Decomposing the rural-urban disparities in overweight and obesity among women of reproductive age in Nigeria.

BACKGROUND: Overweight and obese women face various reproductive and other health challenges, and in some cases, even mortality. Despite evidence of rural-urban disparities in overweight and obesity among women of reproductive age, there is limited evidence regarding the predictors of these disparities. This study aims to investigate the factors associated with overweight and obesity and examine the contributors to rural-urban disparities in overweight and obesity among women of reproductive age in Nigeria. METHODS: We utilized the 2018 Nigeria Demographic and Health Survey dataset. The survey employed a two-stage cluster sampling technique based on Nigeria's 2006 census enumeration areas for sample selection. Overweight and obesity were defined as a body mass index (BMI) ≥ 25. Data analyses were conducted using the Logistic Regression Model and the threefold Blinder-Oaxaca decomposition model (α0.05). RESULTS: The study revealed that older women (OR = 2.44; CI = 2.11-2.83), those with higher wealth (OR = 2.05; CI = 1.81-2.31), contraceptive users (OR = 1.41; CI = 1.27-1.57), and residents of the South-South region (OR = 1.24; CI = 1.07-1.45) were more likely to be overweight/obese. The decomposition analysis indicated that the mean predicted prevalence of overweight and obesity is 35.5% in urban areas, compared to 21.1% in rural areas of Nigeria. Factors such as wealth status, educational level, media exposure, and contraceptive use were identified as significant contributors to these disparities. CONCLUSION: The findings underscore the importance of addressing socioeconomic disparities when designing healthcare interventions to reduce the burden of overweight and obesity, particularly in urban areas. Prioritizing these factors can facilitate efforts to promote healthier lifestyles and enhance overall well-being.

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries.

BACKGROUND: Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region. METHODS: We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality. RESULTS: The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor. CONCLUSIONS: Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

The co-occurrence of the SAVA syndemic, depression and anxiety as barriers to antiretroviral therapy adherence among sub-Saharan Africa population groups: A scoping review protocol.

INTRODUCTION: The scale-up of access to antiretroviral therapy has transformed HIV from an acute, terminal disease to a manageable chronic illness. Yet, sustaining high levels of antiretroviral therapy adherence remain a challenge, especially in the sub-Saharan Africa region which is disproportionately affected by HIV. This protocol proposes a scoping review to explore literature reporting on the antiretroviral therapy adherence levels among people who experience substance abuse and violence (SAVA) syndemics, as well as mood disorders such as anxiety and depression among people living with HIV in sub-Saharan Africa. METHODS AND ANALYSIS: This proposed scoping review will follow Arksey and O'Malley's methodological framework for conducting scoping reviews as refined by Levac et al. The review will follow the Joanna Briggs Institute's manual for conducting scoping reviews. Literature searches will be conducted using six databases: Academic search complete; APA PsycArticles; CINAHL; MEDLINE; SocINDEX and Web of science. Title screening will see the "Participant, Concept, Context" framework applied to identify relevant literature and will not include the appraisal of search results. Data charting will follow an adapted version of Trico and colleagues' PRISMA-ScR and results will be mapped descriptively and in tabular format. Furthermore, results will be discussed within the syndemics model of health, and summarised as a biosocial conceptual model. ETHICS AND DISSEMINATION: The study will make use of secondary data that are readily available to the public and will not require ethical approval. We intend to publish our results in a peer-reviewed journal and disseminate our findings at relevant conferences and seminars.

Same but Different? Comparing Attitudes Regarding Gender, Gender Diversity, and Sexual Diversity Among Early Adolescents in South Africa and Belgium.

PURPOSE: This study aims to compare low socioeconomic status, urban early adolescents' (EAs) attitudes toward gender, gender diversity and sexual diversity in two contexts with similar progressive legal frameworks for gender equality and nondiscrimination, South Africa and Belgium, to understand the ways in which adolescents modify or conform to prevailing attitudes. METHODS: The study used a cross-sectional design and sampled 1,102 and 569 EAs (between 11 and 15 years old) in Belgium and South Africa respectively. Quantitative data were collected using tablets. Sample characteristics and gender attitude scales are described and compared in the two countries, and between boys and girls within each country. Comparisons are conducted on the mean score for the 5-point Likert scale items on the gender attitude scales. RESULTS: Girls in both countries expressed more tolerant attitudes toward same-sex romantic relationships and experienced more gender diverse emotional attraction and physical attraction to same-sex individuals than boys. Generally, boys endorsed more heteronormative relationship norms and other stereotypical attitudes than girls. Conversely, girls tended to embrace sexual double standards more than boys. South African EAs exhibited more sexual diversity but less tolerant attitudes toward gender and gender diversity. Belgian EAs, especially girls, tended to exhibit more tolerant attitudes toward diversity in gender identity. DISCUSSION: There were important differences in attitudes toward gender, gender diversity, and sexual diversity among EAs, despite the countries' similar progressive legislative frameworks. In the future, sociocultural and other determinants of EAs' attitudes should be further explored at different levels from the individual to the societal.

Expressions of actor power in implementation: a qualitative case study of a health service intervention in South Africa.

BACKGROUND: Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how interventions at the front line of health systems confront or shape existing power relations. This paper reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal and child health care quality and outcomes in a rural district of South Africa. METHODS: A retrospective qualitative case study based on interviews with 34 actors in three 'implementation units' - a district hospital and surrounding primary health care services - of the district, selected as purposefully representing full, moderate and low implementation of the intervention, some three years after it was first introduced. Data are analysed using Veneklasen and Miller's typology of the forms of power - namely 'power over', 'power to', 'power within' and 'power with'. RESULTS: Multiple expressions of actor power were evident during implementation and played a plausible role in shaping variable implementation, while the intervention itself acted to change power relations. As expected, a degree of buy-in of managers (with power over) in implementation units was necessary for the intervention to proceed. Beyond this, the ability to mobilise collective action (power with), combined with support from champions with agency (power within) were key to successful implementation. However, local empowerment may pose a threat to hierarchical power (power over) at higher levels (district and provincial) of the system, potentially affecting sustainability. CONCLUSIONS: A systematic approach to the analysis of power in implementation research may provide insights into the fate of interventions. Intervention designs need to consider how they shape power relations, especially where interventions seek to widen participation and responsiveness in local health systems.

Motivational determinants of physical activity in disadvantaged populations with (pre)diabetes: a cross-cultural comparison.

BACKGROUND: Understanding motivational determinants of physical activity (PA) is essential to guide the implementation of PA at individual and population level. Knowledge about the cross-cultural generalizability of these determinants is lacking and they have mostly been studied as separate factors. This study compares a motivational process model across samples from diverse populations with, or at risk of diabetes. METHODS: Measurement invariance of barrier identified regulation, barrier self-efficacy and social support was assessed in a rural Ugandan sample (n = 712) and disadvantaged samples with high proportions of immigrants in urban South Africa (n = 566) and Sweden (n = 147). These motivational determinants were then compared through multigroup structural equation modeling. RESULTS: The studied motivational constructs showed scalar invariance. Latent mean levels of perceived social support and barrier self-efficacy were lower in South Africa and Sweden. Structural models (for different PA outcomes) were not consistent across settings except for the association between perceived social support and identified regulation. Identified regulation was only associated with vigorous PA in Uganda and with moderate PA in South Africa. The association between social support and PA outcomes ranged from weak to not significant and the association between self-efficacy and PA was not significant. Self-reported PA was highest in Uganda and lowest in Sweden. Self-reported vigorous PA was significantly related to lower hemoglobin A1c levels, while moderate PA was not. CONCLUSIONS: Findings suggest that: 1) it is feasible to compare a motivational process model across diverse settings; 2) there is lower perceived social support and self-efficacy in the urban, migrant samples; 3) identified regulation is a more promising determinant of PA than self-efficacy or social support in these populations; 4) associations between motivational determinants and PA depend on the perceived type and/or intensity of PA; 5) perceived relatedness functions as a basic psychological need across diverse settings; and 6) people's perception of the PA they perform depends on their perceived level of intensity of PA which would have major implications for health promotion.

An exploration of the impact of COVID-19 on mental health in South Africa.

In response to the COVID-19 pandemic, South Africa implemented a strict stay-at-home order. The mental health effects of the pandemic and related containment measures are minimally documented in this region. This study examines the association between COVID-19 related stressors and mental health during a strict stay-at-home order in South Africa. A total of 860 self-selected participants residing in the Western Cape province completed an online survey from 20-31 May 2020. This sample consisted mainly of higher socioeconomic and higher educated segments of the population. Structural equation modelling was used to assess how sociodemographic factors, membership of vulnerable groups and COVID-19 related stressors were associated with PHQ-9 (depression) and GAD-7 (anxiety) scores. 46.0% and 47.2% of participants met the diagnostic threshold of anxiety and depressive disorder, respectively. Considerable daily life repercussions were linked to these scores. Among these participants, less than 20% consulted a formal practitioner and this was 12% for participants without a pre-existing mental health condition. Distress related to containment measures and distress about being infected were significantly associated with more anxiety and depressive symptoms. Having a pre-existing mental health condition was associated with poorer mental health, but being an active health worker was not. Younger age, being female, and living in a non-rural area were associated with poorer mental health. Our findings suggest a considerable mental health impact of this pandemic and related containment measures, but low attendance of mental health services. The accessibility to tailored mental health support is essential under these circumstances, especially for vulnerable groups.

Unequal Gender Norms Are Related to Symptoms of Depression Among Young Adolescents: A Cross-Sectional, Cross-Cultural Study.

PURPOSE: This study was undertaken among 10- to 14-year-old girls and boys in disadvantaged areas of Shanghai, China; Cuenca, Ecuador; Flanders, Belgium; and Denpasar and Semarang, Indonesia. It aimed to assess whether gender norms are related to depressive symptomatology, and to examine whether sex differences in depressive symptoms can be explained by differences in gender norm perceptions. METHODS: We examined the distributions of depressive symptoms and two gender norms scales, gender stereotypical traits (GST), and sexual double standard (SDS), across sites and by sex. We next assessed crude and adjusted associations between each of the gender norms scales and depressive symptoms. Finally, we conducted path analysis to examine the mediating role of gender perceptions in sex differences in depressive symptoms. RESULTS: Girls reported more depressive symptoms than boys in all sites except Denpasar. SDS perceptions were more unequal among girls in most sites, while GST perceptions were more unequal among boys in all sites except Semarang. Gender-equal SDS and GST perceptions were associated with fewer depressive symptoms, while unequal perceptions were related to more symptoms. Gendered perceptions about traits and relationships appeared to partially mediate relationships between sex and depressive symptoms in Shanghai, Cuenca, and Semarang. CONCLUSIONS: Unequal gender norm perceptions were linked to poor mental health among boys and girls, suggesting that gender norms may play a role in psychological wellbeing for adolescents of both sexes. Gender norm perceptions appear to play a role in mental health sex disparities we observed across sites.

Development and testing of a composite index to monitor the continuum of maternal health service delivery at provincial and district level in South Africa.

INTRODUCTION: The continuum of care is a recommended framework for comprehensive health service delivery for maternal health, and it integrates health system and social determinants of health. There is a current lack of knowledge on a measurement approach to monitor performance on the framework. In this study we aim to develop and test a composite index for assessing the maternal health continuum in a province in South Africa with the possibility of nationwide use. MATERIALS AND METHODS: The composite index was computed as a geometric mean of four dimensions of adequacy of the continuum of care. Data was sourced from the district health information system, household surveys and the census. The index formula was tested for robustness when alternative inputs for indicators and standardization methods were used. The index was used to assess performance in service delivery in the North West province of South Africa, as well as its four districts over a five-year period (2013-2017). The index was validated by assessing associations with maternal health and other outcomes. And factor analysis was used to assess the statistical dimensions of the index. RESULTS: The provincial level index score increased from 62.3 in 2013 to 74 in 2017, showing general improvement in service delivery over time. The district level scores also improved over time, and our analysis identified areas for performance improvement. These include social determinants of health in some districts, and access and linkages to care in others. The provincial index was correlated with institutional maternal mortality rates (rs = -0.90, 90% CI = (-1.00, -0.25)) and the Human Development Index (r = 0.97, 95% CI = (0.63, 0.99). It was robust to alternative approaches including z-score standardization of indicators. Factor analysis showed three groupings of indicators for the health system and social determinants of health. CONCLUSIONS: This study demonstrated the development and testing of a composite index to monitor and assess service delivery on the continuum of care for maternal health. The index was shown to be robust and valid, and identified potential areas for service improvement. A contextualised version can be tested in other settings within and outside of South Africa.

The pandemic of online research in times of COVID-19.

The COVID-19 pandemic has led to an explosion of online research using rating scales. While this approach can be useful, two of the major challenges affecting the quality of this type of research include selection bias and the use of non-validated scales. Online research is prone to various forms of selection bias, including self-selection bias, non-response bias or only reaching specific subgroups. The use of rating scales requires contextually validated scales that meet psychometrical properties such as validity, reliability and-for cross-country comparisons-invariance across settings. We discuss options to prevent or tackle these challenges. Researchers, readers, editors and reviewers need to take a critical stance towards research using this type of methodology.

Social and Structural Determinants of Household Support for ART Adherence in Low- and Middle-Income Countries: A Systematic Review .

Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people living with HIV (PLWH). Interventions to support ART adherence are increasingly focused on the household as a source of social support. This review aims to examine the social and structural determinants of support for ART adherence within households and families in low- and middle-income countries (LMICs). The review methodology followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Seven databases were searched for peer-reviewed literature. The terms searched thematically covered (1) ART adherence, (2) household and family and (3) support and care. Thirty-three studies conducted in 15 LMICs were selected and a mixed methods synthesis was undertaken. Social and structural determinants affected the type, quality and amount of support for PLWH of all ages, which affected PLWH's ART adherence. Gender norms affected the type of support that household members give to PLWH. Education moderated household support for ART adherence through literacy and language skills. Cultural context, religious beliefs, and social norms reinforced or undermined household support for ART adherence. Stigma affected disclosure, generated secrecy around giving medication and impeded access to support from the community. Supporting PLWH exacerbated economic hardship for household members. Health system dysfunction negatively impacted trust and communication between household members and health professionals. Intersecting social and structural determinants particularly affected the care given by household members who were older, female, with little education and low socioeconomic status. Household members were able to overcome some of these barriers when they received support themselves. Household interventions to support PLWH's ART adherence should take structural factors into account to have maximum impact.

Review of health and non-health sector indicators for monitoring service provision along the continuum of care for maternal health.

OBJECTIVE: This study uses health and non-health sector data sources to select and assess available indicators for service provision along the continuum of care for maternal health at subnational levels in South Africa. It applies the adequacy approach established in another study to assess the multi-dimensionality of available indicators. Using adequacy and the process of assessment in the study, the comprehensiveness of the continuum of care for improving maternal health outcomes can be assessed. RESULTS: We found 27 indicators of care utilization and access, linkages of care, and quality of care from the routine district health information system. The General Household Survey contained 11 indicators for the social determinants of health on the continuum of care framework. Indicator gaps include health promotion during and after pregnancy, maternal nutrition, empowerment and quality of care. At present, the available indicators measure about 74% of the interventions on the continuum of care framework. We make recommendations regarding improvements needed to better measure and monitor the continuum of care for maternal health. These involve actions within the health system and include integration of non-health system indicators.

District Governance and Improved Maternal, Neonatal and Child Health in South Africa: Pathways of Change.

District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not take governance as their primary lens on health system strengthening. This paper is a case study of a district and sub-district governance mechanism, the Monitoring and Response Unit (MRU), which aimed to improve MNCH outcomes in two districts of South Africa. The MRU was introduced as a decision-making and accountability structure, and constituted of a "triangle" of managers, clinicians and information officers. An independent evaluation of the MRU initiative was conducted, three years after establishment, involving interviews with 89 district actors. Interviewees reported extensive changes in the scope, quality and organization of MNCH services, attributing these to the introduction of the MRU and enhanced support from district clinicians. We describe both the formal and informal aspects of the MRU as a governance mechanism, and then consider the pathways through which the MRU plausibly acted as a catalyst for change, using the institutional constructs of credible commitment, coordination and cooperation. In particular, the MRU promoted the formation of non-hierarchical collaborative networks; improved coordination between community, PHC and hospital services; and shaped collective sense-making in positive ways. We conclude that innovations in governance could add significant value to the district health system strengthening for improved MNCH. However, this requires a shift in focus from strengthening the front-line of service delivery, to change at the meso-level of sub-district and district decision-making; and from purely technical, data-driven to more holistic approaches that engage collective mindsets, widen participation in decision-making and nurture political leadership skills.

Improving the validity, relevance and feasibility of the continuum of care framework for maternal health in South Africa: a thematic analysis of experts' perspectives.

BACKGROUND: The continuum of care is a key strategy for ensuring comprehensive service delivery for maternal health, while acknowledging the role of the social determinants of health. However, there is little research on the operationalisation of the framework by decision-makers and implementers to address maternal health challenges. The framework should be measurable and feasible for implementation in low- and middle-income country contexts. In this study, we explore experts' perspective on monitoring indicators for continuum of care and key issues related to their use in the South African context. METHODS: We conducted key informant interviews with a range of experts in decision-making and programme implementation roles in the health system and relevant sectors. Key informants provided their perspectives on systematically selected, nationally representative monitoring indicators in terms of validity, relevance and feasibility. We interviewed 13 key informants and conducted a thematic analysis of their responses using multi-stage coding techniques in Atlas.ti 8.4. RESULTS: Experts believed that the continuum of care framework and monitoring indicators offer a multisectoral perspective for maternal health intervention missing in current programmes. To improve validity of monitoring indicators, experts suggested reflection on the use of proxy indicators and improvement of data to allow for equity analysis. In terms of relevance and feasibility, experts believe there was potential to foster co-accountability using continuum of care indicators. However, as experts stated, new indicators should be integrated that directly measure intersectoral collaboration for maternal health. In addition, experts recommended that the framework and indicators should evolve over time to reflect evolving policy priorities and public health challenges. CONCLUSION: Experts, as decision-makers and implementers, helped identify key issues in the application of the continuum of care framework and its indicators. The use of local indicators can bring the continuum of care framework from an under-utilised strategy to a useful tool for action and decision-making in maternal health. Our findings point to measurement issues and systematic changes needed to improve comprehensive monitoring of maternal health interventions in South Africa. Our methods can be applied to other low- and middle-income countries using the continuum of care framework and locally available indicators.

Task-sharing of psychological treatment for antenatal depression in Khayelitsha, South Africa: Effects on antenatal and postnatal outcomes in an individual randomised controlled trial.

The study's objective was to determine the effectiveness of a task-sharing psychological treatment for perinatal depression using non-specialist community health workers. A double-blind individual randomised controlled trial was conducted in two antenatal clinics in the peri-urban settlement of Khayelitsha, Cape Town. Adult pregnant women who scored 13 or above on the Edinburgh Postnatal Depression rating Scale (EPDS) were randomised into the intervention arm (structured six-session psychological treatment) or the control arm (routine antenatal health care and three monthly phone calls). The primary outcome was response on the Hamilton Depression Rating Scale (HDRS) at three months postpartum (minimum 40% score reduction from baseline) among participants who did not experience pregnancy or infant loss (modified intention-to-treat population) (registered on Clinical Trials: NCT01977326). Of 2187 eligible women approached, 425 (19.4%) screened positive on the EPDS and were randomised; 384 were included in the modified intention-to-treat analysis (control: n = 200; intervention: n = 184). There were no significant differences in response on the HDRS at three months postpartum between the intervention and control arm. A task-sharing psychological treatment was not effective in treating depression among women living in Khayelitsha, South Africa. The findings give cause for reflection on the strategy of task-sharing in low-resource settings.

Delivering the Thinking Healthy Programme for perinatal depression through peers: an individually randomised controlled trial in India.

BACKGROUND: The Thinking Healthy Programme (THP) is a psychological intervention recommended for the treatment of perinatal depression. However, efforts to integrate the intervention at scale into the routines of community health workers who delivered the THP when it was first evaluated were compromised by the competing responsibilities of community health workers. We aimed to assess the effectiveness and cost-effectiveness of THP peer-delivered (THPP) in Goa, India. METHODS: In this single-blind, individually randomised controlled trial, we recruited pregnant women aged 18 years or older who scored at least 10 on the Patient Health Questionnaire-9 (PHQ-9) from antenatal clinics in Goa. Participants were randomly allocated (1:1) to receive enhanced usual care (EUC; so-called because, in India, perinatal depression is not typically treated) only (control group) or THPP in addition to EUC (intervention group) in randomly sized blocks that were stratified by area of residence (urban or rural). Group allocations were concealed from participants and researchers before assignments were made by use of sequentially numbered opaque envelopes. The primary outcomes were the severity of depressive symptoms (assessed by PHQ-9 score) and the prevalence of remission (defined as a PHQ-9 score of less than 5) in participants with available data 6 months after childbirth, which was assessed by researchers who were masked to treatment allocations. We analysed outcomes by intention to treat, adjusting for covariates that were defined a priori or that showed imbalance at baseline. The trial is registered with ClinicalTrials.gov, number NCT02104232. FINDINGS: Between Oct 24, 2014, and June 24, 2016, we assessed 118 260 women for their eligibility for screening, of whom 111 851 (94·6%) women were ineligible. 6409 (5·4%) women were eligible for screening and 6369 (99·4%) of these women consented to be screened with the PHQ-9 (40 women did not consent), of whom 333 (5·2%) screened positive for depression (defined as a PHQ-9 score of at least 10). We enrolled 280 (84·1%) women with perinatal depression; 140 women were assigned to the THPP and EUC group and 140 women to the EUC only group. The final treatment was given on May 27, 2017. The final 6-month outcome assessment was completed on June 9, 2017. At 6 months after birth, 122 (87%) women in the THPP and EUC group and 129 (92%) women in the EUC only group were assessed for the primary outcome. There was a higher prevalence of remission at 6 months after birth in the THPP and EUC group compared with the EUC only group (89 [73%] women in the intervention group vs 77 [60%] women in the control group; prevalence ratio 1·21, 95% CI 1·01 to 1·45; p=0·04), but there was no evidence of a difference in symptom severity between the groups (mean PHQ-9 score 3·47 [SD 4·49] in the intervention group vs 4·48 [5·11] in the control group; standardised mean difference -0·18, 95% CI -0·43 to 0·07; p=0·16). There was no evidence of significant differences in serious adverse events between the groups. INTERPRETATION: THPP had a moderate effect on remission from perinatal depression over the 6-month postnatal period. THPP is relatively cheap to deliver and is cost-saving through reduced health-care, time and productivity costs. FUNDING: National Institute of Mental Health (USA).

Delivering the Thinking Healthy Programme for perinatal depression through volunteer peers: a cluster randomised controlled trial in Pakistan.

BACKGROUND: The Thinking Healthy Programme (THP), which is endorsed by WHO, is an evidence-based intervention for perinatal depression. We adapted THP for delivery by volunteer peers (laywomen from the community) to address the human resource needs in bridging the treatment gap, and we aimed to assess its effectiveness and cost-effectiveness in Rawalpindi, Pakistan. METHODS: In this cluster randomised controlled trial, we randomly assigned 40 village clusters (1:1) to provide either THP peer-delivered (THPP) and enhanced usual care (EUC; intervention group) or EUC only (control group) to the participants within clusters. These villages were randomly selected from eligible villages by an independent researcher. The participants were pregnant women aged 18 years or older who had scored at least 10 on the Patient Health Questionnaire-9 (PHQ-9), who we recruited from households within communities in Rawalpindi, Pakistan. The research teams who were responsible for recruiting trial participants were masked to treatment allocations. Participants attended follow-up visits at 3 and 6 months after childbirth. The primary outcomes were the severity of depressive symptoms (assessed by PHQ-9 score) and the prevalence of remission (defined as a PHQ-9 score of less than 5) in participants with available data 6 months after childbirth, which was assessed by researchers who were masked to treatment allocations. We analysed outcomes by intention to treat, adjusting for covariates that were defined a priori or that showed imbalance at baseline. The trial was registered with ClinicalTrials.gov, number NCT02111915. FINDINGS: Between April 15 and July 30, 2014, we randomly selected 40 of 46 eligible village clusters for assessment, as per sample size calculations. Between Oct 15, 2014, and Feb 25, 2016, we identified and screened 971 women from 20 village clusters that had been randomly assigned to the THPP and EUC group and 939 women from 20 village clusters that had been randomly assigned to the EUC only group. In the intervention group, 79 women were ineligible for inclusion, 11 women refused screening, 597 women screened negative on the PHQ-9, and one woman did not consent to participate. In the control group, 75 women were ineligible for inclusion, 14 women refused screening, 562 women screened negative on the PHQ-9, and one woman did not consent to participate. We enrolled 283 (29%) women in the intervention group and 287 (31%) women in the control group. At 6 months after childbirth, 227 (80%) women in the THPP and EUC group and 226 (79%) women in the EUC only group were assessed for the primary outcome. The severity of depression (assessed by PHQ-9 scores; standardised mean difference -0·13, 95% CI -0·31 to 0·06; p=0·07) and prevalence of remission (49% in the intervention group vs 45% in the control group; prevalence ratio 1·12, 95% CI 0·95 to 1·29; p=0·14) did not significantly differ between the groups 6 months after childbirth. There was no evidence of significant differences in serious adverse events between the groups. INTERPRETATION: THPP had no effect on symptom severity or remission from perinatal depression at 6 months after childbirth, but we found that it was beneficial on some other metrics of severity and disability and that it was cost-effective. THPP could be a step towards use of an unused human resource to address the treatment gap in perinatal depression. FUNDING: National Institute of Mental Health (USA).

Opportunities for linking research to policy: lessons learned from implementation research in sexual and reproductive health within the ANSER network.

BACKGROUND: The uptake of findings from sexual and reproductive health and rights research into policy-making remains a complex and non-linear process. Different models of research utilisation and guidelines to maximise this in policy-making exist, however, challenges still remain for researchers to improve uptake of their research findings and for policy-makers to use research evidence in their work. METHODS: A participatory workshop with researchers was organised in November 2017 by the Academic Network for Sexual and Reproductive Health and Rights Policy (ANSER) to address this gap. ANSER is a consortium of experienced researchers, some of whom have policy-making experience, working on sexual and reproductive health and rights issues across 16 countries and 5 continents. The experiential learning cycle was used to guide the workshop discussions based on case studies and to encourage participants to focus on key lessons learned. Workshop findings were thematically analysed using specific stages from Hanney et al.'s (Health Res Policy Syst 1:2, 2003) framework on the place of policy-making in the stages of assessment of research utilisation and outcomes. RESULTS: The workshop identified key strategies for translating research into policy, including joint agenda-setting between researchers and policy-makers, as well as building trust and partnerships with different stakeholders. These were linked to stages within Hanney et al.'s framework as opportunities for engaging with policy-makers to ensure uptake of research findings. CONCLUSION: The engagement of stakeholders during the research development and implementation phases, especially at strategic moments, has a positive impact on uptake of research findings. The strategies and stages described in this paper can be applied to improve utilisation of research findings into policy development and implementation globally.

Measurement approaches in continuum of care for maternal health: a critical interpretive synthesis of evidence from LMICs and its implications for the South African context.

BACKGROUND: Global strategies recommend a continuum of care for maternal health to improve outcomes and access to care in low and middle income countries (LMICs). South Africa has already set priority interventions along the continuum of care for maternal health, and mandated their implementation at the district health level. However, the approach for monitoring access to this continuum of care has not yet been defined. This review assessed measurement approaches in continuum of care for maternal health among LMICs and their implications for the South African context. METHODS: We conducted a critical interpretive synthesis of quantitative and qualitative research sourced from Academic Search Complete (EBSCO), MEDLINE (Pubmed), Cambridge Journals Online, Credo Reference and Science Direct. We selected 20 out of 118 articles into the analysis, following a rigorous quality appraisal and relevance assessment. The outcomes of the synthesis were new constructs for the measurement of continuum of care for maternal health, derived from the existing knowledge gaps. RESULTS: We learned that coverage was the main approach for measuring and monitoring the continuum of care for maternal health in LMICs. The measure of effective coverage was also used to integrate quality into coverage of care. Like coverage, there was no uniform definition of effective coverage, and we observed gaps in the measurement of multiple dimensions of quality. From the evidence, we derived a new construct called adequacy that incorporated timeliness of care, coverage, and the complex nature of quality. We described the implications of adequacy to the measurement of the continuum of care for maternal health in South Africa. CONCLUSIONS: Critical interpretive synthesis allowed new understandings of measurement of the continuum of care for maternal health in South Africa. The new construct of adequacy can be the basis of a new measure of access to the continuum of care for maternal health. Although adequacy conceptualizes a more holistic approach, more research is needed to derive its indicators and metrics using South African data sources.

What Influences Linkage to Care After Home-Based HIV Counseling and Testing?

To maximize the benefits of test and treat strategies that utilize community-based HIV testing, clients who test positive must link to care in a timely manner. However, linkage rates across the HIV treatment cascade are typically low and little is known about what might facilitate or hinder care-seeking behavior. This qualitative study was conducted within a home-based HIV counseling and testing (HBHCT) intervention in South Africa. In-depth interviews were conducted with 30 HBHCT clients who tested HIV positive to explore what influenced their care-seeking behavior. A set of field notes for 196 additional HBHCT clients who tested HIV positive at home were also reviewed and analyzed. Content analysis showed that linkage to care is influenced by a myriad of factors at the individual, relationship, community, and health system levels. These factors subtly interact and at times reinforce each other. While some factors such as belief in test results, coping ability, social support, and prior experiences with the health system affect clients' desire and motivation to seek care, others such as limited time and resources affect their agency to do so. To ensure that the benefits of community-based testing models are realized through timely linkage to care, programs and interventions must take into account and address clients' emotions, motivation levels, living situations, relationship dynamics, responsibilities, and personal resources.