Oliver Mweemba

A mixed methods and triangulation model for increasing the accuracy of adherence and sexual behaviour data: the Microbicides Development Programme

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]. Methodology/Principal Findings Data were collected from a random subsample of 725 women (7.7% of the trial population) using structured interviews, coital diaries, in-depth interviews, counting returned gel applicators, focus group discussions, and ethnography. The core of the model was a customised, semi-structured in-depth interview. There were two levels of triangulation: first, discrepancies between data from the questionnaires, diaries, in-depth interviews and applicator returns were identified, discussed with participants and, to a large extent, resolved; second, results from individual participants were related to more general data emerging from the focus group discussions and ethnography. A democratic and equitable collaboration between clinical trialists and qualitative social scientists facilitated the success of the model, as did the preparatory studies preceding the trial. The process revealed some of the underlying assumptions and routinised practices in “clinical trial culture” that are potentially detrimental to the collection of accurate data, as well as some of the shortcomings of large qualitative studies, and pointed to some potential solutions. Conclusions/Significance The integration of qualitative social science and the use of mixed methods and triangulation in clinical trials are feasible, and can reveal (and resolve) inaccuracies in data on adherence and sensitive behaviours, as well as illuminating aspects of “trial culture” that may also affect data accuracy.

Re-framing microbicide acceptability: findings from the MDP301 trial

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 womens and mens 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. Womens 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 womens 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 womens and mens sexuality and sexual health.

Assessing the Accuracy of Adherence and Sexual Behaviour Data in the MDP301 Vaginal Microbicides Trial Using a Mixed Methods and Triangulation Model

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.

Awareness and attitudes towards anthrax and meat consumption practices among affected communities in Zambia: A mixed methods approach

Background In Zambia, human anthrax cases often occur following cases of animal anthrax. Human behaviour has been implicated in this transmission. The objective of the study was to explore human behavioural patterns that may contribute to outbreaks of anthrax among affected communities. Methods A mixed methods study was conducted in four districts of Zambia from November 2015 to February 2016. A cross sectional survey involving 1,127 respondents, six focus group discussions and seven key informant interviews with professional staff were conducted. Descriptive statistics on socio-demographic characteristics, awareness of anthrax, attitudes towards cattle vaccination and risk factors for anthrax and vaccination practices were run using STATA 12 for analysis. Results Overall, 88% of respondents heard about anthrax, 85.1% were aware that anthrax is transmitted by eating infected meat and 64.2% knew that animals and humans can be infected with anthrax. However, qualitative data suggested that awareness of anthrax varied across communities. Qualitative findings also indicated that, in Western and Muchinga provinces, human anthrax was transmitted by eating infected beef and hippo (Hippopotamus amphibious) meat, respectively. Although survey data indicated that 62.2% of respondents vaccinated their animals, qualitative interviews and annual vaccination reports indicated low vaccination rates, which were attributed to inadequate veterinary service provision and logistical challenges. While 82% of respondents indicated that they reported animal deaths to veterinary officers, only 13.5% of respondents buried infected carcasses. Majority (78.1%) of respondents either ate, sold or shared meat from dead animals with other community members. Poverty, lack of access to meat protein and economic reasons were cited as drivers for consuming infected meat. Conclusions Health education campaigns must be intensified to reduce the risk of human exposure. Veterinary extension services should be strengthened and cold chain facilities decentralized in order to improve accessibility to anthrax vaccine. It is also important to involve the affected communities and collaborate with other disciplines in order to effectively tackle poverty, improve veterinary services and address inherent meat consumption practices within the communities.

Assessing capacity and readiness to manage NCDs in primary care setting: Gaps and opportunities based on adapted WHO PEN tool in Zambia

Introduction Sub-Saharan Africa is experiencing an epidemiological transition as the burden of NCDs overtake communicable diseases. However, it is unknown what capacity and gaps exist at primary care level to address the growing burden of NCDs. This study aimed to assess the Zambian health system’s capacity to address in NCDs, using an adapted WHO Essential Non Communicable Disease Interventions (WHO PEN) tool. Methodology This was a cross-sectional facility survey in the three districts conducted from September 2017 to October 2017. We defined facility readiness along five domains: basic equipment, essential services, diagnostic capacity, counseling services, and essential medicines. For each domain, we calculated an index as the mean score of items expressed as percentage. These indices were compared to an agreed cutoff at 70%, meaning that a facility index or district index below 70% off was considered as ‘not ready’ to manage NCDs at that level. All analysis were performed using Stata 15 MP. Results There appeared to be wide heterogeneity between facilities in respect of readiness to manage NCDs. Only 6 (including the three 1st level hospitals) out of the 46 facilities were deemed ready to manage NCDs. Only the first level hospitals scored a mean index higher than the 70% cut off; With regard to medications needed to manage NCDs, urban and rural health facilities were comparably equipped. However, there was evidence that calcium channel blockers (p = 0.013) and insulin (p = 0.022) were more likely to be available in urban and semi-urban health facilities compared to rural facilities. Conclusion Our study revealed gaps in primary health care capacity to manage NCDs in Zambia, with almost all health facilities failing to reach the minimum threshold. These results could be generalized to other similar districts in Zambia and the sub-region, where health systems remain focused on infectious rather than non-communicable Disease. These results should attract policy attention and potentially form the basis to review current approach to NCD care at the primary care level in Zambia and Sub-Saharan Africa.

Involving both parents in hiv prevention during pregnancy and breastfeeding

Over the past decade, services to prevent mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) have expanded rapidly, resulting in reductions in paediatric acquired immunodeficiency syndrome (AIDS) worldwide.1 However, although an emerging literature demonstrates high maternal HIV incidence during pregnancy and breastfeeding,2 efforts have not focused as much on preventing new infections among pregnant women or their partners. Although recent World Health Organization (WHO) recommendations for pre-exposure prophylaxis are encouraging,3 in subSaharan Africa, few – if any – structured interventions are offered to women or their partners during pregnancy and breastfeeding. Most women who access PMTCT care test HIV-negative and for most, engagement in HIV prevention typically ends with individual post-test counselling. To address this gap, we describe a framework to guide HIV prevention efforts for pregnant or breastfeeding women and their partners. This approach considers the unique characteristics of pregnancy, including healthseeking behaviours of women and engagement of male partners, to stratify couples according to HIV transmission and acquisition risk. The approach also leverages the robust infrastructure of existing PMTCT programmes and integrates it within the broader context of general HIV prevention.

Factors affecting accessibility of cervical cancer screening services for women with physical and sensory disabilities in Lusaka District, Zambia

Aims: The study sought to examine service related factors which influence cervical cancer screening among women with physical and sensory disabilities. Methods: The study used a qualitative case study design using in depth interviews, field observations and document study to collect data. A purposive sample of primary respondents included 12 women with physical and sensory disabilities aged between 18 years old and 49 years old, these were recruited based on type and severity of disability. Six key informants were recruited from organizations working with people with disabilities and cervical cancer screening service providers. Key informants from disability organizations identified eligible primary participants. Thematic analysis was done using Nvivo 10 software. Results: Women with disabilities identified various factors which affect accessibility of cervical cancer screening services, namely; structural design of the health facility, inappropriate screening equipment, inadequate access to information, education and communication (IEC) materials, confidentiality of service, and limited skills of service providers. Mazuba Hachipola1, Oliver Mweemba2, Sitali, Doreen3 Affiliations: 1Bed (sp), Student, Public Health, University of Zambia, Lusaka, Zambia; 2PhD, MPhil Lecturer, Public Health, University of Zambia, Lusaka, Zambia; 3MPH, Bsc, Lecturer, Public Health, University of Zambia, Lusaka, Zambia. Corresponding Author: Mazuba Hachipola, University of Zambia, School of Medicine, Department of Public Health, Ridgeway campus, P.O. Box 50110, Lusaka, Zambia; Email: mhachipola@gmail.com Received: 12 January 2017 Accepted: 03 March 2017 Published: 29 March 2017 Conclusion: Women with physical and sensory disabilities encounter various barriers in accessing cervical cancer screening. This may lead to delayed detection and increased complications on clients who are found with an advanced stage of cervical cancer. Health service providers require skills in working with women with disabilities. Although legislature exists through the Persons with Disability Act of Zambia to promote accessible health services, it has not been fully enacted, therefore, there ought to be rigorous enforcement of existing legislature which promotes accessible health services.

Experiences and coping strategies of adolescents living with HIV at community level in Zambia

Aims: Although interventions for addressing the health aspects of adolescents living with HIV are in place, studies however indicate that there is limited documentation of experiences of adolescents living with HIV. Such knowledge could help HIV programs to better respond to their needs. This study explored experiences of adolescents aged 10–19 living with HIV in Kanyama community, Lusaka district of Zambia. Methods: A phenomenological study design was used to explore experiences of adolescents living with HIV and what helps them to cope with their condition. Data were collected using in-depth interviews with 24 adolescents living with HIV and analyzed using thematic analysis. Results: There were variations regarding their experience with HIV disclosure process. While some adolescents felt good after disclosure, others were sad after being told that they were HIV positive. Some adolescents were not pleased with the idea of disclosing their HIV status without their consent. Most adolescents felt Purity M. Linyaku1,2, Oliver Mweemba1, Joseph M. Zulu2 Affiliations: 1Department of Public Health, Section of Health Promotion and Education, School of Medicine, University of Zambia, Lusaka, P.O. Box 50110, Zambia; 2Minstry of Health, Lusaka District, Zambia. Corresponding Author: Purity M. Linyaku, Department of Public Health, Section of Health Promotion and Education, School of Medicine, University of Zambia, Lusaka, P.O. Box 50110, Zambia; Email: simasikupurity@gmail. com Received: 13 August 2017 Accepted: 26 August 2017 Published: 14 September 2017 supported by their family members while a few experienced stigma which contributed to stress and depression. Adolescents appreciated the use of drugs, however, they reported that they experienced difficulties in adhering to treatment. Some adolescents reported being denied to visit friends as their guardians feared that they may forget to take the drugs. Both girls and boys had concerns about antiretroviral therapy services provided only during week days as they expected to be in class thus limiting accessibility to services. Copying strategies for the challenges experienced included resilience, treatment, non-disclosure, spiritual intervention, social support and support from non-governmental organizations. Conclusion: Understanding both the positive and negative experiences of adolescents living with HIV and copying strategies may help in developing interventions that enhance positive living among adolescents.

Situational analysis of communication of HIV and AIDS information to persons with visual impairment: a case of Kang’onga Production Centre in Ndola, Zambia

BackgroundDespite the increases in health promotion and educational programs on HIV and AIDS, lack of information and communication on HIV and AIDS for the visually impaired persons continues. The underlying factors that create the information and communication gaps have not been fully explored in Zambia. It is therefore important that, this situational analysis on HIV and AIDS information dissemination to persons with visual impairments at Kang’onga Production Centre in Ndola was conducted. The study commenced in December 2014 to May 2015.MethodsA qualitative case study design was employed. The study used two focus group discussions with males and females. Each group comprised twelve participants. Eight in-depth interviews involving the visually impaired persons and five key informants working with visually impaired persons were conducted. Data was analysed thematically using NVIVO 8 software. Ethical clearance was sought from Excellency in Research Ethics and Science. Reference Number 2014-May-030.ResultsIt was established that most visually impaired people lacked knowledge on the cause, transmission and treatment of HIV and AIDS resulting in misconceptions. It was revealed that health promoters and people working with the visually impaired did not have specific HIV and AIDS information programs in Zambia. Further, it was discovered that the media, information education communication and health education were channels through which the visually impaired accessed HIV and AIDS information. Discrimination, stigma, lack of employment opportunities, funding and poverty were among the many challenges identified which the visually impaired persons faced in accessing HIV and AIDS information. Integration of the visually impaired in HIV and AIDS programs would increase funding for economic empowerment and health promotions in order to improve communication on HIV and AIDS information. The study showed that, the visually impaired persons in Zambia are not catered for in the dissemination of HIV and AIDS information. Available information is not user-friendly because it is in unreadable formats thereby increasing the potential for misinformation and limitations to their access. This calls for innovations in the communication on HIV and AIDS information health promotion to the target groups.