A method for small-area estimation of population mortality in settings affected by crises.

BACKGROUND: Populations affected by crises (armed conflict, food insecurity, natural disasters) are poorly covered by demographic surveillance. As such, crisis-wide estimation of population mortality is extremely challenging, resulting in a lack of evidence to inform humanitarian response and conflict resolution. METHODS: We describe here a 'small-area estimation' method to circumvent these data gaps and quantify both total and excess (i.e. crisis-attributable) death rates and tolls, both overall and for granular geographic (e.g. district) and time (e.g. month) strata. The method is based on analysis of data previously collected by national and humanitarian actors, including ground survey observations of mortality, displacement-adjusted population denominators and datasets of variables that may predict the death rate. We describe the six sequential steps required for the method's implementation and illustrate its recent application in Somalia, South Sudan and northeast Nigeria, based on a generic set of analysis scripts. RESULTS: Descriptive analysis of ground survey data reveals informative patterns, e.g. concerning the contribution of injuries to overall mortality, or household net migration. Despite some data sparsity, for each crisis that we have applied the method to thus far, available predictor data allow the specification of reasonably predictive mixed effects models of crude and under 5 years death rate, validated using cross-validation. Assumptions about values of the predictors in the absence of a crisis provide counterfactual and excess mortality estimates. CONCLUSIONS: The method enables retrospective estimation of crisis-attributable mortality with considerable geographic and period stratification, and can therefore contribute to better understanding and historical memorialisation of the public health effects of crises. We discuss key limitations and areas for further development.

The scale, scope, coverage, and capability of childbirth care.

All women should have access to high quality maternity services-but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.

Availability of long-acting and permanent family-planning methods leads to increase in use in conflict-affected northern Uganda: evidence from cross-sectional baseline and endline cluster surveys.

Humanitarian assistance standards require specific attention to address the reproductive health (RH) needs of conflict-affected populations. Despite these internationally recognised standards, access to RH services is still often compromised in war. We assessed the effectiveness of our programme in northern Uganda to provide family planning (FP) services through mobile outreach and public health centre strengthening. Baseline (n=905) and endline (n=873) cross-sectional surveys using a multistage cluster sampling design were conducted in the catchment areas of four public health centres in 2007 and 2010. Current use of any modern FP method increased from 7.1% to 22.6% (adjusted odds ratio [OR] 3.34 [95% confidence interval (CI) 2.27-4.92]); current use of long-acting and permanent methods increased from 1.2% to 9.8% (adjusted OR 9.45 [95%CI 3.99-22.39]). The proportion of women with unmet need for FP decreased from 52.1% to 35.7%. This study demonstrates that when comprehensive FP services are provided among conflict-affected populations, women will choose to use them. The combination of mobile teams and health systems strengthening can make a full range of methods quickly available while supporting the health system to continue to provide those services in challenging and resource-constrained settings.

HIV prevalence and characteristics of sex work among female sex workers in Hargeisa, Somaliland, Somalia.

OBJECTIVE: To measure prevalence of HIV and syphilis and describe characteristics of sex work among female sex workers (FSWs) in Hargeisa, Somaliland, Somalia. METHODS: A cross-sectional survey recruited 237 FSWs using respondent-driven sampling (RDS). A face-to-face, structured interview using handheld-assisted personal interviewing (HAPI) on personal digital assistants (PDAs) was completed and blood collected for serological testing. RESULTS: FSWs 15-19 years old accounted for 6.9% of the population; 20-24 year-old constituted an additional 18.0%. The majority (86.6%) never attended school. International (59.0%) and interzonal (10.7%) migration was common. Most (95.7%) reported no other source of income; 13.8% had five or more clients in the last 7 days. A minority (38.4%) had heard of STIs, even fewer (6.9%) held no misconceptions about HIV. Only 24% of FSW reported using a condom at last transactional sex, and 4% reported ever been tested for HIV. HIV prevalence was 5.2% and syphilis prevalence was 3.1%. CONCLUSION: Sex work in Hargeisa, Somaliland, Somalia, is characterized by high numbers of sexual acts and extremely low knowledge of HIV. This study illustrates the need for targeted HIV prevention interventions focusing on HIV testing, risk-reduction awareness raising, and review of condom availability and distribution mechanisms among FSWs and males engaging with FSWs.

Sexual health knowledge, attitudes and behaviours: variations among a religiously diverse sample of young people in London, UK.

OBJECTIVE: To report young people's variations in sexual health knowledge, attitudes and behaviours by religious affiliation. DESIGN: A cross-sectional, questionnaire-based survey administered in 16 Secondary/High schools in London, UK. The sample consisted of 3007 students in school Years 11-13 (aged 15-18), present in school on the day of questionnaire administration. Excluding those who described themselves as 'Other religious', 15.9% (n=418) described themselves as having no religious affiliation, 36.3% (n=957) were Christian, 25.8% (n=679) were Muslim and 22.1% were Hindu (n=582). The religious affiliation varied within and across different ethnic groups. METHOD: Self-administered questionnaire completed under 'exam' conditions, either in tutor groups or a school hall. The 30-minute questionnaires were distributed and collected by a team of ethnically and religiously diverse fieldworkers. RESULTS: Religious students, as opposed to those reporting no religious affiliation, generally reported poorer sexual health knowledge, and were more conservative in their attitudes to sex. Among males and females, those with no religious affiliation and Christian students reported the highest prevalence of sexual intercourse by some margin (around 20 percentage points) over the Hindus and Muslims. Christian males most frequently reported sexual intercourse at 49.7%, and Muslim females the least at 9.0%. Among those reporting sexual intercourse, risk behaviours among all religious and non-religious students were evident. Over one-third of Muslim females who had sexual intercourse did not use contraception on their first occasion compared to 10% of those with no religious affiliation, 12% of Christians and 20% of Hindus. Christian and Muslim females reported the highest prevalence of ever not using contraception at 55%, and non-use of contraception with two or more sexual intercourse partners at 14%. CONCLUSION: The findings demonstrate diverse sexual health knowledge, sexual attitudes and sexual behaviours among young people with different religious affiliations. These variations demonstrate the importance of tailoring health education and promotion interventions to meet the specific needs of young people from a variety of different religions. The challenge ahead is to find ways to work with these young people to broach such sensitive issues.

Experience of sexual intercourse and reported risk behaviour among an ethnically diverse sample of young people.

BACKGROUND: Certain Black and Minority Ethnic (BME) groups have been identified as bearing a disproportionate burden of sexual ill health in the UK. There still exists a significant gap in the evidence-base concerning the sexual behaviours of BME youth. METHODS: We conducted a cross-sectional survey of 16 secondary schools in London, where the proportion of BME students exceeded two-thirds of the intake. The aim was to identify the factors associated with sexual intercourse and sexual risk behaviours. RESULTS: 2801 students aged 15 to 18 completed questionnaires. Compared with White British males, Black males were significantly more likely to report sexual intercourse (OR 3.04, 95% CI 1.92-4.81). Compared with White British females, Asian females were significantly less likely to report sexual intercourse (OR 0.43, 95% CI 0.27-0.69). Both sexes reporting school as their main source of information, as opposed to their family, had a lower likelihood of intercourse (males OR 0.33, 95% CI 0.21-0.53, females OR 0.39, 95% CI 0.25-0.62). Compared with White British males, contraceptive use at first ever intercourse was significantly less likely among Black males (OR 0.35, 95% CI 0.16-0.98) and males of Mixed ethnicity (OR 0.24, 95% CI 0.06-0.92). Among females, higher sexual health knowledge was associated with contraceptive use (OR 4.69, 95% CI 1.76-12.49). Males reporting higher sexual health knowledge were more likely to be 'sexually competent' at first ever intercourse (OR 2.28, 95% CI 1.10-4.69). CONCLUSIONS: Given the importance of sexual health knowledge, ensuring this is improved among all ethnic groups, especially the Black and Mixed male groups, is a key message to arise from this study. Delivering this information in a 'culturally competent' manner is an important goal.

Accessing research participants in schools: a case study of a UK adolescent sexual health survey.

While methods and results of school-based studies have been reported widely in the literature, little published information exists on the practical aspects of recruiting schools and students into a study. This paper reflects on the experiences of a UK-based sexual health survey among 3007 students aged 15-18 years. The survey explored beliefs, attitudes and behaviours in relation to sexual health. This case study highlights significant aspects of planning and conducting successful large-scale research in schools, focusing on the process of conducting the research rather than outcomes. As such, the paper will benefit those intending to sample a school-based population. The key features of effective and feasible research in schools are outlined in four areas: (i) adopting suitable research tools, (ii) selecting and contacting schools, (iii) selecting students within schools and (iv) the importance of fieldworkers. On-site and post-data collection feedback from teachers are incorporated into the discussion of good practice in partnership working with schools and students in research. We conclude by discussing fieldwork experiences and outlining key recommendations for researchers across disciplines engaging in school-based studies.