Integration of systematic screening for tuberculosis in outpatient departments of urban primary healthcare facilities in Zambia: a case study of Kitwe district.

BACKGROUND: Tuberculosis (TB) is the leading cause of death from a single infectious agent globally, killing about 1.5 million people annually, yet 3 million cases are missed every year. The World Health Organization recommends systematic screening of suspected active TB patients among those visiting the healthcare facilities. While many countries have scaled-up systematic screening of TB, there has been limited assessment of the extent of its integration into the health system. This study sought to explore factors that shape the integration of systematic screening of TB in outpatient departments of primary healthcare facilities in Kitwe district, Zambia. METHODS: This was a qualitative case study with health providers including district managers, TB focal point persons and laboratory personnel working in six purposively selected primary healthcare facilities. Data was collected through key informant (n = 8) and in-depth (n = 15) interviews. Data analysis was conducted using QDA Miner software and guided by Atun's Integration framework. RESULTS: The facilitators to integration of systematic screening for TB into out patient departments of primary health facilities included the perceived high burden TB, compatibility of the systematic screening for TB program with healthcare workers training and working schedules, stakeholder knowledge of each others interest and values, regular performance management and integrated outreach of TB screening services. Constraining factors to integration of systematic screening for TB into outpatient departments included complexity of screening for TB in children, unbalanced incentivization mechanisms, ownership and legitimacy of the TB screening program, negative health worker attitudes, social cultural misconceptions of TB and societal stigma as well as the COVID-19 pandemic. CONCLUSION: Systematic screening of TB is not fully integrated into the primary healthcare facilities in Zambia to capture all those suspected with active TB that make contact with the health system. Finding the missing TB cases will, therefore, require contextual adaptation of the systematic screening for TB program to local needs and capacities as well as strengthening the health system.

High Prevalence of Low Birth Weight Babies Born to Pregnant Women Referred to a District Hospital in Rural Zambia.

OBJECTIVES: Low birthweight (LBW) is a significant public health problem in sub-Saharan Africa and LBW in rural Zambia is high. Our study explored the prevalence of LBW for newborns whose mothers were referred from a rural health center to a district referral hospital in Lundazi, Zambia. METHODS: A five-month retrospective record review of Ministry of Health data was performed to examine birthweight characteristics of a convenience sample of newborns from ten facilities referring to one district hospital (n = 234). RESULTS: Among all cases, 21% (n = 49) of newborns were LBW. For LBW newborns, 73% (n = 36) were preterm with mothers having a pregnancy duration of less than 37 weeks. Newborns whose mothers experienced twin pregnancies (p = .021) and prolonged labor (p = .033) were more often LBW. However, regression models demonstrated no difference among newborns with and without LBW for prolonged labor (p = .344) and twin pregnancies (p = .324) when controlling for variables that could interact with the maternal-newborn delivery outcomes. CONCLUSIONS: for Practice Healthcare providers and policy makers need to address the short and long-term effects of LBW throughout the lifecycle in rural Zambia. More maternal-newborn health research is needed to understand the underlying socioeconomic, social, and cultural determinants influencing LBW in rural Zambia.

The Association Between Maternity Waiting Home Use and Maternal-Newborn Knowledge: Latent Class Analysis.

BACKGROUND AND PURPOSE: An exploratory latent class analysis (LCA) was performed assessing the association between maternity waiting home (MWH) use and maternal-newborn care knowledge. METHODS: A two-group comparison design using a face-to-face interview (n = 250) was conducted to understand if MWH use was associated with greater maternal knowledge of newborn care. RESULTS: High levels of maternal knowledge of newborn care were associated with MWH use. Mothers with low levels of knowledge were less likely to use an MWH prior to delivery and more likely to have fewer pregnancies, attend less than four antenatal care (ANC) visits, and receive no education about newborn health problems during ANC. CONCLUSIONS: Nurses need to target younger, primigravida mothers attending fewer ANC visits with educational opportunities while advocating for expansion of health education at MWHs to potentiate long-term benefits for improved maternal-newborn health and delivery outcomes.

Maternal knowledge of essential newborn care in rural Zambia.

Maternity waiting homes (MWHs) may offer an intervention to improve newborn outcomes in rural Zambia. This study compared maternal knowledge of newborn care for women referred from facilities with and without MWHs. Topics assessed included: (1) umbilical cord care; (2) thermal and skin care; (3) nutrition, and; (4) prevention of diarrhea, and; (5) newborn danger signs prompting care-seeking. A two-group comparison design with a convenience sample was employed using a face-to-face interviews at one district hospital. Descriptive, inferential, and multivariate analyses were employed to compare knowledge. Overall, mothers demonstrated newborn care knowledge in accordance with World Health Organization (WHO) guidelines for newborn health and there were no significant differences in maternal knowledge of newborn care practices among MWH and non-MWH users. Younger mothers more often did not know about umbilical cord care, newborn skin care, and newborn danger signs. MWH users went more often for antenatal care than non-MWH users. In both groups, we found as the number of ANC visits increases, odds of answering "Don't know" decreases. This study is the first to assess maternal newborn care knowledge and MWH use in rural Zambia. Both MWH users and non-users in the rural district were knowledgeable about essential newborn care.

Operationalization of the Ecological Systems Theory to Guide the Study of Cultural Practices and Beliefs of Newborn Care in Rural Zambia.

Introduction: A wide gap in knowledge exists about the factors associated with newborn care in rural Zambia. In this year of the nurse and midwife, the purpose of this article is to provide transcultural researchers with an example of how Bronfenbrenner's Ecological Systems Theory (EST) can be used to guide an exploration of the cultural practices, knowledge, and beliefs of newborn care and health-seeking behaviors in rural Zambia. Methodology: Based on the EST, maternal knowledge represents the microsystem while family and community members embody the mesosystem. Health care organization denotes the exosystem with culture representing the macrosystem and health policy the chronosystem. Results: Numerous implications for transcultural nursing practice emerged from this adaptation of the ecological systems approach. Findings reveal a maternal dualism faced by Zambian mothers as they navigate the complex interplay between cultural newborn care practices and evidence-based newborn care promoted by the health care system. Discussion: Based on our proposed operationalization of the EST for a transcultural nursing study, the EST can be applied globally, further validating the theory.

Cultural beliefs and health-seeking practices: Rural Zambians' views on maternal-newborn care.

BACKGROUND: - Far too many newborns die or face serious morbidity in Zambia, as in many other sub-Saharan African countries. New knowledge is needed to enhance our understanding of newborn care and the cultural factors influencing the ways mothers seek newborn care. This study adds to the literature about rural Zambians' cultural beliefs and practices related to newborn care and health-seeking practices that influence maternal-newborn health. OBJECTIVE: - The goal of this study was to describe the factors associated with newborn care in rural Zambia. DESIGN: - Sixty focus groups were conducted. Each group contained a minimum of 8 and maximum of 12 participants. Recruitment was conducted orally by word of mouth through the nurse in charge at the health facilities and village chiefs. SETTING: - Data were collected between June and August 2016 in 20 communities located in Zambia's rural Lundazi (Eastern province), Mansa, and Chembe (Luapula province) Districts. PARTICIPANTS: - The study included community members (n = 208), health workers (n = 225), and mothers with infants younger than 1-year-old (n = 213). FINDINGS: - The following themes emerged. From mothers with infants, the dominant theme concerned traditional and protective newborn rituals. From community members, the dominant theme was a strong sense of family and community to protect the newborn, and from health workers, the major theme was an avoidance of shame. A fourth theme, essential newborn care, was common among all groups. KEY CONCLUSIONS: - Together the themes pointed toward a maternal dualism for mothers in rural Zambia. Mothers with infants in rural Zambia likely experience a dualistic sense of responsibility to satisfy both cultural and health system expectations when caring for their newborns. Mothers are pulled to engage in traditional protective newborn care rituals while at the same time being pushed to attend ANC and deliver at the health facility. These findings can be used to understand how mothers care for their newborns to develop interventions aimed at improving maternal-child health outcomes. IMPLICATIONS FOR PRACTICE: - There were findings about the culture-specific prevention of cough, care of the umbilical cord, and early introduction of traditional porridge that carry implications for nursing practice. There is an obvious need to reinforce the importance of partner testing for STIs during routine ANC even though there is a desire to preserve dignity.

Sustainability and Scale of the Saving Mothers, Giving Life Approach in Uganda and Zambia.

BACKGROUND: Saving Mothers, Giving Life (SMGL) significantly reduced maternal and perinatal mortality in Uganda and Zambia by using a district health systems strengthening approach to address the key delays women and newborns face in receiving quality, timely, and appropriate medical care. This article documents the transition of SMGL from pilot to scale in Uganda and Zambia and analyzes the sustainability of the approach, examining the likelihood of maintaining positive trends in maternal and newborn health in both countries. METHODS: We analyzed the potential sustainment of SMGL achievements using a tool adapted from the HIV-focused domains and elements of the U.S. President's Emergency Plan for AIDS Relief Sustainability Index and Dashboard for maternal and neonatal health pro-gramming adding a domain on community normative change. Information for each of the 5 resulting domains was drawn from SMGL and non-SMGL reports, individual stakeholder interviews, and group discussions. FINDINGS: In both Uganda and Zambia, the SMGL proof-of-concept phase catalyzed commitment to saving mothers and newborns and a renewed belief that significant change is possible. Increased leadership and accountability for maternal and newborn health, particularly at the district and facility levels, was bolstered by routine maternal death surveillance reviews that engaged a wide range of local leadership. The SMGL district-strengthening model was found to be cost-effective with cost of death averted estimated at US$177-206 per year of life gained. When further considering the ripple effect that saving a mother has on child survival and the household economy, the value of SMGL increases. Ministries of health and donor agencies have already demonstrated a willingness to pay this amount per year of life for other programs, such as HIV and AIDS. CONCLUSION: As SMGL scaled up in both Uganda and Zambia, the intentional integration of SMGL interventions into host country systems, alignment with other large-scale programs, and planned reductions in annual SMGL funding all contributed to increasing host government ownership of the interventions and set the SMGL approach on a path more likely to be sustained following the close of the initiative. Lessons from the learning districts resulted in increased efficiency in allocation of resources for maternal and newborn health, better use of strategic information, improved management capacities, and increased community engagement.