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This article traces the origin, sustenance and implications of a persistent rumour that is responsible for low measles mumps and rubella (MMR) vaccination uptake in the Somali diaspora in a number of countries across the globe. The rumour stipulates that the MMR vaccine – the silent shot – causes autism spectrum disorder (ASD). Although the association between MMR and ASD is non-causal, and various public health initiatives have promoted health information campaigns, the rumour continues to circulate in the Somali diaspora in many countries, including Sweden. This paper shows that there are valid reasons for this. The findings from this paper draw on a systematic scoping review and qualitative interview data from Sweden. The results show that the Somali community experiences higher than average rates of ASD compared to the general population. Moreover, ASD does not exist in the Somali language or their home country, is considered a Western disease that only affects Somali children in the diaspora, and is a highly stigmatised disease. Also, the Somali diaspora has had negative experiences with ASD diagnosis and care. The rumour has been sustained by the absence of an answer to their ASD fear and through active diaspora networks on social media. The network that surrounds the rumour has arguably further helped to create an epistemic community for a community whose concerns have been silenced. [ABSTRACT FROM AUTHOR]

This paper utilises empirical data to explore the value of 'body work' performed by last responders charged with the duty of dead body management, with a focus on the Global South. While frontline staff work to save lives, little is known about the experiences and roles of those who care for the dead in global health in times of crises and even during normal times. This paper discusses ethical and socio-cultural challenges pathologists face in 'working on the bodies of others' while conducting any form of post-mortem procedures – necessary for ascertaining and recording the causes of death. Identifying and reporting the cause of death have significant public health benefits and provide closure for bereaved families. Despite the foregoing, the pathology field does not attract funding from governments or donors, and it is overlooked compared to other disciplines. Autopsy procedure bears social stigma – as it is associated with body mutilation and therefore disrespecting the dead; certain cultural beliefs or taboos about impurity and death persist, further raising some social and ethical tensions. As a result, the dearth of autopsy procedures contributes to the cause of death uncertainty in global health. [ABSTRACT FROM AUTHOR]

Community engagement is gaining prominence in global health research. But communities rarely have a say in the agendas or conduct of the very health research projects that aim to help them. This paper provides new evidence on how to share power in priority-setting in ways that seek to overcome structural constraints created by the funding environment. The five strategies were identified through case study research on the Participation for Local Action project in Karnataka, India. That project was carried out by researchers in partnership with the Zilla Budakattu Girijana Abhivrudhhi Sangha, an indigenous community development organisation representing the Solega people. The paper describes each identified strategy for sharing power in priority-setting, followed by a report of the pitfalls and challenges that arose when implementing it. Thus, the study also demonstrates that even where actions and strategies are used to address power imbalances, pitfalls will arise that need to be navigated. Given those challenges, considerations to reflect upon before employing the identified strategies are suggested. Ultimately, the paper aims to communicate strategies for sharing power during and after priority-setting and lessons on how to implement them effectively that can be used by global health researchers in the current funding environment. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has created an unprecedented natural experiment in drug policy, treatment delivery, and harm reduction strategies by exposing wide variation in public health infrastructures and social safety nets around the world. Using qualitative data including ethnographic methods, questionnaires, and semi-structured interviews with people who use drugs (PWUD) and Delphi-method with experts from field sites spanning 13 different countries, this paper compares national responses to substance use during the first wave of the COVID-19 pandemic. Field data was collected by the Substance Use x COVID-19 (SU x COVID) Data Collaborative, an international network of social scientists, public health scientists, and community health practitioners convened to identify and contextualise health service delivery models and social protections that influence the health and wellbeing of PWUD during COVID-19. Findings suggest that countries with stronger social welfare systems pre-COVID introduced durable interventions targeting structural drivers of health. Countries with fragmented social service infrastructures implemented temporary initiatives for PWUD led by non-governmental organisations. The paper summarises the most successful early pandemic responses seen across countries and ends by calling for greater systemic investments in social protections for PWUD, diversion away from criminal-legal systems toward health interventions, and integrated harm reduction, treatment and recovery supports for PWUD. [ABSTRACT FROM AUTHOR]

Access to clean and functional toilet is quintessential in meeting children's physiological and psychosocial needs in a learning environment. However, little is known on experiences of children's access to quality toilets while in preschool institutions within urban settings of sub-Saharan Africa countries. This paper draws from a study that explored experiences of vulnerable children in early childhood development education (ECDE) institutions in underserved and informal urban settings of Kenya and South Africa. 11 urban ECDE centres were purposively selected and 17 teachers were recruited as key informants. Data was collected using an adapted infrastructural checklist, observation and conversational interviews. Findings indicated that a majority of toilets in ECDE centres were inadequate, inappropriate, poorly maintained, or had structural weaknesses which affected children's experiences of access and use of the facilities. Scheduled toilet visits as a control measure and toilet avoidance potentially exposed them to psychosocial and health risks. Insights into children's toilet facilities, managing their access in institutions located within informal and low resourced areas, and investment policies that target preschool children' sanitary facilities are given. Suggestions are made for interventions for children's positive toilet experiences in poor urban areas. [ABSTRACT FROM AUTHOR]

In this paper, we share some personal reflections of straddling different research roles in a doctoral study entitled Queering Sex Work and Mobility in South Africa. We highlight the importance of using a Feminist Participatory Action Research (FPAR) methodology when conducting studies with migrant and mobile sex workers as it offers participants an opportunity to express their lived realities and embodied knowledge(s) beyond linguistic barriers. Through our reflections, we demonstrate that marginalised communities can become co-creators in knowledge production processes, not just the givers of stories (aka 'poverty porn') but integral members of the research team who actively contribute towards the conceptualisation, data collection, analysis, publishing and distribution of scholarship. [ABSTRACT FROM AUTHOR]

Kenyan sex worker-led organisations (SWLOs) often play a key role in the national HIV response. Accounts of these organisations frequently focus on their community-led approaches to promote sexual health. This paper addresses sensitisation, an underexplored but significant activity in the political agency of sex workers (SWs). Drawing on ethnographic fieldwork in a male SWLO in Nairobi, we examine how male SWs strategically use their position in the national HIV response to create spaces of police sensitisation. Taking police sensitisation as a manifestation of community-led advocacy and a 'politics of small steps', we examine how SWs respond to, resist and remake the political landscape of police violence. The strategy supports SWs in changing existing power relationships between themselves and the police, albeit within the confines of a criminalising legal system. The analysis of sensitisation practices supports a reimagining of SWLOs that stresses their political agency in the production of new political spaces and expands the focus on African SWLOs beyond HIV work to their political activities, which advance SWs' health, rights and social justice. [ABSTRACT FROM AUTHOR]

Research conducted in various parts of the globe suggests that young people who can openly communicate with their parents about sexuality benefit in many ways. Correspondingly, in Bangladesh, the lack of an open communication on sexuality in the youth–parent relationship is considered a barrier to ensuring young people's sexual and reproductive health and overall well-being. Taking 'silence' as a core concept, this paper investigates what silence on sexuality means to Bangladeshi young people in their relationship with parents. It draws on findings from an ethnographic study conducted among 72 middle-class boys and girls aged between 15 and 19 years and 18 parents living in Dhaka over a year between 2016 and 2017. The findings suggest that silence is not always perceived as problematic by young people, and this is particularly true for topics related to sexual pleasure. This paper challenges the monolithic understanding that silence is necessarily bad and hinders young people from getting what they need. It offers an additional conceptual understanding to silence for studying sexuality among youths and designing interventions for their sexual and reproductive well-being. [ABSTRACT FROM AUTHOR]

Buyer's clubs were first recognised during the HIV/AIDS pandemic in the 1980s and focussed on knowledge curation and distribution of treatments. In the past decade, there has been a resurgence of buyer's clubs, mostly focussed on hepatitis C treatment and PrEP. This paper aims to increase understanding of buyer's clubs and stimulate discussion on their role in achieving equitable access to medicines. Our proposed definition of a buyer's club is 'a community-led organisation or group which seeks to improve an individual's access to medication through knowledge sharing and/or distribution as its primary goal'. The logistical and relational infrastructures of buyer's clubs have been mapped out. Networks and communities are integral to buyer's clubs by facilitating practical aspects of buyer's clubs and creating a sense of community that serves as a foundation of trust. For a user to receive necessary medical support, doctors play a crucial role, yet, obtaining this support is difficult. Whilst buyer's clubs are estimated to have enabled thousands of people to access medicines, and they run the risk of perpetuating health inequities and injustices. They may have the potential to serve as a health activism tool to stimulate sustainable changes; however, this needs to be explored further. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic, where the need-resource gap has necessitated decision makers in some contexts to ration access to life-saving interventions, has demonstrated the critical need for systematic and fair priority setting and resource allocation mechanisms. Disease outbreaks are becoming increasingly common and priority setting lessons from previous disease outbreaks could be better harnessed to inform decision making and planning for future disease outbreaks. The purpose of this paper is to discuss how priority setting and resource allocation could, ideally, be integrated into the WHO pandemic planning and preparedness framework and used to inform the COVID-19 pandemic recovery plans and plans for future outbreaks. Priority setting and resource allocation during disease outbreaks tend to evoke a process similar to the 'rule of rescue'. This results in inefficient and unfair resource allocation, negative effects on health and non-health programs and increased health inequities. Integrating priority setting and resource allocation activities throughout the four phases of the WHO emergency preparedness framework could ensure that priority setting during health emergencies is systematic, evidence informed and fair. [ABSTRACT FROM AUTHOR]

Substance use and depressive psychiatric symptoms have been associated with migration and mobility. The Mexico-Guatemala border is a key transit point for internal, regional, and international migration flows. However, there is limited knowledge of the role of substance use, migration, and mobility on mental health among migrants at this border. Our paper explores the association of migration and mobility patterns with possible major depressive symptoms among migrants at this key geographic region. We recruited 392 substance-using migrants using modified time-location sampling. Crude and adjusted logistic regression models were developed. We found that 12% of the sample had possible major depressive symptoms. After adjusting for relevant covariates, including gender, income, and perceived homelessness, we found that recent rural-urban and short-term migrants had higher odds of possible major depressive symptoms, whereas international migrants had lower odds. Findings of this paper suggest that although migrants experience hardship and uncertainty, they may respond with complex and nuanced forms of coping and planning. [ABSTRACT FROM AUTHOR]

Mobility, access to transport and healthcare play a crucial part in healthy ageing. However, these often posechallenges for older adults in the global South. This study applies the three concepts of 'motility' (access, competence and appropriation), to explore transport inequalities and barriers to access healthcare services for older adults in Bengaluru, India. The paper draws on interviews with sixty adults, aged 50 years and over, residing in urban Bengaluru. A semi-structured in-depth interview guide was employed to explore the transport inequalities. Applying thematic analysis, we present the mobility and transport barriers to access healthcare. Restricted access to healthcare services due to unavailable and unaffordable transportation resulted in missed appointments, delayed care and deterioration of health conditions. To cope with the barriers, older adults often visited less specialised clinics for regular check-ups and those with financial constraints resorted to self-medication. These actions further deteriorated health and led to adverse health outcomes. Our findings suggest that integrated health and transport policies must be designed to ensure equitable access to transportation services. Enabling older adults to have more independent lives and improve access to preventive healthcare is essential for better health outcomes. [ABSTRACT FROM AUTHOR]

The health burden due to mental health has historically been underestimated with focus on communicable diseases and deaths and little consideration of disability and comorbidity effects of poor mental health. Recent data show increasing trends of mental health disorders as a share of global health burdens and vulnerability of adolescents. This paper aims to explore social determinants of mental health as experienced by adolescent girls, drawing attention to gendered risks during the COVID-19 pandemic. Semi-structured interviews with twenty-two adolescent girls in urban informal settlements in Kenya and Nigeria reveal unique environmental, socio-cultural, economic and educational factors that threatened their mental wellbeing. The pandemic exacerbated these determinants. An equitable recovery will require a consideration of not only disproportional mental health outcomes, but also social determinants that contribute to these outcomes. As more than half of the urban population in sub-Saharan Africa reside in informal settlements, this study has implications for youth-focused mental health interventions in these and similar settings. [ABSTRACT FROM AUTHOR]

Climate change is an important driver of migration, but little research exists on whether migrant communities in the U.S. identify climate change-related factors as reasons for migrating. In 2021, we conducted a multidisciplinary, collaborative project to better understand the nexus of climate change and immigrant health in the Atlanta area. This paper presents one arm of this collaboration that explored both the role of climate change in decisions to immigrate to Georgia and the ways that climate change intersects with other possible drivers of migration. First generation migrants from Latin America were recruited primarily through CPACS Cosmo Health Center and were invited to participate in an intake survey and an in-depth interview. Results were analyzed using descriptive statistics and thematic analysis. Findings suggest that while participants may not have explicitly identified climate change as a primary reason for migration, in both surveys and in-depth interviews, participants reported multiple and intersecting social, economic, political, and environmental factors that are directly or indirectly influenced by climate change and that are involved in their decisions to migrate. The narratives that emerged from in-depth interviews further contextualised survey data and elucidated the complex nexus of climate change, migration, and health. [ABSTRACT FROM AUTHOR]

In 2020, the New Zealand (NZ) Parliament voted to decriminalise abortion. Although NZ's abortion law formally opposes sex selective abortions, there is considerable complexity in the gender politics of 'choice' and 'agency' in multi-ethnic societies, and interpretations of reproductive rights for ethnic minority women and for the girl child, respectively. This paper explores these complexities through the perspectives of reproductive and maternity care practitioners who are situated at the interface of legal systems, health service provision, and delivery of culturally sensitive care. Thirteen practitioners were interviewed as part of this study. The analysis highlights strains in framings of 'reproductive choice' (underpinned by western liberal notions of rights) and 'gender equality' (abortion rights that acknowledge the complexity of cultural son-preference) for ethnic minority women. These tensions are played out in three aspects of the post-reform landscape: (a) everyday practice and accountability; (b) consumerism and choice; (c) custodianship and gender rights. The findings point to the limitations in operationalising choices for ethnic women in health systems wherein trust deficit prevails, and cultural dynamics render complex responses to abortion. They also highlight reconfigurations of client-expert relationships that may have implications for practitioners' abilities to advocate for ethnic women's rights against cultural influences. [ABSTRACT FROM AUTHOR]

Leadership by health professionals is key in any health system, but health leadership training programmes are varied in their conceptualisation, learning objectives, and design. This paper describes an undergraduate leadership and management module for health students at the University of Sierra Leone and provides lessons from the design process. Our methods included an initial scoping review and qualitative study, followed by a co-design process of 10 workshops and 17 consultation meetings. The result was a curriculum with learning outcomes emphasising leadership identity, proactiveness, management of people and of change, and the formation of peer relationships. Learning methods included group teaching, team quality improvement projects, mentoring, and reflective practice. Lessons from the design process included the importance of support from university leadership and extensive consultation. Virtual workshops enabled broader participation but limited relationship building. Integrating doctoral research into the process facilitated inclusion of evidence and theory but risked reducing ownership by faculty. The importance of interprofessionalism and management skills in leadership training emerged during the process, illustrating the effectiveness of a co-design approach. Our programme is broadly aligned with other health leadership frameworks and is distinctive due to its undergraduate focus, offering insights for leadership training design in other settings. [ABSTRACT FROM AUTHOR]

Researchers and practitioners recognise the importance of context when implementing healthcare interventions, but the influence of wider environment is rarely mapped. This paper identifies the country and policy-related factors potentially explaining the country differences in outcomes of an intervention focused on improving detection and management of heavy alcohol use in primary care in Colombia, Mexico and Peru. Qualitative data obtained through interviews, logbooks and document analysis are used to explain quantitative data on number of alcohol screenings and screening providers in each of the countries. Existing alcohol screening standards in Mexico, and policy prioritisation of primary care and consideration of alcohol as a public health issue in Colombia and Mexico positively contributed to the outcome, while the COVID-19 pandemic had a negative impact. In Peru, the context was unsupportive due to a combination of: political instability amongst regional health authorities; lack of focus on strengthening primary care due to the expansion of community mental health centres; alcohol considered as an addiction rather than a public health issue; and the impact of COVID-19 on healthcare. We found that wider environment-related factors interacted with the intervention implemented and can help explain country differences in outcomes. [ABSTRACT FROM AUTHOR]

Financial technology tools have been utilised to create readily available mobile loan platforms for urban-based, daily-wage earners in Kenya. From a financial lending perspective, this development signals greater inclusion and equality in formal bank financing systems. In this paper, however, we examine mobile loans and their repayment from the perspective of women who sell sex in Nairobi, drawing upon the qualitative findings of two community-based studies conducted in close collaboration with sex worker-led organisations serving the sexual health needs of their peers. Our findings suggest that mobile loans may undermine the financial security strategies and economic independence of sex workers, leaving these women in more precarious economic circumstances, which have been shown in other instances to have effects on sexual risk taking and vulnerability to HIV infection. [ABSTRACT FROM AUTHOR]

Global health practitioners and policymakers have become increasingly vocal about the complex challenges of identifying and quantifying the causes of death of the world's poorest people. To address this cause-of-death uncertainty and to minimise longstanding sensitivities about full autopsies, the Bill and Melinda Gates Foundation have been one of the foremost advocates of minimally invasive autopsy technology (MIA). MIA involves using biopsy needles to collect samples from key organs and body fluids; as such, it is touted as potentially more acceptable and less invasive than a complete autopsy, which requires opening the cadaver. In addition, MIA is considered a good means of collecting accurate bodily samples and can provide the crucial information needed to address cause-of-death uncertainty. In this paper, we employ qualitative data to demonstrate that while MIA technology has been introduced as a solution to the enduring cause-of-death uncertainty, the development and deployment of technologies such as these always constitute interventions in complex social and moral worlds; in this respect, they are both the solutions to and the causes of new kinds of uncertainties. We deconstruct the ways in which those new dimensions of uncertainty operate at different levels in the global health context. [ABSTRACT FROM AUTHOR]

Globally, women with disabilities experience heightened and unique forms of violence compared to men with disabilities and women without disabilities. Yet formalised guidelines for their inclusion in gender-based violence (GBV) research is lacking. This paper draws on ethical guidelines for researching violence against women, and studies on the ethicality of including people with disabilities in research, to advocate for women with disabilities' inclusion and safety in GBV research. Reflecting on lessons from a qualitative study on violence against women living with disabilities in South Africa, the paper considers what could be of value for GBV researchers and ethics review committees in low-middle income countries (LMICs). It aims to stimulate debate around the integration of reasonable accommodation, accessibility, and equal participation of women with disabilities in planning and conducting ethical GBV research. The paper recommends that considerations are practically applied and tested in other LMICs, and thereafter critiqued in consultation with a range of stakeholders and women with disabilities, to enhance best practice and form a basis for developing guidelines for undertaking ethical and inclusive GBV research in LMICs. [ABSTRACT FROM AUTHOR]

Global health donors increasingly embrace international non-governmental organisations (INGOs) as partners, often relying on them to conduct political advocacy in recipient countries, especially in controversial policy domains like reproductive health. Although INGOs are the primary recipients of donor funding, they are expected to work through national affiliates or counterparts to enable 'locally-led' change. Using prospective policy analysis and ethnographic evidence, this paper examines how donor-funded INGOs have influenced the restrictive policy environments for safe abortion and family planning in South Sudan and Malawi. While external actors themselves emphasise the technical nature of their involvement, the paper analyses them as instrumental political actors who strategically broker alliances and resources to shape policy, often working 'behind the scenes' to manage the challenging circumstances they operate under. Consequently, their agency and power are hidden through various practices of effacement or concealment. These practices may be necessary to rationalise the tensions inherent in delivering a global programme with the goal of inducing locally-led change in a highly controversial policy domain, but they also risk inciting suspicion and foreign-national tensions. [ABSTRACT FROM AUTHOR]

Sexual and Reproductive Health Rights are fundamental human rights. Previous studies on gender and sexuality in displacement settings have often focused on sexual and gender-based violence and the reproductive health problems of women while underplaying their needs for sexual expression, pleasure and procreation. This paper examines the influence of conflict and displacement on gender relations, sexuality and natality of internally displaced women in Nigeria. It draws on data from a larger study in which focus group discussions and in-depth interviews were used to explore 52 women's gendered experiences with Boko Haram insurgency and displacement. A critical thematic analysis of data revealed that the women's relationships with their men were complex and ambiguous, characterised by both tensions and solidarity. The women saw their men as partners in their struggle against multi-level oppression, including the structural barriers that undermine their mutual sexual expressions and pleasure, as well as their desire to procreate and repopulate their decimated ancestral communities. We recommend collaborative efforts to promote and protect the Sexual and Reproductive Health Rights of displaced women which includes building physical structures and living conditions that promote healthy, safe and pleasurable sexual expressions, and socio-political structures that create access to the long term social security. [ABSTRACT FROM AUTHOR]

India’s experience with the National Rural Health Mission (NRHM) is notable on account of nationally formalising – at scale – community action in service delivery,monitoring, and planning of health services. A study was undertaken to document and create a historical record of NRHM’s ‘communitization’ processes. The oral history method of the Witness Seminar was adopted and two virtual seminars with five and nine participants, respectively, were conducted, and supplemented with 4 in depth interviews. Analysis of transcripts was done using ATLAS.ti 22 with the broad themes of emergence, evolution, and evaluation and impact of ‘communitization’ under NRHM. This paper engages with the theme of ‘emergence’ and adopts the Multiple Streams Framework (MSF) conceptualised by John Kingdon for analysis. Key findings include the pioneering role of boundary spanning decision makers and the Jan Swasthya Abhiyan (JSA) in advocacy and design of ‘communitization’ structures, and the legacy of rights based social mobilizations and state-civil society partnerships in health during the 1990s influencing the ethos underlying ‘communitization’. Democracy, leadership from the civil society in policy design and implementation, and state-civil society partnerships are linked to the positive results witnessed as part of ‘communitization’ in NRHM. [ABSTRACT FROM AUTHOR]

Young mothers often encounter stigma and discrimination, affecting their lives and that of their children. This paper explores stigma management strategies and their effectiveness for young mothers in rural Nigeria. Ten key informants and 24 young mothers were recruited from Ife-East in South-Western Nigeria. Data from semi-structured interviews showed that societal disapproval of pregnant teenagers and young mothers were common experiences. Women used a range of strategies to actively cope with stigma including: belief in predestination, avoidance, concealment, and cohabitation. These strategies could be seen as tools to mitigate negative stereotypes and discrimination. However, they also had the unintended consequences of compounding many young women’s difficult circumstances and exposing them to adverse outcomes, including gender-based violence, repeat pregnancies, poor mental health, and low uptake of services. The results show the need for policy frameworks to actively combat stigma by addressing the negative framing of early pregnancy and motherhood and promoting supportive environments for young mothers. Health professionals need to be trained to offer de-stigmatising services to encourage young mothers to seek help and reduce pre-existing inequities in access to services, and policies need to include measures that address the rights of young mothers and protect them from violence and abuse. [ABSTRACT FROM AUTHOR]

The government of India introduced the Accredited Social Health Activist (ASHA) programme in 2006 to connect marginalised communities to the health system. ASHAs are mandated to increase the uptake of modern contraception through the doorstep provision of services. There is currently no evidence on the impact of ASHAs on the uptake of contraception at the national level. This paper examines the impact of ASHAs on the uptake of modern contraception using nationally representative National and Family Health Survey data collected in 2019– 21 in India. A multilevel logistic regression analysis was performed to determine the effect of contact with ASHAs on the uptake of modern contraception, controlling for regional variability and socio-demographic variables. The data provide strong evidence that ASHAs have succeeded in increasing modern contraceptive use. Women exposed to ASHAs had twice the odds of being current users of modern contraception compared to those with no contact, even after controlling for household and individual characteristics. However, only 28.1% of women nationally reported recent contact with ASHA workers. The ASHA programme should remain central to the strategy of the government of India and should be strengthened to achieve universal access to modern contraception and meet sustainable development goals by 2030. [ABSTRACT FROM AUTHOR]

Young people in Colombia present high rates of mental health problems, to which the country’s history of armed internal conflict contributes in complex ways. Mental health services in Colombia are fragmented, inadequate, and difficult to access for many. Young people’s help)seeking is often hindered by mental health stigma and/or poor experiences with services. This paper presents a thematic analysis of qualitative data from a mixed-methods study aimed at developing and testing a mental health intervention for Colombian youths. We draw upon theoretical lenses from scholarly work on stigma and Sen’s ‘capabilities approach’ to inform our analysis of interviews and group discussions with staff and young people involved in the state-funded human capital building programme ‘Jovenes en Acción’ (JeA). By illustrating how study participants talked about stigma, vulnerability, mental health services organisation, and the challenges of discussing mental health topics in a learning environment, we illuminate aspects of mental health support and anti-stigma interventions that might need enhancing. In particular, we suggest that more emphasis on ‘community competencies’ as complementary to and interrelated with individual competencies would strengthen young people’s individual and collective resources for mental wellbeing while being in line with the sociocritical principles of existing human capital-enhancing programmes. [ABSTRACT FROM AUTHOR]

Building synergies is seen as an effective strategy to address and decrease existing fragmentation in health systems of low-and middle-income countries (LMICs). To that end, different programmes, such as the Sector Wide Approach, have been adopted to increase health system synergies. Despite these efforts, fragmentation remains an enduring problem, hampering health system performance in LMICs. This study is part of the Lancet Commission on synergies between Universal Health Coverage, Health Security, and Health Promotion; we aimed to document synergising strategies adopted by Rwanda. Data for this paper came from a qualitative study including in-depth interviews of 15 key informants and a document review. A thematic analysis embracing deductive and inductive approaches was used to analyse the data. We found that Rwanda adopted three main strategies to increase health system synergies: (1) alignment of health programmes with national health policies and strategies, (2) increased coordination across national health institutions, and (3) effective monitoring and evaluation frameworks. Achieving synergies in a low-resource country is challenging but not impossible. To meet the target of global health agendas such as the Sustainable Development Goals and the prevention of future global pandemics, efforts to increase health system synergies in LMICs need to be strengthened. [ABSTRACT FROM AUTHOR]

This paper examines health worker experiences in two areas of post-epidemic preparedness in Sierra Leone – vaccine trials and laboratory strengthening – to reflect on the place of people in current models of epidemic response. Drawing on ethnographic research and interviews with health workers in the aftermath of Ebola, it explores the hopes and expectations that interventions foster for frontline workers in under-resourced health systems, and describes the unseen work involved in sustaining robust response infrastructures. Our analysis focuses on what it means for the people who sustain health systems in an emergency to be 'prepared' for an epidemic. Human preparedness entails more than the presence of a labour force; it involves building and maintaining 'relational infrastructures', often fragile social and moral relationships between health workers, publics, governments, and international organisations. The COVID-19 pandemic has underscored the value of rethinking human resources from an anthropological perspective, and investing in the safety and support of people at the forefront of response. In describing the labour, personal losses, and social risks undertaken by frontline workers for protocols and practicality to meet in an emergency context, we describe the social process of preparedness; that is, the contextual engineering and investment that make response systems work. [ABSTRACT FROM AUTHOR]

Human African trypanosomiasis (HAT) is considered a highly promising candidate for elimination within the next decade. This paper argues that the experiential knowledge of frontline health workers will be critical to achieve this goal. Interviews are used to explore the ways in which HAT workers understand, maintain, and adjust their skills amidst global and national challenges. We contrast two cases: South Sudan where HAT expertise is scattered and has been repeatedly rebuilt, and the Democratic Republic of Congo (DRC) where specialised mobile detection teams have pro-actively tested people at risk for almost a century. We describe HAT careers where skills are built through participation in HAT technology trials and screening programmes; in the DRC expertise is also supported through formal rotations in screening teams and HAT referral centres for new health workers. As cases fade, de-skilling is a real threat as awareness of populations and authorities diminishes and previously vertical programmes evolve, re-configuring professional development and career paths and associated opportunities for HAT practice. To avoid repeating the mistakes of the 1960s, when elimination also seemed close at hand, we need to recognise that the 'last mile' of elimination hinges on protecting the fragile expertise of frontline health workers. [ABSTRACT FROM AUTHOR]

Thailand's antimicrobial stewardship strategy has focussed on promoting 'rational drug use' in the public sector, to reduce the threat of drug resistance and control healthcare expenditure. The strategy's next ambition is to attend to the private sector, where antibiotics are widely available over the counter without prescription. Using ethnographic and survey data, this paper follows antibiotics through community pharmacies, to explore drug distribution and access, and identify potential challenges for stewardship. We extend the analytical frame beyond 'irrational' dispenser-customer transactions, to explore the logics of practice of a multiplicity of actors in the context of a highly competitive pharmaceutical market. Highlighting the role of the pharmaceutical industry in mystifying medicines, we show how antibiotics are collapsed into a category of 'strong medicines' and requested by customers using 'prescriptions by proxy'. We further examine how Thailand's drug regulation and classificatory systems, historically orientated around access to medicines, enable the proliferation of antibiotics in the context of contemporary efforts to control distribution. Recognising the negotiations involved in dispensing antibiotics in a pluralistic health system, we attempt to reconfigure allocations of responsibility, advocating for stewardship approaches that take into account local ecologies of care, as well as implications for access, equity, and accountability. [ABSTRACT FROM AUTHOR]

According to the World Health Organization, intimate partner violence (IPV) affects 35% of women worldwide and 40% of pregnant women, often resulting in maternal and infant death and harm. Displaced persons are at higher risk of abuse compared to the general population. While few studies have explored IPV in Iraq, research from Erbil, Iraq showed nearly 60% of women reported experiencing IPV in their lifetime. No publications examining IPV among displaced women in Iraq exist. Considering the severe impacts of IPV in pregnancy and the associated risks for IPV among women in refugee camps, this paper presents the first analysis of prevalence and factors associated with lifetime IPV among displaced pregnant women in two Iraqi refugee camps. Thirteen percent of women reported experiencing any abuse and experiencing IPV was associated with receiving fewer years of schooling (p = 0.04), not having a private doctor (p = 0.002), attending the first prenatal visit during the third trimester (p = 0.03), feeling pressure to have a child (p = 0.003), knowing someone who was physically injured by their husband (p = 0.05), experiencing suicidal ideation (p = 0.02), and being worried about harming one's baby (p = 0.02). Policy and programme recommendations for screening and prevention of IPV in resource-limited settings are provided. [ABSTRACT FROM AUTHOR]

In this paper, we examine a prominent interpretation of HIV risk in a rural South African setting experiencing a severe HIV epidemic well into older ages: the discourse of caregiving HIV transmission. By caregiving transmission, we refer to HIV infection resulting from caring for family members who are living with HIV and may be sick with AIDS-related illnesses. We draw on individual life history and community focus group interviews with men and women aged 40–80+, as well as interviews with health workers providing HIV counselling and testing services at local health facilities in their communities. We illustrate the social and strategic role caregiving HIV transmission discourses play in re-signifying HIV as a sexless infection for older women, thereby promoting HIV testing as well as blameless acceptance of an HIV diagnosis. We further highlight the role of rural health workers who serve as medical epistemic bricoleurs, vernacularising global HIV counselling and prevention messages by blending ideas of gender, generation, and local lived experiences and practices so that they resonate with community norms, values and understandings. Our study highlights the gendered and generational complexities and challenges experienced by rural South Africans aging in a community over-burdened by an HIV epidemic and AIDS-related mortality. [ABSTRACT FROM AUTHOR]

The Covid-19 pandemic inaugurated a new global order of public life and health marked by death, despair and alienation. As a crisis of a global scale, it made the task of (re)imagination simultaneously necessary and extremely difficult. It is this double bind of the difficulty and imminence of imagination that motivates the curation of this special issue. In this introduction, we map the connections between the theme of this volume and the key ideas that constitute its varied contributions, which we organised under three broad mobilising ideas: Rights and Resilience; Sexuality, Health and Justice; and Politics of Knowledge Production and Collaborations. Contributions cover myriad issues, engage in methodological innovations and play with diverse genres. Alongside more traditional academic writings, there are community-based research papers, activist conversations, visual essays, reflective pieces and interviews. The geographical span of the contributions brings insights from around the world and the number of topics covered in this issue are equally vast including, among others, mental health, disability, environment, sex work, violence, queerness, LGBTQ+ experiences, love and anger. The aim of this special issue, then, is to challenge the Manichean distinctions that are often drawn between research and activism, and by extension, between theory and practice. [ABSTRACT FROM AUTHOR]

Community mobilisation is recognised as an important strategy to shift inequitable gender norms and ensure an enabling environment to prevent gender-based violence (GBV). Yet there is a need to better understand the factors that facilitate effective community activism in particular contexts. Although fundamental to the success of mobilisation programmes, there is also limited appreciation of the experiences and agency of engaged community activists. This paper draws on qualitative evaluations from two community mobilisation GBV prevention programmes: the Gender Violence in the Amazon of Peru (GAP) Project and the Indashyikirwa programme in Rwanda. In Peru, participatory data was collected, in addition to baseline and endline interviews with 8 activists. In Rwanda, baseline and endline interviews and observations were conducted with 12 activists, and interviews were conducted with 8 staff members. The data was thematically analysed, and a comparative case study approach was applied to both data sets. The comparative study identified similar programmatic aspects that could hinder or enable activist's engagement and development, and how these are embedded within contextual social and structural factors. We discuss these insights in reference to the current emphasis in public health on individualistic programming, with insufficient attention to how wider environments influence violence prevention programming. [ABSTRACT FROM AUTHOR]

This paper offers a new interpretation of the ‘resistance’ carried out by local civil society organisations in Cambodia against intimate partner violence (IPV). In this, the paper explores the nexus between ‘rupture’, ‘resistance’ and ‘repetition’ and concludes that different ‘repetitions’ can contribute to acts of violence while simultaneously creating possibilities for resisting IPV. In regard to the latter, the concept of ‘rupture’ is investigated as a performative politics through which organisations try to disrupt the ‘repetitions’ of violent masculinities. Furthermore, it is argued that the importance of ‘repetitions’ and the concept of time should be acknowledged. The French criminal defence lawyer Jacques Vergès’ understanding of ‘rupture’ and the French philosopher Gilles Deleuze's notions of ‘repetition’ inform the analysis. To exemplify our discussion and findings, the paper embraces stories of a number of civil society workers who facilitate various men's groups in Cambodia in order to negotiate the practice of IPV. [ABSTRACT FROM AUTHOR]

Decades of collective and cumulative work by practitioners, activists and researchers have made violence prevention an important part of international development agendas. However, violence prevention and response work addressing women and children has historically been siloed. Those working at the intersection of violence against women (VaW) and violence against children (VaC) have wrestled with the age–gender divide. Addressing the historical and political influences that underpin this divide will likely enhance progress towards more integrated strategies. This paper examines the origins and development of this polarisation and potential strategies for a more coordinated and collaborative agenda. This paper draws on the insights gained from eleven (11) semi-structured interviews conducted with key violence prevention actors in VaW and VaC from across the globe, alongside relevant published literature. Informants were purposively sampled on the basis of their expertise in the field. Findings reveal key differences and tensions between the two fields, including in collection and use of research and evidence, core conceptual frameworks, and the development, funding and implementation of policy and practice. Potential opportunities for future synergies between the two fields are highlighted, particularly through a focus on the adolescent girl. [ABSTRACT FROM AUTHOR]

Several health research organisations whose work focuses on international collaboration outline guidelines that support ethical practice in health research partnerships including building consensus around good collaborative research practice. This paper explores researcher's perspectives, experiences, and reflections on the elements of successful health research partnerships between Northern and Southern countries/institutions. The study adopted a qualitative research approach using in-depth interviews to explore what an authentic partnership is as experienced and aspired by stakeholders in health research partnerships in Zambia. Interviews were conducted with stakeholders implementing various health research activities in the country. Our findings revealed that Southern partners aspired for equal status and participation, transparency, and accountability, interdependency, and reciprocity, commitment to shared goals, open dialogue and sustainability in partnerships. While to some extent these aspirations overlap with the categories covered throughout the different partnership guidelines, some key aspects go beyond what is included in existing recommendations such as status and recognition which are salient in the broader guidelines. An important aspect in dismantling power structures that causes inequality in partnerships is through generating knowledge and innovation using local resources in the South to address local needs which can be subsequently re-used to address challenges at the global level. [ABSTRACT FROM AUTHOR]

This paper uses empirical data collected from 117 female sex workers living in informal settlements in Nairobi and 15 healthcare providers to highlight specific effects of COVID-19 and related restrictions on healthcare access for the sex workers. We highlight the existing gender and health inequalities that have now been reinforced by the initial outbreak of the COVID-19 pandemic. Specifically, we focus on the most concerning healthcare needs for the sex workers including HIV prevention, care and treatment and sexual and reproductive healthcare. Our study findings reveal that the various restrictions imposed by the government to help curb the spread of COVID-19 to a large extent made it difficult for the sex workers to access their healthcare needs. The paper discusses the challenges of healthcare service delivery reflecting on some innovative and pioneering responses from health care providers to address the emergency situation. [ABSTRACT FROM AUTHOR]

There has been an increase in attention to intimate partner violence (IPV) as a health issue that contributes to the spread of HIV, physical and emotional stress, depression, substance use, serious injuries, and higher rates of mortality in low-income settings. This paper explores the ethical implications raised by research on IPV by global health scholars. Drawing on Hedgecoe’s work on critical bioethics to analyse a qualitative study of IPV in Rwanda, this paper discusses the risks and benefits of conducting research on IPV as part of the global health agenda. We discuss ethical issues that have become evident through our work in this area, including: raising IPV as an issue of concern in women’s lives in settings where economic support for women experiencing IPV may not exist; recording interviews and focus group discussions in contexts with significant government surveillance; ethical tensions in appropriating local voices in ways that position women as ‘victims’ of violence; and the risks associated with framing IPV as a global health issue separate from feminist advocacy. We recommend more tailored approaches to ethics in IPV research, which considers the specificity of the social, cultural and economic context. [ABSTRACT FROM AUTHOR]

Men who have sex with men (MSM) in Kenya bear a heavy burden of HIV/STIs and are a priority population in the national HIV/AIDS response, yet remain criminalised and stigmatised within society. HIV pre-exposure prophylaxis (PrEP) offers an opportunity to significantly impact the HIV epidemic, as does the concept of U = U, whereby those who are living with HIV and on treatment are uninfectious when their viral load has been suppressed so as to be undetectable. However, the value of such innovations will not be realised without sufficient understanding of, and respect for, the sexual health service provision needs of MSM. This paper describes findings from 30 in-depth interviews with MSM living in Nairobi that explored engagement with sexual health service providers, barriers to access and perceived opportunities to improve service design and delivery. Findings indicate concern relating to the professionalism of some staff working within public hospitals as well as feelings that many sexual health services were not considered safe spaces for the discussion of MSM-specific sexual behaviour. Diverse views were expressed relating to comfort in public, community and private sexual health services as well as how these are and should be organised. [ABSTRACT FROM AUTHOR]

The recommendation to start antiretroviral treatment independently of CD4 or viral load count is adopted as a strategy for reducing HIV/AIDS incidence rates in countries with a high prevalence rate, such as Lesotho. For example, the number of new HIV infections has lowered from 20,000 in 2010 to 11,000 in 2018 [UNAIDS Country Factsheets. (2019). ]. Lesotho introduced the 'test and treat' strategy in 2013 to address the HIV/AIDS pandemic, representing a shift from the provider-initiated HIV testing and counselling guidelines. The purpose of this paper was to understand pregnant women's concerns about starting antiretroviral treatment to limit risks of mother-to-child HIV-transmission during the implementation of 'test and treat' protocol in Lesotho. The study used a qualitative research approach and collected information from Lesotho public antenatal clinics. In-depth interviews were conducted with eighteen pregnant women living with HIV/AIDS and data were analysed manually following the constructivist grounded theory. Findings reveal the sadness experienced at the diagnosis stage, concerns about accessing treatment and maintaining adherence, and concerns about disclosure. It was concluded that these factors stemmed from fears about triggering enacted stigma in the illness experience of pregnant women, which could hamper the implementation of the 'test and treat' protocol in Lesotho. [ABSTRACT FROM AUTHOR]

Continued pregnancy after an abortion attempt is a likely outcome in countries where unsafe abortions prevail. Yet there is a paucity of literature on the consequences and implications of failed abortions. This study explored young women's abortion decision-making, their experiences of failed abortion and its consequences in South-Western Nigeria. It presents findings from semi-structured interviews conducted with 14 women who had become unintentionally pregnant as unmarried teenagers, desired abortions, yet became mothers. Whilst the fear of the stigma associated with young unmarried motherhood gave rise to participants' desire for abortion, restrictive abortion laws influenced their experiences and abortion decision-making. Participants who attempted an abortion failed and were forced to carry their unwanted pregnancies to term. They then experienced continued discrimination, forced motherhood, and a rejection of maternalism. Their experiences are analysed as responses to the complex interplay between social norms, abortion restrictions, stigma and forced motherhood. The paper makes a case for improving women's reproductive autonomy in decision-making, – highlighting the social and mental health consequences of restricted access to abortion, and reinforce the importance of taking a holistic approach to addressing the sexual health of young women, by focusing not only on physical health but also on ensuring wellbeing. [ABSTRACT FROM AUTHOR]

Objectives: Recent research demonstrates that economic interventions may positively effect HIV risk among adolescent girls and young women (AGYW) in sub-Saharan Africa. Some evidence reveals potential associations between financial decision-making and bargaining power in sexual relationships. However, this evidence is mixed, nuanced, and limited. This paper explores how AGYW in Zambia understand financial agency and its effect on intimate relationships. Methods: In-depth qualitative interviews were conducted with 30 females aged 15–24 years residing in Kalingalinga, a low income, high-density residential area in Lusaka. Data were analysed using thematic content analysis. Results: Participants spoke of the ability to earn and spend money as reality for some and aspirational for many others, intrinsic to cultural and religious caveats influencing perceptions of agency for women. The transfer of financial independence to sexual agency within relationships was viewed as a mechanism for HIV risk reduction; however, male sexual privilege was an obstacle irrespective of financial decision-making. Conclusions: Programmes aiming to enhance financial agency for AGYW have the potential to reduce HIV sexual risk. Yet, to be most effective, integration with gender-transformative programmes is needed to address norms of male dominance that keep AGYW in positions of vulnerability. [ABSTRACT FROM AUTHOR]

High levels of adolescent pregnancy and child marriage rates in low- and middle-income countries is an issue of concern to many stakeholders, including in Zambia where almost one-third of women give birth before age 18. The aim of this paper is to explore and analyse social norms concerning adolescents' sexual behaviour within the context of an intervention trial in rural communities in southern Zambia. It is based on a qualitative study applying individual interviews, focus group discussions and participatory research methods. We apply the distinction between injunctive and descriptive norms to demonstrate that adolescent girls are caught between conflicting norms. Injunctive norms express that premarital sex, contraceptive use, and discussions about sex between adults and youths are socially condemned. At the same time poor girls are reported to feel pressure towards having sexual relations for the economic benefits such relations can bring, and this practice is considered so common that it amounts to a descriptive norm. Norms and structural conditions combine to create a disabling and disempowering environment for adolescent sexual and reproductive health, which limits girls' agency and exposes them to unwanted pregnancies. [ABSTRACT FROM AUTHOR]

This paper explores adolescent girls' and young women's (AGYW) aspirations, factors that influence aspirations, and how their aspirations inform their sexual decision-making and behaviour. This study employed a qualitative design involving six participatory focus group discussions and 17 in-depth interviews with AGYW in – and out-of-school. Fieldwork was undertaken in rural and urban Tanzania. Thematic analysis was conducted using NVIVO software. Aspirations of AGYW's were categorised as short and long-term. Short-term aspirations were associated with the social status derived from obtaining trendy items such as nice clothing, or smart phones. Long-term aspirations included completing secondary education, having a professional job, being respected, getting married and having children. Aspirations were influenced by aspects of the social context, such as peers and structural factors that dictated what was acceptable for respectable AGYW. AGYW lacked the independent capabilities to meet long-term aspirations such as completing education. In pursuit of their short – and long-term aspirations, AGYW engaged in higher risk sexual behaviours such as transactional sex, age-disparate sex and condomless sex. AGYW's aspirations were important in determining their sexual decision making. Interventions should capitalise on AGYW's aspirations when addressing their SRH risks by finding innovative ways of engaging them based on their circumstances and aspirations. [ABSTRACT FROM AUTHOR]

Economically vulnerable women engaged in sex work (WESW) comprise one of the key populations with higher prevalence of HIV globally. In Uganda, HIV prevalence among WESW is estimated at 37% and accounts for 18% of all new infections in the country. This paper describes the strategies by which we have engaged community stakeholders in a randomised clinical trial aimed at evaluating the efficacy of adding economic empowerment components to traditional HIV risk reduction to reduce the incidence of STIs and HIV among WESW in Uganda. We demonstrate that stakeholder engagement, including the engagement of WESW themselves, plays a critical role in the adaptation, implementation, uptake, and potential sustainability of evidence-based interventions. To our knowledge, this is the first study to utilise stakeholder engagement involving WESW in Uganda. Researchers working with hard-to-reach populations, such as WESW, are encouraged to invest time and resources to engage key stakeholders through a full range of collaborative activities; and ensure that research is culturally appropriate and meets the needs of all stakeholders involved. ClinicalTrials.gov identifier: NCT03583541. [ABSTRACT FROM AUTHOR]

This paper explores the dynamics of access under the state-funded universal health insurance scheme in Chhattisgarh, India, and specifically the relationship between choice, affordability and acceptability. A qualitative case study of patients from the slums of Raipur City incurring significant heath expenditure despite using insurance, was conducted, examining the way patients and their families sought to navigate and negotiate hospitalisation under the scheme. Eight purposefully selected ('revelatory') instances of patients (and their families) utilising private hospitals are presented. Patients and their family exercised their agency to the extent that they could. Negotiations on payments took place at every stage, from admission to post-hospitalisation. Once admitted, however, families rapidly lost the initiative, and faced mounting costs, and increasingly harsh interactions with providers. The paper analyses how these outcomes were produced by a combination of failures of key regulatory mechanisms (notably the 'smart card'), dominant norms of care as a market transaction (rather than a right), and wider cultural acceptance of illegal informal healthcare payments. The unfavourable normative and cultural context of (especially) private sector provisioning in India needs to be recognised by policy makers seeking to ensure financial risk protection through publicly financed health insurance. [ABSTRACT FROM AUTHOR]

Ensuring that biomedical information about research procedures is adequately understood by participants and their communities is key for conducting ethical research. This article explores participants' understanding of trial procedures for an experimental vaccine against Ebola virus disease (EVD) in a West African context. We found that some trial participants believed there was a chance of contracting Ebola and other sicknesses from the vaccine, and others believed both the vaccine and the placebo control would be able to prevent other illnesses than EVD. While these beliefs might be understood as misconceptions about the vaccine trial, this paper shows that such a conclusion is problematic because it excludes local explanatory health models and logics of causality. The paper invites bioethicists to work with anthropologists to take seriously different models of health knowledge in global health research. Investigating and addressing such differences could be the key to understanding human subjects' motives for participation, and to creating space for studies of empirical ethics. [ABSTRACT FROM AUTHOR]

Non-state actors, including humanitarian agencies, play a prominent role in providing health care in low- and middle-income countries. Between 2007 and 2009, Musina, a South African municipality bordering Zimbabwe, became the site of several interventions by non-state organisations as an unprecedented number of Zimbabweans crossed the border, putting strain on already burdened local systems. After the initial need for humanitarian relief dissipated, organisations started to implement projects that were more developmental in nature. For example, Médecins sans Frontières developed a mobile clinic programme to improve health care access for migrant farm workers, a programme that was subsequently integrated into the Department of Health. Since the handover of the programme, it has faced multiple challenges. Using qualitative methodology and a case study approach, this paper traces the development of the programme, exploring the changing relationship between MSF and the state during this time. This research raises questions about the implications of short-term 'innovative' interventions targeting the access that migrants have to care, within a context in which policy and programmatic responses to health are not migration aware. Furthermore, it highlights the ways in which the energies and resources of local DoH employees were redirected by MSF's involvement in the area. [ABSTRACT FROM AUTHOR]

This paper reports on a qualitative study on social norms and child marriage in rural Cameroon, a country with high prevalence of child marriage but largely ignored in the literature. Study participants (n = 80) were men and women from four different ethnic groups living in four rural villages (two in the Far-North, two in the East). With the assistance of four local interviewers, we conducted 16 semi-structured focus groups to understand how existing social norms contributed to child marriage in participants' communities. We found great variety in the influence of social norms on people's health-related practices: across these four communities, social norms made compliance with the child marriage practice (respectively) possible, tolerated, appropriate, and obligatory. Effective health promotion interventions should be grounded within sound theoretical understandings of the varying influence of social norms. Using data on child marriage, this paper offers a case study of how that understanding can be developed. [ABSTRACT FROM AUTHOR]