Kate Macintyre

Understanding Perceptions of HIV Risk Among Adolescents in KwaZulu-Natal

Risk perception has been theorized to be an important antecedent for adopting protective behavior. It is a key construct of research applying the Health Belief Model and other behavior change models. In relation to HIV, risk perception is an indicator of perceived susceptibility to infection, a measure for ones understanding of AIDS transmission as well as willingness to consider behavioral changes. However, there remains much we do not know about what drives risk perception, especially among youth. This study identifies factors that influence the calculation of HIV-risk perception among a group of adolescents in South Africa. Data, collected in 1999 from 2,716 adolescents aged 14–22, are used to explore factors predicting risk perception. Logistic regression models suggest connectedness to parents and community for males and females, self-efficacy to use a condom among males, and living in a household with a chronically ill member for females are associated with HIV risk perception. We conclude that a greater understanding of the connection of adolescents to their communities and adults in their lives is needed, and ways in which programs can alter the environments in which adolescents form opinions, make choices, and act should be incorporated into program design.

Rolling out insecticide treated nets in Eritrea: examining the determinants of possession and use in malarious zones during the rainy season.

Objective  This paper describes determinants of insecticide treated net (ITN) ownership and use in malarious areas of Eritrea. With ITN distribution and re‐treatment now free for all living in these areas, we examine barriers (other than cost) to access and use of ITNs. We explore the differences between use of an ITN as a proportion of all households in the survey (the roll back malaria indicator), and use of an ITN as a proportion of those households who already own an ITN.

Characterization of potential larval habitats for Anopheles mosquitoes in relation to urban land-use in Malindi, Kenya

BackgroundThis study characterized Anopheles mosquito larval habitats in relation to ecological attributes about the habitat and community-level drainage potential, and investigated whether agricultural activities within or around urban households increased the probability of water body occurrence. Malindi, a city on the coast of Kenya, was mapped using global positioning system (GPS) technology, and a geographic information system (GIS) was used to overlay a measured grid, which served as a sampling frame. Grid cells were stratified according to the level of drainage in the area, and 50 cells were randomly selected for the study. Cross-sectional household and entomological surveys were conducted during November and December 2002 within the 50 grid cells. Chi-square analysis was used to test whether water bodies differed fundamentally between well and poorly drained areas, and multi-level logistic regression was used to test whether household-level agricultural activity increased the probability of water body occurrence in the grid cell.ResultsInterviews were conducted with one adult in 629 households. A total of 29 water bodies were identified within the sampled areas. This study found that characteristics of water bodies were fundamentally the same in well and poorly drained areas. This study also demonstrated that household-level urban agriculture was not associated with the occurrence of water bodies in the grid cell, after controlling for potential confounders associated with distance to the city center, drainage, access to resources, and population density.ConclusionsHousehold-level urban agricultural activity may be less important than the other types of human perturbation in terms of mosquito larval habitat creation. The fact that many larvae were coming from few sites, and few sites in general were found under relatively dry conditions suggests that mosquito habitat reduction is a reasonable and attainable goal in Malindi.

Referral revisited: community financing schemes and emergency transport in rural Africa.

Referral between first and second levels of care in rural African health systems is an extremely complex problem. Problems that have plagued the process of referral include poor service quality, low availability of trained personnel, inadequate supplies of drugs and medical diagnostic equipment and inadequate communication infrastructure. In this paper, the authors analyse the role of transport costs in the utilization of referral and how community health insurance schemes can help reduce the economic burden of transport costs, thereby improving referral utilization and health outcomes. Following the introduction, the authors provide a conceptual framework of the individual-, household- and community-level factors that affect referral in the rural African context, with particular emphasis on the role of the time and monetary costs of transport and the potential role of community risk-sharing schemes. The paper then presents a detailed case study from Kenya where a community has been experimenting with a health insurance scheme which provides emergency transport for emergency referral. Data from the past eight years of experience in northern Kenya suggests that support for the insurance scheme has depended on the reliability of the health system, as well as the seasons and various external problems, such as political interference, drought and insecurity. Conclusions drawn support the idea of community financing schemes for transport, not merely as a life-saving strategy in remote and resource-poor health infrastructures, but also as a means to help build trust in the health system itself and thus improve sustainability through local institutional support.

Pregnant or positive: adolescent childbearing and HIV risk in KwaZulu Natal, South Africa.

Abstract In communities where early age of childbearing is common and HIV prevalence is high, adolescents may place themselves at risk of HIV because positive or ambivalent attitudes towards pregnancy reduce their motivation to abstain from sex, have sex less often or use condoms. In this study, we analyse cross-sectional survey data from KwaZulu Natal, South Africa, to explore whether an association exists between the desire for pregnancy and perceptions of HIV risk among 1,426 adolescents in 110 local communities. Our findings suggest that some adolescents, girls more than boys, were more concerned about a pregnancy if they lived in environments where youth were perceived to be at high risk of HIV infection. The probability that pregnancy was considered a problem by boys was positively correlated with the proportion of adult community members who thought youth were at risk of acquiring HIV, and for girls by the proportion of peers in the community who thought youth were at risk of HIV. We also found that becoming pregnant would be a bigger problem for the African girls than the white and Indian girls. The analysis suggests that for some adolescents, in addition to effects on educational and employment opportunities, the danger of HIV infection is becoming part of the calculus of the desirability of a pregnancy.

Interpreting household survey data intended to measure insecticide-treated bednet coverage: results from two surveys in Eritrea

BackgroundAs efforts are currently underway to roll-out insecticide-treated bednets (ITNs) to populations within malarious areas in Africa, there is an unprecedented need for data to measure the effectiveness of such programmes in terms of population coverage. This paper examines methodological issues to using household surveys to measure core Roll Back Malaria coverage indicators of ITN possession and use.MethodsITN coverage estimates within Anseba and Gash Barka Provinces from the 2002 Eritrean Demographic and Health Survey, implemented just prior to a large-scale ITN distribution programme, are compared to estimates from the same area from a sub-national Bednet Survey implemented 18 months later in 2003 after the roll-out of the ITN programme.ResultsMeasures of bednet possession were dramatically higher in 2003 compared to 2002. In 2003, 82.2% (95% confidence interval (CI) 77.4–87.0) of households in Anseba and Gash Barka possessed at least one ITN. RBM coverage indicators for ITN use were also dramatically higher in 2003 as compared to 2002, with 76.1% (95% CI 69.9–82.2) of children under five years old and 52.4% (95% CI 38.2–66.6) of pregnant women sleeping under ITNs. The ITN distribution programme resulted in a gross increase in ITN use among children and pregnant women of 68.3% and 48% respectively.ConclusionEritrea has exceeded the Abuja targets of 60% coverage for ITN household possession and use among children under five years old within two malarious provinces. Results point to several important potential sources of bias that must be considered when interpreting data for ITN coverage over time, including: disparate survey universes and target populations that may include non-malarious areas; poor date recall of bednet procurement and treatment; and differences in timing of surveys with respect to malaria season.

Attitudes, Perceptions and Potential Uptake of Male Circumcision among Older Men in Turkana County, Kenya Using Qualitative Methods

Background In many communities, older men (i.e., over 25 years of age) have not come forward for Voluntary Medical Male Circumcision (VMMC) services. Reasons for low demand among this group of men are not well understood, and may vary across geographic and cultural contexts. This paper examines the facilitators and barriers to VMMC demand in Turkana County, Kenya, with a focus on older men. This is one of the regions targeted by the VMMC program in Kenya because the Turkana ethnic group does not traditionally circumcise, and the rates of HIV and STD transmission are high. Methods and Findings Twenty focus group discussions and 69 in-depth interviews were conducted with circumcised and uncircumcised men and their partners to elicit their attitudes and perceptions toward male circumcision. The interviews were conducted in urban, peri-urban, and rural communities across Turkana. Our results show that barriers to circumcision include stigma associated with VMMC, the perception of low risk for HIV for older men and their “protection by marriage,” cultural norms, and a lack of health infrastructure. Facilitators include stigma against not being circumcised (since circumcision is associated with modernity), protection against disease including HIV, and cleanliness. It was also noted that older men should adopt the practice to serve as role models to younger men. Conclusions Both men and women were generally supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services will be challenging. The justification of circumcision being a biomedical procedure for protection against HIV will be the most important message for any communication strategy.

SELF-REPORTED MALARIA AND MOSQUITO AVOIDANCE IN RELATION TO HOUSEHOLD RISK FACTORS IN A KENYAN COASTAL CITY

A geographically stratified cross-sectional survey was conducted in 2002 to investigate household-level factors associated with use of mosquito control measures and self-reported malaria in Malindi, Kenya. A total of 629 households were surveyed. Logistic regressions were used to analyse the data. Half of all households (51%) reported all occupants using an insecticide-treated bed net and at least one additional mosquito control measure such as insecticides or removal of standing water. Forty-nine per cent reported a history of malaria in the household. Of the thirteen household factors analysed, low (OR=0.23, CI 0.11, 0.48) and medium (OR=0.50, CI 0.29, 0.86) education, mud--wood--coral (OR=0.0.39, CI 0.24, 0.66) and mud block--plaster (OR=0.47, CI 0.25, 0.87) wall types, farming (OR=1.38, CI 1.01, 1.90) and travel to rural areas (OR=0.48, CI 0.26, 0.91) were significantly associated with the use of mosquito control, while controlling for other covariates in the model. History of reported malaria was not associated with the use of mosquito control (OR=1.22, CI 0.79, 1.88). Of the thirteen covariates analysed in the second model, only two household factors were associated with history of malaria: being located in the well-drained stratum (OR=0.49, CI 0.26, 0.96) and being bitten while in the house (OR=1.22, CI 0.19, 0.49). These results suggest that high socioeconomic status is associated with increased household-level mosquito control use, although household-level control may not be enough, as many people are exposed to biting mosquitoes while away from the house and in areas that are more likely to harbour mosquitoes.

The influence of orphan care and other household shocks on health status over time: a longitudinal study of children's caregivers in rural Malawi

In the context of rising rates of orphanhood in AIDS-affected settings, very little is understood about implications for caregiver well-being given increasing and intensifying responsibilities for the care of orphaned children. Emotional distress and self-reported health status as well as shifts in household orphan care, wealth, food security and recent illness and death among household members were measured among a panel of 1219 caregivers in rural Malawi between 2007 and 2009. Logistic regression was used to identify predictors of improved and diminished caregiver health and emotional distress. Results suggest that becoming an orphan caregiver is associated with a shift from good to poor health status (adjusted odds ratio [AOR]=2.29, 95% confidence interval [CI]=1.16–4.54), and that elevated levels of distress and poor health both persist over time in comparison with care for non-orphans only. Once engaged in orphan care, taking on additional orphans is associated with increased emotional distress in relation to not caring for orphans (AOR=3.16, 95% CI=1.30–7.73) as well as in relation to maintaining the same number of orphans in care over time (AOR=2.84, 95% CI=1.04–7.70). In addition, findings illustrate the strong influence of household wealth and food security on caregiver well-being. Food insecurity and poverty that persist or develop over time are associated with increasing distress. Conversely, maintenance or improvement in food security and household wealth are associated with decreases in distress. Providing all aspects of household maintenance and care for children, primary caregivers are key to the extended family solution for orphaned and vulnerable children. Bolstering the foundation of rural African families to ensure care and protection of these children involves targeting support to orphan caregivers but must also include addressing the issues of poverty and food insecurity that pose a wider threat to caregiving capacity.

Regional and temporal trends in malaria commodity costs: an analysis of Global Fund data for 79 countries

BackgroundAlthough procurement consumes nearly 40% of Global Fund’s money, no analyses have been published to show how costs vary across regions and time. This paper presents an analysis of malaria-related commodity procurement data from 79 countries, as reported through the Global Fund’s price and quality reporting (PQR) system for the 2005–2012 period.MethodsData were analysed for the three most widely procured commodities for prevention, diagnosis and treatment of malaria. These were long-lasting insecticide-treated nets (LLINs), malaria rapid diagnostic tests (RDTs) and the artemether/lumefantrine (AL) combination treatment. Costs were compared across time (2005–2012), regions, and between individual procurement reported through the PQR and pooled procurement reported through the Global Fund’s voluntary pooled procurement (VPP) system. All costs were adjusted for inflation and reported in US dollars.ResultsThe data included 1,514 entries reported from 79 countries over seven years. Of these, 492 entries were for LLINs, 330 for RDTs and 692 for AL. Considerable variations were seen by commodity, although none showed an increase in cost. The costs for LLINs, RDTs and AL all dropped significantly over the period of analysis. Regional variations were also seen, with the cost for all three commodities showing significant variations. The median cost for a single LLIN ranged from USD 4.3 in East Asia to USD 5.0 in West and Central Africa. The cost of a single RDT was lowest in West and Central Africa at US