Rural Zambia Research Articles

Agricultural Informatization and Technical Efficiency in Maize Production in Zambia

The cropland productivity gap between Africa and the rest of the world is widening. Fortunately, increasing farmers’ access to useful agricultural information reduces the costs of searching for information, thereby leading to higher agricultural productivity and sustainability. This study investigates the association between the adoption of mobile phones to collect agricultural information and farmers’ technical efficiency (TE) in Zambia. Different from previous studies, we focus on the actual use of mobile phones by farmers rather than mere ownership. Farmers were selected using a two-stage sampling procedure, and the Cobb-Douglas (CD) production function is adopted to estimate the association using two approaches—the conventional stochastic production frontier (SPF) and propensity score matching-stochastic production frontier (PSM-SPF) model. In both cases, we found that the use of mobile phones is significantly and positively associated with farmers’ TE. However, the conventional SFP model exaggerates the TE scores by 5.3% due to its failure to mitigate biases from observed variables. Regarding the agricultural growth indicators (income and output) related to TE, a close inspection reveals that increasing mobile phone use to close the TE gap between the two groups could result in a 5.13% and 8.21% reduction in severity of poverty and extreme poverty, respectively. Additional research is essential to corroborate the findings and analyze the potential causal mechanisms. Our study provides strong evidence to promote mobile phone use in agricultural production in rural Zambia.

Assessment of interventions to attract and retain health workers in rural Zambia: a discrete choice experiment

BackgroundWorkforce shortages, particularly in rural areas, limit the delivery of health services in Zambia. Policymakers and researchers co-created this study to identify potential non-monetary employment incentives and assess their cost-effectiveness to attract and retain public sector health workers to the rural areas of Zambia.MethodsThe study consisted of two key phases: a discrete choice experiment (DCE), preceded by a qualitative component to inform DCE questionnaire development. Firstly, in qualitative interviews with 25 health workers and focus group discussions (FGDs) with 253 health students, participants were asked to discuss job attributes and potential incentives that would influence their job choices. Based on this exercise and in consultation with policymakers, job attributes were selected for inclusion in a discrete choice experiment (DCE) questionnaire. Secondly, this questionnaire, consisting of hypothetical job “choice sets,” was presented to 474 practicing health workers and students. A conditional logit regression model was applied to the data from this DCE questionnaire to estimate preferences for various job attributes. Using administrative data, we estimated the cost of implementing potential attraction and retention strategies per health worker year worked.ResultsAlthough health workers preferred urban jobs to rural jobs (OR 1.39, 95% CI 1.11–1.75), employment incentives influenced health workers’ decision to choose rural jobs. If superior housing was offered in a rural area compared to a basic housing allowance in an urban job, participants would be five times as likely to choose the rural job (OR 5.04, 95% CI 4.12–6.18). Education incentives and facility-based improvements also increased the likelihood of rural job uptake. Housing benefits were estimated to have the lowest total costs per health worker year worked, and offer high value in terms of cost per percentage point increase in rural job uptake.ConclusionsNon-monetary incentives such as housing, education, and facility improvements can be important motivators of health worker choice of location and could mitigate rural health workforce shortages. These results can provide valuable insight into the types of job attributes and incentives that are most likely to be effective in attracting and retaining health workers in rural areas.

Assessment of maternal referral systems used for a rural Zambian hospital: the development of setting specific protocols for the identification of complications.

In resource-limited countries, it is estimated that up to 75% of maternal deaths are preventable. Maternal referral systems are an effective measure to help prevent these deaths. The objective of this study was to delineate criteria that health care workers use to identify obstetrical emergencies and make referrals, in order to evaluate the effectiveness of the established referral system and to implement improvements to this system. Using a qualitative study design, the individuals with the highest level of formal obstetrics training at 10 health posts that refer to a rural Zambian hospital were surveyed using semi-structured interviews regarding their referral protocols. Data were analyzed through open-coding. At the conclusion of the interview, standardized referral protocols for obstetric emergencies derived from published guidelines and local practices were distributed. Identified complications resulting in referral most commonly included post-partum hemorrhage (70%), prolonged labor (70%), malpresentation (50%), antepartum hemorrhage (40%), and retained placenta (40%). While numerous reasons for referral were identified, there was little consensus on the referral protocol used for each complication. Obstacles to successful referral most commonly included cellular network disruptions (70%), distance (50%), and lack of transportation (30%).The referral protocols distributed to health posts covered only 11 of the 23 complications cited as the most common reason for referral. The referral criteria and protocols were updated to include all of the reported complications. We propose this document for others working in resource-limited settings attempting to establish or evaluate a maternal referral systems.

Application of an HIV Prevention Cascade to Identify Gaps in Increasing Coverage of Voluntary Medical Male Circumcision Services in 42 Rural Zambian Communities

Increased coverage of voluntary medical male circumcision (VMMC) is needed in countries with high HIV prevalence. We applied an HIV-prevention cascade to identify gaps in male circumcision coverage in Zambia. We used survey data collected in 2013 and 2014/15 to describe circumcision coverage at each time-point, and prevalence of variables related to demandfor and supplyof VMMC. We explored whether circumcision coverage in 2014/15 was associated with demand and supply among uncircumcised men in 2013. Results show that circumcision coverage was 11.5% in 2013 and 18.0% in 2014/15. Levels of having heard of circumcision and agreeing with prevention benefits was similar at both time-points (79.8% vs 83.2%, and 49.7% vs 50.7%, respectively). In 2013, 39.3% of men perceived services to be available compared to 54.7% in 2014/15. Levels ofhaving heard of circumcision in 2013 was correlated with and higher perceived service availability associated with coverage in 2014/15. VMMC coverage was low in these study sites. Knowledge of prevention tools and of service availability are necessary to increase coverage but alone are insufficient.

Dietary Intake Patterns among Lactating and Non-Lactating Women of Reproductive Age in Rural Zambia.

Insufficient dietary intake, micronutrient deficiencies, and infection may result in malnutrition. In Zambia, an estimated 14% of women are vitamin A-deficient, ~50% are anemic, 10% are underweight, and 23% are overweight/obese. A cross-sectional survey determined food and nutrient intakes of randomly selected Zambian women (n = 530) of reproductive age (15–49 years). Dietary intake data were collected using interactive multiple-pass 24-h recalls. Carbohydrate, fat, protein, and selected micronutrient intakes were estimated. Prevalence of adequate intakes were determined using the estimated average requirement (EAR) cut-point method and comparisons between lactating and non-lactating women were made by two-sample t-tests. The response rate was 98.7%. Overweight/obesity occurred in 20.7% (95% confidence interval (CI: 17.2, 24.5)). Almost all micronutrient intakes were inadequate, with values between 22.3% and 99.9%. Mean iron intake was >EAR, and 8.2% of women tested (12/146, 95% CI: 4.1, 13.0) were anemic (hemoglobin <115 g/L). Calcium intake was higher in lactating than non-lactating women (p = 0.004), but all intakes need improvement. Vitamin intakes in rural Zambian women are inadequate, suggesting a need for health promotion messages to encourage intake of locally available micronutrient-dense foods as well as supplementation, fortification, and biofortification initiatives. Nutritional support is important because maternal nutrition directly impacts child health.

Do asset transfers build household resilience?

We estimate the impact of an asset transfer program on household resilience. We measure resilience as the probability that a household will sustain at least the threshold asset level required to support consumption above the poverty line. Using six rounds of data collected over 42 months in rural Zambia, we construct a measure of resilience based on households' conditional welfare distributions to estimate program impacts. We find that the program increased household resilience; beneficiaries' likelihood of being non-poor in future periods increased by 44%. The program both increased mean assets and decreased variance, signaling an upward shift in households’ conditional asset distributions. Our method demonstrates the added value of the resilience estimation compared with a conventional impact assessment; numerous households classified as non-poor are unlikely to remain non-poor over time and the relationship between wealth and resilience is driven by changes in both the conditional mean and the conditional variance.

Partnering with traditional Chiefs to expand access to cervical cancer prevention services in rural Zambia.

To evaluate how the influence of traditional Chiefs can be leveraged to promote access to cervical cancer prevention services in rural Zambia. A retrospective review of outcome data was conducted for all screening outreach events that occurred in Zambian Chiefdoms between October 4, 2015, and October 3, 2016. Members of the health promotion team of the Cervical Cancer Prevention Program in Zambia visited local Chiefs to inform them of the importance of cervical cancer prevention. The local Chiefs then summoned adults living within their Chiefdoms to assemble for cervical cancer prevention health talks. Screen-and-treat services were implemented within each of the Chiefdoms over a 1-week period. VIA-enhanced digital imaging of the cervix (digital cervicography) was offered to 8399 women in ten Chiefdoms as part of a village-based screening (VBS) program. In all, 419 (4.9%) women had positive screening test results. Of these women, 276 (65.8%) were treated immediately with thermocoagulation and 143 (34.1%) were referred to provincial government hospitals to undergo either the loop electrosurgical excision procedure/large loop excision of the transformation zone (n=109, 26.0%) or punch biopsy (n=34, 8.1%). The influence of traditional Chiefs was leveraged to facilitate access to cervical cancer prevention services in rural Zambia.

Screening for Atrial Fibrillation in Zambia’s Western Province

BACKGROUND: The prevalence of atrial fibrillation (AF) is increasing in sub-Saharan Africa and contributes to significant morbidity and mortality from stroke and other cardiovascular diseases. Case finding in some areas of the country, such as in rural Zambia is especially challenging with limited availability of ambulatory electrocardiogram monitoring devices. Moreover, there is very little qualitative research exploring Zambian patients&amp;rsquo; experiences living with AF.&#x0D; &#x0D; AIMS: The two-fold purpose of this study was i) to explore the use of a screening tool for detecting AF in Western Province, Zambia and ii) to understand the patient experience of living with AF.&#x0D; &#x0D; SETTING: Mongu and Limulunga Districts in the Western Province of Zambia.&#x0D; &#x0D; METHODS: Mixed methods. Convenience sampling for both quantitative and qualitative arms of the study was used to recruit participants attending public &amp;lsquo;Health Checks.&amp;rsquo; Quantitative data were collected by means of an interview-administered survey and qualitative data were obtained through individual interviews.&#x0D; &#x0D; RESULTS: An irregular manual pulse was found in 12.6% (n=33) of Zambians who attended the Health Checks and two participants were confirmed to have AF. Zambians with an irregular pulse had a significantly higher prevalence of hypertension and were significantly less sedentary than those without pulse irregularities. Two themes emerged from the interview with two patients diagnosed with AF: symptoms and healthcare access.&#x0D; &#x0D; CONCLUSION: Hypertension continues to be a problem in adult Zambians and is an independent risk factor for stroke and, when diagnosed in conjunction with AF, further compounds stroke risk. Access to screening and diagnostic care for AF is essential, especially in currently underserved rural areas. In addition, participants presented with unique risk factors, such as consolidated periods of exercise, that require further research to determine context and seasonal variation so as to improve education and prevention strategies.

Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls

IntroductionWhile in school, girls require an environment that is supportive of menstrual hygiene management (MHM) in order to ensure regular school attendance and participation. Little is known about schoolgirls access to and practice of MHM in rural Zambia. This study explores girls’ experiences of MHM in rural schools of Zambia from the perspectives of schoolgirls, schoolboys and community and school-based adults key to MHM for schoolgirls.MethodsIn July and August 2015, we conducted this qualitative exploratory study in six rural schools of Mumbwa and Rufunsa districts of Zambia. Twelve in-depth interviews (IDIs) and six focus group discussions (FGDs) were conducted among girls ages 14–18 who had begun menstruating. Two FGDs with boys ages 14–18 and 25 key informant interviews were also conducted with teachers, female guardians and traditional leaders to provide the context within which schoolgirls practice MHM.ResultsMost girls reported learning about menstruation only at menarche and did not know the physiological basis of menstruation. They reported MHM-related challenges, including: use of non-absorbent and uncomfortable menstrual cloth and inadequate provision of sanitary materials, water, hygiene and sanitation facilities (WASH) in schools. In particular, toilets did not have soap and water or doors and locks for privacy and had a bad odor. Girls’ school attendance and participation in physical activities was compromised when menstruating due to fear of teasing (especially by boys) and embarrassment from menstrual leakage. Boys said they could tell when girls were menstruating by the smell and their behaviour, for instance, moving less and isolating themselves from their peers. Girls complained of friction burns on their inner thighs during their long journey to school due to chaffing of wet non-absorbent material used to make menstrual cloth. Girls preferred to dispose used menstrual materials in pit latrines and not waste bins for fear that they could be retrieved for witchcraft against them. Though traditional leaders and female guardians played a pivotal role in teaching girls MHM, they have not resolved challenges to MHM among schoolgirls.ConclusionWhen menstruating, schoolgirls in rural Zambia would rather stay home than be uncomfortable, inactive and embarrassed due to inadequate MHM facilities at school. A friendly and supportive MHM environment that provides education, absorbent sanitary materials and adequate WASH facilities is essential to providing equal opportunity for all girls.

Maternity Waiting Home Use by HIV-positive Pregnant Women in Zambia: Opportunity for Improved Prevention of Maternal to Child Transmission of HIV.

Background:Maternity waiting homes (MWHs), defined as residential lodging near health facilities, are an intervention to improve access to maternal care recommended by the World Health Organization. Little is known about utilization of MWHs by HIV-positive women. This paper describes: 1) maternal awareness and utilization of MWHs in rural Zambia among HIV-positive women, and 2) health outcomes for HIV-positive women and their infants with regards to utilization of MWHs.Methods:Data were collected from recently delivered women (delivered after 35 weeks in the previous 12 months) living >9.5 km from 40 health facilities in rural Zambia. For our analysis, primary outcomes were compared between self-identified HIV-positive and HIV-negative women in the sample. Primary outcomes include: 1) awareness of MWHs and 2) utilization of MWHs. We summarized simple descriptive statistics, stratified by maternal self-reported HIV status. We conducted bivariate analyses using chi-square tests, t-tests and Wilcoxon rank sum test.Results:Among 2,381 women, 50 (2.4%) self-identified as HIV-positive. HIV-positive women were older and had more pregnancies and children than HIV-negative women (p<0.001). There was no difference in awareness of MWHs, but HIV-positive women were more likely to use a MWH than HIV-negative women. There was no difference in receipt of infant antiretroviral prophylaxis between women who did or did not stay at a MWH.Conclusion and Global Health Implications:Though HIV prevalence in this sample was lower than expected, MWHs may represent a useful strategy to improve prevention of mother to child transmission of HIV in high prevalence, low-resource settings.

Partnering with traditional Chiefs to expand access to cervical cancer prevention services in rural Zambia

Partnering with traditional Chiefs to expand access to cervical cancer prevention services in rural Zambia

HIV Retesting of HIV-Negative Pregnant Women in the Context of Prevention of Mother-to-Child Transmission of HIV in Primary Health Centers in Rural Zambia: What Did We Learn?

Background:This observational study describes implementation of HIV retesting of HIV-negative women in prevention of mother-to-child transmission (PMTCT) services in Zambia.Methods:Uptake of retesting and PMTCT services were compared across age, parity, and weeks of gestation at the time of the first HIV test, antiretrovirals regime, and HIV early diagnosis results from infants born to HIV-positive mothers.Results:A total of 19 090 pregnant women were tested for HIV at their first antenatal visit, 16 838 tested HIV-negative and were offered retesting 3 months later: 11 339 (67.3%) were retested; of those, 55 (0.5%) were HIV positive. Uptake of the PMTCT package by women HIV positive at retest was not different but HIV-exposed infants born to women who retested HIV positive were infected at a higher rate (11.1%) compared to those born to women who tested HIV positive at their initial test (3.2%).Conclusion:We suggest rigorously (1) measuring the proportion of MTCT attributable to women who seroconvert during pregnancy and possibly adjust PMTCT approaches and (2) addressing the substantial loss to follow-up of HIV-negative pregnant women before HIV retesting.

A pilot study of a novel, incentivised mHealth technology to monitor the vaccine supply chain in rural Zambia.

IntroductionThe World Health Organization estimates that up to half of vaccines are wasted, however only a minority of mHealth programs in Africa have been directed at vaccine supply chain optimisation. We piloted a novel mHealth solution dependent only on short message services (SMS) technology that allowed workers in rural health centres in Zambia to report vaccine stock levels directly to an online platform. Small airtime incentives were offered to encourage users to engage with the system, as well as weekly reminder messages asking for stock updates.MethodsThe primary outcome measured was the percentage-of-doses-tracked, calculated over the study period. Each vaccine box was randomly allocated to offer either a standard or double airtime incentive and either weekly or daily reminders, in a 2 x 2 design; ANOVA was used to calculate if any of these factors affected time-to-reply.ResultsOver the study period, the total percentage-of-doses-tracked was 39.9%. Within the subset of users who sent at least one message to the platform, the percentage-of-doses-tracked was 93.8%. There was no significant difference in average time-to-reply between the standard airtime incentive and double airtime incentive groups, nor was there a significant difference between the standard reminder and daily follow-up reminder groups.ConclusionThis pilot study found that in an active subgroup of health workers, an incentivised mHealth solution was able to collect tracking data for 93.8% of doses. More research is needed to identify methods to encourage healthcare workers to engage in timely stock reporting practices.

A Model for Improving E-Tax Systems Adoption in Rural Zambia Based on the TAM Model

The objective of this study was to assess the factors that influence the level of e-tax systems adoption in Zambia. The study focused on TaxOnline system used by domestic taxes division in Zambia. The study was conducted in rural Zambia. In this study, the researcher used Technology Acceptance Model (TAM). The sample size was purposively selected from various taxpayers who were coming through to Zambia Revenue Authority Solwezi internet bureau. 100 semi structured survey questionnaires were distributed with 100% response. The data collected was analyzed using descriptive statistics. The results showed that, E-tax system in Zambia is useful, easy to use and also secure. Based on the findings, majority of the taxpayers are filing their returns and paying taxes online. However, there are few taxpayers who still feel E-tax is not useful, easy to use and secure. Therefore, more awareness and taxpayer education must continue to bring everyone on board. E-Tax involves E-Filing and E-Payment which is the process of submitting returns over the internet using an approved E-Tax system. Adoption is the action or fact of choosing to take up or follow something. Technology Acceptance Model is an information system theory that models how users come to accept and use a technology. TaxOnline is a system used in Zambia to file returns and pay taxes online.

Effect of Cash Transfer on School Dropout Rates using Longitudinal Data Modelling: A Randomized Trial of Research Initiative to Support the Empowerment of girls (RISE) in Zambia

Background: School dropout rates, as well as early marriages and pregnancies, are high among adolescent girls in rural Zambia. In the quest to fight this, the Research Initiative to Support the Empowerment of girls (RISE) trial has been providing cash transfers and community dialogues to adolescent girls in rural Zambia. The overall goal of the study was to establish the effects of cash transfers on adolescent girls’ school dropout rates in selected provinces of Zambia. Methods: The study was nested in the RISE trial which is a cluster randomized trial conducted in Central and Southern provinces of Zambia. A total of 3500 adolescent girls were included in the study. Random intercepts model was used to model the individual effects estimates, taking account of the dependency that was likely to occur due to the repeated measurements and clustering in the study. Results: Girls who were married or cohabiting and girls who had given birth, were significantly less likely to be in school (OR=0.004, 95% CI {0.001-0.02}, p-value=&lt;0.0001) and (OR=0.003, 95% CI {0.02-0.04}, p-value=&lt;0.0001) respectively. Consistently receiving cash transfers increased the chance of a girl being in school (OR=8.51, 95% CI {4.50-16.08}, p-value=&lt;0.0001). There was an indication that the combined intervention arm had a reduced chance of girls being in school, however, we could not rule out chance finding (OR=0.89, 95% CI {0.59-1.36}, p=0.606). Conclusion: The study found that marriage or cohabiting and giving birth whilst in school reduce the chances of the girl continuing schooling. No significant association could be attributed to the type of intervention, However, consistent receipt of cash transfers was shown to be a protective factor of school dropout rates in the study.

Obesity matters but is not perceived: A cross-sectional study on cardiovascular disease risk factors among a population-based probability sample in rural Zambia.

BackgroundSub-Saharan Africa, including Zambia, has experienced an increase in overweight and obesity due to rapid lifestyle changes associated with recent economic growth. We explored the prevalence and correlates of overweight and obesity in rural Zambia. We also investigated the role of self-perception of body weight in weight control given the local socio-cultural context.MethodsIn this cross-sectional study, we recruited 690 residents of the Mumbwa district aged 25–64 years through a multistage, clustered, household random sampling. We administered a questionnaire and collected anthropometric and bio-behavioral data from May to July 2016. Factors associated with body mass index (BMI) ≥25 kg/m2 and underestimation of body weight were assessed using multiple logistic regression.ResultsOf the weighted sample of 689 participants (335 men and 354 women), 185 (26.8%) had BMI ≥25 kg/m2. In multivariate analyses, female gender, age 45–64 years, tertiary education, higher fruit and vegetable intake, high blood pressure, abnormal blood lipid profile, and Hemoglobin A1c ≥5.7% were significantly associated with BMI ≥25 kg/m2. Among participants with BMI ≥25 kg/m2, 14.2% and 58.2% perceived themselves as being underweight and normal weight, respectively. Age 45–64 years was the only factor significantly associated with body weight underestimation. Preference for obesity was reported by 17.5% and 3.6% of respondents with BMI <25 kg/m2 and BMI≥25 kg/m2, respectively; “looks attractive” and “fear of being perceived as HIV-positive” were the main reasons.ConclusionIn rural Zambia, overweight and obesity are prevalent and significantly associated with alterations in blood pressure, blood lipid profile, and glucose metabolism. However, most subjects with BMI ≥25 kg/m2 underestimated their body weight; some preferred obesity, in part due to cultural factors and HIV-related stigma. A health promotion program that addresses such perceptions and body weight underestimation should be urgently introduced in Zambia.

The feasibility of fingerstick blood collection for point-of-care HIV-1 viral load monitoring in rural Zambia.

Viral load monitoring for HIV treatment is recommended but not feasible in many settings. A point-of-care test using capillary blood would increase access but may require up to 200 μL of blood to achieve a lower limit of detection of 1000 copies/mL. This cross-sectional study evaluated the feasibility of collecting 200 μL of capillary blood and blood collection preferences among adults in rural Zambia. Adults seeking HIV counseling and testing at Macha Hospital were recruited in 2015. Capillary blood was collected in four 50 μL tubes. Blood collection was categorized as complete (200 μL collected), partial (all tubes filled but <200 μL obtained due to collection techniques), or incomplete (1-4 tubes attempted; <200 μL obtained due to insufficient blood flow). One fingerstick was required for 90% of the 201 participants. A median blood volume of 196 μL was collected. Complete, partial and incomplete collection was achieved in 34%, 59% and 6% of participants. The majority of participants (95%) preferred fingerstick over venous blood collection. A point-of-care viral load test requiring up to 200 μL of blood is feasible in a rural setting but would require training and supervision to ensure that sufficient blood was collected.

Gender, culture and energy transitions in rural Africa

Research over the past two decades on links between energy, gender and development suggests that greater inclusion of gender concerns in energy sector decision-making improves development outcomes. In practice, this has typically led to gendered energy approaches that focus more on technological fixes rather than providing appropriate energy services, and on meeting women’s immediate needs rather than addressing the broader cultural, socio-economic and political contexts important for attaining genuine gender equity. In this paper, we take a systems perspective to explore gender issues in the context of a transition from traditional to modern energy services, such as lighting, powering appliances and charging mobile phones. Viewing gender through the lens of the Energy Cultures Framework, we analyse the case of the Mpanta solar mini-grid in rural northern Zambia. We find that the transition to more modern energy services is far from gender neutral: despite providing broad benefits within the community, the benefits derived from a new technology and service were not evenly distributed between men and women due to broader socio-cultural practices and norms. This paper extends the application of the Energy Cultures Framework in two important ways. Firstly, it incorporates an explicit gender dimension into the framework. Secondly, it applies the framework in a new context – rural energy transitions in low-income countries. In doing so, this paper offers important insights for research and practice in energy, gender and development.

How a woman's interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework

To reduce maternal mortality, countries must continue to seek ways to increase access to skilled care during pregnancy and delivery. In Zambia, while antenatal attendance is high, many barriers exist that prevent women from delivering with a skilled health provider. This study explores how the individuals closest to a pregnant woman in rural Zambia can influence a woman's decision to seek and her ability to access timely maternity care. At four rural health centers, a free listing (n = 167) exercise was conducted with mothers, fathers, and community elders. Focus group discussions (FGD) (n = 135) were conducted with mothers, fathers, mothers-in-law, and community health workers (CHWs) to triangulate findings. We analyzed the FGD data against a framework that overlaid the Three Delays Framework and the Social Ecological Model. Respondents cited husbands, female relatives, and CHWs as the most important influencers during a woman's maternity period. Husbands have responsibilities to procure resources, especially baby clothes, and provide the ultimate permission for a woman to attend ANC or deliver at a facility. Female relatives escort the woman to the facility, assist during her wait, provide emotional support, assist the nurse during delivery, and care for the woman after delivery. CHWs educate the woman during pregnancy about the importance of facility delivery. No specific individual has the role of assisting with the woman's household responsibilities or identifying transport to the health facility. When husbands, female relatives, or CHWs do not fulfill their roles, this presents a barrier to a woman deciding to deliver at the health facility (Delay 1) or reaching a health facility (Delay 2). An intervention to help women better plan for acquiring the needed resources and identifying the individuals to escort her and those to perform her household responsibilities could help to reduce these barriers to accessing timely maternal care.

Can conservation agriculture save tropical forests? The case of minimum tillage in Zambia

Minimum tillage (MT) is a key component in the promotion of conservation agriculture (CA). This paper asks whether MT reduces cropland expansion and thus deforestation. We develop a theoretical household model of land expansion, and test hypotheses by estimating a double hurdle model using household survey data from 368 smallholders in rural Zambia. About 19% of the farmers expanded cropland into forests, clearing an average of 0.14 ha over one year. Overall, we do not find significant associations between MT adoption and reduced deforestation among households in our sample, while higher labor availability and crop yield stimulate expansion. Yield augmenting agricultural technologies (such as MT) may not reduce expansion unless combined with other forest conservation measures.