School-based sex education is a cornerstone of HIV prevention for adolescents who continue to bear a disproportionally high HIV burden globally. We systematically reviewed and meta-analyzed the ...existing evidence for school-based sex education interventions in low- and middle-income countries to determine the efficacy of these interventions in changing HIV-related knowledge and risk behaviors.
We searched five electronic databases, PubMed, Embase, PsycInfo, CINAHL, and Sociological Abstracts, for eligible articles. We also conducted hand-searching of key journals and secondary reference searching of included articles to identify potential studies. Intervention effects were synthesized through random effects meta-analysis for five outcomes: HIV knowledge, self-efficacy, sexual debut, condom use, and number of sexual partners.
Of 6191 unique citations initially identified, 64 studies in 63 articles were included in the review. Nine interventions either focused exclusively on abstinence (abstinence-only) or emphasized abstinence (abstinence-plus), whereas the remaining 55 interventions provided comprehensive sex education. Thirty-three studies were able to be meta-analyzed across five HIV-related outcomes. Results from meta-analysis demonstrate that school-based sex education is an effective strategy for reducing HIV-related risk. Students who received school-based sex education interventions had significantly greater HIV knowledge (Hedges g = 0.63, 95% Confidence Interval (CI): 0.49-0.78, p<0.001), self-efficacy related to refusing sex or condom use (Hedges g = 0.25, 95% CI: 0.14-0.36, p<0.001), condom use (OR = 1.34, 95% CI: 1.18-1.52, p<0.001), fewer sexual partners (OR = 0.75, 95% CI:0.67-0.84, p<0.001) and less initiation of first sex during follow-up (OR = 0.66, 95% CI: 0.54-0.83, p<0.001).
The paucity of abstinence-only or abstinence-plus interventions identified during the review made comparisons between the predominant comprehensive and less common abstinence-focused programs difficult. Comprehensive school-based sex education interventions adapted from effective programs and those involving a range of school-based and community-based components had the largest impact on changing HIV-related behaviors.
To investigate the relationship between maternal depression and child growth in developing countries through a systematic literature review and meta-analysis.
Six databases were searched for studies ...from developing countries on maternal depression and child growth published up until 2010. Standard meta-analytical methods were followed and pooled odds ratios (ORs) for underweight and stunting in the children of depressed mothers were calculated using random effects models for all studies and for subsets of studies that met strict criteria on study design, exposure to maternal depression and outcome variables. The population attributable risk (PAR) was estimated for selected studies.
Seventeen studies including a total of 13,923 mother and child pairs from 11 countries met inclusion criteria. The children of mothers with depression or depressive symptoms were more likely to be underweight (OR: 1.5; 95% confidence interval, CI: 1.2-1.8) or stunted (OR: 1.4; 95% CI: 1.2-1.7). Subanalysis of three longitudinal studies showed a stronger effect: the OR for underweight was 2.2 (95% CI: 1.5-3.2) and for stunting, 2.0 (95% CI: 1.0-3.9). The PAR for selected studies indicated that if the infant population were entirely unexposed to maternal depressive symptoms 23% to 29% fewer children would be underweight or stunted.
Maternal depression was associated with early childhood underweight and stunting. Rigorous prospective studies are needed to identify mechanisms and causes. Early identification, treatment and prevention of maternal depression may help reduce child stunting and underweight in developing countries.
Summary A community empowerment-based response to HIV is a process by which sex workers take collective ownership of programmes to achieve the most effective HIV outcomes and address social and ...structural barriers to their overall health and human rights. Community empowerment has increasingly gained recognition as a key approach for addressing HIV in sex workers, with its focus on addressing the broad context within which the heightened risk for infection takes places in these individuals. However, large-scale implementation of community empowerment-based approaches has been scarce. We undertook a comprehensive review of community empowerment approaches for addressing HIV in sex workers. Within this effort, we did a systematic review and meta-analysis of the effectiveness of community empowerment in sex workers in low-income and middle-income countries. We found that community empowerment-based approaches to addressing HIV among sex workers were significantly associated with reductions in HIV and other sexually transmitted infections, and with increases in consistent condom use with all clients. Despite the promise of a community-empowerment approach, we identified formidable structural barriers to implementation and scale-up at various levels. These barriers include regressive international discourses and funding constraints; national laws criminalising sex work; and intersecting social stigmas, discrimination, and violence. The evidence base for community empowerment in sex workers needs to be strengthened and diversified, including its role in aiding access to, and uptake of, combination interventions for HIV prevention. Furthermore, social and political change are needed regarding the recognition of sex work as work, both globally and locally, to encourage increased support for community empowerment responses to HIV.
Social capital is important to disadvantaged groups, such as sex workers, as a means of facilitating internal group-related mutual aid and support as well as access to broader social and material ...resources. Studies among sex workers have linked higher social capital with protective HIV-related behaviors; however, few studies have examined social capital among sex workers in sub-Saharan Africa. This cross-sectional study examined relationships between two key social capital constructs, social cohesion among sex workers and social participation of sex workers in the larger community, and HIV-related risk in Swaziland using respondent-driven sampling. Relationships between social cohesion, social participation, and HIV-related risk factors were assessed using logistic regression. HIV prevalence among the sample was 70.4% (223/317). Social cohesion was associated with consistent condom use in the past week (adjusted odds ratio AOR = 2.25, 95% confidence interval CI: 1.30-3.90) and was associated with fewer reports of social discrimination, including denial of police protection. Social participation was associated with HIV testing (AOR = 2.39, 95% CI: 1.36-4.03) and using condoms with non-paying partners (AOR = 1.99, 95% CI: 1.13-3.51), and was inversely associated with reported verbal or physical harassment as a result of selling sex (AOR = 0.55, 95% CI: 0.33-0.91). Both social capital constructs were significantly associated with collective action, which involved participating in meetings to promote sex worker rights or attending HIV-related meetings/ talks with other sex workers. Social- and structural-level interventions focused on building social cohesion and social participation among sex workers could provide significant protection from HIV infection for female sex workers in Swaziland.
Despite the enormous expansion of HIV testing services (HTS), an estimated 40% of people with HIV infection remain undiagnosed. To enhance the efficiency of HTS, new approaches are needed. The WHO ...conducted a systematic review on the effectiveness of assisted partner notification in improving HIV test uptake and diagnosis, and the occurrence of adverse events, to inform the development of normative guidelines.
We systematically searched five electronic databases through June 2016. We also contacted experts in the field and study authors for additional information where needed. Eligible studies compared assisted HIV partner notification services to passive or no notification. Where multiple studies reported comparable outcomes, meta-analysis was conducted using a random-effects model to produce relative risks (RRs) or risk ratios and 95% confidence intervals (CIs).
Of 1742 citations identified, four randomized controlled trials and six observational studies totalling 5150 index patients from eight countries were included. Meta-analysis of three individually randomized trials showed that assisted partner notification services resulted in a 1.5-fold increase in HTS uptake among partners compared with passive referral (RR = 1.46; 95% CI: 1.22-1.75; I = 0%). The proportion of HIV-positive partners was 1.5 times higher with assisted partner notification than with passive referral (RR = 1.47; 95% CI: 1.12-1.92; I = 0%). Few instances of violence or harm occurred.
Assisted partner notification improved partner testing and diagnosis of HIV-positive partners, with few reports of harm. WHO strongly recommends voluntary assisted HIV partner notification services to be offered as part of a comprehensive package of testing and care.
IntroductionHuman papillomavirus (HPV) self-sampling test kits may increase screening for and early detection of cervical cancer and reduce its burden globally. To inform WHO self-care guidelines, we ...conducted a systematic review and meta-analysis of HPV self-sampling among adult women on cervical (pre-)cancer screening uptake, screening frequency, social harms/adverse events and linkage to clinical assessment/treatment.MethodsThe included studies compared women using cervical cancer screening services with HPV self-sampling with women using standard of care, measured at least one outcome, and were published in a peer-reviewed journal. We searched PubMed, the Cumulative Index to Nursing and Allied Health Literature (CNIAHL), Latin American and Caribbean Health Sciences Literature (LILACS) and Embase through October 2018. Risk of bias was assessed using the Cochrane tool for randomised controlled trials (RCTs) and the Evidence Project tool for non-randomised studies. Meta-analysis was conducted using random-effects models to generate pooled estimates of relative risk (RR).Results33 studies in 34 articles with 369 017 total participants met the inclusion criteria: 29 RCTs and 4 observational studies. All studies examined HPV self-sampling; comparison groups were standard of care (eg, Pap smear, visual inspection with acetic acid, clinician-collected HPV testing). 93% of participants were from high-income countries. All 33 studies measured cervical cancer screening uptake. Meta-analysis found greater screening uptake among HPV self-sampling participants compared with control (RR: 2.13, 95% CI 1.89 to 2.40). Effect size varied by HPV test kit dissemination method, whether mailed directly to home (RR: 2.27, 95% CI 1.89 to 2.71), offered door-to-door (RR: 2.37, 95% CI 1.12 to 5.03) or requested on demand (RR: 1.28, 95% CI 0.90 to 1.82). Meta-analysis showed no statistically significant difference in linkage to clinical assessment/treatment between arms (RR: 1.12, 95% CI 0.80 to 1.57). No studies measured screening frequency or social harms/adverse events.ConclusionA growing evidence base, mainly from high-income countries and with significant heterogeneity, suggests HPV self-sampling can increase cervical cancer screening uptake compared with standard of care, with a marginal effect on linkage to clinical assessment/treatment.Systematic review registration numberPROSPERO CRD42018114871.
HIV self-testing may encourage greater uptake of testing, particularly among key populations and other high-risk groups, but local community perceptions will influence test uptake and use. We ...conducted 33 in-depth interviews and 6 focus group discussions with healthcare providers and community members in high-risk fishing communities (including sex workers and fishermen) and lower-risk mainland communities in rural Uganda to evaluate values and preferences around HIV self-testing. While most participants were unfamiliar with HIV self-testing, they cited a range of potential benefits, including privacy, convenience, and ability to test before sex. Concerns focused on the absence of a health professional, risks of careless kit disposal and limited linkage to care. Participants also discussed issues of kit distribution strategies and cost, among others. Ultimately, most participants concluded that benefits outweighed risks. Our findings suggest a potential role for HIV self-testing across populations in these settings, particularly among these key populations. Program implementers will need to consider how to balance HIV self-testing accessibility with necessary professional support.
Social capital, defined as the nature of the social relationship and the resources embedded within the social network of an individual or community, influences how individuals within a group interact ...and collaborate within their communities or organizations. While it is acknowledged that social capital can be drawn from as a coping strategy to mitigate financial stress, there is a notable absence of the lived experience in the literature on how social capital influences households to tap resources from their social network. We have investigated the role of social capital in healthcare financing in rural Uttar Pradesh, India, highlighting the challenges faced by households in managing healthcare expenses. We took a qualitative research approach, conducting in-depth interviews with 24 households in the Hardoi District of Uttar Pradesh in August 2017 to explore participants’ lived experience of accruing support from their community during their healthcare crisis. Data analysis followed a thematic content analysis approach. The study finds that households leverage social capital for both financial and non-financial support during health crises. Social networks, trust, and community cohesion play critical roles in resource acquisition. However, overreliance on social capital can be coercive, leading to inequity, privacy invasion, and dependency. Though social capital serves as a crucial resource of support in healthcare emergencies, its unequal distribution and potential for misuse highlight the need for more structured health financing policies in India. The findings underscore the importance of integrating community-driven resources into broader health financing strategies, considering local social structures and community dynamics.
•Rural Indian families from Uttar Pradesh use social capital to fund health cost.•Social capital impacts equal access to community resources during a health crisis.•Community's contribution included financial, logistical, and emotional support.•Reciprocal trust catalyzes a cycle of social cohesion and continuous mutual support.•Excessive reliance on social capital may coerce or invade privacy.
Healthcare providers on the frontlines McMahon, Shannon A.; Ho, Lara S.; Brown, Hannah ...
Health policy and planning,
11/2016, Volume:
31, Issue:
9
Journal Article
Peer reviewed
Open access
Although research on the epidemiology and ecology of Ebola has expanded since the 2014–15 outbreak in West Africa, less attention has been paid to the mental health implications and the psychosocial ...context of the disease for providers working in primary health facilities (rather than Ebola-specific treatment units). This study draws on 54 qualitative interviews with 35 providers working in eight peripheral health units of Sierra Leone’s Bo and Kenema Districts. Data collection started near the height of the outbreak in December 2014 and lasted 1 month. Providers recounted changes in their professional, personal and social lives as they became de facto first responders in the outbreak. A theme articulated across interviews was Ebola’s destruction of social connectedness and sense of trust within and across health facilities, communities and families. Providers described feeling lonely, ostracized, unloved, afraid, saddened and no longer respected. They also discussed restrictions on behaviors that enhance coping including attending burials and engaging in physical touch (hugging, handshaking, sitting near, or eating with colleagues, patients and family members). Providers described infection prevention measures as necessary but divisive because screening booths and protective equipment inhibited bonding or ‘suffering with’patients. To mitigate psychiatric morbidities and maladaptive coping mechanisms—and to prevent the spread of Ebola—researchers and program planners must consider the psychosocial context of this disease and mechanisms to enhance psychological first aid to all health providers, including those in peripheral health settings.
Bien que la recherche sur l’épidémiologie et l’écologie du virus Ebola se soit développée depuis l’épidémie de 2014-15 en Afrique de l’Ouest, on accorde peu d’attention à ses répercussions sur la santé mentale et le contexte psychosocial de la maladie pour les prestataires travaillant dans les établissements de soins de santé primaires (plutôt que des unités chargées spécifiquement du traitement d’Ebola). La présente étude se fonde sur 54 entretiens qualitatifs avec 35 prestataires travaillant dans huit centres de santé périphériques des districts de Bo et Kenema en Sierra Leone. La collecte des données a commencé peu avant le climax de l’épidémie en décembre 2014 et a duré 1 mois. Les prestataires ont relaté les changements survenus dans leur vie professionnelle, personnelle et sociale puisqu’ils étaient devenus de facto les premiers intervenants dans la lutte contre l’épidémie. La destruction par Ebola, des liens sociaux et du sentiment de confiance au sein et au-delà des formations sanitaires, des communautés et des familles, est un thème récurrent lors des entrevues. Les prestataires ont raconté qu’ils se sentaient seuls, ostracisés, mal aimés, apeurés, attristés et qu’ils n’étaient plus respectés. Ils ont également discuté des restrictions sur les comportements qui améliorent l’adaptation, notamment assister aux enterrements et accepter les contacts physiques (embrassades, poignées de main, s’asseoir ou manger avec des collègues, des patients et des membres de la famille). Les prestataires ont décrit les mesures de prévention de l’infection comme étant nécessaires, mais controversées, parce que les cabines de dépistage et l’équipement de protection empêchaient l’instauration de liens affectifs ou « d’empathie » avec les patients. Pour atténuer les mécanismes de morbidité psychiatrique et d’inadaptation - et prévenir la propagation du virus Ebola -, les chercheurs et les planificateurs des programmes doivent tenir compte du contexte psychosocial de cette maladie et mettre en place des mécanismes permettant d’améliorer l’assistance psychologique à tous les prestataires de soins de santé, notamment dans les centres de santé périphériques.
Aunque la investigación sobre la epidemiología y la ecología del Ébola se ha expandido desde la epidemia del 2014-15 en África occidental, se le ha prestado menos atención a las implicaciones para la salud mental y el contexto psicosocial de la enfermedad de los proveedores que trabajan en centros de atención primaria de salud (en lugar de unidades de tratamiento específicos para el Ébola). Este estudio se basa en 54 entrevistas cualitativas con 35 proveedores que trabajan en ocho unidades de salud periféricas de los distritos de Bo y Kenema de Sierra Leona. La recolección de datos se inició cerca del punto más alto de la epidemia en diciembre de 2014 y duró l mes. Los proveedores describieron los cambios en su vida profesional, personal y social, a medida que se convirtieron en los primeros en responder de facto a la epidemia. Un tema articulado a través de las entrevistas fue la destrucción de la conexión social y el sentido de la confianza dentro y fuera de los centros de salud, las comunidades y las familias causada por el Ébola. Los proveedores describieron sentirse solos, aislados, sin amor, con miedo, tristes y ya no respetados. También discutieron las restricciones sobre los comportamientos que mejoran el acople incluyendo asistir a los entierros y la participación en el contacto físico (abrazos, apretón de manos, sentarse cerca, o comer con colegas, pacientes y miembros de la familia). Los proveedores describieron las medidas de prevención de infecciones como necesarias pero divisivas ya que las cabinas de examinación y equipos de protección inhibieron el acercamiento o ’el sufrimiento con’ los pacientes. Para mitigar las morbilidades psiquiátricas y mecanismos inadecuados de acople- y para evitar la propagación del Ébola- los investigadores y planificadores de programas deben tener en cuenta el contexto psicosocial de esta enfermedad y los mecanismos para mejorar los primeros auxilios psicológicos a todos los proveedores de salud, incluyendo aquellos en centros de salud periféricos.
尽管关于埃博拉的流行和生态的研究已经解释了2014-2015年 间在西非的爆发, 却很少有人关注在初级医疗机构（不是专门 治疗埃博的机构）提供医疗服务的人员的精神健康心理。本 文使用的数据来自于对塞拉利昂Bo和Kenema地区8个周边医 疗单位工作的35个服务提供者进行的54个定性访谈。数据的 收集始于2014年12月, 大概是疾病爆发的高峰, 并持续了一个 月。这些人讲述了他们在疾病爆发中职业、个人和生活上的 变化。一个大家共同提到的主题是埃博拉破坏了社会连接和 机构中、社区中和家庭中大家的信任感。医疗服务提供者描 述自己感到孤单、排斥、不被爱、害怕、悲伤和不再受到尊 重。他们同时也提到了一个行为上的限制, 包括参加葬礼和身 体接触（拥抱, 握手, 坐的比较近, 与同事、病人和家庭成员 吃饭）。他们形容预防感染的措施是需要的, 但是造成了间 隔, 因为这些防御措施阻止了他们与病人之间的互动。为了抵 消精神创伤和心理应对机制——同时防止埃博拉的传染—— 研究人员和项目规划者应该疾病给医护人员带来的心理情境, 以及应对这种问题的机制。
Progression through the HIV continuum of care, from HIV testing to lifelong retention in antiretroviral therapy (ART) care and treatment programs, is critical to the success of HIV treatment and ...prevention efforts. However, significant losses occur at each stage of the continuum and little is known about contextual factors contributing to disengagement at these stages. This study sought to explore multi-level barriers and facilitators influencing entry into and engagement in the continuum of care in Iringa, Tanzania. We used a mixed-methods study design including facility-based assessments and interviews with providers and clients of HIV testing and treatment services; interviews, focus group discussions and observations with community-based providers and clients of HIV care and support services; and longitudinal interviews with men and women living with HIV to understand their trajectories in care. Data were analyzed using narrative analysis to identify key themes across levels and stages in the continuum of care. Participants identified multiple compounding barriers to progression through the continuum of care at the individual, facility, community and structural levels. Key barriers included the reluctance to engage in HIV services while healthy, rigid clinic policies, disrespectful treatment from service providers, stock-outs of supplies, stigma and discrimination, alternate healing systems, distance to health facilities and poverty. Social support from family, friends or support groups, home-based care providers, income generating opportunities and community mobilization activities facilitated engagement throughout the HIV continuum. Findings highlight the complex, multi-dimensional dynamics that individuals experience throughout the continuum of care and underscore the importance of a holistic and multi-level perspective to understand this process. Addressing barriers at each level is important to promoting increased engagement throughout the continuum.
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