Maternity protection policies and the enabling environment for breastfeeding in the Philippines: a qualitative study.

BACKGROUND: The Philippines has enacted maternity protection policies, such as the 105-Day Expanded Maternity Leave Law and the Expanded Breastfeeding Promotion Act of 2009, to protect, promote, and support breastfeeding. This study aimed to review the content and implementation of maternity protection policies in the Philippines and assess their role in enabling recommended breastfeeding practices. It also identified bottlenecks to successful implementation from the perspectives of mothers and their partners, employers, and authorities from the government and non-government organizations involved in developing, implementing, monitoring, and enforcing maternity protection policies. METHODS: This study employed a desk review of policies, guidelines, and related documents on maternity protection, and in-depth interviews. Of the 87 in-depth interviews, there were 12 employed pregnant women, 29 mothers of infants, 15 partners of the mothers, 12 employers and 19 key informants from the government and non-government organizations. Respondents for the in-depth interviews were from the Greater Manila Area and were recruited using purposive snowball sampling. Data were collected from December 2020 to April 2021. RESULTS: The study shows that maternity protection policies in the Philippines are mostly aligned with the maternity protection standards set by the International Labour Organization. However, their role in improving breastfeeding practices is limited because: (1) not all working women have access to maternity protection entitlements; (2) the duration of maternity leave entitlements is inconsistent with the World Health Organization's recommended duration of exclusive breastfeeding; (3) there are gaps in policy implementation including: a lack of monitoring systems to measure the availability, functionality, and usage of lactation spaces; limited workplace support for breastfeeding; poor communication of maternity and paternity entitlements; and limited breastfeeding advocacy and promotion; and (4) there is limited integration between maternity protection and breastfeeding promotion interventions. CONCLUSIONS: There is a need to (1) strengthen communication about and promotion of maternity and paternity entitlements for mothers, fathers and employers, (2) improve monitoring and enforcement mechanisms to ensure utilization of entitlements among mothers, (3) develop modalities to extend the coverage of maternity entitlements to the informal sector, (4) fully cover paid leave entitlements from social insurance or public funding sources in line with International Labour Organization recommendations, and (5) revisit the limitations on the coverage of paternity entitlement.

Birth and newborn care policies and practices limit breastfeeding at maternity facilities in Vietnam.

The prevalence of early and exclusive breastfeeding in Vietnam remains sub-optimal. The objective of this study was to determine factors associated with early initiation of breastfeeding (EIBF) and exclusive breastfeeding for the first 3 days after birth (EBF3D). We conducted a population-based, cross-sectional survey of 726 mothers with children aged 0-11 months in two provinces and one municipality from May to July 2020. Multinomial logistic regression was used to examine factors associated with EIBF and EBF3D. The prevalence of EIBF was 39.7% and EBF3D 18.0%. The EIBF prevalence is positively associated with immediate and uninterrupted skin-to-skin contact (SSC) for 10-29 min (aOR: 2.55; 95% CI: 1.49, 4.37), 30-59 min (aOR: 4.15; 95% CI: 2.08, 8.27), 60-80 min (aOR: 4.35; 95% CI: 1.50, 12.6), or ≥90 min (aOR: 5.87; 95% CI: 3.14, 10.98). EIBF was negatively associated with cesarean birth (aOR: 0.24; 95% CI: 0.11, 0.51), bringing infant formula to the birth facility (aOR: 0.49; 95% CI: 0.30, 0.78), purchased it after arrival (aOR: 0.37; 95% CI: 0.24, 0.60), or did both (aOR: 0.43; 95% CI: 0.21, 0.89). EBF3D was negatively associated with cesarean section birth (aOR: 0.15; 95% CI: 0.06, 0.39), vaginal birth with episiotomy (aOR: 0.40; 95% CI: 0.18, 0.88), bringing formula to the maternity facility (aOR: 0.03; 95% CI: 0.01, 0.07), purchased it after arrival (aOR: 0.02; 95% CI: 0.01, 0.06) or did both (aOR: 0.04; 95% CI: 0.02, 0.10). Receiving counseling from any source was not significantly associated with early breastfeeding practices. Policy and health service delivery interventions should be directed at eliminating infant formula from birthing environments, reducing unnecessary cesarean sections and episiotomies, providing immediate and uninterrupted SSC for all births, and improving breastfeeding counseling and support.

Facilitators and barriers to participation in health mothers' groups in improving maternal and child health and nutrition in Nepal : A mixed-methods study.

BACKGROUND: In Nepal, Health Mother's Groups (HMG) are women's group-based programmes for improving maternal and child health. However, they remain underutilised with only 27% of reproductive-aged women participating in an HMG meeting in 2016. This study aimed to understand the facilitators and barriers to HMG meeting participation. METHODS: We conducted a convergent mixed-methods study using cross-sectional quantitative data from the 2016 Nepal Demographic and Health Survey and primary data collected via 35 in-depth interviews and eight focus group discussions with 1000-day women and their family members, female community health volunteers (FCHVs) and health facility staff in two geographies of Nepal, Kaligandaki and Chapakot. Quantitative data were analysed using logistic regression and qualitative data using deductive coding. The results were triangulated and thematically organised according to the socio-ecological model (SEM). RESULTS: Facilitators and barriers emerged across individual, interpersonal and community levels of the SEM. In the survey, women with more children under five years of age, living in a male-headed household, or in rural areas had increased odds of HMG participation (p < 0.05) while belonging to the Janajati caste was associated with lower odds of participation (p < 0.05). Qualitative data helped to explain the findings. For instance, the quantitative analysis found women's education level associated with HMG participation (p < 0.05) while the qualitative analysis showed different ways women's education level could facilitate or hinder participation. Qualitative interviews further revealed that participation was facilitated by women's interest in acquiring new knowledge, having advanced awareness of the meeting schedule and venue, and engagement with health workers or non-government organisation staff. Participation was hindered by the lack of meeting structure and work obligations during the agricultural season. CONCLUSIONS: To improve women's participation in HMGs in Nepal, it is necessary to address factors at the SEM's individual, interpersonal, and community levels, such as enhancing FCHV literacy, providing advance notice of the meeting schedule, upgrading the meeting venues and reducing women's workload through family support, particularly during agricultural season. These improvements are essential for strengthening effective implementation of HMG meetings and similar women's group-based platforms, and for ultimately improving maternal and child health in Nepal.

Implementation and Effectiveness of Policies Adopted to Enable Breastfeeding in the Philippines Are Limited by Structural and Individual Barriers.

The Philippines has adopted policies to protect, promote, and support breastfeeding on par with global standards, yet the impact of these policies is not well understood. This study assesses the adequacy and potential impact of breastfeeding policies, as well as the perceptions of stakeholders of their effectiveness and how to address implementation barriers. This mixed methods study entailed a desk review of policies and documents and in-depth interviews with 100 caregivers, employees, employers, health workers, and policymakers in the Greater Manila Area. Although the Philippines has a comprehensive breastfeeding policy framework, its effectiveness was limited by structural and individual barriers. Structural barriers included inconsistent breastfeeding promotion, limited access of mothers to skilled counseling, limited workplace breastfeeding support, gaps in legal provisions, weak monitoring and enforcement of the Philippine Milk Code, and the short duration and limited coverage of maternity leave. Individual barriers included knowledge and skills gaps, misconceptions, and low self-confidence among mothers due to insufficient support to address breastfeeding problems, misconceptions in the community that undermine breastfeeding, limited knowledge and skills of health workers, and insufficient support extended to mothers by household members. Breastfeeding policies in the Philippines are consistent with global standards, but actions to address structural and individual barriers are needed to enhance their effectiveness for improving breastfeeding practices.

Awareness, Perceptions, Gaps, and Uptake of Maternity Protection among Formally Employed Women in Vietnam.

Maternity protection is a normative fundamental human right that enables women to combine their productive and reproductive roles, including breastfeeding. The aim of this study is to examine the uptake of Vietnam's maternity protection policy in terms of entitlements and awareness, perceptions, and gaps in implementation through the lens of formally employed women. In this mixed methods study, we interviewed 494 formally employed female workers, among whom 107 were pregnant and 387 were mothers of infants and conducted in-depth interviews with a subset of these women (n = 39). Of the 494 women interviewed, 268 (54.3%) were working in blue-collar jobs and more than 90% were contributing to the public social insurance fund. Among the 387 mothers on paid maternity leave, 51 (13.2%) did not receive cash entitlements during their leave. Among the 182 mothers with infants aged 6-11 months, 30 (16.5%) returned to work before accruing 180 days of maternity leave. Of 121 women who had returned to work, 26 (21.5%) did not receive a one-hour paid break every day to express breastmilk, relax, or breastfeed, and 46 (38.0%) worked the same or more hours per day than before maternity leave. Although most women perceived maternity leave as beneficial for the child's health (92.5%), mother's health (91.5%), family (86.2%), and society (90.7%), fewer women perceived it as beneficial for their income (59.5%), career (46.4%), and employers (30.4%). Not all formally employed women were aware of their maternity protection rights: women were more likely to mention the six-month paid maternity leave (78.7%) and one-hour nursing break (62.3%) than the other nine entitlements (2.0-35.0%). In-depth interviews with pregnant women and mothers of infants supported findings from the quantitative survey. In conclusion, although Vietnam's maternity protection policy helps protect the rights of women and children, our study identified implementation gaps that limit its effectiveness. To ensure that all women and their families can fully benefit from maternity protection, there is a need to increase awareness of the full set of maternity entitlements, strengthen enforcement of existing policies, and expand entitlements to the informal sector.

Malnutrition matters: Association of stunting and underweight with early childhood development indicators in Nepal.

Malnutrition is a threat to optimal child development, with its occurrence during foetal and infancy stages associated with poor cognitive, motor and socio-emotional skills. However, information on the effects of various types of malnutrition on early childhood development (ECD) is limited in Nepal. To assess the association of stunting, wasting and underweight (three prominent forms of malnutrition) with the four domains of the ECD index (literacy-numeracy, physical, social-emotional and learning development) among children 36-59 months of age, we conducted an adjusted logistic regression using Nepal's national household Multiple Indicator Cluster Survey (MICS) 2019 data set. The study sample consisted of children aged 36-59 months (n = 2871). Children were considered developmentally on track if they met criteria in each of the four ECD domains. Regarding ECD status of children 36-59 months old, 35% of children were not developmentally on track for the ECD index. The adjusted odds ratio indicated that stunting was associated with lower odds of not being developmentally on track according to the ECD index as well as the literacy-numeracy, physical and learning domains of the ECD index. Likewise, underweight was associated with lower odds of not being developmentally on track according to the ECD index, primarily for ECD domains of literacy-numeracy, physical and learning. Notably, no association between wasting and ECD indicators was observed. Children's nutrition status impacts child development outcomes. Adding ECD interventions, such as responsive and stimulating caregiving, within nutrition programmes among children who are stunted and underweight could improve child development outcomes.

Beliefs and Norms Associated with the Use of Ultra-Processed Commercial Milk Formulas for Pregnant Women in Vietnam.

Commercial milk formula for pregnant women (CMF-PW) is an expensive, ultra-processed food with a high concentration of sugar, the consumption of which may be linked to negative health outcomes. However, CMF-PWs are promoted as beneficial for pregnant women and lactating mothers as well as their children. To date, little is known about the factors associated with the use of CMF-PW among pregnant women. We performed this analysis to examine the association between the use of CMF-PW and related beliefs and norms among pregnant women in Vietnam. We interviewed 268 pregnant women in their second and third trimesters from two provinces and one municipality representing diverse communities in Vietnam. Multinomial (polytomous) logistic regression, structural equation modeling (SEM), and propensity score matching (PSM) analysis were used to examine associations between beliefs and social norms related to CMF-PW and reported consumption, characterized as occasional, recent, and never during the current pregnancy. Overall, 64.6% of pregnant women reported using CMF-PW during the current pregnancy and 34.7% consumed CMF-PW on the day prior to the interview. Strong beliefs that CMF-PW will make a child smart and healthy (53.7%) and the perception that use of CMF-PW is common (70.9%) were associated with increased use on the previous day (beliefs: aOR: 3.56; 95% Confidence Interval (95% CI): 1.65, 7.71; p < 0.01 and social norms aOR: 2.29; 95% CI: 1.13, 4.66; p < 0.05). SEM and PSM analyses confirmed these findings for both occasional and regular CMF-PW use. Results are consistent with observations of CMF-PW product labels and marketing tactics in Vietnam. The prevalent use of CMF-PW in Vietnam is associated with the belief that these products make children smart and healthy and the perceived social norm that most mothers use these products, which mirrors marketing messages and approaches employed by the CMF industry.

Implementation of the Code of Marketing of Breast-Milk Substitutes in Vietnam: Marketing Practices by the Industry and Perceptions of Caregivers and Health Workers.

BACKGROUND: The promotion of breastmilk substitutes (BMS) is an important barrier to successful breastfeeding. OBJECTIVE: To examine the enactment and implementation of the Code of Marketing of Breast-Milk Substitutes (the Code) in Vietnam with a focus on marketing practices by the baby food industry and perceptions of caregivers, health workers, and policy makers. METHODS: From May to July 2020, we conducted a mixed-method, cross-sectional study including a survey of 268 pregnant women and 726 mothers of infants aged 0-11 months and in-depth interviews with a subset of interviewed women (n = 39), policy makers, media executives, and health workers (n = 31). RESULTS: In the previous 30 days, two mothers (out of 726) participating in the quantitative survey reported that health workers had recommended BMS, at private hospitals in both cases. In-depth interviews with health workers showed that hospitals have internal procedures to prevent the promotion of BMS by health workers. However, companies employed representatives to promote products not covered under the Code (e.g., commercial milk formula for pregnant women) at antenatal care visits and by gaining contact information from women and using this information to promote BMS outside the hospital, often on social media. In the 30 days preceding the survey, one-fifth of pregnant women were exposed to promotions of commercial milk formula for pregnant women and 7.1% to promotions of BMS. Among mothers of infants, 7.3% and 10.7% of respondents with infants aged 0-5 and 6-11 months, respectively, were exposed to some form of BMS promotion in the past 30 days. Around the time of birth, parents commonly brought BMS to maternity facilities (52.5%) or purchased it nearby (35.4%). CONCLUSIONS: Although Vietnam has a strong regulatory environment for the protection, promotion, and support of breastfeeding, there are implementation, monitoring, and enforcement gaps. Stronger enforcement of national policies to regulate the presence of BMS industry representatives in health facilities-both public and private-and the promotion of BMS products on digital platforms are needed.

Exploring the Use of Mobile Health to Improve Community-Based Health and Nutrition Service Utilization in the Hills of Nepal: Qualitative Study.

BACKGROUND: With mobile phone coverage and ownership expanding globally, mobile health (mHealth) interventions are increasingly being used to improve coverage and quality of health and nutrition services. However, evidence on mHealth intervention feasibility and factors to consider during program design is limited in low- and middle-income countries like Nepal. OBJECTIVE: This study aimed to examine the potential of using text messages to improve health and nutrition services by exploring mobile phone ownership and sharing; mobile phone use and skills; and interest, preferences, and limitations regarding mHealth interventions. METHODS: We conducted 35 in-depth interviews with 1000-day women (the period from conception to a child's second birthday), health facility staff, and female community health volunteers (FCHVs), as well as eight focus group discussions with health facility staff, FCHVs, and 1000-day household decision-makers (ie, husbands, mothers-in-law, and fathers-in-law). We also conducted a mobile phone skills test. We employed thematic analysis using framework matrices and analytical memos. RESULTS: The study included 70 study participants, of whom 68 (97%) had a mobile phone, and phone sharing was uncommon. Use of text messages was most commonly reported by 1000-day women and health facility staff than household decision-makers and FCHVs. More than 8 in 10 participants (54/64, 84%) could dial numbers, and the majority (28/34, 82%) of 1000-day women, health facility staff, and male decision-makers could also read and write text messages. We found that 1000-day women preferred educational and reminder messages, whereas health facility staff and FCHVs desired educational and motivational messages. Participants suggested different types of texts for 1000-day women, families, FCHVs, and health facility staff, and reported less value for texts received from unknown phone numbers. CONCLUSIONS: A text message-based mHealth intervention is acceptable in the hills of Nepal and has the potential to improve community health and nutrition service utilization, particularly by sending meeting reminders and by providing information. Our findings contribute to text message-based mHealth intervention design in under-resourced settings.

Assessing the Effectiveness of Policies Relating to Breastfeeding Promotion, Protection, and Support in Southeast Asia: Protocol for a Mixed Methods Study.

BACKGROUND: Despite its well-known benefits, breastfeeding practices remain suboptimal worldwide, including in Southeast Asia. Many countries in the region have thus enacted policies, such as maternity protection and the World Health Assembly International Code of Marketing of Breast-milk Substitutes (the Code), that protect, promote, and support breastfeeding. Yet the impact of such national legislation on breastfeeding practices is not well understood. OBJECTIVE: This study aims to review the content, implementation, and potential impact of policies relating to maternity protection and the Code in Myanmar, the Philippines, Thailand, and Vietnam. METHODS: This mixed methods study includes a desk review, trend and secondary data analyses, and quantitative and qualitative data collection. Desk reviews will examine and compare the contents, implementation strategies, coverage, monitoring, and enforcement of national policies focusing on maternity protection and the Code in each country with global standards. Trend and secondary data analyses will examine the potential impact of these policies on relevant variables such as breast milk substitute (BMS) sales and women's workforce participation. Quantitative data collection and analysis will be conducted to examine relevant stakeholders' and beneficiaries' perceptions about these policies. In each country, we will conduct up to 24 in-depth interviews (IDI) with stakeholders at national and provincial levels and 12 employers or 12 health workers. Per country, we will survey approximately 930 women who are pregnant or have a child aged 0-11 months, of whom approximately 36 will be invited for an IDI; 12 partners of the interviewed mothers or fathers of children from 0-11 months will also be interviewed. RESULTS: This study, funded in June 2018, was approved by the Institutional Review Boards of the relevant organizations (FHI 360: April 16, 2019 and May 18, 2020; and Hanoi University of Public Health: December 6, 2019). The dates of data collection are as follows: Vietnam: November and December 2019, May and June 2020; the Philippines: projected August 2020; Myanmar and Thailand: pending based on permissions and funding. Results are expected to be published in January 2021. As of July 2020, we had enrolled 1150 participants. We will present a comparison of key contents of the policies across countries and against international standards and recommendations and a comparison of implementation strategies, coverage, monitoring, and enforcement across countries. We will also present findings from secondary data and trend data analyses to propose the potential impact of a new or amended policy. For the surveys with women, we will present associations between exposure to maternity protection or BMS promotion on infant and young child feeding practices and their determinants. Findings from IDIs will highlight relevant stakeholders' and beneficiaries' perceptions. CONCLUSIONS: This study will increase the understanding of the effectiveness of policy interventions to improve breastfeeding, which will be used to advocate for stronger policy adoption and enforcement in study countries and beyond. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21286.

National nutrition strategies that focus on maternal, infant, and young child nutrition in Southeast Asia do not consistently align with regional and international recommendations.

We examined the consistency of national nutrition strategies and action plans (NNS) focusing on maternal, infant, and young child nutrition in Southeast Asia with regional and international recommendations. Between July and December 2017, we identified and extracted information on context, objectives, interventions, indicators, strategies, and coordination mechanisms from the most recent NNS in nine Southeast Asian countries. All NNS described context, objectives, and the following interventions: antenatal care, micronutrient supplementation during pregnancy, breastfeeding promotion, improved complementary feeding, nutrition in emergencies, and food fortification or dietary diversity. Micronutrient supplementation for young children was included in eight NNS; breastfeeding promotion during pregnancy and support at birth in seven; and school feeding, deworming, and treatment of severe acute malnutrition in six. All NNS contained programme monitoring and evaluation plans with measurable indicators and targets. Not all NNS covered wasting, exclusive breastfeeding, low birthweight, and childhood overweight. Strategies for achieving NNS goals and objectives were health system strengthening (nine), social and behaviour change communication (nine), targeting vulnerable groups (eight), and social or community mobilization (four). All addressed involvement, roles and responsibilities, and collaboration mechanisms among sectors and stakeholders. There was a delay in releasing NNS in Indonesia, Myanmar, and the Philippines. In conclusion, although Southeast Asian NNS have similarities in structure and contents, some interventions and indicators vary by country and do not consistently align with regional and international recommendations. A database with regularly updated information on NNS components would facilitate cross-checking completeness within a country, comparison across countries, and knowledge sharing and learning.

The Role of the Opinion Leader Research Process in Informing Policy Making for Improved Nutrition: Experience and Lessons Learned in Southeast Asia.

Opinion leader research (OLR) has been widely used in public health to identify influential persons or organizations to affect health care practice, inform policy-making processes, and help shape communication strategies. We used OLR to gather information related to barriers and possible solutions to guide strategic engagement for strengthening policy making for improved maternal, infant, and young child nutrition (MIYCN) practices in 5 Southeast Asian countries-Cambodia, Laos, Indonesia, Timor-Leste, and Thailand. In most countries, MIYCN policies and policymaker interest exist, but effective implementation and/or enforcement of current policies is weak. This article aims to share our experience in and lessons learned from using OLR as an advocacy tool: It helped identify opinion leaders with interest and influence to affect nutrition-related policies, it raised opinion leaders' interest in MIYCN, and it identified themes that would help generate political priority setting. Based on our experience, we recommend OLR as a strategic activity for informing and generating support for MIYCN policy-making processes.

Adapting a health video library for use in Afghanistan: provider-level acceptability and lessons for strengthening operational feasibility.

BACKGROUND: Community health workers (CHWs) in Afghanistan are a critical care extender for primary health services, including reproductive, maternal, neonatal, and child health (RMNCH) care. However, volunteer CHWs face challenges including an ever-expanding number of tasks and insufficient time to conduct them. We piloted a health video library (HVL) intervention, a tablet-based tool to improve health promotion and counseling by CHWs. We qualitatively assessed provider-level acceptability and operational feasibility. METHODS: CHWs implemented the HVL pilot in three rural districts of Balkh, Herat, and Kandahar provinces. We employed qualitative methods, conducting 47 in-depth interviews (IDIs) with male and female CHWs and six IDIs with community health supervisors. We used semi-structured interview guides to explore provider perceptions of program implementation processes and solicit feedback on how to improve the HVL intervention to inform scale-up. We conducted a thematic analysis. RESULTS: CHWs reported that the HVL increased time efficiencies, reduced work burden, and enhanced professional credibility within their communities. CHWs felt video content and format were accessible for low literacy clients, but also identified challenges to operational feasibility. Although tablets were considered easy-to-use, certain technical issues required continued support from supervisors and family. Charging tablets was difficult due to inconsistent electricity access. Although some CHWs reported reaching most households in their catchment area for visits with the HVL, others were unable to visit all households due to sizeable populations and gender-related barriers, including women's limited mobility. CONCLUSIONS: The HVL was acceptable and feasible for integration into existing CHW duties, indicating it may improve RMNCH counseling, contributing to increased care-seeking behaviors in Afghanistan. Short-term challenges with technology and hardware can be addressed through continued training and provision of solar chargers. Longer-term challenges, including tablet costs, community coverage, and gender issues, require further consideration with an emphasis on equitable distribution.

Social, economic, and political events affect gender equity in China, Nepal, and Nicaragua: a matched, interrupted time-series study.

Background: Progress in gender equity can improve health at the individual and country levels.Objectives: This study's objective was to analyze recent trends in gender equity and identify historical and contextual factors that contributed to changes in gender equity in three countries: China, Nepal, and Nicaragua.Methods: To assess gender equity trends, we used the Gender Gap Index (GGI) from the World Economic Forum's Global Gender Gap Report (2006-2017). The GGI incorporated data on economic participation, educational attainment, health, and political empowerment for almost 150 countries. We selected China, Nepal, and Nicaragua because of their major changes in GGI and diversity in geographical location and economic status. We reviewed major social, economic, and political events during 2006-2017, and identified key events in each country. We compared countries' GGI with matched controls average using interrupted time-series analysis.Results: Nepal and Nicaragua both had dramatic increases in GGI (improvement in equity), Nepal (ß = 0.029; 95% CI: 0.003, 0.056) and Nicaragua (ß = 0.035; 95% CI: 0.005, 0.065). This was strongly influenced by political empowerment, which likely impacted access to education and employment opportunities. Despite major economic growth and new policies to address gender inequities (e.g. the One-Child Policy), China saw a significant decline in GGI between 2010 and 2017 (ß = -0.014; 95% CI: -0.024, -0.004), largely resulting from decreased gender equity in educational attainment, economic participation, and health/survival sub-indices.Conclusions: Key social, economic, and political events helped explain trends in countries' gender equity. Our study suggested that supportive social and political environments would play important roles in empowering women, which would advance human rights and promote health and well-being of individuals, households, communities, and countries.

Intimate partner violence and contraceptive use among married women in Nepal.

OBJECTIVE: To examine relationships between lifetime experience of intimate partner violence (IPV), and current contraceptive use and method among married women of reproductive age in Nepal. METHODS: A cross-sectional analysis of 2016 Nepal Demographic Health Survey data on contraceptive use and IPV experience among ever-married women of reproductive age. Weighted percentages were reported and multinomial logistic regression was used to assess associations between IPV (physical, sexual, emotional, or any form) and contraception use (modern reversible, sterilization, or traditional). RESULTS: Among 3562 women who responded to the violence module, 26% reported experiencing any form (physical, sexual or emotional) of IPV in their lifetime. Lifetime exposure to any form of IPV was associated with sterilization (adjusted odds ratio [aOR], 1.50; 95% confidence interval [CI], 1.12-2.00) and lifetime exposure to physical violence only was significantly associated with having been sterilized (aOR, 1.59; 95% CI, 1.17-2.16). CONCLUSION: Experience of violence, particularly physical violence, was found to be associated with sterilization in Nepal. Research is needed to understand the causes of this association, and the decision-making power dynamics related to contraceptive use, husbands' attitudes toward sterilization, and the reasons why sterilization-relative to other contraceptive options-was the contraceptive method of choice.

Enhancing governance and strengthening advocacy for policy change of large Collective Impact initiatives.

Nutrition issues are increasingly being addressed through global partnerships and multi-sectoral initiatives. Ensuring effective governance of these initiatives is instrumental for achieving large-scale impact. The Collective Impact (CI) approach is an insightful framework that can be used to guide and assess the effectiveness of this governance. Despite the utility and widespread use of this approach, two gaps are identified: a limited understanding of the implications of expansion for an initiative operating under the conditions of CI and a lack of attention to advocacy for policy change in CI initiatives. In this paper, a case study was undertaken in which the CI lens was applied to the advocacy efforts of Alive & Thrive (A&T), UNICEF and partners. The initiative expanded into a regional movement and achieved meaningful policy changes in infant and young child feeding policies in seven countries in Southeast Asia. These efforts are examined in order to address the two gaps identified in the CI approach. The objectives of the paper are (a) to examine the governance of this initiative and the process of expansion from a national to a regional, multilayered initiative, with attention to challenges, adaptations, and key elements, and (b) to compare advocacy in the A&T-UNICEF initiative and in typical CI initiatives and gain insight into how the practice of advocacy for policy change can be strengthened in CI initiatives.

Determining barriers to creating an enabling environment in Cambodia: results from a baseline study with key populations and police.

INTRODUCTION: Cambodian law enforcement's limited acceptance of harm reduction has hindered HIV program effectiveness. With funding from the Australian Department of Foreign Affairs and Trade, FHI 360 supported the Ministry of Interior to implement the Police Community Partnership Initiative (PCPI) in Cambodia's capital Phnom Penh. To guide this, FHI 360 conducted a baseline study examining police and key populations' attitudes and practices towards one another, including fear and occurrence of arrest. METHODS: Between December 2012 and January 2013, a cross-sectional survey of 199 police post officers, 199 people who use drugs (PWUD) including people who inject drugs (PWID), 199 men who have sex with men (MSM), 200 transgender women (TGW) and 200 female entertainment workers (FEW) was conducted in five Phnom Penh districts. Eligible participants were ≥18 years, members of a key population from selected hotspots or police officers, deputy chiefs or chiefs. RESULTS: Key populations' median age was 25 years (IQR: 22-30); 40% had completed only primary school. Police were male (99.5%), with median age 43 years (IQR: 30 to 47), and 45 and 25% high school and university completion rates, respectively. Key populations feared arrest for carrying needles and syringes (67%), condoms (23%) and 19% felt afraid to access health services. Close to 75% of police reported body searching and 58% arresting key populations in the past six months for using drugs (64%), selling or distributing drugs (36%) or being violent (13%). Self-reported arrests (23% PWUD, 6% MSM, 6% TGW, 12% FEW; p<0.05), being verbally threatened (45% PWUD, 21% MSM, 25% TGW, 27% FEW; p<0.001) and body searched (44% PWUD, 28% MSM, 23% TGW, 8% FEW; p<0.001) was significantly higher among PWUD than other key populations. The majority (94%) of police believed arrest was an appropriate solution to reduce HIV and drug use and reported selling sex (88%) and carrying needles and syringes (55%) as valid reasons for arrest. CONCLUSIONS: Key populations' fear of accessing harm reduction and health services and police's negative attitudes and practices towards key populations present major barriers to HIV prevention efforts in Cambodia. To create an enabling environment and ensure police are allies in the Cambodian HIV response, interventions should tackle underlying negative attitudes among police towards key populations and vice versa.

HIV Prevalence and Risks Associated with HIV Infection among Transgender Individuals in Cambodia.

INTRODUCTION: Recognizing transgender individuals have a high risk of HIV acquisition, and to inform policies and programming, we conducted an HIV prevalence and risk behaviors survey among transgender individuals in Cambodia. METHODS: Cross-sectional survey using a respondent driven sampling method with self-administered audio-computer assisted interviews. HIV testing was performed prior to the questionnaire with results available immediately after. Eligible participants were ≥18 years, identified as male at birth and self-identified/expressed as a different gender, and reported having sex with at least one male partner in past year. From six major urban centers of Cambodia, 891 transgender individuals were recruited. RESULTS: The majority of the 891 participants self-identified as third gender or female (94.5%), were young (median age 23, IQR [20-27]), had secondary education or higher (80.5%), not married (89.7%), and employed (90.2%). The majority had first sex before 18 years (66.8%), with a male (79.9%), 37.9% having been paid or paying for this first sex. The rate of HIV positivity among participants was found to be 4.15%. Consistent condom use with male and female partners was low with all partner types, but particularly low with male partners when paying for sex (20.3%). The majority of participants reported having experienced discrimination in their lifetime (54.8%) and 30.3% had been assaulted. Multivariate analysis revealed that older age (adjusted OR = 14.73 [4.20, 51.67] for age 35-44 and adjusted OR = 7.63 [2.55, 22.81] for age 30-34), only having a primary school education or no schooling at all (adjusted OR = 2.62 [1.18, 5.80], being a resident of Siem Reap (adjusted OR = 7.44 [2.37, 23.29], receiving payment at first sex (adjusted OR = 2.26 [1.00, 5.11], having sex during/after using drugs (adjusted OR = 2.90 [1.09, 7.73]), inconsistent condom use during last anal sex (adjusted OR = 3.84 [1.58, 9.33]), and reporting low self-esteem (adjusted OR = 3.25 [1.35, 7.85]) were independently associated with HIV infection. CONCLUSIONS: This study confirms transgender individuals as one of the highest-risk groups for HIV infection in Cambodia. It suggests the need for programmatic strategies that mitigate identified associated risks and facilitate access to HIV care for this population.

The village/commune safety policy and HIV prevention efforts among key affected populations in Cambodia: finding a balance.

The Village/Commune Safety Policy was launched by the Ministry of Interior of the Kingdom of Cambodia in 2010 and, due to a priority focus on "cleaning the streets", has created difficulties for HIV prevention programs attempting to implement programs that work with key affected populations including female sex workers and people who inject drugs. The implementation of the policy has forced HIV program implementers, the UN and various government counterparts to explore and develop collaborative ways of delivering HIV prevention services within this difficult environment. The following case study explores some of these efforts and highlights the promising development of a Police Community Partnership Initiative that it is hoped will find a meaningful balance between the Village/Commune Safety Policy and HIV prevention efforts with key affected populations in Cambodia.