Women's empowerment through homestead food production in rural Bangladesh.

BACKGROUND: Women in rural Bangladesh face multiple, inter-related challenges including food insecurity, malnutrition, and low levels of empowerment. We aimed to investigate the pathway towards empowerment experienced by women participating in a three-year nutrition-sensitive homestead food production (HFP) program, which was evaluated through the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial. METHODS: We conducted 44 in-depth interviews and 12 focus group discussions with men and women in both intervention and control communities of the FAARM study site in rural, north-eastern Bangladesh. Using a modified grounded theory approach to data collection and analysis, we developed a framework to explain the pathway towards empowerment among HFP program participants. RESULTS: The analysis and resulting framework identified seven steps towards empowerment: 1) receiving training and materials; 2) establishing home gardens and rearing poultry; 3) experiencing initial success with food production; 4) generating social or financial resources; 5) expanding agency in household decision-making; 6) producing renewable resources (e.g. farm produce) and social resources; and 7) sustaining empowerment. The most meaningful improvements in empowerment occurred among participants who were able to produce food beyond what was needed for household consumption and were able to successfully leverage these surplus resources to gain higher bargaining power in their household. Additionally, women used negotiation skills with their husbands, fostered social support networks with other women, and developed increased self-efficacy and motivation. Meanwhile, the least empowered participants lacked support in critical areas, such as support from their spouses, social support networks, or sufficient space or time to produce enough food to meaningfully increase their contribution and therefore bargaining power within their household. CONCLUSIONS: This study developed a novel framework to describe a pathway to empowerment among female participants in an HFP intervention, as implemented in the FAARM trial. These results have implications for the design of future nutrition-sensitive agriculture interventions, which should prioritize opportunities to increase empowerment and mitigate the barriers identified in our study. TRIAL REGISTRATION: FAARM is registered with ClinicalTrials.gov ( NCT02505711 ).

Factors associated with postpartum contraception in Togo, West Africa.

The health benefits of postpartum contraception are well established. Using 2013/14 Togo Demographic and Health Survey (DHS) data, we examine the association between contraceptive use among women who gave birth within 24 months of the DHS and four health service use indicators - antenatal care, institutional delivery, postpartum care, and immunization of the last child - in addition to socio-demographic factors. Factors associated with postpartum contraceptive use in Togo included having their last birth in a health facility, having a postnatal check within two months of birth, youngest child receiving the first diphtheria-pertussis-tetanus vaccine, wanting to space children more than two years from last birth or not have more children, living outside the Savanes region, husband's desire for number of children agreeing with the woman's, and increasing breastfeeding duration. These findings highlight the need for programming which strengthens the integration of contraception into reproductive and immunization services in Togo.

The Co-Occurrence of Overweight and Micronutrient Deficiencies or Anemia among Women of Reproductive Age in Malawi.

BACKGROUND: In low-resource settings, urbanization may contribute to the individual-level double burden of malnutrition (DBM), whereby under- and overnutrition co-occur within the same individuals. OBJECTIVE: We described DBM prevalence among Malawian women by urban-rural residence, examined whether urban residence was associated with DBM, and assessed whether DBM prevalence was greater than the prevalence expected by chance given population levels of under- and overnutrition, which would suggest DBM is a distinct phenomenon associated with specific factors. METHODS: We analyzed nationally representative data of 723 nonpregnant women aged 15-49 y from the 2015-2016 Malawi Micronutrient Survey. DBM was defined as co-occurring overweight or obesity (OWOB) and ≥1 micronutrient deficiency or anemia. We used Poisson regression models to examine the association between urban residence and DBM and its components. The Rao-Scott modified chi-square test compared the observed and expected DBM prevalence. RESULTS: Nationally, 10.8% (95% CI: 7.0, 14.5) of women had co-occurring OWOB and any micronutrient deficiency and 3.4% (95% CI: 1.3, 5.5) had co-occurring OWOB and anemia. The prevalence of co-occurring OWOB and any micronutrient deficiency was 2 times higher among urban women than rural women [urban 32.6 (24.1, 41.2) compared with rural 8.6 (5.2, 11.9), adjusted prevalence ratio: 2.0 (1.1, 3.5)]. Co-occurring OWOB and anemia prevalence did not significantly differ by residence [urban 6.9 (0.6, 13.2) compared with rural 3.0 (0.8, 5.3)]. There were no statistically significant differences in observed and expected prevalence estimates of DBM. CONCLUSIONS: This analysis shows that co-occurring OWOB and any micronutrient deficiency was higher among women in urban Malawi compared with rural areas. However, our finding that co-occurring OWOB and any micronutrient deficiency or anemia may be due to chance suggests that there may not be common causes driving DBM in Malawian women. Thus, there may not be a need to design and target interventions specifically for women with DBM.

Human and economic resources for empowerment and pregnancy-related mental health in the Arab Middle East: a systematic review.

This systematic review synthesizes research on the influence of human and economic resources for women's empowerment on their pre- and postnatal mental health, understudied in the Arab world. We include articles using quantitative methods from PubMed and Web of Science. Two researchers reviewed databases and selected articles, double reviewing 5% of articles designated for inclusion. Twenty-four articles met inclusion criteria. All 24 articles measured depression as an outcome, and three included additional mental health outcomes. Nine of 17 studies found an inverse association between education and depression; two of 12 studies found contradictory associations between employment and depression, and four of six studies found a positive association between financial stress and depression. These results suggest that there is a negative association between education and depression and a positive association between financial stress and depression among women in the Arab world. Firm conclusions warrant caution due to limited studies meeting inclusion criteria and large heterogeneity in mental health scales used, assessment measures, and definitions of human and economic resources for women's empowerment. It is likely that education reduces depression among postpartum women and that financial stress increases their depression. These findings can be used to aid in the design of interventions to improve mother and child outcomes. However, more research in the Arab world is needed on the relationship between human and economic resources for women's empowerment and perinatal mental health, and more consistency is needed in how resources and mental health are measured.

What Influences Saturation? Estimating Sample Sizes in Focus Group Research.

Saturation is commonly used to determine sample sizes in qualitative research, yet there is little guidance on what influences saturation. We aimed to assess saturation and identify parameters to estimate sample sizes for focus group studies in advance of data collection. We used two approaches to assess saturation in data from 10 focus group discussions. Four focus groups were sufficient to identify a range of new issues (code saturation), but more groups were needed to fully understand these issues (meaning saturation). Group stratification influenced meaning saturation, whereby one focus group per stratum was needed to identify issues; two groups per stratum provided a more comprehensive understanding of issues, but more groups per stratum provided little additional benefit. We identify six parameters influencing saturation in focus group data: study purpose, type of codes, group stratification, number of groups per stratum, and type and degree of saturation.

"I have no choice": Influences on Contraceptive Use and Abortion among Women in the Democratic Republic of the Congo.

In 2015, the Democratic Republic of the Congo (DRC) recorded an estimated maternal mortality ratio of 693/100,000 live births. Strict abortion laws, high fertility rates, low contraceptive prevalence, and lack of emergency obstetric care all contribute to the high maternal mortality ratio. This study explored influences on contraceptive use and abortion in the DRC. Qualitative in-depth interviews were conducted with 32 women and 10 healthcare providers in four provinces. Participants were recruited at health centers and households in the study communities. Thematic analysis was used and identified that Congolese women's contraceptive decision-making was shaped by a range of external influences rather than their own independent decisions. Non- autonomous decisions and strict abortion laws influenced the methods used to abort a pregnancy, exposing risks of infection, complication, and fatality. These findings highlight that Congolese women's decisions about their fertility and family planning are constrained by policy and socio-cultural influences.

Integrating micronutrient status assessment into the 2015-2016 Malawi Demographic and Health Survey: A qualitative evaluation.

Demand for national-level micronutrient status data continues to grow, yet little is known about the implementation of different approaches for collecting these data. We conducted an evaluation of the process of linking the 2015-2016 Malawi Demographic and Health Survey (MDHS) and 2015-2016 Malawi Micronutrient Survey (MNS). We conducted 24 in-depth interviews with stakeholders from the Malawi government and international agencies and field staff. Interview questions explored perceptions of what worked and what was challenging during three phases of implementation: preparation; data collection; and data analysis, reporting, and dissemination. Data were analysed using thematic analysis. Results showed that there was strong government interest to integrate the MDHS and MNS. Perceived benefits included potential cost savings and lower respondent burden. However, government and international agency stakeholders did not view the linkage of the surveys to be a fully integrated approach. The lack of full integration produced challenges throughout implementation, such as complex field logistics and duplication in nutrition indicators assessed and reported. Some stakeholders believed integration was not attainable primarily due to timing. The MDHS and MNS were originally designed as stand-alone surveys, and planning for each survey was at an advanced stage once the government sought to integrate the surveys. Additionally, the MNS could not be incorporated as a module within the MDHS given the complexity of the MNS data collection and short timeframe for planning. These findings can inform decisions about implementing the next MNS and may be transferable to other countries that are conducting micronutrient surveys to address data gaps.

Retention in HIV care depends on patients' perceptions of the clinic experience.

Institutional barriers in HIV primary care settings can contribute substantially to disparities in retention in HIV treatment and HIV-related outcomes. This qualitative study compared the perceptions of clinic experiences of persons living with HIV (PLWH) in a Veterans Affairs HIV primary care clinic setting who were retained in care with the experiences of those who were not retained in care. Qualitative data from 25 in-depth interviews were analyzed to identify facilitators and barriers to retention in HIV care. Results showed that participants not retained in care experienced barriers to retention involving dissatisfaction with clinic wait times, low confidence in clinicians, and customer service concerns. For participants retained in care, patience with procedural issues, confidence in clinicians, and interpersonal connections were factors that enhanced retention despite the fact that these participants recognized the same barriers as those who were not retained in care. These findings can inform interventions aimed at improving retention in HIV care.

Pathways to adolescent childbearing among Kaqchikel women in Guatemala.

One-in-five children in Guatemala is born to a mother aged 15-19 years, which poses social, economic and health risks to both mother and child. In Guatemala, adolescent childbearing is directly associated with education, ethnicity and poverty, which increases vulnerability among Indigenous young women living in poverty. This study examines the context and experiences of adolescent childbearing from the perspectives of young mothers in the Kaqchikel Indigenous ethnic group of Sololá, Guatemala. Data were collected in 19 qualitative in-depth interviews with women who had given birth to one or more children when aged 15 to 19 years. Grounded theory and narrative analysis were used to develop a conceptual framework of the process and influences on childbearing. Four distinct pathways were identified, which were influenced by gender expectations, limited communication about sex and stigma around sex. The study identifies key sociocultural influences that lead to adolescent childbearing and reveals variability within these. Identifying distinct pathways to early childbearing and their influences enables a clearer understanding of potential opportunities to interrupt these pathways with culturally relevant policies and programmes, in particular those that promote gender equality and intergenerational communication about sex.

Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough?

Saturation is a core guiding principle to determine sample sizes in qualitative research, yet little methodological research exists on parameters that influence saturation. Our study compared two approaches to assessing saturation: code saturation and meaning saturation. We examined sample sizes needed to reach saturation in each approach, what saturation meant, and how to assess saturation. Examining 25 in-depth interviews, we found that code saturation was reached at nine interviews, whereby the range of thematic issues was identified. However, 16 to 24 interviews were needed to reach meaning saturation where we developed a richly textured understanding of issues. Thus, code saturation may indicate when researchers have "heard it all," but meaning saturation is needed to "understand it all." We used our results to develop parameters that influence saturation, which may be used to estimate sample sizes for qualitative research proposals or to document in publications the grounds on which saturation was achieved.

Bridging the Gaps in Obstetric Care: Perspectives of Service Delivery Providers on Challenges and Core Components of Care in Rural Georgia.

Objectives In 2011, a workforce assessment conducted by the Georgia Maternal and Infant Health Research Group found that 52 % of Primary Care Service Areas outside metropolitan Atlanta, Georgia, had an overburdened or complete lack of obstetric care services. In response to that finding, this study's aim was twofold: to describe challenges faced by providers who currently deliver or formerly delivered obstetric care in these areas, and to identify essential core components that can be integrated into alternative models of care in order to alleviate the burden placed on the remaining obstetric providers. Methods We conducted 46 qualitative in-depth interviews with obstetricians, maternal-fetal medicine specialists, certified nurse midwives, and maternal and infant health leaders in Georgia. Interviews were digitally recorded, transcribed verbatim, uploaded into MAXQDA software, and analyzed using a Grounded Theory Approach. Results Providers faced significant financial barriers in service delivery, including low Medicaid reimbursement, high proportions of self-pay patients, and high cost of medical malpractice insurance. Further challenges in provision of obstetric care in this region were related to patient's late initiation of prenatal care and lacking collaboration between obstetric providers. Essential components of effective models of care included continuity, efficient use of resources, and risk-appropriate services. Conclusion Our analysis revealed core components of improved models of care that are more cost effective and would expand coverage. These components include closer collaboration among stakeholder populations, decentralization of services with effective use of each type of clinical provider, improved continuity of care, and system-wide changes to increase Medicaid benefits.

Working Towards Safe Motherhood: Delays and Barriers to Prenatal Care for Women in Rural and Peri-Urban Areas of Georgia.

Objectives Georgia has the highest rate of maternal mortality in the United States, and ranks 40th for infant mortality. The Georgia Maternal and Infant Health Research Group was formed to investigate and address the shortage of obstetric care providers outside the Atlanta area. Because access to prenatal care (PNC) can improve maternal and infant health outcomes, we used qualitative methods to identify the access barriers experienced by women who live in rural and peri-urban areas of the state. Methods We conducted semi-structured, in-depth interviews with 24 mothers who gave birth between July and August 2013, and who live in either shortage or non-shortage obstetric care service areas. We also conducted key informant interviews with four perinatal case managers, and analyzed all data using applied thematic analysis. We then utilized Thaddeus and Maine's "Three Delays to Care" theoretical framework structure to describe the recognized barriers to care. Results We identified delays in a woman's decision to seek PNC (such as awareness of pregnancy and stigma); delays in accessing an appropriate healthcare facility (such as choosing a doctor and receiving insurance coverage); and delays in receiving adequate and appropriate care (such as continuity of care and communication). Moreover, many participants perceived low self-worth and believed this influenced their PNC exchanges. Conclusion As a means of supporting Georgia's pregnant women who face barriers and delays to PNC, these data provide a rationale for developing contextually relevant solutions to both mothers and their providers.

Pathways That Affect Wives' HIV Risk Among Serodiscordant Couples in India: Results From the Positive Jeevan Saathi Study.

This study examined factors that mitigate or heighten HIV risk among HIV-negative wives in serodiscordant relationships in Gujarat, India. Grounded theory was used to analyze 46 interviews (23 couples) where husbands were HIV-positive and wives were HIV-negative. A conceptual framework emerged from analysis from which we identified five pathways and four key behaviors: (a) safer sex, (b) no sex, (c) coercive sex, and (d) unprotected sex. Most couples either practiced safe sex or abstained from sex. Factors such as wives' assertiveness, a wife's fear of acquiring HIV, mutual understanding, positive sex communication, and a husband's desire to protect wife influenced safe sex/sexual abstinence. Factors such as desire for children, a husband's alcohol use, and intimate partner violence influenced coercive and unprotected sex. Counseling topics on sex communication, verbal and non-verbal safer sex strategies, as well as addressing intimate partner violence and alcohol use may be important in preventing risk to HIV-negative wives.

Individual and interpersonal characteristics that influence male-dominated sexual decision-making and inconsistent condom use among married HIV serodiscordant couples in Gujarat, India: results from the positive Jeevan Saathi study.

Approximately 40 % of new infections occur among married women. No studies have examined the factors that may contribute to HIV transmission among HIV-negative wives in HIV serodiscordant relationships in Gujarat, India. In 2010, a cross-sectional survey with 185 HIV serodiscordant, married couples (i.e. 185 HIV-positive husbands and their 185 HIV-negative wives) in Gujarat was conducted. Socio-demographic, individual, and interpersonal characteristics of HIV-positive husbands and their HIV negative wives were examined. The association of these characteristics with inconsistent condom use and male-dominated sexual decision-making, were examined using multivariate logistic regression analyses. Approximately 10 % of couples reported inconsistent condom use in the past 3 months and 20 % reported intimate partner violence (IPV). Reports of IPV were associated with a higher odds of inconsistent condom use among HIV-positive husbands (aOR = 6.281). Husbands who reported having received couples counseling had a lower odds of male-dominated decision making about condom use (aOR = 0.372). HIV-negative wives who reported sex communication had a lower odds of male-dominated decision making about condom use (aOR = 0.322) with their HIV-positive husbands. Although condom use is a traditional measure of risk behavior, other factors that facilitate risk, such as male-dominated sexual decision-making need to be considered in analyses of risk.

The role of women in water management and conflict resolution in Marsabit, Kenya.

We employed qualitative methods to explore how conflict over water collection and use impacts women, and the role that women play in water management and conflict resolution in Marsabit, Kenya. Conflicts between domestic and livestock water led to insufficient water for domestic use and intra-household conflict. Women's contributions to water management were valued, especially through informal initiatives, though involvement in statutory water management committees was not culturally appropriate. Promoting culturally appropriate ways to involve women in water management, rather than merely increasing the percentage of women on water committee, may reduce conflicts and increase women's access to domestic water supplies.

Quality issues of court reporters and transcriptionists for qualitative research.

Transcription is central to qualitative research, yet few researchers identify the quality of different transcription methods. We explored the quality of verbatim transcripts from traditional transcriptionists and court reporters by reviewing 16 transcripts from 8 focus group discussions using four criteria: transcription errors, cost, time of transcription, and effect on study participants. Transcriptionists made fewer errors, captured colloquial dialogue, and errors were largely influenced by the quality of the recording. Court reporters made more errors, particularly in the omission of topical content and contextual detail, and were less able to produce a verbatim transcript; however, the potential immediacy of the transcript was advantageous. In terms of cost, shorter group discussions favored a transcriptionist and longer groups a court reporter. Study participants reported no effect by either method of recording. Understanding the benefits and limitations of each method of transcription can help researchers select an appropriate method for each study.

Adapting and scaling a proven diabetes prevention program across 11 worksites in India: the INDIA-WORKS trial.

BACKGROUND: Structured lifestyle change education reduces the burden of cardiometabolic diseases such as diabetes. Delivery of these programs at worksites could overcome barriers to program adoption and improve program sustainability and reach; however, tailoring to the worksite setting is essential. METHODS: The Integrating Diabetes Prevention in Workplaces (INDIA-WORKS) study tested the implementation and effectiveness of a multi-level program for reducing cardiometabolic disease risk factors at 11 large and diverse worksites across India. Herein, we describe and classify program adaptations reported during in-depth interviews and focus group discussions with worksite managers, program staff, and peer educators involved in program delivery, and program participants and drop-outs. We used thematic analysis to identify key themes in the data and classified reported program adaptations using the FRAME classification system. RESULTS: Adaptations were led by worksite managers, peer educators, and program staff members. They occurred both pre- and during program implementation and were both planned (proactive) and unplanned (proactive and reactive). The most frequently reported adaptations to the individual-level intervention were curriculum changes to tailor lessons to the local context, make the program more appealing to the workers at the site, or add a wider variety of exercise options. Other content adaptations included improvements to the screening protocol, intervention scheduling, and outreach plans to tailor participant recruitment and retention to the sites. Environment-level content adaptations included expanding or leveraging healthy food and exercise options at the worksites. Challenges to adaptation included scheduling and worksite-level challenges. Participants discussed the need to continue adapting the program in the future to continue making it relevant for worksite settings and engaging for employees. CONCLUSION: This study describes and classifies site-specific modifications to a structured lifestyle change education program with worksite-wide health improvements in India. This adds to the literature on implementation adaptation in general and worksite wellness in India, a country with a large and growing workforce with, or at risk of, serious cardiometabolic diseases. This information is key for program scale-up, dissemination, and implementation in other settings. TRIAL REGISTRATION: Clinicaltrials.gov NCT02813668. Registered June 27, 2016.

Adapting and scaling a proven diabetes prevention program across 11 worksites in India: the INDIA-WORKS trial.

Background: Delivery of proven structured lifestyle change education for reducing the burden of cardiometabolic diseases such as diabetes at worksites could overcome barriers to program adoption and improve sustainability and reach of these programs; however, tailoring to the worksite setting is essential. Methods: The Integrating Diabetes Prevention in Workplaces (INDIA-WORKS) study tested the implementation and effectiveness of a multi-level program for reducing cardiometabolic disease risk factors at eleven large and diverse worksites across India. Herein, we describe and classify program adaptations reported during in-depth interviews and focus group discussions with worksite managers, program staff, peer educators involved in program delivery, and program participants and drop-outs. We used thematic analysis to identify key themes in the data and classified reported program adaptations using the FRAME classification system. Results: Adaptations were led by worksite managers, peer educators, and program staff members. They occurred both pre- and during program implementation and were both planned (proactive) and unplanned (proactive and reactive). The most frequently reported adaptations to the individual-level intervention were curriculum changes to tailor lessons to the local context, make the program more appealing to the workers at the site, or add exercise options. Other content adaptations included improvements to the screening protocol, intervention scheduling, and outreach plans to tailor participant recruitment and retention to the sites. Environment-level content adaptations included expanding or leveraging healthy food and exercise options at the worksites. Challenges to adaptation included scheduling and worksite-level challenges. Participants discussed the need to continue adapting the program in the future to continue making it relevant for worksite settings and engaging for employees. Conclusion: This study describes and classifies site-specific modifications to a structured lifestyle change education program with worksite-wide health improvements in India. This adds to the literature on implementation adaptation in general and worksite wellness in India, a country with a large and growing workforce with, or at risk of, serious cardiometabolic diseases. This information is key for program scale-up, dissemination, and implementation in other settings. Trial Registration: Clinicaltrial.gov NCT02813668, registered June 27, 2016.

A qualitative study of sexual behavior change and risk compensation following adult male circumcision in urban Swaziland.

Male circumcision has been shown to reduce the risk of heterosexual transmission of HIV infection in men by up to 60% in three randomized controlled trials. Less is known, however, about sexual behavior change in men who have been circumcised and whether male circumcision's protective effect leads to riskier sexual behaviors. This study used qualitative in-depth interviews to understand men's sexual behavior after circumcision and to determine whether and how men participated in riskier sexual behaviors following male circumcision. Men in urban Swaziland, circumcised in the previous 12 months, were recruited and asked about their perceptions of sexual risk and sexual behavior post-circumcision. Results showed that following circumcision, men experience changes in both their sexual attitudes and behavior, which can be considered both protective and risky for HIV transmission. Most of them described protective changes (e.g., more responsible attitudes towards safe sex, reducing sexual temptation and partners, easier condom use). A minority, however, experienced increased sexual risk-taking, typically during a brief period of sexual experimentation shortly after circumcision. HIV counseling and counseling throughout the circumcision process is shown to be critical in influencing protective behaviors. Findings in this study confirm the existence of risk compensation following circumcision; however, this study adds important contextual insight about precisely when and why such risk-taking occurs. Nevertheless this study suggests that male circumcision scale-up as an HIV prevention strategy is likely to foster protective behavior change among men. The integration of HIV counseling with circumcision provision remains critical for effectively mitigating HIV risk behavior as male circumcision gains momentum as a viable HIV prevention tool.

Sample sizes for saturation in qualitative research: A systematic review of empirical tests.

OBJECTIVE: To review empirical studies that assess saturation in qualitative research in order to identify sample sizes for saturation, strategies used to assess saturation, and guidance we can draw from these studies. METHODS: We conducted a systematic review of four databases to identify studies empirically assessing sample sizes for saturation in qualitative research, supplemented by searching citing articles and reference lists. RESULTS: We identified 23 articles that used empirical data (n = 17) or statistical modeling (n = 6) to assess saturation. Studies using empirical data reached saturation within a narrow range of interviews (9-17) or focus group discussions (4-8), particularly those with relatively homogenous study populations and narrowly defined objectives. Most studies had a relatively homogenous study population and assessed code saturation; the few outliers (e.g., multi-country research, meta-themes, "code meaning" saturation) needed larger samples for saturation. CONCLUSIONS: Despite varied research topics and approaches to assessing saturation, studies converged on a relatively consistent sample size for saturation for commonly used qualitative research methods. However, these findings apply to certain types of studies (e.g., those with homogenous study populations). These results provide strong empirical guidance on effective sample sizes for qualitative research, which can be used in conjunction with the characteristics of individual studies to estimate an appropriate sample size prior to data collection. This synthesis also provides an important resource for researchers, academic journals, journal reviewers, ethical review boards, and funding agencies to facilitate greater transparency in justifying and reporting sample sizes in qualitative research. Future empirical research is needed to explore how various parameters affect sample sizes for saturation.