Assessment of the robustness of recent births in estimating infant mortality using multi-country Demographic Health Survey data

Includes bibliographical references.This dissertation investigates the robustness of recent births in estimating infant mortality rates from the proportion of deaths observed among births reported in a 24month period. The Blacker Brass technique is applied to all births reported in the 24month period and to most recent births in the 24 month period. The study uses birth history data from 76 Demographic and Health Surveys conducted in 16 countries across the developing world between 1986 and 2011. All births (and the deaths of those births) occurring in five 2-year periods before each survey were extracted to obtain five estimates of infant mortality using the Blacker-Brass and direct estimation methods from each dataset. This allows trends in infant mortality for the 10-year period before the survey to be compared and relative errors to be calculated. The results showed a decline in infant mortality in most datasets and are consistent with the United Nations and the World Health Organisation 2013 estimates. The relative errors did not indicate any systematic bias of the Blacker-Brass method applied to all births; however, further investigations showed that the method underestimated infant mortality in the period closest to the survey date in most datasets. Furthermore, the relative errors were positively correlated with the directly estimated level of infant mortality. There were, however, no significant differences in the relative errors across countries

The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe

Peer reviewedPublisher PD

HIV self-testing: breaking the barriers to uptake of testing among men and adolescents in sub-Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe.

INTRODUCTION: Social, structural and systems barriers inhibit uptake of HIV testing. HIV self-testing (HIVST) has shown promising uptake by otherwise underserved priority groups including men, young people and first-time testers. Here, we use characteristics of HIVST kit recipients to investigate delivery to these priority groups during HIVST scale-up in three African countries. METHODS: Kit distributors collected individual-level age, sex and testing history from all clients. These data were aggregated and analysed by country (Malawi, Zambia and Zimbabwe) for five distribution models: local community-based distributor (CBD: door-to-door, street and local venues), workplace distribution (WD), integration into HIV testing services (IHTS), or public health facilities (IPHF) and during demand creation for voluntary male medical circumcision (VMMC). Used kits were collected and re-read from CBD and IHTS recipients. RESULTS: Between May 2015 and July 2017, 628,705 HIVST kits were distributed in Malawi (172,830), Zambia (190,787) and Zimbabwe (265,091). Community-based models, the first to be established, accounted for 519,658 (82.7%) of kits distributed, with 275,419 (53.0%) used kits returned. Subsequent model diversification delivered 54,453 (8.7%) test-kits through IHTS, 23,561 (3.7%) through VMMC, 21,183 (3.4%) through IPHF and 9850 (1.7%) through WD. Men took 294,508 (48.2%) kits, and 263,073 (43.1%) went to young people (16 to 24 years). A higher proportion of male self-testers (65,577; 22.3%) were first-time testers than women (54,096; 17.1%) with this apparent in Zimbabwe (16.2% vs. 11.4%), Zambia (25.4% vs. 17.7%) and Malawi (27.9% vs. 25.9%). The highest proportions of first-time testers were in young (16 to 24 years) and older (>50 years) men (country-ranges: 18.7% to 35.9% and 13.8% to 26.8% respectively). Most IHTS clients opted for HIVST in preference to standard HTS in each of 12 delivery sites, with those selecting HIVST having lower HIV prevalence, potentially due to self-selection. CONCLUSIONS: HIVST delivered at scale using several different models reached a high proportion of men, young people and first-time testers in Malawi, Zambia and Zimbabwe, some of whom may not have tested otherwise. As men and young people have limited uptake under standard facility-and community-based HIV testing, innovative male- and youth-sensitive approaches like HIVST may be essential to reaching UNAIDS fast-track targets for 2020

Innovative demand creation strategies to increase voluntary medical male circumcision uptake: a pragmatic randomised controlled trial in Zimbabwe.

INTRODUCTION: Reaching men aged 20-35 years, the group at greatest risk of HIV, with voluntary medical male circumcision (VMMC) remains a challenge. We assessed the impact of two VMMC demand creation approaches targeting this age group in a randomised controlled trial (RCT). METHODS: We conducted a 2×2 factorial RCT comparing arms with and without two interventions: (1) standard demand creation augmented by human-centred design (HCD)-informed approach; (2) standard demand creation plus offer of HIV self-testing (HIVST). Interpersonal communication (IPC) agents were the unit of randomisation. We observed implementation of demand creation over 6 months (1 May to 31 October 2018), with number of men circumcised assessed over 7 months. The primary outcome was the number of men circumcised per IPC agent using the as-treated population of actual number of months each IPC agent worked. We conducted a mixed-methods process evaluation within the RCT. RESULTS: We randomised 140 IPC agents, 35 in each arm. 132/140 (94.3%) attended study training and 105/132 (79.5%) reached at least one client during the trial period and were included in final analysis. There was no evidence that the HCD-informed intervention increased VMMC uptake versus no HCD-informed intervention (incident rate ratio (IRR) 0.87, 95% CI 0.38 to 2.02; p=0.75). Nor did offering men a HIVST kit at time of VMMC mobilisation (IRR 0.65, 95% CI 0.28 to 1.50; p=0.31). Among IPC agents that reported reaching at least one man with demand creation, both the HCD-informed intervention and HIVST were deemed useful. There were some challenges with trial implementation; <50% of IPC agents converted any men to VMMC, which undermined our ability to show an effect of demand creation and may reflect acceptability and feasibility of the interventions. CONCLUSION: This RCT did not show evidence of an effect of HCD-informed demand intervention or HIVST on VMMC uptake. Findings will inform future design and implementation of demand creation evaluations. TRIAL REGISTRATION NUMBER: PACTR201804003064160

Zimbabwe (2015): Quantitative Study Evaluating Knowledge and Behaviours on Family Planning, Violence against Women and Girls and Cervical Cancer Screening Behaviours among men and women aged 15 - 49 years.

The goal of this study was to add to the body of knowledge on Family Planning, Violence Against Women and Girls and Cervical Cancer Screening. This quantitative study provided evidence for monitoring, segmentation and evaluating the implementation of PSI Zimbabwe's programs and impact of their interventions. This information will be used to develop interventions and communications for the interventions. Study objectives for this study aims to answer three fundamental questions related to segmentation i). What are the levels and trends in knowledge of family planning,VAWG and cervical cancer screening?.ii). Monitoring What are the trends and current levels in family planning, VAWG and cervical behaviors and correlates identified through qualitative studies?, iii). Evaluation is exposure to PSI Zimbabwe communication activities leading to changes in knowledge and behaviors of family planning, VAWG, cervical cancer screening?. This study was conducted among men and women aged between 15-49 years in Zimbabwe. The study was a stratified multi-stage cluster sampling approach. Respondents for this study were selected from 100 enumeration areas (35 in urban and 65 in rural). Data was collected using structured questionnaires and smartphones. Analysis was done using stata version 13. Analyses consisted of descriptive statistics for key program indicators and Analysis of Variance (ANOVA) to examine trends over time. Bivariate analysis was done using place of residence as exposure variables and program indicators as outcome variables.

Zimbabwe (2014): MAP Study Evaluating the Coverage and Quality of Coverage of Protector Plus and CARE condoms in Zimbabwe.

Population Services International Zimbabwe (PSI/Z) uses commercial marketing and distribution strategies to bring health products, services and messages to vulnerable populations in urban and rural Zimbabwe. PSI/Z is implementing a multi-year USAID and DFID funded HIV prevention programs targeting sexually active Zimbabwean men and women ages 15-49 years. This MAP survey (Round 6) was conducted to assess the geographical coverage and quality of coverage of Protector Plus male condoms and CARE female condoms. The study also estimated numeric distribution of Protector Plus condoms. Total Market Approach (TMA) metrics were calculated using estimates of market volume, market value and brand diversity for Condoms in Zimbabwe. Lot Quality Assurance Sampling (LQAS) technique was used to draw a sample of 19 wards within each supervision area (SA), i.e. a district. A sample size of 19 gives reasonably accurate estimates with an acceptable error margin for decision making. A total of 92 districts and 43 high-risk areas comprising 19 growth points, 19 mining areas and 5 border towns were selected. In cases where a district had fewer than 19 wards, a census of all the wards was done and direct percentage value was calculated to determine whether the SA reaches the target coverage standard or not. Data were collected in September 2014 using Survey ToGo software on android phones. Data cleaning and analysis was done using STATA version 13.0

Is the PrePex device an alternative for surgical male circumcision in adolescents ages 13-17 years? Findings from routine service delivery during active surveillance in Zimbabwe.

BackgroundMale circumcision devices have the potential to accelerate adolescent voluntary medical male circumcision roll-out. Here, we present findings on safety, acceptability and satisfaction from active surveillance of PrePex implementation among 618 adolescent males (13-17 years) circumcised in Zimbabwe.MethodsThe first 618 adolescents consecutively circumcised from October 2015 to October 2016 using PrePex during routine service delivery were actively followed up. Outcome measures included PrePex uptake, attendance for post-circumcision visits and adverse events (AEs). A survey was conducted amongst 500 consecutive active surveillance clients to assess acceptability and satisfaction with PrePex.ResultsA total of 1,811 adolescent males were circumcised across the three PrePex active surveillance sites. Of these, 870 (48%) opted for PrePex but only 618/870 (71%) were eligible. Among the 618, two (0.3%) self-removals requiring surgery (severe AEs), were observed. Four (0.6%) removals by providers (moderate AEs) did not require surgery. Another 6 (1%) mild AEs were due to: bleeding (n = 2), swelling (n = 2), and infection (n = 2). All AEs resolved without sequelae. Adherence to follow-up appointments was high (97.7% attended 7 day visit). A high proportion (71.6%) of survey respondents said they heard about PrePex from a mobilizer; 49.8% said they chose PrePex because they wanted to avoid the pain associated with the surgical procedure/surgery on their penis. Acceptability and satisfaction with PrePex was high; 95.4% indicated willingness to recommend PrePex to peers. A majority (92%) reported experiencing pain when PrePex was being removed.ConclusionsActive surveillance of the first 618 adolescent males circumcised using PrePex suggests that the device is both safe and acceptable when used in routine service delivery among 13-17 year-olds. There is need to intensify specific demand generation activities for PrePex male circumcision among this group of males

Strategic donor investments for strengthening condom markets: The case of Zimbabwe.

BACKGROUND:Zimbabwe faces an uncertain future for condom funding and potential condom insecurity as international donors prioritize creating more self-sustaining markets and the government identifies how to best ensure access and uptake. We tested the impact of an intensive intervention on demand and supply after a price increase to the social marketed condom, Protector Plus. The study occurred during a deteriorating economy and pressure to reach sustainability quickly. We highlight where strategic donor investments can impact condom programming and markets. METHODS:We randomized ten purposively selected districts in Zimbabwe and assigned them to two study groups to test the impact of an intensive social marketing intervention. To the best of our knowledge, this is the first experimental study conducted within a larger market strengthening context. We tracked sales of Protector Plus and distribution of the public sector condom monthly. We conducted baseline and follow-up surveys among consumers and traders, and used the difference-in-difference method to test the intervention's impact on condom preferences and brand equity. RESULTS:Protector Plus sales rebounded to previous levels after the price increase. We detected no significant difference in sales between the experimental and control districts. Among traders, there were no significant differences in brand preference for Protector Plus attributed to the intervention. Among consumers, there was a significant increase in emotional attachment and beliefs about condom efficacy in the experimental districts. DISCUSSION:Study findings demonstrate where international donor and government investments can impact condom programming and condom markets. Broader findings from the intervention highlight where investments can improve condom coverage, cost recovery, and collaboration between the public, social marketing, and commercial sectors. Strategic investments for strengthening condom markets include: consumer research to segment markets, willingness to pay studies to set price points, distribution system improvements to increase efficiency, intensive demand generation to increase demand and use, market facilitation across sectors, and market intelligence to inform decision making. When a disciplined social marketing approach is used, the market benefits: subsidies can be better targeted, branded products can appeal to the right audiences, and room can be made for the commercial sector to enter the market