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The cervical cancer screening and precancer treatment journey: a qualitative study of experiences among Zambian women living with and without HIV
(2025-12-13) Moono, Misinzo; Sharma, Anjali; Bohlius, Julia; Mwanahamuntu, Mulindi; Taghavi, Katayoun; Mwamba, Chanda; Katota, Ntenje; Mwamba, Kabwe; Chipungu, Mwati; Hamweemba, Esther; Manasyan, Albert
Abstract Background: Zambia has the third highest cervical cancer incidence rate globally, and it remains the leading cause of cancer-related death among women. We explored the experiences of Zambian women who accessed cervical cancer screening and precancer treatment services to understand factors influencing care-seeking and access across urban, peri-urban, and rural settings. Methods: In 2020, we conducted eight focus group discussions with women living with and without Human Immunodeficiency Virus (HIV) who underwent cervical cancer screening between 2016 and 2020. To explore their care journey, participants were grouped by screening outcome—those with cervical precancerous lesions and those without. We also conducted 18 in-depth interviews with healthcare workers providing antiretroviral treatment, cervical cancer screening, or precancer treatment at government health facilities. Transcripts were coded and analyzed using thematic analysis. Results: Care-seeking unfolded across five stages: recognition of need to screen, hesitation and consultation, screening, result interpretation, and treatment. Women were generally knowledgeable about cervical cancer and sought screening promptly, though some delayed due to fear. Social networks and interactions with healthcare workers facilitated screening, while logistical and financial barriers, along with delays in histopathology services particularly in rural areas, hindered access to timely diagnosis and treatment. Conclusion: Improving cervical cancer screening and precancer treatment in Zambia requires addressing systemic inefficiencies by strengthening laboratory capacity, decentralizing diagnostics, and training healthcare workers to provide respectful, consistent counselling. Expanding community engagement to counter misinformation, leveraging social networks, and providing financial protection are also critical to ensuring timely, equitable, and reassuring care. DOI: 10.1093/oncolo/oyaf412
Feasibility of Vital Signs Assessment by Community Health Workers during Antenatal Care Community Outreach in Lusaka, Zambia: A Qualitative Study
(2022-09-13) Tembo, Taniya; Muttau, Nobutu; Manasyan, Albert; Mwamba, Chanda P.; Mwamba, Kabwe; Nyirenda, Herbert; Zulu, Tukiya K.; Hamweemba, Esther; Sharma, Anjali; Cauvel, Teresa; Shah, Sona; Nantume, Assumpta
Abstract Introduction The integration of digital tools in health initiatives marks a pivotal shift in traditional healthcare delivery methods. Technology-supported antenatal care (ANC) interventions have helped healthcare providers and community health workers (CHWs) to choose the course of action for individual patients. This study aimed to explore the suitability, feasibility, and acceptability of a wearable monitor, neoSpot, for measuring vital signs among pregnant women attending routine ANC visits during community outreach in Lusaka, Zambia. Methods This pilot feasibility trial was implemented between March and May 2023 at Kanyama 1st Level Hospital. We conducted 24 in-depth interviews (IDIs) among 12 purposively selected pregnant women and 12 trained CHWs. NeoSpot was placed on a pregnant woman’s arm to monitor vital signs and blood pressure. Thematic framework analysis used inductive and deductive reasoning for coding using NVivo and Excel for data organization. Qualitative data was analysed using NVivo. The suitability-feasibility-acceptability (SFA) framework was used to evaluate the potential of neoSpot as a tool for monitoring vital signs during routine ANC community outreach activities. Results The study revealed that neoSpot was accepted by pregnant women and CHWs for its ability to comprehensively assess vital signs, including those not typically assessed at clinics. Participants valued its speed, efficiency, and user-friendliness, believing it could reduce waiting times at antenatal clinics. Initially, pregnant women expressed concerns and apprehension about the new device, fuelled by misinformation and fears of its impact on their unborn babies and their skin. Conclusion Overall, all the study participants found the use of neoSpot to be suitable, feasible, and acceptable, and for use during ANC community outreach, largely due to its time efficiency, ability to simultaneously measure multiple vital signs, comfortable design, portability, and rechargeable battery. Incorporating recommendations could enhance the device’s efficiencies and its acceptability by community members and CHWs.
Admission to the kangaroo mother care ward and maternal postpartum depression in Lusaka, Zambia: a randomised controlled trial study protocol
(2026-10-26) Manasyan, Albert; Lakhwani, Jyoti; Kapesa, Herbert; Menon, Anitha J.; Sharma, Anjali; Pry, Jake M.; Brown, Catherine; Tembo, Taniya; Carlo, Waldemar A.
Abstract Introduction: Postpartum depression (PPD) is a serious public health problem affecting 17% of women globally with higher rates (up to 40%) recorded in southern Africa. Admission to the neonatal intensive care unit (NICU) is a risk factor for PPD. The study aims to determine whether initiation of Kangaroo Mother Care (KMC) at the NICU followed by admission to the KMC Ward for continued support for more than 2 days before discharge home reduces maternal PPD and other maternal and infant adverse outcomes in low-resource settings. Methods and analysis: This study will enrol mother-infant dyads (n=612), fathers (up to n=612) and a purposive subset of mothers (n=24), fathers (n=24) and family members (n=24) who will complete in-depth interviews (IDIs). Mother-infant dyads will be recruited from the NICU at the Women and Newborn Hospital - University Teaching Hospitals in Lusaka, Zambia. Once deemed stable for admission to the KMC Ward as part of step-down care, mother-infant dyads will be randomised to either the control arm where they will remain at the KMC Ward ≤2 days per standard of care or the intervention arm where they will remain at the KMC Ward for >2 days. The primary outcome is maternal PPD at 6–8 weeks postnatal screened using the Edinburgh Postnatal Depression Scale (EPDS) screening tool. IDIs will explore the feasibility and barriers to practising KMC post-discharge from the perspective of the parents and other family members. Ethics and dissemination: The study was approved by the University of Zambia Biomedical Research Ethics Committee, the National Health Research Authority and the University of Alabama at Birmingham Institutional Review Board. A Data Safety Monitoring Board (DSMB) has been constituted. Dissemination will be via publications in peer-reviewed journals, conferences, social media and revision of national guidelines.
Raising the bar: translating global guidelines to achieve local policy on cholera elimination in Zambia-a qualitative case study.
(2026-Sep-10) Mwamba, Chanda; Banda, Tikulirekuti ; Mazaba, Mazyanga ; Mukonka, Victor; Malama, Kennedy; Hamweemba, Esther; Syulikwa, Mainza; Chilengi, Roma; Sharma, Anjali; Fahim, Christine; Marten, Robert ; Yangchen, Sonam; Straus, Sharon
BACKGROUND: The global roadmap to eliminating cholera by 2030 relies on early detection and response, vaccination in hotspots and effective partnerships. In sub-Saharan Africa, where 60% of the 2.8 million annual cases occur, cholera elimination requires a multisectoral response. To accelerate progress, improved understanding of how to translate a multisectoral approach to eliminate cholera is needed. METHODS: We evaluated implementation of Zambia's Multisectoral Cholera Elimination Plan (MCEP) using six phases of Graham's Knowledge-to-Action (KTA) framework (adaption, assessing barriers, implementation, monitoring, evaluation and sustaining knowledge use). We reviewed the MCEP to assess the policy environment for supporting implementation and triangulated information from 24 key informant interviews with policy-makers and implementers, 12 in-depth interviews with cholera survivors and focus group discussions with 28 community-based neighbourhood health committee members. Thematic analysis was used to analyse the data. We present our findings under each KTA phase. RESULTS: The MCEP prioritizes actions in hotspots, and vaccinations through a multisectoral governance and coordination structure. The appointment of a coordinator and formation of multisectoral technical working groups (TWGs) have improved dissemination, coordination and the case for additional investments in laboratory capacity, cholera vaccines and infrastructure for water, sanitation, hygiene and decentralized solid waste management. However, slow institutionalization of plans, weak coordination, inadequate funding, poor infrastructure and the coronavirus disease 2019 (COVID-19) pandemic has led to fragmented implementation. The sustainability of the MCEP is not assured without: (1) comprehensive advocacy; (2) resource mobilization (international and national budget commitment); (3) monitoring and evaluation (M&E) of progress; and (4) information synthesis and dissemination for end users. CONCLUSIONS: A multisectoral approach can help gain adequate momentum and efficiencies to eliminate cholera in Zambia, provided stakeholders are fully committed and funding is allocated to support plans. An adaptive collaborative strategy within national guidelines and policies that includes target communities is needed to support local translation, adaptation and concerted efforts to eliminate cholera.
Effect of a person-centered care intervention on return and sustained reengagement after treatment interruptions from HIV care in Zambia: A post-hoc analysis of a stepped-wedged cluster randomized trial.
(2026-Sep) Mody, Aaloke; Sikombe, Kombatende; Simbeza, Sandra ; Mukamba, Njekwa ; Beres, Laura K.; Pry, Jake M.; Sharma, Anjali; Mutale, Jacob; Dube, Alida Z.; Mulabe, Musunge; Mulenga, Lloyd ; Sivile, Suilanji; Ratliff, April; Goss, Charles W.; Holmes, Charles B.; Bolton-Moore, Carolyn ; Sikazwe, Izukanji; Geng, Elvin H.
BACKGROUND: Poor client-provider interactions lead to reinforcing cycles of treatment interruptions (TIs) from HIV care and fear of return, undermining sustained retention. We previously demonstrated a multi-component person-centered care intervention (PCC) targeting healthcare worker (HCW) behavior improved client experience and retention in HIV care. To understand mechanisms of improved retention, we evaluated the effect of the PCC intervention on return after TIs and sustained retention after return in a post-hoc analysis, hypothesizing that friendlier HCW attitudes enable successful reengagement into care. METHODS AND FINDINGS: We implemented the PCC intervention at 24 clinics in Zambia in a stepped-wedge, cluster randomized trial from Aug 2019 to Nov 2021. Clinics were allocated into 4 groups (8 clinics in Groups 1 and 4, and 4 each in Groups 2 and 3) and randomly assigned to crossover from control to intervention every 6 months. Under control, clinics provided routine HIV care without additional support. Afterwards, clinics received the PCC intervention targeting caring aspects of HCW behavior with 1) training and coaching on PCC practices, 2) measurement and feedback of client experience (via exit interviews), and 3) small facility-level incentives. We examined individuals living with HIV who became >30 days late to a scheduled visit (i.e., TI), categorizing intervention exposure based on the last visit prior to TI. We used electronic health records to assess the effect of the PCC intervention on 1) return to HIV care after a TI, and 2) repeat TIs among those who returned. We used multistate analytic methods to estimate crude incidence of return and repeat TIs and prevalence of being in care at 1-year. We used shared frailty Cox proportional hazards and mixed-effects Poisson models to obtain formal comparisons that accounted for the stepped-wedge design. Individuals were censored at intervention crossover or database closure. During the study period, 128,910 clients (n = 69,671 control, n = 59,239 intervention) became >30 days late (64.3% female, median age 38y [IQR 31,45], median years in care 2.5y [IQR 0.6,6.7]). The PCC intervention increased incidence of return after TI at 12-months (72.3% intervention versus 67.7% control, crude risk difference [RD] +4.6% [CI 4.1,5.2], adjusted hazard ratio [aHR] 1.16 [CI 1.12,1.20]; p < 0.001). Among returners, the intervention decreased incidence of repeat TIs (44.3% versus 55.6%, RD -11.4% [CI -12.2,-10.6], aHR 0.50 [CI 0.45,0.55]; p < 0.001) and increased the proportion in care (with or without repeat TIs) (82.7% versus 73.4%, RD +9.3% [CI 8.6,10.0], adjusted risk ratio [aRR] 1.14 [CI 1.05,1.25]; p = 0.002) at 12-months after return. Overall, the PCC intervention increased the proportion in care 12-months after a TI from 51.5% to 60.1% (RD +8.7% [CI 8.0,9.3], aRR 1.19 [CI 1.05,1.35]; p = 0.008). Effect sizes were similar in direction and magnitude in multiple sensitivity analyses with varying precision. Limitations included post-hoc analysis and those associated with stepped-wedge design. CONCLUSIONS: The PCC intervention likely improved rates of return to care after TIs, sustained reengagement after return, and overall retention among individuals with TIs. Strategies targeting caring aspects of HCW behavior and client experience may help lower barriers to and address persistent challenges with reengagement in care.
Postpartum Depressive Symptoms and Mother-Infant Bonding: A Mixed-Methods Study Among Postpartum Women in Ghana.
(2026) Tornyevah, Leticia; Henrichs, Jens; Sharma, Anjali; de Jonge, Ank; Bosomprah, Samuel
Mother-infant bonding difficulties can impair the emotional connection between mother and child and affect child development. We examined the association between postpartum depressive symptoms (PPDS) and mother-infant bonding in the first year postpartum and explored sociocultural factors that may influence bonding. We employed a cross-sectional mixed-methods approach at three health facilities. Surveys included 399 mothers within 12 months postpartum. PPDS were assessed using the Patient Health Questionnaire-9 with a cut-off score > 9, and bonding was measured with the Pre- and Postnatal Bonding Scale. We used a log-normal multivariable regression model to estimate the association between PPDS and mother-infant bonding, adjusting for potential confounders. Qualitative interviews were conducted with 31 mothers (19 with depressive symptoms and 12 without) and were analysed thematically. Overall, 29% of mothers screened positive for depressive symptoms. Screening positive was associated with a small, statistically significant reduction of 3% in bonding (adjusted mean ratio 0.97; 95% confidence interval 0.95-0.99;
The pattern of diabetic care and glycemic control among the ambulatory diabetic patients in tertiary care settings in Bangladesh.
(2024-Nov-25) Farzana, Noshin; Islam, Saimul ; Selim, Shahjada ; Lakshmi, Josyula K.; Kappor, Deksha; Sharma, Anjali; Abdullah ABM; Naheed, Aliya
Diabetes mellitus is a major public health concern in Bangladesh. The pattern of diabetic care and control of blood sugar among diabetic patients are not well described. We assessed the pattern of diabetic care among ambulatory diabetic patients attending tertiary care hospitals in Bangladesh, and explored the relationship of glycemic control with behavioral and metabolic risks. Any patient 18 years and older attending the medicine outpatient department (OPD) at randomly selected three government tertiary hospitals in three divisions in Bangladesh were examined by hospital doctors. If a patient who was diagnosed as having diabetes and produced any medical document to support the diagnosis was recruited following an informed consent. Data on socio-demographic characteristics, diabetic care plan and behavioral risks, including tobacco use, physical activity, healthy diet (daily fruits and vegetable consumption) and salt intake were obtained from study participants by recall. Three milliliters of venous blood were tested to determine uncontrolled diabetes by measuring glycated hemoglobin (HbA1C > 7.0), and hyperlipidemia by measuring total cholesterol (> 200 mg/dL), high density lipoprotein/HDL (< 40 Mg/dL, low density lipoprotein/ LDL (> 200 mg/dL), and Triglyceride (> 160 mg/dL). A Total of 465 patients were enrolled. The Mean age was 49 years (SD:11) and 58% were women. Sixty percent patients were on a treatment plan of anti-diabetic drugs (drug), healthy diet (diet) and physical activity (PA), 13.3% diet and drug, 9.7% on drug only, 6.4% on diet and PA, 3.9% on PA and drug, 1.3% on PA only and 0.9% on diet only. Two- third of the patients (68.6%) had uncontrolled diabetes, which was three times higher, if a patient had diabetes for more than five years than otherwise (OR: 3.31, 95% CI 2.06-5.33), two times higher if a patient did not consume fruits (OR: 2.28, 1.34-3.87), or three times higher, if a patient did not consume vegetables (OR: 3.70, 95% CI 1.80-7.59) than otherwise, 78% higher, if a patient had taken extra salt in meal than otherwise (OR: 1.78, 95% CI 1.13-2.80) and nine times higher, if a patient had a raised total cholesterol level (> 200 mg/dL) than otherwise (OR: 9.60, 95% CI 2.60-35.40) and three times higher, if a patient had a raised LDL level compared than otherwise (OR: 3.33, 95% CI: 1.93-5.70). Diabetic patients seeking care at tertiary hospitals in Bangladesh follow diverse diabetic care plans and the majority of them do not have diabetes under control. Unhealthy dietary practice and hyperlipidemia among diabetic patients contribute to uncontrolled diabetes. Routine monitoring of blood glucose and enforcing lifestyle modifications could promote effective control of diabetes among diabetic patients in Bangladesh.
Contextual factors and implementation strategies for a biomarker-augmented alcohol screening with brief intervention and referral to treatment (SBIRT) program for HIV-affected adolescents in Zambia: a qualitative study guided by RE-AIM / PRISM.
(2025-Aug-11) Paniagua-Avila, Alejandra; Kanguya, Tukiya; Mwamba, Chanda; Hahn, Judith A.; Latkin, Carl; Chander, Geetanjali; Martins, Silvia S.; Munthali, Saphira; McDonell, Michael G.; Sharma, Anjali; Kane, Jeremy
INTRODUCTION: Screening, Brief Interventions and Referral to Treatment (SBIRT) programs reduce unhealthy alcohol use among adolescents. However, self-report screening alone may lead to false negatives and low service use, especially in HIV care settings. This study explored the contextual implementation factors and strategies of an alcohol biomarker-augmented SBIRT program for HIV-affected adolescents in Zambia, where alcohol use and HIV prevalence are high. METHODS: We conducted key informant interviews (n=7) with mental health providers and policymakers and focus groups (n=16 groups; 10-11 participants each) with healthcare providers, adolescents, and caregivers, guided by a case vignette of the biomarker-augmented SBIRT program. Thematic analysis followed the implementation frameworks Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Practical, Robust Implementation and Sustainability Model (PRISM). RESULTS: Participants perceived the SBIRT program as appropriate for adolescent alcohol use. Key contextual factors included: lack of alcohol treatment programs, community stigma against HIV and alcohol use, and robust implementation infrastructure through HIV healthcare. Strategies to enhance acceptability included making alcohol screening universal to avoid labeling adolescents, privacy and confidentiality during biomarker sampling, and peer-led age-matched counseling at screening. To enhance reach, participants suggested designing the program with attention to gender-specific needs and integrating it into HIV healthcare and alcohol use hotspots (e.g. schools). CONCLUSIONS: Implementation strategies should be designed to reduce stigma, build trust, engage adolescents across genders, and reach youth through clinical and community channels. Future research should define how to select, train, and evaluate peer counselors and assess the effectiveness of alcohol biomarkers within SBIRT programs in motivating behavior change.
Selfie consents, remote rapport, and Zoom debriefings: collecting qualitative data amid a pandemic in four resource-constrained settings.
(2021-Jan) Reñosa, Mark D. C.; Mwamba, Chanda; Meghani, Ankita; West, Nora S.; Hariyani, Shreya; Ddaaki, William; Sharma, Anjali; Beres, Laura K.; McMahon, Shannon
In-person interactions have traditionally been the gold standard for qualitative data collection. The COVID-19 pandemic required researchers to consider if remote data collection can meet research objectives, while retaining the same level of data quality and participant protections. We use four case studies from the Philippines, Zambia, India and Uganda to assess the challenges and opportunities of remote data collection during COVID-19. We present lessons learned that may inform practice in similar settings, as well as reflections for the field of qualitative inquiry in the post-COVID-19 era. Key challenges and strategies to overcome them included the need for adapted researcher training in the use of technologies and consent procedures, preparation for abbreviated interviews due to connectivity concerns, and the adoption of regular researcher debriefings. Participant outreach to allay suspicions ranged from communicating study information through multiple channels to highlighting associations with local institutions to boost credibility. Interviews were largely successful, and contained a meaningful level of depth, nuance and conviction that allowed teams to meet study objectives. Rapport still benefitted from conventional interviewer skills, including attentiveness and fluency with interview guides. While differently abled populations may encounter different barriers, the included case studies, which varied in geography and aims, all experienced more rapid recruitment and robust enrollment. Reduced in-person travel lowered interview costs and increased participation among groups who may not have otherwise attended. In our view, remote data collection is not a replacement for in-person endeavours, but a highly beneficial complement. It may increase accessibility and equity in participant contributions and lower costs, while maintaining rich data collection in multiple study target populations and settings.
Beyond the pill: Understanding barriers and enablers to oral and long-acting injectable PrEP among women in sex work in Zambia.
(2025) Kumar, Ramya; Mwale, Chisomo; Maritim, Patricia; Phiri, Jamia; Barrington, Wendy; Zyambo, Ruth; Zimba, Martin; Mugwanya, Kenneth; Herce, Michael; Musheke, Maurice; Rao, Deepa; Sharma, Anjali
Women engaging in sex work (WESW) in low- and middle-income countries face a disproportionately high risk of HIV infection. This study explores enablers and barriers to the uptake and persistence of oral pre-exposure prophylaxis (PrEP) and long-acting injectable PrEP (LAI-PrEP) among WESW in Lusaka, Zambia. We evaluated Capability, Opportunity, and Motivation behavioral domains, using the COM-B model, which affectied behavioral engagement with PrEP services among newly-initiated WESW from community-based safe spaces. Participants were recruited from July-October 2023 and interviewed using a semi-structured guide to explore barriers and enablers to engagement with HIV prevention. We used a rapid analysis approach-a two-step qualitative method-to identify themes aligned with COM-B domains. Interviews were conducted in English, ChiNyanja, or IchiBemba, audio-recorded, translated into English when necessary, and transcribed verbatim. Among 18 participants with a median age of 28 years (IQR:23-33) and 5 years in sex work (IQR:2,7), education during outreach by peer navigators and program staff was crucial to building trust and demystifying PrEP. Persistent knowledge gaps and misconceptions, especially about daily adherence and alcohol use, were significant barriers. Trustworthy program staff and reliable service provision facilitated continued PrEP use, and women preferring that drugs be delivered to them. Social support systems were mixed, offering both aid and competition. Personal empowerment and health protection motivated PrEP use, with LAI-PrEP preferred for eliminating daily pill burdens and associated stigma. However, inconsistent supply and misconceptions about LAI-PrEP were potential barriers. This study underscores the importance of person-centered care in addressing the complex interplay of individual, community, and programmatic factors influencing PrEP engagement among WESW in Zambia. A holistic focus, and adaptive health service delivery approach are both crucial to ensure that advances in HIV prevention translate into tangible benefits for WESW. Reliable, respectful healthcare programs that provide accurate, and trusted information are essential for improving PrEP uptake and persistence.

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