Piloting the adaptation of the Kaufman Assessment Battery for Children-2 nd edition (KABC-II) to assess school-age neurodevelopment in rural Zimbabwe.

Background: Neurodevelopment assessment tools for low-resource settings are urgently needed. However, most available tools were developed in high-income settings and may lack cross-cultural validity. Methods: We piloted and adapted two subtests within the planning domain of the Kaufman Assessment Battery for Children-2nd edition (KABC-II) for use in rural Zimbabwean children aged 7years. After initial assessments of face validity, we created 4 substitutions for the story completion subtest and 7 additions for the pattern reasoning subtest through a co-design process with fieldworkers and child development experts. To assess how successful the changes were, T-tests adjusting for unequal variances were used to compare scores between the original and adapted versions of the same subtest. ANOVA and pairwise analysis was performed to compare the performance of KABC-II subtests across domains. Intraclass correlation coefficient was calculated to explore the variability between domains. Results: Initial test scores on the planning domain were significantly lower than the other three domains of learning, sequential memory and simultaneous reasoning (P<0.001) in 50 children (mean age 7.6(SD 0.2) years). Modified subtests were administered to another 20 children (mean age 7.6(SD 0.2) years), who showed story completion scores that were 0.7 marks higher (95% CI 0.0, 1.4; P=0.05) and pattern reasoning scores 1.8 marks higher (95% CI 0.5, 3.2; P=0.01). Overall, the planning domain mean score increased from 8.1 (SD 2.9) to 10.6 (SD 3.4). The intra class correlation coefficient between all four KABC-II domains was initially 0.43 (95% CI 0.13, 0.64) and after modification was 0.69 (95% CI 0.37, 0.87), suggesting an increase in the construct validity. Conclusions: The KABC-II planning domain was successfully adapted to improve cross-cultural validity. Construct validity was enhanced, based on increased inter-correlations among scales. The process of co-design to modify tests for new settings may be beneficial for other commonly used neurodevelopmental tools.

'How poor are you?' -- a comparison of four questionnaire delivery modes for assessing socio-economic position in rural zimbabwe.

BACKGROUND: Assessing socio-economic position can be difficult, particularly in developing countries. Collection of socio-economic data usually relies on interviewer-administered questionnaires, but there is little research exploring how questionnaire delivery mode (QDM) influences reporting of these indicators. This paper reports on results of a trial of four QDMs, and the effect of mode on poverty reporting. METHODS: This trial was nested within a community-randomised trial of an adolescent reproductive health intervention conducted in rural Zimbabwe. Participants were randomly allocated to one of four QDMs (three different self-administered modes and one interviewer-administered mode); a subset was randomly selected to complete the questionnaire twice. Questions covered three socio-economic domains: i) ownership of sellable and fixed assets; ii) ability to afford essential items; and iii) food sufficiency. Statistical analyses assessed the association between QDM and reporting of poverty, and compared the extent of response agreement between questionnaire rounds. RESULTS: 96% (n = 1483) of those eligible took part; 395 completed the questionnaire twice. Reported levels of poverty were high. Respondents using self-administered modes were more likely to report being unable to afford essential items and having insufficient food. Among those completing the questionnaire twice using different modes, higher levels of poverty and food insufficiency were reported when they completed the questionnaire using a self-administered mode. CONCLUSION: These data suggest that QDM plays a significant role in how different socio-economic indicators are reported, and reminds us to consider the mode of collection when identifying indicators to determine socio-economic position.

Burden of HIV among primary school children and feasibility of primary school-linked HIV testing in Harare, Zimbabwe: a mixed methods study.

Population-based surveys in Southern Africa suggest a substantial burden of undiagnosed HIV-infected long-term survivors of mother-to-child transmission. We conducted an HIV prevalence survey of primary school pupils in Harare, Zimbabwe, and evaluated school-linked HIV counselling and testing (HCT) for pupils, their families and schoolteachers. Population-weighted cluster sampling was used to select six primary schools. Randomly selected class-grade pupils underwent anonymous HIV testing, with concurrent school-linked family HCT offered during the survey. Focus group discussions and interviews were conducted with pupils, parents/guardians, counsellors, and schoolteachers. About 4386 (73%) pupils provided specimens for anonymous HIV testing. Median age was 9 years (IQR 8-11), and 54% were female. HIV prevalence was 2.7% (95% CI: 2.2-3.1) with no difference by gender. HIV infection was significantly associated with orphanhood, stunting, wasting, and being one or more class grades behind in school due to illness (p<0.001). After adjusting for covariates, orphanhood and stunting remained significantly associated with being HIV positive (p<0.001). Uptake of diagnostic HIV testing by pupils was low with only 47/4386 (1%) pupils undergoing HCT. The HIV prevalence among children under 15 years who underwent HIV testing was 6.8%. The main barrier to HIV testing was parents' fear of their children experiencing stigma and of unmasking their own HIV status should the child test HIV positive. Most guardians believed that a child's HIV-positive result should not be disclosed and the child could take HIV treatment without knowing the reason. Increased recognition of the high burden of undiagnosed HIV infection in children is needed. Despite awareness of the benefits of HIV testing, HIV-related stigma still dominates parents/guardians' psychological landscape. There is need for comprehensive information and support for families to engage with HIV testing services.

How you ask really matters: randomised comparison of four sexual behaviour questionnaire delivery modes in Zimbabwean youth.

OBJECTIVE: A sexual health survey among rural Zimbabwean youth was used to compare the validity and reliability of sexual behaviour measures between four questionnaire delivery modes. METHODS: Using a random permuted block design, 1495 youth were randomised to one of four questionnaire delivery modes: self-administered questionnaire (SAQ=373); SAQ accompanied by an audio soundtrack (Audio-SAQ=376); face-to-face interview with sensitive questions placed in a confidential voting box (Informal confidential voting interview; ICVI=365); and audio computer-assisted survey instrument (ACASI=381). Key questions were selected a priori to compare item non-response and rates of reporting of sensitive behaviours between questionnaire delivery modes. Qualitative data were collected on perceived method acceptability (n=115). RESULTS: Item non-response was significantly higher with SAQ and Audio-SAQ than with ICVI and ACASI (p<0.001). After adjusting for covariates, the odds of reporting sexual activity among Audio-SAQ and ACASI users were twice as high as the odds for SAQ users (Audio-SAQ AOR=2.05 (95% CI 1.2 to 3.4); ACASI AOR=2.0 (95% CI 1.2 to 3.2)), with no evidence of reporting difference between ICVI and SAQ users (ICVI AOR=1.0 (95% CI 0.6 to 1.8)). ACASI users reported a lower age at first intercourse and were more likely to report a greater number of partners (mean difference=1.06; 95% CI 0.33 to 1.78; p=0.004). They reported an increased ability to answer questions honestly (p=0.004) and believed their answers would be kept secret. Participants claimed increased comprehension when hearing questions while reading them. ICVI users expressed difficulty answering sensitive questions, despite understanding that their answers were unknown to the interviewer. CONCLUSION: ACASI appears to reduce bias significantly, and is feasible and acceptable in resource-poor settings with low computer literacy. Its increased use would likely improve the quality of questionnaire data in general and sexual behaviour data specifically.

Survey of children accessing HIV services in a high prevalence setting: time for adolescents to count?

OBJECTIVE: To establish the proportion of adolescents among children infected with human immunodeficiency virus (HIV) in Zimbabwe who receive HIV care and support, and what clinic staff perceives to be the main problems faced by HIV-infected children and adolescents. METHODS: In July 2008, we sent a questionnaire to all 131 facilities providing HIV care in Zimbabwe. In it we requested an age breakdown of the children (aged 0-19 years) registered for care and asked what were the two major problems faced by younger children (0-5 years) and adolescents (10-19 years). FINDINGS: Nationally, 115 (88%) facilities responded. In 98 (75%) that provided complete data, 196 032 patients were registered and 24 958 (13%) of them were children. Of children under HIV care, 33% were aged 0-4 years; 25%, 5-9 years; 25%, 10-14 years; and 17%, 15-19 years. Staff highlighted differences in the problems most commonly faced by younger children and adolescents. For younger children, such problems were malnutrition and lack of appropriate drugs (cited by 46% and 40% of clinics, respectively); for adolescents they concerned psychosocial issues and poor drug adherence (cited by 56% and 36%, respectively). CONCLUSION: Interventions for the large cohort of adolescents who are receiving HIV care in Zimbabwe need to target the psychosocial concerns and poor drug adherence reported by staff as being the main concerns in this age group.

Acceptability and challenges of implementing voluntary counselling and testing (VCT) in rural Zimbabwe: evidence from the Regai Dzive Shiri Project.

Voluntary counselling and testing (VCT) is an important component of HIV prevention and care. Little research exists on its acceptability and feasibility in rural settings. This paper examines the acceptability and feasibility of providing VCT using data from two sub-studies: (1) client-initiated VCT provided in rural health centres (RHCs) and (2) researcher-initiated VCT provided in a non-clinic community setting. Nurses provided client-initiated VCT in 39 RHCs in three Zimbabwean provinces (2004-2007). Demographic data and HIV status were collected. Qualitative data were also collected to assess rural communities' impressions of services. In a second study in 2007, VCT was offered to participants in a population-based HIV prevalence survey. Quantitative data from clinic-based VCT show that of 3585 clients aged > or =18, 79.4% (95% CI: 78.0-80.7%) were female; young people (aged 18-24) comprised 21.1%. Overall, 32.9% (95% CI: 31.4-34.5%) tested HIV positive. Young people were less likely to be HIV positive 13.5% (95% CI: 11.1-16.1%) vs. 38.1% (95% CI: 36.3-39.9%). In the second study conducted in a non-clinic setting, 27.0% (n=1368/5052) of participants opted to test. Young people were as likely to test as adults (27.3% vs. 26.9%) and an equal proportion of men and women tested. Overall during the second survey, 18.8% (95% CI: 16.7-21.0%) of participants tested positive (youth = 8.4% (95% CI: 6.4-10.7%); adults = 29.1% (95% CI: 25.7-32.7%)). Qualitative data, unique to clinics only, suggested that adults identify RHCs as acceptable VCT sites, whereas young people expressed reservations around these venues. Males reported considering VCT only after becoming ill. While VCT offered through RHCs is acceptable to women, it seems that men and youth are less comfortable with this venue. When VCT was offered in a non-clinic setting, numbers of men and women testing were similar. These data suggest that it may be possible to improve testing uptake in rural communities using non-clinic settings.

What is 'sex' exactly? Using cognitive interviewing to improve the validity of sexual behaviour reporting among young people in rural Zimbabwe.

Self-reporting of sensitive data is often unreliable, particularly when questions are asked about culturally or socially censured behaviours. This study aimed to improve the validity of questionnaire responses through cognitive interviewing of young people in Zimbabwe to better understand their underlying thought processes when responding to sexual behaviour questions. A questionnaire was developed in English and translated into Shona. Three rounds of cognitive interviewing were conducted with 65 young people. Data were coded and analysed using principles of grounded theory. Young women emphasised that they would not admit to having participated in sexual activities if questions were phrased in such a way that they could be seen as having initiated them. They suggested that in order to legitimise women's participation, the wording of their sexual questions should use the passive tense. The Shona term for 'vaginal sex' is used to refer to both consensual and non-consensual sex. In Shona, there is no formal term for anal sex and phrasing this activity in a way that was both acceptable and understood proved particularly challenging. Cognitive interviewing is useful in exploring the underlying thought processes and the cultural context behind question responses. Examining the cultural and societal norms within a study population is key to obtaining valid responses.