A scoping review on family medicine in sub-Saharan Africa: practice, positioning and impact in African health care systems.

BACKGROUND: Family medicine (FM) is a relatively new discipline in sub-Saharan Africa (SSA), still struggling to find its place in the African health systems. The aim of this review was to describe the current status of FM in SSA and to map existing evidence of its strengths, weaknesses, effectiveness and impact, and to identify knowledge gaps. METHODS: A scoping review was conducted by systematically searching a wide variety of databases to map the existing evidence. Articles exploring FM as a concept/philosophy, a discipline, and clinical practice in SSA, published in peer-reviewed journals from 2000 onwards and in English language, were included. Included articles were entered in a matrix and then analysed for themes. Findings were presented and validated at a Primafamed network meeting, Gauteng 2018. RESULTS: A total of 73 articles matching the criteria were included. FM was first established in South Africa and Nigeria, followed by Ghana, several East African countries and more recently additional Southern African countries. In 2009, the Rustenburg statement of consensus described FM in SSA. Implementation of the discipline and the roles and responsibilities of family physicians (FPs) varied between and within countries depending on the needs in the health system structure and the local situation. Most FPs were deployed in district hospitals and levels of the health system, other than primary care. The positioning of FPs in SSA health systems is probably due to their scarcity and the broader mal-distribution of physicians. Strengths such as being an "all- round specialist", providing mentorship and supervision, as well as weaknesses such as unclear responsibilities and positioning in the health system were identified. Several studies showed positive perceptions of the impact of FM, although only a few health impact studies were done, with mixed results. CONCLUSIONS: FM is a developing discipline in SSA. Stronger evidence on the impact of FM on the health of populations requires a critical mass of FPs and shared clarity of their position in the health system. As FM continues to grow in SSA, we suggest improved government support so that its added value and impact on health systems in terms of health equity and universal health coverage can be meaningfully explored.

Access factors linked to maternal deaths in Lundazi district, Eastern Province of Zambia: a case control study analysing maternal death reviews.

BACKGROUND: Access factors associated with maternal death are important to understand because they are considered to be an essential measure of women's health and indicative of the performance of health care systems in any community globally. This study aimed to analyse the access risk factors linked to maternal deaths in Lundazi district of the Eastern Province of Zambia using secondary data obtained from maternal death reviews and delivery registers. METHODS: This was a case-control study with cases being recorded maternal deaths for Lundazi district (n = 100) while controls were randomly selected Lundazi District Hospital deliveries (n = 300) for the period 2010 to 2015. STATA™ (Stata Corporation, Texas, TX, USA) version 12.0 was used to analyse data. Odds ratio and 95% confidence intervals with associated p-values were used to analyse disparities between cases and controls while bivariate and multivariate regression analyses were done to show associations. RESULTS: The likelihood of experiencing maternal death was 94% less among women who completed their scheduled antenatal care visits than those who did not (OR 0.06, 95% CI = 0.01-0.27, p = < 0.001). Delayed referral associated with maternal deaths and complications were 30% (30) for cases, 12% (37) for controls and 17% (67) for both cases and controls. Long distances, unskilled deliveries were 3%, (15) for both cases and controls with 13% (13) for cases and 1% (2) for controls only. CONCLUSION: Antenatal care is important in screening for pre-existing risk conditions as well as complications in early stages of pregnancy that could impact adversely during pregnancy and childbirth. Delay in seeking health care during pregnancy could be minimised if health services are brought closer to the communities to reduce on distances covered by pregnant women in Lundazi. Maternal education appears to influence antenatal health care utilisation because greater knowledge and understanding of the importance of antenatal care might increase the ability to select most appropriate service. Therefore, there is need for Lundazi District Health Office to scale up interventions that motivate women to make at least four scheduled antenatal care visits during pregnancy as recommended by the World Health Organization.

Community based interventions for strengthening adolescent sexual reproductive health and rights: how can they be integrated and sustained? A realist evaluation protocol from Zambia.

BACKGROUND: Research that explores how community-based interventions for strengthening adolescent sexual reproductive health and rights (SRHR) can be integrated and sustained in community health systems, is, to the best of our knowledge, very scarce, if not absent. It is important to document mechanisms that shape integration process in order to improve health systems' responsiveness towards adolescents' SRHR. This realist evaluation protocol will contribute to this knowledge in Zambia where there is increased attention towards promoting maternal, neonatal and child health as a means of addressing the current high early pregnancy and marriage rates. The protocol will ascertain: why, how, and under what conditions the integration of SRHR interventions into Zambian community health systems will optimise (or not) acceptability and adoption of SRHR services. This study is embedded within a randomized controlled trial - "Research Initiative to Support the Empowerment of Girls (RISE)"- which aims to reduce adolescent girl pregnancies and marriages through a package of interventions including economic support to families, payment of school fees to keep girls in school, pocket money for girls, as well as youth club and community meetings on reproductive health. METHODS: This is a multiple-case study design. Data will be collected from schools, health facilities and communities through individual and group interviews, photovoice, documentary review, and observations. The study process will involve 1) developing an initial causal theory that proposes an explanation of how the integration of a community-based intervention that aimed to integrate adolescent SRHR into the community health system may lead to adolescent-friendly services; 2) refining the causal theory through case studies; 3) identifying contextual conditions and mechanisms that shape the integration process; and 4) finally proposing a refined causal theory and set of recommendations to guide policy makers, steer further research, and inform teaching programmes. DISCUSSION: The study will document relevant values as well as less formal and horizontal mechanisms which shape the integration process of SRHR interventions at community level. Knowledge on mechanisms is essential for guiding development of strategies for effectively facilitating the integration process, scaling up processes and sustainability of interventions aimed at reducing SRH problems and health inequalities among adolescents.

Seroprevalence and determinants of toxoplasmosis in pregnant women attending antenatal clinic at the university teaching hospital, Lusaka, Zambia.

BACKGROUND: Toxoplasmosis is a neglected zoonotic disease which is prevalent among pregnant women especially in Africa. This study aimed to determine the seroprevalence and determinants of the disease among pregnant women attending antenatal clinic at the University Teaching Hospital (UTH). METHOD: A cross-sectional study was employed where 411 pregnant women attending antenatal clinic at UTH were interviewed using closed ended questionnaires. Their blood was also tested for Toxoplasma gondii IgG and IgM antibodies using the OnSite Toxo IgG/IgM Combo Rapid test cassettes by CTK Biotech, Inc, USA. RESULT: The overall seroprevalence of the infection (IgG) was 5.87%. There was no seropositive IgM result. Contact with cats showed 7.81 times the risk of contracting the infection in the pregnant women and being a farmer/being involved in construction work showed 15.5 times likelihood of contracting the infection. Socio-economic status of the pregnant women also presented an inverse relationship (showed association) with the infection graphically. However, though there were indications of association between contact with cats, employment type as well as socioeconomic status of the pregnant women with the infection, there was not enough evidence to suggest these factors as significant determining factors of Toxoplasma gondii infection in our study population. CONCLUSION: There is a low prevalence of Toxoplasma gondii infection among pregnant women in Lusaka, Zambia. Screening for the infection among pregnant women can be done once or twice during pregnancy to help protect both mother and child from the disease. Health promotion among women of child bearing age on the subject is of immense importance in order to help curb the situation. Further studies especially that of case-control and cohort studies should be carried out in the country in order to better ascertain the extent of the condition nationwide.

Education for primary health care in Africa.

No abstract available.

Etiologic pattern of genital ulcers in Lusaka, Zambia: has chancroid been eliminated?

BACKGROUND: Genital ulcers are a public health problem in developing countries. The World Health Organization recommends the use of syndromic guidelines for sexually transmitted infection treatment in resource-constrained countries. Monitoring local etiologies provides information that may aid policy for sexually transmitted infection treatment. We investigated the etiology of genital ulcer disease among outpatients in Lusaka, Zambia. METHODOLOGY: Swabs from genital ulcers of 200 patients were tested using polymerase chain reaction for Treponema pallidum, herpes simplex virus types 1 (HSV-1) and 2 (HSV-2), Haemophilus ducreyi, and Chlamydia trachomatis. RESULTS: The prevalence of the detected pathogens was as follows; HSV-2, 28%; T. pallidum, 11.5%; C. trachomatis, 3%; HSV-1, 0.5%; and H. ducreyi, 0%. Coinfection with HSV-2 and T. pallidum was 1.5%, and coinfection of HSV-2 and C. trachomatis was 1%. In 55% of the patients, no etiologic diagnosis could be established. CONCLUSIONS: H. ducreyi was not detected, whereas HSV-2 and T. pallidum were the commonest pathogens. Nondetection of H. ducreyi requires further studies. If the present findings are validated, treatment guidelines would require to be revised in Zambia.

Declining syphilis trends in concurrence with HIV declines among pregnant women in Zambia: observations over 14 years of national surveillance.

BACKGROUND: Zambia has a serious HIV epidemic and syphilis infection remains prevalent in the adult population. We investigated syphilis trends using national antenatal clinic (ANC) sentinel surveillance data in Zambia and compared the findings with population-based data. METHODS: The analyses are based on ANC data from 22 sentinel sites from five survey rounds conducted between 1994 and 2008. The data comprised information from interviews and syphilis and HIV test results. The syphilis estimates for 2002 and 2008 were compared with data from the Demographic and Health Surveys 2001/2002 and 2007, which are nationally representative data, and also included syphilis testing and HIV. RESULTS: The overall syphilis prevalence dropped during the period 1994-2008 among both urban and rural women aged 15 to 49 years (9.8% to 2.8% and 7.5% to 3.2%, respectively). However, provincial variations were striking. The decline was steep irrespective of educational level, but among those with the highest level the decline started earlier and was steeper than among those with low education. The comparison with Zambia Demographic and Health Surveys 2001/2002 and 2007 findings also showed an overall reduction in syphilis prevalence among urban and rural men and women in the general population. CONCLUSIONS: The syphilis prevalence declined by 65% in urban and 59% in rural women. Provincial variations need to be further studied to better guide specific sexually transmitted infection prevention and control programmes in different geographical settings. The national ANC-based HIV and syphilis surveillance system provided good proxies of syphilis prevalence and trends.

Risk factors, healthcare-seeking and sexual behaviour among patients with genital ulcers in Zambia.

BACKGROUND: Genital ulcers (GU) are associated with an increased risk of HIV transmission. Understanding risk factors for genital ulcers and sexual behaviour patterns after onset of symptoms and health seeking behaviour among GU-patients can provide useful information to aid design effective prevention strategies for genital ulcers. We investigated risk factors of self-reported GUs and care-seeking in the general population, and assessed GU patients regarding past care-seeking, recent sexual behaviour and partner awareness of the disease. METHODS: We analysed national data on genital ulcers from the 2007 Zambia Demographic and Health Survey, and data from a cross-sectional survey of genital ulcer patients from primary health care facilities in Lusaka, Zambia. RESULTS: The prevalence of GU in 2007 in the general population of Lusaka was 3.6%. Important predictors for genital ulcers were age 25-29 years, being widowed/separated/divorced and having a high number of life-time sexual partners. No differences in care-seeking were observed by residence, wealth and gender, and 60% of the respondents sought care from public health facilities. Among patients with GUs in Lusaka, 14% sought care >2 weeks after symptom onset. Forty-two percent were not aware of their HIV status, 57% reported sex after onset of symptoms and only 15% reported consistent condom use. CONCLUSIONS: Low awareness of HIV status despite high probability of being infected and low condom use after onset of genital ulcer symptoms leads to a high potential for transmission to sexual partners. This, combined with the fact that many patients with GUs delayed seeking care, shows a need for awareness campaigns about GUs and the importance of abstinence or use of condoms when experiencing such symptoms.

Resident perception on the impact of point-of-care ultrasound in clinical care at a family medicine training program in Zambia.

BACKGROUND: Patient access to necessary medical imaging in low- and middle-income countries (LMICs) remains a major obstacle, complicating clinician decision-making and compromising patient outcomes. METHODS: We implemented a longitudinal point-of-care ultrasound (POCUS) training program at a new Family Medicine residency in Zambia and subsequently evaluated residents' perceptions on the impact of POCUS in patient care. Data were documented by the scanning resident via a post-scan survey, which assessed if/how the scan assisted in medical management, and if/how the scan changed that management. The primary endpoint was frequency of scans assisting and changing management. Data were summarized using descriptive statistics. RESULTS: Over the 1-year study period, 366 patient encounters occurred in which POCUS was utilized, resulting in a total of 542 unique POCUS scans. POCUS assisted in decision-making in 95.6% (350/366) of patient encounters, most commonly by helping to determine a diagnosis. POCUS changed management in 65.8% (235/357) of patient encounters, most commonly leading to a medication change. CONCLUSIONS: Zambian resident physicians perceived POCUS to be very helpful in their clinical decision-making. These data support the need to advance POCUS education at the residency level throughout LMICs, which may be an ideal strategy to promote widespread utilization of POCUS in low-resource settings globally.

Epidemiology of Cancers in Zambia: A significant variation in Cancer incidence and prevalence across the nation.

BACKGROUND: Cancer is one of the leading causes of death worldwide. More than two-thirds of deaths due to cancers occur in low- and middle-income countries where Zambia belongs. This study, therefore, sought to assess the epidemiology of various types of cancers in Zambia. METHODS: We conducted a retrospective observational study using the Zambia National Cancer Registry (ZNCR) population based data from 2007 to 2014. Zambia Central Statistics Office (CSO) demographic data were used to determine catchment area denominator used to calculate prevalence and incidence rates of cancers. Age-adjusted rates and case fatality rates were estimated using standard methods. We used a Poisson Approximation for calculating 95% confidence intervals (CI). RESULTS: The seven most cancer prevalent districts in Zambia were Luangwa, Kabwe, Lusaka, Monze, Mongu, Katete and Chipata. Cervical cancer, prostate cancer, breast cancer and Kaposi's sarcoma were the four most prevalent cancers as well as major causes of cancer related deaths in Zambia. Age adjusted rates and 95% CI for these cancers were: cervix uteri (186.3; CI = 181.77 - 190.83), prostate (60.03; CI = 57.03 - 63.03), breast (38.08; CI = 36.0 - 40.16) and Kaposi's sarcoma (26.18; CI = 25.14 - 27.22). CFR were: Leukaemia (38.1%); pancreatic cancer (36.3%); lung cancer (33.3%); and brain, nervous system (30.2%). The cancer population was associated with HIV with p-value of 0.000 and a Pearson correlation coefficient of 0.818. CONCLUSIONS: The widespread distribution of cancers with high prevalence observed in the southern zone may have been perpetrated by lifestyle and sexual culture (traditional male circumcision known to prevent STIs is practiced in the northern belt) as well as geography. Intensifying cancer screening and early detection countrywide as well as changing the lifestyle and sexual culture would greatly help in the reduction of cancer cases in Zambia.

Epidemiology of Kaposi's sarcoma in Zambia, 2007 - 2014.

BACKGROUND: Kaposi's sarcoma (KS) is the most prevalent HIV and AIDS-associated cancer in the world. Zambia has been considered as part of the "KS belt", where endemic KS has been prevalent. This study, therefore, aimed to present the descriptive epidemiology of Kaposi's sarcoma in Zambia from 2007 - 2014. METHODS: We conducted the descriptive epidemiology of Kaposi's sarcoma in Zambia nested on two data sources; the Zambia National Cancer Registry (ZNCR) Kaposi's sarcoma (KS) data, and population-based HIV data from the Zambia National AIDS Council (NAC). Central Statistics Office (CSO) demographic data were used to determine the prevalence and annual incidence of KS. KS sample was 2521while HIV data from NAC were already population-based (HIV impact assessment survey). We used Microsoft Excel and SPSS version 21 in graphical computation and statistical analyses. RESULTS: Both HIV and KS were highly prevalent in Lusaka, Central, and Southern provinces. ART coverage ranged from 40% - 60%; HIV prevalence was 14.9% in females and 9.5% in males while KS prevalence was 13/100,000 in females and 21/100,000 in males. HIV prevalence was associated with KS prevalence with r = 0.827 and a p-value of 0.001 in males, and r = 0.898 with a p-value of 0.000 in females. There were 61% confirmed HIV seropositive KS, 18% confirmed HIV seronegative KS and 21% unknown HIV status KS. CONCLUSION: The high prevalence of KS in Zambia is as a result of the high prevalence of HIV. The identified two key interventions for the reduction of KS morbidity are; reducing HIV infection rate and improving ART coverage across the country.

Trends and factors associated with acute respiratory infection among under five children in Zambia: evidence from Zambia's demographic and health surveys (1996-2014).

INTRODUCTION: acute respiratory infection (ARI) is one of the leading causes of morbidity and mortality among children under the age of five years globally accounting for 16% of deaths. In Zambia, ARI accounts for 30-40% of children's outpatient attendance and 20-30% of hospital admissions. We assessed trends and factors associated with ARI among under-five children in Zambia from 1996 to 2014. METHODS: we analysed the Zambia demographic and health survey data for 1996, 2002, 2007 and 2014 of under five children and their mothers. We extracted data using a data extraction tool from the women's file. We analysed trends using chi square for trends. We conducted a complex survey multivariable logistic regression analysis, reported adjusted odds ratios (AOR) 95% confidence intervals (CI) and p-values. RESULTS: we included a total of 6,854 and 2,389 (8%) had symptoms consistent with ARI. A 2% upward trend was noted between the 1996 and 2002 surveys but a sharp decline of 10% occurred in 2007. The chi2 trend test was significant p < 0.001. Children whose mothers had secondary or higher education were less likely to have ARI (AOR 0.30 95% CI 0.15-0.58) compared to those with no education. Underweight children had 1.50 times increased odds of having ARI (AOR 1.50 95% CI 1.25 - 1.68) compared with children who were not. Use of biomass fuels such as charcoal (AOR 2.67 95% CI 2.09 - 3.42) and wood (2.79 95% CI 2.45 -3.19) were associated with high odds for ARI compared to electricity. CONCLUSION: the prevalence of ARI has declined in Zambia from 1996 to 2014. Factors associated with occurrence of ARI included being a child under one year, underweight, use of biomass fuel such as charcoal and wood. Interventions to reduce the burden of ARI should be targeted at scaling up nutrition programs, as well as promoting use of cleaner fuels.

Place of Delivery Associated With Postnatal Care Utilization Among Childbearing Women in Zambia.

OBJECTIVE: Postnatal care (PNC) utilization is critical to the prevention of maternal morbidity and mortality. Despite its importance, the proportion of women utilizing this service is still low in Zambia. We investigated if place of delivery was associated with PNC utilization in the first 48 h among childbearing women in Zambia. METHODS: Data from the 2013/14 Zambia Demographic and Health Survey for women, aged 15-49 years, who reported giving birth in the 2 years preceding the survey was used. The data comprised of sociodemographic and other obstetric data, which were cleaned, recoded, and analyzed using STATA version 13 (Stata Corporation, College Station, TX, USA). Multivariate logistic regression was used to examine the association of place of delivery and other background variables. RESULTS: Women who delivered in a health facility were more likely to utilize PNC in the first 48 h compared to those who did not deliver in a health facility: government hospital (AOR 7.24, 95% CI 4.92-11.84), government health center/clinic (AOR 7.15 95% CI 4.79-10.66), other public sector (AOR 23.2 95% CI 3.69-145.91), private hospital/clinic (AOR 10.08 95% CI 3.35-30.35), and Mission hospital/clinic (AOR 8.56 95% CI 4.71-15.53). Additionally, women who were attended to by a skilled personnel during delivery of the baby were more likely to utilize PNC (AOR 2.30, 95% CI 1.57-3.37). Women from rural areas were less likely to utilize PNC in the first 48 h (AOR 0.70, 95% CI 0.53-0.90). CONCLUSION: Place of delivery was found to be linked with PNC utilization in this population although access to health care is still driven by inequity-related dynamics and imbalances. Given that inequity stresses are heaviest in the rural and poor groups, interventions should aim to reach this group. SIGNIFICANCE: The study results will help program managers to increase access to health facility delivery and direct interventional efforts toward the affected subpopulations, such as the young and rural women. Furthermore, results will help promote maternal health education on importance of health facility delivery and advise policy makers and program implementers.

Hepatitis B vaccination coverage and the determinants of vaccination among health care workers in selected health facilities in Lusaka district, Zambia: an exploratory study.

BACKGROUND: Hepatitis B is a viral infection of the liver and causes both acute and chronic disease. It is transmitted through contact with an infected person's bodily fluids. It is an occupational hazard for healthcare workers and can be prevented by the administration of a vaccine. It is recommended that healthcare workers be vaccinated against vaccine preventable diseases including hepatitis B. The study objective was to determine the prevalence and determinants of hepatitis B vaccination among healthcare workers in selected health facilities in Lusaka. METHODS: The study took place in seven health facilities across Lusaka district in Zambia. A total sample size of 331 healthcare workers was selected of which; 90 were nurses, 88 were doctors, 86 were laboratory personnel and 67 were general workers. A self-administered structured questionnaire was given to a total of 331 healthcare workers. Investigator led stepwise approach was used to select the best predictor variables in a multiple logistic regression model and all analyses were performed using STATA software, version 12.1 SE (Stata Corporation, College Station, TX, USA). RESULTS: Only 64(19.3%) of the healthcare workers were vaccinated against hepatitis B, with 35 (54.7%) of these being fully vaccinated and 29 (45.3%) partially vaccinated. Analysis showed that; age of the healthcare worker, sharp injuries per year and training in infection control were the variables that were statistically significant in predicting a healthcare worker's vaccination status. CONCLUSION: It is reassuring to learn that healthcare workers have knowledge regarding hepatitis B and the vaccine and are willing to be vaccinated against it. Health institutions should bear the cost for vaccinating staff and efforts should be made for appropriate health education regarding hepatitis B infection and its prevention. Establishment of policies on compulsory hepatitis B vaccination for healthcare workers in Zambia is recommended.

Factors influencing breast milk HIV RNA viral load among Zambian women.

In a longitudinal cohort study we investigated factors contributing to breast milk HIV RNA viral load among lactating women in Lusaka, Zambia. Detailed data from 135 HIV-infected women were collected by questionnaires concerning postpartum maternal and infant health and infant feeding practice. Maternal blood was collected during pregnancy and at 6 weeks postpartum. Milk samples collected from each breast at 10 days and 6 weeks postpartum plus a subset collected at other time points were analyzed for HIV RNA viral load. Increased milk viral load was associated in univariate analyses with maternal symptoms of poor health, raised plasma alpha(1)-acid glycoprotein (AGP) at week 6, raised milk sodium/potassium (Na/K) ratio, postpartum need for antibiotics, preterm delivery, and low birth weight infants. In a multiple regression 49% of variability in mean milk viral load was explained by milk Na/K ratio and need for antibiotics, with borderline contributions from plasma AGP and plasma viral load. Maternal blood hemoglobin or receipt of iron supplements and infant feeding variables such as changing the infant's diet by moving from exclusive to nonexclusive breastfeeding or adding solid foods were not associated with milk viral load. Thus maternal health was the main factor contributing to milk viral load. The lack of effect of feeding practices on milk viral load and the previously determined association of poor maternal health with reduced duration of exclusive breastfeeding in this cohort suggest the relation between exclusive breastfeeding and decreased HIV transmission may be secondary to poor maternal health.

Higher Educational Attainment Associated with Optimal Antenatal Care Visits among Childbearing Women in Zambia.

OBJECTIVE: Attendance of at least four antenatal care (ANC) visits over the period of pregnancy has been accepted by World Health Organization to comprise the optimal and adequate standard of ANC because of its positive association with good maternal and neonatal outcomes during the prenatal period. Despite free ANC being provided, many pregnant women have been found not to meet this minimum number of ANC visits in Zambia. We investigated if educational attainment is associated with optimal ANC visits among childbearing women in Zambia. METHODS: Data stem from the 2007 Zambia Demographic and Health Survey for women, aged 15-49 years, who reported ever having been pregnant in the 5 years preceding the survey. The linked data comprised sociodemographic and other obstetrical data, which were cleaned, recoded, and analyzed using STATA version 12 (Stata Corporation, College Station, TX, USA). Multivariate logistic regression was used to examine the association of educational attainment and other background variables. RESULTS: Women who had higher education level were more likely to attend at least four ANC visits compared to those with no education (AOR 2.8, 95% CI 1.51-5.15; p = 0.001); this was especially true in the urban areas. In addition, women with partners with higher education level were also more likely to have optimal ANC attendance (OR 2.0, 95% CI 1.3-3.1; p = 0.002). CONCLUSION: Educational attainment-associated differentials found to be linked with optimal ANC attendance in this population suggests that access to health care is still driven by inequity-related dynamics and imbalances. Given that inequity stresses are heaviest in the uneducated and probably rural and poor groups, interventions should aim to reach this group. SIGNIFICANCE: The study results will help program managers to increase access to ANC services and direct interventional efforts towards the affected subpopulations, such as the young, uneducated, and rural women. Furthermore, results will help promote maternal health education and advise policy makers and program implementers.

Effectiveness of a girls' empowerment programme on early childbearing, marriage and school dropout among adolescent girls in rural Zambia: study protocol for a cluster randomized trial.

BACKGROUND: Adolescent pregnancies pose a risk to the young mothers and their babies. In Zambia, 35% of young girls in rural areas have given birth by the age of 18 years. Pregnancy rates are particularly high among out-of-school girls. Poverty, low enrolment in secondary school, myths and community norms all contribute to early childbearing. This protocol describes a trial aiming to measure the effect on early childbearing rates in a rural Zambian context of (1) economic support to girls and their families, and (2) combining economic support with a community intervention to enhance knowledge about sexual and reproductive health and supportive community norms. METHODS/DESIGN: This cluster randomized controlled trial (CRCT) will have three arms. The clusters are rural schools with surrounding communities. Approximately 4900 girls in grade 7 in 2016 will be recruited from 157 schools in 12 districts. In one intervention arm, participating girls and their guardians will be offered cash transfers and payment of school fees. In the second intervention arm, there will be both economic support and a community intervention. The interventions will be implemented for approximately 2 years. The final survey will be 4.5 years after recruitment. The primary outcomes will be "incidence of births within 8 months of the end of the intervention period", "incidence of births before girls' 18th birthday" and "proportion of girls who sit for the grade 9 exam". Final survey interviewers will be unaware of the intervention status of respondents. Analysis will be by intention-to-treat and adjusted for cluster design and confounders. Qualitative process evaluation will be conducted. DISCUSSION: This is the first CRCT to measure the effect of combining economic support with a community intervention to prevent adolescent childbearing in a low- or middle-income country. We have designed a programme that will be sustainable and feasible to scale up. The findings will be relevant for programmes for adolescent reproductive health in Zambia and similar contexts. TRIAL REGISTRATION: ISRCTN registry: ISRCTN12727868 , (4 March 2016).

Factors affecting the duration of exclusive breastfeeding among HIV-infected and -uninfected women in Lusaka, Zambia.

Exclusive breastfeeding (EBF) is optimal for infant health and is associated with decreased risk of mother-to-child HIV transmission compared with mixed feeding of breast milk and other foods. To investigate why many women stop EBF before the recommended 6 months, maternal and infant health and infant-feeding data were collected from 177 HIV-infected and 177-uninfected Zambian women regularly from 34 weeks gestation to 16 weeks postpartum. Despite strong support for good breastfeeding practice, only 37% of women were still EBF at week 16. Factors significantly associated with shorter duration of EBF were primiparity, maternal systemic illness, and infant length at 6 weeks. The results suggest that the association of EBF with lower rates of mother-to-child HIV transmission may not be causal but may be secondary to the reduced duration of EBF associated with poor maternal or infant health. Programs supporting EBF should include support for maternal health.

Decline in HIV prevalence among young women in Zambia: national-level estimates of trends mask geographical and socio-demographic differences.

BACKGROUND: A decline in HIV incidence has been reported in Zambia and a number of other sub-Saharan countries. The trend of HIV prevalence among young people is a good marker of HIV incidence. In this study, different data sources are used to examine geographical and sub-population group differentials in HIV prevalence trends among men and women aged 15-24 years in Zambia. DESIGN AND METHODS: We analysed ANC data for women aged 15-24 years from 22 sentinel sites consistently covered in the period 1994-2008, and HIV data for young men and women aged 15-24 years from the ZDHS 2001/2 and 2007. In addition, we systematically reviewed peer-reviewed articles that have reported findings on HIV prevalence and incidence among young people. FINDINGS: Overall trends of the ANC surveillance data indicated a substantial HIV prevalence decline among young women in both urban and rural areas. However, provincial declines differed substantially, i.e. between 10% and 68% among urban women, and from stability to 86% among rural women. Prevalence declines were steeper among those with the highest educational attainments than among the least educated. The ZDHS data indicated a significant reduction in prevalence between the two survey rounds among young women only. Provincial-level ZDHS changes were difficult to assess because the sample sizes were small. ANC-based trend patterns were consistent with those observed in PMTCT-based data (2002-2006), whereas population-based surveys in a selected urban community (1995-2003) suggested that the ANC-based data underestimated the prevalence declines in the general populations of both young both men and women. CONCLUSION: The overall HIV prevalence declined substantially among young women in Zambia and this is interpreted as indicating a decline in HIV incidence. It is noteworthy that overall national trends masked substantial differences by place and by educational attainment, demonstrating critical limitations in the current focus on overall country-level trends in epidemiological reports.