Joanna Crichton

HIV/AIDS among youth in urban informal (slum) settlements in Kenya: What are the correlates of and motivations for HIV testing?

BackgroundAlthough HIV counseling and testing (HCT) is widely considered an integral component of HIV prevention and treatment strategies, few studies have examined HCT behavior among youth in sub-Saharan Africa-a group at substantial risk for HIV infection. In this paper we examine: the correlates of HIV testing, including whether associations differ based on the context under which a person gets tested; and the motivations for getting (or not getting) an HIV test.MethodsDrawing on data collected in 2007 from 4028 (51% male) youth (12-22 years) living in Korogocho and Viwandani slum settlements in Nairobi (Kenya), we explored the correlates of and motivations for HIV testing using the Health Belief Model (HBM) as a theoretical framework. Multinomial and binary logistic regression analyses were employed to examine correlates of HIV testing. Bivariate analyses were employed to assess reasons for or against testing.ResultsNineteen percent of males and 35% of females had been tested. Among tested youth, 74% of males and 43% of females had requested for their most recent HIV test while 7% of males and 32% of females reported that they were required to take their most recent HIV test (i.e., the test was mandatory). About 60% of females who had ever had sex received an HIV test because they were pregnant. We found modest support for the HBM in explaining variation in testing behavior. In particular, we found that perceived risk for HIV infection may drive HIV testing among youth. For example, about half of youth who had ever had sex but had never been tested reported that they had not been tested because they were not at risk.ConclusionsTargeted interventions to help young people correctly assess their level of risk and to increase awareness of the potential value of HIV testing may help enhance uptake of testing services. Given the relative success of Prevention of Mother-to-Child Transmission (PMTCT) services in increasing HIV testing rates among females, routine provider-initiated testing and counseling among all clients visiting medical facilities may provide an important avenue to increase HIV status awareness among the general population and especially among males.

Changing fortunes: analysis of fluctuating policy space for family planning in Kenya

Policies relating to contraceptive services (population, family planning and reproductive health policies) often receive weak or fluctuating levels of commitment from national policy elites in Southern countries, leading to slow policy evolution and undermining implementation. This is true of Kenya, despite the governments early progress in committing to population and reproductive health policies, and its success in implementing them during the 1980s. This key informant study on family planning policy in Kenya found that policy space contracted, and then began to expand, because of shifts in contextual factors, and because of the actions of different actors. Policy space contracted during the mid-1990s in the context of weakening prioritization of reproductive health in national and international policy agendas, undermining access to contraceptive services and contributing to the stalling of the countrys fertility rates. However, during the mid-2000s, champions of family planning within the Kenyan Government bureaucracy played an important role in expanding the policy space through both public and hidden advocacy activities. The case study demonstrates that policy space analysis can provide useful insights into the dynamics of routine policy and programme evolution and the challenge of sustaining support for issues even after they have reached the policy agenda.

Self-reported drunkenness among adolescents in four sub-Saharan African countries: associations with adverse childhood experiences.

BackgroundConsumption of alcohol is associated with acute and chronic adverse health outcomes. There is a paucity of studies that explore the determinants of alcohol use among adolescents in sub-Saharan Africa and, in particular, that examine the effects of adverse childhood experiences on alcohol use.MethodsThe paper draws on nationally-representative data from 9,819 adolescents aged 12-19 years from Burkina Faso, Ghana, Malawi, and Uganda. Logistic regression models were employed to identify correlates of self-reported past-year drunkenness. Exposure to four adverse childhood experiences comprised the primary independent variables: living in a food-insecure household, living with a problem drinker, having been physically abused, and having been coerced into having sex. We controlled for age, religiosity, current schooling status, the household heads sex, living arrangements, place of residence, marital status, and country of survey. All analyses were conducted separately for males and females.ResultsAt the bivariate level, all independent variables (except for coerced sex among males) were associated with the outcome variable. Overall, 9% of adolescents reported that they had been drunk in the 12 months preceding the survey. In general, respondents who had experienced an adverse event during childhood were more likely to report drunkenness. In the multivariate analysis, only two adverse childhood events emerged as significant predictors of self-reported past-year drunkenness among males: living in a household with a problem drinker before age 10, and being physically abused before age 10. For females, exposure to family-alcoholism, experience of physical abuse, and coerced sex increased the likelihood of reporting drunkenness in the last 12 months. The association between adverse events and reported drunkenness was more pronounced for females. For both males and females there was a graded relationship between the number of adverse events experienced and the proportion reporting drunkenness.ConclusionsWe find an association between experience of adverse childhood events and drunkenness among adolescents in four sub-Saharan African countries. The complex impacts of adverse childhood experiences on young peoples development and behavior may have an important bearing on the effectiveness of interventions geared at reducing alcohol dependence among the youth.

What shapes research impact on policy? Understanding research uptake in sexual and reproductive health policy processes in resource poor contexts

Assessing the impact that research evidence has on policy is complex. It involves consideration of conceptual issues of what determines research impact and policy change. There are also a range of methodological issues relating to the question of attribution and the counter-factual. The dynamics of SRH, HIV and AIDS, like many policy arenas, are partly generic and partly issue- and context-specific. Against this background, this article reviews some of the main conceptualisations of research impact on policy, including generic determinants of research impact identified across a range of settings, as well as the specificities of SRH in particular. We find that there is scope for greater cross-fertilisation of concepts, models and experiences between public health researchers and political scientists working in international development and research impact evaluation. We identify aspects of the policy landscape and drivers of policy change commonly occurring across multiple sectors and studies to create a framework that researchers can use to examine the influences on research uptake in specific settings, in order to guide attempts to ensure uptake of their findings. This framework has the advantage that distinguishes between pre-existing factors influencing uptake and the ways in which researchers can actively influence the policy landscape and promote research uptake through their policy engagement actions and strategies. We apply this framework to examples from the case study papers in this supplement, with specific discussion about the dynamics of SRH policy processes in resource poor contexts. We conclude by highlighting the need for continued multi-sectoral work on understanding and measuring research uptake and for prospective approaches to receive greater attention from policy analysts.

Operationalising sexual and reproductive health and rights in sub-Saharan Africa: constraints, dilemmas and strategies

BackgroundThe continued poor sexual and reproductive health (SRH) outcomes in sub-Saharan Africa highlight the difficulties in reforming policies and laws, and implementing effective programmes. This paper uses one international and two national case studies to reflect on the challenges, dilemmas and strategies used in operationalising sexual and reproductive health and rights (SRHR) in different African contexts.MethodsThe international case study focuses on the progress made by African countries in implementing the African Union’s Maputo Plan of Action (for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights) and the experiences of state and non-state stakeholders in this process. The case was developed from an evaluation report of the progress made by nine African countries in implementing the Plan of Action, qualitative interviews exploring stakeholders’ experiences and perceptions of the operationalisation of the plan (carried out as part of the evaluation) in Botswana and Nigeria, and authors’ reflections. The first national case study explores the processes involved in influencing Ghana’s Domestic Violence Act passed in 2007; developed from a review of scientific papers and organisational publications on the processes involved in influencing the Act, qualitative interview data and authors’ reflections. The second national case study examines the experiences with introducing the 2006 Sexual Offences Act in Kenya, and it is developed from organisational publications on the processes of enacting the Act and a review of media reports on the debates and passing of the Act.ResultsBased on the three cases, we argue that prohibitive laws and governments’ reluctance to institute and implement comprehensive rights approaches to SRH, lack of political leadership and commitment to funding SRHR policies and programmes, and dominant negative cultural framing of women’s issues present the major obstacles to operationalising SRH rights. Analysis of successes points to the strategies for tackling these challenges, which include forming and working through strategic coalitions, employing strategic framing of SRHR issues to counter opposition and gain support, collaborating with government, and employing strategic opportunism.ConclusionThe strategies identified show future pathways through which challenges to the realisation of SRHR in Africa can be tackled.

Emotional and Psychosocial Aspects of Menstrual Poverty in Resource-Poor Settings: A Qualitative Study of the Experiences of Adolescent Girls in an Informal Settlement in Nairobi

We introduce the concept of “menstrual poverty” to categorize the multiple deprivations relating to menstruation in resource-poor settings across the Global South, and we examine how this affects the psychological well-being of adolescent girls in an urban informal settlement in Kenya. We use qualitative data collected through 34 in-depth interviews and 18 focus group discussions with girls, women, and key informants. Menstrual poverty involved practical and psychosocial challenges affecting girls at home and at school. Its emotional impacts included anxiety, embarrassment, fear of stigma, and low mood. Further research is needed on how menstrual poverty affects girls’ psychological and educational outcomes.

Strengthening the research to policy and practice interface: exploring strategies used by research organisations working on sexual and reproductive health and HIV/AIDS

This commentary introduces the HARPS supplement on getting research into policy and practice in sexual and reproductive health (SRH). The papers in this supplement have been produced by the Sexual Health and HIV Evidence into Practice (SHHEP) collaboration of international research, practitioner and advocacy organizations based in research programmes funded by the UK Department for International Development.The commentary describes the increasing interest from research and communication practitioners, policy makers and funders in expanding the impact of research on policy and practice. It notes the need for contextually embedded understanding of ways to engage multiple stakeholders in the politicized, sensitive and often contested arenas of sexual and reproductive health. The commentary then introduces the papers under their respective themes: (1) The theory and practice of research engagement (two global papers); (2) Applying policy analysis to explore the role of research evidence in SRH and HIV/AIDS policy (two papers with examples from Ghana, Malawi, Uganda and Zambia); (3) Strategies and methodologies for engagement (five papers on Kenya, South Africa, Ghana, Tanzania and Swaziland respectively); (4) Advocacy and engagement to influence attitudes on controversial elements of sexual health (two papers, Bangladesh and global); and (5) Institutional approaches to inter-sectoral engagement for action and strengthening research communications (two papers, Ghana and global).The papers illustrate the many forms research impact can take in the field of sexual and reproductive health. This includes discursive changes through carving out legitimate spaces for public debate; content changes such as contributing to changing laws and practices, procedural changes such as influencing how data on SRH are collected, and behavioural changes through partnerships with civil society actors such as advocacy groups and journalists.The contributions to this supplement provide a body of critical analysis of communication and engagement strategies across the spectrum of SRH and HIV/AIDS research through the testing of different models for the research-to-policy interface. They provide new insights on how researchers and communication specialists can respond to changing policy climates to create windows of opportunity for influence.

Engaging media in communicating research on sexual and reproductive health and rights in sub-Saharan Africa: experiences and lessons learned

BackgroundThe mass media have excellent potential to promote good sexual and reproductive health outcomes, but around the world, media often fail to prioritize sexual and reproductive health and rights issues or report them in an accurate manner. In sub-Saharan Africa media coverage of reproductive health issues is poor due to the weak capacity and motivation for reporting these issues by media practitioners. This paper describes the experiences of the African Population and Health Research Center and its partners in cultivating the interest and building the capacity of the media in evidence-based reporting of reproductive health issues in sub-Saharan Africa.MethodsThe paper utilizes a case study approach based primarily on the personal experiences and reflections of the authors (who played a central role in developing and implementing the Center’s communication and policy engagement strategies), a survey that the Center carried out with science journalists in Kenya, and literature review.ResultsThe African Population and Health Research Center’s media strategy evolved over the years, moving beyond conventional ways of communicating research through the media via news releases and newspaper stories, to varying approaches that sought to inspire and build the capacity of journalists to do evidence-based reporting of reproductive health issues. Specifically, the approach included 1) enhancing journalists’ interest in and motivation for reporting on reproductive health issues through training and competitive grants for outstanding reporting ; 2) building the capacity of journalists to report reproductive health research and the capacity of reproductive health researchers to communicate their research to media through training for both parties and providing technical assistance to journalists in obtaining and interpreting evidence; and 3) establishing and maintaining trust and mutual relationships between journalists and researchers through regular informal meetings between journalists and researchers, organizing field visits for journalists, and building formal partnerships with professional media associations and individual journalists.ConclusionOur experiences and reflections, and the experiences of others reviewed in this paper, indicate that a sustained mix of strategies that motivate, strengthen capacity of, and build relationships between journalists and researchers can be effective in enhancing quality and quantity of media coverage of research.

Strategies and tensions in communicating research on sexual and reproductive health, HIV and AIDS: a qualitative study of the experiences of researchers and communications staff

BackgroundSexual and Reproductive Health (SRH) and HIV issues are often controversial and neglected, leading to challenges with engaging policy actors. Research evidence is complex, posing further challenges for ensuring that policy and practice are evidence-based. Many health researchers are adopting innovative approaches to engaging stakeholders in their research, yet these experiences are not often shared. This qualitative study focuses on the research communication and policy influencing objectives, strategies and experiences of four research consortia working on SRH, HIV and AIDS.MethodsWe carried out 22 in-depth interviews with researchers and communications specialists (research actors) from the four consortia and their partners, working in nine countries in sub-Saharan Africa and Asia. Using the ‘framework’ approach to qualitative data analysis, we identified factors that affect the interaction of research evidence with policy and practice. We used the ODI RAPID analytical framework to present these results, adapting this tool by incorporating the actions, strategies and positionality of research actors.ResultsThe characteristics of researchers and their institutions, policy context, the multiplicity of actors, and the nature of the research evidence all play a role in policy influencing processes. Research actors perceived a trend towards increasingly intensive and varied communication approaches. Effective influencing strategies include making strategic alliances and coalitions and framing research evidence in ways that are most attractive to particular policy audiences. Tensions include the need to identify and avoid unnecessary communication or unintended impacts, challenges in assessing and attributing impact and the need for adequate resources and skills for communications work.ConclusionsWe contend that the adapted RAPID framework can serve as a tool for research actors to use in resolving these tensions, through facilitating a reflexive approach to considering their own combination of attributes, skills, networks and objectives and the ways these relate to policy contexts, actors and processes.

Sexual and reproductive health rights in Africa

Sexual and reproductive rights have been on the international health-policy agenda since the Inter national Conference on Population and Development in 1994. International laws on human rights provide well-established conceptual frameworks for sexual and reproductive health rights but how far are they relevant to the policy debate in eastern and southern Africa? The gulf between legal human rights and the reality in a region is huge particularly for poor women men girls and boys. The obstacles to making sexual and reproductive health rights a reality are multiple and mutually reinforcing encompassing sociocultural norms gender inequalities resource and capacity constraints and unfavourable legal environments. These are the challenges being explored by a new Research Programme Consortium on Realising Sexual and Reproductive Health Rights. The Realising Rights Consortium is funded by the UK Department for International Development and brings together the African Population and Health Research Center (APHRC) the Bangladesh Rural Advancement Committee Engender Health the INDEPTH Network the Institute of Development Studies at the University of Sussex and the London School of Hygiene and Tropical Medicine in a 5-year programme which will address shortfalls and constraints in sexual and reproductive health measurement access to services and technologies and rights and entitlements and which will focus on the unmet needs of poor and vulnerable populations. (excerpt)