Challenges in the diagnosis of asthma in children, what are the solutions? A scoping review of 3 countries in sub Saharan Africa

Background

Asthma is the commonest chronic respiratory tract disease in children. In low-income countries, challenges exist in asthma diagnosis. In surveys done in children, the prevalence of ‘asthma’ defined by symptoms is high compared to ‘doctor diagnosed asthma’. The questions answered by this review are (i) What challenges have been experienced in the diagnosis of asthma in children? (ii) What solutions will address these challenges?

Methods

The Arksey and O’Malley’s framework for scoping reviews was used for the study methodology, while the PRISMA-ScR checklist guided the reporting process. Electronic databases: PubMed Central, EMBASE and Google Scholar were searched. Primary quantitative and qualitative studies and reviews from 2010 to 2021, from Nigeria, South Africa and Uganda written in English or translated to English, which answered the study questions were included. The author, title, country, study type, methods, purpose, findings and references were captured onto a predefined data collection table. The ‘Preview, Question, Read, Summarise’ system was used and a narrative report was used to summarise the findings.

Results

A total of 28 studies were included. The causes of under-diagnosis of asthma include lack of community knowledge and perception of asthma, poor accessibility to health care, strained health systems, lack of diagnostic tests including spirometry, low levels of knowledge among health-care workers and lack of or non-implementation of asthma guidelines. Strategies to improve asthma diagnosis will include community and school based education programmes, revision of asthma diagnostic terms, guideline development and implementation and health systems strengthening.

Conclusion

This scoping review provides research evidence for policy makers and health-workers involved in the care of asthmatic children on challenges faced in asthma diagnosis and strategies to improve asthma diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02170-y.

Caregiver self-efficacy to talk about sex predicts conversations about HIV transmission risk with perinatally infected young people in Zimbabwe

Given advances in care and treatment for HIV, perinatally infected young people are surviving into adolescence. These young people are making decisions about engaging in sexual relationships and it is critical to ensure they have the information they need to engage responsibly in sexual activity, particularly in an era where adherence to treatment could make their virus undetectable. The main objective of this analysis was to examine whether an HIV-positive young person's knowledge about forward transmission is associated with caregiver self-efficacy to talk about sex and general caregiver communication. Using data from a 12-month prospective cohort of caregivers of HIV-positive children aged 9-15 on ART and pre-ART in rural Zimbabwe, we found that caregiver self-efficacy to talk about sex predicted whether conversations about HIV transmission would occur between caregiver and the young person. However, by the end of 12-months, nearly two-thirds of caregivers of HIV-positive teenagers in our sample had still not explained how their adolescents could spread the virus to others despite these caregivers saying their adolescent should know this information at baseline. We discuss the implications for designing sexual and reproductive health (SRH) programs among populations of young people perinatally infected with HIV to ensure that this breakthrough generation receives the SRH support they need.

Etiology and risk factors of meningitis in patients admitted at a Central Hospital in Harare

OBJECTIVE

To determine etiology and risk factors of meningitis in patients admitted a tertiary referral Hospital in Harare.

DESIGN

Cross-Sectional Study.

SETTING

Urban Referral Health Facility.

SUBJECTS

Patients suspected of having Meningitis admitted at Parirenyatwa Hospital were consecutively consented and recruited into the study until sample size accrual.

MAIN OUTCOME MEASURES

Prevalence of pathogens associated with Meningitis. Risk factors of meningitis.

RESULTS

Two Hundred and Ninety Six (296) clinically suspected meningitis patients were recruited into the study, 51.7 %( n=115) were male. Meningitis was confirmed in 20.6% (n=61) cases with the following pathogen proportions, C. neoformans - 45.9 %( n=28), S. pneumoniae – 27.9 % (n=17), TBM – 4.9 %( n=3), probable viral meningitis – 6.6% (n=4 and other bacteria- 14.8% (n=9). Patients from crowded households were also more likely to suffer from meningitis than those from sparsely populated households (p<0.001).

CONCLUSION

The use of Latex agglutination increases the proportion of detected pathogens both fungal and bacterial when used in conjunction with CSF gram stain and culture. Cryptococcus neoformans and S. pneumoniae are the leading causes of meningitis in patients admitted at Parirenyatwa Hospital.

Non-adherence to highly active antiretroviral therapy in children attending HIV treatment clinic at harare Children's Hospital, Zimbabwe

BACKGROUND

Non-adherence reduces the effectiveness of antiretroviral therapy. Knowledge of factors associated with non-adherence would assist clinicians and program planners to design and implement interventions to improve adherence and therefore treatment outcomes.

OBJECTIVE

To determine the prevalence and factors associated with non-adherence to Highly Active Antiretroviral Therapy (HAART) in children less than 10 years of age.

METHODS

A cross-sectional study of 216 caregivers and children less than 10 years of age who had received HAART for at least 60 days prior to this study. Non-adherence was defined as taking less than 95% of prescribed doses. Caregiver self-reports of missed doses in the 30 days preceding a clinic visit, and clinic based pill counts were used to determine non-adherence.

RESULTS

Of the 228 children selected, 216 (94.7%) study participants were assessed using the self-report method. Pill count assessment was done on only 96 (44%) participants who produced unused pills on their review dates. Caregiver self-reports (n=216) estimated the prevalence of non-adherence to be 7.4% (95%: CI 3.90 10.90) whereas clinic-based pill counts (n=96) yielded a higher estimate of 18.8% (95% CI 10.94 26.56). In a regression analysis based on pill count, two or fewer siblings (OR=6.26, 95% CI 1.64-23.95) or adults (OR=3.73, 95% CI: 1.01-13.78) in the household were independently associated with non-adherence to HAART. Of the 16 participants who were non adherent by pill count the reasons for missing doses were, attending gatherings (funeral, church), caregiver forgetting to give dose, medication running out, not understanding dosing instructions, concurrently taking other medicines such as anti tuberculosis drugs and cotrimoxazole, child visiting relatives during school vacation, and inconsistent supply of drugs in the hospital.

CONCLUSION

The prevalence of non adherence using pill count method was high at this clinic. Caregiver reports of missed doses underestimated the prevalence of non-adherence to HAART. Having fewer siblings or adults in the household to assist with dosing are strongly associated with non-adherence to HAART in this population of children.

Clinical predictors of HIV infection in hospitalized children aged 2-18 months in Harare, Zimbabwe

BACKGROUND

In Africa without antiretroviral treatment more than half of the HIV infected children die by 2 years. The recommended HIV virological testing for early infant diagnosis is not widely available in developing countries therefore a presumptive diagnosis is made in infants presenting with symptoms suggestive of HIV disease.

OBJECTIVES

To identify presenting signs and symptoms predictive of HIV infection in hospitalized children aged between 2- 18 months at Harare Hospital, Zimbabwe.

METHODS

In a cross sectional study the baseline clinical information was collected and HIV infection confirmed using DNA PCR. Multiple logistic regression analysis was used to identify significant predictors of symptomatic HIV infection. Diagnostic parameters (sensitivity, specificity) and their 95% confidence intervals were calculated.

RESULTS

355 children with an overall median age of 6 months (IQR: 3, 10.5 months) of whom 203 (57.2%) were HIV DNA PCR positive. Clinical signs independently predictive of HIV infection were cyanosis, generalized lymphadenopathy, oral thrush, weight for age z-score <-2 and splenomegaly. The sensitivity of these signs ranged from 43-49% with a higher specificity (ranging from 72.3-89.5%).

CONCLUSION

Clinical identification using individual signs for probable HIV infection in hospitalized children below 18 months would provide an opportunity for early diagnosis, treatment.

Risk factors for mortality in smear-negative tuberculosis suspects: a cohort study in Harare, Zimbabwe

OBJECTIVE

To investigate mortality rates and risk factors for death among smear-negative tuberculosis (TB) suspects.

DESIGN

Cohort study nested within a cluster-randomised trial of community-based active case finding. Smear-negative TB suspects were followed for 12 months, with home tracing where necessary. We calculated mortality rates and used regression analysis to investigate the relationship between clinical characteristics and death.

RESULTS

Between February 2006 and June 2007, 1195 smear-negative TB suspects were followed for 1136.8 person-years. Human immunodeficiency virus (HIV) prevalence was 63.3%. During follow-up, 139 participants died (11.6%) and mortality rates remained high throughout; 119 (16.5%) HIV-positive individuals and 13 (3.1%) HIV-negative individuals died (HR = 5.8, 95%CI 3.3-10.4, P < 0.001). Advanced immunosuppression was the main risk factor for death among HIV-positive participants, with CD4 count < 50 cells/μ l associated with a 13-fold increased risk of death. Antiretroviral treatment (ART) was initiated by only 106 (14.7%), with long delays in accessing care.

CONCLUSION

HIV-positive smear-negative TB suspects are at high and sustained risk of death. Current guidelines for the management of HIV-infected TB suspects are limited, and this study adds to evidence that specific policies are required to promote earlier HIV and TB diagnosis and reduce delays in ART initiation.

Realities and Challenges of a Five Year Follow Up of Mother and Child Pairs on a PMTCT Program in Zimbabwe

Background:

Complete follow up is an essential component of observational cohorts irrespective of the type of disease.

Objectives:

To describe five years follow up of mother and child pairs on a PMTCT program, highlighting loss to follow up (LTFU) and mortality (attrition).

Study Design:

A cohort of pregnant women was enrolled from the national PMTCT program at 36 weeks gestational age attending three peri urban clinics around Harare offering maternal and child health services. Mother-infant pairs were followed up from birth and twice yearly for five years.

Results:

A total of 479 HIV infected and 571 HIV negative pregnant women were enrolled, 445(92.9%) and 495(86.6%) were followed up whereas 14(3.0%) and 3(0.5%) died in the 1st year respectively; RR (95%CI) 5.3(1.5-18.7). At five years 227(56.7%) HIV infected and 239(41.0%) HIV negative mothers turned up, whereas mortality rates were 34 and 7 per 100 person years respectively. Birth information was recorded for 401(83.7%) HIV exposed and 441(77.2%) unexposed infants, 247(51.6%) and 232(40.6) turned up in the first year whilst mortality was 58(12.9%) and 22(4.4%) respectively, RR (95%CI) 3.2(2.0-5.4). At five years 210(57.5%) HIV exposed and 239(44.3%) unexposed infants were seen, whilst mortality rates were 53 per 1000 and 15 per 1 000 person years respectively. Mortality rate for HIV infected children was 112 compared to 21 per 1 000 person years for the exposed but uninfected.

Conclusion:

HIV infected mothers and their children succumbed to mortality whereas the HIV negatives were LTFU. Mortality rates and LTFU are high within PMTCT program.

Risk factors of HIV vertical transmission in a cohort of women under a PMTCT program at three peri-urban clinics in a resource-poor setting

OBJECTIVE

To identify the risk factors of HIV vertical transmission in pregnant women.

STUDY DESIGN

Observational cohort study. Between 2002 and 2003, 479 HIV-infected pregnant women in a PMTCT (prevention of the mother-to-child transmission) program were followed up with their infants at delivery, until 15 months with infant HIV testing.

RESULTS

Of these 281 infants had a definitive HIV result by 15 months of age, and 31.7% of the infants become HIV infected. In univariate analysis the risk factor identified were presence of vaginal discharge, genital itchiness, genital ulcers, dysuria, abnormal breast and vaginal infections (Trichomonas, Bacteria vaginosis and Candida) in the mother at enrolment. In multivariate analysis vaginal infections risk ratio (RR) 1.72(1.03-2.88) and abnormal breast RR 4.36(2.89-6.58) were predictors of HIV vertical transmission.

CONCLUSION

There is need to screen for vaginal infections (Trichomonas, Bacteria vaginosis and Candida) and examine pregnant women for mastitis to identify women at risk of HIV vertical transmission for prevention.

Low level technology tool (LLTT) in screening for blindness: test qualities in the outpatients department of a tertiary eye unit using the Snellen chart

OBJECTIVE

To validate the use of finger counting (low level technology tool) in screening for blindness in the outpatients department of a tertiary eye unit with the view of employing the test for screening illiterate people in hard to reach parts of the country where the conventional visual acuity charts are not available.

DESIGN

Aperformance evaluation of counting fingers (LLTT) in screening for blindness against the standard test (Snellen chart).

SETTING

Sekuru Kaguvi Eye Unit, Parirenyatwa Hospital, Zimbabwe.

SUBJECTS

Patients presenting to the Eye Outpatient Department at Sekuru Kaguvi Eye Unit with various eye problems.

MAIN OUTCOME MEASURE

Sensitivity of low level technology tool (LLTT) in identifying blind people.

RESULTS

Sensitivity and specificity of LLTT in detecting blindness in all age groups combined was 100% and 88.5% respectively. Although sensitivity was not affected by patient age, specificity decreased with increasing age. The overall positive predictive value for the test was 53.3% and the prevalence of blindness among outpatient attendees was 11.6%.

CONCLUSION

Finger counting is an effective tool that can be employed in screening for blindness in communities which are hard to reach, have low literacy rate and when conventional methods of testing visual acuity are not available.

Compliance and loss to follow up of HIV negative and positive mothers recruited from a PMTCT programme in Zimbabwe

OBJECTIVE

To describe the methodological challenges of a nine months follow up study of mothers recruited from a national Prevention of Mother To Child Transmission (PMTCT) programme with regards to defaulters, drop outs and compliance.

DESIGN

Nested case control study.

SETTING

Three peri-urban clinics in Zimbabwe namely: Epworth, St Mary's, Seke North.

METHOD

Pregnant women who enrolled at 36 weeks of gestation were recruited for a follow up of mother and child from delivery, six weeks, four and nine months post partum. Follow up trend of these women was compared between the HIV positive and negative mothers with regards to defaulting, drop outs, full and partial compliance. Statistical significance was computed using the Chi-square test.

RESULTS

Of the enrolled 1050 pregnant women with a known HIV status (594 HIV negative and 456 HIV positive) 851 (457 HIV negative and 394 HIV positive) showed up at one or more visits scheduled up to nine months. The denominator was dropping at each point and time. The overall dropout rate was 19% without a significant difference between the HIV positive and negative women at delivery. At six weeks the drop out rate was 35 (7.7%) for the HIV positive versus 75 (12.9%) p=0.010 and at four months 12 (2.9%) versus 39 (7.7%) p=0.002 respectively. However, at nine months the drop out rate was not different (p=0.747). The defaulter rate was significantly different at every stage between the HIV positive and negative mothers from delivery to six weeks, becoming even more significant at the four and nine months visit (p=<0.001). The overall full compliance at nine months was 46.1% with a significant difference between the HIV positive (55.6%) versus (37.9%) for the HIV negative (p=<0.001).

CONCLUSION

Drop out is highest among the HIV negative as opposed to the HIV positive with the peak period being at "six weeks". There is high defaulting among the HIV negative compared to the HIV positive with the peak being at "four months". The study has shown that the HIV negative women are more likely to drop out whereas the HIV positive were twice as likely to fully comply. It is surprising that the peak drop out period, "six weeks visit" is a cardinal existing national scheduled visit where both mother and baby undergo a full medical examination with the mother having a pap smear taken.

A historical perspective of registered cases of malignant ocular tumors in Zimbabwe (1990 to 1999). Is HIV infection a factor?

INTRODUCTION

Anecdotal and published reports suggest that ocular tumours are on the increase in Zimbabwe.

OBJECTIVES

To determine the trends in incidence rates of common malignant ocular tumours registered with the Zimbabwe Cancer Registry during the last decade (1990 to 1999).

DESIGN

Retrospective study.

SETTING

Data were collected from the Zimbabwe National Cancer Registry, the Zimbabwe National Census 1992 and 2002 Reports, and patient records from hospitals.

SUBJECTS

All cases of malignant ocular tumours registered with the Zimbabwe National Cancer Registry between 1 January 1990 and 31 December 1999.

MAIN OUTCOME MEASURES

Age standardized annual incidence rates for registered cases of common ocular tumours.

RESULTS

The age-adjusted annual incidence rates of squamous cell carcinoma of the conjunctiva had a more than 10-fold increase from 0.17 to 1.8 per 100,000 people during periods 1990 and 1999 respectively. Retinoblastoma dropped by more than half from 0.8 to 0.34 per 100,000 during the same period. The annual age standardised incidence rates for all ocular tumours showed a significant upward linear trend (chi2: 362.78, df=9 and p < 0.001). There was no significant gender difference in the distribution of these tumours amongst the study population.

CONCLUSION

The increasing trend in the age-adjusted annual incidence rates of ocular surface squamous neoplasms could be attributed to the worsening HIV and AIDS pandemic in Zimbabwe or improved access/utilization of health services by the public.

Decline in HIV prevalence among women of childbearing age in Moshi urban, Tanzania

The objective of this study was to describe trends over time in HIV prevalence, sexually transmitted infections (STIs) and sexual behaviour among women in Moshi urban, Tanzania. Two cross-sectional studies were conducted in 1999 and in 2002-04 among women attending three primary health-care clinics. They were interviewed and screened for HIV and STIs. There was a significant decrease in HIV prevalence (11.5-6.9%). The decline was greatest among women aged 15-24 years. Syphilis, trichomoniasis, bacterial vaginosis, genital ulcers and reported STI symptoms also decreased significantly over the three-year inter-survey period. The proportion of women reporting casual sex decreased and knowledge of STI symptoms and health-care seeking behaviour improved. Herpes simplex virus type 2, genital warts, age at sexual debut, age at first pregnancy and condom use remained unchanged. In conclusion, decline in curable STIs and casual sex partners may partly explain the observed decline in HIV seroprevalence. Both STIs and sexual behaviour should be monitored in HIV sentinel surveillance. There remains a gap between knowledge of preventive behaviour and actual preventive practices.

Human immunodeficiency virus, smoking and self-rated health in Harare, Zimbabwe

SETTING

Twenty-two urban factories in Harare.

OBJECTIVE

To determine the relationship between the human immunodeficiency virus (HIV), smoking and self-rated health in a high HIV prevalence urban workforce.

DESIGN

Cross-sectional survey.

RESULTS

Of 7482 employees, 6111 (82%) consented to interview and anonymous HIV serology; 88% were male; median age was 34 years. HIV prevalence was 19%. Current (median 6 cigarettes per day) and former smoking were reported by 17% and 7%, respectively. Smoking (current or former) was more common among HIV-positive (27%) than -negative participants (17%; P < 0.001). Factors significantly associated with being a smoker on multivariate analysis were being HIV-infected (OR 1.5, 95% CI 1.4-1.7), older age (P < 0.001), non-Christian (OR 1.6, 95% CI 1.2-2.2) and manual job (OR 1.4, 95% CI 1.2-1.6). Women (OR 0.05, 95% CI 0.03-0.11) and the better educated (OR 0.7, 95% CI 0.5-0.9) were significantly less likely to smoke. HIV-positive smokers had the highest risk of reporting poor health (adjusted OR compared to HIV-negative non-smokers 3.4, 95% CI 2.3-5.0).

CONCLUSIONS

Smoking was significantly more common among HIV-positive than -negative employees in this predominantly male workforce. There was evidence of a combined effect on self-rated poor health, a variable shown to be a strong independent predictor of mortality in industrialised countries. Interventions to encourage smoking cessation may be an important component of HIV care in Southern Africa.

Ocular surface squamous neoplasia (OSSN) and human immunodeficiency virus at Sekuru Kaguvi Eye Unit in Zimbabwe: the role of operational research studies in a resource poor environment?

OBJECTIVE

To determine the extent of association and relative risk of developing ocular surface squamous neoplasia (OSSN) among HIV positive patients seen in July 2004 at Sekuru Kaguvi Eye Unit, in Harare, Zimbabwe.

DESIGN

Prospective study.

SETTING

Sekuru Kaguvi Eye Unit.

SUBJECTS

All patients who presented with conjunctival growths in July 2004.

MAIN OUTCOME MEASURE

Relative risk.

RESULTS

The relative risk of being HIV positive among patients with ocular surface squamous neoplasia was 3.6 with 95% CI 1.5 to 8.6. The mean CD4 cell count level was significantly lower among OSSN patients when compared to patients with non-ocular surface squamous neoplasia.

RECOMMENDATIONS

1. HIV related malignancies can be used as an indicator of when to commence patients on anti-retroviral (ARVs) when CD4 counts are not accessible; 2. Medical practitioners in resource-poor settings should conduct meaningful operational research as part and parcel of their routine clinical work using available resources, since funding is not readily available.

A pilot study to assess the immunologic and virologic efficacy of generic nevirapine, zidovudine and lamivudine in the treatment of HIV-1 infected women with pre-exposure to single dose nevirapine or short course zidovudine and their spouses in Chitungwiza, Zimbabwe

OBJECTIVE

A pilot study to assess effectiveness of generic Nevirapine (NVP)+Zidovudine (AZT)+Lamivudine (3TC) as potent antiretroviral therapy (ART) in women exposed to either SD NVP or short course (SC) AZT through participation in prevention of mother-to-child transmission of HIV-1 (pMTCT) interventions, and their spouses.

DESIGN

A pilot study of antiretroviral treatment of adults with AIDS.

SETTING

Primary health care clinics; Seke North and St Mary's in Chitungwiza, Zimbabwe.

SUBJECTS

Women with pre-exposure to SD NVP or SC AZT and their spouses with CD4 count < 200 cells/

INTERVENTIONS

Generic AZT/3TC twice daily plus NVP daily for the first 14 days and then twice a day thereafter, administered to the cohort.

MAIN OUTCOME MEASURES

The baseline median CD4 count for women and men was 128.5 and 119.0 cells/ microL respectively. The geomean virus load was similar for the women and men. At weeks 16, 24 and 48, 82.8%, 85.1% and 73.8% had < 400 copies/ml of HIV RNA respectively. Only at 16 weeks, was the proportion of women (75.9%) with undetectable virus significantly lower than that for men (93.9%), p = 0.031. Median CD4 count for both men and women increased significantly, p < 0.001. There were no significant differences in virologic responses between the women with pre-exposure to SD NVP and SC AZT. The mean adherence for women and men was similar, > 98%.

CONCLUSION

Women showed a significantly reduced response top ART relative to men only at 16. However, prior exposure to SD NVP for PMTCT was no more likely to negatively influence responses to ART than use of SC AZT.

Ranula: another HIV/AIDS associated oral lesion in Zimbabwe?

AIM

To show that sublingual ranula is associated with HIV/AIDS and as such should be considered an HIV/AIDS associated oral lesion in Zimbabwe.

OBJECTIVES

To retrospectively study the prevalence, age and gender distribution, the HIV serostatus of ranula patients and the trend in prevalence of ranula and Kaposi's sarcoma (KS) in patients at the two largest referral Oral and Maxillofacial Surgery specialist centres in Harare, Zimbabwe. To use this information to infer an association between ranula and HIV/AIDS in Zimbabwe.

DESIGN

Descriptive study with a retrospective and prospective component.

SETTING

Oral and Maxillofacial Surgical clinics at specialist referral hospitals, Harare Central Hospital and Parirenyatwa Government Hospital, Harare, Zimbabwe.

SUBJECTS

Eighty-three cases of ranula were studied: 45 cases retrospectively and 38 consecutively. A total of 231 cases of KS were studied retrospectively.

METHODS

Histopathologic records of patients who presented with ranula and KS during the period January 1981 to September 2003 were studied. Gender and age were recorded for each case. Thirty-eight ranula patients studied consecutively during the period June 1999 to September 2003 were consented for HIV testing.

RESULTS

There were 83 cases of ranula; 43.4% male and 56.6% female. There were 231 cases of KS, 61.2% male and 38.8% female. Male to female ratio was 1:1.3 for ranula and for KS was 1:0.6. Ranula was predominant in the 0-10 year age group (73.5%) while KS was most common in the 21-40 year age group (76.4%). Ranula and KS both had a marked rise in prevalence from 1992 to 2003. A total of 88.5% of the ranula cases tested HIV positive with 95% in the 0-10 year age group.

CONCLUSION

There was a rising prevalence of ranula which mirrors that of KS (an HIV/AIDS associated oral lesion) and that 88.5% of ranula patients were HIV positive with 95% of them in the 0-10 year age group. Sublingual ranula should thus be considered another HIV/AIDS associated lesion in Zimbabwe, especially in children.

Survival pattern among infants born to human immunodeficiency virus type-1 infected mothers and uninfected mothers in Harare, Zimbabwe

OBJECTIVES

To determine the mother-to-child transmission (MTCT) rate of HIV-1 and to compare the survival patterns among infants born to HIV-1 infected and seronegative mothers.

DESIGN

A two year prospective study from 1991 to 1995.

METHODS

345 HIV-1 infected mothers and 351 seronegative mothers and their infants were examined at regular intervals up to 24 months of age.

RESULTS

The intermediate estimate of MTCT rate of HIV-1 was found to be 31.9%; (95% confidence interval (CI) 26.9 to 37.1). Of infants born to HIV-1 infected mothers 17% died compared with 2% of infants born to seronegative mothers. Forty six (43%) of the 107 HIV-1 infected infants died compared with 16 (219%) of the 559 uninfected infants. In a multivariate analysis, risk factors independently associated with infant mortality were low birth weight (hazard ratio (HR) 2.80; CI 1.52 to 5.13), HIV infected infant (HR 10.50; CI 5.48 to 20.15), HIV infected mother (HR 3.23; CI 3.17 to 15.85) and maternal death (HR 2.77; CI (1.09 to 7.06).

CONCLUSION

The estimated MTCT rate of HIV-1 is comparable with rates of 25% to 45% reported from the African region. The poor survival of HIV-1 infected infants indicates the necessity for effective and comprehensive HIV/AIDS control strategies in Zimbabwe.

Cancer of the cervix: knowledge, beliefs and screening behaviours of health workers in Mudzi District in Mashonaland East Province, Zimbabwe

OBJECTIVE

To assess the knowledge, beliefs and screening behaviours on cervical cancer among health workers in Mudzi District.

DESIGN

Cross sectional survey.

SETTINGS

Mudzi District Hospital and all the 20 rural health centres in Mudzi District of Mashonaland East.

SUBJECTS

Sixty health workers in Mudzi District.

MAIN OUTCOME MEASURES

Knowledge of cervical cancer risk factors, screening methods and treatment options. Beliefs and screening behaviours.

RESULTS

The knowledge levels were lower for many of the predisposing factors of cervical cancer except for the use of vaginal herbs or chemicals, which 85% of the health workers knew. Though 50% of the respondents knew of the Pap smear as a screening method for cervical cancer, 86.6% did not know the human papiloma virus screening and 90% did not know of the visual inspection of the cervix using acetic acid. There were also very low knowledge levels for most of the treatment options for pre-cancer with all health workers not knowing the leep and the Laser options. The majority 73.3% believed that they where not at risk of developing cervical cancer. Most of the respondents, 81.7%, had not undergone any form of cervical cancer screening. However, the main reason for non screening was that there were no cervical cancer screening facilities in Mudzi District.

CONCLUSION

The study revealed low knowledge levels, negative beliefs about the risk of developing cervical cancer and poor screening behaviours among health workers in Mudzi District. Training in cervical cancer is, therefore, recommended for the health workers. However, the training should be combined with setting up facilities for cervical cancer screening.

The trend of ocular surface squamous neoplasia among ocular surface tumour biopsies submitted for histology from Sekuru Kaguvi Eye Unit, Harare between 1996 and 2000

OBJECTIVE

To determine the trend in the prevalence of ocular surface squamous neoplasia (OSSN) among ocular surface tumour biopsies submitted for histology from Sekuru Kaguvi Eye Unit (SKEU), Harare between January 1996 and August 2000.

DESIGN

The study was a retrospective records review of patients who had biopsies of ocular surface tumours done during the study period.

SETTING

National Referral Centre for eye patients (Sekuru Kaguvi Eye Unit), Parirenyatwa Hospital, Harare, Zimbabwe.

SUBJECTS

A total of 1,587 records of patients who had ocular surface tumour biopsies performed were reviewed.

MAIN OUTCOME MEASURE

Period prevalence of OSSN among ocular surface tumour biopsy specimens submitted for histology during the period under review.

RESULTS

The median age of patients with OSSN was significantly different from the median age of patients with other conjunctival tumours: 35 years (interquartile range [IQR] 25 to 47 years) versus 51 years (IQR 25 to 60 years), p < 0.0005 respectively. Four hundred and thirty out of 615 (70%) patients with OSSN were females. The overall period prevalence of OSSN was 615 of the total of 1,587 (38.8%). The annual prevalence of OSSN among ocular surface tumour biopsy specimens was found to be on the increase and ranged from 33% (115) in 1996 and 57.9% (165) during the year 2000. The Chi-squared test for trend analysis showed a significant upward linear trend (x2 = 27.4, p < 0.004). Fifty three percent of the tumours were OSSN, 42% were pterygium and 5% were pyogenic granulomas of the conjunctiva.

CONCLUSION

OSSN is the commonest tumour of the ocular surface whose primary site is the conjunctiva. Its prevalence in Zimbabwe is on the increase and it has a predilection for females over males. Further studies on the natural history, treatment and patient profile would pave a way to better quality of patient care and establish its association with HIV/AIDS.

Effect of HIV Disease in Treatment Outcome of Cervical Squamous Intraepithelial Lesions Among Zimbabwean Women

OBJECTIVE.: To compare the treatment outcome of cervical intraepithelial neoplasia (CIN 2,3) on HIV-infected and uninfected women treated by cryotherapy or loop electrosurgical excision procedure (LEEP). METHODS.: A total of 147 women were recruited into the study between April 1997 and May 1998. Cryotherapy was performed in 75 women and LEEP in 72 women after randomization. RESULTS.: A total of 109 (74.1%) women tested positive and 38 (25.9%) tested negative for HIV-1. At 12 months follow-up visit, cryotherapy had 59.5% cure rate on HIV-positive women and 84.2% success among HIV-negative women (p = .057). LEEP had 86% cure rate on HIV-positive and 100% cure rate on HIV-negative women (p = .328). CONCLUSION.: HIV-1-infected women harboring cervical squamous intraepithelial lesions have a high failure rate (40.5%) when treated by cryotherapy.

Misoprostol versus oxytocin in the third stage of labor

OBJECTIVES

A double blind randomized controlled trial was performed at the tertiary hospital in Harare, Zimbabwe to compare oral misoprostol with intramuscular oxytocin in the management of third stage of labor.

METHODS

A total of 499 women were randomized to receive either 400 microg misoprostol orally or 10 IU oxytocin intramuscularly. The incidences of postpartum hemorrhage and side effects were examined.

RESULTS

The demographic and labor characteristics were comparable. Postpartum hemorrhage occurred in 15.2% of women given misoprostol and in 13.3% of those given oxytocin (P=0.534). Measured blood loss of more than 1000 ml occurred in 3.7% of the misoprostol group compared with 2% in the oxytocin group (P=0.237). There was no significant difference in the need for additional oxytocic drugs or blood transfusion in women given misoprostol (P values 0.137 and 0.600, respectively). Significant side effects of misoprostol were shivering [RR=1.32 (95% CI 1.11-1.58); P=0.002) and a rise in temperature [RR=2.02 (95% CI 1.75-2.33); P<0.001].

CONCLUSIONS

Oral misoprostol is as effective as intramuscular oxytocin in the prevention of PPH. Shivering and transient pyrexia were specific side effects of misoprostol. Misoprostol has potential in reducing the high incidence of PPH in developing countries.

A randomised clinical trial of loop electrosurgical excision procedure (LEEP) versus cryotherapy in the treatment of cervical intraepithelial neoplasia

The objective of the treatment of cervical intraepithelial neoplasia (CIN) is the prevention of invasive carcinoma of the cervix, which still remains the most common cancer in Zimbabwean women, as in most other low-resource countries where screening facilities are grossly inadequate. We conducted a randomised prospective study to compare CIN treatment outcome after cryotherapy and loop electrosurgical excision procedure (LEEP) in 400 women with histologically confirmed high grade squamous intra-epithelial lesions (HGSIL). Treatment outcome measures were immediate complications, persistent disease and recurrent disease evaluated at follow-up visits. Eighty-two per cent of the women (159 cryotherapy, 168 LEEP) completed their 6-month and 12-month follow-up visits. LEEP had a significantly higher overall cure rate of 96.4% (absence of persistent or recurrent disease) compared to 88.3% cryotherapy (P=0.026). Although cryotherapy was not superior to LEEP, its cure rate (88.3%) is acceptable and therefore provides a viable treatment option for low resource countries such as Zimbabwe where the majority of women at risk for cervical cancer reside in rural areas.

Mercury poisoning: prevalence, knowledge and frequency of gold panning and doing retort among alluvial gold panners in Chiweshe and Tafuna communal lands in Zimbabwe

OBJECTIVES

To estimate the prevalence of mercury poisoning, to estimate the knowledge level that mercury can be a poison, and to establish the frequency of gold panning and doing retorts.

DESIGN

Cross sectional study.

SETTING

Chiweshe and Tafuna communal lands.

SUBJECTS

Gold panners.

MAIN OUTCOME MEASURE

Mercury levels in blood and urine.

RESULTS

Totals of 23 respondents from Chiweshe and 43 respondents from Tafuna were recruited. Four out of 43 respondents in Tafuna and seven out of 23 respondents in Chiweshe had levels of mercury greater than 0.05 mg/L in blood (p = 0.040). Out of 43 respondents in Tafuna, four (9.3%) had levels of mercury of more than 0.01 mg/L in urine. Totals of 18 out of 37 and seven out of 22 respondents from Tafuna and Chiweshe, respectively, did not know that mercury could be a poison. Altogether, 35 (56.5%) out of 62 respondents were full time gold panners. Significantly more respondents in Chiweshe (14/19) than in Tafuna (8/29) did less than four retorts per month (p = 0.005). Respondents who did four or more retorts per month were 3.21 (95% CI 1.06 to 9.72) times more likely to have had raised levels of mercury in their blood compared with persons who did less than four retorts per month.

CONCLUSION

Mercury poisoning among gold panners in Chiweshe and Tafuna communal lands is of public health importance. Panners should be educated on the possibilities of mercury being a poison. A low cost and safe technology to separating mercury from the amalgam should be introduced to the panners.

Serum IgG subclasses levels in paediatric patients with pneumonia

OBJECTIVES

To determine the IgG subclass levels of patients admitted to Harare Central Hospital paediatric wards with pneumonia.

DESIGN

A cross sectional study.

SETTING

Harare Central Hospital, Departments of Immunology and Paediatrics, University of Zimbabwe; Department of Paediatric Immunology, University of Utrecht, The Netherlands.

SUBJECTS

56 paediatric patients.

MAIN OUTCOME MEASURES

IgG subclass profiles of children with pneumonia.

RESULTS

Of the 56 children tested, 40 (71%) had antibodies to human immunodeficiency virus (HIV). The levels of IgG1 and IgG3 subclasses were significantly higher in HIV antibody positive children (p < 0.001, p < 0.01 respectively) than in those without detectable HIV antibodies in their sera. There was no significant relationship between IgG subclass levels and the presence of HIV p24 antigen. Furthermore, age and gender also had no significant influence on the levels of IgG subclasses in this population.

CONCLUSION

High levels of IgG1 and IgG3, but not IgG2 and IgG4, occur frequently in children with pneumonia and are associated with the presence of HIV antibodies.

Comparative evaluation and assessment of the diagnostic usefulness of four commercial HIV-1/HIV-2 antibody assays using two well-characterized serum panels from Blood Transfusion Service and the National Health Laboratory Services in Zimbabwe

OBJECTIVE

To evaluate four Enzyme Linked Immunosorbent Assay (ELISA) HIV kits for possible use as a combination at the National Health Laboratory Services (NHLS) in Zimbabwe.

DESIGN

Laboratory evaluation, sensitivity, specificity and cost effectiveness of HIV diagnostic kits.

SETTING

Blood Transfusion Service (BTS) and Parirenyatwa Hospital in Zimbabwe.

SUBJECTS

A total of 346 samples from 245 patients referred to Parirenyatwa Hospital and 101 blood donors at BTS.

MAIN OUTCOME

The main goal was to come out with the best combination of ELISA kits in terms of sensitivity, specificity and cost effectiveness for use in diagnosis of HIV infection in Zimbabwe.

RESULTS

The best combination kit was the Murex/Innotest with 100% sensitivity and 98.9% specificity, being slightly superior to the Genelavia/Vironostika combination kits in current use at NHLS. In addition, the Murex/Innotest combination has the shortest assay running time and requires fewer internal controls thereby increasing the number of test specimens per run.

CONCLUSION

We recommend the use of the Murex/Innotest kits as a suitable combination for HIV infection diagnosis in Zimbabwe. The combination has a relatively low number of discordant results, drastically reducing the cost of running a third confirmatory test to resolve the discordant results. Most importantly, this combination maximizes HIV infection diagnosis by its ability to detect antibodies to HIV-1 groups M and O as well as HIV-2.

Situation analysis for cervical cancer diagnosis and treatment in east, central and southern African countries

OBJECTIVE

To determine the factors influencing cervical cancer diagnosis and treatment in countries of East, Central and Southern Africa (ECSA).

METHODS

Data were collected from randomly selected primary health care centres, district and provincial hospitals, and tertiary hospitals in each participating country. Health care workers were interviewed, using a questionnaire; the facilities for screening, diagnosing, and treating cervical cancer in each institution were recorded, using a previously designed checklist.

FINDINGS

Although 95% of institutions at all health care levels in ECSA countries had the basic infrastructure to carry out cervical cytology screening, only a small percentage of women were actually screened. Lack of policy guidelines, infrequent supply of basic materials, and a lack of suitable qualified staff were the most common reasons reported.

CONCLUSIONS

This study demonstrates that there is an urgent need for more investment in the diagnosis and treatment of cervical cancer in ECSA countries. In these, and other countries with low resources, suitable screening programmes should be established.

A review of cervical cancer patients presenting in Harare and Parirenyatwa Hospitals in 1998

OBJECTIVE

To document the socio-demographic profile, presenting symptoms, disease stage and treatment modality offered to all women attending Harare and Parirenyatwa Hospitals with a histological diagnosis of invasive cervical cancer in 1998.

DESIGN

A cross sectional study.

SETTING

Parirenyatwa Hospital and Harare Central Hospital.

SUBJECTS

All women with a histological diagnosis of cervical cancer admitted between 11 January 1998 and 14 December 1998 were recruited into the study.

RESULTS

A total of 196 patients, with a median age of 47 years (range 24 to 80 years) were recruited into the study. A high proportion (63.3%) of the women were from rural areas. The mean age at first pregnancy was 17.9 years (SD 2.8) and 112 (63.3%) first sought treatment at the primary health care centre. Persistent vaginal discharge was the most frequent (69.4%) presenting complaint. One hundred and ninety five patients (99.5%) had histological confirmation of invasive cervical cancer (91.8% squamous cell carcinoma, 7.7% adenocarcinoma). Clinical staging by The International Federation of Gynaecology and Obstetrics (FIGO) classification confirmed that the majority (80.3%) of the cancers had spread from the cervix into the parametrium and beyond (stage 2b and above) at the time of presentation. Radiation therapy was the most commonly used (77.0%) treatment modality.

CONCLUSION

This study demonstrates that the burden of cervical cancer occurs around the peak age of 47 years and that the majority of women present with advanced disease. None of the women had ever been screened for cervical cancer. The planned introduction of a cervical cancer screening programme by visual inspection of the cervix with acetic acid (VIA), together with a health education campaign may result in a shift towards more women presenting with early curable cervical cancer cases.

The reported quality of condom use by young adult Zimbabwean males at higher learning centres in Harare

OBJECTIVE

To examine the level of reported quality of condom use by young adult Zimbabwean males at higher learning institutions.

DESIGN

A cross sectional descriptive survey.

SETTING

Two technical colleges in Harare, Zimbabwe.

SUBJECTS

A sample of 400 subjects (200 from each of the higher learning centres).

MAIN OUTCOME MEASURES

Reported quality of condom use.

RESULTS

All participants were males who had at least completed 'O' levels, or the equivalent of high school. The majority of the participants were single (78.2%), while a fifth (20.2%) were married and the remaining few were separated or living with a partner. Among those who were married about one fifth had children. The majority 136 (36.8%) were Roman Catholic. The mean age of students surveyed was 24 (SD 3.5) years. The reported quality of condom use in the last 12 months in this sample was measured by four items: 24.6% reported using condoms every time; 27.7% put the condom on every time before the penis entered the vagina for the first time; 29.3% still had an erection every time they withdrew from the vagina and 26.9% held onto the condom every time they withdrew. In this study the results indicated that behaviour specific influences i.e. attitudes towards condom use, use of marijuana, the situational influences of bars, and condom self-efficacy were independently predictive of the reported quality of condom use.

CONCLUSION

Using the health promotion model the results indicated that marital status, having been shown how to use condoms, attitudes towards condom use and use of marijuana were all independently predictive of the reported quality of condom use.

Situation analysis of obstetric care services in a rural district in Zimbabwe

OBJECTIVE

To conduct a situation analysis of obstetric services in a rural district of Zimbabwe.

DESIGN

Observational study.

SETTING

13 primary health care centres in Murewa district in Zimbabwe.

MAIN OUTCOME MEASURES

Number of maternity beds, antenatal attendance, deliveries per month, availability of antenatal, intrapartum and neonatal care equipment, intrapartum monitoring and neonatal resuscitation skills.

RESULTS

13 of 15 primary health care clinics providing obstetric care in Murewa district were surveyed in 1995. Median number of maternity beds were nine (Q1 = 0, Q3 = 11) per clinic, median number of first ANC attenders per month was 15 (Q1 = 3, Q3 = 18), median number of deliveries per clinic per month were eight (Q1 = 0, Q3 = 16). While all clinics had laboratory facilities, 6/13 could estimate haemoglobin, 5/13 syphilis serology, none of the clinics sent blood to district hospitals for blood grouping and there were no microscopes at clinics for malaria parasite determination. Only 6/13 clinics used partographs for monitoring labour, 10/13 had suction machines for neonatal resuscitation while only 3/13 had ambu bags, 3/13 had oxygen and 2/13 had heaters. Correct methods for neonatal resuscitation were used in 3/13 clinics. Clean water supply, reliable power supply and the referral system were not optimal.

CONCLUSION

Basic equipment for antenatal, intrapartum and neonatal care was inadequate. Essential laboratory facilities for obstetric care were lacking. Skills for intrapartum monitoring and neonatal resuscitation were inadequate. The referral system was poor. There is need for more strategic planning at primary health care level in this district which is known to have high perinatal and neonatal death rates. More emphasis should be placed on strengthening basic laboratory back up service for obstetric care, strengthening infrastructural and referral systems as well as training in areas of lost or no skills.

Perinatal practices in two rural districts of Zimbabwe: a community perspective

OBJECTIVE

To describe perinatal practices from a community perspective and identify factors associated with perinatal death.

DESIGN

Cross sectional community based survey.

SETTING

Murewa and Madziwa rural areas, Zimbabwe.

SUBJECTS

Women aged 15 to 50 years who had been pregnant within the 24 months preceding the survey.

MAIN OUTCOME MEASURES

Where delivered, where preferred to deliver, model of delivery, use of herbs in labour, duration of labour, assistant at delivery, time of delivery, condition of baby at birth, resuscitation methods, birth weight, initiation of breast feeding, illness in the first week and outcome of pregnancy.

RESULTS

644 women were interviewed; 581/644 stated where they would have liked to deliver and 505/644 stated where they actually delivered their last baby. The majority 369/581 (62.4%) preferred to delivery at a government hospital and 240/505 (47.5%) actually delivered at a government hospital. Of the home deliveries only 27/581 (4.6%) preferred to deliver at home and yet 123/505 (24.4%) actually delivered at home. Primary care clinics were less preferred 151/581 (25.5%) as a place for delivery and 89/505 (17.6%) actually delivered there. Labour lasting more than 12 hours occurred in 20.4% of deliveries. Nurses were the commonest attendants at delivery 309/508 (60.4%) and morbidity following delivery was noted in 72/495 (14.5%). Resuscitation was carried out in 61/72 infants. Beating/shaking 36/61 (58.0%) and pouring cold water over the baby 11/61 (18.0%) were the commonest methods of resuscitation. Being delivered by a doctor compared to a nurse and being in Murewa district were statistically significant risk factors for mortality with Odds Ratio (OR) 5.21 (95% CI 2.86 to 9.51) and 3.90 (95% CI 1.51 to 10.09) respectively. The odds of dying when delivered by breech extraction were high, but not statistically significant OR 3.73 (95% CI 0.92 to 13.97) when compared to being delivered by vertex delivery. Labour more than 12 hours, use of herbs in pregnancy and time of delivery were not significantly associated with mortality with OR (95% CI) of 1.02 (0.40 to 2.19), 0.92 (0.00 to 4.38), 1.05 (0.56 to 1.97) respectively. On logistic regression analysis only being delivered in Murewa district remained significant.

CONCLUSION

The utilisation of primary health care centres for delivery was unexpectedly low and home deliveries were unacceptably high. Increased mortality when delivered by a doctor and high early neonatal morbidity suggest poor monitoring and delayed intervention in labour. Infant morbidity following delivery was high and methods for neonatal resuscitation inappropriate. There is a need for more studies looking into health worker skills particularly in the areas of partogram use and neonatal resuscitation in these districts.

Risk awareness of HIV/AIDS among commercial farm workers in Zimbabwe

OBJECTIVE

To determine levels of perceived risk of HIV infection and the determinants of these perceptions among commercial farm workers.

DESIGN

Cross sectional.

SETTING

Commercial farms in Manicaland, Mashonaland Central, Mashonaland West and Mashonaland East provinces of Zimbabwe.

SUBJECTS

406 male and 411 female adults.

MAIN OUTCOME MEASURES

Perceived risk of HIV infection.

RESULTS

Out of 33 female respondents aged less than 20 years, 19 (57.6%) reported that they had no chance of acquiring the HIV infection. The majority (15) of these 19 teenagers indicated that they had no chance of being HIV infected because they had sex only with their spouses. Of the respondents aged 20 years or more, 235 (64.6%) males and 182 (55.3%) females reported that they had no chance of being HIV infected (OR = 1.47, 95% CI 1.07 to 2.02, p = 0.016). Most males (57.0%) and females (59.9%) of age 20 years or more said that they had no chance of being HIV infected because they had sex with only their spouses. Among the respondents of age 20 years or more who indicated they had a moderate to high chance of being infected or were already infected, 35 (33.3%) of the males reported that they had multiple partners and 41 (40.6%) of the females reported that their spouses had multiple partners.

CONCLUSION

In general, despite high seroprevalence rates in Zimbabwe, many individuals do not perceive themselves at risk. Future health education intervention studies should seek to increase the general perception of low risk so that adequate precaution can be taken against being infected.

Antenatal care patterns and factors associated with perinatal outcome in two rural districts in Zimbabwe

OBJECTIVE

To study antenatal care (ANC) patterns, to identify factors associated with poor perinatal outcome and quality of ANC.

DESIGN

Cross sectional community based survey.

SETTING

Murewa and Madziwa rural Districts.

SUBJECTS

644 women aged between 15 to 50 years who had been pregnant in the immediate 24 months preceding the survey.

MAIN OUTCOME MEASURES

Perinatal outcome, ANC attendance, distance from health centre, ability to pay for ANC, gestation at first booking, frequency of ANC visits, use of herbs in pregnancy, pregnancy related morbidity and quality of ANC.

RESULTS

A total of 644 women were interviewed. Overall perinatal mortality was 115 per 1,000 births. 511/644 (79.3%) visited a health centre for ANC. The woman herself (41.8%) as well as husbands (41.8%) were commonly the decision makers regarding starting ANC. Only 298/510 (58.4%) of women used primary health care facilities for ANC. 211/629 (35.1%) of women lived more than 5 kms from the health care centre. 153/629 (24.3%) were not able to pay for ANC. Only 110/509 (21.6%) started ANC in the first trimester. 307/495 (62.0%) made five or less ANC visits. Pregnancy related morbidity was high 209/644 (32.5%) and use of traditional herbs was common 158/644 (24.%). There were significant differences between districts as far as perinatal outcome, ANC attendance, distance from health centre, ability to pay for ANC, gestation at first booking, frequency of ANC visits, use of herbs in pregnancy, pregnancy related morbidity and quality of care all having p values of 0.001 or less. On further analysis using logistic regression, having problems with pregnancy and vaginal bleeding were significant predictors of poor perinatal outcome with odds ratio (95% CI) of 2.8 (1.4 to 5.9) and 3.0 (1.1 to 8.6) respectively. Quality of ANC was rated as sub-optimal.

CONCLUSION

Majority of rural women attended clinics for ANC. Perinatal mortality rate and pregnancy related morbidity were high. Vaginal bleeding was the strongest predictor for mortality. There is need to improve quality of antenatal care as this was found to be suboptimal. More objective oriented antenatal care visits and waiting mother's shelters form part of the solutions. Further studies are called for.

Prophylactic augmentin in prelabor preterm rupture of the membranes

OBJECTIVE

To determine whether the use of prophylactic Augmentin in PPROM prolongs gestation and reduces neonatal and maternal morbidity due to sepsis.

METHOD

Study setting was Harare Maternity Hospital, Zimbabwe. Women with PPROM between 26 and 36 weeks' gestation were randomly allocated either to a group given a course of prophylactic oral Augmentin or another receiving no prophylactic antibiotic treatment. The calculated sample size was 72 women per group. Data were analyzed using the EPI INFO program.

RESULTS

A total of 171 women were recruited into the study, 84 in the Augmentin group and 87 in the No Treatment group. The group receiving prophylactic Augmentin had a significantly longer latency period between rupture of membranes and delivery. There was a trend towards increased neonatal and maternal morbidity due to sepsis in the No Treatment group although no statistical significance was reached.

CONCLUSION

The use of prophylactic Augmentin in PPROM significantly prolongs gestation. It appears to decrease neonatal and maternal morbidity due to sepsis.

Visual inspection of the cervix as a primary means of cervical cancer screening: results of a pilot study

OBJECTIVE

To measure the effectiveness of unaided visual inspection (UVI) of the cervix as a primary means of cervical cancer screening.

DESIGN

A cross sectional study.

SETTING

Five primary health care clinics in Mashonaland Province, Zimbabwe.

SUBJECTS

1,000 women aged between 25 and 55 years.

MAIN OUTCOME MEASURES

Sensitivity and specificity of UVI.

METHODS

1,000 women attending primary health care clinics were screened for cervical cancer by six qualified nurses. An unlubricated bivalve speculum was inserted into the vagina under good light to visualize the cervix and a cervical cytology specimen was obtained followed by visual inspection of the cervix stained by 4% acetic acid. All women found to have abnormal cervices by visual inspection and/or by cervical cytology report were scheduled for colposcopy examination at Harare Central Hospital.

RESULTS

236 (23.6%) women had an abnormal cervical appearance after application with 4% acetic acid, out of which 157 (15.7%) were reported abnormal by cytology. True disease as defined by positive colposcopy and positive cytology was confirmed in 38 (3.8%) women. The sensitivity of UVI using colposcopy and cytology as a reference standard was 68.4%, specificity was 3.4%.

CONCLUSION

The results of this study suggest that naked eye inspection of the cervix after application of acetic acid is a practical alternative to cervical cytology in screening for cervical cancer in countries with few resources like Zimbabwe.

Extra-amniotic saline infusion versus extra-amniotic prostaglandin F2alpha for cervical ripening and induction of labor

OBJECTIVE

To compare the effectiveness of extra-amniotic saline infusion versus extra-amniotic prostaglandin F2alpha for cervical ripening, induction of labor and achievement of vaginal delivery in patients with unfavorable cervices.

METHOD

A randomized trial of extra-amniotic saline infusion versus extra-amniotic prostaglandin F2alpha performed at Harare Central Hospital Maternity Unit, Zimbabwe. One hundred and sixty-four patients were recruited from those referred to Harare Central Hospital Maternity Unit who required induction of labor for either maternal or fetal indications.

RESULTS

162 patients (extra-amniotic PgF2alpha group, N = 81; extra-amniotic saline infusion group, N = 81) had complete information. Two patients (one from each group) were lost to follow up. The demographic characteristics of the patients and the indications for induction were not statistically different. There was a marginally statistically significant difference in the change of Bishop Score in favor of the extra-amniotic saline infusion (4.0, S.D. = 1.4) as compared to (4.5, S.D. = 1.5) for extra-amniotic PgF2alpha (P value = 0.047). All other parameters showed no statistically significant differences. Maternal and fetal complications were minimal and not significantly different. Extra-amniotic saline infusion was however almost six times cheaper than PgF2alpha.

CONCLUSION

Extra-amniotic saline infusion is as effective as PgF2alpha, safe, but much cheaper than PgF2alpha and should be seriously considered as a method of first choice in resource-poor settings.

Situation analysis for cervical cancer diagnosis and treatment in Zimbabwe

OBJECTIVE

To establish factors influencing early diagnosis and treatment of cervical cancer in Zimbabwean women.

DESIGN

A cross sectional study.

SETTING

A random selection of 29 primary health care facilities, 11 district/provincial and four tertiary hospitals in Zimbabwe.

RESULTS

All the institutions at primary health care, district, provincial and tertiary levels had the basic infrastructure to perform exfoliative cytology screening (Pap. smear). An average of only nine pap. smears per month were performed at primary health clinics and at district/provincial and tertiary levels seven and 23 Pap. smears per week were done respectively. Infrequent supplies of consumable materials and lack of policy guidelines were the most common reasons for not screening women. Surgical treatment for cervical cancer was offered in all tertiary hospitals but only 22% of provincial hospital had facilities to perform hysterectomy.

CONCLUSION AND RECOMMENDATIONS

There is an urgent need to improve screening for cervical pre-cancer in Zimbabwean women with emphasis to provide adequate treatment facilities especially at district and provincial Hospitals. A national policy guideline should be drawn to address specific ages and frequency of screening for cervical cancer.

Adolescent pregnancy in Zimbabwe: distribution by socio-demographic factors

We conducted a further analysis of the Zimbabwe 1994 demographic health survey data to determine demographic and social factors associated with adolescent pregnancies in Zimba notbwe. Out of a total of 1486 female adolescents sampled, 12 did not provide information on whether they had begun child bearing, and were therefore excluded from the analysis. Significantly elevated odds ratios (OR) were noted for age (OR=2.27,95% confidence interval (CI) 2.01-2.58) and having primary or no education (OR=1.58, 95%CI 1.35,1.87). Watching television every week was protective (OR=0.69, 95%CI 0.57-0.83). Heads of households with less than 25 years of age were 2.10 (95%CI 1.54-2.87) times more likely to have adolescents who were pregnant when compared with heads of households of age 35 years or more. We conclude that electronic media should be continued to be used to deliver sex education messages to adolescents in order to curb the adolescent pregnancy epidemic.

A randomized controlled trial of low-dose aspirin in women at risk from pre-eclampsia

OBJECTIVES

To determine whether low-dose aspirin reduces the incidence of pre-eclampsia, reduces perinatal mortality and improves birth weights in pregnant women considered at high risk of developing pre-eclampsia.

METHOD

Two-hundred fifty subjects were recruited from the antenatal clinics at Harare Central Hospital with either a previous history of pregnancy-induced hypertension or pre-existing chronic hypertension and were randomized to receive either 75 mg of aspirin (ASA) or placebo (PLA).

RESULTS

Two-hundred thirty subjects (ASA, n = 113; PLA, n = 117) completed the trial. The odds of developing pre-eclampsia for those on aspirin was 0.72 times those on placebo (95% CI, 0.34-1.52). The mean birth weight was 2774 g for those on aspirin and 2694 g for those on placebo (P = 0.80). No difference was noted in the perinatal deaths (OR = 0.38; 95% CI, 0.10-1.20).

CONCLUSION

Prophylactic use of aspirin was not associated with a significant effect on the major pregnancy outcomes assessed in this study.

Perinatal mortality rates and associated socio-demographic factors in two rural districts in Zimbabwe

OBJECTIVE

To determine perinatal mortality rates and associated socio-demographic factors in two rural districts in Zimbabwe.

DESIGN

Cross sectional community based survey.

SETTING

Murewa and Madziwa rural districts.

SUBJECTS

Women aged 15 to 50 years who had been pregnant over the preceding two years before the study.

MATERIALS AND METHODS

A questionnaire was administered to eligible women by trained interviewers. Information pertaining to the women's socio-demographic characteristics, reproductive health profile and pregnancy outcome was documented. A post hoc case control analysis was undertaken to determine the risk factors associated with poor perinatal outcome. Women who had a poor perinatal outcome were designated cases and those with a good outcome were designated controls.

RESULTS

The average perinatal mortality rate for both districts was 111 per 1,000 live births (Murewa 182 per 1,000 and Madziwa 48 per 1,000). Factors significantly associated with perinatal mortality were ethnicity, marital status, subjective standard of living and the women's level of formal education. Being Zezuru or being married was associated with poor perinatal outcome. Living well and having high levels of education were also associated with poor perinatal outcome. Perinatal mortality was not significantly associated with maternal age or spouse level of education.

CONCLUSION

This study showed unacceptability high perinatal mortality rates in these rural districts. The true socio-demographic factors associated with perinatal mortality could not be ascertained in this study because of confounding factors. There is need to study quality of antenatal, intrapartum and neonatal care offered by health centres in these districts. In addition there is need to strongly advocate a perinatal programme to address these high mortality rates.

Effects of a randomized health education intervention on aspects of reproductive health knowledge and reported behaviour among adolescents in Zimbabwe

Unwanted teenage pregnancy and the attendant morbidity and mortality necessitate an understanding of the factors influencing adolescent sexuality and the implementation of programmes designed to improve their knowledge and reproductive behaviour. A randomized controlled study on reproductive health knowledge and behaviour was undertaken among adolescent pupils drawn from a multi-stage random cluster sample. A self-administered questionnaire was used to assess aspects of reproductive health knowledge and behaviour at baseline followed by a health education intervention, except for control schools. Results are based on 1689 responses made up of 1159 intervention and 530 control respondents. There was a significant increase in correct knowledge about aspects of menstruation in intervention as compared with control schools [odds ratio (OR) = 4.5, 95% confidence interval (CI) = 3.4-6.1). Significantly, (OR = 2.0, 95%CI = 1.1-3.9) more pupils from intervention than control schools scored correctly on practice relating to menstruation. Pupils from intervention schools were more likely (P < 0.001) to know that a boy experiencing wet dreams could make a girl pregnant and that a girl could get pregnant at her first sexual intercourse (OR = 1.4, 95%CI = 1.1-1.9). Knowledge of family planning was low in both groups at baseline but was high at five months follow-up in the intervention schools. The findings point to the need for early school-based reproductive health education programmes, incorporating correct information on reproductive biology and the subsequent prevention of reproductive ill health.

Trends in reproductive health knowledge following a health education intervention among adolescents in Zimbabwe

BACKGROUND

Unwanted teenage pregnancy, sexually transmitted infections and the attendant morbidity and mortality necessitate the need for understanding factors influencing adolescent sexuality and the implementation of programmes designed to improve their knowledge, reproductive behaviour, sexual and reproductive health.

OBJECTIVE

To determine the impact of an intervention package on knowledge levels of various reproductive health issues through trend analysis.

DESIGN

Randomized controlled trial of a health education intervention in schools stratified for representativeness.

SETTING

Rural and urban secondary schools in Zimbabwe.

SUBJECTS

1,689 students recruited from 11 secondary schools in Mashonaland Central.

MAIN OUTCOME MEASURE

Knowledge level before and after intervention.

RESULTS

The demographic characteristics of the pupils at baseline, five months and nine months were comparable between the two groups. There was an overall increase in knowledge on menstruation. Students from the intervention schools were more likely to have correct knowledge over time on aspects of reproductive biology. A significant linear trend (p = 0.017) was observed in the area of family planning and contraception. A linear decreasing trend (p = 0.001) was observed on pregnancy risk. Though not significantly linear, the general trend of knowledge levels in all the areas of reproductive health, pregnancy risk, STDs and HIV/AIDS showed an upward trend, from 20% to 96%. Worth noting was that in all the areas the intervention group had knowledge above that in the control group.

CONCLUSION

The reproductive health education intervention had an impact on aspects of reproductive biology and contraception as measured by the increased scoring at follow up when comparing intervention and control schools. The overall findings point to the need for early school based reproductive health education programmes incooperating correct information on reproductive biology and the prevention of subsequent reproductive morbidity by imparting information on non-risk behaviour during the early developmental years.

Ability of caregivers to recognise signs of pneumonia in coughing children aged below five years

OBJECTIVES

This survey was carried out to determine: 1. The ability of caregivers to recognise signs of pneumonia in children aged below five years who are coughing. 2. The proportion of caregivers who possess a watch and are able to use that watch to count respiratory rates in children. 3. The home remedies used for cough.

DESIGN

A cross sectional study.

SETTING

Three Primary Health Care Clinics and a tertiary level hospital in Harare.

MATERIALS AND METHODS

413 children aged less than five years attending a health care centre for cough were studied. Socio-demographic and personal characteristics of both mother and child were documented. An inventory of home remedies that were being used since onset of cough was taken. The child was also examined for signs of pneumonia by both caregiver and research nurse. The sensitivity and specificity of the caregiver's ability to recognise signs of pneumonia compared to the research nurse was calculated.

RESULTS

The ability of caregivers to recognise signs of pneumonia was high (sensitivity 95pc for hospitalized cases and 85pc for the clinic cases). Sensitivity tended to drop with increase in child's age. The caregiver's ability to recognise signs of pneumonia was not significantly related to the number of children she had or her level of education. Only 19.5pc of caregivers owned a watch and could use a watch to count respiratory rates correctly. Those who owned a watch were more likely to count respiratory rates correctly. Those who claimed ability to use a watch actually counted respiratory rates correctly. Sixty six pc had used some remedy to treat the cough at home.

CONCLUSIONS

Caregivers were able to recognise signs of pneumonia without a watch. Only a small proportion of caregivers own watches and are able to use them correctly to count respiratory rates. National ARI control programmes should emphasize caregivers observing breathing when a child has a cough and encourage seeking early and appropriate health care when pneumonia is detected. Watches or timers should be made available and be recommended for use by trained health workers in health centres only. Use of potentially harmful remedies should be discouraged.

Non-condom use among female nurses in Zambia

OBJECTIVES

To estimate non-condom user rate and to characterize non-condom users among female nurses.

DESIGN

Cross sectional.

SETTING

Health institutions.

SUBJECTS

Data from 640 (86.5pc) out of 740 consenting female nurses were available for analyses.

MAIN OUTCOME MEASURE

Non-condom user rate.

RESULTS

Non-condom user rate (per 100) among the female nurses was 73.1pc (95pc CI69.7 to 76.5). Non-condom users tended to be aged above 30 years (OR 1.57; 95pc CI 1.02 to 2.40), midwives (OR 1.56; 95pc CI 1.03 to 2.37), married (OR 2.70; 95pc CI 1.73 to 4.21), not to think that spouse/partner has had sex with other partners (OR 1.72; 95pc CI 1.11 to 2.68) and to have had a sexually transmitted disease (OR 2.61; 95pc CI 1.25 to 5.43).

CONCLUSION

There was a surprising high level of non-condom users among female nurses, probably due to the inability for females to initiate or negotiate condom use.

Reproductive biology knowledge, and behaviour of teenagers in East, Central and Southern Africa: the Zimbabwe case study

Sexuality in the teenager is often complicated by unplanned/unwanted pregnancy, abortion and the risks of STDs including AIDS. There is therefore a need for improved understanding of factors affecting adolescent sexuality and the implementation of programmes designed to improve their knowledge, risk awareness and subsequent behavioural outcomes. A multicentre study of reproductive health knowledge and behaviour followed by a health education intervention was undertaken amongst teenagers in selected countries of East, Central and Southern Africa. Reported here are findings at baseline derived from the Zimbabwe component on reproductive biology knowledge and behavior. A self-administered questionnaire was used among 1 689 adolescent pupils drawn from rural, urban, co-education, single sex, boarding and day secondary schools in Zimbabwe. Correct knowledge on reproductive biology as measured by the meaning and interpretation of menstruation and wet dreams varied by school from 68 pc to 86 pc, with a significant trend (p < 0,01) based on level of education at baseline. The reported mean age at which menarche took place was 13,5 years +/- 1,3 (mean +/- SD). First coitus was reported to have taken place at the mean age of 12 years for boys and 13,6 years for girls. Seventeen pc of the adolescent pupils reported that they were sexually experienced and 33,2 had relationships. There were misconceptions reported on menstruation with 23 pc reporting that it was an illness. Peers, followed by magazines were the first sources of information on various aspects of reproductive biology, both of which might not provide the correct first information. Among pupils reporting that they were sexually experienced, the largest proportion (56 pc) had unprotected sex. The findings point to the need for targeting the adolescent pupils for information on reproductive biology and increased awareness on the risks of pregnancy, STDs and HIV.

A randomised controlled trial of a dietary advice program for relatives of heart attack victims

OBJECTIVE

To compare two interventions for reducing dietary fat intake in first degree relatives of recent heart attack victims.

DESIGN

A randomised controlled trial comparing a low cost mail-out advice program; referral to a general practitioner (GP); and no intervention (control group).

PARTICIPANTS

Adult children or siblings, aged less than 70 years, of survivors of definite or suspected heart attack who had been admitted to hospitals in the Lower Hunter Region of New South Wales.

MAIN OUTCOME MEASURES

Dietary fat intake (evaluated with a validated short questionnaire) and measurement of blood cholesterol levels at six months.

RESULTS

Of the 342 relatives who participated (36% of those invited), 109, 120 and 113, respectively, were randomly assigned to receive a mail-out intervention, advice from their GP or to be part of a control group. The six-month follow-up questionnaire was completed by only 59% of those in the mail-out intervention group compared with 71% of the GP group and 77% of the control group. Younger participants, cigarette smokers and children (compared with siblings) were less likely to return a follow-up questionnaire. The mail-out group showed a statistically significant 20% reduction in self-reported dietary fat intake, but this was not seen in either the GP group or the controls. The low response rate meant the study had insufficient power to detect hypothesised changes in blood cholesterol.

CONCLUSION

Because of the poor response rate and possible biases from a differential response to follow-up, we conclude that this low intensity intervention for relatives of people with recent heart attack produces only a modest improvement in reported dietary fat intake. Alternative strategies may be more effective in reducing the risk of heart disease.