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Does peer education go beyond giving reproductive health information? A cohort study in Bulawayo and Mount Darwin, Zimbabwe ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2019-034436
Article Type: Original research
Date Submitted by the 19-Sep-2019 Author:
Complete List of Authors: Mangombe, Aveneni; Ministry of Health and Child Care, Family Health Owiti, Philip; International Union Against Tuberculosis and Lung Disease (The Union); National Tuberculosis, Leprosy and Lung Disease Program Madzima, Bernard; Ministry of Health and Child Care Xaba, Sinokuthemba; Ministry of Health and Child Care, Harare Zimbabwe Makoni, Talent; Ministry of Health and Child Care, AIDS and TB Unit ; World Health Organization , Zimbabwe, HIV Prevention Takarinda, Kudakwashe ; Ministry of Health and Child Care Timire, Collins ; International Union Against Tuberculosis and Lung Disease (The Union)
Chimwaza, Anesu; Ministry of Health and Child Care http://bmjopen.bmj.com/ Senkoro, Mbazi; National Institute for Medical Research – Muhimbili Centre Mabaya, Simbarashe; World Health Organization Regional Office for Africa Ameyan, Wole ; World Health Organization Samuelson, Julia; World Health Organization Tapera, Talent ; Africaid Zwangobani, Nonhlahla; Zimbabwe National Family Planning Council, Health Tripathy, Jaya; PGIMER, Community Medicine on September 30, 2021 by guest. Protected copyright. Kumar, Ajay; International Union Against Tuberculosis and Lung Disease (The Union), South East Asia Office, Operational Research; International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
Adolescents, Young people, voluntary medical male circumcision, Keywords: adolescent sexual and reproductive health, SORT IT
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1 2 3 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the terms applicable for US Federal Government officers or employees acting as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author Forunless you peer are acting as review an employee on behalf only of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 1 Title: Does peer education go beyond giving reproductive health information? A cohort 2 3
4 2 study in Bulawayo and Mount Darwin, Zimbabwe BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 3 Manuscript type: Original research article 8 9 10 4 Short Running Title: Enhanced reproductive health service uptake through peer education 11 12 5 in Zimbabwe 13 14 15 6 Investigators and Affiliations 16 17 1 2,3 1 1 18 7 Aveneni MangombeFor, Philip peer Owiti , reviewBernard Madzima only, Sinokuthemba Xaba , Talent 19 20 8 Makoni1, Kudakwashe Collin Takarinda1,2, Collins Timire1,2, Anesu Chimwaza1, Mbazi 21 22 9 Senkoro4, Simbarashe Mabaya5, Julia Samuelson6, Wole Ameyan6, Talent Tapera7, 23 24 8 9,10 2,9,11 25 10 Nonhlanhla Zwangobani , Jaya Prasad Tripathy , Ajay MV Kumar 26 27 11 28 29 12 1. Ministry of Health and Child Care, Harare, Zimbabwe 30 31 32 13 2. International Union Against Tuberculosis and Lung Disease (The Union), Paris, France; 33 34 14 3. National Tuberculosis, Leprosy and Lung Disease Program, Nairobi, Kenya 35 36 15 4. National Institute for Medical Research – Muhimbili Centre, Dar es Salaam, Tanzania http://bmjopen.bmj.com/ 37 38 16 5. World Health Organization, Harare. Zimbabwe 39 40 41 17 6. World Health Organization, Geneva, Switzerland 42 43 18 7. Africaid, Harare, Zimbabwe 44 on September 30, 2021 by guest. Protected copyright. 45 19 8. Zimbabwe National Family Planning Council, Harare, Zimbabwe 46 47 48 20 9. International Union Against Tuberculosis and Lung Disease, South-East Asia Office, New 49 50 21 Delhi, India 51 52 22 10. All India Institute of Medical Sciences, Nagpur, India 53 54 55 23 11. Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru, India 56 57 24 58 59 25 60 1
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1 26 Corresponding Author: 2 3
4 27 Aveneni Mangombe, National Adolescent and Youth Sexual Reproductive Health BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 28 Programme Coordinator, Ministry of Health and Child Care, Harare, Zimbabwe. 7 8 29 Email: [email protected] Telephone: +263773302742 9 10 11 30 12 13 31 Manuscript details 14 15 16 32 Word count: Abstract: 300 words; Main text: 3575 17 18 For peer review only 19 33 Number of tables: 6; Number of figures: 0 20 21 22 34 Number of references: 25 23 24 25 26 27 28 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 2
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1 2 36 ABSTRACT 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 37 Objective: Peer education has largely been a community-based intervention within the 6 7 38 voluntary medical male circumcision (VMMC) – adolescent sexual and reproductive health 8 9 10 39 (ASRH) linkages pilot project in Bulawayo and Mount Darwin, Zimbabwe since 2016. 11 12 40 However, little is known if benefits extend beyond information-giving. We assessed the 13 14 41 extent of and factors affecting referral and receipt of HIV testing services (HTS), 15 16 42 contraception, diagnosis and treatment of sexually transmitted infections (STIs) and VMMC 17 18 For peer review only 19 43 services by young people (10 – 24 years) counselled by peer educators in the two project 20 21 44 areas during October – December 2018. 22 23 24 45 Design: A cohort study utilizing the project’s routinely collected secondary data. 25 26 27 46 Setting: All the ASRH and VMMC sites in Mt Darwin and Bulawayo. 28 29 30 47 Participants: 95 peer educators. 31 32 33 34 48 Primary outcome measures: The censor date for assessing receipt of services was 31 35 49 January 2019. Factors affecting non-referral and non-receipt of services were assessed by 36 http://bmjopen.bmj.com/ 37 50 log-binomial regression. Adjusted risk ratios (aRR) were calculated. 38 39 40 51 Results: Of the 3370 counseled, 65% were referred for at-least one service. 58% of the 41 42 52 counseled males were referred for VMMC. Other services had 5-13% referrals. Non-referral 43 44 53 for HTS decreased with clients’ age(aRR:~0.9) but higher among group-counselled than on September 30, 2021 by guest. Protected copyright. 45 46 individually-counselled (aRR:1.16). Counseling by male peers(aRR:0.77) and rural 47 54 48 49 55 location(aRR:0.61) reduced the risks of non-referral for VMMC while age increased 50 51 56 it(aRR≥1.59). Receipt of services was high at 64-80% except for those referred for STIs 52 53 57 (39%). Group counseling and rural location(aRR:~0.52) and male peer educators(aRR:0.76) 54 55 56 58 reduced risk of non-receipt of VMMC. Rural location increased risk of non-receipt of 57 58 59 contraception(aRR:3.18) while marriage reduced it(aRR:0.20). 59 60 3
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1 60 Conclusion: This study found moderate levels of referrals with variations by service types 2 3
4 61 but high levels of receipt of services among referred clients. Type of counselling, gender of BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 62 peer educators and location affected receipt of services. The study recommends qualitative 7 8 63 approaches to further understand the reasons for non-referrals and non-receipt of services. 9 10 11 64 12 13 14 15 65 Key words: Adolescents, Young people, ASRH, Sexual and reproductive health, voluntary 16 17 66 medical male circumcision, HIV Testing, Contraception, Sexually transmitted infections, 18 For peer review only 19 67 Uptake and SORT IT. 20 21 22 68 Article Summary 23 24 25 69 Strengths and Limitations of this Study: 26 27 28 29 70 This study included all the clients who were counselled by peer educators during the 30 31 71 study period in the two project districts; 32 33 34 72 It used routine programme data, thus making the findings a likely true reflection of 35 36 73 the situation; http://bmjopen.bmj.com/ 37 38 39 40 74 The conduct and reporting of the study adhered to Strengthening the reporting of 41 42 75 observational studies in epidemiology (STROBE) guidelines. 43 44 on September 30, 2021 by guest. Protected copyright. 45 76 The study couldn’t exclude clients not in need of referral from the analysis due to 46 47 lack of data from the peer educator registers in determining the reason for non- 48 77 49 50 78 referral; 51 52 53 79 Due to small sample size of those referred for STI diagnosis and treatment, the study 54 55 80 lacked statistical power to carry out further analyses. 56 57 58 59 81 60 4
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1 2 82 INTRODUCTION 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 83 Human Immunodeficiency Virus (HIV) still remains a major global public health concern, 6 7 84 with 1.8 million new infections and 940,000 deaths reported in 2017.(1) Of concern is the 8 9 10 85 slower decline of Acquired Immune Deficiency Syndrome (AIDS)-related illnesses and 11 12 86 deaths among young people (10-24 years) compared to adults.(2) Coverage of HIV testing 13 14 87 and access to treatment remain significantly low among young people, especially in sub- 15 16 17 88 Saharan Africa.(2) Studies and systematic reviews have reported high rates of sexually 18 For peer review only 19 89 transmitted infections (STIs), teenage pregnancy and suicide attempts, coupled with poor 20 21 90 receipt of sexual and reproductive health (SRH) and HIV services among young people.(2,3) 22 23 24 91 Zimbabwe is a low-income country with a population of nearly 13.5 million as of 2017.(4) A 25 26 27 92 third of the country’s population are young people aged 10-24 years.(5) Mirroring the global 28 29 93 scenario, the Zimbabwe Demographic Health Survey (ZDHS) 2015 reported a high fertility 30 31 94 rate among young girls (15-19 years), low coverage of HIV testing among 15-19 years old 32 33 34 95 (35%-46%) and low comprehensive knowledge on HIV.(6) Though SRH and HIV 35 36 96 interventions focused on young people have been in existence for the past three decades, in http://bmjopen.bmj.com/ 37 38 97 Zimbabwe, the first 5-year strategic plan was developed in 2010. Among other things, this 39 40 98 phase defined a minimum package of interventions that recognised the role of community- 41 42 43 99 based youth peer educators in educating young people on SRH and HIV. 44 on September 30, 2021 by guest. Protected copyright. 45 46 100 There is no universally agreed upon definition of peer education. We define it as a structured 47 48 101 process of sharing of relevant information, values and behaviours among members of similar 49 50 102 status, in an appropriate setting for both the educator and learner. Following a series of 51 52 53 103 reviews, peer education has been noted to be an effective youth-led approach for influencing 54 55 104 positive behavioural outcomes among beneficiaries, if given appropriate support systems and 56 57 105 contextualized to different settings and needs of beneficiaries.(7,8) Peer education has been 58 59 60 5
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1 106 established to be more effective in reaching out to key populations (for example, adolescents 2 3
4 107 selling sex and who are sexually exploited) and delivering messages that are considered BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 108 taboo to be delivered through schools, religious and family settings.(9) Integration of peer 7 8 109 education interventions with holistic and well-coordinated interventions make it more 9 10 11 110 effective towards improving health outcomes among beneficiaries in different 12 13 111 contexts.(10,11) 14 15 16 112 In 2016, a project to link Voluntary Medical Male Circumcision (VMMC) with the 17 18 113 Adolescent SexualFor and Reproductive peer Health review (ASRH) services only (“Smart LyncAges Project”) 19 20 21 114 was started. In 2017, the scope of this project was expanded to engage youth peer educators 22 23 115 in promoting referral and receipt of SRH and VMMC services in Bulawayo and Mount 24 25 116 Darwin districts. Informed by Michielsen et al’s review(12), the re-designing incorporated 26 27 28 117 provision of an updated training that introduced relevant tools for delivering the messages 29 30 118 (distribution of information, education and communication materials and social media 31 32 119 platforms such as facebook and WhatsApp), which defined a clear referral pathway 33 34 120 (including referral forms, tracking and two-way feedback mechanism) and provision of 35 36 http://bmjopen.bmj.com/ 37 121 adequate tools for documentation. 38 39 40 122 Since the re-designing of the peer education component, no study has been conducted to 41 42 123 determine the effect of peer educators beyond just providing information to their peers. 43 44 Within this background, we carried out a study to assess the referral and receipt of HIV on September 30, 2021 by guest. Protected copyright. 45 124 46 47 125 testing services (HTS), contraception, diagnosis and treatment of sexually transmitted 48 49 126 infections (STIs) and VMMC services among young people (10 – 24 years) counselled by the 50 51 127 peer educators and their associated factors within the two pilot districts (Bulawayo and 52 53 54 128 Mount Darwin) in Zimbabwe. 55 56 57 58 59 60 6
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1 2 130 METHODS 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 131 Study design: 6 7 8 132 This was a cohort study involving secondary analysis of routinely collected data under the 9 10 133 VMMC - ASRH linkages pilot project in Zimbabwe. 11 12 13 14 134 Setting: 15 16 17 135 General setting 18 For peer review only 19 20 136 In 2009, Zimbabwe devised the National ASRH strategy 2010-15 to promote adoption of 21 22 137 safer SRH practices and increase availability, access and utilization of SRH and HIV services 23 24 138 by young people.(13) The strategy outlined three settings for providing ‘friendly’ SRH and 25 26 27 139 HIV services: health facility, community and school-based. The health facility approach 28 29 140 required every facility to establish and equip special rooms (youth-friendly corners). The 30 31 141 community approach involved establishment of ‘community youth centres (CYCs)’ whilst 32 33 34 142 the school-based approach focussed on the provision of life skills education and counselling 35 36 143 mainly by teachers. http://bmjopen.bmj.com/ 37 38 144 39 40 145 In 2015, an extensive review of the 2010-2015 interventions in Zimbabwe was conducted so 41 42 43 146 as to inform the development of the National ASRH Strategy II: 2016-2020.(14) One of the 44 on September 30, 2021 by guest. Protected copyright. 45 147 review’s conclusions acknowledged peer education as an important tool in ASRH 46 47 148 programming, though with some modifications.(15) This strategy seeks to strengthen 48 49 50 149 comprehensive sexuality education (CSE) and provision of quality-assured and adolescent- 51 52 150 friendly services, delivered through schools and colleges, public health facilities and the 53 54 151 community. As part of expanding comprehensive sexuality education in both the in- and out- 55 56 57 152 of-school settings, Zimbabwe aligned its tools and training materials with the 2018 United 58 59 153 Nations Educational, Scientific and Cultural Organization (UNESCO) revised international 60 7
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1 154 technical guidance on sexuality education.(16) The minimum package of SRH services for 2 3
4 155 young people includes contraception, STI diagnosis and treatment, HTS and integration of BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 156 VMMC. 7 8 157 9 10 11 158 The VMMC - ASRH linkages project 12 13 14 159 The VMMC - ASRH linkages project has been implemented in Bulawayo and Mount 15 16 160 Darwin, Zimbabwe since 2016. Bulawayo is an urban city with 27 public health facilities 17 18 161 while Mount DarwinFor is a ruralpeer district review with 19 public healthonly facilities. In Mount Darwin, 19 20 21 162 VMMC services are provided at the Mount Darwin Hospital, whilst diagnosis and treatment 22 23 163 of STIs, contraception and HTS services are being provided at Mount Darwin Hospital and 24 25 164 two CYCs (Mt Darwin and Dotito) supported through the Zimbabwe National Family 26 27 28 165 Planning Council. In Bulawayo, VMMC services are provided at the Bulawayo Male 29 30 166 Circumcision (MC) site and the Lobengula MC site and sometimes through outreach camps 31 32 167 in the 15 CYCs and clinics. The CYCs in Bulawayo are primarily focused on imparting 33 34 168 information and counselling services, edutainment services through films, drama and sports, 35 36 http://bmjopen.bmj.com/ 37 169 library services and vocational and life skills training. All the service delivery points under 38 39 170 this project were oriented on the VMMC – ASRH linkages service delivery protocols and 40 41 171 ASRH. The VMMC – ASRH service delivery protocols clearly highlight the scope of work, 42 43 44 172 reporting, referral, coordination and supervision mechanisms for peer educators. Demand on September 30, 2021 by guest. Protected copyright. 45 46 173 creation for both SRH and VMMC services for young people relies heavily on community- 47 48 174 based peer educators and VMMC mobilisers. 49 50 51 175 Peer education 52 53 54 55 176 Each CYC is expected to coordinate and supervise the work of 5 – 6 peer educators at any 56 57 177 point in time. Peer educators are volunteers aged 10-24 years, residing in the community and 58 59 178 nominated by the young people in stakeholder community meetings. They must be able to 60 8
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1 179 read and write in English and the respective local language and should have passed at least 3 2 3 th 4 180 subjects at the end of secondary level (13 grade). Under the Smart LyncAges project, peer BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 181 educators undergo a seven-day standard training, which also addresses the referral pathway. 7 8 182 They are attached to the nearest CYC and are allocated a catchment area to cover. Peer 9 10 11 183 educators are expected to contribute at least two hours a day for at least 3 days in a week to 12 13 184 the project. Active peer educators receive a fixed monthly allowance of 15 USD, paid upon 14 15 185 submission of daily and monthly summary reports of their activities. 16 17 18 186 While peer educatorsFor spend peer most of review their time in the only community conducting outreach 19 20 21 187 sessions, they do sit in CYCs on a rotation basis to cater for the walk-in clients. Peer 22 23 188 educators reach clients through both individual (one-on-one) and group counselling sessions. 24 25 189 They choose places such as recreation parks, play grounds, schools and community halls 26 27 28 190 where young people usually congregate. In addition to providing information and counselling 29 30 191 services, peer educators also distribute condoms to the clients. However, they refer clients for 31 32 192 such when they run out of stock or are in settings (such as churches and schools) where 33 34 193 condom distribution is prohibited. 35 36 http://bmjopen.bmj.com/ 37 38 194 Peer educators also facilitate referrals to ASRH and VMMC sites. The referral process 39 40 195 includes providing information regarding location of the service delivery point, hours of 41 42 196 operation, user fees (if any) and details of contact person (if available). They also complete 43 44 referral forms in triplicate (one copy kept for records and two copies sent with the client to on September 30, 2021 by guest. Protected copyright. 45 197 46 47 198 the destination service delivery point). One copy of the latter is retained at the service 48 49 199 delivery point, while the other is given to the client who is expected to return it to the 50 51 200 respective peer educator. The form retained at the service delivery point is sent to the 52 53 54 201 respective CYC by post or hand-delivered. This system facilitates feedback on receipt of 55 56 202 services by referred clients. Monthly, the peer educators are expected to track all the referred 57 58 203 clients, through verification of redeemed referral forms, physical home visits or by telephone 59 60 9
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1 204 (where possible). In some cases, peer educators accompany clients to the service delivery 2 3
4 205 points to ensure that they avail the service. BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 206 As part of documentation, each peer educator maintains individualized “daily and monthly 8 9 207 summary peer educator registers’ where they document the socio-demographic details of the 10 11 208 clients who received counselling, the referrals and receipt of the services. Each service 12 13 14 209 delivery point under the VMMC - ASRH Linkages project also uses primary registers for 15 16 210 SRH and HIV services provision. 17 18 For peer review only 19 211 Study population: 20 21 22 212 All young people (10-24 years) who were counselled by youth peer educators during the 23 24 25 213 period October – December 2018 in Bulawayo city and Mount Darwin district were included 26 27 214 in the study. 28 29 30 215 Data variables, sources of data and data collection: 31 32 33 216 A structured proforma was used to collect the following data variables: socio-demographic 34 35 characteristics of clients (age, sex, marital status, location, schooling status, and type of 36 217 http://bmjopen.bmj.com/ 37 38 218 counselling sessions undergone), the age and sex of their peer educators, whether referred or 39 40 219 not, services referred for and if the clients received the services. The source of data was the 41 42 220 peer educator registers. ‘Referral’ in this study meant that clients consented to receive some 43 44 on September 30, 2021 by guest. Protected copyright. 45 221 post-counseling services (such as HIV testing, VMMC, contraception or STI diagnosis and 46 47 222 treatment) and were given a referral form. ‘Receipt’ of a service meant receiving/getting the 48 49 223 services at a referral service delivery point by the young person who had been referred by 50 51 52 224 peer educators (between October and December 2018) by end of January 2019. 53 54 55 225 Data Analysis and statistics: 56 57 58 59 60 10
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1 226 Data entry and validation was performed using EpiData software (v4.4.1.0, EpiData 2 3
4 227 Association, Odense, Denmark) while analyses were carried out using EpiData Analysis BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 228 (v2.2.2.186) and STATA (v14, StataCorp, College Station, Texas, USA) softwares. 7 8 229 Proportions were used to summarize referrals and receipt of services for those referred. 9 10 11 230 There were four major services for which the clients were referred: HTS, VMMC, 12 13 231 contraception and STI diagnosis and treatment. Of these, factors associated with non-referral 14 15 232 were assessed for HTS and VMMC services only. Factors associated with non-referrals for 16 17 contraception and STI diagnosis and treatment were not analyzed as it was not possible to 18 233 For peer review only 19 20 234 establish the appropriate denominator defining the eligibility for these services. Factors 21 22 235 associated with non-receipt of services were assessed for VMMC and contraceptive use only. 23 24 236 Non-receipt of HTS was not analyzed as HTS can also be provided as an opt-out provider- 25 26 27 237 initiated testing and counseling (PITC) service at all the service delivery points, irrespective 28 29 238 of the reason for which the client was referred. HTS was also a necessary service prior to 30 31 239 conducting VMMC. Non-receipt of STI services amongst those referred was not analyzed 32 33 34 240 due to small sample size. The strength of associations were initially expressed using 35 36 241 unadjusted relative risks and then further expressed using adjusted relative risks (aRR) and http://bmjopen.bmj.com/ 37 38 242 95% confidence intervals, using log-binomial regression methods. Two-sided P<0.05 were 39 40 41 243 considered statistically significant. 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 11
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1 2 245 RESULTS 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 246 There were 95 peer educators (52% males) in the study sites with a median age of 22 years 6 7 247 (range: 15-24). A total of 3370 young people received counselling services from the peer 8 9 10 248 educators (Table 1). Forty percent of young people were aged 15-19 years, with the majority 11 12 249 being males (66%) and single (98%). Majority were still in school (69%) and received group 13 14 250 counselling (78%). 15 16 17 251 Referrals and receipt of services 18 For peer review only 19 20 21 252 Table 2 shows the proportions of clients who were referred and those who received the 22 23 253 services among those referred. Sixty five percent of the young people counselled were 24 25 254 referred for SRH services. Of those referred, 77% had been referred for only one service, 26 27 28 255 with the rest being referred for two or more services. Majority (75%) of those referred 29 30 256 received the services they had been referred for. 31 32 33 257 Of the males counselled, 58% were referred for VMMC services, of whom, 69% received the 34 35 36 258 services. The other services for which the adolescents were referred for include HIV testing http://bmjopen.bmj.com/ 37 38 259 (13%), contraception (13%) and diagnosis and treatment of STIs (5%). Among the services 39 40 260 referred for, the receipt for STI services was lowest (39%). 41 42 43 261 Factors associated with non-referrals for HTS and VMMC 44 on September 30, 2021 by guest. Protected copyright. 45 46 262 Non-referral for HIV Testing Services (Table 3) 47 48 49 50 263 In multivariable analysis, only age of client and type of counseling were significantly 51 52 264 associated with non-referral for HTS. Adolescents aged 15-19 years had a 9% (95% CI: 0.81- 53 54 265 1.03) reduced risk of non-referral for HTS as compared to those aged 10-14 years old. Those 55 56 266 who underwent group counseling had 16% (95% CI: 1.04-1.27) increased risk of non-referral 57 58 59 267 for HTS. Sex and marital status of the peer educators did not influence referral for HTS. 60 12
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1 268 Non-referral for VMMC services (Table 4) 2 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 269 Compared to clients in the 10-14 year age group, those in the 15-19 year and 20-24 year age 6 7 270 group had 59% (95% CI: 1.34-1.87) and 83% (95% CI: 1.49-2.26) increased risk of non- 8 9 271 referral for VMMC, respectively. Clients in the rural district of Mount Darwin were at 39% 10 11 272 (95% CI: 0.52-0.71) reduced risk of non-referral compared to those in the urban city of 12 13 14 273 Bulawayo. Clients counseled on VMMC by male peer educators were at 23% (95% CI: 0.67- 15 16 274 0.80) reduced risk for non-referral as compared to those counselled by female peer educators. 17 18 For peer review only 19 275 Factors associated with non-receipt for VMMC and contraception 20 21 22 276 Non-receipt of VMMC services (Table 5) 23 24 25 277 Clients referred by male peer educators had a 24% (95% CI: 0.62-0.94) lower risk of non- 26 27 28 278 receipt of services than those referred by their female counterparts. Those referred from the 29 30 279 rural district of Mount Darwin (aRR: 0.52, 95% CI: 0.41-0.67) and those referred through 31 32 280 group counselling sessions (aRR: 0.52, 95% CI: 0.41-0.66) had significantly lower risk of 33 34 35 281 non-receipt of VMMC services as compared to urban Bulawayo and individual counseling 36 http://bmjopen.bmj.com/ 37 282 sessions, respectively. Age of the clients did not influence receipt of VMMC services. 38 39 40 283 Non-receipt of contraception services (Table 6) 41 42 43 284 Clients referred from the rural district had 3.2 times (95% CI: 1.93-5.22) higher risk of non- 44 on September 30, 2021 by guest. Protected copyright. 45 46 285 receipt of contraception services as compared to the urban-based counterparts. Married 47 48 286 clients had 80% (95% CI: 0.07-0.58) reduced risk of not receiving contraception services 49 50 287 than the single clients. 51 52 53 54 55 56 57 58 59 60 13
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1 2 289 DISCUSSION 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 290 This study, the first one assessing the role of the peer educators in the referral and receipt of 6 7 291 selected SRH and VMMC services among young people in Zimbabwe found relatively 8 9 10 292 moderate levels of referrals, particularly for VMMC services. However, for those referred, 11 12 293 receipt of the services was high except for STI diagnosis and treatment. Majority of the 13 14 294 referred clients had been referred for just one service, perhaps indicating limited counselling 15 16 295 or reflecting the lack of need. The risk of not being referred for HTS services decreased 17 18 For peer review only 19 296 slightly with older age of clients, though for VMMC services younger aged adolescents were 20 21 297 more likely to be referred. Slightly increased non-referral for HTS services was observed in 22 23 298 clients who underwent group counseling sessions as compared to individual sessions. With 24 25 26 299 regard to VMMC services, those counseled by male peer educators were more likely to be 27 28 300 referred and to receive, likewise to the clients in the rural district. Rural setting increased risk 29 30 301 of not receiving contraception services while being married reduced this risk. 31 32 33 302 The low referral for diagnosis and treatment of STIs might have been influenced by: 1) lack 34 35 36 303 of confidence by peer educators in determining the need for referral. 2) limited self-reports of http://bmjopen.bmj.com/ 37 38 304 STI-like symptoms. In any population, only a minority will have STI or STI - like symptoms 39 40 305 and referrals rates may be low. However, the low receipt of the diagnosis and treatment of 41 42 43 306 STIs services among the referred clients might have been due to the associated user fees 44 on September 30, 2021 by guest. Protected copyright. 45 307 levied (mostly in council clinics and hospitals) in both the rural and urban settings.(17),(18) 46 47 308 Abolishing or largely subsidizing these costs, while maintaining or sustaining supply and 48 49 309 diagnostics may improve receipt of services by young people. 50 51 52 53 310 Low risk perception among early adolescents has been established to be one of the barriers 54 55 311 for referral and receipt of HTS services.(19) Other studies have also shown that demand for 56 57 312 HTS services are reduced in adolescents who require parental/guardian consent, especially 58 59 60 14
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1 313 due to the perceived negative reactions from parents/guardians.(19) With Zimbabwe’s age of 2 3
4 314 consent for HTS at 16 years, this may explain the reduced non-referral for HTS as the BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 315 client’s age increases. Individualized or client-centered counseling has been established to be 7 8 316 a more effective approach for HTS and post-test services than group counseling,(20) as 9 10 11 317 demonstrated also by this study. 12 13 318 14 15 319 Group counseling sessions may have provided an opportunity for client peer influence on 16 17 receipt of VMMC services. Counseling by male peer educators may also encourage openness 18 320 For peer review only 19 20 321 among the male clients leading to more referral and receipt of VMMC services. As regards 21 22 322 contraception, urban areas present more convenient service delivery points for accessing 23 24 323 contraceptives than rural areas, explaining why non-receipt is lower in the urban setups. 25 26 , 27 324 Myths on the association between modern contraception and future infertility(21) (22) may 28 29 325 have resulted in the higher non-receipt rates of contraception among the adolescent girls 30 31 326 referred. This belief may be more common in the rural setups and at times is propagated by 32 33 , 34 327 other health workers.(22) (17) 35 36 http://bmjopen.bmj.com/ 37 328 Strengths: This study had several strengths. We included all the clients who were counselled 38 39 329 by peer educators during the study period in the two project districts, which were the only 40 41 330 districts implementing this intervention in the whole country. As we used routine programme 42 43 44 331 data, the findings are likely a true reflection of the situation. The data was extracted into on September 30, 2021 by guest. Protected copyright. 45 46 332 standard proformas by the principal investigator and trained data collectors – this enhanced 47 48 333 quality. Lastly, the conduct and reporting of the study adhered to Strengthening the 49 50 51 334 Reporting of observational studies in epidemiology (STROBE) cohort reporting 52 53 335 guidelines.(23) 54 55 56 336 Limitations: However, there were also limitations. First, due to deficiencies in 57 58 337 documentation in the peer educator registers, we could not determine if the reason for non- 59 60 15
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1 338 referral (for VMMC or HTS) was related to ‘need’, that is, they had already received VMMC 2 3
4 339 or HTS services before. We, therefore couldn’t exclude clients not in need from the analysis. BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 340 In certain circumstances, like referral for contraception and STI diagnosis and treatment, we 7 8 341 could not perform further analyses as it was not possible to establish the appropriate 9 10 11 342 denominator defining the eligibility for these services. Second, we were not able to establish 12 13 343 exact reasons for non-referral and non-receipt of services. This requires qualitative and 14 15 344 youth-led study approaches. Third, due to small sample size of those referred for STI 16 17 diagnosis and treatment, we lacked statistical power to carry out further analyses. Many 18 345 For peer review only 19 20 346 reviews on peer education have largely focused on assessing the designs or models of peer 21 22 347 education without focusing on the outputs and the immediate positive outcomes of peer 23 24 348 education in relation to receipt of diagnosis and treatment of STIs, HTS, contraception and 25 26 27 349 VMMC services. Therefore, there were no study results to compare with. Whilst the results 28 29 350 and conclusions of this study may be used in different peer education interventions, they 30 31 351 cannot be generalised. 32 33 34 352 Implications: The study has the following implications: 35 36 http://bmjopen.bmj.com/ 37 38 353 There is need for a review of peer education data collection tools to capture more 39 40 354 client and peer educator data, for example, on details and quality of sessions and 41 42 355 eligibility of clients for the various services in line with the recently adapted revised 43 44 on September 30, 2021 by guest. Protected copyright. 45 356 international guidelines on CSE in Zimbabwe.(24) The review will also need to be 46 47 357 followed with refresher training on the new concepts. This will help in determining 48 49 358 actual output and factors associated with it. 50 51 52 359 The project needs to consider integrating parent-child communication interventions 53 54 55 360 into the VMMC – ASRH linkages project so as to mobilize parents to support the 56 57 361 young people to access services (both psychosocially and financially). In the long run, 58 59 60 16
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1 362 this may also provide opportunities for home-based HTS and supervised HIV self- 2 3
4 363 testing. BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 364 While HTS services are better provided through individual sessions, VMMC services 8 9 365 are better received when group counseling sessions are provided. There is thus need 10 11 12 366 to focus on differentiated service provisions depending on circumstances, even as 13 14 367 services are integrated. 15 16 17 368 In view of the male peer educators having higher chances of effectively referring 18 For peer review only 19 369 clients for VMMC, the peer education component needs to differentiate approaches 20 21 22 370 which might include pairing of female peer educators with their male counterparts. 23 24 25 371 There is a need to review and possibly abolish user fees attached to the diagnosis and 26 27 372 treatment of STIs among the adolescents and young people in need of such services. 28 29 30 373 Global standards on provision of quality health services to young people should be 31 32 33 374 adopted and client satisfaction surveys prioritized to enhance quality service 34 35 375 delivery.(17),(25) This will help contextualize peer education into service delivery 36 http://bmjopen.bmj.com/ 37 376 and help understand the reasons for non-referral and non-receipt of services. 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 17
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1 2 378 CONCLUSION 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 379 This operational study found moderate levels of referrals among clients counseled by young 6 7 380 peer educators with variation by service type. Receipt of contraception, VMMC and HTS 8 9 10 381 services was high among those referred. Factors affecting non-referral included age of client, 11 12 382 sex of peer educator and type of counseling session (individual/group) while type of setting 13 14 383 (rural/urban), age of client and sex of peer educators affected non-receipt of services. Peer 15 16 384 education service differentiation based on gender and service type may further enhance 17 18 For peer review only 19 385 uptake. There is also a need to review the output of the peer educator project with a view to 20 21 386 enhancing the quality of care provided to the adolescents and young people. 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 18
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1 2 388 Acknowledgements 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 389 This research was conducted through the Structured Operational Research and Training 6 7 390 Initiative (SORT IT), a global partnership led by the Special Programme for Research and 8 9 10 391 Training in Tropical Diseases at the World Health Organization (WHO/TDR). The training 11 12 392 model is based on a course developed jointly by the International Union Against 13 14 393 Tuberculosis and Lung Disease (The Union) and Medécins sans Frontières (MSF). The 15 16 394 specific SORT IT program which resulted in this publication was implemented by the Centre 17 18 For peer review only 19 395 for Operational Research, The Union, Paris, France. Mentorship and the 20 21 396 coordination/facilitation of this particular SORT IT workshop was provided through the 22 23 397 Centre for Operational Research, The Union, Paris, France; the Department of Tuberculosis 24 25 26 398 and HIV, The Union, Paris, France; the University of Washington, School of Public Health, 27 28 399 Department of Global Health, Seattle, Washington, USA; National Institute for Medical 29 30 400 Research, Muhimbili Centre, Dar es Salaam, Tanzania; and AIDS & TB Department, 31 32 33 401 Ministry of Health & Child Care, Harare, Zimbabwe 34 35 36 402 Funding http://bmjopen.bmj.com/ 37 38 39 403 The training course under which this study was conducted was funded by: the United 40 41 Kingdom’s Department for International Development (DFID); The Global Fund to Fight 42 404 43 44 405 AIDS, Tuberculosis and Malaria (GFATM) and the World Health Organization. The funders on September 30, 2021 by guest. Protected copyright. 45 46 406 had no role in study design, data collection and analysis, decision to publish, or preparation 47 48 407 of the manuscript. 49 50 51 52 408 Author contributions 53 54 409 AM – the Principal Investigator 55 56 57 410 AM, TM, NZ, SM, SX and BM conceived the study. 58 59 411 AM, PO, AK, KCT, CT, JPT, NZ, SM, AC and TT designed the study protocol. 60 19
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1 412 AM, TM, NZ, SM, SX, BM, JS, WA, JPT and AC read and approved the protocol. 2 3
4 413 AM, TM collected the data. BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 414 AM, PO, AK, KCT, CT, JPT, NZ, SM, AC and TT contributed to analyzing and interpreting 7 8 415 the data. 9 10 11 416 AM, AK, PO and TT drafted the manuscript. 12 13 417 AM, AK, PO, TM, NZ, SM, JS, WA, AC, JPT, SX and BM critically revised the manuscript 14 15 418 for intellectual content 16 17 All authors read and approved the final manuscript. 18 419 For peer review only 19 20 420 Disclosure Statement 21 22 23 421 The authors report no conflicts of interest 24 25 422 Ethics and Consent 26 27 28 423 Permission to undertake the study was granted by the Ministry of Health and Child Care. 29 30 31 424 Ethics approval was obtained from the Medical Research Council of Zimbabwe 32 33 425 (MRCZ/E/223) and the Ethics Advisory Group of the International Union Against 34 35 426 Tuberculosis and Lung Disease, Paris, France (EAG number: 62/18). As this was a 36 http://bmjopen.bmj.com/ 37 38 427 retrospective analysis of de-identified routine data, the need for individual client consent was 39 40 428 waived by both ethics committees. 41 42 43 429 Data availability statement 44 on September 30, 2021 by guest. Protected copyright. 45 46 430 The corresponding author can avail the data set on request without undue reservation. 47 48 49 431 Patient and Public Involvement 50 51 52 432 The principal investigator and enumerators had no interaction directly with the adolescents 53 54 55 433 and young people whose records were reviewed. The registers were accessed from peer 56 57 434 educators, community youth centre and health facility staff. 58 59 60 20
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1 436 REFERENCES 2 3
4 437 1. Joint United Nations Programme on HIV/AIDS. Global HIV & AIDS statistics — BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 438 2018 fact sheet [Internet]. 2018 [cited 2018 Aug 10]. Available from: 6 439 http://www.unaids.org/en/resources/fact-sheet 7 8 440 2. UNAIDS. Ending the AIDS epidemic for adolescents, with adolescents A practical 9 441 guide to meaningfully engage adolescents in the AIDS response [Internet]. 2016 [cited 10 442 2019 May 9]. Available from: 11 443 http://www.unaids.org/sites/default/files/media_asset/ending-AIDS-epidemic- 12 444 adolescents_en.pdf 13 14 445 3. Denno DM, Hoopes AJ, Chandra-Mouli V. Effective Strategies to Provide Adolescent 15 16 446 Sexual and Reproductive Health Services and to Increase Demand and Community 17 447 Support. J Adolesc Heal [Internet]. 2015 Jan [cited 2018 Aug 10];56(1):S22–41. 18 448 Available from:For http://www.ncbi.nlm.nih.gov/pubmed/25528977 peer review only 19 20 449 4. Zimbabwe National Statistics Agency. Inter-Censal Demographic Survey, 2017. 21 450 Harare; 2017. 22 23 451 5. Zimbabwe National Statistics Agency. Zimbabwe Population Census 2012 [Internet]. 24 452 Harare; 2013. Available from: 25 453 http://www.zimstat.co.zw/dmdocuments/Census/CensusResults2012/National_Report. 26 454 pdf 27 28 455 6. Zimbabwe National Statistics Agency and ICF International. Zimbabwe Demographic 29 30 456 and Health Survey 2015: Final Report. Rockville, Maryland, USA; 2016. 31 32 457 7. Abdi F, Simbar M. The Peer Education Approach in Adolescents- Narrative Review 33 458 Article. Iran J Public Health [Internet]. 2013 Nov [cited 2019 May 8];42(11):1200–6. 34 459 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26171331 35 36 460 8. Campbell C, Scott K, Mupambireyi Z, Nhamo M, Nyamukapa C, Skovdal M, et al. http://bmjopen.bmj.com/ 37 461 Community resistance to a peer education programme in Zimbabwe. BMC Health 38 462 Serv Res [Internet]. 2014 Dec 19 [cited 2019 May 8];14(1):574. Available from: 39 463 https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-014-0574-5 40 41 464 9. Hutton G, Wyss K, N’Diékhor Y. Prioritization of prevention activities to combat the 42 465 spread of HIV/AIDS in resource constrained settings: a cost-effectiveness analysis 43 44 466 from Chad, Central Africa. Int J Health Plann Manage [Internet]. 2003 Apr [cited 2019 on September 30, 2021 by guest. Protected copyright. 45 467 May 9];18(2):117–36. Available from: 46 468 http://www.ncbi.nlm.nih.gov/pubmed/12841152 47 48 469 10. Medley A, Kennedy C, O’Reilly K, Sweat M. Effectiveness of Peer Education 49 470 Interventions for HIV Prevention in Developing Countries: A Systematic Review and 50 471 Meta-Analysis. AIDS Educ Prev [Internet]. 2009 Jun [cited 2018 Aug 9];21(3):181– 51 472 206. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19519235 52 53 473 11. Chandra-Mouli V, Lane C, Wong S. What Does Not Work in Adolescent Sexual and 54 474 Reproductive Health: A Review of Evidence on Interventions Commonly Accepted as 55 56 475 Best Practices. Glob Heal Sci Pract [Internet]. 2015 Aug 31 [cited 2018 Aug 57 476 9];3(3):333–40. Available from: 58 477 http://www.ghspjournal.org/lookup/doi/10.9745/GHSP-D-15-00126 59 60 21
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1 478 12. Michielsen K, Chersich MF, Luchters S, De Koker P, Van Rossem R, Temmerman M. 2 3 479 Effectiveness of HIV prevention for youth in sub-Saharan Africa: systematic review
4 480 and meta-analysis of randomized and nonrandomized trials. AIDS [Internet]. 2010 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 481 May [cited 2019 May 8];24(8):1193–202. Available from: 6 482 https://insights.ovid.com/crossref?an=00002030-201005150-00014 7 8 483 13. Ministry of Health and Child Care Zimbabwe. National Adolescent Sexual and 9 484 Reproductive Health Strategy: 2010 - 2015. Harare; 2009. 10 11 485 14. Ministry of Health and Child Care Zimbabwe. National Adolescent and Youth Sexual 12 486 and Reproductive Health (ASRH) Strategy II: 2016 -2020. Harare; 2016. 13 14 487 15. Blum RW, Mmari K, Alfonso NY, Posner E. ASRH Strategic Plan Review for 15 488 Zimbabwe. Harare, Zimbabwe; 2015. 16 17 489 16. UNESCO. International technical guidance on sexuality education An evidence- 18 For peer review only 19 490 informed approach [Internet]. 2018 [cited 2019 May 9]. Available from: 20 491 http://www.unaids.org/sites/default/files/media_asset/ITGSE_en.pdf 21 22 492 17. Youth Engage. Mystery Client Visits in Zimbabwe Report: June 2017 - July 2018. 23 493 2018. 24 25 494 18. Ministry of Health and Child Care Zimbabwe. Zimbabwe Health Financing Strategy. 26 495 2017. 27 28 496 19. World Health Organisation. Adolescent HIV testing and counselling: a review of the 29 497 literature [Internet]. World Health Organization; 2013 [cited 2019 May 8]. Available 30 498 from: https://www.ncbi.nlm.nih.gov/books/NBK217943/ 31 32 499 20. Sheon N. Theory and Practice of Client-Centered Counseling and Testing [Internet]. 33 500 2006. 2006 [cited 2019 May 8]. Available from: 34 35 501 http://hivinsite.ucsf.edu/InSite?page=kb-07-01-04#S9.1X 36 http://bmjopen.bmj.com/ 37 502 21. Remez L, Woog V MM. Sexual and Reproductive Health Needs Of Adolescents in 38 503 Zimbabwe. Brief, New York, Guttmacher Inst [Internet]. [cited 2019 May 8];2014 39 504 Serie(No 3):8. Available from: 40 505 https://www.guttmacher.org/sites/default/files/report_pdf/ib-zimbabwe_0.pdf 41 42 506 22. Ngome E, Odimegwu C. The social context of adolescent women’s use of modern 43 507 contraceptives in Zimbabwe: a multilevel analysis. Reprod Health [Internet]. 2014 Dec 44 508 10 [cited 2019 May 8];11(1):64. Available from: on September 30, 2021 by guest. Protected copyright. 45 509 http://www.ncbi.nlm.nih.gov/pubmed/25108444 46 47 510 23. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. 48 49 511 Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) 50 512 statement: guidelines for reporting observational studies. Lancet (London, England) 51 513 [Internet]. 2007 Oct 20 [cited 2019 May 8];370(9596):1453–7. Available from: 52 514 http://www.ncbi.nlm.nih.gov/pubmed/18064739 53 54 515 24. Herat J, Plesons M, Castle C, Babb J, Chandra-Mouli V. The revised international 55 516 technical guidance on sexuality education - a powerful tool at an important crossroads 56 517 for sexuality education [Internet]. Vol. 15, Reproductive Health. BioMed Central; 57 518 2018 Dec [cited 2019 May 9]. Available from: https://reproductive-health- 58 59 519 journal.biomedcentral.com/articles/10.1186/s12978-018-0629-x 60 22
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1 520 25. Ministry of Health and Child Care Zimbabwe. National Guidelines on Clinical 2 3 521 Adolescent and Youth Friendly Sexual and Reproductive Health Services Provision
4 522 (YFSP). 2016. BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 23
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1 524 Table 1: Socio-demographic characteristics of young people counselled by peer 2 3 525 educators in Bulawayo and Mount Darwin, Zimbabwe (October – December
4 526 2018): BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 527 Characteristics N (%) 7 Total 3370 (100) 8 528 Age (years) 9 10 – 14 1242 (36.9) 10 11 529 15 – 19 1346 (39.9) 12 20 – 24 782 (23.2) 13 530 Sex 14 Male 2207 (65.5) 15 Female 1163 (34.5) 16 531 17 Marital Status 18 For peerSingle review 3288 (97.6) only 532 19 Married 77 (2.3) 20 Divorced/Separated 5 (0.1) 21 533 Schooling status 22 In-school 2334 (69.3) 23 534 24 Out of school 1036 (30.7) 25 535 Type of counseling session received 26 Individual 741 (22.0) 27 Group 2629 (78.0) 28 536 29 Type of Setting 30 537 Bulawayo (Urban) 2160 (64.1) 31 Mount Darwin (Rural) 1210 (35.9) 32 538 Age of peer educator (years) a 33 15 - 19 751 (22.3) 34 539 35 20 - 24 2619 (77.7) 36 Sex of peer educator b 540 http://bmjopen.bmj.com/ 37 Male 1624 (48.2) 38 541 Female 1746 (51.8) 39 40 542 41 42 543 a Refers to the number of clients who were counselled by the peer educators aged 15 – 19 and 43 44 544 20 - 24 years. on September 30, 2021 by guest. Protected copyright. 45 b 46 545 Refers to the number of clients who were counselled by male and female peer educators. 47 48 546 49 50 51 52 53 54 55 56 57 58 59 60 24
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1 548 Table 2: Services for which counselled young people were referred for by peer 2 3 549 educators and received in Bulawayo and Mount Darwin districts, Zimbabwe (October – 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 550 December 2018) 6 7 551 Type of Service Referred** Received** 8 9 10 552 n (%)a n (%)b 11 12 13 553 Referred for any service 2191 (65.0) 1645 (75.1) 14 15 554 HTS 424 (12.6) 271 (63.9) 16 17 18 555 VMMC (amongFor males peer only; n=2207) review1287 only(58.3) 881 (68.5) 19 20 556 Contraception* 452 (13.4) 363 (80.3) 21 22 23 557 STI diagnosis and treatment 171 (5.1) 67 (39.2) 24 25 558 Other SRH and HIV service 497 (14.7) 397 (79.9) 26 27 28 559 29 30 560 a – denominator is the total number counselled (N=3370), except for VMMC 31 32 561 b – denominator is the total number referred in the respective category 33 34 562 *Contraception refers to condoms, oral pills, injectables and implants. 35 36 563 ** Percentages may not add up to 100% for some clients were referred for more than one http://bmjopen.bmj.com/ 37 38 564 service 39 40 565 HTS – HIV Testing Services; VMMC – Voluntary Male Medical Circumcision; 41 42 566 STI – Sexually Transmitted Infections; SRH – Sexual and Reproductive Health 43 44 567 HIV – Human Immuno-deficiency Virus on September 30, 2021 by guest. Protected copyright. 45 46 568 47 48 569 49 50 51 570 52 53 571 54 55 56 57 58 59 60 25
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1 572 Table 3: Factors associated with non-referral for HIV Testing Services among 2 3 573 counselled young people in Bulawayo and Mount Darwin, Zimbabwe (October – 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 574 December 2018) 6 7 Socio-demographic Total Not referred Unadjusted Adjusted 8 9 characteristics couns for HTS 10 elled 11 N (%) RR (95% CI)) aRR (95% CI) 12 13 Total 3370 2946 (100) 14 15 Age (years) 16 10 – 14 1242 1178 (94.8) Ref Ref 17 15 – 19 1346 1134 (84.2) 0.89 (0.82-0.96) 0.91 (0.83-0.99) 18 For peer review only 19 20 – 24 782 634 (81.1) 0.85 (0.78-0.94) 0.92 (0.81-1.03) 20 Sex 21 Male 2207 1937 (87.8) 1.01 (0.93-1.01) 0.98 (0.90-1.05) 22 Female 1163 1009 (86.8) Ref Ref 23 Marital Status 24 25 Single 3288 2889 (87.9) Ref Ref 26 Married 77 52 (67.5) 0.77 (0.58-1.01) 0.88 (0.67-1.17) 27 Divorced or Separated 5 5 (100. 1.14 (0.47-2.74) 1.35 (0.58-3.25) 28 School status 29 0) 30 In-school 2334 2118 (90.7) Ref Ref 31 Out of school 1036 828 (79.9) 0.88 (0.81-0.95) 0.95 (0.86-1.05) 32 Counseling session 33 Individual 741 554 (74.8) Ref Ref 34 Group 2629 2392 (91.0) 1.22 (1.11-1.33) 1.16 (1.04-1.27) 35 36 Type of setting http://bmjopen.bmj.com/ 37 Bulawayo (urban) 2160 1958 (90.6) Ref Ref 38 Mount Darwin (rural) 1210 988 (81.7) 0.90 (0.83-0.97) 0.93 (0.85-1.01) 39 Age of peer educator 40 41 (years)a 42 15 - 19 751 673 (89.6) Ref Ref 43 20 - 24 2619 2273 (86.8) 0.97 (0.89-1.05) 0.96 (0.85-1.03) 44 b on September 30, 2021 by guest. Protected copyright. 45 Sex of peer educator 46 Male 1624 1421 (87.5) 1.00 (0.93-1.07) 1.01 (0.93-1.08) 47 Female 1746 1525 (87.3) Ref Ref 48 575 49 50 576 a Refers to the number of clients who were counselled by peer educators aged 15 – 19 and 20 51 577 - 24 years. 52 53 578 b Refers to the number of clients who were counselled by male and female peer educators. 54 55 579 HTS – HIV Testing Services; RR – Relative Risk; aRR – adjusted Relative Risk; CI – 56 580 Confidence Interval 57 58 581 In bold – statistically significant at p<0.05 59 60 26
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1 582 Table 4: Factors associated with non-referral for VMMC services among counselled 2 3 583 young people in Bulawayo and Mount Darwin, Zimbabwe (October – December 2018) 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 Socio-demographic Total Not Unadjusted Adjusted 7 characteristics counsel referred 8 led N for(%) RR (95% CI)) aRR (95% CI) 9 10 VMMC 11 Total 2207 92 (100) 12 13 Age (years) 0 14 10 – 14 944 28 (30.4) Ref Ref 15 15 – 19 795 36 (45.5) 1.50 (1.28-1.74) 1.59 (1.34-1.87) 7 16 20 – 24 468 27 (57.9) 1.90 (1.61-2.25) 1.83 (1.49-2.26) 2 17 Marital Status 18 For peer1 review only 19 Single 2179 90 (41.5) Ref Ref 20 Married 27 154 (55.6) 1.34 (0.80-2.23) 1.31 (0.78-2.22) 21 Divorced or Separated 1 1 (100) 2.41 (0.34-17.1) 2.46 (0.34-1.77) 22 School status 23 In-school 1613 60 (37.4) Ref Ref 24 Out of school 594 31 (53.2) 1.42 (1.24-1.63) 1.09 (0.92-1.30) 25 4 Counseling session 26 6 27 Individual 427 20 (48.2) Ref Ref 28 Group 1780 71 (40.1) 0.83 (0.71-0.97) 0.86 (0.73-1.01) 6 29 Type of setting 30 4 31 Bulawayo (urban) 1392 64 (46.3) Ref Ref Mount Darwin (rural) 815 27 (33.9) 0.73 (0.64-0.84) 0.61 (0.52-0.71) 32 4 33 Age of peer educator 6 34 (years)a 35 36 15 - 19 507 21 (42.8) Ref Ref http://bmjopen.bmj.com/ 37 20 - 24 1700 70 (41.4) 0.97 (0.83-1.13) 0.92 (0.78-1.08) 38 7 Sex of peer educatorb 39 3 40 Male 1159 44 (38.0) 0.83 (0.73-0.94) 0.77 (0.67-0.80) 41 Female 1048 48 (45.8) Ref Ref 42 0 43 584 0 44 a on September 30, 2021 by guest. Protected copyright. 45 585 Refers to the number of clients who were counselled by peer educators aged 15 – 19 and 20 46 586 - 24 years. 47 48 587 b Refers to the number of clients who were counselled by male and female peer educators. 49 50 588 VMMC – Voluntary Medical Male Circumcision; RR – Relative Risk; aRR – adjusted 51 589 Relative Risk; CI – Confidence Interval 52 53 590 In bold – statistically significant at p<0.05 54 55 56 57 58 59 60 27
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1 592 Table 5: Factors associated with non-receipt of VMMC services among referred young 2 3 593 people in Bulawayo and Mount Darwin, Zimbabwe (October – December 2018) 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 Socio-demographic Total No receipt Unadjusted Adjusted 7 characteristics referr for VMMC 8 ed services 9 10 N (%) RR (95% CI)) aRR (95% CI) 11 Total 1287 406 (100) 12 13 Age (years) 14 10 – 14 657 202 (30.7) Ref Ref 15 15 – 19 433 136 (31.4) 1.02 (0.82-1.27) 1.24 (0.84-1.51) 16 20 – 24 197 68 (34.5) 1.12 (0.85-1.48) 1.29 (0.91-1.83) 17 Marital Status 18 For peer review only 19 Single 1275 403 (31.6) Ref Ref 20 Married 12 3 (25.0) 0.79 (0.25-2.46) 0.87 (0.28-2.74) 21 School status 22 In-school 1009 328 (32.5) Ref Ref 23 Out of school 278 78 (28.1) 0.86 (0.67-1.10) 0.80 (0.58-1.10) 24 25 Counseling session 26 Individual 221 102 (46.2) Ref Ref 27 Group 1066 304 (28.5) 0.62 (0.49-0.77) 0.52 (0.41-0.66) 28 Type of setting 29 Bulawayo (urban) 748 284 (38.0) Ref Ref 30 31 Mount Darwin (rural) 539 122 (22.6) 0.60 (0.48-0.74) 0.52 (0.41-0.67) 32 Age of peer educator 33 (years)a 34 35 15 - 19 290 67 (23.1) Ref Ref 36 20 - 24 997 339 (34.0) 1.47 (1.13-1.91) 1.13 (0.84-1.51) http://bmjopen.bmj.com/ 37 Sex of peer educatorb 38 39 Male 719 218 (30.3) 0.92 (0.75-1.11) 0.76 (0.62-0.94) 40 Female 568 188 (33.1) Ref Ref 41 594 42 43 44 595 a Refers to the number of clients who were referred by peer educators aged 15 – 19 and 20 - on September 30, 2021 by guest. Protected copyright. 45 596 24 years. 46 47 597 b Refers to the number of clients who were referred by male and female peer educators. 48 49 598 VMMC – Voluntary Medical male Circumcision; RR – Relative Risk; aRR – adjusted 50 599 Relative Risk; CI – Confidence Interval 51 52 600 In bold – statistically significant at p<0.05 53 54 601 55 56 602 57 58 59 60 28
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1 603 Table 6: Factors associated with non-receipt of contraception services* among referred 2 3 604 young people in Bulawayo and Mount Darwin, Zimbabwe (October – December 2018) 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 Socio-demographic Total No receipt for Unadjusted Adjusted 7 characteristics referre Contraception 8 d services 9 10 N (%) RR (95% CI)) aRR (95% CI) 11 12 Total 452 89 (100%) 13 Age (years) 14 10 – 14 29 5 (17.2) Ref Ref 15 16 15 – 19 175 30 (17.1) 0.99 (0.39-2.56) 0.93 (0.35-2.44) 17 20 – 24 248 54 (21.8) 1.26 (0.51-3.16) 1.42 (0.55-3.67) 18 Sex For peer review only 19 Male 246 44 (17.9) 0.82 (0.54-1.24) 0.73 (0.46-1.14) 20 Female 206 45 (21.8) Ref Ref 21 22 Marital Status 23 Single 399 82 (20.6) Ref Ref 24 Married 48 4 (8.3) 0.41 (0.15-1.11) 0.20 (0.07-0.58) 25 Divorced or Separated 5 3 (60.0) 2.92 (0.92-9.24) 1.38 (0.42 -4.52) 26 27 School status 28 In-school 116 30 (25.9) Ref Ref 29 Out of school 336 59 (17.6) 0.68 (0.44-1.05) 0.83 (0.51-1.35) 30 Counseling session 31 Individual 170 43 (25.3) Ref Ref 32 33 Group 282 46 (16.3) 0.64 (0.43-0.98) 0.71 (0.46-1.11) 34 Type of setting 35 Bulawayo (urban) 284 32 (11.3) Ref Ref 36 Mount Darwin (rural) 168 57 (33.9) 3.01 (1.95-4.64) 3.18 (1.93-5.22) http://bmjopen.bmj.com/ 37 Age of peer educator 38 a 39 (years) 40 15 - 19 49 18 (36.7) Ref Ref 41 20 - 24 403 71 (17.6) 0.48 (0.29-0.80) 1.00 (0.56-1.82) 42 b 43 Sex of peer educator 44 Male 180 26 (14.4) 0.62 (0.39-0.98) 0.81 (0.49-1.32) on September 30, 2021 by guest. Protected copyright. 45 Female 272 63 (23.2) Ref Ref 46 605 47 48 606 a Refers to the number of clients who were referred by peer educators aged 15 – 19 and 20 - 49 607 24 years. 50 51 608 b Refers to the number of clients who were referred by male and female peer educators. 52 53 609 RR – Relative Risk; aRR – adjusted Relative Risk; CI – Confidence Interval 54 55 610 *Contraceptives included condoms, injectables, oral pills and implant hormonal 56 57 611 contraceptives 58 59 612 In bold – statistically significant at p<0.05 60 29
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1 2 3 1 Role of youth peer educators in the uptake of sexual and reproductive health services by 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 2 adolescents (10-19 years) in two selected districts of Zimbabwe 6 7 8 3 Investigators and Institution 9 1 2,3,4 2,3,4 1 10 4 Aveneni Mangombe , Jaya Prasad Tripathy , Ajay MV Kumar , Bernard Madzima , 11 1 2,3,4 5 1 12 5 Sinokuthemba Xaba , Phillip O Owiti , Mbazi Senkoro , Kudakwashe Takarinda , Margaret 13 6 Nyandoro1, Simbarashe Mabaya6,7, Julie Sumelston6,7, Talent Makoni1, Talent Tapera8, 14 15 7 Nonhlanhla Zwangobani9 16 17 8 18 For peer review only 19 9 1. Ministry of Health and Child Care, Harare, Zimbabwe 20 21 10 2. International Union Against Tuberculosis and Lung Disease, Paris, France 22 11 23 3. International Union Against Tuberculosis and Lung Disease, South-East Asia Office, New 24 12 Delhi, India 25 26 13 4. International Union Against Tuberculosis and Lung Disease (The Union), Paris, France; 27 28 14 National Tuberculosis, Leprosy and Lung Disease Program, Nairobi, Kenya 29 30 15 5. National Institute for Medical Research – Muhimbili Centre, Dar es Salaam, Tanzania 31 32 16 6. World Health Organization, Harare Zimbabwe 33 17 7. World Health Organization, Geneva, Switzerland 34 35 18 8. Africaid, Harare, Zimbabwe 36 http://bmjopen.bmj.com/ 37 19 9. Zimbabwe National Family Planning Council, Harare, Zimbabwe 38 39 20 40 41 21 Corresponding Author: 42 43 22 Aveneni Mangombe 44 23 National Adolescent Sexual Reproductive Health Programme Coordinator, on September 30, 2021 by guest. Protected copyright. 45 46 24 Ministry of Health, Harare, Zimbabwe. 47 48 25 Email: [email protected] 49 50 26 Telephone: +263773302742 51 52 27 53 54 28 55 56 57 58 59 60 Page 1 of 12
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1 2 3 29 BACKGROUND 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 30 Human Immunodeficiency Virus (HIV) is a major public health problem globally, with 1.8 7 8 31 million new infections and 0.94 million deaths in 2017.(1) However, global commitment and 9 10 32 sustained efforts have led to a decline in new HIV infections by 18% and AIDS-related deaths 11 12 33 by 34% since 2010. Despite this, low rates of HIV diagnosis and treatment initiation among 13 14 34 adolescents and young people continue to pose a significant challenge in the fight against 15 35 the disease.(2) 16 17 18 36 Against a global declineFor in death peer rate due review to AIDS-related only illnesses, the rate of death among 19 20 37 adolescents has been slower compared to adults, which is a concern worldwide.(2) 21 22 38 Coverage of HIV testing and access to treatment remain significantly low among young 23 24 39 people, especially in Sub-Saharan Africa.(2) Studies show low uptake of contraception, high 25 40 26 rates of sexually transmitted infections (STIs), teenage pregnancy, adolescent suicide 27 41 attempts, alcohol and drug use among this vulnerable age group.(2) Systematic reviews 28 29 42 have also reported poor uptake of Adolescent Sexual and Reproductive Health (ASRH) 30 31 43 services in different settings.(3) 32 33 34 44 Zimbabwe is one of the countries with the highest proportion of adolescents in the world, 35 45 with a quarter of the population between the ages 10-19 years.(4) These adolescents face a 36 http://bmjopen.bmj.com/ 37 46 myriad of challenges with respect to their sexual and reproductive health. Mirroring the 38 39 47 global scenario, Zimbabwe Demographic Health Survey (ZDHS) 2015 reports high fertility 40 41 48 rate among young girls (15-19 years), low coverage of HIV testing among 15-19 years old 42 43 49 (46% and 35% ever tested among boys and girls respectively) and poor knowledge about 44 on September 30, 2021 by guest. Protected copyright. 45 50 HIV prevention methods.(5) This increases the vulnerability of adolescents to acquire HIV 46 51 which is also highlighted in the National ASRH Strategy II: 2016-2020.(6) 47 48 49 52 To address these gaps in access and utilization of services for adolescents, the Zimbabwe 50 51 53 ASRH programme was established in 2009. The National ASRH Strategy 2016 – 2020 defines 52 53 54 an essential set of ASRH services to be delivered through four different settings: schools, 54 55 55 tertiary colleges, community and health facilities. A recent review of the ASRH program 56 56 highlighted several challenges and limitations including poor program coordination that has 57 58 57 impacted service provision and access.(7) 59 60 Page 2 of 12
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1 2 3 58 The Ministry of Health and Child Care (MoHCC) also adopted voluntary medical male 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 59 circumcision (VMMC) as an additional HIV prevention strategy in 2009 among male 6 7 60 adolescents.(8,9) The common challenges affecting the adolescents, significant overlap of 8 9 61 the interventions, as well as their mutually reinforcing nature justify the integration of 10 11 62 VMMC and ASRH programmes to maximise the reach and service provision. 12 13 63 In line with this, the MoHCC with support from the World Health Organisation (WHO) 14 15 64 commenced the pilot implementation of the VMMC - ASRH Linkages project in two 16 17 65 jurisdictions: Bulawayo city and Mount Darwin district in 2016. Various models for 18 For peer review only 19 66 integrating services were implemented in a range of settings including hospitals, clinics and 20 21 67 other health facilities, youth corners, youth-friendly centres and the community. Within this 22 68 23 project, the role of incentivized youth peer educators is integral in reaching out to the 24 69 adolescents in the community and linking them to appropriate ASRH and VMMC services in 25 26 70 designated facilities through a referral network. 27 28 29 71 Peer education has been found consistently to increase knowledge and improve attitudes 30 31 72 and intentions. Two systematic reviews have demonstrated no to moderate effect of peer 32 73 interventions in improving access to ASRH services suggesting further research. Chandra- 33 34 74 Mouli et al. in a comprehensive review, concluded that, coordinated and complementary 35 36 75 approaches are needed to improve the effectiveness of peer interventions and other ASRH http://bmjopen.bmj.com/ 37 38 76 programs.(10,11) The VMMC - ASRH linkage project is one such unique coordinated 39 40 77 approach that seeks to expand the scope of work for youth peer educators in promoting 41 42 78 SRH service uptake. 43 44 79 AIM: on September 30, 2021 by guest. Protected copyright. 45 46 47 80 In this context, we plan to conduct an operational research study to assess the role of youth 48 49 81 peer educators in uptake of sexual and reproductive health (SRH) and voluntary male 50 51 82 medical circumcision (VMMC) services among adolescents (10 – 19 years) within a pilot 52 83 linkage project setting in Zimbabwe 53 54 55 84 56 57 58 85 59 60 Page 3 of 12
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1 2 3 86 OBJECTIVES: 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 87 Among adolescents (10-19 years) who were counselled by youth peer educators in 7 8 88 Bulawayo city and Mt Darwin district in Zimbabwe during October-November 2018, to 9 10 11 89 Describe their socio-demographic characteristics, 12 90 Determine the number and proportion referred by peer educators and describe the 13 14 91 services for which they were referred 15 16 92 Determine the number and proportion among those referred who availed HIV 17 18 93 testing, FamilyFor Planning, peer STI diagnosis review and treatment only and VMMC services, and assess 19 20 94 the socio-demographic characteristics of the peer educators and the referred 21 22 95 adolescents associated with it 23 24 96 METHODS: 25 26 27 97 Study Design: 28 29 30 98 This is a cohort study involving analysis of routinely collected data under the VMMC-ASRH 31 99 linkage pilot project 32 33 34 100 Setting: 35 36 http://bmjopen.bmj.com/ 37 101 General setting: Zimbabwe is a landlocked low income country with a population of nearly 38 39 102 13.5 million as of 2017.(12) The 2012 National census indicated that adolescents (10-19 40 103 years) constitute 24% of the population(4). Zimbabwe has 10 provinces of which eight are 41 42 104 rural and two are city provinces. Bulawayo is a city inhabited by 6,53,337 people.(4) It has 43 44 105 27 public health facilities including 3 central hospitals, one urban hospital and 23 clinics. on September 30, 2021 by guest. Protected copyright. 45 46 106 Mount Darwin is a rural district with 2,12,725 people.(4) Health care in the district is 47 48 107 provided by 19 public facilities which include one district hospital, one rural hospital, 17 49 50 108 primary care facilities (13 rural health centres and four clinics). 51 52 109 Specific setting: 53 54 55 110 ASRH Programme in Zimbabwe 56 57 111 In 2009, Zimbabwe devised the National ASRH strategy 2010-15 to promote adoption of 58 59 112 safer SRH practices and increase availability, access and utilization of SRH services by young 60 Page 4 of 12
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1 2 3 113 people. The strategy outlined three key approaches for providing ‘friendly’ ASRH services: 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 114 health facility, community, and school-based. The health facility approach required that 6 7 115 every facility establish and equip special rooms called ‘youth-friendly corners.’ The 8 9 116 community approach generally referred to ‘community youth centres (CYCs) ’, SRH drop-in 10 11 117 centers or clubs. Finally, the school-based approach is essentially the provision of life skills 12 13 118 education and counselling by both teachers and peer educators in schools. 14 119 15 16 120 The package of services included education and counselling on various topics, provision of 17 18 121 contraceptives, pregnancyFor testingpeer and management,review STI onlydiagnosis and management, post- 19 20 122 rape care, HIV testing and counselling, post-abortion care, VMMC, recreational activities, 21 22 123 referral and life and livelihood skills.(13) 23 124 24 25 125 Following this, the second National ASRH Strategy II: 2016 – 2020 was developed. This 26 27 126 strategy is based largely on comprehensive sexuality education and WHO-standard based 28 29 127 youth-friendly service provision, with a special focus on reducing new HIV infection, early 30 31 128 marriages and adolescent fertility. Under this new strategy, ASRH is a package of 32 33 129 interventions provided for those aged between 10 and 24 years delivered through schools 34 130 and colleges (primarily comprehensive sexual health education), community based activities 35 36 131 and public health facilities. The CYCs are primarily focused on recreational services by http://bmjopen.bmj.com/ 37 38 132 promoting youth development through sports, other recreational services, counselling and 39 40 133 life skills training. The adolescents are registered for ASRH services at youth centres and 41 42 134 referred to public health facilities in case they require any clinical services. 43 44 135 on September 30, 2021 by guest. Protected copyright. 45 136 VMMC services 46 47 137 48 49 138 The MoHCC accepted VMMC as an additional HIV prevention strategy in 2009(14). At the 50 51 139 inception of the programme, it targeted the 20 – 29 year olds and later on reached out to 52 53 140 the infants and adolescent boys from 2014. The VMMC services are being provided at 54 55 141 secondary and tertiary level hospitals, selected clinics and outreach camps by doctors and 56 142 trained nurses. Clients are mobilized from the community by community based VMMC 57 58 143 mobilizers and peer educators. Incentives are provided for mobilizers, for each client they 59 60 Page 5 of 12
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1 2 3 144 successfully refer to VMMC site. Zimbabwe plans to provide VMMC services to all infants 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 145 upto 2 months and at least 80% of all males aged 10-29 years. 6 7 146 8 9 147 The VMMC-ASRH Linkages Project – “Smart LyncAges Project” 10 11 12 148 With support from the WHO, the Ministry of Health and Child Care commissioned an VMMC 13 149 - ASRH Linkages project in Bulawayo city and Mount Darwin district in 2014.(9) The project 14 15 150 is premised on the understanding that linking VMMC and ASRH programmes provide entry 16 17 151 points for each other thereby improving access to and utilization of services. The 18 For peer review only 19 152 implementation of the project began in 2016, following a series of planning meetings and 20 21 153 development of the relevant VMMC- ASRH Linkages protocols. The project was branded 22 154 23 “Smart LyncAges Project” during the course of implementation through a participatory 24 155 process. 25 26 27 156 In Mount Darwin district, VMMC services are provided through the district hospital, whilst 28 29 157 ASRH services are being provided at Mount Darwin Hospital, Mt Darwin and Dotito CYCs. In 30 31 158 Bulawayo city, VMMC services are being provided through the Bulawayo Male Circumcision 32 159 (MC) site and the Lobengula MC site (supported by an NGO called Population Services 33 34 160 International (PSI)) and sometimes through outreach camps in the CYCs and clinics. The 35 36 161 Bulawayo City Department of Housing also runs 15 CYCs which provide basic ASRH services http://bmjopen.bmj.com/ 37 38 162 through youth officers and peer educators, whilst the City health department’s 22 clinics 39 40 163 also provide SRH services. 41 42 164 The first phase of the project had limitations in data monitoring and reporting which 43 44 165 preclude us from doing a cohort-wise monitoring of the beneficiaries. However, in the on September 30, 2021 by guest. Protected copyright. 45 46 166 second phase which is planned for September - December 2018, the routine data collection 47 48 167 and reporting formats have been revised to allow cohort-wise tracking of adolescents from 49 50 168 the first point of contact to the point of service delivery to assess whether the beneficiaries 51 52 169 have actually received the service or not. 53 54 170 Peer education intervention 55 56 57 171 In both Mount Darwin and Bulawayo, peer education is an integral component of the 58 59 172 project. Peer educators (both males and females) are community based volunteers aged 60 Page 6 of 12
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1 2 3 173 18-24 years, selected through participatory community based platforms. They undergo a 7- 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 174 day standard training on ASRH, using the National Standard ASRH Training Manual for 6 7 175 Service Providers. Under this project, the peer educators additionally received an extra day 8 9 176 to orient them on the project and their scope of work. They receive a USD 20 monthly 10 11 177 allowance. They are supposed to be holders of at least 3 ordinary level qualifications and 12 13 178 need to demonstrate ability to read and write. Each Community Youth Centre is expected to 14 179 have a minimum of 5 peer educators at any particular time. Mount Darwin has 10 peer 15 16 180 educators whilst Bulawayo city has a total of 75. They distribute condoms and provide 17 18 181 counseling on sexualFor and peer reproductive review health issues, only education, career, drug abuse, 19 20 182 relationship problems, etc. through individual and group approaches. Peer educators 21 22 183 facilitated referrals to ASRH and VMMC sites using referral slips for services like diagnosis 23 184 24 and management of STIs, HIV testing and counselling, VMMC, family planning and 25 185 management of pregnancy. Peer educators are also expected to track the referred clients 26 27 186 and in some cases accompany them to the service delivery points to ensure that they avail 28 29 187 the service. Every month, each peer educator has a target of reaching 40 adolescent clients 30 31 188 aged 10-24, two thirds being the 10-19 year olds. 32 33 189 Every peer educator maintains a ‘peer educator register’ where they document the socio- 34 35 190 demographic details of the people who received counselling. They also record whether 36 http://bmjopen.bmj.com/ 37 191 adolescents were referred and the type of services for which they were referred to. During 38 39 192 referral, the peer educator fills a client referral form in triplicate: one copy is retained with 40 41 193 the peer educator whilst the other two copies are given to the adolescent client to redeem 42 43 194 at the referral service delivery point. After the client receives the services, the service 44 195 provider at the referral centre fills details of the services provided to the client in both the on September 30, 2021 by guest. Protected copyright. 45 46 196 copies of the referral form; one is retained by the referral centre whilst the other one is 47 48 197 posted back to the referring peer educator or delivered in person. Every service delivery 49 50 198 point also enters the client details into the primary registers for HTS, VMMC, Family 51 52 199 Planning and STI diagnosis and treatment. After the peer educator receives the referral slip, 53 54 200 s/he fills the column “availed service” in the peer educator register to denote that the client 55 201 has received a particular service. 56 57 58 202 59 60 Page 7 of 12
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1 2 3 203 Study population: 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 204 All adolescents (10-19 years) who were counselled by youth peer educators during the 7 8 205 period October – November 2018 period in project sites of Bulawayo city and Mount Darwin 9 10 206 district will be included in the study. We expect around 3500 adolescents to be counselled 11 12 207 during the study period. 13 14 208 Data variables, sources of data and data collection: 15 16 17 209 Data variables are listed according to study objectives: 18 For peer review only 19 210 20 Objective 1 (baseline socio-demographic characteristics): data variables include: age group 21 211 (10-14, 15-19 years), sex, marital status, school status of adolescent clients (in/out); type of 22 23 212 counselling session (group/individual). The source of data will be the Peer Educator 24 25 213 registers. 26 27 28 214 Objective 2 (the number and proportion referred by peer educators and describe the 29 215 30 services they were referred for): data variables include: referred (yes/no), type of service 31 216 (HIV testing, VMMC, Family Planning, STI diagnosis and management and others). The 32 33 217 source of data will be the Peer Educator registers. 34 35 36 218 Objective 3 (the number and proportion among those referred who availed the SRH http://bmjopen.bmj.com/ 37 38 219 services, and the socio-demographic characteristics of the peer educators and the referred 39 220 adolescents associated with it): data variables include referred (yes/no), age and sex of peer 40 41 221 educators; age group (10-14, 15-19 years), sex (male/female) and school status of 42 43 222 adolescent clients (in/out), type of service availed (HIV Testing (yes/no), VMMC (yes/no), 44 on September 30, 2021 by guest. Protected copyright. 45 223 Family Planning (yes/no) and STI management (yes/no)). The source of data will be the Peer 46 47 224 Educator registers. Client referral forms will be used to validate the responses in 10% of the 48 49 225 referred clients. 50 51 226 Data will be collected into a structured proforma between January - March 2019 (See 52 53 227 Annexure 1). 54 55 56 228 57 58 229 59 60 Page 8 of 12
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1 2 3 230 Analysis and statistics: 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 231 Double data entry, validation and analysis will be performed using EpiData software 7 8 232 (Version 3.1 for entry and 2.2.2.180 for analysis; EpiData Association, Odense, Denmark). 9 10 233 Proportions will be used to summarise referral, type of service for which referred and 11 12 234 whether clients availed the service or not. Chi-square test (Fischer’s Exact test wherever 13 235 applicable) will be used to study the association of socio-demographic variables with 14 15 236 availing service. The strength of association will be expressed using relative risk (RR) and 16 17 237 adjusted RR with 95% CI using a log binomial regression method. Factors with a p value <0.2 18 For peer review only 19 238 in unadjusted analysis will be included in the regression model using STATA version 12. 20 21 239 22 Ethics approval 23 24 240 Ethics Issues: Permission for the study will be sought from the Ministry of Health and Child 25 26 241 Care of Zimbabwe. Local ethics approval will be sought from Zimbabwe Medical Research 27 28 242 Council of Zimbabwe (MRCZ). Ethics approval will also be sought from the Union Ethics 29 30 243 Advisory Group, Paris, France. 31 32 244 Data confidentiality: Data will be entered in a designed format based on the information 33 34 245 recorded in the registers. Names of clients will be used to trace patients and validate the 35 36 246 data, but confidentiality will be maintained by keeping data collection forms securely in a http://bmjopen.bmj.com/ 37 38 247 lockable cabinet and the electronic data file will be kept in a password protected computer. 39 40 248 Both data sets will be maintained securely for five years after completion of study. The 41 249 names will be removed from the final dataset before analysis. Data will only be accessible to 42 43 250 the study investigators. 44 on September 30, 2021 by guest. Protected copyright. 45 46 251 Specific patient benefits: The results of this study will inform management about the ASRH 47 48 252 – VMMC linkages referral practices by peer educators. This will result is strengthening the 49 50 253 referral pathway for provision of integrated adolescent health services to the beneficiaries. 51 52 254 Community participation and benefits: The results will provide recommendations for 53 54 255 strengthening the referral pathway, thereby maximizing service uptake and in the long run 55 56 256 reduce incidence of STIs, HIV and unintended pregnancies among the general population as 57 58 257 a whole. 59 60 Page 9 of 12
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1 2 3 258 Feedback and dissemination of results: The results of this study will be disseminated to the 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 259 service providers and peer educators in Bulawayo and Mount Darwin and all supporting 6 7 260 partners for the ASRH – VMMC Linkages project. The results will also be presented at 8 9 261 national level through the National ASRH Coordination Forum, HIV Prevention partnership 10 11 262 forums and international conferences. They will also be submitted in a peer reviewed 12 13 263 journal. 14 15 264 Implications for policy and practice: There may be implications for policy and practice 16 17 265 depending on the results of the study. It may provide additional evidence for the national 18 For peer review only 19 266 scale up of the VMMC-ASRH linkages project. 20 21 267 22 Collaborative partnerships: These will be between the ASRH – VMMC Linkages Project 23 268 partners (WHO, Harare, Zimbabwe, WHO, Geneva, Switzerland and Ministry of Health and 24 25 269 Child Care, Zimbabwe) and The Union, Paris, France. 26 27 28 270 BUDGET: 29 30 271 31 Local project funds will be used for this study to train the peer educators on effective 32 272 documentation, travel, stationary and overnight accommodation in Bulawayo and Mount 33 34 273 Darwin. The submission of the paper to an open access journal will be supported by funds 35 36 274 from The Union, Paris, France. http://bmjopen.bmj.com/ 37 38 39 275 REFERENCES 40 41 276 1. Joint United Nations Programme on HIV/AIDS. Global HIV & AIDS statistics — 2018 42 43 277 fact sheet [Internet]. 2018 [cited 2018 Aug 10]. Available from: 44 278 http://www.unaids.org/en/resources/fact-sheet on September 30, 2021 by guest. Protected copyright. 45 46 279 2. UNAIDS. Ending the AIDS epidemic for adolescents, with adolescents. 2016;36. 47 48 280 3. Denno DM, Hoopes AJ, Chandra-Mouli V. Effective Strategies to Provide Adolescent 49 281 Sexual and Reproductive Health Services and to Increase Demand and Community 50 282 Support. J Adolesc Heal. 2015 Jan;56(1):S22–41. 51 52 283 4. Zimbabwe National Statistics Agency. Zimbabwe Population Census 2012. Harare; 53 54 284 2013. 55 56 285 5. Zimbabwe National Statistics Agency and ICF International. Zimbabwe Demographic 57 286 and Health Survey 2015: Final Report. Rockville, Maryland, USA; 2016. 58 59 287 6. Ministry of Health and Child Care Zimbabwe. National Adolescent and Youth Sexual 60 Page 10 of 12
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1 2 3 288 and Reproductive Health (ASRH) Strategy II: 2016 -2020. Harare; 2016. 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 289 7. Blum RW, Mmari K, Alfonso NY, Posner E. ASRH Strategic Plan Review for Zimbabwe. 6 7 290 Harare, Zimbabwe; 2015. 8 9 291 8. Ministry of Health and Child Care Zimbabwe. Zimbabwe Policy Guidelines on 10 292 Voluntary Medical Male Circumcision: Revised 2014. Harare; 2014. 11 12 293 9. Ministry of Health and Child Care Zimbabwe. Service Delivery Protocol for 13 294 Strengthening Integration and Linkages between VMMC and ASRH Programmes in 14 295 Zimbabwe. Harare; 2014. 15 16 296 10. Medley A, Kennedy C, O’Reilly K, Sweat M. Effectiveness of Peer Education 17 18 297 InterventionsFor for HIV Preventionpeer inreview Developing Countries: only A Systematic Review and 19 298 Meta-Analysis. AIDS Educ Prev. 2009 Jun;21(3):181–206. 20 21 299 11. Chandra-Mouli V, Lane C, Wong S. What Does Not Work in Adolescent Sexual and 22 300 Reproductive Health: A Review of Evidence on Interventions Commonly Accepted as 23 301 Best Practices. Glob Heal Sci Pract. 2015 Aug 31;3(3):333–40. 24 25 302 12. Zimbabwe National Statistics Agency. Inter-Censal Demographic Survey, 2017. 26 27 303 Harare; 2017. 28 29 304 13. Ministry of Health and Child Care Zimbabwe. National Adolescent Sexual and 30 305 Reproductive Health Strategy: 2010 - 2015. Harare; 2009. 31 32 306 14. Ministry of Health and Child Care Zimbabwe. Accelerated Strategic and Operational 33 307 Plan 2014 – 2018: Voluntary Medical Male Circumcision. Harare; 2014. 34 35 308 15. Ministry of Health and Child Care Zimbabwe. Zimbabwe Voluntary Medical Male 36 309 http://bmjopen.bmj.com/ 37 Circumcision (VMMC) – Adolescent Sexual and Reproductive Health (ASRH) Linkages 38 310 Pilot Project March 2016 – March 2017 (draft). Harare; 2018. 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 11 of 12
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1 2 3 Annexure 1 Data Collection Proforma 4 5 6 Name of peer educator: ______Age: ______Sex (M/F):______7 District: ______Service delivery name: ______Type of SDP: MC site/CYC 8 Age Marital 21=FP 22=STIs 27=HTC 28=VMMC Other services 9 group status School Referr 10 Name of Sex Counselli 11 ID (1: 10- (use status ed adolescent (M/F) ng (I/G) R A R A R A R A 12 14, 2: Forcodes peer(I/O) review(Y/N) only 13 15-19) below) R A 14 15
16 http://bmjopen.bmj.com/ 17 18 19 20 21 22 23
24 on September 30, 2021 by guest. Protected copyright. 25 26 27 28 29 30 31 32 33 34 312 MC: Male Circumcision; CYC: Community Youth Centre; Marital status: 1=Single and Never Married 2=Married 3=Divorced or Separated 4=Widowed ; 35 313 R: Referred; A: Availed; Please write ‘Y’ which stands for Yes, if service is referred/availed and ‘N’ which stands for No if service is not referred/availed; 36 314 M: Male; F: Female; I: Individual; G: Group; I: In; O: Out of school; HTS: HIV Testing and Counselling; FP: Family Planning; VMMC: Voluntary Medical Male 37 315 Circumcision; STI: Sexually Transmitted Infections; 38 39 40 Page 12 of 12 41 42 43 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 43 of 44 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 1 2 3 Reporting checklist for Aveneni Mangombe’s cohort study. 4 5 6 Based on the STROBE cohort guidelines. 7 8 Page 9 10 Reporting Item Number 11 12 Title and abstract 13 14 Title #1a Indicate the study’s design with a commonly used term in the title or the abstract 1 15 16 For peer review only 17 Abstract #1b Provide in the abstract an informative and balanced summary of what was done and what was 3 18 found 19 20 21 Introduction 22 23 Background / #2 Explain the scientific background and rationale for the investigation being reported 5 24 25 rationale 26 27 Objectives #3 State specific objectives, including any prespecified hypotheses 6 28 29 Methods 30 31 Study design #4 Present key elements of study design early in the paper 7
32 http://bmjopen.bmj.com/ 33 34 Setting #5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, 7 35 36 follow-up, and data collection 37 38 Eligibility criteria #6a Give the eligibility criteria, and the sources and methods of selection of participants. Describe 7 39 methods of follow-up.
40 on September 30, 2021 by guest. Protected copyright. 41 42 Eligibility criteria #6b For matched studies, give matching criteria and number of exposed and unexposed 7 43 44 Variables #7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. 7 45 46 Give diagnostic criteria, if applicable 47 48 Data sources / #8 For each variable of interest give sources of data and details of methods of assessment 7 49 50 measurement (measurement). Describe comparability of assessment methods if there is more than one group. 51 Give information separately for for exposed and unexposed groups if applicable. 52 53 54 Bias #9 Describe any efforts to address potential sources of bias 11 55 56 Study size #10 Explain how the study size was arrived at 10 57 58 Quantitative #11 Explain how quantitative variables were handled in the analyses. If applicable, describe which 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 44 of 44 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from variables groupings were chosen, and why 1 2 3 Statistical methods #12a Describe all statistical methods, including those used to control for confounding 11 4 5 Statistical methods #12b Describe any methods used to examine subgroups and interactions N/A 6 7 Statistical methods #12c Explain how missing data were addressed 10 8 9 10 Statistical methods #12d If applicable, explain how loss to follow-up was addressed N/A 11 12 Statistical methods #12e Describe any sensitivity analyses N/A 13 14 15 Results 16 For peer review only 17 Participants #13a Report numbers of individuals at each stage of study—eg numbers potentially eligible, 12 18 examined for eligibility, confirmed eligible, included in the study, completing follow-up, and 19 20 analysed. Give information separately for for exposed and unexposed groups if applicable. 21 22 Participants #13b Give reasons for non-participation at each stage N/A 23 24 25 Participants #13c Consider use of a flow diagram Table 1 26 27 Descriptive data #14a Give characteristics of study participants (eg demographic, clinical, social) and information on 12 28 29 exposures and potential confounders. Give information separately for exposed and unexposed 30 groups if applicable. 31
32 http://bmjopen.bmj.com/ 33 Descriptive data #14b Indicate number of participants with missing data for each variable of interest 12 34 35 Descriptive data #14c Summarise follow-up time (eg, average and total amount) 12 36 37 Outcome data #15 Report numbers of outcome events or summary measures over time. Give information 12 38 39 separately for exposed and unexposed groups if applicable.
40 on September 30, 2021 by guest. Protected copyright. 41 Main results #16a Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision 12 - 13 42 43 (eg, 95% confidence interval). Make clear which confounders were adjusted for and why they 44 were included 45 46 47 Main results #16b Report category boundaries when continuous variables were categorized 26 48 49 Main results #16c If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time N/A 50 51 period 52 53 Other analyses #17 Report other analyses done—e.g., analyses of subgroups and interactions, and sensitivity N/A 54 analyses 55 56 57 Discussion 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 45 of 44 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 1 Key results #18 Summarise key results with reference to study objectives 14 2 3 4 Limitations #19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. 15 5 Discuss both direction and magnitude of any potential bias. 6 7 Interpretation #20 Give a cautious overall interpretation considering objectives, limitations, multiplicity of 18 8 9 analyses, results from similar studies, and other relevant evidence. 10 11 Generalisability #21 Discuss the generalisability (external validity) of the study results 16 12 13 14 Other 15 Information 16 For peer review only 17 18 Funding #22 Give the source of funding and the role of the funders for the present study and, if applicable, 19 19 for the original study on which the present article is based 20 21 22 None The STROBE checklist is distributed under the terms of the Creative Commons Attribution License CC-BY. This checklist can be 23 completed online using https://www.goodreports.org/, a tool made by the EQUATOR Network in collaboration with Penelope.ai 24 25 26 27 28 29 30 31
32 http://bmjopen.bmj.com/ 33 34 35 36 37 38 39
40 on September 30, 2021 by guest. Protected copyright. 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from
Does peer education go beyond giving reproductive health information? A cohort study in Bulawayo and Mount Darwin, Zimbabwe ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2019-034436.R1
Article Type: Original research
Date Submitted by the 24-Dec-2019 Author:
Complete List of Authors: Mangombe, Aveneni; Ministry of Health and Child Care, Family Health Owiti, Philip; International Union Against Tuberculosis and Lung Disease (The Union); National Tuberculosis, Leprosy and Lung Disease Program Madzima, Bernard; Ministry of Health and Child Care Xaba, Sinokuthemba; Ministry of Health and Child Care, Harare Zimbabwe Makoni, Talent; Ministry of Health and Child Care, AIDS and TB Unit ; World Health Organization , Zimbabwe, HIV Prevention Takarinda, Kudakwashe ; Ministry of Health and Child Care Timire, Collins ; International Union Against Tuberculosis and Lung Disease (The Union)
Chimwaza, Anesu; Ministry of Health and Child Care http://bmjopen.bmj.com/ Senkoro, Mbazi; National Institute for Medical Research – Muhimbili Centre Mabaya, Simbarashe; World Health Organization Regional Office for Africa Samuelson, Julia; World Health Organization Ameyan, Wole ; World Health Organization Tapera, Talent ; Africaid Zwangobani, Nonhlanhla; Zimbabwe National Family Planning Council Tripathy, Jaya; PGIMER, Community Medicine Kumar, Ajay; International Union Against Tuberculosis and Lung Disease on September 30, 2021 by guest. Protected copyright. (The Union), South East Asia Office, Operational Research; International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
Primary Subject Sexual health Heading:
Secondary Subject Heading: Health services research
Adolescents, Young people, voluntary medical male circumcision, Keywords: adolescent sexual and reproductive health, SORT IT
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1 2 3 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the terms applicable for US Federal Government officers or employees acting as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author Forunless you peer are acting as review an employee on behalf only of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 1 Title: Does peer education go beyond giving reproductive health information? A cohort 2 3
4 2 study in Bulawayo and Mount Darwin, Zimbabwe BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 3 Manuscript type: Original research article 8 9 10 4 Short Running Title: Enhanced reproductive health service uptake through peer education 11 12 5 in Zimbabwe 13 14 15 6 Investigators and Affiliations 16 17 1 2,3 1 1 18 7 Aveneni MangombeFor, Philip peer Owiti , reviewBernard Madzima only, Sinokuthemba Xaba , Talent 19 20 8 Makoni1, Kudakwashe Collin Takarinda1,2, Collins Timire1,2, Anesu Chimwaza1, Mbazi 21 22 9 Senkoro4, Simbarashe Mabaya5, Julia Samuelson6, Wole Ameyan6, Talent Tapera7, 23 24 8 9,10 2,9,11 25 10 Nonhlanhla Zwangobani , Jaya Prasad Tripathy , Ajay MV Kumar 26 27 11 28 29 12 1. Ministry of Health and Child Care, Harare, Zimbabwe 30 31 32 13 2. International Union Against Tuberculosis and Lung Disease (The Union), Paris, France; 33 34 14 3. National Tuberculosis, Leprosy and Lung Disease Program, Nairobi, Kenya 35 36 15 4. National Institute for Medical Research – Muhimbili Centre, Dar es Salaam, Tanzania http://bmjopen.bmj.com/ 37 38 16 5. World Health Organization, Harare. Zimbabwe 39 40 41 17 6. World Health Organization, Geneva, Switzerland 42 43 18 7. Africaid, Harare, Zimbabwe 44 on September 30, 2021 by guest. Protected copyright. 45 19 8. Zimbabwe National Family Planning Council, Harare, Zimbabwe 46 47 48 20 9. International Union Against Tuberculosis and Lung Disease, South-East Asia Office, New 49 50 21 Delhi, India 51 52 22 10. All India Institute of Medical Sciences, Nagpur, India 53 54 55 23 11. Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru, India 56 57 24 58 59 25 60 1
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1 26 Corresponding Author: 2 3
4 27 Aveneni Mangombe, National Adolescent and Youth Sexual Reproductive Health BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 28 Programme Coordinator, Ministry of Health and Child Care, Harare, Zimbabwe. 7 8 29 Email: [email protected] Telephone: +263773302742 9 10 11 30 12 13 31 Manuscript details 14 15 16 32 Word count: Abstract: 300 words; Main text: 3907 17 18 For peer review only 19 33 Number of tables: 6; Number of figures: 0 20 21 22 34 Number of references: 25 23 24 25 26 27 28 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 2
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1 2 36 ABSTRACT 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 37 Objective: Peer education is an intervention within the voluntary medical male circumcision 6 7 38 (VMMC)-adolescent sexual reproductive health (ASRH) linkages project in Bulawayo and 8 9 10 39 Mount Darwin, Zimbabwe since 2016. Little is known if results extend beyond increasing 11 12 40 knowledge. We therefore assessed extent of and factors affecting referral by peer educators 13 14 41 and receipt of HIV testing services (HTS), contraception, management of sexually 15 16 42 transmitted infections (STIs) and VMMC services by young people (10–24years) counselled. 17 18 For peer review only 19 20 43 Design: A cohort study involving all young people counselled by 95 peer educators during 21 22 44 October-December 2018, through secondary analysis of routinely collected data. 23 24 25 45 Setting: All ASRH and VMMC sites in Mt Darwin and Bulawayo. 26 27 28 46 Participants: All young people counselled by 95 peer educators. 29 30 31 47 Outcome measures: Censor date for assessing receipt of services was 31 January 2019. 32 33 34 48 Factors (clients’ age, gender, marital & schooling status, counseling type, location and peer 35 36 49 educators’ age & gender) affecting non-referral and non-receipt of services (dependent http://bmjopen.bmj.com/ 37 38 50 variables) were assessed by log-binomial regression. Adjusted risk ratios (aRR) were 39 40 51 calculated. 41 42 43 44 52 on September 30, 2021 by guest. Protected copyright. 45 46 53 Results: Of the 3370 counselled (66% males), 65% were referred for at-least one service. 47 48 54 58% of males were referred for VMMC. Other services had 5-13% referrals. Non-referral for 49 50 55 HTS decreased with clients’ age(aRR:~0.9) but higher among group-counselled (aRR:1.16). 51 52 53 56 Counseling by males (aRR:0.77) and rural location(aRR:0.61) reduced risks of non-referral 54 55 57 for VMMC while age increased it(aRR≥1.59). Receipt of services was high (64-80%) except 56 57 58 for STI referrals (39%). Group-counseling and rural location(aRR:~0.52) and male peer 58 59 60 3
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1 59 educators(aRR:0.76) reduced risk of non-receipt of VMMC. Rural location increased risk of 2 3
4 60 non-receipt of contraception(aRR:3.18) while marriage reduced it(aRR:0.20). BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 61 Conclusion: We found varying levels of referral ranging from 5.1%(STIs) to 8 9 62 58.3%(VMMC) but high levels of receipt of services. Type of counselling, peer educators’ 10 11 63 gender and location affected receipt of services. We recommend qualitative approaches to 12 13 14 64 further understand reasons for non-referrals and non-receipt of services. 15 16 17 65 Key words: Adolescents, Young people, ASRH, Sexual and reproductive health, voluntary 18 For peer review only 19 66 medical male circumcision, HIV Testing, Contraception, Sexually transmitted infections, 20 21 Uptake and SORT IT. 22 67 23 24 25 68 Article Summary 26 27 28 69 Strengths and Limitations of this Study: 29 30 31 70 This study included all the clients who were counselled by peer educators during the 32 33 71 study period in the two project districts; 34 35 36 72 It used routine programme data, thus making the findings a likely true reflection of http://bmjopen.bmj.com/ 37 38 39 73 the situation; 40 41 42 74 The conduct and reporting of the study adhered to Strengthening the reporting of 43 44 75 observational studies in epidemiology (STROBE) guidelines. on September 30, 2021 by guest. Protected copyright. 45 46 47 The study couldn’t exclude clients not in need of referral from the analysis due to 48 76 49 50 77 lack of data from the peer educator registers in determining the reason for non- 51 52 78 referral; 53 54 55 79 Due to small sample size of those referred for STI diagnosis and treatment, the study 56 57 58 80 lacked statistical power to carry out further analyses. 59 60 4
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1 2 81 INTRODUCTION 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 82 Human Immunodeficiency Virus (HIV) still remains a major global public health concern, 6 7 83 with 1.8 million new infections and 940,000 deaths reported in 2017.(1) Of concern is the 8 9 10 84 slower decline of Acquired Immune Deficiency Syndrome (AIDS)-related illnesses and 11 12 85 deaths among young people (10-24 years) compared to adults.(2) Coverage of HIV testing 13 14 86 and access to treatment remain significantly low among young people, especially in sub- 15 16 17 87 Saharan Africa.(2) Studies and systematic reviews have reported high rates of sexually 18 For peer review only 19 88 transmitted infections (STIs), teenage pregnancy and suicide attempts, coupled with poor 20 21 89 receipt of sexual and reproductive health (SRH) and HIV services among young people.(2,3) 22 23 24 90 Zimbabwe is a low-income country with a population of nearly 13.5 million as of 2017.(4) A 25 26 27 91 third of the country’s population are young people aged 10-24 years.(5) Mirroring the global 28 29 92 scenario, the Zimbabwe Demographic Health Survey (ZDHS) 2015 reported a high fertility 30 31 93 rate among young girls (15-19 years), low coverage of HIV testing among 15-19 years old 32 33 34 94 (35%-46%) and low comprehensive knowledge on HIV.(6) Though SRH and HIV 35 36 95 interventions focused on young people have been in existence for the past three decades, in http://bmjopen.bmj.com/ 37 38 96 Zimbabwe, the first 5-year strategic plan was developed in 2010. Among other things, this 39 40 97 phase defined a minimum package of interventions that recognised the role of community- 41 42 43 98 based youth peer educators in educating young people on SRH and HIV. 44 on September 30, 2021 by guest. Protected copyright. 45 46 99 There is no universally agreed upon definition of peer education. We define it as a structured 47 48 100 process of sharing of relevant information, values and behaviours among members of similar 49 50 101 status, in an appropriate setting for both the educator and learner. Following a series of 51 52 53 102 reviews, peer education has been noted to be an effective youth-led approach for influencing 54 55 103 positive behavioural outcomes among beneficiaries, if given appropriate support systems and 56 57 104 contextualized to different settings and needs of beneficiaries.(7,8) Peer education has been 58 59 60 5
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1 105 established to be more effective in reaching out to key populations (for example, adolescents 2 3
4 106 selling sex and who are sexually exploited) and delivering messages that are considered BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 107 taboo to be delivered through schools, religious and family settings.(9) Integration of peer 7 8 108 education interventions with holistic and well-coordinated interventions make it more 9 10 11 109 effective towards improving health outcomes among beneficiaries in different 12 13 110 contexts.(10,11) 14 15 16 111 In 2016, a project to link Voluntary Medical Male Circumcision (VMMC) with the 17 18 112 Adolescent SexualFor and Reproductive peer Health review (ASRH) services only (“Smart LyncAges Project”) 19 20 21 113 was started in Bulawayo city and Mount Darwin district. With a special focus on VMMC, the 22 23 114 project targets both males and females for ASRH services. In 2017, the scope of the project 24 25 115 was expanded to engage youth peer educators in promoting referral and receipt of SRH and 26 27 28 116 VMMC services, informed by Michielsen et al’s review(12). 29 30 31 117 Since the re-design, no study has been conducted to determine the effect of the new peer 32 33 118 education model on the uptake of SRH and VMMC services, beyond just providing 34 35 119 information to their peers. Within this background, we carried out a study to assess the 36 http://bmjopen.bmj.com/ 37 38 120 referral and receipt of HIV testing services (HTS), contraception, diagnosis and treatment of 39 40 121 sexually transmitted infections (STIs) and VMMC services among young people (10 – 24 41 42 122 years) counselled by the peer educators and their associated factors under the “Smart 43 44 LyncAges Project. on September 30, 2021 by guest. Protected copyright. 45 123 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 6
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1 2 125 METHODS 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 126 Study design and study population: 6 7 8 127 This was a cohort study involving young people aged 10-24 years (both males and females) 9 10 128 counselled by 95 peer educators under the VMMC - ASRH linkages project in Bulawayo city 11 12 13 129 and Mount Darwin district of Zimbabwe during October-December 2018. Secondary data 14 15 130 routinely collected under the project on peer education and clients’ service uptake were 16 17 131 analysed. 18 For peer review only 19 20 132 Setting: 21 22 23 24 133 General setting 25 26 27 134 In 2009, Zimbabwe devised the National ASRH strategy 2010-15 to promote adoption of 28 29 135 safer SRH practices and increase availability, access and utilization of SRH and HIV services 30 31 136 by young people.(13) The strategy outlined three settings for providing ‘friendly’ SRH and 32 33 34 137 HIV services: health facility, community and school-based. The health facility approach 35 36 138 required every facility to establish and equip special rooms (youth-friendly corners). The http://bmjopen.bmj.com/ 37 38 139 community approach involved establishment of ‘community youth centres (CYCs)’ whilst 39 40 140 the school-based approach focussed on the provision of life skills education and counselling 41 42 43 141 mainly by teachers. 44 on September 30, 2021 by guest. Protected copyright. 45 142 46 47 143 In 2015, an extensive review of the 2010-2015 interventions in Zimbabwe was conducted so 48 49 50 144 as to inform the development of the National ASRH Strategy II: 2016-2020.(14) One of the 51 52 145 review’s conclusions acknowledged peer education as an important tool in ASRH 53 54 146 programming, though with some modifications.(15) This strategy seeks to strengthen 55 56 57 147 comprehensive sexuality education (CSE) and provision of quality-assured and adolescent- 58 59 148 friendly services, delivered through schools and colleges, public health facilities and the 60 7
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1 149 community. As part of expanding comprehensive sexuality education in both the in- and out- 2 3
4 150 of-school settings, Zimbabwe aligned its tools and training materials with the 2018 United BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 151 Nations Educational, Scientific and Cultural Organization (UNESCO) revised international 7 8 152 technical guidance on sexuality education.(16) The minimum package of SRH services for 9 10 11 153 young people includes contraception, STI diagnosis and treatment, HTS and integration of 12 13 154 VMMC. 14 15 155 16 17 The VMMC - ASRH linkages project 18 156 For peer review only 19 20 21 157 The VMMC - ASRH linkages project has been implemented in Bulawayo and Mount 22 23 158 Darwin, Zimbabwe since 2016. Bulawayo is an urban city with 27 public health facilities 24 25 159 while Mount Darwin is a rural district with 19 public health facilities. In Mount Darwin, 26 27 28 160 VMMC services are provided at the Mount Darwin Hospital, whilst diagnosis and treatment 29 30 161 of STIs, contraception and HTS services are being provided at Mount Darwin Hospital and 31 32 162 two CYCs (Mt Darwin and Dotito) supported through the Zimbabwe National Family 33 34 163 Planning Council. In Bulawayo, VMMC services are provided at the Bulawayo Male 35 36 http://bmjopen.bmj.com/ 37 164 Circumcision (MC) site and the Lobengula MC site and sometimes through outreach camps 38 39 165 in the 15 CYCs and clinics. The CYCs in Bulawayo are primarily focused on imparting 40 41 166 information and counselling services, edutainment services through films, drama and sports, 42 43 44 167 library services and vocational and life skills training. All the service delivery points under on September 30, 2021 by guest. Protected copyright. 45 46 168 this project were oriented on the VMMC – ASRH linkages service delivery protocols and 47 48 169 ASRH. The VMMC – ASRH service delivery protocols clearly highlight the scope of work, 49 50 51 170 reporting, referral, coordination and supervision mechanisms for peer educators. Demand 52 53 171 creation for both SRH and VMMC services for young people relies heavily on community- 54 55 172 based peer educators and VMMC mobilisers. Though the project has a special focus on 56 57 173 males for VMMC, it targets both males and female for ASRH services. 58 59 60 8
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1 174 In 2017, the “Smart LyncAges Project” project was redesigned and expanded the work of 2 3
4 175 youth peer educators in promoting referral and receipt of SRH and VMMC services. The BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 176 project also provided an updated training that introduced relevant tools for delivering the 7 8 177 messages (distribution of information, education and communication materials and social 9 10 11 178 media platforms such as facebook and WhatsApp), a clearly defined referral pathway 12 13 179 (including referral forms, tracking and two-way feedback mechanism) and provision of 14 15 180 adequate tools for documentation. 16 17 18 181 Peer education For peer review only 19 20 21 Each CYC is expected to coordinate and supervise the work of 5 – 6 peer educators at any 22 182 23 24 183 point in time. Peer educators are male and female volunteers aged 10-24 years, residing in 25 26 184 the community and nominated by the young people in stakeholder community meetings. 27 28 185 They must be able to read and write in English and the respective local language and should 29 30 th 31 186 have passed at least 3 subjects at the end of secondary level (13 grade). Under the Smart 32 33 187 LyncAges project, peer educators undergo a seven-day standard training, which also 34 35 188 addresses the referral pathway. Each peer educator is attached to the nearest CYC and 36 http://bmjopen.bmj.com/ 37 38 189 allocated a catchment area to cover. Peer educators are expected to contribute at least two 39 40 190 hours a day for at least 3 days in a week to the project. Active peer educators receive a fixed 41 42 191 monthly allowance of 15 USD, paid upon submission of daily and monthly summary reports 43 44 of their activities. on September 30, 2021 by guest. Protected copyright. 45 192 46 47 48 193 While peer educators usually spend most of their time in the community conducting outreach 49 50 194 sessions in pairs, they do sit in CYCs on a rotation basis to cater for the walk-in clients. At 51 52 195 CYCs, considerations are made to ensure that at least one male and one female peer educator 53 54 55 196 is available during the operating hours. Peer educators reach clients through both individual 56 57 197 (one-on-one) and group counselling sessions (either individually or in pairs). The average 58 59 198 duration of group counseling sessions is one hour whilst the size ranges from 15 to 25 60 9
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1 199 participants. Depending on the sensitivity of the subject matter/topic, young people are 2 3
4 200 usually grouped into 10 – 14 years, 15 – 19 years and 20 – 24 years clusters. Both peer BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 201 educators and young people agree on the choice of places for group counseling sessions, such 7 8 202 as recreation parks, play grounds, schools and community halls where young people usually 9 10 11 203 congregate. In addition to providing information and counselling services, peer educators 12 13 204 also distribute condoms to the clients. However, they refer clients for such when they run out 14 15 205 of stock or are in settings (such as churches and schools) where condom distribution is 16 17 prohibited. 18 206 For peer review only 19 20 21 207 Peer educators also facilitate referrals to ASRH and VMMC sites. The referral process 22 23 208 includes providing information regarding location of the service delivery point, hours of 24 25 209 operation, user fees (if any) and details of contact person (if available). They also complete 26 27 28 210 referral forms in triplicate (one copy kept for records and two copies sent with the client to 29 30 211 the destination service delivery point). One copy of the latter is retained at the service 31 32 212 delivery point, while the other is given to the client who is expected to return it to the 33 34 213 respective peer educator. The form retained at the service delivery point is sent to the 35 36 http://bmjopen.bmj.com/ 37 214 respective CYC by post or hand-delivered. This system facilitates feedback on receipt of 38 39 215 services by referred clients. Monthly, the peer educators are expected to track all the referred 40 41 216 clients, through verification of redeemed referral forms, physical home visits or by telephone 42 43 44 217 (where possible). In some cases, peer educators accompany clients to the service delivery on September 30, 2021 by guest. Protected copyright. 45 46 218 points to ensure that they avail the service. 47 48 49 219 As part of documentation, each peer educator maintains individualized “daily and monthly 50 51 220 summary peer educator registers’ where they document the socio-demographic details of the 52 53 54 221 clients who received counselling, the referrals and receipt of the services. Each service 55 56 222 delivery point under the VMMC - ASRH Linkages project also uses primary registers for 57 58 223 SRH and HIV services provision. 59 60 10
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1 224 Data variables, sources of data and data collection: 2 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 225 A structured data collection tool was used to collect the following data variables: socio- 6 7 226 demographic characteristics of clients (age, sex, marital status, location, schooling status, and 8 9 227 type of counselling sessions undergone), the age and sex of their peer educators, whether 10 11 228 referred or not, services referred for and if the clients received the services. The source of 12 13 14 229 data was the peer educator registers. ‘Referral’ in this study meant that clients consented to 15 16 230 receive some post-counseling services (such as HIV testing, VMMC, contraception or STI 17 18 231 diagnosis and treatment)For andpeer were given review a referral form. only ‘Receipt’ of a service meant 19 20 21 232 receiving/getting the services at a referral service delivery point by the young person who 22 23 233 had been referred by peer educators (between October and December 2018) by end of 24 25 234 January 2019. 26 27 28 235 Data Analysis and statistics: 29 30 31 32 236 Data entry and validation was performed using EpiData software (v4.4.1.0, EpiData 33 34 237 Association, Odense, Denmark) while analyses were carried out using EpiData Analysis 35 36 238 (v2.2.2.186) and STATA (v14, StataCorp, College Station, Texas, USA) softwares. http://bmjopen.bmj.com/ 37 38 239 Proportions were used to summarize referrals and receipt of services for those referred. 39 40 41 240 There were four major services for which the clients were referred: VMMC (for males only), 42 43 241 and HTS, STI diagnosis and treatment and contraception (for both males and females). Thus, 44 on September 30, 2021 by guest. Protected copyright. 45 242 the referral and receipt of these services were the key outcome variables for this study. Of 46 47 48 243 these, factors associated with non-referral were assessed for HTS and VMMC services only. 49 50 244 Factors associated with non-referrals for contraception and STI diagnosis and treatment were 51 52 245 not analyzed as it was not possible to establish the appropriate denominator defining the 53 54 55 246 eligibility for these services. Factors associated with non-receipt of services were assessed 56 57 247 for VMMC and contraceptive use only. Non-receipt of HTS was not analyzed as HTS can 58 59 248 also be provided as an opt-out provider-initiated testing and counseling (PITC) service at all 60 11
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1 249 the service delivery points, irrespective of the reason for which the client was referred. HTS 2 3
4 250 was also a necessary service prior to conducting VMMC. Non-receipt of STI services BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 251 amongst those referred was not analyzed due to small sample size. The strength of 7 8 252 associations were initially expressed using unadjusted relative risks and then further 9 10 11 253 expressed using adjusted relative risks (aRR) and 95% confidence intervals, using log- 12 13 254 binomial regression methods. Two-sided P<0.05 were considered statistically significant. 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 12
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1 2 256 RESULTS 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 257 There were 95 peer educators (52% males) in the study sites with a median age of 22 years 6 7 258 (range: 15-24). A total of 3370 young people (2207 males and 1163 females) received 8 9 10 259 counselling services from the peer educators (Table 1). Forty percent of young people were 11 12 260 aged 15-19 years, with the majority being males (66%) and single (98%). Majority were still 13 14 261 in school (69%) and received group counselling (78%). 15 16 17 262 Referrals and receipt of services 18 For peer review only 19 20 21 263 Table 2 shows the proportions of clients who were referred and those who received the 22 23 264 services among those referred. Of the 3370 counselled young people, sixty five percent (75% 24 25 265 of males and 47% of females) were referred for SRH services. Of those referred, 77% had 26 27 28 266 been referred for only one service, with the rest being referred for two or more services. 29 30 267 Seventy five percent (75% of males and 76% of females) of those referred received the 31 32 268 services they had been referred for. 33 34 35 36 269 Of the males counselled, 58% were referred for VMMC services, of whom, 69% received the http://bmjopen.bmj.com/ 37 38 270 services. The other services for which the adolescents were referred for include HIV testing 39 40 271 (13%), contraception (13%) and diagnosis and treatment of STIs (5%). Among the services 41 42 272 referred for, the receipt for STI services was lowest (39%). 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 273 Factors associated with non-referrals for HTS and VMMC 47 48 49 274 Non-referral for HIV Testing Services (Table 3) 50 51 52 275 In multivariable analysis, only age of client and type of counseling were significantly 53 54 276 associated with non-referral for HTS, holding other factors that influence HTS referral and 55 56 277 receipt constant. Adolescents aged 15-19 years had a 9% (95% CI: 0.81-1.03) reduced risk of 57 58 59 278 non-referral for HTS as compared to those aged 10-14 years old. Those who underwent 60 13
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1 279 group counseling had 16% (95% CI: 1.04-1.27) increased risk of non-referral for HTS. Sex 2 3
4 280 and marital status of the peer educators did not influence referral for HTS. BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 281 Non-referral for VMMC services (Table 4) 8 9 10 282 Compared to clients in the 10-14 year age group, those in the 15-19 year and 20-24 year age 11 12 283 group had 59% (95% CI: 1.34-1.87) and 83% (95% CI: 1.49-2.26) increased risk of non- 13 14 15 284 referral for VMMC, respectively. Clients in the rural district of Mount Darwin were at 39% 16 17 285 (95% CI: 0.52-0.71) reduced risk of non-referral compared to those in the urban city of 18 For peer review only 19 286 Bulawayo. Clients counseled on VMMC by male peer educators were at 23% (95% CI: 0.67- 20 21 0.80) reduced risk for non-referral as compared to those counselled by female peer educators. 22 287 23 24 25 288 Factors associated with non-receipt for VMMC and contraception 26 27 28 289 Non-receipt of VMMC services (Table 5) 29 30 31 290 Clients referred by male peer educators had a 24% (95% CI: 0.62-0.94) lower risk of non- 32 33 291 receipt of services than those referred by their female counterparts. Those referred from the 34 35 rural district of Mount Darwin (aRR: 0.52, 95% CI: 0.41-0.67) and those referred through 36 292 http://bmjopen.bmj.com/ 37 38 293 group counselling sessions (aRR: 0.52, 95% CI: 0.41-0.66) had significantly lower risk of 39 40 294 non-receipt of VMMC services as compared to urban Bulawayo and individual counseling 41 42 295 sessions, respectively. Age of the clients did not influence receipt of VMMC services. 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 296 Non-receipt of contraception services (Table 6) 47 48 49 297 Clients referred from the rural district had 3.2 times (95% CI: 1.93-5.22) higher risk of non- 50 51 298 receipt of contraception services as compared to the urban-based counterparts. Married 52 53 299 clients had 80% (95% CI: 0.07-0.58) reduced risk of not receiving contraception services 54 55 56 300 than the single clients. 57 58 59 60 14
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1 2 302 DISCUSSION 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 303 This study, the first one assessing the role of the peer educators in the referral and receipt of 6 7 304 selected SRH and VMMC services among young people in Zimbabwe found relatively 8 9 10 305 moderate levels of referrals, particularly for VMMC services. A higher proportion of 11 12 306 females/girls were referred for each of the individual services as compared to males/boys. 13 14 307 However, overall more males were referred for any service compared to females likely due to 15 16 308 VMMC (for males only). However, for those referred, receipt of the services was high except 17 18 For peer review only 19 309 for STI diagnosis and treatment. Majority of the referred clients had been referred for just 20 21 310 one service, perhaps indicating limited counselling or reflecting the lack of need. The risk of 22 23 311 not being referred for HTS services decreased slightly with older age of clients, though for 24 25 26 312 VMMC services younger aged adolescents were more likely to be referred. Slightly 27 28 313 increased non-referral for HTS services was observed in clients who underwent group 29 30 314 counseling sessions as compared to individual sessions. 31 32 33 315 As regards receipt of services, generally more males received the services referred for as 34 35 36 316 compared to females. With regard to VMMC services, those counseled by male peer http://bmjopen.bmj.com/ 37 38 317 educators were more likely to be referred and to receive, likewise to the clients in the rural 39 40 318 district. Rural setting increased risk of not receiving contraception services while being 41 42 43 319 married reduced this risk. 44 on September 30, 2021 by guest. Protected copyright. 45 46 320 The low referral for diagnosis and treatment of STIs might have been influenced by: 1) lack 47 48 321 of confidence by peer educators in determining the need for referral. 2) limited self-reports of 49 50 322 STI-like symptoms. In any population, only a minority will have STI or STI - like symptoms 51 52 53 323 and referrals rates may be low. However, the low receipt of the diagnosis and treatment of 54 55 324 STIs services among the referred clients might have been due to the associated user fees 56 57 325 levied (mostly in council clinics and hospitals) in both the rural and urban settings.(17),(18) 58 59 60 15
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1 326 Abolishing or largely subsidizing these costs, while maintaining or sustaining supply and 2 3
4 327 diagnostics may improve receipt of services by young people. BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 328 Low risk perception among early adolescents has been established to be one of the barriers 8 9 329 for referral and receipt of HTS services.(19) Other studies have also shown that demand for 10 11 330 HTS services are reduced in adolescents who require parental/guardian consent, especially 12 13 14 331 due to the perceived negative reactions from parents/guardians.(19) With Zimbabwe’s age of 15 16 332 consent for HTS at 16 years, this may explain the reduced non-referral for HTS as the 17 18 333 client’s age increases.For Individualized peer or reviewclient-centered counseling only has been established to be 19 20 21 334 a more effective approach for HTS and post-test services than group counseling,(20) as 22 23 335 demonstrated also by this study. 24 25 336 26 27 28 337 Group counseling sessions may have provided an opportunity for client peer influence on 29 30 338 receipt of VMMC services. Counseling by male peer educators may also encourage openness 31 32 339 among the male clients leading to more referral and receipt of VMMC services. As regards 33 34 340 contraception, urban areas present more convenient service delivery points for accessing 35 36 http://bmjopen.bmj.com/ 37 341 contraceptives than rural areas, explaining why non-receipt is lower in the urban setups. 38 39 342 Myths on the association between modern contraception and future infertility(21),(22) may 40 41 343 have resulted in the higher non-receipt rates of contraception among the adolescent girls 42 43 44 344 referred. This belief may be more common in the rural setups and at times is propagated by on September 30, 2021 by guest. Protected copyright. 45 46 345 other health workers.(22),(17) 47 48 49 346 Strengths: This study had several strengths. We included all the clients who were counselled 50 51 347 by peer educators during the study period in the two project districts, which were the only 52 53 54 348 districts implementing this intervention in the whole country. As we used routine programme 55 56 349 data, the findings are likely a true reflection of the situation. The data was extracted into 57 58 350 standard proformas by the principal investigator and trained data collectors – this enhanced 59 60 16
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1 351 quality. Lastly, the conduct and reporting of the study adhered to Strengthening the 2 3
4 352 Reporting of observational studies in epidemiology (STROBE) cohort reporting BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 353 guidelines.(23) 7 8 9 354 Limitations: However, there were also limitations. First, due to deficiencies in 10 11 355 documentation in the peer educator registers, we could not determine if the reason for non- 12 13 14 356 referral (for VMMC or HTS) was related to ‘need’, that is, they had already received VMMC 15 16 357 or HTS services before. We, therefore couldn’t exclude clients not in need from the analysis. 17 18 358 In certain circumstances,For like peer referral for review contraception andonly STI diagnosis and treatment, we 19 20 21 359 could not perform further analyses as it was not possible to establish the appropriate 22 23 360 denominator defining the eligibility for these services. Second, we were not able to establish 24 25 361 exact reasons for non-referral and non-receipt of services. This requires qualitative and 26 27 28 362 youth-led study approaches. Third, due to small sample size of those referred for STI 29 30 363 diagnosis and treatment, we lacked statistical power to carry out further analyses. Many 31 32 364 reviews on peer education have largely focused on assessing the designs or models of peer 33 34 365 education without focusing on the outputs and the immediate positive outcomes of peer 35 36 http://bmjopen.bmj.com/ 37 366 education in relation to receipt of diagnosis and treatment of STIs, HTS, contraception and 38 39 367 VMMC services. Therefore, there were no study results to compare with. Whilst the results 40 41 368 and conclusions of this study may be used in different peer education interventions, they 42 43 44 369 cannot be generalised. on September 30, 2021 by guest. Protected copyright. 45 46 47 370 Implications: The study has the following implications: 48 49 50 371 There is need for a review of peer education data collection tools to capture more 51 52 372 client and peer educator data, for example, on details and quality of sessions and 53 54 55 373 eligibility of clients for the various services in line with the recently adapted revised 56 57 374 international guidelines on CSE in Zimbabwe.(24) The review will also need to be 58 59 60 17
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1 375 followed with refresher training on the new concepts. This will help in determining 2 3
4 376 actual output and factors associated with it. BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 377 The project needs to consider integrating parent-child communication interventions 8 9 378 into the VMMC – ASRH linkages project so as to mobilize parents to support the 10 11 12 379 young people to access services (both psychosocially and financially). In the long run, 13 14 380 this may also provide opportunities for home-based HTS and supervised HIV self- 15 16 381 testing. 17 18 For peer review only 19 382 While HTS services are better provided through individual sessions, VMMC services 20 21 22 383 are better received when group counseling sessions are provided. There is thus need 23 24 384 to focus on differentiated service provisions depending on circumstances, even as 25 26 385 services are integrated. 27 28 29 386 In view of the male peer educators having higher chances of effectively referring 30 31 32 387 clients for VMMC, the peer education component needs to differentiate approaches 33 34 388 which might include pairing of female peer educators with their male counterparts, to 35 36 389 enhance the acceptability, confidence and capacity of female peer educators to http://bmjopen.bmj.com/ 37 38 39 390 mobilise, counsel and refer for VMMC services. 40 41 42 391 There is a need to review and possibly abolish user fees attached to the diagnosis and 43 44 392 treatment of STIs among the adolescents and young people in need of such services. on September 30, 2021 by guest. Protected copyright. 45 46 47 393 Global standards on provision of quality health services to young people should be 48 49 50 394 adopted and client satisfaction surveys prioritized to enhance quality service 51 52 395 delivery.(17),(25) This will help contextualize peer education into service delivery 53 54 396 and help understand the reasons for non-referral and non-receipt of services. 55 56 57 58 59 60 18
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1 2 398 CONCLUSION 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 399 This study found varying levels of referrals ranging from 5.1% (STIs) to 58.3% (VMMC) but 6 7 400 high levels of receipt of services among referred clients. Receipt of contraception, VMMC 8 9 10 401 and HTS services was high among those referred. Factors affecting non-referral included age 11 12 402 of client, sex of peer educator and type of counseling session (individual/group) while type of 13 14 403 setting (rural/urban), age of client and sex of peer educators affected non-receipt of services. 15 16 404 Peer education service differentiation based on gender and service type may further enhance 17 18 For peer review only 19 405 uptake. Advocacy efforts for user fees removal and exemptions on SRH services for young 20 21 406 people require accelerated investment to increase service uptake. There is also a need to 22 23 407 review the output of the peer educator project with a view to enhancing the quality of care 24 25 26 408 provided to the adolescents and young people. The study also recommends qualitative 27 28 409 approaches to further understand reasons for non-referrals and non-receipt of services. 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 19
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1 2 411 Acknowledgements 3
4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 412 This research was conducted through the Structured Operational Research and Training 6 7 413 Initiative (SORT IT), a global partnership led by the Special Programme for Research and 8 9 10 414 Training in Tropical Diseases at the World Health Organization (WHO/TDR). The training 11 12 415 model is based on a course developed jointly by the International Union Against 13 14 416 Tuberculosis and Lung Disease (The Union) and Medécins sans Frontières (MSF). The 15 16 417 specific SORT IT program which resulted in this publication was implemented by the Centre 17 18 For peer review only 19 418 for Operational Research, The Union, Paris, France. Mentorship and the 20 21 419 coordination/facilitation of this particular SORT IT workshop was provided through the 22 23 420 Centre for Operational Research, The Union, Paris, France; the Department of Tuberculosis 24 25 26 421 and HIV, The Union, Paris, France; the University of Washington, School of Public Health, 27 28 422 Department of Global Health, Seattle, Washington, USA; National Institute for Medical 29 30 423 Research, Muhimbili Centre, Dar es Salaam, Tanzania; and AIDS & TB Department, 31 32 33 424 Ministry of Health & Child Care, Harare, Zimbabwe 34 35 36 425 Funding http://bmjopen.bmj.com/ 37 38 39 426 The training course under which this study was conducted was funded by: the United 40 41 Kingdom’s Department for International Development (DFID); The Global Fund to Fight 42 427 43 44 428 AIDS, Tuberculosis and Malaria (GFATM) and the World Health Organization. The funders on September 30, 2021 by guest. Protected copyright. 45 46 429 had no role in study design, data collection and analysis, decision to publish, or preparation 47 48 430 of the manuscript. 49 50 51 52 431 Author contributions 53 54 432 AM – the Principal Investigator 55 56 57 433 AM, TM, NZ, SM, SX and BM conceived the study. 58 59 434 AM, PO, AK, KCT, CT, JPT, NZ, SM, AC, MS and TT designed the study protocol. 60 20
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1 435 AM, TM, NZ, SM, SX, BM, JS, WA, JPT and AC read and approved the protocol. 2 3
4 436 AM, TM collected the data. BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 437 AM, PO, AK, KCT, CT, JPT, NZ, SM, AC, MS and TT contributed to analyzing and 7 8 438 interpreting the data. 9 10 11 439 AM, AK, PO, MS and TT drafted the manuscript. 12 13 440 AM, AK, PO, TM, NZ, SM, JS, WA, AC, MS, JPT, SX and BM critically revised the 14 15 441 manuscript for intellectual content 16 17 All authors read and approved the final manuscript. 18 442 For peer review only 19 20 443 Disclosure Statement 21 22 23 444 The authors report no conflicts of interest 24 25 445 Ethics and Consent 26 27 28 446 Permission to undertake the study was granted by the Ministry of Health and Child Care. 29 30 31 447 Ethics approval was obtained from the Medical Research Council of Zimbabwe 32 33 448 (MRCZ/E/223) and the Ethics Advisory Group of the International Union Against 34 35 449 Tuberculosis and Lung Disease, Paris, France (EAG number: 62/18). As this was a 36 http://bmjopen.bmj.com/ 37 38 450 retrospective analysis of de-identified routine data, the need for individual client consent was 39 40 451 waived by both ethics committees. 41 42 43 452 Data availability statement 44 on September 30, 2021 by guest. Protected copyright. 45 46 453 The corresponding author can avail the data set on request without undue reservation. 47 48 49 454 Patient and Public Involvement 50 51 52 455 The principal investigator and enumerators had no interaction directly with the adolescents 53 54 55 456 and young people whose records were reviewed. The registers were accessed from peer 56 57 457 educators, community youth centre and health facility staff. 58 59 60 21
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1 459 REFERENCES 2 3
4 460 1. Joint United Nations Programme on HIV/AIDS. Global HIV & AIDS statistics — BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 461 2018 fact sheet [Internet]. 2018 [cited 2018 Aug 10]. Available from: 6 462 http://www.unaids.org/en/resources/fact-sheet 7 8 463 2. UNAIDS. Ending the AIDS epidemic for adolescents, with adolescents A practical 9 464 guide to meaningfully engage adolescents in the AIDS response [Internet]. 2016 [cited 10 465 2019 May 9]. Available from: 11 466 http://www.unaids.org/sites/default/files/media_asset/ending-AIDS-epidemic- 12 467 adolescents_en.pdf 13 14 468 3. Denno DM, Hoopes AJ, Chandra-Mouli V. Effective Strategies to Provide Adolescent 15 16 469 Sexual and Reproductive Health Services and to Increase Demand and Community 17 470 Support. J Adolesc Heal [Internet]. 2015 Jan [cited 2018 Aug 10];56(1):S22–41. 18 471 Available from:For http://www.ncbi.nlm.nih.gov/pubmed/25528977 peer review only 19 20 472 4. Zimbabwe National Statistics Agency. Inter-Censal Demographic Survey, 2017. 21 473 Harare; 2017. 22 23 474 5. Zimbabwe National Statistics Agency. Zimbabwe Population Census 2012 [Internet]. 24 475 Harare; 2013. Available from: 25 476 http://www.zimstat.co.zw/dmdocuments/Census/CensusResults2012/National_Report. 26 477 pdf 27 28 478 6. Zimbabwe National Statistics Agency and ICF International. Zimbabwe Demographic 29 30 479 and Health Survey 2015: Final Report. Rockville, Maryland, USA; 2016. 31 32 480 7. Abdi F, Simbar M. The Peer Education Approach in Adolescents- Narrative Review 33 481 Article. Iran J Public Health [Internet]. 2013 Nov [cited 2019 May 8];42(11):1200–6. 34 482 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26171331 35 36 483 8. Campbell C, Scott K, Mupambireyi Z, Nhamo M, Nyamukapa C, Skovdal M, et al. http://bmjopen.bmj.com/ 37 484 Community resistance to a peer education programme in Zimbabwe. BMC Health 38 485 Serv Res [Internet]. 2014 Dec 19 [cited 2019 May 8];14(1):574. Available from: 39 486 https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-014-0574-5 40 41 487 9. Hutton G, Wyss K, N’Diékhor Y. Prioritization of prevention activities to combat the 42 488 spread of HIV/AIDS in resource constrained settings: a cost-effectiveness analysis 43 44 489 from Chad, Central Africa. Int J Health Plann Manage [Internet]. 2003 Apr [cited 2019 on September 30, 2021 by guest. Protected copyright. 45 490 May 9];18(2):117–36. Available from: 46 491 http://www.ncbi.nlm.nih.gov/pubmed/12841152 47 48 492 10. Medley A, Kennedy C, O’Reilly K, Sweat M. Effectiveness of Peer Education 49 493 Interventions for HIV Prevention in Developing Countries: A Systematic Review and 50 494 Meta-Analysis. AIDS Educ Prev [Internet]. 2009 Jun [cited 2018 Aug 9];21(3):181– 51 495 206. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19519235 52 53 496 11. Chandra-Mouli V, Lane C, Wong S. What Does Not Work in Adolescent Sexual and 54 497 Reproductive Health: A Review of Evidence on Interventions Commonly Accepted as 55 56 498 Best Practices. Glob Heal Sci Pract [Internet]. 2015 Aug 31 [cited 2018 Aug 57 499 9];3(3):333–40. Available from: 58 500 http://www.ghspjournal.org/lookup/doi/10.9745/GHSP-D-15-00126 59 60 22
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1 501 12. Michielsen K, Chersich MF, Luchters S, De Koker P, Van Rossem R, Temmerman M. 2 3 502 Effectiveness of HIV prevention for youth in sub-Saharan Africa: systematic review
4 503 and meta-analysis of randomized and nonrandomized trials. AIDS [Internet]. 2010 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 504 May [cited 2019 May 8];24(8):1193–202. Available from: 6 505 https://insights.ovid.com/crossref?an=00002030-201005150-00014 7 8 506 13. Ministry of Health and Child Care Zimbabwe. National Adolescent Sexual and 9 507 Reproductive Health Strategy: 2010 - 2015. Harare; 2009. 10 11 508 14. Ministry of Health and Child Care Zimbabwe. National Adolescent and Youth Sexual 12 509 and Reproductive Health (ASRH) Strategy II: 2016 -2020. Harare; 2016. 13 14 510 15. Blum RW, Mmari K, Alfonso NY, Posner E. ASRH Strategic Plan Review for 15 511 Zimbabwe. Harare, Zimbabwe; 2015. 16 17 512 16. UNESCO. International technical guidance on sexuality education An evidence- 18 For peer review only 19 513 informed approach [Internet]. 2018 [cited 2019 May 9]. Available from: 20 514 http://www.unaids.org/sites/default/files/media_asset/ITGSE_en.pdf 21 22 515 17. Youth Engage. Mystery Client Visits in Zimbabwe Report: June 2017 - July 2018. 23 516 2018. 24 25 517 18. Ministry of Health and Child Care Zimbabwe. Zimbabwe Health Financing Strategy. 26 518 2017. 27 28 519 19. World Health Organisation. Adolescent HIV testing and counselling: a review of the 29 520 literature [Internet]. World Health Organization; 2013 [cited 2019 May 8]. Available 30 521 from: https://www.ncbi.nlm.nih.gov/books/NBK217943/ 31 32 522 20. Sheon N. Theory and Practice of Client-Centered Counseling and Testing [Internet]. 33 523 2006. 2006 [cited 2019 May 8]. Available from: 34 35 524 http://hivinsite.ucsf.edu/InSite?page=kb-07-01-04#S9.1X 36 http://bmjopen.bmj.com/ 37 525 21. Remez L, Woog V MM. Sexual and Reproductive Health Needs Of Adolescents in 38 526 Zimbabwe. Brief, New York, Guttmacher Inst [Internet]. [cited 2019 May 8];2014 39 527 Serie(No 3):8. Available from: 40 528 https://www.guttmacher.org/sites/default/files/report_pdf/ib-zimbabwe_0.pdf 41 42 529 22. Ngome E, Odimegwu C. The social context of adolescent women’s use of modern 43 530 contraceptives in Zimbabwe: a multilevel analysis. Reprod Health [Internet]. 2014 Dec 44 531 10 [cited 2019 May 8];11(1):64. Available from: on September 30, 2021 by guest. Protected copyright. 45 532 http://www.ncbi.nlm.nih.gov/pubmed/25108444 46 47 533 23. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. 48 49 534 Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) 50 535 statement: guidelines for reporting observational studies. Lancet (London, England) 51 536 [Internet]. 2007 Oct 20 [cited 2019 May 8];370(9596):1453–7. Available from: 52 537 http://www.ncbi.nlm.nih.gov/pubmed/18064739 53 54 538 24. Herat J, Plesons M, Castle C, Babb J, Chandra-Mouli V. The revised international 55 539 technical guidance on sexuality education - a powerful tool at an important crossroads 56 540 for sexuality education [Internet]. Vol. 15, Reproductive Health. BioMed Central; 57 541 2018 Dec [cited 2019 May 9]. Available from: https://reproductive-health- 58 59 542 journal.biomedcentral.com/articles/10.1186/s12978-018-0629-x 60 23
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1 543 25. Ministry of Health and Child Care Zimbabwe. National Guidelines on Clinical 2 3 544 Adolescent and Youth Friendly Sexual and Reproductive Health Services Provision
4 545 (YFSP). 2016. BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 24
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1 547 Table 1: Socio-demographic characteristics of young people counselled by peer 2 3 548 educators in Bulawayo and Mount Darwin, Zimbabwe (October – December
4 549 2018): BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 550 Characteristics N (%) 7 Total 3370 (100) 8 551 Age of young people (years) 9 10 – 14 1242 (36.9) 10 11 552 15 – 19 1346 (39.9) 12 20 – 24 782 (23.2) 13 553 Sex of young people 14 Male 2207 (65.5) 15 Female 1163 (34.5) 16 554 17 Marital Status of young people 18 For peerSingle review 3288 (97.6) only 555 19 Married 77 (2.3) 20 Divorced/Separated 5 (0.1) 21 556 Schooling status of young people 22 In-school 2334 (69.3) 23 557 24 Out of school 1036 (30.7) 25 558 Type of counseling session received 26 Individual 741 (22.0) 27 Group 2629 (78.0) 28 559 29 Type of Setting 30 560 Bulawayo (Urban) 2160 (64.1) 31 Mount Darwin (Rural) 1210 (35.9) 32 561 Age of peer educator (years) a 33 15 - 19 751 (22.3) 34 562 35 20 - 24 2619 (77.7) 36 Sex of peer educators 563 http://bmjopen.bmj.com/ 37 Male 49 (51.6) 38 564 Female 46 (48.4) 39 Sex of peer educators reach b 40 565 41 Male 1626 (48.2) 42 Female 1744 (51.8) 566 43 44 567 a Refers to the number of clients who were counselled by the peer educators aged 15 – 19 and on September 30, 2021 by guest. Protected copyright. 45 46 568 20 - 24 years. 47 b 48 569 Refers to the number of clients who were counselled by male and female peer educators. 49 50 570 51 52 53 54 55 56 57 58 59 60 25
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1 572 Table 2: Services for which counselled young people were referred for by peer 2 3 573 educators and received in Bulawayo and Mount Darwin districts, Zimbabwe (October – 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 574 December 2018) 6 7 Type of Service Referred** Received** 8 9 10 n (%)a n (%)b 11 12 13 Referred for any service 2191 (65.0) 1645 (75.1) 14 15 Females 544 (46.8) 413 (75.9) 16 17 Males 1647 (74.6) 1232 (74.8) 18 For peer review only 19 HTS 424 (12.6) 271 (63.9) 20 21 22 Females 154 (13.2) 88 (57.1) 23 24 Males 270 (12.2) 183 (67.8) 25 26 VMMC (among males only; n=2207) 1287 (58.3) 881 (68.5) 27 28 Contraception* 452 (13.4) 363 (80.3) 29 30 31 Females 206 (17.7) 161 (78.2) 32 33 34 Males 246 (11.2) 202 (82.1) 35 36
STI diagnosis and treatment 171 (5.1) 67 (39.2) http://bmjopen.bmj.com/ 37 38 39 Females 87 (7.5) 28 (32.2) 40 41 Males 84 (3.8) 39 (46.4) 42 43 44 Other SRH and HIV service 497 (14.7) 397 (79.9) on September 30, 2021 by guest. Protected copyright. 45 46 Females 251 (21.6) 207 (82.5) 47 48 49 Males 246 (11.2) 190 (77.2) 50 51 575 a – denominator is the total number counselled (N=3370), except for VMMC 52 53 576 b – denominator is the total number referred in the respective category 54 55 577 *Contraception refers to condoms, oral pills, injectables and implants. 56 57 578 ** Percentages may not add up to 100% for some clients were referred for more than one 58 59 579 service 60 26
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1 580 HTS – HIV Testing Services; VMMC – Voluntary Male Medical Circumcision; 2 3 STI – Sexually Transmitted Infections; SRH – Sexual and Reproductive Health
581 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 4 5 582 HIV – Human Immuno-deficiency Virus 6 7 583 8 9 10 584 11 12 13 585 14 15 586 16 17 18 587 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 30, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 27
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1 588 Table 3: Factors associated with non-referral for HIV Testing Services among 2 3 589 counselled young people in Bulawayo and Mount Darwin, Zimbabwe (October – 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 590 December 2018) 6 7 Socio-demographic Total Not referred Unadjusted Adjusted 8 9 characteristics couns for HTS 10 elled 11 N (%) RR (95% CI)) aRR (95% CI) 12 13 Total 3370 2946 (100) 14 15 Age (years) 16 10 – 14 1242 1178 (94.8) Ref Ref 17 15 – 19 1346 1134 (84.2) 0.89 (0.82-0.96) 0.91 (0.83-0.99) 18 For peer review only 19 20 – 24 782 634 (81.1) 0.85 (0.78-0.94) 0.92 (0.81-1.03) 20 Sex 21 Male 2207 1937 (87.8) 1.01 (0.93-1.01) 0.98 (0.90-1.05) 22 Female 1163 1009 (86.8) Ref Ref 23 Marital Status 24 25 Single 3288 2889 (87.9) Ref Ref 26 Married 77 52 (67.5) 0.77 (0.58-1.01) 0.88 (0.67-1.17) 27 Divorced or Separated 5 5 (100. 1.14 (0.47-2.74) 1.35 (0.58-3.25) 28 School status 29 0) 30 In-school 2334 2118 (90.7) Ref Ref 31 Out of school 1036 828 (79.9) 0.88 (0.81-0.95) 0.95 (0.86-1.05) 32 Counseling session 33 Individual 741 554 (74.8) Ref Ref 34 Group 2629 2392 (91.0) 1.22 (1.11-1.33) 1.16 (1.04-1.27) 35 36 Type of setting http://bmjopen.bmj.com/ 37 Bulawayo (urban) 2160 1958 (90.6) Ref Ref 38 Mount Darwin (rural) 1210 988 (81.7) 0.90 (0.83-0.97) 0.93 (0.85-1.01) 39 Age of peer educator 40 41 (years)a 42 15 - 19 751 673 (89.6) Ref Ref 43 20 - 24 2619 2273 (86.8) 0.97 (0.89-1.05) 0.96 (0.85-1.03) 44 b on September 30, 2021 by guest. Protected copyright. 45 Sex of peer educator 46 Male 1624 1421 (87.5) 1.00 (0.93-1.07) 1.01 (0.93-1.08) 47 Female 1746 1525 (87.3) Ref Ref 48 591 49 50 592 a Refers to the number of clients who were counselled by peer educators aged 15 – 19 and 20 51 593 - 24 years. 52 53 594 b Refers to the number of clients who were counselled by male and female peer educators. 54 55 595 HTS – HIV Testing Services; RR – Relative Risk; aRR – adjusted Relative Risk; CI – 56 596 Confidence Interval 57 58 597 In bold – statistically significant at p<0.05 59 60 28
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1 598 Table 4: Factors associated with non-referral for VMMC services among counselled 2 3 599 young people in Bulawayo and Mount Darwin, Zimbabwe (October – December 2018) 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 Socio-demographic Total Not Unadjusted Adjusted 7 characteristics counsel referred 8 led N for(%) RR (95% CI)) aRR (95% CI) 9 10 VMMC 11 Total 2207 92 (100) 12 13 Age (years) 0 14 10 – 14 944 28 (30.4) Ref Ref 15 15 – 19 795 36 (45.5) 1.50 (1.28-1.74) 1.59 (1.34-1.87) 7 16 20 – 24 468 27 (57.9) 1.90 (1.61-2.25) 1.83 (1.49-2.26) 2 17 Marital Status 18 For peer1 review only 19 Single 2179 90 (41.5) Ref Ref 20 Married 27 154 (55.6) 1.34 (0.80-2.23) 1.31 (0.78-2.22) 21 Divorced or Separated 1 1 (100) 2.41 (0.34-17.1) 2.46 (0.34-1.77) 22 School status 23 In-school 1613 60 (37.4) Ref Ref 24 Out of school 594 31 (53.2) 1.42 (1.24-1.63) 1.09 (0.92-1.30) 25 4 Counseling session 26 6 27 Individual 427 20 (48.2) Ref Ref 28 Group 1780 71 (40.1) 0.83 (0.71-0.97) 0.86 (0.73-1.01) 6 29 Type of setting 30 4 31 Bulawayo (urban) 1392 64 (46.3) Ref Ref Mount Darwin (rural) 815 27 (33.9) 0.73 (0.64-0.84) 0.61 (0.52-0.71) 32 4 33 Age of peer educator 6 34 (years)a 35 36 15 - 19 507 21 (42.8) Ref Ref http://bmjopen.bmj.com/ 37 20 - 24 1700 70 (41.4) 0.97 (0.83-1.13) 0.92 (0.78-1.08) 38 7 Sex of peer educatorb 39 3 40 Male 1159 44 (38.0) 0.83 (0.73-0.94) 0.77 (0.67-0.80) 41 Female 1048 48 (45.8) Ref Ref 42 0 43 600 0 44 a on September 30, 2021 by guest. Protected copyright. 45 601 Refers to the number of clients who were counselled by peer educators aged 15 – 19 and 20 46 602 - 24 years. 47 48 603 b Refers to the number of clients who were counselled by male and female peer educators. 49 50 604 VMMC – Voluntary Medical Male Circumcision; RR – Relative Risk; aRR – adjusted 51 605 Relative Risk; CI – Confidence Interval 52 53 606 In bold – statistically significant at p<0.05 54 55 56 57 58 59 60 29
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1 608 Table 5: Factors associated with non-receipt of VMMC services among referred young 2 3 609 people in Bulawayo and Mount Darwin, Zimbabwe (October – December 2018) 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 Socio-demographic Total No receipt Unadjusted Adjusted 7 characteristics referr for VMMC 8 ed services 9 10 N (%) RR (95% CI)) aRR (95% CI) 11 Total 1287 406 (100) 12 13 Age (years) 14 10 – 14 657 202 (30.7) Ref Ref 15 15 – 19 433 136 (31.4) 1.02 (0.82-1.27) 1.24 (0.84-1.51) 16 20 – 24 197 68 (34.5) 1.12 (0.85-1.48) 1.29 (0.91-1.83) 17 Marital Status 18 For peer review only 19 Single 1275 403 (31.6) Ref Ref 20 Married 12 3 (25.0) 0.79 (0.25-2.46) 0.87 (0.28-2.74) 21 School status 22 In-school 1009 328 (32.5) Ref Ref 23 Out of school 278 78 (28.1) 0.86 (0.67-1.10) 0.80 (0.58-1.10) 24 25 Counseling session 26 Individual 221 102 (46.2) Ref Ref 27 Group 1066 304 (28.5) 0.62 (0.49-0.77) 0.52 (0.41-0.66) 28 Type of setting 29 Bulawayo (urban) 748 284 (38.0) Ref Ref 30 31 Mount Darwin (rural) 539 122 (22.6) 0.60 (0.48-0.74) 0.52 (0.41-0.67) 32 Age of peer educator 33 (years)a 34 35 15 - 19 290 67 (23.1) Ref Ref 36 20 - 24 997 339 (34.0) 1.47 (1.13-1.91) 1.13 (0.84-1.51) http://bmjopen.bmj.com/ 37 Sex of peer educatorb 38 39 Male 719 218 (30.3) 0.92 (0.75-1.11) 0.76 (0.62-0.94) 40 Female 568 188 (33.1) Ref Ref 41 610 42 43 44 611 a Refers to the number of clients who were referred by peer educators aged 15 – 19 and 20 - on September 30, 2021 by guest. Protected copyright. 45 612 24 years. 46 47 613 b Refers to the number of clients who were referred by male and female peer educators. 48 49 614 VMMC – Voluntary Medical male Circumcision; RR – Relative Risk; aRR – adjusted 50 615 Relative Risk; CI – Confidence Interval 51 52 616 In bold – statistically significant at p<0.05 53 54 617 55 56 618 57 58 59 60 30
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1 619 Table 6: Factors associated with non-receipt of contraception services* among referred 2 3 620 young people in Bulawayo and Mount Darwin, Zimbabwe (October – December 2018) 4 BMJ Open: first published as 10.1136/bmjopen-2019-034436 on 8 March 2020. Downloaded from 5 6 Socio-demographic Total No receipt for Unadjusted Adjusted 7 characteristics referre Contraception 8 d services 9 10 N (%) RR (95% CI)) aRR (95% CI) 11 12 Total 452 89 (100%) 13 Age (years) 14 10 – 14 29 5 (17.2) Ref Ref 15 16 15 – 19 175 30 (17.1) 0.99 (0.39-2.56) 0.93 (0.35-2.44) 17 20 – 24 248 54 (21.8) 1.26 (0.51-3.16) 1.42 (0.55-3.67) 18 Sex For peer review only 19 Male 246 44 (17.9) 0.82 (0.54-1.24) 0.73 (0.46-1.14) 20 Female 206 45 (21.8) Ref Ref 21 22 Marital Status 23 Single 399 82 (20.6) Ref Ref 24 Married 48 4 (8.3) 0.41 (0.15-1.11) 0.20 (0.07-0.58) 25 Divorced or Separated 5 3 (60.0) 2.92 (0.92-9.24) 1.38 (0.42 -4.52) 26 27 School status 28 In-school 116 30 (25.9) Ref Ref 29 Out of school 336 59 (17.6) 0.68 (0.44-1.05) 0.83 (0.51-1.35) 30 Counseling session 31 Individual 170 43 (25.3) Ref Ref 32 33 Group 282 46 (16.3) 0.64 (0.43-0.98) 0.71 (0.46-1.11) 34 Type of setting 35 Bulawayo (urban) 284 32 (11.3) Ref Ref 36 Mount Darwin (rural) 168 57 (33.9) 3.01 (1.95-4.64) 3.18 (1.93-5.22) http://bmjopen.bmj.com/ 37 Age of peer educator 38 a 39 (years) 40 15 - 19 49 18 (36.7) Ref Ref 41 20 - 24 403 71 (17.6) 0.48 (0.29-0.80) 1.00 (0.56-1.82) 42 b 43 Sex of peer educator 44 Male 180 26 (14.4) 0.62 (0.39-0.98) 0.81 (0.49-1.32) on September 30, 2021 by guest. Protected copyright. 45 Female 272 63 (23.2) Ref Ref 46 621 47 48 622 a Refers to the number of clients who were referred by peer educators aged 15 – 19 and 20 - 49 623 24 years. 50 51 624 b Refers to the number of clients who were referred by male and female peer educators. 52 53 625 RR – Relative Risk; aRR – adjusted Relative Risk; CI – Confidence Interval 54 55 626 *Contraceptives included condoms, injectables, oral pills and implant hormonal 56 57 627 contraceptives 58 59 628 In bold – statistically significant at p<0.05 60 31
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