Nuala McGrath

Background: Suboptimal resource allocation limits uptake of essential health services in sub-Saharan Africa. Reliable population denominators and coverage estimates are needed to better match health facility resources to local demand. An estimation approach utilising routine health data has previously been used at region-/district-level. This ecological study aimed to explore its use at lower administrative levels, taking Ghana as an example. Methods: Data collected by Ghanaian health facilities from 2017-2020 were obtained from the District Health Information Management System and used to estimate childhood vaccination coverage and diarrhoea service utilisation in 2020 for the Eastern region, districts therein, and selected sub-districts and facilities. The estimation approach derived the denominator from routine data quantifying uptake of the first dose of the pentavalent vaccine and was calibrated and evaluated using household survey data. Results: Here we show region-level coverage of 90.3% and 92.4% for second (Penta2) and third pentavalent doses, respectively, and 83.8% for the first dose of the measles-rubella vaccine. The variability and proportion of implausible (>100%) coverage estimates increase through lower levels; the Penta2 district-level median was 93.6% (IQR:87.3%-96.2%) and facility-level median 96.5% (IQR:92.0%-104.5%). At all levels, diarrhoea service utilisation estimates are lower than the survey-derived estimate; the district-level median was 7.7% (IQR:5.9%-9.6%) and facility-level median 2.3% (IQR:0.0%-5.5%). Conclusions: Whilst this approach is useful for uncovering local variation in service uptake, integrating routine health data within geostatistical estimation approaches able to model the spatial/aspatial determinants of health-seeking may produce more accurate estimates, better informing facility-level resource allocation.

Non-communicable diseases are increasingly prevalent in sub-Saharan Africa, and goal setting is often used to promote healthy self-management behaviours. In this review, we aimed to synthesise literature around how goal setting is used, for application in future interventions in the region. A systematic search was conducted in six databases and results screened for eligibility. Study characteristics, intervention details, goal setting components, feedback from participants and facilitators were extracted. Data were analysed using narrative synthesis and thematic analysis. The Mixed Methods Appraisal Tool was used to assess study quality. We included 24 publications describing 18 unique interventions. Included studies were of high to moderate methodological quality. Goal setting intervention components were informed by a variety of frameworks and involved a range of tasks. Interventions were often facilitator-led; many were conducted in group settings. Participants reported goal setting as useful for putting self-management into practice but encountered challenges related to language and literacy levels. Adequate detail on goal setting intervention components was not always present. Through this review, we provide a comprehensive picture of the variability of goal setting approaches in chronic disease prevention and management in sub-Saharan Africa and recommend more standardised use and reporting of goal setting intervention components.

Background: Sexually transmitted infections pose a significant public health challenge in the United Kingdom, prompting the Department of Health and Social Care to prioritise sexually transmitted infection rate reduction as a means of addressing sexual health inequalities. Correct and consistent condom use is the most effective method of reducing sexually transmitted infection transmission. Methods: A randomised controlled trial with three arms (two intervention arms and one control arm) was conducted to evaluate the effectiveness and cost-effectiveness of the home-based intervention strategy United Kingdom intervention in reducing chlamydia test positivity among 16- to 25-year-old men, and individuals with a penis, at risk of sexually transmitted infections. The home-based intervention strategy United Kingdom intervention, delivered either face to face by health promotion professionals or digitally through an interactive website, aimed to enhance condom use experiences and improve correct and consistent condom use. The control group received usual condom distribution care. Chlamydia screening was conducted at baseline and 6 months post randomisation, with follow-up through online questionnaires. Of the 2387 individuals assessed for eligibility, 1233 were eligible, and 725 participants completed all baseline assessments and were randomised (health promotion professionals: 241, interactive website: 243, control: 241). Five hundred and eighty men received the intervention arm as randomised (health promotion professionals: 51.9%, interactive website: 93.8%, control: 94.2%); 51.7% of participants engaged during follow-up, with 21.4% providing baseline and follow-up chlamydia screening results. Results: Findings showed the home-based intervention strategy United Kingdom to be well received, with participants valuing the condom kit and materials promoting pleasurable condom use. At the primary end point, home-based intervention strategy United Kingdom participants showed a 4.9 percentage point reduction in chlamydia test positivity compared to the control (7.9% vs. 12.8%). The odds of a positive test were 55% lower for home-based intervention strategy United Kingdom participants compared to the control. However, this reduction was not statistically significant due to the lower-than-planned participant recruitment (a consequence of COVID-19) affecting the trial’s power. Home-based intervention strategy United Kingdom positively impacted recent condom use along with significant reductions in condom use errors and problems compared to the control. While no marked effect on consistent condom use emerged, attitudinal shifts were highly significant, with sustained positive condom attitudes, reduced perceived barriers and increased confidence in condom use among home-based intervention strategy United Kingdom participants. Conclusion: The home-based intervention strategy United Kingdom education and training programme, in conjunction with the provision of a broad selection of products, demonstrated a positive impact on attitudes towards condoms and lubricants, increased confidence in correct condom use and reduced errors and problems. Recent condom and lubricant use increased, but consistent condom usage showed no significant improvement. The odds of a positive chlamydia test were lower for home-based intervention strategy United Kingdom participants, though not statistically significant. This study provides valuable insights into the potential of home-based intervention strategy United Kingdom to enhance sexual health practices among at-risk populations. While it is recognised that home-based intervention strategy United Kingdom is more costly than usual condom distribution care, incorporating key elements of the intervention and messaging into existing practice could offer benefits without making implementation unfeasible. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 17/54/06.

Background: It is challenging to design usable and effective digital health interventions (DHIs). The person-based approach (PBA) has been proposed to incorporate users’ perspectives for the design of DHIs. However, it does not explicitly describe the iterative stages of design and evaluation that are essential in moving from early planning to deployment. For this, we draw on methods from human computer interaction (HCI) that have been developed for various situations. Objective: This study aimed to reflect on the adaptation and synthesis of PBA and HCI approaches to developing DHIs. We present a case study applying both approaches to develop Empowering People through Informed Choices for HIV (EPIC-HIV1), a DHI designed for men living in rural KwaZulu-Natal, South Africa, intended to support them in making an informed choice about whether to take an HIV test and, if necessary, engage in care. Methods: We conducted a retrospective analysis of the documentation generated during the development of EPIC-HIV1 including findings about requirements, design representations, and the results of iterative rounds of testing. We developed an account of the process, the outcomes, and the strengths and limitations of the design and evaluation techniques applied. We also present the design of EPIC-HIV1 and summarize considerations when designing for hard-to-reach people in such settings. Results: The PBA was applied to deliver a first prototype. This helped identify key messages to convey and how to manage issues such as user privacy, but the resulting prototype was judged by the team not to be engaging for potential users, and it was unclear whether the design was inclusive of people with low digital or health literacy. We therefore introduced methods from HCI to iteratively test and refine the app. Working with local community representatives, we conducted four refinement cycles with 29 participants, adapting and retesting the app until no further changes were needed. Key changes included making it clearer what the consequences of selecting options in the app were and changing wording to minimize misconceptions (eg, that the app would test for HIV) while addressing common concerns about testing and emphasizing long-term benefits of engaging with care, if needed. Conclusions: Techniques for developing DHIs need to be situationally appropriate. The PBA enabled us to establish both empirical data and theory to design the content of EPIC-HIV1, but it did not directly inform interaction design to make the app usable and effective for the intended users; HCI techniques tailored to the setting enabled us to refine the app to be easy for men with little familiarity with digital technologies to use within the constraints of the setting. Iterative testing ensured the app was easy to use and that the intended clinical messages were communicated effectively.

Background: Evidence indicating persistent geographic inequalities in health outcomes signifies a need for routine subnational monitoring of health-related Sustainable Development Goal targets in sub-Saharan Africa. Health facilities may be an appropriate subnational unit for monitoring purposes, but a lack of suitable demographic data complicates the production of baseline facility-level population denominators against which progress can be reliably measured. This scoping review aimed to map the methods and data sources used to estimate health facility catchment areas and translate them to population denominators for child health indicators in the region. Methods: Peer-reviewed research publications and grey literature reports were identified by searching bibliographic databases and relevant organisational websites. The inclusion criteria required that studies were conducted in sub-Saharan Africa since January 2000, described quantitative method(s) for estimating health facility catchment areas and/or population denominators, and focussed on children as the population of interest. Following title/abstract then full text screening of search results, relevant data were extracted using a standard form. Thematic analysis was undertaken to extract themes and present a narrative synthesis. Results: Overall, 33 research publications and 3 grey literature reports were included. Of these, only 7 research studies and 1 technical guidance document outlined aims explicitly framed around methods development and/or evaluation. Studies increasingly estimated catchment areas using complex geostatistical or travel time-based modelling approaches rather than simpler proximity metrics, and produced denominators by intersecting catchment boundaries with gridded population surfaces rather than aggregating area-based administrative counts. Few studies used data produced by or describing health facilities to link estimation methods to service utilisation patterns, inter-facility competition or facility characteristics. Conclusion: There is a need for catchment population estimation methods that can be scaled to national-level facility networks and replicated across the region. This could be achieved by leveraging routinely collected health data and other readily available and nationally consistent data sources. Future methodological development should emphasise modern geostatistical approaches drawing upon the relative strengths of multiple data sources and capturing the range of spatial, supply-side, individual-level and environmental factors with potential to influence catchments’ extent, shape and demographic composition.

Type 2 Diabetes Mellitus (T2D) can negatively impact relationships which may affect health and disease management. This can be moderated by positive communication between partners. Our aims were first, to identify ways in which couples’ communication and T2D impact each other. Second, we aimed to explore how improving couples’ communication may enhance self-management for people living with T2D (PLWD) and their partners in South Africa. We conducted secondary data analysis of qualitative interview and focus group data from an intervention pilot study designed to improve T2D self-management – ‘Diabetes Together’. 14 PLWD and their partners took part in two diabetes self-management workshops, including communication skills training, and were offered two couples counselling sessions. Inductive thematic and dyadic analysis explored how T2D and couples’ communication were connected, and how participants perceived the impact of couples’ communication skills training. Findings were compared to data collected from qualitative interviews with intervention-naive participants. We generated four themes linking couples’ communication and T2D: tone of discussions; listening; openness; and being informed about T2D. Participants described that T2D can create negative moods and stress (both from the disease and its management) and this can make communication challenging. They reported that negative communication styles can create stress worsening T2D and making it harder to manage. Participants felt that positive communication could ease stress, enable problem-solving and support behaviour change, which may improve T2D management. Couples reported that communication skills training helped them to address communication-related issues in their relationships. This included managing negative moods, changing communication styles and developing skills to discuss, listen and collaborate on improving T2D self-management. PLWD and their partners perceived that T2D and couples’ communication can affect one another positively and negatively. Equipping couples with effective communication skills may empower them to manage T2D more effectively.

Introduction: Couple-based behavioral interventions (CBIs) have been associated with improved HIV virological outcomes for pregnant women and their male partners living with HIV in observational settings, but have never been tested in a randomized controlled trial (RCT). Setting: Bwaila District Hospital Antenatal Clinic (Lilongwe, Malawi). Methods: An RCT was conducted among 500 pregnant women living with HIV (index clients) randomized 1:1 to the standard of care (SOC) or CBI and followed for 1 year. The CBI offered an initial session for index clients, HIV-assisted partner notification, 2 enhanced couple counseling and testing sessions, illustrated materials, and antiretroviral therapy pickup for either couple member at the antenatal clinic. At 12 months, viral load among index clients and male partners with HIV was measured. Risk differences (RD) and 95% confidence intervals (CIs) compared viral suppression (P = 0.04) in the CBI arm (84%) than in the SOC arm (76.0%). Social harms were rare (3.6%) and comparable between arms (P = 0.8). Conclusions: This CBI had a positive impact on couple viral suppression. Scaling this CBI to antenatal clients with HIV and their male partners could improve HIV outcomes among expecting families.

Background: There is a growing prevalence of type 2 diabetes (T2D) in South Africa and a high proportion of people have poor glycaemic control. Aim: Having developed ‘Diabetes Together’, a couples-based intervention to support diabetes self-management, we explored places of worship as potential options for recruiting couples in the community. Setting: Places of worship in low-income settings in Cape Town, South Africa. Methods: Community entry involved approaching leadership of each place of worship to discuss the programme and our target of recruiting 15–20 eligible couples, where one partner was living with T2D. The research team and study were introduced to each congregation. Enrolment took place at the first of three intervention sessions. Attendance, participant feedback and facilitator observations were recorded. Recruitment and retention outcomes were summarised using descriptive statistics. Participant and facilitator feedback was deductively coded based on the evaluation questions and overarching themes identified. Results: The intervention was conducted in two churches and one mosque after engaging with leaders of six places of worship. A total of 37 people living with T2D were screened; 34 were eligible and had a self-reported T2D diagnosis, 32 partners were screened. Twenty-nine couples were eligible, and 24 couples enrolled. Retention was good across all three places, minimum 75% by session three. Participant and facilitator feedback revealed that participants gained new knowledge, reported having a positive attitude towards diabetes management and valued group interaction and open communication. Conclusion: Recruitment of couples from places of worship in low-income settings in Cape Town was feasible under certain conditions. The intervention was acceptable and retention of couples for repeated sessions was high. Contribution: As there is limited evidence on using community settings like places of worship for diabetes management programmes, we present practical considerations for successful recruitment from these settings in South Africa.

BACKGROUND It is challenging to design usable and effective digital health interventions (DHIs). The person-based approach (PBA) has been proposed to incorporate users’ perspectives for the design of DHIs. However, it does not explicitly describe the iterative stages of design and evaluation that are essential in moving from early planning to deployment. For this, we draw on methods from human computer interaction (HCI) that have been developed for various situations. OBJECTIVE This study aimed to reflect on the adaptation and synthesis of PBA and HCI approaches to developing DHIs. We present a case study applying both approaches to develop Empowering People through Informed Choices for HIV (EPIC-HIV1), a DHI designed for men living in rural KwaZulu-Natal, South Africa, intended to support them in making an informed choice about whether to take an HIV test and, if necessary, engage in care. METHODS We conducted a retrospective analysis of the documentation generated during the development of EPIC-HIV1 including findings about requirements, design representations, and the results of iterative rounds of testing. We developed an account of the process, the outcomes, and the strengths and limitations of the design and evaluation techniques applied. We also present the design of EPIC-HIV1 and summarize considerations when designing for hard-to-reach people in such settings. RESULTS The PBA was applied to deliver a first prototype. This helped identify key messages to convey and how to manage issues such as user privacy, but the resulting prototype was judged by the team not to be engaging for potential users, and it was unclear whether the design was inclusive of people with low digital or health literacy. We therefore introduced methods from HCI to iteratively test and refine the app. Working with local community representatives, we conducted four refinement cycles with 29 participants, adapting and retesting the app until no further changes were needed. Key changes included making it clearer what the consequences of selecting options in the app were and changing wording to minimize misconceptions (eg, that the app would test for HIV) while addressing common concerns about testing and emphasizing long-term benefits of engaging with care, if needed. CONCLUSIONS Techniques for developing DHIs need to be situationally appropriate. The PBA enabled us to establish both empirical data and theory to design the content of EPIC-HIV1, but it did not directly inform interaction design to make the app usable and effective for the intended users; HCI techniques tailored to the setting enabled us to refine the app to be easy for men with little familiarity with digital technologies to use within the constraints of the setting. Iterative testing ensured the app was easy to use and that the intended clinical messages were communicated effectively.

Introduction: In South Africa, the HIV care cascade remains suboptimal. We investigated the impact of small conditional financial incentives (CFIs) and male‐targeted HIV‐specific decision‐support application (EPIC‐HIV) on the HIV care cascade.Methods: In 2018, in uMkhanyakude district, 45 communities were randomly assigned to one of four arms: (i) CFI for home‐based HIV testing and linkage to care within 6 weeks (R50 [US$3] food voucher each); (ii) EPIC‐HIV which are based on self‐determination theory; (iii) both CFI and EPIC‐HIV; and (iv) standard of care. EPIC‐HIV consisted of two components: EPIC‐HIV 1, provided to men through a tablet before home‐based HIV testing, and EPIC‐HIV 2, offered 1 month later to men who tested positive but had not yet linked to care. Linking HITS trial data to national antiretroviral treatment (ART) programme data and HIV surveillance programme data, we estimated HIV status awareness after the HITS trial implementation, ART status 3 month after the trial and viral load suppression 1 year later. Analysis included all known individuals living with HIV in the study area including those who did not participated in the HITS trial.Results: Among the 33,778 residents in the study area, 2763 men and 7266 women were identified as living with HIV by the end of the intervention period and included in the analysis. After the intervention, awareness of HIV‐positive status was higher in the CFI arms compared to non‐CFI arms (men: 793/908 [87.3%] vs. 1574/1855 [84.9%], RR = 1.03 [95% CI: 0.99−1.07]; women: 2259/2421 [93.3%] vs. 4439/4845 [91.6%], RR = 1.02 [95% CI: 1.00−1.04]). Three months after the intervention, no differences were found for linkage to ART between arms. One year after the intervention, only 1829 viral test results were retrieved. Viral suppression was higher but not significant in the EPIC‐HIV intervention arms among men (65/99 [65.7%] vs. 182/308 [59.1%], RR = 1.11 [95% CI: 0.88−1.40]).Conclusions: Small CFIs can contribute to achieve the first step of the HIV care cascade. However, neither CFIs nor EPIC‐HIV was sufficient to increase the number of people on ART. Additional evidence is needed to confirm the impact of EPIC‐HIV on viral suppression.