Condom use increased after a peer group intervention implemented by community volunteers in Malawi.

BACKGROUND: HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi. METHODS: Three communities sequentially rolled out the program. Effectiveness was evaluated using a stepped wedge design. Repeated surveys 11-13 months apart were conducted between 2016 and 2019. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 771) and condom use at last sex (N = 880). The analytical sample included all sexually active persons answering that question at one or more time points. Mixed-effects cumulative logit and Generalized Estimating Equation (GEE) models were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication. RESULTS: This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final adjusted models with non-significant factors removed, condom use in the last two months increased for the intervention group vs. control group [Time 2: Adjusted Odds Ratio (AOR) = 1.59 (1.15, 2.21); Time 3: AOR 2.01 (1.23, 3.30)]. Similarly, condom use at last sex increased for the intervention group vs. control group [Time 2: AOR = 1.48 (1.08, 2.03); Time 3: AOR 1.81 (1.13, 2.90)]. Other significant predictors of greater condom use were also described. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use. CONCLUSIONS: In this community-engaged implementation study, an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Community ownership and program delivery by trained volunteers offer an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening healthcare systems in sub-Saharan Africa. TRIAL REGISTRATION: Clinical Trials.gov NCT02765659 Registered May 6, 2016.

A peer group intervention implemented by community volunteers increased HIV prevention knowledge.

BACKGROUND: HIV prevention knowledge levels are low in sub-Saharan Africa. In our efficacy study, the Mzake ndi Mzake (Friend-to-Friend; hereafter Mzake) 6-session peer group intervention, delivered by health workers, improved HIV prevention knowledge and other outcomes in Malawi. To expand HIV prevention approaches, this implementation study tested whether the intervention remained effective when implemented by trained community volunteers. HIV prevention knowledge findings are presented. METHODS: Using a stepped wedge design, three communities implemented the Mzake program sequentially in randomly assigned order. Repeated surveys assessed outcomes, and participants served as controls until they completed the program. At Time 2, Community 1 became the intervention group, and at Time 3, Communities 1 and 2 were the intervention group. HIV prevention knowledge, the primary outcome, was assessed through two indicators: UNAIDS comprehensive knowledge (UNAIDS Knowledge), defined as correctly answering five HIV prevention questions (Yes/No), and a 9-item HIV/PMTCT Knowledge Index (number correct). Multivariate generalized estimating equation logistic regression (UNAIDS Knowledge) and mixed-effects regression models (HIV/PMTCT Knowledge Index) were used to assess knowledge controlling for five sociodemographic factors. RESULTS: In bivariate analyses of UNAIDS Knowledge, more persons answered correctly in the intervention group than the control group at Time 2 (56.8% vs. 47.9%, p < 0.01), but the difference was not significant at Time 3. In logistic regression, there was a significant linear increase in the proportion who correctly answered all questions in the control group, but the increase was significantly higher in the intervention group (log-odds estimate = 0.17, SE = 0.06, p-value < 0.01). The HIV/PMTCT Knowledge Index scores increased over time for both groups, but in the intervention group the increase was significantly higher than the control group (0.11 at Time 2; 0.21 at Time 3). In youth and adult subsamples analyses, the intervention was highly effective in increasing knowledge for youth, but not for adults. CONCLUSION: This implementation study showed that Mzake was effective in increasing HIV prevention knowledge when delivered by community members. Community approaches offer an important strategy to increase HIV prevention in rural communities without burdening healthcare systems. TRIAL REGISTRATION: ClinicalTrials.gov NCT02765659. Registered 06/05/2016.

The H-HOPE behavioral intervention plus Kangaroo Mother Care increases mother-preterm infant responsivity in Malawi: a prospective cohort comparison.

BACKGROUND: Early behavioral intervention to promote development is recommended as the standard of care for preterm infants, yet is not provided in Malawi. One such intervention is H-HOPE (Hospital to Home: Optimizing the Premature Infant's Environment). In US studies, H-HOPE increased mother-preterm infant responsivity at 6-weeks corrected age (CA). Kangaroo Mother Care (KMC) improves infant survival and is the standard of care for preterm infants in Malawi. This is the first study to examine whether H-HOPE is feasible and promotes mother-preterm infant responsivity in Malawi, and the first to examine the impact of H-HOPE when KMC is the standard of care. METHOD: This pilot was conducted in a KMC unit using a prospective cohort comparison design. Because the unit is an open room without privacy, random assignment would have led to contamination of the control cohort. H-HOPE includes participatory guidance for mothers and Massage + , a 15 min multisensory session provided by mothers twice daily. H-HOPE began when infants were clinically stable and at least 32 weeks postmenstrual age. Mothers participated if they were physically stable and willing to return for follow-up. Mother-preterm infant dyads were video-recorded during a play session at 6-weeks CA. Responsivity was measured using the Dyadic Mutuality Code (DMC). RESULTS: The final sample included 60 H-HOPE + KMC and 59 KMC only mother-preterm infant dyads. Controlling for significant maternal and infant characteristics, the H-HOPE + KMC dyads were over 11 times more likely to have higher responsivity than those in the KMC only dyads (AOR = 11.51, CI = 4.56, 29.04). The only other factor related to higher responsivity was vaginal vs. Caesarian delivery (AOR = 5.44, CI = .096, 30.96). CONCLUSION: This study demonstrated that H-HOPE can be provided in Malawi. Mother-infant dyads receiving both H-HOPE and KMC had higher responsivity at 6-weeks CA than those receiving KMC only. H-HOPE was taught by nurses in this study, however the nursing shortage in Malawi makes H-HOPE delivery by nurses challenging. Training patient attendants in the KMC unit is a cost-effective alternative. H-HOPE as the standard of care offers benefits to preterm infants and mothers that KMC alone does not provide.

A randomized group antenatal care pilot showed increased partner communication and partner HIV testing during pregnancy in Malawi and Tanzania.

BACKGROUND: HIV testing at antenatal care (ANC) is critical to achieving zero new infections in sub-Saharan Africa. Although most women are tested at ANC, they remain at risk for HIV exposure and transmission to their infant when their partners are not tested. This study evaluates how an HIV-enhanced and Centering-based group ANC model-Group ANC+ that uses interactive learning to practice partner communication is associated with improvements in partner HIV testing during pregnancy. METHODS: A randomized pilot study conducted in Malawi and Tanzania found multiple positive outcomes for pregnant women (n = 218) assigned to Group ANC+ versus individual ANC. This analysis adds previously unpublished results for two late pregnancy outcomes: communication with partner about three reproductive health topics (safer sex, HIV testing, and family planning) and partner HIV testing since the first antenatal care visit. Multivariate logistic regression models were used to assess the effect of type of ANC on partner communication and partner testing. We also conducted a mediation analysis to assess whether partner communication mediated the effect of type of care on partner HIV testing. RESULTS: Nearly 70% of women in Group ANC+ reported communicating about reproductive health with their partner, compared to 45% of women in individual ANC. After controlling for significant covariates, women in group ANC were twice as likely as those in individual ANC to report that their partner got an HIV test (OR 1.99; 95% CI: 1.08, 3.66). The positive effect of the Group ANC + model on partner HIV testing was fully mediated by increased partner communication. CONCLUSIONS: HIV prevention was included in group ANC health promotion without compromising services and coverage of standard ANC topics, demonstrating that local high-priority health promotion needs can be integrated into ANC using a Group ANC+. These findings provide evidence that greater partner communication can promote healthy reproductive behaviors, including HIV prevention. Additional research is needed to understand the processes by which group ANC allowed women to discuss sensitive topics with partners and how these communications led to partner HIV testing.

Protocol for implementation of an evidence based parentally administered intervention for preterm infants.

BACKGROUND: Multi-sensory behavioral interventions for preterm infants have the potential to accelerate feeding, growth, and optimize developmental trajectories and increase parents' interactive engagement with their infants. However, few neonatal intensive care units (NICUs) provide evidence-based standardized early behavioral interventions as routine care. Lack of implementation is a major gap between research and clinical practice. H-HOPE, is a standardized behavioral intervention with an infant- directed component (Massage+) and a parent-directed component (four participatory guidance sessions that focus on preterm infants' behaviors and appropriate responses). H-HOPE has well documented efficacy. The purpose of this implementation study is to establish H-HOPE as the standard of care in 5 NICUs. METHODS: The study employs a Type 3 Hybrid design to simultaneously examine the implementation process and effectiveness in five NICUs. To stagger implementation across the clinical sites, we use an incomplete stepped wedge design. The five participating NICUs were purposively selected to represent different acuity levels, number of beds, locations and populations served. Our implementation strategy integrates our experience conducting H-HOPE and a well-established implementation model, the Consolidated Framework for Implementation Research (CFIR). The CFIR identifies influences (facilitators and barriers) that affect successful implementation within five domains: intervention characteristics, outer setting (the hospital and external events and stakeholders), inner setting (NICU), implementers' individual characteristics, and the implementation process. NICUs will use the CFIR process, which includes three phases: Planning and Engaging, Executing, and Reflecting and Evaluating. Because sustaining is a critical goal of implementation, we modify the CFIR implementation process by adding a final phase of Sustaining. DISCUSSION: This study builds on the CFIR, adding Sustaining H-HOPE to observe what happens when sites begin to maintain implementation without outside support, and extends its use to the NICU acute care setting. Our mixed methods analysis systematically identifies key facilitators and barriers of implementation success and effectiveness across the five domains of the CFIR. Long term benefits have not yet been studied but may include substantial health and developmental outcomes for infants, more optimal parent-child relationships, reduced stress and costs for families, and substantial indirect societal benefits including reduced health care and special education costs. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT04555590 , Registered on 8/19/2020.

An effectiveness-implementation hybrid type 1 trial assessing the impact of group versus individual antenatal care on maternal and infant outcomes in Malawi.

BACKGROUND: Sub-Saharan Africa has the world's highest rates of maternal and perinatal mortality and accounts for two-thirds of new HIV infections and 25% of preterm births. Antenatal care, as the entry point into the health system for many women, offers an opportunity to provide life-saving monitoring, health promotion, and health system linkages. Change is urgently needed, because potential benefits of antenatal care are not realized when pregnant women experience long wait times and short visits with inconsistent provisioning of essential services and minimal health promotion, especially for HIV prevention. This study answers WHO's call for the rigorous study of group antenatal care as a transformative model that provides a positive pregnancy experience and improves outcomes. METHODS: Using a hybrid type 1 effectiveness-implementation design, we test the effectiveness of group antenatal care by comparing it to individual care across 6 clinics in Blantyre District, Malawi. Our first aim is to evaluate the effectiveness of group antenatal care through 6 months postpartum. We hypothesize that women in group care and their infants will have less morbidity and mortality and more positive HIV prevention outcomes. We will test hypotheses using multi-level hierarchical models using data from repeated surveys (four time points) and health records. Guided by the consolidated framework for implementation research, our second aim is to identify contextual factors related to clinic-level degree of implementation success. Analyses use within and across-case matrices. DISCUSSION: This high-impact study addresses three global health priorities, including maternal and infant mortality, HIV prevention, and improved quality of antenatal care. Results will provide rigorous evidence documenting the effectiveness and scalability of group antenatal care. If results are negative, governments will avoid spending on less effective care. If our study shows positive health impacts in Malawi, the results will provide strong evidence and valuable lessons learned for widespread scale-up in other low-resource settings. Positive maternal, neonatal, and HIV-related outcomes will save lives, impact the quality of antenatal care, and influence health policy as governments make decisions about whether to adopt this innovative healthcare model. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT03673709. Registered on September 17, 2018.

A hybrid design testing a 3-step implementation model for community scale-up of an HIV prevention intervention in rural Malawi: study protocol.

BACKGROUND: Scaling-up evidence-based behavior change interventions can make a major contribution to meeting the UNAIDS goal of no new HIV infections by 2030. We developed an evidence-based peer group intervention for HIV prevention and testing in Malawi that is ready for wider dissemination. Our innovative approach turns over ownership of implementation to rural communities. We adapted a 3-Step Implementation Model (prepare, roll-out and sustain) for communities to use. Using a hybrid design, we simultaneously evaluate community implementation processes and program effectiveness. METHODS: Three communities in southern Malawi begin implementation in randomly-assigned order using a stepped wedge design. Our evaluation sample size of 144 adults and 144 youth per community provides sufficient power to examine primary outcomes of condom use and HIV testing. Prior to any implementation, the first participants in all three communities are recruited and complete the Wave 1 baseline survey. Waves 2-4 surveys occur after each community completes roll-out. Each community follows the model's three steps. During Prepare, the community develops a plan and trains peer group leaders. During Roll-Out, peer leaders offer the program. During Sustain, the community makes and carries out plans to continue and expand the program and ultimately obtain local funding. We evaluate degree of implementation success (Aim 1) using the community's benchmark scores (e.g, # of peer groups held). We assess implementation process and factors related to success (Aim 2) using repeated interviews and observations, benchmarks from Aim 1 and fidelity assessments. We assess effectiveness of the peer group intervention when delivered by communities (Aim 3) using multi-level regression models to analyze data from repeated surveys. Finally, we use mixed methods analyses of all data to assess feasibility, acceptability and sustainability (Aim 4). DISCUSSION: The project is underway, and thus far the first communities have enthusiastically begun implementation. We have had to make several modifications along the way, such as moving from rapid-tests of STIs to symptoms screening by a nurse due to problems with test reliability and availability. If successful, results will provide a replicable evidence-based model for future community implementation of this and other health interventions. TRIAL REGISTRATION: Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Maternal weight status and responsiveness to preterm infant behavioral cues during feeding.

BACKGROUND: Parental obesity is highly predictive of child obesity, and preterm infants are at greater risk of obesity, but little is known about obese and non-obese mothers' responsiveness to preterm infant cues during feeding. The relationship between maternal weight status and response to preterm infant behavioral cues during feeding at 6-weeks corrected age was examined. METHODS: This secondary analysis used data from a randomized clinical trial. Maternal weight was coded during a play session. Mother-infant interaction during feeding was coded using the Nursing Child Assessment Satellite Training Feeding Scale (NCAST). We used multivariate linear regressions to examine NCAST scores and multivariate logistic regressions for the two individual items, satiation cues and termination of feeding. RESULTS: Of the 139 mothers, 56 (40.3%) were obese, two underweight women were excluded. Obese mothers did not differ from overweight/normal weight mothers for overall NCAST scores, but they had higher scores on response to infant's distress subscale (mean = 10.2 vs. 9.6, p = 0.01). The proportion of infants who exhibited satiation cues did not differ by maternal weight. Obese mothers were more likely than overweight/normal weight mothers to terminate the feeding when the infant showed satiation cues (82.1% vs. 66.3%, p = 0.04, adjusted OR = 2.31, 95% CI = 0.97, 5.48). CONCLUSIONS: Limitations include lack of BMI measures and small sample size. Additional research is needed about maternal weight status and whether it influences responsiveness to preterm infant satiation cues. Results highlight the need for educating all mothers of preterm infants regarding preterm infant cues. TRIAL REGISTRATION: NCT02041923 . Feeding and Transition to Home for Preterms at Social Risk (H-HOPE). Registered 15 January 2014.

Randomized controlled pilot of a group antenatal care model and the sociodemographic factors associated with pregnancy-related empowerment in sub-Saharan Africa.

BACKGROUND: The links between empowerment and a number of health-related outcomes in sub-Saharan Africa have been documented, but empowerment related to pregnancy is under-investigated. Antenatal care (ANC) is the entry point into the healthcare system for most women, so it is important to understand how ANC affects aspects of women's sense of control over their pregnancy. We compare pregnancy-related empowerment for women randomly assigned to the standard of care versus CenteringPregnancy-based group ANC (intervention) in two sub-Saharan countries, Malawi and Tanzania. METHODS: Pregnant women in Malawi (n = 112) and Tanzania (n = 110) were recruited into a pilot study and randomized to individual ANC or group ANC. Retention at late pregnancy was 81% in Malawi and 95% in Tanzania. In both countries, individual ANC, termed focused antenatal care (FANC), is the standard of care. FANC recommends four ANC visits plus a 6-week post-birth visit and is implemented following the country's standard of care. In group ANC, each contact included self- and midwife-assessments in group space and 90 minutes of interactive health promotion. The number of contacts was the same for both study conditions. We measured pregnancy-related empowerment in late pregnancy using the Pregnancy-Related Empowerment Scale (PRES). Independent samples t-tests and multiple linear regressions were employed to assess whether group ANC led to higher PRES scores than individual ANC and to investigate other sociodemographic factors related to pregnancy-related empowerment. RESULTS: In Malawi, women in group ANC had higher PRES scores than those in individual ANC. Type of care was a significant predictor of PRES and explained 67% of the variation. This was not so in Tanzania; PRES scores were similar for both types of care. Predictive models including sociodemographic variables showed religion as a potential moderator of treatment effect in Tanzania. Muslim women in group ANC had a higher mean PRES score than those in individual ANC; a difference not observed among Christian women. CONCLUSIONS: Group ANC empowers pregnant women in some contexts. More research is needed to identify the ways that models of ANC can affect pregnancy-related empowerment in addition to perinatal outcomes globally.

Cognitive Interviews for Validating the Family Nutrition Physical Activity Instrument for Korean-American Families With Young Children.

PURPOSE: Childhood obesity is a growing health concern for Korean-Americans (KA). The purpose of this study was to develop a culturally appropriate Korean-language version of the Family Nutrition Physical Activity (FNPA) instrument and evaluate its comprehensibility and cultural appropriateness of the FNPA for KAs. DESIGN AND METHODS: The FNPA was translated into Korean and cognitive interviews were conducted with 19 KA mothers in the Chicago metropolitan area. RESULTS: Overall, participants reported that the FNPA is easy to understand and said they had no difficulty answering items using a 4-point Likert scale. Six out of 20 items had minor revisions due to: items that were not specific enough, had confusing wording, or led to incorrect interpretations. CONCLUSIONS: Cognitive interviews confirmed the cultural appropriateness of the translated FNPA in the KA context. It is crucial that child's age and cultural aspects of a child's household routines should be taken into consideration when the original FNPA is being used with culturally diverse populations. PRACTICE IMPLICATIONS: Health care professionals may use the FNPA when assessing family environment in their efforts to prevent and control childhood obesity among KAs.

Korean Immigrant Motherhood: Child-Rearing and Child Weight.

Health problems among immigrant children may persist not only throughout childhood but also into adulthood. The purpose of this study was to elicit information about Korean immigrant mothers' experiences with parenting, immigration, and raising their children in the United States. Four focus group interviews were conducted in the Chicago metropolitan area. Content analysis showed that Korean immigrant mothers practice intensive parenting and worry about it. They described the strategies they use to raise healthy children. Culturally appropriate intervention programs are needed to reduce stress, encourage a healthy lifestyle, and link this to the health of their children.

Predictors of readiness for oral rapid HIV testing by Chilean health care providers.

OBJECTIVE: This study identified the personal characteristics that affect Chilean health care providers' readiness to adopt HIV Oral Rapid Testing (ORT) in Chile as a new clinical evidence-based practice (EBP). METHODS: Using a cross-sectional research design, the study sampled 150 nurses, midwives, and physicians employed at four clinics within the Pontifícia Universidad Católica de Chile Health Network in Santiago. Participants completed a self-administered survey asking about their demographic background, EBP attitudes and experience, personal beliefs related to HIV, the importance of HIV testing, and perceived self-comfort in performing a rapid HIV test. RESULTS: Of the participants, 90% believed that incorporating ORT would make a positive difference in their practice and said that they would be willing to adopt the technology for that reason. Nonetheless, the providers reported a mean "readiness to implement ORT" score of 15.1 out of a possible value of 20, suggesting only moderate self-perceived readiness to adopt the EBP. Education, beliefs about evidence-based practice, perceived comfort in performing ORT, and perceived importance of HIV testing explained 43.6% of the variance in readiness to adopt ORT. CONCLUSION: The findings of this first ORT pre-implementation study in Chile can help guide policy makers and HIV stakeholders to prepare for and increase primary health care providers' readiness to successfully adopt this evidence-based technology. Successful adoption of ORT could increase Chile's capacity to reach HIV-vulnerable Chileans for testing and referral to care if infected, thus helping the country to reduce further transmission of the virus and its medical complications.

Family Factors and Body Mass Index Among Korean-American Preschoolers.

PURPOSE: The purpose of this study was to examine family factors related to BMI z-scores and overweight/obesity among Korean-American (KA) preschoolers. METHODS: A cross-sectional study was conducted with 104 KA preschoolers and their mothers in the Chicago metropolitan area. KA mothers completed questionnaires and their preschool-age children's weights and heights were measured. Hierarchical multiple linear regression and multiple logistic regression were performed. RESULTS: Twenty-two percent of preschoolers were overweight or obese (BMI ≥85th percentile). Family factors explained 30% of the variance in the children's BMI z-scores, with parenting feeding style and family functioning contributing most. In logistic regression, children were more likely to be overweight/obese if: a family had more children, the mother perceived her child as overweight/obese, and the family had regular child routines. CONCLUSION: Health care providers should consider the family as one unit of care and use that unit to implement culturally appropriate childhood overweight/obesity prevention for Korean-American preschool-aged children. Parental feeding style and parents' attitudes about child weight should be considered when advising Korean-Americans about reducing children's overweight/obesity.

Empowering peer group leaders for HIV prevention in Malawi.

PURPOSE: Behavioral change interventions using peer group leaders are effective and widely used, but few studies have examined how being a peer group leader affects the leaders. This study describes how participants felt being a peer group leader affected their lives. DESIGN: This descriptive qualitative study interviewed 18 experienced peer group leaders who had conducted a multisession human immunodeficiency virus (HIV) prevention peer group intervention in rural Malawi. METHODS: We used inductive content analysis and comparisons within and between cases. FINDINGS: Three major themes were identified. All leaders said they experienced personal changes in their knowledge, attitudes, or HIV prevention behaviors. They described interacting with family, neighbors, and friends, and speaking at church or community meetings, to discuss HIV prevention issues. They increased their self-efficacy to engage others in sensitive HIV prevention issues, developed a self-identity as a change agent, and came to be recognized in their community as trustworthy advisors about HIV and acquired immunodeficiency syndrome. These three themes, taken together, form the meta-theme of psychological empowerment. CONCLUSION: Being a peer group leader empowered the leaders as change agents for HIV prevention and had impacts in the community after the intervention ended, potentially increasing the long-term effectiveness and cost effectiveness of peer group interventions. CLINICAL RELEVANCE: Healthcare workers and community volunteers who led HIV prevention sessions continued HIV prevention activities in the community and workplace after the program ended. Training health workers as volunteer HIV prevention leaders offers a strategy to bring HIV prevention to limited-resource settings, despite health worker shortages.

Stressors, resources, and stress responses in pregnant African American women: a mixed-methods pilot study.

This research aimed to develop an initial understanding of the stressors, stress responses, and personal resources that impact African American women during pregnancy, potentially leading to preterm birth. Guided by the ecological model, a prospective, mixed-methods, complementarity design was used with 11 pregnant women and 8 of their significant others. Our integrated analysis of quantitative and qualitative data revealed 2 types of stress responses: high stress responses (7 women) and low stress responses (4 women). Patterns of stress responses were seen in psychological stress and cervical remodeling (attenuation or cervical length). All women in the high stress responses group had high depression and/or low psychological well-being and abnormal cervical remodeling at one or both data collection times. All but 1 woman had at least 3 sources of stress (racial, neighborhood, financial, or network). In contrast, 3 of the 4 women in the low stress responses group had only 2 sources of stress (racial, neighborhood, financial, or network) and 1 had none; these women also reported higher perceived support. The findings demonstrate the importance of periodically assessing stress in African American women during pregnancy, particularly related to their support network as well as the positive supports they receive.

Matroniya: the lived experiences of rural auxiliary midwives in Koutiala, Mali.

Our team explored the lived experiences of rural auxiliary midwives, or matrones, in Mali. Since matrones attend more births than all other health workers combined, they are critical to efforts to reduce maternal mortality. Currently, their experiences are not well understood. This study used interpretive phenomenology to describe the experiences of seven matrones. We suggest that matrones provide a vital connection between traditional approaches to birth and the biomedical services offered by the formal health sector. Matrones' unique role as both health professionals and rural women creates challenges and opportunities that affect their effectiveness and personal lives.

Women's perceptions of childbirth experience at a hospital in rural Tanzania.

Tanzania's health care provider shortage, especially in rural areas, makes it challenging to meet women's support needs in hospitals. We describe women's perceptions of childbirth support at a hospital in rural Tanzania. We interviewed 25 women within 24 hours after delivery using semistructured interviews. Most women sought life-saving technological support in case of complications. They also valued having family present to provide care and affection. Women's needs, however, were difficult to fulfill at this busy facility. Increasing women-centered childbirth support and recognizing family as important contributors may provide a strategy to meet the needs of both women and providers.

Condom use increased after a peer group intervention implemented by community volunteers in Malawi.

Background: HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi. Methods: Three communities sequentially rolled out the program. Effectiveness was evaluated using repeated surveys. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 776) and condom use at last sex (N = 880). For each indicator, the sample included all sexually active persons answering that question at one or more time points. Regression analyses were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication. Results: This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final regression models. Other predictors of greater condom use for at least one condom use indicator included younger age group (13-19), male gender, not married/cohabiting, high involvement in religiously affiliated activities, higher safer sex self-efficacy, and greater partner communication. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use. Conclusions: This community engaged implementation study found that an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Leveraging community strengths and human capital resources facilitated implementation of this effective HIV prevention program in rural Malawi. Community ownership and program delivery by trained local volunteers offers an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening heathcare systems in sub. Trial registration: Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Changes in clients' care ratings after HIV prevention training of hospital workers in Malawi.

OBJECTIVE: To examine the changes in clients' health-care ratings before and after hospital workers received an HIV prevention intervention in Malawi, which increased the workers' personal and work-related HIV prevention knowledge, attitudes and preventive behaviors. DESIGN: Pre- and post-intervention client surveys. SETTING: A large urban referral hospital in Malawi. PARTICIPANTS: Clients at purposefully selected inpatient and outpatient units on designated days (baseline, n = 310 clients; final, n = 683). INTERVENTION: Ten-session peer-group intervention for health workers focused on HIV transmission, personal and work-related prevention, treating clients and families respectfully and incorporating HIV-related teaching. MAIN OUTCOME MEASURES: Brief face-to-face clients' interview obtaining ratings of confidentiality of HIV, whether HIV-related teaching occurred and ratings of service quality. RESULTS: Compared with baseline, at the final survey, clients reported higher confidence about confidentiality of clients' HIV status (83 vs. 75%, P < 0.01) and more clients reported that a health worker talked to them about HIV and AIDS (37 versus 28%, P < 0.01). More clients rated overall health services as 'very good' (five-item mean rating, 68 versus 59%, P < 0.01) and this was true for both inpatients and outpatients examined separately. However, there was no improvement in ratings of the courtesy of laboratory or pharmacy workers or of the adequacy of treatment instructions in the pharmacy. CONCLUSIONS: HIV prevention training for health workers can have positive effects on clients' ratings of services, including HIV-related confidentiality and teaching, and should be scaled-up throughout Malawi and in other similar countries. Hospitals need to improve laboratory and pharmacy services.

Working with interpreters in cross-cultural qualitative research in the context of a developing country: systematic literature review.

AIMS: This article is a report of a systematic literature review describing how cross-cultural researchers conducted qualitative studies with interpreters in Tanzania. The purpose was to draw methodological implications for working with interpreters within the context of developing countries. BACKGROUND: In a growing number of cross-cultural nursing studies in developing countries, interpreters play a crucial role for imparting verbal and cultural understanding. In many studies, however, the interpreters' role and their influences on the findings are not adequately described, and therefore the study credibility is weakened. DATA SOURCES: Cross-cultural qualitative studies conducted with interpreters in Tanzania were searched in four databases. Meeting our inclusion criteria were 20 studies published from 1994-2009. REVIEW METHODS: We used Garrard's Matrix Method following Wallin and Ahlström's framework to analyse how cross-cultural researchers described the role of interpreters. RESULTS: We identified three major patterns of how researchers worked with interpreters: (i) invisible assistance, (ii) independent fieldwork and (iii) integrated collaboration. In many studies, interpreters' information was limited. They were often asked to collect data in the field without the presence of the researcher. They were integrated into the research process beyond data collection, such as subject recruitment, review of interviews, transcription and translation and analysis. CONCLUSION: From planning of research to dissemination of the findings, nurse researchers should carefully consider interpreters' influences on the findings. They may use a set of questions we developed for working with interpreters in developing countries to systematically describe the interpreter's role and maximize their research credibility.