Does Economic Strengthening Improve Viral Suppression Among Adolescents Living with HIV? Results From a Cluster Randomized Trial in Uganda.

To assess the effect of a savings-led economic empowerment intervention on viral suppression among adolescents living with HIV. Using data from Suubi + Adherence, a longitudinal, cluster randomized trial in southern Uganda (2012-2017), we examine the effect of the intervention on HIV RNA viral load, dichotomized between undetectable (< 40 copies/ml) and detectable (≥ 40 copies/ml). Cluster-adjusted comparisons of means and proportions were used to descriptively analyze changes in viral load between study arms while multi-level modelling was used to estimate treatment efficacy after adjusting for fixed and random effects. At 24-months post intervention initiation, the proportion of virally suppressed participants in the intervention cohort increased tenfold (ΔT2-T0 = + 10.0, p = 0.001) relative to the control group (ΔT2-T0 = + 1.1, p = 0.733). In adjusted mixed models, simple main effects tests identified significantly lower odds of intervention adolescents having a detectable viral load at both 12- and 24-months. Interventions addressing economic insecurity have the potential to bolster health outcomes, such as HIV viral suppression, by improving ART adherence among vulnerable adolescents living in low-resource environments. Further research and policy dialogue on the intersections of financial security and HIV treatment are warranted.

Exploring Meaning and Types of Trust in Maternity Care in Peri-Urban Kenya: A Qualitative Cross-Perspective Analysis.

Trust offers a distinctive lens on facility responsiveness during labor and birth. Though acknowledged in prior literature, limited work exists linking conceptual and empirical spheres. This study explores trust in the maternity setting in Kenya through a theoretically driven qualitative approach. Focus groups ( n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews ( n = 33) with WRB, frontline providers, and management, were conducted in and around a peri-urban public hospital. Combined coding and memo-writing showed that trust in maternity care is nested within understandings of institutional and societal trust. Content areas of trust include confidence, communication, integrity, mutual respect, competence, fairness, confidentiality, and systems trust. Trust is relevant, multidimensional, and dynamic. Examining trust provides a basis for developing quantitative measures and reveals structural underpinnings, repercussions for trust in other health areas, and health systems inequities, which have implications for maternal health policy, programming, and service utilization.

Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory.

Urban slum adolescents and young adults have disproportionately high rates of HIV compared to rural and non-slum urban youth. Yet, few studies have examined youth's perceptions of the economic drivers of HIV. Informed by traditional and behavioral economics, we applied a scarcity theoretical framework to qualitatively examine how poverty influences sexual risk behaviors among adolescents and young adults. Focus group discussions with one hundred twenty youth in Kenyan's urban slums were transcribed, coded, and analyzed using interpretive phenomenology. Results indicated that slum youth made many sexual decisions considered rational from a traditional economics perspective, such as acquiring more sex when resources were available, maximizing wealth through sex, being price-sensitive to costs of condoms or testing services, and taking more risks when protected from adverse sexual consequences. Youth's engagement in sexual risk behaviors was also motivated by scarcity phenomena explained by behavioral economics, such as compensating for sex lost during scarce periods (risk-seeking), valuing economic gains over HIV risks (tunneling, bandwidth tax), and transacting sex as an investment strategy (internal referencing). When scarcity was alleviated, young women additionally described reducing the number of sex partners to account for non-economic preferences (slack). Prevention strategies should address the traditional and behavioral economics of the HIV epidemic.

Economic Resources and HIV Preventive Behaviors Among School-Enrolled Young Women in Rural South Africa (HPTN 068).

Individual economic resources may have greater influence on school-enrolled young women's sexual decision-making than household wealth measures. However, few studies have investigated the effects of personal income, employment, and other financial assets on young women's sexual behaviors. Using baseline data from the HIV Prevention Trials Network (HPTN) 068 study, we examined the association of ever having sex and adopting sexually-protective practices with individual-level economic resources among school-enrolled women, aged 13-20 years (n = 2533). Age-adjusted results showed that among all women employment was associated with ever having sex (OR 1.56, 95 % CI 1.28-1.90). Among sexually-experienced women, paid work was associated with changes in partner selection practices (OR 2.38, 95 % CI 1.58-3.58) and periodic sexual abstinence to avoid HIV (OR 1.71, 95 % CI 1.07-2.75). Having money to spend on oneself was associated with reducing the number of sexual partners (OR 1.94, 95 % CI 1.08-3.46), discussing HIV testing (OR 2.15, 95 % CI 1.13-4.06), and discussing condom use (OR 1.99, 95 % CI 1.04-3.80). Having a bank account was associated with condom use (OR 1.49, 95 % CI 1.01-2.19). Economic hardship was positively associated with ever having sex, but not with sexually-protective behaviors. Maximizing women's individual economic resources may complement future prevention initiatives.

Association of Household Savings and Expected Future Means with Delivery Using a Skilled Birth Attendant in Ghana and Nigeria: A Cross-Sectional Analysis.

Objectives This study examined the association between household savings and related economic measures with utilization of skilled birth attendants (SBAs) at last birth among women living in peri-urban households (n = 381) in Ghana and Nigeria. Methods Data were drawn from the 2011-2014 Family Health and Wealth Study. Multivariable logistic regression models were used to estimate the odds of delivery with an SBA for individual and composite measures of household savings, expected financial means, debt, lending, and receipt of financial assistance, adjusting for demographic and reproductive characteristics. Results Seventy-three percent (73 %) of women delivered with an SBA during their last birth (89 %, Ghana; 63 %, Nigeria), and roughly one third (34 %) of households reported having any in-cash or in-kind savings. In adjusted analyses, women living in households with savings were significantly more likely to deliver with an SBA compared to women in households without any savings (aOR = 2.02, 95 % CI 1.09-3.73). There was also a consistent downward trend, although non-significant, in SBA utilization with worsening financial expectations in the coming year (somewhat vs. much better: aOR = 0.70, 95 % CI 0.40-1.22 and no change/worse vs. much better: aOR = 0.46, 95 % CI 0.12-1.83). Findings were null for measures relating to debt, lending, and financial assistance. Conclusion Coupling birth preparedness and complication readiness strategies with savings-led initiatives may improve SBA utilization in conjunction with targeting non-economic barriers to skilled care use.

Mobile Technology for Community Health in Ghana: what happens when technical functionality threatens the effectiveness of digital health programs?

BACKGROUND: Despite the growing use of technology in the health sector, little evidence is available on the technological performance of mobile health programs nor on the willingness of target users to utilize these technologies as intended (behavioral performance). In this case study of the Mobile Technology for Health (MOTECH) program in Ghana, we assess the platform's effectiveness in delivering messages, along with user response across sites in five districts from 2011 to 2014. METHODS: MOTECH is comprised of "Client Data Application" (CDA) which allows providers to digitize and track service delivery information for women and infants and "Mobile Midwife" (MM) which sends automated educational voice messages to the mobile phones of pregnant and postpartum women. Using a naturalist study design, we draw upon system generated data to evaluate message delivery, client engagement, and provider responsiveness to MOTECH over time and by level of facility. RESULTS: A total of 7,370 women were enrolled in MM during pregnancy and 14,867 women were enrolled postpa1rtum. While providers were able to register and upload patient-level health information using CDA, the majority of these uploads occurred in Community-based facilities versus Health Centers. For MM, 25% or less of expected messages were received by pregnant women, despite the majority (>77%) owning a private mobile phone. While over 80% of messages received by pregnant women were listened to, postpartum rates of listening declined over time. Only 25% of pregnant women received and listened to at least 1 first trimester message. By 6-12 months postpartum, less than 6% of enrolled women were exposed to at least one message. CONCLUSIONS: Caution should be exercised in assuming that digital health programs perform as intended. Evaluations should measure the technological, behavioral, health systems, and/or community factors which may lead to breaks in the impact pathway and influence findings on effectiveness. The MOTECH platform's technological limitations in 'pushing' out voice messages highlights the need for more timely use of data to mitigate delivery challenges and improve exposure to health information. Alternative message delivery channels (USSD or SMS) could improve the platform's ability to deliver messages but may not be appropriate for illiterate users. TRIAL REGISTRATION: Not applicable.

Effect of savings-led economic empowerment on HIV preventive practices among orphaned adolescents in rural Uganda: results from the Suubi-Maka randomized experiment.

Improving economic resources of impoverished youth may alter intentions to engage in sexual risk behaviors by motivating positive future planning to avoid HIV risk and by altering economic contexts contributing to HIV risk. Yet, few studies have examined the effect of economic-strengthening on economic and sexual behaviors of orphaned youth, despite high poverty and high HIV infection in this population. Hierarchal longitudinal regressions were used to examine the effect of a savings-led economic empowerment intervention, the Suubi-Maka Project, on changes in orphaned adolescents' cash savings and attitudes toward savings and HIV-preventive practices over time. We randomized 346 Ugandan adolescents, aged 10-17 years, to either the control group receiving usual orphan care plus mentoring (n = 167) or the intervention group receiving usual orphan care plus mentoring, financial education, and matched savings accounts (n = 179). Assessments were conducted at baseline, 12, and 24 months. Results indicated that intervention adolescents significantly increased their cash savings over time (b = $US12.32, ±1.12, p < .001) compared to adolescents in the control group. At 24 months post-baseline, 92% of intervention adolescents had accumulated savings compared to 43% in the control group (p < .001). The largest changes in savings goals were the proportion of intervention adolescents valuing saving for money to buy a home (ΔT1-T0 = +14.9, p < .001), pursue vocational training (ΔT1-T0 = +8.8, p < .01), and start a business (T1-T0 = +6.7, p < .01). Intervention adolescents also had a significant relative increase over time in HIV-preventive attitudinal scores (b = +0.19, ±0.09, p < .05), most commonly toward perceived risk of HIV (95.8%, n = 159), sexual abstinence or postponement (91.6%, n = 152), and consistent condom use (93.4%, n = 144). In addition, intervention adolescents had 2.017 significantly greater odds of a maximum HIV-prevention score (OR = 2.017, 95%CI: 1.43-2.84). To minimize HIV risk throughout the adolescent and young adult periods, long-term strategies are needed to integrate youth economic development, including savings and income generation, with age-appropriate combination prevention interventions.

Equity in adherence to antiretroviral therapy among economically vulnerable adolescents living with HIV in Uganda.

Studies from sub-Saharan Africa indicate that children made vulnerable by poverty have been disproportionately affected by HIV with many exposed via mother-to-child transmission. For youth living with HIV, adherence to life-saving treatment regimens are likely to be affected by the complex set of economic and social circumstances that challenge their families and also exacerbate health problems. Using baseline data from the National Institute of Child and Human Development (NICHD) funded Suubi+Adherence study, we examined the extent to which individual and composite measures of equity predict self-reported adherence among Ugandan adolescents aged 10-16 (n = 702) living with HIV. Results showed that greater asset ownership, specifically familial possession of seven or more tangible assets, was associated with greater odds of self-reported adherence (OR 1.69, 95% CI: 1.00-2.85). Our analyses also indicated that distance to the nearest health clinic impacts youth's adherence to an ARV regimen. Youth who reported living nearest to a clinic were significantly more likely to report optimal adherence (OR 1.49, 95% CI: 0.92-2.40). Moreover, applying the composite equity scores, we found that adolescents with greater economic advantage in ownership of household assets, financial savings, and caregiver employment had higher odds of adherence by a factor of 1.70 (95% CI: 1.07-2.70). These findings suggest that interventions addressing economic and social inequities may be beneficial to increase antiretroviral therapy (ART) uptake among economically vulnerable youth, especially in sub-Saharan Africa. This is one of the first studies to address the question of equity in adherence to ART among economically vulnerable youth with HIV.

U.S. Minority Homeless Youth's Access to and Use of Mobile Phones: Implications for mHealth Intervention Design.

Few interventions for homeless youth have leveraged the potential of mHealth technologies, in part because of the limited data on phone behaviors, perceptions, and intervention preferences among youth experiencing homelessness. We conducted 9 focus groups (n = 52 homeless youth) and 41 individual structured interviews also with homeless youth in underserved communities in Baltimore and Washington, DC, to ascertain how youth perceived their mobile phone, acquired and maintained mobile services over time, and thought mHealth programs for this population should be designed. We also measured phone use, functionality, source, duration of ownership, and reasons for changing phones or numbers. Results showed that mobile coverage was high, as most youth self-purchased phones or received gift payments from others. Maintaining mobile connectivity was often challenging because of financial constraints and interpersonal conflict. Youth valued phones to access social support but used several tactics to avoid perceived negative consequences of phone ownership, such as harassment, theft, or relational disputes. Youth most preferred mHealth content relating to sexual, reproductive, and mental health provided that mobile communication was confidential, empowering, and integrated with other digital media. Integrating hidden phones, financial support, and safety management may improve homeless youth's access to and engagement with mHealth strategies over time.

Prevalence and correlates of knowledge of male partner HIV testing and serostatus among African-American women living in high poverty, high HIV prevalence communities (HPTN 064).

Knowledge of sexual partners' HIV infection can reduce risky sexual behaviors. Yet, there are no published studies to-date examining prevalence and characteristics associated with knowledge among African-American women living in high poverty communities disproportionately affected by HIV. Using the HIV Prevention Trial Network's (HPTN) 064 Study data, multivariable logistic regression was used to examine individual, partner, and partnership-level determinants of women's knowledge (n = 1,768 women). Results showed that women's demographic characteristics alone did not account for the variation in serostatus awareness. Rather, lower knowledge of partner serostatus was associated with having two or more sex partners (OR = 0.49, 95 % CI 0.37-0.65), food insecurity (OR = 0.68, 95 % CI 0.49-0.94), partner age >35 years (OR = 0.68, 95 % CI 0.49-0.94), and partner concurrency (OR = 0.63, 95 % CI 0.49-0.83). Access to financial support (OR = 1.42, 95 % CI 1.05-1.92) and coresidence (OR = 1.43, 95 % CI 1.05-1.95) were associated with higher knowledge of partner serostatus. HIV prevention efforts addressing African-American women's vulnerabilities should employ integrated behavioral, economic, and empowerment approaches.

Association between women's empowerment and infant and child feeding practices in sub-Saharan Africa: an analysis of Demographic and Health Surveys.

OBJECTIVE: To explore the relationship between women's empowerment and WHO recommended infant and young child feeding (IYCF) practices in sub-Saharan Africa. DESIGN: Analysis was conducted using data from ten Demographic and Health Surveys between 2010 and 2013. Women's empowerment was assessed by nine standard items covering three dimensions: economic, socio-familial and legal empowerment. Three core IYCF practices examined were minimum dietary diversity, minimum meal frequency and minimum acceptable diet. Separate multivariable logistic regression models were applied for the IYCF practices on dimensional and overall empowerment in each country. SETTING: Benin, Burkina Faso, Ethiopia, Mali, Niger, Nigeria, Rwanda, Sierra Leone, Uganda and Zimbabwe. SUBJECTS: Youngest singleton children aged 6-23 months and their mothers (n 15 153). RESULTS: Less than 35 %, 60 % and 18 % of children 6-23 months of age met the criterion of minimum dietary diversity, minimum meal frequency and minimum acceptable diet, respectively. In general, likelihood of meeting the recommended IYCF criteria was positively associated with the economic dimension of women's empowerment. Socio-familial empowerment was negatively associated with the three feeding criteria, except in Zimbabwe. The legal dimension of empowerment did not show any clear pattern in the associations. Greater overall empowerment of women was consistently and positively associated with multiple IYCF practices in Mali, Rwanda and Sierra Leone. However, consistent negative relationships were found in Benin and Niger. Null or mixed results were observed in the remaining countries. CONCLUSIONS: The importance of women's empowerment for IYCF practices needs to be discussed by context and by dimension of empowerment.

Impact of Male Partner Antenatal Accompaniment on Perinatal Health Outcomes in Developing Countries: A Systematic Literature Review.

Encouraging male partners to accompany women to antenatal care (ANC) is an important first step in engaging men on maternal and newborn health. However, little is known regarding the impact of male partner antenatal accompaniment beyond HIV-related perinatal outcomes. A systematic review was conducted to synthesize the evidence on the influence of male accompaniment on non-HIV outcomes during pregnancy and into the postpartum period. Eligible studies were published in English from 2003 to 2013 and evaluated the effect of male antenatal accompaniment on perinatal health in a developing country. Four electronic databases and selected reference lists were searched. Out of 84 potential citations retrieved, seven publications were retained for the assessment of male antenatal accompaniment's influence using iterative thematic analysis. During pregnancy, male antenatal accompaniment positively impacted women's knowledge of danger signs, but did not affect birth preparedness, ANC utilization, or miscarriages. During labor and delivery, men's ANC presence was associated with increases in institutional delivery and skilled birth attendance, but with no effect for birth-related outcomes. During the early postnatal period, male antenatal accompaniment was associated with higher uptake of postnatal services, but with mixed effects on breastfeeding and newborn survival. Couples' increased communication on pregnancy care and men's subsequent motivation to ensure safe delivery may explain these observed benefits. Inadequate communication, late accompaniment, or partner type may explain the lack of influence on some outcomes. More efforts are needed to expand the implementation and evaluation of male involvement strategies to improve perinatal health.

Do men need empowering too? A systematic review of entrepreneurial education and microenterprise development on health disparities among inner-city black male youth.

Economic strengthening through entrepreneurial and microenterprise development has been shown to mitigate poverty-based health disparities in developing countries. Yet, little is known regarding the impact of similar approaches on disadvantaged U.S. populations, particularly inner-city African-American male youth disproportionately affected by poverty, unemployment, and adverse health outcomes. A systematic literature review was conducted to guide programming and research in this area. Eligible studies were those published in English from 2003 to 2014 which evaluated an entrepreneurial and microenterprise initiative targeting inner-city youth, aged 15 to 24, and which did not exclude male participants. Peer-reviewed publications were identified from two electronic bibliographic databases. A manual search was conducted among web-based gray literature and registered trials not yet published. Among the 26 papers retrieved for review, six met the inclusion criteria and were retained for analysis. None of the 16 registered microenterprise trials were being conducted among disadvantaged populations in the U.S. The available literature suggests that entrepreneurial and microenterprise programs can positively impact youth's economic and psychosocial functioning and result in healthier decision-making. Young black men specifically benefited from increased autonomy, engagement, and risk avoidance. However, such programs are vastly underutilized among U.S. minority youth, and the current evidence is insufficiently descriptive or rigorous to draw definitive conclusions. Many programs described challenges in securing adequate resources, recruiting minority male youth, and sustaining community buy-in. There is an urgent need to increase implementation and evaluation efforts, using innovative and rigorous designs, to improve the low status of greater numbers of African-American male youth.

Women's empowerment and male involvement in antenatal care: analyses of Demographic and Health Surveys (DHS) in selected African countries.

BACKGROUND: Increasing women's status and male involvement are important strategies in reducing preventable maternal morbidity and mortality. While efforts to both empower women and engage men in maternal health care-seeking can work synergistically, in practice they may result in opposing processes and outcomes. This study examines whether a woman's empowerment status, in sum and across economic, socio-familial, and legal dimensions, is associated with male partner accompaniment to antenatal care (ANC). METHODS: Women's empowerment was measured based on the sum of nine empowerment items in the 2010-2011 Demographic and Health Surveys in eight sub-Saharan African countries: Burkina Faso (n = 2,490), Burundi (n = 1,042), Malawi (n = 1,353), Mozambique (n = 414), Rwanda (n = 1,211), Senegal (n = 505), Uganda (n = 428) and Zimbabwe (n = 459). In cross-sectional analyses, bivariate and multivariable logistic regressions models were used to examine the odds of male partner accompaniment to ANC between women with above-average versus below-average composite and dimensional empowerment scores. RESULTS: In the majority of countries, male accompaniment to ANC was not uncommon. However, findings were mixed. Positive associations in women's composite empowerment and male involvement were observed in Burkina Faso (OR = 1.27, 95% CI: 1.08, 1.50) and Uganda (OR = 1.53, 95% CI: 1.00-2.35), and in the economic empowerment dimension in Burkina Faso (OR = 1.24, 95% CI: 1.05-1.47). In Malawi, significant negative associations were observed in the odds of male accompaniment to ANC and women's composite (OR = 0.77, 95% CI: 0.62-0.97) and economic empowerment scores (OR = 0.75, 95% CI: 0.59-0.94). No significant differences were observed in Burundi, Mozambique, Rwanda, Senegal, or Zimbabwe. CONCLUSION: Women's empowerment can be positively or negatively associated with male antenatal accompaniment. Male involvement efforts may benefit from empowerment initiatives that promote women's participation in social and economic spheres, provided that antenatal participation does not undermine women's preferences or autonomy. The observation of mixed and null findings suggests that additional qualitative and longitudinal research may enhance understanding of women's empowerment in sub-Saharan African settings.

Barriers to male involvement in contraceptive uptake and reproductive health services: a qualitative study of men and women's perceptions in two rural districts in Uganda.

BACKGROUND: Spousal communication can improve family planning use and continuation. Yet, in countries with high fertility rates and unmet need, men have often been regarded as unsupportive of their partner's use of family planning methods. This study examines men and women's perceptions regarding obstacles to men's support and uptake of modern contraceptives. METHODS: A qualitative study using 18 focus group discussions (FGDs) with purposively selected men aged 15-54 and women aged 15-49 as well as eight key informant interviews (KIIs) with government and community leaders was conducted in 2012 in Bugiri and Mpigi Districts, Uganda. Open-ended question guides were used to explore men and women's perceptions regarding barriers to men's involvement in reproductive health. All FGDs and KIIs were recorded, translated, and transcribed verbatim. Transcripts were coded and analyzed thematically using ATLAS.ti. RESULTS: Five themes were identified as rationale for men's limited involvement: (i) perceived side effects of female contraceptive methods which disrupt sexual activity, (ii) limited choices of available male contraceptives, including fear and concerns relating to vasectomy, (iii) perceptions that reproductive health was a woman's domain due to gender norms and traditional family planning communication geared towards women, (iv) preference for large family sizes which are uninhibited by prolonged birth spacing; and (v) concerns that women's use of contraceptives will lead to extramarital sexual relations. In general, knowledge of effective contraceptive methods was high. However, lack of time and overall limited awareness regarding the specific role of men in reproductive health was also thought to deter men's meaningful involvement in issues related to fertility regulation. CONCLUSION: Decision-making on contraceptive use is the shared responsibility of men and women. Effective development and implementation of male-involvement family planning initiatives should address barriers to men's supportive participation in reproductive health, including addressing men's negative beliefs regarding contraceptive services.

Influence of mHealth interventions on gender relations in developing countries: a systematic literature review.

INTRODUCTION: Research has shown that mHealth initiatives, or health programs enhanced by mobile phone technologies, can foster women's empowerment. Yet, there is growing concern that mobile-based programs geared towards women may exacerbate gender inequalities. METHODS: A systematic literature review was conducted to examine the empirical evidence of changes in men and women's interactions as a result of mHealth interventions. To be eligible, studies had to have been published in English from 2002 to 2012, conducted in a developing country, included an evaluation of a mobile health intervention, and presented findings on resultant dynamics between women and men. The search strategy comprised four electronic bibliographic databases in addition to a manual review of the reference lists of relevant articles and a review of organizational websites and journals with recent mHealth publications. The methodological rigor of selected studies was appraised by two independent reviewers who also abstracted data on the study's characteristics. Iterative thematic analyses were used to synthesize findings relating to gender-transformative and non-transformative experiences. RESULTS: Out of the 173 articles retrieved for review, seven articles met the inclusion criteria and were retained in the final analysis. Most mHealth interventions were SMS-based and conducted in sub-Saharan Africa on topics relating to HIV/AIDS, sexual and reproductive health, health-based microenterprise, and non-communicable diseases. Several methodological limitations were identified among eligible quantitative and qualitative studies. The current literature suggests that mobile phone programs can influence gender relations in meaningfully positive ways by providing new modes for couple's health communication and cooperation and by enabling greater male participation in health areas typically targeted towards women. MHealth initiatives also increased women's decision-making, social status, and access to health resources. However, programmatic experiences by design may inadvertently reinforce the digital divide, and perpetuate existing gender-based power imbalances. Domestic disputes and lack of spousal approval additionally hampered women's participation. CONCLUSION: Efforts to scale-up health interventions enhanced by mobile technologies should consider the implementation and evaluation imperative of ensuring that mHealth programs transform rather than reinforce gender inequalities. The evidence base on the effect of mHealth interventions on gender relations is weak, and rigorous research is urgently needed.

Exploring the use of mobile phone technology for the enhancement of the prevention of mother-to-child transmission of HIV program in Nyanza, Kenya: a qualitative study.

BACKGROUND: Community-based mobile phone programs can complement gaps in clinical services for prevention of mother-to-child transmission (PMTCT) of HIV in areas with poor infrastructure and personnel shortages. However, community and health worker perceptions on optimal mobile phone communication for PMTCT are underexplored. This study examined what specific content and forms of mobile communication are acceptable to support PMTCT. METHODS: Qualitative methods using focus groups and in-depth interviews were conducted in two district hospitals in Nyanza Province, Kenya. A total of 45 participants were purposefully selected, including HIV-positive women enrolled in PMTCT, their male partners, community health workers, and nurses. Semi-structured discussion guides were used to elicit participants' current mobile phone uses for PMTCT and their perceived benefits and challenges. We also examined participants' views on platform design and gender-tailored short message service (SMS) messages designed to improve PMTCT communication and male involvement. RESULTS: Most participants had access to a mobile phone and prior experience receiving and sending SMS, although phone sharing was common among couples. Mobile phones were used for several health-related purposes, primarily as voice calls rather than texts. The perceived benefits of mobile phones for PMTCT included linking with health workers, protecting confidentiality, and receiving information and reminders. Men and women considered the gender-tailored SMS as a catalyst for improving PMTCT male involvement and couples' communication. However, informative messaging relayed safely to the intended recipient was critical. In addition, health workers emphasized the continual need for in-person counseling coupled with, rather than replaced by, mobile phone reinforcement. For all participants, integrated and neutral text messaging provided antenatally and postnatally was most preferred, although not all topics or text formats were equally acceptable. CONCLUSIONS: Given the ubiquity of mobile phones in Kenya and current health-related uses of mobile phones, a PMTCT mobile communications platform holds considerable potential. This pre-intervention assessment of community and health worker preferences yielded valuable information on the complexities of design and implementation. An effective PMTCT mobile platform engaging men and women will need to address contexts of non-disclosure, phone sharing, and linkages with existing community and facility-based services.

Antenatal counseling in maternal and newborn care: use of job aids to improve health worker performance and maternal understanding in Benin.

BACKGROUND: Antenatal care provides an important opportunity to improve maternal understanding of care during and after pregnancy. Yet, studies suggest that communication is often insufficient. This research examined the effect of a job aids-focused intervention on quality of counseling and maternal understanding of care for mothers and newborns. METHODS: Counseling job aids were developed to support provider communication to pregnant women. Fourteen health facilities were randomized to control or intervention, where providers were trained to use job aids and provided implementation support. Direct observation of antenatal counseling sessions and patient exit interviews were undertaken to assess quality of counseling and maternal knowledge. Providers were also interviewed regarding their perceptions of the tools. Data were collected before and after the job aids intervention and analyzed using a difference-in-differences analysis to quantify relative changes over time. RESULTS: Mean percent of recommended messages provided to pregnant women significantly improved in the intervention arm as compared to the control arm in birth preparedness (difference-in-differences [ΔI-C] = +17.9, 95%CI: 6.7,29.1), danger sign recognition (ΔI-C = +26.0, 95%CI: 14.6,37.4), clean delivery (ΔI-C = +21.7, 95%CI: 10.9,32.6), and newborn care (ΔI-C = +26.2, 95%CI: 13.5,38.9). Significant gains were also observed in the mean percent of communication techniques applied (ΔI-C = +28.8, 95%CI: 22.5,35.2) and duration (minutes) of antenatal consultations (ΔI-C = +5.9, 95%CI: 3.0,8.8). No relative increase was found for messages relating to general prenatal care (ΔI-C = +8.2, 95%CI: -2.6,19.1). The proportion of pregnant women with correct knowledge also significantly improved for birth preparedness (ΔI-C = +23.6, 95%CI: 9.8,37.4), danger sign recognition (ΔI-C = +28.7, 95%CI: 14.2,43.2), and clean delivery (ΔI-C = +31.1, 95%CI: 19.4,42.9). There were no significant changes in maternal knowledge of general prenatal (ΔI-C = -6.4, 95%CI: -21.3,8.5) or newborn care (ΔI-C = +12.7, 95%CI: -6.1,31.5). Job aids were positively perceived by providers and pregnant women, although time constraints remained for health workers with other clinical responsibilities. CONCLUSIONS: This study demonstrates that a job aids-focused intervention can be integrated into routine antenatal care with positive outcomes on provider communication and maternal knowledge. Efforts are needed to address time constraints and other communication barriers, including introduction of on-going quality assessment for long-term sustainability.

Factors affecting recruitment and retention of community health workers in a newborn care intervention in Bangladesh.

BACKGROUND: Well-trained and highly motivated community health workers (CHWs) are critical for delivery of many community-based newborn care interventions. High rates of CHW attrition undermine programme effectiveness and potential for implementation at scale. We investigated reasons for high rates of CHW attrition in Sylhet District in north-eastern Bangladesh. METHODS: Sixty-nine semi-structured questionnaires were administered to CHWs currently working with the project, as well as to those who had left. Process documentation was also carried out to identify project strengths and weaknesses, which included in-depth interviews, focus group discussions, review of project records (i.e. recruitment and resignation), and informal discussion with key project personnel. RESULTS: Motivation for becoming a CHW appeared to stem primarily from the desire for self-development, to improve community health, and for utilization of free time. The most common factors cited for continuing as a CHW were financial incentive, feeling needed by the community, and the value of the CHW position in securing future career advancement. Factors contributing to attrition included heavy workload, night visits, working outside of one's home area, familial opposition and dissatisfaction with pay. CONCLUSIONS: The framework presented illustrates the decision making process women go through when deciding to become, or continue as, a CHW. Factors such as job satisfaction, community valuation of CHW work, and fulfilment of pre-hire expectations all need to be addressed systematically by programs to reduce rates of CHW attrition.

Behavioral Economics Incentives to Support HIV Treatment Adherence (BEST): Protocol for a randomized controlled trial in Uganda.

BACKGROUND: Many HIV-positive patients do not appropriately adhere to their antiretroviral medication (ART). This leads to higher viral loads and greater probability of HIV transmission. Present bias-a tendency to give in to short-term temptations at the expense of long-term outcomes-is a potential driver of low adherence. In this study we test a novel intervention rooted in behavioral economics that is designed to overcome present bias and increase ART adherence. METHODS/DESIGN: We will enroll 330 HIV-positive patients at Mildmay Hospital in Kampala, Uganda, into a 2-year randomized controlled trial. Participants will be randomized to one of three groups. The first intervention group (T1, n = 110) will be eligible for small lottery prizes based on timely clinic visits and demonstration of viral suppression. Group 2 (T2, n = 110) will be eligible for the same lottery prizes conditional on high adherence measured by a medication event management system (MEMS) cap. The control group (n = 110) will receive the usual standard of care. Adherence will be measured continuously throughout the intervention period and for 12 months post-intervention to evaluate effect persistence. Surveys will be conducted at baseline and then every 6 months. Viral loads will be measured annually. Primary outcomes are whether the viral load is detectable and MEMS-measured adherence. Secondary outcomes are the log-transformed viral load as a continuous measure and a binary measure for whether the person took at least 90% of their ART pills. DISCUSSION: Our study is one of the first to investigate the effectiveness of lottery incentives for improving ART adherence, and in addition, it compares the relative efficacy of using electronically measured adherence versus viral load to determine lottery eligibility. MEMS caps are relatively costly, whereas viral load testing is now part of routine clinical care in Uganda. BEST will test whether directly incentivizing viral suppression (which can be implemented using readily available clinic data) is as effective as incentivizing electronically measured adherence. Cost-effectiveness analyses of the two implementation modes will also be performed. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03494777. Registered on 11 April 2018.