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1.  Design of an impact evaluation using a mixed methods model – an explanatory assessment of the effects of results-based financing mechanisms on maternal healthcare services in Malawi 
Background
In this article we present a study design to evaluate the causal impact of providing supply-side performance-based financing incentives in combination with a demand-side cash transfer component on equitable access to and quality of maternal and neonatal healthcare services. This intervention is introduced to selected emergency obstetric care facilities and catchment area populations in four districts in Malawi. We here describe and discuss our study protocol with regard to the research aims, the local implementation context, and our rationale for selecting a mixed methods explanatory design with a quasi-experimental quantitative component.
Design
The quantitative research component consists of a controlled pre- and post-test design with multiple post-test measurements. This allows us to quantitatively measure ‘equitable access to healthcare services’ at the community level and ‘healthcare quality’ at the health facility level. Guided by a theoretical framework of causal relationships, we determined a number of input, process, and output indicators to evaluate both intended and unintended effects of the intervention. Overall causal impact estimates will result from a difference-in-difference analysis comparing selected indicators across intervention and control facilities/catchment populations over time.
To further explain heterogeneity of quantitatively observed effects and to understand the experiential dimensions of financial incentives on clients and providers, we designed a qualitative component in line with the overall explanatory mixed methods approach. This component consists of in-depth interviews and focus group discussions with providers, service user, non-users, and policy stakeholders. In this explanatory design comprehensive understanding of expected and unexpected effects of the intervention on both access and quality will emerge through careful triangulation at two levels: across multiple quantitative elements and across quantitative and qualitative elements.
Discussion
Combining a traditional quasi-experimental controlled pre- and post-test design with an explanatory mixed methods model permits an additional assessment of organizational and behavioral changes affecting complex processes. Through this impact evaluation approach, our design will not only create robust evidence measures for the outcome of interest, but also generate insights on how and why the investigated interventions produce certain intended and unintended effects and allows for a more in-depth evaluation approach.
doi:10.1186/1472-6963-14-180
PMCID: PMC4006400  PMID: 24751213
Mixed methods; Impact evaluation; Performance-based incentives; Study design
2.  Specialization training in Malawi: a qualitative study on the perspectives of medical students graduating from the University of Malawi College of Medicine 
Background
There is a critical shortage of healthcare workers in sub-Saharan Africa, and Malawi has one of the lowest physician densities in the region. One of the reasons for this shortage is inadequate retention of medical school graduates, partly due to the desire for specialization training. The University of Malawi College of Medicine has developed specialty training programs, but medical school graduates continue to report a desire to leave the country for specialization training. To understand this desire, we studied medical students’ perspectives on specialization training in Malawi.
Methods
We conducted semi-structured interviews of medical students in the final year of their degree program. We developed an interview guide through an iterative process, and recorded and transcribed all interviews for analysis. Two independent coders coded the manuscripts and assessed inter-coder reliability, and the authors used an “editing approach” to qualitative analysis to identify and categorize themes relating to the research aim. The University of Pittsburgh Institutional Review Board and the University of Malawi College of Medicine Research and Ethics Committee approved this study and authors obtained written informed consent from all participants.
Results
We interviewed 21 medical students. All students reported a desire for specialization training, with 12 (57%) students interested in specialties not currently offered in Malawi. Students discussed reasons for pursuing specialization training, impressions of specialization training in Malawi, reasons for staying or leaving Malawi to pursue specialization training and recommendations to improve training.
Conclusions
Graduating medical students in Malawi have mixed views of specialization training in their own country and still desire to leave Malawi to pursue further training. Training institutions in sub-Saharan Africa need to understand the needs of the country’s healthcare workforce and the needs of their graduating medical students to be able to match opportunities and retain graduating students.
doi:10.1186/1472-6920-14-2
PMCID: PMC3884020  PMID: 24393278
Medical education; Postgraduate medical education; Specialization training; Medical migration; Sub-Saharan Africa; Qualitative research
3.  Assessment of strategies for male involvement in the prevention of mother-to-child transmission of HIV services in Blantyre, Malawi 
Global Health Action  2013;6:10.3402/gha.v6i0.22780.
Background
Despite the documented benefits of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) services, the uptake remains low in sub-Saharan Africa. The lack of male involvement (MI) may be one of the reasons for this. However, there are limited data on strategies for MI in PMTCT.
Objective
The objective of this study was to identify strategies that may promote MI in PMTCT services in antenatal care (ANC) services in Blantyre, Malawi.
Study design
An exploratory qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) in Blantyre, Malawi. It consisted of six face-to-face key informant interviews (KIIs) with healthcare workers and four focus group discussions (FGDs) with 18 men and 17 pregnant women attending ANC at SLHC. The FGDs were divided according to sex and age. All FGDs and KIIs were digitally recorded and simultaneously transcribed and translated verbatim into English. Data were analyzed using thematic content analysis.
Results
Three major themes with several subcategories emerged. Theme 1 was a gatekeeping strategy with two subcategories: (1) healthcare workers refusing service provision to women accessing antenatal clinic without their partners and (2) women refusing ANC attention in the absence of a partner. Theme 2 comprised extending invitations and had six subcategories: (1) word of mouth, (2) card invites, (3) woman's health passport book invites, (4) telephonic invites, (5) use of influential people, and (6) home visits. Theme 3 was information education and communication, such as health education forums and advertisements. Of all the strategies, an invitation card addressed to the male partner was most preferred by study participants.
Conclusions
There are several strategies by which men may be involved in PMTCT. Healthcare workers should offer a pregnant woman all strategies available for MI for her to select the appropriate one. Further research and consultations with men should continue to achieve higher levels of MI.
doi:10.3402/gha.v6i0.22780
PMCID: PMC3866839  PMID: 24345635
male involvement; HIV and AIDS; PMTCT
4.  Health Workforce Brain Drain: From Denouncing the Challenge to Solving the Problem 
PLoS Medicine  2013;10(9):e1001514.
Giorgio Cometto and colleagues discuss the study by Tankwanchi and colleagues on physician migration to the United States from sub-Saharan Africa and the steps that the US, other destination countries, and SSA countries can take to address the problem.
Please see later in the article for the Editors' Summary
doi:10.1371/journal.pmed.1001514
PMCID: PMC3775719  PMID: 24068895
5.  Using concept mapping to explore why patients become lost to follow up from an antiretroviral therapy program in the Zomba District of Malawi 
Background
Retention in antiretroviral therapy (ART) programmes remains a challenge in many settings including Malawi, in part due to high numbers of losses to follow-up. Concept Mapping (CM), a mix-method participatory approach, was used to explore why patients on ART are lost to follow-up (LTFU) by identifying: 1) factors that influence patient losses to follow-up and 2) barriers to effective and efficient tracing in Zomba, Malawi.
Methods
CM sessions (brainstorming, sorting and rating, interpretation) were conducted in urban and rural settings in Zomba, Malawi. Participants included ART patients, ART providers, Health Surveillance Assistants, and health managers from the Zomba District Health Office. In brainstorming, participants generated statements in response to “A specific reason why an individual on ART becomes lost to follow-up is…” Participants then sorted and rated the consolidated list of brainstormed items. Analysis included inductive qualitative methods for grouping of data and quantitative cluster identification to produce visual maps which were then interpreted by participants.
Results
In total, 90 individuals brainstormed 371 statements, 64 consolidated statements were sorted (participant n = 46), and rated on importance and feasibility (participant n = 69). A nine-cluster concept map was generated and included both patient- and healthcare-related clusters such as: Stigma and Fears, Beliefs, Acceptance and Knowledge of ART, Access to ART, Poor Documentation, Social and Financial Support Issues, Health Worker Attitudes, Resources Needed for Effective Tracing, and Health Worker Issues Related to Tracing. Strategies to respond to the clusters were generated in Interpretation.
Conclusions
Multiple patient- and healthcare focused factors influence why patients become LTFU. Findings have implications particularly for programs with limited resources struggling with the retention of ART patients.
doi:10.1186/1472-6963-13-210
PMCID: PMC3698212  PMID: 23758879
Concept mapping; HIV/AIDS; Antiretroviral therapy (ART); Losses to follow-up; Malawi
6.  Cannabis use and its socio-demographic correlates among in-school adolescents in Zambia 
Background
Cannabis dependence in adolescents predicts increased risks of using other illicit drugs, poor academic performance and reporting psychotic symptoms. The prevalence of cannabis use was estimated two decades ago in Zambia among secondary school students. There are no recent estimates of the extent of the problem; further, correlates for its use have not been documented in Zambia. The objective of study was to estimate the current prevalence of cannabis use and its socio-demographic correlates among in-school adolescents.
Methods
We conducted secondary analysis of data that was obtained from the 2004 Zambia Global School-Based Health Survey. Logistic regression analysis was conducted to identify the socio-demographic factors associated with cannabis use.
Results
A total of 2,257 adolescents participated in the survey of which 53.9% were females. The overall prevalence of self reported ever-used cannabis was 37.2% (34.5% among males and 39.5% among females). In multivariate analysis, males were 8% (AOR = 0.92; 95% CI [0.89, 0.95]) less likely to have ever smoked cannabis. Compared to adolescents aged 16 years or older, adolescents aged 14 years were 45% (AOR = 1.45; 95% CI [1.37, 1.55]) more likely, and those aged 15 years were 44% (AOR = 0.56; 95% CI [0.53, 0.60]) less likely to report to have ever smoked cannabis. Other factors that were significantly associated with cannabis use were history of having engaged in sexual intercourse (AOR = 2.55; 95% CI [2.46, 2.64]), alcohol use (AOR = 4.38; 95% CI [4.24, 4.53]), and having been bullied (AOR = 1.77; 95% CI [1.71, 1.83]). Adolescents who reported being supervised by parents during free time were less likely to have smoked cannabis (AOR = 0.92; 95% CI [0.88, 0.95]).
Conclusions
The use of cannabis is prevalent among Zambian in-school adolescents. Efforts to prevent adolescents’ psychoactive drug use in Zambia should be designed considering the significant factors associated with drug use in the current study.
doi:10.1186/1824-7288-39-13
PMCID: PMC3599579  PMID: 23415178
Prevalence; Cannabis use; In-school; Adolescents; Zambia
7.  Primary health care in rural Malawi - a qualitative assessment exploring the relevance of the community-directed interventions approach 
Background
Primary Health Care (PHC) is a strategy endorsed for attaining equitable access to basic health care including treatment and prevention of endemic diseases. Thirty four years later, its implementation remains sub-optimal in most Sub-Saharan African countries that access to health interventions is still a major challenge for a large proportion of the rural population. Community-directed treatment with ivermectin (CDTi) and community-directed interventions (CDI) are participatory approaches to strengthen health care at community level. Both approaches are based on values and principles associated with PHC. The CDI approach has successfully been used to improve the delivery of interventions in areas that have previously used CDTi. However, little is known about the added value of community participation in areas without prior experience with CDTi. This study aimed at assessing PHC in two rural Malawian districts without CDTi experience with a view to explore the relevance of the CDI approach. We examined health service providers’ and beneficiaries’ perceptions on existing PHC practices, and their perspectives on official priorities and strategies to strengthen PHC.
Methods
We conducted 27 key informant interviews with health officials and partners at national, district and health centre levels; 32 focus group discussions with community members and in-depth interviews with 32 community members and 32 community leaders. Additionally, official PHC related documents were reviewed.
Results
The findings show that there is a functional PHC system in place in the two study districts, though its implementation is faced with various challenges related to accessibility of services and shortage of resources. Health service providers and consumers shared perceptions on the importance of intensifying community participation to strengthen PHC, particularly within the areas of provision of insecticide treated bed nets, home case management for malaria, management of diarrhoeal diseases, treatment of schistosomiasis and provision of food supplements against malnutrition.
Conclusion
Our study indicates that intensified community participation based on the CDI approach can be considered as a realistic means to increase accessibility of certain vital interventions at community level.
doi:10.1186/1472-6963-12-328
PMCID: PMC3576236  PMID: 22995125
8.  Postgraduate career intentions of medical students and recent graduates in Malawi: a qualitative interview study 
BMC Medical Education  2012;12:87.
Background
In 2004, the Malawian Ministry of Health declared a human resource crisis and launched a six year Emergency Human Resources Programme. This included salary supplements for key health workers and a tripling of doctors in training. By 2010, the number of medical graduates had doubled and significantly more doctors were working in rural district hospitals. Yet there has been little research into the views of this next generation of doctors in Malawi, who are crucial to the continuing success of the programme. The aim of this study was to explore the factors influencing the career plans of medical students and recent graduates with regard to four policy-relevant aspects: emigration outside Malawi; working at district level; private sector employment and postgraduate specialisation.
Methods
Twelve semi-structured interviews were conducted with fourth year medical students and first year graduates, recruited through purposive and snowball sampling. Key informant interviews were also carried out with medical school faculty. Recordings were transcribed and analysed using a framework approach.
Results
Opportunities for postgraduate training emerged as the most important factor in participants’ career choices, with specialisation seen as vital to career progression. All participants intended to work in Malawi in the long term, after a period of time outside the country. For nearly all participants, this was in the pursuit of postgraduate study rather than higher salaries. In general, medical students and young doctors were enthusiastic about working at district level, although this is curtailed by their desire for specialist training and frustration with resource shortages. There is currently little intention to move into the private sector.
Conclusions
Future resourcing of postgraduate training opportunities is crucial to preventing emigration as graduate numbers increase. The lesser importance put on salary by younger doctors may be an indicator of the success of salary supplements. In order to retain doctors at district levels for longer, consideration should be given to the introduction of general practice/family medicine as a specialty. Returning specialists should be encouraged to engage with younger colleagues as role models and mentors.
doi:10.1186/1472-6920-12-87
PMCID: PMC3480922  PMID: 22978475
Doctors; Medical students; Postgraduate education; Specialisation; Malawi; Rural health; Brain drain; Emigration
9.  Prevalence and correlates of obesity among Lusaka residents, Zambia: a population-based survey 
Background
Non-communicable lifestyle diseases are a growing public health concern globally. Obesity is a risk factor for premature mortality from cardiovascular diseases and diabetes as well as all-cause mortality. The objective of the study was to estimate the prevalence and associated factors for obesity among Zambian adults in Lusaka district.
Methods
A community-based study was done among adults in Zambia. Descriptive and co-relational analyses were conducted to estimate the prevalence of being obese as well as identify associated factors.
Results
A total of 1,928 individuals participated in the survey, of which 33.0% were males. About half of the participants were aged 25–34 years (53.2%), and about two-thirds had attended at least secondary level of education (63.9%). Overall, 14.2% of the participants (5.1% of males, and 18.6% of females) were obese. Significant factors associated with obesity were sex, age, education, cigarette smoking and blood pressure. Male participants were 55% (AOR = 0.45; 95% CI [0.29, 0.69]) less likely to be obese compared to female participants. Compared to participants who were of age 45 years or older, participants of age 25–34 years were 61% (AOR = 0.39 (95% CI [0.23, 0.67]) less likely to be obese. Compared to participants who attained college or university level of education, participants who had no formal education were 63% (AOR = 0.37; 95% CI [0.15, 0.91]) less likely to be obese; and participants who had attained secondary level of education were 2.22 (95% CI [1.21, 4.07]) times more likely to be obese. Participants who smoked cigarettes were 67% (AOR = 0.33; 95% CI [0.12, 0.95]) less likely to be obese compared to participants who did not smoke cigarettes. Compared to participants who had severe hypertension, participants who had moderate hypertension were 3.46 (95% CI [1.34, 8.95]) times more likely to be obese.
Conclusions
The findings from this study indicate that Zambian women are more at risk of being obese. Prevention and control measures are needed to address high prevalence and gender inequalities in risks for non-communicable diseases in Zambia. Such measures should include policies that support gender specific approaches for the promotion of health behavior changes.
doi:10.1186/1755-7682-5-14
PMCID: PMC3403883  PMID: 22551418
Obesity; Smoking; Lusaka; Zambia
10.  Prevalence and correlates for school truancy among pupils in grades 7-10: results from the 2004 Zambia Global School-based Health Survey 
BMC Research Notes  2012;5:48.
Background
There are limited data on the prevalence and associated factors of truancy in southern Africa. Yet truancy should attract the attention of public health professionals, educators and policy makers as it may be associated with adolescent problem behaviours. The objectives of the study were to estimate the prevalence and determine correlates of school truancy among pupils in Zambia.
Findings
We used data collected in 2004 in the Zambia Global School-based Health Survey. Logistic regression analysis was conducted to identify factors associated with truancy. A total of 2257 pupils participated in the survey of whom 53.9% were male. Overall 58.8% of the participants (58.1% of males and 58.4% of females) reported being truant in the past 30 days. Factors associated with truancy were having been bullied (AOR = 1.34, 95% CI [1.32, 1.36]), current alcohol use (AOR = 2.19, 95% CI [2.16, 2.23]), perception that other students were kind and helpful (AOR = 1.12, 95% CI [1.10, 1.14]), being male and being from the lowest school grade. Pupils whose parents or guardians checked their homework (AOR = 0.91 95% CI, [0.89, 0.92]) and those who reported parental supervision (AOR = 0.94, 95% CI [0.92-0.95]) were less likely to report being truant.
Conclusions
We found a high prevalence of truancy among pupils in grades 7-10 in Zambia. Interventions aimed to reduce truancy should be designed and implemented with due consideration of the associated factors.
doi:10.1186/1756-0500-5-48
PMCID: PMC3284399  PMID: 22260248
11.  Victimization from bullying among school-attending adolescents in grades 7 to 10 in Zambia 
Abstract:
Background:
Among school- attending adolescents, victimization from bullying is associated with anxiety, depression and poor academic performance. There are limited reports on victimization from bullying in Zambia; we therefore conducted this study to determine the prevalence and correlates for victimization from bullying among adolescents in grades 7 to 10 in the country in order to add information on the body of knowledge on victimization from bullying.
Methods:
The 2004 Zambia Global School-based Health Survey (GSHS) data among adolescents in grades 7 to 10 were obtained from the World Health Organization. We estimated the prevalence of victimization from bullying. We also conducted weighted multivariate logistic regression analysis to determine independent factors associated with victimization from bullying, and report adjusted odds ratios (AOR) and their 95% confidence intervals (CI).
Results:
Of 2136 students who participated in the 2004 Zambia GSHS, 1559 had information on whether they were bullied or not. Of these, 1559 students, 62.8% (60.0% of male and 65.0% of female) participants reported having been bullied in the previous 30 days to the survey. We found that respondents of age less than 14 years were 7% (AOR=0.93; 95%CI [0.91, 0.95]) less likely to have been bullied compared to those aged 16 years or older. Being a male (AOR=1.07; 95%CI [1.06, 1.09]), lonely (AOR=1.24; 95%CI [1.22, 1.26]), worried (AOR=1.12; 95%CI [1.11, 1.14]), consuming alcohol (AOR=2.59; 95%CI [2.55, 2.64]), missing classes (AOR=1.30; 95%CI [1.28, 1.32]), and considering attempting suicide (AOR=1.20; 95%CI [1.18, 1.22]) were significantly associated with bullying victimization.
Conclusions:
Victimization from bullying is prevalent among in-school adolescents in grades 7 to 10 in Zambia, and interventions to curtail it should consider the factors that have been identified in this study.
doi:10.5249/jivr.v4i1.84
PMCID: PMC3291278  PMID: 21502789
12.  Prevalence of hypertension and its correlates in Lusaka urban district of Zambia: a population based survey 
Background
Hypertension is a leading cause for ill-health, premature mortality and disability. The objective of the study was to determine the prevalence and associated factors for hypertension in Lusaka, Zambia.
Methods
A cross sectional study was conducted. Odds ratios and their 95% confidence intervals were calculated to assess relationships between hypertension and explanatory variables.
Results
A total of 1928 individuals participated in the survey, of which 33.0% were males. About a third of the respondents had attained secondary level education (35.8%), and 20.6% of males and 48.6% of females were overweight or obese. The prevalence for hypertension was 34.8% (38.0% of males and 33.3% of females). In multivariate analysis, factors independently associated with hypertension were: age, sex, body mass index, alcohol consumption, sedentary lifestyle, and fasting blood glucose level.
Conclusions
Health education and structural interventions to promote healthier lifestyles should be encouraged taking into account the observed associations of the modifiable risk factors.
doi:10.1186/1755-7682-4-34
PMCID: PMC3195701  PMID: 21974840
Hypertension; BMI; alcohol consumption; sedentary behaviour; fasting blood glucose level; Lusaka; Zambia
13.  Prevalence and socio-demographic correlates for serious injury among adolescents participating in the Djibouti 2007 Global School-based Health Survey 
BMC Research Notes  2011;4:372.
Background
Mental health and injury are neglected public health issues especially in low-income nations. The objective of the study was to determine the prevalence and socio-demographic correlates for serious injury in the last 12 months.
Findings
The study used data of the 2007 Djibouti Global School-based Health Survey. Logistic regression analysis was used to establish associations. Of the 1, 777 respondents, 61.1% (63.2% males and 57.8% females) reported having sustained serious injury (SSI). Compared to participants who were not bullied, those who reported being bullied 3-9 days per month were more likely to have sustained serious injury in the last 12 months (AOR = 1.27; 95% CI [1.06, 1.52] for 3-5 days of bullying victimization per month, and AOR = 3.19; 95% CI [2.28, 4.47] for 6-9 days per month. Adolescents who were engaged in physical fighting were 47% (AOR = 1.47, 95% CI [1.40, 1.55] more likely to have sustained serious injury compared to those who were not engaged in the fighting. Meanwhile, adolescents who used substances (cigarettes, other forms of tobacco or drugs) were 30% (AOR = 1.30, 95% CI [1.19, 1.42]) more likely to have sustained serious injury compared to those who did not use substances.
Conclusions
Serious injury is common among adolescents in Djibouti, and we suggest that health workers attending to injured adolescents explore the patients' psycho-social environment. Further, we suggest longitudinal studies where reduction of substance use and bullying may be assessed if they have an impact in reducing serious injury among adolescents.
doi:10.1186/1756-0500-4-372
PMCID: PMC3189130  PMID: 21951721
14.  Self-reported poor oral hygiene among in-school adolescents in Zambia 
BMC Research Notes  2011;4:255.
Background
Dental health is a neglected aspect of adolescent health globally but more so in low-income countries. Secondary analysis using the 2004 Zambia Global School-Based Health Survey (GSHS) was conducted in which we estimated frequencies of relevant socio-demographic variables and explored associations between selected explanatory variables and self-reported poor oral hygiene (not cleaning or brushing teeth) within the last 30 days of the completion of questionnaire.
Findings
Most of the 2257 respondents were males (53.9%) and went hungry (82.5%). More than 4 in 10 respondents drank alcohol (42.2%) while 37.2% smoked cannabis. Overall 10.0% of the respondents reported to have poor oral hygiene. Male respondents were 7% less likely to report to have poor oral hygiene compared to females. Compared to respondents who never drank alcohol, those who drank alcohol were 27% more likely to report to have poor oral hygiene. Respondents who smoked cannabis were 4% more likely to report to have poor oral hygiene compared to those who did not smoke cannabis. Finally, respondents who went hungry were 35% more likely to report to have poor oral hygiene compared to those who did not go hungry.
Conclusions
Results from this study indicate that female gender, alcohol drinking, cannabis smoking, and going hungry were associated with self-reported poor oral hygiene. The identification of these factors should guide the design and implementation of programs aimed to improve oral health among adolescents.
doi:10.1186/1756-0500-4-255
PMCID: PMC3156756  PMID: 21781301
15.  We Are Not Just a “Tiny, Landlocked, Impoverished Sub-Saharan Country with HIV Burden” 
Croatian Medical Journal  2010;51(6):560-562.
doi:10.3325/cmj.2010.51.560
PMCID: PMC3031302  PMID: 21162169
16.  Occupational illnesses in the 2009 Zambian labour force survey 
BMC Research Notes  2010;3:272.
Background
Occupational health has received limited research attention in the Southern African Development Community (SADC). Much of the published data in this region come from South Africa and little has been reported north of the Limpopo. The present study was conducted to estimate the burden of occupational illnesses in Zambia and assess factors associated with their occurrence.
Methods
Data were obtained from the Zambian Labour Force Survey of 2009. Frequencies were used to estimate the prevalence of occupational diseases. Logistic regression analyses were conducted to determine the associations between demographic, social and economic factors and reported illness resulting from occupational exposures. Odds ratios (OR) from bivariate analyses and adjusted odds ratios (AOR) from the multivariate analysis together with their 95% Confidence Intervals (CI) are reported.
Results
Data on 59,118 persons aged 18 years or older were available for analysis, of which 29805 (50.4%) were males. The proportions of the sample that reported to have suffered from an occupational illness were 12.7% among males and 10.4% among females (p < 0.001). Overall the proportions of respondents who reported suffering from fatigue, fever and chest infections were 38.8%, 21.7% and 17.1%, respectively. About two thirds (69.7%) of the study participants had stayed away from work due to the illness suffered at work; there was no sex differences (p = 0.216). Older age, being male, lower education level, married/cohabiting or once married (separated/divorced/widowed), and paid employee or employer/self employed were positively associated with having suffered from illness.
Conclusions
The findings from this study call for urgent effort for specific measures to prevent and mitigate the effects of occupational injuries. These interventions may include: public health campaigns, enforcement or change in work policies and regulations. Special attention may have to be made towards those who were more likely to suffer from occupational illnesses.
doi:10.1186/1756-0500-3-272
PMCID: PMC2987870  PMID: 20979616
17.  “I Can’t Use a Condom, I Am a Christian:” Salvation, Death, and… Naivety in Africa 
Croatian Medical Journal  2010;51(5):468-471.
doi:10.3325/cmj.2010.51.468
PMCID: PMC2969142  PMID: 20960597
18.  Compensation patterns following occupational injuries in Zambia: results from the 2009 Labour Survey 
Background
Occupational injuries have received limited research attention in the Southern African Development Community. Much of the published data come from South Africa and little has been reported elsewhere within the region. The present study was conducted to estimate the prevalence rates of occupational injuries and compensation; and to determine factors associated with occupational injuries and compensation.
Methods
Data were obtained from occupational health and injury questions added to the Zambian Labour Force Survey of 2009 by the Work and Health in Southern Africa programme. Logistic regression analyses were conducted to determine the degree of association between demographic, social and economic factors on one hand and injury and compensation on the other.
Results
Data on 61871 study participants were available for analysis, of whom 4998 (8.1%) reported having been injured (10.0% of males, and 6.2% of females) due to work in the previous 12 months to the survey. Of those injured, 60.5% reported having stayed away from work as a result. The commonest type of injury was "open wound" (81.6%). Male gender, being married or married before, being a paid employee, working for a private company and household were positively associated with serious injuries. Injuries also varied by geographical area. Factors positively associated with receiving compensation for work-related injuries were: male gender, Copperbelt and North-Western provinces, and unpaid family worker. Employer/self employed and having less than 5 employees in a workplace were negatively associated with compensation.
Conclusion
The prevalence of reported injury and its association with a significant level of absence from work, indicate that occupational hazards in Zambia have significant health and economic effects. Female workers should equally be compensated for injuries suffered as their male counterparts.
doi:10.1186/1755-7682-3-19
PMCID: PMC2944123  PMID: 20825646
19.  Goodbye Collaboration, Welcome Partnerships in International Research? 
Croatian Medical Journal  2010;51(4):359-360.
doi:10.3325/cmj.2010.51.359
PMCID: PMC2931443  PMID: 20718091
20.  Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low‐income countries 
Journal of Medical Ethics  2007;33(6):357-361.
Ethical challenges surrounding the implementation of male circumcision as an HIV prevention strategy
doi:10.1136/jme.2006.019901
PMCID: PMC2598273  PMID: 17526688
21.  HIV Prevalence and Associated Behavioral Factors in Lesotho, Kenya, Malawi, and Uganda 
Croatian Medical Journal  2010;51(3):271-273.
doi:10.3325/cmj.2010.51.271
PMCID: PMC2897087  PMID: 20564772
22.  Cigarette smoking among school-going adolescents in Lithuania: Results from the 2005 Global Youth Tobacco Survey 
BMC Research Notes  2010;3:130.
Background
The majority of people who suffer morbidity due to smoking may have initiated smoking during adolescent period. The aim of this study is to determine the prevalence and associated factors for cigarette smoking among school-going adolescents in Lithuania.
Findings
Data from the Global Youth Tobacco Survey (GYTS) 2005 were used to conduct this study. Data were analyzed using SUDAAN software 9.03. Comparisons for categorical variables were done using the Pearson's Chi-square test. The cut of point for statistical significance was set at 5% level. Logistic regression analyses were conducted to determine factors associated with the outcome. Unadjusted odds ratios (OR) and adjusted odds ratios (AOR) together with their 95% confidence intervals (CI) are reported.
Of the 1822 respondents, 35.8% males and 27.1% females reported being current cigarette smokers (p < 0.001). Having friends who smoke cigarettes was associated with smoking after controlling for age, gender, parental smoking status, and perception of risks of smoking (AOR = 3.76; 95% CI [2.33, 6.90] for some friends using tobacco; and AOR = 17.18; 95% CI [10.46, 28.21] for most or all friends using tobacco). Male gender and having one or both parents who smoke cigarettes were associated with smoking (AOR = 1.31; 95% CI [1.03, 1.66]) and AOR = 1.76; 95% CI [1.37, 2.27]) respectively).
Conclusions
There is a high prevalence of cigarette smoking among Lithuanian adolescents. Male adolescents and adolescents who have friends or parents who smoke should be the main target for tobacco control in Lithuania.
doi:10.1186/1756-0500-3-130
PMCID: PMC2873352  PMID: 20459649
23.  Malawi College of Medicine – Still Not an Ivory Tower 
Croatian Medical Journal  2010;51(2):171-172.
doi:10.3325/cmj.2010.51.171
PMCID: PMC2859423  PMID: 20401961
24.  Gender specific factors associated with having stopped smoking among in-school adolescents in Ukraine: results from the Global Youth Tobacco Survey 2005 
BMC Research Notes  2010;3:76.
Background
The prevalence of cigarette smoking in Ukraine is different between genders and is among the highest in the world. There is need to identify gender-specific factors that are associated with having stopped smoking among adolescents.
Findings
We used data from the Ukraine Global Youth Tobacco Survey 2005. We carried out a backward stepwise logistic regression analysis with having stopped smoking as the outcome.
Altogether, 2800 adolescents reported having ever smoked cigarettes. Overall 64.1% (63.4% male, and 65.5% female) adolescents reported having stopped smoking. Male adolescents who stated that smoking decreases body weight were 25% more likely, while female adolescents were 9% less likely to stop smoking. While male adolescents who received support on how to stop smoking from a family member were 7% less likely, female adolescents were 60% more likely to stop smoking. Furthermore, while male adolescents who received a lecture on the harmful effects of smoking were 10% less likely, female adolescents were 9% more likely to stop smoking. Finally both male and female adolescents who were sure or most probably that they would not smoke a cigarette offered to them by their best friends were more likely, and those adolescents who were sure that smoking is harmful to health were less likely to stop smoking.
Conclusions
Our study has identified some factors that are associated with having quit smoking that are gender-specific. We believe public health programs targeting adolescent smoking should consider these factors in their design and implementation of gender sensitive interventions.
doi:10.1186/1756-0500-3-76
PMCID: PMC2845603  PMID: 20233426
25.  What Can Mchinji and Ntcheu Districts in Malawi Tell Maternal Health Pundits Globally? 
Croatian Medical Journal  2010;51(1):89-90.
doi:10.3325/cmj.2009.51.89
PMCID: PMC2829181  PMID: 20162750

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