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Understanding key drivers of performance in the provision of maternal health services in eastern cape, South Africa: a systems analysis using group model building.
BMC Health Services Research. 2018 Nov 29; 18(1):912.BACKGROUND: The Eastern Cape Province reports among the poorest health service indicators in South Africa with some of its districts standing out as worst performing as regards maternal health indicators. To understand key drivers and outcomes of this underperformance and to explore whether a participatory analysis could deepen action-oriented understanding among stakeholders, a study was conducted in one of the chronically poorly performing districts. METHODS: The study used a systems analysis approach to understand the drivers and outcomes affecting maternal health in the district in order to identify key leverage points for addressing the situation. The approach included semi-structured interviews with a total of 24 individuals consisting health system managers at various levels, health facility staff and patients. This was followed by a participatory group model building exercise with 23 key stakeholders to analyze system factors and their interrelationships affecting maternal health in the district using rich pictures and interrelationship diagraphs (IRDs) and finally the development of causal loop diagrams (CLDs). RESULTS: The stakeholders were able to unpack the complex ways in which factors were interrelated in contributing to poor maternal health performance and identified the feedback loops which resulted in the situation being intractable, suggesting strategies for sustainable improvement. Quality of leadership was shown to have a pervasive influence on overall system performance by linking to numerous factors and feedback loops, including staff motivation and capacity building. Staff motivation was linked to quality of care in turn influencing patient attendance and feeding back into staff motivation through its impact on workload. Without attention to workload, patient waiting times and satisfaction, the impact of improved leadership and staff support on staff competence and attitudes would be diminished. CONCLUSION: Understanding the complex interrelationships of factors in the health system is key to identifying workable solutions especially in the context of chronic health systems challenges. Systems modelling using group model building methods can be an efficient means of supporting stakeholders to recognize valuable resources within the context of a dysfunctional system to strengthen systems performance.
SAGE Open Medicine. 2018; 6:2050312118809462.Objectives: Decision aids in the field of healthcare contribute to informed decision making. To increase the usefulness and effectiveness of decision aids, it is important to involve end-users in the development of these tools. This article reports on the development of an online contraceptive decision aid. Methods: An exploratory, qualitative study was conducted in the Netherlands between 2014 and 2016. The development process of the decision aid consisted of six steps and included a needs assessment and field test. Interviews were conducted with 17 female students. Results: The needs assessment provided information on the preferred content and structure of a contraceptive decision aid and guided the development of the online contraceptive decision aid prototype. Participants had an overall positive impression of the decision aid prototype during the field test. Minor revisions were made based on participants' feedback. Participants expected that the decision aid would positively contribute to decision making by increasing knowledge and awareness regarding the available contraceptive methods and their features and attributes, and by opening up to other options than the known methods. Conclusion: The developed contraceptive decision aid can contribute to better informed decision making and consultation preparation. Involving end-users in development seems valuable to adapt decision aids to specific needs and to identify in what way a decision aid influences decision making.
Engaging stakeholders: lessons from the use of participatory tools for improving maternal and child care health services.
Health Research Policy and Systems. 2017 Dec 28; 15(Suppl 2):106.BACKGROUND: Effective stakeholder engagement in research and implementation is important for improving the development and implementation of policies and programmes. A varied number of tools have been employed for stakeholder engagement. In this paper, we discuss two participatory methods for engaging with stakeholders - participatory social network analysis (PSNA) and participatory impact pathways analysis (PIPA). Based on our experience, we derive lessons about when and how to apply these tools. METHODS: This paper was informed by a review of project reports and documents in addition to reflection meetings with the researchers who applied the tools. These reports were synthesised and used to make thick descriptions of the applications of the methods while highlighting key lessons. RESULTS: PSNA and PIPA both allowed a deep understanding of how the system actors are interconnected and how they influence maternal health and maternal healthcare services. The findings from the PSNA provided guidance on how stakeholders of a health system are interconnected and how they can stimulate more positive interaction between the stakeholders by exposing existing gaps. The PIPA meeting enabled the participants to envision how they could expand their networks and resources by mentally thinking about the contributions that they could make to the project. The processes that were considered critical for successful application of the tools and achievement of outcomes included training of facilitators, language used during the facilitation, the number of times the tool is applied, length of the tools, pretesting of the tools, and use of quantitative and qualitative methods. CONCLUSIONS: Whereas both tools allowed the identification of stakeholders and provided a deeper understanding of the type of networks and dynamics within the network, PIPA had a higher potential for promoting collaboration between stakeholders, likely due to allowing interaction between them. Additionally, it was implemented within a participatory action research project. PIPA also allowed participatory evaluation of the project from the perspective of the community. This paper provides lessons about the use of these participatory tools.
Engaging young people for health and sustainable development. Strategic opportunities for the World Health Organization and partners.
Geneva, Switzerland, WHO, 2018. 72 p. (WHO/CDS/TB/2018.22)This report builds on WHO’s long-standing work on young people’s health and rights, including the Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030), the Global Accelerated Action for the Health of Adolescents (AA-HA!) guidance, and contribution to the new UN Youth Strategy. It was developed as part of the roadmap towards the development of a WHO strategy for engaging young people and young professionals. The world today has the largest generation of young people in history with 1.8 billion between the ages of 10 and 24 years. Many of them already are driving transformative change, and many more are poised to do so, but lack the opportunity and means. This cohort represents a powerhouse of human potential that could transform health and sustainable development. A priority is to ensure that no young person is left behind and all can realize their right to health equitably and without discrimination or hindrance. This force for change represents an unparalleled opportunity for the WHO and partners to transform the way they engage with young people, including to achieve the 2030 Agenda for Sustainable Development. This report describes strategic opportunities to meaningfully engage young people in transforming health and sustainable development. This will mean providing opportunities for young people’s leadership and for their engagement with national, regional and global programmes.
Measuring venue-based risk: A programmatic mapping study of key populations in Khomas Region, Namibia.
Chapel Hill, North Carolina, University of North Carolina, MEASURE Evaluation, 2018 Mar. 65 p. (USAID Cooperative Agreement AID-OAA-L-14-00004)Namibia has a generalized HIV epidemic, but certain populations experience a greater disease burden and risk for infection based on their behaviour. Most notably, female sex workers (FSWs), transgender (TG) women, and men who have sex with men (MSM) have higher prevalence rates compared to the general population. Previous studies have examined these populations through their social networks, but this study used a time-location sampling method to (1) identify places where key populations (KP) socialize and can be reached with outreach services and (2) calculate the size of the populations for FSWs, MSM, and TG women in Windhoek, Namibia. The study was designed to provide results to inform KP programming, both in reach and type. It aligns with the goal of the United States Agency for International Development (USAID) to control the HIV epidemic; the goal of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) to “do the right things in the right places at the right times”; and the global 90-90-90 targets, established by the Joint United Nations Programme on HIV/AIDS.
Gender determined roles and under-five mortality among agro-pastoralist communities in Handeni District, Tanzania.
Journal of Population and Social Studies. 2018 Jul; 26(3):195-206.This paper explored gender determined roles and their impact to under-five mortality in the study area. A cross-sectional research design was used to collect data from 160 agro-pastoralist households using a simple random sampling technique. Data were collected in August, 2016 in Handeni District, Tanzania mainly through a questionnaire-based survey. Descriptive statistics showed households prevalence of under-five mortality 12 months prior to the survey for Kibaya, Msomera, Malezi and Kilimilang’ombe villages to be 24.6%, 24.6%, 31.6% and 19.2%, respectively. Binary logistic regression analysis showed that timely household decision, control of household income and equal involvement of household members in the subsistence farming had significant influence on reduction of household under-five mortality. The influence was at ß = -0.071, p = 0.000, odd ratio = 0.931, ß = -1.828, p = 0.032, odd ratio = 0.674 and ß = -1.013, p = 0.022, odd ration = 0.362 respectively. The study findings indicate that women involvement in household decision making and use of household income contribute to the reduction of under-five mortality. It is also the same when subsistence farming is considered as a role for all household members rather than considering it as a women’s role alone. Government, non-governmental organisations and other stakeholders should create awareness campaigns in form of seminars and workshops on gender equality in agro-pastoralist communities. This paper recommends further studies to explore roles of culture on household power dynamics and their implication to under-five mortality.
Naval Medicine's Involvement in Global Health: The Participation of Women's Healthcare Providers in Continuing Promise 2017.
Military Medicine. 2018 Aug 28;Introduction: This is a retrospective review of information collected during operation Continuing Promise 2017 from the Wayuu population in Colombia, South America. Materials and Methods: Team objective was to present an overview of women's health care needs in an isolated underserved population of Colombia by a humanitarian mission of health care providers from the U.S. Navy. We analyzed demographics, contraceptive selection, presenting complaint, diagnosis, and disposition of those female patients presenting for care. Results: The acute care clinics of this mission saw patients for 10 full clinic days in each of the countries of Guatemala, Honduras, and Colombia. In the Wayuu clinic of Colombia, 356 patients were seen in the acute care women's clinic. These women averaged 36 years of age with an age range of 9-77 years of age and a gravidity of 3 +/- 3.3 and a range of 0-18. Of the women less than the age of 50, not permanently sterilized, 186/220 (84.5%) were not using any form of contraception. The most common chief complaints were vaginal discharge and pelvic pain and the most common final diagnosis was bacterial vaginosis. The two most common secondary diagnoses of the pregnant women were urinary tract infection and anemia. Other significant diagnoses included uterine cancer, preterm labor, and fetal posterior urethral valve syndrome. Conclusions: A majority of Wayuu women presenting to an acute clinic setting in Colombia, South America were in their mid-thirties having had three pregnancies and the majority were not using any form of contraception. The most common diagnoses were straightforward diagnoses such as vaginal infections, urinary tract infections, and abnormal uterine bleeding. Our findings suggest a need for access to routine gynecologic care, general hygiene education, and increased availability of birth control among the Wayuu population.
Safety of Tubal Occlusion by Minilaparotomy Provided by Trained Clinical Officers Versus Assistant Medical Officers in Tanzania: A Randomized, Controlled, Noninferiority Trial.
Global Health, Science and Practice. 2018 Oct 3; 6(3):484-499.BACKGROUND: Tubal occlusion by minilaparotomy is a safe, highly effective, and permanent way to limit childbearing. We aimed to establish whether the safety of the procedure provided by trained clinical officers (COs) was not inferior to the safety when provided by trained assistant medical officers (AMOs), as measured by major adverse event (AE) rates. METHODS: In this randomized, controlled, open-label noninferiority trial, we enrolled participants at 7 health facilities in Arusha region, Tanzania, as well as during outreach activities conducted in Arusha and neighboring regions. Consenting, eligible participants were randomly allocated by a research assistant at each site to minilaparotomy performed by a trained CO or by a trained AMO, in a 1:1 ratio. We asked participants to return at 3, 7, and 42 days postsurgery. The primary outcome was the rate of major AEs following minilaparotomy performed by COs versus AMOs, during the procedure and through 42 days follow-up. The noninferiority margin was 2%. The trial is registered with ClinicalTrials.gov, Identifier NCT02944149. RESULTS: We randomly allocated 1,970 participants between December 2016 and June 2017, 984 to the CO group and 986 to the AMO group. Most (87%) minilaparotomies were conducted during outreach services. In the intent-to-treat analysis, 0 of 978 participants had a major AE in the CO group compared with 1 (0.1%) of 984 in the AMO group (risk difference: -0.1% [95% confidence interval: -0.3% to 0.1%]), meeting the criteria for noninferiority. We saw no evidence of differences in measures of procedure performance, participant satisfaction, or provider self-efficacy between the groups. CONCLUSIONS: Tubal occlusion by minilaparotomy performed by trained COs is safe, effective, and acceptable to women, and the procedure can be safely and effectively provided in outreach settings. Our results provide evidence to support policy change in resource-limited settings to allow task shifting of minilaparotomy to properly trained and supported COs, increasing access to female sterilization and helping to meet the rising demand for the procedure among women wanting to avoid pregnancy. They also suggest high demand for these services in Tanzania, given the large number of women recruited in a relatively short time period. (c) Barone et al.
International Journal of Women's Health and Reproduction Sciences. 2018; 6(3):356-362.Objectives: Improving the maternal health requires an understanding of the men’s level of knowledge as well as the attitude about participation in their wives’ perinatal care in different societies. The present study aims to investigate men’s knowledge and attitude about participation in their nulliparous wives’ perinatal care. Materials and Methods: In this descriptive cross-sectional study, 300 husbands of nulliparous women completed the questionnaire of “men’s knowledge and attitude about participation in prenatal care”, in a referral perinatal care clinic in Hamadan, Iran, in 2015. Results: The level of knowledge about the wives’ perinatal care in more than half of the men (58 %) was poor and in nearly half of them (41.7%) was moderate. Based on different aspects of the perinatal care, the knowledge level of 59.7%, 69.7%, 52.3 %, 63.3%, 64.7%, 66.7%, 51.7%, 62%, 84%, and 78.7% of the men was poor in the physical changes, general health, nutrition, exercise, sexual health, risk signs, mental and psychological changes in pregnancy, delivery, puerperium, and neonatal care, respectively. None of the men had good knowledge about the aspects related to postpartum care (including puerperium and neonatal care). Further, the majority of men (65.3%) had a positive attitude towards participation in perinatal care. Conclusions: In the present study, the emphasis was put on the need for training the men interested in participating in various perinatal cares, especially physical changes during pregnancy, prenatal nutrition, risk signs during pregnancy, and maternal as well as neonatal postpartum cares. © 2018 The Author (s).
Effective Collaboration for Scaling Up Health Technologies: A Case Study of the Chlorhexidine for Umbilical Cord Care Experience.
Global Health, Science and Practice. 2018 Mar 21; 6(1):178-191.The global health field is replete with examples of cross-organizational collaborative partnerships, such as networks, alliances, coalitions, task forces, and working groups, often established to tackle a shared global health concern, condition, or threat affecting low-income countries or communities. The purpose of this article is to review factors influencing the effectiveness of a multi-agency global health collaborative effort using the Chlorhexidine Working Group (CWG) as our case study. The CWG was established to accelerate the introduction and global scale-up of chlorhexidine for umbilical cord care to reduce infection-related neonatal morbidity and mortality in low-income countries. Questions included: how current and past CWG members characterized the effectiveness, productivity, collaboration, and leadership of the CWG; what factors facilitated or hindered group function; institutional or individual reasons for participating and length of participation in the CWG; and lessons that might be relevant for future global collaborative partnerships. Data were collected through in-depth, semistructured individual interviews with 19 group members and a review of key guiding documents. Six domains of internal coalition functioning (leadership, interpersonal relationships, task focus, participant benefits and costs, sustainability planning, and community support) were used to frame and describe the functioning of the CWG. Collaboration effectiveness was found to depend on: (1) leadership that maintained a careful balance between discipline and flexibility, (2) a strong secretariat structure that supported the evolution of trust and transparent communication in interpersonal relationships, (3) shared goals that allowed for task focus, (4) diverse membership and active involvement from country-level participants, which created a positive benefit-cost ratio for participants, (5) sufficient resources to support the partnership and build sustainable capacity for members to accelerate the transfer of knowledge, and (6) support from the global health community across multiple organizations. Successful introduction and scale-up of new health interventions require effective collaboration across multiple organizations and disciplines, at both global and country levels. The participatory collaborative partnership approach utilized by the Chlorhexidine Working Group offers an instructive learning case.
Journal of Pediatric Psychology. 2018 Sep 1; 43(8):821-830.Objective: To reduce rates of sexually transmitted infections (STIs) and unwanted pregnancy among adolescents, it is critical to investigate brain connectivity that may underlie adolescents' sexual health decision-making in the context of intercourse. This study explored relationships between adolescent condom use frequency and the brain's resting-state functional connectivity, to identify differential patterns of social-affective processing among sexually active youth. Methods: In this study, N = 143 sexually active adolescents (68.5% male, Mage = 16.2 years, SD = 1.06) completed magnetic resonance imaging and reported past 3-month frequency of condom use. Resting-state connectivity, seeded on a social region of the brain, the temporoparietal junction (TPJ), was assessed to determine its correspondence with protected sex (condom use). Results: Condom use was associated with positive connectivity between the left TPJ and bilateral inferior frontal gyrus (IFG). This relationship was observed in adolescent males only; no connectivity differences were observed with adolescent females. Conclusions: This study reflects functional synchrony between nodes of the "social brain," including the TPJ, and a region of planfulness and control, the IFG. The relationship between these regions suggests that adolescents who have more coordinated systems of communication between these critical components of the brain are more likely to be successful in planning and engaging in safer sexual decision-making; for young males, this differentiated more frequent from less frequent condom use. In turn, interventions designed to reduce STIs/human immunodeficiency virus may benefit from targeting social-planfulness dimensions to help youth implement safer sex behaviors.
[Washington, D.C., PSI], Transform PHARE, 2018 Jan. 102 p.This research was undetaken in order Identify male segments in Niger that were most likely to change their attitudes and behaviors towards FP, and provide high-level principles for the design and implementation of interventions targeting these segments. The objectives of the research were: 1) Identify and capture the factors that influence male decision-making with regards to family planning and 2) Identify segments of men in the three target regions of Maradi, Zinder, and Tillabéri that are more or less likely to change their attitudes and behaviors towards FP.
Parental Gender Expectations by Socioeconomic Status and Nativity: Implications for Contraceptive Use.
Sex Roles. 2018 May; 78(9-10):669-684.Parental gender expectations, which may be egalitarian or not, may vary by nativity and socioeconomic status. Parental gender expectations provide a model for children's gender role attitudes and could also have effects on reproductive health over the life course, including women's contraceptive choices. Yet, parental gender expectations are not often studied quantitatively. Using the National Longitudinal Study of Adolescent to Adult Health, we examine how parental gender expectations in the United States vary by immigrant generation and socioeconomic status, whether parental gender expectations in adolescence are associated with young women's contraceptive use, and if nativity moderates that relationship. Results show that parental gender expectations vary significantly by immigrant generation and parental socioeconomic status. Both first and second generation women are significantly less likely to have lived in households with equal gender expectations compared to the third generation. Higher socioeconomic status is associated with equal gender expectations. Among participants from households with equal gender expectations, the second generation is more likely than the third generation is to use a male-controlled contraceptive method versus no method. Using a nationally representative sample, our study demonstrates that parental gender expectations vary by nativity and by the socioeconomic context of the family in which they are embedded as well as have a unique effect on the contraceptive behavior of second generation women.
Comparison of an additional early visit to routine postpartum care on initiation of long-acting reversible contraception: A randomized trial.
Contraception. 2018 Sep; 98(3):223-227.OBJECTIVE: To investigate whether an early 3-week postpartum visit in addition to the standard 6-week visit increases long-acting reversible contraception (LARC) initiation by 8 weeks postpartum compared to the routine 6-week visit alone. STUDY DESIGN: We enrolled pregnant and immediate postpartum women into a prospective randomized, non-blinded trial comparing a single 6-week postpartum visit (routine care) to two visits at 3 and 6 weeks postpartum (intervention), with initiation of contraception at the 3-week visit, if desired. All participants received structured contraceptive counseling. Participants completed surveys in-person at baseline and at the time of each postpartum visit. A sample size of 200 total participants was needed to detect a 2-fold difference in LARC initiation (20% vs. 40%). RESULTS: Between May 2016 and March 2017, 200 participants enrolled; outcome data are available for 188. The majority of LARC initiation occurred immediately postpartum (25% of the intervention arm and 27% of the routine care arm). By 8 weeks postpartum, 34% of participants in the intervention arm initiated LARC, compared to 41% in the routine care arm (p=.35). Overall contraceptive initiation by 8 weeks was 83% and 84% in the intervention and routine care arms, respectively (p=.79). There was no difference between the arms in the proportion of women who attended at least one postpartum visit (70% vs. 74%, p=.56). CONCLUSION: The addition of a 3-week postpartum visit to routine care does not increase LARC initiation by 8 weeks postpartum. The majority of LARC users desired immediate rather than interval postpartum initiation. CLINICAL TRIAL REGISTRATION: Clinicaltrials.govNCT02769676 IMPLICATIONS: The addition of a 3-week postpartum visit to routine care does not increase LARC or overall contraceptive initiation by 8 weeks postpartum when the option of immediate postpartum placement is available. The majority of LARC users desired immediate rather than interval postpartum initiation. Copyright (c) 2018 Elsevier Inc. All rights reserved.
Elements for harnessing participatory action research to strengthen health managers' capacity: a critical interpretative synthesis.
Health Research Policy and Systems. 2018 Apr 19; 16(1):33.BACKGROUND: Health managers play a key role in ensuring that health services are responsive to the needs of the population. Participatory action research (PAR) is one of the approaches that have been used to strengthen managers' capacity. However, collated knowledge on elements for harnessing PAR to strengthen managers' capacity is missing. This paper bridges this gap by reviewing existing literature on the subject matter. METHODS: A critical interpretive synthesis method was used to interrogate eight selected articles. These articles reported the use of PAR to strengthen health managers' capacity. The critical interpretive synthesis method's approach to analysis guided the synthesis. Here, the authors interpretively made connections and linkages between different elements identified in the literature. Finally, the Atun et al. (Heal Pol Plann, 25:104-111, 2010) framework on integration was used to model the elements synthesised in the literature into five main domains. RESULTS: Five elements with intricate bi-directional interactions were identified in the literature reviewed. These included a shared purpose, skilled facilitation and psychological safety, activity integration into organisational procedures, organisational support, and external supportive monitoring. A shared purpose of the managers' capacity strengthening initiative created commitment and motivation to learn. This purpose was built upon a set of facilitation skills that included promoting participation, self-efficacy and reflection, thereby creating a safe psychological space within which the managers interacted and learnt from each other and their actions. Additionally, an integrated intervention strengthened local capacity and harnessed organisational support for learning. Finally, supportive monitoring from external partners, such as researchers, ensured quality, building of local capacity and professional safety networks essential for continued learning. CONCLUSIONS: The five elements identified in this synthesis provide a basis upon which the use of PAR can be harnessed, not only to strengthen health managers' capacity, but also to foster other health systems strengthening initiatives involving implementation research. In addition, the findings demonstrated the intricate and complex relations between the elements, which further affirms the need for a systems thinking approach to tackling health systems challenges.
The relationship between leadership style and health worker motivation, job satisfaction and teamwork in Uganda.
Journal of Healthcare Leadership. 2018; 10:21-32.Background: Leadership is key to strengthening performance of Health Systems. Leadership styles are important organizational antecedents, especially in influencing employee's motivation, job satisfaction, and teamwork. There is limited research exploring this relationship among health workers in resource-limited settings such as Uganda. The aim of this study was to examine the relationship between transformational, transactional, and laissez-faire leadership styles and motivation, job satisfaction, and teamwork of health workers in Uganda. Method: We conducted a cross-sectional study in 3 geographic regions of Uganda in November 2015, using self-administered questionnaires with 564 health workers from 228 health facilities. Data were collected on health workers' perception of leadership styles displayed by their facility leaders, their level of motivation, job satisfaction, and team work. Using Pearson correlation, relationships among variables were identified and associations of the components of leadership styles with motivation, job satisfaction, and teamwork was found using multivariable logistic regression. Results: Health workers in Uganda preferred leaders who were transformational (62%) compared with being transactional (42%) or laissez-faire (14%). Transformational leadership was positively correlated with motivation (r=0.32), job satisfaction (r=0.38), and team work (r=0.48), while transactional leadership was positively correlated with job satisfaction (r=0.21) and teamwork (r=0.18). Motivation was positively associated with leaders who displayed idealized influence-behavior (odds ratio [OR]=3.7; 95% CI, 1.33-10.48) and intellectual stimulation (OR=2.4; 95% CI, 1.13-5.15) but negatively associated with management by exception (OR=0.4; 95% CI, 0.19-0.82). Job satisfaction was positively associated with intellectual stimulation (OR=5.7; 95% CI, 1.83-17.79). Teamwork was positively associated with idealized influence-behavior (OR=1.07-8.57), idealized influence-attributed (OR=3.9; 95% CI, 1.24-12.36), and contingent reward (OR=5.6; 95% CI, 1.87-17.01). Conclusion: Transformational styles had a positive impact on stimulating motivation, assuring job satisfaction, and consolidating teamwork among health workers compared with those who demonstrated transactional skills or laissez-faire styles. Recommendation: Supporting transformational leadership skills development in health facility leaders could encourage health worker motivation, strengthen job satisfaction, and maintain cohesion among health workers for better service delivery.
Multilevel Influences on Men's Partner Violence Justification, Control Over Family Decisions, and Partner Violence Perpetration in Bangladesh.
Psychology of Violence. 2018;Objective: Men's justification of intimate partner violence (IPV), control, and IPV perpetration persist globally. We tested feminist theories of dominant masculinity norms and gendered social learning in childhood to explain young married men's violent attitudes and behaviors. Method: The sample was ever-married-junior men (18-29 years, n = 774), senior men (30-54 years, n = 2,398), and women (15-49 years, n = 3,841)-in 307 communities from the 2007 Bangladesh Demographic and Health Survey. Two-level logistic regression models tested whether community norms of masculine dominance and childhood exposure to father-on-mother IPV were associated with higher odds of justifying IPV, controlling family decisions, and perpetrating physical IPV. Results: Compared with senior men, junior men more often justified IPV, controlled family decisions, and perpetrated physical IPV in the prior year; junior men also more often were exposed as children to father-on-mother IPV. In multilevel models, witnessing father-on-mother IPV in childhood and living amid stronger norms of masculine dominance were associated, respectively, with higher adjusted odds of justifying IPV (adjusted odds ratios [aORs] = 1.86 and 33.45), controlling family decisions (aORs = 2.03 and 25.03), and perpetrating physical IPV (aORs = 3.19 and 3.39). Conclusion: Findings support a situational, feminist social ecological model of the influences of community norms of masculine dominance and of gendered social learning on young men's violent attitudes and behavior in marriage. Promoting positive masculinities and reducing men's exposure to violence in childhood may be needed to curtail violence against women in Bangladesh and similar settings. © 2018 American Psychological Association.
Facilitators and barriers to participation of private sector health facilities in government-led schemes for maternity services in India: a qualitative study.
BMJ Open. 2017 Jun 22; 7(6):e017092.OBJECTIVE: Despite provision of accreditation of private sector health providers in government-led schemes for maternity services in India, their participation has been low. This has led to an underutilisation of their presence, resources and expertise for providing quality maternal and newborn health services. This study explores the perception of various stakeholders on expectations, benefits, barriers and facilitators to private sector participation in government-led schemes-specifically Janani Suraksha Yojana (JSY)-for maternity service delivery. DESIGN: Narrative-based qualitative study. Face-to-face in-depth interviews were conducted with study participants. The interviews were transcribed, translated and analysed using a reflexive and inductive approach to allow codes, categories and themes to emerge from within the data. SETTING: Private obstetricians, government health officials and FOGSI (Federation of Obstetrics and Gynaecological Societies of India) members, Jharkhand and Uttar Pradesh, India. PARTICIPANTS: Eighteen purposefully selected private obstetricians from 9 cities across states of Uttar Pradesh and Jharkhand, 11 government health officials and 2 FOGSI members. RESULTS: The major factors serving as barriers to participation of private practitioners in JSY-which emerged on thematic analysis-were low reimbursement amounts, delayed reimbursements, process of interaction with the government and administrative issues, previous experiences and trust deficit, lack of clarity on the accreditation process and patient-level barriers. On the other hand, factors which were facilitators to participation of private practitioners were ease of process, better communication, branding, motivation of increasing clientele as well as satisfaction of doing social service. CONCLUSION: Factors such as financial processes and administrative delays, mistrust between the stakeholders, ambiguity in processes, lack of transparency and lack of ease in the process of empanelment of private sector are hindering effective public-private partnerships under JSY. Simplifying and strengthening the processes, communication strategies and branding can help revitalise it. (c) Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Social norms and adolescents’ sexual health: an introduction for practitioners working in low and mid-income African countries.
African Journal of Reproductive Health. 2018 Mar; 22(1):38-46.Donors, practitioners and scholars are increasingly interested in harnessing the potential of social norms theory to improve adolescents‘ sexual and reproductive health outcomes. However, social norms theory is multifaceted, and its application in field interventions is complex. An introduction to social norms that will be beneficial for those who intend to integrate a social norms perspective in their work to improve adolescents‘ sexual health in Africa is presented. First three main schools of thought on social norms, looking at the theoretical standpoint of each, are discussed. Next, the difference between two important types of social norms (descriptive and injunctive) is explained and then the concept of a --reference group is examined. The difference between social and gender norms are then considered, highlighting how this difference is motivated by existing yet contrasting approaches to norms (in social psychology and gender theory). In the last section, existing evidence on the role that social norms play in influencing adolescents' sexual and reproductive health are reviewed. Conclusions call for further research and action to understand how norms affecting adolescents' sexual and reproductive health and rights (SRHR) can be changed in sub-Saharan Africa.
New York, New York, International Rescue Committee, . 4 p. (Sexual and Reproductive Health)Adolescents have unique sexual and reproductive health (SRH) needs and, in humanitarian settings, these needs intensify. Deprived of traditional social structures, adolescents are forced to navigate new and dangerous environments and, with few protection services available, are vulnerable to sexual abuse and exploitation. Young people, particularly girls, encounter significant barriers to accessing quality health care, including provider bias, age restrictions or stigmatization when seeking services, and concerns about confidentiality. Unprotected and early sex, early pregnancies, and STIs increase and childbearing risks are compounded. In the Democratic Republic of the Congo (DRC), where the International Rescue Committee has worked to increase access to sexual and reproductive health since 2006, only 5% of adolescent girls are using a modern contraceptive method. As a result, unintended pregnancy is common and nearly one in three girls under the age of 20 is a mother or pregnant for the first time. The consequences of these unintended and early pregnancies are immense -- physically, mentally and emotionally. With the support of the David & Lucile Packard Foundation, the International Rescue Committee (IRC) developed and piloted a new approach to increase adolescent girls’ access to contraception in three health facilities in Goma, the capital city of North Kivu in eastern DRC.
Life is so easy on ART, once you accept it: Acceptance, denial and linkage to HIV care in Shiselweni, Swaziland.
Social Science and Medicine. 2017 Mar; 176:52-59.BACKGROUND: Timely uptake of antiretroviral therapy, adherence and retention in care for people living with HIV (PLHIV) can improve health outcomes and reduce transmission. Medecins Sans Frontieres and the Swaziland Ministry of Health provide community-based HIV testing services (HTS) in Shiselweni, Swaziland, with high HTS coverage but sub-optimal linkage to HIV care. This qualitative study examined factors influencing linkage to HIV care for PLHIV diagnosed by community-based HTS. METHODS: Participants were sampled purposively, exploring linkage experiences among both genders and different age groups. Interviews were conducted with 28 PLHIV (linked and not linked) and 11 health practitioners. Data were thematically analysed to identify emergent patterns and categories using NVivo 10. Principles of grounded theory were applied, including constant comparison of findings, raising codes to a conceptual level, and inductively generating theory from participant accounts. RESULTS: The process of HIV status acceptance or denial influenced the accounts of patients' health seeking and linkage to care. This process was non-linear and varied temporally, with some experiencing non-acceptance for an extended period of time. Non-acceptance was linked to perceptions of HIV risk, with those not identifying as at risk less likely to expect and therefore be prepared for a positive result. Status disclosure was seen to support linkage, reportedly occurring after the acceptance of HIV status. HIV status acceptance motivated health seeking and tended to be accompanied by a perceived need for, and positive value placed on, HIV health care. CONCLUSIONS: The manner in which PLHIV process a positive result can influence their engagement with HIV treatment and care. Thus, there is a need for individually tailored approaches to HTS, including the potential for counselling over multiple sessions if required, supporting status acceptance, and disclosure. This is particularly relevant considering 90-90-90 targets and the need to better support PLHIV to engage with HIV treatment and care following diagnosis. Copyright (c) 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.
International Journal of offender therapy and Comparative Criminology. 2018 Oct; 62(13):4174-4186.Female homicides are widely prevalent in Turkey with rising trend. The aim of this study is to identify gender role attitudes, childhood trauma histories, and individual characteristics of men who have been involved in the femicide, and to compare them with men who do not exercise violence against women. Participants completed a Sociodemographic and Clinical Information form, Semistructured Interview form, and the Childhood Trauma Questionnaire. Case group was not significantly different than the control group in terms of any measured individual characteristics including childhood traumas, psychopathology, and gender attitudes. Our data indicate that only migration history may be linked to femicide. A unique psychopathology that could be related to being a femicide perpetrator was not identified. Migration and perception of gender roles stand out as factors that separate men who exercise violence from men who do not.
Youth engagement in developing an implementation science research agenda on adolescent HIV testing and care linkages in sub-Saharan Africa.
AIDS. 2017 Jul 1; 31 Suppl 3:S195-S201.BACKGROUND: The importance of youth engagement in designing, implementing and evaluating programs has garnered more attention as international initiatives seek to address the HIV crisis among this population. Adolescents, however, are not often included in HIV implementation science research and have not had opportunities to contribute to the development of HIV-related research agendas. Project Supporting Operational AIDS Research (SOAR), a United States Agency for International Development-funded global operations research project, involved youth living with HIV in a meeting to develop a strategic implementation science research agenda to improve adolescent HIV care continuum outcomes, including HIV testing and counseling (HTC) and linkage to care. METHODS: Project SOAR convened a 2-day meeting of 50 experts, including four youth living with HIV. Participants examined the literature, developed research questions, and voted to prioritize these questions for the implementation science research agenda. This article presents the process of involving youth, how they shaped the course of discussions, and the resulting priority research gaps identified at the meeting. RESULTS: Youth participation influenced working group discussions and the development of the implementation science agenda. Research gaps identified included how to engage vulnerable adolescents, determining the role that stigma, peers, and self-testing have in shaping adolescent HTC behaviors, and examining the costs of different HTC and linkage to care strategies. CONCLUSION: The meeting participants developed the research agenda to guide future implementation science research to improve HIV outcomes among adolescents in sub-Saharan Africa. This process highlighted the importance of youth in shaping implementation science research agendas and the need for greater youth engagement.
Redemption of the "spoiled identity:" the role of HIV-positive individuals in HIV care cascade interventions.
Journal of the International AIDS Society. 2017 Dec; 20(4)INTRODUCTION: The concept of "therapeutic citizenship" has drawn attention to ways in which public testimony, the "story-telling in the public sphere" undertaken by people living with HIV (PLHIV), has shaped the global response to the epidemic. This paper presents qualitative findings from two large studies in eastern Africa that reveal how the advent of population-based HIV testing campaigns and efforts to accelerate antiretroviral "treatment for all" has precipitated a rapidly expanding therapeutic citizenship "project," or social movement. The title of this paper refers to Goffman's original conceptualization of stigma as a social process through which a person's identity is rendered "spoiled." METHODS: Data were derived from qualitative studies embedded within two clinical trials, Sustainable East African Research in Community Health (SEARCH) (NCT# 01864603) in Kenya and Uganda, and START-ART (NCT# 01810289) in Uganda, which aimed to offer insights into the pathways through which outcomes across the HIV care continuum can be achieved by interventions deployed in the studies, any unanticipated consequences, and factors that influenced implementation. Qualitative in-depth semi-structured interviews were conducted among cohorts of adults in 2014 through 2015; across both studies and time periods, 217 interviews were conducted with 166 individuals. Theoretically informed, team-based analytic approaches were used for the analyses. RESULTS: Narratives from PLHIV, who have not always been conceptualized as actors but rather usually as targets of HIV interventions, revealed strongly emergent themes related to these individuals' use of HIV biomedical resources and discourses to fashion a new, empowered subjecthood. Experiencing the benefits of antiretroviral therapy (ART) emboldens many individuals to transform their "spoiled" identities to attain new, valorized identities as "advocates for ART" in their communities. We propose that the personal revelation of what some refer to as the "gospel of ARVs," the telling of personal stories about HIV in the public sphere and actions to accompany other PLHIV on their journey into care, is driven by its power to redeem the "spoiled identity:" it permits PLHIV to overcome self-stigma and regain full personhood within their communities. CONCLUSIONS: PLHIV are playing an unanticipated but vital role in the successful implementation of HIV care cascade interventions. (c) 2017 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.
Atlanta, Georgia, CARE, 2017 Sep. 16 p. (Tipping Point Social Norms Innovations Series Brief 4)This brief documents CARE’s Tipping Point project and how using tea stalls can help change social norms. It offers tips on how to replicate this approach in your own work. Personal relationships often reinforce or challenge power imbalances between men and women. Fathers and brothers hold a great deal of power in the lives of adolescent girls in Bangladesh’s Sunamganj district. For men and older boys, the tea stall is a common spot to socialise with peers. Tea stalls are a productive space to start discussions with men on gender and equity in a familiar setting.