Gender inequalities in health and wellbeing across the first two decades of life: an analysis of 40 low-income and middle-income countries in the Asia-Pacific region

Domestic Violence Against Women in Nepal: A Systematic Review of Risk Factors

A systematic review was conducted to examine the factors that put women at risk of domestic violence in Nepal. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), PubMed, Cochrane, MEDLINE, CINAHL, and PsycINFO were searched supplemented by searching of the reference list manually. Of the 143 studies identified 24 were included in the final review. Search strategy was developed, and studies were included if they considered female participants (age 15-49 years) in heterosexual relationship, with exposure of different factors and whose outcomes were the magnitude of any form of violence (physical, sexual, and emotional/psychological). The Mixed Methods Appraisal Tool was used to assess the quality of the studies included. The findings are categorized based on the four levels of the ecological framework. At the individual level, the alcohol consumption level of husband, education level of both women and men, women's age at the time of marriage and childhood exposure to violence were found to be highly prevalent risk factors. At the relationship level, most prevalent risk factors were controlling husband and decision-making capacity of women. At the community level, belonging to underprivileged community or low caste system and living in Terai region were the risk factors. At the societal level, patriarchal belief and norms supporting violence were the risk factors. The complex nature of violence against women in Nepal requires culturally sensitive interventions along with organized efforts from the local and intra government to improve the status of Nepalese women at all levels of the ecological framework.

Global burden of metabolic dysfunction-associated steatotic liver disease attributable to high fasting plasma glucose in 204 countries and territories from 1990 to 2021

Metabolic dysfunction-associated steatotic liver disease (MASLD) brings heavy clinical and economic burdens to patients worldwide. High fasting plasma glucose (HFPG) was proven to be an important modifiable risk factor. However, the global burden distribution of HFPG-attributable MASLD has not been fully studied. This study aimed to describe the epidemiological distribution and trends of the burden of HFPG-attributable MASLD worldwide. The data source was the 2021 Global Burden of Disease Study. Descriptive statistics were mainly conducted using disability-adjusted life years (DALYs) and deaths of HFPG-attributable MASLD from 1990 to 2021, as well as their age-standardized rates (ASRs) and population-attributable fractions. Subgroup analyses were conducted by region, age group, and sex. We found that 213.48 thousand DALYs and 10.02 thousand deaths in MASLD were attributable to HFPG worldwide in 2021, with an increase of 2.96 and 3.32 times compared with 1990, respectively. Over the past 32 years, age-standardized DALY rates (ASDRs) have fluctuated upward, reaching 2.45 per 100,000 people in 2021, with an increase of 81.21%. The ASDRs continued to rise in low, low-middle, and high social demographic index (SDI) regions, fluctuated upward at high levels in middle SDI regions, and were relatively low in high-middle SDI regions. People aged 50-69 accounted for the largest proportion of DALYs, while people over 70 had the largest increase of 3.73 times. Men had higher ASDRs, and the sex difference has been gradually expanding over the past 32 years, peaking at the age of 45-49. In conclusion, the burden of HFPG-attributable MASLD has continued to increase globally, with differences in geographical area, age, and sex distribution. HFPG, as a modifiable risk factor, should be given more importance. The implementation of targeted health intervention strategies is recommended for each country based on trends in the burden of HFPG-attributable MASLD.

Global burden of chronic kidney disease in adolescents and young adults, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

Background

The global status of chronic kidney disease (CKD) is underestimated, particularly the burden on adolescents and young adults (early-onset, aged 15-39).

Objective

We aim to investigate the pattern and trend of early-onset CKD from 1990 to 2019.

Methods

We analyzed age-specific rates of early-onset CKD incidence, death, and disability-adjusted life years (DALY) using Global Burden of Disease Study 2019 data. We examined the global, regional, national, gender-based, age group-based, and temporal changes of early-onset CKD burden from 1990 to 2019, as well as proportional DALY attributions of various risk factors.

Results

From 1990 to 2019, the global age-specific incidence rate (per 100,000 population) significantly increased from 25.04 (95% confidence interval 18.51, 31.65) to 32.21 (23.73, 40.81) for early-onset CKD. However, the global age-specific death rate significantly decreased from 2.96 (2.76, 3.15) to 2.86 (2.61, 3.11), and the age-specific DALY rate remained stable. Regarding sociodemographic indexes (SDI), countries with middle SDI had the highest incidence rates and the fastest increasing trends, while those with low and low-middle SDI experienced the highest death and DALY rates. Women had a generally higher age-specific incidence rate than men, whereas men showed higher age-specific death and DALY rates. In addition, the burdens of CKD increased with age among adolescents and young adults. Moreover, the main attributable risk factors for DALY of early-onset CKD were high systolic blood pressure (SBP), fasting plasma glucose (FPG), and body mass index (BMI).

Conclusion

The age-specific incidence rate of early-onset CKD increased significantly from 1990 to 2019, and the age-specific DALY rate remained stable. High SBP, high FPG, and high BMI were the primary risk factors. Targeted prevention and healthcare measures should be developed considering age, gender, and region.

Global public concern of childhood and adolescence suicide: a new perspective and new strategies for suicide prevention in the post-pandemic era

BACKGROUND

Suicide is the second leading cause of death in young people worldwide and is responsible for about 52,000 deaths annually in children and adolescents aged 5-19 years. Familial, social, psychological, and behavioral factors play important roles in suicide risk. As traumatic events such as the COVID-19 pandemic may contribute to suicidal behaviors in young people, there is a need to understand the current status of suicide in adolescents, including its epidemiology, associated factors, the influence of the pandemic, and management initiatives.

DATA SOURCES

We investigated global and regional suicide mortality rates among children and adolescents aged 5-19 years using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. The suicide mortality rates from 1990 to 2019 were examined in 204 countries and territories across six World Health Organization (WHO) regions. Additionally, we utilized electronic databases, including PubMed/MEDLINE and Scopus, and employed various combinations of terms such as "suicide", "adolescents", "youth", "children", "risk factors", "COVID-19 pandemic", "prevention", and "intervention" to provide a narrative review on suicide within the pediatric population in the post-pandemic era.

RESULTS

Despite the decreasing trend in the global suicide mortality rate from 1990 to 2019, it remains high. The mortality rates from suicide by firearms or any other specified means were both greater in males. Additionally, Southeast Asia had the highest suicide rate among the six WHO regions. The COVID-19 pandemic seems to contribute to suicide risk in young people; thus, there is still a strong need to revisit appropriate management for suicidal children and adolescents during the pandemic.

CONCLUSIONS

The current narrative review integrates up-to-date knowledge on suicide epidemiology and the effects of the COVID-19 pandemic, risk factors, and intervention strategies. Although numerous studies have characterized trends in suicide among young people during the pre-pandemic era, further studies are required to investigate suicide during the pandemic and new strategies for suicide prevention in the post-pandemic era. It is necessary to identify effective prevention strategies targeting young people, particularly those at high risk, and successful treatment for individuals already manifesting suicidal behaviors. Care for suicidal children and adolescents should be improved with parental, school, community, and clinical involvement.

The spectrum of acute illness and mortality of children and adolescents presenting to emergency services in Sanghar district hospital, Pakistan: a prospective cohort study

OBJECTIVE

To describe presenting diagnoses and rates and causes of death by age category and sex among children with acute illness brought to a district headquarter hospital in Pakistan.

DESIGN

Prospective cohort study.

SETTING

Sanghar district headquarter hospital, Sindh, Pakistan between December 2019 and April 2020 and August 2020 and December 2020.

PARTICIPANTS

3850 children 0-14 years presenting with acute illness to the emergency and outpatient departments and 1286 children admitted to the inpatient department.

OUTCOME MEASURES

The primary outcome was Global Burden of Disease diagnosis category. Secondary outcomes were 28-day mortality rate, cause of death and healthcare delays, defined as delay in care-seeking, delay in reaching the healthcare facility and delay in appropriate treatment.

RESULTS

Communicable diseases were the most common presenting diagnoses among outpatients and among inpatients aged 1 month to 9 years. Non-communicable diseases and nutritional disorders were more common with increasing age. Few children presented with injuries. Newborn period (age <28 days) was associated with increased odds of death (OR 4.34 [95% CI 2.38 to 8.18], p<0.001, reference age 28 days-14 years) and there was no significant difference in odds of death between female vs male children (OR 1.12, 95% CI 0.6 to 2.04, p=0.72). 47 children died in the hospital (3.6%) and three (0.2%) died within 28 days of admission. Most children who died were <28 days old (n=32/50, 64%); leading diagnoses included neonatal sepsis/meningitis (n=13/50, 26%), neonatal encephalopathy (n=7/50, 14%) and lower respiratory tract infections (n=6/50, 12%). Delays in care-seeking (n=15) and in receiving appropriate treatment (n=12) were common.

CONCLUSION

This study adds to sparse literature surrounding the epidemiology of disease and hospital outcomes for children with acute illness seeking healthcare in rural Pakistan and, in particular, among children aged 5-14 years. Further studies should include public and private hospitals within a single region to comprehensively describe patterns of care-seeking and interfacility transfer in district health systems.

World Psychiatric Association-Asian Journal of Psychiatry Commission on Public Mental Health

Although there is considerable evidence showing that the prevention of mental illnesses and adverse outcomes and mental health promotion can help people lead better and more functional lives, public mental health remains overlooked in the broader contexts of psychiatry and public health. Likewise, in undergraduate and postgraduate medical curricula, prevention and mental health promotion have often been ignored. However, there has been a recent increase in interest in public mental health, including an emphasis on the prevention of psychiatric disorders and improving individual and community wellbeing to support life trajectories, from childhood through to adulthood and into older age. These lifespan approaches have significant potential to reduce the onset of mental illnesses and the related burdens for the individual and communities, as well as mitigating social, economic, and political costs. Informed by principles of social justice and respect for human rights, this may be especially important for addressing salient problems in communities with distinct vulnerabilities, where prominent disadvantages and barriers for care delivery exist. Therefore, this Commission aims to address these topics, providing a narrative overview of relevant literature and suggesting ways forward. Additionally, proposals for improving mental health and preventing mental illnesses and adverse outcomes are presented, particularly amongst at-risk populations.

Global burden of type 2 diabetes in adolescents from 1990 to 2019

Purpose

To evaluate the burden of type 2 diabetes (T2D) among adolescents (15-24 years old) from 1990 to 2019.

Methods

The age-standardized incidence rate (ASIR) and disability-adjusted life years (DALYs) rate of adolescents were analyzed according to age, sex, geographical location, and sociodemographic index (SDI). The estimated annual percentage change (EAPC) was estimated to quantify the trends.

Results

From 1990 to 2019, the ASIR (EAPC = 1.07) and age-standardized DALY rate (EAPC = 2.01) of T2D in adolescents showed an increasing trend. The ASIR was higher in males than in females. The burden was greater in the 20-24-year age group. Of the five SDI regions, the highest ASIR and age-standardized DALY rate were found in low-middle-SDI regions, while the greatest increase in these rates was observed in high-SDI regions (EAPC = 3.28 and 3.55, respectively). Of the 21 regions analyzed, the highest ASIR and age-standardized DALY rate were found in Oceania. Of the 204 countries analyzed, the Marshall Islands (651.16) and Kiribati (277.42) had the highest ASIR and DALYs, respectively. The regions with the greatest increase in the ASIR from 1990 to 2019 were Western Europe (EAPC = 4.15), high-income North America (EAPC = 4.72).

Conclusions

The global burden of T2D in adolescents showed an overall upward trend from 1990 to 2019. It is necessary to strengthen prevention measures related to risk factors for T2D among young people, especially in areas with a low-to-medium SDI.

Addressing the Global Burden of Cardiovascular Disease in Women: JACC State-of-the-Art Review

Cardiovascular diseases (CVDs) are responsible for approximately 35% of all deaths in women. In 2019, the global age-standardized CVD prevalence and mortality of women were 6,403 per 100,000 and 204 per 100,000, respectively. Although the age- and population-adjusted prevalence has decreased globally, opposite trends are evident in regions of socioeconomic deprivation. Cardiovascular health and outcomes are influenced by regional socioeconomic, environmental, and community factors, in addition to health care system and individual factors. Cardiovascular care in women is commonly plagued by delayed diagnoses, undertreatment, and knowledge gaps, particularly in women-specific or women-predominant conditions. In this paper, we describe the global epidemiology of CVD and highlight multilevel determinants of cardiometabolic health. We review knowledge and health care gaps that serve as barriers to improving CVD outcomes in women. Finally, we present national, community, health care system, and research strategies to comprehensively address cardiometabolic risk and improve outcomes in women.

Does Matrilineality Reduce Gender Inequality in Environmental and Social Impact Assessment (ESIA) Public Participation? Some Evidence from Malawi

This paper reports on Environmental and Social Impact Assessment (ESIA) public participation in Malawi with a focus on the role of women from matrilineal and patrilineal marriage systems. Six rural ESIA projects are explored of which three are in areas of patrilineal and three are in areas of matrilineal systems. Participation space was found to be consistently dominated by men, with no obvious differences between both systems. The key reasons are likely to be lower educational and social status of women in rural areas throughout the country. This is associated with a number of challenges, including chronic poverty and food insecurity. Affirmative action is needed to achieve a better representation of women in ESIA processes.

Differences across the lifespan between females and males in the top 20 causes of disease burden globally: a systematic analysis of the Global Burden of Disease Study 2021

BACKGROUND

Sex and gender shape health. There is a growing body of evidence focused on comprehensively and systematically examining the magnitude, persistence, and nature of differences in health between females and males. Here, we aimed to quantify differences in the leading causes of disease burden between females and males across ages and geographies.

METHODS

We used the Global Burden of Disease Study 2021 to compare disability-adjusted life-year (DALY) rates for females and males for the 20 leading causes of disease burden for individuals older than 10 years at the global level and across seven world regions, between 1990 and 2021. We present absolute and relative differences in the cause-specific DALY rates between females and males.

FINDINGS

Globally, females had a higher burden of morbidity-driven conditions with the largest differences in DALYs for low back pain (with 478·5 [95% uncertainty interval 346·3-632·8] more DALYs per 100 000 individuals among females than males), depressive disorders (348·3 [241·3-471·0]), and headache disorders (332·9 [48·3-731·9]), whereas males had higher DALY rates for mortality-driven conditions with the largest differences in DALYs for COVID-19 (with 1767·8 [1581·1-1943·5] more DALYs per 100 000 among males than females), road injuries (1012·2 [934·1-1092·9]), and ischaemic heart disease (1611·8 [1405·0-1856·3]). The differences between sexes became larger over age and remained consistent over time for all conditions except HIV/AIDS. The largest difference in HIV/AIDS was observed among those aged 25-49 years in sub-Saharan Africa with 1724·8 (918·8-2613·7) more DALYs per 100 000 among females than males.

INTERPRETATION

The notable health differences between females and males point to an urgent need for policies to be based on sex-specific and age-specific data. It is also important to continue promoting gender-sensitive research, and ultimately, implement interventions that not only reduce the burden of disease but also achieve greater health equity.

FUNDING

Bill & Melinda Gates Foundation.

Prevalence and predictors of prenatal depression during the COVID-19 pandemic: A multistage observational study in Beijing, China

OBJECTIVE

While growing psychological health issues among pregnant women during the COVID-19 pandemic have been clearly validated, most research was conducted in countries with relatively lax quarantine measures. This study aimed to compare the prevalence of prenatal depression among pre-, peak-, and post-COVID-19 in Beijing, the region with a stringent response policy in China. We also explore predictors of prenatal depression throughout the outbreak.

METHODS

We investigated prenatal depression among 742 pregnant women who received antenatal checkups in Beijing from March 28, 2019 to May 07, 2021 using the Edinburgh Postnatal Depression Scale and associative demographic, pregnancy-related, and psychosocial characteristics were measured. The phase was divided into pre-, peak-, and post-COVID-19 in light of the trajectory of COVID-19. Pearson's Chi-square test was used after the examination of confounders homogeneity. The bivariable and multivariable logistic regression was conducted to explore predictors.

RESULTS

The pooled prevalence of prenatal depression was 11.9% throughout the COVID-19 pandemic. Rates at different phases were 10.6%, 15.2%, and 11.1% respectively and no significant difference was observed. Multivariable logistic regression revealed that history of mental illness, number of boy-preference from both pregnant women and husband's family, social support, occupation, and living space were independent predictors of prenatal depression in Beijing.

CONCLUSION

Our data suggested that the impact of this pandemic on prenatal depression in Beijing appears to be not significant, which will strengthen confidence in adhering to current policy for decision-makers and provide important guidance for the development of major outbreak control and management policies in the future. Our findings may also provide a more efficient measure to identify high-risk pregnant women for professionals and help raise gender equity awareness of pregnant women and their husbands' families. Future studies should focus on the value of targeted care and family relations on the mental health of pregnant women.

The great Indian demonetization and gender gap in health outcomes: Evidence from two Indian states

We utilize the timing of India's 2016 demonetization policy to examine whether a negative macroeconomic shock disproportionately affects women's health outcomes relative to men's. Our empirical framework considers women as the treated group and men as the comparison group. Using data from the National Family Health Survey-4 and a household fixed effects model, we find that the induced income shock leads to a 4% decline in hemoglobin for women as compared to the pre-demonetization level. This corresponds to a 21% increase in the gender gap in hemoglobin. The result is further validated with an event study and a variety of robustness checks. An examination of food consumption suggests that this pattern is possibly driven by a widening male-female gap in the consumption of iron-rich foods.

Interpersonal Violence and Gender Inequality in Adolescents: A Systematic Analysis of Global Burden of Disease Data From 1990 to 2019

PURPOSE

Interpersonal violence is a leading cause of adolescent deaths and disability. This study investigates sex differences in burden of interpersonal violence for adolescents and explores associations with gender inequality.

METHOD

Using data from the 2019 Global Burden of Disease study, we report numbers, proportions, rates of interpersonal violence deaths and disability adjusted life years (DALYs) for all ages, and rate of change (from 1990 to 2019) in adolescents aged 10-24 years disaggregated by sex and geography. We explored associations with gender inequality using gender inequality index.

RESULTS

One in four (24.8%) all-age interpersonal violence deaths are in adolescents. In 2019, the rate of deaths in adolescent males was almost six times higher than females (9.3 vs. 1.6 per 100,000); and since 1990, the rate of decline in DALYs for females was double than that for males (-28.9% vs. -12.7%). By contrast, the burden of sexual violence is disproportionately borne by adolescent females, with over double the rate than males (DALYs: 42.8 vs. 17.5 per 100,000). In countries with greater gender inequality, the male-to-female ratio (deaths and DALYs) was increased among older adolescents, pointing to benefits for males in more gender equal settings.

DISCUSSION

Social identities, relationships, and attitudes to violence are established in adolescence, which is an inflection point marking the emergence of disproportionate burdens of interpersonal violence. Our findings affirm that global agendas must be expanded to address interrelated factors driving multiple forms of interpersonal violence experienced by adolescents and reverberating to the next generation.

Adolescent sexual and reproductive health and rights for ethnic minority girls in Vietnam

There has been significant progress in improved adolescent sexual and reproductive health and rights (ASRHR) for girls across low- to- middle-income countries (LMICs). However, progress has been uneven, and disparities persistent across and within countries. For example, Vietnam is one of only nine countries to have achieved the 2015 maternal mortality rate (MMR) target of the Millennium Development Goals (MDGs) as a nation, but for some sub-populations, progress has been much slower, and MMR is more than twice that the national average. Ensuring equity is a current focus of the Sustainable Development Goals (SDGs) agenda that seeks to Leave No One Behind. This paper explores some of these inequities and potential drivers for ethnic minority adolescent girls in Vietnam, with a specific focus on the Tay community, the largest ethnic minority group in Vietnam. This paper highlights the challenges to progress, including areas where there is still limited evidence about the range of socio-cultural factors that may determine sexual and reproductive health outcomes for Tay adolescent girls. In the era of the SDGs, Vietnam's national policy platforms and current aid architecture provide a solid basis on which to build research, policy and practice investments that improve the health of adolescent ethnic minority girls in Vietnam.

Women on the frontline: exploring the gendered experience for Pacific healthcare workers during the COVID-19 pandemic

Background

Women comprise 90% of patient-facing global healthcare workers (HCWs), yet remain underpaid, undervalued, and under-represented in leadership and decision-making positions, particularly across the Pacific region. The COVID-19 pandemic has exacerbated these health workplace inequalities. We sought to understand Pacific women HCWs experience from the COVID-19 frontline to contribute to policies aimed at addressing gendered gaps in regional health systems.

Methods

Our interpretative phenomenological study used critical feminist and social theory, and a gendered health systems analytical framework. Data were collected using online focus groups and in-depth interviews with 36 Pacific regional participants between March 2020 and July 2021. Gender-specific content and women's voices were privileged for inductive analysis by Pacific and Australian women researchers with COVID-19 frontline lived experience.

Findings

Pacific women HCWs have authority and responsibility resulting from their familial, biological, and cultural status, but are often subordinate to men. They were emancipatory leaders during COVID-19, and as HCWs demonstrated compassion, situational awareness, and concern for staff welfare. Pacific women HCWs also faced ethical challenges to prioritise family or work responsibilities, safely negotiate childbearing, and maintain economic security.

Interpretation

Despite enhanced gendered power differentials during COVID-19, Pacific women HCWs used their symbolic capital to positively influence health system performance. Gender-transformative policies are urgently required to address disproportionate clinical and community care burdens and to protect and support the Pacific female health workforce.

Funding

Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Correlates of poor self-rated health among school-going adolescent girls in urban Varanasi, India

BACKGROUND

The concept of self-rated health (SRH) has widely been studied among the adults and older population in developed as well as developing countries, including India. Also, studies are available in abundance examining the various concepts of SRH among adolescents. However, in India, studies on the SRH of adolescents remain scarce, especially those aiming to understand the correlates of SRH among school-going adolescent girls in an urban setting. Therefore, this study aims to determine the correlates of poor SRH among school-going adolescent girls in the urban setting of Varanasi, India.

METHODS

This study is based on the primary data collected in the Varanasi district of Uttar Pradesh, India, from October 2019 to February 2020. Nearly 350 adolescent girls and their mothers were personally interviewed. Self-rated health was the primary outcome variable of this study. The exact wording of the question asked from the adolescent girls was, "In general, how would you say your health is?".

RESULTS

Almost one-fifth (19.4%) of the adolescent girls reported poor SRH. Adolescent girls from Other Backward Class (OBC) [OR: 0.39; 95% CI: .18-.85] and Others caste [OR: 0.58; 95% CI: .23-0.87] were less likely to report poor SRH than their Scheduled Caste/Scheduled Tribe (SC/ST) counterparts. Girls residing in households where number of daughters were more than sons were more likely to report poor SRH [OR: 7.8; 95% CI: 1.5-39.5] than girls who belonged to the daughters only households.

CONCLUSION

Composition of children was one of the important factors as outlined in this study. The role of mothers in improving the overall SRH of the girls is critical as they are involved in caring process of their daughters.

Influence of engaging female caregivers in households with adolescent girls on adopting equitable family eating practices: a quasi-experimental study

Background

In patriarchal societies, female caregivers decide on food allocation within a family based on prevailing gender and age norms, which may lead to inequality that does not favor young adolescent girls. This study evaluated the effect of a community-based social norm intervention involving female caregivers in West Hararghe, Ethiopia. The intervention was engaging female caregivers along with other adult influential community members to deliberate and act on food allocation social norms in a process referred to as Social Analysis and Action (SAA).

Method

We used data from a large quasi-experimental study to compare family eating practices between those who participated in the Social Analyses and Action intervention and those who did not. The respondents were female caregivers in households with young adolescent girls (ages 13 and 14 years). The study's outcome was the practice of family eating together from the same dish. The difference in difference (DID) analysis with the mixed effect logistic regression model was used to examine the effect of the intervention.

Result

The results showed improved family eating practices in both groups, but the improvement was greater in the intervention group. The DID analysis showed an 11.99 percentage points greater improvement in the intervention arm than in the control arm. The mixed-effect regression produced an adjusted odds ratio of 2.08 (95% CI [1.06-4.09]) after controlling selected covariates, p-value 0.033.

Conclusions

The involvement of influential adult community members significantly improves the family practice of eating together in households where adolescent girls are present in our study. The intervention has great potential to minimize household food allocation inequalities and thus improve the nutritional status of young adolescents. Further studies are necessary to evaluate the effectiveness of the intervention in different social norm contexts to formulate policy and guidelines for scale-up.

A nationwide survey on the preference of Indian undergraduate medical students to go abroad for higher studies and residency

Context

Getting residency training abroad is a critical motivator in the emigration of Indian medical students. Brain drain is an emerging issue, especially for developing countries as it causes a shortage of trained staff in the donor country.

Aim

We aimed to survey Indian medical students to know about their intentions to get trained abroad and to understand the factors influencing their decision.

Materials and Methods

In this cross-sectional observational study, we surveyed Indian undergraduate medical students of all professional years, including internship. A validated questionnaire collected data on students' demographics and educational characteristics, intention to study overseas or stay back in India, and factors influencing their decision.

Results

Out of a total of 1199 responses (51.1% males, 48.9% females), 45.0% partakers had planned to pursue their residency abroad, while 33.8% wanted to stay in India and 21.2% were undecided. Better lifestyle and higher pay grades overseas were viewed as the most significant barriers to staying back in India and a key influencer in decision-making among the maximum number of students (412; 76.3%). On the other hand, a whopping 58.2% of participants opined that they wanted to stay back in India for taking care of their parents.

Conclusions

Source countries with better healthcare facilities and better incomes tend to attract medical students. Awareness among medical educators regarding constantly changing curricula, a shift to a competency-based education system, better pay grades, limited working hours, and interventions to mitigate workplace violence could help prevent brain drain among Indian medical students and graduates.

Improving mental ill-health with psycho-social group interventions in South Asia-A scoping review using a realist lens

This scoping review aimed to synthesise current evidence related to psycho-social groups as part of community-based mental health interventions in South Asia. We used a realist lens to pay attention to the contexts and mechanisms supporting positive outcomes. We included studies published from January 2007 to February 2022 that: were based in communities in South Asia, included a group component, reported on interventions with a clear psychosocial component, targeted adults and were implemented by lay community health workers. Two reviewers extracted data on intervention components, groups and facilitators, participant demographics and enabling contexts, mechanisms and outcomes. Expert reference panels including people with lived experience of psycho-social disability, mental health professionals and policy makers confirmed the validity and relevance of initial review findings. The review examined 15 interventions represented by 42 papers. Only four interventions were solely psycho-social and nearly all included psychoeducation and economic support. Only 8 of the 46 quantitative outcome measures used were developed in South Asia. In a context of social exclusion and limited autonomy for people with psychosocial disability, psychosocial support groups triggered five key mechanisms. Trusted relationships undergirded all mechanisms, and provided a sense of inclusion, social support and of being able to manage mental distress due to improved skills and knowledge. Over time group members felt a sense of belonging and collective strength meaning they were better able to advocate for their own well-being and address upstream social health determinants. This led to outcomes of improved mental health and social participation across the realms of intrapersonal, interpersonal and community. Psychosocial groups merit greater attention as an active ingredient in community interventions and also as an effective, relevant, acceptable and scalable platform that can promote and increase mental health in communities, through facilitation by lay community health workers.

Non-communicable disease mortality in young people with a history of contact with the youth justice system in Queensland, Australia: a retrospective, population-based cohort study

BACKGROUND

Young people who have had contact with the criminal justice system are at increased risk of early death, especially from injuries. However, deaths due to non-communicable diseases (NCDs) in this population remain poorly described. We aimed to estimate mortality due to NCDs in people with a history of involvement with the youth justice system, compare NCD mortality rates in this population with those in the general population, and characterise demographic and justice-related factors associated with deaths caused by NCDs in people with a history of contact with the youth justice system.

METHODS

In this retrospective, population-based cohort study (the Youth Justice Mortality [YJ-Mort] study), we included all people aged 10-18 years (at baseline) charged with a criminal offence in Queensland, Australia, between June 30, 1993, and July 1, 2014. We probabilistically linked youth justice records with adult correctional records and national death records up to Jan 31, 2017. Indigenous status was ascertained from youth justice and adult correctional records, with individuals identified as Indigenous in either source classified as Indigenous in the final dataset. We estimated crude mortality rates and standardised mortality ratios (SMRs) for comparisons with data from the Australian general population. We identified risk factors for NCD deaths using competing-risks regression.

FINDINGS

Of 48 670 individuals aged 10-18 years (at baseline) charged with a criminal offence in Queensland, Australia, between June 30, 1993, and July 1, 2014, 11 897 (24·4%) individuals were female, 36 773 (75·6%) were male, and 13 250 (27·2%) were identified as identified as Indigenous. The median age at first contact with the youth justice system was 15 years (IQR 14-16), the median follow-up time was 13·4 years (8·4-18·4), and the median age at the end of the study was 28·6 years (23·6-33·6). Of 1431 deaths, 932 (65·1%) had a known and attributed cause, and 121 (13·0%) of these were caused by an NCD. The crude mortality rate from NCDs was 18·5 (95% CI 15·5-22·1) per 100 000 person-years among individuals with a history of involvement with the youth justice system, which was higher than among the age-matched and sex-matched Australian general population (SMR 1·67 [1·39-1·99]). Two or more admissions to adult custody (compared with none; adjusted sub-distribution hazard ratio 2·09 [1·36-3·22]), and up to 52 weeks in adult custody (compared with none; 1·98 [1·18-3·32]) was associated with NCD death.

INTERPRETATION

Young people with a history of contact with the justice system are at increased risk of death from NCDs compared with age-matched and sex-matched peers in the general Australian population. Reducing youth incarceration and providing young people's rights to access clinical, preventive, and restorative services should be a priority.

FUNDING

National Health and Medical Research Council.

The unfinished agenda of communicable diseases among children and adolescents before the COVID-19 pandemic, 1990-2019: a systematic analysis of the Global Burden of Disease Study 2019

BACKGROUND

Communicable disease control has long been a focus of global health policy. There have been substantial reductions in the burden and mortality of communicable diseases among children younger than 5 years, but we know less about this burden in older children and adolescents, and it is unclear whether current programmes and policies remain aligned with targets for intervention. This knowledge is especially important for policy and programmes in the context of the COVID-19 pandemic. We aimed to use the Global Burden of Disease (GBD) Study 2019 to systematically characterise the burden of communicable diseases across childhood and adolescence.

METHODS

In this systematic analysis of the GBD study from 1990 to 2019, all communicable diseases and their manifestations as modelled within GBD 2019 were included, categorised as 16 subgroups of common diseases or presentations. Data were reported for absolute count, prevalence, and incidence across measures of cause-specific mortality (deaths and years of life lost), disability (years lived with disability [YLDs]), and disease burden (disability-adjusted life-years [DALYs]) for children and adolescents aged 0-24 years. Data were reported across the Socio-demographic Index (SDI) and across time (1990-2019), and for 204 countries and territories. For HIV, we reported the mortality-to-incidence ratio (MIR) as a measure of health system performance.

FINDINGS

In 2019, there were 3·0 million deaths and 30·0 million years of healthy life lost to disability (as measured by YLDs), corresponding to 288·4 million DALYs from communicable diseases among children and adolescents globally (57·3% of total communicable disease burden across all ages). Over time, there has been a shift in communicable disease burden from young children to older children and adolescents (largely driven by the considerable reductions in children younger than 5 years and slower progress elsewhere), although children younger than 5 years still accounted for most of the communicable disease burden in 2019. Disease burden and mortality were predominantly in low-SDI settings, with high and high-middle SDI settings also having an appreciable burden of communicable disease morbidity (4·0 million YLDs in 2019 alone). Three cause groups (enteric infections, lower-respiratory-tract infections, and malaria) accounted for 59·8% of the global communicable disease burden in children and adolescents, with tuberculosis and HIV both emerging as important causes during adolescence. HIV was the only cause for which disease burden increased over time, particularly in children and adolescents older than 5 years, and especially in females. Excess MIRs for HIV were observed for males aged 15-19 years in low-SDI settings.

INTERPRETATION

Our analysis supports continued policy focus on enteric infections and lower-respiratory-tract infections, with orientation to children younger than 5 years in settings of low socioeconomic development. However, efforts should also be targeted to other conditions, particularly HIV, given its increased burden in older children and adolescents. Older children and adolescents also experience a large burden of communicable disease, further highlighting the need for efforts to extend beyond the first 5 years of life. Our analysis also identified substantial morbidity caused by communicable diseases affecting child and adolescent health across the world.

FUNDING

The Australian National Health and Medical Research Council Centre for Research Excellence for Driving Investment in Global Adolescent Health and the Bill & Melinda Gates Foundation.

In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset

OBJECTIVES

We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors.

METHODS

We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors.

RESULTS

Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32).

CONCLUSION

Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.

Race, class, caste, disability, sterilisation and hysterectomy

This interdisciplinary historical paper focuses on the past and current state of diverse forms of surgical hysterectomy as a global phenomenon relating to population control and sterilisation. It is a paper grounded in historical inquiry but is unconventional relative to the norms of historical scholarship both in its wide geographical scope informed by the methodologies of global and intercultural history, in its critique of current clinical practices informed by recent feminist, race, biopolitical and disability studies, and by its engagement with scholarship in health sociology and medical anthropology which has focused on questions of gender and healthcare inequalities. The first part of the paper surveys existing medical, social-scientific and humanistic research on the racial, class, disability and caste inequalities which have emerged in the recent global proliferation of hysterectomy; the second part of the paper is about the diverse global rationales underlying radical gynaecological surgeries as a form of sterilisation throughout the long twentieth century. Radical gynaecological surgeries have been promoted for several different purposes throughout their history and, of course, are sometimes therapeutically necessary. However, they have often disproportionately impacted the most disadvantaged groups in several different global societies and have frequently been concentrated in populations that are already maligned on the basis of race, ethnicity, age, criminality, disability, gender deviation, lower class, caste or poverty. This heritage continues to inform current practices and contributes to ongoing global inequalities of healthcare.

Sex disparity in childhood cancer in India: a multi-centre, individual patient data analysis

BACKGROUND

Sex disparity and its determinants in childhood cancer in India remain unexplored, with scarce information available through summary statistics of cancer registries. This study analysed the degree of sex bias in childhood cancer in India and its clinical and demographical associations.

METHODS

In this retrospective, multicentre cohort study, we collected individual data of children (aged 0-19 years) with cancer extracted from the hospital-based records of three cancer centres in India between Jan 1, 2005, and Dec 31, 2019, and two population-based cancer registries (PBCRs; Delhi [between Jan 1, 2005, and Dec 31, 2014] and Madras Metropolitan Tumour Registry [between Jan 1, 2005, and Dec 31, 2017]). We extracted data on age, sex, and confirmed diagnosis of malignancy (according to the International Classification of Diseases-10 coding),and excluded participants if they were without a recorded diagnosis, had a benign diagnosis, had missing sex information, resided outside of India, or were a donor for haematopoietic stem cell transplantation (HSCT). The primary outcome was the male-to-female incidence rate ratio (MF-IRR) in the two PBCRs and the male-to-female ratios (MFR) from the hospital-based and the HSCT data. For PBCR data, MF-IRR was estimated by dividing the MFR by the total population at risk. MFR was analysed for patients seeking treatment at the cancer centres and for those undergoing HSCT. Logistic regression analyses were done to explore the association of clinical and demographical variables with sex of the patients seeking treatment and those undergoing HSCT in hospital-based data and multivariable analyses were done to determine independent sociodemographic predictors of sex bias. Annual time trends of MFR and MF-IRR during the 15-year study period were ascertained by time series regression analyses.

FINDINGS

We included 11 375 children from PBCRs in the study. 26 891 children from hospital-based records were screened, and data from 22 893 (85·1%) were included (including 514 who underwent HSCT). Residence details were missing for 257 (1·1%) of 22 893 patients from hospital-based records. The crude MFR of children at diagnosis was in favour of boys: 2·00 (95% CI 1·92-2·09) in the Delhi PBCR and 1·44 (1·32-1·57) in Madras Metropolitan Tumour Registry. The MF-IRRs for cancer diagnosis were also skewed in favour of boys in both PBCRs (Delhi 1·69 [95% CI 1·61-1·76]; Madras Metropolitan Tumour Registry 1·37 [1·26-1·49]). The MFR for children seeking treatment from hospital-based records was 2·06 (95% CI 2·00-2·12) in favour of boys. In subgroup analyses, the proportion of boys seeking treatment was higher in northern India than southern India (p<0·0001); in private centres than in centres providing subsidised treatment (p<0·0001); in patients with haematological malignancies than those with solid malignancies (p<0·0001); in those residing 100 km or further from the hospital than those within 100 km of a hospital (p<0·0001); and those living in rural areas than those living in urban areas (p=0·0006). The MFR of 514 children who underwent HSCT was 2·81 (95% CI 2·32-3·43) in favour of boys. Time trend analysis showed that MFR did not show any significant annual change in either the overall cohort or in any of the individual centres for hospital-based data; however, the analysis did show a declining MF-IRR in the Delhi PBCR from 2005 to 2014 (p=0·031).

INTERPRETATION

The sex ratio for childhood cancer in India has a bias towards boys at the level of diagnosis, which is more pronounced in northern India and in situations demanding greater financial commitment. Addressing societal sex bias and enhancing affordable health care for girls should be pursued simultaneously in India.

FUNDING

None.

TRANSLATION

For the Hindi translation of the abstract see Supplementary Materials section.

Person-centered care for diverse women: Narrative review of foundational research

Despite advocacy and recommendations to improve health care and health for persons who identify as women, women continue to face inequities in access to and quality of care. Person-centered care for women is one approach that could reduce gendered inequities. We conducted a series of studies to understand what constitutes person-centered care for women and how to achieve it. The overall aim of this article is to highlight the key findings of those studies that can inform policy, practice, and ongoing research. We conducted a narrative review of all studies related to person-centered care for women conducted in our group starting in 2018 over a 5-year period, which was general at the outset, and increasingly focused on racialized immigrant women who constitute a large proportion of the Canadian population. We organized study summaries by research phase: synthesis of person-centered care for women research, exploration of existing person-centered care for women guidance, consultation with key informants, consensus survey of key informants to prioritize strategies to achieve person-centered care for women, and consensus meeting with key informants to prioritize future research. We conducted the reported research in collaboration with an advisory group of diverse women and managers of community agencies. Our research revealed that little prior research had fully established what constitutes person-centered care for women, and in particular, how to achieve it. We also found little acknowledgment of person-centered care for women or strategies to support it in medical curriculum, clinical guidelines, or healthcare policies. We subsequently consulted women who differed by age, ethno-cultural group, health issue, education and geography, and clinicians of different specialties, who offered considerable insight on strategies to support person-centered care for women. Other diverse women, clinicians, healthcare managers, and researchers prioritized issues that warrant future research. We hope that by compiling a summary of our completed research, we draw attention to the need for person-centered care for women and motivate others to pursue it through policy, practice, and research.

Self-rated health among older adults in India: Gender specific findings from National Sample Survey

INTRODUCTION

The self-rated health (SRH) is a widely adopted indicator of overall health. The sponge hypothesis suggests that predictive power of SRH is stronger among women compared to men. To gain a better understanding of how gender influences SRH, this study examined whether and what determinants of gender disparity exist current self-rated health (SRHcurrent) and change in SRH (SRHchange) among older adults in Indian setting.

MATERIALS AND METHODS

We used cross-sectional data from the 75th National Sample Survey Organizations (NSSO), collected from July 2017 to June 2018. The analytical sample constitutes 42,759 older individuals aged 60 years or older with 21,902 older men and 20,857 older women (eliminating two non-binary individuals). Outcome measures include two variables of poor/worse SRH status (SRHcurrent and SRHchange). We have calculated absolute gaps in the prevalence of poor SRHcurrent and worse SRHchange by background characteristics. We carried out binary logistic regression models to examine the predictors of poor SRHcurrent and worse SRHchange among older adults.

RESULTS

The overall absolute gender gap in poor SRHcurrent was 3.27% and it was 0.58% in worse SRHchange. Older women had significantly higher odds of poor SRHcurrent [AOR = 1.09; CI = 0.99, 1.19] and worse SRHchange [AOR = 1.09; CI = 1.02, 1.16] compared to older men. Older adults belonging to middle-aged, oldest-old, economically dependent, not working, physically immobile, suffering from chronic diseases, belonging to Muslim religion, and Eastern region have found to have higher odds of poor SRHcurrent and worse SRHchange. Educational attainments showed lower odds of have poor SRHcurrent and worse SRHchange compared to those with no education. Respondents belonging to richest income quintile and those who were not covered by any health insurance, belonging to Schedule caste, OBC, Western and Southern regions are found to have lower odds of poor SRHcurrent and worse SRHchange. Compared to those in the urban residence, respondents from rural residence [AOR = 1.09; CI = 1.02, 1.16] had higher odds of worse SRHchange.

CONCLUSIONS

Supporting the sponge hypothesis, a clear gender gap was observed in poor current SRH and worse change in SRH among older adults in India with a female disadvantage. We further found lower socioeconomic and health conditions and lack of resources as determinants of poor current SRH and its worse change, which is crucial to address the challenge of the older people's health and their perception of well-being.

Gender, Stress, and Well-Being in Adulthood

Exposure to stressors may be one of the most critical components of health and well-being. Although research on stress and health abounds, most studies have focused on establishing that stress is harmful to physical and mental health whereas less attention has been paid to analysing the effects of stress on well-being. The main purpose of this study is to investigate the relevance of gender in the association of stress with well-being in adulthood. A cross-sectional study was conducted with 1578 women and 1507 men from the Spanish general population aged between 30 and 59. All participants were assessed by eight self-reports measuring chronic stress, life events, daily hassles, eudaimonic well-being, life satisfaction, masculine/instrumental and feminine/expressive traits, coping styles, and social support. Although stress does not affect women's eudaimonic well-being, a greater number of life events and more daily hassles rendered lower life satisfaction in women. Men's greater chronic stress was associated with lower eudaimonic well-being and life satisfaction; moreover, a greater number of life events was associated with men's lower life satisfaction. We conclude that gender is relevant in the stress and well-being of adults as well as in the association between stress and well-being.

Global burden of type 2 diabetes in adolescents and young adults, 1990-2019: systematic analysis of the Global Burden of Disease Study 2019

OBJECTIVE

To estimate the global burden of type 2 diabetes in adolescents and young adults (aged 15-39 years) from 1990 to 2019.

DESIGN

Systematic analysis.

DATA SOURCE

Global Burden of Disease Study 2019. Participants aged 15-39 years from 204 countries and territories, 1990-2019.

MAIN OUTCOMES MEASURES

Age standardised incidence rate, age standardised disability adjusted life years (DALY) rate, and age standardised mortality rate for type 2 diabetes in people aged 15-39 years from 1990 to 2019, and proportional DALY attributable to different risk factors.

RESULTS

From 1990 to 2019, significant increases in age standardised incidence rate and age standardised DALY rate were found for type 2 diabetes in adolescents and young adults globally (P<0.001). Age standardised incidence rate (per 100 000 population) increased from 117.22 (95% confidence interval 117.07 to 117.36) in 1990 to 183.36 (183.21 to 183.51) in 2019, and age standardised DALY rate (per 100 000 population) increased from 106.34 (106.20 to 106.48) in 1990 to 149.61 (149.47 to 149.75) in 2019. The age standardised mortality rate (per 100 000 population) was modestly increased from 0.74 (0.72 to 0.75) in 1990 to 0.77 (0.76 to 0.78) in 2019. When grouped by countries with different sociodemographic indexes, countries with a low-middle and middle sociodemographic index had the highest age standardised incidence rate and age standardised DALY rate in 2019, whereas countries with a low sociodemographic index had the lowest age standardised incidence rate but the highest age standardised mortality rate. Women generally had higher mortality and DALY rates than men at ages <30 years, but differences between the sexes were reversed in those aged >30 years except in countries with a low sociodemographic index. The main attributable risk factor for DALY for early onset type 2 diabetes was high body mass index in all regions by sociodemographic index. The proportional contribution of other risk factors varied across regions, however, with higher proportions of ambient particulate air pollution and smoking in countries with a high sociodemographic index and higher proportions of household air pollution from solid fuels and diet low in fruit in countries with a low sociodemographic index.

CONCLUSIONS

Early onset type 2 diabetes is a growing global health problem in adolescents and young adults, especially in countries with a low-middle and middle sociodemographic index. A greater disease burden in women aged <30 years was found. Specific measures are needed in countries with different levels of socioeconomic development because of the variable attributable risk factors for type 2 diabetes in adolescents and young adults.

What potential traits do adolescents and early adults look for in mate preferences?

There are universal sex differences in mate preferences. Mostly, women will prioritize greater financial prospects, but men will emphasize physical attractiveness. However, we know little about whether these preferences remain stable in adolescence and early adulthood. The study examines whether these universal differences between men and women in mate preferences can be found in Bangladesh and whether these differences are constant among adolescents and early adults. An online survey was conducted by using a structured close-ended questionnaire to collect data from males and females who were aged no more than 30, yet to be married, had at least a secondary education, and belonged to any religious faith. A total of 2017 people, 1059 males and 958 females, participated in the survey. Independent Samples t-tests were estimated to compare the mean scores of the traits of interest, while Principal Component Analysis (PCA) was used to reduce the dimensions to outline the possible factors that affect mate preferences. The results show that women of Bangladesh prioritize greater financial prospects, whereas men emphasize traits related to fertility and reproduction. However, unlike the universal trend, having a similar religious background is among the top-two priorities of both males and females. Factor-wise differentiation indicates that, compared with males, females emphasize attachment and sociability. In addition, adolescent females put greater emphasis on refinement and neatness, mutual attraction-love, and desire for home and children than early adult females. Compared with adolescent males, early adult males were found emphasizing more on having kind and understanding mates. Therefore, results support universal sex differences, but religion, culturally-defined gender roles, and social environment also affect mate preferences; sometimes people require making some trade-offs between preferences depending on the sociocultural context.

Asking youth and adults about child maltreatment: a review of government surveys

OBJECTIVES

In this review we: (1) identify and describe nationally representative surveys with child maltreatment (CM) questions conducted by governments in low-income, middle-income and high-income countries and (2) describe procedures implemented to address respondents' safety and minimise potential distress.

DESIGN

We conducted a systematic search across eight databases from 1 January 2000 to 5 July 2021 to identify original studies with information about relevant surveys. Additional information about surveys was obtained through survey methods studies, survey reports, survey websites or by identifying full questionnaires (when available).

RESULTS

Forty-six studies representing 139 surveys (98 youth and 41 adult) conducted by governments from 105 countries were identified. Surveys implemented a variety of procedures to maximise the safety and/or reduce distress for respondents including providing the option to withdraw from the survey and/or securing confidentiality and privacy for the respondent. In many surveys, further steps were taken such as providing information for support services, providing sensitivity training to survey administrators when interviews were conducted, among others. A minority of surveys took additional steps to empirically assess potential distress experienced by respondents.

CONCLUSIONS

Assessing risk and protective factors and developing effective interventions and policies are essential to reduce the burden of violence against children. While asking about experiences of CM requires careful consideration, procedures to maximise the safety and minimise potential distress to respondents have been successfully implemented globally, although practices differ across surveys. Further analysis is required to assist governments to implement the best possible safety protocols to protect respondents in future surveys.

Gender Differences in Bullying Reflect Societal Gender Inequality: A Multilevel Study With Adolescents in 46 Countries

PURPOSE

Social patterns in bullying show consistent gender differences in adolescent perpetration and victimization with large cross-national variations. Previous research shows associations between societal gender inequality and gender differences in some violent behaviors in adolescents. Therefore, there is a need to go beyond individual associations and use a more social ecological perspective when examining gender differences in bullying behaviors. The aim of the present study was twofold: (1) to explore cross-national gender differences in bullying behaviors and (2) to examine whether national-level gender inequality relates to gender differences in adolescent bullying behaviors.

METHODS

Traditional bullying and cyberbullying were measured in 11-year-olds to 15-year-olds in the 2017/18 Health Behaviour in School-aged Children study (n = 200,423). We linked individual data to national gender inequality (Gender Inequality Index, 2018) in 46 countries and tested their association using mixed-effects (multilevel) logistic regression models.

RESULTS

Large cross-national variations were observed in gender differences in bullying. Boys had higher odds of perpetrating both traditional and cyberbullying and victimization by traditional bullying than girls. Greater gender inequality at country level was associated with heightened gender differences in traditional bullying. In contrast, lower gender inequality was associated with larger gender differences for cyber victimization.

DISCUSSION

Societal gender inequality relates to adolescents' involvement in bullying and gendered patterns in bullying. Public health policy should target societal factors that have an impact on young people's behavior.

Gender inequality in source country modifies sex differences in stroke incidence in Canadian immigrants

Research suggests that gender inequality, measured using the gender inequality index (GII), influences stroke mortality in women compared to men. We examine how source country GII modifies the rate of ischemic stroke in women compared to men after immigration to Canada, a country with low gender inequality. We used linked health data and immigration records of 452,089, stroke-free immigrants aged 40-69 year who migrated from 123 countries. Over 15 years of follow-up, 5991 (1.3%) had an incident ischemic stroke. We demonstrate (a) a lower adjusted rate of stroke in women compared to men (hazard ratio 0.64; 95% CI 0.61-0.67); (b) that sex differences in stroke incidence were modified by source country GII, as the hazard of stroke in women vs. men attenuated by a factor of 1.06 for every 0.1 increase in the GII of the source country (P_sex*GII = 0.002); and (c) migration to a country with low GII attenuates the adverse effect of source country GII on sex differences in stroke incidence. Evaluating pathways through which source country gender inequality differentially influences stroke risk in immigrant women compared to men could help develop strategies to mitigate the effects of early-life gender inequality on stroke risk.

Are Spanish Surveys Ready to Detect the Social Factors of Obesity?

The social origins of obesity are now recognised: a problem that is initially biological is today a public health problem with a social origin. This paper raises the question of whether the official statistical sources used to understand changes in diet are able to detect this shift in analysis. After reviewing the social factors that explain obesity, we examine the official Spanish statistics that can inform about dietary changes: the ENS National Health Survey, the EPF Family Budget Survey, and the EET Time Use Survey, all carried out by the Spanish Statistical Office. All of them include socio-demographic variables and some locational variables. However, the lack of health variables in the economic survey and the lack of social variables in the health survey prevent the gathering of reliable scientific evidence to offer solid support in stopping the obesity epidemic. Food has become particularly important as one of the main areas where unhealthy decisions and choices involve high risk; the situation also demonstrates the relationship between social inequality and obesity. Obesity is now understood in a radically different way and the origin of the problem lies in social and cultural factors. The current surveys do not provide the resources to capture the social causality of obesity, but slight modifications would help expand their capabilities and offer reliable scientific evidence to stop the obesity epidemic.

Obesity, Pregnancy and the Social Contract with Today's Adolescents

Adolescent health and well-being are of great concern worldwide, and adolescents encounter particular challenges, vulnerabilities and constraints. The dual challenges of adolescent parenthood and obesity are of public health relevance because of the life-altering health and socioeconomic effects on both the parents and the offspring. Prevention and treatment strategies at the individual and population levels have not been successful in the long term, suggesting that adolescent pregnancy and obesity cannot be managed by more of the same. Here, we view adolescent obese pregnancy through the lens of the social contract with youth. The disruption of this contract is faced by today's adolescents, with work, social and economic dilemmas which perpetuate socioeconomic and health inequities across generations. The lack of employment, education and social opportunities, together with obesogenic settings, increase vulnerability and exposure to lifelong health risks, affecting their offspring's life chances too. To break such vicious circles of disadvantage and achieve sustainable solutions in real-world settings, strong efforts on the part of policymakers, healthcare providers and the community must be oriented towards guaranteeing equity and healthy nutrition and environments for today's adolescents. The involvement of adolescents themselves in developing such programs is paramount, not only so that they feel a sense of agency but also to better meet their real life needs.

Interventions for and experiences of shared decision-making underpinning reproductive health, family planning options and pregnancy for women with or at high risk of kidney disease: a systematic review and qualitative framework synthesis

OBJECTIVE

To determine intervention effects and synthesise qualitative research that explored women with or at high risk of kidney disease experiences of shared decision-making in relation to their reproductive health, family planning options and pregnancy.

DESIGN

A systematic review of interventions and a qualitative evidence synthesis.

DATA SOURCES

We searched Cochrane, CINAHL, MEDLINE, Scopus, ProQuest, Elsevier, PubMed, ScienceDirect and Web of Science.

ELIGIBILITY CRITERIA

Shared decision-making interventions and qualitative studies related to reproductive health involving women with or at high risk of kidney disease published from 1980 until January 2021 in English (clinical settings, global perspective).

DATA EXTRACTION AND SYNTHESIS

Titles were screened against the inclusion criteria and full-text articles were reviewed by the whole team. Framework synthesis was undertaken.

RESULTS

We screened 1898 studies. No evidence-based interventions were identified. 18 qualitative studies were included, 11 kidney disease-specific studies and 7 where kidney disease was a common comorbidity. Women frequently felt unprepared and uninformed about their reproductive options. Conversations with healthcare professionals were commonly described as frustrating and unhelpful, often due to a perceived loss of autonomy and a mismatch in preferences and life goals. Examples of shared decision-making were rare. Kidney disease exacerbated societal expectations of traditional gender roles (eg, wife, mother, carer) including capability to have children and associated factors, for example, parenting, (sexual) relationships, body image and independent living (including financial barriers to starting a family). Local interventions were limited to types of counselling. A new health system model was developed to support new interventions.

CONCLUSION

There is a clear need to establish new interventions, test those already in development and develop new clinical guidance for the management of women with or at high risk of kidney disease in relation to their reproductive health, including options to preserve fertility earlier. Other health conditions with established personalised reproductive care packages, for example, cancer, could be used to benchmark kidney practice alongside the new model developed here.

Effect of imbalanced sampling and missing data on associations between gender norms and risk of adolescent HIV

BACKGROUND

Despite strides towards gender equality, inequalities persist or remain unstudied, due potentially to data gaps. Although mapped, the effects of key data gaps remain unknown. This study provides a framework to measure effects of gender- and age-imbalanced and missing covariate data on gender-health research. The framework is demonstrated using a previously studied pathway for effects of pre-marital sex norms among adults on adolescent HIV risk.

METHODS

After identifying gender-age-imbalanced Demographic and Health Survey (DHS) datasets, we resampled responses and restricted covariate data from a relatively complete, balanced dataset derived from the 2007 Zambian DHS to replicate imbalanced gender-age sampling and covariate missingness. Differences in model outcomes due to sampling were measured using tests for interaction. Missing covariate effects were measured by comparing fully-adjusted and reduced model fitness.

FINDINGS

We simulated data from 25 DHS surveys across 20 countries from 2005-2014 on four sex-stratified models for pathways of adult attitude-behaviour discordance regarding pre-marital sex and adolescent risk of HIV. On average, across gender-age-imbalanced surveys, males comprised 29.6% of responses compared to 45.3% in the gender-balanced dataset. Gender-age-imbalanced sampling significantly affected regression coefficients in 40% of model-scenarios (N = 40 of 100) and biased relative-risk estimates away from gender-age-balanced sampling outcomes in 46% (N = 46) of model-scenarios. Model fitness was robust to covariate removal with minor effects on male HIV models. No consistent trends were observed between sampling distribution and risk of biased outcomes.

INTERPRETATION

Gender-health model outcomes may be affected by sampling gender-age-imbalanced data and less-so by missing covariates. Although occasionally attenuated, the effect magnitude of gender-age-imbalanced sampling is variable and may mask true associations, thus misinforming policy dialogue. We recommend future surveys improve balanced gender-age sampling to promote research reliability.

FUNDING

Bill & Melinda Gates Foundation grant OPP1140262 to Stanford University.

Barriers and facilitators regarding the implementation of policies and programmes aimed at reducing adolescent pregnancy in Ghana: an exploratory qualitative study

OBJECTIVES

This study explored the perceived barriers and facilitators regarding the implementation of policies and programmes aimed at reducing adolescent pregnancy among health and education professionals ('professionals'), grassroots workers and adolescent girls in Ghana.

DESIGN AND SETTING

We employed an exploratory qualitative study design involving interviews with professionals, grassroots workers and adolescent girls in the Central Region of Ghana.

PARTICIPANTS

This study involved 15 professionals employed in government or non-governmental organisations, 15 grassroots workers and 51 pregnant/parenting and non-pregnant adolescent girls.

DATA ANALYSIS

Thematic analysis was conducted deductively using the ecological framework for understanding effective implementation.

RESULTS

Eighteen themes mapped to the five domains of the ecological framework emerged. Perceived barriers included gender inequality, family poverty, stigma, community support for early childbearing and cohabitation, inadequate data systems, lack of collaboration between stakeholders and lack of political will. Effective implementation of community by-laws, youth involvement, use of available data, and collaboration and effective coordination between stakeholders were the perceived facilitators.

CONCLUSION

Political leaders and community members should be actively engaged in the implementation of adolescent sexual and reproductive health policies and programmes. Gender empowerment programmes such as education and training of adolescent girls should be implemented and strengthened at both the community and national levels. Community members should be sensitised on the negative effects of norms that support child marriage, gender-based violence and early childbearing.

"Now, I have my baby so I don't go anywhere": A mixed method approach to the 'everyday' and young motherhood integrating qualitative interviews and passive digital data from mobile devices

The impacts of early pregnancy and young motherhood on everyday life, including interpersonal and individual behavior, are not well-known. Passive digital sensing on mobile technology including smartphones and passive Bluetooth beacons can yield information such as geographic movement, physical activity, and mother-infant proximity to illuminate behavioral patterns of a mother's everyday in Nepal. We contribute to mixed-methods research by triangulating passive sensing data (GPS, accelerometry, Bluetooth proximity) with multiple forms of qualitative data to characterize behavioral patterns and experiences of young motherhood in the first year postpartum. We triangulated this digital information in a constant comparative analysis with in-depth interviews, daily diaries, and fieldnotes. We reveal typical behavioral patterns of rural young mothers and highlight opportunities for integrating this information to improve health and well-being.

Burden of non-communicable diseases among adolescents aged 10-24 years in the EU, 1990-2019: a systematic analysis of the Global Burden of Diseases Study 2019

BACKGROUND

Disability and mortality burden of non-communicable diseases (NCDs) have risen worldwide; however, the NCD burden among adolescents remains poorly described in the EU.

METHODS

Estimates were retrieved from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Causes of NCDs were analysed at three different levels of the GBD 2019 hierarchy, for which mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) were extracted. Estimates, with the 95% uncertainty intervals (UI), were retrieved for EU Member States from 1990 to 2019, three age subgroups (10-14 years, 15-19 years, and 20-24 years), and by sex. Spearman's correlation was conducted between DALY rates for NCDs and the Socio-demographic Index (SDI) of each EU Member State.

FINDINGS

In 2019, NCDs accounted for 86·4% (95% uncertainty interval 83·5-88·8) of all YLDs and 38·8% (37·4-39·8) of total deaths in adolescents aged 10-24 years. For NCDs in this age group, neoplasms were the leading causes of both mortality (4·01 [95% uncertainty interval 3·62-4·25] per 100 000 population) and YLLs (281·78 [254·25-298·92] per 100 000 population), whereas mental disorders were the leading cause for YLDs (2039·36 [1432·56-2773·47] per 100 000 population) and DALYs (2040·59 [1433·96-2774·62] per 100 000 population) in all EU Member States, and in all studied age groups. In 2019, among adolescents aged 10-24 years, males had a higher mortality rate per 100 000 population due to NCDs than females (11·66 [11·04-12·28] vs 7·89 [7·53-8·23]), whereas females presented a higher DALY rate per 100 000 population due to NCDs (8003·25 [5812·78-10 701·59] vs 6083·91 [4576·63-7857·92]). From 1990 to 2019, mortality rate due to NCDs in adolescents aged 10-24 years substantially decreased (-40·41% [-43·00 to -37·61), and also the YLL rate considerably decreased (-40·56% [-43·16 to -37·74]), except for mental disorders (which increased by 32·18% [1·67 to 66·49]), whereas the YLD rate increased slightly (1·44% [0·09 to 2·79]). Positive correlations were observed between DALY rates and SDIs for substance use disorders (r_s=0·58, p=0·0012) and skin and subcutaneous diseases (r_s=0·45, p=0·017), whereas negative correlations were found between DALY rates and SDIs for cardiovascular diseases (r_s=-0·46, p=0·015), neoplasms (r_s=-0·57, p=0·0015), and sense organ diseases (r_s=-0·61, p=0·0005).

INTERPRETATION

NCD-related mortality has substantially declined among adolescents in the EU between 1990 and 2019, but the rising trend of YLL attributed to mental disorders and their YLD burden are concerning. Differences by sex, age group, and across EU Member States highlight the importance of preventive interventions and scaling up adolescent-responsive health-care systems, which should prioritise specific needs by sex, age, and location.

FUNDING

Bill & Melinda Gates Foundation.

Sex Differences in Cardiovascular Risk Associated With Long-Term PM2.5 Exposure: A Systematic Review and Meta-Analysis of Cohort Studies

Background

Established evidence suggests risks of developing cardiovascular disease are different by sex. However, it remains unclear whether associations of PM_2.5 with cardiovascular risk are comparable between women and men. The meta-analysis aimed to examine sex differences in associations of ischemic heart disease (IHD) and stroke with long-term PM_2.5 exposure.

Methods

PubMed, EMBASE and Cochrane Library were searched until May 2, 2021. We included cohort studies reporting sex-specific associations of long-term PM_2.5 exposure (e.g., ≥1 year) with IHD and stroke. The primary analysis was to estimate relative risk (RR) of PM_2.5-outcome in women and men separately, and the additional women-to-men ratio of RR (RRR) was explored to compare sex differences, using random-effect models.

Results

We identified 25 eligible studies with 3.6 million IHD and 1.3 million stroke cases among 63.7 million participants. A higher level of PM_2.5 exposure was significantly associated with increased risk of IHD in both women (RR = 1.21; 95% CI, 1.15–1.27) and men (RR = 1.12; 95% CI, 1.07–1.17). The women-to-men RRR of IHD was 1.05 (95% CI, 1.02–1.08) per 10 μg/m³ increment in PM_2.5 exposure, indicating significant excess risk of IHD in women. The significant risks of stroke associated with PM_2.5 were obtained in both women (RR = 1.11; 95% CI, 1.08–1.13) and men (RR = 1.11; 95% CI, 1.07–1.14), but no significant women-to-men RRR was observed in stroke (RRR = 1.00; 95% CI, 0.96–1.04).

Conclusions

The study identified excess risk of IHD associated with long-term PM_2.5 exposure in women. The findings would not only have repercussions on efforts to precisely evaluate the burden of IHD attributable to PM_2.5, but would also provide novel clues for cardiovascular risk prevention accounting for sex-based differences.

Children of more empowered women are less likely to be left without vaccination in low- and middle-income countries: A global analysis of 50 DHS surveys

Background

To help provide a global understanding of the role of gender-related barriers to vaccination, we have used a broad measure of women’s empowerment and explored its association with the prevalence of zero-dose children aged 12-23 months across many low- and middle-income countries, using data from standardized national household surveys.

Methods

We used data from Demographic and Health Surveys (DHS) of 50 countries with information on both women’s empowerment and child immunisation. Zero-dose was operationally defined as the proportion of children who failed to receive any doses of the diphtheria, pertussis, and tetanus containing vaccines (DPT). We measured women’s empowerment using the SWPER Global, an individual-level indicator estimated for women aged 15-49 years who are married or in union and with three domains: social independence, decision-making and attitude towards violence. We estimated two summary measures of inequality, the slope index of inequality (SII) and the concentration index (CIX). Results were presented for individual and pooled countries.

Results

In the country-level (ecological) analyses we found that the higher the proportion of women with high empowerment, the lower the zero-dose prevalence. In the individual level analyses, overall, children with highly-empowered mothers presented lower prevalence of zero-dose than those with less-empowered mothers. The social independence domain presented more consistent associations with zero-dose. In 42 countries, the lowest zero-dose prevalence was found in the high empowerment groups, with the slope index of inequality showing significant results in 28 countries. When we pooled all countries using a multilevel Poisson model, children from mothers in the low and medium levels of the social independence domain had respectively 3.3 (95% confidence interval (CI) = 2.3, 4.7) and 1.8 (95% CI = 1.5, 2.1) times higher prevalence of zero-dose compared to those in the high level.

Conclusions

Our country-level and individual-level analyses support the importance of women’s empowerment for child vaccination, especially in countries with weaker routine immunisation programs.

Global Burden of Vitamin A Deficiency in 204 Countries and Territories from 1990-2019

Vitamin A deficiency (VAD) is one of the important public health issues worldwide. However, a detailed understanding of the incidence and disability-adjusted life years (DALYs) due to VAD in recent years is lacking. We aimed to estimate the incidence and DALYs of VAD at global, regional, and national levels in terms of sex, age, and socio-demographic index (SDI). Using data from the 2019 Global Burden of Disease (GBD) study, the estimated annual percentage change (EAPC) was measured to assess trends in the age-standardized incidence and DALY rates from 1990 to 2019. The global age-standardized incidence and DALY rates of VAD decreased with an EAPC of −3.11% (95% confidence interval (CI): −3.24% to −2.94%) and −2.18% (95% CI: −2.38% to −1.93%), respectively. The age-standardized incidence and DALY rates decreased least in low-SDI regions, which had the highest age-standardized incidence and DALY rates of all SDI regions. Sub-Saharan Africa, especially central sub-Saharan Africa, had the highest age-standardized incidence and DALY rates in 2019. At the national level, Somalia and Niger had the highest age-standardized incidence and DALY rates. The age-standardized incidence and DALY rates were higher in males than in females. Younger children, especially those aged < 5 years in low-SDI regions, had a higher VAD burden than other age groups. Although the global burden of VAD has decreased, future work should aim to improve the prevention and treatment strategies for VAD, particularly in children aged < 5 years in countries and territories with low SDI values, such as sub-Saharan Africa.

Adolescents' Perspectives on the Drivers of Obesity Using a Group Model Building Approach: A South African Perspective

Overweight and obesity increase the risk of a range of poor physiological and psychosocial health outcomes. Previous work with well-defined cohorts has explored the determinants of obesity and employed various methods and measures; however, less is known on the broader societal drivers, beyond individual-level influences, using a systems framework with adolescents. The aim of this study was to explore the drivers of obesity from adolescents' perspectives using a systems approach through group model building in four South African schools. Group model building was used to generate 4 causal loop diagrams with 62 adolescents aged 16-18 years. These maps were merged into one final map, and the main themes were identified: (i) physical activity and social media use; (ii) physical activity, health-related morbidity, and socio-economic status; (iii) accessibility of unhealthy food and energy intake/body weight; (iv) psychological distress, body weight, and weight-related bullying; and (v) parental involvement and unhealthy food intake. Our study identified meaningful policy-relevant insights into the drivers of adolescent obesity, as described by the young people themselves in a South African context. This approach, both the process of construction and the final visualization, provides a basis for taking a novel approach to prevention and intervention recommendations for adolescent obesity.

Women's empowerment and fertility preferences of married women: analysis of demographic and health survey'2016 in Timor-Leste

A recently independent state, Timor-Leste, is progressing towards socioeconomic development, prioritizing women empowerment while its increased fertility rate (4.1) could hinder the growth due to an uncontrolled population. Currently, limited evidence shows that indicators of women's empowerment are associated with fertility preferences and rates. The objective of this study was to assess the association between women empowerment and fertility preferences of married women aged 15 to 49 years in Timor-Leste using nationally representative survey data. The study was conducted using the data of the latest Timor-Leste Demographic and Health Survey 2016. The study included 4040 rural residents and 1810 urban residents of Timor-Leste. Multinomial logistic regression has been performed to assess the strength of association between the exposures indicating women's empowerment and outcome (fertility preference). After adjusting the selected covariates, the findings showed that exposures that indicate women empowerment in DHS, namely, the employment status of women, house and land ownership, ownership of the mobile phone, and independent bank account status, contraceptive use, and the attitude of women towards negotiating sexual relations are significantly associated with fertility preferences. The study shows higher the level of education, the less likely were the women to want more children, and unemployed women were with a higher number of children. Our study also found that the attitude of violence of spouses significantly influenced women's reproductive choice. However, employment had no significant correlation with decision-making opportunities and contraceptive selection due to a lack of substantial data. Also, no meaningful data was available regarding decision-making and fertility preferences. Our findings suggest that women's empowerment governs decision-making in fertility preferences, causing a decline in the fertility rate.

Applying an Evolutionary Approach of Risk-Taking Behaviors in Adolescents

Risk-taking behaviors in adolescents have traditionally been analyzed from a psychopathological approach, with an excessive emphasis on their potential costs. From evolutionary theory we propose that risk-taking behaviors can be means through which adolescents obtain potential benefits for survival and reproduction. The present study analyses sex differences in three contexts of risk (i.e., risk propensity, expected benefits and risk perception) in the evolutionary specific domains and the predictive value of these domains over risk-taking behaviors, separately in female and male adolescents. 749 adolescents (females = 370) valued their risk perception, expected benefits and risk propensity through the Evolutionary Domain-Specific Risk Scale, as well as their engagement in risk-taking behaviors through the Risky Behavior Questionnaire. Male adolescents showed lower risk perception in two evolutionary domains, expected higher benefits in two other domains and showed higher risk propensity in six domains. Female adolescents showed lower risk perception in two domains. Additionally, risk perception, expected benefits and risk propensity in the evolutionary domains predicted the engagement in risk-taking behaviors in male adolescents, whereas in female adolescents only expected benefits and risk propensity showed a predictive effect over risk-taking behaviors. These results suggest the potential role of evolutionary mechanisms on risk-taking behaviors in adolescents. Results have practical implications for interventions programs aimed at reducing risk-taking behaviors. In addition to considering sex differences, intervention programs should consider alternative behaviors through which adolescents can reach their evolutionary goals, and handle the risks related to those behaviors that cannot be replaced but have potential benefits for adolescents.

The gender responsiveness of social entrepreneurship in health - A review of initiatives by Ashoka fellows

There are vocal calls to act on the gender-related barriers and inequities in global health. Still, there are gaps in implementing programmes that address and counter the relevant dynamics. As an approach that focuses on social problems and public service delivery gaps, social entrepreneurship has the potential to be a closer health sector partner to tackle and transform the influence of gender in health to achieve health systems goals better. Nevertheless, social entrepreneurs' engagement and impact on gender and health remain understudied. Using the Ashoka Fellows database as a sampling frame in November 2020 (n = 3352, health n = 129), we identified and reviewed the work of 21 organizations that implemented gender-responsive health-related programmes between 2000 and 2020. We applied the UNU-IIGH 6-I Analytic Framework to review the gender issues, interventions, included populations, investments, implementation, and impact in each organization. We found that a low proportion of fellows engage in gender-responsive health programming (<1%). Many organizations operate in low-and middle-income countries (16/21). The gender-responsive programmes include established health sector practices, to address gendered-cultural dynamics and deliver people-centred resources and services. Interestingly, most organizations self-identify as NGOs and rely on traditional grant funding. Fewer organizations (6/21) adopt market-based and income-generating solutions - a missed opportunity to actualise the potential of social entrepreneurship as an innovative health financing approach. There were few publicly available impact evaluations-a gap in practice established in social entrepreneurship. All organizations implemented programmes at community levels, with some cross-sectoral, structural, and policy-level initiatives. Most focused on sexual and reproductive health and gender-based violence for predominantly populations of women and girls. Closer partnerships between social entrepreneurs and gender experts in the health sector can provide reciprocally beneficial solutions for cross-sectorally and community designed innovations, health financing, evidence generation and impact tracking that improve the gender-responsiveness of health programmes, policies, and systems.

Barriers to Access of Healthcare Services for Rural Women-Applying Gender Lens on TB in a Rural District of Sindh, Pakistan

Background: Women in the rural districts of Pakistan face numerous barriers to healthcare, rendering gender-responsive health programming important, including for the disease of tuberculosis (TB). This study was conducted to assess the general understanding of TB and for women’s access to healthcare, as a first step towards implementation of a gender responsive TB program in Tando Allahyar, a rural district of Pakistan. Methods: A total of 36 participants were interviewed for the study. The focus group discussion guide comprised of questions on: (1) family/household dynamics, (2) community norms, (3) healthcare systems, (4) women’s access to healthcare, (5) TB Awareness, and (6) women’s access to TB Care. Results: Limited autonomy in household financial decision-making, disapproval of unassisted travel, long travel time, lack of prioritization of spending on women’s health and inadequate presence of female health providers, were identified as barriers to access healthcare for women, which is even higher in younger women. Facilitators to access of TB care included a reported lack of TB-related stigma, moderate knowledge about TB disease, and broad understanding of tuberculosis as a curable disease. Other suggested facilitators include health facilities closer to the villages and the availability of higher quality services. Conclusion: Significant barriers are faced by women in accessing TB care in rural districts of Pakistan. Program implementers in high burden countries should shift towards improved gender-responsive TB programming.

Key recommendations to strengthen public-private partnership for adolescent health in resource constrained settings: Formative qualitative inquiry in Mongolia, Myanmar and the Philippines

Background

Public health services can be inaccessible for adolescents. The private sector provides many services, but often in parallel to the public sector. This study aimed to understand current private sector engagement in adolescent health service delivery and develop recommendations to strengthen partnerships.

Methods

The study focussed on Mongolia, Myanmar and the Philippines. An initial participatory workshop in each country was followed by semi-structured key-informant interviews (32 in total) with public and private sector actors and adolescents to explore: perceptions of the public and private sectors, strengths and challenges, existing models of partnership, and insights for successful public-private partnership (PPP). Interview transcripts were analysed thematically, with findings and recommendations verified through a second workshop in Mongolia and the Philippines.

Findings

The private sector already plays a significant role in adolescent health care, and stakeholders reported a genuine willingness for partnership. Strengthened PPP was identified as necessary to improve service accessibility and quality for adolescents, unburden the public sector and introduce new technologies, with advantages for the private sector including improved access to training and resources, and an enhanced public image. Recommendations for strengthened PPP included the need to establish the foundations for partnership, clearly define roles and co-ordinate stakeholders, ensure capacity and sustainability, and monitor and evaluate efforts.

Interpretation

This is the first comprehensive study of public-private partnership for adolescent health in the Asia Pacific region. It identifies stakeholders are willing for stronger partnerships and the benefits this partnership will bring. We define eight key recommendations to enable this partnership across sectors.

The Double Burden of Malnutrition and Associated Factors among South Asian Adolescents: Findings from the Global School-Based Student Health Survey

The health and nutrition of the global adolescent population have been under-researched, in spite of its significant size (1.2 billion). This study investigates the prevalence and associated factors of malnutrition (stunting, thinness and overweight) among adolescents living in South Asia. The sample analysed was 24,053 South Asian schooled adolescents aged 12-15 years that participated in the cross-sectional Global School-Based Student Health Survey (GSHS) between 2009 and 2016. The prevalence of stunting, thinness and overweight was calculated using the World Health Organization (WHO) Child Growth Reference 2007. Associations between the three forms of malnutrition and their possible associated factors were assessed with binary logistic regression analysis using bootstrapping as a resampling method. The overall prevalence of stunting in South Asia was 13%, thinness was 10.8% and overweight was 10.8%. In the logistic regression model of the overall pooled sample, the factors associated with adolescent malnutrition were: age, hygiene behaviours, social support, sedentary behaviour, and tobacco use. A substantial proportion of stunting, thinness and overweight was found among school-going South Asian adolescents, indicating that the double burden of malnutrition is present in this population. Future research should seek to further understand the relationship between all forms of malnutrition and its associated factors in the adolescent population.