle-income countries (LMIC). Mozambique, is a low income country situated in Southern Africa with an emerging burden of NCDs, but still facing a large challenge with regards to communicable diseases. Using the policy prioritisation framework developed by Shiffman and Smith this study aims to present the different elements that have shaped the current policy landscape for NCDs in Mozambique.Results The policy review identified 18 documents, and seven KIs were interviewed. The policy community could be seen as cohesive in that a few leading experts in Mozambique agreed on both the challenges of NCDs and the possible response, but overall leadership was lacking. Although the Ministry of Health and its NCD Department were seen as the guiding institutions the Department was not resourced to be able to fulfil its mandate. Some external resources were available to assist, but these were insufficient. In addition civil society mobilisation was missing. With regards to ideas three disconnects were present: language used in overarching government documents and their translation into practice; the views of experts; and the perceptions of NCDs in a context like Mozambique in contrast to other health issues. The NCD Department and different strategies and government documents laid out the governing structure, but again a lack of resources hampered progress. This was compounded by a lack of understanding of the problem and solutions, as well as barriers to integrate the NCD response with HIV/AIDS for example. Conclusions This study shows that despite gaining prominence on the global health agenda, NCDs have yet to truly gain a strong foothold on the policy agenda of LMICs such as Mozambique. In order to do this both governments and donors need to be sensitised to this issue as well as clear guidance developed to enable countries to have practical solutions to address both prevention and treatment of NCDs in underfunded and weak health systems, but also be able to build on existing initiatives to improve the health and well-being of populations.

OBJECTIVE: To assess the current prevalence, awareness, treatment and control of arterial hypertension in Mozambican population, including adolescents and young adults, and to appraise their trends over the past decade, for the 25-64 years old population. METHODS: A cross-sectional study of a representative sample of the population aged 15-64 years (n=2965) was conducted in 2014-2015, following the Stepwise Approach to Chronic Disease Risk Factor Surveillance. Data from a survey conducted in 2005 using the same methodological approach was used to assess trends in the age group of 25-64 years. RESULTS: The prevalence of hypertension increased significantly, from 33.1 to 38.9% (P=0.048), whereas awareness (2005 vs. 2014-2015: 14.8 vs. 14.5%, P=0.914) and treatment among the aware (2005 vs. 2014-2015: 51.9 vs. 50.1%, P=0.770) remained similar. Control among the treated increased (from 39.9 to 44.5%, P=0.587), although not significantly. Mean blood pressure values increased (SBP: from 132.1 to 134.6mmHg, P=0.089; DBP: from 78.2 to 82.5mmHg, P

Introduction Maternal mortality in Mozambique has not declined significantly in the last 10–15 years, plateauing around 480 maternal deaths per 100,000 live births. Good quality antenatal care and routine and emergency intrapartum care are critical to reducing preventable maternal and newborn deaths. Materials and methods We compare the findings from two national cross-sectional facility-based assessments conducted in 2007 and 2012. Both were designed to measure the availability, use and quality of emergency obstetric and neonatal care. Indicators for monitoring emergency obstetric care were used as were descriptive statistics. Results The availability of facilities providing the full range of obstetric life-saving procedures (signal functions) decreased. However, an expansion in the provision of individual signal functions was highly visible in health centers and health posts, but in hospitals, performance was less satisfactory, with proportionally fewer hospitals providing assisted vaginal delivery, obstetric surgery and blood transfusions. All other key indicators showed signs of improvements: the institutional delivery rate, the cesarean delivery rate, met need for emergency obstetric care (EmOC), institutional stillbirth and early neonatal death rates, and cause-specific case fatality rates (CFRs). CFRs for most major obstetric complications declined between 17% and 69%. The contribution of direct causes to maternal deaths decreased while the proportion of indirect causes doubled during the five-year interval. Conclusions The indicator of EmOC service availability, often used for planning and developing EmONC networks, requires close examination. The standard definition can mask programmatic weaknesses and thus, fails to inform decision makers of what to target. In this case, the decline in the use of assisted vaginal delivery explained much of the difference in this indicator between the two surveys, as did faltering hospital performance. Despite this backsliding, many signs of improvement were also observed in this 5-year period, but indicator levels continue below recommended thresholds. The quality of intrapartum care and the adverse consequences from infectious diseases during pregnancy point to priority areas for programmatic improvement.

Background The Caesarean section (C-section) rate is used as an indicator for availability and utilization of life-saving obstetric services. The purpose of the present study was to explore changes in C-section rates between 1995 and 2011 by area, place of delivery and maternal socioeconomic factors in Mozambique. Methods Cross-sectional data from the Demographic and Health Surveys conducted in Mozambique in 1997, 2003 and 2011 were used, including women having a live birth within 3 years prior to the survey. Descriptive statistics and logistic regressions were used to identify factors associated with having a C-section. Results The C-section rate decreased slightly from 2.5 % in 1995–1997 to 2.1 % in 2001–2003 and then increased to 4.7 % in 2009–2011. In 2009–2011, C-section rates ranged in urban areas from 4.6 % in the northern region to 12.2 % in the southern region and in rural areas from 1.6 % in the northern region to 3.9 % in the southern region. 12.3 % of the richest women had had a C-section, compared to 1.7 % of the poorest women. C-sections were the most common at public hospitals (12.6 % in 2009–2011), but C-sections at health centers increased from the second to the third period. The likelihood of having a C-section was associated with living in urban areas and in the southern region, having a formal education and living in a rich household, even adjusting for age and parity (and study periods). The strongest relationship was for the richest household wealth quintile [OR (95 % CI): 9.8 (6.3–15.3)]. The highest rate (20.6 %) was found among the richest women giving birth at public hospitals in the southern region in 2009–2011. Conclusion In Mozambique, underuse of C-section was likely among the poor and in rural areas, but overuse in the most advantaged groups seemed to be emerging. Electronic supplementary material The online version of this article (doi:10.1186/s12884-015-0686-x) contains supplementary material, which is available to authorized users.

Objectives: The effect of ambient temperature as a stroke trigger is likely to differ by type of stroke and to depend on non-transient exposures that influence the risk of this outcome. We aimed to quantify the association between ambient temperature variation and stroke, according to clinical characteristics of the events, and other risk factors for stroke. Methods: We conducted a case-crossover study based on a 1-year registry of the hospital admissions due to newly occurring ischemic and hemorrhagic stroke events in Maputo, Mozambique's capital city (N = 593). The case-period was defined as the 7 days before the stroke event, which was compared to two control periods (14–21 days and 21–28 days before the event). We computed humidity- and precipitation-adjusted odds ratios (OR) and 95% confidence intervals (95%CI) using conditional logistic regression. Results: An association between minimum temperature declines higher than 2.4 °C in any two consecutive days in the previous week and the occurrence of stroke was observed only for first events (OR = 1.43, 95%CI: 1.15–1.76). Stronger and statistically significant associations were observed for hemorrhagic stroke (OR = 1.50, 95%CI: 1.07–2.09) and among subjects not exposed to risk factors, including smoking, high serum cholesterol or atrial fibrillation. No differences in the effect of temperature were found according to the patients’ vital status 28 days after the event. Conclusions: First stroke events, especially of the hemorrhagic type, were triggered by declines in the minimum temperature between consecutive days of the preceding week.

INTRODUCTION The aim of this study was to compare the 24-h ambulatory blood pressure (ABP) profile in never-treated black hypertensive patients living in Africa, Mozambique (20-80 years), versus never-treated white hypertensive patients living in Europe. PATIENTS AND METHODS ABP recordings of untreated black hypertensive patients and white hypertensive patients with 24-h ABP of 130/80 mmHg or more were retrospectively selected from two computerized database records of ABP and matched for age by decades, sex, and BMI. RESULTS Black hypertensive patients were n=548, 47 ± 12 years, 52% women, BMI=28.0 ± 8.2 kg/m(2), 7% smokers, 7% diabetics; white hypertensive patients were n=604, 47 ± 15 years, 52% women, BMI=27.4 ± 5.1 kg/m(2), 8.4% diabetics, and 18% smokers (P

Background Identifying locale-specific patterns regarding the variation in stroke incidence throughout the year and with atmospheric temperature may be useful to the organization of stroke care, especially in low-resource settings. Goal We aimed to describe the variation in the incidence of stroke hospitalizations across seasons and with short-term temperature variation, in Maputo, Mozambique. Methods Between August 1, 2005, and July 31, 2006, we identified 651 stroke events in Maputo dwellers, according to the World Health Organization’s STEPwise approach. The day of symptom onset was defined as the index date. We computed crude and adjusted (humidity, precipitation and temperature) incidence rate ratios (IRRs) and 95% confidence intervals (CIs) with Poisson regression. Results Stroke incidence did not vary significantly with season (dry versus wet: crude IRR = .98, 95% CI: .84-1.15), atmospheric temperature at the index date, or average atmospheric temperature in the preceding 2 weeks. The incidence rates of stroke were approximately 30% higher when in the previous 10 days there was a decline in the minimum temperature greater than or equal to 3°C between any 2 consecutive days (variation in minimum temperature −5.1 to −3.0 versus −2.3 to −.4, adjusted IRR = 1.31, 95% CI: 1.09-1.57). No significant associations were observed according to the variation in maximum temperatures. Conclusions Sudden declines in the minimum temperatures were associated with a higher incidence of stroke hospitalizations in Maputo. This provides important information for prediction of periods of higher hospital affluence because of stroke and to understand the mechanisms underlying the triggering of a stroke event.

AIDS-associated Kaposi sarcoma occurs in children, but treatment experience reports are very scarce. A retrospective analysis of 28 children treated with highly active antiretroviral therapy and monthly paclitaxel showed unexpected results with 19 children in complete and sustainable remission, including those with the most severe form. Tolerance and feasibility were good, despite a lack of skilled staff in a low-resource setting.

Background: Global Health Initiatives (GHIs), aiming at reducing the impact of specific diseases such as Human Immunodeficiency Virus (HIV), have flourished since 2000. Amongst these, PEPFAR and GFATM have provided a substantial amount of funding to countries affected by HIV, predominantly for delivery of antiretroviral therapy (ARV) and prevention strategies. Since the need for additional human resources for health (HRH) was not initially considered by GHIs, countries, to allow ARV scale-up, implemented short-term HRH strategies, adapted to GHI-funding conditionality. Such strategies differed from one country to another and slowly evolved to long-term HRH policies. The processes and content of HRH policy shifts in 5 countries in Sub-Saharan Africa were examined. Methods: A multi-country study was conducted from 2007 to 2011 in 5 countries (Angola, Burundi, Lesotho, Mozambique and South Africa), to assess the impact of GHIs on the health system, using a mixed methods design. This paper focuses on the impact of GFATM and PEPFAR on HRH policies. Qualitative data consisted of semi-structured interviews undertaken at national and sub-national levels and analysis of secondary data from national reports. Data were analysed in order to extract countries' responses to HRH challenges posed by implementation of HIV-related activities. Common themes across the 5 countries were selected and compared in light of each country context. Results: In all countries successful ARV roll-out was observed, despite HRH shortages. This was a result of mostly short-term emergency response by GHI-funded Non-Governmental Organizations (NGOs) and to a lesser extent by governments, consisting of using and increasing available HRH for HIV tasks. As challenges and limits of short-term HRH strategies were revealed and HIV became a chronic disease, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives, increase in HRH production and mitigation of internal migration of HRH, sometimes in collaboration with GHIs. Conclusion: Sustainable HRH strengthening is a complex process, depending mostly on HRH production and retention factors, these factors being country-specific. GHIs could assist in these strategies, provided that they are flexible enough to incorporate country-specific needs in terms of funding, that they coordinate at global-level and minimise conditionality for countries.