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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.
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.
Home deliveries in the capital: a qualitative exploration of barriers to institutional deliveries in peri-urban areas of Lusaka, Zambia.
(2018-Jun-01) Mulenga, Tamara; Moono, Misinzo; Mwendafilumba, Martha; Manasyan, Albert; Sharma, Anjali
BACKGROUND: A shortage of skilled birth attendants and low quality of care in health facilities along with unattended home deliveries contribute to the high maternal and neonatal mortality in sub Saharan Africa. Identifying and addressing context-specific reasons for not delivering at health care facilities could increase births assisted by skilled attendants who, if required, can provide life-saving interventions. METHODS: We conducted 22 in-depth interviews (IDIs) with midwives at three health facilities in peri-urban communities and 24 semi-structured surveys with mothers in two areas served by health facilities with the highest number of reported home deliveries in Lusaka, Zambia. Both IDIs and surveys were audio-recorded, transcribed and coded to identify themes around delivery and birthing experience. RESULTS: We found that most women preferred institutional deliveries to home deliveries, but were unable to utilize these services due to inability to recognize labour symptoms or lack of resources. Midwives speculated that women used herbal concoctions to reduce the duration of delivery with the result that women either did not present in time or endangered themselves and the baby with powerful contractions and precipitous labour. Respondents suggested that disrespectful and abusive maternity care dissuaded some women from delivering at health facilities. However, some midwives viewed such tactics as necessary to ensure women followed instructions and successfully delivered live babies. CONCLUSION: Difference in beliefs and birthing practices between midwives and mothers suggest the need for open dialogue to co-design appropriate interventions to increase facility usage. Further examination of the pharmaceutical properties and safety of herbal concoctions being used to shorten labour are required. Measures to reduce the economic burden of care seeking within this environment, increase respectful and patient-centred care, and improve the quality of midwifery could increase institutional deliveries.
The health system accountability impact of prison health committees in Zambia.
(2018-Sep-24) Topp, Stephanie M.; Sharma, Anjali; Chileshe, Chisela; Magwende, George; Henostroza, German; Moonga, Clement N.
BACKGROUND: From 2013, the Zambian Corrections Service (ZCS) worked with partners to strengthen prison health systems and services. One component of that work led to the establishment of facility-based Prison Health Committees (PrHCs) comprising of both inmates and officers. We present findings from a nested evaluation of the impact of eight PrHCs 18 months after programme initiation. METHODS: In-depth-interviews were conducted with 11 government ministry and Zambia Corrections Service officials and 6 facility managers. Sixteen focus group discussions were convened separately with PrHC members (21 females and 51 males) and non-members (23 females and 46 males) in 8 facilities. Memos were generated from participant observation in workshops and meetings preceding and after implementation. We sought evidence of PrHC impact, refined with reference to Joshi's three domains of impact for social accountability interventions - state (represented by facility-based prison officials), society (represented here by inmates), and state-society relations (represented by inmate-prison official relations). Further analysis considered how project outcomes influenced structural dimensions of power, ability and justice relating to accountability. RESULTS: Data pointed to a compelling series of short- and mid-term outcomes, with positive impact on access to, and provision of, health services across most facilities. Inmates (members and non-members) reported being empowered via a combination of improved health literacy and committee members' newly-given authority to seek official redress for complaints and concerns. Inmates and officers described committees as improving inmate-officer relations by providing a forum for information exchange and shared decision making. Contributing factors included more consistent inmate-officer communications through committee meetings, which in turn enhanced trust and co-production of solutions to health problems. Nonetheless, long-term sustainability of accountability impacts may be undermined by permanently skewed power relations, high rates of inmate (and thus committee member) turnover, variable commitment from some officers in-charge, and the anticipated need for more oversight and resources to maintain members' skills and morale. CONCLUSION: Our study shows that PrHCs do have potential to facilitate improved social accountability in both state and societal domains and at their intersection, for an extremely vulnerable population. However, sustained and meaningful change will depend on a longer-term strategy that integrates structural reform and is delivered through meaningful cross-sectoral partnership.
Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls.
(2019-Jan-05) Chinyama, Joyce; Chipungu, Jenala; Rudd, Cheryl; Mwale, Mercy; Verstraete, Lavuun; Sikamo, Charity; Mutale, Wilbroad; Chilengi, Roma; Sharma, Anjali
INTRODUCTION: While in school, girls require an environment that is supportive of menstrual hygiene management (MHM) in order to ensure regular school attendance and participation. Little is known about schoolgirls access to and practice of MHM in rural Zambia. This study explores girls' experiences of MHM in rural schools of Zambia from the perspectives of schoolgirls, schoolboys and community and school-based adults key to MHM for schoolgirls. METHODS: In July and August 2015, we conducted this qualitative exploratory study in six rural schools of Mumbwa and Rufunsa districts of Zambia. Twelve in-depth interviews (IDIs) and six focus group discussions (FGDs) were conducted among girls ages 14-18 who had begun menstruating. Two FGDs with boys ages 14-18 and 25 key informant interviews were also conducted with teachers, female guardians and traditional leaders to provide the context within which schoolgirls practice MHM. RESULTS: Most girls reported learning about menstruation only at menarche and did not know the physiological basis of menstruation. They reported MHM-related challenges, including: use of non-absorbent and uncomfortable menstrual cloth and inadequate provision of sanitary materials, water, hygiene and sanitation facilities (WASH) in schools. In particular, toilets did not have soap and water or doors and locks for privacy and had a bad odor. Girls' school attendance and participation in physical activities was compromised when menstruating due to fear of teasing (especially by boys) and embarrassment from menstrual leakage. Boys said they could tell when girls were menstruating by the smell and their behaviour, for instance, moving less and isolating themselves from their peers. Girls complained of friction burns on their inner thighs during their long journey to school due to chaffing of wet non-absorbent material used to make menstrual cloth. Girls preferred to dispose used menstrual materials in pit latrines and not waste bins for fear that they could be retrieved for witchcraft against them. Though traditional leaders and female guardians played a pivotal role in teaching girls MHM, they have not resolved challenges to MHM among schoolgirls. CONCLUSION: When menstruating, schoolgirls in rural Zambia would rather stay home than be uncomfortable, inactive and embarrassed due to inadequate MHM facilities at school. A friendly and supportive MHM environment that provides education, absorbent sanitary materials and adequate WASH facilities is essential to providing equal opportunity for all girls.
"They say that I have lost my integrity by breaking my virginity": experiences of teen school going mothers in two schools in Lusaka Zambia.
(2019-Jan-14) Nkwemu, Shanny; Jacobs, Choolwe N.; Mweemba, Oliver; Sharma, Anjali; Zulu, Joseph M.
BACKGROUND: Adolescent school-going mothers return to school in the rekindled hope of obtaining an education. However, their re-introduction into the school environment requires adequate support from teachers, fellow pupils, and the community. The purpose of this study was to explore the experiences of school-going mothers in Lusaka to understand their coping mechanism in the process of re-integration. METHOD: This is a qualitative case study. We conducted in-depth interviews with 24 school going mothers between the ages of 16-19, purposively selected from 2 schools in Lusaka district. Audio-recorded interviews were transcribed, coded using Nvivo 10 software and analysed using thematic analysis. RESULTS: The girls reported experiencing stigmatization, discrimination, mockery and abuse from their teachers. Some community members labelled, humiliated, gossiped about and isolated the girls from their friends and classmates because of fear of 'contamination'. Families forced some girls into early marriages making them feel rejected. These experiences resulted in low self-esteem, inferiority complex, poor performance in their academic work and identity crises in the young mothers. Therefore, because of the experiences the girls faced, they developed certain behaviours such as beer drinking, truancy and running away from home. They found it difficult to adjust to motherhood while doing their schoolwork. CONCLUSION: There is a need for the teachers to undergo training on how to handle young mothers and have a flexible time-table to accommodate adolescent school going mothers when they miss lessons to attend to their babies. Non-parenting school girls should be counseled so that they do not stigmatize adolescent mothers. Parents need to be educated on how to deal with adolescent mothers in the community. The guidance office should have a qualified psychosocial counselor to help create a conducive learning environment for adolescent mothers, by helping them with missed lessons and seeing to it that they are not stigmatized.
Operational characteristics of antiretroviral therapy clinics in Zambia: a time and motion analysis.
(2019-Apr-24) Tampi, Radhika P.; Tembo, Taniya; Mukumba-Mwenechanya, Mpande; Sharma, Anjali; Dowdy, David W.; Holmes, Charles B.; Bolton-Moore, Carolyn; Sikazwe, Izukanji; Tucker, Austin; Sohn, Hojoon
BACKGROUND: The mass scale-up of antiretroviral therapy (ART) in Zambia has taken place in the context of limited infrastructure and human resources resulting in many operational side-effects. In this study, we aimed to empirically measure current workload of ART clinic staff and patient wait times and service utilization. METHODS: We conducted time and motion (TAM) studies from both the healthcare worker (HCW) and patient perspectives at 10 ART clinics throughout Zambia. Trained personnel recorded times for consecutive discrete activities based on direct observation of clinical and non-clinical activities performed by counselors, clinical officers, nurses, and pharmacy technicians. For patient TAM, we recruited consenting patients and recorded times of arrival and departure and major ART services utilized. Data from 10 clinics were pooled to evaluate median time per patient spent for each activity and patient duration of stay in the clinic. RESULTS: The percentage of observed clinical time for direct patient interaction (median time per patient encounter) was 43.1% for ART counselors (4 min, interquartile range [IQR] 2-7), 46.1% for nurses (3 min, IQR 2-4), 57.2% for pharmacy technicians (2 min, IQR 1-2), and 78.5% for clinical officers (3 min, IQR 2-5). Patient workloads for HCWs were heaviest between 8 AM and 12 PM with few clinical activities observed after 2 PM. The length of patient visits was inversely associated with arrival time - patients arriving prior to 8 AM spent 61% longer at the clinic than those arriving after 8 AM (277 vs. 171 min). Overall, patients spent 219 min on average for non-clinical visits, and 244 min for clinical visits, but this difference was not significant in rural clinics. In comparison, total time patients spent directly with clinic staff were 9 and 12 min on average for non-clinical and clinical visits. CONCLUSION: Current Zambian ART clinic operations include substantial inefficiencies for both patients and HCWs, with workloads heavily concentrated in the first few hours of clinic opening, limiting HCW and patient interaction time. Use of a differentiated care model may help to redistribute workloads during operational hours and prevent backlogs of patients waiting for hours before clinic opening, which may substantially improve ART delivery in the Zambian context.

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