Impact of approval of home use of misoprostol in England on access to medical abortion: An interrupted time series analysis.

OBJECTIVE: In 2018, the Department of Health and Social Care in England approved the use of misoprostol at home for early medical abortions, following administration of mifepristone at clinic. The objective of the present study was to assess the impact of the approval of home administration of misoprostol in England on access to medical abortion, assessed through proxy measures of the proportion of all abortions that were medical and gestational age. METHODS: This study uses the clinical data from the British Pregnancy Advisory Service on abortions in England in years 2018-2019, containing demographic and procedure characteristics of patients. We conducted an interrupted time series analysis to establish the differences before and after the approval in access to medical abortion, measured by the proportion of all abortions that were medical, and gestational age. The analysis also examined whether these changes were equitable, with focus on area-level deprivation. RESULTS: The analysis of the data (145 529 abortions) suggested that there was an increase in the proportion of medical abortions and decrease in gestational age of abortions after the approval. Compared with the situation if former trends had continued, the actual proportion of early medical abortions was 4.2% higher in December 2019, and the mean gestational age 3.4 days lower. We found that the acceleration of existing trends in increase in proportion of medical abortions and decrease in gestational age were larger in the most deprived quintiles and in those reporting a disability, but not equal across ethnic groups, with Black and Black British women experiencing little change in trajectories post-approval. CONCLUSION: The approval of home use of misoprostol as part of an early medical abortion regimen in England was associated with material and equitable improvements in abortion access. Pre-approval trends toward greater uptake of medical abortion and declining gestational age were accelerated post-approval and were greatest in the most deprived areas of England, but not across all racial/ethnic groups. The present findings strongly support the continuation or introduction of home management of medical abortions.

Establishing the health and wellbeing needs of mining host community in Brazil, Chile and Peru: a mixed-method approach to identify priority areas for action to help communities meet their SDG3 targets.

BACKGROUND: The global mining industry is an important partner in advancing the 2030 Agenda for Sustainable Development. In 2018, Anglo American plc published their Sustainable Mining Plan, containing a goal for improving health and wellbeing aligned with the Sustainable Development Goal 3 (SDG3) targets. Having formed an independent multidisciplinary research consortium, we designed and implemented a mixed-methods approach to attain a deeper understanding of SDG3 priorities within the local context of communities hosting Anglo American mining operations located in Latin America. METHODS: In 2019, within the host communities of three mining operations in Chile, three in Brazil, and one in Peru, we conducted a qualitative study which included stakeholder workshops and key informant interviews. We also quantitatively appraised existing health data. Findings emerging from the qualitative and quantitative assessments were compared to identify health and wellbeing priority areas for action relevant to each community. RESULTS: Across the three countries, 120 people took part in workshops and 35 in interviews. In these workshops and interviews, non-communicable diseases (SDG3.4), harmful alcohol consumption (SDG3.5), and pollution, particularly air pollution (SDG3.9), were consistently identified as areas for priority action. There were similarities in the reporting of individual, interpersonal, community, societal, and structural factors underlying these priority areas across the different communities. The availability of quantitative data was generally good at the state level, becoming increasing sparse as we focused on smaller geographies. The priorities identified in the quantitative assessments generally aligned with those highlighted in the qualitative data. CONCLUSIONS: We highlight the importance of engaging with local populations to understand and address health needs. To address the priorities identified, intervention packages tailored to the specific needs of host communities, that tackle associated upstream societal level factors, are required. To facilitate this, appropriate monitoring systems and epidemiological investigations should be implemented to better understand the local context and quantify health issues. In the host communities, it is essential for the mining sector to be a key health partner in promoting integrated programmes that contribute to achieving the priority objectives and targets aligned with the SDG3 agenda.

The social determinants of national tuberculosis incidence rates in 116 countries: a longitudinal ecological study between 2005-2015.

BACKGROUND: Accelerating declines in tuberculosis (TB) incidence is paramount for achieving global goals set for 2030 by the Sustainable Development Goals and the End TB Strategy. The aim of this study was to identify key country-level social determinants of national TB incidence trends. METHODS: This longitudinal ecological study used country-level data extracted from online databases from the period 2005-2015. We used multivariable Poisson regression models allowing for distinct within- and between-country effects to estimate associations between national TB incidence rates and 13 social determinants of health. The analysis was stratified by country income status. RESULTS: The study sample included 48 low- and lower-middle-income countries (LLMICs) and 68 high- and upper-middle income countries (HUMICs), with a total of 528 and 748 observations between 2005-2015, respectively. National TB incidence rates declined in 108/116 countries between 2005-2015, with an average drop of 12.95% in LLMICs and 14.09% in HUMICs. Between LLMICs, higher Human Development Index (HDI), social protection spending, TB case detection, and TB treatment success were associated with lower TB incidence. Higher prevalence of HIV/AIDS was associated with higher TB incidence. Within LLMICs, increases in HDI over time were associated with lower TB incidence rates. Between HUMICs, higher HDI, health spending, and diabetes prevalence were associated with lower TB incidence, whereas higher prevalence of HIV/AIDS and alcohol-use were associated with higher TB incidence. Within HUMICs, increases in HIV/AIDS and diabetes prevalence over time were associated with higher TB incidence. CONCLUSIONS: In LLMICs, TB incidence rates remain highest in countries with low human development, social protection spending and TB programme performance, and high rates of HIV/AIDS. Strengthening human development is likely to accelerate declines in TB incidence. In HUMICs, TB incidence rates remain highest in countries with low human development, health spending and diabetes prevalence, and high rates of HIV/AIDS and alcohol use. Here, slowing rising rates of HIV/AIDS and diabetes is likely to accelerate declines in TB incidence.

A mixed-methods, exploratory, quasi-experimental evaluation of a radio drama intervention to prevent age-disparate transactional sex in Tanzania.

Introduction: Age-disparate transactional sex (ADTS) is associated with HIV, unintended pregnancy, school dropout and violence, yet few interventions have successfully prevented it, and none have set ADTS prevention as their primary outcome. This exploratory evaluation aimed to assess indications of change after exposure to the Learning Initiative on Norms, Exploitation and Abuse (LINEA) intervention, a mass-media, gender-transformative social norms intervention aimed at preventing ADTS in Tanzania. Methods: In a condensed implementation 331 participants were instructed to listen to the LINEA radio drama over seven weeks, and 60 were randomly allocated to household discussion sessions about content. In-depth interviews (n = 81) from girls aged 12-16 years, and women and men caregivers were collected at baseline (September 2021), midline (November) and endline (December 2021). Surveys were conducted (n = 120) at baseline and endline using the Norms and Attitudes on ADTS Scale (NAATSS) and the Gender Roles and Male Provision Expectations (GRMPE) scale. Interviews were thematically analyzed using a framework approach. Age-stratified linear regression models adjusted for baseline scores were used to measure association between the intervention and endline scale scores. Results: Longitudinal data were available from 59 qualitative (73%) and 95 quantitative participants (79%). Qualitative evidence revealed the drama facilitated family conversations about adolescent challenges, allowing caregivers to advise daughters. Some girls gained confidence to refuse men's gifts, learning that accepting them could necessitate sexual reciprocation. Some caregivers felt increased responsibility for supporting girls in the community to avoid ADTS. Blame for ADTS shifted for some from girls to men, suggesting increased understanding of inequitable power dynamics and reductions in victim blaming. Marginal quantitative evidence revealed that highly exposed girls had improved gender equitable beliefs on the GRMPE (ß = -6.26; 95% CI: -12.94, 0.42). Moderately exposed men had increased gender inequitable norms on the NAATSS subscale (ß = 0.42 95% CI: 0.05, 0.79), but there was no effect in highly exposed men. Conclusions: Given the small sample results should be interpreted cautiously. Our initial findings indicate high engagement with the LINEA intervention shows promise in shifting knowledge, behaviors, and attitudes, beliefs and social norms driving ADTS in Shinyanga, Tanzania, supporting a robust impact evaluation.

Health and wellbeing needs and priorities in mining host communities in South Africa: a mixed-methods approach for identifying key SDG3 targets.

BACKGROUND: The global mining industry has an opportunity to mobilize resources to advance progress against the Sustainable Development Goals (SDGs). In 2018, the Anglo-American Group outlined aspirations for mining host communities to meet the SDG3 health targets. To progress from aspiration to action we designed and implemented a mixed-methods approach to attain a deeper understanding of the health and wellbeing priorities within the local context of host communities of fifteen mines in South Africa. METHODS: To identify local needs and priorities relating to SDG3 targets in host communities, stakeholder workshops and key informant interviews were conducted between June and August 2019. A baseline assessment of health data, related to each of the SDG3 targets and indicators and to each host community location, was also conducted. Findings emerging from the qualitative and quantitative baseline assessments were compared to identify the extent to which health issues aligned and health and wellbeing priority areas for action. RESULTS: A total of 407 people participated in the workshops, and 85 key informants were interviewed. Quantitative data were available at sub-national level for seven of the nine SDG3 targets and eleven of the 21 indicators. Key priority areas for action identified through alignment of the qualitative and quantitative data were maternal mortality (SDG3.1), HIV (SDG3.3.1), tuberculosis (SDG3.3.2), substance abuse (SDG3.5), and road traffic accidents (SDG3.6) We found consistency in the individual, interpersonal, community, societal, and structural factors underlying these priority areas. At a structural level, poor access to quality healthcare was raised at every workshop as a key factor underlying the achievement of all SDG3 targets. Of the five priority areas identified, HIV, TB and substance abuse were found to overlap in the study communities in terms of risk, burden, and underlying factors. CONCLUSIONS: We demonstrate a mixed method approach for identifying local health needs and prioritised SDG3 targets in mining host communities. Consistency in reporting suggests the need for effective, efficient and feasible interventions to address five priority areas. Given the prominent economic role of the mining sector in South Africa, it can play a critical role in implementing programmatic activities that further progress towards achieving the SDG3 targets.

Early impact of the DREAMS partnership on young women's knowledge of their HIV status: causal analysis of population-based surveys in Kenya and South Africa.

BACKGROUND: Knowledge of one's HIV status is the gateway to treatment and prevention, but remains low among young people. We investigated the early impact (2016-2017) of Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS), a multisectoral HIV prevention package, on knowledge of HIV status among adolescent girls and young women (AGYW). METHODS: In 2017, randomly selected AGYW were enrolled into surveys, N=1081 aged 15-22 years in Nairobi slum settlements, and N=2174 aged 13-22 years in rural KwaZulu-Natal. We estimated the causal effect of being a DREAMS beneficiary on knowledge of HIV status (those who self-reported as HIV-positive or tested HIV-negative in the past year), accounting for an AGYW's propensity to be a DREAMS beneficiary. RESULTS: In Nairobi, knowledge of HIV status was higher among DREAMS beneficiaries compared with non-beneficiaries (92% vs 69%, adjusted OR=8.7; 95% CI 5.8 to 12.9), with DREAMS predicted to increase the outcome by 28%, from 65% if none were a DREAMS beneficiary to 93% if all were beneficiaries. The increase attributable to DREAMS was larger among younger participants: 32% and 23% among those aged 15-17 and 18-22 years, respectively. In KwaZulu-Natal, knowledge of status was higher among DREAMS beneficiaries aged 13-17 years (37% vs 26% among non-beneficiaries), with a 9% difference due to DREAMS (95% CI 4.8% to 14.4%), and no evidence of effect among 18-22 years (-2.8%; 95% CI -11.1% to 5.7%). CONCLUSION: DREAMS substantially increased knowledge of HIV status among AGYW in Nairobi, and among younger but not older AGYW in KwaZulu-Natal. Adolescent girls can be reached early (before age 18) with community-based HIV testing programmes in diverse high-prevalence settings, with a large impact on the proportion who know their HIV status.

Does Ghana's National Health Insurance Scheme provide financial protection to tuberculosis patients and their households?

Financial barriers are a key limitation to accessing health services, such as tuberculosis (TB) care in resource-poor settings. In Ghana, the National Health Insurance Scheme (NHIS), established in 2003, officially offers free TB care to those enrolled. Using data from the first Ghana's national TB patient cost survey, we address two key questions 1) what are the key determinants of costs and affordability for TB-affected households, and 2) what would be the impact on costs for TB-affected households of expanding NHIS to all TB patients? We reported the level of direct and indirect costs, the proportion of TB-affected households experiencing catastrophic costs (defined as total TB-related costs, i.e., direct and indirect, exceeding 20% of their estimated pre-diagnosis annual household income), and potential determinants of costs, stratified by insurance status. Regression models were used to determine drivers of costs and affordability. The effect of enrolment into NHIS on costs was investigated through Inverse Probability of Treatment Weighting Analysis. Higher levels of education and income, a bigger household size and an multi-drug resistant TB diagnosis were associated with higher direct costs. Being in a low wealth quintile, living in an urban setting, losing one's job and having MDR-TB increased the odds of experiencing catastrophic costs. There was no evidence to suggest that enrolment in NHIS defrayed medical, non-medical, or total costs, nor mitigated income loss. Even if we expanded NHIS to all TB patients, the analyses suggest no evidence for any impact of insurance on medical cost, income loss, or total cost. An expansion of the NHIS programme will not relieve the financial burden for TB-affected households. Social protection schemes require enhancement if they are to protect TB patients from financial catastrophe.

Experiences of violence among adolescent girls and young women in Nairobi's informal settlements prior to scale-up of the DREAMS Partnership: Prevalence, severity and predictors.

INTRODUCTION: We sought to estimate the prevalence, severity and identify predictors of violence among adolescent girls and young women (AGYW) in informal settlement areas of Nairobi, Kenya, selected for DREAMS (Determined Resilient Empowered AIDS-free, Mentored and Safe) investment. METHODS: Data were collected from 1687 AGYW aged 10-14 years (n = 606) and 15-22 years (n = 1081), randomly selected from a general population census in Korogocho and Viwandani in 2017, as part of an impact evaluation of the "DREAMS" Partnership. For 10-14 year-olds, we measured violence experienced either in the past 6 months or ever using a different set of questions from those used for 15-22 year-olds. Among 15-22 year-olds we measured prevalence of violence, experienced in the past 12 months, using World Health Organization (WHO) definitions for violence typologies. Predictors of violence were identified using multivariable logit models. RESULTS: Among 606 girls aged 10-14 years, about 54% and 7% ever experienced psychological and sexual violence, respectively. About 33%, 16% and 5% experienced psychological, physical and sexual violence in the past 6 months. The 10-14 year old girls who engaged in chores or activities for payment in the past 6 months, or whose family did not have enough food due to lack of money were at a greater risk for violence. Invitation to DREAMS and being a non-Christian were protective. Among 1081 AGYW aged 15-22 years, psychological violence was the most prevalent in the past year (33.1%), followed by physical violence (22.9%), and sexual violence (15.8%). About 7% experienced all three types of violence. Severe physical violence was more prevalent (13.8%) than moderate physical violence (9.2%). Among AGYW aged 15-22 years, being previously married/lived with partner, engaging in employment last month, food insecure were all risk factors for psychological violence. For physical violence, living in Viwandani and being a Muslim were protective; while being previously married or lived with a partner, or sleeping hungry at night during the past 4 weeks were risk factors. The odds of sexual violence were lower among AGYW aged 18-22 years and among Muslims. Engaging in sex and food insecurity increased chances for sexual violence. CONCLUSIONS: Prevalence of recent violence among AGYW is high in this population. This calls for increased effort geared towards addressing drivers of violence as an early entry point of HIV prevention effort in this vulnerable group.

The effect of child marriage on the utilization of maternal health care in Nepal: A cross-sectional analysis of Demographic and Health Survey 2016.

A range of demographic and socioeconomic factors are known to account for enormous disparities in the uptake of maternal health care in low- and middle-income countries. In contrast, contextual factors such as child marriage are far less explored as a deterrent to the uptake of maternal health care. The present study aimed to assess the total effect of child marriage on the utilization of maternal health services in Nepal. This study drew on data from the Nepal Demographic and Health Survey 2016. The study restricted its analysis to a subsample of 3,970 currently married women of reproductive age who had at least one live birth in the five years preceding the survey. After descriptive analysis, logistic regression models were constructed to estimate adjusted odds ratios. The results of logistic regression controlling for confounders suggested child marriage decreased the likelihood of antenatal care visits (AOR 0.74; 95% CI 0.63-0.86), skilled attendance at delivery (AOR 0.66; 95% CI 0.56-0.78), facility-based delivery (AOR 0.65; 95% CI 0.56-0.77), and postnatal care use (AOR 0.80; 95% CI 0.67-0.96). The findings of this study reinforced the existing evidence for the adverse effect of child marriage on maternal health-seeking behaviors. Women's restricted access to household resources, limited autonomy in decision-making, social isolation, and the dominant power of husbands and mothers-in-law may play a role in the findings. Addressing women's social vulnerability as a barrier to accessing health care may help to increase the uptake of maternal health services.

Cash transfers to enhance TB control: lessons from the HIV response.

BACKGROUND: The World Health Organization prioritises a more holistic global response to end the tuberculosis (TB) epidemic by 2030. Based on experiences in the HIV response, social protection, and in particular cash transfers, show promise for contributing to this. Currently, individual-level evidence for the potential of cash transfers to prevent TB by addressing the structural social determinants of disease is lacking. To identify priority actions for the TB research agenda, we appraised efforts by the HIV response to establish the role of cash transfers in preventing HIV infection. MAIN BODY: The HIV response has evaluated the effects of cash transfers on risky sexual behaviours and HIV incidence. Work has also evaluated the added effects of supplementing cash transfers with psychosocial support. The HIV response has focused research on populations with disproportionate HIV risk, and used a mix of explanatory evaluations, which use ideal conditions, and pragmatic evaluations, which use operational conditions, to generate evidence that is both causally valid and applicable to the real world. It has always collaborated with multiple stakeholders in funding and evaluating projects. Learning from the HIV response, priority actions for the TB response should be to investigate the effect of cash transfers on intermediary social determinants of active TB disease, and TB incidence, as well as the added effects of supplementing cash transfers with psychosocial support. Work should be focused on key groups in high burden settings, and look to build a combination of explanatory and pragmatic evidence to inform policy decisions in this field. To achieve this, there is an urgent need to facilitate collaborations between groups interested in evaluating the impact of cash transfers on TB risk. CONCLUSIONS: The HIV response highlights several priority actions necessary for the TB response to establish the potential of cash transfers to prevent TB by addresing the structural social determinants of disease.

The impact of social protection and poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1.

BACKGROUND: The End TB Strategy and the Sustainable Development Goals (SDGs) are intimately linked by their common targets and approaches. SDG 1 aims to end extreme poverty and expand social protection coverage by 2030. Achievement of SDG 1 is likely to affect the tuberculosis epidemic through a range of pathways. We estimate the reduction in global tuberculosis incidence that could be obtained by reaching SDG 1. METHODS: We developed a conceptual framework linking key indicators of SDG 1 progress to tuberculosis incidence via well described risk factor pathways and populated it with data from the SDG data repository and the WHO tuberculosis database for 192 countries. Correlations and mediation analyses informed the strength of the association between the SDG 1 subtargets and tuberculosis incidence, resulting in a simplified framework for modelling. The simplified framework linked key indicators for SDG 1 directly to tuberculosis incidence. We applied an exponential decay model based on linear associations between SDG 1 indicators and tuberculosis incidence to estimate tuberculosis incidence in 2035. FINDINGS: Ending extreme poverty resulted in a reduction in global incidence of tuberculosis of 33·4% (95% credible interval 15·5-44·5) by 2035 and expanding social protection coverage resulted in a reduction in incidence of 76·1% (45·2-89·9) by 2035; both pathways together resulted in a reduction in incidence of 84·3% (54·7-94·9). INTERPRETATION: Full achievement of SDG 1 could have a substantial effect on the global burden of tuberculosis. Cross-sectoral approaches that promote poverty reduction and social protection expansion will be crucial complements to health interventions, accelerating progress towards the End TB targets. FUNDING: World Health Organization.

The Unresponsive Partner: Roles of Social Status, Auditory Feedback, and Animacy in Coordination of Joint Music Performance.

We examined temporal synchronization in joint music performance to determine how social status, auditory feedback, and animacy influence interpersonal coordination. A partner's coordination can be bidirectional (partners adapt to the actions of one another) or unidirectional (one partner adapts). According to the dynamical systems framework, bidirectional coordination should be the optimal (preferred) state during live performance. To test this, 24 skilled pianists each performed with a confederate while their coordination was measured by the asynchrony in their tone onsets. To promote social balance, half of the participants were told the confederate was a fellow participant - an equal social status. To promote social imbalance, the other half was told the confederate was an experimenter - an unequal social status. In all conditions, the confederate's arm and finger movements were occluded from the participant's view to allow manipulation of animacy of the confederate's performances (live or recorded). Unbeknownst to the participants, half of the confederate's performances were replaced with pre-recordings, forcing the participant into unidirectional coordination during performance. The other half of the confederate's performances were live, which permitted bidirectional coordination between performers. In a final manipulation, both performers heard the auditory feedback from one or both of the performers' parts removed at unpredictable times to disrupt their performance. Consistently larger asynchronies were observed in performances of unidirectional (recorded) than bidirectional (live) performances across all conditions. Participants who were told the confederate was an experimenter reported their synchrony as more successful than when the partner was introduced as a fellow participant. Finally, asynchronies increased as auditory feedback was removed; removal of the confederate's part hurt coordination more than removal of the participant's part in live performances. Consistent with the assumption that bidirectional coupling yields optimal coordination, an unresponsive partner requires the other member to do all the adapting for the pair to stay together.

Severe, generalized nummular eczema secondary to interferon alfa-2b plus ribavirin combination therapy in a patient with chronic hepatitis C virus infection.

BACKGROUND: With increasing rates of hepatitis C virus infection and diagnosis, more patients are being treated with interferon alfa-2b plus ribavirin therapy. Cutaneous side effects to combination therapy are common and may limit treatment. There are few previous case reports of generalized eczematous dermatoses occurring after combination therapy for hepatitis C virus, none in a North American patient, and none of this severity or recalcitrance. OBSERVATIONS: A man with chronic hepatitis C virus infection and no history of atopy developed severe, recalcitrant nummular eczema secondary to interferon alfa-2b plus ribavirin combination therapy. The cutaneous side effect was more severe than in previously reported cases and did not remit on discontinuation of therapy. CONCLUSIONS: Greater awareness of the range of dermatologic responses to interferon alfa-2b plus ribavirin therapy may lead to improved surveillance for and treatment of these side effects. Investigating the underlying pathologic mechanisms may ultimately allow for a greater understanding of the immunomodulatory effects of this therapy in the setting of chronic hepatitis C virus infection.