Kate Winskell

Infant and young child feeding practices and child undernutrition in Bangladesh: insights from nationally representative data

OBJECTIVE To determine the association between indicators of infant and young child feeding (IYCF) and anthropometric measures of nutritional status among children aged 0-23 months in a nationally representative data set. DESIGN Data from the 2007 Bangladesh Demographic and Health Survey were used. Analyses were conducted using multiple linear regression and logistic regression analyses adjusted for the complex survey design of the survey, controlling for child, maternal and household characteristics, and including regional dummy variables. SETTING Bangladesh. SUBJECTS Pairs (n 2096) of last born infants and their mothers. RESULTS Exclusive breast-feeding under 6 months of age was associated with higher weight-for-height Z-score (effect size (ES) = 0·29; P < 0·05). Appropriate complementary feeding in children aged 6-8 months was associated with higher height-for-age Z-score (HAZ; ES = 0·63; P < 0·01) and higher weight-for-age Z-score (WAZ; ES = 0·30; P < 0·05). Higher dietary diversity index (DDI) was associated with higher HAZ (ES = 0·08; P < 0·01 for every 1 point higher DDI) and higher WAZ (ES = 0·04; P < 0·05). Children who achieved minimum diet diversity had higher HAZ (ES = 0·20; P < 0·05). Logistic regression models confirmed that exclusive breast-feeding was protective against wasting and DDI was protective against stunting and underweight. CONCLUSIONS Our results highlight the importance of IYCF practices as determinants of child growth outcomes in this context, and reinforce the need for interventions that address the spectrum of IYCF practices, from exclusive breast-feeding to age-appropriate complementary feeding, especially diet diversity, in efforts to improve nutrition of infants and young children.

Making sense of condoms: social representations in young people’s HIV-related narratives from six African countries

Condoms are an essential component of comprehensive efforts to control the HIV epidemic, both for those who know their status and for those who do not. Although young people account for almost half of all new HIV infections, reported condom use among them remains low in many sub-Saharan African countries. In order to inform education and communication efforts to increase condom use, we examined social representations of condoms among young people aged 10-24 in six African countries/regions with diverse HIV prevalence rates: Swaziland, Namibia, Kenya, South-East Nigeria, Burkina Faso, and Senegal. We used a unique data source, namely 11,354 creative ideas contributed from these countries to a continent-wide scriptwriting contest, held from 1(st) February to 15(th) April 2005, on the theme of HIV/AIDS. We stratified each country sample by the sex, age (10-14, 15-19, 20-24), and urban/rural location of the author and randomly selected up to 10 narratives for each of the 12 resulting strata, netting a total sample of 586 texts for the six countries. We analyzed the narratives qualitatively using thematic data analysis and narrative-based methodologies. Differences were observed across settings in the prominence accorded to condoms, the assessment of their effectiveness, and certain barriers to and facilitators of their use. Moralization emerged as a key impediment to positive representations of condoms, while humour was an appealing means to normalize them. The social representations in the narratives identify communication needs in and across settings and provide youth-focused ideas and perspectives to inform future intervention efforts.

Making sense of abstinence: social representations in young Africans' HIV-related narratives from six countries

Despite the prominence of abstinence promotion in HIV prevention for young Africans, there is little documentation concerning its reception and interpretation. With the purpose of informing programmatic practice, we examined how young Africans from six countries with contrasting HIV prevalence rates make sense of abstinence. ‘Scenarios from Africa’ scriptwriting contests invite young people to contribute ideas for short films about HIV. Using thematic narrative-based approaches, we analyzed a stratified random sample of these narratives written in 2005 by young women and men aged 10–24 years from Senegal, Burkina Faso, South-East Nigeria, Kenya, Namibia and Swaziland. Abstinence was considerably more prominent as a theme in the samples from SE Nigeria, Kenya and Swaziland. It was articulated in relation to conservative Christian sexual morality and in opposition to condom use with particular intensity in SE Nigeria, with stigmatising implications for non-abstainers. However, cross-national commonalities were more striking than differences. Examples of non-stigmatising pro-abstinence messaging highlighted the appeal of discourses of romantic love and future plans across countries and demographic characteristics. The analysis yielded contextual understanding, youth-driven ideas and recommendations to inform comprehensive HIV-prevention efforts.

‘A living death’: a qualitative assessment of quality of life among women with trichiasis in rural Niger

BACKGROUND Prior to blindness, trachoma is thought to profoundly affect womens abilities to lead normal lives, but supporting evidence is lacking. To better understand the effects of trichiasis, we asked women to define quality of life, how trichiasis affects this idea and their perceptions of eyelid surgery. METHODS Operated and unoperated women were purposively selected for in-depth interviews. These were audio-recorded and transcribed, and codes were identified and applied to the transcripts. Overarching themes, commonalities and differences were identified and matched to quotations. RESULTS Twenty-three women were interviewed. Quality of life was defined as health, security, family, social status and religious participation. Trichiasis caused severe pain and loss of health, leading to loss of security. This affected social, economic and religious activities and caused burden on their families. Surgery improved quality of life, even in cases of surgical failure or recurrent disease. CONCLUSIONS Trichiasis disables most women, even those reporting fewer or less-severe symptoms. While women in rural Niger often live in extreme poverty, trichiasis exacerbates the situation, making women unable to work and undermining their social status. It adds to family burden, as women lose the ability to meaningfully contribute to the household and require additional family resources for their care.

Elements of Condom-Use Decision Making among South African Men Who Have Sex with Men

South African men who have sex with men (MSM) are at increased risk for HIV infection, and male condoms are fundamental to HIV prevention programs. We explored condom use experiences through in-depth interviews with 34 South African MSM from Cape Town and Port Elizabeth. For data analysis, we generated a codebook and used the constant comparison method. Condom use reinforcing elements included use of alternative sexual strategies, having a high level of self-worth that was linked to protective behaviors, and use of ready-made condom negotiation scripts. Elements inhibiting condom use included perceiving substantial declines in sexual pleasure/performance, experiences of condom failure (possibly related to petroleum-based lubricant), and being in trusted relationships. Our findings suggest nuanced HIV prevention approaches such as bolstering condom negotiation skills based on successful tactics already in use. Further research is needed to address how to mitigate perceptions and experiences that condoms negatively impact sexual pleasure and performance.

Making sense of HIV in southeastern Nigeria: fictional narratives cultural meanings and methodologies in medical anthropology.

Fictional narratives have rarely been used in medical anthropological research. This article illustrates the value of such narratives by examining how young people in southeastern Nigeria navigate the cultural resources available to them to make sense of HIV in their creative writing. Using thematic data analysis and narrative-based methodologies, it analyzes a sample (N = 120) from 1,849 narratives submitted by Nigerian youth to the 2005 Scenarios from Africa scriptwriting contest on the theme of HIV. The narratives are characterized by five salient themes: tragedy arising from the incompatibility of sex outside marriage and kinship obligations; female vulnerability and blame; peer pressure and moral ambivalence; conservative Christian sexual morality; and the social and family consequences of HIV. We consider the strengths and limitations of this narrative approach from a theoretical perspective and by juxtaposing our findings with those generated by Daniel Jordan Smith using standard ethnographic research methods with a similar Igbo youth population.

A Case-Based, Problem-Based Learning Approach to Prepare Master of Public Health Candidates for the Complexities of Global Health

Global health is a dynamic, emerging, and interdisciplinary field. To address current and emerging global health challenges, we need a public health workforce with adaptable and collaborative problem-solving skills. In the 2013-2014 academic year, the Hubert Department of Global Health at the Rollins School of Public Health-Emory University launched an innovative required core course for its first-year Master of Public Health students in the global health track. The course uses a case-based, problem-based learning approach to develop global health competencies. Small teams of students propose solutions to these problems by identifying learning issues and critically analyzing and synthesizing new information. We describe the course structure and logistics used to apply this approach in the context of a large class and share lessons learned.

Making sense of HIV testing: Social representations in young Africans' HIV-related narratives from six countries

HIV testing and counselling are a critical intervention to support treatment access and prevent new infections. Despite high rates of infection, few young Africans know their HIV status. With the aim of informing initiatives that encourage HIV testing and access to testing benefits, this study seeks to understand how young Africans make sense of HIV testing. We conducted thematic narrative-based analysis of a stratified random sample (n = 586, ∼5%) from 11,354 narratives written in 2005 by males and females aged 10–24 from six sub-Saharan African countries for the ‘Scenarios from Africa’ scriptwriting contest which invites young people to contribute ideas for short films about HIV. The factors represented by the young authors as influencing testing behaviour and outcomes are complex and interactive, indicating that interventions that are not contextually appropriate are unlikely to affect a shift towards increased testing or improved post-testing outcomes. The narratives point to opportunities to increase HIV testing in this demographic.

Exploring repeat HIV testing among men who have sex with men in Cape Town and Port Elizabeth, South Africa

Despite the high prevalence of HIV among men who have sex with men (MSM) – and the general adult population – in South Africa, there is little data regarding the extent to which MSM seek repeat testing for HIV. This study explores reported histories of HIV testing, and the rationales for test seeking, among a purposive sample of 34 MSM in two urban areas of South Africa. MSM participated in activity-based in-depth interviews that included a timeline element to facilitate discussion. Repeat HIV testing was limited among participants, with three-quarters having two or fewer lifetime HIV tests, and over one-third of the sample having one or fewer lifetime tests. For most repeat testers, the time gap between their HIV tests was greater than the one-year interval recommended by national guidelines. Analysis of the reasons for seeking HIV testing revealed several types of rationale. The reasons for a first HIV test were frequently one-time occurrences, such as a requirement prior to circumcision, or motivations likely satisfied by a single HIV test. For MSM who reported repeat testing at more timely intervals, the most common rationale was seeking test results with a sex partner. Results indicate a need to shift HIV test promotion messaging and programming for MSM in South Africa away from a one-off model to one that frames HIV testing as a repeated, routine health maintenance behavior.

On academics: Incorporating global health competencies into the public health curriculum

The pace of globalization and the resultant profound impacts on population health in all parts of the world demand that greater attention be paid to global perspectives in the training of public health professionals.1 In efforts to expose master’s of public health (MPH) students to global health perspectives, schools of public health have offered elective overview courses in global health and/or sought to infuse global content across the public health curriculum by globalizing the curriculum.2 While overview courses may be criticized for lacking cohesion and failing to provide opportunities for the development of higher-level competencies, globalizing the curriculum is, we believe, almost always an incremental process, as faculty trained in traditional public health disciplines currently often lack global perspective, expertise, and experience. To overcome these challenges, Emory University’s Rollins School of Public Health (RSPH) added a required core course in global health (called “Critical Issues in Global Health” or GH500) to the traditional requirements of training for an MPH starting in the 2011–2012 academic year. Taught by faculty in the Global Health department, the course is required for all students who are not in the Global Health department. The course is competency-driven, interdisciplinary, and case-based, and it incorporates new interactive technologies. Its primary objective is to enable students enrolled in the MPH program in the departments of Behavioral Science and Health Education, Biostatistics, Environmental Health, Epidemiology, and Health Policy and Management to apply principles from these core public health disciplines to authentic global health challenges using a team-based, problem-solving approach.