Carol Underwood

Role of community-level factors across the treatment cascade: A critical review

Abstract:Addressing community-level factors (CLFs) is integral to the ongoing effort to design multilevel, effective, and sustainable interventions to address each element of the HIV/AIDS treatment cascade. This review, the first critical review of this topic, identified 100 articles that (1) assessed CLFs in relation to the HIV/AIDS treatment cascade, (2) had been peer-reviewed, and (3) were based on studies conducted in low- or middle-income countries. Social support and social networks, cultural norms, gender norms, and stigma were the key CLFs associated with treatment and care. This extensive review found only 5 evaluations of interventions designed to affect CLFs, reflecting a major gap in the literature. All were communication interventions designed to create a more positive environment for HIV testing and access to treatment and care, thus pointing to some of the potential extraindividual effects of communication interventions. The qualitative data are rich and vital for understanding the context; yet, more quantitative analysis to provide evidence regarding the distribution of these factors is essential, as only 19 of the studies were quantitative. There is a pressing need to (1) collect community-level data, (2) validate social and gender norm scales, and (3) better use available data regarding social norms, gender norms, and other CLFs. These data could be aggregated at the cluster, neighborhood, or community levels and incorporated into multilevel analysis to help clarify the pathways to enhanced outcomes across the treatment cascade and thereby mitigate HIV sequelae.

An examination of resilience cross-culturally in child and adolescent survivors of the 2008 China earthquake using the Connor-Davidson Resilience Scale (CD-RISC)

BACKGROUND The 2008 Sichuan earthquake in China destroyed towns and village, displaced over a million people and caused thousands of deaths. There is a need to understand how children and adolescents are able to bounce back after this distressing event. This study conducts a psychometric assessment of the Connor-Davidson Resilience Scale (CD-RISC) and the measures validity among children and adolescent survivors in order to identify the factors associated with resilience in this socio-cultural setting. METHODS Translated and culturally verified versions of the CD-RISC, UCLA-PTSD Index and Birleson Self-rating Depression Scale were used to collect data from 2132 children and adolescents located in post-disaster areas 1 year after the event. RESULTS Through exploratory factor analysis, a 2-factor model was found and defined by Chinese scholars as Rational Thinking and Self-Awareness. Internal consistency of total CD-RISC was 0.86, 0.91 for Rational Thinking and 0.74 for Self-Awareness. Convergent validity between items ranged from 0.17-0.69 and 0.12-0.20 to the total score. Items related to post-traumatic stress disorder loaded separately than CD-RISC items, demonstrating discriminant validity. CONCLUSIONS Our findings demonstrate that resilience may be understood and manifested dissimilarly in different socio-cultural settings. This study confirms the applicability of the CD-RISC scale to Chinese children and adolescent earthquake survivors, and adds to the richness of resilience research cross-culturally.

Injustice! That is the cause: a qualitative study of the social, economic, and structural determinants of late diagnosis and treatment of breast cancer in Egypt.

Background: In developing countries, breast cancer is generally diagnosed late. Two companion quantitative studies found that health system shortages were a major cause of delayed diagnosis together with poor health literacy. Yet, patients’ perceptions regarding the delays were missing. Objective: We conducted a qualitative study to deepen our understanding of women’s experiences with diagnosis and treatment delays and highlight nuances not identifiable in the quantitative studies. Interventions/Methods: Fifteen women recruited from the quantitative study were interviewed. Information on diagnosis/treatment delays collected in the quantitative study constituted the basis for the selection of participants, the aim being to ensure a maximum of variability in the types of delays. Results: In addition to women’s health literacy challenges, which likely resulted from the interactions of individual, interpersonal, and systemic factors, barriers attributable to healthcare system weaknesses and financial constraints were revealed to be key factors. Conclusions: To reduce late-stage diagnosis, tackling women’s “lack of breast cancer awareness” is far from sufficient. Although the majority of health professionals are not in a position to address structural and policy barriers, it is nonetheless important for them to be cognizant of these barriers so that they can better advise and guide their patients. Implications for Practice: Our study aimed to provide a deeper understanding of the social, cultural, and structural barriers patients face in Egypt. Such knowledge should help nurses and other health professionals develop a nonjudgmental, compassionate, and perceptive approach to care.

Community Support and Adolescent Girls' Vulnerability to HIV/AIDS: Evidence From Botswana, Malawi, and Mozambique

Girls are vulnerable to HIV in part because the social systems in which they live have failed to support and protect them. The goal of this research was to develop a viable supportive community index and test its association with intermediate variables associated with HIV risk across 16 communities in Botswana, Malawi, and Mozambique. This cross-sectional survey with separate samples randomly drawn in each country (2010) yielded a total sample of 1,418 adolescent girls (aged 11–18). Multilevel, multivariate logistic regression, while controlling for vulnerability, age, religion, and residence, found that an increase in supportive community index is positively associated with the odds of indicating improved community support for girls and with the confidence to refuse unwanted sex with a boyfriend across the three countries, as well as with self-efficacy to insist on condom use in Botswana and Mozambique. Program implementers and decision makers alike can use the supportive community index to identify and measure structural factors associated with girls’ vulnerability to HIV/AIDS; this will potentially contribute to judicious decision making regarding resource allocation to enhance community-level, protective factors for adolescent girls.

A meta-review of school-based disaster interventions for child and adolescent survivors

Background: Children and adolescents are among the most vulnerable groups affected by natural and man-made disaster. To better understand research and practice concerning mental health and psychosocial support efforts in humanitarian settings, the authors conducted a comprehensive review of all intervention programmes within the past decade that universally targeted children and adolescents who were exposed to a natural and/or man-made disaster. Methods: We searched PubMed, PsychINFO, Cochrane Library and CINAHL for mental health and psychosocial interventions (MHPSS) involving children and adolescents. A total of 11 studies, 4 from natural disasters and 7 from conflict-affected areas met the inclusion criteria. Effect sizes were calculated using a random effects model for studies in post-natural disaster and war/terrorist-affected settings separately. Results: The weighted mean effect sizes for interventions in both settings were statistically significant: −0.308, 95% CI=−0.54– −0.07, z=−2.58, p=0.010 after a natural disaster, and −0.514, 95% CI=−0.80 to −0.23, z=−3.57, p<0.001 in conflict areas. This indicates that MHPSS interventions in both disaster settings resulted in a reduction in PTSD symptoms compared to the control. Conclusions: This review suggests that school-based, universal programmes that are conducted by teachers or local paraprofessionals are effective in reducing PTSD symptoms in children and adolescents. The few studies meeting the inclusion criteria of this study demonstrate the need for further expansion of statistical methods and study designs to test for the effects of interventions in challenging humanitarian settings.

Religious leaders gain ground in the Jordanian family-planning movement.

To assess the effect of a training program designed to enhance the role of Muslim religious leaders (RLs) in promoting family welfare, including reproductive health generally and family planning more specifically.

Multi-level Responses to Multi-level Vulnerabilities: Creating an Enabling Environment for HIV Prevention for Girls in Botswana, Malawi, and Mozambique

In sub-Saharan Africa, girls are several times more likely to be infected with HIV than are boys of the same age and young people aged 15–24 years represent more than half of all new infections. An extensive literature review augmented by formative research conducted in Botswana, Malawi and Mozambique reveals that although individual sexual behaviors heighten risk, a complex interaction of structural factors outside of girls’ control is fueling the epidemic. Guided by the understanding that individuals are influenced by a system of socio-cultural relationships – families, social networks, communities and nations – the Go Girls! (GG) Program incorporated a social ecological approach to prevent HIV. Eight multifaceted interventions were designed and implemented to simultaneously reach communities, leaders, teachers, parents/guardians and young people themselves. This chapter highlights evidence that, despite a short implementation period of 10 months or less, positive effects were extended to girls when adults in their communities worked together to create a more enabling environment for their health, well-being and HIV prevention.

‘You already drank my beer, I can decide anything’: using structuration theory to explore the dynamics of alcohol use, gender-based violence and HIV risk among female sex workers in Tanzania

Abstract Female sex workers experience high rates of gender-based violence and HIV. Alcohol has been shown to facilitate women’s risk of both gender-based violence and HIV; however, little research has explored how aspects of the sex work environment shape this risk. Drawing on structuration theory, this study explored how social conduct is patterned across time and space within the sex work environment to influence alcohol consumption, gender-based violence and HIV risk among female sex workers. Qualitative in-depth interviews were conducted with 24 female sex workers enrolled in an ongoing community randomised controlled trial of a combination HIV prevention intervention in Iringa, Tanzania. Data were analysed using both inductive and deductive approaches. Findings reveal how routine interactions between female sex workers and their clients occur at three moments of time and space during the sex exchange process to facilitate alcohol consumption and increase women’s risk of gender-based violence and HIV. Findings also highlight how sex workers utilise collective agency to address aspects of the sex work environment that place them at risk of alcohol abuse, gender-based violence and HIV. Implications for future interventions to prevent gender-based violence and HIV among female sex workers in Tanzania and similar contexts are discussed.

Urbanicity of residence and depression among adults 50 years and older in Ghana and South Africa: an analysis of the WHO Study on Global AGEing and Adult Health (SAGE)

ABSTRACT Objectives: As the primary cause of disability worldwide, depression is a significant contributor to global morbidity and mortality and often disproportionately affects older adults. Several studies have demonstrated a link between urban residence and depression, but few studies have examined this association among older adult populations, and even fewer have studied it within an African context. Given that African societies are aging and urbanizing at rapid rates, this study aimed to assess the relationship between urbanicity and depression within older adult populations in two African countries. Method: Data were drawn from the Ghana and South Africa samples of the World Health Organization Study on Global AGEing and Adult Health (SAGE) wave 1 (2007–2008). Depression over the past 12 months was measured using self-reported treatment and depressive symptoms based on ICD-10 criteria in 4209 Ghanaian and 3148 South African adults aged 50 years and older residing in their current location for over one year. Results: The 12-month prevalence of depression was 7.5% and 4.0% in Ghana and South Africa, respectively; 41.1% and 65.6%, respectively, lived in urban areas. Comparing urban to rural residents, the adjusted odds ratio (OR) for depression in multivariable analysis was 1.13 (95% CI: 0.71–1.79) in South Africa and 0.85 (95% CI: 0.55–1.31) in Ghana. Conclusion: Results do not support a significant urban-rural difference in 12-month depression among Ghanaian or South African SAGE participants. Mental health resources in rural areas should therefore be enhanced in these countries for more equitable distributions between the two settings given similar need.

The (re)productive work of labour migration: the reproductive lives of women with an absent spouse in the central hill region of Nepal

Abstract Limited attention has been given to the effects of labour migration on the reproductive lives of women ‘left behind’ as their partners travel for work. Drawing on two rounds of qualitative interviews with 20 women in the central hill region of Nepal, this paper examines how global economic processes that lead Nepali men to travel for work also affect women’s reproductive work, including childrearing and reproductive decision-making. Women understood their husband’s migration to engage in the wage economy as a response to both immediate and long-term goals for their children and family. As a result, such productive work was intrinsically linked to reproductive work. Men’s migration patterns played a pivotal role in reinforcing women’s immediate childrearing roles and affecting whether and when women used a contraceptive method and what methods they considered. During periods of spousal migration, women’s reproductive lives became targets of gossip and rumours as their intimate and reproductive practices and use of remittances were socially monitored. This complex understanding of women’s lived experiences at the nexus of (re)productive work and labour migration can be practically applied to address the reproductive health needs of women with migrant spouses in Nepal.