Original Article | OPEN ACCESS DOI: 10.23937/2643-461X/1710060

Impact of a Group-Based Video and Interactive Group Session Addressing Diarrheal Disease, Helminthic and Schistosomiasis Infections, Hypertension and Diabetes on Short and Long-Term Improvement in Knowledge and Healthy Behaviors in Seroconcordant HIV-Negative Zambian Couples

T Sharkey, MPH, DrPH (cand)1,3,4, R Parker, MSPH1, KM Wall, PhD2, K Malama, PhD1,3, W Kilembe, MD, MSc1,3, M Inambao, MD, MPH1,3, A Tichacek, MPH1, C Kwok, MPH3, N Ahmed, MPH, DrPH3, R Burke, MPH1, RW Peeling, PhD4 and S Allen, MD, MPH1,3*

1Department of Pathology and Laboratory Medicine, School of Medicine, Rwanda Zambia Health Research Group (RZHRG), Emory University, USA

2Department of Epidemiology, School of Public Health, Emory University, USA

3Center for Family Health Research in Zambia (CFHRZ), Zambia

4London School of Hygiene and Tropical Medicine (LSHTM), United Kingdom



Non-communicable and neglected tropical diseases (NCD and NTD) contribute to high morbidity and mortality in Zambia. While the public health importance of NTD has long been recognized, prevalence of disease remains high. NCD are emerging as causes of morbidity and mortality. Knowledge of risk factors, diagnosis, management, and prevention of NCDs and NTDs in the general population is poor and as a result, low-cost commodities are insufficiently used.


Urban couples recruited in five government health centers (HC) participated in a video-based group intervention addressing hand washing, water treatment, routine deworming, and urinary schistosomiasis screening to prevent morbidity and mortality from NTD. Chlorine, soap, and deworming for the family were provided, along with schistosomiasis treatment. The intervention also promoted lifestyle changes to prevent and ameliorate hypertension and diabetes and emphasized the importance of medical management regardless of symptomatology. Blood pressure screening identified hypertensives that were given low-sodium salt and referrals. Those with glucose on urine dipstick were counseled and referred. Knowledge and observed and self-reported behaviors were measured 1-2 weeks and 6 months after the interventions. All activities took place in the HC and conducted by trained HC staff.

A comparison group recruited at five matched HC was assigned to an HIV prevention intervention and completed the same surveys as the intervention group at baseline and 6 months.


One to two weeks after the intervention, reported use of chlorine treatment for drinking water increased from 24% to 96%, with knowledge of correct volume for dilution of 20 L and 5 L containers improving from 29%-35% to 96%-98%. Knowledge of household deworming increased from 62% to 99%. Observed handwashing technique improved including duration (20 seconds) and scrubbing of back, palms, wrists, between fingers and under fingernails. Knowledge that hypertension and diabetes could be asymptomatic increased from 63% to 82% and recall of potential sequelae also improved including heart disease/attack (14% to 41%), stroke (26% to 61%) and death (65% to 83%). Correct definition of hypertension (BP > = 140/90) increased from 6% to 54% and citing salt reduction as part of management increased from 31% to 85%. An increase in those reporting not adding salt (8% to 20%) corresponded with a decrease in those reporting > = 1/2 teaspoon (16% to 5%). Knowledge that diabetics should reduce sugar intake increased from 48% to 89% and the proportion reporting adding > = 3 tsp to their tea decreased from 42% to 26%. Taking prescribed medication and getting regular medical checks knowledge increased for both hypertension (38% to 73% and 28% to 66%, respectively) and diabetes (32% to 71% and 20% to 60%, respectively). These improvements were retained at 6-month follow-up and sharing-related household duties to prevent NTD and NCD improved. Comparison group surveys confirmed equivalency of NTD and NCD knowledge and behaviors between the two groups at baseline. Surveys at 6 months showed no improvement in the comparison group, confirming that secular trend did not play a role.


Video-based interventions are time and money-saving and ensure consistent messaging. Sustained improvements in knowledge and behavior were reported when low-cost commodities were provided.


Non-communicable diseases, Neglected tropical diseases, Hygiene and sanitation, Helminthiasis, Handwashing, Healthy lifestyle, Video, Couples


BP: Blood Pressure; CLTS: Community-Led Total Sanitation; CNC: Concordant HIV-negative Couples; CRT: Cluster Randomized Trial; CVCT: Couples' HIV Voluntary Counseling and Testing; ELISA: Enzyme-Linked Immunosorbent Assay; GHP: Good Health Package; HC: Health Center; NCD: Non Communicable Diseases; NTD: Neglected Tropical Diseases; SSA: Sub-Saharan Africa; WHO: World Health Organization


Neglected tropical diseases (NTD) and non-communicable diseases (NCD) pose an important threat to health in Africa. In Zambia and many Sub-Saharan Africa (SSA) countries, the most prevalent NTDs are cholera, soil transmitted helminths and schistosomiasis. Among the leading causes of death in Zambia are lower respiratory infections (pneumonia) and diarrheal diseases at 4th and 5th respectively, with children most affected [1,2]. Various studies in SSA including Zambia have shown that handwashing can reduce prevalence of diarrheal diseases by 25% or more [3-8]. Cholera is also a frequent problem in two of the largest cities in Zambia, Lusaka and Ndola, with regular outbreaks occurring during the rainy season since the 1970s [9]. Previous cholera outbreaks have been linked to high fecal contamination of water sources and raw/prepared foods, inadequate safe water supply and sanitation, and insufficient drainage [9-15].

Hypertension and diabetes leading to heart disease and stroke are increasingly common due to urbanization, increase sedentary lifestyles and high salt and high fat diets. Stroke is now the 3rd leading cause of death having increased by almost 60% from 2009 to 2019 and ischemic and hypertensive heart disease are ranked at 7th and 10th position respectively [1]. Risk factors attributable to mortality and morbidity (disability) include water sanitation and hygiene (WaSH) in 4th position and high blood pressure (BP), high body mass index, and dietary risks at 6th-8th position respectively [1].

We previously offered basic NTD/NCD education with a flip chart and a selection of services (blood pressure screening, urine dipstick for blood (schistosomiasis) and sugar (diabetes) and commodities (hand soap, chlorine, deworming for the family, low sodium salt) to couples seeking joint HIV counseling and testing in Lusaka and Ndola, two of Zambia's largest cities [16], and these services were associated with increased follow-up for repeat HIV testing. However, health center (HC) staff reported that knowledge about NTD and NCD was poor, prompting us to develop a more intensive education program.

We present here knowledge and behaviors related to prevention, screening and treatment of common NTD and NCD in seroconcordant HIV-negative Zambian couples (CNC) who participated in a Good Health Package (GHP) comparator arm of a cluster randomized trial (CRT) described in detail elsewhere [17]. Baseline information is compared to survey responses two weeks and six months after a video-based educational session with practicums and provision of low-cost commodities. Outcomes at six months are compared with CNC in clinics randomized to a contemporaneous and unrelated HIV prevention, also described in more depth elsewhere [17]. Our findings will highlight successful couples-based prevention strategies to reduce the morbidity and mortality associated with NTD and NCD through education, practical training, low-cost commodity distribution and screening with treatment/referral.



Approval has been granted by the OHRP-registered University of Zambia Biomedical Regulatory Ethics Committee and Emory University Institutional Review Board and retrospectively registered as NCT02744586 on ClinicalTrials.gov. Couples viewed a verbatim reading of the informed consent on a video, met with a counselor to discuss any questions or clarifications, and jointly signed consent [18-20]. A unique alphanumeric ID was implemented for all data gathering tools. Locator information was stored separately from data to maintain privacy and confidentiality.

Study design

Ten participating clinics (8 in Ndola and 2 in Lusaka) included 5 dyads with non-overlapping catchment areas matched by clinic volume and HIV prevalence. Each dyad was randomized such that one clinic was assigned to the GHP arm and the other to the control arm. An enrollment visit was followed by receipt of the intervention several days later. The short-term impact was measured 1-2 weeks after the intervention with intervention-specific questionnaires. Long-term impact was measured at six months with the same assessments in GHP and control groups, including knowledge and behaviors related to NTDs/NCDs. The trial is ongoing (clinicaltrials.govNCT02744586) with a 60-month follow-up visit to have more detailed comparisons of HIV risk factors between both arms and to assess longer-term knowledge and implementation of strategies in GHP arm. Hypotheses of the CRT are that the GHP arm will sustain improved knowledge and behaviors related to NTD/NCD prevention and treatment than the control arm. Conversely, the control arm will have a lower incidence of HIV risk factors, such as reported outside sexual contacts, incident HIV and STI than the GHP arm.


The purpose of this manuscript is to compare changes in NTD/NCD-related knowledge and behaviors in the GHP arm at baseline (pre-intervention) and post-intervention at two weeks and six months. This study will also compare knowledge and behaviors at six months post-intervention visit between GHP and a comparison group (control) that received an HIV intervention in order to assess potential secular trend due to other NTD/NCD programs.

Study population

At Couples HIV Voluntary Counseling and Testing (CVCT) offered in government health centers in Lusaka and Ndola, two of Zambia's largest cities, couples underwent pre-test counseling, HIV rapid testing per national guidelines adapted for couples [21] and post-test counseling. According to Center for Disease Control and Prevention and World Health Organization (WHO) guidelines, couples received HIV results together and were counseled per their couple HIV status [22,23].

In 2016, couples who received CVCT services and met pre-screening eligibility (both partners HIV-negative, women aged 18-45 and men aged 18-65, cohabiting for > = 3 months, interested, willing and capable of understanding and fulfilling study procedures and providing contact information) were invited the following weekend to return for screening and enrollment.

Study reimbursement

At each visit, couples received approximately 3 USD per person-visit as study reimbursement to cover time at clinic and transport, as described in the informed consent. An additional 2 USD per person was given as a lunch allowance for more extended study visits.

Enrollment visit

After joint informed consent, the couple was separated, and a baseline questionnaire was administered to women by female counselors and men by male counselors and included socio-demographic characteristics, knowledge of and behaviors related to NTDs and NCDs. The visit lasted 2-3 hours.

Intervention visit

The "Good Health Package" (GHP) video rationale and content was developed based on previous use of health education flip chart and a choice of provision of commodities (deworming tablets, chlorine and hand soap) and health screenings (blood pressure, diabetes and schistosomiasis) related to NCDs and NTDs to improve follow-up HIV testing in couples in which at least one partner was HIV-negative [16]. All materials were translated into the vernacular (Bemba and Nyanja) and content was equivalent to or below 8th grade level. During the visit, spouses watched a one-hour video that consisted of two-30-minute parts. Part one content covered risk groups; transmission and mechanism of action; signs and symptoms; key facts and statistics; and prevention strategies. In the first part of the video, spouses were separated into men and women's groups; male counselors led the men's groups, and female counselors led the women's groups. Pauses were incorporated throughout the video in key areas; during these pauses, the counselor actively facilitated discussion points to allow for questions, answers and further discussions/clarifications if needed. Hand washing with soap to prevent respiratory and diarrheal infections and intestinal helminths was emphasized, and during breaks in the video, participants practiced under supervision. Use of drinking water treatment with chlorine to prevent cholera and other causes of diarrhea was described and again participants practiced putting the correct amount of chlorine into 5-liter (one measure of the top of the chlorine bottle cap) and 20-liter (one measure of the bottom of the chlorine bottle cap) containers. Schistosomiasis education highlighted how freshwater areas within a city could be potential sources of infection based on a recent study showing active infection in 10% of healthy adults in Lusaka [24]. (Of note, we did not include discussions of malaria as we were not able to offer bed nets due to their high cost and the focus on pregnant women for available stock).

Modifiable lifestyle changes related to salt and sugar intake, weight maintenance and physical activity were emphasized for prevention of hypertension and diabetes, and salt and sugar measurements were used to illustrate portion control. All couples came back together in part two of video which had a quiz related to topics in the video in addition to discussion on the importance of equal responsibility in terms of household health and implementing strategies at home to improve the family's health. Couples were provided with a bottle of chlorine sufficient for one year of use in an average household, hand soap, and one round of de-worming medication sufficient for the household. Blood pressures were taken, and urine dipsticks were used for detection of urinary schistosomiasis (hematuria) and diabetes (glucosuria). All couples received low sodium salt and messaging for hypertension prevention. Participants with a blood pressure > = 140 mmHg systolic and/or > = 90 mmHg diastolic received added lifestyle and dietary counseling and were referred for medical evaluation. Participants with elevated glucose (> = 500 mg/dl (27.77 mmol/L) in urine were also referred for medical evaluation. Those with hematuria were provided with free treatment for schistosomiasis with praziquantel. The visit lasted 3-4 hours.

Follow-up visits 1-2 weeks and 6 months post-intervention visit

GHP spouses were separated and administered a questionnaire about knowledge, implementation of strategies, sharing of household roles, and behaviors related to their intervention content. At the 6-month follow-up visit, couples in both GHP and control arms responded to the same questions on hypertension, diabetes, diarrheal diseases, schistosomiasis, and helminths.

Data management and analysis

Questionnaire data is managed using Microsoft Access and Research Electronic Data Capture (REDCap) electronic data capture tools hosted at Emory University [25] with IT support from Research and Woodruff Health IT Division grant support (UL1 TR000424). Responses to questionnaires are presented as frequencies. To establish significance, differences in responses between pre-and post-intervention and between men and women are assessed with chi-square tests. Because the number of participants is large, some statistically significant differences are not meaningful, and we thus only highlight in text significant differences of > 5%. Data analysis is conducted using SAS 9.4 (SAS Institute, Cary, N.C.).


Demographic characteristics

In the 570 couples, who participated in the intervention and the first follow-up visit, the average age was 32 for men and 26 for women and the average duration of union was 5.9 years. The couple reported an average of 4.6 people in the household including an average of 2.1 children under 16. Literacy in the vernacular (Bemba or Nyanja) was good with 80% of men and 63% of women reporting reading easily. Most couples earned something with 99% of men and 71% of women reporting some income. Among men, 73% reported reading or understanding English easily compared with 55% of women.

A public tap was the most common source of water (33%) with outdoor tap piped into the yard (26%), a protected well (17%), and bore hole directly (15%) also common. Only 7% reported piped water in the home. Most could access water within a < 15 min walk (82%) or a 16 to 20-minute walk (9%). Two percent of respondents reported having high blood pressure and 36% knew of family members with high blood pressure. Only two respondents reported diabetes though 19% of respondents reported had affected family members.

In the presentation of data from Table 1, Table 2, Table 3 and Table 4 below, differences are significant unless specified and only significant differences of > 5% are mentioned in text.

Table 1: Knowledge and behaviors prior to and 1-2 weeks post GHP intervention. View Table 1

Table 2: Adoption and maintenance of behavior change two weeks and six months post GHP intervention. View Table 2

Table 3: Impact of the GHP intervention on sharing household duties. View Table 3

Table 4: Comparison of knowledge uptake in GHP group with the control group that received a different intervention to assess potential contribution of secular trend due to other programs. View Table 4

Knowledge and behaviors prior to and 1-2 weeks post GHP intervention (Table 1)

At baseline, 46% of respondents (49% of men and 43% of women) did not treat their drinking water, 31% boiled water, and 24% added chlorine. This increased to 96% using chlorine and 15% boiling two weeks post-intervention. Knowledge of how much chlorine to use for 5-liter and 20-liter containers rose from 29-35% to 96-98%. Most respondents knew that handwashing after using the toilet and before cooking and eating were important before the intervention. Handwashing after handling animals, dirty diapers, or rubbish were reported more often though respondents citing after sneezing or coughing into your hands or before and after caring for the sick remained suboptimal at 36-40%. The techniques used during handwashing demonstration also improved with knowledge of scrubbing back of hands, palms, between fingers, and under fingernails, all increasing to > = 70%. For length of time for hand washing (20 seconds), an increase was seen between baseline and post-intervention for self-report (23% to 66%) as well as observed (5% to 43%).

Reported ways to get intestinal worms at baseline included eating dirt/soil (46%), not properly washing raw vegetables and fruits (43%), and undercooked meat (22%), all of which increased to > = 84% after the intervention. Less frequently reported ways to get intestinal worms at baseline, such as not washing hands after touching soil, using the toilet, and before handling food increased from < = 14% to > = 40% post-intervention. Prior to the video, 62% of respondents thought that deworming should include everyone in the home, and 26% thought it involved only the children. This increased to 99% volunteering that everyone in the home should be dewormed.

The knowledge that most hypertensive and/or diabetic patients did not have symptoms increased from 63% to 82%. Knowledge also increased that hypertension could lead to heart attacks (14% to 41%), stroke (26% to 61%) and death (65% to 83%). Only 6% of respondents correctly cited what value is considered high blood pressure (> = 140/90 mmHg) before the intervention; this increased to 54% (61% of men and 48% of women).

Knowledge of lifestyle and dietary changes that people with hypertension should adopt improved for reducing salt intake (31% to 85%), taking prescribed medication (38% to 73%), and getting regular BP checks (28% to 66%). Interestingly, while knowledge of the importance of losing weight if overweight and exercising did improve, fewer than half of respondents mentioned those recommendations even after the intervention. Similar findings were noted with diabetes with reducing sugar intake (48% to 89%), taking prescribed medicine (32% to 71%), and getting sugar levels checked improving substantially (20% to 60%) but far less recall of diet and exercise recommendations.

Respondents did report behavior change after receiving GHP. Participants reporting adding none (or no salt) to their evening meal increased from 8% to 20% after the intervention visit. The percent increase in reporting no salt corresponded to a decrease in those reporting adding a ¼ tsp or more to their evening meal. Similarly, sugar added to a cup of tea of coffee shifted down with those reporting > = 3 tsp dropping from 42% to 26%.

Follow-up, retention and the comparison group (control)

Of the GHP 570 couples who completed baseline, the intervention and the two-week follow-up, 480 completed the 6-month follow-up. The control arm, interviewed at 6 months for comparison, included 489 couples.

Adoption and maintenance of behavior change two weeks and six months post GHP intervention

Table 2 presents strategies ordered by frequency mentioned two weeks post-intervention and compares analogous responses at 6 months. Implemented strategies mentioned at two weeks that were maintained at 6 months included chlorinating drinking water (97%), handwashing with soap (96%), deworming the family (81%) and reducing salt in cooking or using low sodium salt (76%). Some other behaviors adopted with lower frequency were also maintained, including avoiding areas with bilharzia (46%), avoiding salty foods (47% including 50% of men and 44% of women, not shown), and agreeing on food preparation together (35% including 39% of women and 31% of men, not shown).

Other reported health maintenance behaviors were less likely to be maintained over time including limiting sugary drinks, maintaining a healthy weight, avoiding stress, eating plenty of fruits and vegetables, exercising, avoiding tobacco products, limiting alcohol intake and drinking 2 liters of clean water/day.

Impact of the GHP intervention on sharing household duties (Table 3)

While men and women agreed that women usually collected water, the proportion reporting both partners collecting water increased from 15% before the intervention visit to 30% at 6 months, with men more likely to report sharing this duty (35% compared with 24% of women). Similarly, prior to the intervention visit, women assumed most of the responsibility for water chlorination in the 24% of households that used chlorine. After the intervention visit, sharing this responsibility increased to 47% in the 90% of households using chlorine, with the proportion of men reporting sharing 8-9% higher than their wives. Close to half (48%) of respondents at baseline reported sharing food purchasing duties, while a third reported the man took charge of this duty. Sharing food purchasing increased to 65% at two weeks and 79% at 6 months with similar reports from men and women. Food preparation was almost exclusively the woman's responsibility with a modest increase in shared responsibility (from 9% to 22% at two weeks) after the intervention visit. The proportion of couples sharing responsibility for taking care of sick persons in the household increased from 73% prior to the intervention visit to 95% at 6 months. Changing baby's nappy and doing dishes remained primarily a woman's job. Only 20% of households had animals, and handling animals was a shared duty before and after the intervention visit (not shown).

Comparison of knowledge uptake in GHP with the control group that received a different intervention to assess potential contribution of secular trend due to other programs (Table 4)

The control group that received an unrelated HIV intervention was interviewed at 6 months, contemporaneously with participants described in preceding tables, to assess the potential contribution of secular trend due to other water and sanitation, NTD and NCD programs. Knowledge of chlorine for water treatment (97% of GHP group vs. 35% of controls), and how to prepare potable water (96-97% vs. 37%-44%) were higher in the GHP group. When, how long, and the steps involved in hand washing including responses to questions and practical demonstrations were substantially better in the GHP group as was knowledge of how one could get worms and who in the house should be dewormed. The control group respondents reported adding more salt to food and sugar to tea/coffee. The control group was also less likely to know that hypertension and diabetes are usually asymptomatic and can result in heart attack or stroke. Lastly, knowledge of what blood pressure levels are considered high and actions to take if one has high blood pressure or diabetes were uniformly better in the GHP group.


Neglected tropical diseases (NTDs) and non-communicable diseases (NCDs) are prominent causes of morbidity and mortality in Zambia. This study confirms the urgent need for information and practical training in basic hygiene and sanitation, deworming and dietary and lifestyle changes to prevent respiratory and diarrheal disease, helminthic infection, hypertension and diabetes. Video-based group discussions with practical training in preparation of chlorinated potable water and proper hand washing, combined with provision of chlorine and hand soap, prompted substantial improvements in knowledge and reported behavior. Education about transmission, prevention and treatment of helminths, along with distribution of mebendazole or albendazole for household de-worming, reinforced the importance of chlorine and handwashing. Screening with free treatment for schistosomiasis further heightened awareness of this prevalent but often asymptomatic NTD. Misconceptions about the clinical symptoms, sequelae, and management of hypertension and diabetes were reduced, and participants reported adding less salt to their food and sugar to their tea/coffee. These benefits were sustained over time, and a contemporaneous comparison with a group who received an unrelated HIV intervention confirmed that other health promotion programs had not resulted in a secular trend that might confound the interpretation of our findings.

Urban sanitation in Zambia is a challenge due to high population density, unplanned growth, and limited resources for conventional sanitation [26]. In Lusaka and Ndola, pit-latrines combined with leaking sewerage discharge untreated human sewage directly into the aquifers which residents rely on for drinking water [27-31]. Cholera outbreaks occur when potable water is unavailable and basic hygiene is poor. In total, 34,950 cases of cholera were reported in Zambia between 2008 and 2017, and the country is considered endemic for cholera with crowded urban areas at highest risk [13,32,33]. Respiratory and diarrheal diseases, among the leading causes of death in Zambia, particularly in children, along with common parasitic infections of the gut [34], can be prevented with handwashing, water chlorination, and periodic household anti-helminthic treatment [35-43]. WHO and UNICEF Joint Monitoring Programme indicators for Water Supply, Sanitation and Hygiene Models using Demographic and Health Surveys and other studies have predicted safely managed drinking water also reduces stunting and diarrhea in children [44,45], thus averting negative health outcomes which may increase risk of NCD later in life [46-49].

Zambia has attempted to address these problems through community-led total sanitation (CLTS), which has emerged as the most widely implemented policy intervention for improving rural sanitation in low-income countries [50]. The Sanitation and Hygiene Applied Research for Equity Programme funded by the UK Department for International Development has also sponsored human resource strengthening in research capacity in Zambia [51]. In November 2011, CTLS was featured as part of the Zambia Sanitation and Hygiene Program (ZSHP) in order to increase the use of improved sanitation facilities and adopt positive hygiene practices [52]. In a pre- and post-assessment of national-scale CLTS programming in Zambia conducted from 2013 to 2016, the authors measured a 16% increase in access to improved sanitation facilities and modest increases in hand washing behavior and dedicated hand hygiene spaces [50]. Our GHP intervention focused on improving knowledge and skills combined with provision of chlorine, hand soap, and deworming medication. As several CLTS survey areas overlapped with our study area [52], we compared our GHP group with our comparison (control) group that received an HIV intervention to assess the role of secular trend in hygiene and sanitation knowledge and behaviors. Our findings confirm that knowledge and use of chlorine remained poor in our comparison group (35% use compared with 97% in the GHP group), as did knowledge of when and how to effectively hand wash and prepare food to reduce transmission and who in the household should be regularly dewormed. These findings reinforce the importance of ongoing and repeated education and commodity provision efforts.

We have recently shown that schistosomiasis is associated with HIV-1 transmission and death in Lusaka, possibly related to enhanced inflammatory responses caused by egg deposition in the lower genital tract [24,53]. A recent assessment based on literature review estimates nationwide prevalence of schistosome infection exceeding 30% with an adult prevalence of 54% [54]. While our program used urine dipstick to assess prevalence of microhematuria suggestive of Schistosoma haematobium, hepatosplenic schistosomiasis due to Schistosoma mansoni is also a neglected problem in Zambia. On questioning, 68% (75/110) of Zambian patients with portal hypertension (88% of whom were ELISA positive for schistosoma antibodies) knew nothing about schistosomiasis transmission [55]. Although this NTD is generally considered to be concentrated in rural areas or near bodies of water [56], our previous work has shown that 59% of Lusaka residents had positive ELISA titers [24]. Further work is needed to improve knowledge, prevention, screening and treatment for schistosomiasis.

While NTDs, hygiene, and sanitation have long been a focus of concern in Africa, hypertension and diabetes have recently been identified as emerging public health problems. Several studies in Zambia have shown a high prevalence of hypertension in both urban and rural areas [57,58]. In Lusaka, 1,928 individuals participated in the survey, of which 33% were males. 21% of males and 49% of females were overweight or obese. The prevalence for hypertension was 35% (38% of men and 33% of women). Risk factors have been similar to those identified in western countries: older age, male sex, high body mass index, increased alcohol consumption, sedentary lifestyle, higher education and smoking [59-61]. One study showed mean total weight of salt added to food was nearly double the WHO recommendation, with women adding significantly more salt to food than men [62]. As in other studies in Africa, lack of and limited knowledge is a barrier to effective prevention, diagnosis, and management of NCDs in the region [63-68]. Most individuals do not know that they have high BP and others do not take any medication [57]. In focus groups, participants cited westernized diets, lack of physical activity, stress, psychological factors and urbanization as causative factors for hypertension. Participants lacked understanding of BP medications, healthy lifestyles, adherence to treatment and ongoing monitoring [62]. Our study confirmed poor knowledge of the manifestations, sequelae, prevention and management of NCD and demonstrated sustained improvement in this knowledge after the intervention. Reported salt intake declined after the GHP intervention, with the proportion no longer adding salt rising from 8% to 20% and the proportion adding > = 1/2 tsp declining from 16% to 5%. We provided low sodium salt (half potassium and half sodium chloride) which is available in Zambian stores and should be more closely studied. Future efforts to improve hypertension control should focus on population preventive care and primary healthcare provider education on individual management [69].

Surveys including measures in blood sugar have found a 15% prevalence of diabetes mellitus in Ndola bank employees [70]. In a household survey in Lusaka adults, the prevalence for impaired glucose level or diabetes was 4% [71]. As in the west, risk factors included obesity, physical inactivity, older age and mild hypertension. The authors conclude that interventions targeting the younger 25-34 age group should be put in place now to curtail the development of diabetes. Our survey confirmed the need for more education: The knowledge that diabetics should reduce sugar intake was only 48% before the intervention visit, rising to 89% afterwards, with corresponding increases in respondents citing taking prescribed medication and getting sugar levels tested regularly. This knowledge translated into reported behaviors with the proportion of respondents adding > = 3 tsp to their cup of tea or coffee decreased from 42% before to 26% after receiving GHP.

In one qualitative study in Zambia, knowledge of cardiovascular disease risk factors was good but "risk factors were difficult to avoid due to ingrained taste preferences for high salt and sugar, increasingly busy lives that force them to use cooking oil to reduce preparation time, cultural preference for big body size or fatness, especially for women, stigmatized body image attached to HIV, stressful life or life events related to poverty, and financial barriers to affording quality foods and healthcare services" [72]. We make a similar observation in our study: While use of salt and sugar declined and knowledge of manifestations and management increased, a minority of participants cited increasing physical activity, maintaining a healthy weight or eating plenty of vegetables and fruit as important strategies. Government clinic nurses who received training in delivering our intervention underwent screening. A number were found to be hypertensive, which was not surprising as they were generally women aged 40-50 age, and many were overweight by international standards. Their views echoed those mentioned above and reinforce the need to include perceptions of health care providers to better inform NCD policy [73].

Other studies have highlighted male involvement in traditionally women-oriented household roles in the context of maternal and child health [74-78]. We have worked extensively with Zambian couples on HIV and unplanned pregnancy prevention, and collaboration between spouses is strongly associated with success in those domains [18,79,80]. We noted an increase in shared household responsibilities relating to collecting and treating water, food purchasing and preparation and taking care of sick persons. This highlights opportunities to engage men in traditionally women-oriented household roles for the betterment of their family's health. This not only can improve family health but also gender equity within the couple.


Our study was not without limitations. We acknowledge that a limitation was measuring the impact of knowledge uptake on disease outcomes. Given the increased burden of NTD and NCD in SSA, more studies linking biological markers with knowledge uptake are needed. Additionally, there were limitations in our methods of testing and treatment: our schistosomiasis screening did not include detection of S. mansoni as we used urine dipsticks; urine dipstick screening for glucose is less expensive but also less sensitive for diabetes screening than glucometers or HbA1c testing [81-83]; and though we provided albendazole and mebendazole for deworming we understand that this may not adequately treat other helminth infections such as Taenia and protozoa including cryptosporidium, giardia and amoeba [34].


This study shows the feasibility of delivering multiple health education topics without compromising areas. Our study highlights that a video-based intervention focusing on NCDs and NTDs can lead to substantial and sustained knowledge uptake in Zambian couples. As we utilized a simplified flipchart-only version of this tool integrated with CVCT, we would propose expansion of this with CVCT and family planning which is shown to be effective.


This work was supported by the National Institute of Mental Health [NIMH R01 66767]; National Institute of Child Health and Development [NICHD R01 HD40125]; the AIDS International Training and Research Program Fogarty International Center [D43 TW001042]; the Emory Center for AIDS Research [P30 AI050409]; National Institute of Allergy and Infectious Diseases; and the International AIDS Vaccine Initiative. This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents do not necessarily reflect the views of USAID or the United States Government. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

We would like to thank Zambia Ministry of Health; Center for Family Health Research in Zambia staff; staff at the government of Zambia clinics; and the couples who participated in the study.

Statement of Equal Authors' Contribution: Author Contributions

T.S. contributed to Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Validation; Visualization; Roles/Writing - original draft; Writing - review & editing. K.W. contributed to Formal analysis; Methodology; Writing - review & editing. Ra. P. contributed to Formal analysis; Methodology; Writing - review & editing. W.K contributed to Conceptualization; Supervision. M.I. contributed to Conceptualization; Supervision. A.T. contributed to Formal analysis; Methodology. K.M. contributed to Data curation; Supervision; Validation; Writing-review & editing. C.K. contributed to Writing - review & editing; N.A. contributed to Writing - review & editing; R.B. contributed to Writing - review & editing; Ro. P. contributed to Supervision; Writing - review & editing; S.A. contributed to Conceptualization; Funding acquisition; Writing - review & editing.

Trial Registration

Retrospectively registered on ClinicalTrials.gov #: NCT02744586.


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Sharkey T, Parker R, Wall KM, Malama K, Kilembe W, et al. (2022) Impact of a Group-Based Video and Interactive Group Session Addressing Diarrheal Disease, Helminthic and Schistosomiasis Infections, Hypertension and Diabetes on Short and Long-Term Improvement in Knowledge and Healthy Behaviors in Seroconcordant HIV-Negative Zambian Couples. Int J Trop Dis 5:060. doi.org/10.23937/2643-461X/1710060