Search

Background Recent theorisation has pushed stigma research in new directions, arguing for a need to challenge the unequal power relations that impact groups most at risk for HIV-related stigma rather than locate stigma in the individual. Such a conceptualisation resonates with the growing emphasis on structural interventions for HIV prevention that attempt to alter the social context of risk. Methods The paper predominantly relies on longitudinal interviews conducted three times over a 2-year period with sex workers with varying degrees of involvement with the non-governmental organisation (NGO) and community-based organisation. Results Recognising that stigma is socially constructed and structurally reproduced, the NGO helped mobilise marginalised and hitherto scattered female sex workers to form community-based organisations to challenge their disadvantaged status in society. The authors show how stigma alleviation strategies presented a contradiction: emboldening one group of female sex workers to self-identify as sex workers while making others reluctant to access the intervention-run clinic. Conclusion The paper builds on a growing body of research that acknowledges the struggles in implementing structural interventions, particularly for NGOs working in regions with a diverse population of sex workers with varying needs. The authors argue that intervention goals of reducing stigma and increasing the use of sexually transmitted infection services do not have to conflict and, in fact, must go hand-in-hand for an implementation to be considered a structural intervention. [ABSTRACT FROM AUTHOR]

Background This paper describes the process of setting up community-based organisations (CBOs) of sex workers during the 5-year community mobilisation initiative of the Swagati project, an HIV prevention programme in nine coastal districts of Andhra Pradesh. Method The Swagati project facilitated the formation of 11 CBOs through partnerships with local nongovernmental organisations and meetings with groups of sex workers. Activities included peer-led outreach, information campaigns, institution building through community committees and capacity building for organisational development. Results In 2010, a Community Ownership and Preparedness Index tool assessed the CBOs in terms of leadership, democratic governance, decision making and others qualities. All except two CBOs scored in the 'promising' category. One of these CBOs moved to promising stage by the year 2011 indicating good progress, considering how recently they were established. The Community Ownership and Preparedness Index assessments of organisational strengths showed wide variations among the CBOs, despite the essentially similar organisational steps taken by the Swagati programme. A Behavioural Tracking Survey (2010) of individual CBO members also showed district-level differences in sex workers' expressions of confidence in collective action, participation in organisational activities and other indicators. Conclusion Mobilising marginalised populations such as sex workers to form CBOs is a complex process and can be affected by many influences, including the qualities of CBO leadership. Although the CBOs have not yet reached full 'maturity', they have made significant improvements in terms of collectivisation and its translation into collective action as reported by individual sex workers. [ABSTRACT FROM AUTHOR]

Background Community mobilisation interventions for HIV prevention among female sex workers (FSWs) aim to organise FSWs for collective action and challenge the structures of power that underlie HIV risk. Assessing intervention impact is challenging because the importance of direct individual exposure to intervention components may decrease over time as change occurs at social-normative, policy and other structural levels. In this paper, the authors examine changes over time in consistent condom use among FSWs in Rajahmundry, Andhra Pradesh, the location of a long-standing community mobilisation intervention. Methods The authors analyse cross-sectional data collected among FSWs at three time points (n=2276) using respondent-driven sampling. Multiple logistic regression was used to assess the association of programme exposure with consistent condom use and whether this association varied over time. Results The proportion of FSWs having no exposure or only receptive exposure to the intervention decreased over time, while active utilisation increased from 19.4% in 2006 to 48.5% in 2009-2010. Consistent condom use with clients also increased from 56.3% in 2006 to 75.3% in 2009-2010. Multivariate analysis showed that age, age at start of sex work, venue, living conditions and programme exposure were significantly associated with condom use. The positive association between programme exposure and consistent condom use did not vary significantly over time. Conclusions Findings indicate improvements in HIV risk reduction behaviour among FSWs and suggest that the intervention has substantial reach in the FSW population. The intervention's strategies may be contributing to population-level HIV risk reduction among FSWs. [ABSTRACT FROM AUTHOR]

Background This paper examines the association between degree of confidence in collective efficacy and self-efficacy for condom use and empowerment among heterogeneous female sex workers (FSWs) in two metropolitan Indian cities with high HIV prevalence. Methods The study utilises data from the Behavioural Tracking Survey, a cross-sectional behavioural study with 2106 FSWs recruited from 411 intervention sites in Mumbai and Thane. The key independent measures used determine the degree of confidence in collective efficacy (belief in the power to achieve goals and address problems together) and outcome measures included: self-efficacy for condom use with occasional clients and condom use with regular partners, self-confidence in handling a crisis situation and public speaking ability. Univariate and multivariate statistical methods were used to examine the study objectives. Results Of the analytical sample of 2106 FSWs, 532 (25.3%) reported high degree of collective efficacy for achieving certain goals and 1534 (72.8%) reported collective efficacy for addressing specific problems. FSWs reporting a higher collective efficacy as compared with those reporting lower collective efficacy were as follows: more likely to negotiate condom use with occasional clients (60.3% vs 19.7%; adjusted OR (AOR) =6.3, 95% CI 4.8 to 8.4) as well as regular partners (62.8% vs 20.2%; AOR =6.4, 95% CI 4.9 to 8.4); confident in facing troublesome stakeholders (73.5% vs 38.8%; AOR =4.3, 95% CI 3.3 to 5.6), confident in supporting fellow FSWs in a crisis (76.1% vs 49.6%; AOR =2.9, 95% CI 2.2 to 3.7), received help from other FSWs when a client or partner was violent (73.9% vs 46.3%; AOR =3.5, 95% CI 2.7 to 4.5) and had stood up to the police or madams/brokers to help fellow FSWs in the past 1 year (5.8% vs 3.3%; AOR =2.7, 95% CI 1.5 to 4.9). Conclusion The results suggest that the strategy of collectivisation in HIV prevention programme has much broader benefits than merely the promotion of safer sex practices. Future HIV prevention interventions in India and elsewhere may include collectivisation as the core strategy within HIV prevention programmes. [ABSTRACT FROM AUTHOR]

Background To examine the association between the presence of community advocacy groups (CAGs) and female sex workers' (FSWs) access to social entitlements and outcomes of police advocacy. Methods Data were used from a cross-sectional survey conducted in 2010-2011 among 1986 FSWs and 104 NGO outreach workers from five districts of Andhra Pradesh. FSWs were recruited using a probability-based sampling from 104 primary sampling units (PSUs). A PSU is a geographical area covered by one outreach worker and is expected to have an active CAG as per community mobilisation efforts. The presence of active CAGs was defined as the presence of an active committee or advocacy group in the area (PSU). Outcome indicators included acquisition of different social entitlements and measures of police response as reported by FSWs. Multivariate linear and logistic regression analyses were used to examine the associations. Results Areas with active CAGs compared with their counterparts had a significantly higher mean number of FSWs linked to ration cards (12.8 vs 6.8; p<0.01), bank accounts (9.3 vs 5.9; p=0.05) and health insurance (13.1 vs 7.0; p=0.02). A significantly higher percentage of FSWs from areas with active CAGs as compared with others reported that the police treat them more fairly now than a year before (79.7% vs 70.3%; p<0.05) and the police explained the reasons for arrest when arrested the last time (95.7% vs 87%; p<0.05). Conclusion FSWs from areas with active CAGs were more likely to access certain social entitlements and to receive a fair response from the police, highlighting the contributions of CAGs in community mobilisation. [ABSTRACT FROM AUTHOR]

Background To assess the association between female sex workers' (FSWs) degree of community collectivisation and self-efficacy, utilisation of sexually transmitted infection (STI) services from government-run health centres in Andhra Pradesh, India. Methods Cross-sectional analyses of 1986 FSWs recruited using a probability-based sampling from five districts of Andhra Pradesh during 2010-2011. Multiple logistic regression models were constructed to assess associations. The independent variables included-collective efficacy, collective agency and collective action-measured using a series of items that assessed the grouping of the community on issues that concern most sex workers. An additional independent variable included FSWs belonging to an area where there was a project partnership with government health centres to provide STI treatment services to FSWs. The outcome indicators included self-efficacy for service utilisation from government health facilities and the treatment for STIs from government health facilities at least once in the past year experience of STI symptoms. Results Of the 1986 FSWs, nearly two-fifths (39.5%) reported a high level of overall collectivisation (collective efficacy: 89%, collective agency: 50.7%; collective action: 12.7%). Sex workers with a high degree compared with low degree of overall collectivisation were significantly more likely to report high self-efficacy to use government health facilities (75.0% vs 57.3%, adjusted OR 2.5, 95% CI 2.0 to 3.1) and to use government health centres for STI treatment in past 1 year (78.1% vs 63.2%, adjusted OR 2.1, 95% CI 1.6 to 2.8), irrespective of project partnership with government centres. Conclusion The current research findings reinforce the need for stronger community mobilisation for better utilisation of government health facilities for STI and HIV prevention interventions. [ABSTRACT FROM AUTHOR]

Background The majority of children who die from vaccine-preventable diseases (VPDs) live in low-income and-middle-income countries (LMICs). With the rapid urbanisation and rural-urban migration ongoing in LMICs, available research suggests that migration status might be a determinant of immunisation coverage in LMICs, with rural-urban migrant (RUM) children being less likely to be immunised. Objectives To examine and synthesise the data on immunisation coverage in RUM children in LMICs and to compare coverage in these children with non-migrant children. Methods A multiple database search of published and unpublished literature on immunisation coverage for the routine Expanded Programme on Immunisation (EPI) vaccines in RUM children aged 5 years and below was conducted. Following a staged exclusion process, studies that met the inclusion criteria were assessed for quality and data extracted for meta-analysis. Results Eleven studies from three countries (China, India and Nigeria) were included in the review. There was substantial statistical heterogeneity between the studies, thus no summary estimate was reported for the meta-analysis. Data synthesis from the studies showed that the proportion of fully immunised RUM children was lower than the WHO bench-mark of 90% at the national level. RUMs were also less likely to be fully immunised than the urban-non-migrants and general population. For the individual EPI vaccines, all but two studies showed lower immunisation coverage in RUMs compared with the general population using national coverage estimates. Conclusions This review indicates that there is an association between rural-urban migration and immunisation coverage in LMICs with RUMs being less likely to be fully immunised than the urban non-migrants and the general population. Specific efforts to improve immunisation coverage in this subpopulation of urban residents will not only reduce morbidity and mortality from VPDs in migrants but will also reduce health inequity and the risk of infectious disease outbreaks in wider society. [ABSTRACT FROM AUTHOR]

Objective Extend analyses of maternal mental health and infant growth in low- and middle-income countries (LMICs) to children through age eight years, and broaden analyses to cognitive and psychosocial outcomes. Design Community-based longitudinal cohort study in four LMICs (Ethiopia, India, Peru and Vietnam). Surveys and anthropometric assessments were carried out when the children were approximately ages 1, 5 and 8 years. Risk of maternal common mental disorders (rCMDs) was assessed with the Self-Reporting Questionnaire (SRQ)-20 (score ≥8). Setting Rural and urban as well as low- and middle-income communities. Participants 7722 mothers and their children. Main outcome measures Child stunting and underweight (Z score ≤2 of height and weight for age), and <20th centile for: cognitive development (Peabody Picture Vocabulary Test), and the psychosocial outcomes self pride and life satisfaction. Results A high rate of rCMD, stunting and underweight was seen in the cohorts. After adjusting for confounders, significant associations were found between maternal rCMDs and growth variables in the first year of life, with persistence to age 8 years in India and Vietnam, but not in the other countries. India and Vietnam also showed significant associations between rCMDs and lower cognitive development. After adjustment, rCMD was associated with low life satisfaction in Ethiopia but not in the other cohorts. Conclusions Associations of maternal rCMD in the first year of life with child outcomes varied across the study cohorts and, in some cases, persisted across the first 8 years of life of the child, and included growth, cognitive development and psychosocial domains. [ABSTRACT FROM AUTHOR]

Background Indian babies are characterised by the 'thin-fat phenotype' which comprises a 'muscle-thin but adipose' body composition compared with European babies. This body phenotype is of concern because it is associated with an increased risk of diabetes and cardiovascular disease. We examined whether the 'thin-fat phenotype' persists through early childhood, comparing Indian children with white Caucasians in the UK at birth, infancy and childhood, using comparable measurement protocols. Methods We used data from two cohorts, the Pune Maternal Nutrition Study (N=631) and the Southampton Women's Survey (N=2643). Measurements of weight, head circumference, mid-upper arm circumference, height, triceps and subscapular skinfold thickness were compared at birth, 1, 2, 3 and 6 years of age. SD scores were generated for the Pune children, using the Southampton children as a reference. Generalised estimating equations were used to examine the changes in SD scores across the children's ages. Results The Indian children were smaller at birth in all body measurements than the Southampton children and became relatively even smaller from birth to 2 years, before 'catching up' to some extent at 3 years, and more so by 6 years. The deficit for both skinfolds was markedly less than for other measurements at all ages; triceps skinfold showed the least difference between the two cohorts at birth, and subscapular skinfold at all ages after birth. Conclusions The 'thin-fat phenotype' previously found in Indian newborns, remains through infancy and early childhood. Despite being shorter and lighter than UK children, Indian children are relatively adipose. [ABSTRACT FROM AUTHOR]

Background Education of mothers may improve child health. We investigated whether maternal health literacy, a rapidly modifiable factor related to mother's education, was associated with children's receipt of vaccines in two underserved Indian communities. Methods Cross-sectional surveys in an urban and a rural site. We assessed health literacy using Indian child health promotion materials. The outcome was receipt of three doses of diphtheria-tetanus-pertussis (DTP3) vaccine. We used multivariate logistic regression to investigate the relationship between maternal health literacy and vaccination status independently in each site. For both sites, adjusted models considered maternal age, maternal and paternal education, child sex, birth order, household religion and wealth quintile. Rural analyses used multilevel models adjusted for service delivery characteristics. Urban analyses represented cluster characteristics through fixed effects. Results The rural analysis included 1170 women from 60 villages. The urban analysis included 670 women from nine slum clusters. In each site, crude and adjusted models revealed a positive association between maternal health literacy and DTP3. In the rural site, the adjusted OR was 1.57 (95% CI 1.11 to 2.21, p=0.010) for those with medium health literacy, and OR=1.30 (95% CI 0.89 to 1.91, p=0.172) for those with high health literacy. In the urban site, the adjusted OR was 1.10 (95% CI 0.65 to 1.88, p=0.705) for those with medium health literacy, and OR=2.06 (95% CI 1.06 to 3.99, p=0.032) for those with high health literacy. Conclusions In these study settings, maternal health literacy is independently associated with child vaccination. Initiatives targeting health literacy could improve vaccination coverage. [ABSTRACT FROM AUTHOR]

Background: Community-based rehabilitation (CBR) programmes have been described as highly effective means of promoting the rights and opportunities of persons with disabilities (PwD). Although CBR is often the main way in which PwD in low-income and middle-income countries access rehabilitation services, there is little literature providing rigorous evaluation of their impact on people’s well-being. Methods: Data were collected in the Mandya and Ramanagar districts (Karnataka state, India), between December 2009 and May 2010. In total 2540 PwD were interviewed using stratified random sampling: 1919 CBR beneficiaries (who joined the programme between 1997 and 2009) and 621 persons who were living in villages not covered by the programme. We controlled for the systematic differences between people joining and not joining the programme using the propensity score matching method controlling for covariates at individual and village level. We evaluated the impact of the programme on the subgroups of PwD who are disadvantaged on the dimensions of interest: access to pensions, use of aid appliances, access to paid jobs and improvement in personal-practical autonomy after 4 and 7 years of joining the CBR. Results: We observed a positive and significant impact of the programme on access to services, rights and opportunities of PwD. The results indicate that compared with the control group access to pensions and allowances, aid appliances, access to paid jobs and personal-practical autonomy increased by 29.7%, 9.4%, 12.3% and 36.2%, respectively, after 7 years. Conclusions: The CBR programme analysed has a positive impact on access to services and the well-being of PwD who are particularly deprived on outcomes of interest. [ABSTRACT FROM AUTHOR]

Background Few models of how community mobilisation works have been elaborated in the scientific literature, and evaluation of the impact of these programmes on HIV and other health outcomes is extremely limited. Avahan, the India AIDS Initiative, has been implementing community mobilisation as part of its prevention programming with groups of high-risk individuals across six states since 2005. Purpose To articulate a programme theory and evaluation framework for evaluation of Avahan's approach to community mobilisation among female sex workers in four southern states in India. Methods The authors use a goal-based evaluation approach to describe the programme goals and an underlying programme theory that specifies how the programme is expected to work. Using multilevel structural equation modelling with propensity score matching, the evaluation will compare what is observed in the data with the predicted relationships specified by the model. Results The Avahan model of community mobilisation posits that meaningful participation in high-risk group intervention, structural intervention and organisational development activities leads to identification, collectivisation and ownership, which in turn leads to improved programme outcomes. Strong community groups and an enabling environment reinforce social norm and behaviour change outcomes and lead to sustained impact. Discussion Specifying an explicit programme theory can aid in the evaluation of complex interventions, especially when the evaluation design is observational. In addition to articulating Avahan's community mobilisation approach in a model that can be tested, we recommend some specific measures and methods that could be used to improve evaluation efforts in the future. [ABSTRACT FROM AUTHOR]

Background Empowering sex workers to mobilise and influence the structural context that obstructs risk reduction efforts is now seen an essential component of successful HIV prevention programmes. However, success depends on local programme environments and history. Methods The authors analysed data from the Integrated Behavioural and Biological Assessment Round I crosssectional survey among female sex workers in Tamil Nadu and Maharashtra. The authors used propensity score matching to estimate the impact of participation in intervention activities on reduction of risk (consistent condom use) and vulnerability (perceived collective efficacy and community support). Results Background levels of risk and vulnerability as well as intervention impact varied widely across the different settings. The effect size ATT of attending meetings/ trainings on consistent condom use was as high as 21% in Tamil Nadu (outside of Chennai) where overall use was lowest at 51%. Overall, levels of perceived collective efficacy were low at the time of the survey; perceived community support was high in Tamil Nadu and especially in Chennai (93%) contrasting with 33% in Mumbai. Consistent with previous research, the context of Mumbai seems least conducive to vulnerability reduction, yet selfhelp groups had a significant impact on consistent condom use (ATT=10%) and were significantly associated with higher collective efficacy (ATT=31%). Conclusions Significant risk reduction can be achieved by large-scale female sex worker interventions, but the impact depends on the history of programming, the complexity of the context in which sex work happens and pre-existing levels of support sex workers perceive from their peers. [ABSTRACT FROM AUTHOR]

Background Despite high HIV prevalence rates among most-at-risk groups, utilisation of HIV testing, treatment and care services was relatively low in Karnataka prior to 2008. The authors aimed to understand the barriers to and identify potential solutions for improving HIV service utilisation. Methods Focus group discussions were carried out among homogeneous groups of female sex workers, men who have sex with men and transgenders, and programme peer educators in six districts across Karnataka in March and April 2008. Results 26 focus group discussions were conducted, involving 302 participants. Participants had good knowledge about HIV and HIV voluntary counselling and testing (VCT) services, but awareness of other HIV services was low. The fear of the psychological impact of a positive HIV test result and the perceived repercussions of being seen accessing HIV services were key personal and interpersonal barriers to HIV service utilisation. Previous experiences of discrimination at government healthcare services, coupled with discriminatory attitudes and behaviours by VCT staff, were key structural barriers to VCT service uptake among those who had not been HIV tested. Among those who had used government-managed prevention of parent to child transmission and antiretroviral treatment services, poor physical facilities, long waiting times, lack of available treatment, the need to give bribes to receive care and discriminatory attitudes of healthcare staff presented additional structural barriers. Conclusions Embedding some HIV care services within existing programmes for vulnerable populations, as well as improving service quality at government facilities, are suggested to help overcome the multiple barriers to service utilisation. Increasing the uptake of HIV testing, treatment and care services is key to improving the quality and longevity of the lives of HIV-infected individuals. [ABSTRACT FROM AUTHOR]

Background In a participatory approach to health and development interventions, defining and measuring community mobilisation is important, but it is challenging to do this effectively, especially at scale. Methods A cross-sectional, participatory monitoring tool was administered in 2008-2009 and 2009-2010 across a representative sample of 25 community-based groups (CBGs) formed under the Avahan India AIDS Initiative, to assess their progress in mobilisation, and to inform efforts to strengthen the groups and make them sustainable. The survey used a weighted index to capture both qualitative and quantitative data in numeric form. The index permitted broad, as well as highly detailed, analysis of community mobilisation, relevant at the level of individual groups, as well as state-wide and across the whole programme. Results The survey demonstrated that leadership and programme management were the strongest areas among the CBGs, confirming the programme's investment in these areas. Discussion of the Round 1 results led to efforts to strengthen governance and democratic decision making in the groups, and progress was reflected in the Round 2 survey results. CBG engagement with state authorities to gain rights and entitlements and securing the long-term financial stability of groups remain a challenge. Conclusion The survey has proven useful for informing the managers of programmes about what is happening on the ground, and it has opened spaces for discussion within community groups about the nature of leadership, decision making and their goals, which is leading to accelerated progress. The tool provided useful data to manage community mobilisation in Avahan. [ABSTRACT FROM AUTHOR]

Background Community mobilisation is an important component of a participatory approach to health and development interventions. However, it is challenging to define, measure and assess community participation and ownership of a programme, especially at scale. Methods An iterative cross-sectional survey was designed for implementation across a representative sample of community-based groups, using a weighted index that captured both qualitative and quantitative data in a standardised form. These data were aggregated at the level of individual groups, as well as state-wide or across the whole programme. Community participation in the survey is a primary feature of the methodology and was integral to the process of designing the index and administering the survey. Results The survey provided programme management and communities with objective tools for monitoring community mobilisation across a large-scale and complex intervention covering 32 districts in India. The implementation of the survey engaged communities in an open discussion of their goals and capabilities and helped them to challenge the power dynamics between themselves and other stakeholders. Conclusions It is possible to translate the theoretical premises of participatory development into a tool that both measures and fosters meaningful participation. The active participation of community members in the collection and analysis of data on their mobilisation suggests that monitoring of participation can be undertaken to inform a scaled-up programme and can be a useful intervention in its own right. INSET: Community Ownership and Preparedness Index: framework of.... [ABSTRACT FROM AUTHOR]

Debates have raged in development for decades about the appropriateness of participatory approaches and the degree to which they can be managed, scaled and measured. The Avahan programme confronted these issues over the last 7 years and concludes that it is advantageous to manage scaled community mobilisation processes so that participation evolves and programming on the ground is shaped by what is learnt through implementation. The donor (Bill & Melinda Gates Foundation) and its partners determined a standard set of programme activities that were implemented programme-wide but evolved with input from communities on the ground. Difficulties faced in monitoring and measurement in Avahan may be characteristic of similar efforts to measure community mobilisation in a scaled programme, and ultimately these challenges informed methods that were useful. The approach the programme undertook for learning and changing, the activities it built into the HIV prevention programme, and its logic model and measurement tools, may be relevant in other public health settings seeking to integrate community mobilisation. [ABSTRACT FROM AUTHOR]