Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis.

BACKGROUND: This paper responds to the global call to action for respectful maternity care (RMC) by examining whether and how gender inequalities and unequal power dynamics in the health system undermine quality of care or obstruct women's capacities to exercise their rights as both users and providers of maternity care. METHODS: We conducted a mapping review of peer-reviewed and gray literature to examine whether gender inequality is a determinant of mistreatment during childbirth. A search for peer-reviewed articles published between January 1995 and September 2017 in PubMed, Embase, SCOPUS, and Web of Science databases, supplemented by an appeal to experts in the field, yielded 127 unique articles. We reviewed these articles using a gender analysis framework that categorizes gender inequalities into four key domains: access to assets, beliefs and perceptions, practices and participation, and institutions, laws, and policies. A total of 37 articles referred to gender inequalities in the four domains and were included in the analysis. RESULTS: The mapping indicates that there have been important advances in documenting mistreatment at the health facility, but less attention has been paid to addressing the associated structural gender inequalities. The limited evidence available shows that pregnant and laboring women lack information and financial assets, voice, and agency to exercise their rights to RMC. Women who defy traditional feminine stereotypes of chastity and serenity often experience mistreatment by providers as a result. At the same time, mistreatment of women inside and outside of the health facility is normalized and accepted, including by women themselves. As for health care providers, gender discrimination is manifested through degrading working conditions, lack of respect for their abilities, violence and harassment,, lack of mobility in the community, lack of voice within their work setting, and limited training opportunities and professionalization. All of these inequalities erode their ability to deliver high quality care. CONCLUSION: While the evidence base is limited, the literature clearly shows that gender inequality-for both clients and providers-contributes to mistreatment and abuse in maternity care. Researchers, advocates, and practitioners need to further investigate and build upon lessons from the broader gender equality, violence prevention, and rights-based health movements to expand the agenda on mistreatment in childbirth and develop effective interventions.

Effects of men's lifetime adverse events experience on violence, HIV risk, and wellbeing: insights from three countries.

OBJECTIVE: To assess men's experiences of adverse events in both child and adulthood and their effects on violence, HIV risk, and well being in three sub-Saharan countries. DESIGN: We conducted cross-sectional surveys from 2017 to 2018 with men (all 18+) recruited via the PLACE methodology at community hotspots and HIV service sites in Eswatini (n = 1091), South Africa (n = 932), and Malawi (n = 611). METHODS: Prevalence of men's adverse events in childhood (e.g. beaten at home often) and adulthood (e.g. robbed at gunpoint) was described. We examined associations between cumulative effects of these events on health outcomes, via log binomial regression. RESULTS: About 70% of men in each country experienced adverse events in childhood, while adult experience varied from 47 to 64%. There was a dose-response effect of cumulative exposure. Among men with 0, 1-2, and 3+ traumas, for example, 22, 35, and 52% reported depression/anxiety in Malawi, and 8, 17, and 27% perpetrated intimate partner violence (IPV) in South Africa. In multivariate analyses, experiencing at least one event in both childhood and adulthood (vs. neither) was significantly associated with various health outcomes (e.g. multiple sexual partnerships: adjusted risk ratio or aRR = 2.40 in Malawi; IPV perpetration: aRR = 3.59 in South Africa; depression/anxiety: aRR = 1.37 in Eswatini). CONCLUSION: Men who experienced adverse events in childhood or adulthood faced increased HIV risk/negative health outcomes. More events were associated with worse outcomes. Interventions for men addressing trauma in both childhood and adulthood are essential for their (and their partners') health and well being.

Developing and Testing a Chatbot to Integrate HIV Education Into Family Planning Clinic Waiting Areas in Lusaka, Zambia.

BACKGROUND: To maximize protection against both unintended pregnancy and HIV, it is important that family planning (FP) services integrate HIV counseling, both to support method choice and identify potential HIV services of interest, such as pre-exposure prophylaxis (PrEP). However, FP providers often lack sufficient time and knowledge to address HIV vulnerability with clients. To potentially offload some of the initial HIV counseling burden from FP providers, we developed and tested a chatbot that provided information about HIV and dual protection to FP clients in waiting areas of FP clinics in Lusaka, Zambia. CHATBOT DEVELOPMENT: We drafted a scripted conversation and tested it in English in formative workshops with Zambian women between the ages of 15 and 49 years. After translating the content to Bemba and Nyanja, we conducted a second round of workshops to validate the translations, before uploading the content into the chatbot platform. CHATBOT USER TEST: Thirty volunteers tested the chatbot in 3 Lusaka FP clinics, completing an exit survey to provide feedback. A large majority (83%) said they learned new HIV information from the chatbot. Twenty (67%) learned about PrEP for the first time through the chat. Most (96%) reported discussing HIV with the provider, after engaging with the chatbot. In response to an open-ended question, several testers volunteered that they wanted to learn more about PrEP. CONCLUSIONS: Pre-consultation waiting-area time is an underutilized opportunity to impart HIV information to FP clients, thereby preparing them to discuss their dual HIV and pregnancy prevention needs when they see their providers. FP clients expressed particular interest in learning more about PrEP, underscoring the importance of integrating HIV into FP services.

Introduction of digital reporting platform to integrate community-level data into health information systems is feasible and acceptable among various community health stakeholders: A mixed-methods pilot study in Mopti, Mali.

BACKGROUND: Integration of community-level health data within Mali's web-based District Health Information System (DHIS2) is underexplored. This study conducted in Mopti, Mali examined challenges and enablers affecting integration and investigated how digital technology optimizes data quality, availability, and use. METHODS: This pre-post mixed-methods study compared community health workers' (CHWs') experiences reporting routine community-level data using the DHIS2 digital application on tablets and paper forms. 141 CHWs participated in quantitative surveys and focus group discussions at baseline and endline. In-depth interviews were conducted with 18 and eight CHW supervisors and 12 and 11 other stakeholders at baseline and endline, respectively. We calculated changes in CHW performance, and job satisfaction among intervention and comparison groups using the difference-in-difference (DID) estimator controlling for baseline characteristics. Routine longitudinal DHIS2 data described timeliness and completeness of CHW reporting. Thematic analysis of qualitative data explained implementation challenges and enablers, and considerations for data use. RESULTS: The median number of health talks and household visits among intervention group CHWs increased from baseline to endline compared to the comparison group (DID estimator; P < 0.05 for both), as did aspects of job satisfaction (satisfaction with opportunities to contribute ideas to improve services and coordination with supervisors and stakeholders, P < 0.1). CHWs reported high levels of comfort and confidence navigating the tablet for data collection and on-time reporting. While CHWs experienced challenges -tablet quality, limited network connection and increased workload, they preferred the digital to paper system. Stakeholder, supervisor and CHW roles in data review and decision-making appear unchanged from baseline to endline, though some supervisors found the tablets improved data timeliness and completeness. Routine longitudinal DHIS2 data confirm high rates of data timeliness and completeness before and after the intervention, with little or no change over time. CONCLUSIONS: CHW tablet use for data collection and reporting is feasible and desirable, however, program and policy changes are needed for this to be a fully-functional system. Future efforts need to consider how to ensure site-level network connectivity; quality, compatibility and functionality of digital technology; and routine supportive systems for CHWs and community health actors on data use.

Measuring client trust in community health workers: A multi-country validation study.

BACKGROUND: Client trust in community health workers (CHWs) is integral for improving quality and equity of community health systems globally. Despite its recognized conceptual and pragmatic importance across health areas, there are no quantitative measures of trust in the context of community health services. In this multi-country study, we aimed to develop and validate a scale that assesses trust in CHWs. METHODS: To develop the scale, we used a consultative process to conceptualize and adapt items and domains from prior literature to the CHW context. Content validity and comprehension of scale items were validated through 10 focus group discussions with 75 community members in Haiti, and Kenya. We then conducted 1939 surveys with clients who interacted with CHWs recently in Bangladesh (n = 1017), Haiti (n = 616), and Kenya (n = 306). To analyze the 15 candidate scale items we conducted a split sample exploratory/confirmatory factor analysis (EFA/CFA), and then assessed internal consistency reliability of resulting set of items. Finally, we assessed convergent validity via multivariable models examining associations between final scale scores with theoretically related constructs. RESULTS: Factor analyses resulted in a 10-item Trust in CHWs Scale with two factors (sub-scales): Health care competence (5 items) and Respectful communication (5 items). The qualitative data also underscored these two sub-domains. The full scale had good internal consistency reliability in Bangladesh, Haiti and Kenya (alphas 0.87, 0.86, and 0.92, respectively; all alphas for subscales were also > 0.7, most > 0.8). Greater scores on Trust in CHWs were positively associated with increased client empowerment, familiarity with CHWs, satisfaction with recent client-CHW interaction, and positive influence of CHW on client empowerment. Scale scores were not influenced by the age, sex, parity, education, and wealth quintiles in across countries and may be affected by contextual factors. CONCLUSIONS: The Trust in CHWs Scale, which includes Health care competence and Respectful communication sub-scales, is the first such scale developed and validated globally. Our findings suggest this 10-item scale is a reliable and valid tool for quantifying clients' trust in CHWs, with potential utility for tracking and improving CHW and health systems performance over time.

The Client Empowerment in Community Health Systems Scale: Development and validation in three countries.

BACKGROUND: Effectively measuring client empowerment is critical for monitoring and supporting empowerment through interventions, including via community health workers (CHWs) on the front line. Yet a comprehensive measure capturing the multidimensional aspects of client empowerment is not currently available. We aimed to develop and validate the Client Empowerment in Community Health Systems (CE-CHS) Scale in three countries. METHODS: We used data from cross-sectional surveys from 2019-2020 with clients of CHWs in Bangladesh (n = 1384), Haiti (n = 616), and Kenya (n = 306). Nineteen candidate CE-CHS Scale items were adapted from existing health empowerment and sociopolitical control scales. Items spanned three hypothesized sub-domains: personal agency around health (eg, "I feel in control of my health"), agency in sharing health information with others (eg, "I feel confident sharing health information with my family/friends"), and empowerment in community health systems (eg, "Most facility/managers would listen to any concerns I raise"). Face and content validity of items were assessed via two focus group discussions in Haiti. For each country, we conducted split-sample exploratory/confirmatory factor analyses (EFA/CFA) and assessed internal consistency reliability. We assessed convergent validity by comparing final full-scale and sub-dimension scores to theoretically related variables. RESULTS: All participants in Bangladesh and Kenya were female, as were 85% in Haiti. Mean age in Bangladesh and Kenya was around 25 years; 40 in Haiti. EFA/CFA resulted in a final 16-item CE-CHS Scale representing the three hypothesized sub-scales. Three items were dropped in EFA due to poor performance. CFA fit statistics were good for the full-scale and each sub-scale. The mean CE-CHS score (range 1 to 4) was 2.4 in in Bangladesh, 2.8 in Haiti, and 3.0 in Kenya. Cronbach's alpha and ordinal theta of the full and sub-scales were greater than 0.7. Increased empowerment was associated with increased trust in CHWs, influence of CHWs on empowerment, satisfaction with CHW services, number of CHW interactions, civic engagement, and education, with slight variations in magnitude and significance by country. CONCLUSIONS: Findings suggest that the 16-item CE-CHS Scale is valid and reliable. This scale can be used to assess levels and determinants of, and changes in, client empowerment in future implementation research and monitoring of community health systems.

Development and validation of a multi-dimensional scale to assess community health worker motivation.

BACKGROUND: Ensuring that Community Health Workers (CHWs) are motivated is critical to their performance, retention and well-being - and ultimately to the effectiveness of community health systems worldwide. While CHW motivation is as multi-dimensional construct, there is no multi-dimensional measure available to guide programming. In this study, we developed and validated a pragmatic, multi-dimensional measure of CHW motivation. METHODS: Scale validation entailed qualitative and survey research in Mali and Bangladesh. We developed a pool of work satisfaction items as well as several items assessing the importance of hypothesized sub-dimensions of motivation, based on the literature and expert consultations. Qualitative research helped finalize scale sub-dimensions and items. We tested the scale in surveys with CHWs in Mali (n = 152, 40% female, mean age 32) and Bangladesh (n = 76 women, mean age 46). We applied a split-sample exploratory/confirmatory factor analysis (EFA/CFA) in Mali, and EFA in Bangladesh, then assessed reliability. We also gauged convergent/predictive validity, assessing associations between scale scores with conceptually related variables. RESULTS: The final 22-item scale has four sub-dimensions: Quality of supervision, Feeling valued and capacitated in your work, Peer respect and support, and Compensation and workload. Model fit in CFAs was good, as were reliabilities for the full scale (alpha: 0.84 in Mali, 0.93 in Bangladesh) and all sub-dimensions. To construct scores for the final scale, we weighted the scores for each sub-dimension by CHW-reported importance of that sub-dimension. Final possible range was -6 to +6 (sub-dimensions), -24 to +24 (full scale). Mean (standard deviation) of full-scale scores were 5.0 (3.3) in Mali and 14.5 (5.3) in Bangladesh. In both countries, higher motivation was significantly associated with higher overall interest in their work, feeling able to improve health/well-being in their community, as well as indicators of higher performance and retention. CONCLUSIONS: We found that the Multi-dimensional Motivation (MM) scale for CHWs is a valid and reliable measure that comprehensively assesses motivation. We recommend the scale be employed in future research around CHW performance and community health systems strengthening worldwide. The scale should be further evaluated within longitudinal studies assessing CHW performance and retention outcomes over time.

What shapes resilience among people living with HIV? A multi-country analysis of data from the PLHIV Stigma Index 2.0.

OBJECTIVE: To inform efforts to promote greater resilience among people living with HIV (PLHIV), we examined associations between resilience and factors at the individual, interpersonal and structural/policy levels in three countries. DESIGN: Data come from the PLHIV Stigma Index 2.0, a cross-sectional survey with PLHIV, implemented from 2017 to 2019 in Cambodia (n = 1207), the Dominican Republic (n = 891), and Uganda (n = 391). METHODS: Hierarchical multiple regression was used to assess associations between resilience and factors at the individual/interpersonal/structural-policy levels, controlling for potential confounders. Resilience was measured by the previously tested PLHIV Resilience Scale. RESULTS: About 60% of respondents were women; mean time since HIV diagnosis was 11 years in Cambodia and seven in the Dominican Republic /Uganda. Resilience varied substantially across the six province/districts per country (all p < 0.001). In multivariable analyses, higher resilience was associated with lower internalized stigma (all three countries), no experience of human rights abuses (Dominican Republic), no food/housing insecurity (Uganda), and greater community awareness of legal protections for PLHIV (Cambodia and Dominican Republic). HIV-related enacted stigma (i.e., discrimination) in the community was associated with lower resilience in Cambodia, but higher resilience in the Dominican Republic. The set of structural/policy-level factors in Cambodia and the Dominican Republic, and individual-level in Uganda, explained the most variance in resilience. CONCLUSION: Factors at multiple levels affect whether PLHIV in Cambodia, the Dominican Republic, and Uganda report resilience. Multilevel interventions are required to promote resilience among PLHIV, and should incorporate efforts to reduce internalized stigma and promote supportive structural/legal environments including broader awareness of legal protections for PLHIV.

Stigma among key populations living with HIV in the Dominican Republic: experiences of people of Haitian descent, MSM, and female sex workers.

OBJECTIVE(S): To describe stigma among seropositive MSM, female sex workers (FSWs), and Haitian-descent individuals in the Dominican Republic, and to assess whether stigma is associated with HIV treatment outcomes. DESIGN: Cross-sectional survey using Stigma Index 2.0. METHODS: People living with HIV (PLHIV) interviewed seropositive adult MSM, FSWs, Haitian-descent persons, and other PLHIV who did not identify with these communities about experiences of social exclusion, harassment, stigma in healthcare settings, and internalized stigma. Bivariate analyses were conducted to compare experiences between FSWs and other women; MSM and other men; and Haitian-descent participants and non-Haitian PLHIV. Within each community, separate multivariate logistic regression analyses were conducted to examine the association between stigma experiences with viral suppression and with missed antiretroviral doses. RESULTS: The 891 participants consisted of 154 MSM, 216 FSWs, 90 Haitian-descent persons, and 447 who did not identify with any of these three communities. Compared with other women, FSWs reported significantly higher levels of harassment due to their HIV status, and those of Haitian descent reported significantly lower levels of social exclusion compared with non-Haitian PLHIV. In adjusted analyses, MSM who experienced more stigma in HIV-specific services had a significantly lower odds of knowing they had undetectable viral load (adjusted odds ratio 0.37, P < 0.05). Higher internalized stigma scores were significantly associated with missing an antiretroviral treatment dose among FSWs (adjusted odds ratio 1.26, P < 0.05). CONCLUSION: For FSWs and MSM, efforts to mitigate HIV-related stigma are necessary to improve treatment adherence and viral suppression. For Haitian-descent PLHIV, interventions must address not only their HIV-specific needs, but also the broader social and legal barriers to care.

The People Living with HIV Stigma Index 2.0: generating critical evidence for change worldwide.

OBJECTIVE(S): To describe the process of updating the People Living with HIV (PLHIV) Stigma Index (Stigma Index) to reflect current global treatment guidelines and to better measure intersecting stigmas and resilience. DESIGN: Through an iterative process driven by PLHIV, the Stigma Index was revised, pretested, and formally evaluated in three cross-sectional studies. METHODS: Between March and October 2017, 1153 surveys (n = 377, Cameroon; n = 390, Senegal; n = 391, Uganda) were conducted with PLHIV at least 18 years old who had known their status for at least 1 year. PLHIV interviewers administered the survey on tablet computers or mobile phones to a diverse group of purposively sampled respondents recruited through PLHIV networks, community-based organizations, HIV clinics, and snowball sampling. Sixty respondents participated in cognitive interviews (20 per country) to assess if questions were understood as intended, and eight focus groups (Uganda only) assessed relevance of the survey, overall. RESULTS: The Stigma Index 2.0 performed well and was relevant to PLHIV in all three countries. HIV-related stigma was experienced by more than one-third of respondents, including in HIV care settings. High rates of stigma experienced by key populations (such as MSM and sex workers) impeded access to HIV services. Many PLHIV also demonstrated resilience per the new PLHIV Resilience Scale. CONCLUSION: The Stigma Index 2.0 is now more relevant to the current context of the HIV/AIDS epidemic and response. Results will be critical for addressing gaps in program design and policies that must be overcome to support PLHIV engaging in services, adhering to antiretroviral therapy, being virally suppressed, and leading healthy, stigma-free lives.

Internalized stigma among people living with HIV: assessing the Internalized AIDS-Related Stigma Scale in four countries.

OBJECTIVE: Measuring internalized stigma is critical to understanding its impact on the health and quality of life of people living with HIV (PLHIV). The aim of this study was to assess the performance of the Internalized AIDS-Related Stigma Scale (IA-RSS). DESIGN: Secondary analysis of the six-item IA-RSS was conducted using data from four cross-sectional surveys implemented in Cambodia (n = 1207), the Dominican Republic (n = 891), Uganda (n = 391) and Tanzania (n = 529) between 2018 and 2019. METHODS: IA-RSS scale item distribution was described. Multivariate regression models measured correlations between the IA-RSS and depression, antiretroviral therapy (ART) use and viral suppression. Confirmatory factor analysis assessed IA-RSS reliability and performance through analysis of standardized factor loadings and conditional probabilities of scale items. Analysis of qualitative interviews with PLHIV explored acceptability of IA-RSS item content. RESULTS: Mean IA-RSS scores (possible 0-6) ranged from 2.06 (Uganda) to 3.84 (Cambodia), and internal consistency was more than 0.70 in each country (Kuder-Richardson 20), ranging from 0.71 to 0.83. Higher IA-RSS scores were strongly correlated with depression in (P < 0.001 in all countries), and inversely associated with current ART use (Dominican Republic and Tanzania) and self-reported viral suppression (Uganda and Tanzania). Confirmatory factor analysis showed good model fit (all CFI ≥ 0.950), but also that the IA-RSS may summarize two domains related to HIV status disclosure (two items) and PLHIV feelings about themselves (four items). CONCLUSION: Strong performance across countries supports continued use of the IA-RSS. Further study is needed to explore potential item refinements and to better understand the relationship between internalized stigma and HIV treatment outcomes.

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.