Engaging men in women's empowerment: impact of a complex gender transformative intervention on household socio-economic and health outcomes in the eastern democratic republic of the Congo using a longitudinal survey.

BACKGROUND: In the Democratic Republic of the Congo, women in (peri-)urban areas are commonly engaged in small trade, which allows them to meet the basic needs of their families. Microsaving approaches are a low-risk option to obtain financing for economic activities. A project combining men's sensitization on gender equity and women's empowerment through village savings and loan associations were implemented in North and South Kivu to raise the household economic level. OBJECTIVE: This study assessed how involving men in gender equity affects women's health and socio-economic outcomes, including food security. METHODS: A cohort study was conducted with 1812 women at the baseline; out of them 1055 were retrieved at the follow-up. Baseline data collection took place from May to December 2017 and the follow-up from July 2018 to January 2019. To identify socio-economic changes and changes of gender relations, linear and logistic regressions were run. RESULTS: Results showed that the household income improved with intervention (coefficient = 0.327; p = 0.002), while the capacity to pay high bills without contracting debts decreased (coefficient = 0.927; p = 0.001). We did not find enough statistically significant evidence of the influence of the intervention on skilled birth attendance (coefficient = 0.943; p = 0.135), or family planning use (coefficient = 0.216; p = 0.435) nor women's participation in the decision-making (coefficient = 0.033; p = 0.227) nor on couple's cohesion (coefficient = 0.024; p = 0.431). Food insecurity levels decreased over time regardless of being in the intervention or control area. CONCLUSION: Empowering women while sensitizing men on gender aspects improves financial well-being (income). Time, security, and strong politics of government recognizing and framing the approach are still needed to maximize the benefit of such projects on social factors such as women's participation in decision-making and social cohesion.

Family planning in the Eastern Democratic Republic of the Congo: personal beliefs, intimate partner negotiations and social pressure.

The Democratic Republic of the Congo (DRC) has a low prevalence of family planning use. Recent studies have highlighted the significant role that socio-cultural factors play in the decision to use family planning or not. This qualitative study explored barriers to women's use of family planning methods in an ongoing conflict region, South-Kivu, DRC. Focus group discussions and individual in-depth interviews were conducted to understand perceptions and habits regarding family planning. An inductive approach was used to analyse the data. Precariousness of life, religious beliefs and fear of side effects were limiting factors to the use of family planning. Power relations within the couple also played an important role in decision-making. Sole provider ('breadwinner') women were more likely to use family planning, including hormonal methods. Our findings highlight the continued importance of family planning programmes that respond to socio-cultural factors, personal beliefs, and fear of side effects in parallel with addressing availability and accessibility. This will require including the community in their design and implementation in order to meet unmet family planning needs. Health care providers' capacity building and training to help women manage family planning side effects will also be beneficial.

"But at home, with the midwife, you are a person": experiences and impact of a new early postpartum home-based midwifery care model in the view of women in vulnerable family situations.

BACKGROUND: Postpartum home-based midwifery care is covered by basic health insurance in Switzerland for all families with newborns but must be self-organized. To ensure access for all, Familystart, a network of self-employed midwives, launched a new care model in 2012 by ensuring the transition from hospital to home through cooperation with maternity hospitals in the Basel area. It has particularly improved the access to follow-up care for families in vulnerable situations needing support beyond basic services. In 2018, the SORGSAM (Support at the Start of Life) project was initiated by Familystart to enhance parental resources for better postpartum health outcomes for mothers and children through offering improved assistance to psychosocially and economically disadvantaged families. First, midwives have access to first-line telephone support to discuss challenging situations and required actions. Second, the SORGSAM hardship fund provides financial compensation to midwives for services not covered by basic health insurance. Third, women receive financial emergency support from the hardship fund. AIM: The aim was to explore how women living in vulnerable family situations experienced the new early postpartum home-based midwifery care model provided in the context of the SORGSAM project, and how they experienced its impact. METHODS: Findings are reported from the qualitative part of the mixed-methods evaluation of the SORGSAM project. They are based on the results of seven semi-structured interviews with women who, due to a vulnerable family postpartum situation at home, received the SORGSAM support. Data were analyzed following thematic analysis. RESULTS: Interviewed women experienced the early postpartum care at home, as "relieving and strengthening" in that midwives coordinated patient care that opened up access to appropriate community-based support services. The mothers expressed that they felt a reduction in stress, an increase in resilience, enhanced mothering skills, and greater parental resources. These were attributed to familiar and trusting relationships with their midwives where participants acknowledged deep gratitude. CONCLUSION: The findings show the high acceptance of the new early postpartum midwifery care model. These indicate how such a care model can improve the well-being of women in vulnerable family situations and may prevent early chronic stress in children.

Sexual and reproductive health services use among adolescents in pastoralist settings, northeastern Ethiopia.

BACKGROUND: Adolescents have special sexual and reproductive health (ASRH) needs and are susceptible to poor health outcomes. The global burden of ill sexual health includes a significant proportion of Adolescents. The existing ASRH services in Ethiopia and particularly in the Afar region are currently not well suited to meet the needs of pastoralist adolescents. This study assesses the level of ASRH service utilization among pastoralists in Afar regional state, Ethiopia. METHOD: A community based cross-sectional study was conducted from January to March 2021 in four randomly chosen pastoralist villages or kebeles of Afar, Ethiopia. A multistage cluster sampling procedure was used to select 766 volunteer adolescents aged 10-19. SRH services uptake was measured asking whether they had used any SRH service components during the last year. Data was collected through face-to-face interviews with a structured questionnaire; data entry was done with Epi info 3.5.1. Logistic regression analyses was used to assess associations with SRH service uptake. SPSS version 23 statistical software package was used for advanced logistic regression analyses to assess the associations between dependent and predictor variables. RESULTS: The study revealed that two-thirds or 513 (67%) of the respondents are aware of ASRH services. However, only one-fourth (24.5%) of the enrolled adolescents used at least one ASRH service in the past twelve months. ASRH services utilization was significantly associated with gender (being female [AOR = 1.87 (CI 1.29-2.70)], being in school [AOR = 2.38(CI: 1.05-5.41), better family income [AOR = 10.92 (CI; 7.10-16.80)], prior discussions of ASRH issues [AOR = 4.53(CI: 2.52, 8.16)], prior sexual exposure [AOR = 4.75(CI: 1.35-16.70)], and being aware of ASRH services [AOR = 1.96 (CI: 1.02-3.822)]. Being pastoralist, religious and cultural restrictions, fear of it becoming known by parents, services not being available, income, and lack of knowledge were found to deter ASRH service uptake. CONCLUSION: Addressing ASRH needs of pastoralist adolescents is more urgent than ever, sexual health problems are increasing where these groups face broad hurdles to SRH service uptake. Although Ethiopian national policy has created an enabling environment for ASRH, multiple implementation issues require special attention to such neglected groups. "Gender-culture-context-appropriate" interventions are favorable to identify and meet the diverse needs of Afar pastoralist adolescents. Afar regional education bureau and concerned stakeholders need to improve adolescent education to overcome social barriers (e.g. humiliation, disgrace, and deterring gender norms) against ASRH services through community outreach programs. In addition, economic empowerment, peer education, adolescent counseling, and parent-youth communication will help address sensitive ASRH issues.

'The body is difficult': reproductive navigation through sociality and corporeality in rural Burundi.

The route from family planning intentions to practices is not linear, it is contingent on different social factors including the preferences of individuals and couples, their gendered positions and bargaining power, the wider political, economic and social context, and also physical and bodily circumstances. We used qualitative data collected in rural Burundi between 2013 and 2016 to explore how these diverse factors influence reproductive navigation in a context framed by uncertainty and changing social norms. We describe representations of bodily (pre)dispositions for fertility and reproduction, such as the 'natural' capacity for birth spacing or the bodily capacity to use 'natural' (having a regular cycle) and 'modern' methods (not having negative side effects) that contribute collectively to an understanding of 'the body is difficult'. We found that despite these bodily constraints, women enact embodied agency to ensure livelihoods and social status, thus framing their reproductive intentions and practices. In the context of Burundi where corporeality is key to gendered social belonging, family planning programmes fail to respond to the needs and concerns of women and their embodied reproductive experiences.

Local perspectives on policy implementation of free maternity health services in Kenya: Implications for universal health coverage.

Kenya introduced free maternity services (FMS) in 2013 to enable all pregnant women to give birth for free in all government public health facilities. Currently, Kenya is rolling out universal health coverage (UHC), which has been acknowledged as a priority goal for every health system and part of the 'Big Four Agenda' for sustainable national development in Kenya. FMS is one of the core services in Kenya, but since its launch, it is not clear whether the decentralized approach chosen to implement FMS is leading to UHC. This nine-month ethnographic study in Kilifi County, Kenya, was conducted between March-July 2016 and February-July 2017. A narrative approach to analysis was applied. In this article, we interrogate local perceptions of participation during the crafting and implementation of FMS. Findings show that FMS was detached from local realities, and this was a major inadequacy of the top to bottom approach. FMS did not consider local power relations and bargaining power which are requisites during policy formulation and implementation. The participants expressed desire for more localized control over resources from the national government. The findings suggest that as UHC is rolled out in Kenya, consultation of local stakeholders at the grassroots by the state departments would likely improve maternal healthcare outcomes. Such consultations must take into consideration differences in bargaining power and local power relations. Borrowing from the basic tenets of the recent anthropological theorization of constitutionality, this article proposes a bottom to top approach that leverages and integrates local views during policy-making process to create trust, a sense of ownership and accountability.

Exposure to job-related violence among young female sex workers in urban slums of Southwest Nigeria.

BACKGROUND: In Nigeria, many young girls are engaged in commercial sex work as a means of livelihood and support of dependent relatives. Although studies have documented some of the violence related issues among commercial sex workers, the plight of adolescent and young sex workers particularly in urban slums may be different in context and depth. OBJECTIVE: This study explored the lived experiences of violence and health related harm among vulnerable young female sex workers in urban slums in Ibadan and Lagos, Southwest Nigeria. It also analyzed their coping strategies and survival mechanisms. DESIGN: The study is cross-sectional and applied an interpretive phenomenological approach to this qualitative study through in-depth interviews. PARTICIPANTS: Young female sex workers ages (15-24 years) who reported having experienced violence were recruited for the study. Twelve participants completed the interviews out the 20 initially contacted. DATA COLLECTION AND ANALYSIS: Primary data were collected using in-depth interviews (IDIs). Data were transcribed using a phenomenological framework analysis. Participants' reports based on life experiences were identified: lived experience "daily brothel life experience"; sources of violence such as law enforcement agents' intermittent raids; violence experience with clients who often demanded sexual acts beyond the agreed scope; and coping strategies employed to mitigate the challenges. SETTINGS: The study was conducted in brothels of two selected slum areas in Ibadan and Lagos, Southwest Nigeria. RESULTS: The results showed that the major motivation for engaging in commercial sex work was for economic reasons. However, there are inherent risks involved particularly for the vulnerable young people. Stigmatization from the community, clients' uncontrolled-aggressive behavior and harassment from law enforcement agents are some of the frequent violence experiences reported. Self-help coping strategies are usually employed to prevent or mitigate the challenges. CONCLUSION: The plight of this young people required policy and program attention towards alternative economic empowerment to rehabilitate those willing to leave the profession. Also the need to develop arm reduction interventions towards protection of young sex workers against violence.

Non-communicable disease prevention in Kosovo: quantitative and qualitative assessment of uptake and barriers of an intervention for healthier lifestyles in primary healthcare.

BACKGROUND: Smoking, physical inactivity, low fruit and vegetable consumption, and obesity are common in Kosovo. Their prevention is a priority to relieve the health system of from costly non-communicable disease treatments. The Accessible Quality Healthcare project is implementing a primary healthcare intervention that entails nurse-guided motivational counselling to facilitate change in the domains of smoking, diet, alcohol consumption and physical inactivity for at-risk patients. This study quantitatively assesses the uptake of motivational counselling and the distribution of health behaviours and stages of health behaviour change of the participants according to the intervention, as well as qualitatively describes experiences and perceived benefits of motivational counselling. METHODS: Study participants (n = 907) were recruited consecutively in 2019 from patients visiting the Main Family Medical Centres in 12 municipalities participating in the Kosovo Non-Communicable Disease Cohort study as part of the Accessible Quality Healthcare project. For the quantitative study, we used baseline and first follow-up data on smoking status, physical inactivity, obesity, fruit and vegetable as well as alcohol consumption, uptake of counselling, and stages for behavioural change. For the qualitative study, in-depth interviews were conducted with a subset of 26 cohort participants who had undergone motivational counselling. RESULTS: Motivational counselling was obtained by only 22% of the eligible participants in the intervention municipalities. Unhealthy behaviours are high even in persons who underwent counselling (of whom 13% are smokers; 86% physically inactive; 93% with inadequate fruit and vegetable consumption; and 61% are obese); only the rate of smoking was lower in those who obtained counselling. Among smokers, over 80% were still in the pre-contemplation phase of behaviour change. More advanced stages of behaviour change were observed among the highly prevalent group of inactive persons and participants with poor dietary habits, among the 5 intervention municipalities. According to the qualitative study results, the participants who obtained motivational counselling were very satisfied with the services but requested additional services such as group physical activity sessions and specialized services for smoking cessation. CONCLUSIONS: More tailored and additional primary health care approaches in accordance with patients' views need to be considered for the motivational counselling intervention to reach patients and efficiently facilitate lifestyle behaviour change.

Measures adopted by indigent mothers in Kilifi County to tackle maternal health challenges during the COVID-19 pandemic: A qualitative study.

Many sub-Saharan African countries have experienced various challenges that threaten the quality of health services offered to the population. The COVID-19 pandemic disrupted access to healthcare services in many countries as they grappled with implementing measures to curb its spread. The consequences of COVID-19 have been catastrophic for maternal and newborn health. There is a dearth of information on expectant mothers' negotiation mechanisms to access maternal health services during COVID-19 in Kenya. This rapid qualitative study draws data from purposefully selected 15 mothers who were either pregnant or had newborn babies during the COVID-19 pandemic in Kilifi county in Kenya. Data were analyzed thematically and presented in a textual description. Women used the following alternatives to access maternal health: giving birth at the homes of traditional birth attendants (TBAs), substituting breastfeeding with locally available food supplements, relying on limited resources and neighbours for delivery and local savings and rotating credit associations. This study shows that urgent measures are needed to provide high quality maternal and child health services during and after the COVID-19 pandemic. These include but are not limited to developing special interventions for the pregnant women for any emergency and establishing trust between communities and individuals through the TBAs.

Impact of a complex gender-transformative intervention on maternal and child health outcomes in the eastern Democratic Republic of Congo: protocol of a longitudinal parallel mixed-methods study.

BACKGROUND: In the eastern part of the Democratic Republic of Congo (DRC) Village Savings and Loan Associations (VSLAs) programs targeting women are implemented. In the context of the 'Mawe Tatu' program more equitable intra-household decision-making is stipulated by accompanying women's participation in VSLAs with efforts to engage men for more gender equality, expecting a positive effect of this combined intervention on the household economy, on child nutritional status, on the use of reproductive health services including family planning, and on reducing sexual and gender-based violence (SGBV). METHODS: A longitudinal parallel mixed method study is conducted among women participating in VSLAs in randomly selected project areas and among a control group matched for socioeconomic characteristics. Descriptive statistics will be calculated and differences between intervention and control groups will be assessed by Chi2 tests for different degrees of freedom for categorical data or by t-tests for continuous data. Structural equation modelling (SEM) will be conducted to investigate the complex and multidimensional pathways that will affect household economic status, child nutritional status and use of reproductive health services. Analysis will be conducted with STATA V.15. Concomitantly, qualitative data collection will shed light on the intra-household processes related to gender power-relations that may be linked to women's participation in economic activities and may lead to improvements of maternal and child health. Focus group discussions and in-depth interviews will be conducted. All narrative data will be coded (open coding) with the help of qualitative data analysis software (Atlas TI). DISCUSSION: Women's empowerment has long been identified as being able to bring about progress in various areas, including health. It has been shown that men's commitment to transforming gender norms is a sinequanone factor for greater equity and better health, especially in terms of reproductive health and child nutrition. This study is one of the first in this genre in DRC and results will serve as a guide for policies aimed at improving the involvement of men in changing attitudes towards gender norms for higher household productivity and better health.

Clinical trials in low-resource settings: the perspectives of caregivers of paediatric participants from Uganda, Tanzania and Kenya.

OBJECTIVES: Vaccine clinical trials in low-resource settings have unique challenges due to structural and financial inequities. Specifically, protecting participant and caregiver autonomy to participate in the research study can be a major challenge, so understanding the setting and contextual factors which influence the decision process is necessary. This study investigates the experience of caregivers consenting on behalf of paediatric participants in a malaria vaccine clinical trial where participation enables access to free, high-quality medical care. METHODS: We interviewed a total of 78 caregivers of paediatric participants previously enrolled in a phase II or III malaria vaccine clinical trial in Uganda, Tanzania and Kenya. Interviews were qualitative and analysed using a thematic framework analysis focusing on the embodied caregiver in the political, economic and social reality. RESULTS: Caregivers of participants in this study made the decision to enrol their child based on economic, social and political factors that extended beyond the trial into the community and the home. The provision of health care was the dominant reason for participation. Respondents reported how social networks, rumours, hierarchal structures, financial constraints and family dynamics affected their experience with research. CONCLUSIONS: The provision of medical care was a powerful motivator for participation. Caregiver choice was limited by structural constraints and scarce financial resources. The decision to participate in research extended beyond individual consent and was embedded in community and domestic hierarchies. Future research should assess other contexts to determine how the choice to participate in research is affected when free medical care is offered.

OBJECTIFS: Les essais cliniques de vaccins dans les régions à faibles ressources présentent des défis uniques en raison d'iniquités structurelles et financières. En particulier, la protection de l'autonomie des participants et des soignants dans la participation à l'étude de recherche peut être un défi majeur. Il est donc nécessaire de comprendre le contexte et les facteurs contextuels qui influencent le processus de décision. Cette étude examine l'expérience de soignants consentants au nom de participants pédiatriques à un essai clinique de vaccin antipaludique où la participation permet l'accès à des soins médicaux gratuits et de haute qualité. MÉTHODES: Nous avons interviewé un total de 78 soignants de participants pédiatriques qui avaient participé à un essai clinique de vaccin antipaludique de phase II ou III en Ouganda, en Tanzanie et au Kenya. Les entretiens ont été qualitatifs et analysés à l'aide d'une analyse de cadre thématique centrée sur le soignant, en tenant compte de la réalité politique, économique et sociale. RÉSULTATS: Les soignants des participants à cette étude ont pris la décision d'inscrire leur enfant sur base de facteurs économiques, sociaux et politiques qui s'étendaient au-delà de l'essai dans la communauté et à la maison. La fourniture de soins de santé était la principale raison de la participation. Les répondants ont rapporté comment les réseaux sociaux, les rumeurs, les structures hiérarchiques, les contraintes financières et la dynamique familiale ont affecté leur expérience avec la recherche. CONCLUSIONS: La fourniture de soins médicaux était un puissant facteur de motivation pour la participation. Le choix du soignant était limité par des contraintes structurelles et les ressources financières limitées. La décision de participer à la recherche allait au-delà du consentement individuel et s'inscrivait dans les hiérarchies communautaires et domestiques. Les recherches futures devraient évaluer d'autres contextes afin de déterminer comment le choix de participer à la recherche est affecté par la gratuité des soins médicaux.

Explaining patient delay in healthcare seeking and loss to diagnostic follow-up among patients with presumptive tuberculosis in Tanzania: a mixed-methods study.

BACKGROUND: Delay in healthcare seeking and loss to diagnostic follow-up (LDFU) contribute to substantial increase in tuberculosis (TB) morbidity and mortality. We examined factors, including perceived causes and prior help seeking, contributing to delay and LDFU during referral to a TB clinic among patients with presumptive TB initially seeking help at the pharmacies in Dar es Salaam Tanzania. METHODS: In a TB clinic, a semi-structured interview based on the explanatory model interview catalogue (EMIC) framework for cultural epidemiology was administered to presumptive TB patients enrolled at pharmacies during an intervention study. We assessed delay in seeking care at any medical care provider for a period of ≥3 weeks after the onset of symptoms, LDFU during referral (not reaching the TB clinic), and LDFU for three required TB clinic visits among the presumptive and confirmed TB patients. Logistic regression models were used to assess factors associated with delay and LDFU. RESULTS: Among 136 interviewed patients, 86 (63.2%) were LDFU from pharmacies and TB clinic while 50 (36.8%) were non-LDFU. Out of 136 patients 88 (64.7%) delayed seeking care, of whom 59 (67%) were females. Among the 86 (63.2%) patients in LDFU group, 62 (72.1%) delayed seeking care, while among the 50 (36.8%) non-LDFU, 26 (52.0%) had also delayed seeking care. Prior consultation with a traditional healer (aOR 2.84, 95% CI 1.08-7.40), perceived causes as ingestion (water and food) (aOR 0.38 CI 0.16-0.89), and substance use (smoking and alcohol) (aOR 1.45 CI 0.98-2.14) were all associated with patient delay. Female gender was associated with LDFU (aOR 3.80, 95% CI 1.62-8.87) but not with delay. Other conditions as prior illness and heredity were also associated with LDFU but not delay (aOR 1.48 CI 1.01-2.17). CONCLUSION: Delay and LDFU after referral from the pharmacies were substantial. Notable effects of diagnosis and female gender indicate a need for more attention to women's health to promote timely and sustained TB treatment. Public awareness to counter misconceptions about the causes of TB is needed.

Navigating fertility, reproduction and modern contraception in the fragile context of South Kivu, Democratic Republic of Congo: 'Les enfants sont une richesse'.

Modern contraception has created new possibilities for reimagining reproductive norms and has generated new socio-cultural uncertainties in South Kivu province, Democratic Republic of Congo. Using inductive analysis of women's reproductive narratives, this paper explores how women in a high fertility context encounter and integrate recently introduced family planning and modern contraceptive education and services into their lives. As foundational socio-cultural norms confront the new reproductive possibilities offered by contraception, power dynamics shift and norms are called into question, re-interpreted and re-negotiated. Reproduction is located as a socially constructed process at the intersection of fertility norms, power dynamics, institutional practices, embodied realties and personal desires. In many ways the possibilities created by contraception - meant to increase certainty in the lives of users - actually increase uncertainty. The complexity of reproductive navigation reveals the shortcomings of reproductive theory and health and development discourses which view women and men as autonomous decision makers, removing them from the multiplicity of influencing factors, histories and power dynamics within which they realise their reproductive lives.

[Social determinants of health - how gendergot lost on the way]. / Déterminants sociaux de la santéen Suisse ­ comment le genres'est perdu en chemin.

Since four decades epidemiological research has emphasised the necessity to consider social determinants and the social distribution of illnesses in the Swiss population, particularly by gender. Gender influences social position, living conditions as well as health behaviours over the life-course which all together influence health outcomes. Despite this evidence, national health policies and strategies tend to consider gender as a background factor, if not to omit its influence on health. The Health2020 policy and the recent specific national strategies are particularly illustrative. To exclude or reduce gender as a mere biological factor however hampers the implementation of specific interventions aiming at reducing health inequalities in the name of the social justice principle.

Depuis quatre décennies, la recherche épidémiologique a mis en évidence la nécessité de considérer les déterminants sociaux et la distribution sociale des maladies dans la population suisse, en particulier en fonction du genre. Le genre influence la situation sociale, les conditions et les parcours de vie et les comportements en matière de santé qui influencent ensemble la santé. Malgré ces acquis, les politiques et stratégies nationales de santé tendent à considérer le genre comme un facteur de second plan, voire à omettre totalement son influence sur la santé. La politique Santé2020 et les stratégies nationales spécifiques récentes en témoignent tout particulièrement. Or, exclure ou réduire le genre à un facteur biologique entrave la mise en place d'interventions spécifiques visant la réduction des inégalités de santé au nom du principe de justice sociale.

Linking gender, extramarital affairs, and HIV: a mixed methods study on contextual determinants of extramarital affairs in rural Tanzania.

BACKGROUND: Extramarital sex is a potential driver of human immunodeficiency virus (HIV) transmission for long-term couples in sub-Saharan Africa. It is increasingly recognized that preventing sexual risk behaviours requires an understanding and adjustment of sexual relationship factors beyond the individual level. We investigated the association between extramarital affairs and HIV status, factors associated with extramarital affairs, and created insights in the context and pathways for married men and women in rural Tanzania who engage in extramarital affairs. METHODS: A cross-sectional sequential explanatory mixed method design was employed. The WHO-Social determinants of health perspective guided the study. Using logistic regression, we analysed the MZIMA project community surveillance representative sample of 3884 married partners aged 15+ residing in Ifakara town, Tanzania (2012-2013). Multinomial logistic regression analysis established the relative risk ratio (RRR) of different social and economic factors with lifetime (proxy) and recent (12 months prior to survey) extramarital affairs. Logistic regression analysis determined the association between extramarital affairs and HIV status. Semi-structured interviews and focus group discussions explored the quantitative findings, capturing the experiences and norms regarding extramarital affairs. RESULTS: We found a significant association between lifetime (proxy) extramarital affairs and HIV infection among women only. The RRR of having extramarital affairs (lifetime proxy) was significantly higher among Village Community Bank (VICOBA) members, the re-married, consumers of alcohol, those from southern regions, non-Muslims, and those with older age. In the case of recent extramarital affairs (12 months prior to survey), associations were significant for the same variables except for religion, having an income was also associated with the outcome. Qualitative narratives reflected that, desire to prove manhood (masculinity) supported by societal normative beliefs such as; 'it is not realistic for a man to stay without extramarital partner' and religious beliefs; 'a man shall dominate a woman' encouraged men's extramarital affairs. For women, striving for financial autonomy, obligations to pay back debts borrowed from several VICOBA, and limited support from their husbands encouraged their engagement in extramarital affairs. Low relationship quality (conflict and sexual dissatisfaction) were reported to encourage both men and women's extramarital affairs. CONCLUSIONS: The findings show that the link between extramarital affairs and HIV has a gender dimension in which women are more likely to acquire HIV through extramarital affairs (case of recent extramarital affairs (12 months prior to survey). Future programs seeking to address risk sexual behaviors in Tanzanian marriages can consider context-sensitive interventions which address aspects beyond 'individual risk' and women's financial uncertainties, and include couple's relationship quality, excessive alcohol behaviors, normative masculinity ideology and societal norms, that encourage women's economic dependence and men's engagement in multiple sexual partnerships. Microfinance projects (e.g. VICOBA) could be a platform for gender-transformative approaches, combining economic empowerment and HIV risk protection strategies.

The context of emergency contraception use among young unmarried women in Accra, Ghana: a qualitative study.

BACKGROUND: Over the past decade, awareness and use of emergency contraceptive pills (ECPs) among young women has rapidly increased in Ghana; however, the rate of unintended pregnancy among this group remains high. We conducted a qualitative study to better understand the context and patterns of ECP use among young unmarried women in Ghana. METHODS: We conducted in-depth interviews with unmarried sexually active women aged 18-24 in Accra, Ghana to explore their perceptions, experiences, and opinions regarding sexual relationships and contraceptive methods, and to examine the factors that influence choice of ECPs. A total of 32 young women participated in the study. RESULTS: Most participants had used ECPs at least once. Participants described being unable to plan for sexual encounters, and as a result preferred ECPs as a convenient post-coital method. Despite being widely and repeatedly used, women feared the disruptive effects of ECPs on the menstrual cycle and were concerned about long-term side-effects. ECPs were sometimes used as a back-up in cases of perceived failure of traditional methods like withdrawal. Misinformation about which drugs were ECPs, correct dosage, and safe usage were prevalent, and sometimes spread by pharmacists. Myths about pregnancy prevention techniques such as urinating or washing after sex were commonly believed, even among women who regularly used ECPs, and coincided with a misunderstanding about how hormonal contraception works. CONCLUSIONS: ECPs appear to be a popular contraceptive choice among young urban women in Ghana, yet misinformation about their correct usage and safety is widespread. While more research on ECP use among young people is needed, these initial results point to the need to incorporate information about ECPs into adolescent comprehensive sexuality education and youth-friendly services and programmes.

Talking about sex in pregnancy: reflections from the field in urban South Africa.

Qualitative research with close engagement in the field allows researchers and participants to build relationships and establish trust, enabling researchers to collect meaningful and sensitive information. Drawing on findings from a study conducted in an urban setting in South Africa, we discuss the challenges faced when interviewing pregnant women with HIV infection, retaining them in the study, and extending the study to include their partners. We discuss the dynamics of pregnancy and draw lessons from interviews concerned with personal, sensitive issues. The study on which we draw was conducted in Johannesburg, South Africa, and was nested in a larger prospective cohort study of women and their infants, which in turn was part of a case control study. Sensitive topics are difficult and complex, but to ignore these and stay in safe territory is to ignore some of the most pressing questions of our time. It is important that those who conduct interviews are well trained and able to engage empathetically with participants, and that some form of counselling is available for both participants and researchers.

Baby-Friendly Hospital designation has a sustained impact on continued breastfeeding.

The Baby-Friendly Hospital (BFH) Initiative has led to an increase in breastfeeding rates and duration worldwide. But little is known about whether the beneficial effects persist beyond a facility's designation as a BFH. To investigate the association of BFH designation (current, former, and never) and compliance with Baby-Friendly (BF) practices on breastfeeding in Switzerland, this study combined nationwide survey data on breastfeeding with BFH monitoring data. In this cross-sectional study, 1,326 children were born in 34 current (N = 508), 28 former (N = 425), and 34 never designated BFHs (N = 393). We compared exclusive and any breastfeeding according to BFH designation over the first year of life, using Kaplan-Meyer Survival curves. Logistic regression models were applied to analyse breastfeeding prevalence, and Cox-regression models were used for exclusive (0-6 months) and continued (6-12 months) breastfeeding duration. Average duration of exclusive breastfeeding (13.1 weeks, 95% confidence interval [12.0, 17.4]) and any breastfeeding (32.7 weeks, 95% confidence interval [30.5, 39.2]) were the longest for babies born in currently accredited BFHs. Exclusive breastfeeding was associated with high compliance with monitored BF practices in current BFHs and with the number of BF practices experienced in all hospitals. Continued breastfeeding was significantly longer when babies were born in current BFHs (cessation hazard ratio 0.60, 95% confidence interval [0.42, 0.84]) or in former BFHs (cessation hazard ratio 0.68, 95% confidence interval [0.48, 0.97]). Overall, the results support continued investment into BFHs, because babies born in current BFHs are breastfed the most and the longest, whereas a former BFH designation shows a sustained effect on continued breastfeeding.

Evaluating the comparative effectiveness of different demand side interventions to increase maternal health service utilization and practice of birth spacing in South Kivu, Democratic Republic of Congo: an innovative, mixed methods approach.

BACKGROUND: In this protocol we describe a mixed methods study in the province of South Kivu, Democratic Republic of Congo evaluating the effectiveness of different demand side strategies to increase maternal health service utilization and the practice of birth spacing. Conditional service subsidization, conditional cash transfers and non-monetary incentives aim to encourage women to use maternal health services and practice birth spacing in two different health districts. Our methodology will comparatively evaluate the effectiveness of different approaches against each other and no intervention. METHODS/DESIGN: This study comprises four main research activities: 1) Formative qualitative research to determine feasibility of planned activities and inform development of the quantitative survey; 2) A community-based, longitudinal survey; 3) A retrospective review of health facility records; 4) Qualitative exploration of intervention acceptability and emergent themes through in-depth interviews with program participants, non-participants, their partners and health providers. Female community health workers are engaged as core members of the research team, working in tandem with female survey teams to identify women in the community who meet eligibility criteria. Female community health workers also act as key informants and community entry points during methods design and qualitative exploration. Main study outcomes are completion of antenatal care, institutional delivery, practice of birth spacing, family planning uptake and intervention acceptability in the communities. Qualitative methods also explore decision making around maternal health service use, fertility preference and perceptions of family planning. DISCUSSION: The innovative mixed methods design allows quantitative data to inform the relationships and phenomena to be explored in qualitative collection. In turn, qualitative findings will be triangulated with quantitative findings. Inspired by the principles of grounded theory, qualitative analysis will begin while data collection is ongoing. This "conversation" between quantitative and qualitative data will result in a more holistic, context-specific exploration and understanding of research topics, including the mechanisms through which the interventions are or are not effective. In addition, engagement of female community health workers as core members of the research team roots research methods in the realities of the community and provides teams with key informants who are simultaneously implicated in the health system, community and target population.

Ambiguous care: siblings and the economies of HIV-related care in Zambia.

While kinship used to be considered a backbone of the creation of mutual obligations for care in pre-industrial societies, economic and social change has altered how care is provided. Notwithstanding changing kinship obligations, relatives continue to provide much of the care for those in need. In this article, I consider the active production of relationships among siblings through individual biographies, to understand how mutual obligations are created and affect the care provided to HIV-positive persons. I draw on two phases of ethnographic research conducted in Zambia, in Southern Province and Lusaka, between 2002 and 2011. Findings revealed that siblings are normally considered an important source of support, but their willingness and capacity to provide support may be limited by resource constraints and biographical experiences. Helping or not is at the conjunction of kinship-based obligations and a sense of connectedness, deriving from the history of growing up together, often in the context of disrupted families. The experiences of siblings in their past reach beyond individual histories. Structural factors jeopardise the support between and within generations, and must be addressed while promoting social protection programmes.