Effects of the ECHO tele-mentoring program on HIV/TB service delivery in health facilities in Zambia: a mixed-methods, retrospective program evaluation.

BACKGROUND: In the quest to ensure that quality healthcare is provided to all citizens through building healthcare worker capacity and extending reach for expert services, Zambia's Ministry of Health (MoH) in collaboration with its partners PEPFAR through the CDC and HRSA, began to implement the Extension for Community Healthcare Outcomes (ECHO) tele-mentoring program across the country through the Health Workers for the 21st Century (HW21) Project and University Teaching Hospital HIV/AIDS Project (UTH-HAP). This ECHO tele-mentoring approach was deemed pivotal in helping to improve the human immunodeficiency virus (HIV) service delivery capacity of health care workers. METHOD: The study used a mixed method, retrospective program evaluation to examine ECHO participants' performance in the management of HIV/AIDS patients in all the 10 provinces of Zambia. CASE PRESENTATION: A phenomenological design was applied in order to elicit common experiences of ECHO users through focus group discussions using semi-structured facilitation guides in four provinces (Eastern, Lusaka, Southern and Western) implementing ECHO tele-mentoring approach. These provinces were purposively selected for this study. From which, only participants that had a monthly frequency of ECHO attendance of ten (10) and above were selected. The participants were purposively selected based on the type of cadre as well as facility type so that the final sample consisted of Doctors, Nurses, Midwives, Clinical Officers, Medical Licentiates, Pharmacy and Laboratory Personnel. All sessions were audio recorded and transcribed by the data collectors. A thematic content analysis approach was adopted for analyzing content of the interview's transcripts. RESULTS: Enhanced knowledge and skills of participants on HIV/TB improved by 46/70 (65.7%) in all provinces, while 47/70 (67.1%) of the participants reported that ECHO improved their clinical practice. Further, 12/70 (17.1%) of participants in all provinces reported that presenter/presentation characteristics facilitated ECHO implementation and participation. While, 15/70(21.4%) of the participants reported that ownership of the program had contributed to ECHO implementation and participation. Coordination, another enabler accounted for 14/70 (20%). Inclusiveness was reported as a barrier by 16/70 (22.8%) of the participants while 6/70 (8.6%) of them reported attitudes as a barrier (8.6%) to ECHO participation. In addition, 34/70 (48.6%) reported poor connectivity as a barrier to ECHO implementation and participation while 8/70 (11.5%) of the participants reported that the lack of ownership of the ECHO program was a barrier. 22/70 (31.4%) reported that increased workload was also a barrier to the program's implementation. CONCLUSION: Consistent with its logical pathway model, healthcare providers' participation in ECHO sessions and onsite mentorship contributed to improved knowledge on HIV/TB among health care providers and patient health outcomes. In addition, barriers to ECHO implementation were intrinsic to the program its self, such as coordination, presenter and presentation characteristics other barriers were extrinsic to the program such as poor connectivity, poor infrastructure in health facilities and negative attitudes towards ECHO. Improving on intrinsic factors and mitigating extrinsic factors may help improve ECHO outcomes and scale-up plans.

Attachment goes to court: child protection and custody issues.

Attachment theory and research are drawn upon in many applied settings, including family courts, but misunderstandings are widespread and sometimes result in misapplications. The aim of this consensus statement is, therefore, to enhance understanding, counter misinformation, and steer family-court utilisation of attachment theory in a supportive, evidence-based direction, especially with regard to child protection and child custody decision-making. The article is divided into two parts. In the first, we address problems related to the use of attachment theory and research in family courts, and discuss reasons for these problems. To this end, we examine family court applications of attachment theory in the current context of the best-interest-of-the-child standard, discuss misunderstandings regarding attachment theory, and identify factors that have hindered accurate implementation. In the second part, we provide recommendations for the application of attachment theory and research. To this end, we set out three attachment principles: the child's need for familiar, non-abusive caregivers; the value of continuity of good-enough care; and the benefits of networks of attachment relationships. We also discuss the suitability of assessments of attachment quality and caregiving behaviour to inform family court decision-making. We conclude that assessments of caregiver behaviour should take center stage. Although there is dissensus among us regarding the use of assessments of attachment quality to inform child custody and child-protection decisions, such assessments are currently most suitable for targeting and directing supportive interventions. Finally, we provide directions to guide future interdisciplinary research collaboration.

Predicting Zambian Grandmothers' Sensitivity Toward Their Grandchildren.

Whereas child care by grandmothers is widespread in the African cultural context, few studies have examined predictors of the quality of grandmaternal care in Africa. In the current study, we collected observational data to investigate predictors of the quality of grandmother-grandchild interactions in Zambia. Data were collected from 46 grandmothers and their 12 to 27-month-old infant grandchildren. The results revealed that grandmothers with fewer children and those who enjoyed the grandparenting tasks more were more sensitive in their interactions with their grandchildren. Unexpectedly, parenting beliefs favoring sensitive parenting predicted lower observed sensitivity in grandmothers. Further, grandmothers with a more individualistic cultural orientation were more intrusive toward their grandchildren. The results underscore the importance of time and emotional resources as predictors of sensitive parenting among grandmothers.

Infant-mother and infant-sibling attachment in Zambia.

This study, the first in Zambia using the Strange Situation Procedure (SSP) to observe attachment relationships and the "very first" observational study of infant-sibling attachment, examined patterns of infant-mother and infant-sibling attachment, and tested their association. We included siblings who were substantially involved in caregiving activities with their younger siblings. We hypothesized that infants would develop attachment relationships to both mothers and siblings; the majority of infants would be classified as securely attached to both caregivers, and infant-mother and infant-sibling attachment would be unrelated. The sample included 88 low-income families in Lusaka, Zambia (average of 3.5 children; SD = 1.5). The SSP distributions (infant-mother) were 59% secure, 24% avoidant and 17% resistant, and 46% secure, 20% avoidant, 5% resistant and 29% disorganized for three- and four-way classifications, respectively. The infant-sibling classifications were 42% secure, 23% avoidant and 35% resistant, and 35% secure, 23% avoidant, 9% resistant and 33% disorganized for three- and four-way classifications, respectively. Infant-mother and infant-sibling attachment relationships were not associated.

Using Implementation Research to Inform Scaling of Parenting Programs: Independently Conducted Case Studies from Zambia and Bhutan.

Two case studies of parenting programs for parents of children 0 to 36 months of age, developed and implemented by Save the Children/Ministry of Health/Khesar Gyalpo University in Bhutan and UNICEF Zambia, were conducted by an independent research group. The focus was on how program delivery and scale-up were revised on the basis of feedback from implementation research. Feedback on workforce delivery quality was based on observations of deliveries using a monitoring form, as well as survey and interview data collected from the workforce. In-depth interviews with the resource team during the fourth year of implementation revealed how the feedback was used to address horizontal and vertical scaling. Delivery quality was improved in some cases by revising the delivery manual, offering refresher courses, and instituting regular monitoring. Scaling challenges in Zambia included slow progress with regard to reaching families in the two districts, which they addressed by trialing group sessions, and stemming workforce attrition. The challenges in Bhutan were low attendance and reducing the workload of providers. Vertical scaling challenges for both countries concerned maintaining demand through continuous advocacy at community and government levels to sustain financing and to show effectiveness in outcomes.

Parent-mediated intervention training for caregivers of children with developmental differences in Zambia.

BACKGROUND: Lower- and middle-income countries (LAMICs) are under-resourced and have limited intervention services for children with developmental differences and their families. A logical method to address service gaps within resource-scarce contexts is to train caregivers as interventionists, specifically using empirically-supported parent-mediated Naturalistic Developmental Behavioral Interventions (P-M NDBIs; Kasari et al., 2010; Ingersoll & Wainer, 2013). AIMS: The study implemented the first P-M NDBI in Zambia and aimed to train caregivers and improve children's social-communication skills. METHODS/PROCEDURES: The current study utilized a mixed-methods, pre-post design and implemented Project ImPACT (Ingersoll & Dvortcsak, 2010, 2019). Participants included 19 Zambian caregivers of children (n = 20) with developmental differences including autism spectrum condition, Down syndrome, and cerebral palsy. OUTCOMES/RESULTS: Findings indicated that children's language skills and pretend play skills significantly improved from pre- to post-assessment, and caregivers most frequently used intervention strategies for modeling communication and prompting communication. CONCLUSIONS/IMPLICATIONS: The success and feasibility of implementing Project ImPACT in Zambia, and recommendations for culturally adapting and implementing P-M NDBIs in LAMICs, were discussed.