Psychosocial support for adolescent girls in post-conflict settings: beyond a health systems approach

Adaptive and adequately resourced health systems are necessary to achieve good health outcomes in post-conflict settings, however domains beyond the health system are also critical to ensure broader wellbeing. This paper focuses on the importance of psychosocial support services for adolescent girls in fragile contexts. Its starting point is that adolescence is a pivotal time in the life course but given the physical, cognitive and emotional changes triggered by the onset of puberty, it can also be a period of heightened sensitivity and vulnerability to trauma, social isolation, bullying by peers, a lack of supportive adults and gender-based and sexual violence. Our findings highlight why humanitarian and biomedical approaches in their current form are inadequate to address these complexities. Drawing on qualitative fieldwork (consisting of in-depth and key informant interviews as well as group discussions in Gaza, Liberia and Sri Lanka involving a total of 386 respondents across the three countries), we argue that going beyond biomedical approaches and considering the social determinants of health, including approaches to tackle discriminatory gendered norms and barriers to service access, are critical for achieving broader health and wellbeing. While all three case study countries are classified as post-conflict, the political economy dynamics vary with associated implications for experiences of psychosocial vulnerabilities and the service environment. The study concludes by reflecting on actions to address psychosocial vulnerabilities facing adolescent girls. These include: tailoring services to ensure gender and age-sensitivity; investing in capacity building of service providers to promote service uptake; and enhancing strategies to regulate and coordinate actors providing mental health and psychosocial support services.Acknowledgements We would like to acknowledge the support of a number of people. In Liberia, The Liberia Center for Outcomes Research led this work supported by Janice Cooper, with Abayomi Cole and Elton Gbollie as research coordinators. In Sri Lanka the work was led by the Good Practice Group and in particular Kusala Wettesinghe, Sarala Emmanuel and Ananda Galappatti. In Gaza the study was led by Bassam Abu Hamad and Nadja Al Bayoumi from Al Quds University. We would also like to thank all the data collectors in the three countries. We also want to acknowledge support from Maria Stavropoulou for her work on the background literature review and Ingrid Gercama for support on data analysis. The Research in Gender and Ethics (RinGs): Building Stronger Health Systems Partnership (funded by DFID) provided invaluable inputs during the development and revision of this paper. Finally, we would like to thank all respondents for giving us their time and sharing their stories with us. Funding This study was funded by the ReBUILD consortium, a multi-year multi-country UK Department for International Development (DFID) funded research programme, and we would like to thank them for their ongoing support and contribution to this research. The views expressed within this paper are not necessarily those of DFID

Metabolic imprinting, programming and epigenetics - a review of present priorities and future opportunities

Metabolic programming and metabolic imprinting describe early life events, which impact upon on later physiological outcomes. Despite the increasing numbers of papers and studies, the distinction between metabolic programming and metabolic imprinting remains confusing. The former can be defined as a dynamic process whose effects are dependent upon a critical window(s) while the latter can be more strictly associated with imprinting at the genomic level. The clinical end points associated with these phenomena can sometimes be mechanistically explicable in terms of gene expression mediated by epigenetics. The predictivity of outcomes depends on determining if there is causality or association in the context of both early dietary exposure and future health parameters. The use of biomarkers is a key aspect of determining the predictability of later outcome, and the strengths of particular types of biomarkers need to be determined. It has become clear that several important health endpoints are impacted upon by metabolic programming/imprinting. These include the link between perinatal nutrition, nutritional epigenetics and programming at an early developmental stage and its link to a range of future health risks such as CVD and diabetes. In some cases, the evidence base remains patchy and associative, while in others, a more direct causality between early nutrition and later health is clear. In addition, it is also essential to acknowledge the communication to consumers, industry, health care providers, policy-making bodies as well as to the scientific community. In this way, both programming and, eventually, reprogramming can become effective tools to improve health through dietary intervention at specific developmental point

La juventud cubana: actitudes cambiantes hacia la salud sexual y reproductiva

Cuba sigue siendo uno de los pocos países todavía gobernados por un partido comunista. A pesar de sus compromisos socialistas, incluida la igualdad de género, estos no se han cumplido plenamente, y las normas relativas a los roles de género a menudo están en desacuerdo con los valores revolucionarios. Este artículo se basa en datos primarios recopilados en Cuba en 2018-19 para explorar las decisiones de salud sexual y reproductiva de los jóvenes, y en especial de mujeres jóvenes. El análisis destaca cómo a pesar de los servicios de planificación familiar y de las oportunidades educativas puestas a su disposición las opciones reproductivas y sexuales de las mujeres jóvenes a menudo están determinadas por los hombres y por valores que otorgan primacía al matrimonio y a la maternidad, a medida que los valores conservadores ganan cada vez más terreno

Drivers of health system strengthening: learning from implementation of maternal and child health programmes in Mozambique, Nepal and Rwanda.

There is a growing understanding that strong health systems are crucial to sustain progress. Health systems, however, are complex and much of their success depends on factors operating at different levels and outside the health system, including broader governance and political commitment to health and social development priorities. Recognizing these complexities, this article offers a pragmatic approach to exploring the drivers of progress in maternal and child health in Mozambique, Nepal and Rwanda. To do this, the article builds on a semi-systematic literature review and case study findings, designed and analysed using a multi-level framework. At the macro level, governance with effective and committed leaders was found to be vital for achieving positive health outcomes. This was underpinned by clear commitment from donors coupled by a significant increase in funding to the health sector. At the meso level, where policies are operationalized, inter-sectoral partnerships as well as decentralization and task-shifting emerged as critical. At micro (service interface) level, community-centred models and accessible and appropriately trained and incentivized local health providers play a central role in all study countries. The key drivers of progress are multiple, interrelated and transversal in terms of their operation; they are also in a constant state of flux as health systems and contexts develop. Without seeking to offer a blueprint, the study demonstrates that a 'whole-system' approach can help elicit the key drivers of change and potential pathways towards desirable outcomes. Furthermore, understanding the challenges and opportunities that are instrumental to progress at each particular level of a health system can help policy-makers and implementers to navigate this complexity and take action to strengthen health systems

Picturing the nation : The Celtic periphery as discursive other in the archaeological displays of the museum of Scotland

Using the archaeological displays at the Museum of Scotland in Edinburgh, this paper examines the exhibition as a site of identity creation through the negotiations between categories of same and Other. Through an analysis of the poetics of display, the paper argues that the exhibition constructs a particular relationship between the Celtic Fringe and Scottish National identity that draws upon the historical discourses of the Highlands and Islands of Scotland as a place and a time \u27apart\u27. This will be shown to have implications for the display of archaeological material in museums but also for contemporary understandings of Scottish National identity. <br /

High risk of HIV in non-brothel based female sex workers in India

BACKGROUND: Heterosexual contact is the most common mode of HIV transmission in India that is largely linked to sex work. We assessed the non-use of condoms in sex work and with regular sex partners by female sex workers (FSWs), and identified its associations that could assist in planning HIV prevention programmes. METHODS: Detailed documentation of various aspects of sex work, and sexual behaviour with regular sex partners, was done through confidential interviews for 6648 FSWs in 13 districts in the Indian state of Andhra Pradesh. Multivariate analysis was done to understand condom non-use with clients. RESULTS: 5010 (75.4%), 1499 (22.5%), and 139 (2.1%) FSWs were street-, home-, and brothel-based, respectively. Of the total 6648 FSWs, 6165 (92.7%) had penetrative vaginal/anal sex with at least one client in the last 15 days, and of these 2907 (47.2%; 95% CI 41.2–53.2%) reported non-use of condom with at least one of her last three clients. Lack of knowledge that HIV could be prevented (odds ratio 5.01; 95% CI 4.38–5.73), no access to free condoms (odds ratio 3.45; 95% CI 2.99–3.98), being street-based as compared with brothel-based (odds ratio 3.36; 95% CI 1.87–6.04), and no participation in FSW support groups (odds ratio 2.02; 95% CI 1.50–2.70) were the most significant predictors of condom non-use with clients. Other associations included lower social support, lower income, age >24 years, illiteracy, and living in medium-size urban or rural areas. Of the 2582 who had penetrative sex with regular sex partner within the last 7 days, 2428 (94%; 95% CI 92.1–95.9%) had not used condom at last sex, and 1032 (41.8%) had neither used condom consistently with clients nor with regular sex partner. CONCLUSION: About half the FSWs do not use condom consistently with their clients in this Indian state putting them at high risk of HIV infection. Non-brothel-based FSWs, who form the majority of sex workers in India, were at a significantly higher risk of HIV infection as compared with brothel-based FSWs. With their high vulnerability, the success of expansion of HIV prevention efforts will depend on achieving and sustaining an environment that enables HIV prevention with the non-brothel based FSWs

Engaging communities in supporting HIV prevention and adherence to antiretroviral therapy in Zambia

In Zambia, the prevalence of HIV is estimated at 16 percent among 15–49-year-olds. This brief presents findings from an operations research study to access the outcomes of the Antiretroviral Community Education and Referral (ACER) project in two urban areas in Zambia—Lusaka and Ndola. The ACER project was implemented by the International HIV/AIDS Alliance, based in England, and the Alliance’s Zambia office, in conjunction with local Zambian partners. Launched in mid-2004, the two-year project built on previous formative research that examined knowledge and attitudes about prevention and treatment. The research was conducted by the Institute of Eco­nomic and Social Research in Zambia and the Horizons Program. The study documents many positive trends among people on ART and community members in the research sites, including increased knowledge about HIV prevention and ART, greater uptake of HIV test­ing, increased use of peer networks as an information source, and reduced stigma. Despite these improvements, there were few statisti­cally significant differences between the intervention and comparison sites

Correlates of condom use in a sample of MSM in Ecuador

BACKGROUND: In Ecuador, the prevalence of HIV in the general population is approximately 0.3%. However, up to 17% prevalence has been reported among specific groups of homosexual and bisexual men. The objective of this study is to explore correlates of condom use among men who have sex with men (MSM) across eight cities in Ecuador. METHODS: A cross-sectional survey design was used. A questionnaire including variables on sexual behaviour, demographics, and socio-economic characteristics was distributed to a sample of MSM in eight Ecuadorian cities. RESULTS: Information was obtained for 2,594 MSM across the eight cities. The largest subcategory of self-identification was active bisexuals (35%), followed by those who described themselves as "hombrados" (masculine gays, 22%). The mean age was 25 years, and the majority were unmarried (78%), with a median of 10 years of schooling (IQR 7 – 12). Regarding condom use, 55% of those interviewed had unprotected penetrative sex with each of their last three partners, and almost 25% had never used a condom. The most important correlates of condom use were single status, high life-skills rating, and high socio-economic status (RP 5.45, 95% CI 4.26 – 6.37; RP 1.84, 95% CI 1.79 – 1.86, and RP 1.20, 95% CI 1.01 – 1.31, respectively). CONCLUSION: Our data illustrate the urgent need for targeted HIV-prevention programs for MSM populations in Ecuador. MSM have the highest HIV prevalence in the country, and condom use is extremely low. It is imperative that prevention strategies be re-evaluated and re-prioritized to more effectively respond to the Ecuadorian epidemic

Vulnerability to HIV and AIDS: a social research on cross border mobile population from Bangladesh to India

"Baseline Research on cross border migration was initiated to understand the drivers of mobility, access to services for migrants at source and destination, and to understand the risk and vulnerabilities associated with migration and HIV and AIDS. The study was conducted using quantitative methods and a separate qualitative study was conducted to enhance and complement the quantitative data.