Wilbroad Mutale

BACKGROUND: Adverse consequences of neonatal hyperbilirubinemia disproportionately affect babies in low- and middle-income countries. Laboratory measurement of total serum bilirubin is limited in low-resource settings, necessitating simpler alternatives. Our study aimed to evaluate the diagnostic accuracy of visual inspection of jaundice via the World Health Organization Integrated Management of Childhood Illnesses algorithm compared to transcutaneous bilirubinometry for the identification of hyperbilirubinemia in community settings. METHODS: Hyperbilirubinemia was assessed by visual inspection for jaundice and transcutaneous bilirubinometry at 0-72 hours, 3-5 days, and 5-14 days postnatal in the PRISMA prospective cohort study in six sites in Asia and Africa. We assessed sensitivity, specificity, and positive and negative percent agreement. RESULTS: We analyzed data from 14,331 infants, including 1,852 preterm infants. 15% had hyperbilirubinemia, as defined by transcutaneous bilirubin values and the NICE nomograms, at 3-5 days postnatal. Visual inspection had a sensitivity of 16%, specificity of 96%, positive percent agreement of 56%, and negative percent agreement of 86% at 3-5 days postnatal age, pooled across all sites and gestational ages, versus transcutaneous bilirubin defined by NICE nomograms. CONCLUSION: The poor sensitivity of visual inspection underscores an urgent need for accurate, affordable screening tools to improve screening for hyperbilirubinemia. Impact Statement: We found poor sensitivity of visual inspection, identifying fewer than one in five neonatal jaundice cases, suggesting much worse diagnostic accuracy in this community-based context across five low- and middle-income countries (LMICs) as compared to the previous studies conducted in health facilities. Among preterm infants, sensitivity was modestly higher than in term infants but remained clinically inadequate, reinforcing that visual inspection alone is insufficient for this high-risk group. Despite standardized training and biannual refresher sessions, our study suggests that training for health care workers alone is unlikely to make visual inspection a reliable case-detection tool. Our findings suggest that the WHO should re-evaluate the IMCI recommendations to include tools with higher diagnostic accuracy to identify neonatal jaundice. Community-level jaundice screening should move beyond visual inspection alone towards validated, low-cost, objective tools; icterometers and smartphone apps with high diagnostic accuracy are promising alternatives.

Background: Hypertension is a leading contributor to cardiovascular morbidity in sub-Saharan Africa. BMI, waist circumference (WC), waist-to-height ratio (WHtR), and waist-to-hip ratio (WHpR) are widely used for screening, yet their optimal thresholds and predictive utility vary by population. This study evaluated these indices for hypertension prediction in Zambian adults using traditional and machine learning approaches. Methods: This cross-sectional study assessed hypertension in 4,302 adults aged 18–69 years from the 2017 Zambia WHO STEPS survey. ROC analysis with Youden's Index identified optimal sex-stratified cut-offs for BMI, WC, WHtR, and WHpR. Five machine learning classifiers — logistic regression, linear SVM, random forest, gradient boosting, and XGBoost — were then trained on anthropometric, sociodemographic, and behavioural covariates using stratified 5-fold cross-validation, with recall prioritised as the primary metric given the imbalanced outcome. Results: Hypertension prevalence was 23.7% (n=1,021), higher in men (25.4% vs. 22.7%; p=0.046) and urban than rural residents (27.0% vs. 21.7%; p<0.001). WC and WHtR showed the highest discrimination (men: AUC 0.63/0.62; women: 0.66/0.66); locally derived cut-offs were below WHO thresholds (WC: 80.35/81.85 cm; WHtR: 0.48/0.53; BMI: 21.97/24.12 kg/m²). Logistic regression and linear SVM achieved the best ROC-AUC (0.74; recall 0.69–0.70; F1=0.51); ensemble models showed higher accuracy (0.78–0.79) but lower recall (0.22–0.26). Conclusion: Central adiposity measures (WC and WHtR) outperformed BMI for hypertension identification in Zambian adults, with locally derived cut-offs consistently below WHO thresholds. Logistic regression and linear SVM demonstrated the best predictive performance, supporting their utility in risk stratification using routinely collected data.

PURPOSE: Zambia is among the countries with the highest cervical cancer incidence and mortality rates globally. Stigma can hinder treatment adherence and overall quality of life for patients with cervical cancer. Research on this topic, however, is lacking in Zambia. This study aimed to assess the levels of stigma among patients with cervical cancer in Zambia and examine the association between social support and quality of life. METHODS: We enrolled patients newly diagnosed with cervical cancer at the Cancer Diseases Hospital in Lusaka, Zambia, from July to October 2024. In-person or telephone interviewers collected information on demographic, clinical, and socioeconomic status before treatment. Stigma was assessed using a modified Perceived Stigma Scale, quality of life using the PROMIS-57, and social support with the Multidimensional Scale of Perceived Social Support. Associations between stigma, social support, and quality of life were analyzed using multivariable logistic regression, adjusting for age, education, income, and cancer stage, with significance set at P < .05. RESULTS: A total of 213 participants were included in the study with a response rate of 96%. Of the total participants, 30.5% were classified as having high stigma. High levels of support from family (odds ratio [OR], 0.44 [95% CI, 0.22 to 0.87]) and friends (OR, 0.43 [95% CI, 0.21 to 0.91]) reduced the odds of stigma. Severe anxiety, depression, fatigue, sleep disturbances, pain, poor physical function, and low social well-being were all strongly associated with higher stigma (all P ≤ .004). CONCLUSION: Perceived cervical cancer–related stigma in Zambia is associated with limited social support and poorer quality of life. Programs to strengthen social network support, as well as targeted mental health treatment, are needed to improve the well-being of patients with cervical cancer in Zambia.

Background: Anemia remains a major health concern, particularly during pregnancy. However, blood draws, laboratory capacity, processing time, and equipment cost required for hemoglobin testing to diagnose anemia can be prohibitive. The Total Hemoglobin SpHb Rad-67 Pulse CO-Oximeter offers a non-invasive, portable, and affordable point-of-care alternative. We aimed to validate SpHb against complete blood count (CBC) in a pregnant and postpartum population. Methods: This was a substudy of the Pregnancy Risk, Infant Surveillance, and Measurement Alliance (PRISMA) Maternal and Newborn Health Study. A total of 2,700 participants in Zambia, Kenya, and Pakistan provided hemoglobin measurements both by CBC and the Rad-67 Masimo SpHb device at four visits during pregnancy and at six-weeks postpartum. We assessed agreement between SpHb and CBC and used mixed models to identify factors that explained or influenced differences between the two methods. Results: We found the mean hemoglobin measurement by SpHb (12.8±1.6 g/dL) was higher than by CBC (11.0±1.6 g/dL). However, this overall positive bias masked systematic misclassification at the extremes: SpHb overestimated values among women with very low hemoglobin (Mean Difference (MD) =-3.95; 95%CI-4.28,-3.62) and underestimated values at very high hemoglobin levels (MD = 2.44; 95%CI 2.14, 2.74), even after adjustment. Using CBC, 48% of observations were classified as anemic (<11 g/dL), compared to 9% by SpHb; conversely, just 7% of CBC readings fell within 13-15 g/dL, compared to 38% by SpHb. Agreement metrics consistently showed poor concordance between the two methods. Conclusions: SpHb systematically overestimated hemoglobin on average and showed poor agreement with CBC, particularly at clinically relevant extremes. Until greater accuracy of SpHb is demonstrated in this population, hemoglobin testing with laboratory-based methods is recommended to inform clinical decision-making in pregnancy. AUTHOR SUMMARY: Anemia is a major global health challenge linked with maternal morbidity, adverse birth outcomes, and impaired infant development. Accurate and accessible hemoglobin testing is critical for timely anemia diagnosis and treatment. The gold standard for hemoglobin testing is complete blood count using venous blood; however, this method requires laboratory infrastructure, blood sample collection, and trained personnel, limiting feasibility in low-resource and rural settings where anemia burden is highest. We evaluated the accuracy of the Masimo Total Hemoglobin SpHb® measured by Rad-67® Pulse CO-Oximeter®: a device that measures hemoglobin via an optical sensor placed on the patient’s finger. We found the mean hemoglobin measurement by SpHb (12.8±1.6 g/dL) was higher than by CBC (11.0±1.6 g/dL).We found that the Masimo device consistently overestimated hemoglobin at very low levels and underestimated at very high levels. Masimo SpHb classified 9% of women as anemic (i.e. hemoglobin <11 g/dL), compared to 48% using the gold standard method. The Masimo SpHb was even less accurate for women later in gestation, living with HIV, and who reported using betelnut, tobacco, or smoking. Device improvements or software-based correction factors are needed to improve performance of the Total Hemoglobin SpHb Rad-67 Pulse CO-Oximeter before it can be used to measure hemoglobin in pregnancy.

Background Studies on the association of community-level deprivation indices with breast cancer risk and survival after breast cancer diagnosis have yielded mixed results, and few have included large enough samples of low-income and ethnic minority individuals and considered individual-level risk factors. Methods This study included 43,384 cancer-free female participants enrolled from 2002-2009 in the Southern Community Cohort Study (SCCS), a prospective cohort study of predominantly low- income individuals and followed through December 2019 to ascertain incident breast cancer and survival outcomes. In-person or mailed baseline surveys collected information on demographic, reproductive and lifestyle factors. Neighbourhood deprivation index (NDI) was estimated based on participants’ residential zip codes and the 2000 census tract data. We conducted multivariable Cox regression analyses to evaluate the association of NDI with the risk of developing breast cancer and breast cancer-specific survival while adjusting for confounding effects of reproductive, lifestyle, clinical, and individual-level socioeconomic factors. Results Approximately 69% of participants were Black, 31% were white, and 78% had family income < $25,000/year. After a median follow-up of 12.8 years, 1,363 women were diagnosed with incident breast cancer (median age at diagnosis of 54.0 (IQR 13.0) years); 365 of them died, and 218 died from breast cancer. White women living in the least deprived communities had a significantly increased risk of developing breast cancer but not dying from breast cancer, with a hazard ratio (HR) of 1.44 (95% confidence interval (CI) 1.05-1.96) and 1.11 (95% CI; 0.48- 2.59), respectively. Among Black women, NDI was not associated with breast cancer risk or survival. Conclusion This large cohort of Black and white women with predominantly low-income background found no evidence that living in a deprived neighbourhood further increases the incidence and mortality of breast cancer.

Background: People living with HIV (PLWH) who use tobacco face significant public health risks compared to non-users, including an average loss of 12.3 years of life expectancy. Tobacco use increases the likelihood of non-communicable diseases (NCDs), such as cardiovascular diseases, hypertension, diabetes mellitus, and non-AIDS-related cancers. Aim: This study investigated factors associated with tobacco smoking and smokeless tobacco (SLT) use among PLWH in Zambia. Methods: Data were obtained from a national cross-sectional survey involving 5,204 PLWH from 193 clinics across Zambia’s 10 provinces. Tobacco smoking, SLT use, behavioral patterns, and clinical characteristics were assessed. Logistic regression was used to determine unadjusted (UOR) and adjusted odds ratios (AOR) at a 95% confidence interval (CI). Results: Among the 5,204 PLWH surveyed, 9.7% were current tobacco smokers (21.9% men, 3.7% women), while 1.4% used smokeless tobacco (1.81% men, 1.26% women). In the multivariable analysis, several factors were identified as predictors of tobacco smoking. Male individuals had significantly higher odds of smoking (AOR: 4.81, 95% CI: 3.36–6.90). In contrast, higher educational attainment was associated with lower odds of smoking (AOR: 0.29, 95% CI: 0.16–0.52). Alcohol consumption was associated with an increased likelihood of smoking (AOR: 4.97, 95% CI: 2.93–8.44). Additionally, overweight or obese individuals were less likely to smoke, with adjusted odds ratios of 0.55 (95% CI: 0.35–0.85) and 0.36 (95% CI: 0.17–0.79), respectively. Non-adherence to antiretroviral therapy (ART) was also associated with higher smoking rates (AOR: 1.75, 95% CI: 1.14–2.67). Similarly, several factors were identified as predictors of smokeless tobacco (SLT) use. Individuals with an annual income exceeding 4,000 ZMW had lower odds of using SLT (AOR: 0.31, 95% CI: 0.14–0.73). In contrast, alcohol users exhibited significantly higher odds of SLT use (AOR: 14.74, 95% CI: 1.99–109.02). Furthermore, non-adherence to ART was associated with an increased likelihood of SLT use (AOR: 3.32, 95% CI: 1.54–7.17). Conclusions: Our findings highlight the urgent need for targeted interventions to reduce tobacco use among PLWH in Zambia. Integrating these measures within the existing healthcare framework can maximize impact. Gender-specific programs addressing unique risk factors, alongside economic empowerment initiatives for low-income females, could help curb SLT use. Additionally, reinforcing ART adherence through tobacco cessation counseling within HIV care settings may lower smoking rates. Given the strong association between alcohol consumption and tobacco use, structured behavioral interventions and support programs should also be prioritized. Strengthening collaborations between health authorities and community organizations can further enhance accessibility and outreach. By embedding these strategies within primary care and ART clinics, Zambia can effectively reduce tobacco use among PLWH, ultimately improving overall health outcomes and strengthening HIV management efforts.

Background: There has been tremendous progress in reducing vertical transmission of HIV in the past two decades due to the broad availability of antiretroviral therapy (ART) globally. Despite this progress, new paediatric infections are still occurring. Methods: In a pilot study, we evaluated a combination adherence support package, which included an adapted motivational interviewing-informed counselling approach (Integrated Next Step Counselling, iNSC) and an optional adherence supporter, for pregnant and breastfeeding women living with HIV. Participants were recruited from the antenatal clinic in Lilongwe, Malawi. Eligible participants were randomly allocated 1:1 to receive either the combination adherence package (intervention) or standard care (control) at the health facility. Our clinical outcome, measured at three- and six-month follow-up, was a composite endpoint of study retention with HIV viral suppression (HIV RNA <40 copies per mL). Results: We screened 106 women living with HIV between March and July 2020. Of these, 100 women enrolled and were randomly assigned to intervention (n=51) or control (n=49). The majority of participants (94 of 100; 94%) were newly diagnosed with HIV. Retention in care was 92% at three months and 84% at six months. Three-quarters of women retained in care were virally suppressed at the three- and six-month study visits. At three months, our composite outcome (retention & viral suppression) was achieved by 70.6% (36/51) and 69.4% (34/49) of women in the intervention and control groups, respectively. At six months, this composite outcome was achieved by 68.6% (35/51) of the intervention group and 61.2% (30/49) of the control group (probability difference: 7.4%, 95% CI: -11.3%, 26.1%). Conclusion: These encouraging pilot findings suggest that this combination adherence package could be used to support ART adherence among pregnant and breastfeeding women living with HIV. We demonstrate feasibility of using a combined measure of adherence and viral suppression as an outcome measure. Trial registration: ClinicalTrials.gov (NCT04330989).

Background: The Global Resilience Oral Workshops (GROW) Free and Strong programs take a strengths-based, positive youth development (PYD) approach to promoting thriving. Through both prevention (GROW Strong) and intervention (GROW Free) exercises, these programs aim to build character and emotional resilience while also lowering unhealthy alcohol use. Objective: To meaningfully assess the impact of the GROW programs on health and PYD, ecologically and psychometrically valid measures of character strengths were needed, with a focus on the strengths of hope, forgiveness, spirituality, prudence, and self-control (self-regulation) promoted by GROW. Method: We tested a series of exploratory and confirmatory factor analyses of these five key constructs using two samples: a school-based youth sample enrolled in GROW Strong (n = 460; M _age = 15.04 years, SD _age = 1.21; 53.0% female); and a community-based adult sample enrolled in GROW Free (n = 457; M _age = 20.60 years, SD _age = 1.88; 49.7% female); both enrolled using a waitlist-control design. Results: Measures demonstrated strong invariance across specific subgroups present in the data sets, with differences emerging across ages, urban/rural locations, and baseline study conditions. Conclusions: To meaningfully document PYD programs and character development in the majority world, measurement models must be theory-predicated, robust, and empirically validated for the specific context. The results provide evidence for such a measure that will be useful in future intervention studies promoting character strengths to address unhealthy alcohol use in Zambia.

Background: Women in Africa disproportionately acquire human immunodeficiency virus type 1 (HIV-1). Understanding which women are most likely to acquire HIV-1 can guide focused prevention with preexposure prophylaxis (PrEP). Our objective was to identify women at the highest risk of HIV-1 and estimate PrEP efficiency at different sensitivity levels. Methods: Nationally representative data were collected from 2015 through 2019 from 15 population-based household surveys. This analysis included women aged 15–49 who tested HIV-1 seronegative or had recent HIV-1. Least absolute shrinkage and selection operator regression models were fit with 28 variables to predict recent HIV-1. Models were trained on the full population and internally cross-validated. Performance was evaluated using area under the receiver operating characteristic curve (AUC), sensitivity, and number needed to treat (NNT) with PrEP to avert 1 infection. Results: Among 209 012 participants, 248 had recent HIV-1 infection, representing 118 million women and 402 000 (95% confidence interval [CI], 309 000–495 000) annual infections. Two variables were retained: living in a subnational area with high HIV-1 viremia and having a sexual partner living outside the home. The full-population AUC was 0.80 (95% CI, .76–.84); cross-validated AUC was 0.79 (95% CI, .75–.84). At 33% sensitivity, 130 000 cases could be averted if 7.9 million women were perfectly adherent to PrEP; NNT would be 61. At 67% sensitivity, 260 000 cases could be averted if 25.1 million women were perfectly adherent; NNT would be 96. Conclusions: This risk assessment tool was generalizable, predictive, and parsimonious with trade-offs between reach and efficiency.