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Mohd Tohit NF, Haque M. Forbidden Conversations: A Comprehensive Exploration of Taboos in Sexual and Reproductive Health. Cureus 2024; 16:e66723. [PMID: 39139803 PMCID: PMC11319820 DOI: 10.7759/cureus.66723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2024] [Indexed: 08/15/2024] Open
Abstract
This scoping review aims to comprehensively explore the landscape of taboos and their impact on sexual and reproductive health. Titled "Forbidden Conversations," it delves into the intricate web of societal, cultural, and religious norms that have contributed to the elusive and often stigmatized nature of sexual and reproductive health topics. The review navigates through the multifaceted dimensions of these taboos, shedding light on their impact on individuals, communities, and public health while advocating for a paradigm shift toward open, inclusive, and informed dialogue. The analysis within this review spans a decade, capturing the most recent and relevant literature to map the landscape of taboos in sexual and reproductive health. It explores the persistent societal apprehensions and subsequent stigmatization surrounding topics such as menstruation, contraception, fertility, sexual orientation, and gender identity. The review contextualizes the multifaceted challenges presented by these prevailing norms by tracing historically rooted taboos and their evolution across different cultures and contexts. The scoping review identifies the profound implications of these taboos on public health, highlighting how they contribute to disparities in access to healthcare, perpetuate misinformation, and infringe upon the fundamental rights of individuals. It addresses the challenges in sexual education, emphasizing how these taboos impede comprehensive understanding and enforcement of sexual and reproductive health rights among adolescents and young adults. The intersectional approach taken in this review situates these taboos within broader systems of inequality, emphasizing the compounded impact they have on marginalized populations. Through this comprehensive exploration, the review aims to provide actionable insights and identify existing research, policy, and practice gaps. It seeks to lay the foundation for future initiatives that advocate for destigmatization, empowerment, and equity in sexual and reproductive health. Ultimately, "Forbidden Conversations" aims to steer the conversation toward openness and inclusivity while advocating for unbiased, comprehensive sexual and reproductive healthcare with dignity for all individuals.
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Affiliation(s)
- Nor Faiza Mohd Tohit
- Department of Community Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, MYS
| | - Mainul Haque
- Department of Research, Karnavati Scientific Research Center (KSRC) School of Dentistry, Karnavati University, Gandhinagar, IND
- Department of Pharmacology and Therapeutics, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, MYS
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Adugna MB, Ghahari S, Lysaght R. Disability stigma and the pursuit of inclusion among children with physical disabilities in northwest Ethiopia. Disabil Rehabil 2024:1-11. [PMID: 38832395 DOI: 10.1080/09638288.2024.2356016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 05/12/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE Globally, many children with physical disabilities (CwPDs) are excluded from their education and social life, mainly due to stigma and its effects. However, information on disability stigma is scarce in low-and middle-income countries like Ethiopia. The purpose of this study, therefore, was to explore the lived experience of stigma from the perspective of CwPDs and their caregivers in northwest Ethiopia. METHODS The study incorporated a constructivist grounded theory approach. Data were gathered through observations, in-depth interviews, and key informant interviews. Inductive and iterative grounded theory techniques were used to code and categorize data through constant comparison. FINDINGS The study showed that CwPDs are bullied and talked about, subject to pity, socially excluded, and held in contempt at home, in their neighborhood, and at school. They live in fear and uncertainty and struggle with stigma. These factors affect their emotions, social relationships, and educational activities. CONCLUSIONS This study makes theoretical and practical contributions to understanding and addressing disability stigma and can help to introduce inclusive education policy, school practice, and disability advocacy. The study results highlight the need for disability awareness-raising programs, interventions for empowerment, and informing disability policy and practice.
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Affiliation(s)
| | - Setareh Ghahari
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
| | - Rosemary Lysaght
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
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3
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Liu XQ, Wang X. Adolescent suicide risk factors and the integration of social-emotional skills in school-based prevention programs. World J Psychiatry 2024; 14:494-506. [PMID: 38659598 PMCID: PMC11036461 DOI: 10.5498/wjp.v14.i4.494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/24/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024] Open
Abstract
Adolescents are considered one of the most vulnerable groups affected by suicide. Rapid changes in adolescents' physical and mental states, as well as in their lives, significantly and undeniably increase the risk of suicide. Psychological, social, family, individual, and environmental factors are important risk factors for suicidal behavior among teenagers and may contribute to suicide risk through various direct, indirect, or combined pathways. Social-emotional learning is considered a powerful intervention measure for addressing the crisis of adolescent suicide. When deliberately cultivated, fostered, and enhanced, self-awareness, self-management, social awareness, interpersonal skills, and responsible decision-making, as the five core competencies of social-emotional learning, can be used to effectively target various risk factors for adolescent suicide and provide necessary mental and interpersonal support. Among numerous suicide intervention methods, school-based interventions based on social-emotional competence have shown great potential in preventing and addressing suicide risk factors in adolescents. The characteristics of school-based interventions based on social-emotional competence, including their appropriateness, necessity, cost-effectiveness, comprehensiveness, and effectiveness, make these interventions an important means of addressing the crisis of adolescent suicide. To further determine the potential of school-based interventions based on social-emotional competence and better address the issue of adolescent suicide, additional financial support should be provided, the combination of social-emotional learning and other suicide prevention programs within schools should be fully leveraged, and cooperation between schools and families, society, and other environments should be maximized. These efforts should be considered future research directions.
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Affiliation(s)
- Xin-Qiao Liu
- School of Education, Tianjin University, Tianjin 300350, China
| | - Xin Wang
- School of Education, Tianjin University, Tianjin 300350, China
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Hartog K, Peters RMH, Tukahiirwa RK, Jordans MJD. Reducing stigma impacting children and adolescents in low- and middle-income countries: The development of a common multi-component stigma reduction intervention. PLoS One 2023; 18:e0292064. [PMID: 37906579 PMCID: PMC10617710 DOI: 10.1371/journal.pone.0292064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 09/12/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION Stigmatisation impedes health and quality of life. Evidence regarding stigma reduction interventions is, albeit growing, limited. There is a gap in the availability and evidence of interventions for reducing stigma among children and adolescents, especially in low- and middle-income countries. This paper describes the process that led to a stigma reduction intervention impacting children and adolescents in low- and middle-income countries, following previously conducted formative research. METHODS In this study, we conducted (i) online stakeholder consultations (FGD) (n = 43), including a survey assessing intervention acceptability, appropriateness, feasibility and scalability (n = 16); and (ii) preliminary field-testing of intervention content online and in a refugee settlement in Uganda. FINDINGS Stakeholder consultation showed the initial version of STRETCH (Stigma Reduction to Trigger Change for Children), albeit positively received, required adaptations. We made adjustments to i) take into account implementation duration, intervention flexibility and intersectionality; (ii) strengthen the involvement of individuals, including adolescents/youth, with lived stigma experience; (iii) target people close to individuals with lived stigma experience; and (iv) address feasibility and sustainability concerns. Preliminary field-testing simplified STRETCH while adding a community outreach component and revisiting the intervention setup, to ensure STRETCH can also be applied from a modular perspective. CONCLUSION We conducted a process to develop a child-focused multi-component stigma reduction intervention, with intended applicability across stigmas and settings. This paper provides an overview of the intervention development process, generating intervention-specific learnings with generic value. STRETCH aims to reduce stigmatisation at the implementing organisation, create community-wide reflection and stigma reduction demand, and reduce stigmatisation among various target groups.
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Affiliation(s)
- Kim Hartog
- Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Amsterdam, The Netherlands
- Research and Development Department, War Child, Amsterdam, The Netherlands
| | - Ruth M. H. Peters
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Mark J. D. Jordans
- Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Amsterdam, The Netherlands
- Research and Development Department, War Child, Amsterdam, The Netherlands
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Crea TM, Collier KM, Klein EK, Sevalie S, Molleh B, Kabba Y, Kargbo A, Bangura J, Gbettu H, Simms S, O'Leary C, Drury S, Schieffelin JS, Betancourt TS. Social distancing, community stigma, and implications for psychological distress in the aftermath of Ebola virus disease. PLoS One 2022; 17:e0276790. [PMID: 36322544 PMCID: PMC9629629 DOI: 10.1371/journal.pone.0276790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Background The 2013–2016 Ebola virus disease (EVD) epidemic resulted in more infections and deaths than all prior outbreaks in the 40-year history of this virus combined. This study examines how experiences of EVD infection, and preventive measures such as social distancing, were linked to experiences of stigma and social exclusion among those reintegrating into their communities. Methods Key informant interviews (n = 42) and focus group discussions (n = 27) were conducted in districts with a high prevalence of EVD and representing geographical and ethnic diversity (n = 228 participants). The final sample was composed of adults (52%) and children (48%) who were EVD-infected (46%) and -affected (42%) individuals, and community leaders (12%). Data were coded using a Grounded Theory approach informed by Thematic Content Analysis, and analyzed using NVivo. Interrater reliability was high, with Cohen’s κ = 0.80 or higher. Findings Participants described two main sources of EVD-related stress: isolation from the community because of social distancing and other prevention measures such as quarantine, and stigma related to infected or affected status. Participants linked experiences of social isolation and stigma to significant distress and feelings of ostracization. These experiences were particularly pronounced among children. Sources of support included community reintegration over time, and formal community efforts to provide education and establish protection bylaws. Interpretation This study found that social distancing and EVD-related stigma were each prominent sources of distress among participants. These results suggest that isolation because of infection, and the enduring stigmatization of infected individuals and their families, demand coordinated responses to prevent and mitigate additional psychosocial harm. Such responses should include close engagement with community leaders to combat misinformation and promote community reintegration.
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Affiliation(s)
- Thomas M Crea
- School of Social Work, Boston College, Chestnut Hill, Massachusetts, United States of America
| | - K Megan Collier
- School of Social Work, Boston College, Chestnut Hill, Massachusetts, United States of America
| | - Elizabeth K Klein
- School of Social Work, Boston College, Chestnut Hill, Massachusetts, United States of America
| | | | | | - Yusuf Kabba
- Sierra Leone Association of Ebola Survivors, Freetown, Sierra Leone
| | - Abdulai Kargbo
- Sierra Leone Association of Ebola Survivors, Freetown, Sierra Leone
| | | | | | - Stewart Simms
- School of Social Work, Boston College, Chestnut Hill, Massachusetts, United States of America
| | - Clara O'Leary
- School of Social Work, Boston College, Chestnut Hill, Massachusetts, United States of America
| | - Stacy Drury
- School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - John S Schieffelin
- School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Theresa S Betancourt
- School of Social Work, Boston College, Chestnut Hill, Massachusetts, United States of America
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Mulikaburt T, Apidechkul T, Wongnuch P, Kitchanapaibul S, Udplong A, Srichan P, Upala P, Chomchoei C, Yeemard F, Tamornpark R, Singkhorn O. Components of stigma and its impact on maternal and child health service and outcomes: perspective of Akha hill tribe women in Thailand. BMC Health Serv Res 2022; 22:1263. [PMID: 36261838 PMCID: PMC9583464 DOI: 10.1186/s12913-022-08622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 09/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal and child health (MCH) is crucial to the well-being of mothers and children. Stigma regarding access to MCH services is a major challenge, especially for hill tribe people in Thailand. The study aimed to understand the components of stigma and its impact on MCH service and outcomes including experiences and expectations to address the stigma in perspective of Akha hill tribe women in Thailand. METHODS A phenomenological qualitative approach was used to gather information from Akha women who had attended MCH service one year prior and had an experience with stigma. A validated question guide was used in the study. The interview was conducted in private and confidential rooms in the Akha hill tribe villages between June and September 2021. A thematic analysis was used to extract the major and minor themes and develop the findings. RESULTS A total of 61 Akha postdelivery participants were recruited to provide information; the average age was 28.9 years, 32.8% had no Thai ID card, and 93.4% were married. Language, traditional clothing, poverty, and name were identified as drivers of stigma, while health care providers' background, gender differences between clients and health care providers, and knowledge gaps facilitated the stigma. Being a member of a hill tribe acted as the stigma marker. Stigma manifestation was presented in the forms of verbal or physical abuse, refusal to provide treatment, and intentional disclosure of personal information to the public. Accepting the situation with no better option, defending oneself to receive better care and services, and using a private care service were experiences in addressing the stigma. Gender matching, active MCH service, mobile emergency clinics, and appropriate, permanent medical equipment in health care facilities located in their villages were the expectations. CONCLUSION Akha women face a variety of stigmas in access to MCH services, with substantial impacts on health outcomes, especially the rate of services in women and child health. Creating laws to prevent the occurrence of any forms of stigma and implementing gender matching in MCH services should be considered.
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Affiliation(s)
| | - Tawatchai Apidechkul
- School of Health Sciences, Mae Fah Luang University, Chiang Rai, Thailand. .,Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, Chiang Rai, Thailand. .,School of Health Science, Mae Fah Luang University, 333 Moo 1, Ta Sud Subdistrict, Muang District, 57100, Chiang Rai Province, Thailand.
| | - Pilasinee Wongnuch
- School of Health Sciences, Mae Fah Luang University, Chiang Rai, Thailand.,Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, Chiang Rai, Thailand
| | - Siwarak Kitchanapaibul
- School of Health Sciences, Mae Fah Luang University, Chiang Rai, Thailand.,Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, Chiang Rai, Thailand
| | - Anusorn Udplong
- School of Health Sciences, Mae Fah Luang University, Chiang Rai, Thailand
| | - Peeradone Srichan
- School of Health Sciences, Mae Fah Luang University, Chiang Rai, Thailand.,Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, Chiang Rai, Thailand
| | - Panupong Upala
- Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, Chiang Rai, Thailand
| | - Chalitar Chomchoei
- Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, Chiang Rai, Thailand
| | - Fartima Yeemard
- Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, Chiang Rai, Thailand
| | - Ratipark Tamornpark
- School of Health Sciences, Mae Fah Luang University, Chiang Rai, Thailand.,Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, Chiang Rai, Thailand
| | - Onnalin Singkhorn
- Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, Chiang Rai, Thailand.,School of Nursing, Mae Fah Luang University, Chiang Rai, Thailand
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7
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Gavan L, Hartog K, Holland WC, Koppenol-Gonzalez G, Gronholm PC, Feddes AR, Kohrt BA, Jordans MJ, Peters RH. Assessing stigma in low- and middle-income countries: A systematic review of scales used with children and adolescents. Soc Sci Med 2022; 307:115121. [DOI: 10.1016/j.socscimed.2022.115121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 11/26/2022]
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8
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Polat F, Şenol DK. Examining the correlation between sexual and reproductive health stigmatization level and gender perception: a case of a university in Turkey - a descriptive cross-sectional study. SAO PAULO MED J 2022; 141:146-153. [PMID: 36102465 PMCID: PMC10005470 DOI: 10.1590/1516-3180.2022.0278.03062022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/03/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Stigmatization, which emerges depending on the sexual behavior of young individuals, leads to negative health and social outcomes, such as shame, social marginalization, violence, and mental health morbidity. OBJECTIVE This study aimed to examine the correlation between the level of sexual and reproductive health stigma and gender perception in female university students. DESIGN AND SETTING This descriptive cross-sectional study was conducted at the Faculty of Health Sciences of a university in Turkey. METHODS The data of this study were collected from digital media between July and October 2020 from a study population of 385 students. The data were collected using the Personal Information Form, including the socio-demographic characteristics of students, the Sexual and Reproductive Health Stigmatization Scale in Young Women and the Perception of Gender Scale. Descriptive statistics, independent samples t-test, analysis of variance, and Pearson's correlation test were used to assess the data. RESULTS It was determined that there was a negative correlation between the Sexual and Reproductive Health Stigmatization Scale in Young Women and the Perception of Gender Scale (r = -0.173, P = 0.001). CONCLUSION It was determined that as the gender perception in the young women who participated in the study increased, the sexual and reproductive health stigmatization level decreased. The sexual and reproductive health stigmatization levels of the participants were at an above average level, and gender perception was at a medium level.
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Affiliation(s)
- Filiz Polat
- PhD. Assistant Professor, Department of Midwifery, Faculty of Health
Sciences, Osmaniye Korkut Ata University, Osmaniye, Turkey
| | - Derya Kaya Şenol
- PhD. Assistant Professor, Department of Midwifery, Faculty of
Health Sciences, Osmaniye Korkut Ata University, Osmaniye, Turkey
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Bohren MA, Vazquez Corona M, Odiase OJ, Wilson AN, Sudhinaraset M, Diamond-Smith N, Berryman J, Tunçalp Ö, Afulani PA. Strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings: A mixed-methods systematic review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000582. [PMID: 36962453 PMCID: PMC10021469 DOI: 10.1371/journal.pgph.0000582] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 05/13/2022] [Indexed: 11/19/2022]
Abstract
Stigma and discrimination are fundamental causes of health inequities, and reflect privilege, power, and disadvantage within society. Experiences and impacts of stigma and discrimination are well-documented, but a critical gap remains on effective strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We aimed to address this gap by conducting a mixed-methods systematic review and narrative synthesis to describe strategy types and characteristics, assess effectiveness, and synthesize key stakeholder experiences. We searched MEDLINE, CINAHL, Global Health, and grey literature. We included quantitative and qualitative studies evaluating strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We used an implementation-focused narrative synthesis approach, with four steps: 1) preliminary descriptive synthesis, 2) exploration of relationships between and across studies, 3) thematic analysis of qualitative evidence, and 4) model creation to map strategy aims and outcomes. Of 8,262 articles screened, we included 12 articles from 10 studies. Nine articles contributed quantitative data, and all measured health worker-reported outcomes, typically about awareness of stigma or if they acted in a stigmatizing way. Six articles contributed qualitative data, five were health worker perspectives post-implementation and showed favorable experiences of strategies and beliefs that strategies encouraged introspection and cultural humility. We mapped studies to levels where stigma can exist and be confronted and identified critical differences between levels of stigma strategies aimed to intervene on and evaluation approaches used. Important foundational work has described stigma and discrimination in sexual and reproductive healthcare settings, but limited interventional work has been conducted. Healthcare and policy interventions aiming to improve equity should consider intervening on and measuring stigma and discrimination-related outcomes. Efforts to address mistreatment will not be effective when stigma and discrimination persist. Our analysis and recommendations can inform future intervention design and implementation research to promote respectful, person-centered care for all.
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Affiliation(s)
- Meghan A Bohren
- Gender and Women's Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Martha Vazquez Corona
- Gender and Women's Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Osamuedeme J Odiase
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Alyce N Wilson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
- Nossal Institute, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - May Sudhinaraset
- Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Nadia Diamond-Smith
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Jim Berryman
- Brownless Biomedical Library, University of Melbourne, Melbourne, Victoria, Australia
| | - Özge Tunçalp
- Department of Sexual and Reproductive Health and Research, including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
| | - Patience A Afulani
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America
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Casey SE, Isa GP, Isumbisho Mazambi E, Giuffrida MM, Jayne Kulkarni M, Perera SM. Community perceptions of the impact of war on unintended pregnancy and induced abortion in Protection of Civilian sites in Juba, South Sudan. Glob Public Health 2021; 17:2176-2189. [PMID: 34323171 DOI: 10.1080/17441692.2021.1959939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Conflict and mass displacement into Protection of Civilian (POCs) sites in South Sudan led to the breakdown of community and family structures, increasing women and girls' vulnerability to gender-based violence and exacerbating already poor sexual and reproductive health outcomes. As one component of a study on post-abortion care, this study explores community perceptions of unintended pregnancy and abortion in a POC in Juba. Four focus group discussions were conducted with 36 women and married men aged 18-45 living in the POC. Although initial reactions to induced abortion were generally negative, participants discussed that unintended pregnancy and induced abortion appeared to have increased during the current conflict. Their discussion of abortion became less condemnatory as they described changes in people's situation due to war, including instability and poverty, transactional sex, disruption of marital norms, rape, and low contraceptive use. This is one of the first studies to investigate community perceptions and practices related to unintended pregnancy and abortion in South Sudan. Despite the beliefs that these are taboo topics, the discussions provide an opening to reduce abortion stigma. To ensure lasting stigma reduction, investment in women and girls to improve gender equity is needed.
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Affiliation(s)
- Sara E Casey
- RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | | | - Monica M Giuffrida
- RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Meghana Jayne Kulkarni
- RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
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11
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Bridge G. Consider the Whole Picture When Discussing Infant Formula and Breast Milk. J Nutr 2021; 151:1375-1377. [PMID: 34036339 DOI: 10.1093/jn/nxab132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/10/2021] [Accepted: 04/16/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Gemma Bridge
- Centre for Clinical Trials & Methodology, Institute of Population Health Sciences, Queen Mary University of London, London, United Kingdom
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12
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Parrott S, Eckhart N. Stigma in the News: The Representation and Trivialization of Stigma in U.S. News Publications. HEALTH COMMUNICATION 2021; 36:440-447. [PMID: 31739679 DOI: 10.1080/10410236.2019.1693132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Stigma represents an important social issue, one rooted in communication. The present study used a quantitative content analysis to examine the representation of the term stigma in one national and six regional news publications in the United States between 2000 and 2018. In the 1,524 stories examined, journalists explicitly defined stigma once. Stigma was discussed in relation to serious, often dehumanized conditions such as schizophrenia, substance abuse, and HIV/AIDS. However, journalists and news sources frequently trivialized stigma by referencing it in relation to bad football teams, food, motor vehicles, and other objects that do not experience the full impact of stigma: stereotypes, prejudice, and discrimination.
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Affiliation(s)
- Scott Parrott
- Department of Journalism & Creative Media, The University of Alabama
| | - Nicholas Eckhart
- College of Communication & Information Sciences, The University of Alabama
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13
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Hearst MO, Adelli R, Hepperlen R, Biggs J, DeGracia D, Ngulube E, Maluskiku-Mwewa B, Johnson DE, Rabaey P. Community-based intervention to reduce stigma for children with disabilities in Lusaka, Zambia: a pilot. Disabil Rehabil 2020; 44:2295-2304. [DOI: 10.1080/09638288.2020.1829105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Mary O. Hearst
- Public Health, Henrietta Schmoll School of Health, St. Catherine University, Saint Paul, MN, USA
| | - Rakesh Adelli
- Public Health, Henrietta Schmoll School of Health, St. Catherine University, Saint Paul, MN, USA
| | | | - Jennifer Biggs
- Physical Therapy, Henrietta Schmoll School of Health, St. Catherine University, Saint Paul, MN, USA
| | - Donna DeGracia
- Physician Assistant Studies, Henrietta Schmoll School of Health, St. Catherine University, Saint Paul, MN, USA
| | | | | | - Dana E. Johnson
- Division of Neonatology and Global Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Paula Rabaey
- Occupational Therapy, Henrietta Schmoll School of Health, St. Catherine University, Saint Paul, MN, USA
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14
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Mchome Z, Bailey A, Kessy F, Darak S, Haisma H. Postpartum sex taboos and child growth in Tanzania: Implications for child care. MATERNAL AND CHILD NUTRITION 2020; 16:e13048. [PMID: 32633462 PMCID: PMC7507495 DOI: 10.1111/mcn.13048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 05/24/2020] [Accepted: 06/02/2020] [Indexed: 12/04/2022]
Abstract
The social context and cultural meaning systems shape caregivers' perceptions about child growth and inform their attention to episodes of poor growth. Thus, understanding community members' beliefs about the aetiology of poor child growth is important for effective responses to child malnutrition. We present an analysis of caregivers' narratives on the risks surrounding child growth during postpartum period and highlight how the meanings attached to these risks shape child care practices. We collected data using 19 focus group discussions, 30 in‐depth interviews and five key informant interviews with caregivers of under‐five children in south‐eastern Tanzania. Parental non‐adherence to postpartum sexual abstinence norms was a dominant cultural explanation for poor growth and development in a child, including different forms of malnutrition. In case sexual abstinence is not maintained or when a mother conceives while still lactating, caregivers would wean their infants abruptly and completely to prevent poor growth. Mothers whose babies were growing poorly were often stigmatized for breaking sex taboos by the community and by health care workers. The stigma that mothers face reduced their self‐esteem and deterred them from taking their children to the child health clinics. Traditional rather than biomedical care was often sought to remedy growth problems in children, particularly when violation of sexual abstinence was suspected. When designing culturally sensitive interventions aimed at promoting healthy child growth and effective breastfeeding in the community, it is important to recognize and address people's existing misconceptions about early resumption of sexual intercourse and a new pregnancy during lactation period.
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Affiliation(s)
- Zaina Mchome
- Population Research Centre, Faculty of Spatial Sciences, University of Groningen, Groningen, The Netherlands.,National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Ajay Bailey
- Department of Human Geography and Spatial Planning, International Development Studies, Utrecht University, Utrecht, The Netherlands.,Manipal Academy of Higher Education, Manipal, India
| | - Flora Kessy
- Tanzania Training Center for International Health, Morogoro, Tanzania
| | | | - Hinke Haisma
- Population Research Centre, Faculty of Spatial Sciences, University of Groningen, Groningen, The Netherlands.,International Union for Nutrition Sciences Task Force 'Toward Multi-dimensional Indicators of Child Growth and Development, London, UK
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15
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Hartog K, Hubbard CD, Krouwer AF, Thornicroft G, Kohrt BA, Jordans MJD. Stigma reduction interventions for children and adolescents in low- and middle-income countries: Systematic review of intervention strategies. Soc Sci Med 2019; 246:112749. [PMID: 31978636 DOI: 10.1016/j.socscimed.2019.112749] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/13/2019] [Accepted: 12/16/2019] [Indexed: 11/18/2022]
Abstract
Stigmatisation and discrimination are common worldwide, and have profound negative impacts on health and quality of life. Research, albeit limited, has focused predominantly on adults. There is a paucity of literature about stigma reduction strategies concerning children and adolescents, with evidence especially sparse for low- and middle-income countries (LMIC). This systematic review synthesised child-focused stigma reduction strategies in LMIC, and compared these to adult-focused interventions. Relevant publications were systematically searched in July and August 2018 in the following databases; Cochrane, Embase, Global Health, HMIC, Medline, PsycINFO, PubMed and WorldWideScience.org, and through Google Custom Search. Included studies and identified reviews were cross-referenced. Three categories of search terms were used: (i) stigma, (ii) intervention, and (iii) LMIC settings. Data on study design, participants and intervention details including strategies and implementation factors were extracted. Within 61 unique publications describing 79 interventions, utilising 14 unique stigma reduction strategies, 14 papers discussed 21 interventions and 10 unique strategies involving children. Most studies targeted HIV/AIDS (50% for children, 38% for adults) or mental illness (14% vs 34%) stigma. Community education (47%), individual empowerment (15%) and social contact (12%) were most employed in child-focused interventions. Most interventions were implemented at one socio-ecological level; child-focused interventions mostly employed community-level strategies (88%). Intervention duration was mostly short; between half a day and a week. Printed or movie-based material was key to deliver child-focused interventions (37%), while professionals most commonly implemented adult-focused interventions (53%). Ten unique, child-focused strategies were all evaluated positively, using a diverse set of scales. Children and adolescents are under-represented in stigma reduction in LMIC. More stigma reduction interventions in LMIC, addressing a wider variety of stigmas, with children as direct and indirect target group, are needed. This systematic review is registered under International Prospective Register of Systematic Reviews PROSPERO, reference number #CRD42018094700.
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Affiliation(s)
- Kim Hartog
- War Child Holland, Research and Development, Helmholzstraat 61-G, 1098, LE, Amsterdam, the Netherlands; Amsterdam Institute for Social Science Research, University of Amsterdam, Postbus 15718, 1001, NE, Amsterdam, the Netherlands.
| | - Carly D Hubbard
- London School of Hygiene and Tropical Medicine, Keppel St., Bloomsbury, London, WC1E, 7HT, United Kingdom.
| | - Angelica F Krouwer
- War Child Holland, Research and Development, Helmholzstraat 61-G, 1098, LE, Amsterdam, the Netherlands.
| | - Graham Thornicroft
- Centre for Global Mental Health, Institute for Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, Camberwell, London, SE5 8AB, United Kingdom.
| | - Brandon A Kohrt
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington University, 2120 L Street, NW, Suite 600, Washington, DC, 20037, USA.
| | - Mark J D Jordans
- War Child Holland, Research and Development, Helmholzstraat 61-G, 1098, LE, Amsterdam, the Netherlands; Amsterdam Institute for Social Science Research, University of Amsterdam, Postbus 15718, 1001, NE, Amsterdam, the Netherlands.
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Stangl AL, Earnshaw VA, Logie CH, van Brakel W, C. Simbayi L, Barré I, Dovidio JF. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med 2019; 17:31. [PMID: 30764826 PMCID: PMC6376797 DOI: 10.1186/s12916-019-1271-3] [Citation(s) in RCA: 620] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 01/23/2019] [Indexed: 12/18/2022] Open
Abstract
Stigma is a well-documented barrier to health seeking behavior, engagement in care and adherence to treatment across a range of health conditions globally. In order to halt the stigmatization process and mitigate the harmful consequences of health-related stigma (i.e. stigma associated with health conditions), it is critical to have an explicit theoretical framework to guide intervention development, measurement, research, and policy. Existing stigma frameworks typically focus on one health condition in isolation and often concentrate on the psychological pathways occurring among individuals. This tendency has encouraged a siloed approach to research on health-related stigmas, focusing on individuals, impeding both comparisons across stigmatized conditions and research on innovations to reduce health-related stigma and improve health outcomes. We propose the Health Stigma and Discrimination Framework, which is a global, crosscutting framework based on theory, research, and practice, and demonstrate its application to a range of health conditions, including leprosy, epilepsy, mental health, cancer, HIV, and obesity/overweight. We also discuss how stigma related to race, gender, sexual orientation, class, and occupation intersects with health-related stigmas, and examine how the framework can be used to enhance research, programming, and policy efforts. Research and interventions inspired by a common framework will enable the field to identify similarities and differences in stigma processes across diseases and will amplify our collective ability to respond effectively and at-scale to a major driver of poor health outcomes globally.
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Affiliation(s)
- Anne L. Stangl
- International Center for Research on Women, 1120 20th St. NW, Suite 500N, Washington, DC, 20036 USA
| | - Valerie A. Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, DE USA
| | - Carmen H. Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto and Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario Canada
| | | | - Leickness C. Simbayi
- Human Sciences Research Council & Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
| | - Iman Barré
- International Center for Research on Women, 1120 20th St. NW, Suite 500N, Washington, DC, 20036 USA
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Zuurmond M, Nyante G, Baltussen M, Seeley J, Abanga J, Shakespeare T, Collumbien M, Bernays S. A support programme for caregivers of children with disabilities in Ghana: Understanding the impact on the wellbeing of caregivers. Child Care Health Dev 2019; 45:45-53. [PMID: 30259548 PMCID: PMC7379711 DOI: 10.1111/cch.12618] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/09/2018] [Accepted: 08/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Four fifths of the estimated 150 million children with disability in the world live in resource poor settings where the role of the family is crucial in ensuring that these children survive and thrive. Despite their critical role, evidence is lacking on how to provide optimal support to these families. This study explores the impact of a participatory training programme for caregivers delivered through a local support group, with a focus on understanding caregiver wellbeing. METHODS A qualitative longitudinal study was conducted to investigate the impact of a training programme, "getting to know cerebral palsy," with caregivers on their wellbeing. Eighteen caregivers, from four districts, were interviewed up to three times over 14 months, to assess impact and the reasons for any changes. RESULTS Low levels of knowledge, high levels of stigma, physical and emotional exhaustion, and often difficult family relationships with social exclusion of the child and caregiver were common themes at the outset. Caregivers struggled to combine their caring and economic activities. This was exacerbated by the common absence of the father. Two months after completion of the training, their reported wellbeing had improved. The reasons for this were an improved understanding about their child's condition, positive attitudinal change towards their child, feelings of hope, and through the group support, a profound realisation that they are "not on their own." While relationships within the family remained complex in many cases, the support group offered an important and alternative social support network. CONCLUSIONS This study illustrates the many benefits of a relatively simple caregiver intervention, which has the potential to offer a mechanism to provide sustainable social support for caregivers and children with cerebral palsy. Any future programme needs to also address more structural issues, including stigma and discrimination, and strengthen approaches to family engagement.
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Affiliation(s)
- Maria Zuurmond
- International Centre for Evidence in DisabilityLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Janet Seeley
- London School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Martine Collumbien
- Faculty of Public Health and PolicyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Sarah Bernays
- Sydney School of Public Health, Sydney Medical SchoolLondon School of Hygiene and Tropical MedicineLondonUK
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Dewi Satiawati KDK, Januraga PP. Attitudes toward Supplemental Nutrition Assistance Programs in Caregivers of Children with Moderate-Acute Malnutrition Younger than 5 Years in Denpasar, Bali: A Qualitative Study. Food Nutr Bull 2018; 39:465-474. [PMID: 30037275 DOI: 10.1177/0379572118788663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Providing additional nutriment represents one strategy for overcoming moderate-acute malnutrition (MAM) in children younger than 5 years. However, it is important to examine how well received such Supplemental Nutrition Assistance Programs (SNAP) are by caregivers in order to ensure optimal results. OBJECTIVE This study explores SNAP's reception by caregivers of MAM children younger than 5 years. METHODS Qualitative research was conducted through semi-structured, in-depth interviews with 16 selected caregivers and 5 Nutritional Executives from October to November, 2016 at 4 health centers in Denpasar, Bali, Indonesia. The results are presented to highlight the underlying patterns of SNAP's acceptance. RESULTS Overall, the informants responded negatively to SNAP, reporting that it was of limited usefulness. The results show 4 main themes relating to the receipt of SNAP. The first relates to the caregiver's preferences in terms of the types of supplementary food on offer. Second, caregiver's perceptions that the child was not, in fact, in a state of illness or disease due to a medical issue. Third, that the caregiver does not require supplementary food as they maintain that they are able to buy it independently. Fourth, factors related to the lack of support for health-care workers working with malnourished children. CONCLUSION The study finds that strengthening the role of health workers in terms of enabling them to effectively communicate the benefits of supplementary food to caregivers as well as adjusting the range of foods available according to the recipient's preferences is critical in overcoming malnutrition in children younger than 5 years.
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Affiliation(s)
| | - Pande Putu Januraga
- 1 Center for Public Health Innovation (CPHI), Faculty of Medicine, Udayana University, Bali, Indonesia.,2 Discipline of Public Health, Flinders University, Adelaide, South Australia, Australia
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Said-Mohamed R, Pettifor JM, Norris SA. Life History theory hypotheses on child growth: Potential implications for short and long-term child growth, development and health. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2017; 165:4-19. [PMID: 29072305 DOI: 10.1002/ajpa.23340] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/27/2017] [Accepted: 10/01/2017] [Indexed: 12/12/2022]
Abstract
Life history theory integrates ecological, physiological, and molecular layers within an evolutionary framework to understand organisms' strategies to optimize survival and reproduction. Two life history hypotheses and their implications for child growth, development, and health (illustrated in the South African context) are reviewed here. One hypothesis suggests that there is an energy trade-off between linear growth and brain growth. Undernutrition in infancy and childhood may trigger adaptive physiological mechanisms prioritizing the brain at the expense of body growth. Another hypothesis is that the period from conception to infancy is a critical window of developmental plasticity of linear growth, the duration of which may vary between and within populations. The transition from infancy to childhood may mark the end of a critical window of opportunity for improving child growth. Both hypotheses emphasize the developmental plasticity of linear growth and the potential determinants of growth variability (including the role of parent-offspring conflict in maternal resources allocation). Implications of these hypotheses in populations with high burdens of undernutrition and infections are discussed. In South Africa, HIV/AIDS during pregnancy (associated with adverse birth outcomes, short duration of breastfeeding, and social consequences) may lead to a shortened window of developmental plasticity of growth. Furthermore, undernutrition and infectious diseases in children living in South Africa, a country undergoing a rapid nutrition transition, may have adverse consequences on individuals' cognitive abilities and risks of cardio-metabolic diseases. Studies are needed to identify physiological mechanisms underlying energy allocation between biological functions and their potential impacts on health.
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Affiliation(s)
- Rihlat Said-Mohamed
- Department of Paediatrics and Child Health, MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng 2193, South Africa
| | - John M Pettifor
- Department of Paediatrics and Child Health, MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng 2193, South Africa
| | - Shane A Norris
- Department of Paediatrics and Child Health, MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng 2193, South Africa
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20
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Mosdøl A, Lidal IB, Straumann GH, Vist GE. Targeted mass media interventions promoting healthy behaviours to reduce risk of non-communicable diseases in adult, ethnic minorities. Cochrane Database Syst Rev 2017; 2:CD011683. [PMID: 28211056 PMCID: PMC6464363 DOI: 10.1002/14651858.cd011683.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Physical activity, a balanced diet, avoidance of tobacco exposure, and limited alcohol consumption may reduce morbidity and mortality from non-communicable diseases (NCDs). Mass media interventions are commonly used to encourage healthier behaviours in population groups. It is unclear whether targeted mass media interventions for ethnic minority groups are more or less effective in changing behaviours than those developed for the general population. OBJECTIVES To determine the effects of mass media interventions targeting adult ethnic minorities with messages about physical activity, dietary patterns, tobacco use or alcohol consumption to reduce the risk of NCDs. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, ERIC, SweMed+, and ISI Web of Science until August 2016. We also searched for grey literature in OpenGrey, Grey Literature Report, Eldis, and two relevant websites until October 2016. The searches were not restricted by language. SELECTION CRITERIA We searched for individual and cluster-randomised controlled trials, controlled before-and-after studies (CBA) and interrupted time series studies (ITS). Relevant interventions promoted healthier behaviours related to physical activity, dietary patterns, tobacco use or alcohol consumption; were disseminated via mass media channels; and targeted ethnic minority groups. The population of interest comprised adults (≥ 18 years) from ethnic minority groups in the focal countries. Primary outcomes included indicators of behavioural change, self-reported behavioural change and knowledge and attitudes towards change. Secondary outcomes were the use of health promotion services and costs related to the project. DATA COLLECTION AND ANALYSIS Two authors independently reviewed the references to identify studies for inclusion. We extracted data and assessed the risk of bias in all included studies. We did not pool the results due to heterogeneity in comparisons made, outcomes, and study designs. We describe the results narratively and present them in 'Summary of findings' tables. We judged the quality of the evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology. MAIN RESULTS Six studies met the inclusion criteria, including three RCTs, two cluster-RCTs and one ITS. All were conducted in the USA and comprised targeted mass media interventions for people of African descent (four studies), Spanish-language dominant Latino immigrants (one study), and Chinese immigrants (one study). The two latter studies offered the intervention in the participants' first language (Spanish, Cantonese, or Mandarin). Three interventions targeted towards women only, one pregnant women specifically. We judged all studies as being at unclear risk of bias in at least one domain and three studies as being at high risk of bias in at least one domain.We categorised the findings into three comparisons. The first comparison examined mass media interventions targeted at ethnic minorities versus an equivalent mass media intervention intended for the general population. The one study in this category (255 participants of African decent) found little or no difference in effect on self-reported behavioural change for smoking and only small differences in attitudes to change between participants who were given a culturally specific smoking cessation booklet versus a booklet intended for the general population. We are uncertain about the effect estimates, as assessed by the GRADE methodology (very low quality evidence of effect). No study provided data for indicators of behavioural change or adverse effects.The second comparison assessed targeted mass media interventions versus no intervention. One study (154 participants of African decent) reported effects for our primary outcomes. Participants in the intervention group had access to 12 one-hour live programmes on cable TV and received print material over three months regarding nutrition and physical activity to improve health and weight control. Change in body mass index (BMI) was comparable between groups 12 months after the baseline (low quality evidence). Scores on a food habits (fat behaviours) and total leisure activity scores changed favourably for the intervention group (very low quality evidence). Two other studies exposed entire populations in geographical areas to radio advertisements targeted towards African American communities. Authors presented effects on two of our secondary outcomes, use of health promotion services and project costs. The campaign message was to call smoking quit lines. The outcome was the number of calls received. After one year, one study reported 18 calls per estimated 10,000 targeted smokers from the intervention communities (estimated target population 310,500 persons), compared to 0.2 calls per estimated 10,000 targeted smokers from the control communities (estimated target population 331,400 persons) (moderate quality evidence). The ITS study also reported an increase in the number of calls from the target population during campaigns (low quality evidence). The proportion of African American callers increased in both studies (low to very low quality evidence). No study provided data on knowledge and attitudes for change and adverse effects. Information on costs were sparse.The third comparison assessed targeted mass media interventions versus a mass media intervention plus personalised content. Findings are based on three studies (1361 participants). Participants in these comparison groups received personal feedback. Two of the studies recorded weight changes over time. Neither found significant differences between the groups (low quality evidence). Evidence on behavioural changes, and knowledge and attitudes typically found some effects in favour of receiving personalised content or no significant differences between groups (very low quality evidence). No study provided data on adverse effects. Information on costs were sparse. AUTHORS' CONCLUSIONS The available evidence is inadequate for understanding whether mass media interventions targeted toward ethnic minority populations are more effective in changing health behaviours than mass media interventions intended for the population at large. When compared to no intervention, a targeted mass media intervention may increase the number of calls to smoking quit line, but the effect on health behaviours is unclear. These studies could not distinguish the impact of different components, for instance the effect of hearing a message regarding behavioural change, the cultural adaptation to the ethnic minority group, or increase reach to the target group through more appropriate mass media channels. New studies should explore targeted interventions for ethnic minorities with a first language other than the dominant language in their resident country, as well as directly compare targeted versus general population mass media interventions.
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Affiliation(s)
- Annhild Mosdøl
- Norwegian Institute of Public HealthKnowledge Centre for the Health ServicesPO BOX 4404 NydalenOsloNorway
| | - Ingeborg B Lidal
- Norwegian Institute of Public HealthKnowledge Centre for the Health ServicesPO BOX 4404 NydalenOsloNorway
- Sunnaas Rehabilitation HospitalTRS National Resource Centre for Rare DisordersNesoddtangenNorway1450
| | - Gyri H Straumann
- Norwegian Institute of Public HealthKnowledge Centre for the Health ServicesPO BOX 4404 NydalenOsloNorway
| | - Gunn E Vist
- Norwegian Knowledge Centre for the Health ServicesPrevention, Health Promotion and Organisation UnitPO Box 7004St Olavs PlassOsloNorway0130
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Ng CK, Tsai AC. Proximate Context of HIV-Related Stigma and Women's Use of Skilled Childbirth Services in Uganda. AIDS Behav 2017; 21:307-316. [PMID: 27106877 DOI: 10.1007/s10461-016-1401-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
HIV-related stigma compromises both HIV prevention and treatment and has recently been described as a barrier to utilization of skilled childbirth services in sub-Saharan Africa. This study uses the 2011 Uganda Demographic Health Survey to estimate the associations between HIV-related stigma, measured both at the individual and community level, and use of facility delivery among women. Consistent with theoretical predictions, higher levels of stigma are associated with reduced likelihood of facility delivery. The negative relationship between stigma and facility delivery is especially pronounced when stigma is measured at the community level, highlighting the importance of understanding the proximate context of HIV-related stigma and its potential effects on behavior. Reducing the stigma of HIV will be critical to achieving the twin goals of reducing overall maternal mortality and preventing mother-to-child HIV transmission.
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Affiliation(s)
- Courtney K Ng
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Ave, 11th Floor, Boston, MA, 02115, USA.
| | - Alexander C Tsai
- MGH Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Center for Population and Development Studies, Cambridge, MA, USA
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Rudrum S, Brown H, Oliffe JL. Understanding the meaning and role of gifts given to Ugandan mothers in maternity care settings: 'The help they give when they've seen how different you are'. SOCIOLOGY OF HEALTH & ILLNESS 2016; 38:1318-1335. [PMID: 27554163 DOI: 10.1111/1467-9566.12456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The provision of gifts to new mothers in Uganda is laden with significance that varies by the social location of the giver and receiver and the context and conditions under which the gift is made available. Here, we examine the act of gift giving and receiving within a Ugandan maternity care setting, describing the connections between these material objects and social relations. A study investigating the social organisation of maternity care in post-conflict northern Uganda found that gift-giving to new mothers functioned to create a material and discursive context wherein women's desire to access these goods was leveraged to create an incentive to attend formal maternity care during pregnancy and for delivery. In this article we describe the material and discursive processes surrounding gift-giving to new mothers in this global South health care setting. This article contributes critical analyses of the function of gifts in healthcare settings as constructing shared identities, social differences and normative values about health citizenship, and an incentive politic that affects equitable access to maternity care. Drawing on intersectional theory and analysis of how specific practices function ideologically to reward or incentivise pregnant women, we integrate material culture studies into the sociology of women's reproductive health.
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Affiliation(s)
- Sarah Rudrum
- Institute for Gender Race Sexuality and Social Justice, University of British Columbia, Canada.
| | - Helen Brown
- School of Nursing, University of British Columbia, Canada
| | - John L Oliffe
- School of Nursing, University of British Columbia, Canada
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23
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Pilasant S, Kulpeng W, Werayingyong P, Tritasavit N, Yamabhai I, Teerawattananon Y, Wangmo S, Tantivess S. Maternal and child health voucher scheme in Myanmar: a review of early stage implementation. BMC Health Serv Res 2016; 16:600. [PMID: 27769242 PMCID: PMC5073954 DOI: 10.1186/s12913-016-1850-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 10/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Maternal and Child Health Voucher Scheme (MCHVS) was introduced in Myanmar to address the high rate of maternal and infant mortalities. It aimed to increase access to maternal and child health (MCH) services by skilled birth attendants (SBAs) and improve the health of pregnant women and their babies. A study to pilot a voucher scheme was implemented in May 2013 in Yedarshey Township. This paper provides a report on a mid-term review of the programme after 7 months of implementation to determine the outcomes of the programme and its impediments. METHODS Quantitative and qualitative approaches were used. Secondary quantitative data were analysed in order to measure the coverage and utilisation of the programme. Semi-structured interviews were conducted in groups and individually with 79 key informants to explore qualitative information on voucher communication, beneficiary's identification, voucher distribution, and challenges for beneficiaries and providers under the MCHVS. RESULTS The results showed that 63 % of eligible pregnant women who registered to the programme received voucher booklets, while the utilisation of most of the MCH services increased over time; in particular, delivery by SBAs increased significantly (P < 0.01) after implementing MCHVS. Overall, the programme was implemented well in terms of promoting and communicating the programme to people in Yedarshey Township. Although a number of targeted poor pregnant women were included in the programme, some beneficiaries were overlooked for a variety of reasons. Nevertheless, both providers and beneficiaries who experienced the MCHVS service utilisation were satisfied with the programme. The evaluation indicated several programme challenges, i.e. external and internal programme communication, voluntary voucher distributor recruitment, incentive and support for voucher distributors, beneficiary screening criteria, and approaches to increase access of services for pregnant women living in remote areas. CONCLUSIONS Generally, the MCHVS pilot programme is a promising initiative to increase access to and utilisation of the MCH services for pregnant women and their babies in Myanmar. However, increasing coverage of the programme and overcoming the barriers should be considered as high-priority issues that need to be addressed.
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Affiliation(s)
- Songyot Pilasant
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Tiwanon Road, Muang, Nonthaburi Thailand
| | - Wantanee Kulpeng
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Tiwanon Road, Muang, Nonthaburi Thailand
| | - Pitsaphun Werayingyong
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Tiwanon Road, Muang, Nonthaburi Thailand
| | - Nattha Tritasavit
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Tiwanon Road, Muang, Nonthaburi Thailand
| | - Inthira Yamabhai
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Tiwanon Road, Muang, Nonthaburi Thailand
| | - Yot Teerawattananon
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Tiwanon Road, Muang, Nonthaburi Thailand
| | - Sangay Wangmo
- International Health Policy Program (IHPP), Ministry of Public Health, Tiwanon Road, Muang, Nonthaburi Thailand
| | - Sripen Tantivess
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Tiwanon Road, Muang, Nonthaburi Thailand
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Kuwawenaruwa A, Mtei G, Baraka J, Tani K. Implementing demand side targeting mechanisms for maternal and child health-experiences from national health insurance fund program in Rungwe District, Tanzania. Global Health 2016; 12:41. [PMID: 27480025 PMCID: PMC4970262 DOI: 10.1186/s12992-016-0180-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 07/04/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Low and middle income countries have adopted targeting mechanisms as a means of increasing program efficiency in reaching marginalized people in the community given the available resources. Design of targeting mechanisms has been changing over time and it is important to understand implementers' experience with such targeting mechanisms since such mechanisms impact equity in access and use of maternal health care services. METHODS The case study approach was considered as appropriate method for exploring implementers' and decision-makers' experiences with the two targeting mechanisms. In-depth interviews in order to explore implementer experience with the two targeting mechanisms. A total of 10 in-depth interviews (IDI) and 4 group discussions (GDs) were conducted with implementers at national level, regional, district and health care facility level. A thematic analysis approach was adopted during data analysis. RESULTS The whole process of screening and identifying poor pregnant women resulted in delay in implementation of the intervention. Individual targeting was perceived to have some form of stigmatization; hence beneficiaries did not like to be termed as poor. Geographical targeting had a few cons as health care providers experienced an increase in workload while staff remained the same and poor quality of information in the claim forms. However geographical targeting increase in the number of women going to higher level of care (district/regional referral hospital), increase in facility revenue and insurance coverage. CONCLUSION Interventions which are using targeting mechanisms to reach poor people are useful in increasing access and use of health care services for marginalized communities so long as they are well designed and beneficiaries as well as all implementers and decision makers are involved from the very beginning. Implementation of demand side financing strategies using targeting mechanisms should go together with supply side interventions in order to achieve project objectives.
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Affiliation(s)
- August Kuwawenaruwa
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Gemini Mtei
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Jitihada Baraka
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Kassimu Tani
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
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Gupta A, Dhillon PK, Govil J, Bumb D, Dey S, Krishnan S. Multiple Stakeholder Perspectives on Cancer Stigma in North India. Asian Pac J Cancer Prev 2016; 16:6141-7. [PMID: 26320509 DOI: 10.7314/apjcp.2015.16.14.6141] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cancer is a leading cause of death worldwide. A large proportion of cancer deaths are preventable through early detection but there are a range of social, emotional, cultural and financial dimensions that hinder the effectiveness of cancer prevention and treatment efforts. Cancer stigma is one such barrier and is increasingly recognized as an important factor influencing health awareness and promotion, and hence, disease prevention and control. The impact and extent of stigma on the cancer early detection and care continuum is poorly understood in India. OBJECTIVES To evaluate cancer awareness and stigma from multiple stakeholder perspectives in North India, including men and women from the general population, health care professionals and educators, and cancer survivors. MATERIALS AND METHODS A qualitative study was conducted with in-depth interviews (IDIs) and focus group discussions (FGDs) among 39 individuals over a period of 3 months in 2014. Three groups of participants were chosen purposively - 1) men and women who attended cancer screening camps held by the Indian Cancer Society, Delhi; 2) health care providers and 3) cancer survivors. RESULTS Most participants were unaware of what cancers are in general, their causes and ways of prevention. Attitudes of families towards cancer patients were observed to be positive and caring. Nevertheless, stigma and its impact emerged as a cross cutting theme across all groups. Cost of treatment, lack of awarenes and beliefs in alternate medicines were identified as some of the major barriers to seeking care. CONCLUSIONS This study suggests a need for spreading awareness, knowledge about cancers and assessing associated impact among the people. Also Future research is recommended to help eradicate stigma from the society and reduce cancer-related stigma in the Indian context.
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Affiliation(s)
- Adyya Gupta
- South Asia Network for Chronic Disease (SANCD), Public Health Foundation of India, New Delhi, India E-mail :
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Abstract
Considerable progress has been made towards reducing under-5 childhood mortality in the Millennium Development Goals era. Reduction in newborn mortality has lagged behind maternal and child mortality. Effective implementation of innovative, evidence-based, and cost-effective interventions can reduce maternal and newborn mortality. Interventions aimed at the most vulnerable group results in maximal impact on mortality. Intervention coverage and scale-up remains low, inequitable and uneven in low-income countries due to numerous health-systems bottle-necks. Innovative service delivery strategies, increased integration and linkages across the maternal, newborn, child health continuum of care are vital to accelerate progress towards ending preventable maternal and newborn deaths.
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Beck-Sagué CM, Dévieux JG, Pinzón-Iregui MC, Abreu-Pérez R, Lerebours-Nadal L, Gaston S, Dean AG, Halpern M, Rouzier V, Bertrand R, Rosenberg R, Pape JW, Nicholas SW, Blasini I. Depression in caregivers of status-naïve pediatric HIV patients participating in a status disclosure study in Haiti and the Dominican Republic: preliminary report. J Trop Pediatr 2015; 61:65-8. [PMID: 25389181 PMCID: PMC4375385 DOI: 10.1093/tropej/fmu060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A pilot study is underway to assess safety and acceptability of an intervention to disclose their HIV infection status to status-naïve pediatric antiretroviral therapy patients in Hispaniola [the island shared by Haiti and the Dominican Republic (DR)]. Of 22 Haiti and 47 DR caregivers recruited to date, 68.2% Haiti and 34.0% DR caregivers had clinically significant depressive symptomatology at the time of enrollment (p = 0.008). Depressive symptom prevalence was higher in Haiti caregivers who were female (81.3% vs. 0 in males; p = 0.02) and in DR caregivers who were patients' mothers (50.0%) or grandmothers (66.7%; 56.0% combined) than others (9.1%), (p < 0.001). Internalized stigma was more commonly reported by Haiti (85.7%) than DR (53.2%; p = 0.01) caregivers; 56.4% of Haiti and DR caregivers reporting internalized stigma vs. 26.1% of caregivers denying it had depressive symptoms (p = 0.02). Depression is common in Hispaniola caregivers possibly affecting disclosure timing. Study participation presents opportunities for addressing caregiver depression.
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Affiliation(s)
- Consuelo M Beck-Sagué
- Department of Health Promotion and Disease Prevention, Florida International University, Robert Stempel College of Public Health and Social Work, Miami, FL, USA 33199
| | - Jessy G Dévieux
- Department of Health Promotion and Disease Prevention, Florida International University, Robert Stempel College of Public Health and Social Work, Miami, FL, USA 33199
| | - María Claudia Pinzón-Iregui
- Department of Health Promotion and Disease Prevention, Florida International University, Robert Stempel College of Public Health and Social Work, Miami, FL, USA 33199
| | - Rosa Abreu-Pérez
- Robert Reid Cabral Children's Hospital, Santo Domingo, Dominican Republic (DR)
| | | | - Stephanie Gaston
- Groupe Haïtien d'Etude du Sarcoma de Kaposi et des Infections Opportunistes (GHESKIO), Department of Adolescent Medicine, Port-au-Prince, Haiti
| | - Andrew G Dean
- Department of Epidemiology Voluntary Faculty, University of Miami, Miami, FL, USA 33136
| | - Mina Halpern
- Clínica de Familia La Romana, Department of Research, La Romana, DR
| | - Vanessa Rouzier
- Groupe Haïtien d'Etude du Sarcoma de Kaposi et des Infections Opportunistes (GHESKIO), Department of Adolescent Medicine, Port-au-Prince, Haiti
| | - Rachel Bertrand
- Groupe Haïtien d'Etude du Sarcoma de Kaposi et des Infections Opportunistes (GHESKIO), Department of Adolescent Medicine, Port-au-Prince, Haiti
| | - Rhonda Rosenberg
- Department of Health Promotion and Disease Prevention, Florida International University, Robert Stempel College of Public Health and Social Work, Miami, FL, USA 33199
| | - Jean William Pape
- Groupe Haïtien d'Etude du Sarcoma de Kaposi et des Infections Opportunistes (GHESKIO), Department of Adolescent Medicine, Port-au-Prince, Haiti Cornell University School of Medicine, Cornell Medical College Center for Global Health, New York, NY, USA 10065
| | - Stephen W Nicholas
- Clínica de Familia La Romana, Department of Research, La Romana, DR Columbia College of Physicians and Surgeons, New York, NY, USA 10032
| | - Ileana Blasini
- Department of Pediatrics Voluntary Faculty, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico 00931-1839
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Waisbord S. Where do we go next? Behavioral and social change for child survival. JOURNAL OF HEALTH COMMUNICATION 2014; 19 Suppl 1:216-22. [PMID: 25207454 PMCID: PMC4205915 DOI: 10.1080/10810730.2014.933288] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Silvio Waisbord
- School of Media and Public Affairs, George Washington University
,
Washington
,
District of Columbia
,
USA
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29
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Fox E, Obregón R. Population-level behavior change to enhance child survival and development in low- and middle-income countries. JOURNAL OF HEALTH COMMUNICATION 2014; 19 Suppl 1:3-9. [PMID: 25207445 PMCID: PMC4205918 DOI: 10.1080/10810730.2014.934937] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Elizabeth Fox
- Office of Health, Infectious Diseases and Nutrition
, Global Health Bureau, U.S. Agency for International Development
,
Washington
,
District of Columbia
,
USA
- U.S. Agency for International Development, 1300 Pennsylvania Ave NW,
Washington
,
DC
,
20004
,
USA
E-mail:
| | - Rafael Obregón
- Programme Division
, Communication for Development Section, United Nations Children's Fund (UNICEF)
,
New York
,
New York
,
USA
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30
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Vélez LF, Sanitato M, Barry D, Alilio M, Apfel F, Coe G, Garcia A, Kaufman M, Klein J, Kutlesic V, Meadowcroft L, Nilsen W, O'Sullivan G, Peterson S, Raiten D, Vorkoper S. The role of health systems and policy in producing behavior and social change to enhance child survival and development in low- and middle-income countries: an examination of the evidence. JOURNAL OF HEALTH COMMUNICATION 2014; 19 Suppl 1:89-121. [PMID: 25207449 PMCID: PMC4205911 DOI: 10.1080/10810730.2014.939313] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Evidence-based behavior change interventions addressing health systems must be identified and disseminated to improve child health outcomes. Studies of the efficacy of such interventions were identified from systematic searches of the published literature. Two hundred twenty-nine of the initially identified references were judged to be relevant and were further reviewed for the quality and strength of the evidence. Studies were eligible if an intervention addressed policy or health systems interventions, measured relevant behavioral or health outcomes (e.g., nutrition, childhood immunization, malaria prevention and treatment), used at least a moderate quality research design, and were implemented in low- or middle-income countries. Policy or systems interventions able to produce behavior change reviewed included media (e.g., mass media, social media), community mobilization, educational programs (for caregivers, communities, or providers), social marketing, opinion leadership, economic incentives (for both caregiver and provider), health systems strengthening/policy/legislation, and others. Recommendations for policy, practice, and research are given based on fairly strong data across the areas of health service delivery, health workforce, health financing, governance and leadership, and research.
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Affiliation(s)
| | - Mary Sanitato
- Bureau for Global Health, U.S. Agency for International Development
,
Washington
,
District of Columbia
,
USA
| | - Donna Barry
- Center for American Progress
,
Washington
,
District of Columbia
,
USA
| | - Martin Alilio
- U.S. Agency for International Development
,
Washington
,
District of Columbia
,
USA
| | - Franklin Apfel
- World Health Communication Associates
,
Somerset
,
United Kingdom
| | - Gloria Coe
- U.S. Agency for International Development
,
Washington
,
District of Columbia
,
USA
| | - Amparo Garcia
- U.S. Forest Service
,
Washington
,
District of Columbia
,
USA
| | - Michelle Kaufman
- Center for Communication Programs
, Johns Hopkins Bloomberg School of Public Health
,
Baltimore
,
Maryland
,
USA
| | - Jonathan Klein
- American Academy of Pediatrics
,
Elk Grove Village
,
Illinois
,
USA
| | - Vesna Kutlesic
- National Institutes of Health
,
Bethesda
,
Maryland
,
USA
| | | | - Wendy Nilsen
- Office of Behavioral and Social Sciences Research
, National Institutes of Health
,
Bethesda
,
Maryland
,
USA
| | | | | | - Daniel Raiten
- National Institutes of Health
,
Bethesda
,
Maryland
,
USA
| | - Susan Vorkoper
- National Institutes of Health
,
Bethesda
,
Maryland
,
USA
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