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Abstract Background HIV counseling and testing is an important intervention in the prevention, control and management of the human immunodeficiency virus (HIV). Counseling and testing can be an entry point for prevention, care and support. Knowledge of the quality of services and motivations for testing by individuals is important for effective understanding of the testing environment. Methods A cross sectional explorative study of clients accessing HIV voluntary counseling and testing (VCT) and counselors was conducted in 6 government health centers in Blantyre City, Malawi. We aimed to assess the availability of critical clinic supplies and identify the motivations of clients seeking counseling and testing services. We also aimed to identify the health professional cadres that were providing VCT in Blantyre city. Results 102 VCT clients and 26 VCT counselors were interviewed. Among the VCT clients, 74% were <=29 years, 58.8% were females and only 7% reported no formal education. 42.2% were single, 45.1% married, 8.8% widowed and 3.9% divorced or separated. The primary reasons for seeking HIV counseling and testing were: recent knowledge about HIV (31.4%), current illness (22.5%), self-assessment of own behavior as risky (15.5%), suspecting sexual partner's infidelity (13.7%) and seeking HIV confirmatory test (9.8%) and other reasons (6.9%). Of the 26 VCT counselors, 14 were lay volunteers, 7 health surveillance assistants and 5 nurses. All except one had been trained specifically for HIV counseling and testing. All 6 facilities were conducting rapid HIV testing with same day test results provided to clients. Most of the supplies were considered adequate for testing. Conclusion HIV counseling and testing facilities were available in Blantyre city in all the six public health facilities assessed. The majority of counseling and testing clients were motivated by perceptions of being at risk of HIV infection. In a country with 12% of individuals 15 to 49 years infected, there is need to encourage testing among population groups that may not perceive themselves to be at risk of infection.

Abstract Background The migration of health professionals from southern Africa to developed nations is negatively affecting the delivery of health care services in the source countries. Oftentimes however, it is the reasons for the out-migration that have been described in the literature. The work and domestic situations of those health professionals continuing to serve in their posts have not been adequately studied. Methods The present study utilized a qualitative data collection and analysis method. This was achieved through focus group discussions and in-depth interviews with health professionals and administrators to determine the challenges they face and the coping systems they resort to and the perceptions towards those coping methods. Results Health professionals identified the following as some of the challenges there faced: inequitable and poor remuneration, overwhelming responsibilities with limited resources, lack of a stimulating work environment, inadequate supervision, poor access to continued professionals training, limited career progression, lack of transparent recruitment and discriminatory remuneration. When asked what kept them still working in Malawi when the pressures to emigrate were there, the following were some of the ways the health professionals mentioned as useful for earning extra income to support their families: working in rural areas where life was perceived to be cheaper, working closer to home village so as to run farms, stealing drugs from health facilities, having more than one job, running small to medium scale businesses. Health professionals would also minimize expenditure by missing meals and walking to work. Conclusion Many health professionals in Malawi experience overly challenging environments. In order to survive some are involved in ethically and legally questionable activities such as receiving "gifts" from patients and pilfering drugs. The efforts by the Malawi government and the international community to retain health workers in Malawi are recognized. There is however need to evaluate of these human resources-retaining measures are having the desired effects.

Abstract

Background
Tobacco is a leading cause of death globally. There are limited reports on current cigarette smoking prevalence and its associated-antismoking messages among adolescents in conflict zones of the world. We, therefore, conducted secondary analysis of data to estimate the prevalence of current cigarette smoking, and to determine associations of antismoking messages with smoking status.


Methods
We used data from the Somaliland Global Youth Tobacco Survey (GYTS) of 2004 to estimate the prevalence of smoking. We also assessed whether being exposed to anti-smoking media, education and having discussed with family members on the harmful effects of smoking were associated with smoking. Logistic regression analysis was used to assess these associations. Current smoking was defined as having reported smoking cigarettes, even a single puff, in the last 30 days preceding the survey (main outcome).


Results
Altogether 1563 adolescents participated in the survey. However, 1122 had data on the main outcome. Altogether, 15.8% of the respondents reported having smoked cigarettes (10.3% among males, and 11.1% among females). Factors that were associated with reported non-smoking were: discussing harmful effects of smoking cigarettes with their family members (OR = 0.61, 95% CI 0.52, 0.71); being taught that smoking makes teeth yellow, causes wrinkles and smokers smell badly (OR = 0.62, 95% CI 0.52, 0.74); being taught that people of the respondent's age do not smoke (OR = 0.81, 95% CI 0.69, 0.95); and having reported that religious organizations discouraged young people smoking (OR = 0.70, 95% CI 0.60, 0.82). However, exposure to a lot many antismoking messages at social gatherings was associated with smoking. Exposure to antismoking print media was not associated with smoking status.


Conclusion
A combination of school and home based antismoking interventions may be effective in controlling adolescent smoking in Somaliland.

Abstract

Background
Many adult cigarette smokers initiated the habit as adolescents. Adolescent tobacco use may be a marker of other unhealthy behaviours. There are limited data on the prevalence and correlates of cigarette smoking among in-school adolescents in Iraq. We aimed to estimate the prevalence of, and assess the socio-demographic correlates of current cigarette smoking among in-school adolescents in Kurdistan region of Iraq.


Methods
Secondary data analysis of the Global Youth Tobacco Survey, conducted in the region of Kurdistan, Iraq in 2006. Logistic regression analysis was conducted to assess the association between current cigarette smoking and explanatory variables.


Results
One thousand nine hundred eighty-nine adolescents participated in the Kurdistan-Iraq Global Youth Tobacco Survey. Of these, 58.1% and 41.9% were boys and girls respectively. The overall prevalence of current cigarette smoking was 15.3%; 25.1% and 2.7% in boys and girls respectively. The factors associated with adolescent smoking were: parents' smoking, smoking in closest friends, male gender, having pocket money and perceptions that boys or girls who smoked were attractive.


Conclusion
We suggest that public health interventions aimed to curb adolescent cigarette smoking should be designed, implemented and evaluated with due recognition to the factors that are associated with the habit.

Many Malawian politicians have exploited religious and cultural discourses, encouraging the discourse of the "God-fearing Malawi nation" while also acknowledging the country as a secular state. This discourse -which most recently underwent further development in the early 1980s when Christians and Muslims, funded by donor money, accelerated their evangelical drives in the context of a one-party Malawi – resonates with a patriarchal, conservative political dispensation. This paper traces the evolution of the "God-fearing nation" discourse in Malawian politics. It posits that the government used the "gay rights issue" as a strategy to disorient human rights activists and donors. Gay rights were de-linked from other civil rights, forcing a binary approach toward gay rights, which were seen by government supporters as "anti-Christian", "anti-Malawian" concepts. The debate with donors enabled the government to claim "sovereign autonomy" and galvanise the population into an anti-aid mentality (better no aid than aid that supports homosexuality).

Many Malawian politicians have exploited religious and cultural discourses, encouraging the discourse of the "God-fearing Malawi nation" while also acknowledging the country as a secular state. This discourse -which most recently underwent further development in the early 1980s when Christians and Muslims, funded by donor money, accelerated their evangelical drives in the context of a one-party Malawi – resonates with a patriarchal, conservative political dispensation. This paper traces the evolution of the "God-fearing nation" discourse in Malawian politics. It posits that the government used the "gay rights issue" as a strategy to disorient human rights activists and donors. Gay rights were de-linked from other civil rights, forcing a binary approach toward gay rights, which were seen by government supporters as "anti-Christian", "anti-Malawian" concepts. The debate with donors enabled the government to claim "sovereign autonomy" and galvanise the population into an anti-aid mentality (better no aid than aid that supports homosexuality).

Few medical schools and sustained emigration have led to low numbers of doctors in many sub-Saharan African countries. The opportunity to undertake specialty training has been shown to be particularly important in retaining doctors. Yet limited training capacity means that doctors are often sent to other countries to specialise, increasing the risk that they may not return. Expanding domestic training, however, may be constrained by the reluctance of doctors to accept training in their home country. We modelled different policy options in an example country, Malawi, to examine the cost-effectiveness of expanding specialty training to retain doctors in sub-Saharan Africa. We designed a Markov model of the physician labour market in Malawi, incorporating data from graduate tracing studies in 2006 and 2012, a 2013 discrete choice experiment on 148 Malawian doctors and 2015 cost data. A government perspective was taken with a time horizon of 40 years. Expanded specialty training in Malawi or South Africa with increasing mandatory service before training was compared against baseline conditions. The outcome measures were cost per doctor-year and cost per specialist-year spent working in the Malawian public sector. Expanding specialty training in Malawi is more cost-effective than training outside Malawi. At least two years of mandatory service would be more cost-effective, with five years adding the most value in terms of doctor-years. After 40 years of expanded specialty training in Malawi, the medical workforce would be over fifty percent larger with over six times the number of specialists compared to current trends. However, the government would need to be willing to pay at least 3.5 times more per doctor-year for a 5% increase and a third more per specialist-year for a four-fold increase. Greater returns are possible from doctors with more flexible training preferences. Sustained funding of specialty training may improve retention in sub-Saharan Africa.

Few medical schools and sustained emigration have led to low numbers of doctors in many sub-Saharan African countries. The opportunity to undertake specialty training has been shown to be particularly important in retaining doctors. Yet limited training capacity means that doctors are often sent to other countries to specialise, increasing the risk that they may not return. Expanding domestic training, however, may be constrained by the reluctance of doctors to accept training in their home country. We modelled different policy options in an example country, Malawi, to examine the cost-effectiveness of expanding specialty training to retain doctors in sub-Saharan Africa. We designed a Markov model of the physician labour market in Malawi, incorporating data from graduate tracing studies in 2006 and 2012, a 2013 discrete choice experiment on 148 Malawian doctors and 2015 cost data. A government perspective was taken with a time horizon of 40 years. Expanded specialty training in Malawi or South Africa with increasing mandatory service before training was compared against baseline conditions. The outcome measures were cost per doctor-year and cost per specialist-year spent working in the Malawian public sector. Expanding specialty training in Malawi is more cost-effective than training outside Malawi. At least two years of mandatory service would be more cost-effective, with five years adding the most value in terms of doctor-years. After 40 years of expanded specialty training in Malawi, the medical workforce would be over fifty percent larger with over six times the number of specialists compared to current trends. However, the government would need to be willing to pay at least 3.5 times more per doctor-year for a 5% increase and a third more per specialist-year for a four-fold increase. Greater returns are possible from doctors with more flexible training preferences. Sustained funding of specialty training may improve retention in sub-Saharan Africa.

Few medical schools and sustained emigration have led to low numbers of doctors in many sub-Saharan African countries. The opportunity to undertake specialty training has been shown to be particularly important in retaining doctors. Yet limited training capacity means that doctors are often sent to other countries to specialise, increasing the risk that they may not return. Expanding domestic training, however, may be constrained by the reluctance of doctors to accept training in their home country. We modelled different policy options in an example country, Malawi, to examine the cost-effectiveness of expanding specialty training to retain doctors in sub-Saharan Africa. We designed a Markov model of the physician labour market in Malawi, incorporating data from graduate tracing studies in 2006 and 2012, a 2013 discrete choice experiment on 148 Malawian doctors and 2015 cost data. A government perspective was taken with a time horizon of 40 years. Expanded specialty training in Malawi or South Africa with increasing mandatory service before training was compared against baseline conditions. The outcome measures were cost per doctor-year and cost per specialist-year spent working in the Malawian public sector. Expanding specialty training in Malawi is more cost-effective than training outside Malawi. At least two years of mandatory service would be more cost-effective, with five years adding the most value in terms of doctor-years. After 40 years of expanded specialty training in Malawi, the medical workforce would be over fifty percent larger with over six times the number of specialists compared to current trends. However, the government would need to be willing to pay at least 3.5 times more per doctor-year for a 5% increase and a third more per specialist-year for a four-fold increase. Greater returns are possible from doctors with more flexible training preferences. Sustained funding of specialty training may improve retention in sub-Saharan Africa.

BACKGROUND: In 2013, Malawi with its development partners introduced a Results-Based Financing for Maternal and Newborn Health (RBF4MNH) intervention to improve the quality of maternal and newborn health-care services. Financial incentives are awarded to health facilities conditional on their performance and to women for delivering in the health facility. We assessed the effect of the RBF4MNH on quality of care from women's perspectives. METHODS: We used a mixed-method prospective sequential controlled pre- and post-test design. We conducted 3060 structured client exit interviews, 36 in-depth interviews and 29 focus group discussions (FGDs) with women and 24 in-depth interviews with health service providers between 2013 and 2015. We used difference-in-differences regression models to measure the effect of the RBF4MNH on experiences and perceived quality of care. We used qualitative data to explore the matter more in depth. RESULTS: We did not observe a statistically significant effect of the intervention on women's perceptions of technical care, quality of amenities and interpersonal relations. However, in the qualitative interviews, most women reported improved health service provision as a result of the intervention. RBF4MNH increased the proportion of women reporting to have received medications/treatment during childbirth. Participants in interviews expressed that drugs, equipment and supplies were readily available due to the RBF4MNH. However, women also reported instances of neglect, disrespect and verbal abuse during the process of care. Providers attributed these negative instances to an increased workload resulting from an increased number of women seeking services at RBF4MNH facilities. CONCLUSION: Our qualitative findings suggest improvements in the availability of drugs and supplies due to RBF4MNH. Despite the intervention, challenges in the provision of quality care persisted, especially with regard to interpersonal relations. RBF interventions may need to consider including indicators that specifically target the provision of respectful maternity care as a means to foster providers' positive attitudes towards women in labour. In parallel, governments should consider enhancing staff and infrastructural capacity before implementing RBF.