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Damerow SM, Adrian HV, Indjai B, Cá EJC, Maaløe N, Fisker AB, Sørensen JB. Timeliness and quality of peripartum care provision during a health system strengthening initiative in rural Guinea-Bissau: a qualitative situation analysis. BMC Pregnancy Childbirth 2024; 24:478. [PMID: 39003482 PMCID: PMC11245816 DOI: 10.1186/s12884-024-06669-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 07/01/2024] [Indexed: 07/15/2024] Open
Abstract
Guinea-Bissau has among the world's highest maternal and perinatal mortality rates. To improve access to quality maternal and child health (MCH) services and thereby reduce mortality, a national health system strengthening initiative has been implemented. However, despite improved coverage of MCH services, perinatal mortality remained high. Using a systems-thinking lens, we conducted a situation analysis to explore factors shaping timeliness and quality of facility-based care during labour, childbirth, and the immediate postpartum period in rural Guinea-Bissau. We implemented in-depth interviews with eight peripartum care providers and participant observations at two health facilities (192 h) in 2021-22, and analysed interview transcripts and field notes using thematic network analysis. While providers considered health facilities as the only reasonable place of birth and promoted facility birth uptake, timeliness and quality of care were severely compromised by geographical, material and human-resource constraints. Providers especially experienced a lack of human resources and materials (e.g., essential medicines, consumables, appropriate equipment), and explained material constraints by discontinued donor supplies. In response, providers applied several adaptation strategies including prescribing materials for private purchase, omitting tests, and delegating tasks to birth companions. Consequences included financial barriers to care, compromised patient and occupational safety, delays, and diffusion of health worker responsibilities. Further, providers explained that in response to persisting access barriers, women conditioned care seeking on their perceived risk of developing birthing complications. Our findings highlight the need for continuous monitoring of factors constraining timeliness and quality of essential MCH services during the implementation of health system strengthening initiatives.
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Affiliation(s)
- Sabine Margarete Damerow
- Bandim Health Project, Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Studiestræde 6, Copenhagen K, 1455, Denmark.
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.
| | | | - Bucar Indjai
- National Institute for Studies and Research (INEP), Bissau, Guinea-Bissau
| | | | - Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Gynaecology and Obstetrics, Copenhagen University Hospital - Herlev Hospital, Copenhagen, Denmark
| | - Ane Bærent Fisker
- Bandim Health Project, Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Studiestræde 6, Copenhagen K, 1455, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Jane Brandt Sørensen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Lichtwarck HO, Mbotwa CH, Kazaura MR, Moen K, Mmbaga EJ. Early disengagement from HIV pre-exposure prophylaxis services and associated factors among female sex workers in Dar es Salaam, Tanzania: a socioecological approach. BMJ Glob Health 2023; 8:e013662. [PMID: 38154811 PMCID: PMC10759139 DOI: 10.1136/bmjgh-2023-013662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/25/2023] [Indexed: 12/30/2023] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool when taken as prescribed. However, suboptimal use may challenge its real-life impact. To support female sex workers in their efforts to prevent themselves from HIV, it is essential to identify factors that contribute to early disengagement from PrEP care. In this study, we aimed to estimate the risk of early disengagement from PrEP services among female sex workers in Tanzania and associated factors using a socioecological model as a guiding framework. METHODS The study was conducted as part of a pragmatic mHealth trial for PrEP roll-out in Dar es Salaam in 2021. We estimated the risk of early disengagement, defined as not presenting for the first follow-up visit (within 56 days of enrolment), and its associations with individual, social, behavioural and structural factors (age, self-perceived HIV risk, mental distress, harmful alcohol use, condom use, number of sex work clients, female sex worker stigma and mobility) using multivariable logistic regression models, with marginal standardisation to obtain adjusted relative risks (aRR). RESULTS Of the 470 female sex workers enrolled in the study, 340 (74.6%) did not attend the first follow-up visit (disengaged). Mental distress (aRR=1.14; 95% CI 1.01 to 1.27) was associated with increased risk of disengagement. Participants who reported a higher number of clients per month (10-29 partners: aRR=0.87; 95% CI 0.76 to 0.98 and ≥30 partners: aRR=0.80; 95% CI 0.68 to 0.91) and older participants (≥35 years) (RR=0.75; 95% CI 0.56 to 0.95) had a lower risk of disengagement. CONCLUSIONS AND RECOMMENDATIONS Early disengagement with the PrEP programme was high. Mental distress, younger age and having fewer clients were risk factors for disengagement. We argue that PrEP programmes could benefit from including mental health screening and treatment, as well as directing attention to younger sex workers and those reporting fewer clients.
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Affiliation(s)
- Hanne Ochieng Lichtwarck
- Department of Community Medicine and Global Health, University of Oslo, Faculty of Medicine, Oslo, Norway
| | - Christopher Hariri Mbotwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- University of Dar es Salaam, Mbeya College of Health and Allied Sciences, Mbeya, Tanzania
| | | | - Kåre Moen
- Department of Community Medicine and Global Health, University of Oslo, Faculty of Medicine, Oslo, Norway
| | - Elia John Mmbaga
- Department of Community Medicine and Global Health, University of Oslo, Faculty of Medicine, Oslo, Norway
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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de Vos L, Mudzingwa EK, Fynn L, Atujuna M, Mugore M, Gandhi M, Celum C, Hosek S, Bekker L, Daniels J, Medina‐Marino A. Factors that influence adolescent girls and young women's re-initiation or complete discontinuation from daily oral PrEP use: a qualitative study from Eastern Cape Province, South Africa. J Int AIDS Soc 2023; 26:e26175. [PMID: 37758649 PMCID: PMC10533377 DOI: 10.1002/jia2.26175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) face barriers that jeopardize their prevention-effective use of daily oral pre-exposure prophylaxis (PrEP). We sought to understand factors that influence AGYW's prolonged breaks in PrEP use, and their decisions to re-initiate or discontinue using PrEP in the context of a community-based adherence support intervention. METHODS In-depth interviews (IDIs) were conducted between December 2019 and April 2021 with purposively selected AGYW (aged 16-25) enrolled in the Community PrEP Study (CPS) in Buffalo City Metro Health District, Eastern Cape Province, South Africa. AGYW were offered monthly PrEP for 24 months at two community-based study sites. Interview guides were informed by the Information-Motivation-Behavioural Skills Model, and data were analysed using illustrative code reports and a case analysis. RESULTS A total of 603 participants were enrolled and initiated on PrEP in the parent study. Fifty-three IDIs were conducted with 50 CPS participants. Findings revealed that external factors (e.g. local movement, school holidays and medication side-effects) and social conflicts (e.g. discretion and partner mistrust) directly influenced breaks in PrEP usage. A decrease in one's self-perception of HIV risk prolonged the duration of these "PrEP breaks." Once PrEP refill visits were missed, some AGYW delayed returning for refills out of fear of being scolded by study staff. The differences between those participants who eventually re-initiated PrEP and those who disengaged from PrEP use can be attributed to social support and encouragement, level of familiarity with PrEP, risk perceptions, self-initiated discussions with staff and diminishing side effects. CONCLUSIONS Despite implementing a community-based PrEP delivery platform and behavioural intervention that included support for daily oral PrEP adherence and disclosure, participants struggled with consistent daily oral PrEP use. Unpredictable life events, including local movement and schooling schedules, in addition to being judged for their perceived behaviours, pose a challenge for consistent pill pick-up for AGYW and habit formation. Long-acting injectable PrEP may mitigate a number of these external barriers. Interventions that integrate long-term planning skills, how to navigate existing social judgements and how to access sources of social support may further improve habit formation for PrEP use, regardless of its formulation.
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Affiliation(s)
- Lindsey de Vos
- Research UnitFoundation for Professional DevelopmentEast LondonSouth Africa
| | - Emily Krogstad Mudzingwa
- The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
- Institute for Collaboration on Health, Intervention, and PolicyUniversity of ConnecticutStorrsConnecticutUSA
| | - Lauren Fynn
- The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
| | - Millicent Atujuna
- The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
| | - Matinatsa Mugore
- Mailman School of Public HealthColumbia UniversityNew YorkNew YorkUSA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of MedicineUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Connie Celum
- Departments of Global Health, Medicine, and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Sybil Hosek
- Division of Infectious DiseasesStroger Hospital of Cook CountyChicagoIllinoisUSA
- Division of Child and Adolescent PsychiatryDepartment of PsychiatryStroger Hospital of Cook CountyChicagoIllinoisUSA
| | - Linda‐Gail Bekker
- The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
| | - Joseph Daniels
- Edson College of Nursing and Health InnovationArizona State UniversityPhoenixArizonaUSA
| | - Andrew Medina‐Marino
- The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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4
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Abbas S, Kermode M, Khan MD, Denholm J, Adetunji H, Kane S. What Makes People With Chronic Illnesses Discontinue Treatment? A Practice Theory Informed Analysis of Adherence to Treatment among Patients With Drug-Resistant Tuberculosis in Pakistan. Int J Health Policy Manag 2023; 12:6576. [PMID: 37579474 PMCID: PMC10125133 DOI: 10.34172/ijhpm.2022.6576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 12/27/2022] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Non-adherence to treatment is a frequently observed phenomenon amongst those on long-term treatment for chronic illnesses. This qualitative study draws upon the tenets of 'practice theory' to reveal what shapes patients' ability to adhere to the demanding treatment for drug-resistant tuberculosis (DR-TB) at three treatment sites in Khyber-Pakhtunkhwa (KP) province of Pakistan. METHODS This qualitative study involved observation of service provision over a period of nine months of stay at, and embedment within the three treatment sites and in-depth interviews with 13 service providers and 22 patients who became non-adherent to their treatment. RESULTS Consistent with the extensive research based on the barriers and facilitator approach, both patients, and providers in our study also talked of patients' doubts about diagnosis and treatment efficacy, side-effects of drugs, economic constraints, unreliable disbursements of monetary incentive, attitude of providers and co-morbidities as reasons for non-adherence to treatment. Applying a practice theory perspective yielded more contextualised insights; inadequate help with patients' physical complaints, unempathetic responses to their queries, and failure to provide essential information, created conditions which hindered the establishment and maintenance of the 'practice' of adhering to treatment. These supply-side gaps created confusion, bred resentment, and exacerbated pre-existing distrust of public health services among patients, and ultimately drove them to disengage with the TB services and stop their treatment. CONCLUSION We argue that the lack of supply-side 'responsiveness' to patient needs beyond the provision of a few material inputs is what is lacking in the existing DR-TB program in Pakistan. We conclude that unless Pakistan's TB program explicitly engages with these supply side, system level gaps, patients will continue to struggle to adhere to their treatments and the TB program will continue to lose patients. Conceptually, we make a case for reimagining the act of adherence (or not) to long-term treatment as a 'Practice.'
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Affiliation(s)
- Shazra Abbas
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Michelle Kermode
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | | | - Justin Denholm
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC, Australia
| | - Hamed Adetunji
- Faculty of Public Health & Health Informatics, Umm Al Qura University, Makkah Almukarramah, Saudi Arabia
| | - Sumit Kane
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
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Sørensen JB, Housseine N, Maaløe N, Bygbjerg IC, Pinkowski Tersbøl B, Konradsen F, Sequeira Dmello B, van Den Akker T, van Roosmalen J, Mookherji S, Siaity E, Osaki H, Khamis RS, Kujabi ML, John TW, Wolf Meyrowitsch D, Mbekenga C, Skovdal M, L Kidanto H. Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study. Glob Health Action 2022; 15:2034136. [PMID: 35311627 PMCID: PMC8942528 DOI: 10.1080/16549716.2022.2034136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study’s programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen – safe and respectful clinical childbirth care – is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants’ motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.
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Affiliation(s)
- Jane Brandt Sørensen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Natasha Housseine
- Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
| | - Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Konradsen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Sequeira Dmello
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania.,Comprehensive Community Based Rehabilitation in Tanzania Tanzania
| | - Thomas van Den Akker
- Athena Institute is the department, Athena Institute, VU University, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jos van Roosmalen
- Athena Institute is the department, Athena Institute, VU University, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sangeeta Mookherji
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington DC, US
| | - Eunice Siaity
- Medical college, Aga Khan University, School of Nursing and Midwifery East Africa, Dar Es Salaam Campus Tanzania
| | - Haika Osaki
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
| | - Rashid Saleh Khamis
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Monica Lauridsen Kujabi
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Wiswa John
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Columba Mbekenga
- Medical college, Aga Khan University, School of Nursing and Midwifery East Africa, Dar Es Salaam Campus Tanzania
| | - Morten Skovdal
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Hussein L Kidanto
- Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
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Skovdal M, Clausen CL, Magoge-Mandizvidza P, Dzamatira F, Maswera R, Nyamwanza RP, Nyamukapa C, Thomas R, Gregson S. How gender norms and 'good girl' notions prevent adolescent girls and young women from engaging with PrEP: qualitative insights from Zimbabwe. BMC Womens Health 2022; 22:344. [PMID: 35974360 PMCID: PMC9379870 DOI: 10.1186/s12905-022-01928-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 08/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pre-exposure prophylaxis, or PrEP, has been hailed for its promise to provide women with user-control. However, gender-specific challenges undermining PrEP use are beginning to emerge. We explore the role of gender norms in shaping adolescent girls and young women's (AGYW) engagement with PrEP. METHODS We draw on qualitative data from 12 individual interviews and three focus group discussions with AGYW from eastern Zimbabwe. Interviews were transcribed and thematically coded in NVivo 12. Emerging themes were further investigated using Connell's notion of 'emphasised femininity'. RESULTS Participants alluded to the patriarchal society they are part of, with 'good girl' notions subjecting them to direct and indirect social control. These controls manifest themselves through the anticipation of intersecting sexuality- and PrEP-related stigmas, discouraging AGYW from engaging with PrEP. AGYW recounted the need for permission to engage with PrEP, forcing them to consider engaging with PrEP in secrecy. In addition, limited privacy at home, and fear of disclosure of their health clinic visits, further heightened their fear of engaging with PrEP. PrEP is not simply a user-controlled HIV prevention method, but deeply entrenched within public gender orders. CONCLUSION AGYW face significant limitations in their autonomy to initiate and engage with PrEP. Those considering PrEP face the dilemma of Scylla and Charybdis: The social risks of stigmatisation or risks of HIV acquisition. Efforts to make PrEP available must form part of a combination of social and structural interventions that challenge harmful gender norms.
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Affiliation(s)
- Morten Skovdal
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen, Denmark.
| | - Camilla Lysemose Clausen
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen, Denmark
| | - Phyllis Magoge-Mandizvidza
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Freedom Dzamatira
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Rufurwokuda Maswera
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Constance Nyamukapa
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Simon Gregson
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Skovdal M, Magoge-Mandizvidza P, Dzamatira F, Maswera R, Nyamukapa C, Thomas R, Mugurungi O, Gregson S. Improving access to pre-exposure prophylaxis for adolescent girls and young women: recommendations from healthcare providers in eastern Zimbabwe. BMC Infect Dis 2022; 22:399. [PMID: 35461220 PMCID: PMC9035262 DOI: 10.1186/s12879-022-07376-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, adolescent girls and young women (AGYW) are at high risk of acquiring HIV. A growing number of sub-Saharan African countries are beginning to avail pre-exposure prophylaxis, or PrEP, but with limited success. Unpacking strategies to overcome barriers to the uptake of PrEP is critical to prevent HIV amongst AGYW. This article explores health professionals' views and recommendations on what is required to increase uptake of PrEP. METHODS The study draws on interview data from 12 providers of HIV prevention services in eastern Zimbabwe. The healthcare providers were purposefully recruited from a mix of rural and urban health facilities offering PrEP. The interviews were transcribed and imported into NVivo 12 for thematic coding and network analysis. RESULTS Our analysis revealed six broad strategies and 15 concrete recommendations which detail the range of elements healthcare providers consider central for facilitating engagement with PrEP. The healthcare providers called for: (1) PrEP marketing campaigns; (2) youth-friendly services or corners; (3) improved PrEP delivery mechanisms; (4) improvements in PrEP treatment; (5) greater engagement with key stakeholders, including with young people themselves; and (6) elimination of costs associated with PrEP use. These recommendations exemplify an awareness amongst healthcare providers that PrEP access is contingent on a range of factors both inside and outside of the clinical setting. CONCLUSIONS Healthcare providers are at the frontline of the HIV epidemic response. Their community-embeddedness, coupled with their interactions and encounters with AGYW, make them well positioned to articulate context-specific measures for improving access to PrEP. Importantly, the breadth of their recommendations suggests recognition of PrEP use as a complex social practice that requires integration of a combination of interventions, spanning biomedical, structural, and behavioural domains.
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Affiliation(s)
- Morten Skovdal
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen, Denmark.
| | - Phyllis Magoge-Mandizvidza
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Freedom Dzamatira
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Rufurwokuda Maswera
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Constance Nyamukapa
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Owen Mugurungi
- AIDS and TB Programme, Ministry of Health and Child Welfare, Harare, Zimbabwe
| | - Simon Gregson
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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8
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Williamson A, Barbarin A, Campbell B, Campbell T, Franzen S, Reischl TM, Zimmerman M, Veinot TC. Uptake of and Engagement With an Online Sexual Health Intervention (HOPE eIntervention) Among African American Young Adults: Mixed Methods Study. J Med Internet Res 2021; 23:e22203. [PMID: 34269689 PMCID: PMC8325088 DOI: 10.2196/22203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 04/16/2021] [Accepted: 05/16/2021] [Indexed: 01/30/2023] Open
Abstract
Background Regarding health technologies, African American young adults have low rates of uptake, ongoing usage, and engagement, which may widen sexual health inequalities. Objective We aimed to examine rates of uptake and ongoing usage, and factors influencing uptake, ongoing usage, and engagement for a consumer health informatics (CHI) intervention for HIV/sexually transmitted infection (STI) prevention among African American young adults, using the diffusion of innovation theory, trust-centered design framework, and O’Brien and Toms’ model of engagement. Methods This community-based participatory mixed methods study included surveys at four time points (n=315; 280 African American participants) among young adults aged 18 to 24 years involved in a blended offline/online HIV/STI prevention intervention (HIV Outreach, Prevention, and Education [HOPE] eIntervention), which was described as a “HOPE party.” Qualitative interviews were conducted with a subset of participants (n=19) after initial surveys and website server logs indicated low uptake and ongoing usage. A generalized linear mixed-effects model identified predictors of eIntervention uptake, server logs were summarized to describe use over time, and interview transcripts were coded and thematically analyzed to identify factors affecting uptake and engagement. Results Participants’ initial self-reported eIntervention uptake was low, but increased significantly over time, although uptake never reached expectations. The most frequent activity was visiting the website. Demographic factors and HOPE party social network characteristics were not significantly correlated with uptake, although participant education and party network gender homophily approached significance. According to interviews, one factor driving uptake was the desire to share HIV/STI prevention information with others. Survey and interview results showed that technology access, perceived time, and institutional and technological trust were necessary conditions for uptake. Interviews revealed that factors undermining uptake were insufficient promotion and awareness building, and the platform of the intervention, with social media being less appealing due to previous negative experiences concerning discussion of sexuality on social media. During the interaction with the eIntervention, interview data showed that factors driving initial engagement were audience-targeted website esthetics and appealing visuals. Ongoing usage was impeded by insufficiently frequent updates. Similarly, lack of novelty drove disengagement, although a social media contest for sharing intervention content resulted in some re-engagement. Conclusions To encourage uptake, CHI interventions for African American young adults can better leverage users’ desires to share information about HIV/STI prevention with others. Ensuring implementation through trusted organizations is also important, though vigorous promotion is needed. Visual appeal and targeted content foster engagement at first, but ongoing usage may require continual content changes. A thorough analysis of CHI intervention use can inform the development of future interventions to promote uptake and engagement. To guide future analyses, we present an expanded uptake and engagement model for CHI interventions targeting African American young adults based on our empirical results.
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Affiliation(s)
- Alicia Williamson
- School of Information, University of Michigan, Ann Arbor, MI, United States
| | | | | | - Terrance Campbell
- YOUR Center, Flint, MI, United States.,TigerLIFE, University of Memphis, Memphis, TN, United States
| | - Susan Franzen
- Prevention Research Center of Michigan, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Thomas M Reischl
- Prevention Research Center of Michigan, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Marc Zimmerman
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, United States.,Department of Psychology, University of Michigan, Ann Arbor, MI, United States
| | - Tiffany Christine Veinot
- School of Information, University of Michigan, Ann Arbor, MI, United States.,Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, United States
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9
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Busza J, Phillips AN, Mushati P, Chiyaka T, Magutshwa S, Musemburi S, Cowan FM. Understanding early uptake of PrEP by female sex workers in Zimbabwe. AIDS Care 2020; 33:729-735. [PMID: 33043688 DOI: 10.1080/09540121.2020.1832192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Female sex workers (FSW) are prioritised for increased access to pre-exposure prophylaxis (PrEP), although rates of uptake remain sub-optimal, particularly across Southern Africa. In the first two years of its availability in Zimbabwe, 37.1% of FSW in trial sites initiated PrEP and received at least one re-supply. We conducted a qualitative study on perceptions of PrEP among 19 early users selected from sites with varying rates of PrEP initiation. Narrative interviews examined the pathways taken by FSW from hearing about PrEP, through their decision to start taking it, and early experiences. FSW appreciated PrEP's introduction within familiar and trusted "friendly" services tailored for sex workers and valued positive encouragement from clinic staff and peers over negative influence from family members. They also found PrEP difficult to understand at first, and feared side effects and rare adverse complications described in information leaflets. While FSW identified individual strategies for remembering to take their medication, they also relied on structured peer adherence support, leading some FSW to actively promote the method to other FSW as "PrEP champions". Information on how early users experience a new prevention technology such as PrEP can inform design of interventions that leverage existing support structures and target key barriers.
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Affiliation(s)
- Joanna Busza
- Centre for Evaluation, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Phillis Mushati
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe
| | - Tarisai Chiyaka
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe
| | | | | | - Frances M Cowan
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe.,Liverpool School of Tropical Medicine, Liverpool, UK
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Skovdal M, Beckmann N, Maswera R, Nyamukapa C, Gregson S. Uncertainties, work conditions and testing biases: Potential pathways to misdiagnosis in point-of-care rapid HIV testing in Zimbabwe. PLoS One 2020; 15:e0237239. [PMID: 32790692 PMCID: PMC7425930 DOI: 10.1371/journal.pone.0237239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/22/2020] [Indexed: 01/26/2023] Open
Abstract
Disconcerting levels of misdiagnosis are common in point-of-care rapid HIV testing programmes in sub-Saharan Africa. To investigate potential pathways to misdiagnosis, we interviewed 28 HIV testers in Zimbabwe and conducted weeklong observations at four testing facilities. Approaching adherence to national HIV testing algorithms as a social and scripted practice, dependent on the integration of certain competences, materials and meanings, our thematic analysis revealed three underlying causes of misdiagnosis: One, a lack of confidence in using certain test-kits, coupled with changes in testing algorithms and inadequate training, fed uncertainties with some testing practices. Two, difficult work conditions, including high workloads and resource-depleted facilities, compounded these uncertainties, and meant testers got distracted or resorted to testing short-cuts. Three, power struggles between HIV testers, and specific client-tester encounters created social interactions that challenged the testing process. We conclude that these contexts contribute to deviances from official and recommended testing procedures, as well as testing and interpretation biases, which may explain cases of misdiagnoses. We caution against user-error explanations to misdiagnosis in the absence of a broader recognition of how broader structural determinants affect HIV testing practices.
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Affiliation(s)
- Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nadine Beckmann
- Centre for Research in Evolutionary, Social and Inter-Disciplinary Anthropology, University of Roehampton, London, United Kingdom
| | - Rufurwokuda Maswera
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Constance Nyamukapa
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Simon Gregson
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
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11
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Chabata ST, Hensen B, Chiyaka T, Mushati P, Busza J, Floyd S, Birdthistle I, Hargreaves JR, Cowan FM. Condom use among young women who sell sex in Zimbabwe: a prevention cascade analysis to identify gaps in HIV prevention programming. J Int AIDS Soc 2020; 23 Suppl 3:e25512. [PMID: 32602611 PMCID: PMC7325503 DOI: 10.1002/jia2.25512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/31/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW), including those who sell sex in sub-Saharan Africa, are especially vulnerable to HIV. Reaching them with effective prevention is a programmatic priority. The HIV prevention cascade can be used to track intervention coverage, and identify gaps and opportunities for programme strengthening. The aim of this study was to characterise gaps in condom use and identify reasons underlying these gaps among young women who sell sex (YWSS) in Zimbabwe using data from enrolment into an impact evaluation of the DREAMS programme. DREAMS provided a package of biomedical, social and economic interventions to AGYW aged 10 to 24 with the aim of reducing HIV incidence. METHODS In 2017, we recruited YWSS aged 18 to 24 using respondent-driven sampling in six sites across Zimbabwe. We measured knowledge about efficacy of, access to, and effective (consistent) use of condoms with the most recent three sexual partners, separately by whether YWSS self-identified as female sex workers (FSW) or not. Among YWSS without knowledge about efficacy of, not having access to, and not effectively using condoms, we described the potential reasons underlying the gaps in the condom cascade. To identify socio-demographic characteristics associated with effective condom use, we used logistic regression modelling. All analyses were RDS-II weighted and restricted to YWSS testing HIV-negative at enrolment. RESULTS We enrolled 2431 YWSS. Among 1842 (76%) YWSS testing HIV-negative, 66% (n = 1221) self-identified as FSW. 89% of HIV-negative YWSS demonstrated knowledge about efficacy of condoms, 80% reported access to condoms and 58% reported using condoms consistently with the three most recent sexual partners. Knowledge about efficacy of and effective use of condoms was similar regardless of whether or not YWSS self-identified as FSW, but YWSS self-identifying as FSW reported better access to condoms compared to those who did not (87% vs 68%; age- and site-adjusted (adjOR) = 2.69; 95% CI: 2.01 to 3.60; p < 0.001). Women who reported experiencing sexual violence in the past year and common mental disorder in the past week were less likely to use condoms consistently (43% vs. 60%; adjOR = 0.49; 95% CI: 0.35 to 0.68; p < 0.001) and (51% vs. 61%; adjOR = 0.76; 95% CI: 0.60 to 0.97; p = 0.029), respectively. CONCLUSIONS Despite high knowledge about efficacy of and access to condoms, there remain large gaps in self-reported consistent condom use among YWSS. Addressing the structural determinants of YWSS' inconsistent condom use, including violence, could reduce this gap. YWSS who do not self-identify as FSW have less access to condoms and may require additional programmatic intervention.
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Affiliation(s)
- Sungai T Chabata
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
| | - Bernadette Hensen
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Tarisai Chiyaka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
| | - Phillis Mushati
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
| | - Joanna Busza
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Sian Floyd
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - James R Hargreaves
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
- Faculty of Clinical Sciences and International Public HealthLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
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12
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Thomas R, Skovdal M, Galizzi MM, Schaefer R, Moorhouse L, Nyamukapa C, Maswera R, Mandizvidza P, Hallett TB, Gregson S. Improving risk perception and uptake of voluntary medical male circumcision with peer-education sessions and incentives, in Manicaland, East Zimbabwe: study protocol for a pilot randomised trial. Trials 2020; 21:108. [PMID: 31973744 PMCID: PMC6979356 DOI: 10.1186/s13063-020-4048-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 01/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) is a key component of combination HIV-prevention programmes. Several high-HIV-prevalence countries in sub-Saharan Africa, including Zimbabwe, are looking to scale up VMMC activities. There is limited evidence on how a combination of social learning from peer education by a role model with different behavioural incentives influences demand for VMMC in such settings. METHODS/DESIGN This matched-cluster randomised controlled trial with 1740 participants will compare two behavioural incentives against a control with no intervention. In the intervention clusters, participants will participate in an education session delivered by a circumcised young male ("role model") on the risks of HIV infection and the benefits from medical male circumcision. All participants will receive contributions towards transport costs to access medical male circumcision at participating clinics. Via blocked randomisation, in the intervention clusters participants will be randomly assigned to receive one of two types of incentives - fixed cash payment or lottery payment - both conditional on undergoing surgical VMMC. In two sites, a community-led intervention will also be implemented to address social obstacles and to increase support from peers, families and social structures. Baseline measures of endpoints will be gathered in surveys. Follow-up assessment at 6 months will include self-reported uptake of VMMC triangulated with clinic data. DISCUSSION This is the first trial to pilot-test social learning to improve risk perception and self-efficacy and to address the fear of pain associated with VMMC and possible present-biased preferences with front-loaded compensations as well as fixed or lottery-based cash payments. This study will generate important knowledge to inform HIV-prevention policies about the effectiveness of behavioural interventions and incentives, which could be easily scaled-up. TRIAL REGISTRATION This trial has been registered on ClinicalTrials.gov (identifier: NCT03565588). Registered on 21 June 2018.
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Affiliation(s)
- Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, Cowdray House, London, WC2 2AE UK
| | - Morten Skovdal
- Section of Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5 opg, B, Postb 15, Building: 15.0.17, 1014 København K, Denmark
| | - Matteo M. Galizzi
- Department of Psychological and Behavioural Science, London School of Economics and Political Science, London, WC2 2AE UK
| | - Robin Schaefer
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
| | - Louisa Moorhouse
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
| | - Constance Nyamukapa
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Rufurwokuda Maswera
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Phyllis Mandizvidza
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
| | - Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
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13
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Ward H, Garnett GP, Mayer KH, Dallabetta GA. Maximizing the impact of HIV prevention technologies in sub-Saharan Africa. J Int AIDS Soc 2019; 22 Suppl 4:e25319. [PMID: 31328415 PMCID: PMC6643073 DOI: 10.1002/jia2.25319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/16/2019] [Indexed: 11/23/2022] Open
Affiliation(s)
- Helen Ward
- Infectious Disease EpidemiologyImperial College LondonLondonUnited Kingdom
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