Determinants of Adherence to the Exclusive Breastfeeding Option among HIV Positive Mothers in Eight Selected Health Centres in Lusaka District

Background: Exclusive breastfeeding practice in high prevalence settings remains a challenge because of likelihood of HIV transmission through breast milk. Understanding determinants influencing adherence to exclusive breastfeeding in Zambia is also a challenge. We investigated determinants of adherence to exclusive breastfeeding among HIV infected mothers aged 18 to 49 years with children aged 0 to 12 months in eight selected health centres in Lusaka district.Methods: A cross-sectional survey among 400 respondents was conducted in selected health centres using probability proportional to size stratified random sampling. Multivariate logistic regression results were stratified by age and educational level. Focus Group Discussions with 44 respondents and In-depth Interviews with eight nurses were also conducted. Framework analysis (Ritchie and Spencer 1994) was used for qualitative data analysis.Results: Overall, most mothers (74.0%, n=296, CI: 0.69, 0.78) adhered to exclusive breastfeeding. Multivariate results showed that being married (AOR, 2.88; 95% CI 1.45, 5.71) and having not suffered from breast conditions (AOR, 5.34; 95% CI 2.08, 13.7) determined adherence irrespective of age and educational level. Those of incomes less than $125 were more likely to report adherence (AOR 2.44; 95$125 despite secondary education status. Focus Group Discussions and In-depth Interviews' results complemented these findings. Women who received nutrition education (n=17) and understood that mixed feeding facilitated Mother-To-Child-Transmission (MTCT) of HIV (n=10) reported adherence. In-depth Interview results revealed that mothers who understood benefits and risks of breastfeeding through counselling also adhered to exclusive breastfeeding. Both women and nurses reported that non-availability of resources to sustain Exclusive Replacement Feeding for first six months determined adherence.Conclusion: High adherence among married respondents irrespective of age suggests a role for social support in determining adherence. Higher odds of adherence among those without breast related conditions regardless of educational level and with incomes below $125, suggests importance of understanding that reduced risk of MTCT of HIV in the absence of breast related conditions and inadequate finances to sustain exclusive replacement feeding with formula could have determined adherence

Staff competencies at health facilities implementing an outpatient therapeutic programme for severely acute malnourished children

Background: Malnutrition continues to be a major cause of disease burden, especially in low-income countries, killing millions of children. In order to reduce morbidity and mortality, the management of children with severe acute malnutrition (SAM) requires knowledgeable and skilled staff. In the study reported on in this article, we measured the level of knowledge of staff working in the outpatient therapeutic programme (OTP) in Lusaka, Zambia.Methods: The study targeted healthcare workers managing SAM from five randomly selected health facilities of the 12 health centres that have been implementing the OTP since 2005. At facility level, staff were first listed and then randomly selected for interviews. Four members of staff were selected for the self-administered questionnaire, three for the in-depth interviews and three for observations.Findings: Overall, the aggregated knowledge of the healthcare staff of integrated management of acute malnutrition procedures were slightly above 50%. Most staff could not correctly cite key knowledge segments to ensure that they would adequately manage SAM children.Conclusion: There was average knowledge to manage SAM among the healthcare staff; this suggested a need to strengthen staff's knowledge base and skills in certain areas critical to manage SAM children adequately

Factors associated with home deliveries in a low income rural setting-observations from Nchelenge district, Zambia

Objectives: To determine the proportion of and factors associated with home deliveries in Nchelenge district, Zambia.Design: A population-based cross sectional study survey using simple random sampling was carried out among women (n=499) who attended immunization posts that were randomly selected. Binary multivariate logistic regression was used to determine factors associated with home deliveries.Main outcome measure: Percentage of deliveries reported to have occurred at home.Results: Overall (n=499), the prevalence of home deliveries was 43%, 95% CI (38.62, 47.48). Women who had four years of schooling or less, were 63% (AOR=1.63, 95% CI [1.06, 2.51]) more likely to deliver at home than a health facility compared to those who had at least five years of schooling.  Women who lived within a radius of 5 kilometers to the nearest health facility providing maternal health and delivery services were 39% (AOR=0.61, 95% CI [0.41, 0.90]) less likely to deliver at home compared to those who lived more than 5 km away. Aspects of traditional beliefs, personal experiences of mothers and the perspectives of community members were among possible reasons cited for this outcome. Response rate was 96% (< 5% refused).Conclusion: The association of home deliveries with access to health care suggests a need for structural response coupled with ethnographic studies to explore linked aspects of traditional beliefs, personal experiences of mothers and the perspectives of community members.Keywords: Zambia, Home deliveries, Factors, Crosssectional Surve

Set criteria in the management of severely malnourished children in Zambia: evidence from the evaluation of an 'outpatient therapeutic care program (OTP)'

Background: Severe malnutrition is still a leading cause of morbidity and mortality in sub-Saharan Africa. The Outpatient Therapeutic Care Program (OTP) is one of the interventions that seek to reduce the burden associated with severe malnutrition in children. Performance of the OTP against the Integrated Management of Acute Malnutrition (IMAM) set criteria in the selected public health facilities in Lusaka urban, Zambia was evaluated.Methods: Records of children (n=828), discharged from OTP between September 2005 and September 2007 in eleven health centres where this program was running, were evaluated for performance. The selection process adapted a multistage sampling technique using proportional to size approach in order to get the number of records for each site. Performance was determined by developing a compost indicator from weight gain, length of period of stay in the OTP, recovery rate, default rate and mortality. Logistic regression was used to assess performance and its determinants. In addition, a sampling frame of health care staff working in the OTP was made for each health facility from which twenty five of them participated in in-depth interviews assessing corroborative evidence for performance of the program (results reported elsewhere). Health facility and sex were used as indicator for completeness of data and as a measure for non-participation. Lack of completeness of records was the most important cause of non-response.Findings: Overall prevalence of good performance was 86% (n=828). However, the study showed contrasting differential performance by health facility (Ranging from 73% for N'gombe to 100% for Matero). Disaggregating the composite indicators revealed that 60% of children gained acceptable weight (above 4 g per kg body weight per day, mean weight gain of 5.7 g per day, SD 1.2); 75% stayed less than 60 days recommended (median length of stay of 48 days); Recovery rate of 59%, 31% default rate and 3.2% death rate. In multivariate logistic regression, source of admission and appetite were the main determinants of performance. Poor performance was associated with referrals from a health facility (Prevalence, 86.7%; OR=0.01, 95CI%CI 0.001-0.301) and reported lack of or inadequate breastfeeding at the time of admission to the program (OR=0.481, 95%CI 0.27-.85).Conclusion: Good overall program performance of the OTP suggests high feasibility to fight severe malnutrition in this setting. However, it was not clear how some factors such as poor appetite affected performance, suggests that there may be interplay of factors at work and further research is needed to explore them. Nonetheless, finding that breastfeeding was associated with good performance suggests how important this factor might be to child survival as a whole. Inversely, its lack could be pointing to limitations to breastfeeding interventions in the community

Factors associated with neonatal mortality in the general population: Evidence from the 2007 Zambia Demographic and Health Survey (ZDHS); a cross sectional study

Introduction: neonatal mortality accounts for almost 40 percent of  under-five child mortality globally and this could be associated with a complex chain of factors including but not limited to socio-economic, biological and healthcare-related factors. We examined factors that may be associated with neonatal mortality in Zambia. Methods: using across-sectional design, data were extracted from the 2007 Zambia Demographic and Health Survey for women using a "Women's Questionnaire" for respondents aged 15-49 years in the selected households. Records of women who reported having given birth to live infants within the five years preceding the survey defined the study population. However only records on those infants who could have lived through the first month (28 days) were assessed (de facto population). Results: overall (n=6 435), there were 3204(49.8%) males and 3231(50.2%)females. There were 219  (3.4%) neonatal deaths recorded. Low birth weight and overweight were  reported as the prominent factors. The odds of dying were significantly  higher for infants with low birth weight compared to infants born with normalweight, (aOR=2.58, 95%CI 1.02-6.49). The pattern was the same in both rural though insignificant. Over weight born babies showed increased odds of dying (aOR 3.21, 95%CI 1.36-7.59). Compared to infants born from Mothers with no education, infants born from mothers with higher education were associated with increased odds of dying (aOR 3.55, CI 95%, 1.26-9.94). Conclusion: neonatal survival is still a challenge in this population and determinants show varying socio-demographic contrasts. This may suggest limitations in past efforts to improve neonatal health.Future strategies need to continue but should account for varying setting specific epidemiological contrasts

Factors associated with late antenatal care attendance in selected rural and urban communities of the copperbelt province of Zambia

Background: Despite antenatal care services being provided free of charge or sometimes at a minimal cost in Zambia, only 19% of women attend antenatal care by their fourth month of pregnancy, as recommended by World Health Organization (WHO). An estimated 21% of pregnant women in urban and 18% in rural districts make their first ANC visit by 4th months of pregnancy. A number of factors have been found to contribute to late initiation of Antenatal care among pregnant women and these may vary between rural and urban areas. Therefore, a study aimed at examining factors associated with late ANC attendance amongst pregnant women in selected communities of the Copperbelt Province was conducted.Methodology: A cross- sectional study using a semistructured questionnaire was conducted in selected health facilities of Mpongwe and Ndola districts. A total number of 613 women attending antenatal clinic, distributed evenly between Mpongwe rural district (51% (307/613) and Ndola urban district (49% (306/613) were included in the study. Data from the completed questionnaires was entered using Epi InfoTM 3.5.1 and finally analyzed with SPSS version 16.0.Results: The prevalence of late ANC attendance was 72.0 % (n=221) and 68.6% (n=210) in rural and urban districts respectively. However, the difference between two districts was not statistically significant [OR 0.851 (95% CI=0.6, 1.2), p=0.363]. In the rural district, nulliporous women were 59% (AOR 0.411, 95% CI 0.238, 0.758) less likely to initiate ANC late compared to multiparous women, while the proportion the urban was 48% (AOR 0.518, 95% CI 0.316, 0.848). Inadequate knowledge about ANC resulted into 2.2 times high odds for late ANC attendance (AOR 2.205, 95% CI 1.021, and 4.759) than women who had adequate knowledge in urban district. Women who fell pregnant unintentionally had a higher odds of starting ANC late in both rural [4.2 times (AOR 4.258, 95% CI 1.631, 11.119)] and urban [3.1 times (AOR 3.103, 95% CI 1.261, 7.641)] respectively. The perception of no benefits derived from commencement of ANC early was associated with 4 times (AOR 3.983, 95% CI 1.365, 11.627) likelihood of late attendance in the urban district. Compared to lack of privacy at health institutions, pregnant women in rural were 3.4 times (AOR 3.377, 95% CI 1.180, and 9.660) more likely to initiate ANC late because of long distance to health facilities. Compared to misconceptions on ANC, pregnant women in rural areas were 2.2 times (AOR 2.211 95% CI 1.049, 4.660) more likely to start ANC late because of community norm(less value attached to ANC); while in urban late ANC attendance was 2.9 times (AOR 2.899, 95% CI 1.372, 6.083) higher due to cultural beliefs than misconceptions.Conclusion: Late antenatal care attendance remains high in both rural and urban districts indicating the need for intensified and more focused utilization of resources aimed at increasing sensitization of the importance of early attendance for high risk groups, such as women with unplanned pregnancies, inadequate knowledge about ANC, cultural beliefs and women who are multiporous

The social determinants of tuberculosis and their association with TB/HIV co-infection in Lusaka, Zambia

Introduction: Tuberculosis (TB) is a major public health problem globally.Progress made in TB control through the implementation of the DOTS strategy, has been retarded by factors such as poverty, the HIV pandemic and the advent of multidrug resistant tuberculosis. There is currently an increasing shift in TB control strategies to emphasize the importance of social determinants of TB if notable impact has to be attained. However, limited data exist that describe these determinants in high burden settings such as Zambia. This study was conducted to explore the social determinants of TB and their association with TB/HIV co-infection, in order to inform TB control strategies that would lead to appropriate action for impact.Method: A cross-section study of TB patients presenting to four peri-urban health facilities in Lusaka through administration of a standard structured questionnaire. STATA 12 Version 1 was used for analysis.Results: There were 1,259 TB patients enrolled. The median age was 35 (IQR; 29 – 41). The main determinants that were associated with TB/HIV co-infection were: being in the age-group 24-49 (p = 0.0001); being female (p = 0.0001); re-treatment (p = 0.0001); having extrapulmonary TB (p = 0.02); being married or widowed (p = 0.05 and p = 0.01, respectively)Conclusions: Describing the social determinants of TB and their association with TB/HIV co-infection highlighted a number of opportunities to strengthen control beyond the Stop TB Strategy

Childbearing and family planning choices of women living with HIV and AIDS: the lived experiences

Objective: The main objective of this study was to assess the reproductive choices for Women Living with HIV on ART in the urban health centres within Lusaka.Methods: Nine hundred and fifty six HIV-positive women receiving care in the zoned health centres were randomly sampled and 12 health care workers who were purposefully sampled and were available in the ART setting participated in the study. A survey questionnaire, in-depth interviews and focus group discussions were the main data collection tools used. Quantitative data was analysed using SPSS while qualitative data was analysed using qualitative content analysis rooted in grounded theory (Precaution Adoption Model (PAPM).Results: The majority of the respondents in this study n = 503 (64%) felt that it was important to be safe from becoming pregnant whereas n = 429 (46%) felt that it was not. Health workers counselled the respondents on nearly all of the available contraceptive methods, with an emphasis on the oral pill, injectable hormonal drug, and on male and female condoms – with the greatest emphasis on the male condom. The reasons that women had for selecting particular family planning methods varied temporally. Some women engaged in unprotected sex because their partner was also HIV seropositive. Even in situations when an HIV-positive woman was told of her sero status and given counselling on the risks of motherto- child-transmission (MTCT), the majority of women would still engage in unprotected sex that often led to pregnancy. Nurses preferentially discouraged the women from getting pregnant using the counselling methods described. The rationale for the counselling methods was based on age, education, medical and gynaecological complications. In the current health care setup, it was not demonstrated that reproductive health issues of people living with HIV and AIDS could be provided within the ART clinic.Conclusion: As HIV continues to spread among women of childbearing age, there is an increasing need for support programs for infected women regarding sex, safer sex, pregnancy and family planning. The healthcare challenges for this group must be addressed with a twopronged approach- women must prioritize the risk to their health with repeated exposures to HIV and the healthcare workers must empower them to make these decisions. For this to occur, it is crucial that HIV positive women have easy access to reproductive healthcare counselling in juxtaposition to the ART Clinic. The health care workers that directly counsel these women have a pivotal role in addressing these concerns. Nursing professionals who comprise the bulk of healthcare workers providing these services can play a major role in meeting these needs

Use of laboratory-developed assays in global HIV-1 treatment-monitoring and research

There has been a surge in the emergence of HIV-1 drug resistance in Low and Middle-Income Countries (LMICs) due to poor drug-adherence and limited access to viral load testing, the current standard for treatment-monitoring. It is estimated that only 75% of people living with HIV (PLWH) worldwide have access to viral load testing. In LMICs, this figure is below 50%. In a recent WHO survey in mostly LMICs, 21 out of 30 countries surveyed found HIV-1 first-line pre-treatment drug resistance in over 10% of study participants. In the worst-affected regions, up to 68% of infants born to HIV-1 positive mothers were found to harbour first-line HIV-1 treatment resistance. This is a huge public health concern. Greater access to treatment-monitoring is required in LMICs if the UNAIDS "third 95" targets are to be achieved by 2030. Here, we review the current challenges of viral load testing and present the case for greater utilization of Laboratory-based assays that quantify intracellular HIV-1 RNA and/or DNA to provide broader worldwide access to HIV-1 surveillance, drug-resistance monitoring, and cure-research

High Prevalence of DHFR and DHPS Molecular Markers in Plasmodium Falciparum in Pregnant Women of Nchelenge District, Northern Zambia

Background: Sulphadoxine-pyrimethamine (SP) is the recommended drug for intermittent preventive treatment in pregnancy (IPTp) in most African countries, including Zambia. However, malaria is still one of the leading causes of morbidity and mortality in pregnant women despite reports of greater than 50% of women taking at least two doses of SP in IPTp. Studies have shown that resistance to SP is associated with mutations in the dhfr and dhps gene of Plasmodium falciparum. This study examined the prevalence of dhfr and dhps polymorphisms in P. falciparum found in pregnant women of Nchelenge district. Method: This cross-sectional study was conducted in 2013 in Nchelenge, a holoendemic area with malaria prevalence estimated at 50% throughout the year. Three rural health centres were randomly selected and a census survey carried out at each health centre. A questionnaire was administered and malaria testing done using RDT and microscopy, with collection of a dried blood spot. A chelex extraction was done to extract parasite DNA from dried blood spots followed by nested PCR and enzyme restriction digestion. Results: Of the enrolled participants (n∈=∈375), the median age of the women was 23. The prevalence of malaria by PCR was 22%. The PCR positive samples examined (n∈=∈72) showed a high prevalence of dhfr triple (Asn-108∈+∈Arg-59∈+∈Ile-59) mutant (68%) and dhps double (Gly -437∈+∈Glu-540) mutant (21%). The quintuple haplotype was found in 17% with 2 samples with an additional Gly-581mutation. In addition 6% mutations at Val-16 were found and none found at Thr-108 respectively, these both confer resistance to cycloguanil. Multivariate analysis showed that there was an association between malaria and women aged 30-34 years old p∈\u3c∈0.05(AOR: 0.36) at 95% CI. Conclusion: This study showed a high number of mutations in the dhfr and dhps genes. The high malaria endemicity in the general population of this area may have contributed to the high prevalence of resistant parasites in pregnant women, suggesting a need to examine the efficacy of SP given that it is the only approved drug for IPTp in Zambia. © 2015 Siame et al.; licensee BioMed Central