Showing papers by "University of Zambia published in 2010"

Newborn-care training and perinatal mortality in developing countries.

Abstract: Background Of the 37 million neonatal deaths and 33 million stillbirths each year, 98% occur in developing countries An evaluation of community-based interventions designed to reduce the number of these deaths is needed Methods With the use of a train-the-trainer model, local instructors trained birth attendants from rural communities in six countries (Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan, and Zambia) in the World Health Organization Essential Newborn Care course (which focuses on routine neonatal care, resuscitation, thermoregulation, breast-feeding, “kangaroo” [skin-to-skin] care, care of the small baby, and common illnesses) and (except in Argentina) in a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (which teaches basic resuscitation in depth) The Essential Newborn Care intervention was assessed among 57,643 infants with the use of a before-and-after design The Neonatal Resuscitation Program intervention was assessed as a cluster-randomized, controlled trial involving 62,366 infants The primary outcome was neonatal death in the first 7 days after birth Results The 7-day follow-up rate was 992% After birth attendants were trained in the Essential Newborn Care course, there was no significant reduction from baseline in the rate of neonatal death from all causes in the 7 days after birth (relative risk with training, 099; 95% confidence interval [CI], 081 to 122) or in the rate of perinatal death; there was a significant reduction in the rate of stillbirth (relative risk with training, 069; 95% CI, 054 to 088; P = 0003) In clusters of births in which attendants had been randomly assigned to receive training in the Neonatal Resuscitation Program, as compared with control clusters, there was no reduction in the rates of neonatal death in the 7 days after birth, stillbirth, or perinatal death Conclusions The rate of neonatal death in the 7 days after birth did not decrease after the introduction of Essential Newborn Care training of community-based birth attendants, although the rate of stillbirths was reduced Subsequent training in the Neonatal Resuscitation Program did not significantly reduce the mortality rates (ClinicalTrials gov number, NCT00136708)

Patient-reported barriers and drivers of adherence to antiretrovirals in sub-Saharan Africa: a meta-ethnography

Abstract: This meta-ethnography aims at providing a synthesis and an interpretation of the findings of recent social science research on the questions of retention in antiretroviral therapy (ART) programmes in sub-Saharan Africa (SSA). The literature reviewed comprises ethnographic studies of the barriers to adherence to ART in various cultural settings. The results show that the quality of services, treatment-related costs, as well as the need to maintain social support networks - which can be negatively affected by HIV-related stigma - are important barriers to adherence. In addition, they show how African concepts of personhood are incompatible with the way services are conceived and delivered, targeting the individual. In SSA, individuals must balance physical health with social integrity, which is sometimes achieved by referring to traditional medicine. The ability of local concepts of illness to address social relations in addition to health, together with a historically grounded distrust in Western medicine, explains why traditional medicine is still widely used as an alternative to ART

Termite-induced heterogeneity in African savanna vegetation: mechanisms and patterns

Abstract: Objectives: To (1) assess the strength of evidence for the role of termites in vegetation heterogeneity in African savannas, and (2) identify the mechanisms by which termites induce such heterogeneity. Location: African savannas. Methods: We conducted a review of the literature, a meta-analysis and qualitative systems analysis to identify mechanisms to explain the observed patterns. Results: The review provided evidence for termite-induced heterogeneity in floristic composition and vegetation patterning in savannas across Africa. Termites induced vegetation heterogeneity directly or indirectly through their nest-building and foraging activities, associated nutrient cycling and their interaction with mammalian herbivores and fire. The literature reviewed indicated that termite mounds essentially act as islands of fertility, which are responsible for ecosystem-level spatial heterogeneity in savannas. This was supported by the meta-analysis, which demonstrated that mounds of Ancistrotermes, Macrotermes, Odontotermes (family Macrotermitinae), Cubitermes (family Termitinae) and Trinervitermes (Nasutitermitinae) are significantly enriched in clay (75%), carbon (16%), total nitrogen (42%), calcium (232%), potassium (306%) and magnesium (154%) compared to the surrounding savanna soil. Conclusions: Termite activity is one of the major factors that induce vegetation patterning in African savannas. The implications of this are discussed and research questions for future studies and modelling efforts are indicated.

Newborn Care Training of Midwives and Neonatal and Perinatal Mortality Rates in a Developing Country

Abstract: OBJECTIVE: This study was designed to test the hypothesis that 2 training programs would reduce incrementally 7-day neonatal mortality rates for low-risk institutional deliveries. METHODS: Using a train-the-trainer model, certified research midwives sequentially trained the midwives who performed deliveries in low-risk, first-level, urban, community health clinics in 2 cities in Zambia in the protocol and data collection, in the World Health Organization Essential Newborn Care (ENC) course (universal precautions and cleanliness, routine neonatal care, resuscitation, thermoregulation, breastfeeding, kangaroo care, care of small infants, and common illnesses), and in the American Academy of Pediatrics Neonatal Resuscitation Program (in-depth basic resuscitation). Data were collected during 3 periods, after implementation of each training course. RESULTS: A total of 71 689 neonates were enrolled in the 3 study periods. All-cause, 7-day neonatal mortality rates decreased from 11.5 deaths per 1000 live births to 6.8 deaths per 1000 live births after ENC training (relative risk: 0.59 [95% confidence interval: 0.48–0.77]; P CONCLUSIONS: ENC training for midwives reduced 7-day neonatal mortality rates in low-risk clinics. Additional in-depth basic training in neonatal resuscitation may reduce mortality rates further.

Home-based voluntary HIV counselling and testing found highly acceptable and to reduce inequalities

Abstract: Background: Low uptake of voluntary HIV counselling and testing (VCT) in sub-Saharan Africa is raising acceptability concerns which might be associated with ways by which it is offered. We investigated the acceptability of home-based delivery of counselling and HIV testing in urban and rural populations in Zambia where VCT has been offered mostly from local clinics. Methods: A population-based HIV survey was conducted in selected communities in 2003 (n = 5035). All participants stating willingness to be HIV tested were offered VCT at home and all counselling was conducted in the participants' homes. In the urban area post-test counselling and giving of results were done the following day whereas in rural areas this could take 1-3 weeks. Results: Of those who indicated willingness to be HIV tested, 76.1% (95%CI 74.9-77.2) were counselled and received the test result. Overall, there was an increase in the proportion ever HIV tested from 18% before provision of homebased VCT to 38% after. The highest increase was in rural areas; among young rural men aged 15-24 years up from 14% to 42% vs. for urban men from 17% to 37%. Test rates by educational attainment changed from being positively associated to be evenly distributed after home-based VCT. Conclusions: A high uptake was achieved by delivering HIV counselling and testing at home. The highest uptakes were seen in rural areas, in young people and groups with low educational attainment, resulting in substantial reductions in existing inequalities in accessing VCT services.

Mental health policy process: a comparative study of Ghana, South Africa, Uganda and Zambia.

Abstract: Background Mental illnesses are increasingly recognised as a leading cause of disability worldwide, yet many countries lack a mental health policy or have an outdated, inappropriate policy. This paper explores the development of appropriate mental health policies and their effective implementation. It reports comparative findings on the processes for developing and implementing mental health policies in Ghana, South Africa, Uganda and Zambia as part of the Mental Health and Poverty Project.

Elevations in mortality associated with weaning persist into the second year of life among uninfected children born to HIV-infected mothers.

Abstract: BACKGROUND: Early weaning has been recommended to reduce postnatal human immunodeficiency virus (HIV) transmission. We evaluated the safety of stopping breast-feeding at different ages for mortality of uninfected children born to HIV-infected mothers. METHODS: During a trial of early weaning 958 HIV-infected mothers and their infants were recruited and followed up from birth to 24 months postpartum in Lusaka Zambia. One-half of the cohort was randomized to wean abruptly at 4 months and the other half of the cohort was randomized to continue breast-feeding. We examined associations between uninfected child mortality and actual breast-feeding duration and investigated possible confounding and effect modification. RESULTS: The mortality rate among 749 uninfected children was 9.4% by 12 months of age and 13.6% by 24 months of age. Weaning during the interval encouraged by the protocol (4-5 months of age) was associated with a 2.03-fold increased risk of mortality (95% confidence interval [CI] 1.13-3.65) weaning at 6-11 months of age was associated with a 3.54-fold increase (95% CI 1.68-7.46) and weaning at 12-18 months of age was associated with a 4.22-fold increase (95% CI 1.59-11.24). Significant effect modification was detected such that risks associated with weaning were stronger among infants born to mothers with higher CD4(+) cell counts (>350 cells/microL). CONCLUSION: Shortening the normal duration of breast-feeding for uninfected children born to HIV-infected mothers living in low-resource settings is associated with significant increases in mortality extending into the second year of life. Intensive nutritional and counseling interventions reduce but do not eliminate this excess mortality.

A Mixed Methods and Triangulation Model for Increasing the Accuracy of Adherence and Sexual Behaviour Data: The Microbicides Development Programme

Abstract: Background The collection of accurate data on adherence and sexual behaviour is crucial in microbicide (and other HIV-related) research. In the absence of a “gold standard” the collection of such data relies largely on participant self-reporting. After reviewing available methods, this paper describes a mixed method/triangulation model for generating more accurate data on adherence and sexual behaviour in a multi-centre vaginal microbicide clinical trial. In a companion paper some of the results from this model are presented [1].

Mental illness - stigma and discrimination in Zambia

Abstract: Objective: The aim of this qualitative study was to explore the presence, causes and means of addressing individual and systemic stigma and discrimination against people with mental illness in Zambia. This is to facilitate the development of tailor-made antistigma initiatives that are culturally sensitive for Zambia and other low-income African countries. This is the first in-depth study on mental illness stigma in Zambia. Method: Fifty semi-structured interviews and 6 focus group discussions were conducted with key stakeholders drawn from 3 districts in Zambia (Lusaka, Kabwe and Sinazongwe). Transcripts were analyzed using a grounded theory approach. Results: Mental illness stigma and discrimination is pervasive across Zambian society, prevailing within the general community, amongst family members, amid general and mental health care providers, and at the level of government. Such stigma appears to be fuelled by misunderstandings of mental illness aetiology; fears of contagion and the perceived dangerousness of people with mental illness; and associations between HIV/AIDS and mental illness. Strategies suggested for reducing stigma and discrimination in Zambia included education campaigns, the transformation of mental health policy and legislation and expanding the social and economic opportunities of the mentally ill. Conclusion: In Zambia, as in many other lowincome African countries, very little attention is devoted to addressing the negative beliefs and behaviours surrounding mental illness, despite the devastating costs that ensue. The results from this study underscore the need for greater commitment from governments and policy-makers in African countries to start prioritizing mental illness stigma as a major public health and development issue. Key words: Mental health; Stigma and discrimination; Qualitative study; Zambia

Heavy metal accumulation in lake sediments, fish (Oreochromis niloticus and Serranochromis thumbergi), and crayfish (Cherax quadricarinatus) in Lake Itezhi-tezhi and Lake Kariba, Zambia.

Abstract: We measured the level of heavy metal accumulation in lake sediments, herbivorous (Oreochromis niloticus) and carnivorous (Serranochromis thumbergi) fish, and crayfish (Cherax quadricarinatus) from Lake Itezhi-tezhi (ITT) and Lake Kariba. We used atomic absorption spectrophotometry to quantify the levels of seven heavy metals (Cr, Co, Cu, Zn, Cd, Pb, and Ni). The sediment and the herbivorous fish O. niloticus accumulated a very high concentration of Cu in Lake ITT, most likely due to the discharge of Cu waste from a mining area 450 km upstream. The aquatic species we sampled in Lake Kariba had higher concentrations of Cr, Ni, and Pb relative to those in Lake ITT. This is most likely due to anthropogenic activities, such as the use of leaded petrol and antifouling agents in marine paints. Interestingly, we observed a negative correlation between the coefficient of condition (K) and Ni concentration in the crayfish hepatopancreas. Both O. niloticus and the crayfish had much higher biota-sediment accumulation factors (BSAF) for Cu, Zn, and Cd relative to Cr, Co, Pb, and Ni. The rank of BSAF values for O. niloticus (Cu > Cd > Zn) and C. quadricarinatus (Zn > Cd > Cu) differed from the expected ranks based on the general order of affinity of metals (Cd >> Zn > Cu).

National and subnational HIV/AIDS coordination: are global health initiatives closing the gap between intent and practice?

Abstract: Background: A coordinated response to HIV/AIDS remains one of the ‘grand challenges’ facing policymakers today. Global health initiatives (GHIs) have the potential both to facilitate and exacerbate coordination at the national and subnational level. Evidence of the effects of GHIs on coordination is beginning to emerge but has hitherto been limited to single-country studies and broad-brush reviews. To date, no study has provided a focused synthesis of the effects of GHIs on national and subnational health systems across multiple countries. To address this deficit, we review primary data from seven country studies on the effects of three GHIs on coordination of HIV/AIDS programmes: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President’s Emergency Plan for AIDS Relief (PEPFAR), and the World Bank’s HIV/AIDS programmes including the Multi-country AIDS Programme (MAP). Methods: In-depth interviews were conducted at national and subnational levels (179 and 218 respectively) in seven countries in Europe, Asia, Africa and South America, between 2006 and 2008. Studies explored the development and functioning of national and subnational HIV coordination structures, and the extent to which coordination efforts around HIV/AIDS are aligned with and strengthen country health systems. Results: Positive effects of GHIs included the creation of opportunities for multisectoral participation, greater political commitment and increased transparency among most partners. However, the quality of participation was often limited, and some GHIs bypassed coordination mechanisms, especially at the subnational level, weakening their effectiveness. Conclusions: The paper identifies residual national and subnational obstacles to effective coordination and optimal use of funds by focal GHIs, which these GHIs, other donors and country partners need to collectively address.

Re-framing microbicide acceptability: findings from the MDP301 trial.

Abstract: Microbicides are most usually conceptualised within a disease prevention framework and studies usually define acceptability in terms of product characteristics, willingness to use and risk reduction. This starting point has led to assumptions about microbicides which, rather than being challenged by empirical studies, have tended to foreclose the data and subsequent conceptual models. Few studies take an emic ('insider') perspective or attempt to understand how microbicides fit into the broader context of women's and men's everyday lives. As part of the integrated social science component of the MDP301 Phase III microbicide trial, in-depth interviews were conducted with female trial participants in South Africa, Zambia, Tanzania and Uganda. Women's experiences of the gel challenge several assumptions that have commonly been reiterated about microbicides. Our analysis suggests that current definitions and conceptual frameworks do not adequately account for the range of meanings that women attribute to gel. Even within the context of a clinical trial, it is possible to obtain a richer, ethnographic and cross-cultural concept of acceptability based on women's practice and emic interpretations. We now need to move beyond limited notions of acceptability and consider how microbicides fit into a more holistic picture of women's and men's sexuality and sexual health.

Couples' voluntary counselling and testing and nevirapine use in antenatal clinics in two African capitals: a prospective cohort study

Abstract: With the accessibility of prevention of mother to child transmission (PMTCT) services in sub-Saharan Africa, more women are being tested for HIV in antenatal care settings. Involving partners in the counselling and testing process could help prevent horizontal and vertical transmission of HIV. This study was conducted to assess the feasibility of couples' voluntary counseling and testing (CVCT) in antenatal care and to measure compliance with PMTCT. A prospective cohort study was conducted over eight months at two public antenatal clinics in Kigali, Rwanda, and Lusaka, Zambia. A convenience sample of 3625 pregnant women was enrolled. Of these, 1054 women were lost to follow up. The intervention consisted of same-day individual voluntary counselling and testing (VCT) and weekend CVCT; HIV-positive participants received nevirapine tablets. In Kigali, nevirapine syrup was provided in the labour and delivery ward; in Lusaka, nevirapine syrup was supplied in pre-measured single-dose syringes. The main outcome measures were nurse midwife-recorded deliveries and reported nevirapine use. In eight months, 1940 women enrolled in Kigali (984 VCT, 956 CVCT) and 1685 women enrolled in Lusaka (1022 VCT, 663 CVCT). HIV prevalence was 14% in Kigali, and 27% in Lusaka. Loss to follow up was more common in Kigali than Lusaka (33% vs. 24%, p = 0.000). In Lusaka, HIV-positive and HIV-negative women had significantly different loss-to-follow-up rates (30% vs. 22%, p = 0.002). CVCT was associated with reduced loss to follow up: in Kigali, 31% of couples versus 36% of women testing alone (p = 0.011); and in Lusaka, 22% of couples versus 25% of women testing alone (p = 0.137). Among HIV-positive women with follow up, CVCT had no impact on nevirapine use (86-89% in Kigali; 78-79% in Lusaka). Weekend CVCT, though new, was feasible in both capital cities. The beneficial impact of CVCT on loss to follow up was significant, while nevirapine compliance was similar in women tested alone or with their partners. Pre-measured nevirapine syrup syringes provided flexibility to HIV-positive mothers in Lusaka, but may have contributed to study loss to follow up. These two prevention interventions remain a challenge, with CVCT still operating without supportive government policy in Zambia.

Cattle owners' awareness of bovine tuberculosis in high and low prevalence settings of the wildlife-livestock interface areas in Zambia

Abstract: Background: Awareness of bovine tuberculosis (BTB) by cattle owners is of extreme importance to policy makers when considering mitigation However, to our knowledge, little is known on cattle owners' awareness of BTB in Zambia Similarly, such knowledge is uncommon within and outside Africa The current study investigates the epidemiological characteristics of BTB in Zambian cattle in relation to awareness by cattle owners in high and low cattle BTB prevalence settings A cross sectional study was designed and data was gathered based on 106 cattle owners and cattle herds; subjected to an interviewer-administered questionnaire and comparative intradermal tuberculin test using a cut-off for positivity of 4 mm, respectively Results: Reported levels of cattle and wildlife contact by respondents was at 40%, 582% and 18%, were relatively proportional to herd level prevalence of cattle BTB at 648%, 581% and 59% in Blue lagoon, Lochinvar and Kazungula respectively Although 42/106 (396%) of cattle owners had heard of BTB, only 3 (7%) had an idea on how the disease was spread Cattle contact with wildlife was associated with high levels of awareness by cattle owners (χ2 = 435, df = 2, P < 0001) Awareness of BTB in low prevalence settings was lower compared to high prevalence settings Conclusions: Our study has revealed low levels of awareness among cattle owners on BTB These results could be useful for policy makers when planning mitigation measures to consider awareness levels by cattle owners for effective implementation Such information is useful for determining sensitisation programs for cattle owners before mitigation These results further provide useful insights that disease control is a multi-factorial process with cattle owners as an integral part that can support policy implementation

Development of Loop-Mediated Isothermal Amplification (LAMP) Assays for Rapid Detection of Ehrlichia ruminantium

Abstract: The rickettsial bacterium Ehrlichia ruminantium is the causative agent of heartwater, a potential zoonotic disease of ruminants transmitted by ticks of the genus Amblyomma. The disease is distributed in nearly all of sub-Saharan Africa and some islands of the Caribbean, from where it threatens the American mainland. This report describes the development of two different loop-mediated isothermal amplification (LAMP) assays for sensitive and specific detection of E. ruminantium. Two sets of LAMP primers were designed from the pCS20 and sodB genes. The detection limits for each assay were 10 copies for pCS20 and 5 copies for sodB, which is at least 10 times higher than that of the conventional pCS20 PCR assay. DNA amplification was completed within 60 min. The assays detected 16 different isolates of E. ruminantium from geographically distinct countries as well as two attenuated vaccine isolates. No cross-reaction was observed with genetically related Rickettsiales, including zoonotic Ehrlichia species from the USA. LAMP detected more positive samples than conventional PCR but less than real-time PCR, when tested with field samples collected in sub-Saharan countries. Due to its simplicity and specificity, LAMP has the potential for use in resource-poor settings and also for active screening of E. ruminantium in both heartwater-endemic areas and regions that are at risk of contracting the disease.

An Empirical Approach to Defining Loss to Follow-up Among Patients Enrolled in Antiretroviral Treatment Programs

Abstract: In many programs providing antiretroviral therapy (ART), clinicians report substantial patient attrition; however, there are no consensus criteria for defining patient loss to follow-up (LTFU). Data on a multisite human immunodeficiency virus (HIV) treatment cohort in Lusaka, Zambia, were used to determine an empirical “days-late” definition of LTFU among patients on ART. Cohort members were classified as either “in care” or LTFU as of December 31, 2007, according to a range of days-late intervals. The authors then looked forward in the database to determine which patients actually returned to care at any point over the following year. The interval that best minimized LTFU misclassification was described as “best-performing.” Overall, 33,704 HIV-infected adults on ART were included. Nearly one-third (n = 10,196) were at least 1 day late for an appointment. The best-performing LTFU definition was 56 days after a missed visit, which had a sensitivity of 84.1% (95% confidence interval (CI): 83.2, 85.0), specificity of 97.5% (95% CI: 97.3, 97.7), and misclassification of 5.1% (95% CI: 4.8, 5.3). The 60-day threshold performed similarly well, with only a marginal difference (<0.1%) in misclassification. This analysis suggests that ≥60 days since the last appointment is a reasonable definition of LTFU. Standardization to empirically derived definitions of LTFU will permit more reliable comparisons within and across programs.

Effectiveness of non-nucleoside reverse-transcriptase inhibitor-based antiretroviral therapy in women previously exposed to a single intrapartum dose of nevirapine: a multi-country, prospective cohort study.

Abstract: Background: Intrapartum and neonatal single-dose nevirapine (NVP) reduces the risk of mother-to-child HIV transmission but also induces viral resistance to non-nucleoside reverse transcriptase inhibitor (NNRTI) drugs. This drug resistance largely fades over time. We hypothesized that women with a prior single-dose NVP exposure would have no more than a 10% higher cumulative prevalence of failure of their NNRTI-containing antiretroviral therapy (ART) over the first 48 wk of therapy than would women without a prior exposure. Methods and Findings: We enrolled 355 NVP-exposed and 523 NVP-unexposed women at two sites in Zambia, one site in Kenya, and two sites in Thailand into a prospective, non-inferiority cohort study and followed them for 48 wk on ART. Those who died, discontinued NNRTI-containing ART, or had a plasma viral load $400 copies/ml at either the 24 wk or 48 wk study visits and confirmed on repeat testing were characterized as having failed therapy. Overall, 114 of 355 NVP-exposed women (32.1%) and 132 of 523 NVP-unexposed women (25.2%) met criteria for treatment failure. The difference in failure rates between the exposure groups was 6.9% (95% confidence interval [CI] 0.8%–13.0%). The failure rates of women stratified by our predefined exposure interval categories were as follows: 47 of 116 women in whom less than 6 mo elapsed between exposure and starting ART failed therapy (40%; p,0.001 compared to unexposed women); 25 of 67 women in whom 7–12 mo elapsed between exposure and starting ART failed therapy (37%; p=0.04 compared to unexposed women); and 42 of 172 women in whom more than 12 mo elapsed between exposure and starting ART failed therapy (24%; p=0.82 compared to unexposed women). Locally weighted regression analysis also indicated a clear inverse relationship between virologic failure and the exposure interval. Conclusions: Prior exposure to single-dose NVP was associated with an increased risk of treatment failure; however, this risk seems largely confined to women with a more recent exposure. Women requiring ART within 12 mo of NVP exposure should not be prescribed an NNRTI-containing regimen as first-line therapy. Please see later in the article for the Editors’ Summary.

Household Consumption and Natural Resource Management around National Parks in Zambia

Abstract: Game Management Areas in Zambia aim to combine nature conservation with economic empowerment of rural households. This study determines the impact of community-based wildlife management and participation in related community institutions on household welfare. The results indicate that the gains from living in Game Management Areas and from participating in natural resource management are large but unevenly distributed. Only Game Management Areas with limited alternative livelihoods exhibit significant consumption benefits. However, the gains accrue mainly to the relatively well off, while the poor do not gain even if they participate. The results also show that infrastructure development does not necessarily translate into household level consumption gains in the short run. The design of community-based natural resource management programmes needs to respond to the inherent diversity among both the national parks and the community members. There is a need to address impediments to effective parti...

Integrating mental health into primary health care in Zambia: a care provider's perspective

Abstract: Background Despite the 1991 reforms of the health system in Zambia, mental health is still given low priority. This is evident from the fragmented manner in which mental health services are provided in the country and the limited budget allocations, with mental health services receiving 0.4% of the total health budget. Most of the mental health services provided are curative in nature and based in tertiary health institutions. At primary health care level, there is either absence of, or fragmented health services.

Task sharing in Zambia: HIV service scale-up compounds the human resource crisis.

Abstract: Background: Considerable attention has been given by policy makers and researchers to the human resources for health crisis in Africa. However, little attention has been paid to quantifying health facility-level trends in health worker numbers, distribution and workload, despite growing demands on health workers due to the availability of new funds for HIV/AIDS control scale-up. This study analyses and reports trends in HIV and non-HIV ambulatory service workloads on clinical staff in urban and rural district level facilities. Methods: Structured surveys of health facility managers, and health services covering 2005-07 were conducted in three districts of Zambia in 2008 (two urban and one rural), to fill this evidence gap. Intra-facility analyses were conducted, comparing trends in HIV and non-HIV service utilisation with staff trends. Results: Clinical staff (doctors, nurses and nurse-midwives, and clinical officers) numbers and staff population densities fell slightly, with lower ratios of staff to population in the rural district. The ratios of antenatal care and family planning registrants to nurses/nurse-midwives were highest at baseline and increased further at the rural facilities over the three years, while daily outpatient department (OPD) workload in urban facilities fell below that in rural facilities. HIV workload, as measured by numbers of clients receiving antiretroviral treatment (ART) and prevention of mother to child transmission (PMTCT) per facility staff member, was highest in the capital city, but increased rapidly in all three districts. The analysis suggests evidence of task sharing, in that staff designated by managers as ART and PMTCT workers made up a higher proportion of frontline service providers by 2007. Conclusions: This analysis of workforce patterns across 30 facilities in three districts of Zambia illustrates that the remarkable achievements in scaling-up HIV/AIDS service delivery has been on the back of sustained non-HIV workload levels, increasing HIV workload and stagnant health worker numbers. The findings are based on an analysis of routine data that are available to district and national managers. Mixed methods research is needed, combining quantitative analyses of routine health information with follow-up qualitative interviews, to explore and explain workload changes, and to identify and measure where problems are most acute, so that decision makers can respond appropriately. This study provides quantitative evidence of a human resource crisis in health facilities in Zambia, which may be more acute in rural areas.

Intestinal helminths and protozoa in children in pre-schools in Kafue district, Zambia.

Abstract: Intestinal parasitic infections are among the most widespread of human infections in developing countries, and children are the most vulnerable. The aim of this study was to determine the prevalence of the protozoa Cryptosporidium and Giardia, as well as prevalence and intensity of intestinal helminths in children attending pre-school or day-care centres in Kafue District, Zambia. Single stool samples were collected from 403 children from 10 pre-schools and were subjected to duplicate Kato-Katz thick smears to identify and quantify helminths. A commercial immunofluorescence kit was used to identify Cryptosporidium- and Giardia-positive samples. The overall prevalence of helminth infection was 17.9%. Ascarislumbricoides was found in 12.0%, hookworm in 8.3%, Taenia spp. in 0.9%, Hymenolepisnana in 0.6% and Schistosomamansoni in 0.3%. The overall prevalence of Cryptosporidium and Giardia was 28.0 and 29.0%, respectively, with more girls infected with Giardia (33.8%) than boys (22.7%) (P=0.02). Significant differences in infections with A. lumbricoides and Cryptosporidium were observed between the various pre-schools (P < 0.001). These findings indicate that intestinal parasites are prevalent in children enrolled in pre-schools in Zambia. Future studies should explore local factors associated with transmission of these infections, and consequently provide the necessary health education to parents and teachers.

A comparative study of the seroprevalence of brucellosis in commercial and small-scale mixed dairy–beef cattle enterprises of Lusaka province and Chibombo district, Zambia

Abstract: A cross-sectional study was conducted between January 2007 and February 2008 to estimate seroprevalence of brucellosis and identify risk factors associated with Brucella infections in commercial cattle in three districts of Lusaka province (Chongwe, Luangwa, and Kafue; n = 849) and in one rural district from the Central province (n = 48). A total of 897 serum samples were randomly collected from 55 farms along with animal-level data such as sex, age, and parity. Sera were screened for presence of anti-Brucella antibodies using the Rose Bengal test, and positive samples were confirmed using competitive enzyme-linked immunosorbent assay. At the animal level, seroprevalence was estimated at 7.9% (95% CI = 4.4-11.4%) in the Lusaka province and 18.7% (95% CI = 7.5-29.9%) for Chibombo district. Brucellosis seroprevalence varied according to district, with Chongwe district recording the highest compared to other districts. Seroprevalence also varied according to sex with bulls (n = 96) having higher seroprevalence (12.5%; 95% CI = 3.8-21.1%) compared to females (8.1%; 95% CI = 4.6-11.6). Similarly, seroprevalence varied according to age groups, with the age category 1-4 years recording the highest (10.7%). The study recorded relatively low Brucella seroprevalence in commercial farms in Lusaka, compared to the traditional small-scale farms. We suggest that testing and stamping out of infected animals is likely to improve the situation and significantly reduce the public health risk associated with Brucella infections in animals.

Assessing the accuracy of adherence and sexual behaviour data in the MDP301 vaginal microbicides trial using a mixed methods and triangulation model

Abstract: Background: Accurate data on adherence and sexual behaviour are crucial in microbicide (and other HIV-related) research. In the absence of a ‘‘gold standard’’ the collection of such data relies largely on participant self-reporting. The Microbicides Development Programme has developed a mixed method/triangulation model for generating more accurate data on adherence and sexual behaviour. Methodology/Principal Findings: Data were collected from a random subsample of 725 women using structured case record form (CRF) interviews, coital diaries (CD) and in-depth interviews (IDI). Returned used and unused gel applicators were counted and additional data collected through focus group discussions and ethnography. The model is described in detail in a companion paper [1]. When CRF, CD and IDI are compared there is some inconsistency with regard to reporting of sexual behaviour, gel or condom use in more than half. Inaccuracies are least prevalent in the IDI and most prevalent in the CRF, where participants tend to under-report frequency of sex and gel and condom use. Women reported more sex, gel and condom use than their partners. IDI data on adherence match the applicator-return data more closely than the CRF. The main reasons for inaccuracies are participants forgetting, interviewer error, desirability bias, problems with the definition and delineation of key concepts (e.g. ‘‘sex act’’). Most inaccuracies were unintentional and could be rectified during data collection. Conclusions/Significance: The CRF – the main source of self-report data on behaviour and adherence in many studies – was the least accurate with regard to measuring sexual behaviour, gel and condom use. This has important implications for the use of structured questionnaires for the collection of data on sexual behaviour and adherence. Integrating in-depth interviews and triangulation into clinical trials could increase the richness and accuracy of behavioural and adherence data. Citation: Pool R, Montgomery CM, Morar NS, Mweemba O, Ssali A, et al. (2010) Assessing the Accuracy of Adherence and Sexual Behaviour Data in the MDP301

Comparative Validity of Screening Instruments for Mental Distress in Zambia

Abstract: Background: The recognition of mental health as a major contributor to the global burden of disease has led to an increase in the demand for the inclusion of mental health services in primary health care as well as in community-based health surveys in order to improve screening, diagnosis and treatment of mental distress. Many screening instruments are now available. However, the cultural validity of these instruments to detect mental distress has rarely been investigated in developing countries. In these countries, limited trained staff and specialized psychiatric facilities hamper improvement of mental health services. It is therefore imperative to develop a quick, low cost screening instrument that does not require specialized training. We validated different well established screening instruments among primary health care clinic attendees in Lusaka, Zambia. We also assess the face, content and criterion validity of the SRQ’s and determined the most commonly reported symptoms for mental distress.

Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia

Abstract: Background: Shortages of health workers are obstacles to utilising global health initiative (GHI) funds effectively in Africa. This paper reports and analyses two countries’ health workforce responses during a period of large increases in GHI funds. Methods: Health facility record reviews were conducted in 52 facilities in Malawi and 39 facilities in Zambia in 2006/07 and 2008; quarterly totals from the last quarter of 2005 to the first quarter of 2008 inclusive in Malawi; and annual totals for 2004 to 2007 inclusive in Zambia. Topic-guided interviews were conducted with facility and district managers in both countries, and with health workers in Malawi. Results: Facility data confirm significant scale-up in HIV/AIDS service delivery in both countries. In Malawi, this was supported by a large increase in lower trained cadres and only a modest increase in clinical staff numbers. Routine outpatient workload fell in urban facilities, in rural health centres and in facilities not providing antiretroviral treatment (ART), while it increased at district hospitals and in facilities providing ART. In Zambia, total staff and clinical staff numbers stagnated between 2004 and 2007. In rural areas, outpatient workload, which was higher than at urban facilities, increased further. Key informants described the effects of increased workloads in both countries and attributed staff migration from public health facilities to non-government facilities in Zambia to PEPFAR. Conclusions: Malawi, which received large levels of GHI funding from only the Global Fund, managed to increase facility staff across all levels of the health system: urban, district and rural health facilities, supported by task-shifting to lower trained staff. The more complex GHI arena in Zambia, where both Global Fund and PEPFAR provided large levels of support, may have undermined a coordinated national workforce response to addressing health worker shortages, leading to a less effective response in rural areas.