Experiences of Early and Enhanced Clinical Exposure for Postgraduate Neonatal Nursing Students at the University of Zambia, School of Nursing Sciences: Lessons and Implications for the Future

Background and Objectives

Early and Enhanced Clinical Exposure immediately places postgraduate students in a clinical setting and incorporates continual hands-on instruction throughout their studies. It aims to motivate students by strengthening their academics, improving clinical and communication skills, and increasing their confidence. The underlying principles are to provide a clinical context and to ensure that the patient remains the centre of learning. The School of Nursing Sciences implemented this model in 2021 to produce hands-on Masters-level neonatal practitioners who can work in multidisciplinary clinical contexts. Therefore, this study explored the experiences of postgraduate nursing students on the Early and Enhanced Clinical Exposure model and draw implications for the future.

Methods

A phenomenological study design was utilized at the University of Zambia, School of Nursing Sciences and comprised of eight Master of Science Neonatal Nursing students in their second year. Convenience sampling was used to select the study site and participants. Data was collected between 15th January 2023 and 31st January 2023 using an in-depth interview guide. Audio recording and notes were transcribed immediately after data collection. Data analysis was conducted using thematic analysis and codes and themes were constructed from the coded data. Ethical clearance and permission were sought before conducting the study.

Results

Four major themes emerged from the study: identity and role confusion, challenging and hectic experiences, positive educational experiences, and personal and professional growth. These themes contributed to the promotion of evidence-based practice by helping students to assess, diagnose, and treat various conditions, as well as gain interest, experience, knowledge, and exposure.

Conclusion

The model has a significant impact on motivation to learn, as evidenced by reported increased skill level with potential for use in clinical practice. It is recommended that it be implemented in all postgraduate programs for full-time students.

Exploring communication and implementation challenges of the HIV/AIDS policy change to test-and-treat-all in selected public health facilities in Lusaka District, Zambia

BACKGROUND

The World Health Organization has promoted a shift towards the test-and-treat-all strategy to accelerate the elimination of HIV/AIDS. Zambia was one of the early African countries to adopt this strategy as the policy change was officially announced on national television by the republican president on 15th August 2017. This study explored the communication and implementation challenges of the HIV/AIDS policy change to test-and-treat-all in selected public health facilities in Lusaka District, Zambia.

METHODS

A qualitative case study design was employed with a purposeful sample of policy makers, international partners, National AIDS Council representatives, health facility managers, and frontline health providers in selected tertiary, secondary and primary health facilities in the Lusaka District, Zambia. Thematic data analysis was performed using NVivo 12 Pro software.

RESULTS

In total, 22 key informant interviews and 3 focus group discussions were conducted. The government relied on formal and informal channels to communicate the test-and-treat-all policy change to health providers. Whilst HIV policy changes were reflected in the National HIV/AIDS Strategic Framework, there was little awareness of this policy by the frontline providers. The use of informal communication channels such as verbal and text instructions affected health providers' implementation of the test-and-treat-all. Electronic and print media were ineffective in communicating the test-and-treat-all policy change to some sections of the public. Top-down stakeholder engagement, limited health worker training, and poor financing negatively affected the implementation of the test-and-treat-all policy change. Acceptability of the test-and-treat-all policy change was shaped by positive provider perceptions of its benefits, limited sense of policy ownership, and resistance by the non-treatment-ready patients. Furthermore, unintended consequences of the test-and-treat-all policy change on human resources for health and facility infrastructure were reported.

CONCLUSION

Effective test-and-treat-all policy change communication is vital for successful policy implementation as it enhances interpretation and adoption among health providers and patients. There is a need to enhance collaboration among policy makers, implementers and the public to develop and apply communication strategies that facilitate the adoption of the test-and-treat-all policy changes to sustain gains in the fight against HIV/AIDS.

Effect of anti-retroviral regimen on proximal tubular function in Zambian adolescents and young adults living with HIV: A cross sectional study

Background: Tenofovir regimens remain the preferred formulations in the HIV guidelines for adolescents and young adults in Zambia and globally. However, some adolescents and young adults are maintained on abacavir by clinicians because of anxiety about possible proximal tubular dysfunction from tenofovir. We assessed the effect of two regimens on proximal tubular function in adolescents and young adults living with HIV. Methods: This was a cross-sectional study involving 180 participants with HIV receiving either tenofovir or abacavir for ≥12 months at the largest tertiary teaching hospital. Two first-morning urine and blood specimens were collected and analyzed for proximal tubular markers, glomerular function, electrolytes, and routine monitoring tests. Proximal tubular function was determined by measuring the fractional excretion of phosphate (FePO4). Proximal tubular dysfunction was defined by FePO4 ≥20% regardless of serum phosphate and FePO4  ≥10-20% when serum phosphate was below 0.81mmol/L. Results: The prevalence of proximal tubular dysfunction was 6% and was higher in the tenofovir group than the abacavir (10% vs. 2%, p<0.058). However, after adjusting for potential confounders, tenofovir was not associated with worse proximal tubular function. Age, urine b2-microglobulin: creatinine ratio, C-reactive protein, and urine protein: creatinine ratio was all associated with worsening proximal tubular dysfunction. Reduced estimated glomelurar filtration rate (eGFR) was found in four (2.2%) participants; three of which were on tenofovir. Conclusions: Proximal tubular dysfunction defined by FePO4 was more prevalent in the tenofovir group than the abacavir group, but not after adjusting for age. Our findings should be interpreted with caution as age differences between the two groups confounded the results.

Sex differences in hypertension among people living with HIV after initiation of antiretroviral therapy

Background

Hypertension is common in people living with HIV (PLWH) on antiretroviral therapy (ART). In the general population and in experimental animal models, the incidence of hypertension is greater in males than in females, especially during the premenopausal period. However, it is not known whether there are sex differences in hypertension associated with HIV and ART, and the factors contributing to incident hypertension among PLWH have not been well characterized. In this study, we aimed to determine the time course, sex differences and factors associated with incident hypertension in PLWH initiating ART.

Methods and results

We conducted a retrospective study in which we used programmatic data from the ART registry to identify sex differences in the determinants of incident hypertension among PLWH initiating the ART regimen from Livingstone University Teaching Hospital in Zambia and followed for 8 years. Males developed hypertension earlier, 2 years after initiating ART, compared to 6 years in females. In multivariable analysis, increasing age, baseline systolic blood pressure and baseline mean arterial pressure (MAP) were associated with increased risk for developing incident hypertension. Also, participants who switched to the integrase strand transfer inhibitor, dolutegravir (DTG) or the protease inhibitor, lopinavir boosted with ritonavir were 2 and 3 times more likely to develop hypertension when compared to those on non-nucleoside reverse transcriptase inhibitors (NNRTIs). However, these relationships were abrogated by sex, as self-reported male sex was the major contributor in predicting incident hypertension. While none of the factors remained significantly associated with incident hypertension upon multivariate analysis among females, body mass index (BMI), and use of protease inhibitors remained strongly associated with hypertension among males.

Conclusion

Our results indicate that the use of protease inhibitors and BMI are important predictors of incident hypertension among males. Thus, blood pressure and BMI should be closely monitored, particularly in males living with HIV on protease inhibitors. In addition, identifying specific factors that protect females from developing hypertension early is important but remains to be determined.

Immediate pressor response to oral salt and its assessment in the clinic: a time series clinical trial

BACKGROUND

High blood pressure (BP) is associated with high-salt consumption especially in sub-Saharan Africa. Although the pressor effect of salt is viewed as a chronic effect, some studies suggest that a salty meal may increase BP immediately in some individuals, and that this effect may cause endothelial dysfunction. Therefore, the aim of our research was to study the immediate pressor response to oral salt (IPROS) and its determinants, with the expectation that a simple methodology may be devised to diagnose it in the clinic or in low-resource environments.

METHODS

We conducted a time series trial at Livingstone Central Hospital. We present data in 127 normotensive participants who ingested 2 g of sodium chloride; their BP was monitored for 120 minutes in intervals of 10 minutes. Sociodemographic and clinical data were collected. Descriptive and inferential statistics were used for analyses of data.

RESULTS

Median age was 30 years (interquartile range, 22-46 years) and 52% were female patients. An increase of ≥10 mmHg in mean arterial pressure (MAP), considered a clinically significant IPROS, was present in 62% of participants. Systolic BP 30 minutes after the salt load was a significant predictor of IPROS, avoiding the need to calculate MAP in the clinic setting.

CONCLUSIONS

We confirm the presence of an IPROS in a high proportion (62%) of otherwise normotensive participants. The average time course for this response was 30 minutes and its duration was sustained for the 120-minutes period of study in most of the participants. Prediction of IPROS by ∆SBP (change in systolic blood pressure) at 30 minutes allows for easy assessment of possible responder status in the clinic. Our data indicate that the IPROS to oral salt-loads in the range currently consumed by the Western world and African populations in single meals may increase the 24-hour BP load, which is a risk factor for hypertension and target organ damage. The relevance of our findings indicates the need to include dietary sodium assessment in the diagnosis, prevention, and management of high BP.

Initiatives to enhance medical subspecialist training in Zambia: A cross-sectional analysis

Introduction

There is a significant shortage of medical subspecialists in Zambia. The government of Zambia, through programmes at the Ministry of Health, spends considerable resources to send patients outside the country for subspecialist medical treatment. The objective of this analysis was to evaluate the current situation pertaining to medical subspecialty training at the University of Zambia School of Medicine (UNZASOM) and to illustrate the new programmes that are to be introduced.

Methods

We collected data from formal desk reviews on the state of medical specialisation in Zambia, the UNZASOM graduation archives and patient referral records at the Ministry of Health (MoH). In addition, information on planned subspecialist programmes is presented.

Results

From the first graduates in 1986up to 2019,UNZASOM produced 351medical specialists, 63 (18%) in Internal Medicine, 77 (22%) in Obstetrics &Gynaecology, 82 (23%) in Paediatrics&Child Health, 68 (19%) in General Surgery, 17 (5%) in Anaesthesia & Critical Care, 20 (6%) in Orthopaedics &Trauma and 8 (2%) in Urology. The remaining graduates were in Ophthalmology, Psychiatry, Infectious Diseases, Paediatric Surgery and Pathology contributing 1% each. To enhance medical subspecialist training at UNZASOM, new curricula for Breast Surgery, Urology, Glaucoma, Vitreo-retinalSurgery, Adult Gastroenterology, Forensic Pathology, Dermatology & Venereology, Ophthalmology, Gynaecological Oncology and Paediatric anaesthesia, Infectious Diseases, and Gastroenterology were developed. Since 2013, only 44% of patients requiring subspecialist treatment out of Zambia got assisted with the remainder still on the waiting list or having had bad outcomes.

Conclusions

These programmes will provide an opportunity for accessible and affordable medical subspecialization training for Zambia and its neighbouring countries. With enhanced infrastructural support, the subspecialists will contribute toward enhanced healthcare provision and improvement in patient outcomes. They will also form a cohort of trainers to expand the space for quality training and skills building of specialists and subspecialists in the region and beyond.

Prevalence and correlates of hypertension in HIV-positive adults from the Livingstone Central Hospital, Zambia

Introduction

HIV-infection and treatment with antiretroviral therapy (ART) are risk factors for the development of hypertension, which is more prevalent in people living with HIV compared with the general population. Although there is a shift to Integrase Strand Transfer Inhibitor (INSTI)-based ART across the sub-Saharan Africa, there is limited information with regard to INSTIs and hypertension association in this region, making this, a critical question to address. Hence, the study aimed to determine the relationship between hypertension and ART regimen in people living with HIV.

Methods

this was a cross-sectional study conducted at the Livingstone Central Hospital, southern province of Zambia. This study utilized programmatic data. Demographic and clinical data of 348 persons living with HIV who had been on ART for more than 2 years was abstracted in the adult ART database registry. Descriptive and inferential statistics were used for analyses of data.

Results

prevalence of hypertension was 18.4% (n=64). Hypertensives were older than normotensives with median (interquartile range) age of 55 (49, 61) and 46 (41, 52), respectively. At multivariate analysis, age (aOR: 1.07, 95% CI 1.04-1.11; p = 0.001) and body mass index (aOR: 1.10, 95% CI 1.04-1.16; p = 0.002) were positively associated with hypertension. Participants on dolutegravir based regimen were 2 times (aOR: 2.44, 95% CI 1.22-4.86; p = 0.01) more likely to be hypertensive compared to those on non-nucleoside reverse transcriptase inhibitors (efavirenz or nevirapine).

Conclusion

we confirm that increasing age, body mass index (BMI) and use of dolutegravir are risk factors for hypertension. Close monitoring for persons with HIV with these known risk factors is required.

Health research knowledge translation into policy in Zambia: policy-maker and researcher perspectives

Background

The translation of public health research evidence into policy is critical to strengthening the capacity of local health systems to respond to major health challenges. However, a limited amount of public health research evidence generated in developing countries is actually translated into policy because of various factors. This study sought to explore the process of health research knowledge translation into policy and to identify factors that facilitate or hinder the process in Zambia.

Methods

This work was an exploratory qualitative study comprising two phases. Firstly, a document review of health policies and strategic frameworks governing research was undertaken to understand the macro-environment for knowledge translation in Zambia. Secondly, key informant interviews were conducted with those responsible for health research and policy formulation. The study interviewed 15 key informants and a thematic analysis approach was used.

Results

The document review showed that there are policy efforts to promote knowledge translation through improvement of the research macro-environment. However, the interviews showed that coordination and linkage of the knowledge creation, translation and policy-making processes remains a challenge owing to lack of research knowledge translation capacity, limited resources and lack of knowledge hubs. Emerging local research leadership and the availability of existing stock of underutilized local health research data provide an opportunity to enhance knowledge translation to feed into policy processes in Zambia.

Conclusions

Public health research knowledge translation into policy remains a challenge in Zambia. To enhance the uptake of research evidence in policy-making, this study suggests the need for improved coordination, financing and capacity-building in knowledge translation processes for both health researchers and policy-makers.

Elevated Eosinophils as a Feature of Inflammation Associated With Hypertension in Virally Suppressed People Living With HIV

Background

People living with HIV (PLWH) are at increased risk of cardiovascular disease, including hypertension, which persists despite effective plasma viral suppression on antiretroviral therapy. HIV infection is characterized by long‐term alterations in immune function, but the contribution of immune factors to hypertension in PLWH is not fully understood. Prior studies have found that both innate and adaptive immune cell activation contributes to hypertension.

Methods and Results

We hypothesized that chronic inflammation may contribute to hypertension in PLWH. To test this hypothesis, we enrolled a cohort of 70 PLWH (44% hypertensive) on a long‐term single antiretroviral therapy regimen for broad phenotyping of inflammation biomarkers. We found that hypertensive PLWH had higher levels of inflammatory cytokines, including tumor necrosis factor‐α receptor 1, interleukin‐6, interleukin‐17, interleukin‐5, intercellular adhesion molecule 1 and macrophage inflammatory protein‐1α. After adjustment for age, sex, and fat mass index, the circulating eosinophils remained significantly associated with hypertension. On the basis of these results, we assessed the relationship of eosinophils and hypertension in 2 cohorts of 50 and 81 039 similar HIV‐negative people; although eosinophil count was associated with prevalent hypertension, this relationship was abrogated by body mass index.

Conclusions

These findings may represent a unique linkage between immune status and cardiovascular physiological characteristics in HIV infection, which should be evaluated further.

HIV Research Training Partnership of the University of Zambia and Vanderbilt University: Features and Early Outcomes

Background

Despite the burden of HIV being highest in sub-Saharan Africa (SSA), research expertise and capacity to address scientific questions regarding complications of HIV and ART, especially chronic non-communicable conditions, is limited in the region. The comorbidities prevalent in persons with HIV are mediated through diverse mechanisms, many of which can be context or region-specific and are yet to be elucidated. The phenotype, risk factors, and effective interventions for these conditions may differ between populations and settings, and therefore there is an urgent need for research to help understand these processes and how to best address them in SSA. Here, we report the research capacity building activities in SSA conducted by the University of Zambia (UNZA)-Vanderbilt Training Partnership for HIV-Nutrition-Metabolic Research (UVP), drawing lessons and challenges for a wide global health audience.

Methods

We reviewed program data and conducted interviews with program leaders and participants to understand and document the progress and outcomes of the partnership. We report the program's early achievements, highlighting drivers and challenges.

Results

Between 2015 and 2019, UVP made substantial progress on its goals of training new UNZA PhD scientists to investigate complex nutritional and metabolic factors related to long-term HIV complications and comorbidities. The program has supported 11 UNZA PhD students with dual UNZA-Vanderbilt mentorship; three have graduated, and other candidates are progressing in their PhD studies. The project also supported institutional capacity through UNZA faculty participation in Vanderbilt grant writing workshops, with strong success in obtaining grants among those who participated. UVP also supported development of greater structure to UNZA's PhD program and a mentorship curriculum, both now adopted by UNZA. The major drivers for success included UVP's alignment of goals between UNZA and Vanderbilt, and local institutional ownership. The longstanding history of collaborations between the two institutions contributed substantially to alignment and mutual support of UVP's goals. Several challenges were noted, including limits on direct research funding for students and a relatively small pool of funded investigators at UNZA.

Conclusions

Despite some challenges, UVP has achieved positive outcomes over its first four years. Longstanding partnerships and local institutional ownership were the main drivers. We expect the challenges to mitigated as the project continues and produces more UNZA researchers and teams and more funded projects, collectively building the local research community. With continued resources and clear focus, we expect that UNZA's investigators and partners will attract research funding and generate high-impact research outputs across a broad range of studies in HIV as well as newer threats from non-communicable conditions experienced by long-term survivors of HIV and by the general population.

Insulin Resistance is Associated with Higher Plasma Viral Load Among HIV-Positive Adults Receiving Longer-Term (1 Year) Combination Antiretroviral Therapy (ART)

BACKGROUND

As HIV-positive persons survive longer due to the success of combination antiretroviral therapy (ART) in decreasing mortality, the burden of non-communicable diseases including diabetes mellitus (DM) is anticipated to rise. HIV is characterized by systemic inflammations, markers of which decrease quickly following ART initiation, but typically do not completely normalize. Inflammation may be accompanied by insulin resistance (IR), and both are implicated in the pathogenesis of DM in HIV-positive individuals. Sub-Saharan Africa accounts for almost two-thirds of the global HIV burden but there are few reports of IR, DM and HIV in this region. We assessed the relationship between IR and viral suppression among HIV-positive adults in the Zambian national ART program.

METHODS

We conducted a cross-sectional survey evaluating HIV-positive adults that had received first line ART (usually TDF/FTC/EFV) for 12 months (± 3 months). Twenty clinics were sampled systematically based on the random starting-point, sampling interval and cumulative population size. Eligible patients had plasma viral load (VL), fasting insulin, and glucose performed. Insulin resistance was determined using Homeostatic model assessment (HOMA). We determined proportions for each outcome using linearized standard error 95% confidence intervals and summary estimates. Viral suppression was defined according to the detection threshold of<20 copies/mL and treatment failure was defined as VL>1,000 copies/mL.

RESULTS

Of 473 patients enrolled, 46.8% were male and 53.2% were female. 142 (30%) [95% CI: 0.26-0.34] had IR. Among those with IR, 55 (38.7%) were male whereas 87 (61.3%) were female (p value=0.104). 19% of individuals with IR had treatment failure compared to 5.7% without IR (p value<0.0001). 427 (90.3%) participants had treatment success (VL<1,000 copies/mL), and this was associated with a lower likelihood of IR (odds ratio (OR)=0.26 [0.14, 0.48], p value<0.0001). In addition, a significantly lower proportion of patients with IR were virologically suppressed at one-year compared to individuals without IR, 58% [0.54-0.70] versus 70% [0.65-0.75], respectively (p value=0.042).

CONCLUSION

In Zambian adults on ART for a year, the development of insulin resistance was strongly associated with suboptimal HIV outcomes, specifically non-viral suppression and treatment failure. Further investigations are warranted to determine if this positive association between IR and VL is causally related, and if so in which direction.

HIV, immune activation and salt-sensitive hypertension (HISH): a research proposal

Objective

The objective of this study is to quantify and compare the effect of excess dietary salt on immune cell activation and blood pressure in HIV versus HIV negative individuals.

Results

Salt-sensitivity is associated with increased immune cell activation in animal studies. This concept has not been tested in people living with HIV. This study will therefore add more information in elucidating the interaction between HIV infection and/or anti-retroviral therapy (ART), immune-activation/inflammation and hypertension.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4470-2) contains supplementary material, which is available to authorized users.

Patho-immune Mechanisms of Hypertension in HIV: a Systematic and Thematic Review

PURPOSE OF REVIEW

To systematically review recent findings on the role of immune cell activation in the pathogenesis of hypertension in people living with HIV (PLWH) and compare studies from Sub-Saharan Africa with what is reported in the USA and European literature according to guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RECENT FINDINGS

PLWH have an increased risk for development of hypertension and cardiovascular disease. Chronic immune activation contributes to hypertension but the inflammatory milieu that predisposes PLWH to hypertension is poorly understood. We identified 45 relevant studies from 13 unique African countries. The prevalence of hypertension in PLWH on antiretroviral therapy (ART) and the ART-naive PLWH ranged from 6 to 50% and 2 to 41%, respectively. Interleukin (IL)-17A, interferon (IFN)-γ, and higher CD4+ T cell counts were associated with hypertension in ART-treated participants. Targeting adaptive immune activation could provide improved care for hypertensive PLWH. Further research is needed to characterize the inflammatory milieu contributing to hypertension in PLWH especially in African populations where the global burden of HIV is the highest.

Establishing common leadership practices and their influence on providers and service delivery in selected hospitals in Lusaka province, Zambia

In an evolving health care environment, hospitals need managers with high levels of technical and professional expertise who do not only concentrate on patient care, but also go further to demonstrate good leadership practices. In Zambia, the health sector’s mission is “to provide equity of access to cost-effective quality health services as close to the family as possible”. Only competent leadership can drive such an agenda. This study, conducted in selected 1^st level Lusaka hospitals aimed at establishing the existing common leadership practices and their influence on healthcare providers and service delivery. The study employed a cross-sectional qualitative research method design, to establish and examine the leadership practices through 10 health system managers and 32 healthcare providers. The data was obtained using in-depth interviews, focus group discussion, participant observation and document review. Data analysis was done by first transcribing audio-recorded interviews and grouping them into data sets (matrixes) where emerging themes were categorized manually. The information obtained assisted in making conclusions and interpretations by providing eminent explanations pointing to specific leadership styles and influence caused on healthcare providers and service delivery. The common leadership practices obtained in this study was the transformational leadership followed by transactional leadership while laissez-faire was rare type of leadership. This conclusion was arrived at through the practices that were pointing to transformational and transactional leadership as preferred by the leaders and perceived or experienced by providers. These practices were explained as networking, interpersonal relationships, human/material resources management, monitoring and evaluation, dictatorial tendencies and overworking of employees. Furthermore, these practices were seen to have strong influence on healthcare providers through enhanced confidence, motivation for hard work and compromised quality of care. The resultant impact on service delivery was high quality performance as well as poor performance. Leadership styles affect employees’ commitment, motivation, satisfaction, extra effort and efficiency. This in turn has a bearing on performance and directly or indirectly influences patient care and its quality. Health system managers have a significant role in using leadership styles that promote good practice. It can be safely concluded that hospital performance and quality health care delivery services is a product of several factors. The analysis of leadership practices in this study shows two of the factors influencing hospital performance. The first factor is the effectiveness of leaders within the hospital and secondly the dedication, motivation, commitment and performance of employees that will improve health care services.

Evaluation of oral hygiene services in selected public health facilities in Lusaka district of Zambia

Around the globe many people are suffering from oral pain and other problems of the mouth or teeth. This public health problem is growing rapidly in developing countries where oral health services are limited. This study was conducted in the public health centers and first level hospitals with dental units (DUs) in Lusaka district. Adequacy of dental equipment, instruments and materials required for scaling and polishing (S&P) and oral hygiene instructions (OHI) was evaluated. Challenges faced by the dental therapists (DTs) in the entire DUs were also evaluated. This was a mixed method study; quantitative data was collected using a structured questionnaire which contained a standard facility assessment check list. Qualitative data was collected by conducting in-depth interviews. The study results showed that the oral hygiene services offered by the selected DUs in Lusaka district were inadequate. A fully functional dental chair was available only in fifty percent of the DUs, only twenty percent of the facilities had fully functional ultrasonic scaling unit, none of the facilities had all the instruments for polishing. The DTs work under stressful conditions as sixty percent of the facilities were understaffed; the supply of dental instruments and materials was poor; delay in repairing faulty equipment; risk of exposure to air borne infections as most of the facilities have space and ventilation problems. Recommendations of this study point towards an urgent need to improve and coordinate the oral health care system.

Health care needs assessment among adolescents in correctional institutions in Zambia: an ethical analysis

Background

While health care needs assessments have been conducted among juveniles or adolescents by researchers in developed countries, assessments using an ethics framework particularly in developing countries are lacking. We analysed the health care needs among adolescents at the Nakambala Correctional Institution in Zambia, using the Beauchamp and Childress ethics framework. The ethics approach facilitated analysis of moral injustices or dilemmas triggered by health care needs at the individual (adolescent) level.

Methods

The research team utilized 35 in-depth interviews with juveniles, 6 key informant interviews and 2 focus group discussions to collect data. We analysed the data using thematic analysis. The use of three sources of data facilitated triangulation of data.

Results

Common health problems included HIV/AIDS, STIs, flu, diarrhoea, rashes, and malaria. Although there are some health promotion strategies at the Nakambala Approved School, the respondents classified the health care system as inadequate. The unfavourable social context which included clouded rooms and lack of adolescent health friendly services unfairly exposed adolescents to several health risks and behaviours thus undermining the ethics principle of social justice. In addition, the limited prioritisation of adolescent centres by the stakeholders and erratic funding also worsened injustices by weakening the health care system. Whereas the inadequate medical and drug supplies, shortage of health workers in the nearby health facilities and weak referral systems excluded the juveniles from enjoying maximum health benefits thus undermining adolescents’ wellbeing or beneficence. Inadequate medical and drug supplies as well as non-availability of adolescent friendly health services at the nearest health facility did not only affect social justice and beneficence ethics principles but also threatened juveniles’ privacy, liberty and confidentiality as well as autonomy with regard to health service utilisation.

Conclusion

Adequately addressing the health needs in correctional institutions may require adopting an ethics framework in conducting health needs assessment. An ethics approach is important because it facilitates understanding of moral dilemmas that arise due to health needs. Furthermore, strategies for addressing health needs related to one ethics principle may have a positive ripple effect over other health needs as the principles are intertwined thus facilitating a comprehensive response to health needs.

Strengthening and expanding the capacity of health worker education in Zambia

INTRODUCTION

Zambia is facing a chronic shortage of health care workers. The paper aimed at understanding how the Medical Education Partnership Initiative (MEPI) program facilitated strengthening and expanding of the national capacity and quality of medical education as well as processes for retaining faculty in Zambia.

METHODS

Data generated through documentary review, key informant interviews and observations were analyzed using a thematic approach.

RESULTS

The MEPI program triggered the development of new postgraduate programs thereby increasing student enrollment. This was achieved by leveraging of existing and new partnerships with other universities and differentiating the old Master in Public Health into specialized curriculum. Furthermore, the MEPI program improved the capacity and quality of training by facilitating installation and integration of new technology such as the eGranary digital library, E-learning methods and clinical skills laboratory into the Schools. This technology enabled easy access to relevant data or information, quicker turn around of experiments and enhanced data recording, display and analysis features for experiments. The program also facilitated transforming of the academic environment into a more conducive work place through strengthening the Staff Development program and support towards research activities. These activities stimulated work motivation and interest in research by faculty. Meanwhile, these processes were inhibited by the inability to upload all courses on to Moodle as well as inadequate operating procedures and feedback mechanisms for the Moodle.

CONCLUSION

Expansion and improvement in training processes for health care workers requires targeted investment within medical institutions and strengthening local and international partnerships.

Banning traditional birth attendants from conducting deliveries: experiences and effects of the ban in a rural district of Kazungula in Zambia

Background

In 2010 the government of the republic of Zambia stopped training traditional birth attendants and forbade them from conducting home deliveries as they were viewed as contributing to maternal mortality. This study explored positive and negative maternal health related experiences and effects of the ban in a rural district of Kazungula.

Methods

This was a phenomenological study and data were collected through focus group discussions as well as in-depth interviews with trained traditional birth attendants (tTBAs) and key informant interviews with six female traditional leaders that were selected one from each of the six zones. All 22 trained tTBAs from three clinic catchment areas were included in the study. Content analysis was used to analyse the data after coding it using NVIVO 8 software.

Results

Home deliveries have continued despite the community and tTBAs being aware of the ban. The ban has had both negative and positive effects on the community. Positive effects include early detection and management of pregnancy complications, enhanced HIV/AIDS prevention and better management of post-natal conditions, reduced criticisms of tTBAs from the community in case of birth complications, and quick response at health facilities in case of an emergency. Negatives effects of the ban include increased work load on the part of health workers, high cost for lodging at health facilities and traveling to health facilities, as well as tTBAs feeling neglected, loss of respect and recognition by the community.

Conclusion

Countries should design their approach to banning tTBAs differently depending on contextual factors. Further, it is important to consider adopting a step wise approach when implementing the ban as the process of banning tTBAs may trigger several negative effects.

Developing a Family Medicine Postgraduate Training Program in Zambia

The last decade has seen a number of educational programs in family medicine begin throughout the African region as many countries have recognized that family medicine offers an efficient way to meet the growing health demands of their country. Zambia's health situation is similar to many countries in sub-Saharan Africa by having a wide array of compelling health demands and a health sector with a limited capacity to meaningfully respond. This paper describes the efforts to begin Zambia's first post-graduate training program for family medicine. Several different methods were used to assist with the launch of Zambia's first postgraduate training program in family medicine: developing a logistical framework, regional site visits, building consensus among stakeholders, defining family medicine specifically for Zambia, and the development of a curriculum. Significant outputs achieved during the start-up period include: changes to the organizational structure of the medical school, budget reconciliation, and recruitment of the teaching faculty. Challenges that remain for the near-term include identifying appropriate district-level teaching facilities and the recruitment and retention of qualified faculty. Zambia's experience in developing family medicine may prove useful to other academic medical institutions throughout the region or in comparable socioeconomic circumstances as they look to address similar health sector challenges.

A study on usefulness of a set of known risk factors in predicting maternal syphilis infections in three districts of Western Province, Zambia

Introduction

Despite roll-out of cost-effective point-of-care tests, less than half antenatal attendees in rural western Zambia are screened for syphilis. This study formulated a clinical, risk-based assessment criteria and evaluated its usefulness as a non-biomedical alternative for identifying high-risk prenatal cases.

Methods

We conducted a cross-sectional survey of antenatal clinic attendees in Kaoma, Luampa and Nkeyema districts to collect data on exposure to nine pre-selected syphilis risk factors. These factors were classified into major and minor factors based on their observed pre-study association strengths to maternal syphilis. Clinical disease was defined as exposure to either two major factors, one major with two minor factors or three minor factors. Sensitivity, specificity and predictive values of the clinical protocol were then calculated in comparison to rapid plasmin reagin results.

Results

The observed syphilis prevalence was 9.3% (95% CI: 7.4 - 11.6%) and the overall sensitivity of the study criteria was 62.3% with positive predictive value of 72.9%. Sensitivities of individual case-defining categories were even lower; from 17.4% to 33.3%. Results confirmed that abortion history, still birth, multiple sexual partners, previous maternal syphilis infection, partner history of sexually transmitted infection and maternal co-morbid conditions of HIV and genital ulcer disease were significantly associated to maternal syphilis in study population as well.

Conclusion

The criteria was not as effective as biomedical tests in identifying maternal syphilis. However, it could be a useful adjunct/alternative in antenatal clinics when biomedical tests are either inadequate or unavailable.

How we implemented an analytical support clinic to strengthen student research capacity in Zambia

BACKGROUND

Research outputs in sub-Saharan Africa may be limited by a scarcity of clinical research expertise. In Zambia, clinical and biomedical postgraduate students are often delayed in graduation due to challenges in completing their research dissertations. We sought to strengthen institutional research capacity by supporting student and faculty researchers through weekly epidemiology and biostatistics clinics.

METHODS

We instituted a weekly Analytical Support Clinic at the University of Zambia, School of Medicine. A combination of biostatisticians, clinical researchers and epidemiologists meet weekly with clients to address questions of proposal development, data management and analysis. Clinic sign-in sheets were reviewed.

RESULTS

109 students and faculty members accounted for 197 visits to the Clinic. Nearly all clients (107/109, 98.2%) were undergraduate or postgraduate students. Reasons for attending the Clinic were primarily for proposal development (46.7%) and data management/analysis (42.1%). The most common specific reasons for seeking help were data analysis and interpretation (36.5%), development of study design and research questions (26.9%) and sample size calculation (21.8%).

CONCLUSIONS

The Analytical Support Clinic is an important vehicle for strengthening postgraduate research through one-on-one and small group demand-driven interactions. The clinic approach supplements mentorship from departmental supervisors, providing specific expertise and contextual teaching.

Molecular identification of non-tuberculous mycobacteria isolated from clinical specimens in Zambia

BACKGROUND

The emergence of Acquired Immunodeficiency Syndrome has highlighted the increased incidence and importance of the disease caused by Non-tuberculous Mycobacteria (NTM). While disease due to M. avium-intracellulare complex is apparently common throughout the world, other Non-tuberculous mycobacterial species have been isolated from both immunocompromised and immunocompetent individuals. The increasing number of infections caused by these organisms has made it clinically important to quickly identify mycobacterial species. The diagnosis of a pathogenic versus a non-pathogenic species not only has epidemiological implications but is also relevant to the demands of patient management. Since antibiotic treatment varies according to the species encountered, species identification would reduce the burden of some of these emerging opportunistic pathogens especially in immunocompromised patients and improve their quality of life.

FINDINGS

A total of 91 NTM suspected isolates from four regions of Zambia were included in the study. These isolates were identified using the sequence analysis of the 16S-23S rRNA intergenic transcribed spacer (ITS) region of Mycobacteria. Fifty-four of the 91 (59%) isolates were identified as NTM and these included M. intracellulare (27.8%), M. lentiflavum (16.7%), M. avium (14.8%), M. fortuitum (7.4%), M. gordonae (7.4%), M. kumamotonense (3.7%), M. indicus pranii (3.7%), M. peregrinum (3.7%), M. elephantis (1.85%), M. flavescens (1.85%), M. asiaticum (1.85%), M. bouchedurhonense (1.85%), M. chimaera (1.85%), M. europaeum (1.85%), M. neourum (1.85%), M. nonchromogenicum (1.5%).

CONCLUSION

The study has shown that DNA sequencing of the ITS region may be useful in the preliminary identification of NTM species. All species identified in this study were potentially pathogenic.

A scoping review of training and deployment policies for human resources for health for maternal, newborn, and child health in rural Africa

BACKGROUND

Most African countries are facing a human resources for health (HRH) crisis, lacking the required workforce to deliver basic health care, including care for mothers and children. This is especially acute in rural areas and has limited countries' abilities to meet maternal, newborn, and child health (MNCH) targets outlined by Millennium Development Goals 4 and 5. To address the HRH challenges, evidence-based deployment and training policies are required. However, the resources available to country-level policy makers to create such policies are limited. To inform future HRH planning, a scoping review was conducted to identify the type, extent, and quality of evidence that exists on HRH policies for rural MNCH in Africa.

METHODS

Fourteen electronic health and health education databases were searched for peer-reviewed papers specific to training and deployment policies for doctors, nurses, and midwives for rural MNCH in African countries with English, Portuguese, or French as official languages. Non-peer reviewed literature and policy documents were also identified through systematic searches of selected international organizations and government websites. Documents were included based on pre-determined criteria.

RESULTS

There was an overall paucity of information on training and deployment policies for HRH for MNCH in rural Africa; 37 articles met the inclusion criteria. Of these, the majority of primary research studies employed a variety of qualitative and quantitative methods. Doctors, nurses, and midwives were equally represented in the selected policy literature. Policies focusing exclusively on training or deployment were limited; most documents focused on both training and deployment or were broader with embedded implications for the management of HRH or MNCH. Relevant government websites varied in functionality and in the availability of policy documents.

CONCLUSIONS

The lack of available documentation and an apparent bias towards HRH research in developed areas suggest a need for strengthened capacity for HRH policy research in Africa. This will result in enhanced potential for evidence uptake into policy. Enhanced alignment between policy-makers' information needs and the independent research agenda could further assist knowledge development and uptake. The results of this scoping review informed an in-depth analysis of relevant policies in a sub-set of African countries.

The Socio-economic Impact of Stroke on Households in Livingstone District, Zambia: A Cross-sectional Study

Background:

Stroke is the leading cause of adult disability. Stroke, which affects mostly the productive age group, leaves about 65% of its victims disabled, leads to increased loss of manpower both at individual and national levels. Little is known about the socio-economic burden of the disease in terms of its impacts on the individual, family and community both directly and indirectly in Sub-Sahara Africa region and Zambia at large.

Aim:

The study was aimed at assessing the socio-economic impact of stroke households in Livingstone district, Zambia.

Subjects and Methods:

A total of 50 households were randomly selected from the registers of Livingstone General Hospital. Self-administered questionnaires and focus group discussions were used to collect quantitative and qualitative data respectively. The data was analyzed using Statistical Package for Social Sciences version 16 (IBM Corporation) and content analysis. Chi-square test was used to make associations between variables.

Results:

The social impacts on the victim were depression, difficult to get along with, resentfulness, apathy, needy, separation, divorce, general marital problems, neglect on the part of the victim and fear. The economic impacts were loss of employment, reduced business activity and loss of business on the part of the victim. Economic activities such as food provision, payment of school fees, accommodation were affected as a result of stroke and this led to financial insecurities in households with lost incomes in form of salaries and businesses. The activities forgone by stroke households were food provision, housing and education. The study also revealed an association between period of stroke and relationship changes (P < 0.001). Gender and family relationship changes were highly associated (P < 0.00), as more females than males experienced relationship changes.

Conclusion:

The results of the present study show that stroke has considerable socio-economic impact on households in Livingstone district, which can deter the victims’ development as well as the household and the nation at large.

Strengthening faculty recruitment for health professions training in basic sciences in Zambia

Zambia is facing a crisis in its human resources for health, with deficits in the number and skill mix of health workers. The University of Zambia School of Medicine (UNZA SOM) was the only medical school in the country for decades, but recently it was joined by three new medical schools--two private and one public. In addition to expanding medical education, the government has also approved several allied health programs, including pharmacy, physiotherapy, biomedical sciences, and environmental health. This expansion has been constrained by insufficient numbers of faculty. Through a grant from the Medical Education Partnership Initiative (MEPI), UNZA SOM has been investing in ways to address faculty recruitment, training, and retention. The MEPI-funded strategy involves directly sponsoring a cohort of faculty at UNZA SOM during the five-year grant, as well as establishing more than a dozen new master's programs, with the goal that all sponsored faculty are locally trained and retained. Because the issue of limited basic science faculty plagues medical schools throughout Sub-Saharan Africa, this strategy of using seed funding to build sustainable local capacity to recruit, train, and retain faculty could be a model for the region.

Determination of the prevalence of African trypanosome species in indigenous dogs of Mambwe district, eastern Zambia, by loop-mediated isothermal amplification

Background

Dogs have been implicated to serve as links for parasite exchange between livestock and humans and remain an important source of emerging and re-emerging diseases including trypanosome infections. Yet, canine African trypanosomosis (CAT), particularly in indigenous dogs (mongrel breed) remains under- reported in literature. This study evaluated the performance of loop-mediated isothermal amplification (LAMP) in detecting trypanosomes in blood from indigenous dogs of tsetse-infested Mambwe district in eastern Zambia.

Methods

A cross sectional survey of CAT was conducted within 5 chiefdoms (Msoro, Kakumbi, Munkanya, Nsefu, Malama) of Mambwe district, eastern Zambia, during October 2012. Blood samples from 237 indigenous hunting dogs were collected and screened by microscopy and LAMP.

Results

Of the 237 dogs screened for CAT, 14 tested positive by microscopy (5.9%; 95% CI: 2.9 – 8.9%), all of which also tested positive by LAMP. In addition, LAMP detected 6 additional CAT cases, bringing the total cases detected by LAMP to 20 (8.4%; 95% CI: 4.9 – 12.0%). Irrespective of the detection method used, CAT was only recorded from 3 chiefdoms (Munkanya, Nsefu, Malama) out of the 5. According to LAMP, these infections were caused by Trypanosoma congolense, Trypanosoma brucei brucei and the zoonotic Trypanosoma brucei rhodesiense. Although these CAT cases generally did not manifest clinical illness, an association was observed between infection with Trypanosoma brucei subspecies and occurrence of corneal opacity.

Conclusions

This communication reports for the first time the occurrence of CAT in indigenous Zambian dogs. Our study indicates that LAMP is a potential diagnostic tool for trypanosome detection in animals. LAMP was more sensitive than microscopy and was further capable of distinguishing the closely related T. b. brucei and T. b. rhodesiense. In view of the sporadic cases of re-emerging HAT being reported within the Luangwa valley, detection of the human serum resistant associated (SRA) gene in trypanosomes from mongrels is intriguing and indicative of the risk of contracting HAT by local communities and tourists in Mambwe district. Consequently, there is a need for continuous trypanosome surveillances in animals, humans and tsetse flies using sensitive and specific tests such as LAMP.

Antimalarial drug sensitivity patterns in the western province of Zambia. Implications for the management of primary health care (PHC)

The management of acute malaria consists of chemotherapy aimed at restoring the normal function of all organs. Appropriate treatment is dependent upon extensive knowledge of the drug sensitivity patterns of the malaria parasites in the area. This is also important for chemoprophylaxis. Drug sensitivity patterns and recrudescence rates for Mongu (Western Province in Zambia) are suggestive of a likely increase in resistance to both chloroquine and sulfadoxine-pyrimethamine (Fansidar). We found RI (19.4%), RII (1.5%) and RIII (4.4%) resistance to chloroquine and RII (4.3%) resistance to Fansidar. This calls for careful consideration of treatment schedules, legislation pertaining to the distribution of drugs in the general public and alternative antimalarial control strategies.