Background: The United States Agency for International Development Medicines, Technologies, and Pharmaceutical Services (MTaPS) program supported partner countries to implement infection prevention and control (IPC)-related programs. We evaluated the extent to which MTaPS-supported IPC programs fostered local ownership, such that members of local or national-level health systems had agency in developing and running programs. Methods: We surveyed three respondent groups involved in MTaPS IPC programs across eight African countries: (1) healthcare facility staff, (2) national-level stakeholders, and (3) MTaPS-contracted country implementers. Multiple-choice survey questions asked respondents to rate the quality of collaboration and capacity-building between their country and MTaPS, and the extent to which MTaPS fosters local ownership. Open-response questions inquired about factors that did or did not foster local ownership. We described the proportion of respondents reporting each multiple-choice response option, and conducted qualitative content analysis of open responses to generate themes about respondent perceptions of MTaPS support and local ownership. Results: We included 85 survey respondents: health facility staff (56%), MTaPS-contracted country implementers (29%) and national-level stakeholders (14%). Nearly all respondents rated the quality of MTaPS collaboration and capacity building "good" or "excellent." Overall, 75%-92% of respondents rated the quality of MTaPS collaboration and capacity strengthening as "mostly" supportive of local ownership and 8%-25% rated it "sometimes," supportive (0% selected "rarely/never"). Qualitatively, respondents described six activities as conducive to local ownership, including training, data collection/monitoring, stakeholder engagement, guideline/protocol standardization, creation/development of local committees, and supervision/mentorship/direct technical assistance. A reported barrier to MTaPS' support of local ownership was the inconsistent implementation of activities. Conclusions: IPC programs should continue to prioritize strategies for fostering local ownership, particularly as the funding landscape shifts. To increase IPC program sustainability in advance of future infectious disease threats, additional resources are needed to scale up activities perceived as conducive to local ownership.

BackgroundA growing number of people living with HIV (PLHIV) also have non-communicable diseases (NCDs). Shifting to an integrated delivery model may facilitate care-seeking and improve outcomes for people with a dual burden of HIV and NCDs. We describe the current state of integration of hypertension and diabetes care into HIV treatment in Malawi, South Africa and Zambia.MethodsWe administered structured interviews to HIV treatment providers in 41 primary healthcare facilities to evaluate how NCD care is provided to PLHIV accessing antiretroviral therapy (ART). We defined integration as provision of NCD services within the HIV clinic. The potential degree of integration in HIV clinics ranged from not integrated at all (no NCD services) to fully integrated (all NCD services). We also surveyed a sample of ART clients about their access to integrated care.ResultsThe degree of integration varied across the facilities and countries. All facilities in South Africa reported being fully integrated for HIV care and hypertension and diabetes, and most providers in South Africa identified no barriers to integration. Integration was much less complete in Malawi and Zambia, with most facilities offering hypertension and diabetes screening/diagnosis and support but limited treatment or disease monitoring services. Frequently cited barriers to integration in Malawi and Zambia were limited staff knowledge of integrated care provision and facility space constraints. ART clients' experience with integrated services mirrored provider responses. Over 90% of survey participants in South Africa reported HIV and non-HIV visit and medication collection alignment, compared to less than half in Malawi and Zambia.ConclusionsThe level of integration of hypertension and diabetes care with HIV treatment varies widely across facilities in Malawi, South Africa, and Zambia, despite each country having national guidelines that promote integration. Interventions to increase integration must consider differences among facilities at baseline.

Background Interruptions in HIV care pose a major challenge to achieving HIV control goals in many countries, with 30% of clients who initiate antiretroviral therapy (ART) in South Africa experiencing an interruption of >28 days during their first six months on treatment. South Africa introduced revised guidelines in 2023 to improve outcomes during this early treatment period, but guideline compliance remains incomplete and gaps in the support provided to both clients and providers to optimize service delivery and health outcomes. Protocol BRIDGE (Behavioral Risk Identification and Decision Guidance for Engagement) is a mixed-methods evaluation of a package of light-touch, low-cost interventions aimed at improving the experiences of both clients and providers of care, increasing compliance with the 2023 guidelines, supporting clients to remain in care, and ultimately reducing the incidence of missed visits during the early treatment period. Components of the BRIDGE Retention Toolkit include an intervention navigator to help clients self-assess areas of vulnerability for disengagement from care and identify appropriate interventions; client roadmap to explain the treatment journey for the early treatment period; WhatsApp-based counseling tool for clients; guideline reference for providers; and tracing job aids. The tookit will be piloted at 6-8 public sector primary health facilities for a one-month period. The primary outcome will be the probability of returning less than 28 days late for the next scheduled clinic visit, assessed using electronic medical record data for the pilot and comparison sites. Pilot outcomes will be compared to both their own probabilities prior to the pilot and to probabilities from comparable non-pilot facilities. Implementation outcomes to be assessed using qualitative interview data from both clients and providers will include reach, implementation fidelity, adoption (uptake), costs, feasibility, appropriateness, and acceptability. Discussion The evaluation will assess the implementation and preliminary effectiveness of a set of interventions designed to improve client outcomes during the early HIV treatment period. If some or all of the BRIDGE tools are found to be helpful and/or are associated with a reduction in missed clinic visits, they will comprise a readily scalable and affordable intervention to help address a major barrier in large-scale HIV treatment programs. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT07439003 ### Funding Statement Funding for the study was provided by the Gates Foundation through INV-031690 to Boston University. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The BRIDGE evaluation protocol was approved by the Institutional Review Board at Boston University Medical Campus (BUMC IRB H-46408, approved March 6, 2026) and the Human Research Ethics Committee (Medical) of the University of the Witwatersrand (251124, approved January 19, 2026). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes No data are associated with this article.

BackgroundHuman immunodeficiency virus (HIV) cases among people who inject drugs increased during the US overdose crisis. Although HIV pre-exposure prophylaxis (PrEP) decreases HIV acquisition, and medications for opioid use disorder (MOUD) reduce overdose deaths, uptake remains suboptimal. The CHORUS + study will test the efficacy of a comprehensive peer recovery coaching intervention to increase PrEP and MOUD initiation and adherence.MethodsThis two-arm RCT will enroll 284 people who inject opioids (PWIO) and are negative for HIV from two sites. Participants randomized to the CHORUS + intervention will receive a study smartphone, motivational interviewing sessions, assistance connecting to PrEP and/or MOUD, and support to access resources addressing social needs such as employment and housing. We will also incorporate adapted 'Life-Steps for PrEP' modules to increase adherence. The control arm will receive information on local organizations with access to PrEP and MOUD. Participants will complete assessments at baseline, 1-, 3-, 6-, and 12-month visits. The primary outcome is adherence to HIV PrEP, assessed by tenofovir-diphosphate drug levels at 6-months post enrollment. Secondary outcomes include PrEP adherence assessed at 3- and 12-months, measured by drug levels (3-months), prescription refills, and self-report; and MOUD receipt at 3-, 6-, and 12-months, measured by prescription refills, self-report, and urine toxicology. The primary analysis will employ intent-to-treat logistic regression to assess differences in adherence between treatment arms, adjusting for stratification factors including site, race and sex assigned at birth. We will analyze secondary outcomes using similar methods. We will use multilevel growth curve modeling to evaluate changes in adherence over time by treatment group, incorporating random intercepts and slopes to account for individual trajectories. We will use exploratory multilevel structural equation modeling to assess mediators including HIV risk perception and PrEP/MOUD knowledge to understand pathways that may influence adherence.DiscussionThe CHORUS + intervention integrates a novel, theory-based, peer-delivered, smartphone-supported approach to address HIV prevention and opioid use disorder, while tackling social and structural barriers to care. Findings will inform strategies for linking PWIO to rapid HIV prevention and substance use treatment.Trial registrationClinicalTrials.gov number: NCT05769218.

BACKGROUND:Healthcare resources have been concentrated in urban areas, leaving rural regions vulnerable to poorer health outcomes. The Problem Solving for Better Health (PSBH) program was implemented to enhance healthcare systems in resource-limited regions by training personnel to maximize existing resources in problem-solving. This study evaluated the implementation effectiveness of PSBH-Nursing (PSBHN), a nationally led initiative to train nurses in PSBH in Lesotho. METHODS:A mixed-methods study employing a single-group pre-test post-test design was conducted, guided by the RE-AIM theory. Training occurred from November 2021 to June 2022. Nurses completed the Problem-Solving Inventory (PSI) before and 3-6 months after training to measure changes in problem-solving efficacy. Quality scores were assigned to nurses' planned quality improvement projects; project implementation was assessed 3-6 months after training. In-depth interviews (IDIs) explored changes in knowledge, problem-solving efficacy, and skills. Statistical analyses utilized paired T-tests and logistic regressions using STATA 17; content analysis was conducted on IDIs using NVivo12. RESULTS:Of 300 nurses, 89 were trained (30%) in the first year. Mainly medium or high-quality scores were achieved for the project designed. However, among 79 participants, only 49.4% reported initiating their projects. Overall problem-solving efficacy improved 3-6 months after training, but the increase was not statistically significant. Nurses reported improved knowledge, confidence and communication skills, enhanced problem-solving approaches, and increased emotional maturity in solving problems. A one-unit increase in project quality score correlated with a 35.0% increase in the odds of project initiation. CONCLUSION:PSBHN demonstrated improved knowledge and minimal improvement in problem-solving efficacy among nurses 3-6 months post-training. However, application of skills gained in implementing their projects was insufficient. Still, PSBHN shows promise in addressing healthcare challenges in resource-limited settings. Some participants were able to start their projects but the inconsistency in follow-through suggests a need for more research into the factors that can improve completion of implementation for better health outcomes.

For clients on HIV treatment in sub-Saharan Africa, early disengagement from care is a critical obstacle to achieving UNAIDS's second 95 target. While South Africa's Differentiated Service Delivery Guideline on Fast Track Initiation and Counseling (FTIC) defines normative procedures, the impact of implementation and drivers of disengagement remain unclear. The PREFER mixed-methods study enrolled a prospective cohort of adult clients initiating ART, returning to care after disengagement, or on ART for ≤6 months at 18 public healthcare facilities in South Africa. A survey collected demographic, clinical, and preference data. Participants were followed for up to 7 months using routinely collected medical records to estimate continuity of care (attendance at all scheduled visits within 28 days). Focus group discussions (FGDs) were conducted 12 months post-enrollment among participants who had expressed concerns about retention. A content analysis was conducted; emergent themes were situated within the Socio-Ecological Model framework. During the study period 7/9/2022-30/6/2023, PREFER-SA enrolled 1,049 participants (72% female, median age 33 years, 24% with CD4 < 200 cells/mm³); 122 also joined FGDs. By 6 months on ART, 23% were not continuously in care. New ART initiators were more likely to experience treatment interruption than those already retained for ≥1 visit. Disengagement was more likely among men, younger clients (18-24 years), those reporting food insecurity, and those not initiated on dolutegravir regimens. No differences were observed by relationship status, CD4 count or preferences for HIV care. FGDs revealed barriers to retention across all levels of the SEM, especially related to facility experience. Among adults initiating or re-initiating ART in South Africa, the highest risk of disengagement occurs immediately after initiation. Several potentially modifiable individual and social factors were associated with early disengagement. Strengthening implementation of South Africa's Service Delivery Guidelines and improving facility experiences may support better retention in early treatment.

BACKGROUND:Understanding factors affecting adoption of an innovation is critical to its long-term success. Maternity waiting homes (MWHs) increase access to facility-based delivery in low-resourced settings; yet, quality issues deter utilization of this innovative approach. We sought to understand how attributes that are thought to promote diffusion of innovations (e.g., relative advantage, compatibility, observability, complexity, etc.) affected MWH use after implementation of an improved quality MWH model in rural Zambia compared to standard of care. METHODS:We conducted 158 in-depth interviews (IDIs) with randomly selected rural-living women who had delivered a baby in the prior 12 months. Half lived in catchment areas where new quality MWHs were constructed, half in catchment areas with standard of care (ranging from low quality community structures to no MWH). We applied content analysis to identify themes. RESULTS:Utilization of MWHs was higher among intervention (65.4%) than control women (42.5%). Respondents in both study arms perceived relative advantages to pregnant women staying at MWHs compared to going directly to health facilities when labor begins. MWH stays allowed for clinical staff to routinely check on and educate women, and address complications immediately. Compatibility of the homes with cultural values and needs depended on implementation. While some women from intervention sites complained about overcrowding, women in control sites more often perceived the lack of cleanliness, amenities, and safety as deterrents to utilization. Women at intervention sites received sensitization about MWHs from a wider range of sources, including traditional leaders. Required preparations needed to stay at MWHs (e.g. delivery supplies, food, and childcare) made adoption complex and may have deterred utilization. CONCLUSIONS:The improved MWH model addressed most community concerns around quality. Having opinion leaders who communicate the relative advantage of MWHs to pregnant women and their social networks may facilitate MWH utilization. The complexity of decisions and resources needed to stay at MWHs remains a critical barrier to use. To facilitate equitable adoption of MWHs among the most vulnerable women, planners should explore how to support women during their delivery preparations and MWH stays, particularly regarding food security and lack of social support for childcare. TRIAL REGISTRATION:clinicaltrials.gov, NCT02620436, Registered 02 December 2015, https://clinicaltrials.gov/study/NCT02620436?term=NCT02620436&rank=1.

Human immunodeficiency virus (HIV) cases among people who inject drugs increased during the US overdose crisis. Although HIV pre-exposure prophylaxis (PrEP) decreases HIV acquisition, and medications for opioid use disorder (MOUD) reduce overdose deaths, uptake remains suboptimal. The CHORUS + study will test the efficacy of a comprehensive peer recovery coaching intervention to increase PrEP and MOUD initiation and adherence. This two-arm RCT will enroll 284 people who inject opioids (PWIO) and are negative for HIV from two sites. Participants randomized to the CHORUS + intervention will receive a study smartphone, motivational interviewing sessions, assistance connecting to PrEP and/or MOUD, and support to access resources addressing social needs such as employment and housing. We will also incorporate adapted ‘Life-Steps for PrEP’ modules to increase adherence. The control arm will receive information on local organizations with access to PrEP and MOUD. Participants will complete assessments at baseline, 1-, 3-, 6-, and 12-month visits. The primary outcome is adherence to HIV PrEP, assessed by tenofovir-diphosphate drug levels at 6-months post enrollment. Secondary outcomes include PrEP adherence assessed at 3- and 12-months, measured by drug levels (3-months), prescription refills, and self-report; and MOUD receipt at 3-, 6-, and 12-months, measured by prescription refills, self-report, and urine toxicology. The primary analysis will employ intent-to-treat logistic regression to assess differences in adherence between treatment arms, adjusting for stratification factors including site, race and sex assigned at birth. We will analyze secondary outcomes using similar methods. We will use multilevel growth curve modeling to evaluate changes in adherence over time by treatment group, incorporating random intercepts and slopes to account for individual trajectories. We will use exploratory multilevel structural equation modeling to assess mediators including HIV risk perception and PrEP/MOUD knowledge to understand pathways that may influence adherence. The CHORUS + intervention integrates a novel, theory-based, peer-delivered, smartphone-supported approach to address HIV prevention and opioid use disorder, while tackling social and structural barriers to care. Findings will inform strategies for linking PWIO to rapid HIV prevention and substance use treatment. ClinicalTrials.gov number: NCT05769218.

Background Implementation fidelity measures are critical for understanding complex interventions. Though maternity waiting homes (MWHs) are recommended by the WHO and have been used to help pregnant women access health facilities for decades, a gap exists regarding fidelity studies on MWHs. To better understand intervention outcomes results, we assessed the fidelity of implementation of an improved Core MWH Model in 10 facilities in rural Zambia.Methods We analysed indicators for fidelity employing a widely used conceptual framework. We compared performance from October 2016 to July 2018 to goals set out during intervention design. The Core MWH Model consists of three pillars—infrastructure, policies and linkages to care—each designed to be culturally appropriate and responsive to community standards for safety and comfort.Results 70% of sites exhibited high adherence to the Core MWH Model components. User experience corroborated poorer performing elements: insufficient lighting, small cooking spaces, non-locking cabinets and few educational classes. Mission statements and governing documents were not always visible or available. The proportion of 3206 users who came from>10 km away was higher than the proportion of the surrounding population living at that distance except in two sites with low populations of remote-living women. Women stayed for just below the target of 14 nights. MWH occupancy rate overall was lower (52%) than the target (80%). MWH users reported high quality and satisfaction. Only three MWHs reached 50% female membership on their governance committees but met other key indicators for community ownership and engagement.Conclusions This fidelity evaluation of an MWH model in rural Zambia helps bridge the evidence–practice gap for the WHO’s recommendation on implementing MWHs and adds to the expanding body of literature on implementation fidelity studies in global health.Trial registration number NCT02620436.

Purpose:Differentiated service delivery (DSD) models for antiretroviral therapy (ART) for HIV aim to increase patient-centeredness, a concept that incorporates patient choice of service delivery options. We explored choice in DSD model enrollment at 42 public sector clinics in Malawi, South Africa, and Zambia. Methods:From 09/2022-05/2023, we surveyed people receiving HIV treatment to ask if they had a choice about DSD model enrollment and healthcare providers about their practices in offering choice. We estimated risk differences for ART clients' self-reported offer of choice and report risk differences. We thematically analyzed open-ended questions and report key themes. Results:We enrolled 1049 people receiving HIV treatment (Malawi 409, South Africa 362, Zambia 278) and 404 providers (Malawi 110, South Africa 175, Zambia 119). The proportion of study participants indicating that they had been offered a choice ranged from 4% in Malawi to 17% in Zambia to 47% in South Africa. Over 90% of people receiving HIV treatment in all three countries reported that they were happy to be enrolled in their current DSD model. Participants from urban (ARD 0.94 [0.90-0.99]) and medium-volume facilities (2000-4000 ART clients, 0.91 [0.84-0.98]) were slightly less likely to be offered DSD enrollment. Participants in community-based models 1.21 [1.12-1.30] and those satisfied with their current model 1.06 [1.01-1.13] were more likely to be offered a choice. Among providers, 64% in Malawi, 80% in South Africa, and 59% in Zambia said they offered clients the choice to enroll in DSD or remain in conventional care. Conclusion:As of 2023, relatively few people receiving HIV treatment in Malawi, South Africa, and Zambia reported being offered a choice about enrolling in a DSD model, despite most providers reporting offering such a choice. The value of patient choice in improving clinical outcomes and satisfaction should be explored further.

Disengagement from antiretroviral therapy (ART) is highest in the early treatment period (≤ 6 months after initiation/re-initiation), but low intensity models designed to increase retention generally exclude these clients. We describe client preferences for HIV service delivery in the early treatment period. From 9/2022 to 6/2023, we surveyed adult clients who were initiating or on ART for ≤ 6 months at primary health facilities in South Africa and Zambia. We collected data on experiences with and preferences for HIV treatment. We enrolled 1,098 participants in South Africa (72

Vaccine hesitancy has played a major role in slowing the global COVID-19 response. Using cross-sectional, primarily qualitative data collected in four rural districts in Zambia, we aimed to explore community perceptions of COVID-19 disease and vaccines, including perceived motivators, cues to action, benefits, and barriers to vaccine uptake as guided by the Health Belief Model. In-depth interviews (IDIs) were conducted in late 2021 with women of reproductive age who were enrolled in an early childhood development study. Although two-thirds of the 106 respondents reported low perceived risk of catching COVID-19, they expressed concern that the COVID-19 pandemic had impacted their daily lives and feared effects of the disease. They had generally positive beliefs that the vaccine would be accepted among their communities when it became more widely available. Reported motivators to vaccine uptake included desire for protection against COVID-19 and understanding vaccine purpose, due to ongoing education from health personnel, neighbors, friends, radio, and church leaders. Misinformation or reported bad experiences served as cues away from vaccine uptake. Examples of misinformation included the vaccine causing COVID-19 or another disease and death and vaccines being associated with the devil and against Christian beliefs. Accounts of pain after receiving the vaccine also discouraged uptake. Perceived benefits included a desire to be protected from the disease, belief in the effectiveness of the vaccine, fear of catching COVID-19, and belief the vaccine would limit negative effects. Health system implementers and policy makers should consider recipient motivators and cues to action to further increase vaccination rates.

Background:Public-private partnerships (PPP) are one strategy to finance and deliver healthcare in lower-resourced settings. Lesotho's Queen 'Mamohato Memorial Hospital Integrated Network (QMMH-IN) was sub-Saharan Africa's first and largest integrated healthcare PPP. Objective:We assessed successes and challenges to performance of the QMMH-IN PPP. Methods:We conducted 26 semi-structured interviews among QMMH-IN executive leadership and staff in early 2020. Questions were guided by the WHO Health System Building Blocks Framework. We conducted a thematic analysis. Findings:Facilitators of performance included: 1) PPP leadership commitment to quality improvement supported by protocols, monitoring, and actions; 2) high levels of accountability and discipline; and 3) well-functioning infrastructure, core systems, workflows, and internal referral network. Barriers to performance included: 1) human resource management challenges and 2) broader health system and referral network limitations. Respondents anticipated the collapse of the PPP and suggested better investing in training incoming managerial staff, improving staffing, and expanding QMMH-IN's role as a training facility. Conclusions:The PPP contract was terminated approximately five years before its anticipated end date; in mid-2021 the government of Lesotho assumed management of QMMH-IN. Going forward, the Lesotho government and others making strategic planning decisions should consider fostering a culture of quality improvement and accountability; ensuring sustained investments in human resource management; and allocating resources in a way that recognizes the interdependency of healthcare facilities and overall system strengthening. Contracts for integrated healthcare PPPs should be flexible to respond to changing external conditions and include provisions to invest in people as substantively as infrastructure, equipment, and core systems over the full length of the PPP. Healthcare PPPs, especially in lower-resource settings, should be developed with a strong understanding of their role in the broader health system and be implemented in conjunction with efforts to ensure and sustain adequate capacity and resources throughout the health system.

Background For patients on HIV treatment in sub-Saharan Africa, the highest risk for loss from care remains the first six months after antiretroviral (ART) initiation, when patients are not yet eligible for differentiated service delivery (DSD) models that offer lower-burden, patient-centred care and thus improve treatment outcomes. To reduce early disengagement from care, the PREFER study will use a sequential mixed-methods approach to describe the characteristics, needs, concerns, and preferences of patients in South Africa and Zambia 0-6 months after ART initiation or re-initiation. Protocol PREFER is an observational, prospective cohort study of adults on ART for ≤6 months at 12 public healthcare facilities in Zambia and 18 in South Africa. Its objective is to describe and understand the needs and preferences of initiating and re-initiating ART clients to inform the design of DSD models for the early HIV treatment period, improve early treatment outcomes, and distinguish the barriers encountered by naïve patients from those facing re-initiators. It has four components: 1) survey of clients 0-6 months after ART initiation (identify characteristics and preferences of clients starting ART); 2) follow up through routinely collected medical records for <24 months after enrollment (describe resource utilization and patterns and predictors of engagement in care); 3) focus group discussions and discrete choice experiment (explore reported barriers to and facilitators of retention); and 4) in South Africa only, collection of blood samples (assess the prevalence of ARV metabolites indicating prior ART use). Conclusions PREFER aims to understand why the early treatment period is so challenging and how service delivery can be amended to address the obstacles that lead to early disengagement from care. It will generate information about client characteristics and preferences to help respond to patients’ needs and design better strategies for service delivery and improve resource allocation going forward.

AbstractIntroductionDifferentiated service delivery (DSD) models aim to increase the responsiveness of HIV treatment programmes to the individual needs of antiretroviral therapy (ART) clients to improve treatment outcomes and quality of life. Little is known about how DSD client experiences differ from conventional care.MethodsFrom May to November 2021, we interviewed adult (≥18) ART clients at 21 primary clinics in four districts of South Africa. Participants were enrolled consecutively at routine visits and stratified into four groups: conventional care‐not eligible for DSD (conventional‐not‐eligible); conventional care eligible for but not enrolled in DSD (conventional‐not‐enrolled); facility pickup point DSD model; and external pickup point DSD model. Satisfaction was assessed using questions with 5‐point Likert‐scale responses. Mean scores were categorized as not satisfied (score ≤3) or satisfied (>3). We used logistic regression to assess differences and report crude and adjusted odds ratios (aORs). Qualitative themes were identified through content analysis.ResultsEight hundred and sixty‐seven participants (70% female, median age 39) were surveyed: 24% facility pick‐up points; 27% external pick‐up points; 25% conventional‐not‐eligible; and 24% conventional‐not‐enrolled. Seventy‐four percent of all study participants expressed satisfaction with their HIV care. Those enrolled in DSD models were more likely to be satisfied, with an aOR of 6.24 (95% CI [3.18–12.24]) for external pick‐up point versus conventional‐not‐eligible and an aOR of 3.30 (1.95–5.58) for facility pick‐up point versus conventional‐not‐eligible. Conventional‐not‐enrolled clients were slightly but not significantly more satisfied than conventional‐not‐eligible clients (1.29, 0.85–1.96). Those seeking outside healthcare (crude OR 0.57, 0.41–0.81) or reporting more annual clinic visits (0.52, 0.29–0.93) were less likely to be satisfied. Conventional care participants reporting satisfaction with their current model of care perceived providers as helpful, respectful, and friendly and were satisfied with care despite long queues. DSD model participants emphasized ease and convenience, particularly not having to queue.ConclusionsMost adult ART clients in South Africa were satisfied with their care, but those enrolled in DSD models expressed slightly greater satisfaction than those remaining in conventional care. Efforts should focus on enrolling more eligible patients into DSD models, expanding eligibility criteria to cover a wider client base, and further improving the models’ desirable characteristics.

Abstract Introduction: Differentiated service delivery (DSD) models for HIV treatment aim to improve healthcare providers’ quality of professional life by reducing the patient/provider ratio and allowing for more time with recipients-of-care in need. We investigate current job satisfaction and perceived changes in job satisfaction among HIV treatment providers in Malawi, South Africa, and Zambia after the adoption of DSD models of care in each country. Methods: We conducted a concurrent, cross-sectional mixed-methods survey with clinical and non-clinical HIV care providers between April 2021 and January 2022 at public sector clinics in Malawi (n-12), South Africa (n=21), and Zambia (n=12). Questions investigated the effect of DSD models on provider responsibilities, work burden, time allocation, and job satisfaction. We conducted a principal components analysis using questions with responses to create an index score for job satisfaction and estimated odds ratios using logistic regression for associations between key variables and low reported job satisfaction. We reported emerging qualitative themes. We use Herzberg’s two-factor theory to organize and interpret the results of the study, identifying motivating factors (which lead to job satisfaction) and hygiene factors (which we refer to as maintenance factors and which lead to dissatisfaction if lacking). Results: Providers had generally high job satisfaction. Providers from Malawi were more likely to report lower job satisfaction than those from South Africa or Zambia. (adjusted odds ratio (aOR) 4.56, 95% confidence interval (CI) [2.12, 9.80]) ). Providers who believed their jobs became harder after the introduction of the DSD models (2.82[1.14-6.96]) or did not change (6.50[2.50-16.89]) were more likely to report lower job satisfaction. Qualitatively, providers felt DSD models improved their working conditions by decongesting the clinics and allowed them to spend more time on other tasks. Providers were particularly motivated when they could spend more time with patients. Conclusion: Findings highlight the importance of DSD models in maintaining or improving healthcare providers' quality of professional life and underscore the need for continued monitoring of the impact of these models on job satisfaction among HIV treatment providers in resource constrained settings.

Introduction: Early reading interventions hold promise for increasing language and literacy development in young children and improving caregiver-child interactions. To engage rural caregivers and young children in home reading, Zambian child psychologists and education specialists developed a culturally representative, local language children’s book targeted at pre-grade 1 children. Objectives: We qualitatively assessed community acceptability and use of the book distributed to households with young children in two provinces of Zambia. Methods: We conducted 15 focus group discussions (FGDs) with women (n=117) who received the “Zambian folktales adapted stories for young children” book. A codebook was created a priori, based on established themes in the guide; content analysis was conducted in Nvivo v12. Data were interpreted against the Theoretical Framework on Acceptability. Findings: Respondents described wide acceptability of the children’s book across multiple framework constructs. Respondents believed the book was culturally appropriate for its folktale structure and appreciated the morals and lessons provided by the stories. Respondents described using the book in multiple ways including reading in one-on-one or group settings, asking the child questions about the narrative or pictures, and providing additional commentary on the actions or figures in the pictures. Respondents believed the books were helping children grow their vocabulary and early literacy skills. The book’s simple vocabulary facilitated use by less educated caregivers. The primary concern voiced was the ability of low literacy caregivers to utilize the book for reading. Discussion: The children’s book was widely considered acceptable by rural Zambian communities. It provided a platform for an additional method of caregiver-child interactions in these households for reading, dialogue, and oral storytelling. Shared reading experiences have potentially substantial benefits for the language development and emergent literacy of young children. Programs to develop and deliver culturally acceptable books to households with limited access should be considered by governments and funders.

The COVID-19 pandemic has increased social and emotional stressors globally, increasing mental health concerns and the risk of psychiatric illness worldwide. To date, relatively little is known about the impact of the pandemic on vulnerable groups such as women and children in low-resourced settings who generally have limited access to mental health care. We explore two rounds of data collected as part of an ongoing trial of early childhood development to assess mental health distress among mothers of children under 5-years-old living in two rural areas of Zambia during the COVID-19 pandemic. We examined the prevalence of mental health distress among a cohort of 1105 mothers using the World Health Organization's Self-Reporting Questionnaire (SRQ-20) before the onset of the COVID-19 pandemic in August 2019 and after the first two infection waves in October-November 2021. Our primary outcome was mental health distress, defined as SRQ-20 score above 7. We analyzed social, economic and family level characteristics as factors modifying to the COVID-19 induced changes in the mental health status. At baseline, 22.5% of women were in mental health distress. The odds of mental health distress among women increased marginally over the first two waves of the pandemic (aOR1.22, CI 0.99-1.49). Women under age 30, with lower educational background, with less than three children, and those living in Eastern Province (compared to Southern Province) of Zambia, were found to be at highest risk of mental health deterioration during the pandemic. Our findings suggest that the prevalence of mental health distress is high in this population and has further worsened during COVID-19 pandemic. Public health interventions targeting mothers' mental health in low resource settings may want to particularly focus on young mothers with limited educational attainment.

Maternity waiting homes (MWHs) are one strategy to improve access to skilled obstetric care in low resource settings such as Zambia. The Maternity Homes Access in Zambia project built 10 MWHs at rural health centers in Zambia for women awaiting delivery and postnatal care (PNC) visits. The objective of this paper is to summarize the costs associated with setup of 10 MWHs, including infrastructure, furnishing, stakeholder engagement, and activities to build the capacity of local communities to govern MWHs. We do not present operational costs after setup was complete. We used a retrospective, top-down program costing approach. We reviewed study documentation to compile planned and actual costs by site. All costs were annuitized using a 3% discount rate and organized by cost categories: (1) Capital: infrastructure and furnishing, and (2) Installation: capacity building activities and stakeholder engagement. We assumed lifespans of 30 years for infrastructure; 5 years for furnishings; and 3 years for installation activities. Annuitized costs were used to estimate cost per night stayed and per visit for delivery and PNC-related stays. We also modeled theoretical utilization and cost scenarios. The average setup cost of one MWH was $85,284 (capital: 76%; installation: 24%). Annuitized setup cost per MWH was USD$12,516 per year. At an observed occupancy rate of 39%, setup cost per visit to the MWH was USD$70, while setup cost per night stayed was USD$6. The cost of stakeholder engagement activities was underbudgeted by half at the beginning of this project.This analysis serves as a planning resource for governments and implementers that are considering MWHs as a component of their overall maternal and child health strategy. Planning considerations should include the annuitized cost, value of capacity building and stakeholder engagement, and that cost per bed night and visit are dependent upon utilization.

ABSTRACT. In early 2020, the Zambian Ministry of Health instituted prevention guidelines to limit spread of COVID-19. We assessed community knowledge, motivations, behavioral skills, and perceived community adherence to prevention behaviors (i.e., hand hygiene, mask wearing, social distancing, and limiting gatherings). Within a cluster-randomized controlled trial in four rural districts, in November 2020 and May 2021, we conducted in-depth interviews with health center staff ( N = 19) and community-based volunteers ( N = 34) and focus group discussions with community members ( N = 281). A content analysis was conducted in Nvivo v12. Data were interpreted using the Information-Motivation-Behavioral Skills Model. Generally, respondents showed good knowledge of COVID-19 symptoms, spread, and high-risk activities, with some gaps. Prevention behavior performance was driven by personal and social factors. Respondents described institutional settings (e.g., clinics and church) having higher levels of perceived adherence due to stronger enforcement measures and clear leadership. Conversely, informal community settings (e.g., weddings, funerals, football matches) lacked similar social and leadership expectations for adherence and had lower perceived levels of adherence. These settings often involved higher emotions (excitement or grief), and many involved alcohol use, resulting in community members “forgetting” guidelines. Doubt about disease existence or need for precautions persisted among some community members and drove non-adherence more generally. Although COVID-19 information successfully penetrated these very remote rural communities, more targeted messaging may address persistent COVID-19 doubt and misinformation. Engaging local leaders in religious, civic, and traditional leadership positions could improve community behaviors without adding additional monitoring duties on an already overburdened, resource-limited health system.