The Multidimensional, Intersecting Impacts of COVID-19 on Young People's Lives: Evidence From Cross-Sectional Surveys in Mexico, India, and Kenya.

PURPOSE: Studies have documented diverse adverse effects of the COVID-19 pandemic on young people's lives-for instance on mental health, education/employment prospects, and intrafamily violence. We sought to generate much-needed evidence regarding whether, and which, young people are experiencing multiple intersecting effects. METHODS: Data come from cross-sectional surveys with young people ages 15-25 years in Mexico (nationwide, n = 55,692), Kenya (four counties, n = 2,750), and India (two states, n = 3,537), collected from late 2020 to early 2022. We used latent class analysis to identify subgroups based on multiple adverse effects, then examined associations between these subgroups and COVID-19 infections/family deaths, and sociodemographic characteristics. RESULTS: We found prevalent adverse impacts overall and two distinct subgroups in each country-one experiencing higher levels of all impacts, such as on mental health (44%-78% across countries), education/employment (22%-84%), intrafamily violence (22%-49%), and friendships (66%-86%). This subgroup comprised 40% of the sample in Mexico, 25% in Kenya, and 35% in India. In multivariate analyses, this group consistently had greater odds of experiencing COVID-19-related infections and deaths of loved ones. They were more likely socioeconomically disadvantaged, older, urban residents. Associations with other characteristics were country-specific. DISCUSSION: This study provides novel cross-country evidence that a subgroup of young people has experienced intersecting adverse impacts of COVID-19 on their lives. Findings also confirm prior evidence of multiple elevated vulnerabilities in general. Expanded provision of multiple layers of support is required, particularly for the most vulnerable subgroup, as are multi-sectoral policies and interventions to prevent intersectional effects in future times of crisis.

Exploring the accuracy of self-reported maternal and newborn care in select studies from low and middle-income country settings: do respondent and facility characteristics affect measurement?

BACKGROUND: Accurate data on the receipt of essential maternal and newborn health interventions is necessary to interpret and address gaps in effective coverage. Validation results of commonly used content and quality of care indicators routinely implemented in international survey programs vary across settings. We assessed how respondent and facility characteristics influenced the accuracy of women's recall of interventions received in the antenatal and postnatal periods. METHODS: We synthesized reporting accuracy using data from a known sample of validation studies conducted in Sub-Saharan Africa and Southeast Asia, which assessed the validity of women's self-report of received antenatal care (ANC) (N = 3 studies, 3,169 participants) and postnatal care (PNC) (N = 5 studies, 2,462 participants) compared to direct observation. For each study, indicator sensitivity and specificity are presented with 95% confidence intervals. Univariate fixed effects and bivariate random effects models were used to examine whether respondent characteristics (e.g., age group, parity, education level), facility quality, or intervention coverage level influenced the accuracy of women's recall of whether interventions were received. RESULTS: Intervention coverage was associated with reporting accuracy across studies for the majority (9 of 12) of PNC indicators. Increasing intervention coverage was associated with poorer specificity for 8 indicators and improved sensitivity for 6 indicators. Reporting accuracy for ANC or PNC indicators did not consistently differ by any other respondent or facility characteristic. CONCLUSIONS: High intervention coverage may contribute to higher false positive reporting (poorer specificity) among women who receive facility-based maternal and newborn care while low intervention coverage may contribute to false negative reporting (lower sensitivity). While replication in other country and facility settings is warranted, results suggest that monitoring efforts should consider the context of care when interpreting national estimates of intervention coverage.

Reaching women at work with health programming in Bangladesh: results of difference-in-differences analysis among female factory workers.

The rapid growth of Bangladesh's ready-made garment sector has transformed the country's economy while also employing a predominantly female workforce. Companies have begun collaborating with NGOs to provide health messages to and expand health services for workers. This study evaluates the effect of the Health Enables Return (HER) health model's approach of using peer health educators to deliver health messages and increased availability of health products. Using repeated cross-sectional data from female workers in HERhealth and comparison factories between May 2015 and March 2017, baseline (n = 1704) and endline (n = 1503) samples were matched on eight characteristics and then difference-in-differences estimations were used to determine the effect of the HERhealth model on knowledge and behaviours. The average changes over time in knowledge and behaviours were statistically different between the HERhealth and comparison factories. Knowledge of when a woman is at higher risk for pregnancy during her menstrual cycle increased from baseline to endline in both groups but was 12 percentage points greater in the HERhealth factories than in the comparison. An increase in family planning use among ever-married women was observed in the HERhealth factories but decreased in the comparison factories leading to a 12 percentage point difference-in-differences. The greatest effect of the HERhealth model was observed on women's use of sanitary products for menstrual management which significantly increased in both groups, but the increase was 35% greater in the HERhealth factories. The HERhealth model is effective in increasing knowledge and in improving health behaviours when health products are available in factory infirmaries.

The Validity of Women's Reports of Family Planning Service Quality in Cambodia and Kenya.

Population-based indicators of the coverage of key elements of high-quality family planning services are tracked via household surveys with female respondents, yet little work has been done to establish their validity. We take advantage of existing data sets from Cambodia and Kenya to compare women's responses at exit interviews following a health facility visit against the observations of a trained third-party observer during the visit. The results, which treat the observations as the reference standard, show that indicators that measure contraceptive methods received are accurately reported while indicators of whether the woman received her preferred method and whether information was "discussed" or "explained" during counseling are less reliably reported. Studies designed explicitly to assess the validity of family planning questions in household surveys, especially questions in large survey programs critical for monitoring demographic trends and programmatic coverage, are needed.

Health workforce demography: a framework to improve understanding of the health workforce and support achievement of the Sustainable Development Goals.

The ambition of universal health coverage entails estimation of the number, type and distribution of health workers required to meet the population need for health services. The demography of the population, including anticipated or estimated changes, is a factor in determining the 'universal' needs for health and well-being. Demography is concerned with the size, breakdown, age and gender structure and dynamics of a population. The same science, and its robust methodologies, is equally applicable to the demography of the health workforce itself. For example, a large percentage of the workforce close to retirement will impact availability, a geographically mobile workforce has implications for health coverage, and gender distribution in occupations may have implications for workforce acceptability and equity of opportunity. In a world with an overall shortage of health workers, and the expectation of increasing need as a result of both population growth in the global south and population ageing in the global north, studying and understanding demographic characteristics of the workforce can help with future planning. This paper discusses the dimensions of health worker demography and considers how demographic tools and techniques can be applied to the analysis of the health labour market. A conceptual framework is introduced as a step towards the application of demographic principles and techniques to health workforce analysis and planning exercises as countries work towards universal health coverage, the reduction of inequities and national development targets. Some illustrative data from Nepal and Finland are shown to illustrate the potential of this framework as a simple and effective contribution to health workforce planning.

Relationship between self-efficacy and HIV testing uptake among young men who have sex with men in Myanmar: a cross-sectional analysis.

Men who have sex with men (MSM) are disproportionally affected by the HIV epidemic. Self-efficacy is an important individual psychosocial factor associated with access to and use of health and HIV-related services. We estimated HIV testing prevalence and examined the relationship between HIV testing self-efficacy and self-reported HIV testing behavior among young MSM (YMSM) in Myanmar. We enrolled 585 MSM aged 18-24 years from six urban areas using respondent-driven sampling (RDS) technique. RDS analyses were performed to provide estimates for the key outcome of interest. More than a third (34.5%) had never been tested for HIV, whereas 27.5% and 38.0% had their most recent HIV test more than three months and within the past three months from the time of interview, respectively. Young MSM who reported high self-efficacy (adjusted relative risk ratio [ARR]=7.35, 95%CI = 2.29-23.5) and moderate self-efficacy (ARR = 8.61, 95%CI = 3.09-24.0) were more likely to report having tested for HIV in the past three months compared to their counterparts who reported low self-efficacy. Findings highlight a positive association between self-efficacy and HIV testing uptake, indicating a potential causal relationship. Further research is needed to examine the direction of this association and inform future public health interventions targeting YMSM in Myanmar.

Making free public healthcare attractive: optimizing health equity funds in Cambodia.

BACKGROUND: Following the introduction of user fees in Cambodia, Health Equity Funds (HEF) were developed to enable poor people access to public health services by paying public health providers on their behalf, including non-medical costs for hospitalised beneficiaries (HEFB). The national scheme covers 3.1 million pre-identified HEFB. Uptake of benefits, however, has been mixed and a substantial proportion of poor people still initiate care at private facilities where they incur considerable out-of-pocket costs. We examine the benefits of additional interventions compared to existing stand-alone HEF scenarios in stimulating care seeking at public health facilities among eligible poor people. METHODS: We report on three configurations of HEF and their ability to attract HEFB to initiate care at public health facilities and their degree of financial risk protection: HEF covering only hospital services (HoHEF), HEF covering health centre and hospital services (CHEF), and Integrated Social Health Protection Scheme (iSHPS) that allowed non-HEFB community members to enrol in HEF. The iSHPS also used vouchers for selected health services, pay-for-performance for quantity and quality of care, and interventions aimed at increasing health providers' degree of accountability. A cross sectional survey collected information from 1636 matched HEFB households in two health districts with iSHPS and two other health districts without iSHPS. Respondents were stratified according to the three HEF configurations for the descriptive analysis. RESULTS: The findings indicated that the proportion of HEFB who sought care first from public health providers in iSHPS areas was 55.7%, significantly higher than the 39.5% in the areas having HEF with health centres (CHEF) and 13.4% in the areas having HEF with hospital services only (HoHEF). The overall costs (out-of-pocket and transport) associated with the illness episode were lowest for cases residing within iSHPS sites, US$10.4, and highest in areas where health centres were not included in the package (HoHEF), US$20.7. Such costs were US$19.5 at HEF with health centres (CHEF). CONCLUSIONS: The findings suggest that HEF encompassing health centre and hospital services and complemented by additional interventions are better than stand-alone HEF in attracting sick HEFB to public health facilities and lowering out-of-pocket expenses associated with healthcare seeking.

Factors associated with HIV testing among young men who have sex with men in Myanmar: a cross-sectional study.

INTRODUCTION: In Myanmar, men who have sex with men (MSM) experience high risk of HIV infection. However, access to HIV testing and prevention services remains a challenge among this marginalized population. The objective of this study was to estimate population prevalence and correlates of prior HIV testing among young MSM (YMSM) and informs the development of HIV testing and intervention programmes that respond to the specific needs of this population. METHODS: Five hundred and eighty-five YMSM aged 18 to 24 years were recruited using respondent-driven sampling (RDS) in a cross-sectional survey conducted in six townships of Myanmar. RDS-adjusted population estimates were calculated to estimate prevalence of HIV testing; RDS-weighted logistic regression was used to examine correlates of HIV testing in the past 6 months and in a lifetime. RESULTS: There were 12 participants who reported receiving a HIV-positive test; of those, five were tested in the past 6 months. The RDS-weighted prevalence estimates of lifetime (any prior) HIV testing was 60.6% (95% CI: 53.3% to 66.4%) and of recent (≤ 6 months) HIV testing was 50.1% (95% CI: 44.1% to 55.5%). In multivariable analysis, sexual identity was associated with lifetime but not recent HIV testing. Lifetime and recent HIV testing were associated with having three or more male sexual partners in the past 12 months (adjusted ORs (aORs) = 2.28, 95% CIs: 1.21 to 4.32 and 2.69, 95% CI: 1.59 to 4.56), having good HIV-related knowledge (aORs = 1.96, 95% CIs: 1.11 to 3.44 and 1.77, 95% CI: 1.08 to 2.89), reporting high HIV testing self-efficacy (aORs = 13.5, 95% CIs: 6.0 to 30.1 and 9.81, 95% CI: 4.27 to 22.6) and having access to and use of non-HIV health-related services in the past 12 months (aORs = 13.2, 95% CIs: 6.85 to 25.6 and 7.15, 95% CI: 4.08 to 12.5) respectively. CONCLUSIONS: HIV testing coverage among YMSM aged 18 to 24 years old in Myanmar is still suboptimal. Integrated HIV testing and prevention services in existing health service provision systems with tailored HIV information and education programmes targeting YMSM to improve HIV-related knowledge and self-efficacy may help to promote regular HIV testing behaviour and contribute to sustainable control of the HIV epidemic among this marginalized population in Myanmar.

Effectiveness of an Integrated Community- and Clinic-Based Intervention on HIV Testing, HIV Knowledge, and Sexual Risk Behavior of Young Men Who Have Sex With Men in Myanmar.

PURPOSE: Young men who have sex with men (YMSM) in Myanmar are disproportionately affected by HIV, with prevalence five times that of the general population. The Link Up project implemented an intervention using peer education and outreach providing education and counseling on health seeking around sexually transmitted infections and reproductive health, combined with focused clinic capacity building to improve the sexual and reproductive health of YMSM. This study aimed to evaluate the effectiveness and acceptability of the intervention. METHODS: Using a mixed-methods approach, and employing a quasi-experimental design, we conducted two quantitative repeat cross-sectional surveys in purposively selected control (no intervention) and intervention townships, before and after implementation of the Link Up intervention. Respondent-driven sampling was used to recruit YMSM aged 15-24 years, and study participants were administered a structured questionnaire assessing intervention exposure, health service access, knowledge of HIV, and sexual risk behavior. Focus group discussions were held to elicit perspectives on the use and acceptability of the health services and peer outreach. RESULTS: At baseline, 314 YMSM were recruited in the intervention townships and 309 YMSM in the control townships. At end line, 267 (intervention) and 318 (control) YMSM were recruited. Coverage of the program was relatively low, with one-third of participants in the intervention townships having heard of the Link Up program by the end line. Comparing changes between baseline and end line, a greater proportion of HIV-negative or unknown status YMSM accessed HIV testing in the past 3 months in intervention townships (from 45.0% to 57.1%) compared with those in control townships (remained at 29.0%); however, this difference in the effect over time was not statistically significant in multivariate modeling (adjusted odds ratio: 1.45; 95% confidence interval: .66-3.17). Qualitative findings showed that the intervention was acceptable to YMSM. CONCLUSIONS: Overall, the intervention was perceived as acceptable. Although not statistically significant, results showed some trends toward improvements among YMSM in accessing HIV testing services and HIV-related knowledge. The modest coverage and short time frame of the evaluation likely limits the ability for any significant behavioral improvements.

Family Planning Vouchers in Low and Middle Income Countries: A Systematic Review.

Family planning (FP) vouchers have targeted subsidies to disadvantaged populations for quality reproductive health services since the 1960s. To summarize the effect of FP voucher programs in low- and middle-income countries, a systematic review was conducted, screening studies from 33 databases through three phases: keyword search, title and abstract review, and full text review. Sixteen articles were selected including randomized control trials, controlled before-and-after, interrupted time series analyses, cohort, and before-and-after studies. Twenty-three study outcomes were clustered around contraceptive uptake, with study outcomes including fertility in the early studies and equity and discontinuation in more recent publications. Research gaps include measures of FP quality, unintended outcomes, clients' qualitative experiences, FP voucher integration with health systems, and issues related to scale-up of the voucher approach.

Increasing Uptake of Long-Acting Reversible Contraceptives in Cambodia Through a Voucher Program: Evidence From a Difference-in-Differences Analysis.

OBJECTIVE: This article evaluates the use of modern contraceptives among poor women exposed to a family planning voucher program in Cambodia, with a particular focus on the uptake of long-acting reversible contraceptives (LARCs). METHODS: We used a quasi-experimental study design and data from before-and-after intervention cross-sectional household surveys (conducted in 2011 and 2013) in 9 voucher program districts in Kampong Thom, Kampot, and Prey Veng provinces, as well as 9 comparison districts in neighboring provinces, to evaluate changes in use of modern contraceptives and particularly LARCs in the 12 months preceding each survey. Survey participants in the analytical sample were currently married, non-pregnant women ages 18 to 45 years (N = 1,936 at baseline; N = 1,986 at endline). Difference-in-differences (DID) analyses were used to examine the impact of the family planning voucher. RESULTS: Modern contraceptive use increased in both intervention and control areas between baseline and endline: in intervention areas, from 22.4% to 31.6%, and in control areas, from 25.2% to 31.0%. LARC use also increased significantly between baseline and endline in both intervention (from 1.4% to 6.7%) and control (from 1.9% to 3.5%) areas, but the increase in LARC use was 3.7 percentage points greater in the intervention area than in the control area (P = .002), suggesting a positive and significant association of the voucher program with LARC use. The greatest increases occurred among the poorest and least educated women. CONCLUSION: A family planning voucher program can increase access to and use of more effective long-acting methods among the poor by reducing financial and information barriers.

Distance, transportation cost, and mode of transport in the utilization of facility-based maternity services: evidence from rural Bangladesh.

Although the maternal mortality ratio in Bangladesh has decreased, significant underutilization of facilities continues to be a persistent challenge to policy makers. Women face long distances and significant transportation cost to deliver at health facilities. This study identifies the distance traveled to utilize facilities, associated transportation cost, and transport mode used for maternal healthcare services. A total of 3,300 mothers aged 18-49 years, who had given birth in the year before the survey, were interviewed from 22 sub-districts in 2010. Findings suggest that facility-based maternal healthcare service utilization was very poor. Only 53% of women received antenatal care, 20% used delivery care. and 10% used postnatal care from health centers. Median distance traveled for antenatal and postnatal check-ups was 2 kilometers but 4 kilometers for complication management care and delivery. Most women used non-motorized rickshaw or van to reach a health facility. On average, women spent Taka 100 (US$1.40) as transportation cost for antenatal care, Taka 432 (US$6.17) for delivery, and Taka 132 (US$1.89) for postnatal check-up. For each additional kilometer, the cost increased by Taka 9 (US$0.13) for antenatal, Taka 31 (US$0.44) for delivery, and Taka 8 (US$0.11) for postnatal care.

Microcredit and domestic violence in Bangladesh: an exploration of selection bias influences.

This article explores the relationship between women's participation in microcredit groups and domestic violence in Bangladesh. Several recent studies have raised concern about microcredit programs by reporting higher levels of violence among women who are members. These results, however, may be attributable to selection bias because members might differ from nonmembers in ways that make them more susceptible to violence to begin with. Using a sample of currently married women from the 2007 Bangladesh Demographic Health Survey (BDHS) (N = 4,195), we use propensity score matching (PSM) as a way of exploring selection bias in this relationship. Results suggest that the previously seen strong positive association between membership and violence does not hold when an appropriate comparison group, generated using PSM, is used in the analyses. Additional analyses also suggest that levels of violence do not differ significantly between members and nonmembers and instead could depend on context-specific factors related to poverty. Members for whom a match is not found report considerably higher levels of violence relative to nonmembers in the unmatched group. The background characteristics of members and nonmembers who do not match suggest that they are more likely to be younger and from relatively well-to-do households.

Poverty, marriage timing, and transitions to adulthood in Nepal.

This study examines the influence of household poverty during early childhood on schooling, workforce participation, and early marriage among adolescent girls in Nepal. Longitudinal data from the two-wave panel of the Nepal Living Standards Survey (NLSS) were used to examine these relationships. For 5-9-year-old girls contacted in NLSS I and again when aged 13-17 in NLSS II (N = 400), multinomial logit regression estimates indicate that household poverty during early childhood is associated with greater likelihood of marrying early or joining the workforce rather than remaining in school. Analyzing the data by household wealth quintiles reveals that these associations are largest for the second-poorest quintile, not the poorest. This study highlights the role of household rather than individual characteristics in adolescent girls' decisionmaking.

The Role of Grandparents in the Lives of Youth.

Recent demographic trends suggest that grandparents may play influential roles in the lives of their grandchildren. Despite this, the role of grandparents in the lives of youth remains an understudied topic. Using data from a nationally-representative group of youth aged 14-19 from the 1992 Wave Two National Survey of Families and Households (NSFH), this study seeks to better understand the role of grandparents in the lives of grandchildren by examining which factors predict the quality of the grandparent-grandchild relationship, and what the implications of this relationship are for youth. Key factors influencing the quality of the grandparent-grandchild relationship are distance, the parent's relationship with both the grandparent and the child, and age of both the child and parent. Results do not support the hypothesis that grandparents influence the dimensions of youth well-being examined here.

Evaluation of the impact of the voucher and accreditation approach on improving reproductive behaviors and status in Cambodia.

BACKGROUND: Cost of delivering reproductive health services to low income populations will always require total or partial subsidization by government and/or development partners. Broadly termed "demand-side financing" or "output-based aid", these strategies include a range of interventions that channel government or donor subsidies to the user rather than the service provider. Initial pilot assessments of reproductive health voucher programs suggest that they can increase access, reduce inequities, and enhance program efficiency and service quality. However, there is a paucity of evidence describing how these programs function in different settings for various reproductive health services. METHODS/DESIGN: Population Council, funded by the Bill and Melinda Gates Foundation, intends to generate evidence around the "voucher and accreditation" approaches to improving the reproductive health of low-income women in Cambodia. The study comprises of four populations: facilities, providers, women of reproductive age using facilities, and women and men who have been pregnant and/or used family planning within the previous 12 months. The study will be carried out in a sample of 20 health facilities that are accredited to provide maternal and newborn health and family planning services to women holding vouchers from operational districts in three provinces: Kampong Thom, Kampot and Prey Veng and a matched sample of non-accredited facilities in three other provinces. Health facility assessments will be conducted at baseline and endline to track temporal changes in quality-of-care, client out-of-pocket costs, and utilization. Facility inventories, structured observations, and client exit interviews will be used to collect comparable data across facilities. Health providers will also be interviewed and observed providing care. A population survey of about 3000 respondents will also be conducted in areas where vouchers are distributed and similar non-voucher locations. DISCUSSION: A quasi-experimental study will investigate the impact of the voucher approach on improving reproductive health behaviors, reproductive health status and reducing inequities at the population level and assess effects on access, equity and quality of care at the facility level. If the voucher scheme in Cambodia is found effective, it may help other countries adopt this approach for improving utilization and access to reproductive health and family planning services.

Maternal working conditions and child well-being in welfare-leaving families.

In the wake of welfare reform, thousands of low-income single mothers have transitioned into the labor market. In this article, the authors examine how the work conditions of mothers leaving welfare for employment are associated with the emotional well-being of 372 children ages 5 to 15 years. The authors examine the cumulative incidence, over a 5-year period, of maternal non-family-friendly work conditions, including long work hours, erratic work schedules, nonday shifts, and lengthy commute times, in association with children's internalizing and externalizing behavior problems and levels of positive behavior. The authors found that mothers' lengthy commute times are associated with higher levels of internalizing problem behaviors and lower levels of positive behaviors.