Setting In Zambia Research Articles

Fairness and legitimacy of decisions during delivery of malaria services and ITN interventions in zambia

BackgroundMalaria is the leading cause of morbidity and the second leading cause of mortality in Zambia. Perceptions of fairness and legitimacy of decisions relating to treatment of malaria cases within public health facilities and distribution of ITNs were assessed in a district in Zambia. The study was conducted within the framework of REsponse to ACcountable priority setting for Trust in health systems (REACT), a north-south collaborative action research study, which evaluates the Accountability for Reasonableness (AFR) approach to priority setting in Zambia, Tanzania and Kenya.MethodsThis paper is based on baseline in-depth interviews (IDIs) conducted with 38 decision-makers, who were involved in prioritization of malaria services and ITN distribution at district, facility and community levels in Zambia, one Focus Group Discussion (FGD) with District Health Management Team managers and eight FGDs with outpatients' attendees. Perceptions and attitudes of providers and users and practices of providers were systematized according to the four AFR conditions relevance, publicity, appeals and leadership.ResultsConflicting criteria for judging fairness were used by decision-makers and patients. Decision-makers argued that there was fairness in delivery of malaria treatment and distribution of ITNs based on alleged excessive supply of free malaria medicines, subsidized ITNs, and presence of a qualified health-provider in every facility. Patients argued that there was unfairness due to differences in waiting time, distances to health facilities, erratic supply of ITNs, no responsive appeal mechanisms, inadequate access to malaria medicines, ITNs and health providers, and uncaring providers. Decision-makers only perceived government bodies and donors/NGOs to be legitimate stakeholders to involve during delivery. Patients found government bodies, patients, indigenous healers, chiefs and politicians to be legitimate stakeholders during both planning and delivery.ConclusionPoor status of the AFR conditions of relevance, publicity, appeals and leadership corresponds well to the differing perceptions of fairness and unfairness among outpatient attendees and decision-makers. This may have been re-enforced by existing disagreements between the two groups regarding who the legitimate stakeholders to involve during service delivery were. Conflicts identified in this study could be resolved by promoting application of approaches such as AFR during priority setting in the district.

Neonatal Resuscitation: A Global Challenge

Two studies of neonatal care appear in this issue of Pediatrics : “Newborn Care Training for Midwives and Neonatal and Perinatal Mortality Rates in a Developing Country”1 and “High Mortality Rates of Very Low Birth Weight Infants in Developing Countries Despite Training.”2 Results of the first study of 71 689 infants born in a hospital setting in Zambia indicates that an education program focused on cleanliness, thermal protection, neonatal resuscitation, early breastfeeding, skin-to-skin care with the mother, care of the small infant, recognition of infant danger signs, and initial management effectively lowered the early neonatal mortality rate from 11.5 in 1000 to 6.8 in 1000 live births. The addition of enhanced neonatal resuscitation training was associated with further reduction of the 7-day neonatal mortality rate but required substantial statistical modeling to account for changing follow-up rates throughout the course of this facility-based study.1 In the second article, Carlo et al2 report on the outcome of 500- to 1499-g infants in a 6-country, 7-site study of the same educational intervention conducted in rural communities in which most deliveries occurred at home or in first-level facilities. Neither the simple newborn care package with resuscitation nor the additional neonatal resuscitation training was associated with a decrease in the 7-day mortality rate. … Address correspondence to William Keenan, MD, Department of Pediatrics, Saint Louis University, 1465 S Grand Blvd, St Louis, MO 63119. E-mail: keenanwj{at}slu.edu

Reducing Pediatric HIV Infection: Estimating Mother-to-Child Transmission Rates in a Program Setting in Zambia

Vertical transmission of HIV remains the main source of pediatric HIV infection in Africa with transmission rates as high as 25%-45% without intervention. Even though effective interventions to reduce vertical transmission of HIV are now available and remarkable progress has been made in scaling up prevention of mother-to-child transmission (PMTCT) services, the effectiveness of PMTCT interventions is unknown in Zambia. In this study, we estimate HIV vertical transmission rates at different age bands among perinatally exposed children. The study analyzed program data of DNA polymerase chain reaction results and selected client information on dried blood spot samples from perinatally exposed children aged 0-12 months sent to the polymerase chain reaction laboratory from 5 provinces between September 2007 and January 2009. Samples of 8237 babies between 0 and 12 months were analyzed, with 84% of the mothers having ever breastfed their children. The observed transmission rate was 6.5% (5.1%, 7.8%) among infants aged 0-6 weeks when both mother and infant received interventions compared with 20.9% (12.3%, 29.5%) where no intervention was given to either mother or baby. Observed HIV transmission with single-dose nevirapine (sdNVP) was 8.5% (5.9%, 11.0%) among infants aged 0-6 weeks, whereas zidovudine with sdNVP (zidovudine + NVP) and highly active antiretroviral therapy were associated with observed transmission rates of 6.8% (4.5%, 9.1%) and 5.0% (3.0%, 7.0%), respectively; whereas these estimates were not significantly different from one another, they were all significantly lower than no intervention for which the estimated rate was 20.9%. Regardless of the intervention, the observed transmission rates were higher among infants aged 6-12 months. PMTCT interventions, including sdNVP, are working in program settings. However, postnatal transmission especially after 6 months through suboptimal feeding practises remains an important challenge to further reduce pediatric HIV.

Isolation of non-tuberculous mycobacteria at three rural settings in Zambia; a pilot study

To assess the role of non-tuberculous mycobacteria (NTM) as a cause of tuberculosis-like diseases in Zambia, 167 chronically ill patients, hospitalized in three rural hospitals in Katete, Sesheke and Chilonga, were examined by microscopy and liquid culture for the presence of NTM. The percentages of patients with a positive culture for Mycobacterium tuberculosis complex were similar in the three geographical locations (19-25%). In contrast, the percentage of NTM ranged from 78% in Katete and 65% in Sesheke to 21% in Chilonga. Furthermore, the distribution of NTM species was different at the three geographical sites. In seven patients, true NTM-associated disease was suspected: five with Mycobacterium lentiflavum and two with Mycobacterium intracellulare. Analysis of possible risk factors indicated that the OR for NTM culture-positive sputum was significantly higher for patients living in Katete and Sesheke. Female gender and chest X-ray appearances of tuberculosis were independently associated with NTM culture-positive sputum. NTM colonization and disease in hospitalized, chronically ill patients in rural Zambia appear to be common.

ZAMSTAR, The Zambia South Africa TB and HIV Reduction Study: design of a 2 x 2 factorial community randomized trial.

BackgroundTB and HIV form a deadly synergy in much of the developing world, especially Africa. Interventions to reduce the impact of these diseases at community level are urgently needed. This paper presents the design of a community randomised trial to evaluate the impact of two complex interventions on the prevalence of tuberculosis (TB) in high HIV prevalence settings in Zambia and South Africa.MethodsThe interaction between TB and HIV is reviewed and possible interventions that could reduce the prevalence of TB in HIV-endemic populations are discussed. Two of these interventions are described in detail and the design of a 2 × 2 factorial community randomised trial to test these interventions is presented. The limitations and challenges of the design are identified and discussed.ConclusionThere is an urgent need to reduce the prevalence of TB in communities highly affected by HIV. Potential interventions are complex and require innovative trial designs to provide the rigorous evidence needed to inform health policy makers and to ensure that resources are used optimally.Trial RegistrationNumber: ISRCTN36729271

Adherence Support Workers: A Way to Address Human Resource Constraints in Antiretroviral Treatment Programs in the Public Health Setting in Zambia

BackgroundIn order to address staff shortages and improve adherence counseling for people on antiretroviral therapy (ART), the Zambia Prevention, Care and Treatment Partnership (ZPCT) developed an innovative strategy of training community volunteers to provide adherence support at the health facility and community levels. The objective of this study was to assess the effectiveness of these ‘adherence support workers’ (ASWs) in adherence counseling, treatment retention and addressing inadequate human resources at health facilities.Methodology/Principal FindingsThe study used quantitative and qualitative research techniques at five selected ART sites in four provinces in Zambia. Five hundred patients on ART were interviewed using a structured questionnaire to compare the quality of adherence counseling before and after the ASW scheme was introduced at the selected sites and between ASWs and HCWs after the introduction of ASWs. In addition, 3,903 and 4,972 electronic records of all new patients accessing antiretroviral therapy for the time period of 12 months before and 12 months after the introduction of ASWs respectively, were analyzed to assess loss to follow-up rates. Two focus group discussions with ASWs and health care workers (HCWs) were conducted in each clinic. Key informant interviews in the ART clinics were also conducted. There was a marked shift of workload from HCWs to ASWs without any compromise in the quality of counseling. Quality of adherence counseling by ASWs was comparable to HCWs after their introduction. The findings suggest that the deployment of ASWs helped reduce waiting times for adherence counseling. Loss to follow-up rates of new clients declined from 15% to 0% after the deployment of ASWs.ConclusionAdherence counseling tasks can be shifted to lay cadres like ASWs without compromising the quality of counseling. Follow-up of clients by ASWs within the community is necessary to improve retention of clients on ART.

Stigma, HIV/AIDS and prevention of mother-to-child transmission in Zambia

This report evaluates the extent of perceived and enacted HIV/AIDS-related stigma in a rural setting in Zambia. Stigmatisation is abundant, ranging from subtle actions to the most extreme degradation, rejection and abandonment. Women with HIV and pregnant women assumed to be HIV positive are repeatedly subjected to extensive forms of stigma, particularly once they become sick or if their child dies. Despite increasing access to prevention of mother to child transmission initiatives, including anti-retroviral drugs, the perceived disincentives of HIV testing, particularly for women, largely outweigh the potential gains from available treatments. HIV/AIDS related stigma drives the epidemic underground and is one of the main reasons that people do not wish to know their HIV status. Unless efforts to reduce stigma are, as one peer educator put it, “written in large letters in any HIV/AIDS campaign rather than small”, stigma will remain a major barrier to curbing the HIV/AIDS pandemic.

Traditional healers in Zambia and their care for patients with urethral/vaginal discharge.

The aim of this study was to describe the knowledge and practices of traditional healers in relation to the management of patients with urethral/vaginal discharge. Eighty (80) traditional healers, 54 from an urban and 26 from a rural setting in Zambia, who attend to patients with urethral/vaginal discharge, were interviewed using a semistructured questionnaire. All of the traditional healers had knowledge of urethral/vaginal discharge being a symptom of a sexually transmitted disease (STD) and that individuals get the infection through sexual relations with infected persons. The healers were all able to cite other symptoms associated with urethral/vaginal discharge. The treatment the healers used was mostly herbal preparations in the form of roots or powders administered orally to induce diarrhea, vomiting, and diuresis. Patients were not allowed to combine traditional and biomedical therapies. Almost half of the healers did apply some biomedical practices in the management of patients with urethral/vaginal discharge, such as history taking and examination of patients before diagnosis and prescription. The healers also advised patients to avoid sex while on treatment and to avoid reinfection by remaining with one partner and using condoms. Some healers advised their patients to bring their sexual partners for consultation. Because traditional healers attend to patients with STDs, both in rural and urban areas, efforts should be made to promote cooperation between traditional and biomedical health care providers, so that treatment of patients and their partners could be improved. Traditional management that concurs with biomedical practices could thus be a starting point for discussion and cooperation.

Quality of STD care in an urban Zambian setting: the providers' perspective

The aim of this paper is to analyse obstacles to optimal STD care in an urban setting in Zambia. Eighty-two health professionals answered a questionnaire with closed and open-ended questions. More than 50% were not satisfied with their working conditions, due to heavy workload, lack of equipment/drugs, poor salary and lack of continuing education. Negative opinions about STD patients were common. Treatment and preventive activities were considered important but most respondents found patient compliance poor—especially for partner notification. To improve the quality of STD care, training in STD management should be combined with improved working conditions.

Social Acceptance of Children with Intellectual Disabilities in an Integrated School Setting in Zambia: a pilot study

The social acceptance of a group of Zambian primary school children with intellectual disabilities by two groups of nondisabled children was examined. One group were in direct contact with the children with disabilities over a period of six months while the other was not. Nondisabled boys who had been in contact with children with disabilities had more positive attitudes than boys who had no direct contact, while no exposure effects were observed amongst girls. Gender differences amongst nondisabled children who had contact with peers with disabilities were not significant. Amongst the nondisabled children who had no contact with children with disabilities, girls had more positive attitudes than boys. The findings are preliminary, but offer directions for further research and have some implications for integrating children with disabilities into mainstream schools.