Voluntary Counselling, HIV Testing and Sexual Behaviour Among Patients with Tuberculosis in a Rural District of Malawi.

OBJECTIVES: A study was conducted in new patients registered with tuberculosis (TB) in a rural district of Malawi in order to 1) verify the acceptability of voluntary counselling and testing for human immunodeficiency virus (HIV) infection; 2) describe sexual behaviour and condom use; and 3) identify socio-demographic and behavioural risk factors associated with 'no condom use'. DESIGN: Cross-sectional study. METHODS: Consecutive patients diagnosed with TB between January and December 2000 were offered voluntary counselling and HIV testing (VCT) and were subsequently interviewed. RESULTS: There were 1,049 new TB patients enrolled in the study. Of these, 1,007 (96%) were pre-test counselled, 955 (91%) underwent HIV testing and 912 (87%) were post-test counselled; 43 (4%) patients refused HIV testing. The overall HIV infection rate was 77%. Of all HIV-positive TB patients, 691 (94%) were put on cotrimoxazole. There were 479 (49%) TB patients who reported sexual encounters, of whom only 6% always used condoms. Unprotected sex was associated with having TB symptoms for over 1 month, having had less than 8 years of school education, being single, divorced or widowed or having sex with the same partner. CONCLUSIONS: Offering VCT to TB patients in this setting has a high acceptance rate and provides an opportunity to strengthen and integrate TB and HIV programmes

An interdisciplinary study exploring how health communication can most effectively explain Antiretroviral Medication (ART) and motivate adherence among young people

The aim of this study was to explore factors contributing to the success of health communication strategies and supporting visual communication tool(s) designed to explain antiretroviral medication (ART) adherence, and motivate young people who live with HIV to follow an adherence regime. The study drew from the social sciences, including psychology, health sciences and communication. Currently there are an estimated 6.8 million people living with HIV in South Africa, making it the site of the largest HIV epidemic in the world (UNAIDS, 2014). Antiretroviral Therapy (ART) is the only effective treatment for HIV and is one of the most demanding medicine regimes, requiring a 90% compliance. Various studies have documented worryingly poor levels of adherence to ART, especially amongst adolescents and young adults in South Africa. The empirical research consisted of a qualitative case study in Khayelitsha, a periurban township on the edge of Cape Town. It focused on young people from Khayelitsha and health care professionals - doctors, nurses, HIV counsellors and pharmacists. Using grounded theory data collection was carried out during two phases of fieldwork, interspersed with periods for data processing and analysis. The principal methods used were focus groups, semi-structured interviews and participant observation. Two key factors emerged from the data that form the basis of a new theoretical understanding: first, concerning how young people become motivated to learn about treatment and adhere to it, and second, concerning how information about treatment can best be communicated to them. In relation to the first of these, findings showed that young people were traumatised by an HIV diagnosis, fearing both that they would get sick and suffer an early death and also that they would be rejected by their belonging groups. This meant that they could not take in the factual information offered, and in addition, had no motivation to do so because the diagnosis resulted in a loss of hope for their present and future lives. According to young people, motivation was an outcome of re-connecting to one or more trusted significant other(s) from within their belonging group, who accepted and supported them. This in turn affirmed their prior belonging identities of son, daughter, cousin or close friend and then reconnected them to their present and future hopes. This renewed motivation to live was the basis for their becoming motivated to learn about treatment and adhere to it. In relation to the second factor, this study found that current communications about treatment were not effective. Specifically, the use of metaphors, which was seen among clinicians as a method of simplifying the complexity of ART adherence messages, was in fact creating confusion. Also, the use of printed information in isolation was not effective; communication was much more effective when it provided a space for discussion. These two key factors form the basis of a health communication strategy for young people who live with HIV and need to adhere to ART. Following on from these findings the study included the production of a film and animation that were identified as the visual communication media that would best support young people's understanding and motivation to adherence. The film presents a case study of a young person who overcame their initial diagnosis shock and, through the acceptance and support of his family, learned to live a normal life with HIV. Young people had said that they wanted to be able to view a film of this kind soon after their diagnosis. The animation, which was designed using a participatory process, used 'iso-type' as the central visual language. It was piloted, and this showed that the best use of a visual communication tool was in a setting that allowed young people to talk about prior losses to HIV within their families and community and about their confusion about treatment, and to ask questions about the meaning of complex biomedical concepts such as an undetectable viral load. All young people who visited the clinics, irrespective of test results, said that they wanted to learn about ART so that they could support friends and family members who lived with HIV, change perceptions about HIV among peers and better prepare in the case of becoming HIV positive themselves. Therefore it is recommended that communication strategies should target patients, their belonging groups and the wider community. This substantive theory contributes knowledge relevant to how ART adherence is communicated to young people. More broadly, this thesis argues that an interdisciplinary approach is required if communication practitioners are to properly understand the meaning that a population attributes to a health challenge; especially in the context of motivation and understanding. It is only when those meanings are fully identified through consolidated social science research that a communication strategy and supporting visual tools can be successfully designed

Unequal prospects: disparities in the quantity and quality of labour supply in sub-Saharan Africa

ASC – Publicaties niet-programma gebonde

Sugar Ka Saathi – A Case Study Designing Digital Self-management Tools for People Living with Diabetes in Pakistan

This paper presents the results of an iterative participatory process to design a smart self-management tool for less-literate people living with diabetes in Pakistan. Initially, interviews and focus groups with sixty-nine people living with diabetes identified issues that they face when self-managing including un-controllable factors, lack of diabetes awareness, low-tech mobile phones, and poor internet availability. We developed personas grounded in the scoping results and adjusted our PD approach to focus on more tangible design artefacts before running narrative scoping PD sessions. Working from older, illiterate persona, we designed a phone-line delivered Interactive Voice Response (IVR) system. We developed a functional IVR Prototype “Sugar ka Saathi” (Diabetes Companion) with input from a group of 4 Pakistan-based healthcare professionals, to act as a design probe in the PD process. We tested the IVR probe with fifty-seven of the original scoping participants which validated the knowledge transferred by the IVR and its acceptability. Invisible design videos were shown to elaborate the IVR and community concept to thirteen participants through two filmed videos using our existing persona characters from the scoping studies, these videos helped to engage older people with diabetes in PD sessions

Poverty, inequality, and geographic targeting: Evidence from Small-Area Estimates in Mozambique

"Typical living standards surveys can provide a wealth of information about welfare levels, poverty, and other household and individual characteristics. However, these estimates are necessarily at a high level of aggregation, because such surveys usually include only a few thousand households, with coarse spatial stratification. Larger databases, such as national censuses, provide sufficient observations for more disaggregated analysis, but typically collect very little socioeconomic information. This paper combines data from the 1996–97 Mozambique National Household Survey of Living Conditions with the 1997 National Population and Housing Census to generate small-area (subdistrict) estimates of welfare, poverty, and inequality, with the associated standard errors. These small-area estimates are then used to explore several dimensions of poverty and inequality in Mozambique, particularly with regard to geographical targeting of antipoverty efforts. Reliably identifying and targeting the poor can be administratively costly, especially in rural Africa, where low population density and weak administrative capacity are common. Geographical targeting, or targeting poor areas, is sometimes proposed as a feasible alternative to targeting poor people, and poverty maps may serve as a valuable tool in this regard. Unfortunately, the notion of poor areas might not always be especially useful, as appears to be the case in Mozambique. The poverty maps do not reveal a particularly strong spatial concentration of poverty; the differences in poverty levels between areas tend to be subtle. This pattern is also observed in the decomposition of small-area inequality estimates, which shows that only about 20 percent of consumption inequality is accounted for by inequality between districts or between administrative posts. The picture that emerges of the poor living alongside the nonpoor indicates that targeting poor areas is likely to result in leakage to the nonpoor in that area, and considerable under-coverage of the significant numbers of poor households in areas that are less poor.”" Authors' AbstractInequality ,Geographic targeting ,Small area estimation ,Poverty mapping ,

The role of mothers-in-law in antenatal care decision-making in Nepal: a qualitative study

Background Antenatal care (ANC) has been recognised as a way to improve health outcomes for pregnant women and their babies. However, only 29% of pregnant women receive the recommended four antenatal visits in Nepal but reasons for such low utilisation are poorly understood. As in many countries of South Asia, mothers-in-law play a crucial role in the decisions around accessing health care facilities and providers. This paper aims to explore the mother-in-law’s role in (a) her daughter-in-law’s ANC uptake; and (b) the decision-making process about using ANC services in Nepal. Methods In-depth interviews were conducted with 30 purposively selected antenatal or postnatal mothers (half users, half non-users of ANC), 10 husbands and 10 mothers-in-law in two different (urban and rural) communities. Results Our findings suggest that mothers-in-law sometime have a positive influence, for example when encouraging women to seek ANC, but more often it is negative. Like many rural women of their generation, all mothers-in-law in this study were illiterate and most had not used ANC themselves. The main factors leading mothers-in-law not to support/ encourage ANC check ups were expectations regarding pregnant women fulfilling their household duties, perceptions that ANC was not beneficial based largely on their own past experiences, the scarcity of resources under their control and power relations between mothers-in-law and daughters-in-law. Individual knowledge and social class of the mothers-in-law of users and non-users differed significantly, which is likely to have had an effect on their perceptions of the benefits of ANC. Conclusion Mothers-in-law have a strong influence on the uptake of ANC in Nepal. Understanding their role is important if we are to design and target effective community-based health promotion interventions. Health promotion and educational interventions to improve the use of ANC should target women, husbands and family members, particularly mothers-in-law where they control access to family resources

Exploring informed consent in HIV clinical trials: A case study in Uganda

Introduction: In settings with low literacy levels ensuring that participants are fully-informed before they consent to participate in clinical trials is a challenge. We explored the experiences and concerns of key actors in the informed consent process in two HIV clinical trials. Method: Semi-structured interviews were conducted with 46 respondents including trial participants, research study team and research ethics committee members about their experiences during the informed consent process. Three focus group discussions were conducted with 14 Community Advisory Board (CAB) members and 17 trial participants. Data were analysed to identify key themes. Findings: The consent process was highlighted as an important procedure by all the key actors however each group had a particular area of emphasis. Signing a consent form was given importance by research team and ethics committee members, because it provided documented evidence of a participant’s willingness to join a clinical trial. Participants did not welcome the presence of a witness for a non-literate participant because understanding study information was not closely related to an ability to read and write. Conclusion: This study’s findings indicated that obtaining a volunteer’s signature or thumbprint on a consent form did not necessarily mean that the participant was fully-informed about the information relevant to their taking part nor that they understood all the information shared with them. Informed consent requires sufficient time in the research process to have staff trained well enough before research begins. Ensuring and gaining informed consent should be understood and treated as a relation-centred, dynamic supportive process throughout the duration of a research study

The role of HIV literacy: a community health worker perspective

HIV literacy has been emphasised as part of HIV/AIDS campaigns throughout the world. The South African Government’s allocation of past and present funding indicates substantial support for HIV/AIDS education with the emphasis on prevention. Commitment to the new HIV and AIDS and STI National Strategic Plan 2007-2011 for addressing the epidemic emphasises the importance of speeding up the delivery of HAART in South. The link between education and the provision of antiretroviral therapy lies in the need for patients to understand the nature of the HI virus and the way the medication works physiologically in order to ensure adherence, control side effects and provide the best care possible for people living with HIV/AIDS. This paper assesses the role of HIV literacy from the perspective of community health workers working in clinics in the Western Cape Province in South Africa. It looks at their daily interaction with clinic patients, as well as their experience of the HAART rollout. It aims to evaluate the impact of HIV literacy on the communities they work in and the limitations of education in supporting the provision of health care for people living with HIV/AIDS

Investigating mobile graphic-based reminders to support compliance of tuberculosis treatment

The phenomenon of rapid increment of the mobile phones can be utilized through supporting patients, such as those who have tuberculosis, for treatment adherence. This utilization will enable these patients to directly communicate their needs and requirements or receive health information such as reminder messages from healthcare facilities. However, the current mobile interventions, such as text messaging and speech reminder systems have limited use for people with low literacy levels. To overcome these challenges, this study proposed that the mobile graphic-based reminders be used to support tuberculosis patients to improve compliance with treatment regimens, especially for semi-literate and illiterate patients. A review of the literature and initial investigation study were carried out. The findings from the review were useful in understanding both the current practice of tuberculosis treatment regimens and the patients' needs and requirements. These findings, in addition, were referred in the choices of the components of the mobile graphic-based reminders to be implemented. A visual aid for communication theory was applied to the design and development of graphic-based reminder prototypes. An application prototype was implemented for the Android platform. Experiments were conducted to investigate the effects of an application prototype in supporting tuberculosis treatment. To measure the effect, the recovery rate was measured based on the effect of: (1) the graphic-based reminder group versus the control group; and (2) the graphic-based reminder group versus the speech-based reminder group. Data was collected using application event logs, interviews, field notes and audio recordings. It was found that treatment adherence of patients in the graphic-based group was higher than in the speech-based or in the control groups. It was further noted that the number of reminder responses in the graphic-based group was higher than in the speech-based group. Additionally, it was observed that patients in the graphic-based group responded sooner after receiving reminder messages compared to those in the speech-based group. The qualitative feedback also indicated that most patients not only found graphic-based reminders more useful to supporting their treatment than speech-based reminders and traditional care but believed that the application met their needs. This study provides empirical evidence that graphic-based reminders, designed for and based on patients' needs and requirements, can support the treatment of tuberculosis for patients of all literacy levels