Challenges and opportunities for improving access to adolescent and youth sexual and reproductive health services and information in the coastal counties of Kenya: a qualitative study.

BACKGROUND: Globally, adolescents and youth experience high unmet need for sexual and reproductive health (SRH) information and services. In Kenya, evidence shows that more than half of teenage pregnancies are unintended and that half of all new HIV infections occur in people ages 15-24-year-olds, with the majority of those being female. The coastal counties in Kenya record a relatively high adolescent pregnancy rate and higher rates of unmet need for contraception for all women of reproductive age compared to the national average. This study focused on gaining a deeper understanding of the existing challenges to and opportunities for accessing SRH information and services among adolescents and youth (AY) at the Kenyan coast. METHODS: Using qualitative methods, this study conducted thirty-six focus group discussions with adolescents, youth, and community health volunteers across all the six coastal counties in Kenya. The sample included adolescents aged 10-14 years in school (male and female), adolescents aged 15-19 years not in education (male and female), youths aged 20-24 years (mix of both male and female), and community health volunteers who were conveniently sampled. Thematic analysis was used to examine the data and report the study results. RESULTS: The barriers to accessing AYSRH identified in the study are individual factors (feelings of shame, lack of information, and fear of being judged) parental factors, healthcare worker and health institution factors, teacher/educators factors, and broader contextual factors such as culture, religion, poverty, and illiteracy. Factors that facilitate access to AYSRH information and services included, supportive parenting and culture, AYSRH sessions in schools, peer support, supportive health institutions, gender inclusivity, and digital technology. CONCLUSIONS: AYSRH information and services at the Kenyan coast is strongly influenced by a range of individual, social, cultural, and economic factors. Improving access to AYSHR necessitates meaningful AY engagement, provision of youth-friendly services, use of digital technology as alternative pathways for sharing SRH information, strengthening parent-AY relationships, embracing peer-to-peer support, and the adoption of gender-inclusive approaches in AYSRH programming.

Exploring the impact of health worker strikes on maternal and child health in a Kenyan county.

BACKGROUND: Studies of the impact of health care workers' strikes tend to look at facility-level activity rather than populations, with evidence from low and middle-income countries relatively sparse. This study explored the effect of national strikes on maternal and child health. It looked at the impact on health system activity in both public and non-public sectors (e.g. private, faith-based), on health promotion investments like immunisation, and on disease detection like post-partum haemorrhage (PPH). A 100 day doctors' strike started in December 2016, a 150 day nurses strike from June 2017 and then the clinical officers for 21 days that September. METHODS: Time series descriptive analysis of attendance data from the Kenyan Health Management Information System (public, non-public sector facilities). The setting was Kilifi, a coastal county in Kenya with a population of about 1.5 million. RESULTS: Along the care pathway from antenatal, postnatal and out-patient child health clinics, activity levels dropped markedly in the public sector with only partial compensatory increases in non-public sector activity. The number of fully immunised children fell during the nurses strike as did women seen with PPH during all strikes. These health care strikes caused significant adverse health impacts at the time and potentially inter-generationally as exemplified by the fall in antenatal haematinics supplementation and syphilis testing. Some post-strike ''catch-up" activity occurred, however this may have been too late in some instances. CONCLUSIONS: Policy-makers at national and county level need to ensure population health is protected at times of strikes and ideally resolve disputes without such action. Not to do so risks major negative effects on maternal and child health. Increased use of the non-public health sector could be done by the authorities in mitigation should strikes occur again.

Cesarean section: More than a maternal health issue.

A cesarean section (CS) can be a lifesaving intervention when medically indicated, but it may also lead to adverse short- and long-term health effects for women and children.

The use of future scenario thinking for child public health in a local authority.

BACKGROUND: Socioeconomic, cultural, technological, environment and ecological changes are rapidly transforming how children and young people (CYP) grow up, yet their impacts on CYP are difficult to predict. The traditional ways that Public Health practitioners work may not capture such complex and dynamic change. To address this, Lambeth Council used future scenario thinking. METHODS: A literature review looked at political, socioeconomic and other 'transitions' in the borough. Interviews, focus groups and workshops were held with CYP, parents, carers, local statutory and non-statutory stakeholders about the future for Lambeth CYP in the decade ahead. Themes were analysed to identify which had the potential for the biggest impact or the most uncertainty. RESULTS: The main transitions were described, 100 stakeholders interviewed, and five 'drivers' of the future were identified: protracted austerity, technological explosion, demographic shift, 'democratic shake-up' and planetary health. From all these data, four future scenarios were developed: 'communities care for themselves', 'collaborating to care for all', 'nobody cares' and 'who cares?' CONCLUSIONS: New insights were gained about promoting more responsibility for, and active participation of CYP. This led to Lambeth's CYP Plan and the 'Made in Lambeth' campaign aiming to enlist the community and business in creating a child-friendly borough.

Intimate partner violence against adolescents and young women in sub-Saharan Africa: who is most vulnerable?

BACKGROUND: Intimate partner violence (IPV) is a global public health and human rights issue that affects millions of women and girls. While disaggregated national statistics are crucial to assess inequalities, little evidence exists on inequalities in exposure to violence against adolescents and young women (AYW). The aim of this study was to determine inequalities in physical or sexual IPV against AYW and beliefs about gender based violence (GBV) in sub-Saharan Africa (SSA). METHODS: We used data from the most recent Demographic and Health Surveys (DHS) conducted in 27 countries in SSA. Only data from surveys conducted after 2010 were included. Our analysis focused on married or cohabiting AYW aged 15-24 years and compared inequalities in physical or sexual IPV by place of residence, education and wealth. We also examined IPV variations by AYW's beliefs about GBV and the association of country characteristics such as gender inequality with IPV prevalence. RESULTS: The proportion of AYW reporting IPV in the year before the survey ranged from 6.5% in Comoros to 43.3% in Gabon, with a median of 25.2%. Overall, reported IPV levels were higher in countries in the Central Africa region than other sub-regions. Although the prevalence of IPV varied by place of residence, education and wealth, there was no clear pattern of inequalities. In many countries with high prevalence of IPV, a higher proportion of AYW from rural areas, with lower education and from the poorest wealth quintile reported IPV. In almost all countries, a greater proportion of AYW who approved wife beating for any reason reported IPV compared to their counterparts who disapproved wife beating. Reporting of IPV was weakly correlated with the Gender Inequality Index and other societal level variables but was moderately positively correlated with adult alcohol consumption (r = 0.48) and negative attitudes towards GBV (r = 0.38). CONCLUSION: IPV is pervasive among AYW, with substantial variation across and within countries reflecting the role of contextual and structural factors in shaping the vulnerability to IPV. The lack of consistent patterns of inequalities by the stratifiers within countries shows that IPV against women and girls cuts across socio-economic boundaries suggesting the need for comprehensive and multi-sectoral approaches to preventing and responding to IPV.

Inequalities in early marriage, childbearing and sexual debut among adolescents in sub-Saharan Africa.

BACKGROUND: Adolescent sexual and reproductive health (ASRH) is a major public health concern in sub-Saharan Africa (SSA). However, inequalities in ASRH have received less attention than many other public health priority areas, in part due to limited data. In this study, we examine inequalities in key ASRH indicators. METHODS: We analyzed national household surveys from 37 countries in SSA, conducted during 1990-2018, to examine trends and inequalities in adolescent behaviors related to early marriage, childbearing and sexual debut among adolescents using data from respondents 15-24 years. Survival analyses were conducted on each survey to obtain estimates for the ASRH indicators. Multilevel linear regression modelling was used to obtain estimates for 2000 and 2015 in four subregions of SSA for all indicators, disaggregated by sex, age, household wealth, urban-rural residence and educational status (primary or less versus secondary or higher education). RESULTS: In 2015, 28% of adolescent girls in SSA were married before age 18, declined at an average annual rate of 1.5% during 2000-2015, while 47% of girls gave birth before age 20, declining at 0.6% per year. Child marriage was rare for boys (2.5%). About 54% and 43% of girls and boys, respectively, had their sexual debut before 18. The declines were greater for the indicators of early adolescence (10-14 years). Large differences in marriage and childbearing were observed between adolescent girls from rural versus urban areas and the poorest versus richest households, with much greater inequalities observed in West and Central Africa where the prevalence was highest. The urban-rural and wealth-related inequalities remained stagnant or widened during 2000-2015, as the decline was relatively slower among rural and the poorest compared to urban and the richest girls. The prevalence of the ASRH indicators did not decline or increase in either education categories. CONCLUSION: Early marriage, childbearing and sexual debut declined in SSA but the 2015 levels were still high, especially in Central and West Africa, and inequalities persisted or became larger. In particular, rural, less educated and poorest adolescent girls continued to face higher ASRH risks and vulnerabilities. Greater attention to disparities in ASRH is needed for better targeting of interventions and monitoring of progress.

Interventions to reduce unnecessary caesarean sections in healthy women and babies.

Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women's and health professionals' concerns, as well as health system and financial factors.

The impact of COVID-19 mitigation measures on sexual and reproductive health in low- and middle-income countries: a rapid review.

Pandemic mitigation measures can have a negative impact on access and provision of essential healthcare services including sexual and reproductive health (SRH) services. This rapid review looked at the literature on the impact of COVID-19 mitigation measures on SRH and gender-based violence (GBV) on women in low- and middle-income countries (LMIC) using WHO rapid review guidance. We looked at relevant literature published in the English language from January 2020 to October 2021 from LMICs using WHO rapid review methods. A total of 114 articles were obtained from PubMed, Google Scholar and grey literature of which 20 met the eligible criteria. Our review found that there was an overall reduction in; (a) uptake of services as shown by lower antenatal, postnatal and family planning clinic attendance, (b) service delivery as shown by reduced health facility deliveries, and post abortion care services and (c) reproductive health outcomes as shown by an increase in incidence of GBV especially intimate partner violence. COVID-19 mitigation measures negatively impact SRH of women in LMICs. Findings from this review could inform policy makers in the health sector to recognise the potential adverse effects of COVID-19 responses on SRH in the country, and therefore implement mitigation measures.

An economic perspective on Malawi's medical "brain drain".

BACKGROUND: The medical "brain drain" has been described as rich countries "looting" doctors and nurses from developing countries undermining their health systems and public health. However this "brain-drain" might also be seen as a success in the training and "export" of health professionals and the benefits this provides. This paper illustrates the arguments and possible policy options by focusing on the situation in one of the poorest countries in the world, Malawi. DISCUSSION: Many see this "brain drain" of medical staff as wrong with developed countries exploiting poorer ones. The effects are considerable with Malawi facing high vacancy rates in its public health system, and with migration threatening to outstrip training despite efforts to improve pay and conditions. This shortage of staff has made it more challenging for Malawi to deliver on its Essential Health Package and to absorb new international health funding.Yet, without any policy effort Malawi has been able to demonstrate its global competitiveness in the training ("production") of skilled health professionals. Remittances from migration are a large and growing source of foreign exchange for poor countries and tend to go directly to households. Whilst the data for Malawi is limited, studies from other poor countries demonstrate the power of remittances in significantly reducing poverty. Malawi can benefit from the export of health professionals provided there is a resolution of the situation whereby the state pays for training and the benefits are gained by the individual professional working abroad. Solutions include migrating staff paying back training costs, or rich host governments remitting part of a tax (e.g. income or national insurance) to the Malawi government. These schemes would allow Malawi to scale up training of health professionals for local needs and to work abroad. SUMMARY: There is concern about the negative impacts of the medical "brain-drain". However a closer look at the evidence for and against the medical "brain-drain" in Malawi suggests that there are potential gains in managing medical migration to produce outcomes that are beneficial to individuals, households and the country. Finally we present several policy options.

HIV/AIDS mitigation strategies and the State in sub-Saharan Africa--the missing link?

BACKGROUND: The HIV/AIDS pandemic in sub-Saharan Africa is widely recognised as a development disaster threatening poverty reduction, economic growth and not merely a health issue. Its mitigation includes the societal-wide adoption and implementation of specific health technologies, many of which depend on functional institutions and State. DISCUSSION: Donor and International Institutions' strategies to mitigate HIV/AIDS in sub-Saharan Africa are premised on a single optimal model of the State, one which focuses on the decentralised delivery of public goods alone (such as healthcare) - the service delivery state. The empirical evidence, though sparse, of "successful" and "unsuccessful" sub-Saharan Africa states' performance in mitigating HIV/AIDS does not support this model. Rather, the evidence suggests an alternative model that takes a country context specific approach - encompassing political power, institutional structures and the level of health technology needed. This model draws on the historical experience of East Asian countries' rapid development. SUMMARY: For international public health policies to be effective, they must consider a country tailored approach, one that advocates a coordinated strategy designed and led by the State with involvement of wider society specific to each country's particular history, culture, and level of development.

Sharing specialist skills for diabetes in an inner city: a comparison of two primary care organisations over 4 years.

OBJECTIVE: To evaluate the effects of organizational change and sharing of specialist skills and information technology for diabetes in two primary care groups (PCGs) over 4 years. METHODS: In PCG-A, an intervention comprised dedicated specialist sessions in primary care, clinical guidelines, educational meetings for professionals and a shared diabetes electronic patient record (EPR). Comparison was made with the neighbouring PCG-B as control. In intervention and control PCGs, practice development work was undertaken for a new contract for family doctors. Data were collected for clinical measures, practice organizational characteristics and professional and patient views. RESULTS: Data were analysed for 26 general practices including 17 in PCG-A and nine in PCG-B. The median practice-specific proportions of patients with HbA1c recorded annually increased in both areas: PCG-A from median 65% to 77%, while PCG-B from 53% to 84%. For cholesterol recording, PCG-A increased from 50% to 76%, and PCG-B from 56% to 80%. Organizational changes in both PCGs included the establishment of recall systems, dedicated clinics and educational sessions for patients. In both PCGs, practices performing poorly at baseline showed the greatest improvements in organization and clinical practice. Primary care professionals' satisfaction with access and communication with diabetes specialist doctors and nurses increased, more so in the intervention PCG. Only 16% of primary care professional respondents used the diabetes EPR at least monthly. Patient satisfaction and knowledge did not change. CONCLUSIONS: Improvements in practices' organizational arrangements were associated with improvements in clinical care in both PCGs. Sharing specialist skills in one PCG was associated with increased professional satisfaction but no net improvement in clinical measures. A shared diabetes EPR is unlikely to be used, unless integrated with practice information systems.

The impact of health professionals' attitudes about being registered donors on the availability of organs.

The mismatch between supply and demand in organ donation is well documented. Although there are many reasons for this mismatch, failure of health professionals to identify potential donors or to gain consent from bereaved relatives is considered to be significant. Such failures may be due to the attitudes of health professionals themselves towards becoming organ donors. This study focuses on the level of commitment shown by health care professionals and their student equivalents to organ donation, and assesses the ways in which they identify themselves as potential organ donors. These findings are evaluated and suggestions for future practice are offered.

How useful are child death reviews: a local area's perspective.

BACKGROUND: Child Death Overview Panels (CDOP) provide a multidisciplinary and confidential forum to learn from and reduce deaths in those under 18 years. How well they perform and how to improve their effectiveness is a question posed at both local and national levels in England. With this in mind, this study looked at the child death review process in two London boroughs with a joint CDOP. FINDINGS: Data on cases reviewed from April 2008 to January 2011 were analysed focusing on cause of death and modifiable factors. Key stakeholders involved in the child death review process were interviewed regarding the effectiveness of the local death review process with responses analysed thematically. CONCLUSIONS: The current process is bureaucratic, should better address neonatal deaths and needs more focus on implementing recommendations. Solutions include simpler forms, neonates-only subgroups, and linking recommendations to strategic initiatives such as Health and Wellbeing Boards.

Life as a league table bottom dweller: teenage pregnancy in Lambeth.

In mid-2004, the lead for tackling teenage pregnancy in Lambeth moved from the Council to Public Health in the coterminous Primary Care Trust. Lambeth is a deprived inner-city London borough with a culturally rich and diverse population. The under-18 teenage conception rate had risen by 19% over the 5-year period (1998-2003) following the launch of the National Teenage Pregnancy Strategy. There was considerable pressure from local and national agencies to reduce this high rate (then standing at twice the English average). This article describes how we attempted to do this.