A systematic review of the association between history of sexually transmitted infections and subsequent condom use in adolescents.

Sexually transmitted infections (STIs) are common among adolescents. According to the Health Belief Model, cues to action influence preventive behaviors. Cues to action can include health experiences such as being diagnosed with an STI. The impact of a history of STIs on subsequent condom use among adolescents remains largely unexamined, despite high rates of recurrence and their health impacts. This project aimed to systematically review the literature on the association between curable STIs and subsequent condom use among adolescents. The systematic review, reported following PRISMA guidelines, was conducted using the Joanna Briggs Institute method. Eligible studies, in the form of cohort studies, case-control studies, or cross-sectional studies, targeted adolescents aged 10 to 24, with or without a history of curable STIs; the outcome was subsequent condom use. MEDLINE (Ovid), Embase (Elsevier), and Web of Science were searched from January 2012 to December 2022 with the assistance of an information specialist. Two reviewers independently selected articles and extracted data. Risk of bias analysis was performed using ROBINS-E. The review explores results, with tables, based on population characteristics, exposure, and outcome, and addresses the influence of gender, ethnicity, and age. Of 3088 articles identified, seven studies were retained. Almost all the studies focused on African-American, Nigerian, or Rwandan adolescents, and several included only girls. Among girls, a history of STI increased subsequent condom use in combination with other contraceptive methods (n = 4). Among boys and older adolescents of both genders, a history of STI was associated with a decrease in condom use (n = 3). No study distinguished between different STIs. While all the studies (n = 7) presented a high risk of bias, six did not present a threat to conclusion validity. All the studies indicated that a history of STI could influence subsequent protective behaviors, possibly by acting as a cue to action, as posited by the Health Belief Model. This information enhances our understanding of factors leading to the adoption of preventive health measures among adolescents and could apply to other infectious experiences.Registration The protocol is registered in PROSPERO (CRD42023397443).

Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium.

COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.

The unintended consequences of COVID-19 mitigation measures matter: practical guidance for investigating them.

BACKGROUND: COVID-19 has led to the adoption of unprecedented mitigation measures which could trigger many unintended consequences. These unintended consequences can be far-reaching and just as important as the intended ones. The World Health Organization identified the assessment of unintended consequences of COVID-19 mitigation measures as a top priority. Thus far, however, their systematic assessment has been neglected due to the inattention of researchers as well as the lack of training and practical tools. MAIN TEXT: Over six years our team has gained extensive experience conducting research on the unintended consequences of complex health interventions. Through a reflexive process, we developed insights that can be useful for researchers in this area. Our analysis is based on key literature and lessons learned reflexively in conducting multi-site and multi-method studies on unintended consequences. Here we present practical guidance for researchers wishing to assess the unintended consequences of COVID-19 mitigation measures. To ensure resource allocation, protocols should include research questions regarding unintended consequences at the outset. Social science theories and frameworks are available to help assess unintended consequences. To determine which changes are unintended, researchers must first understand the intervention theory. To facilitate data collection, researchers can begin by forecasting potential unintended consequences through literature reviews and discussions with stakeholders. Including desirable and neutral unintended consequences in the scope of study can help minimize the negative bias reported in the literature. Exploratory methods can be powerful tools to capture data on the unintended consequences that were unforeseen by researchers. We recommend researchers cast a wide net by inquiring about different aspects of the mitigation measures. Some unintended consequences may only be observable in subsequent years, so longitudinal approaches may be useful. An equity lens is necessary to assess how mitigation measures may unintentionally increase disparities. Finally, stakeholders can help validate the classification of consequences as intended or unintended. CONCLUSION: Studying the unintended consequences of COVID-19 mitigation measures is not only possible but also necessary to assess their overall value. The practical guidance presented will help program planners and evaluators gain a more comprehensive understanding of unintended consequences to refine mitigation measures.

Unintended uses, meanings, and consequences: HIV self-testing among female sex workers in urban Uganda.

ABSTRACTFemale sex workers (FSWs) are at increased risk of HIV and face significant barriers to clinic-based HIV testing, including provider stigma and privacy constraints. HIV self-testing (HIVST) has been proven to significantly increase HIV testing among FSWs. Less is known, however, about how FSWs make meaning of oral-fluid HIV self-tests, and the unintended ways they use and understand this novel technology. From October 2016 to March 2017, we conducted 61 in-depth interviews with FSWs (n = 31) in Kampala, Uganda. Eligible participants were: female, ≥18 years, exchanged sex for money or goods, and had not recently tested for HIV. We used inductive coding to identify emerging themes and re-arranged these into an adapted framework. Unintended desirable ways FSWs described self-testing included as a means to test others, to bolster their reputation as a health-conscious sex worker, and to avoid bearing witness to suffering at health facilities. Unintended undesirable meanings ascribed to self-testing included misunderstandings about how HIV is transmitted (via saliva versus blood) and whether self-tests also test for other infections. HIVST can increase FSWs' knowledge of their own HIV status and that of their sexual partners, but messaging and intervention design must address misunderstandings and misuses of self-testing.Trial registration: ClinicalTrials.gov identifier: NCT02846402.

The unintended consequences of combining equity measures with performance-based financing in Burkina Faso.

BACKGROUND: User fees and poor quality of care contribute to low use of healthcare services in Burkina Faso. The government implemented an innovative intervention that combines equity measures with performance-based financing (PBF). These health equity measures included a community-based selection of indigents to receive user fee exemptions and paying healthcare centres higher purchase prices for services provided to indigents. Research suggests complex interventions can trigger changes not targeted by program planners. To date, however, there is a knowledge gap regarding the unintended consequences that can emerge from combining PBF with health equity measures. Our objective is to document unintended consequences of the equity measures in this complex intervention. METHODS: We developed a conceptual framework using the diffusion of innovations theory. For the design, we conducted a multiple case study. The cases were four healthcare facilities in one district. We collected data through 93 semi-structured interviews, informal discussions, observation, as well as intervention documents. We conducted thematic analysis using a hybrid deductive-inductive approach. We also used secondary data to describe the monthly evolution of services provided to indigent and non-indigent patients before and after indigent cards were distributed. Time series graphs were used to validate some results. RESULTS: Local actors, including members of indigent selection committees and healthcare workers, re-invented elements of the PBF equity measures over which they had control to increase their relative advantage or to adapt to implementation challenges and context. Some individuals who did not meet the local conceptualization of indigents were selected to the detriment of others who did. Healthcare providers believed that distributing free medications led to financial difficulties and drug shortages, especially given the low purchase prices and long payment delays. Healthcare workers adopted measures to limit free services delivered to indigents, which led to conflicts between indigents and providers. Ultimately, selected indigents received uncertain and unequal coverage. CONCLUSIONS: The severity of unintended consequences undermined the effectiveness and equity of the intervention. If the intervention is prolonged and expanded, decision-makers and implementers will have to address these unintended consequences to reduce inequities in accessing care.

A reflection on the challenge of protecting confidentiality of participants while disseminating research results locally.

BACKGROUND: Researchers studying health systems in low-income countries face a myriad of ethical challenges throughout the entire research process. In this article, we discuss one of the greatest ethical challenges that we encountered during our fieldwork in West Africa: the difficulty of protecting the confidentiality of participants (or groups of participants) while locally disseminating results of health systems research to stakeholders. METHODS: This reflection is based on experiences of authors involved in conducting evaluative research of interventions aimed at improving health systems in West Africa. Our observation and collaboration with the research projects' stakeholders informed our analysis. Examples from two research projects illustrate the issues raised. RESULTS: We found that in some cases there is a risk that local stakeholders may be able to identify research participants, or at least groups of participants, during the dissemination of results, even if they are anonymized. Four factors can interact and influence this challenge: 1) hierarchical structure, 2) small milieu, 3) immersion in a few sites, and 4) vested interests of decision-makers. For example, local stakeholders can sometimes find out when and where the data were collected. Moreover, health systems, especially rural healthcare centres, in West African countries can be small settings, so people often know each other. Some types of participants have unique characteristics or positions in the health system that may make them more easily identifiable by local stakeholders familiar with the environment. We identified a number of potential strategies that can help researchers minimize this difficulty and improve ethical research practices. These strategies pertain to the development of the study design, the process of obtaining informed consent, the dissemination of results, and the researchers' reflexivity. CONCLUSION: Researchers must develop and adopt strategies that enable them to respect their promise of confidentiality while effectively disseminating sometimes sensitive results. Reflections surrounding ethical issues in global health research should be deepened to better address how to manage competing ethical responsibilities while promoting valuable research uptake.

Twelve months of implementation of health care performance-based financing in Burkina Faso: A qualitative multiple case study.

To improve health services' quantity and quality, African countries are increasingly engaging in performance-based financing (PBF) interventions. Studies to understand their implementation in francophone West Africa are rare. This study analysed PBF implementation in Burkina Faso 12 months post-launch in late 2014. The design was a multiple and contrasted case study involving 18 cases (health centres). Empirical data were collected from observations, informal (n = 224) and formal (n = 459) interviews, and documents. Outside the circle of persons trained in PBF, few in the community had knowledge of it. In some health centres, the fact that staff were receiving bonuses was intentionally not announced to populations and community leaders. Most local actors thought PBF was just another project, but the majority appreciated it. There were significant delays in setting up agencies for performance monitoring, auditing, and contracting, as well as in the payment. The first audits led rapidly to coping strategies among health workers and occasionally to some staging beforehand. No community-based audits had yet been done. Distribution of bonuses varied from one centre to another. This study shows the importance of understanding the implementation of public health interventions in Africa and of uncovering coping strategies.

Setting performance-based financing in the health sector agenda: a case study in Cameroon.

BACKGROUND: More than 30 countries in sub-Saharan Africa have introduced performance-based financing (PBF) in their healthcare systems. Yet, there has been little research on the process by which PBF was put on the national policy agenda in Africa. This study examines the policy process behind the introduction of PBF program in Cameroon. METHODS: The research is an explanatory case study using the Kingdon multiple streams framework. We conducted a document review and 25 interviews with various types of actors involved in the policy process. We conducted thematic analysis using a hybrid deductive-inductive approach for data analysis. RESULTS: By 2004, several reports and events had provided evidence on the state of the poor health outcomes and health financing in the country, thereby raising awareness of the situation. As a result, decision-makers identified the lack of a suitable health financing policy as an important issue that needed to be addressed. The change in the political discourse toward more accountability made room to test new mechanisms. A group of policy entrepreneurs from the World Bank, through numerous forms of influence (financial, ideational, network and knowledge-based) and building on several ongoing reforms, collaborated with senior government officials to place the PBF program on the agenda. The policy changes occurred as the result of two open policy windows (i.e. national and international), and in both instances, policy entrepreneurs were able to couple the policy streams to effect change. CONCLUSION: The policy agenda of PBF in Cameroon underlined the importance of a perceived crisis in the policy reform process and the advantage of building a team to carry forward the policy process. It also highlighted the role of other sources of information alongside scientific evidence (eg.: workshop and study tour), as well as the role of previous policies and experiences, in shaping or influencing respectively the way issues are framed and reformers' actions and choices.

QF2011: a protocol to study the effects of the Queensland flood on pregnant women, their pregnancies, and their children's early development.

BACKGROUND: Retrospective studies suggest that maternal exposure to a severe stressor during pregnancy increases the fetus' risk for a variety of disorders in adulthood. Animal studies testing the fetal programming hypothesis find that maternal glucocorticoids pass through the placenta and alter fetal brain development, particularly the hypothalamic-pituitary-adrenal axis. However, there are no prospective studies of pregnant women exposed to a sudden-onset independent stressor that elucidate the biopsychosocial mechanisms responsible for the wide variety of consequences of prenatal stress seen in human offspring. The aim of the QF2011 Queensland Flood Study is to fill this gap, and to test the buffering effects of Midwifery Group Practice, a form of continuity of maternity care. METHODS/DESIGN: In January 2011 Queensland, Australia had its worst flooding in 30 years. Simultaneously, researchers in Brisbane were collecting psychosocial data on pregnant women for a randomized control trial (the M@NGO Trial) comparing Midwifery Group Practice to standard care. We invited these and other pregnant women to participate in a prospective, longitudinal study of the effects of prenatal maternal stress from the floods on maternal, perinatal and early childhood outcomes. Data collection included assessment of objective hardship and subjective distress from the floods at recruitment and again 12 months post-flood. Biological samples included maternal bloods at 36 weeks pregnancy, umbilical cord, cord blood, and placental tissues at birth. Questionnaires assessing maternal and child outcomes were sent to women at 6 weeks and 6 months postpartum. The protocol includes assessments at 16 months, 2½ and 4 years. Outcomes include maternal psychopathology, and the child's cognitive, behavioral, motor and physical development. Additional biological samples include maternal and child DNA, as well as child testosterone, diurnal and reactive cortisol. DISCUSSION: This prenatal stress study is the first of its kind, and will fill important gaps in the literature. Analyses will determine the extent to which flood exposure influences the maternal biological stress response which may then affect the maternal-placental-fetal axis at the biological, biochemical, and molecular levels, altering fetal development and influencing outcomes in the offspring. The role of Midwifery Group Practice in moderating effects of maternal stress will be tested.

Evolution of Sleep Duration and Screen Time Between 2018 and 2022 Among Canadian Adolescents: Evidence of Drifts Accompanying the COVID-19 Pandemic.

PURPOSE: We quantified the joint evolution of sleep duration and screen time between 2018 and 2022 in a large sample of adolescents from Quebec, Canada, to ascertain changes that occurred during the COVID-19 pandemic. METHODS: A natural experiment design was used to compare variations from year to year and in association with the pandemic outbreak. Using structural equation modeling on data collected between 2018 and 2022 among adolescents attending 63 high schools, we analyzed the joint evolution of sleep duration and screen time while adjusting for previous year values, concurrent flourishing score, sex, age, and family level of material deprivation. RESULTS: A total of 28,307 adolescents, aged on average 14.9 years, were included in the analyses. Between 2019 and 2022, sleep duration increased by 9.6 (5.7, 13.5) minutes and screen time by 129.2 (120.5, 138.0) minutes on average. In 2022, the adolescents spent almost equal amounts of time sleeping and using screens. Lower flourishing scores were associated with shorter sleep duration and lengthier screen time. Girls' screen time became similar to boys' over time. DISCUSSION: Adolescents now spend almost equal amounts of time sleeping and using screens, a situation that calls for urgent public health actions. These findings highlight the importance of tracking changes in adolescents' behaviours over time, to design and implement interventions adapted to the changing health needs of different groups.

Cervical cancer prevention in Burkina Faso: a stakeholder's collaboration for the development of awareness messaging.

Background: Cervical Cancer stands as the second leading cause of both incident female cancers and deaths in Burkina Faso. Unfortunately, the prevention, early detection, and care of cervical cancers are suboptimal at individual, institutional, and national levels. In October 2023, we organized a stakeholder's workshop to develop cervical cancer awareness messaging for disease control in the country. Methods: A one-text workshop was organized with stakeholders working toward improving health in general or women's health and well-being. A participatory, learning, and adaptive approach was used to facilitate discussions and activities, ensuring the contribution of all participants. Contextual evidence-based and empirical elements about cervical cancer burden and preventive strategies were presented to the participants by key informants. These served as the foundation for a collaborative formulation of messaging content that aimed at raising awareness about cervical cancer. Results: Sixty-two participants from 28 organizations attended the workshop. They work mainly at local and international non-governmental organizations, civil society organizations, universities, university hospitals, research centers, and the Ministry of Health. During the first and second days of the workshop, the participants explored cervical cancer data, its preventive and treatment options available in Burkina Faso, communication strategies for behavioral change, and determinants of the use of prevention and health promotion services. During the following three days, 3 working groups were formed to define strategies, and key messages adapted to diverse tools and targeted audiences. All information was validated during plenary sessions before the end of the workshop and available to all participants and their organizations for cancer awareness activities. Conclusion: Upon conclusion of the workshop, the participants provided insightful information for the development of cervical awareness messaging in Burkina Faso. They formed the first community of practice to serve as a dynamic platform for implementation, monitoring, evaluation, and continued learning activities.

The association between single and dual use of cannabis and alcohol and driving under the influence and riding with an impaired driver in a large sample of Canadian adolescents.

OBJECTIVE: Dual use of cannabis and alcohol has increased in adolescents, but limited research has examined how it relates to impaired driving or riding with an impaired driver (IDR) compared to single substance use. This study aimed to examine the odds of alcohol- and/or cannabis-IDR among adolescents based on their use of alcohol and/or cannabis, and whether associations differed by gender and age. METHODS: Cross-sectional survey data were used from a sample of 69,621 students attending 182 Canadian secondary schools in the 2021/22 school year. Multilevel logistic regression estimated the odds of exclusive alcohol-IDR, exclusive cannabis-IDR, and both alcohol and cannabis IDR (alcohol-cannabis-IDR). Substance use interactions with gender and age were tested. RESULTS: Overall, 14.7% of participants reported IDR; 7.5% reported exclusive alcohol-IDR, 3.2% reported exclusive cannabis-IDR, 4.0% reported alcohol-cannabis-IDR, and 7.4% were unsure if they had experienced IDR. The prevalence of IDR varied across substance use groups, 8.0% among nonuse, 21.9% among alcohol-only use, 35.9% among cannabis-only use, and 49.6% among dual use groups. Gender diverse, older, and students with lower socioeconomic status exhibited a higher likelihood of reporting alcohol-cannabis-IDR. Dual use was significantly associated with 9.5 times higher odds of alcohol-cannabis-IDR compared to alcohol-only use, and 3.0 times higher odds compared to cannabis-only use. Dual use was also associated with an increased likelihood of either alcohol- or cannabis-IDR. CONCLUSIONS: This study highlights that all students, regardless of substance use, are at risk of IDR, but students engaged in dual use of alcohol and cannabis face an elevated risk compared to both peers who do not use substances and those who use only a single substance. These findings emphasize the importance of targeted interventions that address the risks associated with IDR.

What are the determinants of variation in caretaker satisfaction with sick child consultations? A cross-sectional analysis in five low-income and middle-income countries.

OBJECTIVES: The objective of this study was to explore determinants of variation in overall caretaker satisfaction with curative care for sick children under the age of 5 in five low-income and middle-income countries. DESIGN: A pooled cross-sectional analysis was conducted using data from the Service Provision Assessment. SETTING: We used data collected in five countries (Afghanistan, Democratic Republic of the Congo, Haiti, Malawi and Tanzania) between 2013 and 2018. PARTICIPANTS: Respondents were 13 149 caretakers of children under the age of 5 who consulted for a sick child visit. PRIMARY OUTCOMES MEASURED: The outcome variable was whether the child's caretaker was very satisfied versus more or less satisfied or not satisfied overall. Predictors pertained to child and caretaker characteristics, health system foundations and process of care (eg, care competence, user experience). Two-level logistic regression models were used to assess the extent to which these categories of variables explained variation in satisfaction. The main analyses used pooled data; country-level analyses were also performed. RESULTS: Process of care, including user experience, explained the largest proportion of variance in caretaker satisfaction (13.8%), compared with child and caretaker characteristics (0.9%) and health system foundations (3.8%). The odds of being very satisfied were lower for caretakers who were not given adequate explanation (OR: 0.56, 95% CI 0.46 to 0.67), who had a problem with medication availability (OR: 0.31, 95% CI 0.27 to 0.35) or who encountered a problem with the cost of services (OR: 0.57, 95% CI 0.48 to 0.66). The final model explained only 21.8% of the total variance. Country-level analyses showed differences in variance explained and in associations with predictors. CONCLUSIONS: Better process of care, especially user experience, should be prioritised for its benefit regarding caretaker satisfaction. Unmeasured factors explained the majority of variation in caretaker satisfaction and should be explored in future studies.

Population Preferences for Primary Care Models for Hypertension in Karnataka, India.

Importance: Hypertension contributes to more than 1.6 million deaths annually in India, with many individuals being unaware they have the condition or receiving inadequate treatment. Policy initiatives to strengthen disease detection and management through primary care services in India are not currently informed by population preferences. Objective: To quantify population preferences for attributes of public primary care services for hypertension. Design, Setting, and Participants: This cross-sectional study involved administration of a household survey to a population-based sample of adults with hypertension in the Bengaluru Nagara district (Bengaluru City; urban setting) and the Kolar district (rural setting) in the state of Karnataka, India, from June 22 to July 27, 2021. A discrete choice experiment was designed in which participants selected preferred primary care clinic attributes from hypothetical alternatives. Eligible participants were 30 years or older with a previous diagnosis of hypertension or with measured diastolic blood pressure of 90 mm Hg or higher or systolic blood pressure of 140 mm Hg or higher. A total of 1422 of 1927 individuals (73.8%) consented to receive initial screening, and 1150 (80.9%) were eligible for participation, with 1085 (94.3%) of those eligible completing the survey. Main Outcomes and Measures: Relative preference for health care service attributes and preference class derived from respondents selecting a preferred clinic scenario from 8 sets of hypothetical comparisons based on wait time, staff courtesy, clinician type, carefulness of clinical assessment, and availability of free medication. Results: Among 1085 adult respondents with hypertension, the mean (SD) age was 54.4 (11.2) years; 573 participants (52.8%) identified as female, and 918 (84.6%) had a previous diagnosis of hypertension. Overall preferences were for careful clinical assessment and consistent availability of free medication; 3 of 5 latent classes prioritized 1 or both of these attributes, accounting for 85.1% of all respondents. However, the largest class (52.4% of respondents) had weak preferences distributed across all attributes (largest relative utility for careful clinical assessment: ß = 0.13; 95% CI, 0.06-0.20; 36.4% preference share). Two small classes had strong preferences; 1 class (5.4% of respondents) prioritized shorter wait time (85.1% preference share; utility, ß = -3.04; 95% CI, -4.94 to -1.14); the posterior probability of membership in this class was higher among urban vs rural respondents (mean [SD], 0.09 [0.26] vs 0.02 [0.13]). The other class (9.5% of respondents) prioritized seeing a physician (the term doctor was used in the survey) rather than a nurse (66.2% preference share; utility, ß = 4.01; 95% CI, 2.76-5.25); the posterior probability of membership in this class was greater among rural vs urban respondents (mean [SD], 0.17 [0.35] vs 0.02 [0.10]). Conclusions and Relevance: In this study, stated population preferences suggested that consistent medication availability and quality of clinical assessment should be prioritized in primary care services in Karnataka, India. The heterogeneity observed in population preferences supports considering additional models of care, such as fast-track medication dispensing to reduce wait times in urban settings and physician-led services in rural areas.

Using natural disasters to study the effects of prenatal maternal stress on child health and development.

Research on the developmental origins of health and disease highlights the plasticity of the human fetus to a host of potential teratogens. Experimental research on laboratory animals has demonstrated a variety of physical and behavioral effects among offspring exposed to prenatal maternal stress (PNMS). However, these studies cannot elucidate the relative effects of the objective stress exposure and the subjective distress in a way that would parallel the stress experience in humans. PNMS research with humans is also limited because there are ethical challenges to designing studies that involve the random assignment of pregnant women to varying levels of independent stressors. Natural disasters present opportunities for natural experiments of the effects of pregnant women's exposure to stress on child development. In this review, we present an overview of the human and animal research on PNMS, and highlight the results of Project Ice Storm which has been following the cognitive, behavioral, motor and physical development of children exposed in utero to the January 1998 Quebec Ice Storm. We have found that both objective degree of exposure to the storm and the mothers' subjective distress have strong and persistent effects on child development, and that these effects are often moderated by the timing of the ice storm in pregnancy and by the child's sex.

Mapping of initiatives to increase membership in mutual health organizations in Benin.

INTRODUCTION: Mutual health organizations (MHO) have been implemented across Africa to increase access to healthcare and improve financial protection. Despite efforts to develop MHOs, low levels of both initial enrolment and membership renewals continue to threaten their financial viability. The purpose of this study was to map initiatives implemented to increase the pool of MHO members in Benin. METHODS: A multiple case study was conducted to assess MHOs supported by five major promoters in Benin. Three months of fieldwork resulted in 23 semi-structured interviews and two focus groups with MHO promoters, technicians, elected members, and health professionals affiliated with the MHOs. Fifteen non-structured interviews provided additional information and a valuable source of triangulation. RESULTS: MHOs have adopted a wide range of initiatives targeting different entry points and involving a variety of stakeholders. Initiatives have included new types of collective health insurance packages and efforts to raise awareness by going door-to-door and organizing health education workshops. Different types of partnerships have been established to strengthen relationships with healthcare professionals and political leaders. However, the selection and implementation of these initiatives have been limited by insufficient financial and human resources. CONCLUSIONS: The study highlights the importance of prioritizing sustainable strategies to increase MHO membership. No single MHO initiative has been able to resolve the issue of low membership on its own. If combined, existing initiatives could provide a comprehensive and inclusive approach that would target all entry points and include key stakeholders such as household decision-makers, MHO elected members, healthcare professionals, community leaders, governmental authorities, medical advisors, and promoters. There is a need to evaluate empirically the implementation of these interventions. Mechanisms to promote dialogue between MHO stakeholders would be useful to devise innovative strategies, avoid repeating unsuccessful ones, and develop a coordinated plan to promote MHOs.

An Exploration of the Unintended Consequences of Performance-Based Financing in 6 Primary Healthcare Facilities in Burkina Faso.

BACKGROUND: Performance-based financing (PBF) is promoted to improve the quality and quantity of healthcare services in low-income countries. Despite the complexity of the intervention, little attention has been given to studying its unintended consequences. Our objective is to increase evidence on the unintended consequences of PBF in Burkina Faso. METHODS: Using the diffusion of innovations theory, we conducted a multiple case study. The cases were 6 healthcare facilities in two districts. Between April 2015 and 2016, we collected data through 101 semi-structured interviews, discussions, observations, and documents. We conducted thematic analysis using a hybrid deductive-inductive approach. Secondary data was used to illustrate the evolution of reported services. We conducted a cross-case synthesis to identify the results arising independently from more than 1 case. RESULTS: A desirable unintended consequence of PBF was that 3 facilities limited the sale of non-prescribed medication to encourage patients to consult. Undesirable unintended consequences were found in the majority of facilities including fixation on measures rather than on underlying objectives, the pursuit of narrow and less relevant performance indicators, gaming, and teaching trainees improper practices. Providers in all facilities deliberately manipulated medical registers and documents, such that the reported quantity and quality of care differed from what was actually delivered. While most participants indicated that PBF was more advantageous than previous practices, the long payment delays were a source of dissatisfaction and demotivation across all facilities. Dissatisfaction also emerged in relation to the distribution of subsidies and the non-attribution of quality points for services delivered by certain staff considered "unqualified" in guidelines. Results in many facilities revealed suboptimal planning, a perception of the intervention as "budgetivorous," as well as tensions related to the principle of managerial autonomy. CONCLUSION: PBF led to numerous unintended consequences that could undermine the intervention's effectiveness. The findings contribute to a more comprehensive picture of the consequences of implementing PBF. Policy-makers can use the results of this study to devise effective strategies before, during and after the implementation of the intervention to minimize undesirable unintended consequences and promote desirable ones.

Evidence attack in public health: Diverse actors' experiences with translating controversial or misrepresented evidence in health policy and systems research.

Bringing evidence into policy and practice discussions is political; more so when evidence from health studies or programme data are deemed controversial or unexpected, or when results are manipulated and misrepresented. Furthermore, opinion and misinformation in recent years has challenged our notions about how to achieve evidence-informed decision-making (EIDM). Health policy and systems (HPS) researchers and practitioners are battling misrepresentation that only serves to detract from important health issues or, worse, benefit powerful interests. This paper describes cases of politically and socially controversial evidence presented by researchers, practitioners and journalists during the Health Systems Research Symposium 2020. These cases cut across global contexts and range from public debates on vaccination, comprehensive sexual education, and tobacco to more inward debates around performance-based financing and EIDM in refugee policy. The consequences of engaging in controversial research include threats to commercial profit, perceived assaults on moral beliefs, censorship, fear of reprisal, and infodemics. Consequences for public health include research(er) hesitancy, contribution to corruption and leakage, researcher reflexivity, and ethical concerns within the HPS research and EIDM fields. Recommendations for supporting researchers, practitioners and advocates include better training and support structures for responding to controversy, safe spaces for sharing experiences, and modifying incentive structures.