Understanding barriers to safer sex practice in Zimbabwean marriages: implications for future HIV prevention interventions.

Against the backdrop of high human immunodeficiency virus (HIV) prevalence in stable relationships in Southern Africa, our study presents sociocultural barriers to safer sex practice in Zimbabwean marriages. We conducted 36 in-depth interviews and four focus group discussions with married men and women in Zimbabwe in 2008. Our aim was to identify barriers faced by married women when negotiating for safer sex. Participants identified individual, relational and community-level barriers. Individual level barriers made women voiceless to negotiate for safer sex. Being voiceless emanated from lack sexual decision-making power, economic dependence, low self-efficacy or fear of actual or perceived consequences of negotiating for safer sex. Relational barriers included trust and self-disclosure. At the community level, extended family members and religious leaders were said to explicitly or implicitly discourage women's safer sex negotiation. Given the complexity and multi-levelled nature of barriers affecting sexual behaviour in marriage, our findings suggest that HIV prevention interventions targeted at married women would benefit from empowering individual women, couples and also addressing the wider community.

Traditional gender roles, forced sex and HIV in Zimbabwean marriages.

Little is known on how forced sex contributes to the sexual transmission of HIV in marriage. This paper describes traditional gender norms surrounding forced sex in Zimbabwean marriage. Data were collected from 4 focus group discussions and 36 in-depth interviews with married women and men in Harare. Results indicate that hegemonic masculinity characterised by a perceived entitlement to sex, male dominance and being a provider contributed to forced sex in marriage. A femininity characterised by a tolerance of marital rape, the desire to please the husband and submission contributed to women experiencing forced sex. An alternative femininity characterised by sexual pleasure-seeking contributed to women forcing their spouses to have sex. Future HIV interventions must go beyond narrowly advocating for safer sex within marriage and instead address practices that increase risk as well as promote positive marital relationship needs such as mutual respect, love and friendship.

Published Research on COVID-19 in the Eastern Mediterranean Region: Bibliometric Analysis.

BACKGROUND: The challenges presented by the COVID-19 pandemic have led to unprecedented global research activity. The Eastern Mediterranean Region (EMR) continues to contribute to COVID-19 research driven by the unique challenges of the region, including the protracted conflicts, already stressed health systems, and serious health and social inequalities. OBJECTIVE: This study aims to provide an overview of the publication activities and trends in COVID-19 research in the EMR from the onset of the disease to early 2022 using bibliometric methods. METHODS: A literature search using Scopus was conducted from December 1, 2019, to January 31, 2022, using keywords relevant to COVID-19 and the World Health Organization (WHO) EMR country list. Data were exported and analyzed using Microsoft Excel and the Citation Overview function on Scopus. The quality of journals was determined using SCImago Journal Rank and CiteScore. VOSviewer software was used to visualize the relationships between authors, countries, and key terms used in the retrieved documents. RESULTS: A total of 6880 documents were retrieved, of which 1805 (26.24%) were from the Kingdom of Saudi Arabia (KSA) and 1782 (25.90%) from Iran, followed by Pakistan, Egypt, and Jordan. Most published documents were affiliated with EMR universities, primarily the Tehran University of Medical Sciences in Iran and King Saud University in KSA (396/6880, 5.76%, and 370/6880, 5.4%, respectively), while only 407 (5.92%) of 6880 documents were associated with universities outside the EMR. For most of the identified publications (5020/6880, 72.97%), no funding source was reported, while King Saud University contributed the largest share (282/1860, 15.16%) of funded publications. Retrieved documents were cited 53,516 times, with an average of 7.78 (SD 34.30). Iran was the EMR country with the most links to other countries (77 links and total link strength of 1279). The 5 authors with the most publications were from KSA, Qatar, and Jordan. There were 290 high-frequency keywords that occurred ≥10 times and were linked in 7 different clusters. The cluster with the most linked keywords was related to epidemiology and mortality. Recent topics included vaccines, vaccination, machine learning, and online learning. CONCLUSIONS: This is the first study to show trends in and project future developments of COVID-19 research activity in the EMR. Authors and institutions who led research on COVID-19 in the region were from Iran and KSA. There were multiple regional collaborative efforts; however, international collaboration was limited. Recently, interest has been shifting toward topics related to vaccination, machine learning, and online learning. Understanding the current state of research is instrumental to future research production, and our study will inform regional research initiatives on emerging concepts, as well as opportunities for collaboration and funding.

Evaluating the Effects of Training to Improve Teaching Skills of Health Sciences Educators in Sudan.

Purpose: This evaluation draws evidence on the outcome of learning and teaching courses that were offered to a number of teaching staff (referred to as trainers) of the Academies of Health Sciences, Midwifery Schools and Centre for Continuous Professional Development in Sudan. Methods: The evaluation was a cross-sectional, institution-based study conducted from October 2017 to January 2018 involving qualitative design. It consisted of direct observations of teaching, focus group discussions with students and semi-structured interviews with managers of teaching institutions. Results: The findings of direct observations revealed that the learning and teaching course has positive effects on the trainers' ability to have clear, well-stated learning objectives; their presentation skills; and their use of different teaching methods. Moreover, the observations showed that trainers who attended the learning and teaching course now encourage the students to ask questions and are providing them with timely feedback about their learning. As students were the main beneficiaries for improved teaching, focus group discussions have shown that students were generally satisfied with trainers' performance regarding the stated learning outcomes, curricula design, use of a range of teaching methods and assessment methods. During in-depth interviews, managers of training institutions expressed satisfaction with the trainers' performance regarding the development of training materials, learners' assessment, supervision, and evaluation of training. Conclusion: Short courses on teaching and learning were a valuable investment for trainers, students, and the overall performance of health sciences training institutions. The evaluation revealed that trainers were able to apply what they have learnt. Moreover, students and managers noticed improvement in the performance of trainers in teaching, course delivery and assessment. It is recommended to expand, cascade and institutionalize the short courses on learning and teaching to all states to improve the capabilities of trainers, which would eventually contribute to the production of competent allied health professions in Sudan.

Mental health policy development and implementation in four African countries.

The purpose of the research programme introduced in this article is to provide new knowledge regarding comprehensive multisectoral approaches to breaking the negative cycle of poverty and mental ill-health. The programme undertakes an analysis of existing mental health policies in four African countries (Ghana, South Africa, Uganda, Zambia), and will carry out and evaluate interventions to assist in the development and implementation of mental health policies in those countries, over a five-year period. The four countries in which the programme is being conducted represent a variety of scenarios in mental health policy development and implementation.

In-country capacity development of a training institute: an Iranian experience.

PURPOSE: The purpose of this paper is to review the Government initiative for developing the in-country capacity of the National Public Health Management Centre (NPMC) in Tabriz. The UNDP definition of capacity has been used as a framework for assessment with the primary focus of the current assessment being on the training component. DESIGN/METHODOLOGY/APPROACH: The pape shows that Iran, which is a lower-middle income country, has a network of training institutions for both pre-service and continuing education of its human resources in health. This collaborative initiative between NPMC, Nuffield Centre for International Health and Development (NCIHD) and World Health Organization (WHO), attempted to create conditions for designing, organising and conducting a training programme in health planning and management for mid-level health managers in Iran. FINDINGS: The paper finds that the experience of capacity development through training, described here, is in contrast with usual practice, where candidates are sent abroad for training. Overall, the process for developing in-country capacity of a local institute by a foreign institute was well thought out. However, there are some lessons to be learned from the process. ORIGINALITY/VALUE: The paper shows that capacity has been built in NPMC for organising in-country short course on health planning and management for health sector reform. The paper concludes by arguing that, in order to sustain these training programmes over a long period of time, in addition to including training in its mandate, NPMC should: consider networking with allied institutions in the country and beyond for sharing knowledge; and make twinning arrangements with a foreign institute for continuously upgrading the knowledge and skills of its trainers.

Health system decentralisation in Nepal: identifying the issues.

PURPOSE: The purpose of this paper is to describe and discuss policy analysis in Nepal and review the wide range of choices feasible in decentralisation decision making. DESIGN/METHODOLOGY/APPROACH: In this paper an iterative qualitative method was developed and used in the research, which consisted of focus group interviews, key informant interviews, document analysis, including descriptive statistics, and analysis of the policy context. Participants in the research reflected the urban/rural mix of districts and the geography of Nepal. Analysis combined transcribed interviews with findings from document searches and analysis of the policy context. Coding was pre-determined during the training workshop and further codes were generated during and after the fieldwork. FINDINGS: The paper finds that Nepal is in the process of decentralising public services from the central level to the local level, particularly to local bodies: District Development Committees (DDCs), Village Development Committees (VDCs) and Municipalities. Key contextual factors referred to are the overall structure of decentralisation, the social context of poverty and the political instability leading to a fluid political situation characterised by political tension, armed conflict, controversies and agreements while carrying out the research. The key issues identified and discussed in the paper are the policy process leading to decentralisation, the organisational structure and tension in the proposed system, the systems of resource generation, allocation, planning and management and lastly the forms of accountability, participation, public-private relations and collaborative strategies. ORIGINALITY/VALUE: The paper discusses the challenges faced in conducting such a policy analysis, the broad ranging and unremitting nature of the decentralisation process, and the contextual setting of the process of change.

HIV/AIDS and female genital mutilation in the Somali's nomads of eastern Ethiopia: a discussion paper.

Female Genital Mutilation (FGM) is widely practised among the Somali nomads in Eastern Ethiopia. It may be categorized as one of many harmful traditional practices such as uvula cutting, gum piercing, cauterization and blood letting, which are conducted by unskilled traditional healers in unhygienic conditions, and which potentially increase the risk of HIV transmission. Other factors also play a significant role in the perpetuation of the HIV/AIDS epidemic in the region, such as lack of awareness, misconception about the routes of HIV transmission and ways of prevention, the practice of polygamy, and window inheritance. Pervasive poverty and recurrent famine also fuel the epidemic. Lack of official pastoralist-specific policy and strategy on HIV and FGM further complicates the problem. This paper discusses the possible relationship in terms of health risk between HIV/AIDS and FGM in the Horn of Africa and calls for more concerted efforts, including further research in order to address this potential risk.

Filling the assessment gap: using a learning portfolio in international development courses.

PURPOSE: The purpose of this research is to describe an action research project that proposed, monitored and evaluated the introduction of a learning portfolio used to replace examinations that were formerly used to assess the core courses. DESIGN/METHODOLOGY/APPROACH: An action research project was undertaken to find out whether the introduction of a portfolio was successful and what could be improved in the process of its implementation. FINDINGS: The findings indicate that portfolios are effective to support and assess the academic development of international students. ORIGINALITY/VALUE: The introduction of a portfolio to replace written examinations in the NCIHD was welcomed by all concerned.

Concurrent sexual partnerships among married Zimbabweans - implications for HIV prevention.

BACKGROUND: Concurrent sexual partnerships play a key role in sustaining the HIV epidemic in Zimbabwe. Married couples are at an increased risk of contracting HIV from sexual networks produced by concurrent sexual partnerships. Addressing these partnerships is an international HIV prevention priority. METHODS: Our qualitative study presents the socioeconomic factors that contribute to the occurrence of concurrent sexual partnerships among married people in Zimbabwe. We conducted 36 in-depth interviews and four focus group discussions with married men and women in Zimbabwe in 2008 to understand the organizations of concurrent sexual partnerships. Data were analyzed using framework analysis. RESULTS: Our study indicates that relationship dissatisfaction played a key role in the engagement of concurrent sexual partnerships. Depending on the source of the dissatisfaction, there were four possible types of concurrent sexual relationships that were formed: sex worker, casual partner, regular girlfriend or informal polygyny which was referred to as "small house". These relationships had different levels of intimacy, which had a bearing on practicing safer sex. Participants described three characteristics of hegemonic masculinity that contributed to the sources of dissatisfaction leading to concurrent sexual activity. Similarly, various aspects of emphasized femininity were described as creating opportunities for the occurrence of concurrent sexual relationships. Economic status was also listed as a factor that contributed to the occurrence of concurrent sexual partnerships. CONCLUSION: Marital dissatisfaction was indicated as a contributing factor to the occurrence of concurrent sexual relationships. There were several reports of satisfying marital relationships in which affairs did not occur. Lessons from these marriages can be made part of future HIV prevention interventions targeted at preventing concurrent sexual partnerships by married couples.

A rapid appraisal of access to and utilisation of psychotropic medicines in Bihar, India.

BACKGROUND: A major aspect of providing mental healthcare is access to and use of psychotropic medications. Bihar is a state in northeast India with limited mental healthcare provision; consequently access to and utilisation of psychotropic medications are likely to be limited. However, to date there has been no research assessing the situation. This study therefore aims to analyse the psychotropic medications management cycle (selection, procurement, distribution and use), and identify the barriers to access and utilisation, and their underlying causes. METHOD: A rapid appraisal method was used in which primary and secondary data sources were collected and analysed. Semi-structured interviews were conducted with twenty-two stakeholders and twenty-one service users from the government, non-governmental organisation (NGO) and private sectors. The qualitative data collected was analysed using a comparative thematic approach. The research was supported by the NGOs BasicNeeds and Nav Bharat Jagriti Kendra. RESULTS: Availability, distance and cost were the main barriers to access and utilisation. At the medical college hospital level a lack of supply appears to be due to a discrepancy between orders made by the hospital and medications supplied by the manufacturers. At the primary health centre and district hospital level the main barrier is a cycle between lack of demand for treatments for mental illness by doctors and patients. CONCLUSION: Further investigation and monitoring is necessary to ensure the availability of psychotropic medications at the medical college hospital level. In addition, implementation of the District Mental Health Programme is likely to address the access and utilisation barriers due to its potential to break the current cycle of lack of demand.

The role of the health system in the prevention of hearing loss among children in Sub-Saharan Africa.

Around 1.2 million children living in Sub-Saharan Africa have a hearing impairment (HI) or hearing loss (HL). Limited attention and scarce resources dedicated to this condition means that such children often receive no management for their problem. This has substantial negative effects on their development, and ultimately results in poverty. Half of the number of cases of HI in such countries results from preventable causes. Formulation of effective prevention strategies to address the causes requires an understanding of the factors that lead to the causes of HI in Sub-Saharan Africa. A number of preventable causes were shown to significantly contribute to the prevalence of HI. The most significant causes include perinatal problems, middle ear problems, infective diseases, and ototoxic drugs. These causes persist because there are few effective prevention strategies in place, and those which exist are poorly implemented. There is little public and health care worker awareness about HL and its prevention. Few resources are allocated to the prevention of HL, meaning that these issues are not addressed. Evidence have shown that current failings in the prevention of HI from such causes include widespread limited resources, inadequate staff training, and absent or ineffectual prevention guidelines. The burden of HL has been shown to be significantly reduced through effective prevention strategies, both in the developed and developing world, justifying the need for increased attention and more resources in Sub-Saharan Africa.

The role of strategic health planning processes in the development of health care reform policies: a comparative study of Eritrea, Mozambique and Zimbabwe.

This paper reports on comparative analysis of health planning and its relationship with health care reform in three countries, Eritrea, Mozambique and Zimbabwe. The research examined strategic planning in each country focusing in particular on its role in developing health sector reforms. The paper analyses the processes for strategic planning, the values that underpin the planning systems, and issues related to resources for planning processes. The resultant content of strategic plans is assessed and not seen to have driven the development of reforms; whilst each country had adopted strategic planning systems, in all three countries a more complex interplay of forces, including influences outside both the health sector and the country, had been critical forces behind the sectoral changes experienced over the previous decade. The key roles of different actors in developing the plans and reforms are also assessed. The paper concludes that a number of different conceptions of strategic planning exist and will depend on the particular context within which the health system is placed. Whilst similarities were discovered between strategic planning systems in the three countries, there are also key differences in terms of formality, timeframes, structures and degrees of inclusiveness. No clear leadership role for strategic planning in terms of health sector reforms was discovered. Planning appears in the three countries to be more operational than strategic.

Decentralization, health care and policy process in the Punjab, Pakistan in the 1990s.

The Province of the Punjab underwent a number of attempts to decentralize the health sector in the 1990s. Among the most important were the decentralization of financial management within the district, the Sheikhupura PHC Pilot Project, the establishment of the District Health Authorities and District Health Management Teams, the creation of semi-autonomous hospitals and the programme of District Health Government (DHG). These usually received donor support and promotion, and emerged from within the provincial Department of Health, and more specifically the Secretariat and the internationally supported Second Family Health Project (FH2). Of particular significance was the DHG change, which involved a decentralization to the district, the appointment of powerful Chief Executives, the formation of District Management Committees and purchaser-provider separation. The paper reviews these proposals, focusing on the need to build on experiences and learning lessons from pilot projects, reform continuity, developing consultation and involvement and policy analysis. The latter indicates the importance of developing more in-depth policy analysis around the role of the central organization, the form of decentralization and the purchaser-provider separation. The paper concludes by underlining the need to ensure that political strategy and in-depth policy are appropriately coordinated in the policy process.