Evaluation of a Complex Health Intervention in Zambia: The case of the Better Health Outcome through Mentorship and Assessment (BHOMA) Applying system wide approaches to measuring health system strengthening: Essential Markers and Impact Pathway

Introduction: In many low income countries the delivery of quality health services is hampered by health system-wide barriers which are often interlinked, however empirical evidence on how to assess the level and scope of these barriers is scarce. It has been recognised that taking a more comprehensive approach to assessing these barriers is more likely to provide lessons on what works and why. WHO has been advocating the use of systems wide approaches such as systems thinking to guide intervention design and evaluation. This thesis reports system-wide assessment of a complex health system intervention in Zambia known as Better Health Outcome through Mentorship and Assessment (BHOMA) that aimed to improve service quality at the health facility and influence service demand from the community. Methodology: This study is nested within a cluster randomised trial of the BHOMA intervention that aims to strengthen the health system in three rural districts covering 42 health facilities in Zambia. The main trial has a stepped wedge design where the intervention is being rolled-out to all the 42 health facilities over a period of 4 years. A baseline health facility survey was done in 2011. This was followed by a 12 months post-intervention evaluation survey. At the time of the follow up survey 24 health facilities had received the intervention while 18 had not. Data collection used both quantitative and qualitative methods. The study was guided by a systems thinking theoretical framework which was inspired by the WHO building blocks for health system strengthening. Results: The baseline survey validated tools and indicators for assessing health system building blocks. Research paper 2 applied an innovative measure of health worker motivation which was initially applied in Kenya. The results showed that this simple tool was reliable with cronbach’s alpha of 0.73 for the 21 item measures of health workers’ motivation. Baseline assessment of health worker motivation showed variation in motivation score based on gender and access to training. Research paper 3 tested and applied a new tool for measuring health systems governance at health facility level. The new tool for measuring governance was reliable with the 16 item one side cronbach’s alpha ranging between 0.69-0.74.The tool was simple to use and found to be applicable in the Zambian health care setting. A balanced scorecard approach was applied to measure the baseline health system characteristics for the target districts. Differences in performance were noted by district and residence in most domains with finance and service delivery domains performing poorly in all study districts. Regression modelling showed that children’s clinical observation scores were negatively correlated with drug availability (coeff 20.40, p = 0.02) while Adult clinical observation scores were positively association with adult service satisfaction score (coeff 0.82, p = 0.04) Baseline qualitative results are presented in paper 5. The results showed close linkages between health system building blocks. Challenges noted in service delivery were linked to human resources, medical supplies, information flow, governance and finance building blocks either directly or indirectly. The 12 months post intervention survey applied both quantitative and qualitative methods. Research paper 6 presents 12 months post intervention quantitative results applying the balanced scorecard approach as at baseline. Comparison was made between the control and intervention health facilities. The results showed significant mean differences between intervention (I) and control (C) sites in the following domains: Training domain (Mean I:C;87.5.vs 61.1, mean difference 23.3,p=0.031),adult clinical observation domain (mean I:C;73.3 vs.58.0, mean difference 10.9,p=0.02 ). The 12 months post intervention qualitative evaluation applied systems thinking approach and the conceptual framework developed before the intervention. The findings are presented in research paper 7. The overall results showed that the community had accepted the intervention with increasing demand for services reported in all sites where the BHOMA intervention was implemented. The indications were that in the short term there was increased demand for services but the health workers’ capacity was not severely affected. However, from a systems thinking perspective, it was clear that several unintended consequences also occurred during the implementation of the BHOMA. Conclusion: In evaluation of complex interventions such as the BHOMA attention should be paid to context. Using system wide approaches and triangulating data collection methods seems to be important to successful evaluation of such complex intervention

Exploring the challenges faced by informal home based palliative (HBP) caregivers in Ndola District, Zambia

In order to explore informal Home-based palliative caregivers’ challenging experiences, this study gives an overview of the need of Home-based palliative caregivers in communities. Dialogs using In-depth interviews (IDI’s) with twenty-five (25) purposively and conveniently selected respondents aged 18 years and over were conducted. They were not professional caregivers but volunteers from within the community attached to health facilities in Ndola. Discussions on global, Africa and Zambian’ situations, and Ndola in particular were included. The findings, using thematic analysis, were lack of supporting resources, inadequate coordination, lack of training, undesirable working conditions and unreliable transport network. The study will facilitate formulation of guiding principles and policies for palliative care practices through recommendations based on results from this study to improve and sustain palliative care services

Prevalence of persistent hypertension following pregnancy complicated by hypertensive disorders in low- and middle-income countries: a systematic review

Background: Hypertensive disorders of pregnancy can lead to persistent hypertension (pHTN) in the months and even years following delivery. However, its prevalence in low- and middle-income countries (LMICs) is not well characterized. Objective: To synthesize available evidence on the pHTN prevalence following a pregnancy complicated by hypertensive disorders of pregnancy in LMICs. Search strategy: PubMed, CINAHL Plus, Global Health (EBSCOhost), and Scopus from inception through a search date of July 12, 2022, and updated on January 2, 2024. Selection criteria: Cross-sectional studies and cohort studies reporting pHTN prevalence were eligible. Data collection and analysis: We conducted a narrative synthesis of data and categorized reported prevalence time points into several broader categories. We used the Newcastle-Ottawa checklist to assess the risk of bias. The protocol is registered in PROSPERO (CRD42022345739). Results: We reviewed 1,584 abstracts and identified 22 studies that reported pHTN between 2000 and 2023 from 14 LMICs. The overall prevalence of pHTN ranged between 6.9% and 62.2%, with the highest prevalence noted within African studies and the lowest in South American studies. Estimates at different follow-up periods postpartum were 6.9%–42.9% at six weeks, 34.0%–62.2% at three months, 14.8%–62.2% at six months, 12.7%–61.2% at 12 months, and 7.5%–31.8% at more than 12 months. The quality score of the selected studies ranged from 50% to 100%. Conclusions: The extant literature reports a high prevalence of pHTN in LMICs following a pregnancy complicated by hypertensive disorders. To reduce long-term complications of pHTN, programs should emphasize early screening and linkages to long-term care for at-risk women. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=345739, PROSPERO (CRD42022345739

Measuring governance at health facility level: developing and validation of simple governance tool in Zambia.

BACKGROUND: Governance has been cited as a key determinant of economic growth, social advancement and overall development. Achievement of millennium development goals is partly dependant on governance practices. In 2007, Health Systems 20/20 conducted an Internet-based survey on the practice of good governance. The survey posed a set of good practices related to health governance and asked respondents to indicate whether their experience confirmed or disconfirmed those practices. We applied the 17 governance statements in rural health facilities of Zambia. The aim was to establish whether the statements were reliable and valid for assessing governance practices at primary care level. METHODS: Both quantitative and qualitative methods were used. We first applied the governance statements developed by the health system 20/20 and then conducted focus group discussion and In-depth interviews to explore some elements of governance including accountability and community participation. The target respondents were the health facility management team and community members. The sample size include 42 health facilities. Data was analyzed using SPSS version 17 and Nvivo version 9. RESULTS: The 95% one-sided confidence interval for Cronbach's alpha was between 0.69 and 0.74 for the 16 items.The mean score for most of the items was above 3. Factor analysis yielded five principle components: Transparency, community participation, Intelligence & vision, Accountability and Regulation & oversight. Most of the items (6) clustered around the transparency latent factor. Chongwe district performed poorly in overall mean governance score and across the five domains of governance. The overall scores in Chongwe ranged between 51 and 94% with the mean of 80%. Kafue and Luangwa districts had similar overall mean governance scores (88%). Community participation was generally low. Generally, it was noted that community members lacked capacity to hold health workers accountable for drugs and medical supplies. CONCLUSIONS: The study successfully validated and applied the new tool for evaluating health system governance at health facility level. The results have shown that it is feasible to measure governance practices at health facility level and that the adapted tool is fairly reliable with the 95% one-sided confidence interval for Cronbach's alpha laying between 0.69 and 0.74 for the 16 items. Caution should be taken when interpreting overall scores as they tended to mask domain specific variations

Redefining and revisiting cost estimates of routine ART care in Zambia: An analysis of ten clinics

INTRODUCTION: Accurate costing is key for programme planning and policy implementation. Since 2011, there have been major changes in eligibility criteria and treatment regimens with price reductions in ART drugs, programmatic changes resulting in clinical task-shifting and decentralization of ART delivery to peripheral health centres making existing evidence on ART care costs in Zambia out-of-date. As decision makers consider further changes in ART service delivery, it is important to understand the current drivers of costs for ART care. This study provides updates on costs of ART services for HIV-positive patients in Zambia. METHODS: We evaluated costs, assessed from the health systems perspective and expressed in 2016 USD, based on an activity-based costing framework using both top-down and bottom-up methods with an assessment of process and capacity. We collected primary site-level costs and resource utilization data from government documents, patient chart reviews and time-and-motion studies conducted in 10 purposively selected ART clinics. RESULTS: The cost of providing ART varied considerably among the ten clinics. The average per-patient annual cost of ART service was $116.69 (range:$59.38 to $145.62) using a bottom-up method and$130.32 (range: $94.02 to$162.64) using a top-down method. ART drug costs were the main cost driver (67% to 7% of all costs) and are highly sensitive to the types of patient included in the analysis (long-term vs. all ART patients, including those recently initiated) and the data sources used (facility vs. patient level). Missing capacity costs made up 57% of the total difference between the top-down and bottom-up estimates. Variability in cost across the ten clinics was associated with operational characteristics. CONCLUSIONS: Real-world costs of current routine ART services in Zambia are considerably lower than previously reported estimates and sensitive to operational factors and methods used. We recommend collection and monitoring of resource use and capacity data to periodically update cost estimates

Uptake of home-based voluntary HIV testing in sub-Saharan Africa: a systematic review and meta-analysis

Improving access to HIV testing is a key priority in scaling up HIV treatment and prevention services. Home-based voluntary counselling and testing (HBT) as an approach to delivering wide-scale HIV testing is explored here

Frequency of HIV-testing and factors associated with multiple lifetime HIV-testing among a rural population of Zambian men

Abstract Background Across sub-Saharan Africa, men's levels of HIV-testing remain inadequate relative to women’s. Men are less likely to access anti-retroviral therapy and experience higher levels of morbidity and mortality once initiated on treatment. More frequent HIV-testing by men at continued risk of HIV-infection is required to facilitate earlier diagnosis. This study explored the frequency of HIV-testing among a rural population of men and the factors associated with more frequent HIV-testing. Methods We conducted a secondary analysis of a population-based survey in three rural district in Zambia, from February-November, 2013. Households (N = 300) in randomly selected squares from 42 study sites, defined as a health facility and its catchment area, were invited to participate. Individuals in eligible households were invited to complete questionnaires regarding demographics and HIV-testing behaviours. Men were defined as multiple HIV-testers if they reported more than one lifetime test. Upon questionnaire completion, individuals were offered rapid home-based HIV-testing. Results Of the 2376 men, more than half (61 %) reported having ever-tested for HIV. The median number of lifetime tests was 2 (interquartile range = 1-3). Just over half (n = 834; 57 %) of ever-testers were defined as multiple-testers. Relative to never-testers, multiple-testers had higher levels of education and were more likely to report an occupation. Among the 719 men linked to a spouse, multiple-testing was higher among men whose spouse reported ever-testing (adjusted prevalence ratio = 3.02 95 % CI: 1.37-4.66). Multiple-testing was higher in study sites where anti-retroviral therapy was available at the health facility on the day of a health facility audit. Among ever-testers, education and occupation were positively associated with multiple-testing relative to reporting one lifetime HIV-test. Almost half (49 %) of ever-testers accepted the offer of home-based HIV-testing. Discussion Reported HIV-testing increased among this population of men since a 2011/12 survey. Yet, only 35 % of all men reported multiple lifetime HIV-tests. The factors associated with multiple HIV-testing were similar to factors associated with ever-testing for HIV. Men living with HIV were less likely to report multiple HIV-tests and employment and education were associated with multiple-testing. The offer of home-based HIV-testing increased the frequency of HIV-testing among men. Conclusion Although men's levels of ever-testing for HIV have increased, strategies need to increase the lifetime frequency of HIV-testing among men at continued risk of HIV-infection

Male partners’ support and influence on pregnant women’s oral PrEP use and adherence in Malawi

Introduction: Daily oral pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention method for pregnant and postpartum women, but adherence barriers exist. Understanding the role of male partners in supporting PrEP use may inform strategies to support PrEP adherence among pregnant and breastfeeding women. Methods: To understand male partners’ involvement in women's use of PrEP, we conducted in-depth interviews with pregnant women in Lilongwe, Malawi who had recently decided to use PrEP (n = 30) and their male partners (n = 20) in the context of a PrEP adherence trial. Women were purposively recruited to ensure variation in their partners’ HIV status. Interviews were conducted in Chichewa using a semistructured guide. We followed a thematic approach to analyze the interview data. Results: Most male partners were receptive to women using PrEP during pregnancy because it eased their fears of the woman and baby acquiring HIV. Men often played a key role in women's PrEP adherence by providing daily reminders and encouragement to adhere to their medication. The majority of women appreciated this support from the men as it lessened the burden of remembering to take their medications daily on their own and aided their adherence. However, several women who lacked male partner support spoke of wanting their partners to be more involved. Many men living with HIV found the mutual support beneficial for their antiretroviral therapy adherence, while men without HIV or with status unknown appreciated knowing that the family was protected. While most men were open to women continuing PrEP beyond the current study, some would only support it if women were still at risk for acquiring HIV. Conclusion: In this study, male partners were strongly motivated to support the PrEP adherence of their female partners as a way of ensuring that the pregnant women and unborn babies were protected against HIV. Promoting disclosure and tangible support that arises organically among men may be helpful, but programs to enhance this support and identify ways to support women who do not receive support from their partners or do not wish to disclose their PrEP use to partners may be needed. 2023 Young, Saidi, Phanga, Tseka, Bula, Mmodzi, Pearce, Maman, Golin, Mutale, Chi and Hill

Frequency of HIV-testing and factors associated with multiple lifetime HIV-testing among a rural population of Zambian men

BACKGROUND: Across sub-Saharan Africa, men's levels of HIV-testing remain inadequate relative to women's. Men are less likely to access anti-retroviral therapy and experience higher levels of morbidity and mortality once initiated on treatment. More frequent HIV-testing by men at continued risk of HIV-infection is required to facilitate earlier diagnosis. This study explored the frequency of HIV-testing among a rural population of men and the factors associated with more frequent HIV-testing. METHODS: We conducted a secondary analysis of a population-based survey in three rural district in Zambia, from February-November, 2013. Households (N = 300) in randomly selected squares from 42 study sites, defined as a health facility and its catchment area, were invited to participate. Individuals in eligible households were invited to complete questionnaires regarding demographics and HIV-testing behaviours. Men were defined as multiple HIV-testers if they reported more than one lifetime test. Upon questionnaire completion, individuals were offered rapid home-based HIV-testing. RESULTS: Of the 2376 men, more than half (61%) reported having ever-tested for HIV. The median number of lifetime tests was 2 (interquartile range = 1-3). Just over half (n = 834; 57%) of ever-testers were defined as multiple-testers. Relative to never-testers, multiple-testers had higher levels of education and were more likely to report an occupation. Among the 719 men linked to a spouse, multiple-testing was higher among men whose spouse reported ever-testing (adjusted prevalence ratio = 3.02 95% CI: 1.37-4.66). Multiple-testing was higher in study sites where anti-retroviral therapy was available at the health facility on the day of a health facility audit. Among ever-testers, education and occupation were positively associated with multiple-testing relative to reporting one lifetime HIV-test. Almost half (49%) of ever-testers accepted the offer of home-based HIV-testing. DISCUSSION: Reported HIV-testing increased among this population of men since a 2011/12 survey. Yet, only 35% of all men reported multiple lifetime HIV-tests. The factors associated with multiple HIV-testing were similar to factors associated with ever-testing for HIV. Men living with HIV were less likely to report multiple HIV-tests and employment and education were associated with multiple-testing. The offer of home-based HIV-testing increased the frequency of HIV-testing among men. CONCLUSION: Although men's levels of ever-testing for HIV have increased, strategies need to increase the lifetime frequency of HIV-testing among men at continued risk of HIV-infection