Remote data collection for public health research in a COVID-19 era: ethical implications, challenges and opportunities.

Physical distancing measures have lead many public health researchers to transition to remote data collection, via mobile phones, online or other virtual platforms. These methods pose a number of challenges related to obtaining informed consent

Menstrual product choice and uptake among young women in Zimbabwe: a pilot study.

BACKGROUND: Menstrual health and hygiene (MHH) is a human rights issue; yet, it remains a challenge for many, especially in low- and middle-income countries (LMICs). MHH includes the socio-political, psychosocial, and environmental factors that impact women's menstrual experiences. High proportions of girls and women in LMICs have inadequate MHH due to limited access to menstrual knowledge, products, and stigma reinforcing harmful myths and taboos. The aim of this pilot was to inform the design of an MHH sub-study and the implementation and scale-up of an MHH intervention incorporated into a community-based cluster-randomized trial of integrated sexual and reproductive health (SRH) services for youth in Zimbabwe. The objectives were to investigate (1) uptake of a novel MHH intervention, (2) menstrual product preference, and (3) the factors that informed uptake and product choice among young women. METHODS: Female participants aged 16-24 years old attending the community-based SRH services between April and July 2019 were offered the MHH intervention, which included either a menstrual cup or reusable pads, analgesia, and MHH education. Descriptive statistics were used to quantitatively assess uptake and product choice. Focus group discussions and in-depth interviews with participants and the intervention team were used to investigate the factors that influenced uptake and product choice. RESULTS: Of the 1732 eligible participants, 1414 (81.6%) took up the MHH intervention at first visit. Uptake differed by age group with 84.6% of younger women (16-19 years old) compared to 79.0% of older women (20-24 years old) taking up the intervention. There was higher uptake of reusable pads (88.0%) than menstrual cups (12.0%). Qualitative data highlighted that internal factors, such as intervention delivery, influenced uptake. Participants noted the importance of access to free menstrual products, analgesics, and MHH education in a youth-friendly environment. External factors such as sociocultural factors informed product choice. Barriers to cup uptake included fears that the cup would compromise young women's virginity. CONCLUSIONS: Pilot findings were used to improve the MHH intervention design and implementation as follows: (1) cup ambassadors to improve cup promotion, sensitization, and uptake; (2) use of smaller softer cups; and (3) education for community members including caregivers and partners. TRIAL REGISTRATION: Registry: Clinicaltrials.gov Registration Number: NCT03719521 Registration Date: 25 October 2018

Acceptability of self-collected vaginal swabs for sexually transmitted infection testing among youth in a community-based setting in Zimbabwe.

BACKGROUND: Youth are a high-risk group for sexually transmitted infections (STIs). To increase access to STI testing, convenient approaches for sampling and testing are needed. We assessed the acceptability of self-collected vaginal swabs (SCVS) for STI testing among young women (16-24 years) attending a community-based sexual and reproductive health service in Zimbabwe. METHODS: A SCVS was used for point-of-care testing for Trichomonas vaginalis and a urine sample for testing for Chlamydia trachomatis and Neisseria gonorrhoeae. A questionnaire was administered to investigate the acceptability of SCVS versus self-collected urine samples. In-depth interviews (IDIs) explored the experience of SCVS and reasons for sample collection preference. Qualitative analysis was predominantly deductive. RESULTS: We recruited 129 women who took up STI testing (median age 20 years, IQR 18-22 years) and conducted 12 IDIs. Most participants reported that they understood the instructions (93.0%) and found SCVS easy (90.7%). Many participants felt relaxed (93.0%), in control (88.4%) and that they had enough privacy (90.7%). Pain or discomfort were reported by 16.3% and embarrassment by 15.5%. Among the 92 (71.3%) participants who provided both a SCVS and urine sample, 60.9% preferred SCVS. Sample collection method preferences were similar between 16-19 and 20-24year-olds. In IDIs, clear instructions, privacy, trust in the service and same-day results were perceived as important facilitators to taking up SCVS. Participants frequently described feeling relaxed and confident whilst taking a SCVS. Pain and discomfort were uncommon experiences. CONCLUSIONS: SCVS for STI testing are acceptable to young women and a feasible method of sample collection in community-based settings

"It was difficult to offer same day results": evaluation of community-based point-of-care testing for sexually transmitted infections among youth using the GeneXpert platform in Zimbabwe.

BACKGROUND: Point-of-care testing for sexually transmitted infections (STIs) may improve diagnosis and treatment of STIs in low- and middle-income counties. We explored the facilitators and barriers to point-of-care testing for Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) for youth in community-based settings in Zimbabwe. METHODS: This study was nested within a cluster randomised trial of community-based delivery of integrated HIV and sexual and reproductive health services for youth aged 16 to 24 years. On-site CT/NG testing on urine samples using the Xpert® CT/NG test was piloted in four intervention clusters, with testing performed by service providers. On-site testing was defined as sample processing on the same day and site as sample collection. Outcomes included proportion of tests processed on-site, time between sample collection and collection of results, and proportion of clients receiving treatment. In-depth interviews were conducted with nine service providers and three staff members providing study co-ordination or laboratory support to explore facilitators and barriers to providing on-site CT/NG testing. RESULTS: Of 847 Xpert tests, 296 (35.0%) were performed on-site. Of these, 61 (20.6%) were positive for CT/NG; one (1.6%) received same day aetiological treatment; 33 (54.1%) presented later for treatment; and 5 (8.2%) were treated as a part of syndromic management. There was no difference in the proportion of clients who were treated whether their sample was processed on or off-site (64% (39/61) vs 60% (66/110); p = 0.61). The median (IQR) number of days between sample collection and collection of positive results was 14 (7-35) and 14 (7-52.5) for samples processed on and off-site, respectively, The interviews revealed four themes related to the provision of on-site testing associated with the i) diagnostic device ii) environment, iii) provider, and iv) clients. Some of the specific barriers identified included insufficient testing capacity, inadequate space, as well as reluctance of clients to wait for their results. CONCLUSIONS: In addition to research to optimise the implementation of point-of-care tests for STIs in resource-limited settings, the development of new platforms to reduce analytic time will be necessary to scale up STI testing and reduce the attrition between testing and treatment. TRIAL REGISTRATION: Registered in clinical trials.gov ( NCT03719521 )

Uptake of and factors associated with testing for sexually transmitted infections in community-based settings among youth in Zimbabwe: a mixed-methods study.

BACKGROUND: The prevalence of sexually transmitted infections (STIs) among youth is high in sub-Saharan Africa. We investigated the uptake of testing for and prevalence of Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhoea) infections among youth in community-based settings in Zimbabwe, and explored the facilitators and barriers to testing. METHODS: This study was nested within a cluster randomised trial of community-based delivery of integrated HIV and sexual and reproductive health services for youth aged 16-24 years. Chlamydia and gonorrhoea testing via urine samples using the Xpert CT/NG test was offered in the four intervention clusters in Harare, Zimbabwe. Factors associated with testing uptake were investigated in a subset of participants (n=257) using hierarchical multivariate logistic regression. In-depth interviews with a separate purposively selected sample (n=26) explored facilitators and barriers to STI testing and partner notification and were analysed using thematic analysis. FINDINGS: Between June 1, 2019, and Jan 31, 2020, there were 6200 attendances by 4440 participants (78·2% women, 21·8% men) median age 20·3 (IQR 17·9-22·8) years. 1478 participants had 1501 tests done, and 248 tests were positive and 1253 tests were negative for chlamydia or gonorrhoea, or both. STI test uptake was 33·3% (95% CI 31·9-34·7), increasing from 11·7% in June, 2019, to 37·1% in January, 2020. The prevalence of chlamydia or gonorrhoea, or both, was 16·5% (95% CI 14·7-18·5; 248 of 1501), with only seven participants (3%) showing symptoms. The overall yield of testing was 4·0% (95% CI 3·5-4·5; 248 of 6200). Uptake was associated with having symptoms (adjusted odds ratio [OR] 14·8, 95% CI 1·66-132·07) and negatively associated with being single (adjusted OR 0·33, 95% CI 0·13-0·84) or having a boyfriend or girlfriend (adjusted OR 0·19, 95% CI 0·087-0·43) compared with being married, and being a student compared with being employed (adjusted OR 0·26, 95% CI 0·10-0·68). Perceived risk and symptoms of STIs were motivators for testing whereas misinformation, anticipated stigma, and concern about confidentiality were barriers. INTERPRETATION: The prevalence of chlamydia or gonorrhoea, or both, was high among youth but only a minority were symptomatic. Therefore most infections would remain untreated without access to STI testing. Provision of education, counselling, and confidentiality are essential to improve uptake and acceptability of STI testing. FUNDING: Wellcome Trust

Identifying youth at high risk for sexually transmitted infections in community-based settings using a risk prediction tool: a validation study.

BACKGROUND : Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the most common bacterial sexually transmitted infections (STIs) worldwide. In the absence of affordable point-of-care STI tests, WHO recommends STI testing based on risk factors. This study aimed to develop a prediction tool with a sensitivity of > 90% and efficiency (defined as the percentage of individuals that are eligible for diagnostic testing) of < 60%. METHODS: This study offered CT/NG testing as part of a cluster-randomised trial of community-based delivery of sexual and reproductive health services to youth aged 16-24 years in Zimbabwe. All individuals accepting STI testing completed an STI risk factor questionnaire. The outcome was positivity for either CT or NG. Backwards-stepwise logistic regression was performed with p ≥ 0.05 as criteria for exclusion. Coefficients of variables included in the final multivariable model were multiplied by 10 to generate weights for a STI risk prediction tool. A maximum likelihood Receiver Operating Characteristics (ROC) model was fitted, with the continuous variable score divided into 15 categories of equal size. Sensitivity, efficiency and number needed to screen were calculated for different cut-points. RESULTS: From 3 December 2019 to 5 February 2020, 1007 individuals opted for STI testing, of whom 1003 (99.6%) completed the questionnaire. CT/NG prevalence was 17.5% (95% CI 15.1, 19.8) (n = 175). CT/NG positivity was independently associated with being female, number of lifetime sexual partners, relationship status, HIV status, self-assessed STI risk and past or current pregnancy. The STI risk prediction score including those variables ranged from 2 to 46 with an area under the ROC curve of 0.72 (95% CI 0.68, 0.76). Two cut-points were chosen: (i) 23 for optimised sensitivity (75.9%) and specificity (59.3%) and (ii) 19 to maximise sensitivity (82.4%) while keeping efficiency at < 60% (59.4%). CONCLUSIONS: The high prevalence of STIs among youth, even in those with no or one reported risk factor, may preclude the use of risk prediction tools for selective STI testing. At a cut-point of 19 one in six young people with STIs would be missed

Process evaluation of the family planning intervention for young women (16-24 years) accessing CHIEDZA in Zimbabwe

Background: Although Zimbabwe has one of the highest rates of modern contraceptive use in sub-Saharan Africa, it also has among the highest prevalence of adolescent pregnancy in east and southern Africa. CHIEDZA is a community-based intervention that integrated HIV and sexual and reproductive health (SRH) services for young people in the context of a cluster randomised controlled trial across three provinces in Zimbabwe (April 2019-March 2022). CHIEDZA provided information and a wide choice of contraceptive methods to young women at its one-stop-shop “youth friendly” venues. This PhD applied the Medical Research Council’s Process Evaluation framework to analyse fidelity,feasibility and quality of the family planning intervention (implementation); the family planning needs and experiences of young women, and how this influenced access to and use of family planning (mechanisms of change); and local factors shaping delivery and uptake of family planning within CHIEDZA (context). As part of understanding implementation and providing context, the routine family planning uptake data from CHIEDZA is presented as background information within the thesis. Methods: The PhD study utilised qualitative (interviews, observations, meeting minutes and field notes) methods between April 2019 and March 2022. The interviews began at the start of the COVID-19 pandemic (April 2020), and therefore methods were adapted to explore adaptations and changes related to COVID-19. A total of 42 interviews with providers implementing CHIEDZA, 49 interviews with young people accessing CHIEDZA, and 18 non-participant observations were conducted. Field notes and meeting notes also captured contextual nuances throughout the intervention implementation phase. Reflexive thematic analysis was iterative, inductive and theory driven. Results: This is a “thesis by publication” consisting of four manuscripts. The first manuscript analyses primary providers’ experiences and perspectives of delivering the family planning intervention including the adaptations and effects on feasibility and quality. The second manuscript examines provider and client experiences of the intervention in light of the COVID-19 pandemic. This paper details how the CHIEDZA intervention functioned before the pandemic, and then tracks the effect of the pandemic on access and use of family planning methods. The third manuscript analyses the family planning needs and experiences of young women living with and without HIV, and demonstrates how integrated family planning interventions support young women living with HIV by acknowledging their SRH needs beyond HIV status and thus can positively contribute to both HIV and family planning outcomes. The fourth and last manuscript then explores young women’s decision-making about family planning use. Conclusion: Process evaluations that purposefully address context may be better equipped to interpret what works or does not work, and is transferrable for family planning intervention for young people. Young women are not a homogenous group. Socio-cultural expectations, physiological changes, and/or the contexts in which they live in can determine how they perceive, access and use family planning services and methods. In addition to engaging with these determinants, public health interventions need to ensure method-mix and competent, youth-friendly providers are available to provide services. Providers’perceptions and values around family planning use by young people, also need to engaged with

Community perspectives on the covid-19 response, zimbabwe [Perspectives communautaires dans la lutte contre la covid-19 au zimbabwe] [Opiniones de la comunidad sobre la respuesta a la covid-19, zimbabue]

Objective To investigate community and health-care workers' perspectives on the coronavirus disease 2019 (COVID-19) pandemic and on early pandemic responses during the first 2 weeks of national lockdown in Zimbabwe. Methods Rapid qualitative research was carried out between March and April 2020 via phone interviews with one representative from each of four community-based organizations and 16 health-care workers involved in a trial of community-based services for young people. In addition, information on COVID-19 was collected from social media platforms, news outlets and government announcements. Data were analysed thematically. Findings Four themes emerged: (i) individuals were overloaded with information but lacked trusted sources, which resulted in widespread fear and unanswered questions; (ii) communities had limited ability to comply with prevention measures, such as social distancing, because access to long-term food supplies and water at home was limited and because income had to be earned daily; (iii) health-care workers perceived themselves to be vulnerable and undervalued because of a shortage of personal protective equipment and inadequate pay; and (iv) other health conditions were sidelined because resources were redirected, with potentially wide-reaching implications. Conclusion It is important that prevention measures against COVID-19 are appropriate for the local context. In Zimbabwe, communities require support with basic needs and access to reliable information to enable them to follow prevention measures. In addition, health-care workers urgently need personal protective equipment and adequate salaries. Essential health-care services and medications for conditions other than COVID-19 must also continue to be provided to help reduce excess mortality and morbidity

Integration of a menstrual health intervention in a community-based sexual and reproductive health service for young people in Zimbabwe: a qualitative acceptability study.

BACKGROUND: Despite being fundamental to the health and well-being of women, menstrual health is often overlooked as a health priority and access to menstrual health education, products, and support is limited. Consequently, many young women are unprepared for menarche and face challenges in accessing menstrual health products and support and in managing menstruation in a healthy and dignified way. In this paper, we examine the acceptability of a comprehensive menstrual health and hygiene (MHH) intervention integrated within a community-based sexual and reproductive health (SRH) service for young people aged 16-24 years in Zimbabwe called CHIEDZA. METHODS: We conducted focus group discussions, that included participatory drawings, with CHIEDZA healthcare service providers (N = 3) and with young women who had attended CHIEDZA (N = 6) between June to August 2020. Translated transcripts were read for familiarisation and thematic analysis was used to explore acceptability. We applied Sekhon's thematic framework of acceptability that looks at seven key constructs (affective attitudes, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy). Data from FGDs and meeting minutes taken during the study time period were used to triangulate a comprehensive understanding of MHH intervention acceptability. RESULTS: The MHH intervention was acceptable to participants as it addressed the severe prevailing lack of access to menstrual health education, products, and support in the communities, and facilitated access to other SRH services on site. In addition to the constructs defined by Sekhon's thematic framework, acceptability was also informed by external contextual factors such as sociocultural norms and the economic environment. Providers highlighted the increased burden in their workload due to demand for MHH products, and how sociocultural beliefs around insertable menstrual products compromising virginity can negatively affect acceptability among young people and community members. CONCLUSIONS: MHH interventions are acceptable to young women in community-based settings in Zimbabwe as there is great unmet need for comprehensive MHH support. The integration of MHH in SRH services can serve as a facilitator to female engagement with SRH services. However, it is important to note that contextual external factors can affect the implementation and acceptability of integrated SRH and MHH services within communities. TRIAL REGISTRATION: Registry: Clinicaltrials.gov, Registration Number: NCT03719521 , Registration Date: October 25, 2018

A mixed-methods study measuring the effectiveness of a menstrual health intervention on menstrual health knowledge, perceptions and practices among young women in Zimbabwe.

OBJECTIVES: While integral to women's physical and mental well-being, achieving good menstrual health (MH) remains a challenge for many women. This study investigated the effectiveness of a comprehensive MH intervention on menstrual knowledge, perceptions and practices among women aged 16-24 years in Harare, Zimbabwe. DESIGN: A mixed-methods prospective cohort study with pre-post evaluation of an MH intervention. SETTING: Two intervention clusters in Harare, Zimbabwe. PARTICIPANTS: Overall, 303 female participants were recruited, of whom 189 (62.4%) were seen at midline (median follow-up 7.0; IQR 5.8-7.7 months) and 184 (60.7%) were seen at endline (median follow-up 12.4; IQR 11.9-13.8 months). Cohort follow-up was greatly affected by COVID-19 pandemic and associated restrictions. INTERVENTION: The MH intervention provided MH education and support, analgesics, and a choice of menstrual products in a community-based setting to improve MH outcomes among young women in Zimbabwe. PRIMARY AND SECONDARY OUTCOMES: Effectiveness of a comprehensive MH intervention on improving MH knowledge, perceptions, and practices among young women over time. Quantitative questionnaire data were collected at baseline, midline, and endline. At endline, thematic analysis of four focus group discussions was used to further explore participants' menstrual product use and experiences of the intervention. RESULTS: At midline, more participants had correct/positive responses for MH knowledge (adjusted OR (aOR)=12.14; 95% CI: 6.8 to 21.8), perceptions (aOR=2.85; 95% CI: 1.6 to 5.1) and practices for reusable pads (aOR=4.68; 95% CI: 2.3 to 9.6) than at baseline. Results were similar comparing endline with baseline for all MH outcomes. Qualitative findings showed that sociocultural norms, stigma and taboos around menstruation, and environmental factors such as limited access to water, sanitation and hygiene facilities affected the effect of the intervention on MH outcomes. CONCLUSIONS: The intervention improved MH knowledge, perceptions and practices among young women in Zimbabwe, and the comprehensive nature of the intervention was key to this. MH interventions should address interpersonal, environmental and societal factors. TRIAL REGISTRATION NUMBER: NCT03719521