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Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda.
Health Research Policy and Systems. 2017 Dec 28; 15(Suppl 2):107.BACKGROUND: The use of participatory monitoring and evaluation (M&E) approaches is important for guiding local decision-making, promoting the implementation of effective interventions and addressing emerging issues in the course of implementation. In this article, we explore how participatory M&E approaches helped to identify key design and implementation issues and how they influenced stakeholders' decision-making in eastern Uganda. METHOD: The data for this paper is drawn from a retrospective reflection of various M&E approaches used in a maternal and newborn health project that was implemented in three districts in eastern Uganda. The methods included qualitative and quantitative M&E techniques such as key informant interviews, formal surveys and supportive supervision, as well as participatory approaches, notably participatory impact pathway analysis. RESULTS: At the design stage, the M&E approaches were useful for identifying key local problems and feasible local solutions and informing the activities that were subsequently implemented. During the implementation phase, the M&E approaches provided evidence that informed decision-making and helped identify emerging issues, such as weak implementation by some village health teams, health facility constraints such as poor use of standard guidelines, lack of placenta disposal pits, inadequate fuel for the ambulance at some facilities, and poor care for low birth weight infants. Sharing this information with key stakeholders prompted them to take appropriate actions. For example, the sub-county leadership constructed placenta disposal pits, the district health officer provided fuel for ambulances, and health workers received refresher training and mentorship on how to care for newborns. CONCLUSION: Diverse sources of information and perspectives can help researchers and decision-makers understand and adapt evidence to contexts for more effective interventions. Supporting districts to have crosscutting, routine information generating and sharing platforms that bring together stakeholders from different sectors is therefore crucial for the successful implementation of complex development interventions.
Knowledge and practice of polio vaccination among mothers of infants attending community health centre of northern Kerala.
International Journal of Community Medicine and Public Health. 2018 Jul; 5(7):2911-2915.Background: Poliomyelitis is a highly infectious disease caused by polio virus which invades the nervous system causing irreversible total paralysis. The aim of the study is to assess the knowledge and practice of mothers regarding polio vaccination. Methods: It s a descriptive type of study conducted in mothers of Infants who had attended Community health centre of Kannur district during a study period of 2 weeks (June 1 to June 14, 2017). Written consent was obtained from the mothers. Data was collected using a semi structured questionnaire with 3 sections -demographic details, knowledge and practice. Data was analyzed and the results are expressed in terms of frequency and percentage. Results: A total of 220 women were studied. Out of 220 mothers, 93.6% had satisfactory knowledge and 90.45% mothers had their child immunized up to age according to National Immunization Schedule. All of them were taking their children to government hospital for vaccination and their main source of knowledge were health workers. Conclusions: In the present study, majority of the mothers had attended immunization class and had satisfactory knowledge. In order to achieve 100% vaccination coverage, we have to emphasize more on awareness campaigns.
Sociodemographic and cultural determinants of seeking family planning knowledge and practice among a Sudanese community.
International Journal of Community Medicine and Public Health. 2018 Aug; 5(8):3248-3256.Background: About 214 million women in the reproductive age in the developing countries who need to prevent and plan for their pregnancy are not using methods of modern contraceptives. The aim of this study was to investigate the socio-demographic and cultural elements that inform the health-seeking behavior towards family planning among Sudanese women in Sharq-Alneel locality in the Sudan-Africa. Furthermore, the study aimed to identify individuals within Sudanese families, who predominantly interfered with the decision of the women in using of contraceptives for family planning. Methods: A cross-sectional community based study was conducted in September-2017 to February-2018 using structured questionnaire to 576 Sudanese women age of 15-49 years from 4 administrative units. A multistage cluster sampling technique was adopted. Binary and multinomial logistic regression models were used to analyze the results using SPSS version 22. Results: Women respondents were (57.1%), and (42.9%) from rural and urban areas respectively. Women (89.3%) of respondents were married for more than five years. A 381 (66%) women respondents were not using contraception at the time of the study. Women in rural areas were 0.9 less likely to obtain information from other sources than from PHC. There was significant association (p<0.001) between women’s educational level and awareness about contraception. Conclusions: Women use of contraception in Sharq-Alneel was low. Barrier to contraception use for majority of women was that they believe their healths are at risk for using modern contraceptives. There was also high prevalence of respondents’ husbands refused the use of contraceptives.
International Journal of Community Medicine and Public Health. 2018 Sep; 5(9):3930-3935.Background: Emergency contraception has the potential to greatly reduce the number of unintended pregnancies. The level of knowledge among the medical student population about EC has not been adequately investigated. This study aims to assess the knowledge, attitude and practice of EC (Emergency Contraception) amongst the medical under graduate students in Government college of Surat. Methods: This study was carried out among 339 medical under graduate students during the month of October, 2016. A predesigned self-administered questionnaire was used to collect the data. Results: Majority of students knew about some form of contraception. Only quarter of students knew about EC pill. Varied responses were observed regarding various knowledge aspects of EC. Internet and books were the most common source of knowledge. As far as their attitudes are concerned, almost 40% believed that EC would lead more irresponsible behaviour and more STD/HIV cases, while 30% believed that it would lead to promiscuity, and be inexpensive, if they are readily available. More than half number of students opined that EC should be made available for women aged only 18 years and above. As far as practice is concerned, only one student reported using EC. However, more than 40% were willing to use it, if required and would also encourage friends and relatives to use it. Conclusions: Awareness of EC was low among students. Attitude was favorable towards EC. Study also document very low level of practice of EC among the students.
Utilization of Antenatal and Postnatal Care Services Among Adolescents and Young Mothers in Rural Communities in South-Western Nigeria.
African Journal of Biomedical Research. 2018 May; 21(2):133-137.Antenatal and postnatal care services have been found to be a proximate determinant of maternal outcomes as they enable early detection of at risk-mothers and provision of prevention services. However, factors affecting the utilization of antenatal and postnatal care services among young mothers in rural settings are poorly documented. A community based cross-sectional study was carried out among parturient adolescent and young women selected through a 4-stage sampling procedure. A pretested interviewer administered questionnaire was used to collect information on mother’s socio-demographics and use of maternal health care services. Data collected was analysed using Chi-square test and binary logistic regression. Almost half (47.9%) had given birth to only one child. Only 45.4% of the mothers attended four Antenatal care sessions. The mean gestational age at booking was 19.5± 4.8 weeks and the mean number of ANC visits was 3.6±1.1visits. Overall the proportion of young mothers who accessed antenatal care at least once was 86.2% and postnatal was (5.8%). However less than half attended at least 4 full ANC services. Unskilled working mothers are 3 times less likely to attend post-natal care services (OR=0.34, 95% CI=0.12-0.97) while those delivered by caesarean section were 5 times more likely to attend post natal services (OR=4.9, 95% CI= 1.6 – 14.8). The findings suggest low utilization of full antenatal and postnatal services are related to personal health and economic factors, and indicates the need for increase awareness campaign on the benefits of these services to improve uptake.
Role of Religious Leaders in Promoting Contraceptive Use in Nigeria: Evidence From the Nigerian Urban Reproductive Health Initiative.
Global Health, Science and Practice. 2018 Oct 3; 6(3):500-514.BACKGROUND: Despite the many supply- and demand-side interventions aimed at increasing contraceptive uptake, the modern contraceptive prevalence rate in Nigeria has remained very low (9.8%). Religion is an important part of the sociocultural fabric of many communities. As such, religious leaders have the power to inhibit or facilitate effective adoption of contraceptive methods to support family health. We assess the association of exposure to religious leaders' tailored scriptural family planning messages with contraceptive use in Nigeria. METHODS: This cross-sectional study used data from a Measurement, Learning and Evaluation Project survey conducted in 2015 in 4 Nigerian states-Federal Capital Territory, Kaduna, Kwara, and Oyo. The final study sample was restricted to 9,725 non-pregnant women aged 15 to 49 years. Data analysis included descriptive statistics and binary logistic regression analysis to explore significant relationships between current use of a modern contraceptive method, exposure to family planning messages from religious leaders, and selected background characteristics. RESULTS: About 2 in 5 women reported being exposed to family planning messages from religious leaders in the past year. Bivariate results revealed a higher uptake of modern contraceptives among women with high exposure to different NURHI interventions (35.5%) compared with respondents in the low or medium exposure categories (14.5% and 24.5%, respectively). The multivariable analysis revealed significantly higher contraceptive uptake among women who had exposure to family planning messages from religious leaders relative to those with no exposure (odds ratio=1.70; 95% confidence interval, 1.54 to 1.87; P<.001). This association remained significant after adjustment for background characteristics and other selected variables. CONCLUSION: Interventions that engage clerics of different faiths as change agents for shaping norms and informing behaviors about family planning and contraceptive use are crucial for increasing contraceptive uptake in Nigeria. (c) Adedini et al.
Ways and channels for voice regarding perceptions of maternal health care services within the communities of the Makamba and Kayanza provinces in the Republic of Burundi: an exploratory study.
BMC Health Services Research. 2018 Jan 29; 18(1):46.BACKGROUND: Increased availability of maternal health services alone does not lead to better outcomes for maternal health.The services need to be utilized first.One way to increase service utilization is to plan responsive health care services by taking into account the community's views or expressed needs. Burundi has a high maternal mortality ratio, and despite improvements in health infrastructure, skilled staff and the abolition of user fees for pregnant women,utilization of maternal health services remains low. Possible reasons for this include a lack of responsive healthcare services. An exploratory study was conducted in 2013 in two provinces of Burundi (Makamba and Kayanza), with the aim to collect the experiences of women and men with the maternal health services,their views regarding those services, channels used to express these experiences, and the providers' reaction. METHODS: Semi-structured interviews were used to collect data from men and women and key informants, including community health workers, health committee members, health providers, local authorities, religious leaders and managers of non-governmental organizations. Data analysis was facilitated by MAXQDA 11 software. RESULTS: Negative experiences with maternal health services were reported and included poor staff behavior towards women and a lack of medicine. Health committees and suggestion boxes were introduced by the government to channel the community's views. However, they are not used by the community members, who prefer to use community health workers as intermediaries. Fear of expressing oneself linked to the post-war context of Burundi, social and gender norms, and religious norms limit the expression of community members' views, especially those of women. The limited appreciation of community health workers by the providers further hampers communication and acceptance of the community's views by health providers. CONCLUSION: In Burundi, the community voice to express views on maternal health services is encountering obstacles and needs to be strengthened,especially the women's voice. Community mobilization in the form of a mass immunization campaign day organized by women fora, and community empowerment using participatory approaches could contribute towards community voice strengthening.
Gendered norms of responsibility: reflections on accountability politics in maternal health care in Malawi.
International Journal For Equity In Health. 2018 Sep 24; 17(1):131.BACKGROUND: This paper aims to provide insights into the role of traditional authorities in two maternal health programmes in Northern Malawi. Among strategies to improve maternal health, these authorities issue by-laws: local rules to increase the uptake of antenatal and delivery care. The study uses a framework of gendered institutions to critically assess the by-law content, process and effects and to understand how responsibilities and accountabilities are constructed, negotiated and reversed. METHODS: Findings are based on a qualitative study in five health centre catchment areas in Northern Malawi. Data were collected using meeting observations and document search, 36 semi-structured individual interviews and 19 focus group discussions with female maternal health service users, male community members, health workers, traditional leaders, local officials and health committee members. A gender and power sensitive thematic analysis was performed focusing on the formulation, interpretation and implementation process of the by-laws as well as its effects on women and men. RESULTS: In the study district, traditional leaders introduced three by-laws that oblige pregnant women to attend antenatal care; bring their husbands along and; and to give birth in a health centre. If women fail to comply with these rules, they risk being fined or denied access to maternal health services. The findings show that responsibilities and accountabilities are negotiated and that by-laws are not uniformly applied. Whereas local officials support the by-laws, lower level health cadres' and some community members contest them, in particular, the principles of individual responsibility and universality. CONCLUSIONS: The study adds new evidence on the understudied phenomenon of by-laws. From a gender perspective, the by-laws are problematic as they individualise the responsibility for maternal health care and discriminate against women in the definition and application of sanctions. Through the by-laws, supported by national policies and international institutions, women bear the full responsibility for failures in maternal health care, suggesting a form of 'reversed accountability' of women towards global maternal health goals. This can negatively impact on women's reproductive health rights and obstruct ambitions to achieve gender inequality and health equity. Contextualised gender and power analysis in health policymaking and programming as well as in accountability reforms could help to identify these challenges and potential unintended effects.
Mentor Mothers Zithulele: exploring the role of a peer mentorship program in rural PMTCT care in Zithulele, Eastern Cape, South Africa.
Paediatrics and International Child Health. 2018 Aug 13; 1-7.BACKGROUND: The majority of global HIV infections in children under 10 years of age occur during pregnancy, delivery or breastfeeding, despite improved coverage of 'prevention of mother-to-child transmission' (PMTCT) guidelines to reduce vertical transmission. This article looks closer at one community-based peer mentorship programme [Mentor Mothers Zithulele (MMZ)] in the Eastern Cape, South Africa which aims to supplement the existing heavily burdened antenatal programmes and improve PMTCT care. METHODS: Semi-structured interviews were undertaken with HIV-positive women participating in MMZ and women receiving standard PMTCT care without any intervention. A focus group discussion (FGD) was conducted with women working as Mentor mothers (MMs) for MMZ to explore their experience of the impact of peer mentoring on the rural communities they serve. RESULTS: Six main themes were identified in the interviews with antenatal patients: (i) MMs were a key educational resource, (ii) MMs were important in promoting exclusive breastfeeding, (iii) encouraging early HIV testing during pregnancy and (iv) providing psychosocial support to patients in their homes, thereby reducing stigma and sense of alienation. Respondents requested (v) additional focus on HIV education. MMs can (vi) function as a link between patients and health-care providers, improving treatment adherence. During the FGD two themes emerged; MMs fill the gap between patients and health services, and MMZ should focus on HIV awareness and stigma reduction. CONCLUSION: Peer mentoring programmes can play an important role in reducing vertical HIV transmission in resource-limited, rural settings by providing participants with education, psychosocial support, and a continuum of care.
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Educating religious leaders to promote uptake of male circumcision in Tanzania: a cluster randomised trial.
Lancet. 2017 Mar 18; 389(10074):1124-1132.BACKGROUND: Male circumcision is being widely deployed as an HIV prevention strategy in countries with high HIV incidence, but its uptake in sub-Saharan Africa has been below targets. We did a study to establish whether educating religious leaders about male circumcision would increase uptake in their village. METHODS: In this cluster randomised trial in northwest Tanzania, eligible villages were paired by proximity (<60 km) and the time that a free male circumcision outreach campaign from the Tanzanian Ministry of Health became available in their village. All villages received the standard male circumcision outreach activities provided by the Ministry of Health. Within the village pairs, villages were randomly assigned by coin toss to receive either additional education for Christian church leaders on scientific, religious, and cultural aspects of male circumcision (intervention group), or standard outreach only (control group). Church leaders or their congregations were not masked to random assignment. The educational intervention consisted of a 1-day seminar co-taught by a Tanzanian pastor and a Tanzanian clinician who worked with the Ministry of Health, and meetings with the study team every 2 weeks thereafter, for the duration of the circumcision campaign. The primary outcome was the proportion of male individuals in a village who were circumcised during the campaign, using an intention-to-treat analysis that included all men in the village. This trial is registered with ClinicalTrials.gov, number NCT 02167776. FINDINGS: Between June 15, 2014, and Dec 10, 2015, we provided education for church leaders in eight intervention villages and compared the outcomes with those in eight control villages. In the intervention villages, 52.8% (30 889 of 58 536) of men were circumcised compared with 29.5% (25 484 of 86 492) of men in the eight control villages (odds ratio 3.2 [95% CI, 1.4-7.3]; p=0.006). INTERPRETATION: Education of religious leaders had a substantial effect on uptake of male circumcision, and should be considered as part of male circumcision programmes in other sub-Saharan African countries. This study was conducted in one region in Tanzania; however, we believe that our intervention is generalisable. We equipped church leaders with knowledge and tools, and ultimately each leader established the most culturally-appropriate way to promote male circumcision. Therefore, we think that the process of working through religious leaders can serve as an innovative model to promote healthy behaviour, leading to HIV prevention and other clinically relevant outcomes, in a variety of settings. FUNDING: Bill & Melinda Gates Foundation, National Institutes of Health, and the Mulago Foundation. Copyright (c) 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.
Influence of peer support on HIV/STI prevention and safety amongst international migrant sex workers: A qualitative study at the Mexico-Guatemala border.
PloS One. 2018; 13(1):e0190787.BACKGROUND: Migrant women engaged in precarious employment, such as sex work, frequently face pronounced social isolation alongside other barriers to health and human rights. Although peer support has been identified as a critical HIV and violence prevention intervention for sex workers, little is known about access to peer support or its role in shaping health and social outcomes for migrant sex workers. This article analyses the role of peer support in shaping vulnerability and resilience related to HIV/STI prevention and violence among international migrant sex workers at the Mexico-Guatemala border. METHODS: This qualitative study is based on 31 semi-structured interviews conducted with international migrant sex workers in the Mexico-Guatemala border communities of Tapachula, Mexico and Tecun Uman and Quetzaltenango, Guatemala. RESULTS: Peer support was found to be critical for reducing social isolation; improving access to HIV/STI knowledge, prevention and resources; and mitigating workplace violence, particularly at the initial stages of migration and sex work. Peer support was especially critical for countering social isolation, and peers represented a valuable source of HIV/STI prevention knowledge and resources (e.g., condoms), as well as essential safety supports in the workplace. However, challenges to accessing peer support were noted, including difficulties establishing long-lasting relationships and other forms of social participation due to frequent mobility, as well as tensions among peers within some work environments. Variations in access to peer support related to country of work, work environment, sex work and migration stage, and sex work experience were also identified. CONCLUSIONS: Results indicate that peer-led and community empowerment interventions represent a promising strategy for promoting the health, safety and human rights of migrant sex workers. Tailored community empowerment interventions addressing the unique migration-related contexts and challenges faced by migrant sex workers should be a focus of future community-based research, alongside promotion of broader structural changes.
Impact of Muslim opinion leaders’ training of healthcare providers on the uptake of MNCH services in Northern Nigeria.
Global Public Health. 2018 May 15; 14 p.Expanding access to maternal, newborn and child health (MNCH) services in traditional societies is a public health challenge, often complicated by cultural and religious beliefs about what is permitted or not permitted within a faith group. This is particularly true in the Muslim majority North of Nigeria, where deep suspicions of Western public health programmes, coupled with failing and underfunded health system, have led to the emergence of a new generation of Muslim Opinion Leaders (MOLs) with counter-narratives against family planning, immunisation and nutrition programmes. This paper reports on an innovative project implemented under the Saving Lives at Birth global partnership programme, where conservative MOLs transformed as champions were engaged as health communicators to train health providers on correct religious precepts related to MNCH. A matched subject type of study design was used to compare healthcare providers’ performance in control and intervention health facilities. The result indicates a significant difference both in perception and in practices between healthcare providers in intervention and control facilities, with respect to MNCH uptake. This paper highlights the need for renewed focus on engaging faith leaders and organisations in health communication and service delivery and presents a model of sustainable engagement of champions in MNCH.
Contraception. 2018 Apr 18;BACKGROUND: Unprotected intercourse is common, especially among teens and young women. Access to intrauterine device (IUD) as emergency contraception (EC) can help interested patients more effectively prevent unintended pregnancy and can also offer ongoing contraception. This study evaluated young women's awareness of IUD as EC and interest in case of need. STUDY DESIGN: We conducted a secondary analysis of data from young women aged 18-25years, not desiring pregnancy within 12months, and receiving contraceptive counseling within a cluster-randomized trial in 40US Planned Parenthood health centers in 2011-2013 (n=1500). Heath centers were randomized to receive enhanced training on contraceptive counseling and IUD placement, or to provide standard care. The intervention did not focus specifically on IUD as EC. We assessed awareness of IUD as EC, desire to learn more about EC and most trusted source of information of EC among women in both intervention and control groups completing baseline and 3- or 6-month follow-up questionnaires (n=1138). RESULTS: At follow-up, very few young women overall (7.5%) visiting health centers had heard of IUD as EC. However, if they needed EC, most (68%) reported that they would want to learn about IUDs in addition to EC pills, especially those who would be very unhappy to become pregnant (adjusted odds ratio [aOR], 1.3; 95% confidence interval, 1.0-1.6, p<.05). Most (91%) reported a doctor or nurse as their most trusted source of EC information, over Internet (6%) or friends (2%), highlighting providers' essential role. CONCLUSION: Most young women at risk of unintended pregnancy are not aware of IUD as EC and look to their providers for trusted information. Contraceptive education should explicitly address IUD as EC. IMPLICATIONS: Few young women know that the IUD can be used for EC or about its effectiveness. However, if they needed EC, most reported that they would want to learn about IUDs in addition to EC pills, especially those very unhappy to become pregnant. Contraceptive education should explicitly address IUD as EC. Copyright (c) 2018 Elsevier Inc. All rights reserved.
Sustainability. 2018; 10(4)This study was conducted in Zambia from 2002 to 2008, a country greatly affected by the HIV (Human Immunodeficiency Virus)/AIDS (Acquired Immune Deficiency Syndrome) epidemic. The global, national, as well as local discourses on spread and mitigation were clustered around scientific knowledge and the local context and cultural traditions. The education sector struggled with implementing the national HIV/AIDS education strategy but by a broader stakeholder involvement, and a close collaboration between the educational sector and tribal chiefs and their traditional internal structures, a localized approach emerged. The overall objective of the paper is to illustrate how a multi-voiced strategy can bring about sustainable change, illustrated by this study. The study used qualitative constructivist and grounded theoretical approaches, and applied the third generation of cultural and historical activity theory (CHAT) as an analytical tool. Bernstein's concept, symbolic control, contributes to a broader understanding of the underlying processes and outcomes of the study. The findings revealed that the strategically monitored multi-voiced participation of local stakeholders created a learning space where both scientific and indigenous knowledge were blended, and thereby creating solutions to preventive action meeting the local needs. The study exemplifies these processes by identifying contradictions between the various levels and activity systems involved, by listing some of their characteristics, manifestations and finally their negotiated solutions. These solutions, or the third space interventions, the outcome of the multi-voiced participation, is in the paper used to explore a theoretical framework for an ethical and decolonized development strategy; a precondition for sustained local development. © 2018 by the authors.
Cracking the Egg Potential: Traditional Knowledge, Attitudes, and Practices in a Food-Based Nutrition Intervention in Highland Ecuador.
Food and Nutrition Bulletin. 2018 Jun; 39(2):206-218.BACKGROUND: Food-based interventions can reduce the prevalence of undernutrition and improve household food security, but nutritious and accessible foods may be underutilized. In Ecuador, eggs are inexpensive and widely available, but while they are a valuable source of essential nutrients for infants and young children, medical advice and community-based information have limited their inclusion in infants' diets. OBJECTIVE: A qualitative component was conducted to understand local perceptions, knowledge, and practices to complement a randomized control trial that studied the effect of introducing eggs on nutritional status and growth in infants from 6 to 9 months in rural communities in the highland province of Cotopaxi, Ecuador. METHODS: The qualitative inquiry consisted of key informant interviews, focus group discussions (FGDs), and structured observations in order to understand perceptions, knowledge, and practices related to household egg consumption and to the introduction of eggs in infants' diets. RESULTS: The two principal findings were that: (i) eggs are an available and culturally acceptable food source although they are not always a part of the diet; and (ii) perceptions and practices related to household consumption and the introduction of eggs into the diet of infants are shaped by local knowledge and practices, which are shaped by biomedical information and advice provided by public health professionals. CONCLUSION: Through an effective food-based intervention that includes qualitative research and a social marketing component, the behaviors of mothers and other caregivers can be modified, enabling children to realize the nutritional advantages of early introduction of eggs into their diet.
At our age, we would like to do things the way we want: a qualitative study of adolescent HIV testing services in Kenya.
AIDS. 2017 Jul 1; 31 Suppl 3:S213-S220.OBJECTIVES: Adolescents in Africa have low HIV testing rates. Better understanding of adolescent, provider, and caregiver experiences in high-burden countries such as Kenya could improve adolescent HIV testing programs. DESIGN: We conducted 16 qualitative interviews with HIV-positive and HIV-negative adolescents (13-18 years) and six focus group discussions with Healthcare workers (HCWs) and caregivers of adolescents in Nairobi, Kenya. METHODS: Semi-structured interviews and focus groups were recorded and transcribed. Analysis employed a modified constant comparative approach to triangulate findings and identify themes influencing testing experiences and practices. RESULTS: All groups identified that supportive interactions during testing were essential to the adolescent's positive testing experience. HCWs were a primary source of support during testing. HCWs who acted respectful and informed helped adolescents accept results, link to care, or return for repeat testing, whereas HCWs who acted dismissive or judgmental discouraged adolescent testing. Caregivers universally supported adolescent testing, including testing with the adolescent to demonstrate support. Caregivers relied on HCWs to inform and encourage adolescents. Although peers played less significant roles during testing, all groups agreed that school-based outreach could increase peer demand and counteract stigma. All groups recognized tensions around adolescent autonomy in the absence of clear consent guidelines. Adolescents valued support people during testing but wanted autonomy over testing and disclosure decisions. HCWs felt pressured to defer consent to caregivers. Caregivers wanted to know results regardless of adolescents' wishes. CONCLUSION: Findings indicate that strengthening HCW, caregiver, and peer capacities to support adolescents while respecting their autonomy may facilitate attaining '90-90-90' targets for adolescents.
Culture, Health and Sexuality. 2018 Nov; 20(11):1244-1258.Well-being is a term commonly used in discussions of sexuality, reproduction and sexual health, yet the meaning of the term is elusive and often disregarded. As an example, the ‘well-being’ component of sexual and reproductive health and well-being is often not explicitly addressed in research, policy and program development. The goal of this paper is to explore the meanings of sexual and reproductive well-being among young people in Fiji and their implications. Fourteen focus group discussions with young people aged 15 to 19 years and 40 key informant interviews were held in four Fijian settings. We found both different and shared meanings of sexual and reproductive well-being and suggest areas in which it can be strengthened in Fiji.
International Perspectives On Sexual and Reproductive Health. 2017 Jun 1; 43(2):75-87.CONTEXT: Levels of fertility and contraceptive use have long fluctuated in Kenya. The multicomponent Tupange program, part of the Urban Reproductive Health Initiative, was initiated in 2011 to increase use of modern family planning methods. METHODS: Women aged 15-49 in the five Kenyan cities where Tupange was implemented were interviewed in 2010 and reinterviewed in 2014 to obtain information on their contraceptive use and exposure to components of the Tupange program. Fixed-effects models were estimated to identify associations between program exposure and use of modern family planning methods. Analyses were performed to determine the relative cost-effectiveness of program components. RESULTS: During the four-year follow-up period, the proportion of women using modern contraceptives increased from 45% to 52%, and the proportion of users who were using long-acting or permanent methods rose from 6% to 19%. The fixed-effects model indicated that modern method use was associated with having heard Tupange-related local radio programming and marginally associated with having discussed family planning with a community health worker (CHW); among women who were unmarried or did not give birth during the study period, modern method use was associated with living near program facilities. Local radio programming was the most cost-effective program component, followed by proximity to Tupange facilities and discussions with CHWs. CONCLUSIONS: Urban reproductive health programs seeking to increase use of modern family planning methods in Kenya and other Sub-Saharan African settings should consider multicomponent approaches that include CHW activities, local radio programming and improvements to the supply environment.
The doing and undoing of male household decision-making and economic authority in Rwanda and its implications for gender transformative programming.
Culture, Health and Sexuality. 2017 Dec 1; 1-16.This paper explores two key norms that underpin intimate partner violence in Rwanda: men’s roles as economic providers and decision-making authorities in the household. It describes the political, legal and socio-economic factors affecting these norms and how they create opportunities and barriers to ‘undoing’ restrictive gender norms. Findings are drawn from an evaluation of Inadshyikirwa, an intimate partner violence prevention program operating in Rwanda. Across three intervention sectors, 24 focus groups were conducted with unmarried and married men and women residing in intervention communities. Thirty interviews with couples and nine interviews with opinion leaders were conducted before they completed program training designed to shift gender norms underlying intimate partner violence. The data indicate a strong awareness of and accountability to Rwandan laws and policies supporting women’s economic empowerment and decision-making, alongside persisting traditional notions of men as household heads and primary breadwinners. Transgression of these norms could be accommodated in some circumstances, especially those involving economic necessity. The data also identified increasing recognition of the value of a more equitable partnership model. Findings highlight the importance of carefully assessing cracks in the existing gender order that can be exploited to support gender equality and non-violence.
Understanding men's networks and perceptions of leadership to promote HIV testing and treatment in Agincourt, South Africa.
Global Public Health. 2018 Sep; 13(9):1296-1306.Understanding informal leadership in high HIV prevalence settings is important for the success of popular opinion leader (POL) and other HIV testing and treatment promotion strategies which aim to leverage the influence of these leaders. We conducted a study in Mpumalanga province, South Africa, in which we aimed to: (1) describe men’s personal networks and key social relationships; and (2) describe the types of individuals men identify as leaders. We administered a structured questionnaire with 45 men (15 HIV-positive and 30 HIV-negative) in which men enumerated and described characteristics of individuals they share personal matters with, and people they considered as leaders. We further conducted in-depth interviews with 25 of these men to better understand men’s conceptualization of leadership in their community. Family members were prominent in men’s personal networks and among the leaders they nominated. Men living with HIV were much more likely to know others living with HIV, and described friendships on the basis of the shared experience of HIV treatment. Future POL interventions aiming to promote HIV testing and care among men in rural South Africa should consider the importance of family in community leadership, and seek to leverage the influence of connections between men living with HIV.
Arlington, Virginia, SPRING, 2017 Sep. 8 p. (USAID Cooperative Agreement No. AID-OAA-A-11-00031)Transforming sociocultural beliefs around gender roles is critical to better nutrition outcomes. As part of SPRING’s HYPERLINK "/technical-areas/sbcc"social and behavior change communication (SBCC) strategy, we piloted the Gender Champion Approach, which aims to increase men and women’s partnership within the household in order to improve nutrition outcomes. We did this by encouraging women’s participation in household financial and nutrition-related decision making, as well as men’s involvement in nutrition- and hygiene-related tasks. The Gender Champion Approach identifies men who are already well known in their communities for performing desired gender-equitable practices and equips them with the knowledge and tools to become advocates for gender equality. As they take on this role, the champion couples become recognized as leaders and begin to influence others to follow their example, ultimately improving nutrition outcomes in their communities.
[Washington, D.C.], Maternal and Child Survival Program [MCSP], 2017 May. 21 p. (USAID Cooperative Agreement No. AID-OAA-A-14-00028)A formative research study was conducted in Kagera Region, Tanzania, to understand current service delivery practices, perceptions of family planning and immunization services, and barriers and opportunities for service integration to inform the development of an integrated service delivery approach for FP and immunization.
Re-establishing safer medical-circumcision-integrated initiation ceremonies for HIV prevention in a rural setting in Papua New Guinea. A multi-method acceptability study.
PloS One. 2017; 12(11):e0187577.BACKGROUND: Efforts to stem the spread of Human Immunodeficiency Virus (HIV) in Papua New Guinea (PNG) are hampered by multiple interrelated factors including limited health services, extreme diversities in culture and language and highly prevalent gender inequity, domestic violence and poverty. In the rural district of Yangoru-Saussia, a revival of previously ceased male initiation ceremonies (MICs) is being considered for a comprehensive approach to HIV prevention. In this study, we explore the local acceptability of this undertaking including replacing traditional penile cutting practices with medical male circumcision (MMC). METHODS: A multi-method study comprising three phases. Phase one, focus group discussions with male elders to explore locally appropriate approaches to HIV prevention; Phase two, interviews and a cross-sectional survey with community men and women to assess views on MICs that include MMC for HIV prevention; Phase three, interviews with cultural leaders and a cross sectional survey to assess the acceptability of replacing traditional penile bleeding with MMC. RESULTS: Cultural leaders expressed that re-establishing MICs was locally appropriate for HIV prevention given the focus on character building and cultural preservation. Most surveyed participants (81.5%) supported re-establishing MICs and 92.2% supported adapting MICs with MMC. Changes to penile bleeding emerged as a contentious and contested issue given its cultural significance in symbolizing initiates' transition from childhood to adulthood. Participants were concerned about potential clash with modern education, introduced religious beliefs and limited government support in leadership and funding. CONCLUSIONS: Most people in this study in Yangoru-Saussia support re-establishing MICs and replacing traditional penile bleeding with MMC. This culturally-sensitive alignment of MMC (and HIV prevention) with revived MICs responds to a national health priority in PNG and acts as an example of providing culturally-sensitive male circumcision for HIV prevention recommended by WHO/UNAIDS. However, the implementation of this undertaking will require considerable effort, especially when modern pursuits in education and religion must be factored and when there is expectation for local authorities to lead and provide funding.
Qualitative Assessment of Vaccination Hesitancy Among Members of the Apostolic Church of Zimbabwe: A Case Study.
Journal of Religion and Health. 2017 Oct; 56(5):1683-1691.Vaccine hesitancy or lack of confidence in vaccines is considered a threat to the success of vaccination programs. The rise and spread of measles outbreaks in southern Africa in 2009–2010 were linked to objections among Apostolic Church members, estimated at about 3.5 million in Zimbabwe as of 2014. To inform planning of interventions for a measles–rubella vaccination campaign, we conducted an assessment of the factors contributing to vaccine hesitancy using data from various stakeholders. Among nine districts in three regions of Zimbabwe, we collected data on religious attitudes toward, and perceptions of, vaccines through focus group discussions with health workers serving Apostolic communities and members of the National Expanded Programme on Immunization; semi-structured interviews with religious leaders; and open-ended questions in structured interviews with Apostolic parents/caregivers. Poor knowledge of vaccines, lack of understanding and appreciation of the effectiveness of vaccinations, religious teachings that emphasize prayers over the use of medicine, lack of privacy in a religiously controlled community, and low levels of education were found to be the main factors contributing to vaccine hesitancy among key community members and leaders. Accepting vaccination in public is a risk of sanctions. Poor knowledge of vaccines is a major factor of hesitancy which is reinforced by religious teachings on the power of prayers as alternatives. Because parents/caregivers perceive vaccines as dangerous for their children and believe they can cause death or disease, members of the Apostolic Church have more confidence in alternative methods such as use of holy water and prayers to treat diseases. Under these circumstances, it is important to debunk the myths about the power of holy water on the one hand and disseminate positive information of the efficacy of vaccines on the other hand in order to reduce hesitancy. Education about vaccines and vaccination in conjunction with government intervention, for example, through the use of social distancing policies can provide a framework for reducing hesitancy and increasing demand for vaccination.