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Mee P, Rice B, Lemsalu L, Hargreaves J, Sambu V, Harklerode R, Todd J, Somi G. Changes in patterns of retention in HIV care and antiretroviral treatment in Tanzania between 2008 and 2016: an analysis of routinely collected national programme data. J Glob Health 2019; 9:010424. [PMID: 30992984 PMCID: PMC6445500 DOI: 10.7189/jogh.09.010424] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tanzania is a high HIV burden country in Sub-Saharan Africa with 1.5 million people infected. Unless monitored and responded to, low levels of retention in care may lead to poor HIV associated clinical outcomes and an increased likelihood of onward viral transmission. Using routine data, we assessed changes in retention in care and on treatment for HIV over time in Tanzanian facilities, using the national care and treatment programme (CTC) database. METHODS Data were extracted from the CTC database and analysed using two approaches: a series of cross-sectional analyses for each calendar year between 2008 and 2016 to assess the changing characteristics of the population in care and on treatment, and, a longitudinal analysis using survival analysis methods for a series of cohorts representing i) all engaging in care and ii) all initiating treatment in each calendar year from 2008 to 2015. Multivariate analyses were carried out to explore the independent effect of calendar year when controlling for other factors. RESULTS The total number of individuals enrolled in care increased from 160 268 in 2008 to 548 296 in 2016. The percentage of the in-care population enrolled for more than 3 years increased from 9.9% in 2008 to 54.5% in 2016. The overall rates of retention in care were 80.9%, 57.3% and 45.4% at 12, 24 and 36 months respectively. The rates of retention on antiretroviral therapy (ART) ART at 12, 24 and 36 months after treatment-initiation were 83.9%, 64.0% and 53.5%. There were small but statistically significant differences in the retention rates between cohorts and evidence for a significant decrease in the rates of retention in the most recent years analysed. CONCLUSIONS Data from Tanzania show that while the number of People Living with HIV (PLHIV) who were in care and monitored through the routine data system increased over time, the retention rates in care and treatment remained relatively stable. These rates were similar to other regional estimates. Systematic reviews of tracing studies indicate that mortality among those lost to follow up has decreased over time, partly underpinned by an increase in the numbers transferring between clinics. True retention rates may therefore be higher than we report here, and this underpins the need for data systems that can track patients between clinics.
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Affiliation(s)
- Paul Mee
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Brian Rice
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Liis Lemsalu
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
- Department of Drug and Infectious Diseases Epidemiology, National Institute for Health Development, Tallinn, Estonia
| | - James Hargreaves
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Veryeh Sambu
- Strategic Information Unit, National AIDS Control Programme, Dodoma Tanzania
| | - Richelle Harklerode
- University of California San Francisco, Global Health Sciences, San Francisco, California, USA
| | - Jim Todd
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Geoffrey Somi
- Strategic Information Unit, National AIDS Control Programme, Dodoma Tanzania
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Lines M, Suleman F. Patients' perceptions of a rural decentralised anti-retroviral therapy management and its impact on direct out-of-pocket spending. Afr Health Sci 2017; 17:746-752. [PMID: 29085402 PMCID: PMC5656207 DOI: 10.4314/ahs.v17i3.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Geographical and financial barriers hamper accessibility to HIV services for rural communities. The government has introduced the nurse initiated management of anti-retroviral therapy at primary health care level, in an effort to improve patient access and reduce patient loads on facilities further up the system. OBJECTIVES To ascertain the perceptions and satisfaction of patients in terms of the decentralised anti-retroviral policy and the direct out-of-pocket expenses of patients accessing this care in a rural setting. METHOD Using a cross-sectional study design, 117 patients from five different primary health care collection points and a hospital anti-retroviral clinic were interviewed using a standard questionnaire. RESULTS More clinic patients walked to their clinic to collect their medicines as compared to hospital patients (71.2% versus 14.6%). Hospital patients spent more than clinic patients on monthly transport costs (ZAR71.92 versus ZAR25.81, Anova F=12.42, p=0.0009). All clinic patients listed their respective clinic as their preferred medicine collection point despite recording lower levels of satisfaction with anti-retroviral services (89% compared to 95.5%). CONCLUSION Patients seem to indicate that they preferred decentralisation of HIV care to PHC level and that this might minimise out-of-pocket spending. Further studies are required to confirm these findings.
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Affiliation(s)
- Monique Lines
- Postgraduate Student, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal
| | - Fatima Suleman
- Prof Fatima Suleman, Associate Professor, Discipline of Pharmaceutical Sciences, School of Health Sciences, Westville Campus, University of KwaZulu-Natal
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Khuzwayo LS, Moshabela M. The perceived role of ward-based primary healthcare outreach teams in rural KwaZulu-Natal, South Africa. Afr J Prim Health Care Fam Med 2017; 9:e1-e5. [PMID: 28582992 PMCID: PMC5458574 DOI: 10.4102/phcfm.v9i1.1388] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 01/27/2017] [Accepted: 02/02/2017] [Indexed: 11/05/2022] Open
Abstract
Background The aim of ward-based outreach teams (WBOTs) is to improve access to primary healthcare (PHC) services including health promotion and disease prevention in South Africa. Limited information is available in South Africa on user perceptions of services provided by WBOTs in rural households. Aim The study aimed to explore community awareness and perception of WBOTs, as well people’s motivation to engage and use WBOT services. Setting The study was conducted between July and September 2015 in iLembe district, KwaZulu-Natal. Methods This was exploratory-descriptive qualitative research. Purposive sampling technique was used in this study. A total of 16 key informant interviews and 4 focus group discussions were conducted. The voice recordings were transcribed in isiZulu and translated into English. Results Four themes emerged from the data analysis, namely bringing services closer, organising services, expanding services and forming bridges. Respondents demonstrated insightful knowledge and understanding of services provided by WBOTs. They expressed an appreciation of the way WBOT services brought healthcare closer to people and serve to bridge the gap between the community and local healthcare facilities. Respondents identified unclear WBOT work schedules and the failure to carry medication other than vitamin A as the main challenges. However, WBOTs did deliver medication for controlled chronic patients in their households. Conclusion The study suggests that WBOTs provide a commendable service, but need to expand their service package to further increase access to PHC services and cater for community health needs.
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Long LC, Rosen SB, Brennan A, Moyo F, Sauls C, Evans D, Modi SL, Sanne I, Fox MP. Treatment Outcomes and Costs of Providing Antiretroviral Therapy at a Primary Health Clinic versus a Hospital-Based HIV Clinic in South Africa. PLoS One 2016; 11:e0168118. [PMID: 27942005 PMCID: PMC5152901 DOI: 10.1371/journal.pone.0168118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 11/27/2016] [Indexed: 12/02/2022] Open
Abstract
Background In 2010 South Africa revised its HIV treatment guidelines to allow the initiation and management of patients on antiretroviral therapy (ART) by nurses, rather than solely doctors, under a program called NIMART (Nurse Initiated and Managed Antiretroviral Therapy). We compared the outcomes and costs of NIMART between the two major public sector HIV treatment delivery models in use in South Africa today, primary health clinics and hospital-based HIV clinics. Methods and findings The study was conducted at one hospital-based outpatient HIV clinic and one primary health clinic (PHC) in Gauteng Province. A retrospective cohort of adult patients initiated on ART at the PHC was propensity-score matched to patients initiated at the hospital outpatient clinic. Each patient was assigned a 12-month outcome of alive and in care or died/lost to follow up. Costs were estimated from the provider perspective for the 12 months after ART initiation. The proportion of patients alive and in care at 12 months did not differ between the PHC (76.5%) and the hospital-based site (74.2%). The average annual cost per patient alive and in care at 12 months after ART initiation was significantly lower at the PHC (US$238) than at the hospital outpatient clinic (US$428). Conclusions Initiating and managing ART patients at PHCs under NIMART is producing equally good outcomes as hospital-based HIV clinic care at much lower cost. Evolution of hospital-based clinics into referral facilities that serve complicated patients, while investing most program expansion resources into PHCs, may be a preferred strategy for achieving treatment coverage targets.
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Affiliation(s)
- Lawrence C. Long
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- * E-mail:
| | - Sydney B. Rosen
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
| | - Alana Brennan
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
| | - Faith Moyo
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | - Celeste Sauls
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | - Denise Evans
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
| | | | - Ian Sanne
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
- Right to Care, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Internal Medical, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Lê G, Morgan R, Bestall J, Featherstone I, Veale T, Ensor T. Can service integration work for universal health coverage? Evidence from around the globe. Health Policy 2016; 120:406-19. [DOI: 10.1016/j.healthpol.2016.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 01/12/2016] [Accepted: 02/16/2016] [Indexed: 11/15/2022]
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Moyo F, Chasela C, Brennan AT, Ebrahim O, Sanne IM, Long L, Evans D. Treatment outcomes of HIV-positive patients on first-line antiretroviral therapy in private versus public HIV clinics in Johannesburg, South Africa. Clin Epidemiol 2016; 8:37-47. [PMID: 27051316 PMCID: PMC4807894 DOI: 10.2147/clep.s93014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Despite the widely documented success of antiretroviral therapy (ART), stakeholders continue to face the challenges of poor HIV treatment outcomes. While many studies have investigated patient-level causes of poor treatment outcomes, data on the effect of health systems on ART outcomes are scarce. OBJECTIVE We compare treatment outcomes among patients receiving HIV care and treatment at a public and private HIV clinic in Johannesburg, South Africa. PATIENTS AND METHODS This was a retrospective cohort analysis of ART naïve adults (≥18.0 years), initiating ART at a public or private clinic in Johannesburg between July 01, 2007 and December 31, 2012. Cox proportional-hazards regression was used to identify baseline predictors of mortality and loss to follow-up (>3 months late for the last scheduled visit). Generalized estimating equations were used to determine predictors of failure to suppress viral load (≥400 copies/mL) while the Wilcoxon rank-sum test was used to compare the median absolute change in CD4 count from baseline to 12 months post-ART initiation. RESULTS 12,865 patients initiated ART at the public clinic compared to 610 at the private clinic. The patients were similar in terms of sex and age at initiation. Compared to public clinic patients, private clinic patients initiated ART at higher median CD4 counts (159 vs 113 cells/mm(3)) and World Health Organization stage I/II (76.1% vs 58.5%). Adjusted hazard models showed that compared to public clinic patients, private clinic patients were less likely to die (adjusted hazard ratio [aHR] 0.50; 95% confidence interval [CI] 0.35-0.70) but were at increased risk of loss to follow-up (aHR 1.80; 95% CI 1.59-2.03). By 12 months post-ART initiation, private clinic patients were less likely to have a detectable viral load (adjusted relative risk 0.65; 95% CI 0.49-0.88) and recorded higher median CD4 change from baseline (184 cells/mm(3) interquartile range 101-300 vs 158 cells/mm(3) interquartile range 91-244), when compared to public clinic patients. CONCLUSION We identified differences in treatment outcomes between the two HIV clinics. Findings suggest that the type of clinic at which ART patients initiate and receive treatment can have an impact on treatment outcomes. Further research is necessary to provide more conclusive results.
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Affiliation(s)
- Faith Moyo
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Chasela
- Epidemiology and Biostatistics Department, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Epidemiology and Strategic Information (ESI), HIV/AIDS/STIs and TB, Human Sciences Research Council, Pretoria, South Africa
| | - Alana T Brennan
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Center for Global Health and Development, Boston University, Boston, MA, USA
| | | | - Ian M Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Right to Care, Helen Joseph Hospital, Westdene, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Magadzire BP, Budden A, Ward K, Jeffery R, Sanders D. Frontline health workers as brokers: provider perceptions, experiences and mitigating strategies to improve access to essential medicines in South Africa. BMC Health Serv Res 2014; 14:520. [PMID: 25370799 PMCID: PMC4230357 DOI: 10.1186/s12913-014-0520-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 10/13/2014] [Indexed: 11/30/2022] Open
Abstract
Background Front-line health providers have a unique role as brokers (patient advocates) between the health system and patients in ensuring access to medicines (ATM). ATM is a fundamental component of health systems. This paper examines in a South African context supply- and demand- ATM barriers from the provider perspective using a five dimensional framework: availability (fit between existing resources and clients’ needs); accessibility (fit between physical location of healthcare and location of clients); accommodation (fit between the organisation of services and clients’ practical circumstances); acceptability (fit between clients’ and providers’ mutual expectations and appropriateness of care) and affordability (fit between cost of care and ability to pay). Methods This cross-sectional, qualitative study uses semi-structured interviews with nurses, pharmacy personnel and doctors. Thirty-six providers were purposively recruited from six public sector Community Health Centres in two districts in the Eastern Cape Province representing both rural and urban settings. Content analysis combined structured coding and grounded theory approaches. Finally, the five dimensional framework was applied to illustrate the interconnected facets of the issue. Results Factors perceived to affect ATM were identified. Availability of medicines was hampered by logistical bottlenecks in the medicines supply chain; poor public transport networks affected accessibility. Organization of disease programmes meshed poorly with the needs of patients with comorbidities and circular migrants who move between provinces searching for economic opportunities, proximity to services such as social grants and shopping centres influenced where patients obtain medicines. Acceptability was affected by, for example, HIV related stigma leading patients to seek distant services. Travel costs exacerbated by the interplay of several ATM barriers influenced affordability. Providers play a brokerage role by adopting flexible prescribing and dispensing for ‘stable’ patients and aligning clinic and social grant appointments to minimise clients’ routine costs. Occasionally they reported assisting patients with transport money. Conclusion All five ATM barriers are important and they interact in complex ways. Context-sensitive responses which minimise treatment interruption are needed. While broad-based changes encompassing all disease programmes to improve ATM are needed, a beginning could be to assess the appropriateness, feasibility and sustainability of existing brokerage mechanisms.
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Houle B, Clark SJ, Gómez-Olivé FX, Kahn K, Tollman SM. The unfolding counter-transition in rural South Africa: mortality and cause of death, 1994-2009. PLoS One 2014; 9:e100420. [PMID: 24959714 PMCID: PMC4068997 DOI: 10.1371/journal.pone.0100420] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/28/2014] [Indexed: 01/19/2023] Open
Abstract
The HIV pandemic has led to dramatic increases and inequalities in adult mortality, and the diffusion of antiretroviral treatment, together with demographic and socioeconomic shifts in sub-Saharan Africa, has further changed mortality patterns. We describe all-cause and cause-specific mortality patterns in rural South Africa, analyzing data from the Agincourt health and socio-demographic surveillance system from 1994 to 2009 for those aged 5 years and older. Mortality increased during that period, particularly after 2002 for ages 30-69. HIV/AIDS and TB deaths increased and recently plateaued at high levels in people under age 60. Noncommunicable disease deaths increased among those under 60, and recently also increased among those over 60. There was an inverse gradient between mortality and household SES, particularly for deaths due to HIV/AIDS and TB and noncommunicable diseases. A smaller and less consistent gradient emerged for deaths due to other communicable diseases. Deaths due to injuries remained an important mortality risk for males but did not vary by SES. Rural South Africa continues to have a high burden of HIV/AIDS and TB mortality while deaths from noncommunicable diseases have increased, and both of these cause-categories show social inequalities in mortality.
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Affiliation(s)
- Brian Houle
- Department of Sociology, University of Washington, Seattle, Washington, United States of America
- Institute of Behavioral Science (IBS), University of Colorado at Boulder, Boulder, Colorado, United States of America
| | - Samuel J. Clark
- Department of Sociology, University of Washington, Seattle, Washington, United States of America
- Institute of Behavioral Science (IBS), University of Colorado at Boulder, Boulder, Colorado, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- ALPHA Network, London, United Kingdom
| | - F. Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- Institute of Behavioral Science (IBS), University of Colorado at Boulder, Boulder, Colorado, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Global Health Research, Umeå University, Umeå, Sweden
- INDEPTH Network, Accra, Ghana
| | - Stephen M. Tollman
- Institute of Behavioral Science (IBS), University of Colorado at Boulder, Boulder, Colorado, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Global Health Research, Umeå University, Umeå, Sweden
- INDEPTH Network, Accra, Ghana
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