Evaluating the Appropriateness of Podcasts to Improve the Knowledge and Awareness of Selected Health Topics Among Undergraduate General Nursing Students: Protocol for an International Feasibility Study.

BACKGROUND: Podcasts have proven to be a successful alternative source of educational material for students. Given the ability to listen to podcasts 24/7 and while on the go, this technology has the potential to provide informative and educational material to a large number of people at any given time. Podcasts are usually freely available on commonly used mobile devices, such as smartphones, laptops, and tablets. OBJECTIVE: This paper describes the impact of health-related podcasts as an intervention tool to support the knowledge and awareness of nursing students on a given topic. METHODS: Pre- and postpodcast questionnaires will gather data regarding the participants' knowledge and awareness of two topics-gestational diabetes and mental health. This intervention will be tested on general nursing undergraduate students. The total number of students (N=2395) from the participating universities are broken down as follows: (1) University College Cork (n=850) and the University of Galway (n=450) in Ireland, (2) Mzuzu University in Malawi (n=719), and (3) University of Fort Hare in South Africa (n=376). RESULTS: The study received ethical approval from the University College Cork Ethics Committee (2022-027A1). The approval obtained from University College Cork sufficed as ethics coverage for the University of Galway in Ireland. Ethics approval was also received from the Mzuzu University Research Ethics Committee (ID MZUNIREC/DOR/23/28) and the Inter-Faculty Research Ethics Committee of the University of Fort Hare (ID CIL002-21). Data collection is currently underway and will continue until the end of February 2024. The quantitative and qualitative data are expected to be analyzed in March 2024. CONCLUSIONS: Results from this study will allow for an investigation into the impact of podcasts in different settings: a high-income country (Ireland), an upper-middle-income country (South Africa), and a low-to-middle-income country (Malawi). The data gathered from this feasibility study will provide more clarity on the potential utility of podcasts as an intervention tool. We will gather data regarding listener demographics (eg, country of residence, age, gender, and year of study). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50735.

Coronavirus Disease 2019 (COVID-19) Reinfection Rates in Malawi: A Possible Tool to Guide Vaccine Prioritisation and Immunisation Policies.

As the fight against the COVID-19 pandemic continues, reports indicate that the global vaccination rate is still far below the target. Understanding the levels of reinfection may help refocus and inform policymakers on vaccination. This retrospective study in Malawi included individuals and patients who tested for COVID-19 infections via reverse transcriptase polymerase chain reaction (rt-PCR) from the data at the Public Health Institute of Malawi (PHIM). We included all data in the national line list from April 2020 to March 2022. Upon review of 47,032 records, 45,486 were included with a reported 82 (0.18) reinfection representing a rate of 0.55 (95% CI: 0.44-0.68) per 100,000 person-days of follow-up. Most reinfections occurred in the first 90 to 200 days following the initial infection, and the median time to reinfection was 175 days (IQR: 150-314), with a range of 90-563 days. The risk of reinfection was highest in the immediate 3 to 6 months following the initial infection and declined substantially after that, and age demonstrated a significant association with reinfection. Estimating the burden of SARS-CoV-2 reinfections, a specific endurance of the immunity naturally gained, and the role played by risk factors in reinfections is relevant for identifying strategies to prioritise vaccination.

Six months survival and risk factors for attrition for patients detected with cryptococcal antigenemia through screening in Malawi.

MAIN OBJECTIVE: A cohort of adult Malawian people living with HIV (PLHIV) testing positive for cryptococcal antigenemia was observed and followed to determine the outcomes and risk factors for attrition. METHODS CONCEPT: Eligible PLHIV were enrolled at 5 health facilities in Malawi, representing different levels of health care. ART naïve patients, ART defaulters returning to care, and patients with suspected or confirmed ART treatment failure with CD4 <200 cells/µL or clinical stage 3 or 4 were enrolled and received CrAg tests on whole blood specimens from August 2018 to August 2019. Hospitalized PLHIV were enrolled and tested for CrAg from January 2019 to August 2019, regardless of CD4 or clinical stage. Patients with cryptococcal antigenemia were managed per Malawian clinical guidelines and were followed up for six months. Survival and risk factors for attrition at six months were assessed. RESULTS: A total of 2146 patients were screened and 112 (5.2%) had cryptococcal antigenemia. Prevalence ranged from 3.8% (Mzuzu Central Hospital) to 25.8% (Jenda Rural Hospital). Of the 112 patients with antigenemia, 33 (29.5%) were diagnosed with concurrent CM at the time of enrollment. Six-month crude survival of all patients with antigenemia (regardless of CM status) ranged from 52.3% (assuming lost-to-follow-up (LTFU) patients died) to 64.9% (if LTFU survived). Patients who were diagnosed with concurrent CM by CSF test had poor survival (27.3-39.4%). Patients with antigenemia who were not diagnosed with concurrent CM had 71.4% (if LTFU died)- 89.8% (if LTFU survived) survival at six months. In adjusted analyses, patients with cryptococcal antigenemia detected after admission to inpatient care (aHR: 2.56, 1.07-6.15) and patients with concurrent CM at the time of positive antigenemia result (aHR: 2.48, 1.04-5.92) had significantly higher hazard of attrition at six months. CONCLUSIONS: Overall, our findings indicate a need for routine access to CrAg screening and pre-emptive fluconazole treatment as a way to detect cryptococcal antigenemia and prevent CM in outpatient and inpatient settings. Rapid access to diagnosis and treatment for cryptococcal meningitis (CM) with gold-standard antifungals is needed to improve survival of patients with advanced HIV in Malawi.

Patient satisfaction with health care at a tertiary hospital in Northern Malawi: results from a triangulated cross-sectional study.

BACKGROUND: In 2016 the Malawi government embarked on several interrelated health sector reforms aimed at improving the quality of health services at all levels of care and attain Universal Health Coverage by 2030. Patient satisfaction with services is an important proxy measure of quality. We assessed patient satisfaction at a tertiary hospital in Northern Malawi to understand the current state. METHODS: We conducted exit interviews with patients aged ≥ 18 years using a 28 statement interviewer administered questionnaire. Patients were asked to express their level of agreement to each statement on a five-point Likert scale - strongly disagree to strongly agree, corresponding to scores of 1 to 5. Overall patient satisfaction was calculated by summing up the scores and dividing the sum by the number of statements. Mean score > 3 constituted satisfaction while mean score ≤ 3 constituted dissatisfaction. A χ2 test was used to assess the association between overall patient satisfaction and demographic variables, visit type and clinic consulted at alpha 0.05. Patient self-rated satisfaction was determined from a single statement that asked patients to rate their satisfaction with services on a five-point Likert scale. We also asked patients to mention aspects of hospital care that they did not like. Responses were summarized into major issues which are presented according to frequencies. RESULTS: Overall patient satisfaction was 8.4% (95% CI: 5.2 - 12.9%). Self-rated patient satisfaction was 8.9% (95% CI: 5.5 - 13.4%). There was no significant association between overall patient satisfaction and all predictor variables assessed. Patients raised six major issues that dampened their health care seeking experience, including health workers reporting late to work, doctors not listening to patients concerns and neither examining them properly nor explaining the diagnosis, shortage of medicines, diagnostics and medical equipment, unprofessional conduct of health workers, poor sanitation and cleanliness, and health worker behaviour of favouring relatives and friends over other patients. CONCLUSIONS: We found very low levels of patient satisfaction, suggesting that quality of services in the public health sector is still poor. It is, therefore, critical to accelerate and innovate the Ministry of Health's quality improvement initiatives to attain Malawi's health goals.

Histopathological profile of orbito-ocular cancers at a tertiary hospital in Northern Malawi: a retrospective cross-sectional study.

Objective: Orbito-ocular cancers are a common cause of morbidity and mortality in our population, yet these cancers have not been adequately described in Malawi. This study sought to describe the burden and histopathological profile of orbito-ocular cancers in Northern Malawi. Methods and Analysis: A retrospective review of pathology reports was done. Descriptive analyses were performed to summarise patients' demographic and clinical characteristics, and histopathological results. A binary logistic regression was used to explore the association between demographic variables, site of lesion and cancer. Results: 210 pathology reports of orbito-ocular biopsies were reviewed. 60.0% of patients were female. The majority (39.5%) of patients were in the 31 to 40 age group but overall mean age (±SD) was 34.81±15.9 years. Cancer was diagnosed in 84 (40.0%) patients. Squamous cell carcinoma constituted the majority (82.1%) of cancers followed by retinoblastoma at 7.1%. Orbito-ocular cancers were associated with HIV infection (OR5.9, 95% CI 2.0 to 17.2) and intraocular tumours were 8.3 times (OR 8.3, 95% CI 2.0 to 33.8) more likely to be malignant. However, squamous cell carcinoma was the only type of cancer found in patients with HIV infection and mostly affected the conjunctiva, constituting 94.4% of cancers affecting this site. Retinoblastoma on the other hand only affected children less than 10 years of age. Conclusion: Cancer constituted a substantial proportion of orbito-ocular lesions in our study population, with conjunctiva being the common site. This calls for improved capacity to prevent, diagnose and manage orbito-oracular cancers in Northern Malawi and similar settings.

Histopathological profile of cervical biopsies in northern Malawi: a retrospective cross-sectional study.

OBJECTIVES: According to the WHO (2014), cervical cancer is the second most common cancer in women globally. More than 85% of the global cervical cancer morbidity and mortality occur in low-income and middle-income countries and the highest risk region is in Eastern and Southern Africa. Malawi has the highest age-standardised rate of cervical cancer in the world. This study was carried out to determine the histopathological profile of cervical biopsies in a public tertiary hospital in Mzuzu, northern region of Malawi. SETTING: A public tertiary hospital in Mzuzu, northern region of Malawi. PARTICIPANTS: This was a retrospective study of all cervical biopsy specimen reports received in a public tertiary hospital in northern Malawi over a period of 5 years from July 2013 to June 2018. Demographic, clinical and diagnostic data were obtained from original histopathology reports. RESULTS: A total of 500 cervical biopsy reports were reviewed during the study period. The mean age of the patients was 41.99±12.5. Age ranged from 15 to 80 years. Cervicitis accounted for 46.0% (n=162) of the total non-malignant lesions seen, followed by cervical intraepithelial neoplasm, at 24.4% (n=86) and endocervical polyp, at 20.5% (n=72). Squamous cell carcinoma (SCC) accounted for 15.6% (n=78) of the total cervical biopsies studied and 85.7% of all total malignant lesions. Adenocarcinoma and undifferentiated carcinoma were 8.8% and 4.4%, respectively of the total malignant diagnosis. All patients with malignant lesions had HIV. CONCLUSION: Our study shows that cervicitis and SCC were most common among non-malignant and malignant cervical biopsies, respectively. Since the frequency of cervical cancer is high, there is a need to have well detailed national policies to be put in place to increase detection of preinvasive lesions in order to reduce the prevalence of cervical cancer.

Paediatric sickle cell disease at a tertiary hospital in Malawi: a retrospective cross-sectional study.

Introduction: Sickle cell disease (SCD) remains a major cause of childhood mortality and morbidity in Malawi. However, literature to comprehensively describe the disease in the paediatric population is lacking. Methods: A retrospective review of clinical files of children with SCD was conducted. Descriptive statistics were performed to summarise the data. χ2 or Fisher's exact test was used to look for significant associations between predictor variables and outcome variables (case fatality and length of hospital stay). Predictor variables that were significantly associated with outcome variables (p≤0.05) in a χ2 or Fisher's exact test were carried forward for analysis in a binary logistic regression. A multivariable binary logistic regression was used to identify covariates that independently predicted length of hospital stay. Results: There were 16 333 paediatric hospitalisations during the study period. Of these, 512 were patients with SCD representing 3.1% (95% CI: 2.9%- 3.4%). Sixty-eight of the 512 children (13.3%; 95% CI: 10.5% - 16.5%) were newly diagnosed cases. Of these, only 13.2% (95% CI: 6.2% - 23.6%) were diagnosed in infancy. Anaemia (94.1%), sepsis (79.5%) and painful crisis (54.3%) were the most recorded clinical features. The mean values of haematological parameters were as follows: haemoglobin (g/dL) 6.4 (SD=1.9), platelets (×109/L) 358.8 (SD=200.9) while median value for white cell count (×109/L) was 23.5 (IQR: 18.0-31.2). Case fatality was 1.4% (95% CI: 0.6% - 2.8%)and 15.2% (95% CI: 12.2% -18.6%) of the children had a prolonged hospital stay (>5 days). Patients with painful crisis were 1.7 (95% CI: 1.02 - 2.86) times more likely to have prolonged hospital stay than those without the complication. Conclusion: Anaemia, sepsis and painful crisis were the most common clinical features paediatric patients with SCD presented with. Patients with painful crisis were more likely to have prolonged hospital stay. Delayed diagnosis of SCD is a problem that needs immediate attention in this setting. Although somewhat encouraging, the relatively low in-hospital mortality among SCD children may under-report the true mortality from the disease considering community deaths and deaths occurring before SCD diagnosis is made.

Aetiology and severity of childhood pneumonia in primary care in Malawi: a cohort study.

OBJECTIVE: To determine the aetiology of community acquired pneumonia in children presenting to primary care in Northern Malawi, and to ascertain predictors for identification of children requiring hospitalisation. DESIGN: The BIOmarkers TO diagnose PnEumonia study was a prospective cohort study conducted from March to June 2016. SETTING: Primary care in Northern Malawi. PATIENTS: 494 children aged 2 -59 months with WHO defined pneumonia. MAIN OUTCOMES AND MEASURES: Number of children with bacterial infection identified and the sensitivity/specificity of WHO markers of severity for need for hospitalisation. RESULTS: 13 (2.6%) children had a bacterium consistent with pneumonia identified. A virus consistent with pneumonia was identified in in 448 (90.7%) of children. 56 children were admitted to hospital and two children died within 30 days. 442 (89.5%) received antibiotic therapy. Eleven children (2.6%) had HIV. WHO severity markers at baseline demonstrated poor sensitivity for the need for hospitalisation with a sensitivity of 0.303 (95% CI 0.188 to 0.441) and a specificity 0.9 (95% CI 0.868 to 0.926). A prediction rule to indicate the need for hospitalisation was developed. CONCLUSIONS AND RELEVANCE: The low rate of bacterial infection and high use of antibiotics in the setting of high immunisation rates highlights the changing profile of childhood pneumonia. Similarly, the markers of need for hospitalisation may have changed in the setting of extended immunisation. Further studies are required to examine this.

Considerations for Improved Mobile Health Evaluation: Retrospective Qualitative Investigation.

BACKGROUND: Mobile phone use and, consequently, mobile health (mHealth) interventions have seen an exponential increase in the last decade. There is an excess of 318,000 health-related apps available free of cost for consumers to download. However, many of these interventions are not evaluated and are lacking appropriate regulations. Randomized controlled trials are often considered the gold standard study design in determining the effectiveness of interventions, but recent literature has identified limitations in the methodology when used to evaluate mHealth. OBJECTIVE: The objective of this study was to investigate the system developers' experiences of evaluating mHealth interventions in the context of a developing country. METHODS: We employed a qualitative exploratory approach, conducting semistructured interviews with multidisciplinary members of an mHealth project consortium. A conventional content analysis approach was used to allow codes and themes to be identified directly from the data. RESULTS: The findings from this study identified the system developers' perceptions of mHealth evaluation, providing an insight into the requirements of an effective mHealth evaluation. This study identified social and technical factors which should be taken into account when evaluating an mHealth intervention. CONCLUSIONS: Contextual issues represented one of the most recurrent challenges of mHealth evaluation in the context of a developing country, highlighting the importance of a mixed method evaluation. There is a myriad of social, technical, and regulatory variables, which may impact the effectiveness of an mHealth intervention. Failure to account for these variables in an evaluation may limit the ability of the intervention to achieve long-term implementation and scale.

The added value of a mobile application of Community Case Management on referral, re-consultation and hospitalization rates of children aged under 5 years in two districts in Northern Malawi: study protocol for a pragmatic, stepped-wedge cluster-randomized controlled trial.

BACKGROUND: There is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities. Integrating a digitized version of paper-based methods of Community Case Management (CCM) could strengthen delivery, increasing urgent referral rates and preventing unnecessary re-consultations and hospital admissions. This trial aims to evaluate the added value of the Supporting LIFE electronic Community Case Management Application (SL eCCM App) compared to paper-based CCM on urgent referral, re-consultation and hospitalization rates, in two districts in Northern Malawi. METHODS/DESIGN: This is a pragmatic, stepped-wedge cluster-randomized trial assessing the added value of the SL eCCM App on urgent referral, re-consultation and hospitalization rates of children aged 2 months and older to up to 5 years, within 7 days of the index visit. One hundred and two health surveillance assistants (HSAs) were stratified into six clusters based on geographical location, and clusters randomized to the timing of crossover to the intervention using simple, computer-generated randomization. Training workshops were conducted prior to the control (paper-CCM) and intervention (paper-CCM + SL eCCM App) in assigned clusters. Neither participants nor study personnel were blinded to allocation. Outcome measures were determined by abstraction of clinical data from patient records 2 weeks after recruitment. A nested qualitative study explored perceptions of adherence to urgent referral recommendations and a cost evaluation determined the financial and time-related costs to caregivers of subsequent health care utilization. The trial was conducted between July 2016 and February 2017. DISCUSSION: This is the first large-scale trial evaluating the value of adding a mobile application of CCM to the assessment of children aged under 5 years. The trial will generate evidence on the potential use of mobile health for CCM in Malawi, and more widely in other low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02763345 . Registered on 3 May 2016.

Assessing the feasibility of mobile phones for follow-up of acutely unwell children presenting to village clinics in rural northern Malawi.

BACKGROUND: Patient follow-up is a routine component of clinical practice and valuable for evaluating the effectiveness of interventions, but because of the broad dispersion of health facilities and lack of standardised medical reporting in Malawi, collecting patient outcome data can be challenging. Increasing accessibility and affordability of mobile technology in resource-poor settings may facilitate patient follow-up in the community. The objective of this study was to evaluate the potential utility of mobile phones for collecting follow-up clinical data from parents or caregivers of acutely unwell under-5 children, for intervention evaluation purposes. METHODS: Parents' or caregivers' mobile phone numbers were obtained by health surveillance assistants (HSAs) during study enrollment. Guardians who provided a telephone number were contacted by the study team to establish re-consultations or hospitalisations of their child(ren) within 14 days of recruitment. Health records at village clinics and higher-level health facilities were hand-searched to identify or confirm presentations and abstract clinical data. RESULTS: 87 out of 149 (58.4%) guardians provided a mobile telephone number, of whom the study team could contact 44 (29.5%). Seven guardians stated they took their child for further treatment: three of these returned to village clinics and four presented to secondary care facilities; attendance could only be confirmed from health records for one child. CONCLUSIONS: With continued expansion of cellular network coverage and mobile ownership in Malawi, mobile phones may facilitate collection of patient outcomes for intervention evaluation purposes. Future consideration should also be given to integrating mobile technologies into HSA clinical practice.

Taipei's use of a multi-channel mass risk communication program to rapidly reverse an epidemic of highly communicable disease.

BACKGROUND: In September 2007, an outbreak of acute hemorrhagic conjunctivitis (AHC) occurred in Keelung City and spread to Taipei City. In response to the epidemic, a new crisis management program was implemented and tested in Taipei. METHODOLOGY AND PRINCIPAL FINDINGS: Having noticed that transmission surged on weekends during the Keelung epidemic, Taipei City launched a multi-channel mass risk communications program that included short message service (SMS) messages sent directly to approximately 2.2 million Taipei residents on Friday, October 12th, 2007. The public was told to keep symptomatic students from schools and was provided guidelines for preventing the spread of the disease at home. Epidemiological characteristics of Taipei's outbreak were analyzed from 461 sampled AHC cases. Median time from exposure to onset of the disease was 1 day. This was significantly shorter for cases occurring in family clusters than in class clusters (mean+/-SD: 2.6+/-3.2 vs. 4.39+/-4.82 days, p = 0.03), as well as for cases occurring in larger family clusters as opposed to smaller ones (1.2+/-1.7 days vs. 3.9+/-4.0 days, p<0.01). Taipei's program had a significant impact on patient compliance. Home confinement of symptomatic children increased from 10% to 60% (p<0.05) and helped curb the spread of AHC. Taipei experienced a rapid decrease in AHC cases between the Friday of the SMS announcement and the following Monday, October 15, (0.70% vs. 0.36%). By October 26, AHC cases reduced to 0.01%. The success of this risk communication program in Taipei (as compared to Keelung) is further reflected through rapid improvements in three epidemic indicators: (1) significantly lower crude attack rates (1.95% vs. 14.92%, p<0.001), (2) a short epidemic period of AHC (13 vs. 34 days), and (3) a quick drop in risk level (1 approximately 2 weeks) in Taipei districts that border Keelung (the original domestic epicenter). CONCLUSIONS AND SIGNIFICANCE: The timely launch of this systematic, communication-based intervention proved effective at preventing a dangerous spike in AHC and was able to bring this high-risk disease under control. We recommend that public health officials incorporate similar methods into existing guidelines for preventing pandemic influenza and other emerging infectious diseases.

Establishing a nationwide emergency department-based syndromic surveillance system for better public health responses in Taiwan.

BACKGROUND: With international concern over emerging infectious diseases (EID) and bioterrorist attacks, public health is being required to have early outbreak detection systems. A disease surveillance team was organized to establish a hospital emergency department-based syndromic surveillance system (ED-SSS) capable of automatically transmitting patient data electronically from the hospitals responsible for emergency care throughout the country to the Centers for Disease Control in Taiwan (Taiwan-CDC) starting March, 2004. This report describes the challenges and steps involved in developing ED-SSS and the timely information it provides to improve in public health decision-making. METHODS: Between June 2003 and March 2004, after comparing various surveillance systems used around the world and consulting with ED physicians, pediatricians and internal medicine physicians involved in infectious disease control, the Syndromic Surveillance Research Team in Taiwan worked with the Real-time Outbreak and Disease Surveillance (RODS) Laboratory at the University of Pittsburgh to create Taiwan's ED-SSS. The system was evaluated by analyzing daily electronic ED data received in real-time from the 189 hospitals participating in this system between April 1, 2004 and March 31, 2005. RESULTS: Taiwan's ED-SSS identified winter and summer spikes in two syndrome groups: influenza-like illnesses and respiratory syndrome illnesses, while total numbers of ED visits were significantly higher on weekends, national holidays and the days of Chinese lunar new year than weekdays (p < 0.001). It also identified increases in the upper, lower, and total gastrointestinal (GI) syndrome groups starting in November 2004 and two clear spikes in enterovirus-like infections coinciding with the two school semesters. Using ED-SSS for surveillance of influenza-like illnesses and enteroviruses-related infections has improved Taiwan's pandemic flu preparedness and disease control capabilities. CONCLUSION: Taiwan's ED-SSS represents the first nationwide real-time syndromic surveillance system ever established in Asia. The experiences reported herein can encourage other countries to develop their own surveillance systems. The system can be adapted to other cultural and language environments for better global surveillance of infectious diseases and international collaboration.

Temperature drops and the onset of severe avian influenza A H5N1 virus outbreaks.

Global influenza surveillance is one of the most effective strategies for containing outbreaks and preparing for a possible pandemic influenza. Since the end of 2003, highly pathogenic avian influenza viruses (HPAI) H5N1 have caused many outbreaks in poultries and wild birds from East Asia and have spread to at least 48 countries. For such a fast and wide-spreading virulent pathogen, prediction based on changes of micro- and macro-environment has rarely been evaluated. In this study, we are developing a new climatic approach by investigating the conditions that occurred before the H5N1 avian influenza outbreaks for early predicting future HPAI outbreaks and preventing pandemic disasters. The results show a temperature drop shortly before these outbreaks in birds in each of the Eurasian regions stricken in 2005 and 2006. Dust storms, like those that struck near China's Lake Qinghai around May 4, 2005, exacerbated the spread of this HPAI H5N1 virus, causing the deaths of a record number of wild birds and triggering the subsequent spread of H5N1. Weather monitoring could play an important role in the early warning of outbreaks of this potentially dangerous virus.

Knowledge, attitudes, and behavior relating to diabetes and its main risk factors among urban residents in Cameroon: a qualitative survey.

Diabetes, obesity, and physical inactivity are common in urban areas in sub-Saharan Africa. This paper reports an investigation of lay knowledge, attitudes, and behaviors relating to diabetes and its main risk factors of urban Cameroonians. We carried out a qualitative study in four urban health districts, one from each of the main ecological areas of Cameroon. Participants were purposively selected to include a range of community key participants and articulate community members. Data were collected through in-depth interviews by using a pre-tested, semi-structured interview guide. Sixty-two interviews were conducted across the four sites. Awareness of diabetes and knowledge of its causes, clinical course, and complications were limited. Many participants believed diabetes was caused by excessive sugar consumption rather than excessive energy intake, obesity, or physical inactivity. Obesity, particularly in men, was largely perceived positively as a sign of "good living." Many participants underestimated the degree to which they were overweight. Physical activity was mostly viewed positively, although negative views were common about simple methods of increasing physical activity, such as walking. Several constraints to the adoption of healthy behaviors were identified. For diet, these included lack of knowledge of the composition of a healthy diet. Barriers to undertaking more physical activity included lack of facilities and inadequate time available. The results indicate the need for health education about diabetes and its main risk factors in these communities. Health education should be informed by lay perspectives to maximize the appropriateness of the messages and their effect on knowledge, attitudes, and behavior.