Giving voice to the voiceless: Understanding the perceived needs of dementia family carers in Soweto, a South African township

This qualitative study aimed to provide family caregivers with an independent platform to reflect on and identify their needs in the role of dementia caregiver. Thirty caregivers were interviewed using a semi-structured approach, and data analysis followed a reflective thematic analysis method. The study revealed that Black African caregivers in townships require sufficient information and orientation to dementia-specific services, psychoeducation on dementia as a disease and its behavioural manifestations, as well as practical skills to manage the disease process. Caregivers expressed the need for in-depth, accessible education to boost their confidence and resilience in handling the challenges of dementia caregiving. They also proposed community initiatives to raise awareness, promote knowledge, and facilitate early detection and diagnosis of dementia. Additional needs included informational and educational workshops, resources like transportation services and helplines, day care facilities, media campaigns, and collaboration with the government for funding and policy change. New caregivers were advised to seek comprehensive education, support, and services while preserving the dignity of their family members with dementia. Remarkably, the identified needs and community initiatives aligned with the priority areas outlined by ADI for a National Dementia Plan, which South Africa currently lacks. The study highlights the importance of developing a National Dementia Plan in South Africa through collaboration among stakeholders, including communities, policy-makers, and multidisciplinary healthcare teams, while ensuring that individuals and families affected by dementia have a voice.

The Last Mile-Community Engagement and Conditional Incentives to Accelerate Polio Eradication in Pakistan: Study Protocol for a Quasi-Experimental Trial

Poliomyelitis is a condition of great concern and is endemic in only two countries of the world: Pakistan and Afghanistan. Community mobilization plays a vital role in raising awareness and can help reduce polio vaccine refusals. The objective of this study will be to decrease polio vaccine refusals and zero-dose vaccines by motivating behavior change through the provision of conditional-collective-community-based incentives (C3Is) based on a reduction in polio vaccine refusals. The project will adopt a pretest/post-test quasi-experimental design with two intervention high-risk union councils (HRUCs) and two control union councils (UCs) of peri-urban (Karachi) and rural (Bannu) settings in Pakistan. A participatory community engagement and demand creation strategy with trust-building community mobilization with C3Is, to reduce vaccine refusals and improve polio immunization coverage in two HRUCs, will be used. These UCs will be divided into clusters based on the polio program framework and community groups will be formed in each cluster. These community groups will carry out awareness activities and will be given serial targets to reduce vaccine refusals and those who qualify will be provided C3Is. The project intends to create a replicable model that the government can integrate within health systems for long-term sustainability until the goal of eradication of poliovirus is achieved. The evaluation will be carried out by an independent data collection and analysis team at baseline and endline (after 12 months of intervention). The trial is registered with linicalTrials.gov with number NCT05721274.

Image-Based Awareness Campaign and Community Mobilization in the Control of Schistosomiasis

Community awareness and participation in mass screening is critical for schistosomiasis control. This study assessed the impact of sharing anonymized image-based positive test results on the uptake of screening during community mobilization outreach. We conducted an observational study to compare the population response to standard and image-based strategies in 14 communities in Abuja, Nigeria. Six hundred and ninety-one (341 females, 350 males) individuals participated in this study. We analyzed the response ratio, relative increase, and sample collection time. The potential treatment uptake and change in social behavior were determined based on a semi-structured questionnaire. The mean response ratio of the image-based strategy was 89.7% representing a significantly higher ratio than the 27.8%, which was observed under the standard mobilization approach (p ≤ 0.001). The image-based method was associated with 100% of the participants agreeing to provide urine samples, 94% willing to be treated, 89% claiming to have been invited to participate in the study by a friend, and 91% desiring to change a predisposing behavioral habit. These findings indicate that image-based community awareness campaigns may increase the population's perception about schistosomiasis transmission and treatment. This raises new possibilities for local resource mobilization to expand services in reaching the last mile in schistosomiasis control.

Process and Outcome of Community Engagement Event on Substance Use and Addiction Risks Facing Their Immigrant Communities in Regina, Saskatchewan

Canada is a significant destination for immigrants who are drawn from different ethnic and cultural backgrounds some of whom have a hidden risk for substance use disorders due to acculturation stress and are not screened for risks of substance use or addiction when considering medical admissibility. Not surprisingly, healthcare providers in Regina are reporting a noticeable increase in substance use among immigrants. These immigrants experience barriers in seeking substance use prevention and treatment services due to diverse challenges: stigma, shame, and lack of knowledge of existing services. Considering the discussed challenges and risks of substance use disorders in immigrant communities, creating a safe space for discussing these topics is urgent. To understand and address these challenges, a connection grant from the Saskatchewan Health Research Foundation (SHRF) to mobilize immigrant communities in Regina to explore substance use issues and their impact on the community was sought and received. Subsequently, a Zoom knowledge-sharing event brought settlement agency stakeholders together to deliberate issues on substance use and addiction faced by immigrants in Regina, Saskatchewan. The Zoom session included presentations on immigrants and substance use from the clinical, community, and lived experience perspectives of immigrants. Because of the challenges and risks, this community consultation process revealed that acculturation stress and the ease of obtaining socially acceptable substances fuel substance use and addiction among immigrants in Regina; this is further exacerbated by the lack of programming available to prevent and reduce the risks of substance use in this population. A team of knowledge keepers with lived experiences, service providers, and researchers was assembled to explore substance use and addiction among immigrants. This manuscript reports the process of community engagement to identify solutions to this budding issue. The strengths, challenges, and lessons learned are identified.

"They Kept Going for Answers": Knowledge, Capacity, and Environmental Health Literacy in Michigan's PBB Contamination

The Michigan PBB Oral History Project documented community residents' descriptions of a large-scale chemical contamination-the PBB contamination-that occurred in Michigan in 1973. These oral histories document residents' and others' experiences during and after the contamination. We conducted a grounded theory qualitative analysis of 31 oral histories to examine the experiences of community members, researchers, lawyers, and others who actively sought out and contributed essential information about the contamination and its impacts. Our findings highlight several challenges encountered in the development of this knowledge including four central themes-contested knowledge, community skills, inaction, and uncertainty. Integrating environmental health literacy, community capacity, and contested illness frameworks, we examine the contributions of community residents, scientists (from inside and outside the community), and others to the development of knowledge to inform decisions and sustain action regarding this large-scale contamination. We close with a discussion of lessons learned regarding efforts to build environmental health knowledge within uncertain and often contested contexts and for promoting environmental health and action related to large-scale chemical contaminations. Our findings suggest the importance of integrated frameworks for examining and promoting the critical role of community skills, leadership, participation, sense of community, and community power in promoting environmental health.

Examining Resident Power Building in a Place-Based Initiative

Rates of diseases and disabilities that are otherwise preventable are higher in low-income communities and communities of color. These disparities are attributed, in large part, to a power imbalance between residents and decision makers, and restoring resident power is necessary to improve health outcomes. A key strategy in many health promotion programs, resident power building is a process by which residents gain necessary skills to improve social conditions through their involvement in community change work. This study is part of a larger evaluation of Building Healthy Communities, a ground-breaking 10-year, $1 billion place-based initiative funded by The California Endowment designed to reverse the historical impact of racial and economic discrimination by advancing statewide policy, changing the narrative around health, and transforming underserved communities to achieve health equity. This article presents the resident power framework and identifies five domains that contributed to resident power building: continuity, culture, context, concrete action, and capacity. Continuity and culture mattered most to residents' ability to organize and to their ability to exercise their voice, respectively. While this study examined resident power building within the context of a large-scale place-based initiative, the domains that the authors identified are salient across health promotion programs that use power building as a key strategy to achieve program outcomes. The domains serve as opportunities to modify power-building strategies and allow program staff to allocate resources to specific activities to achieve program outcomes.

Implementation Facilitators and Challenges of a Place-Based Intervention to Reduce Health Disparities in Harlem Through Community Activation and Mobilization

Background

To address significant health inequities experienced by residents of public housing in East and Central Harlem compared to other New Yorkers, NYC Department of Health and Mental Health (DOHMH) collaborated with community and academic organizations and the New York City Housing Authority to develop a place-based initiative to address chronic diseases in five housing developments, including a community activation and mobilization component led by community health organizers (CHOs).

Purpose

Guided by the Consolidated Framework for Implementation Research (CFIR), we evaluated the initial implementation of the community activation and mobilization component to systematically investigate factors that could influence the successful implementation of the intervention.

Methods

Nineteen in-depth qualitative interviews were conducted with a purposive sample of CHOs, community members and leaders, collaborating agencies and DOHMH staff. Interviews were transcribed verbatim, and themes and codes were developed to identify theoretically important concepts of the CFIR and emergent analytic patterns.

Results

Findings identified important facilitators to implementation: positive community perception of the program, CHO engagement and responsiveness to community needs, CHO norms and values and adaptability of DOHMH and CHOs to community needs. Challenges included the instability of the program in the first year, limited ability to address housing related issues, concerns about long term funding, competing community priorities, low expectations by the community for the program, time and labor intensity to build trust within the community, and the dual roles of CHOs as community advocates and DOHMH employees.

Conclusions

Findings will guide future community activation and mobilization activities. The study demonstrates the value of integrating implementation science and health equity frameworks.

Scoping Review of Intervention Strategies for Improving Coverage and Uptake of Maternal Nutrition Services in Southeast Asia

Maternal undernutrition can lead to protein-energy malnutrition, micronutrient deficiencies, or anemia during pregnancy or after birth. It remains a major problem, despite evidence-based maternal-nutrition interventions happening on ground. We conducted a scoping review to understand different strategies and delivery mechanisms to improve maternal nutrition, as well as how interventions have improved coverage and uptake of services. An electronic search was conducted in PubMed and Google Scholar for published studies reporting on the effectiveness of maternal-nutrition interventions in terms of access or coverage, health outcomes, compliance, and barriers to intervention utilization. The search was limited to studies published within ten years before the initial search date, 8 November 2019; later, it was updated to 17 February 2021. Of 31 studies identified following screening and data extraction, 22 studies were included for narrative synthesis. Twelve studies were reported from India and eleven from Bangladesh, three from Nepal, two from both Pakistan and Thailand (Myanmar), and one from Indonesia. Nutrition education and counselling, home visits, directly observed supplement intake, community mobilization, food, and conditional cash transfer by community health workers were found to be effective. There is a need to incorporate diverse strategies, including various health education approaches, supplementation, as well as strengthening of community participation and the response of the health system in order to achieve impactful maternal nutrition programs.

Social and Psychological Readiness to Take Collective Action Against Violence Against Women: A Mixed Methods Study of Informal Settlements in Mumbai, India

Past failures to mobilize communities in collective action against violence against women (VAW) have been ascribed to contextual challenges, but researchers have not systematically mapped community capacity for collective action against VAW. We conducted a mixed methods study in Mumbai, India using quantitative data from a household survey (n = 2,642) and qualitative data from 264 community meetings. We found attitudes supporting gender inequality and violence coexisted with significant enthusiasm and support for collective action against VAW. These findings open up avenues for policymakers to treat communities as less vulnerable and more capable of changing situations and problems that affect them.

Economic Evaluation of Public Health Interventions: An Application to Interventions for the Prevention of Violence Against Women and Girls Implemented by the "What Works to Prevent Violence Against Women and Girls?" Global Program

Violence against women and girls (VAWG) has important social, economic, and public health impacts. Governments and international donors are increasing their investment in VAWG prevention programs, yet clear guidelines to assess the "value for money" of these interventions are lacking. Improved costing and economic evaluation of VAWG prevention can support programming through supporting priority setting, justifying investment, and planning the financing of VAWG prevention services. This article sets out a standardized methodology for the economic evaluation of complex, that is, multicomponent and/or multiplatform, programs designed to prevent VAWG in low- and middle-income countries (LMICs). It outlines an approach that can be used alongside the most recent guidance for the economic evaluation of public health interventions in LMICs. It defines standardized methods of data collection and analysis, outcomes, and unit costs (i.e., average costs per person reached, output or service delivered), and provides guidance to investigate the uncertainty in cost-effectiveness estimates and report results. The costing approach has been developed and piloted as part of the "What Works to Prevent Violence Against Women and Girls?" (What Works?) program in five countries. This article and its supplementary material can be used by both economists and non-economists to contribute to the generation of new cost-effectiveness data on VAWG prevention, and ultimately improve the allocative efficiency and financing across VAWG programs.

Participatory learning and action cycles with women's groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability

WHO recommends participatory learning and action cycles with women's groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range: $61-$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from $135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women's groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations.

Troubling heroes: Reframing the environmental justice contributions of the Flint water crisis

While the story of the Flint water crisis has been shared widely, the popular narrative-described in multiple documentaries and as evidenced by accolades heaped upon a limited few number of actors involved with Flint-largely leaves out the broad experiences and actions of Flint residents in responding to the crisis, raising awareness, and advocating for change. Academic literature has contributed to reinforcing an abbreviated and disempowered version of the narrative where Flint residents needed rescue. In this article, we present an extended description of the Flint water crisis leading up to the water switch in April 2014, including descriptions of community mobilization efforts to call government actions into account and produce investigations that validated the concerns of the residents. We offer a review of prominent academic literature demonstrating patterns of erasure that suggest Flint residents were disempowered. In response, we offer three examples which demonstrate how Flint resident mobilizations have broad historical context, national reach, and individual actions that contradict the narrative that Flint residents lack agency and power. In our analysis, rather than viewing Flint residents as in need of rescue by science, we argue that the community mobilization in Flint is indicative of a highly successful implementation of popular epidemiology with profound effects on national conversations about lead in water, drinking water infrastructure management, and environmental justice.

Mujeres Unidas: Addressing Substance Use, Violence, and HIV Risk through Asset-Based Community Development for Women in the Sex Trade

This paper examines the prevalence of and potential for community mobilization (CM) and its association with HIV/STI risk, substance use, and violence victimization among women, particularly those using substances, in the sex trade in Tijuana, Mexico.

METHODS

195 women participated in Mujeres Unidas (K01DA036439 Urada) under a longitudinal survey study, "Proyecto Mapa de Salud" (R01DA028692, PI: Brouwer). Local health/social service providers (N = 16) were also interviewed.

RESULTS

39% of women who participated in community mobilization activities used substances. In adjusted analyses (n = 135), participation in CM activities (n = 26) was more likely among women who did not report substance use (AOR: 4.36, CI: 1.11-17.16), perceived a right to a life free from violence (AOR: 9.28, CI: 2.03-59.26), talked/worked with peers in the sex trade to change a situation (AOR: 7.87, CI: 2.03-30.57), witnessed violence where they worked (AOR: 4.45, CI: 1.24-15.96), and accessed free condoms (AOR: 1.54, CI: 1.01-2.35). Forty-five of the women using substances demonstrated their potential for engaging in asset-based community development (ABCD) with service providers in Mujeres Unidas meetings.

CONCLUSION

Women using substances, vs. those who did not, demonstrated their potential to engage in ABCD strategies. Women's empowerment, safety, and health could be enhanced by communities engaging in ABCD strategies that build and bridge social capital for marginalized women who otherwise have few exit and recovery options.

Violence in Commercial Sex Work: A Case Study on the Impact of Violence Among Commercial Female Sex Workers in India and Strategies to Combat Violence

Violence is one of the primary contextual factors that significantly raise sex workers' sexually transmitted infection risk. The current study examines how violence affects sexual health behavior among commercial female sex workers in a red light district in Calcutta, India. The study which employs in-depth interviews of 37 commercial female sex workers also discusses an innovative multilayered strategy devised by the sex workers to combat violence through a community mobilization drive. The current study shows that the sex workers can confront the system that precipitates violence and actively engage with it to mitigate the impact of structural barriers to empowerment.

Women Trading Sex in a U.S.-Mexico Border City: A Qualitative Study of the Barriers and Facilitators to Finding Community and Voice

Poverty and income inequality can increase a woman's decision to engage in risky transactional sex, and may lead to unimaginable harms, such as violence, substance use, and human trafficking. This study examines the facilitators and barriers to finding community and voice among women trading sex in Tijuana, Mexico, and what factors, such as socio-structural support, violence, and substance use, may impact their potential to engage with others, including human service providers. Sixty qualitative in-depth interviews were conducted with women trading sex in Tijuana, Mexico. Researchers met with participants for in-depth-face-to-face structured interviews. Data were coded using ATLAS.ti. Participants were aged 19-73 (mean: 37), 98% were of Mexican nationality, 90% reported trading sex independent of the control of others, with 58% identified as independent and street-based. Thirty percent of women trading sex reported substance use (excluding marijuana) and 20% reported injection drug use within 30 days. The majority reported no involvement in mobilization activities, but 85% expressed interest. However, barriers included stigma, cultural gender norms, partner violence, and privacy in regards to disclosure of sex trade involvement, moral conflict (revealing one's involvement in sex trade), involvement in substance use, human trafficking, and feeling powerless. Facilitators were having a safe space to meet, peer support, self-esteem, feeling heard, knowledge of rights, economic need to support families, and staying healthy. Findings imply the potential to go beyond mobilizing limited groups of women in the sex trade and instead involve whole community mobilization; that is, to reach and include the more vulnerable women (substance use, trafficked) in supportive services (social services, exit strategies, better healthcare opportunities, and/or education for healthcare providers to help break societal stigmas regarding women in the sex trade) and to change the status of women in society in general.

The Influence of Organised Diffusion on Social Norms Change: Addressing Intimate Partner Violence in Nepal

Intimate partner violence (IPV) is a significant global health issue. Organised diffusion has potential to influence changes in norms that perpetuate harmful practices by spreading anti-IPV messaging throughout social networks. The Change Starts at Home intervention in Nepal leverages radio programming and community mobilisation to address the perpetration of IPV. This qualitative analysis of couple interviews at the 18-month follow-up (N = 35 individuals) seeks to evaluate how the intervention messaging diffused into the community using organised diffusion as a framework, and how this influenced any changes in norms related to the perpetration of IPV. Overall, this study provides evidence that the Change at Home Intervention effectively diffused into the community and began to promote changes around IPV norms, especially among relationships that were socially and geospatially close. This analysis demonstrates the potential for organised diffusion to facilitate social norms change around IPV.

Effectiveness of a Community-Based Intervention to Increase Supermarket Vendors' Compliance with Age Restrictions for Alcohol Sales in Spain: A Pilot Study

In Spain the legal age to buy alcohol is 18 years. However, official surveys show that minors perceive alcohol availability to be easy. This paper describes the impacts of a community-based intervention to increase vendors' compliance with age limits regarding alcohol sales in supermarkets. The aim of this study was to explore the association between implementation of a multicomponent intervention to reduce adolescents' alcohol use and sale of alcohol to minors in the city of Palma (Spain). Twenty trained adolescents (14-17 years old) conducted 138 alcohol test purchases in nine supermarket chains in August 2018 (baseline; n = 73) prior to the intervention, and again in January 2020 (follow-up; n = 65). Analysis was conducted according to three levels of intervention implemented across the supermarkets: (i) personnel from the supermarkets' Human Resources or Corporate Social Responsibility teams received alcohol service training as trainers (i.e., community mobilization); (ii) managers and vendors training by the capacitated trainers; and (iii) no training of managers or vendors (i.e., control group). In the supermarkets that completed the Training of Trainers and the vendors' training program, average sales decreased significantly from 76.9% in 2018 to 45.5% in 2020, asking for the age of the shopper significantly increased from 3.8% to 45.4%, and asking for proof of age significantly increased from 15.4% to 72.7%. Additionally, a statistically significant increase was observed in the visibility of prohibition to sell alcohol to minors' signs, from 61.5% to 100%. No statistically significant differences were found for the Training of Trainers intervention alone nor in the control group. In conclusion, community mobilization combined with staff training is associated with significant increases in supermarket vendors' compliance with alcohol legislation in Spain.

Enhancing national prevention and treatment services for sex workers in Zimbabwe: a process evaluation of the SAPPH-IRe trial

Targeted HIV interventions for female sex workers (FSW) combine biomedical technologies, behavioural change and community mobilization with the aim of empowering FSW and improving prevention and treatment. Understanding how to deliver combined interventions most effectively in sub-Saharan Africa is critical to the HIV response. The Sisters' Antiretroviral Programme for Prevention of HIV: an Integrated Response (SAPPH-Ire) randomized controlled trial in Zimbabwe tested an intervention to improve FSW engagement with HIV services. After 2 years, results of the trial showed no significant difference between study arms in proportion of FSW with HIV viral load ≥1000 copies/ml as steep declines occurred in both. We present the results of a process evaluation aiming to track the intervention's implementation, assess its feasibility and accessibility, and situate trial results within the national HIV policy context. We conducted a mixed methods study using data from routine programme statistics, qualitative interviews with participants and respondent driven surveys. The intervention proved feasible to deliver and was acceptable to FSW and providers. Intervention clinics saw more new FSW (4082 vs 2754), performed over twice as many HIV tests (2606 vs 1151) and nearly double the number of women were diagnosed with HIV (1042 vs 546). Community mobilization meetings in intervention sites also attracted higher numbers. We identified some gaps in programme fidelity: offering pre-exposure prophylaxis took time to engage FSW, viral load monitoring was not performed, and ratio of peer educators to FSW was lower than intended. During the trial, reaching FSW with HIV testing and treatment became a national priority, leading to increasing attendance at both intervention and control clinics. Throughout Zimbabwe, antiretroviral therapy coverage improved and HIV-stigma declined. Zimbabwe's changing HIV policy context appeared to contribute to positive improvements across the HIV care continuum for all FSW over the course of the trial. More intense community-based interventions for FSW may be needed to make further gains.

Engaging Church Leaders in the Reduction of Teen Birth Rate in High-Risk Areas

Involving faith-based organizations in community health promotion has gained widespread interest and has been a successful approach in addressing various health disparities in vulnerable communities. However, there is comparatively little evidence regarding sexual health promotion among faith-based organizations. Some agencies have responded to the challenge of reducing teen pregnancy with broad-based initiatives involving many different sectors of the community including faith-based organizations. Focus groups with key church leaders (n = 25) from zip codes with identified birth rates of 95 or higher were conducted to explore their perception of teen pregnancy among their communities. Purposive and snowball sampling were utilized. Recruitment was conducted through calls, email, and flyers. This study identified the barriers that church leaders encounter in their efforts to address teen pregnancy in their communities. Common themes that emerged include church education, parent support and communication, cultural barriers, availability of resources, awareness of services, and the need for comprehensive sexual education. Findings and recommendations to help those working in the faith community overcome identified barriers are addressed. Recent decreases in teen birth rates should not lead to complacency; rather they should inspire public health practitioners to do more, especially when some communities have not experienced the same success. Collaborating with faith-based organizations is one method to consider when considering community prevention efforts.

Promoting women's and children's health through community groups in low-income and middle-income countries: a mixed-methods systematic review of mechanisms, enablers and barriers

INTRODUCTION

Community mobilisation through group activities has been used to improve women's and children's health in a range of low-income and middle-income contexts, but the mechanisms through which it works deserve greater consideration. We did a mixed-methods systematic review of mechanisms, enablers and barriers to the promotion of women's and children's health in community mobilisation interventions.

METHODS

We searched for theoretical and empirical peer-reviewed articles between January 2000 and November 2018. First, we extracted and collated proposed mechanisms, enablers and barriers into categories. Second, we extracted and synthesised evidence for them using narrative synthesis. We assessed risk of bias with adapted Downs and Black and Critical Appraisal Skills Programme checklists. We assigned confidence grades to each proposed mechanism, enabler and barrier.

RESULTS

78 articles met the inclusion criteria, of which 39 described interventions based on a participatory group education model, 19 described community-led structural interventions to promote sexual health in marginalised populations and 20 concerned other types of intervention or multiple interventions at once. We did not have high confidence in any mechanism, enabler or barrier. Two out of 15 proposed mechanisms and 10 out of 12 proposed enablers and barriers reached medium confidence. A few studies provided direct evidence relating proposed mechanisms, enablers or barriers to health behaviours or health outcomes. Only two studies presented mediation or interaction analysis for a proposed mechanism, enabler or barrier.

CONCLUSION

We uncovered multiple proposed mechanisms, enablers and barriers to health promotion through community groups, but much work remains to provide a robust evidence base for proposed mechanisms, enablers and barriers.

PROSPERO REGISTRATION NUMBER

CRD42018093695.

Mobilizing civil society for the HIV treatment cascade: a global analysis on democracy and its association with people living with HIV who know their status

INTRODUCTION

Civil society organizations (CSOs) play an essential role in the global HIV/AIDS response. Past studies have described the beneficial role of CSOs in meeting the United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, but have not explored how political conditions, which influence the ability of CSOs to organize, have an impact on the cascade. This study explores the relationship between measures of democracy and its association with diagnosis rates among people living with HIV (PLHIV).

METHODS

This study analyses 2016 data derived from the Economist Intelligence Unit's Democracy Index (EIUDI), UNAIDS country estimates for PLHIV and PLHIV who knew their status in 2016, World Bank's 2016 data on nominal gross domestic product (GDP) per capita and country population, HIV Justice Network's 2016 data on HIV criminalization, and country-level estimates for PLHIV, PLHIV who know their status, and expenditure on HIV prevention from other independent sources. An estimated HIV prevalence variable was constructed by dividing the estimated PLHIV population with the total population of a country. Analyses were limited to countries with available data on PLHIV who know their status (n = 111).

RESULTS

Of the 111 countries in the analytic sample, the mean democracy index score was 5.93 (of the 10), median estimated HIV prevalence was 0.20% (IQR 0.10-0.65), median GDP per capita (in thousands, US dollar) was 4.88 (IQR 2.11-13.79), and mean PLHIV who know their status is 67.12%. Preliminary analysis on the five component measures of the EIUDI revealed multicollinearity, and thus the composite democracy index score was used as the measure for democracy. Multivariate linear regression analyses revealed that democracy index scores (β = 2.10, SE = 1.02, p = 0.04) and GDP per capita (in thousands; β = 0.34. SE = 0.11, p < 0.01) were positively associated with diagnosis rates among PLHIV, controlling for country-level expenditure on HIV prevention, HIV criminalization laws and estimated HIV prevalence.

CONCLUSIONS

Results indicate that higher levels of democracy were positively associated with rates of diagnosis among PLHIV. Further analyses following wider implementation of universal testing and treatment is warranted, as well as the need for further research on the mechanisms through which political cultures specifically influence rates of diagnosis among PLHIV.

Nutrition Interventions Integrated into an Existing Maternal, Neonatal, and Child Health Program Reduce Food Insecurity Among Recently Delivered and Pregnant Women in Bangladesh

Background

Antenatal care may be a means to reduce food insecurity in pregnancy and postpartum periods.

Objective

With the use of a cluster-randomized design, we tested whether participation in nutrition-focused antenatal care intending to improve household knowledge about the importance of nutrition for pregnant and lactating women and encourage allocation of household resources to ensure sufficient quality and quantity of foods, without providing food assistance, would reduce household food insecurity.

Methods

Alive & Thrive integrated nutrition interventions into an existing Maternal, Neonatal, and Child Health (MNCH) program in Bangladesh. The nutrition-focused MNCH package was delivered in 10 subdistricts through antenatal care visits with the use of interpersonal communication, community mobilization, and monitoring of weight gain, aiming to improve maternal diet quality, quantity, and micronutrient intake during pregnancy and breastfeeding. The package included components that could reduce food insecurity, measured using the Household Food Insecurity Access Scale. To examine the impact of the nutrition-focused MNCH package compared with the standard MNCH package, we used linear and multinomial logit regression models, adjusted for subdistrict clustering, to test differences at endline in items, domains, and categories of food insecurity, after first confirming no differences at baseline.

Results

At baseline, nearly half of households were food insecure. At endline, the groups differed in food insecurity, whether expressed as items, domains, or categories, with food insecurity in the nutrition-focused MNCH group 22 percentage points lower than in the standard MNCH group and 20 percentage points lower than at baseline.

Conclusions

Participation in nutrition-focused antenatal care reduced household food insecurity among recently delivered and pregnant women. Integration of social and behavioral nutrition interventions into antenatal care with components that promote food security provides a potentially effective means to reduce food insecurity, without incurring high costs of providing supplemental food, in populations where limited resources can be directed towards accessing adequate and appropriate foods. Registered at clinicaltrials.gov as NCT02745249.

Village community mobilization is associated with reduced HIV incidence in young South African women participating in the HPTN 068 study cohort

INTRODUCTION

Adolescent girls and young women (AGYW) in South Africa bear a disproportionate burden of HIV. Community mobilization (CM), defined as community members taking collective action to achieve a common goal related to health, equity and rights, has been associated with increased HIV testing and condom use and has been called a 'critical enabler' for addressing the HIV epidemic. However, limited research has examined whether CM is associated with HIV incidence among AGYW.

METHODS

We examine the association of CM with incident HIV among AGYW (ages 13 to 21) enrolled in the HPTN 068 cohort in the Agincourt Health and socio-Demographic Surveillance System, South Africa. This analysis includes 2292 participants residing in 26 villages where cross-sectional, population-based surveys were conducted to measure CM among 18- to 35-year-old residents in 2012 and 2014. HPTN 068 participants completed up to five annual visits that included an HIV test (2011 to 2016). Household-level data were collected from AGYW parents/guardians and census data is updated annually. Mean village-level CM scores were created using a validated community mobilization measure with seven components (social cohesion, social control, critical consciousness, shared concerns, organizations and networks, leadership and collective action). We used pooled generalized estimating equation regression with a Poisson distribution to estimate risk ratios (RR) for the association of village-level CM score and CM components with incident HIV infection, accounting for village-level clustering and adjusting for key covariates.

RESULTS

There were 194 incident infections over the follow-up period. For every additional standard deviation of village-level CM there was 12% lower HIV incidence (RR: 0.88, 95% CI: 0.79, 0.98) after adjusting for individual, household and community characteristics. CM components associated with lower HIV incidence included critical consciousness (RR: 0.88; CI: 0.79, 0.97) and leadership (RR: 0.87; CI: 0.79, 0.95); while not statistically significant, social cohesion (RR: 0.91; CI: 0.81, 1.01), shared concerns (RR: 0.90; CI: 0.81, 1.00), and organizations and networks (RR: 0.91; CI: 0.79, 1.03) may also play a protective role.

CONCLUSIONS

These results suggest that having strong community social resources will reduce AGYW's risk of HIV acquisition. Work to mobilize communities, focusing on building social cohesion, shared concerns, critical consciousness, and effective and accountable leadership, can fortify prevention programming for AGYW.

Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda

Background: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation.

Objectives: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy.

Methods: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences.

Results: CHWs’ knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (≥ 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles.

Conclusions: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.

How people-centred health systems can reach the grassroots: experiences implementing community-level quality improvement in rural Tanzania and Uganda

Background

Quality improvement (QI) methods engage stakeholders in identifying problems, creating strategies called change ideas to address those problems, testing those change ideas and scaling them up where successful. These methods have rarely been used at the community level in low-income country settings. Here we share experiences from rural Tanzania and Uganda, where QI was applied as part of the Expanded Quality Management Using Information Power (EQUIP) intervention with the aim of improving maternal and newborn health. Village volunteers were taught how to generate change ideas to improve health-seeking behaviours and home-based maternal and newborn care practices. Interaction was encouraged between communities and health staff.

Aim

To describe experiences implementing EQUIP's QI approach at the community level.

Methods

A mixed methods process evaluation of community-level QI was conducted in Tanzania and a feasibility study in Uganda. We outlined how village volunteers were trained in and applied QI techniques and examined the interaction between village volunteers and health facilities, and in Tanzania, the interaction with the wider community also.

Results

Village volunteers had the capacity to learn and apply QI techniques to address local maternal and neonatal health problems. Data collection and presentation was a persistent challenge for village volunteers, overcome through intensive continuous mentoring and coaching. Village volunteers complemented health facility staff, particularly to reinforce behaviour change on health facility delivery and birth preparedness. There was some evidence of changing social norms around maternal and newborn health, which EQUIP helped to reinforce.

Conclusions

Community-level QI is a participatory research approach that engaged volunteers in Tanzania and Uganda, putting them in a central position within local health systems to increase health-seeking behaviours and improve preventative maternal and newborn health practices.

Changes in engagement in HIV prevention and care services among female sex workers during intensified community mobilization in 3 sites in Zimbabwe, 2011 to 2015

INTRODUCTION

'Sisters with a Voice', Zimbabwe's nationally scaled comprehensive programme for female sex workers (FSWs), intensified community mobilization activities in three sites to increase protective behaviours and utilization of clinical services. We compare indicators among FSWs at the beginning and after implementation.

METHODS

We used mixed methods to collect data at three sites: in-depth interviews (n = 22) in 2015, routine clinical data from 2010 to 2015, and two respondent driven sampling surveys in 2011 and 2015, in which participants completed an interviewer-administered questionnaire and provided a finger prick blood sample for HIV antibody testing. Estimates were weighted using RDS-1 and estimate convergence assessed in both years. We assessed differences in six indicators between 2011 and 2015 using logistic regression adjusted for age, duration in sex work and education.

RESULTS

870 FSWs were recruited from the three sites in 2011 and 915 in 2015. Using logistic regression to adjust for socio-demographic differences, we found higher estimates of the proportion of HIV-positive FSWs and HIV-positive FSWs who knew their status and reported being on ART in Mutare and Victoria Falls in 2015 compared to 2011. Reported condom use with clients did not differ by year; however, condom use with regular partners was higher in 2015 in Mutare and Hwange. Reported HIV testing in the last six months among HIV-negative FSWs was higher in 2015 across sites: for instance, in Victoria Falls it was 13.4% (95% CI 8.7% to 19.9%) in 2011 and 80.8% (95% CI 74.0 to 87.7) in 2015. FSWs described positive perceptions of the Sisters programme, ease of engaging with health services, and improved solidarity among peers. Programme data showed increases in service use by 2015 across all sites.

CONCLUSIONS

Improvements in key HIV care engagement indicators were observed among FSWs in two sites and in testing and prevention indicators across the three sites after implementation of an intensified community mobilization intervention. Engagement with services for FSWs is critical for countries to reach 90-90-90 targets.

Community mobilization to modify harmful gender norms and reduce HIV risk: results from a community cluster randomized trial in South Africa

INTRODUCTION

Community mobilization (CM) is increasingly recognized as critical to generating changes in social norms and behaviours needed to achieve reductions in HIV. We conducted a CM intervention to modify negative gender norms, particularly among men, in order to reduce associated HIV risk.

METHODS

Twenty two villages in the Agincourt Health and Socio-Demographic Surveillance Site in rural Mpumalanga, South Africa were randomized to either a theory-based, gender transformative, CM intervention or no intervention. Two cross-sectional, population-based surveys were conducted in 2012 (pre-intervention, n = 600 women; n = 581 men) and 2014 (post-intervention, n = 600 women; n = 575 men) among adults ages 18 to 35 years. We used an intent-to-treat (ITT) approach using survey regression cluster-adjusted standard errors to determine the intervention effect by trial arm on gender norms, measured using the Gender Equitable Mens Scale (GEMS), and secondary behavioural outcomes.

RESULTS

Among men, there was a significant 2.7 point increase (Beta Coefficient 95% CI: 0.62, 4.78, p = 0.01) in GEMS between those in intervention compared to control communities. We did not observe a significant difference in GEMS scores for women by trial arm. Among men and women in intervention communities, we did not observe significant differences in perpetration of intimate partner violence (IPV), condom use at last sex or hazardous drinking compared to control communities. The number of sex partners in the past 12 months (AOR 0.29, 95% CI 0.11 to 0.77) were significantly lower in women in intervention communities compared to control communities and IPV victimization was lower among women in intervention communities, but the reduction was not statistically significant (AOR 0.53, 95% CI 0.24 to 1.16).

CONCLUSION

Community mobilization can reduce negative gender norms among men and has the potential to create environments that are more supportive of preventing IPV and reducing HIV risk behaviour. Nevertheless, we did not observe that changes in attitudes towards gender norms resulted in desired changes in risk behaviours suggesting that more time may be necessary to change behaviour or that the intervention may need to address behaviours more directly.

CLINICAL TRIALS NUMBER

ClinicalTrials.gov NCT02129530.

Delivering Vitamin A Supplements to Children Aged 6-59 Months: Comparing Delivery through Campaigns and through Routine Health Services in Senegal

BACKGROUND

Using twice-yearly campaigns such as Child Health Days to deliver vitamin A supplements has been a key strategy over the last 2 decades, and was an important component in helping reach the Millennium Development Goals in child health. As countries move to strengthen their routine health services under the Sustainable Development Goals, efforts are underway to shift supplementation from campaign to routine delivery.

OBJECTIVE

The aim of this study was to compare cost, coverage, and user satisfaction between twice-yearly campaigns and routine delivery of vitamin A supplements in Senegal.

METHODS

Information was collected on cost, coverage, and user satisfaction with both types of delivery, using administrative data, interviews at various levels in the health system, and focus group discussions with caregivers. Both qualitative and quantitative information were obtained, for 2 regions using routine delivery and 2 regions using campaign delivery.

RESULTS

Routine delivery receives fewer dedicated resources. Coverage is lower, especially of children >12 mo of age. Districts undertake outreach ("mini-campaigns") to try to improve coverage in regions using routine delivery, in effect using a hybrid approach. Some mothers prefer the administration of supplements at a health facility as it is perceived as more hygienic and involving professional health workers, but others, especially those living further away, prefer house-to-house delivery which was the norm for the campaign mode.

CONCLUSIONS

Advance planning for the shift to routine delivery is important in maintaining coverage, as is strengthening the primary health care system by having an appropriate ratio of salaried workers to population. When the system relies heavily on volunteers, and the small incentive payments to volunteers are discontinued, coverage suffers. Routine delivery also relies on good record-keeping and hence literacy. Community understanding of, and support for, supplementation are even more important for routine than for campaign delivery.

Integrating Nutrition Interventions into an Existing Maternal, Neonatal, and Child Health Program Increased Maternal Dietary Diversity, Micronutrient Intake, and Exclusive Breastfeeding Practices in Bangladesh: Results of a Cluster-Randomized Program Evaluation

Background: Maternal undernutrition is a major concern globally, contributing to poor birth outcomes. Limited evidence exists on delivering multiple interventions for maternal nutrition simultaneously. Alive & Thrive addressed this gap by integrating nutrition-focused interpersonal counseling, community mobilization, distribution of free micronutrient supplements, and weight-gain monitoring through an existing Maternal, Neonatal, and Child Health (MNCH) program in Bangladesh.Objectives: We evaluated the effect of providing nutrition-focused MNCH compared with standard MNCH (antenatal care with standard nutrition counseling) on coverage of nutrition interventions, maternal dietary diversity, micronutrient supplement intake, and early breastfeeding practices.Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n ∼ 300 and 1000 pregnant or recently delivered women, respectively, per survey round). We derived difference-in-difference effect estimates, adjusted for geographic clustering and infant age and sex.Results: Coverage of interpersonal counseling was high; >90% of women in the nutrition-focused MNCH group were visited at home by health workers for maternal nutrition and breastfeeding counseling. The coverage of community mobilization activities was ∼50%. Improvements were significantly greater in the nutrition-focused MNCH group than in the standard MNCH group for consumption of iron and folic acid [effect: 9.8 percentage points (pp); 46 tablets] and calcium supplements (effect: 12.8 pp; 50 tablets). Significant impacts were observed for the number of food groups consumed (effect: 1.6 food groups), percentage of women who consumed ≥5 food groups/d (effect: 30.0 pp), and daily intakes of several micronutrients. A significant impact was also observed for exclusive breastfeeding (EBF; effect: 31 pp) but not for early initiation of breastfeeding.Conclusions: Addressing nutrition during pregnancy by delivering interpersonal counseling and community mobilization, providing free supplements, and ensuring weight-gain monitoring through an existing MNCH program improved maternal dietary diversity, micronutrient supplement consumption, and EBF practices. This trial was registered at clinicaltrials.gov as NCT02745249.

Disaster averted: Community resilience in the face of a catastrophic flood

In the spring of 2009, the Fargo, North Dakota, metropolitan area had 5 days to lay millions of sandbags to avoid devastation from record flooding of the Red River of the North. The community was able to successfully mitigate the flooding and escape potentially catastrophic economic, physical, and mental health consequences. We hypothesized that Fargo flood protection efforts reflected the community resilience factors proposed by Norris, Stevens, Pfefferbaum, et al. (2008): citizen involvement in mitigation efforts, effective organizational linkages, ongoing psychosocial support, and strong civic leadership in the face of rapidly changing circumstances. This community case report utilizes an extensive review of available sources, including news reports, government documents, research articles, and personal communication. Results demonstrate that Fargo's response to the threat of catastrophic flooding was consistent with Norris et al.'s (2008) factors of community resilience. Furthermore, success in 2009 carried over into future flood prevention and response efforts, as well as a structured approach to building psychological resilience. This case study contributes to the literature on community resilience by describing a community's successful efforts to avert a potentially catastrophic disaster.

Advancing Migrant Access to Health Services in Europe (AMASE): Protocol for a Cross-sectional Study

BACKGROUND

Migrants form a substantial proportion of the population affected by the human immunodeficiency virus (HIV) epidemic in Europe, yet HIV prevention for this population is hindered by poor understanding of access to care and of postmigration transmission dynamics.

OBJECTIVE

We present the design and methods of the advancing Migrant Access to health Services in Europe (aMASE) study, the first European cross-cultural study focused on multiple migrant populations. It aims to identify the structural, cultural, and financial barriers to HIV prevention, diagnosis, and treatment and to determine the likely country of HIV acquisition in HIV-positive migrant populations.

METHODS

We delivered 2 cross-sectional electronic surveys across 10 countries (Belgium, France, Germany, Greece, Italy, the Netherlands, Portugal, Spain, Switzerland, and United Kingdom). A clinic survey aimed to recruit up to 2000 HIV-positive patients from 57 HIV clinics in 9 countries. A unique study number linked anonymized questionnaire data to clinical records data (viral loads, CD4 cell counts, viral clades, etc). This questionnaire was developed by expert panel consensus and cognitively tested, and a pilot study was carried out in 2 countries. A Web-based community survey (n=1000) reached those living with HIV but not currently accessing HIV clinics, as well as HIV-negative migrants. It was developed in close collaboration with a community advisory group (CAG) made up of representatives from community organizations in 9 of the participating countries. The CAG played a key role in data collection by promoting the survey to higher-risk migrant groups (sub-Saharan Africans, Latin Americans, men who have sex with men, and people who inject drugs). The questionnaires have considerable content overlap, allowing for comparison. Questions cover ethnicity, migration, immigration status, HIV testing and treatment, health-seeking behavior, sexual risk, and drug use. The electronic questionnaires, which were available in 15 languages, allowed for complex routing, preventing respondents from answering irrelevant questions.

RESULTS

In total, we recruited 2249 participants from 57 HIV clinics as part of the clinic survey and retrieved 1637 complete responses as part of the community survey.

CONCLUSIONS

The findings will provide much-needed information for improving HIV prevention interventions and access to services for migrant communities.

Change over Time in Police Interactions and HIV Risk Behavior Among Female Sex Workers in Andhra Pradesh, India

Little is known about the effectiveness of intervening to change interactions between female sex workers (FSWs) and police in order to reduce HIV risk. Using data collected in the context of a HIV prevention intervention that included components to change policing practices (n = 1,680), we examine the association of FSWs' reports of negative police interactions and HIV risk behaviors and whether these associations varied over time. Results show negative police interactions declined significantly over time. FSWs who had more than one negative police interaction were more likely to experience STI symptoms (AOR 2.97 [95 % CI 2.27-3.89]), inconsistently use condoms with their clients (AOR 1.36 [95 % CI 1.03-1.79]), and accept more money for condomless sex (AOR 2.37 [95 % CI 1.76-3.21]). Over time, these associations were stable or increased. Even where interventions have reduced the number of police incidents experienced by FSWs, stakeholders in HIV prevention must remain vigilant in challenging these incidents.

Integration of Traditional Birth Attendants into Prevention of Mother-to-Child Transmission at Primary Health Facilities in Kaduna, North-West Nigeria

One of the fundamental challenges to implementing successful prevention of mother-to-child transmission (PMTCT) programs in Nigeria is the uptake of PMTCT services at health facilities. Several issues usually discourage many pregnant women from receiving antenatal care services at designated health facilities within their communities. The CRS Nigeria PMTCT Project funded by the Global Fund in its Round 9 Phase 1 in Nigeria, sought to increase demand for HIV counseling and testing services for pregnant women at 25 supported primary health centers (PHCs) in Kaduna State, North-West Nigeria by integrating traditional birth attendants (TBAs) across the communities where the PHCs were located into the project. Community dialogues were held with the TBAs, community leaders and women groups. These dialogues focused on modes of mother to child transmission of HIV and the need for TBAs to refer their clients to PHCs for testing. Subsequently, data on number of pregnant women who were counseled, tested and received results was collected on a monthly basis from the 25 facilities using the national HIV/AIDS tools. Prior to this integration, the average number of pregnant women that were counseled, tested and received results was 200 pregnant women across all the 25 health facilities monthly. After the integration of TBAs into the program, the number of pregnant women that were counseled, tested and received results kept increasing month after month up to an average of 1500 pregnant women per month across the 25 health facilities. TBAs can thus play a key role in improving service uptake and utilization for pregnant women at primary health centers in the community – especially in the context of HIV/AIDS. They thus need to be integrated, rather than alienated, from primary healthcare service delivery.

Adding to the HIV Prevention Portfolio - the Achievement of Structural Changes by 13 Connect to Protect® Coalitions

Opportunities to control risk factors that contribute to HIV transmission and acquisition extend far beyond individuals and include addressing social and structural determinants of HIV risk, such as inadequate housing, poor access to healthcare and economic insecurity. The infrastructure within communities, including the policies and practices that guide institutions and organizations, should be considered crucial targets for change. This paper examines the extent to which 13 community coalitions across the U.S. and Puerto Rico were able to achieve "structural change" objectives (i.e., new or modified practices or policies) as an intermediate step toward the long-term goal of reducing HIV risk among adolescents and young adults (12-24 years old). The study resulted in the completion of 245 objectives with 70% categorized as structural in nature. Coalitions targeted social services, education and government as primary community sectors to adopt structural changes. A median of 12 key actors and six new key actors contributed to accomplishing structural changes. Structural change objectives required a median of seven months to complete. The structural changes achieved offer new ideas for community health educators and practitioners seeking to bolster their HIV prevention agenda.

Female sex worker's participation in the community mobilization process: two distinct forms of participations and associated contextual factors

BACKGROUND

Community mobilization is a participatory intervention strategy used among Female Sex Workers (FSW's) to address HIV risks through behavior change and self empowerment. This study quantitatively measure and differentiate theoretically defined forms of FSW participation's and identify their contextual associated factors.

METHOD

Data was derived from cross-sectional Integrated Bio Behavioral Assessment conducted among FSW's in Andhra Pradesh (AP) (n = 3370), Maharashtra (MH) (n = 3133) and Tamil Nadu (TN) (n = 2140) of India during 2009-2010. Information's about socio-demography, community mobilization and participation experiences were collected. Conceptual model for two contexts of mobilization entailing distinct FSW participations were defined as participation in "collective" and "public" spaces respectively. Bivariate and multiple regression analysis were used.

RESULT

The level of participation in "collective" and "public" spaces was lowest in MH (43.9% & 11.7% respectively), higher in TN (82.2% & 22.5% respectively) and AP (64.7% & 33.1%). Bivariate and multivariate regression analysis highlighted the distinct nature of "participations" through their varied associations with FSW mobilization and background status.In MH, street FSWs showed significantly lower collective participation (36.5%) than brothel FSWs (46.8%) and street FSWs showed higher public participation (16.2%) than brothel FSWs (9.7%). In AP both collective and public participation were significantly high among street FSWs (62.7% and 34.7% respectively) than brothel FSW's (55.2% and 25.4% respectively).Regression analysis showed FSWs with "community identity", were more likely to participate in public spaces in TN and AP (AOR 2.4, 1.5-3.8 & AOR 4.9, CI 2.3-10.7) respectively. FSWs with "collective identity" were more likely to participate in collective spaces in TN, MH and AP (AOR 27.2 CI 13.7-53.9; AOR 7.3, CI 3.8-14.3; AOR 5.7 CI 3-10.9 respectively). FSWs exhibiting "collective agency" were more likely to participate in public spaces in TN, MH and AP (AOR 2.3 CI 1-3.4; AOR 4.5- CI 2.6-7.8; AOR 2.2 CI 1.5-3.1) respectively.

CONCLUSION

Findings reveal FSWs participation as a dynamic process inherently evolving along with the community mobilization process in match with its contexts. Participation in "Collective" and Public spaces" is indicators, symbolizing FSWs passage from the disease prevention objectives towards empowerment, which would help better understand and evaluate community mobilization interventions.

Strengthening malaria service delivery through supportive supervision and community mobilization in an endemic Indian setting: an evaluation of nested delivery models

BACKGROUND

Malaria continues to be a prominent global public health challenge. This study tested the effectiveness of two service delivery models for reducing the malaria burden, e.g. supportive supervision of community health workers (CHW) and community mobilization in promoting appropriate health-seeking behaviour for febrile illnesses in Odisha, India.

METHODS

The study population comprised 120 villages from two purposively chosen malaria-endemic districts, with 40 villages randomly assigned to each of the two treatment arms, one with both supportive supervision and community mobilization and one with community mobilization alone, as well as an observational control arm. Outcome measures included changes in the utilization of bed nets and timely care-seeking for fever from a trained provider compared to the control group. Analysis was by intention-to-treat.

RESULTS

Significant improvements were observed in the reported utilization of bed nets in both intervention arms (84.5% in arm A and 82.4% in arm B versus 78.6% in the control arm; p < 0.001). While overall rates of treatment-seeking were equal across study arms, treatment-seeking from a CHW was higher in both intervention arms (28%; p = 0.005 and 27.6%; p = 0.007) than in the control arm (19.2%). Fever cases were significantly more likely to visit a CHW and receive a timely diagnosis of fever in the combined interventions arm than in the control arm (82.1% vs. 67.1%; p = 0.025). Care-seeking from trained providers also increased with a substitution away from untrained providers. Further, fever cases from the combined interventions arm (60.6%; p = 0.004) and the community mobilization arm (59.3%; p = 0.012) were more likely to have received treatment from a skilled provider within 24 hours than fever cases from the control arm (50.1%). In particular, women from the combined interventions arm were more likely to have received timely treatment from a skilled provider (61.6% vs. 47.2%; p = 0.028).

CONCLUSION

A community-based intervention combining the supportive supervision of community health workers with intensive community mobilization and can be effective in improving care-seeking and preventive behaviour and may be used to strengthen the national malaria control programme.

The impact of SASA!, a community mobilization intervention, on reported HIV-related risk behaviours and relationship dynamics in Kampala, Uganda

INTRODUCTION

Intimate partner violence (IPV) violates women's human rights, and it is a serious public health concern associated with increased HIV risk. SASA!, a phased community mobilization intervention, engages communities to prevent IPV and promote gender equity. The SASA! study assessed the community-level impact of SASA! on reported HIV-related risk behaviours and relationship dynamics.

METHODS

Data were collected as part of a cluster randomized controlled trial conducted between 2007 and 2012 in eight communities in Kampala. An adjusted cluster-level intention to treat analysis, compares secondary outcomes in intervention and control communities at follow-up. The qualitative evaluation explored participants' subjective experience of SASA!. A total of 82 in-depth interviews were audio recorded at follow-up, transcribed verbatim and analyzed using thematic analysis.

RESULTS

Men in intervention communities were significantly more likely than controls to report a broad range of HIV-protective behaviours, including higher levels of condom use (aRR 2.03, 95% CI 1.22-3.39), HIV testing (aRR 1.50, 95% CI 1.13-2.00) and fewer concurrent partners (aRR 0.60, 95% CI 0.37-0.97). They were also more likely to report increased joint decision-making (aRR 1.92, 95% CI 1.27-2.91), greater male participation in household tasks (aRR 1.48, 95% CI 1.09-2.01), more open communication and greater appreciation of their partner's work inside (aRR 1.31, 95% CI 1.04-1.66) and outside (aRR 1.49, 95% CI 1.08-2.06) the home. For women, all outcomes were in the hypothesized direction, but effect sizes were smaller. Only some achieved statistical significance. Women in intervention communities were significantly more likely to report being able to refuse sex with their partners (aRR 1.16, 95% CI 1.00-1.35), joint decision-making (aRR 1.37, 95% CI 1.06-1.78) and more open communication on a number of indicators. Qualitative interviews suggest that shifts operated through broader improvements in relationships, including increased trust and cooperation, participants' greater awareness of the connections between HIV and IPV and their resultant desire to improve their relationships. Barriers to change include partial uptake of SASA!, partner resistance, fear and entrenched previous beliefs.

CONCLUSIONS

SASA! impacted positively on reported HIV-related risk behaviours and relationship dynamics at a community level, especially among men. Social change programmes focusing on IPV and gender equity could play an important role in HIV prevention efforts.

Evidence from community level inputs to improve quality of care for maternal and newborn health: interventions and findings

Annually around 40 million mothers give birth at home without any trained health worker. Consequently, most of the maternal and neonatal mortalities occur at the community level due to lack of good quality care during labour and birth. Interventions delivered at the community level have not only been advocated to improve access and coverage of essential interventions but also to reduce the existing disparities and reaching the hard to reach. In this paper, we have reviewed the effectiveness of care delivered through community level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined community level interventions and report findings from 43 systematic reviews. Findings suggest that home visitation significantly improved antenatal care, tetanus immunization coverage, referral and early initiation of breast feeding with reductions in antenatal hospital admission, cesarean-section rates birth, maternal morbidity, neonatal mortality and perinatal mortality. Task shifting to midwives and community health workers has shown to significantly improve immunization uptake and breast feeding initiation with reductions in antenatal hospitalization, episiotomy, instrumental delivery and hospital stay. Training of traditional birth attendants as a part of community based intervention package has significant impact on referrals, early breast feeding, maternal morbidity, neonatal mortality, and perinatal mortality. Formation of community based support groups decreased maternal morbidity, neonatal mortality, perinatal mortality with improved referrals and early breast feeding rates. At community level, home visitation, community mobilization and training of community health workers and traditional birth attendants have the maximum potential to improve a range of maternal and newborn health outcomes. There is lack of data to establish effectiveness of outreach services, mass media campaigns and community education as standalone interventions. Future efforts should be concerted on increasing the availability and training of the community based skilled health workers especially in resource limited settings where the highest burden exists with limited resources to mobilize.

Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda

BACKGROUND

Intimate partner violence (IPV) and HIV are important and interconnected public health concerns. While it is recognized that they share common social drivers, there is limited evidence surrounding the potential of community interventions to reduce violence and HIV risk at the community level. The SASA! study assessed the community-level impact of SASA!, a community mobilization intervention to prevent violence and reduce HIV-risk behaviors.

METHODS

From 2007 to 2012 a pair-matched cluster randomized controlled trial (CRT) was conducted in eight communities (four intervention and four control) in Kampala, Uganda. Cross-sectional surveys of a random sample of community members, 18- to 49-years old, were undertaken at baseline (n = 1,583) and four years post intervention implementation (n = 2,532). Six violence and HIV-related primary outcomes were defined a priori. An adjusted cluster-level intention-to-treat analysis compared outcomes in intervention and control communities at follow-up.

RESULTS

The intervention was associated with significantly lower social acceptance of IPV among women (adjusted risk ratio 0.54, 95% confidence interval (CI) 0.38 to 0.79) and lower acceptance among men (0.13, 95% CI 0.01 to 1.15); significantly greater acceptance that a woman can refuse sex among women (1.28, 95% CI 1.07 to 1.52) and men (1.31, 95% CI 1.00 to 1.70); 52% lower past year experience of physical IPV among women (0.48, 95% CI 0.16 to 1.39); and lower levels of past year experience of sexual IPV (0.76, 95% CI 0.33 to 1.72). Women experiencing violence in intervention communities were more likely to receive supportive community responses. Reported past year sexual concurrency by men was significantly lower in intervention compared to control communities (0.57, 95% CI 0.36 to 0.91).

CONCLUSIONS

This is the first CRT in sub-Saharan Africa to assess the community impact of a mobilization program on the social acceptability of IPV, the past year prevalence of IPV and levels of sexual concurrency. SASA! achieved important community impacts, and is now being delivered in control communities and replicated in 15 countries.

TRIAL REGISTRATION

ClinicalTrials.gov #NCT00790959.

Grassroots projects aimed at the built environment: Association with neighbourhood deprivation, land-use mix and injury risk to road users

OBJECTIVES

1) To describe grassroots projects aimed at the built environment and associated with active transportation on the Island of Montreal; and 2) to examine associations between the number of projects and indicators of neighbourhood material and social deprivation and the built environment.

METHOD

We identified funding agencies and community groups conducting projects on built environments throughout the Island of Montreal. Through website consultation and a snowballing procedure, we inventoried projects that aimed at transforming built environments and that were carried out by community organizations between January 1, 2006, and November 1, 2010. We coded and validated information about project activities and created an interactive map using Geoclip software. Correlational analyses quantified associations between number of projects, neighbourhood characteristics and deprivation.

RESULTS

A total of 134 community organizations were identified, and 183 grassroots projects were inventoried. A large number of projects were aimed at increasing awareness of/improving active or public transportation (n=95), improving road safety (n=84) and enhancing neighbourhood beautification and greening (n=69). The correlation between the presence of projects and the extent of neighbourhood material deprivation was small (Kendall's t=0.26, p&lt;0.001), but in areas with greater social deprivation there were more projects (Kendall's t=0.38, p&lt;0.001). Larger numbers of projects were also associated with the presence of more extensive land-use mix (Kendall's t=0.23, p&lt;0.001) and a greater proportion of road intersections with injured pedestrians, cyclists and motor vehicle users (Kendall's t=0.43, p&lt;0.001).

CONCLUSION

There is significant community mobilization around built environments and active transportation. Investigations of the implementation processes and impacts are warranted.

Community-based intervention packages facilitated by NGOs demonstrate plausible evidence for child mortality impact

INTRODUCTION

Evidence exists that community-based intervention packages can have substantial child and newborn mortality impact, and may help more countries meet Millennium Development Goal 4 (MDG 4) targets. A non-governmental organization (NGO) project using such programming in Mozambique documented an annual decline in under-five mortality rate (U5MR) of 9.3% in a province in which Demographic and Health Survey (DHS) data showed a 4.2% U5MR decline during the same period. To test the generalizability of this finding, the same analysis was applied to a group of projects funded by the US Agency for International Development. Projects supported implementation of community-based intervention packages aimed at increasing use of health services while improving preventive and home-care practices for children under five.

METHODS

All projects collect baseline and endline population coverage data for key child health interventions. Twelve projects fitted the inclusion criteria. U5MR decline was estimated by modelling these coverage changes in the Lives Saved Tool (LiST) and comparing with concurrent measured DHS mortality data.

RESULTS

Average coverage changes for all interventions exceeded average concurrent trends. When population coverage changes were modelled in LiST, they were estimated to give a child mortality improvement in the project area that exceeded concurrent secular trend in the subnational DHS region in 11 of 12 cases. The average improvement in modelled U5MR (5.8%) was more than twice the concurrent directly measured average decline (2.5%).

CONCLUSIONS

NGO projects implementing community-based intervention packages appear to be effective in reducing child mortality in diverse settings. There is plausible evidence that they raised coverage for a variety of high-impact interventions and improved U5MR by more than twice the concurrent secular trend. All projects used community-based strategies that achieved frequent interpersonal contact for health behaviour change. Further study of the effectiveness and scalability of similar packages should be part of the effort to accelerate progress towards MDG 4.

Expanding the role of community mobilization to accelerate progress towards ending vertical transmission of HIV in Uganda: the Networks model

INTRODUCTION

Efforts to prevent vertical transmission of HIV have gained momentum globally since the launch of the "Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive", reflecting the growing consensus that we now have low-cost, efficacious interventions that promise to end vertical transmission of HIV. Uganda is one of the 22 focus countries in the global plan and one of the 10 countries with the highest need for prevention of vertical transmission globally. In the context of current shortfalls in the prevention of vertical HIV transmission, this paper presents the results of the Networks project, a community mobilisation model implemented by the International HIV/AIDS Alliance in Uganda, and draws out the theoretical foundations and promising community mobilization practices relevant to prevention of vertical transmission.

METHODS

A retrospective review of the Network project's activities, documentation and evaluation was performed.

RESULTS

The Networks project, through community mobilisation and greater involvement of people living with HIV, reached an estimated 1.3 million people with at least one health service. By clustering 750 groups of people living with HIV into larger coalitions, the project supported existing groups to amalgamate their collective strengths and skills in outreach, referral and literacy activities; and improved reach and coverage of HIV services through strengthened linkages with healthcare facilities. Our analysis of the Networks model shows that it could contribute to the prevention of vertical transmission of HIV as a replicable and sustainable community mobilisation approach. In particular, the Networks model increased the uptake of decentralized interventions for preventing vertical transmission through community referrals; promoted male involvement through peer sensitisation; and linked communities to advocacy channels for advancing maternal health and prevention of vertical HIV transmission.

CONCLUSIONS

BY placing persons living with HIV at the centre, the Networks model offers a mechanism for strengthening community and male involvement in preventing vertical transmission of HIV. The role of communities and networks of people living with HIV in planning, service delivery and monitoring of national targets for prevention of vertical transmission should be further strengthened through greater community engagement in service delivery and advocacy and through the regular sharing of data between communities and health facilities.

Laying the foundation for Connect to Protect: a multi-site community mobilization intervention to reduce HIV/AIDS incidence and prevalence among urban youth

Despite the considerable resources that have been dedicated to HIV prevention interventions and services over the past decade, HIV incidence among young people in the United States remains alarmingly high. One reason is that the majority of prevention efforts continue to focus solely on modifying individual behavior, even though public health research strongly suggests that changes to a community's structural elements, such as their programs, practices, and laws or policies, may result in more effective and sustainable outcomes. Connect to Protect is a multi-city community mobilization intervention that focuses on altering or creating community structural elements in ways that will ultimately reduce youth HIV incidence and prevalence. The project, which spans 6 years, is sponsored by the Adolescent Medicine Trials Network for HIV/AIDS Interventions at multiple urban clinical research sites. This paper provides an overview of the study's three phases and describes key factors in setting a firm foundation for the initiation and execution of this type of undertaking. Connect to Protect's community mobilization approach to achieving structural change represents a relatively new and broad direction in HIV prevention research. To optimize opportunities for its success, time and resources must be initially placed into laying the groundwork. This includes activities such as building a strong overarching study infrastructure to ensure protocol tasks can be met across sites; tapping into local site and community expertise and knowledge; forming collaborative relationships between sites and community organizations and members; and fostering community input on and support for changes at a structural level. Failing to take steps such as these may lead to insurmountable implementation problems for an intervention of this kind.

Economic analysis of promotion of hepatitis B vaccinations among Vietnamese-American children and adolescents in Houston and Dallas

OBJECTIVE

To ascertain the cost-effectiveness and benefit-cost ratios of 2 public health campaigns conducted in Dallas and Houston in 1998-2000 for "catch-up" hepatitis B vaccination of Vietnamese-Americans born 1984-1993.

DESIGN

Program evaluation.

SETTING

Houston and Dallas, Texas.

PARTICIPANTS

A total of 14,349 Vietnamese-American children and adolescents.

INTERVENTIONS

Media-led information and education campaign in Houston, and community mobilization strategy in Dallas. Outcomes were compared with a control site: Washington, DC.

MAIN OUTCOME MEASURES

Receipt of 1, 2, or 3 doses of hepatitis B vaccine before and after the interventions, costs of interventions, cost-effectiveness ratios for intermediate outcomes, intervention cost per discounted year of life saved, and benefit-cost ratio of the interventions.

RESULTS

The number of children who completed the series of 3 hepatitis B vaccine doses increased by 1176 at a total cost of 313,904 dollars for media intervention, and by 390 and at 169,561 dollars for community mobilization. Costs per child receiving any dose, per dose, and per completed series were 363 dollars, 101 dollars, and 267 dollars for media intervention and 387 dollars, 136 dollars, and 434 dollars for community mobilization, respectively. For media intervention, the intervention cost per discounted year of life saved was 9954 dollars and 131 years of life were saved; for community mobilization, estimates were 11,759 dollars and 60 years of life. The benefit-cost ratio was 5.26:1 for media intervention and 4.47:1 for community mobilization.

CONCLUSION

Although the increases in the number of children who completed series of 3 doses were modest for both the Houston and Dallas areas, both media education and, to a lesser degree, community mobilization interventions proved cost-effective and cost-beneficial.