Justin Parkhurst

Structural approaches to HIV prevention

Recognition that social, economic, political, and environmental factors directly affect HIV risk and vulnerability has stimulated interest in structural approaches to HIV prevention. Progress in the use of structural approaches has been limited for several reasons: absence of a clear definition; lack of operational guidance; and limited data on the effectiveness of structural approaches to the reduction of HIV incidence. In this paper we build on evidence and experience to address these gaps. We begin by defining structural factors and approaches. We describe the available evidence on their effectiveness and discuss methodological challenges to the assessment of these often complex efforts to reduce HIV risk and vulnerability. We identify core principles for implementing this kind of work. We also provide recommendations for ensuring the integration of structural approaches as part of combined prevention strategies.

Linking migration mobility and HIV.

Population mobility is commonly identified as a key driver of the HIV epidemic, both linking geographically separate epidemics and intensifying transmission through inducing riskier sexual behaviours. However, beyond the well‐known case studies of South African miners and East African truck drivers, the evidence on the links between HIV and mobility is nuanced, contradictory and inconclusive and is in part attributed to the abstract definitions of mobility used in different studies. This problematic conception of mobility, with no reference to who moves, their motivations for moving, or the characteristics of sending and receiving areas, can have a dramatic impact on how one understands the influence which this structural factor has on HIV risk in different settings. Future research on mobility and HIV transmission must incorporate an understanding of migration and mobility as dynamic processes and link different patterns and forms of mobility with location‐specific sexual networks and HIV epidemiology.

Political and institutional influences on the use of evidence in public health policy. A systematic review.

Background There is increasing recognition that the development of evidence-informed health policy is not only a technical problem of knowledge exchange or translation, but also a political challenge. Yet, while political scientists have long considered the nature of political systems, the role of institutional structures, and the political contestation of policy issues as central to understanding policy decisions, these issues remain largely unexplored by scholars of evidence-informed policy making. Methods We conducted a systematic review of empirical studies that examined the influence of key features of political systems and institutional mechanisms on evidence use, and contextual factors that may contribute to the politicisation of health evidence. Eligible studies were identified through searches of seven health and social sciences databases, websites of relevant organisations, the British Library database, and manual searches of academic journals. Relevant findings were extracted using a uniform data extraction tool and synthesised by narrative review. Findings 56 studies were selected for inclusion. Relevant political and institutional aspects affecting the use of health evidence included the level of state centralisation and democratisation, the influence of external donors and organisations, the organisation and function of bureaucracies, and the framing of evidence in relation to social norms and values. However, our understanding of such influences remains piecemeal given the limited number of empirical analyses on this subject, the paucity of comparative works, and the limited consideration of political and institutional theory in these studies. Conclusions This review highlights the need for a more explicit engagement with the political and institutional factors affecting the use of health evidence in decision-making. A more nuanced understanding of evidence use in health policy making requires both additional empirical studies of evidence use, and an engagement with theories and approaches beyond the current remit of public health or knowledge utilisation studies.

Improving Maternal Health: Getting What Works To Happen

Maternal mortality reduction in many countries is unlikely despite the availability of inexpensive, efficacious interventions that are part of official policy. This article explores the reasons why, based on research on maternity services in Bangladesh, Russia, South Africa and Uganda. A simple dynamic responses model shows that the key to understanding challenges in implementation lies in the reflexive, complex and dynamic responses of health workers and community members to policies and programmes. These responses are “dynamic” in that they arise due to forces from within and outside the system, and in turn exert forces of their own. They result in the difference between the health system that is envisaged in policy, and what is implemented by health workers and experienced by users. Programmes aiming to improve maternal health are not only technical but also social interventions that need to be evaluated as such, using methodologies that have been developed for evaluating complex social interventions whose aim is to bring about change. The components of effective programmes have been defined globally. However, in getting what works to happen, context matters. Thus, technical advisors need to give “advice” more circumspectly, local programme managers must be capacitated to make programme-improving adjustments continuously, and the detail related to process, not just outcomes, must be documented in evaluations. Résumé Une réduction du taux de mortalité maternelle est improbable dans beaucoup de pays, malgré la disponibilité d’interventions efficaces et peu coûteuses incluses dans la politique officielle. Cet article cherche à comprendre pourquoi, avec des recherches en Afrique du Sud, au Bangladesh, en Fédération de Russie et en Ouganda. Un modèle simple de réponses dynamiques montre que pour comprendre les problèmes de mise en oeuvre, il faut étudier les réponses dynamiques, complexes et réfléchies des agents de santé et des membres de la communauté aux politiques et programmes. Ces réponses sont « dynamiques » en cela qu’elles sont créées par des forces à l’intérieur et à l’extérieur du système, et qu’elles exercent à leur tour une force. Leur résultat est la différence entre le système de santé envisagé dans la politique et celui qui est appliqué par les agents de santé et que connaissent les usagers. Les programmes d’amélioration de la santé maternelle sont des interventions techniques, mais aussi sociales qui doivent être évaluées comme telles, avec des méthodologies élaborées pour jauger des interventions sociales complexes destinées à déclencher un changement. Les composantes de programmes opérants ont été définies au niveau international. Néanmoins, le contexte est important pour appliquer des mesures efficaces. Les conseillers techniques doivent donc « conseiller » avec plus de circonspection, il faut que les directeurs de programmes locaux soient capables d’ajuster constamment les programmes pour les améliorer et que les évaluations informent des détails liés au processus, et non pas seulement des résultats. Resumen En muchos países, resulta improbable disminuir la tasa de mortalidad materna, pese a la disponibilidad de intervenciones eficaces y poco costosas que son parte de la política oficial. En este artículo se explora el porqué, a raíz de investigaciones sobre los servicios de maternidad en Bangladesh, Rusia, Sudáfrica y Uganda. Un simple modelo de respuestas dinámicas muestra que la clave para entender los retos de la implementación radica en las respuestas reflexivas, complejas y dinámicas de los trabajadores de la salud y miembros de la comunidad a las políticas y los programas. Estas respuestas son “dinámicas” en el sentido de que emergen debido a fuerzas dentro y fuera del sistema, y, a su vez emplean sus propias fuerzas. Tienen como resultado la diferencia entre el sistema de salud que es concebido en la política, y lo que es puesto en práctica por los trabajadores de la salud y experimentado por las usuarias. Los programas que procuran mejorar la salud materna no son sólo técnicos sino también intervenciones sociales que deben ser evaluadas como tal, utilizando metodologías que fueron creadas para evaluar intervenciones sociales complejas cuyo objetivo es promover cambios. Los elementos de los programas eficaces fueron definidos mundialmente. Sin embargo, para lograr que suceda lo que funciona, importa el contexto. Por tanto, los asesores técnicos deben dar “consejos” con más cautela, los administradores de programas locales deben recibir capacitación para realizar ajustes que mejoren los programas continuamente, y el detalle relacionado con el proceso, y no sólo los resultados, debe documentarse en las evaluaciones.

Structural approaches for prevention of sexually transmitted HIV in general populations: definitions and an operational approach

Although biomedical HIV prevention efforts have seen a number of recent promising developments, behavioural interventions have often been described as failing. However, clear lessons have been identified from past efforts, including the need to address influential social, economic and legal structures; to tailor efforts to local contexts; and to address multiple influencing factors in combination. Despite these insights, there remains a pervasive strategy to try to achieve sexual behaviour change through single, decontextualized, interventions or sets of activities. With current calls for structural approaches to HIV as part of combination HIV prevention, though, there is a unique opportunity to define a structural approach to HIV prevention as one which moves beyond these past limitations and better incorporates our knowledge of the social world and the lessons from past efforts.

Cervical cancer and the global health agenda: Insights from multiple policy-analysis frameworks

Cervical cancer is the second leading cause of cancer deaths for women globally, with an estimated 88% of deaths occurring in the developing world. Available technologies have dramatically reduced mortality in high-income settings, yet cervical cancer receives considerably little attention on the global health policy landscape. The authors applied four policy-analysis frameworks to literature on global cervical cancer to explore the question of why cervical cancer may not be receiving the international attention it may otherwise warrant. Each framework explores the process of agenda setting and discerns factors that either facilitate or hinder policy change in cases where there is both a clear problem and a potential effective solution. In combination, these frameworks highlight a number of crucial elements that may be needed to raise the profile of cervical cancer on global health agendas, including improving local (national or sub-national) information on the condition; increasing mobilisation of affected civil society groups; framing cervical cancer debates in ways that build upon its classification as a non-communicable disease (NCD) and an issue of womens rights; linking cervical cancer screening to well-funded services such as those for HIV treatment in some countries; and identifying key global policy windows of opportunity to promote the cervical cancer agenda, including emerging NCD global health discussions and post-2015 reviews of the Millennium Development Goals.

International maternal health indicators and middle-income countries: Russia

Maternal health outcomes for the countries of the former Soviet Union are poorer than for the rest of Europe. Russia in particular is a problem. What measures are suitable for guiding the countrys policy on improving this area of health care?

What Constitutes “Good” Evidence for Public Health and Social Policy-making? From Hierarchies to Appropriateness

Within public health, and increasingly other areas of social policy, there are widespread calls to increase or improve the use of evidence for policy-making. Often these calls rest on an assumption that increased evidence utilisation will be a more efficient or effective means of achieving social goals. Yet a clear elucidation of what can be considered “good evidence” for policy is rarely articulated. Many of the current discussions of best practise in the health policy sector derive from the evidence-based medicine (EBM) movement, embracing the “hierarchy of evidence” that places experimental trials as pre-eminent in terms of methodological quality. However, a number of problems arise if these hierarchies are used to rank or prioritise policy relevance. Challenges in applying evidence hierarchies to policy questions arise from the fact that the EBM hierarchies rank evidence of intervention effect on a specified and limited number of outcomes. Previous authors have noted that evidence forms at the top of such hierarchies typically serve the needs and realities of clinical medicine, but not necessarily public policy. We build on past insights by applying three disciplinary perspectives from political science, the philosophy of science and the sociology of knowledge to illustrate the limitations of a single evidence hierarchy to guide health policy choices, while simultaneously providing new conceptualisations suited to achieve health sector goals. In doing so, we provide an alternative approach that re-frames “good” evidence for health policy as a question of appropriateness. Rather than adhering to a single hierarchy of evidence to judge what constitutes “good” evidence for policy, it is more useful to examine evidence through the lens of appropriateness. The form of evidence, the determination of relevant categories and variables, and the weight given to any piece of evidence, must suit the policy needs at hand. A more robust and critical examination of relevant and appropriate evidence can ensure that the best possible evidence of various forms is used to achieve health policy goals.

Translating evidence into policy in low-income countries: lessons from co-trimoxazole preventive therapy

In the April 2010 issue of this journal, Date et al. expressed concern over the slow scale-up in low-income settings of two therapies for the prevention of opportunistic infections in people living with the human immunodeficiency virus: co-trimoxazole prophylaxis and isoniazid preventive therapy. This short paper discusses the important ways in which policy analysis can be of use in understanding and explaining how and why certain evidence makes its way into policy and practice and what local factors influence this process. Key lessons about policy development are drawn from the research evidence on co-trimoxazole prophylaxis, as such lessons may prove helpful to those who seek to influence the development of national policy on isoniazid preventive therapy and other treatments. Researchers are encouraged to disseminate their findings in a manner that is clear, but they must also pay attention to how structural, institutional and political factors shape policy development and implementation. Doing so will help them to understand and address the concerns raised by Date et al. and other experts. Mainstreaming policy analysis approaches that explain how local factors shape the uptake of research evidence can provide an additional tool for researchers who feel frustrated because their research findings have not made their way into policy and practice.

Measuring concurrent partnerships.

We are encouraged that UNAIDS is developing new indicators to measure concurrent sexual partnerships (Feb 20, p 621). However, we believe that adding a measure of coital frequency to the agency’s proposed list of questions would provide an important improvement. Each additional act of intercourse is associated with a signifi cantly increased risk of infection and thus coital frequency is crucial to the risk of HIV acquisition. Consider a scenario in which a man with two partners has sex with one of them only a few times a year and with the other a dozen times a year. This man would be regarded as practising concurrency according to the UNAIDS defi nition, but even if such behaviour were universal among men and women in a population, it would be very unlikely to generate a signifi cant AIDS epidemic. New modelling research suggests that sustained heterosexual HIV transmission requires that a signifi cant number of overlaps be long enough and coitally frequent enough so that a relatively large number of people have sex with someone who also has another partner, particularly while some of these individuals are in the highly risky “acute phase” of early HIV infection. Little research on coital frequency in concurrent partnerships has been done, but some studies suggest that it may be quite high in some high-HIVprevalence hetero sexual populations that practise concurrency—even when overall partner numbers are low. We recommend that, in addition to the questions listed by UNAIDS, an additional one such as the following be asked for each overlapping partner: “Let’s talk about this partner. During the past year, how often do/did you have intercourse with him/her? (a) only once; (b) more than once, but less than once per month; (c) about once per month; (d) a few times per month; (e) about once per week; (f) about two or three times per week; (g) more than two or three times per week.” Furthermore, we recommend that UNAIDS and others explore better ways to collect more accurate selfreported data on intimate sexual behaviour. Under-reporting of risky sexual activity, especially by women, is a signifi cant problem, particularly if strict confi dentiality is not perceived by inter viewees.