A Community Health Improvement Plan: HIV Prevention in Zambian Couples Emily Downey & Emily Newhouse St. Paul’s Missionary Hospital , Objectives

Emily Downey-- Address the knowledge, Emily Newhouse- To explore and attitudes, and beliefs of Zambian expand my knowledge on a unique couples ages 18-44 and implement culture and experience health care in a appropriate HIV prevention interventions new setting; to gain insight and for optimal health outcomes in an knowledge about HIV-positive adults, international community. ages 18-44, and create a community health intervention plan aimed toward HIV prevention.

2 Background Information

Zambia is located in Southern Africa, with a total population of 16,212,000, as of 2016 (Chisala, 2019). It is a landlocked country surrounded by eight countries, which include the following: Angola, Tanzania, Zimbabwe, Namibia, the Democratic Republic of Congo, Mozambique, Malawi and Botswana. The capital city is Lusaka. As for the different vital statistics of Zambia, there are 98.47 males per 100 females. 46.4% of the population is under the age of 15. The Gross Domestic Product per capita in 2017 was $1,646.14 in US dollars.

Completion rate of primary education is 74% (UNICEF, 2016). About 24% of the population attended upper secondary education (UNICEF, 2016).

Many of the people are part of the Christianity religion, with a small percentage being Atheist, Muslim and Mormon. The Zambian people place a great emphasis on family and togetherness. Everyone is kind and welcoming to one another.

The three major sources of employment for the Zambian people are farming, fishing and market business, where people sell their farmed or homemade goods (Chisala, 2019). The official language of Zambia is English. However, there are 70 other indigenous languages spoken throughout the country, the main ones include Bemba, Lozi, Lunda, Luvale, Nyanja, and Tonga (Loryman, 2018). Many of the poorly educated villagers do not speak any English.

Notable health disparities between people groups: Zambian primary care is more pro-poor populations while hospital utilization for healthcare is primarily more prevalent in populations with higher socioeconomic status (Phiri & Ataguba, 2014). There is a need to improve primary facilities to serve the poor and remove barriers that prevent them from obtaining care (Phiri & Ataguba, 2014). 3 Description of Kashikishi, Zambia

Kashikishi is located in the , the This hospital and community clinics provide free northern part of of Zambia. It lies antiretroviral therapy to all HIV-positive patients, on eastern shores of , bordering the however transportation is often a barrier. People Democratic Republic of Congo (Chisala, 2019). often walk many miles to treatment locations.

● Kashikishi population--185,146 people ● Males to female ratio--52:48. ● Annual growth rate--4.6% ● Fertility rate--7.2% ● Average income-- $3,860 per capita

St. Paul’s Missionary Hospital is a Catholic-based hospital. Many of the residents of the community are also Catholic. 4 Description of Kashikishi, Zambia

Top Five Health Issues Incidence and Prevalence Mortality Co-Morbidities

United States Data 1. Physical Activity and 1. 48.3% 1. 8.3% 1. Obesity, High Nutrition 2. 23.6% 2. 24.8% Cholesterol, Diabetes, 2. Overweight and Obesity 3. 14% 3. 7 million deaths per Heart Disease 3. Tobacco 4. 9.4% year 2. Cancer, Diabetes, 4. Substance Abuse 5. 1.1 million people 4. 70,237 Hyperlipidemia 5. HIV/AIDS 5. 15,807 deaths per year 3. Cancer, COPD, Stroke (University of Rochester Medical 4. Mental Illness Center, 2019) 5. TB

Zambia Data 1. HIV/AIDS 1. Incidence of 13.3% 1. Many of deaths are 1. Immunosuppression 2. Neonatal diseases 2. 45 deaths per 1,000 live caused by HIV-related causes opportunistic 3. Upper respiratory infections births illnesses infections 4. Diarrheal diseases 3. N/A 2. 24.8% 2. Maternal Complications 5. Tuberculosis 4. N/A 3. N/A and Fetal Death 5. 85% cure rate 4. N/A 3. HIV/Immunosuppressed (Chisala, 2019) 5. Cure rate: 85% 4. Malnutrition 5. HIV

Kashikishi Data 1. Malaria 1. 39.4% 1. 15.2 deaths per 1. Malnutrition and failure 2. ARI/Pneumonia 2. N/A 100,000 to thrive 3. Trauma 3. N/A 2. 24.8% 2. Malnutrition 4. Non-blood diarrheal 4. N/A 3. N/A 3. Malnutrition diseases 5. Under 5 years old:7.5% 4. N/A 4. Malnutrition 5. Anemia 5. N/A 5. Malnutrition and malaria

(Chisala, 2019) (Chisala, 2019) 5 Couples In Zambia

Our at-risk population is Zambian adults, ages 18 to 44, with a focus on couplet pairs. The health issue we are focusing on is HIV prevention.

● The aim is to reach 90% of couples in Zambia in accordance with the UNAIDS 90- 90-90: Treatment for all campaign (UNAIDS, 2017). ● This goal is to increase to 95% by 2030 (UNAIDS, 2017). ● Zambian couples in the community will ● Aggregate population: heterosexual couples ages 18-45 come together to overcome the ● The intervention does not individually differentiate community stigma and protect their gender. We aim to address couples as a joint unit and health and wellbeing 6 connect within all of the community. Health Issue: HIV Prevention

● Sub-saharan Africa is disproportionately affected by HIV/AIDS (Kelley et. al, 2016) ● Occurs in 12.3% of the Zambian population (UNAIDS, 2017) ● 35% to 80% of all heterosexual HIV transmissions occur in stable relationships (Kelley et. al, 2016) ● Couples are a primary target group in HIV prevention

Global Health Objective 4: Increase the number of public health professionals trained by Global Disease Detection (GDD) programs worldwide

https://www.undp.org/content/undp/en/home/sustainable- https://www.healthypeople.gov/2020/topics- 7 development-goals/goal-3-good-health-and-well-being.html objectives/topic/global-health/objectives Zambian Adults and HIV Prevention

Prior knowledge: Stigma is a barrier within the community that prevents the population from seeking treatment and receiving care. Obtaining care can become difficult if affordable transportation is not available, particularly in the rainy season when the poorly constructed dirt roads become difficult to travel on.

Readiness to learn: The health professionals did a fantastic job of assessing the learning needs of the community. During their initial testing, they tested each patient for HIV. If found positive, they performed a second test. Before explaining the diagnosis, they would assess the complete knowledge of the illness before explaining how to live with this disease and the treatment associated with it.

Characteristics of group: The Catholic Church had a large influence on the local area that created a barrier to promotion of birth control and family planning. Most of the relationships were heterosexual, since homosexuality is illegal in Zambia.

Modified environment: Further work in the women empowerment and family planning programs can change the perceptions to allow for interventions to be better implemented. Family planning programs are vital for many reasons, 8 including reducing malnutrition in children and overpopulation (Chisala, 2019). What does the literature say?

Promotion of Couples’ Voluntary HIV Counseling and Testing: A Comparison of Influence Networks in Rwanda and Zambia Why is this health issue a problem for this population? ● Heterosexual transmission accounts for the majority of HIV infections in sub-Saharan Africa ● 35% to 80% of all heterosexual HIV transmissions occur in stable relationships What are the current interventions for this problem? ● WHO recommends for couples’ voluntary counseling ● However, only 10% of couples have been jointly tested and counseled What interventions have been successful and what interventions have not been successful? ● Voluntary counseling and testing programs are an effective and feasible approach to increasing serostatus awareness and decreasing high-risk behavior ● Conducting the voluntary counseling and testing programs with couples effectively targets one of the most critical prevention points in sub-Saharan Africa ● Even though this is an effective intervention, it has not had success being implemented in communities ● Measures are needed to increase the communities access to these programs, combat stigma, and increase utilization of these services How does the literature compare to what the team learned specific to the health issue identified in the learning objectives? ● The UNAIDS 90-90-90: Treatment for all campaign aims to ensure 90% of people living with HIV know their status, 90% receive treatment, and 90% have suppressed viral loads. The intervention utilized in this literature promotes testing to increase serostatus 9 awareness, which aligns with the 90-90-90 campaign. What does the literature say?

Female Partner Acceptance as a Predictor of Men’s Readiness to Undergo Voluntary Medical Male Circumcision in Zambia: The Spear and Shield Project Why is this health issue a problem for this population? ● Women have misconceptions and fears of voluntary medical male circumcision (VMMC) which lead men towards Interventions: feeling uncertain about receiving VMMC ● 35% to 80% of all heterosexual HIV transmissions occur in stable relationships Individual level- What are the current interventions for this problem? Voluntary Male ● Currently, circumcision is not required, but the intervention in this study was increased counseling to both sides of Medical Circumcision the relationship to promote female acceptance of VMMC and readiness for men to VMMC Community- What interventions have been successful and what interventions have not been successful? Community/Couple ● Educational sessions with females increased their acceptance of VMMC ● Female acceptance led to increased readiness for men to complete the desired action: VMMC Counseling about ● Some men still had hesitation to complete the desired action due to time spent contemplating the benefits vs. VMMC costs Systems- How does the literature compare to what the team learned specific to the health issue identified in the learning objectives? Implementing policies ● The UNAIDS 90-90-90: Treatment for all campaign aims to ensure 90% of people living with HIV know their status, 90% receive treatment, and 90% have suppressed viral loads. The intervention utilized in this literature promotes to promote legal, safe counseling and education to the community couples to increase VMMC, which can lead to decreased transmission VMMC in hospitals of HIV. ● Much of the literature focuses on interventions outside the body to reduce HIV transmission, but many do not know 10 they can alter their body parts to help aide in this objective of HIV prevention. Priority Outcomes

The national goal for the next 5 years:

To reduce new HIV infections and AIDS-related mortality by 75% and reduce HIV-related stigma and discrimination to zero within the context of ensuring healthy lives and promoting well-being across all ages (Chisala, 2019).

The health promotion plan of HIV prevention in Zambian couples is needed to achieve this national goal.

Primary Intervention: Counseling for couples on safe sexual behaviors and prevention methods for HIV

Secondary : Joint HIV testing for couples to increase awareness of serostatus

Tertiary: Provide ART treatment per protocol for patients with positive status to suppress viral load

Sustainable Development Goal: Met by providing the population with prevention of HIV, early identification of HIV, and early treatment of HIV so people can remain in good health and free from 11 illness. Health Promotion Model

Health Promotion Model: Theory of Reasoned Action and Planned Behavior

This theory implies that a behavior is determined by intention to carry out the behavior. The intention is a function of attitude toward the behavior and what is considered “normal.” The most effective predictor of behavior is intention. “Intention” is the cognitive representation of being fully preparedness to accomplish and do a given behavior. It precedes behavior.

Aim: Change perception of AIDS in community by targeting couples and their behaviors and attitudes towards voluntary male medical circumcision and voluntary HIV testing and counseling. Counseling at the community level allows for equal involvement in preventative measures.

Following the model, health promotion sessions will be held at a local community center for couples, targeting their beliefs and attitudes towards HIV prevention methods and HIV testing. The primary goal for the program leaders (the nurse and counselor) in these sessions is to understand the community’s subjective norms and how this influences the couples’ behaviors regarding different HIV prevention methods. According to this model, the intention to change is driven by the attitude towards the behavior and the subjective norm for the behavior. Using the knowledge gained from the sessions, the program leaders target these subjective norms within the community to combat HIV associated stigma and increase prevention and awareness for couples. The program will use influential community leaders to promote awareness and provide support towards Couple’s Voluntary Counseling and Testing sessions. By targeting and changing the subjective norm with the help of influential community leaders, the program aims to have a higher attendance in Zambian couples participating in counseling. With establishing this new norm, the nurse and counselor with go out into the community to provide in home counseling and HIV testing to couples. An intervention included in the counseling sessions is voluntary male medical circumcision. In this model, the planned behavior change for the community is couples counseling in order to obtain HIV serostatus, education about VMMC and able to share their intention with other members of the community in order to shift the “normal” intention to shift the behavior.

12 Our Professional Highlights From the Trip

Emily Downey- My professional highlight was expanding Emily Newhouse- My greatest professional highlight my cultural awareness to successfully engage in throughout this experience was providing interprofessional collaboration and work with team compassionate care to a completely new population, members throughout the hospital including the theater, all while applying the skills and knowledge I have outpatient clinic, ART clinic, and the mental health clinic. gained in nursing school in the United States. It was truly humbling to witness and participate in health care with such limited resources. An experience that especially touched me was a vaginal delivery where the nurse had to resuscitate the infant. The mother did not have any support system there and delivered the baby without any pain medication. The nurse was able to revive the baby after suctioning. The nurse midwife provided the highest quality of care by treating her physically, but also emotionally. 13 Our Personal Highlights From the Trip

Emily Downey- My personal highlight Emily Newhouse- This trip gave me a brand was encountering such a welcoming new outlook on life. It has made me so culture. The relationships I much more appreciative of life and all of our developed with the local people is blessings. Now, I believe that I am not as what truly made this experience for quick to complain about minor issues, I am me. As humans, we share more thankful for everyone in my life and I similarities while also experiencing have a unique appreciation for friendship. I many differences. It is through learned that regardless of your situation, understanding and celebrating our you can always find light in the darkness. differences and connecting with our This trip allowed me to expand my faith and similarities that makes for has helped me gravitate closer to Jesus. successful collaboration, and brings Our most important purpose in life is to love true beauty to the human life. everybody, always. It is our duty as nurses to care for those who are less fortunate. 14 References

Chisala, E. (2019). St. Paul’s mission general hospital. [PowerPoint slides].

Cook, R., Jones, D., Redding, C., Zulu, R., Chitalu, N. & Weiss, S. (2016). Female partner acceptance as a predictor of men’s readiness to undergo voluntary medical male circumcision in Zambia: The spear and shield project. AIDS and Behavior, 20(11), 2503-2513. doi: 10.1007/s10461-015-1079-x

Kelley, A. L., Hagaman, A. K., Wall, K. M., Karita, E., Kilembe, W., Bayingana, R.,…Allen, S. A. (2016). Promotion of couples’ voluntary HIV counseling and testing: a comparison of influence networks in Rwanda and Zambia. BMC Public Health, 16(1), 1-8.

Phiri, J. & Ataguba, J. (2014). Inequalities in public health care delivery in Zambia. International Journal for Equity in Health, 13, 24. doi:10.1186/1475-9276-13-24.

UNAIDS. (2017). Zambia. Retrieved from http://www.unaids.org/en/regionscountries/countries/zambia

UNICEF. (2016). Zambia: Education. Retrieved from https://www.unicef.org/zambia/education

University of Rochester Medical Center. (2019). Top 10 most common health issues. Retrieved from https://www.urmc.rochester.edu/senior- 15 health/common-issues/top-ten.aspx