Engagement of stakeholders in the development of a Theory of Change for handwashing and sanitation behaviour change

A Theory of Change (ToC) is an approach to map programmes aimed at inducing change in a specific context, with the goal of increasing their impact. We applied this approach to the specific case of handwashing and sanitation practices in low- and middle-income countries and developed a ToC as part of a systematic review exercise. Different existing sources of information were used to inform the initial draft of the ToC. In addition, stakeholder involvement occurred and peer review took place. Our stakeholders included methodological (ToC/quantitative and qualitative research) and content experts (WASH (Water, Sanitation, Hygiene)/behaviour change), as well as end-users/practitioners, policy-makers and donors. In conclusion, the development of a ToC, and the involvement of stakeholders in its development, was critical in terms of understanding the context in which the promotional programmes are being implemented. We recommend ToC developers to work with stakeholders to create a ToC relevant for practice.     

The conflation of gender and sex: Gaps and opportunities in HIV data among transgender women and MSM

ABSTRACT

Historically, HIV studies have conflated men who have sex with men (MSM) with transgender (trans) women, explicitly excluded trans individuals, or included sample sizes of trans people that are too small to reach meaningful conclusions. Despite the heavy burden of HIV among trans women, conflation of this population with MSM has limited the information available on the social and behavioural factors that increase HIV vulnerability among trans women and how these factors may differ from MSM. Using data sets from quantitative studies among MSM (n?=?645) and trans women (n?=?89), as well as qualitative in-depth interviews with 30 trans women in Baltimore, we explore what these data tell us about similarities and differences in HIV vulnerability between the two groups and where they leave gaps in our understanding. We conclude with implications for data collection and intervention development.     

Optimising HIV programming for transgender women in Brazil

In Brazil, little data is available to inform HIV prevention programming for travestis and transgender (‘trans’) women, despite the existence of a social movement that has gained strength in recent years. We conducted formative research in Rio de Janeiro to gather trans women’s perspectives on combination HIV prevention approaches. Framing the analysis within the model of gender affirmation, we found that several social and contextual factors inhibited participants’ access to HIV prevention and treatment. Experienced and anticipated gender-related discrimination and HIV stigma were linked to the avoidance of HIV testing, health services and HIV status disclosure. Participants recommended HIV prevention interventions which combined socio-structural interventions, such as peer-based empowerment and social support, with biomedical interventions such as pre-exposure prophylaxis (PrEP). Participants expressed a preference for programmes and interventions that emphasised a gender-affirmative approach, promoted autonomy and aimed to reduce stigma and discrimination in public health services.     

Vulnerable children in families affected by parental mental illness: The role of theory in programme development

Abstract

People who experience mental illness frequently undertake parenting duties. While this group of parents can parent well, they often experience challenges that are associated with adverse impacts upon their children's mental health. A robust body of evidence does not currently exist to indicate interventions for this group that are most effective in promoting positive outcomes. We argue that, in this context, theory and the use of theoretical models are advantageous for practitioners to increase the effectiveness of interventions. This paper presents an analysis of the explicitly stated theoretical models used to guide published evaluations targeting this vulnerable group of children and young people. Almost half (46%) of the published evaluations examined failed to state explicitly or describe a theoretical underpinning for the intervention programme. Of those programmes that did use theory there was an emphasis on individual-focused theories drawn from psychology, psychiatry and social work rather than mainstream health promotion theories.     

Multi-level experiences and determinants of alcohol misuse and illicit drug use among occupational groups at high-risk of HIV in sub-Saharan Africa: A thematic synthesis of qualitative findings

ABSTRACT

Occupational groups at high-risk of HIV in sub-Saharan Africa (SSA) may be at increased risk of substance use because of occupation-related factors. We synthesised qualitative data on determinants and context of alcohol misuse and illicit drug use in these groups. We systematically searched five databases for qualitative studies reporting on alcohol misuse or illicit drug use in fisherfolk, uniformed personnel, miners, truckers, motorcycle taxi riders, and sex workers in SSA. Qualitative data and interpretations were extracted and synthesised using a systematic iterative process to capture themes and overarching concepts. We searched for papers published prior to January 2018. We identified 5692 papers, and included 21 papers in our review, published from 1993 to 2017. Most studies were conducted among fisherfolk (n?=?4) or sex workers (n?=?12). Ten papers reported on alcohol use alone, three on illicit drug use alone and eight on both. Substance use was commonly examined in the context of work and risky behaviour, key drivers identified included transactional sex, availability of disposable income, poverty, gender inequalities and work/living environments. Substance use was linked to risky behaviour and reduced perceived susceptibility to HIV. Our review underscores the importance of multilevel, integrated HIV prevention and harm reduction interventions in these settings.     

Field-based evaluation of malaria outbreak detection and response in Mudzi and Goromonzi districts,Zimbabwe – 2017

ABSTRACT

National-level evaluations may fail to identify capacity improvements for detecting and responding to outbreaks which begin and are first detected at the local level. In response to this issue, we conducted a field-based assessment of the malaria outbreak surveillance system in Mashonaland East, Zimbabwe. We visited eleven clinics in Mudzi and Goromonzi districts. Twenty-one interviews were conducted with key informants from the provincial (n?=?2), district (n?=?7), and clinic (n?=?12) levels. Interviews focused on surveillance system activities, preparedness, data quality, timeliness, stability, and usefulness. Main themes were captured utilising standard qualitative data analysis techniques. While the surveillance system detects malaria outbreaks at all levels, we identified several gaps. Clinics experience barriers to timely and reliable reporting of outbreaks to the district level and staff cross-training. Stability of resources, including transportation (33% of informants, n?=?7) and staff capacity (48% of informants, n?=?10), presented barriers. Strengthening these surveillance barriers may improve staff readiness to detect malaria outbreaks, resulting in timelier outbreak response and a reduction in malaria outbreaks, cases, and deaths. By focusing at the local level, our assessment approach provides a framework for identifying and addressing gaps that may be overlooked when utilising tools that evaluate surveillance capacity at the national level.     

Masculine gender norms,male circumcision,and men’s engagement with health care in the Dominican Republic

ABSTRACT

Overall, adult men are less likely to seek and receive health care than women, but male circumcision for HIV prevention has been successful in engaging men in health services. The purpose of this paper is to examine the relationship between masculine norms and health care-seeking among men participating in a voluntary male medical circumcision (VMMC) programme in the Dominican Republic (DR). We employed a mixed methods approach integrating survey data collected 6–12 months post-circumcision (n?=?293) and in-depth interviews with a sub-sample of these men (n?=?30). In our qualitative analysis, we found that health care-seeking is connected to masculine norms among men in the DR, including the perceptions of medical facilities as feminine spaces. Participants’ narratives demonstrate that male circumcision programmes may facilitate men overcoming masculinity-related barriers to health care engagement. In quantitative analysis, we found that being concerned about being perceived as masculine was associated with health care-seeking behaviour in the past five years, though this association was not retained in multivariable analyses. Findings indicate that male circumcision programmes can familiarise men with the healthcare system and masculinise health care-seeking and utilisation, easing associated discomfort.     

Religious Faith and Transformational Processes in Marriage

Leading scholars of marital processes strongly recommend supplementing the current focus on marital conflict to include research on transformative processes. This qualitative study examines the connection between religion and the transformative processes of commitment and coping in marriage. The sample for this study includes 184 married couples (N = 368 individuals), making it far larger than most in‐depth, qualitative interview‐based studies. Participants included Christians, Jews, and Muslims with an over sampling of minorities and immigrant families living in all eight regions of the United States. For several decades studies have shown a largely positive correlation between (a) religiosity and marital commitment and (b) religiosity and (generally) positive coping, but with little explanation regarding how and why. Findings of this study indicate that there are specific religious beliefs and practices related to how these couples approach their marriages—including several that relate to the two transformative processes of commitment and coping.     

Asexual Identity,Personality, and Social Motivations in a New Zealand National Sample

Growing research interest in asexuality has led to several notable findings around the differences between asexual people and those with other sexual orientations. These findings have recently extended to personality, but questions remain around differences in personality between asexual people and others. Furthermore, qualitative and quantitative research disagrees about whether asexual people are less interested in close relationships than others. This paper used data from a nationally representative sample of self-identified asexual participants (Analysis 1: n_women?=?216, n_men?=?54, n_{gender diverse}?=?13; Analysis 2: n_women?=?53, n_men?=?19, n_{gender diverse}?=?3) and matched samples of heterosexual and lesbian, gay, and bisexual/plurisexual (LGB) participants (N’s?=?75–283) drawn from the New Zealand Attitudes and Values Study (Ns?=?19,396–54,183) to explore personality (Analysis 1) and approach and avoidance social motivations (Analysis 2). Compared to heterosexuals, asexual participants reported significantly lower extraversion, agreeableness, and conscientiousness, and higher emotionality, openness, and honesty-humility. Compared to those who identified as LGB, asexual participants reported significantly lower extraversion and agreeableness and higher honesty-humility. In addition, asexual participants scored significantly lower on approach (but not avoidance) social motivation than both heterosexual and LGB participants, indicating that they are less motivated to enhance positive experiences and behavior in their social relationships. These results help to clarify how personality and social motivations covary with sexual identity.

     

Simplifying the evaluation of primary health care programmes

Currently, there is considerable attention for health impact--as measured by mortality, morbidity or nutrition indicators, in the evaluation of primary health care (PHC) programmes. In most cases, health impact evaluations tend to be dominated by methodological discussions on data collection, analysis and interpretation, which are not relevant to the majority of PHC programmes. In this paper a theoretical framework of variables, affecting child survival, is presented. The key to this action-oriented framework is the identification of a set of intermediate variables which directly affect the health status of children, but can be influenced by PHC interventions as well. It is recommended that evaluations of PHC programmes should focus on these intermediate variables and be less concerned with health impact of the interventions.     

Women and Waterpipe Tobacco Smoking in the Eastern Mediterranean Region: Allure or Offensiveness

The prevalence of waterpipe tobacco smoking is increasing worldwide, despite evidence indicating its adverse health effects. Women and young people seem more likely to be choosing waterpipe tobacco smoking over cigarettes. The objective of this qualitative study was to understand better whether and why waterpipe smoking is a more acceptable form of tobacco use than cigarettes for women in the Eastern Mediterranean Region, and to understand whether the strategies used by multi-national corporations to attract women to cigarette smoking were perceived to be relevant in the context of waterpipe tobacco use. Focus groups (n?=?81) and in-depth interviews (n?=?38) were conducted with adults in Lebanon, Egypt, Palestine, and Syria. Discussions were thematically analyzed and recurrent themes identified. One of the themes which emerged was the negative image of women smoking waterpipes. Moreover, the sexual allure conveyed through waterpipe smoking as well as waterpipe tobacco smoking as a symbol of emancipation was illustrated. The latter was mainly expressed in Lebanon, in contrast with Egypt where traditional gender roles depict women smoking waterpipes as disrespectful to society. Understanding the social aspects of waterpipe tobacco smoking is crucial to planning future interventions to control waterpipe tobacco smoking among women and in society at large.     

Designs and methods used in published Australian health promotion evaluations 1992–2011

Objective: To describe the designs and methods used in published Australian health promotion evaluation articles between 1992 and 2011. Methods: Using a content analysis approach, we reviewed 157 articles to analyse patterns and trends in designs and methods in Australian health promotion evaluation articles. The purpose was to provide empirical evidence about the types of designs and methods used. Results: The most common type of evaluation conducted was impact evaluation. Quantitative designs were used exclusively in more than half of the articles analysed. Almost half the evaluations utilised only one data collection method. Surveys were the most common data collection method used. Few articles referred explicitly to an intended evaluation outcome or benefit and references to published evaluation models or frameworks were rare. Conclusion: This is the first time Australian‐published health promotion evaluation articles have been empirically investigated in relation to designs and methods. There appears to be little change in the purposes, overall designs and methods of published evaluations since 1992. Implications: More methodologically transparent and sophisticated published evaluation articles might be instructional, and even motivational, for improving evaluation practice and result in better public health interventions and outcomes.     

The Effects of Race,Gender, and Gender-Typed Behavior on Children’s Friendship Appraisals

From a young age, children’s peer appraisals are influenced by the social categories to which peers belong based on factors such as race and gender. To date, research regarding the manner in which race- and gender-related factors might interact to influence these appraisals has been limited. The present study employed an experimental vignette paradigm to investigate the relative influences of target peers’ race, gender, and gender-typed behavior toward 4- to 6-year-old Chinese children’s (N?=?119, 62 girls, 57 boys) peer appraisals. Appraisals were assessed via (1) a rating scale measuring children’s interest in being friends with a range of hypothetical target peers varying in race, gender, and gender-typed behavior, and (2) a forced-choice rank-order task in which children indicated their preferences for four hypothetical target peers who varied from themselves on either race, gender, or gender-typed behavior, or were similar to themselves on all three traits. There was little evidence to suggest children’s rank-ordered peer preferences in relation to race were influenced by whether the other-race presented was White (preferred relatively more) or Black (preferred relatively less). In contrast, gender-related factors (i.e., rater gender, target gender, target gender-typed behavior) had more robust influences on peer preferences for both outcome measures. Gender-conforming peers were preferred over gender-nonconforming peers, and target boys displaying feminine behavior were less preferred than target girls displaying masculine behavior. The results help characterize cross-cultural (in)consistencies in children’s social preferences in relation to peers’ race and gender.

     

Associations between young children’s exposure to household violence and behavioural problems: Evidence from a rural Kenyan sample

ABSTRACT

Little is known about how young children in low- and middle-income countries (LMICs) experience violence in their homes, and how different types of household violence may affect child development. This study reports on levels of exposure to household violence and associations with child behavioural outcomes in preschool-aged children in western Kenya. A sample of 465 caregivers, whose children (n?=?497) attended early learning centres supported by an international NGO, were enrolled in the study. Caregivers reported on exposure to intimate partner violence (IPV), household discipline practices, attitudes about gender roles, and child behavioural outcomes. Multivariable analysis showed significant predictive effects of IPV (regression coefficient?=?1.35, SE?=?0.54, p?=?0.01) and harsh psychological child discipline (regression coefficient?=?0.74, SE?=?0.22, p?=?0.001), but not physical discipline (regression coefficient?=?0.42, SE?=?0.24, p?=?0.08), on worse child behavioural problems. These findings indicate that child exposure to violence in different forms is highly prevalent, and associated with poorer outcomes in young children. Community-based programmes focused on parenting and early child development are well-positioned to address household violence in LMIC settings, but must be supported to provide a broader understanding of violence and its immediate and long-term consequences.     

Psychological outcomes and gender-related development in complete androgen insensitivity syndrome

We evaluated psychological outcomes and gender development in 22 women with complete androgen insensitivity syndrome (CAIS). Participants were recruited through a medical database (n = 10) or through a patient support group (n = 12). Controls included 14 males and 33 females, of whom 22 were matched to women with CAIS for age, race, and sex-of-rearing. Outcome measures included quality of life (self-esteem and psychological general well-being), gender-related psychological characteristics (gender identity, sexual orientation, and gender role behavior in childhood and adulthood), marital status, personality traits that show sex differences, and hand preferences. Women recruited through the database versus the support group did not differ systematically, and there were no statistically significant differences between the 22 women with CAIS and the matched controls for any psychological outcome. These findings argue against the need for two X chromosomes or ovaries to determine feminine-typical psychological development in humans and reinforce the important role of the androgen receptor in influencing masculine-typical psychological development. They also suggest that psychological outcomes in women with CAIS are similar to those in other women. However, additional attention to more detailed aspects of psychological well-being in CAIS is needed.     

HIV and transgender women in Kampala,Uganda – Double Jeopardy

Transgender women in Kampala face stigma, high HIV acquisition or transmission risk and poor access to health services. We explored the HIV and gender-related contexts of their lives. Snowball sampling was used to enrol 45 participants between July-October 2013. Data collection included audio-computer-assisted self-interviews, qualitative face-to-face interviews and blood tests for HIV and CD4. One in five respondents tested HIV positive. Emergent themes revealed highly varied forms of gender identity and gender expression. Almost all respondents asserted that they frequently engaged in sex work, mainly due to lack of employment. HIV-related themes included limited access to non-stigmatising health services, inconsistent condom use, inaccurate perceptions of self and partners' risk, alcohol use, receptive anal sex with men, multiple sex partners, frequent self and enacted stigma, and violence. Findings highlight the urgency of providing members of this marginalised population with tailored, innovative, comprehensive and effective HIV prevention programmes that address structural issues such as access to HIV services and limited employment as well as behavioural issues such as inconsistent condom use, multiple sexual partners, self and enacted stigma, violence and alcohol use.     

Play beliefs and responsive parenting among low-income mothers of preschoolers in the United States

This study examined associations between parents’ developmentally appropriate beliefs about young children’s play and responsive parenting. Low-income parents and their children enrolled in Head Start programmes (n?=?231) in the United States participated in the study. Responsive parenting skills (characterized by high levels of warmth and responsiveness, and lower levels of hostility) were related to parents’ beliefs endorsing play as valuable (Play Support) for promoting preschool children’s social skills and school readiness. Additionally, higher levels of parent depression were negatively associated with Play Support beliefs while higher levels of parent efficacy were positively associated. Parent education showed a positive relation with Play Support beliefs and a negative relationship with beliefs regarding focusing on academic readiness of children without playful learning (Academic Focus). Implications for understanding play-based approaches for promoting children’s developmental outcomes within early childhood programmes and family interventions are discussed.     

Community perceptions of transactional sex with children and adolescent girls,a qualitative study in favelas of Rio de Janeiro

ABSTRACT

The sexual exploitation of children and adolescents is a frequently underestimated health problem which includes transactional sex (TS), or the practice of sexual activity based on an expected return of benefits, favours and/or support in some form. This qualitative study focuses on age-disparate transactional sex (ATS) in urban favela communities of Rio de Janeiro between adult men (over 18) and girls and adolescents (G/A) (under 18), involving a minimum 5-year age disparity. We have employed social norms theory as a framework to identify the prevailing social norms contributing to or protecting children and adolescents from these relationships. Data collection utilised semi-structured interviews (n?=?30) and ten focus groups with a total of 130 men/boys and women/girls selected through purposive sampling and varying in age from 15 to 65. Overall the findings identify factors, especially the essentialisation of gender, which promote the acceptability of ATS. When ATS surpassed the acceptability threshold, social norms discouraged direct interference. Concluding remarks point to possible strategies for reducing the occurrence of ATS. These must include girls, boys, women and men with community involvement in the deconstruction of social norms involving gender, age and economic consumption.     

Psycho-social profile of battered women in Galicia,Spain: Distress as a result of intimate partner violence and child abuse

Abstract

In Spain, a country of great cultural diversity, there is an increasing demand for psychosocial care for victims of gender-based violence. The objective is to describe the psychosocial profile of these women residing in the Autonomous Community of Galicia. In a sample (n?=?40) of victims of intimate partner violence, it was found a high incidence of PTSD, depression, and low self-esteem associated with greater severity of PTSD and depression. A prolonged relationship increases the types of violence experienced, which is associated with particular psychosocial conditions that are analyzed quanti-qualitatively in order to recommend interventions consistent with the problems detected.     

Stakeholder perspectives on the implementation and impact of Indigenous health interventions: A systematic review of qualitative studies

BackgroundEvaluations of health interventions for Indigenous peoples rarely report outcomes that reflect participant and community perspectives of their experiences. Inclusion of such data may provide a fuller picture of the impact of health programmes and improve the usefulness of evaluation assessments.AimTo describe stakeholder perspectives and experiences of the implementation and impact of Indigenous health programmes.MethodsWe conducted a systematic review of qualitative studies evaluating complex health interventions designed for Indigenous communities in high‐income countries. We searched 6 electronic databases (through to January 2020): MEDLINE, PreMEDLINE, Embase, PsycINFO, EconLit and CINAHL and hand‐searched reference lists of relevant articles.ResultsFrom 28 studies involving 677 stakeholders (mostly clinical staff and participants), six main themes were identified: enabling engagement, regaining control of health, improving social health and belonging, preserving community and culture, cultivating hope for a better life, and threats to long‐term programme viability.ConclusionThe prominence of social, emotional and spiritual well‐being as important aspects of the health journey for participants in this review highlights the need to reframe evaluations of health programmes implemented in Indigenous communities away from assessments that focus on commonly used biomedical measures. Evaluators, in consultation with the community, should consistently assess the capacity of health professionals to meet community needs and expectations throughout the life of the programme. Evaluations that include qualitative data on participant and community‐level outcomes can improve decision‐makers'' understanding of the impact that health programmes have on communities.Patient or public contributionThis paper is a review of evaluation studies and did not involve patients or the public.