Female empowerment to improve sexual and reproductive health outcomes and prevent violence in adolescent girls and young women in Uganda: evidence reviews for policy.

Background: Adolescent girls and young women in Uganda face numerous public health challenges including high HIV prevalence, teenage pregnancies, poor sexual and reproductive health rights, child marriage, and violence. Objectives: This evidence review explores which interventions focusing on the empowerment of adolescent girls and young women to address these challenges are suitable for Ugandan policy. Methods: We reviewed the literature to identify experimental studies and systematic reviews of interventions which improve sexual and reproductive health outcomes and/or prevent violence in adolescent girls and young women in low- and middle-income countries (LMICs). Two authors independently reviewed the studies identified through a comprehensive search strategy and assessed their quality. From this evidence base, two policy options were explored in depth considering benefits, harms, equity impacts, and costs, given the Ugandan context. Results: The screen yielded 47 studies, of which 12 remained after applying inclusion and exclusion criteria and relevance, applicability and quality assessment. Feasible policy options included: a vertical cash-incentive approach at a national or local level to support girls' attainment of education; and a horizontal integrated community approach focusing on skills and knowledge building. A combination of both is recommended for young female empowerment in Uganda, allowing for the full range of socio-cultural and economic drivers to be targeted. Conclusion: Research into the link between female empowerment and sexual and reproductive health outcomes is still in early development. This review contributes to evidence on this topic and outlines an approach that is potentially suitable for adoption across similar LMICs in Africa.

Prevalence of child maltreatment in India and its association with gender, urbanisation and policy: a rapid review and meta-analysis protocol.

INTRODUCTION: India is home to 20% of the world's children and yet, little is known on the magnitude and trends of child maltreatment nationwide. The aims of this review are to provide a prevalence of child maltreatment in India with considerations for any effects of gender; urbanisation (eg, urban vs rural) and legislation (Protection of Children from Sexual Offences (POCSO) Act 2012). METHODS AND ANALYSIS: A rapid review will be undertaken of all quantitative peer-reviewed studies on child maltreatment in India between 2005 and 2020. Four electronic databases will be systematically searched: PubMed, EMBASE, Cochrane and PsychInfo. The primary outcomes will include all aspects of child maltreatment: physical abuse, sexual abuse, emotional abuse, emotional neglect and physical neglect. Study participants will be between 0 and 18 years and will have reported maltreatment experiences using validated, reliable tools such as the Adverse Childhood Experiences Questionnaire as well as child self-reports and clinician reports. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the methodological appraisal of the studies will be assessed by the Newcastle-Ottawa Quality assessment scale. A narrative synthesis will be conducted for all included studies. Also, if sufficient data are available, a meta-analysis will be conducted. Effect sizes will be determined from random-effects models stratified by gender, urbanisation and the pre-2012 and post-2012 POCSO Act cut-off. I2 statistics will be used to assess heterogeneity and identify their potential sources and τ2 statistics will indicate any between-study variance. ETHICS AND DISSEMINATION: As this is a rapid review, minimal ethical risks are expected. The protocol and level 1 self-audit checklist were submitted and approved by the Usher Research Ethics Group panel in the Usher Institute (School of Medicine and Veterinary Sciences) at the University of Edinburgh (Reference B126255). Findings from this review will be disseminated widely through peer-reviewed publications and in various media, for example, conferences, congresses or symposia. PROSPERO REGISTRATION NUMBER: CRD42019150403.

Obesity Prevention in Scotland: A Policy Analysis Using the ANGELO Framework.

BACKGROUND: The Scottish Government's 'Route-Map Action Plan' for obesity prevention sets out 62 potential intervention policies across all stages of the life course. We used the ANGELO Framework (Analysis Grid for Environments Linked to Obesity) to assess the appropriateness and likely impact of the balance of measures being proposed. METHODS: Two assessors (JM & RJ) independently allocated a category for each intervention according to its domain (physical, economic, legislative or socio-cultural), scale (macro or micro) and predominant 'focus' (physical activity versus diet). A third assessor (RG) examined discordant allocations. RESULTS: Across the four ANGELO domains, the distribution of interventions was skewed towards socio-cultural measures (37.1%) and the physical environment (33.1%) with less emphasis on legislative or economic interventions (21.8% and 6.4% respectively). Distribution by both intervention scale and focus was more even with just over half of all policies (51.8%) at the macro-level scale and just under half (46.7%) having a dietary focus. CONCLUSION: The predominance of socio-culturally orientated interventions over their legislative and economic counterparts is at odds with the balance of international evidence on what would be most effective for obesity prevention. The ANGELO framework provides a useful tool for policy makers to monitor progress towards an appropriately balanced policy mix.

Rehabilitation experiences after obstetric fistula repair: systematic review of qualitative studies.

OBJECTIVES: To synthesise evidence on women's experiences surrounding rehabilitation and reintegration after obstetric fistula repair in sub-Saharan Africa and explore recommendations from women and health service providers. METHOD: Systematic literature review of qualitative studies surrounding rehabilitation experiences of women in sub-Saharan Africa who have undergone obstetric fistula repair. Using a pre-defined search strategy, seven databases, relevant source publications and grey literature were searched for primary qualitative studies. Data from ten studies were collected, and thematic analysis based on the framework approach was used to analyse the findings. RESULTS: The most important rehabilitating factor for women was fulfilment of social roles. Health service perspectives were more frequent than women's perspectives. Counselling and health education were the most common recommendations from both perspectives. CONCLUSION: Little qualitative evidence is available on rehabilitation after obstetric fistula repair in sub-Saharan Africa. Counselling services and community health education are priorities. Further research should emphasise women's perspectives to better inform interventions aimed at addressing the physical and social consequences of obstetric fistula.

A cross-sectional pilot study of the Scottish early development instrument: a tool for addressing inequality.

BACKGROUND: Early childhood is recognised as a key developmental phase with implications for social, academic, health and wellbeing outcomes in later childhood and indeed throughout the adult lifespan. Community level data on inequalities in early child development are therefore required to establish the impact of government early years' policies and programmes on children's strengths and vulnerabilities at local and national level. This would allow local leaders to target tailored interventions according to community needs to improve children's readiness for the transition to school. The challenge is collecting valid data on sufficient samples of children entering school to derive robust inferences about each local birth cohort's developmental status. This information needs to be presented in a way that allows community stakeholders to understand the results, expediting the improvement of preschool programming to improve future cohorts' development in the early years. The aim of the study was to carry out a pilot to test the feasibility and ease of use in Scotland of the 104-item teacher-administered Early Development Instrument, an internationally validated measure of children's global development at school entry developed in Canada. METHODS: Phase 1 was piloted in an education district with 14 Primary 1 teachers assessing a cohort of 154 children, following which the instrument was adapted for the Scottish context (Scottish Early Development Instrument: SEDI). Phase 2 was then carried out using the SEDI. Data were analysed from a larger sample of 1090 participants, comprising all Primary 1 children within this school district, evaluated by 68 teachers. RESULTS: The SEDI displayed adequate psychometric and discriminatory properties and is appropriate for use across Scotland without any further modifications. Children in the lowest socioeconomic status quintiles were 2-3 times more likely than children in the most affluent quintile to score low in at least one developmental domain. Even in the most affluent quintile though, 17% of children were 'developmentally vulnerable', suggesting that those in need cannot be identified by socioeconomic status alone. CONCLUSIONS: The SEDI offers a feasible means of providing communities with a holistic overview of school readiness for targeting early years' interventions.

Interventions to prevent substance use and risky sexual behaviour in young people: a systematic review.

AIMS: To identify and assess the effectiveness of experimental studies of interventions that report on multiple risk behaviour outcomes in young people. METHODS: A systematic review was performed to identify experimental studies of interventions to reduce risk behaviour in adolescents or young adults and that reported on both any substance (alcohol, tobacco and illicit drug) use and sexual risk behaviour outcomes. Two authors reviewed studies independently identified through a comprehensive search strategy and assessed the quality of included studies. The report was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: From 1129 papers, 18 experimental studies met our inclusion criteria, 13 of which were assigned a strong or moderate quality rating. The substantial heterogeneity between studies precluded the pooling of results to give summary estimates. Intervention effects were mixed, with most programmes having a significant effect on some outcomes, but not others. The most promising interventions addressed multiple domains (individual and peer, family, school and community) of risk and protective factors for risk behaviour. Programmes that addressed just one domain were generally less effective in preventing multiple risk behaviour. CONCLUSIONS: There is some, albeit limited, evidence that programmes to reduce multiple risk behaviours in school children can be effective, the most promising programmes being those that address multiple domains of influence on risk behaviour. Intervening in the mid-childhood school years may have an impact on later risk behaviour, but further research is needed to determine the effectiveness of this approach.

Dual and triple therapy to prevent mother-to-child transmission of HIV in a resource-limited setting - lessons from a South African programme.

OBJECTIVE: To determine outcomes of pregnant women and their infants at McCord Hospital in Durban, South Africa, where dual and triple therapy to reduce HIV vertical transmission have been used since 2004 despite national guidelines recommending simpler regimens. METHOD: We retrospectively examined records of all pregnant women attending McCord Hospital for their first antenatal visit between 1 March 2004 and 28 February 2007. Uptake of HIV testing and HIV prevalence were determined, and clinical, immunological and virological outcomes of HIV-positive women and their infants, followed through to 6 months after delivery, were described. RESULTS: The antenatal clinic was attended by 5 303 women; 4 891 (92%) had an HIV test, and 703 (14%) were HIV positive. The HIV-positive women were subsequently followed up: 653 (93%) received antiretroviral therapy or prophylaxis, including 424 (60%) who received triple therapy. Of the 699 live babies delivered, 661 (94%) received prophylaxis. At 6 weeks 571 babies (82%) were brought back for HIV testing; 16 (2.8%) were HIV positive. After 6 months, only 150 women (21%) were receiving follow-up care at the adult HIV clinic. CONCLUSION: Where a tailored approach to prevention of mother-to-child transmission (PMTCT) is used, which attempts to maximise available technology and resources, good short-term transmission outcomes can be achieved. However, longer-term follow-up of mothers' and babies' health presents a challenge. Successful strategies to link women to ongoing care are crucial to sustain the gains of PMTCT programmes.

A rapid review of key strategies to improve the cognitive and social development of children in Scotland.

OBJECTIVES: Inequalities in health and educational outcomes in Scotland show a strong and persistent socioeconomic status gradient. Our aims were to provide policy-makers with a synthesis of international research evidence that assesses the effectiveness of early childhood interventions aimed at equitably promoting cognitive and social development and suggest potential areas for action in Scotland. METHODS: A rapid review was conducted of review level studies of early childhood interventions with outcome measures relating to child cognitive-language or social-emotional development, subsequent academic and life achievement. Websites were searched and interviews were conducted to identify relevant interventions, policies and programmes delivered in Scotland. RESULTS: : Early childhood intervention programmes can reduce disadvantage due to social and environmental factors. Scottish health policy demonstrates a clear commitment to early childhood development but much work remains in terms of detail of policy implementation, identification of high risk children and families, and early childhood monitoring systems. CONCLUSIONS: Programmes should provide a universal seamless continuum of care and support from pregnancy through to school entry with the intensity of support graded according to need. The current information systems in Scotland would be inadequate for monitoring the effects of early childhood interventions especially in relation to cognitive-language and social-emotional development.

Prevention of mother-to-child transmission of HIV programme: low vertical transmission in KwaZulu-Natal, South Africa.

OBJECTIVE: To describe the operational effectiveness of the prevention of mother-to-child transmission (PMTCT) of HIV programme at McCord Hospital during the period 1 March 2004 - 31 August 2005. DESIGN: Observational cohort study. SETTING: McCord Hospital, Durban, South Africa. SUBJECTS: Antenatal patients attending the PMTCT clinic. MEASUREMENTS AND RESULTS: During the 18 months all 2 624 women (100%) attending the antenatal clinic received HIV counselling, resulting in 91% (2 388) being tested for HIV. The prevalence of HIV in the total cohort was 13% (95% confidence interval (CI) 11.6 - 14.2). Of the HIV-positive mothers 302 (89%) completed their pregnancy at the hospital, and in this group there were 3 intrauterine deaths, 1 miscarriage, 1 maternal death (with the baby in utero) and 297 live births with 1 early neonatal death. Only 11% (36 out of 338) were lost to follow-up. A quarter (668) of the partners of all women attending the antenatal clinic were tested for HIV. Delivery in 70% (209) of live births was by caesarean section. Nevirapine was administered to 98% (290) of live babies and 75% (224) received zidovudine (AZT) as well. The 6-week polymerase chain reaction (PCR) baby test uptake was 81% (239 out of 296 live babies). Of those tested, 2.9% (95% CI 1.3 - 6.2) tested HIV positive. CONCLUSION: Despite challenges faced by PMTCT providers in a resource-constrained setting, this state-aided hospital provides a comprehensive and integrated service and has achieved outcomes that compare favourably with those in the developed world.

Preliminary outcomes of a paediatric highly active antiretroviral therapy cohort from KwaZulu-Natal, South Africa.

BACKGROUND: Few studies address the use of paediatric highly active antiretroviral therapy (HAART) in Africa. METHODS: We performed a retrospective cohort study to investigate preliminary outcomes of all children eligible for HAART at Sinikithemba HIV/AIDS clinic in KwaZulu-Natal, South Africa. Immunologic, virologic, clinical, mortality, primary caregiver, and psychosocial variables were collected and analyzed. RESULTS: From August 31, 2003 until October 31, 2005, 151 children initiated HAART. The median age at HAART initiation was 5.7 years (range 0.3-15.4). Median follow-up time of the cohort after HAART initiation was 8 months (IQR 3.5-13.5). The median change in CD4% from baseline (p < 0.001) was 10.2 (IQR 5.0-13.8) at 6 months (n = 90), and 16.2 (IQR 9.6-20.3) at 12 months (n = 59). Viral loads (VLs) were available for 100 children at 6 months of which 84% had HIV-1 RNA levels < or = 50 copies/mL. At 12 months, 80.3% (n = 61) had undetectable VLs. Sixty-five out of 88 children (73.8%) reported a significant increase (p < 0.001) in weight after the first month. Eighty-nine percent of the cohort (n = 132) reported < or = 2 missed doses during any given treatment month (> 95%adherence). Seventeen patients (11.3%) had a regimen change; two (1.3%) were due to antiretroviral toxicity. The Kaplan-Meier one year survival estimate was 90.9% (95%confidence interval (CI) 84.8-94.6). Thirteen children died during follow-up (8.6%), one changed service provider, and no children were lost to follow-up. All 13 deaths occurred in children with advanced HIV disease within 5 months of treatment initiation. In multivariate analysis of baseline variables against mortality using Cox proportional-hazards model, chronic gastroenteritis was associated with death [hazard ratio (HR), 12.34; 95% CI, 1.27-119.71) and an HIV-positive primary caregiver was found to be protective against mortality [HR, 0.12; 95% CI, 0.02-0.88). Age, orphanhood, baseline CD4%, and hemoglobin were not predicators of mortality in our cohort. Fifty-two percent of the cohort had at least one HIV-positive primary caregiver, and 38.4% had at least one primary caregiver also on HAART at Sinikithemba clinic. CONCLUSION: This report suggests that paediatric HAART can be effective despite the challenges of a resource-limited setting.

A high incidence of nucleoside reverse transcriptase inhibitor (NRTI)-induced lactic acidosis in HIV-infected patients in a South African context.

OBJECTIVE: To determine the incidence of and predisposing risk factors for lactic acidosis in HIV-infected patients on antiretroviral drugs in South Africa. DESIGN: Observational case series. SETTING: Sinikithemba HIV Clinic, McCord Hospital, Durban. SUBJECTS: Eight hundred and ninety-one HIV-positive patients on highly active antiretroviral therapy (HAART) during an 18-month period commencing in January 2004. MEASUREMENTS AND RESULTS: Fourteen cases of lactic acidosis (incidence rate of 19 (95% confidence interval (CI): 9-29) cases per 1,000 person-years of treatment) were reported. All cases were female, with a median age of 36 years and a median weight of 81 kg. The median time on HAART before developing lactic acidosis was 7.5 months and the median peak lactate level was 9.3 mmol/l. All cases were on stavudine (d4T), lamivudine (3TC) and 1 non-NRTI. The case mortality rate was 29% (4 patients). CONCLUSIONS: The incidence rate is higher than reported in studies in developed countries. This may be due to d4T, which is recommended as a first-line antiretroviral drug in South Africa. This implication raises the question whether it is an appropriate drug in first-line treatment of patients with predisposing risk factors such as female gender and being overweight.