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  1. 176
    Peer Reviewed

    A colonial legacy of HIV/AIDS, NTD, and STI super-syndemics: Eugenicist foreign aid and intertwined health burdens in Nigeria.

    Maju M; Sharma A; Beeram A; Ostrach B

    Global Public Health. 2019 Mar 4; 1-20.

    Syndemics theory has been applied to the structurally shaped, biologically facilitated co-occurrence of HIV/AIDS with Neglected Tropical Diseases (NTDs) and with sexually transmitted infections (STIs). The biological and social pathways of interaction between all three ailments have not yet been analysed together. The effects of these diseases are often exacerbated by structural factors including access to care and socioeconomic status. We explore the interrelated biological pathways and structural factors that have further heightened the risk for HIV/AIDS, NTDs, and STIs. Furthermore, we argue women in rural areas are at an increased risk for all three diseases due to biological and social factors including increased distance to quality care and lower reproductive autonomy. This paper integrates the established syndemics of HIV/NTDs and HIV/STIs within the historical and modern contexts of colonisation and neo-colonisation in Nigeria. We explore the effects of colonisation on women's health by evaluating the influence of foreign aid policies, structural programmes, and shifting gender norms. Applying a syndemic approach, juxtaposed by historical contextualisation, offers important implications for the prevention and treatment of HIV/AIDS, STIs, and NTDs. Our analysis suggests a perspective through which to view health of regions with a history of colonisation.
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  2. 177
    Peer Reviewed

    Syphilis and human immunodeficiency virus infections among pregnant women attending antenatal care clinic of Gondar family guidance association, Northwest Ethiopia: implication for prevention of mother to child transmission.

    Biadgo B; Hassen A; Getaneh M; Tesfa H; Jaleta KN; Eshetu T; Kasew D; Melku M

    Reproductive Health. 2019 Mar 4; 16(1):27.

    BACKGROUND: Sexually transmitted infections constitute a major public health problem worldwide. Syphilis and HIV infections cause various adverse pregnancy outcomes. Therefore, the aim of this study was to determine the seroprevalence of HIV and syphilis infections among pregnant women at Gondar Family Guidance Association clinic, northwest Ethiopia. METHODS: A retrospective study was conducted using sociodemographic and laboratory data obtained from registration books of Gondar Family Guidance Association clinic from January 2011 to April 2015. A binary logistic regression model was fit to identify factors associated with HIV and syphilis infections. Odds ratios with 95% confidence intervals were calculated to determine the strength of association between factors associated with HIV and syphilis infections. A p-value /=30 years (AOR: 6.08; 95% CI: 2.04-18.14) compared to age < 20 year, and HIV-infection (AOR: 14.6; 95% CI: 8.49-25.18) were significantly associated with syphilis infection. There was a decline in trend seroprevalence of HIV from 5.2% in 2011 to 2.1% in 2015; and decline in syphilis seroprevalence from 2.6% in 2011 to 1.6% in 2015 but not statistically significant. CONCLUSION: The data showed that syphilis and HIV infections are still critical public health concerns among pregnant women. Screening of all pregnant women for these infections is valuable. Further community-based studies to identify risk factors are necessary.
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  3. 178

    Adult female syphilis prevalence, congenital syphilis case incidence and adverse birth outcomes, Mongolia 2000-2016: Estimates using the Spectrum STI tool.

    Enkhbat E; Korenromp EL; Badrakh J; Zayasaikhan S; Baya P; Orgiokhuu E; Jadambaa N; Munkhbaatar S; Khishigjargal D; Khad N; Mahiane G; Ishikawa N; Jagdagsuren D; Taylor MM

    Infectious Disease Modelling. 2018; 3:13-22.

    Introduction: Mongolia's health ministry prioritizes control of Sexually Transmitted Infections, including syphilis screening and treatment in antenatal care (ANC). Methods: Adult syphilis prevalence trends were fitted using the Spectrum-STI estimation tool, using data from ANC surveys and routine screening over 1997-2016. Estimates were combined with programmatic data to estimate numbers of treated and untreated pregnant women with syphilis and associated incidence congenital syphilis (CS) and CS-attributable adverse birth outcomes (ABO), which we compared with CS case reports. Results: Syphilis prevalence in pregnant women was estimated at 1.7% in 2000 and 3.0% in 2016. We estimated 652 CS cases, of which 410 ABO, in 2016. Far larger, annually increasing numbers of CS cases and ABO were estimated to have been prevented: 1654 cases, of which 789 ABO in 2016-thanks to increasing coverages of ANC (99% in 2016), ANC-based screening (97% in 2016) and treatment of women diagnosed (81% in 2016). The 42 CS cases reported nationally over 2016 (liveborn infants only) represented 27% of liveborn infants with clinical CS, but only 7% of estimated CS cases among women found syphilis-infected in ANC, and 6% of all estimated CS cases including those born to women with undiagnosed syphilis. Discussion/Conclusion: Mongolia's ANC-based syphilis screening program is reducing CS, but maternal prevalence remains high. To eliminate CS (target: <50 cases per 100,000 live births), Mongolia should strengthen ANC services, limiting losses during referral for treatment, and under-diagnosis of CS including still-births and neonatal deaths, and expand syphilis screening and prevention programs.
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  4. 179
    Peer Reviewed

    Initiation and continuity of maternal healthcare: examining the role of vouchers and user-fee removal on maternal health service use in Kenya.

    Dennis ML; Benova L; Abuya T; Quartagno M; Bellows B; Campbell OMR

    Health Policy and Planning. 2019 Mar 6;

    This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health voucher programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the voucher programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the voucher programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women's timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum.
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  5. 180
    Peer Reviewed

    A grounded theory of regaining normalcy and reintegration of women with obstetric fistula in Kenya.

    Khisa AM; Nyamongo IK; Omoni GM; Spitzer RF

    Reproductive Health. 2019 Mar 8; 16(1):29.

    BACKGROUND: Obstetric fistula is a reproductive health problem causing immense suffering to 1% of women in Kenya that is formed as sequelae of prolonged obstructed labour. It is a chronic illness that disrupts women lives, causing stigma and isolation. Fistula illness often introduces a crisis in women's life begetting feelings of shame and serious disruption to their social, psychological, physical and economic lives, in addition to dealing with moral and hygiene challenges. Currently, women undergo free of charge surgery at vesicovaginal fistula (VVF) camps held in national referral hospitals and dedicated fistula centres generating a significant pool of women who have undergone surgery and are ready to regain normal lives. OBJECTIVE: The purpose of this study was to explore experiences of women immersing back into communities and their return to normalcy after surgery in three VVF repair centres in Kenya. We set out to answer the question: what strategies improve obstetric fistula patients' reintegration process? METHODS: We used grounded theory methodology to capture the reintegration and regaining normalcy experiences of women after surgery. Narrative interviews were held with 60 women during community follow-up visits in their homes after 6-19 months postoperatively. Grounded theory processes of theoretical sampling, repeated measurement; constant comparative coding in three stage open, axial and selective coding; memoing, reflexivity and positionality were applied. Emergent themes helped generate a grounded theory of reintegration and regaining normalcy for fistula patients. RESULTS: To regain normal healthy lives, women respond to fistula illness by seeking surgery.. After surgery, four possible outcomes of the reintegration process present; reintegration fully or partially back into their previous communities, not reintegrated or newly integrating away from previous social and family settings. The reintegration statuses point to the diversity outcomes of care for fistula patients and the necessity of tailoring treatment programs to cater for individual patient needs. CONCLUSION: The emerging substantive theory on the process of reintegration and regaining normalcy for fistula patients is presented. The study findings have implications for fistula care, training and policy regarding women's health, suggesting a model of care that encompasses physical, social, economic and psychological aspects of care after surgery and discharge.
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  6. 181
    Peer Reviewed

    Measuring vulnerability among female sex workers in India using a multidimensional framework.

    Mahapatra B; Bhattacharya R; Atmavilas Y; Saggurti N

    PloS One. 2018; 13(9):e0204055.

    Measuring vulnerability and identifying determinants of vulnerability are key to designing interventions for marginalized groups like sex workers. The current study introduces a new approach of measuring vulnerability among female sex workers (FSWs) by adopting a multidimensional poverty measurement framework. A multidimensional vulnerability index was created from four dimensions and 16 indicators using a dual cut-off approach. The study found that 55% of FSWs were multidimensionally vulnerable with 48% of intensity in vulnerability. The overall value of multidimensional vulnerability index was 0.265. FSWs in Maharashtra were most vulnerable (82%). Lack of financial security contributed mostly to FSWs' vulnerability. Further, compared to less vulnerable FSWs, multidimensionally vulnerable ones were more to engage in behaviors that put them at risk such as inconsistent use of condoms with clients, alcohol consumption, engaging in anal sex with clients and experiencing sexually transmitted infections. Findings suggest that structural, social and financial vulnerabilities of FSWs need to be addressed concurrently.
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  7. 182

    Availability of resources in Brazilian National Health System outpatient services for people living with HIV in Mato Grosso, Brazil, 2016. Disponibilidade de recursos dos servicos ambulatoriais do Sistema Unico de Saude

    Astolfo S; Kehrig RT; Oliveira LR

    Epidemiologia e Servicos de Saude. 2018 Oct 22; 27(3):e2017406.

    OBJECTIVE: to evaluate the availability of Brazilian National Health System (SUS) outpatient services for people living with HIV in Mato Grosso state, Brazil. METHODS: this is an evaluative study with descriptive cross-sectional design carried out in 2016; data were collected via the HIV Services Quality Assessment System in all 15 outpatient services; data were analyzed by frequency of answers. RESULTS: five of the 15 services had a sufficient number of physicians; antirretroviral drugs were out of stock for more than seven days in half of the services; other medications for sexually transmitted infections, opportunistic infections, Hepatitis B and C, and metabolic disorders were available in less than 1/3 of the services within the recommended timeframe. CONCLUSION: resources were found to be deficient in services for people living with HIV in Mato Grosso, mainly regarding the availability of professionals and drugs.
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  8. 183
    Peer Reviewed

    Prevalence of sexually transmitted infections (HIV, hepatitis B virus, herpes simplex virus type 2, and syphilis) in pregnant women in Ethiopia: Trends over 10 years (2005-2014).

    Kassa D; Gebremichael G; Tilahun T; Ayalkebet A; Abrha Y; Mesfin G; Belay Y; Demissie M; Gebrexiabher A; Assefa Y

    International Journal of Infectious Diseases. 2019 Feb; 79:50-57.

    OBJECTIVES: This study was performed to determine the trends in seroprevalence of four major sexually transmitted infections (STIs) (HIV, hepatitis B virus (HBV), herpes simplex virus type 2 (HSV-2), and syphilis) over a 10-year period (2005-2014) in pregnant women in Ethiopia. METHODS: Pregnant women (15-49 years old) who were enrolled in the antenatal care-based national HIV surveillance were included. Serological tests for HIV, HBV, HSV-2, and syphilis were done on serum/plasma samples. RESULTS: A total of 4887 pregnant women were included. Results showed a decline in prevalence of these STIs by 40-60% over the 10 years (2005-2014): HIV (10.5% to 5.5%), syphilis (2.5% to 1.1%), HBV (12.6% to 6.7%), and HSV-2 (47.5% to 28.5%). In 2014, 109/4887 (2.2%) women had triple infections. In 2005, 2007, and 2009, the prevalence of HSV-2 in the older age group (35-45 years) (47.1%, 47.4%, and 50.0%, respectively) was higher than that in the younger age group (15-24 years) (40.9%, 19.5%, and 20.2%, respectively). Age category (Chi-square=22.4, p<0.001), study sites/residence (Chi-square=135.2, p=0.001), and time/years (Chi-square=58.9, p=0.001) were associated with a positive HSV-2 test result. CONCLUSIONS: A decline in HIV, HBV, HSV-2, and syphilis of >40% was seen over the years in Ethiopia. However, an intermediate endemicity level of HBV and higher prevalence of HIV and HSV-2 by 2014, suggest the need to strengthen prevention strategy for STIs.
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  9. 184
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    Prevalence and associated factors of Chlamydia trachomatis and Neisseria gonorrhoeae among female commercial sex workers in Hawassa City, Southern Ethiopia.

    Tadele A; Hussen S; Shimelis T

    BMC Infectious Diseases. 2019 Jan 17; 19(1):61.

    BACKGROUND: Chlamydia trachomatis and Neisseria gonorrhoeae are the most common pathogens causing genital tract infections. Female commercial sex workers (FCSWs) are the key population to be affected by sexually transmitted infections (STIs). In Ethiopia, little is known about C. trachomatis and N. gonorrhoeae infections in most at risk population. Therefore, this study aimed to assess the prevalence of these bacterial STIs among FCSWs. METHODS: A cross-sectional study was conducted at the confidential clinic in Hawassa City, Southern Ethiopia from January to April, 2017. A total of 338 FCSWs were selected using systematic random sampling technique and enrolled in the study. Information about socio-demography and associated factors was collected using structured questionnaires. Endocervical swab samples were also collected from the study participants and tested for C. trachomatis using rapid immunochromatography assay. Samples were also cultured to isolate N. gonorrhoeae according to the standard bacteriological method. RESULTS: The prevalence of N. gonorrhoeae and C. trachomatis among FCSWs was 3.3% [95% confidence interval (CI): 1.5-5.3] and 6.8% (95% CI: 3.9-9.5), respectively. FCSWs who consistently practiced sex without condom in the last 6 months had 6.3 times (AOR 6.3; 95% CI 1.61-24.86, P = 0.008), and 4.0 times (AOR 4.0; 95% CI 1.06-15.31, p = 0.040) higher odds of acquiring N. gonorrhoeae and C. trachomatis infections, respectively. CONCLUSION: The observed rates of C. trachomatis and N. gonorrhoeae infections among FCSWs warrant the need to strengthen intervention efforts. In this regard, screening FCSWs for the specified infections and improving the practice of condom use would be important.
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  10. 185
    Peer Reviewed

    Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan.

    Anwar J; Torvaldsen S; Sheikh M; Taylor R

    BMC Public Health. 2018 Apr 2; 18(1):428.

    BACKGROUND: Reliable and timely data on maternal and neonatal mortality is required to implement health interventions, monitor progress, and evaluate health programs at national and sub-national levels. In most South Asian countries, including Pakistan, vital civil registration and health information systems are inadequate. The aim of this study is to determine accurate maternal and perinatal mortality through enhanced surveillance of births and deaths, compared with prior routinely collected data. METHODS: An enhanced surveillance system was established that measured maternal, perinatal and neonatal mortality rates through more complete enumeration of births and deaths in a rural district of Pakistan. Data were collected over a period of 1 year (2015/16) from augmentation of the existing health information system covering public healthcare facilities (n = 19), and the community through 273 existing Lady Health Workers; and with the addition of private healthcare facilities (n = 10), and 73 additional Community Health Workers to cover a total study population of 368,454 consisting of 51,690 eligible women aged 18 to 49 years with 7580 pregnancies and 7273 live births over 1 year. Maternal, neonatal, perinatal and stillbirth rates and ratios were calculated, with comparisons to routine reporting from the previous period (2014-15). RESULTS: Higher maternal mortality, perinatal mortality and neonatal mortality rates were observed through enhanced surveillance compared to mortality rates in the previous 1.5 years from the routine monitoring system from increased completeness and coverage. Maternal mortality was 247 compared to 180 per 100, 000 live births (p = 0.36), neonatal mortality 40 compared to 20 per 1, 000 live births (p < 0.001), and perinatal mortality 60 compared to 47 per 1000 live births (p < 0.001). All the mortality rates were higher than provincial and national estimates proffered by international agencies based on successive Pakistan Demographic and Health Surveys and projections. CONCLUSION: Extension of coverage and improvement in completeness through reconciliation of data from health information systems is possible and required to obtain accurate maternal, perinatal and neonatal mortality for assessment of health service interventions at a local level.
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  11. 186
    Peer Reviewed

    Piloting a participatory, community-based health information system for strengthening community-based health services: findings of a cluster-randomized controlled trial in the slums of Freetown, Sierra Leone.

    O'Connor EC; Hutain J; Christensen M; Kamara MS; Conteh A; Sarriot E; Samba TT; Perry HB

    Journal of Global Health. 2019 Jun; 9(1):010418.

    Background: Although community engagement has been promoted as a strategy for health systems strengthening, there is need for more evidence for effectiveness of this approach. We describe an operations research (OR) Study and assessment of one form of community engagement, the development and implementation of a participatory community-based health information system (PCBHIS), in slum communities in Freetown, Sierra Leone. Methods: A child survival project was implemented in 10 slum communities, which were then randomly allocated to intervention (PCBHIS) and comparison areas. In the 5 PCBHIS communities, the findings from monthly reports submitted by community health workers (CHWs) and verbal autopsy findings for deaths of children who died before reaching 5 years of age, were processed and shared at bimonthly meetings in each community. These meetings, called Community Health Data Review (CHDR) meetings, were attended by community leaders, including members of the Ward Development Committee (WDC) and Health Management Committee (HMC), by the CHW Peer Supervisors, and by representatives of the Peripheral Health Unit. Following a review of the information, attendees proposed actions to strengthen community-based health services in their community. These meetings were held over a period of 20 months from July 2015 to March 2017. At baseline and endline, knowledge, practice and coverage (KPC) surveys measured household health-related behaviors and care-seeking behaviors. The capacity of HMCs and WDCs to engage with the local health system was also measured at baseline and endline. Reports of CHW household contact and assessments of CHW quality were obtained in the endline KPC household survey, and household contacts measured in monthly submitted reports were also tabulated. Results: The self-assessment scores of WDCs' capacity to fulfil their roles improved more in the intervention than in the comparison area for all six components, but for only 1 of the 6 was the improvement statistically significant (monthly and quarterly meetings in which Peer Supervisor and/or CHW supervision was an agenda item). The scores for the HMCs improved less in the intervention area than in the comparison area for all six components, but none of these differences were statistically significant. Topics of discussion in CHDRs focused primarily on CHW functionality. All three indicators of CHW functioning (as measured by reports submitted from CHWs) improved more in the intervention area relative to the comparison area, with 2 out of 3 measures of improvement reaching statistical significance. Five of 7 household behaviors judged to be amenable to promotion by CHWs improved more in the intervention area than in the comparison area, and 2 out of the 5 were statistically significant (feeding colostrum and appropriate infant and young child feeding). Four of the 6 care-seeking behaviors judged to be amenable to promotion by CHWs improved more in the intervention area than in the comparison area, and 1 was statistically significant (treatment of diarrhea with ORS and zinc). None of the findings that favored the comparison area were statistically significant. Conclusions: This study was implemented in challenging circumstances. The OR Study intervention was delayed because of interruptions in finalizing the national CHW policy, two separate cholera epidemics, and the Ebola epidemic lasting more than 2 years. Weaknesses in the CHW intervention severely limited the extent to which the PCBHIS could be used to observe trends in mortality and morbidity. Nonetheless, the positive results achieved in the area of functionality of the CHW intervention and community structure capacity are encouraging. Results suggest there is value in further methodologically rigorous investigations into improving community-based health system functioning through a similar approach to community engagement.
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  12. 187
    Peer Reviewed

    Trends and Determinants of Antenatal Care Service Use in Ethiopia between 2000 and 2016.

    Mekonnen T; Dune T; Perz J; Ogbo FA

    International Journal of Environmental Research and Public Health. 2019 Mar 1; 16(5)

    : Antenatal care (ANC) services are an essential intervention for improving maternal and child health worldwide. In Ethiopia, however, ANC service use has been suboptimal, and examining the trends and factors associated with ANC service use is needed to inform targeted maternal health care interventions. This study aimed to investigate the trends and determinants of ANC service utilisation in Ethiopia for the period ranging from 2000 to 2016. This study draws on the Ethiopia Demographic and Health Survey data for the years 2000 (n = 7928), 2005 (n = 7276), 2011 (n = 7881) and 2016 (n = 7558) to estimate the trends in ANC service utilisation. Multivariate logistic regression models with adjustment for clustering and sampling weights were used to investigate the association between the study factors and ANC service utilisation. Over the sixteen-year period, the proportion of Ethiopian women who received the recommended four or more ANC visits increased from 10.0% (95% confidence interval (95% CI: 8.7(-)12.5%) in 2000 to 32.0% (95% CI: 29.4(-)34.3%) in 2016. Similarly, the proportion of women who received one to three ANC visits increased from 27.0% (95% CI: 23.6(-)30.7%) in 2000 to 62.0% in 2016 (95% CI: 60.4(-)67.3%). Multivariate analyses showed that higher maternal and paternal education, higher household wealth status, urban residency and previous use of a contraceptive were associated with ANC service use (1(-)3 and 4+ ANC visits). The study suggests that while Ethiopian pregnant women's engagement with ANC services improved during the millennium development goal era (2000(-)2015), recommended ANC use remains suboptimal. Improving the utilisation of ANC services among pregnant women is essential in Ethiopia, and efforts should focus on vulnerable women.
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  13. 188
    Peer Reviewed

    Contextual Variation in Early Adolescent Childbearing: A Multilevel Study From 33,822 Communities in 44 Low- and Middle-Income Countries.

    Gausman J; Langer A; Austin SB; Subramanian SV

    Journal of Adolescent Health. 2019 Mar 1;

    PURPOSE: Existing literature calls for a deeper examination into how local context influences adolescent sexual and reproductive health outcomes. We seek to describe individual and contextual variation in early adolescent childbearing (younger than 16 years) in 44 low- and middle-income countries by (1) examining the role of individual-level social disadvantage, (2) exploring the ecological influence of context at the country and community level, and (3) assessing whether ecological effects vary according to a woman's wealth. METHODS: We used nationally representative data from 33,822 communities in 44 low- and middle-income countries. We employed multilevel modeling to examine the variation in early adolescent childbearing apportioned to the individual, community, and country levels. RESULTS: Globally, poverty and low educational attainment are associated with early adolescent childbearing. After accounting for individual-level characteristics, significant residual variance remains at both the community and country levels. Routine, individual-level covariates explain 46.4% of the total variance at the community level and 21.3% of the total variance at the country level in relation to the baseline, age-adjusted model. The variance apportioned to the community level is estimated to equal 43.5% (95% confidence interval: .40, .49) of the total variance among the poorest women compared with 32.6% (95% confidence interval: .25, .39) among the richest women. Across countries, we find substantial heterogeneity in the variance observed at the community level. CONCLUSIONS: Our results point to the need for a continued focus on multilevel interventions that include approaches to target both the individual and population levels. More research is needed to identify the mechanisms through which local context influences adolescent sexual and reproductive health outcomes.
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  14. 189
    Peer Reviewed

    Birth outcomes of second children after community-based home visiting: A research protocol.

    Holland ML; Condon EM; Younts CW; Sadler LS

    Research in Nursing and Health. 2019 Mar 5;

    Birth-related outcomes, such as birth weight, have lifelong impacts on health. Home visiting (HV) is an established approach to improve the health of children and families, parenting practices, and connections to social and health services. Many HV programs target first-time mothers, in part because HV activities related to a first-birth may improve birth outcomes for subsequent children, but few researchers have examined these effects. We will link data from a statewide HV program (Nurturing Families Network [NFN]) to birth certificate data to create comparison groups and measure outcomes in this observational study. Specifically, we will compare birth outcomes for NFN second-children (n = 3000) to those for: (a) first-child older siblings whose birth/gestation led to NFN enrollment (n = 3000); (b) second children of families who were screened as eligible for NFN, but not offered the program due to home visitor availability and other logistical reasons (n = 650); and (c) non-NFN second children in a propensity-score-matched group created using the likelihood of enrollment in NFN based on maternal health, demographics, and neighborhood characteristics (n = 6000). The outcomes we will examine are birth spacing, prenatal care received, cesarean section rate, gestational age, and birth weight in second-children. We will also examine the associations between program attendance (i.e., missed visits, dropout) and birth outcomes, that will generate evidence that may be used in programmatic decisions regarding continued funding and/or modification of NFN, prioritization of specific retention efforts, and targeting of first-time mothers. Use of this evidence should improve outcomes for future NFN families and may inform similar programs.
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  15. 190
    Peer Reviewed

    Is Repeat Abortion a Public Health Problem among Chinese Adolescents? A Cross-Sectional Survey in 30 Provinces.

    Liu J; Wu S; Xu J; Temmerman M; Zhang WH

    International Journal of Environmental Research and Public Health. 2019 Mar 5; 16(5)

    The Chinese Family Planning (FP) programme mainly focuses on married couples, and young unmarried women have limited access. This cross-sectional study aims to identify risk factors related to repeat abortions in Chinese adolescents receiving abortions. Data were collected using a questionnaire for all women seeking abortions within 12 weeks of pregnancy during a period of 2 months in 297 participating hospitals randomly selected across 30 provinces of China in 2013. Only the adolescents (younger than the minimum legal married age of 20 years) were included in this study. Of the 2370 adolescents who were receiving abortions, 927 (39%) were undergoing repeat abortions. The primary reason for the current unintended pregnancies was non-use of contraception (68%). Adolescents receiving abortions who had an increased risk of repeat abortions were those who had children (OR 2.57, 95% CI 1.80(-)3.67), those who resided in a middle-developed region (OR 1.81, 95% CI 1.30(-)2.50), those who resided in a relatively poor region (OR 2.40, 95% CI 1.78(-)3.23), and those who had used contraception during the 6 months preceding the survey (OR 1.38, 95% CI 1.12(-)1.71 for condom use). The occupation as a student was a protective factor for adolescents (OR 0.64, 95% CI 0.50(-)0.83). Adolescents should be offered equal access to FP to that of married women in China to reduce unintended pregnancies and repeat abortions. Correct and consistent contraception practice should be promoted.
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  16. 191

    [Analysis of oral sexual behavior and related factors among male students from college graduation in Hangzhou].

    Chen WY; Pan XH; Guo ZH; Zhou X; Wang H; Ma QQ

    Zhonghua Yu Fang Yi Xue Za Zhi [Chinese Journal of Preventive Medicine]. 2019 Mar 6; 53(3):289-292.

    Objective: To study oral sexual behavior and related factors among male students. Methods: The male students from college graduation in Hangzhou were selected as the study objects, and the inclusion criteria were having had sex and informed the type of behavior. A total of 490 subjects were finally included. Results: Among 490 male students, the 20-22 years old, 23 years old and 24-27 years old age groups accounted for 38.8% (n=190), 37.8% (n=185) and 23.3% (n=114), respectively. A total of 99 (20.2%) cases had oral sexual behavior, of which only 14 (2.9%) cases used condom. After adjusting for unplanned pregnancy, stage of sexual behavior, sexually transmitted diseases infection possibility, sexual orientation factors, normal/unnormal family relationship, more than 2 sexual partners, casual sexual partners, sexual partners from other college, sexual partners from society, sexual behavior in past 1 year were positively associated with oral sexual behavior. The corresponding OR (95%CI) values were 2.77 (1.40-5.50), 2.29 (1.27-4.15), 2.68 (1.23-5.88), 2.45 (1.34-4.48), 2.47 (1.15-5.33) and 2.04 (1.05-3.96), respectively. Use of condoms was negatively associated with oral sexual behavior, the OR (95%CI) value was 0.20 (0.09-0.42). Conclusion: Normal/unnormal family relationship, more than two sexual partners, casual sexual partners, sexual partners from other college, sexual partners from society, sexual behavior in last one year and condom use in each vaginal sexual behavior were associated with oral sexual behavior.
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  17. 192
    Peer Reviewed

    Factors Associated with Sexual Debut in Mexican Adolescents: Results of the National Survey on Drug Use among Students in 2014.

    Barragan V; Berenzon S; Tiburcio M; Bustos M; Villatoro J

    Journal of Sexual Medicine. 2019 Mar; 16(3):418-426.

    INTRODUCTION: Although first sexual experience (understood as first sexual intercourse) is one of the most commonly assessed characteristics of adolescents, recent research emphasizes the importance of understanding other related social factors. This study highlights factors associated with first sexual experience in a nationally representative sample of adolescent students in Mexico. AIMS: The goals of this study were (i) to determine the proportion of adolescents aged 12-17 who had had their first sexual experience; (ii) to identify the factors associated with first sexual experience; and (iii) to analyze the conditions (condom use, substance use) in which first sexual experience takes place. METHOD: The data presented in this study are drawn from the 2014 National Survey on Drug Use in Students (Spanish acronym ENCODE), undertaken with the purpose of identifying the prevalence of drug use and associated variables, including sexual activity, in Mexican students. Kaplan-Meier analysis was used to estimate the probability of first sexual experience at a given age, taking sex as an outcome variable and age as a follow-up period. Logistic regression was used to assess possible factors for sexual initiation. MAIN OUTCOME MEASURES: Validated standard questionnaires were used to assess sociodemographic characteristics, first sexual experience (framed as first sexual intercourse), frequency of sexual relations, sexual partners, sexual preference (framed as preferred sex of partners), substance use, having a physical illness or a behavioral problem, condom or other contraceptive use, as well as the absence or presence of parents, parents' educational attainment, and parents' substance use. RESULTS: A total of 26,187 students aged 12-17 participated. Of this total, 14.8% had already had their first sexual experience, at a median age of 15; 64.5% used some type of contraceptive, and 53.2% used condoms. Proportional probabilities for having first sexual experience using age as a follow-up period showed that the probability of having sex earlier was higher among boys than girls: the probability of having sex at age of 15 was 26.5% for boys and 13.9% for girls. Predictors of first sexual experience included substance use (alcohol OR = 2.5, tobacco OR = 2.6, and other drugs OR = 2.3), having a mother who used drugs (OR= 2.2), sexual preference (female homosexual, OR = 2.2), and sex (male, OR = 2.1). CONCLUSIONS: Boys are more likely to have had a first sexual experience than girls. Future strategies should incorporate specifically targeted elements with different messages that consider adolescents' sex and age. Barragan V, Berenzon S, Tiburcio M, et al. Factors Associated with Sexual Debut in Mexican Adolescents: Results of the National Survey on Drug Use among Students in 2014. J Sex Med 2019;16:418-426.
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  18. 193
    Peer Reviewed

    Social value of a nutritional counselling and support program for breastfeeding in urban poor settings, Nairobi.

    Goudet S; Griffiths PL; Wainaina CW; Macharia TN; Wekesah FM; Wanjohi M; Muriuki P; Kimani-Murage E

    BMC Public Health. 2018 Apr 2; 18(1):424.

    BACKGROUND: In Kenya, poor maternal nutrition, suboptimal infant and young child feeding practices and high levels of malnutrition have been shown among the urban poor. An intervention aimed at promoting optimal maternal infant and young child nutrition (MIYCN) practices in urban poor settings in Nairobi, Kenya was implemented. The intervention involved home-based counselling of pregnant and breastfeeding women and mothers of young children by community health volunteers (CHVs) on optimal MIYCN practices. This study assesses the social impact of the intervention using a Social Return on Investment (SROI) approach. METHODS: Data collection was based on SROI methods and used a mixed methods approach (focus group discussions, key informant interviews, in-depth interviews, quantitative stakeholder surveys, and revealed preference approach for outcomes using value games). RESULTS: The SROI analysis revealed that the MIYCN intervention was assessed to be highly effective and created social value, particularly for mothers and their children. Positive changes that participants experienced included mothers being more confident in child care and children and mothers being healthier. Overall, the intervention had a negative social impact on daycare centers and on health care providers, by putting too much pressure on them to provide care without providing extra support. The study calculated that, after accounting for discounting factors, the input ($USD 419,716) generated $USD 8 million of social value at the end of the project. The net present value created by the project was estimated at $USD 29.5 million. $USD 1 invested in the project was estimated to bring USD$ 71 (sensitivity analysis: USD$ 34-136) of social value for the stakeholders. CONCLUSION: The MIYCN intervention showed an important social impact in which mothers and children benefited the most. The intervention resulted in better perceived health of mothers and children and increased confidence of mothers to provide care for their children, while it resulted in negative impacts for day care center owners and health care providers.
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  19. 194
    Peer Reviewed

    Delivering child health interventions through the private sector in low and middle income countries: challenges, opportunities, and potential next steps.

    Awor P; Peterson S; Gautham M

    BMJ. 2018 Jul 30; 362:k2950.

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  20. 195
    Peer Reviewed

    Underlying determinants of maternal mortality in a rural South African population with high HIV prevalence (2000-2014): A population-based cohort analysis.

    Tlou B

    PloS One. 2018; 13(9):e0203830.

    INTRODUCTION: Maternal mortality is one of the significant health indicators of any country and it's a frequent subject in many global heath discussions. Even though the global trends have shown a decrease on maternal mortality, many countries in sub-Saharan Africa failed to achieve the MDG 5 target in 2015.There is no specific single solution for reducing maternal mortality but there is unanimity that a reliable health system with skilled personal is vital for addressing maternal mortality. This study therefore seeks to identify the risk factors for maternal mortality in typical rural sub-Saharan African countries. METHOD: A longitudinal population based cohort study was conducted using data from 2000-2014 in Africa Health Research Institute (AHRI).The Cox regression method was used to assess the influence of selected risk factors using the Mosley-Chen model on maternal mortality. A total of 20701 women aged 15-49 years were included in the study. RESULTS: The study found 212 maternal deaths from 32,620 live births with a maternal mortality ratio (MMR) of 650 per 100,000 live births. The main causes of death were Communicable diseases (38.2%), Aids and TB (31%) and Unknown causes (11.8%). An increased risk of death was identified on, poor wealth index (HR 3.92[1.01, 15.3]), period of death 2000-2006(HR32.1 [3.79, 71.5]) and number of deliveries (6.76[2.70, 16.9]) were associated with a high risk of maternal mortality after adjusting for other independent variables included in the study. CONCLUSION: Socio-economic status, number of deliveries and period of death were found to be associated with maternal death in rural South Africa.
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  21. 196
    Peer Reviewed

    I should have started earlier, but I was not feeling ill! Perceptions of Kalenjin women on antenatal care and its implications on initial access and differentials in patterns of antenatal care utilization in rural Uasin Gishu County Kenya.

    Riang'a RM; Nangulu AK; Broerse JEW

    PloS One. 2018; 13(10):e0202895.

    AIM: The aim of this study was to explore how Kalenjin women in rural Uasing Gishu County in Kenya perceive antenatal care and how their perceptions impede or motivate earlier access and continuous use of antenatal care services. METHODS: A study was conducted among 188 pregnant and post-natal mothers seeking care in 23 rural public health facilities. Gestational age at the initial antenatal care booking was established from their medical cards. Further researcher-administered questionnaire with closed and open-ended questions was used. Key informant interviews with traditional birth attendants (n = 6) and maternal and child health nursing officers (n = 6) were also conducted for triangulation. Descriptive statistics were applied using SPSS programme. The interviews of women who gave consent to be audio recorded (n = 52) were transcribed and thematically analysed using MAXQDA program, based on Andersen and Newman's (1973) behavioural model of health services utilization. RESULTS: The mean gestational age at booking initial biomedical care was 23.36 weeks. Only 18 patients (10%) booked before 13 weeks and 45% made four or more visits. The main reasons given for early booking were: illness in index pregnancy (42%) checking the foetus position and monitoring foetus progress (7%). The main reasons given for late booking were: no reason (31%), was not feeling sick (16%), fear or shame due to unexpected pregnancy (13%). Almost half of the respondents (44%) used both biomedical and traditional antenatal care services. Main reasons for visiting traditional care were to: check foetus position and reposition it (63%), collect medicinal herbs (31%), relief discomforts through massage (18%). CONCLUSION: Early antenatal care booking is meant for women with unpleasant physical signs and symptoms. Later ANC is meant to check foetus position and reposition it to cephalic presentation and monitor its progress and this is only possible if the foetus is large.
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  22. 197
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    Community Women and Reproductive Autonomy: Building an Infrastructure for Long-Acting Reversible Contraception (LARC) Services in a Mobile Health Clinic.

    Nall M; O'Connor S; Hopper T; Peterson H; Mahajan B

    Journal of Health Care for the Poor and Underserved. 2019; 30(1):47-58.

    This article describes implementation of a long-acting reversible contraception (LARC) program in a free primary care clinic in central Florida. A background of LARC is presented, along with a description of the infrastructure built by the University of Florida Mobile Outreach Clinic, in an effort to share a framework for the provision of LARC services with other resource-limited settings.
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  23. 198

    Provider perspectives on barriers to reproductive health services for HIV-infected clients in Central Malawi.

    Caplan MR; Phiri K; Parent J; Phoya A; Schooley A; Hoffman RM

    Clinical Obstetrics, Gynecology and Reproductive Medicine. 2018 Feb; 4(1)

    Despite widespread availability of Depo-Provera in HIV clinics in Malawi, coverage of family planning (FP) remains low. We sought to understand provider perspectives about the challenges of providing reproductive health services to HIV-infected clients in antiretroviral therapy (ART) clinics in Central Malawi by conducting surveys and semi structured in-depth interviews with 31 ART providers across 16 clinical sites. Additionally, site surveys were performed to assess contraceptive resources. Major barriers to the provision of FP in ART clinics were inadequate staff in the facility, shortage of trained providers, limited time to counsel on FP, and lack of private space for the provision of FP services. These barriers limit the direct delivery of FP in ART clinics. Strategies to integrate FP with HIV/ART services and task shifting FP service provision to non-ART providers should be explored in Malawi as a means to improve coverage of services to HIV-infected clients.
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  24. 199
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    Family planning training needs of auxiliary nurse midwives in Jharkhand, India: Lessons from an assessment.

    Karvande S; Sonawane D; Samal J; Mistry N

    National Medical Journal of India. 2018 Mar-Apr; 31(2):73-78.

    Background.: Auxiliary nurse midwives (ANMs), who play a pivotal role in the provision of maternal health services including family planning services, must be adequately trained and skilled. Systematic assessment of their training needs helps in determining this adequacy. We did a systematic assessment of the training needs of ANMs in Jharkhand. Methods.: We designed a multi-stakeholder study including (i) meeting with government officials and international development partners (n=1 5); (ii) structured observation of health facilities (n=1 7); (iii) review of health management information system data; (iv) interviews with ANMs (n=19); and (v) interviews with contraceptive users (n=31). The data were thematically analysed based on gaps in technical knowledge, skills and practices; communication and counselling; infrastructural gaps; uptake of contraceptives and emerging training needs and approaches. Results.: The ANMs lacked knowledge, e.g. in natural contraceptive methods and skills, e.g. counselling and recordkeeping. Gaps in infrastructure further hampered the provision of uninterrupted service. The belief system of the community about contraception was perceived as a barrier. The lacunae in their knowledge and skills could be attributed to systemic issues such as quality of pre-service education, absence or poor implementation of in-service trainings or individual issues such as incompetence or apathy towards the provision of service. Government training to ANMs in family planning was inadequate. Conclusion.: Our study found inadequacy in the training of ANMs in family planning. We suggest the need for systemic efforts with the life cycle approach to family planning, a mix of theory and practical training, appropriate duration of training, careful selection of trainers, a confidence-building approach and supportive environment to raise competencies of ANMs to help them manage their health facilities.
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  25. 200
    Peer Reviewed

    Contraceptive Methods and the Impact of Menstruation on Daily Functioning in Women with Sickle Cell Disease.

    Day ME; Stimpson SJ; Rodeghier M; Ghafuri D; Callaghan M; Zaidi AU; Hannan B; Kassim A; James AH; DeBaun MR; Sharma D

    Southern Medical Journal. 2019 Mar; 112(3):174-179.

    OBJECTIVES: Women with sickle cell disease (SCD) are living longer as a result of advances in the care of their underlying disease. With the population growing of women living with SCD, reproductive health issues in this population have become an emphasized area of medical care. We sought to describe current patterns of contraception use, menstruation, and quality-of-life (QOL) measures in women with SCD. METHODS: Using a cross-sectional study design, we administered paper surveys at two academic medical centers to women aged 10 to 55 years with SCD to capture current contraceptive use, characteristics of menstrual cycles, and QOL metrics. RESULTS: Of the 103 women who participated, 12.7% (13/102) experienced a duration of menses >7 days (defined here as prolonged menstrual bleeding). Approximately half of women (51.5%, 53/103) used some form of contraception, with depot medroxyprogesterone acetate injections and condoms being the most common. During their last menstrual periods, women with both dysmenorrhea and prolonged menstrual bleeding (6.9%, 7/102) were more likely to experience more days of poor QOL, with more nights with sleep disturbance (P = 0.001) and more days with trouble taking care of themselves (P = 0.003), as well as being unable to do things they previously enjoyed (P = 0.001), compared with those with neither phenomenon (28.2%, 29/103). CONCLUSIONS: Dysmenorrhea and prolonged menstrual bleeding negatively affect the QOL of women with SCD. Menstrual histories and preventive measures for menstruation-related morbidity should be incorporated into routine evaluations of women with SCD.
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