A qualitative study to explore the barriers and enablers for young people with disabilities to access sexual and reproductive health services in Senegal.

Use of sexual and reproductive health (SRH) services is low amongst young people in Senegal. Although the evidence base on young people's SRH needs is growing, research on access to SRH services amongst young people with disabilities is negligible. Our study explored the SRH vulnerabilities and expressed needs for young people with disabilities, experiences of accessing SRH services and what access challenges they face. Male and female peer researchers conducted 17 focus group discussions and 50 interviews with young women and men with disabilities between 18 and 24 years with a physical, visual or hearing impairment in Dakar, Thies and Kaolack in Senegal. Young people with disabilities reported very low knowledge about, and use of, SRH services including contraception and gynaecological consultations, but demonstrated a need for them, and were reliant on others to accompany them to service providers, impeding their access to confidential services. Multiple cases of rape were revealed, particularly amongst women with hearing impairments. Key barriers to SRH services were financial barriers, provider attitudes and accessibility (related to their disability). SRH policies and interventions for young people with disabilities should be based on an understanding of the intersection of youth, disability and gender. Urgent and targeted action is needed to improve provider attitudes and capacity to respond to the needs of young people with disabilities and to address the burden of sexual violence.

Targeting the poorest in a performance-based financing programme in northern Cameroon.

Performance-Based Financing (PBF) is a promising approach to improve health system performance in developing countries, but there are concerns that it may inadequately address inequalities in access to care. Incentives for reaching the poor may prove beneficial, but evidence remains limited. We evaluated a system of targeting the poorest of society ('indigents') in a PBF programme in Cameroon, examining (under)coverage, leakage and perceived positive and negative effects. We conducted a documentation review, 59 key informant interviews and 33 focus group discussions with community members (poor and vulnerable people-registered as indigents and those not registered as such). We found that community health workers were able to identify very poor and vulnerable people with a minimal chance of leakage to non-poor people. Nevertheless, the targeting system only reached a tiny proportion (≤1%) of the catchment population, and other poor and vulnerable people were missed. Low a priori set objectives and implementation problems-including a focus on easily identifiable groups (elderly, orphans), unclarity about pre-defined criteria, lack of transport for identification and insufficient motivation of community health workers-are likely to explain the low coverage. Registered indigents perceived improvements in access, quality and promptness of care, and improvements in economic status and less financial worries. However, lack of transport and insufficient knowledge about the targeting benefits, remained barriers for health care use. Negative effects of the system as experienced by indigents included negative reactions (e.g. jealousy) of community members. In conclusion, a system of targeting the poorest of society in PBF programmes may help reduce inequalities in health care use, but only when design and implementation problems leading to substantial under-coverage are addressed. Furthermore, remaining barriers to health care use (e.g. transport) and negative reactions of other community members towards indigents deserve attention.

Help-seeking behaviour for internalizing problems: perceptions of adolescent girls from different ethnic backgrounds.

OBJECTIVE: Although adolescent girls from ethnic minorities are at an increased risk of internalizing problems (e.g. depression), only a small fraction seeks formal help for these problems. To enhance help-seeking for internalizing problems among ethnic minority adolescent girls, insight into their help-seeking behaviour is required. This study explored the perceptions of adolescent girls from different ethnic backgrounds regarding their help-seeking behaviour for internalizing problems. DESIGN: A qualitative study using focus group discussions (FGDs) was employed. Eight ethnic-specific FGDs were conducted with 50 adolescent girls of mostly Turkish (n=23), Moroccan (n=13), and Dutch (n=10) backgrounds recruited in Rotterdam, a multicultural city in the Netherlands. FGDs were conceptually framed within a help-seeking model, facilitated by a vignette and analysed using NVivo software. RESULTS: When describing the internalizing problems presented in the vignette, participants of non-Dutch FGDs tended to state the causes of the problems (e.g. lack of attention) whereas participants of Dutch FGDs mentioned the emotional state. Participants did not perceive the presented internalizing problems as severe. If participants were to face internalizing problems of their own, their decision to seek help would be hampered by negative attitudes towards professionals and school-based services. Particularly in non-Dutch FGDs the fear of parental and friend's reactions was identified as a barrier. Participants identified their mother and a good friend as primary sources of help. CONCLUSION: In this study, adolescent girls of Turkish, Moroccan and Dutch backgrounds had difficulty recognizing the severity of internalizing problems, and various barriers could hamper their decision to seek help. To enhance utilization of mental health services by youth, promoting a change in their attitudes towards mental health/school-based services is recommended. Guaranteeing confidentiality within school-based services, and training for professionals in communicating with adolescent girls, may also prove beneficial. In ethnic minorities, tackling the negative reactions of family/friends requires attention.

Neighborhood ethnic diversity and behavioral and emotional problems in 3 year olds: results from the Generation R Study.

BACKGROUND: Studies suggest that neighborhood ethnic diversity may be important when it comes to understanding ethnic inequalities in mental health. The primary aim of this study was to investigate whether neighborhood ethnic diversity moderated the association between the ethnic minority status and child behavioral and emotional problems. METHODS: We included 3076 preschoolers participating in the Generation R Study, a birth cohort study in Rotterdam, the Netherlands. At child age 3-years, parents completed the Child Behavior Checklist (CBCL/1,5-5). Individual-level data, assessed with questionnaires, was combined with neighborhood-level data. Multi-level logistic regression models predicted the Odds Ratios for the CBCL total problems score as a function of maternal ethnic background and neighborhood ethnic diversity, computed with the Racial Diversity Index and categorized into tertiles. Interaction on the additive scale was assessed using Relative Access Risk due to Interaction. RESULTS: Being from an ethnic minority was associated with child behavioral and emotional problems in unadjusted (OR 2.76, 95% CI 1.88-4.04) and adjusted models (OR 2.64, 95% CI 1.79-3.92). Residing in a high diversity neighborhood was associated with child behavioral and emotional problems in unadjusted (OR 2.03, 95% CI 1.13-3.64) but not in adjusted models (OR 0.89, 95% CI 0.51-1.57). When stratifying by the three levels of neighborhood ethnic diversity, ethnic inequalities in behavioral and emotional problems were greatest in low diversity neighborhoods (OR 5.24, 95%CI 2.47-11.14), smaller in high diversity neighborhoods (OR 3.15, 95% CI 1.66-5.99) and smallest in medium diversity neighborhoods (OR 1.59, 95% CI 0.90-2.82). Tests for interaction (when comparing medium to low diversity neighborhoods) trended towards negative on both the additive and multiplicative scale for the maternal-report (RERI: -3.22, 95% CI -0.70-0.59; Ratio of ORs: 0.30, 95% CI 0.12-0.76). CONCLUSION: This study suggests that ethnic inequalities in child behavioral and emotional problems may be greatest in ethnically homogeneous neighborhoods.

Mental health of internally displaced preschool children: a cross-sectional study conducted in Bogotá, Colombia.

PURPOSE: Ongoing armed conflicts, like the one in Colombia, have forcibly displaced millions of people including many young children. This study aimed to assess the mental health of internally displaced preschoolers in Bogotá Colombia and to identify correlates of mental health in these children. METHODS: Cross-sectional study conducted among 279 children attending four kindergartens in a deprived neighbourhood in Bogotá. Child mental health was assessed with the Child Behaviour Checklist (CBCL) 1.5-5 years, a parent-report. Univariate analyses and multivariate logistic regressions were performed to assess the association between displacement and child mental health and to identify correlates of mental health in displaced children. RESULTS: Displaced children (n = 90) more often met borderline cut-off scores for the CBCL scales than non-displaced children (n = 189) (e.g. total problems 46.7 vs. 22.8 %; p < 0.001). The association between displacement and presence of CBCL total problems remained after adjustment for socio-demographic factors (Adjusted OR 3.3, 95 % CI 1.5; 6.9). Caretaker's mental health partly explained the association. In displaced children, caretaker's mental health (p < 0.01) and family functioning (p < 0.01) were independently associated with child mental health. Exposure to traumatic events and social support was also associated with child mental health; however, associations were not independent. CONCLUSION: In this deprived neighbourhood in Bogotá, preschool children registered as internally displaced presented worse mental health than non-displaced peers. Family functioning and caretaker's mental health were strongly and independently associated with displaced children's mental health.

Health-related quality of life of infants from ethnic minority groups: the Generation R Study.

PURPOSE: To assess whether the health-related quality of life of infants from ethnic minority groups differs from the health-related quality of life of native Dutch infants and to evaluate whether infant health and family characteristics explain the potential differences. METHODS: We included 4,506 infants participating in the Generation R Study, a longitudinal birth cohort. When the child was 12 months, parents completed the Infant Toddler Quality of Life Questionnaire (ITQOL); ITQOL scale scores in each ethnic subgroup were compared with scores in the Dutch reference population. Influence of infant health and family characteristics on ITQOL scale scores were evaluated using multivariate regression models. RESULTS: Infants from ethnic minority groups presented significantly lower ITQOL scale scores compared to the Dutch subgroup (e.g., Temperament and Moods scale: median score of Turkish subgroup, 70.8 (IQR, 15.3); median score of Dutch subgroup, 80.6 (IQR, 13.9; P < 0.001)). Infant health and family characteristics mediated an important part of the association between the ethnic minority status and infant health-related quality of life. However, these factors could not fully explain all the differences in the ITQOL scale scores. CONCLUSIONS: Parent-reported health-related quality of life is lower in infants from ethnic minority groups compared to native Dutch infants, which could partly be explained by infant health and by family characteristics.

Differences in problem behaviour among ethnic minority and majority preschoolers in the Netherlands and the role of family functioning and parenting factors as mediators: the Generation R Study.

BACKGROUND: Studies have shown that, compared to native counterparts, preschoolers from ethnic minorities are at an increased risk of problem behaviour. Socio-economic factors only partly explain this increased risk. This study aimed to further unravel the differences in problem behaviour among ethnic minority and native preschoolers by examining the mediating role of family functioning and parenting factors. METHODS: We included 4,282 preschoolers participating in the Generation R Study, an ethnically-diverse cohort study with inclusion in early pregnancy. At child age 3 years, parents completed the Child Behavior Checklist (CBCL/1,5-5); information on demographics, socio-economic status and measures of family functioning (maternal psychopathology; general family functioning) and parenting (parenting stress; harsh parenting) were retrieved from questionnaires. CBCL Total Problems scores in each ethnic subgroup were compared with scores in the Dutch reference population. Mediation was evaluated using multivariate regression models. RESULTS: After adjustment for confounders, preschoolers from ethnic minorities were more likely to present problem behaviour than the Dutch subgroup (e.g. CBCL Total Problems Turkish subgroup (OR 7.0 (95% CI 4.9; 10.1)). When considering generational status, children of first generation immigrants were worse off than the second generation (P<0.01). Adjustment for socio-economic factors mediated the association between the ethnic minority status and child problem behaviour (e.g. attenuation in OR by 54.4% (P<0.05) from OR 5.1 (95% CI 2.8; 9.4) to OR 2.9 (95% CI 1.5; 5.6) in Cape Verdean subgroup). However, associations remained significant in most ethnic subgroups. A final adjustment for family functioning and parenting factors further attenuated the association (e.g. attenuation in OR by 55.5% (P<0.05) from OR 2.2 (95% CI 1.3; 4.4) to OR 1.5 (95% CI 1.0; 2.4) in European other subgroup). CONCLUSIONS: This study showed that preschoolers from ethnic minorities and particularly children of first generation immigrants are at an increased risk of problem behaviour compared to children born to a Dutch mother. Although socio-economic factors were found to partly explain the association between the ethnic minority status and child problem behaviour, a similar part was explained by family functioning and parenting factors. Considering these findings, it is important for health care workers to also be attentive to symptoms of parental psychopathology (e.g. depression), poor family functioning, high levels of parenting stress or harsh parenting in first and second generation immigrants with young children.

Systematic development of a self-regulation weight-management intervention for overweight adults.

BACKGROUND: This paper describes the systematic development of an intervention for the prevention of obesity among overweight adults. Its development was guided by the six steps of Intervention Mapping (IM), in which the establishment of program needs, objectives and methods is followed by development of the intervention and an implementation and evaluation plan. METHODS: Weight gain prevention can be achieved by making small changes in dietary intake (DI) or physical activity (PA). The intervention objectives, derived from self-regulation theory, were to establish goal-oriented behaviour. They were translated into a computer-tailored Internet-delivered intervention consisting of four modules. The intervention includes strategies to target the main determinants of self-regulation, such as feedback and action planning.The first module is intended to ensure adults' commitment to preventing weight gain, choosing behaviour change and action initiation. The second and third modules are intended to evaluate behaviour change, and to adapt action and coping plans. The fourth module is intended to maintain self-regulation of body weight without use of the program.The intervention is being evaluated for its efficacy in an RCT, whose protocol is described in this paper. Primary outcomes are weight, waist circumference and skin-fold thickness. Other outcomes are DI, PA, cognitive mediators and self-regulation skills. DISCUSSION: The IM protocol helped us integrating insights from various theories. The performance objectives and methods were guided by self-regulation theory but empirical evidence with regard to the effectiveness of theoretical methods was limited. Sometimes, feasibility issues made it necessary to deviate from the original, theory-based plans. With this paper, we provide transparency with regard to intervention development and evaluation. TRIAL REGISTRATION: NTR1862.