Modeling Pathways to Describe How Maternal Health Care Providers' Mental Health Influences the Provision of Respectful Maternity Care in Malawi.

INTRODUCTION: Maternal health (MH) providers may experience traumatic events, such as maternal or fetal death, that can contribute to stress and burnout. Past trauma, poor working relationships, and under-resourced environments not only affect providers' own emotional well-being but also reduce their ability to provide respectful maternity care (RMC). METHODS: Data were collected in mid-2021 as a cross-sectional survey with 302 MH providers working in 25 maternities in 3 districts in Malawi to measure burnout, depression, and post-traumatic stress disorder (PTSD). We present a pathway model describing how these factors interact and influence RMC. We used the provider-reported person-centered maternity care scale to measure RMC; the Maslach Burnout Inventory, which examines emotional exhaustion, depersonalization, and professional accomplishment; and standard validated screening tools to measure the prevalence of depression and PTSD. RESULTS: Although levels of burnout varied, 30% of MH providers reported high levels of exhaustion, feelings of cynicism manifesting as depersonalization toward their clients (17%), and low levels of professional accomplishment (42%). Moderate to severe depression (9%) and suicidal ideation within the past 2 weeks (10%) were also recorded. Many (70%) reported experiencing an event that could trigger PTSD, and 12% reported at least 4 of 5 symptoms in the PTSD scale. Path analysis suggests that depression and emotional exhaustion negatively influence RMC, and depersonalization is mediated through depression. PTSD has no direct effect on RMC, but increased PTSD scores were associated with increased burnout and depression scores. Positive relationships with facility managers were significantly associated with increased RMC and decreased emotional exhaustion and depersonalization. CONCLUSION: Burnout will continue to be a challenge among MH providers. However, pragmatic approaches for improving teamwork, psychosocial, and managerial support for MH providers working in challenging environments may help mitigate burnout, improve MH provider well-being, and, in turn, RMC for women seeking MH services.

Community-based postnatal care services for women and newborns in Kenya: an opportunity to improve quality and access?

BACKGROUND: In resource-constrained settings, Community Health Workers (CHWs) are the first point of contact between communities and the health system, as providers of maternal and newborn health services. However, little is known of the quality of community-based postnatal care (PNC). We assessed the content of PNC provided by CHWs and women's experiences of care in two Kenyan counties. METHODS: We used a cross-sectional, mixed methods design to examine the quality of PNC services provided by CHWs. Trained observers attended PNC home visits to assess technical quality using a 25-item checklist covering four PNC domains: infant health warning signs, maternal health warning signs, essential newborn care, and breastfeeding. The observers completed an 8-item communication quality checklist. We conducted follow-up surveys with observed PNC clients to assess their experiences of care. Finally, we used in-depth interviews with CHWs and focus group discussions with observed PNC clients to understand the experiential quality of care. RESULTS: Observations suggest shortcomings in the technical quality of PNC home visits. CHWs completed an average of 6.4 (standard deviation SD = 4.1) of the 25 PNC technical quality items. CHWs often lacked essential supplies, and only six percent carried all four of the CHW job aids and tools specified in the national guidelines for maternal health at community level. However, CHWs completed an average of 7.3 (SD = 1.1) of the 8 communication quality items, and most PNC clients (88%) reported being satisfied during follow-up interviews. Higher technical quality scores were associated with older mothers, better communication, longer visit duration, and CHWs who carried at least three job tools. CHWs expressed a strong sense of responsibility for care of their clients, while clients underscored how CHWs were trusted to maintain their clients' confidentiality and were a valuable community resource. CONCLUSION: This study identified gaps in the technical quality of CHW PNC practices, while also recognizing positive elements of experiential quality of care, including communication quality, and trusting relationships. This study also demonstrated the strength of the CHWs' role in establishing linkages between the community and facilities, as long as the CHW are perceived as, and enabled to be, an integral part of the PHC network in Kenya.

Effects of the implementation of the HIV Treat All guidelines on key ART treatment outcomes in Namibia.

BACKGROUND: This study aimed to help the Namibian government understand the impact of Treat All implementation (started on April 1, 2017) on key antiretroviral therapy (ART) outcomes, and how this transition impacts progress toward the UNAIDS's 90-90-90 HIV targets. METHODS: We collected clinical records from two separate cohorts (before and after treat-all) of ART patients in 10 high- and medium-volume facilities in 6 northern Namibia districts. Each cohort contains 12-month data on patients' scheduled appointments and visits, health status, and viral load results. We also measured patients' wait time and perceptions of service quality using exit interviews with 300 randomly selected patients (per round). We compared ART outcomes of the two cohorts: ART initiation within 7 days from diagnosis, loss to follow-up (LTFU), missed scheduled appointments for at least 30 days, and viral suppression using unadjusted and adjusted analyses. RESULTS: Among new ART clients (on ART for less than 3 months or had not yet initiated treatment as of the start date for the ART record review period), rapid ART initiation (within 7 days from diagnosis) was 5.2 times higher after Treat All than that among clients assessed before the policy took effect [AOR: 5.2 (3.8-6.9)]. However, LTFU was higher after Treat All roll-out compared to before Treat All [AOR: 1.9 (1.3-2.8)]. Established ART clients (on ART treatment for at least three months at the start date of the ART record review period) had over 3 times greater odds of achieving viral suppression after Treat All roll-out compared to established ART clients assessed before Treat All [AOR: 3.1 (1.6-5.9)]. CONCLUSIONS AND RECOMMENDATIONS: The findings indicate positive effect of the "Treat All" implementation on ART initiation and viral suppression, and negative effect on LTFU. Additionally, by April 2018, Namibia seems to have reached the UNAIDS's 90-90-90 targets.

Pregnancy Experiences of Female Sex Workers in Adama City, Ethiopia: Complexity of Partner Relationships and Pregnancy Intentions.

Research and programs for female sex workers (FSWs) tend to focus exclusively on HIV prevention, with little attention paid to how pregnancy affects their lives. We examine the circumstances surrounding pregnancy and childbirth among women selling sex in Ethiopia. In Adama City, researchers asked 30 FSWs aged 18 and older who had ever been pregnant to participate in in-depth interviews. The women reported on pregnancies experienced both before and after they had begun selling sex. They identified some of the fathers as clients, former partners, and current partners, but they did not know the identities of the other fathers. Missed injections, skipped pills, and inconsistent condom use were causes of unintended pregnancy. Abortion was common, typically with a medication regimen at a facility. Comprehensive sexual and reproductive health services should be provided to women who sell sex, in recognition and support of their need for family planning and their desire to plan whether and when to have children.

Inequitable Gender Norms From Early Adolescence to Young Adulthood in Uganda: Tool Validation and Differences Across Age Groups.

PURPOSE: We aimed to describe and compare gender norms among 10- to 14-year-olds versus 15- to 24-year-olds and to conduct a rigorous evaluation of the GEM Scale's performance among these two age groups. METHODS: We conducted a two-stage cluster-sampled survey among 387 females and 583 males, aged 10-24 years, in rural and urban communities near Kampala, Uganda. We applied, assessed, and adapted the GEM Scale (Pulerwitz and Barker, 2008), which measures views toward gender norms in four domains. We describe levels of support for (in)equitable norms, by gender and age, and associations with key health outcomes (partner violence). Confirmatory factor analysis and multi-group measurement invariance analysis were used to assess scale performance. RESULTS: All participants reported high levels of support for inequitable gender norms; 10- to 14-year-olds were less gender equitable than their older counterparts. For example, 74% of 10- to 14-year-olds and 67% of 15- to 24-year-olds agreed that "a woman should tolerate violence to keep her family together." Comparing responses from males and females indicated similar support for gender inequity. Analyses confirmed a one-factor model, good scale fit for both age groups, and that several items from the scale could be dropped for this sample. The ideal list of items for each age group differed somewhat but covered all four scale domains in either case. An 18-item adapted scale was used to compare mean GEM Scale scores between the two age groups; responses were significantly associated with early sexual debut and partner violence. CONCLUSIONS: Young people internalize gender norms about sexual and intimate relationships, and violence, at early ages. Programs to address negative health outcomes should explicitly address inequitable gender norms and more consistently expand to reach younger age groups. In this first application of the GEM Scale among 10- to 14-year-olds, we confirm that it is a valid measure in this setting.

Increasing Uptake of HIV, Sexually Transmitted Infection, and Family Planning Services, and Reducing HIV-Related Risk Behaviors Among Youth Living With HIV in Uganda.

PURPOSE: To address barriers to care for youth living with HIV (YLHIV), the Link Up project implemented a peer-led intervention model that provided a comprehensive package of HIV and sexual and reproductive health and rights services through community-based peer support groups for YLHIV. Peer educators delivered targeted counseling and health education, and referred YLHIV to antiretroviral therapy (ART), and reproductive health services that were available at youth-oriented sexual and reproductive health and rights facilities. METHODS: At baseline (October to November 2014), 37 peer support groups for YLHIV were established in Luwero and Nakasongola districts. During this same time period, we recruited a cohort of 473 support group members, aged 15-24 years. After a 9-month intervention period (January to September 2015), we completed the end-line survey with 350 members of the original cohort. Multivariate logistic regression analysis applied to longitudinal data was used to assess changes in key outcomes from baseline to end line. RESULTS: Multivariate analyses showed significant increases at end line, compared with baseline, in self-efficacy (adjusted odds ratio [AOR]: 1.8 [1.3-2.6]), comprehensive HIV knowledge [AOR: 1.8 [1.3-2.6]), HIV disclosure (AOR: 1.6 [1.01-2.6]), condom use at last sex (AOR: 1.7 [1.2-2.5]), sexually transmitted infection uptake (AOR: 2.1 [1.5-2.9]), ART uptake (AOR: 2.5 [1.6-4.0]), ART adherence (AOR: 2.5 [1.3-4.9]), CD4 testing (AOR: 2.4 [1.5-3.6]), and current use of a modern contraceptive method (AOR: 1.7 [1.1-2.7]). CONCLUSIONS: Link Up's intervention strategy likely contributed to observed increases in self-efficacy, knowledge of HIV, condom use, HIV disclosure ART utilization and adherence, CD4 testing, STI testing uptake, and use of modern family planning methods. This model shows promise and should be adapted for use among YLHIV in similar settings and evaluated further.

Paying for Sex by Young Men Who Live on the Streets in Dhaka City: Compounded Sexual Risk in a Vulnerable Migrant Community.

PURPOSE: Dhaka City is home to thousands of migrants from Bangladesh's rural areas who often live in the streets. Prior studies examine street youth's practice of selling sex as a survival mechanism. We assess their less-studied practice of paying for sex and its association with sexual risk behaviors and outcomes. METHODS: As part of the global Link Up project, trained interviewers recruited 447 young men who live on the streets, ages 15-24, from seven Dhaka City "hotspots" to participate in a survey about sexual health. Among those who ever had sex, we examined frequencies and conducted bivariate analyses of sociodemographic characteristics by paying for sex status. We then conducted bivariate and multivariate logistic regression analyses of paying for sex in the last 12 months and sexual health behaviors and outcomes. RESULTS: Median participant age was 18 years. Among those who ever had sex (N = 321), 80% reported paying for sex in the last 12 months and 15% reported selling sex in the last 12 months. In multivariate analyses, those who paid for sex had significantly increased odds of reporting sexually transmitted infection-related symptoms in the last six months (adjusted odds ratio = 1.76, 95% confidence interval [CI] = 1.17-2.64) and engaging in unprotected last sex with a nonprimary partner (adjusted odds ratio = 2.19, CI = 1.58-3.03). CONCLUSIONS: The adverse factors associated with paying for sex among young men who live on the streets in Dhaka City highlight the need for programs to educate on HIV/sexually transmitted infection prevention and promote condom use, STI screening/treatment, and HIV testing in this population.

Stigma Reduction Training Improves Healthcare Provider Attitudes Toward, and Experiences of, Young Marginalized People in Bangladesh.

PURPOSE: Working with health providers to reduce HIV stigma in the healthcare setting is an important strategy to improve service utilization and quality of care, especially for young people who are sexually active before marriage, are sexual minorities, or who sell sex. A stigma reduction training program for health providers in Bangladesh was evaluated. METHODS: A cohort of 300 healthcare providers were given a self-administered questionnaire, then attended a 2-day HIV and sexual and reproductive health and rights training (including a 90-minute session on stigma issues). Six months later, the cohort repeated the survey and participated in a 1-day supplemental training on stigma, which included reflection on personal values and negative impacts of stigma. A third survey was administered 6 months later. A cross-sectional survey of clients age 15-24 years was implemented before and after the second stigma training to assess client satisfaction with services. RESULTS: Provider agreement that people living with HIV should be ashamed of themselves decreased substantially (35.3%-19.7%-16.3%; p < .001), as did agreement that sexually active young people (50.3%-36.0%-21.7%; p < .001) and men who have sex with men (49.3%-38.0%-24.0%; p < .001) engage in "immoral behavior." Young clients reported improvement in overall satisfaction with services after the stigma trainings (63.5%-97.6%; p < .001). CONCLUSIONS: This study indicates that a targeted stigma reduction intervention can rapidly improve provider attitudes and increase service satisfaction among young people. More funding to scale up these interventions is needed.