Michael T. Mbizvo

Defining research to improve health systems.

Robert Terry and colleagues present working definitions of operational research, implementation research, and health systems research within the context of research to strengthen health systems.

Linking sexual and reproductive health and HIV interventions: a systematic review.

BackgroundThe international community agrees that the Millennium Development Goals will not be achieved without ensuring universal access to both sexual and reproductive health (SRH) services and HIV/AIDS prevention, treatment, care and support. Recently, there has been increasing awareness and discussion of the possible benefits of linkages between SRH and HIV programmes at the policy, systems and service delivery levels. However, the evidence for the efficacy of these linkages has not been systematically assessed.MethodsWe conducted a systematic review of the evidence for interventions linking SRH and HIV. Structured methods were employed for searching, screening and data extraction. Studies from 1990 to 2007 reporting pre-post or multi-arm evaluation data from SRH-HIV linkage interventions were included. Study design rigour was scored on a nine-point scale. Unpublished programme reports were gathered as promising practices.ResultsOf more than 50,000 citations identified, 185 studies were included in the review and 35 were analyzed. These studies had heterogeneous interventions, populations, objectives, study designs, rigour and measured outcomes. SRH-HIV linkage interventions were generally considered beneficial and feasible. The majority of studies showed improvements in all outcomes measured. While there were some mixed results, there were very few negative findings. Generally, positive effects were shown for key outcomes, including HIV incidence, sexually transmitted infection incidence, condom use, contraceptive use, uptake of HIV testing and quality of services. Promising practices (n = 23) tended to evaluate more recent and more comprehensive programmes. Factors promoting effective linkages included stakeholder involvement, capacity building, positive staff attitudes, non-stigmatizing services, and engagement of key populations.ConclusionsExisting evidence provides support for linkages, although significant gaps in the literature remain. Policy makers, programme managers and researchers should continue to advocate for, support, implement and rigorously evaluate SRH and HIV linkages at the policy, systems and service levels.

Linking family planning with HIV/AIDS interventions: a systematic review of the evidence.

Objective:To conduct a systematic review of the literature and examine the effectiveness, optimal circumstances, and best practices for strengthening linkages between family planning and HIV interventions. Design:Systematic review of peer-reviewed articles and unpublished program reports (‘promising practices’) evaluating interventions linking family planning and HIV services. Methods:Articles were included if they reported post-intervention evaluation results from an intervention linking family planning and HIV services between 1990 and 2007. Systematic methods were used for searching, screening, and data extraction. Quality assessment was conducted using a 9-point rigor scale. Results:Sixteen studies were included in the analysis (10 peer-reviewed studies and six promising practices). Interventions were categorized into six types: family planning services provided to HIV voluntary counseling and testing (VCT) clients, family planning and VCT services provided to maternal and child health clients, family planning services provided to people living with HIV, community health workers provided family planning and HIV services, VCT provided to family planning clinic clients, and VCT and family planning services provided to women receiving postabortion care. Average study design rigor was low (3.25 out of 9). Most studies reported generally positive or mixed results for key outcomes; no negative results were reported. Conclusion:Interventions linking family planning and HIV services were generally considered feasible and effective, though overall evaluation rigor was low.

The Regai Dzive Shiri Project: a cluster randomised controlled trial to determine the effectiveness of a multi-component community-based HIV prevention intervention for rural youth in Zimbabwe – study design and baseline results

Objectiveu2002 To assess the effectiveness of a community‐based HIV prevention intervention for adolescents in terms of its impact on (1) HIV and Herpes simplex virus type 2 (HSV‐2) incidence and on rates of unintended pregnancy and (2) reported sexual behaviour, knowledge and attitudes.

The Regai Dzive Shiri project: results of a randomized trial of an HIV prevention intervention for youth

Background:HIV prevention among young people in southern Africa is a public health priority. There is little rigorous evidence of the effectiveness of different intervention approaches. We describe findings of a cluster randomized trial of a community-based, multicomponent HIV, and reproductive health intervention aimed at changing social norms for adolescents in rural Zimbabwe. Methods:Thirty rural communities were randomized to early or deferred implementation of the intervention in 2003. Impact was assessed in a representative survey of 18–22-year-olds after 4 years. Participants self-completed a questionnaire and gave a dried blood spot sample for HIV and herpes simplex virus-2 (HSV-2) antibody testing. Young women had a urinary pregnancy test. Analyses were by intention-to-treat and were adjusted for clustering. Findings:Four thousand six hundred and eighty-four, 18–22-year-olds participated in the survey (97.1% of eligible candidates, 55.5% women). Just over 40% had been exposed to at least 10 intervention sessions. There were modest improvements in knowledge and attitudes among young men and women in intervention communities, but no impact on self-reported sexual behavior. There was no impact of the intervention on prevalence of HIV or HSV-2 or current pregnancy. Women in intervention communities were less likely to report ever having been pregnant. Interpretation:Despite an impact on knowledge, some attitudes, and reported pregnancy, there was no impact of this intervention on HIV or HSV-2 prevalence, further evidence that behavioral interventions alone are unlikely to be sufficient to reverse the HIV epidemic. The challenge remains to find effective HIV prevention approaches for young people in the face of continued and unacceptably high HIV incidence, particularly among young women.

Promoting safe motherhood in the community: the case for strategies that include men.

Although a decade has now passed since the launching of the Safe Motherhood Initiative, maternal mortality continues to be the health indicator showing the greatest disparity between developed and developing countries. Recently revised WHO and UNICEF figures indicate that an estimated 90% of the 585,000 worldwide maternal deaths that occur each year take place in sub-Saharan Africa and Asia. In terms of the lifetime risk of maternal death, this disparity remains striking: 1 in 12 women in parts of sub-Saharan Africa, compared with 1 in 4,000 women in Northern Europe. In addition, for every woman who dies, an estimated 16-17 will suffer from pregnancy-related complications. Research suggests that, in addition to biomedical interventions and the strengthening of health care services, improving awareness of obstetric complications among members of a pregnant womans immediate and wider social network is an important step in improving her chances of survival when such complications occur. Many of the interventions implemented so far have focused exclusively on improving womens knowledge and practices as they relate to maternal health issues. Nevertheless, it is now increasingly being recognised that the actions required to achieve improvements in reproductive health outcomes in general, and maternal health in particular, should involve communities in the process and encourage mens active participation. Despite this, very few studies on risk perceptions or interventions to raise community awareness of obstetric risk factors, their complications and their consequences have targeted men. The present article argues for the development and testing of risk awareness interventions, which, in addition to women, target men in their familial and social roles within communities and as workers within health care services as a means of improving maternal health outcomes.

Mortality in the First 2 Years among Infants Born to Human Immunodeficiency Virus-Infected Women in Harare, Zimbabwe

Transmission of human immunodeficiency virus (HIV) and mortality was studied among infants of infected women in Zimbabwe. Of 367 infants born to HIV-infected women, 72 (19.6%) died compared with 20 (5.4%) of 372 infants of uninfected women (P < .01). Infection by HIV DNA polymerase chain reaction among infants who survived >7 days and died within 2 years could be assessed in 87% (58/67) of infants of infected women and 83% (5/6) of infants of uninfected women; transmission occurred in 40 of 58 infants. Among 27 infected infants tested at birth, 19 (70%), 5 (19%), and 3 (11%) were apparently infected via in utero, intrapartum or early postpartum, and late postpartum transmission, respectively. The majority of HIV-infected infants who died in the first 2 years of life were likely to have acquired in utero infection.

Maternal mortality in rural and urban Zimbabwe: Social and reproductive factors in an incident case-referent study

A community-based incidence case-referent study was undertaken in a rural and an urban setting in Zimbabwe in order to define risk factors associated with maternal deaths at family, community, primary and referral health care levels. Referent subjects were drawn from place or area of delivery for each consecutive maternal death. Using a multiple source confidential reporting network for all maternal deaths, the maternal mortality rate for the rural setting was 168/100,000 live births and that for the urban setting was 85/100,000 live births. A model for interacting factors contributing to maternal mortality was designed. Haemorrhage and abortion sepsis were the major direct causes while malaria was the leading indirect cause in the rural setting. In the urban setting, eclampsia, abortion and puerperal sepsis were the leading causes of maternal deaths. It was found that all situations associated with diminished, or absent social support, that is, being single (Odds Ratio = 4.7, 95% CI = 2.2-9.8) divorced, widowed, one of several wives, cohabiting, or self-supporting carried an increased risk for maternal mortality, especially in the rural area. Income and level of education for index and referent subjects were comparable, probably because of the limited part of the population under study that belonged to a more affluent class. Distribution of cases and referents by religious-affiliation was also comparable. Age > 35 years and parity > 6 were significant risk factors for maternal mortality in the rural setting, whereas bad reproductive history with reported stillbirth or abortion constituted a high risk both in the city and in the rural areas (Odds Ratios 4-6).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of a Randomized Health Education Intervention on Aspects of Reproductive Health Knowledge and Reported Behaviour Among Adolescents in Zimbabwe

Unwanted teenage pregnancy and the attendant morbidity and mortality necessitate an understanding of the factors influencing adolescent sexuality and the implementation of programmes designed to improve their knowledge and reproductive behaviour. A randomized controlled study on reproductive health knowledge and behaviour was undertaken among adolescent pupils drawn from a multi-stage random cluster sample. A self-administered questionnaire was used to assess aspects of reproductive health knowledge and behaviour at baseline followed by a health education intervention, except for control schools. Results are based on 1689 responses made up of 1159 intervention and 530 control respondents. There was a significant increase in correct knowledge about aspects of menstruation in intervention as compared with control schools [odds ratio (OR) = 4.5, 95% confidence interval (CI) = 3.4-6.1). Significantly, (OR = 2.0, 95%CI = 1.1-3.9) more pupils from intervention than control schools scored correctly on practice relating to menstruation. Pupils from intervention schools were more likely (P < 0.001) to know that a boy experiencing wet dreams could make a girl pregnant and that a girl could get pregnant at her first sexual intercourse (OR = 1.4, 95%CI = 1.1-1.9). Knowledge of family planning was low in both groups at baseline but was high at five months follow-up in the intervention schools. The findings point to the need for early school-based reproductive health education programmes, incorporating correct information on reproductive biology and the subsequent prevention of reproductive ill health.

Desire for a Future Pregnancy Among Women in Zimbabwe in Relation to Their Self-Perceived Risk of HIV Infection, Child Mortality, and Spontaneous Abortion

In a background of very high prevalence of human immunodeficiency virus (HIV) infection among women of childbearing age and the increasing demand for treatment to prevent mother-to-child transmission, we investigated the desire for a future pregnancy among women in Zimbabwe in relation to (1) self-perceived risk of HIV infection, (2) child mortality, and (3) spontaneous abortion. A random cross-sectional sample of 2250 ever-married women aged 15–49 years was selected from 6,828 households in rural and urban Zimbabwe. The sample was representative of the geographic distribution of women. One eligible subject was selected per household for a structured interview on factors associated with the desire for future pregnancy. Overall, 54% of the participants desired to get pregnant in future; 55% perceived themselves at high risk for HIV infection; 6% reported the death of at least one child less than the age of 5 years in the last 5 years; and 12% reported at least one spontaneous abortion in the last 5 years. In multiple logistic regression analysis, reporting at least one childs death (OR = 1.77; 95% CI 1.13–2.78) and at least one spontaneous abortion in the last 5 years (OR = 1.81; 95% CI 1.08–3.04) were significantly associated with a higher desire to get pregnant; however, high self-perceived risk for HIV infection was not (OR = 0.85; 95% CI 0.67–1.09). High self-perceived risk for infection with HIV was not associated with a lower desire for a future pregnancy among women in Zimbabwe in a high-prevalence area. In fact, our data suggest an increased desire for future pregnancy to replace childhood deaths or spontaneous abortions that may result from HIV infection. Voluntary HIV testing services are challenged with balancing counseling messages on the strong desire for children, the risk of mother-to-child transmission, and poor fetal outcomes. Further research is needed to explore utilitarian–economic, social, and psychological values attributed to children by women and their partners. The involvement of men as partners in childbearing should be explored, as their desire for children may be the primary barrier to protective behavior change among women.