Seema Vyas

The costs of treating curable sexually transmitted infections in low- and middle-income countries : A systematic review

Background: Calls for increased investment in sexually transmitted infection (STI) treatment across the developing world have been made to address the high disease burden and the association with HIV transmission. Goals: The goals of this study were to systematically review evidence on the cost of treating curable STIs and to explore its key determinants. Study: A search of published literature was conducted in PubMed and supplemented by reviews of gray literature. Studies were analyzed by broad focus. Regression analysis explored how intervention characteristics affect unit costs, accounting for differences in costing methods. Results: Fifty-three primary studies were identified, of which 62% used empirical data, 35% presented economic costs, and 22% presented full costs. The median STI treatment cost was

Equity in community health insurance schemes: evidence and lessons from Armenia

17.80. Clinics serving symptomatic patients were consistently cheaper than outreach services, services using syndromic management protocols had lower costs, and unit costs decreased with scale. Conclusions: The compiled cost data provide an evidence base that can be used to help inform resource planning.

STI management in Tanzanian private drugstores: practices and roles of drug sellers.

Introduction Community health insurance (CHI) schemes are growing in importance in low-income settings, where health systems based on user fees have resulted in significant barriers to care for the poorest members of communities. They increase revenue, access and financial protection, but concerns have been expressed about the equity of such schemes and their ability to reach the poorest. Few programmes routinely evaluate equity impacts, even though this is usually a key objective. This lack of evidence is related to the difficulties in collecting reliable data on utilization and socio-economic status. This paper describes the findings of an evaluation of the equity of Oxfams CHI schemes in rural Armenia. Methods Members of a random sample of 506 households in villages operating insurance schemes in rural Armenia were interviewed using a structured questionnaire. Household wealth scores based on ownership of assets were generated using principal components analysis. Logistic and Poisson regression analyses were performed to identify the determinants of health facility utilization, and equity of access across socio-economic strata. Results The schemes have achieved a high level of equity, according to socio-economic status, age and gender. However, although levels of participation compare favourably with international experience, they remain relatively low due to a lack of affordability and a package of primary care that does not include coverage for chronic disease. Conclusion This paper demonstrates that the distribution of benefits among members of this community-financing scheme is equitable, and that such a degree of equity in community insurance can be achieved in such settings, possibly through an emphasis on accountability and local management. Such a scheme presents a workable model for investing in primary health care in resource-poor settings.

Women's Paid Work and Intimate Partner Violence: Insights from Tanzania

Objectives: To describe the role and possible contribution of private drugstores in sexually transmitted infection (STI) management in rural Tanzania. Methods: A cross-sectional study that included drug sellers in private drugstores in eight districts of Tanzania. Data collected through interviews with drug sellers and the simulated client method presenting a male and female STI case. “QATI” scores (Questions, Advice, Treatment and drug Information) were developed to describe overall STI management. Results: Although 74% of drug sellers stated that there were no STI-related drugs in the store, medications were dispensed in 78% of male and 63% of female simulated client visits. The clients were dispensed drugs recommended in the Tanzanian guidelines for syndromic management of urethral or vaginal discharge in 80% of male and 90% of female cases. Drug sellers dispensed antibiotics during 76% of male and 35% of female simulated client visits. Dosage regimens were often incorrect and complete syndromic management rarely provided. Most drug sellers agreed that it is within their professional role to give information on STI treatment (89%) and prevention (95%). Drug-use information was almost always provided. Advice was however seldom given and questions occasionally asked. Overall STI management was better for men than for women. Conclusions: The drug sellers, although aware of the prescription-only status of antibiotics, saw themselves as having a role in STI management and were ready to provide drugs. In this resource-limited setting, drug sellers could provide effective and safe STI management especially to male patients if given appropriate tools to improve practice. The consequences of this for official policy need to be discussed.

Using Propensity Score Matching to Estimate an “Unbiased Effect-Size” Between Women’s Employment and Partner Violence in Tanzania

ABSTRACT Theoretical and empirical research provide conflicting views on whether women who do paid work are less at risk from violence by an intimate partner in low- and middle-income countries. Economic household-bargaining models propose increased access to monetary resources will enhance womens “agency” and hence their bargaining power within the household, which reduces their vulnerability to intimate-partner violence. Feminist theorists also argue, however, that culture, context, and social norms can impede womens ability to access and benefit from employment. This study uses semi-structured interviews conducted in 2009 to explore the implications of paid work among women market traders in Dar es Salaam and Mbeya, Tanzania. While in this sample, informal-sector work did not result in women being able to fully exercise agency, their access to money did have a positive effect on their lives and reduced one major source of conflict and trigger for violence: that of negotiating money from men.

Physical partner violence, women’s economic status and help-seeking behaviour in Dar es Salaam and Mbeya, Tanzania

Estimates of the effect of employment on women’s risk of partner violence in cross-sectional studies are subject to potential “self-selection bias.” Women’s personal choice of whether to pursue employment or not may create fundamental differences between the group of women who are employed and those who are not employed that standard regression methods cannot account for even after adjusting for confounding. The aim of this study is to demonstrate the utility of propensity score matching (PSM), a technique used widely in econometrics, to address this bias in cross-sectional studies. We use PSM to estimate an unbiased effect-size of women’s employment on their risk of experiencing partner violence in urban and rural Tanzania using data from the 2010 Tanzania Demographic and Health Survey (DHS). Three different measures of women’s employment were analyzed: whether they had engaged in any productive work outside of the home in the past year, whether they received payment in cash for this productive work, and whether their employment was stable. Women who worked outside of the home were significantly different from those who did not. In both urban and rural Tanzania, women’s risk of violence appears higher among women who worked in the past year than among those who did not, even after using PSM to account for underlying differences in these two groups of women. Being paid in cash reversed this effect in rural areas whereas stability of employment reduced this risk in urban centers. The estimated size of effect varied by type of matching estimator, but the direction of the association remained largely consistent. This study’s findings suggest substantial self-selection into employment. PSM methods, by compensating for this bias, appear to be a useful tool for estimating the relationship between women’s employment and partner violence in cross-sectional studies.

Marital violence and sexually transmitted infections among women in post-revolution Egypt

ABSTRACT Background: Women’s responses to partner violence are influenced by a complex constellation of factors including: psychological attachment to the partner; context of the abuse; and structural factors, all of which shape available options for women outside of the relationship. Objective: To describe women’s responses to physical partner violence; and to understand the role of women’s economic resources on their responses. Methods: Cross-sectional data from Dar es Salaam and Mbeya, Tanzania. Multivariate logistic regression was used to explore the relationship between women’s economic resources and their responses to violence. Results: In both sites, among physically abused women, over one-half experienced severe violence; approximately two-thirds had disclosed the violence; and approximately 40% had sought help. Abused women were more likely to have sought help from health services, the police and religious leaders in Dar es Salaam, and from local leaders in Mbeya. Economic resources did not facilitate women’s ability to leave violent partners in Dar es Salaam. In Mbeya, women who jointly owned capital assets were less likely to have left. In both sites, women’s sole ownership of capital assets facilitated help-seeking. Conclusion: Although support services are being scaled-up in Tanzania, efforts are needed to increase the acceptability of accessing such services.

Investigating mosquito-net coverage in Nigeria. How useful are consumer marketing surveys?

OBJECTIVES To explore the relationship between past year physical or sexual partner violence against women and womens self-report of sexually transmitted infection (STI) symptoms in post-revolution Egypt; and to examine the effects of mens and womens risky sexual behavioural characteristics and structural dimensions of poverty and gender inequality on this relationship. STUDY DESIGN This study uses the nationally representative cross-sectional demographic and health survey data conducted in 2014. Multivariate logistic regression was used to assess the relationship between past year partner violence and self-report of STI symptoms among currently married women. MAIN OUTCOME MEASURES womens self-report of STI was based on their responses to three questions; whether in the past year they had: got a disease through sexual contact?, a genital sore or ulcer?, or a bad smelling abnormal genital discharge? Women who gave an affirmative response to one or more of these questions were assumed to self-report STI. RESULTS Almost one-third of women self-reported symptoms of STI. Fourteen percent of women reported they had experienced physical or sexual violence by a male partner in the past 12months. Abused women had a 2.76 times higher odds of self-reported STI symptoms (95% CI 2.25-3.38). The significant relationship between self-reported STI and past year partner violence against women did not alter when adjusting for mens and womens behavioural characteristics and factors related to poverty and gender inequality. CONCLUSIONS Public health interventions that address womens sexual and reproductive health need to consider violence response and prevention strategies.

Constructing socio-economic status indices: how to use principal components analysis

Abstract A marketing company conducting a consumer omnibus survey (COS) in April 2000 was paid to include questions about household ownership of mosquito nets. At the time of the survey, which involved 5018 respondents, most and perhaps all of the nets owned by the respondents would have been untreated, as a product for net treatment was then virtually unavailable. Sampling was conducted in all 36 states and the Federal Capital Territory, Abuja. Core questions were asked about socio-demographic and socio-economic characteristics, and commissioned questions were asked about household net ownership, the source of the households newest net, if any, and the price paid for that net. The data were analysed using bivariate and multivariate methods. Socio-economic status was measured using an asset index. The estimated number of nets was adjusted using information on asset ownership from the national Demographic and Health Survey of 1999. After this adjustment for sampling bias, net coverage and the total number of nets in Nigerian households were estimated to be approximately 9% and 3 million, respectively. The single most important association with net ownership was access to a flit-gun. It appears that COS are a potentially useful source of information for assessing mosquito-net coverage at household level and monitoring changes over time. They have the advantage of being administered frequently, and they are relatively low cost. The present results were comparable with those from other studies conducted at a similar time. The main disadvantage of COS is sampling bias but, as shown here, it is often possible to adjust for this.