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Objectives. Networks of franchised health establishments, providing a standardized set of services, are being implemented in developing countries. This article examines associations between franchise membership and family planning and reproductive health outcomes for both the member provider and the client. Methods. Regression models are fitted examining associations between franchise membership and family planning and reproductive health outcomes at the service provider and client levels in three settings. Results. Franchising has a positive association with both general and family planning client volumes, and the number of family planning brands available. Similar associations with franchise membership are not found for reproductive health service outcomes. In some settings, client satisfaction is higher at franchised than other types of health establishments, although the association between franchise membership and client outcomes varies across the settings. Conclusions. Franchise membership has apparent benefits for both the provider and the client, providing an opportunity to expand access to reproductive health services, although greater attention is needed to shift the focus from family planning to a broader reproductive health context. Key Words. Franchising, service delivery, reproductive health, Clinic franchising occurs when service delivery points contribute equity and resources of their own in exchange for the right to offer a defined set of health services of a franchiser [...]

The HIV epidemic in the USA began as a bicoastal epidemic focused in large cities but, over nearly four decades, the epidemiology of HIV has changed. Public health surveillance data can inform an understanding of the evolution of the HIV epidemic in terms of the populations and geographical areas most affected. We analysed publicly available HIV surveillance data and census data to describe: current HIV prevalence and new HIV diagnoses by region, race or ethnicity, and age; trends in HIV diagnoses over time by HIV acquisition risk and age; and the distribution of HIV prevalence by geographical area. We reviewed published literature to explore the reasons for the current distribution of HIV cases and important disparities in HIV prevalence. We identified opportunities to improve public health surveillance systems and uses of data for planning and monitoring public health responses. The current US HIV epidemic is marked by geographical concentration in the US South and profound disparities between regions and by race or ethnicity. Rural areas vary in HIV prevalence; rural areas in the South are more likely to have a high HIV prevalence than rural areas in other US Census regions. Ongoing disparities in HIV in the South are probably driven by the restricted expansion of Medicaid, health-care provider shortages, low health literacy, and HIV stigma. HIV diagnoses overall declined in 2009–18, but HIV diagnoses among individuals aged 25–34 years increased during the same period. HIV diagnoses decreased for all risk groups in 2009–18; among men who have sex with men (MSM), new diagnoses decreased overall and for White MSM, remained stable for Black MSM, and increased for Hispanic or Latino MSM. Surveillance data indicate profound and ongoing disparities in HIV cases, with disproportionate impact among people in the South, racial or ethnic minorities, and MSM.

ObjectivesExpedited partner therapy (EPT) is an effective strategy to reduce rates of chlamydia and gonorrhoea infection and ensure sexual partners are treated. Currently, EPT is provided to heterosexual patients; however, EPT is not routinely recommended for use with gay, bisexual and other men who have sex with men (GBMSM) because of concerns about HIV coinfection. The objective of the qualitative study was to understand provider and community views on the use of EPT with GBMSM.MethodsUsing convenience sampling methods, we recruited a sample of 18 healthcare providers and 21 GBMSM to participate in in-depth, semistructured interviews. Interviews were conducted over the phone and included questions about knowledge, experiences and potential barriers and facilitators to the use of EPT with GBMSM.ResultsMost providers wanted to provide EPT to GBMSM and believed that the potential barriers and concerns to EPT use were not unique to a patient’s sexual orientation. Several providers noted that they were currently providing EPT to GBMSM as part of HIV prevention services. Community members were generally unaware of EPT as a service and most indicated that they would only use EPT if they were in a committed relationship. Barriers included partner allergies and resistance, pharmacy protocols, structural concerns (eg, insurance coverage, pharmacists onsite and transportation) and potential disclosure issues. Facilitators included cultural humility and telemedicine with patients’ partners to overcome these barriers.ConclusionsAcceptability of EPT use for both chlamydia and gonorrhoea was high among providers and community members. Barriers to EPT use, including concerns about patients’ partners’ allergies and resistance, disclosure concerns and linkage to HIV prevention services can be overcome through cultural humility trainings and telemedicine. Changing EPT recommendations at the national level to be inclusive of GBMSM is critical to curtail the rising STI and HIV epidemic.

BackgroundHIV prevention research often involves the use of online surveys as data collection instruments. Incomplete responses to these surveys can introduce bias. We aimed to develop and assess innovative methods to incentivise respondents to complete surveys.MethodsAdult men who have sex with men (MSM) living in the USA were recruited through banner advertisements on Facebook from 27 April 2015 to 6 May 2015 to participate in an online survey about HIV prevention and risk behaviours. Participants were randomised to one of four conditions: a monetary incentive; a series of altruistic messages highlighting the importance of participating in research; access to a dashboard comparing their responses with statistics from other participants after completion; and no incentive. Kaplan-Meier survival methods and univariate Cox proportional hazard models were used to evaluate survey dropout by incentive group and demographic variables of interest.ResultsThere were a total of 1178 participants randomised to the four treatment groups. The rate of survey dropout among participants in the altruistic (HR=0.68, 95% CI 0.49 to 0.93), monetary (HR=0.44, 95% CI 0.32 to 0.61) and dashboard (HR=0.78, 95% CI 0.58 to 1.06) groups was lower than the non-incentivised control group. Regardless of condition, survey dropout was also lower among MSM aged 28–34 (HR=0.67, 95% CI 0.50 to 0.90) compared with those aged 18–22 years old, and MSM who were white (HR=0.78, 95% CI 0.60 to 1.02) compared with non-white participants.ConclusionMonetary incentives and altruistic messaging can improve survey completion in online behavioural HIV prevention research among MSM.Trial registration numberNCT02139566.

While national human papillomavirus (HPV) vaccination estimates exist by sex, little is known about HPV vaccination rates by gender identity.

Wastewater treatment plants world-wide are being squeezed in a classic Catch 22 situation; by treating wastewater to higher discharge standards demanded by regulatory agencies, plants generate more biosolids for disposal. [...]

To describe predictors of contraceptive method discontinuation and switching behaviours among HIV-positive couples receiving couples’ voluntary HIV counselling and testing services in Lusaka, Zambia.

Research on trust, and its influence on teamwork, among health workers in low-resource settings has been understudied. We, therefore, undertook a formative study of trust among three diverse cadres of frontline health workers in Amhara region, Ethiopia. We aimed to develop a comprehensive description of trust in this setting and generate a tool to measure levels of trust within and between cadres. In-depth interviews with 30 frontline workers uncovered a core set of items that seem to define trust in this setting (character/ability/communication), including novel conceptualizations (oneness). Twenty-five items developed from formative data were pilot tested with 92 health workers. The final 10-item scale exhibited strong internal consistency across cadres (alpha>0.83). In support of criterion validity, the scale was positively associated with the sense-of-teamscale (p<0.001) and accounted for greater variance in health workers' sense-of-team(Adj.R2=0.67) than did a composite of single trust items (Adj.R2=0.28). For contrasting group validity, respondents had greater within-group agreement compared to between-group agreement on trust items and displayed higher competence in answering questions about their own cadre. Results demonstrate that the Rural Health Worker Trust Scalecan be validly and reliably used to measure trust among diverse cadres. The scale may be used to develop and evaluate trust-building interventions that aim to encourage and sustain collaboration among heterogeneous frontline workers.

Objective. In Latin America and the Caribbean, Bolivia has the third highest rate of mortality among children under five years of age (57 per 1 000), with 14.0% of under-five deaths attributable to diarrhea. Because a child's world is predominantly controlled by and experienced through his or her mother, this investigation aims to understand what maternal dimensions may determine child diarrhea. Methods. Variables were selected from the 2003 Bolivia Demographic and Health Survey to create indices of three maternal dimensions using principal components analysis: behavior and experience, access to care, and agency. The three indices were included in a logistic regression model while controlling for economic status, maternal education, and residence type. Results. A total of 4 383 women who had children less than 5 years old were included in the final sample and 25.0% of mothers reported that their most recent born child had experienced an episode of diarrhea in the 2 weeks before the survey. Mothers with high levels of maternal agency or of high economic status were significantly less likely to report their child experienced an episode of diarrhea than women of low levels. Women with primary education were significantly more likely to report that their child experienced diarrhea than women with no education. Conclusions. High levels of agency have a significant protective effect even when controlling for other factors. Increasing maternal agency could have a positive impact on child health in Bolivia, and future work should aim to understand what accounts for different levels of agency and how it may be strengthened. [ABSTRACT FROM AUTHOR]

Objectives. To better understand the individual and community factors and perceptions that influence women's health care-seeking behaviors during pregnancy in order to increase women's utilization of maternal health services. Methods. This study investigates the logistical and sociocultural barriers influencing women's utilization of maternal health services through 37 semi-structured in-depth interviews with women from the department of Matagalpa, Nicaragua. Results. Results reveal that delays in seeking health care during pregnancy are influenced not only by poor access to care and economic barriers but also by individual and community knowledge and acceptance of maternal health services. Partner support, previous maternal health care experiences, and the degree of communication with other women and health workers affect women's decisions to seek care. Conclusions. Evidence suggests that in order to improve maternal health outcomes in this region, interventions must be targeted at a hierarchy of levels: individual, household, and community. [ABSTRACT FROM AUTHOR]

AbstractAn empirical study on the Kondhsof Phulbani district of Orissa, India was made by selecting three typical Kondhvillages-Rajikakhola, Nediguda and Badruguda - during 1994-96. Population of these villages varied between 79 to 95. Socio-economic structure of these villages revealed a poor status of the tribals. Ecological parameters including resource base of these villages were described. Difficulties encountered in improving the financial condition of these tribals were also analysed. Suggestions for improvement of these village ecosystems were made.

An interview with filmmaker Trinh T. Minh-ha is presented. Minh-ha sites the differences between the films "Reassemblage" and "Naked Spaces: Living is Round," which include the length, and the strategies adopted by the films. She affirms that the disjunctive aspect of "Reassemblage" is evident. She believes that her film works in terms of raising consciousness.

Little is known about how young Africans have made sense of the dramatic ways in which the HIV epidemic has evolved, and how that sense-making varies across countries with different epidemiological and sociocultural profiles. Symbolic representations of HIV and people living with HIV influence prevention, stigma, treatment-seeking, and illness experience. We compared social representations of HIV among young people from Senegal, Burkina Faso, Nigeria (South-East), Kenya, and Swaziland between 1997 and 2014. From a pool of 32,759 HIV-themed creative narratives contributed by 10–24 year-olds to scriptwriting competitions at eight time points (1997, 2000, 2002, 2005, 2008, 2011, 2013, and 2014), we randomly sampled 1937 narratives, stratified by author's sex, age, and rural/urban residence. We quantified components of each narrative and calculated descriptive statistics and adjusted odds ratios, controlling for year, country, and author demographics. From 2005 onwards, representations of death, treatment access, and hopefulness improved significantly. Representations of death reached their lowest point in 2013, while biomedical treatment and hope peaked in 2011 and 2008, respectively, then declined. Narratives increasingly focused on female protagonists. Nigerian texts had significantly higher odds of death and blame, and lower odds of hope. A focus on life post-infection and representations of support for characters living with HIV increased with country HIV prevalence. Narratives by older authors were less blaming and more hopeful, supportive, and prevention-focused. While aggregate social representations in the narratives from 2005 to 2008-11 reflect increased optimism fostered by access to antiretroviral therapy (ART), positive developments are not sustained at this level. Stigmatizing representations persist, particularly in Nigeria. The hope-promoting and stigma-reducing influence of the advent of ART access may have partially run its course by 2011/2013. However, significant temporal and cross-national differences point to opportunities to reframe HIV in more constructive ways and contribute to improved education, communication, and stigma-reduction efforts.

Statement of purposeThis study examines whether positive deviance to specific community norms is associated with experiences of sexual intimate partner violence (IPV) among women in 30 low- and middle-income countries.Methods/approachPositive deviants are individuals who transcend community norms and obtain better health outcomes than their peers with similar resources. In the first-ever application of positive deviance to IPV, this analysis used 30 nationally-representative Demographic and Health Surveys (DHS) completed in 2010 or later and containing a domestic violence module. Currently-married women ages 15–49 interviewed as part of the domestic violence module (n=350,794) were included. Respondents indicated their husbands ever committed sexual IPV, creating a binary outcome. Twelve theory-derived variables were created and aggregated to the Primary Sampling Unit (PSU) to create community-level norms. Multilevel modelling was used to examine the association between positive departure from community-level norms and individual experiences of sexual IPV. Subsequent analyses stratified countries by IPV prevalence and score on the Gender Inequality Index (GII).ResultsResults show positive deviance from at least one community-level norm was significantly associated with not reporting IPV in all 30 countries. These effects vary considerably by country, country-level IPV prevalence, and GII score.ConclusionsPositive deviance to certain community norms is associated with not experiencing sexual IPV among women across low- and middle-income countries. The increased normativity of abuse in countries with higher scores on the GII and higher rates of IPV may explain the stronger association between positive deviance and sexual IPV in these contexts.Significance/Contribution to Injury and Violence Prevention ScienceThis study is the first to apply positive deviance to the study of IPV and identifies factors that may be used for the primary prevention of IPV. The social proof that these are already adopted by some members of a community indicate scale-up may be possible.

PurposeSexual violence is a significant challenge for universities worldwide and prevention programs are non-existent in Ghana. We used the ADAPT-ITT model, a framework to systematically adapt HIV interventions, to adapt a sexual violence prevention program currently used in the United States to a university in Ghana.MethodsThe ADAPT-ITT model involves eights steps: (1) Assessment of priorities, (2) Decisions on adapting, (3) Administration of intervention, (4) Production of adapted version, (5) Topical experts, (6) Integration of feedback from topical experts, (7) Training staff to implement, and (8) Testing the adapted intervention. We will focus on steps 1–7 that included the use of focus group discussions (FGDs), cognitive interviews, beta testing, topical expert review, and peer facilitator training.ResultsDuring the Assessment, four FGDs highlighted the themes of (1) body language, (2) expectations of abstinence, (3) gendered power differentials; (4) no means yes, (5) violence and control in marriages, and (6) alcohol’s role in sexual violence. Twenty cognitive interviews revealed most of the survey questions were appropriate and well understood. The adapted intervention was Administered to students two times (n=71; n=56). Some pre- and post-test changes were seen in rape myth acceptance, predominantly in males in Round 1, and small but significant changes in views of gender equity, predominantly in females in Round 2. The peer facilitator Training (n=9) demonstrated improvements in self-perceived facilitation skills.ConclusionsAlthough results are preliminary, this adapted program shows promise in changing attitudes known to be associated with sexual violence perpetration. Future work will include completing a pilot study to fulfil Step 8 of the model.SignificanceThis is the first study to use the ADAPT-ITT model for a sexual violence intervention. This model holds significant potential to adapt pre-existing evidenced-based interventions in a systematic way for more efficient uptake with new populations and locations.

Several letters to the editor are presented including the Photoshop alternative made by Pixelmator, the system updates in the HackBook laptop, and the mobile game Pokemon Go.

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IntroductionPre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In the Southern United States, where young Black men who have sex with men (YBMSM) have the highest rates of new HIV infection, PrEP uptake remains low. As part of a longitudinal cohort study, YBMSM were offered optional, non-incentivized PrEP as a standard of HIV prevention care service. Among those who declined PrEP, we sought to understand their motivations, as well as their overall perceptions of PrEP as a prevention tool.MethodsThe EleMENt study is an observational HIV/STI incidence cohort of HIV-negative YBMSM aged 18–29 years in Atlanta, Georgia. We conducted 24 in-depth, semi-structured interviews with men who declined optional PrEP offered by the study. Topics included PrEP knowledge, attitudes, and intentions. We employed a phenomenological lens to identify common themes in participant accounts of the decision to forgo PrEP.ResultsParticipants fell into two categories of PrEP refusal: those who indicated no current or future interest (“nevers”) and those ambivalent about taking PrEP, but who had thus far not filled a prescription (“maybes”). YBMSM in both groups expressed mistrust of biomedical interventions, and despite being indicated for PrEP, often perceived themselves as low risk for HIV acquisition. They employed “othering” strategies, in which PrEP was described as appropriate for individuals in serodiscordant partnerships or with many casual partners. They viewed taking a daily pill as a burdensome measure only appropriate for extremely high-risk men (i.e., “the risky Other”). These perceptions were accentuated by instances of family members actively discouraged participants from taking PrEP.ConclusionWe discuss the role of future research exploring low risk estimation among YBMSM as a potential site of resistance to a public health designation of “high risk” amidst historical legacies of medical mistrust in Black communities. Such concerns must be addressed to design effective HIV and PrEP-specific interventions for this population.

The article discusses the use of solar panels as a renewable source of energy in schools and in homes. There has been an increased concern regarding the raising of issues related to environmental education among adults. One way of reinforcing the curricular input, and reaching adults, would be for a community group to publicise and promote specific, local applications of renewable energy to its target audience. That is what the Round Hill Society has taken on in a planned series, of articles following the installation and use of solar water heating kit in a family home in Round Hill. Residents of Round Hill Clive Baldwin and Ros Alder bought their terraced house in 1995, and immediately saw the solar water heating potential offered by the south facing rear roof, so they installed a twin coil hot water tank as part of the refurbishment, giving them the option to fit solar panels at a later date.

Several letters to the editor are presented in response to articles in previous issues including "Everything but the Kitchen Sink," "Canada, In Brief" and "Tracking Corporate Water Impacts."

AbstractBackground:Married young women’s reproductive needs are a challenge in traditional Pakistani society. The decisions regarding family planning and pregnancy are controlled by the family, often involving complex negotiations. The current study was undertaken to explore how young married women’s involvement in the arrangements surrounding their marriage is associated with their ability to negotiate sexual and reproductive health decisions in marriage.Objective:The study explores the associations between young women’s involvement in their marriage arrangements and their ability to negotiate for contraceptive use and fertility decisions.Methodology:A subset of 1,803 married young women aged 15–24 years was drawn from a nationally representative adolescent and youth survey conducted in Pakistan in 2001–2002 by the Population Council. Regression models were fitted to outcomes: reported agreement with spouse on the number of children to have, current use of contraceptives, intention to use contraceptives in the future, and the time elapsed between marriage and first contraceptive use. Key covariates of interest were variables that measure the involvement of young women in their marriage: (a) having a say in selection of spouse, (b) having met him prior to marriage, and (c) whether he was related to respondent’s family. Other factors explored were respondents’ mobility outside of household, social role, and decision making in their homes.Results:Having a say in the selection of a spouse was significantly associated with agreement with spouse over number of children to have, intention to use contraceptives, and the time between marriage and first contraceptive use. These relationships existed after controlling for education, socioeconomic status, mobility outside of house, and decision making in the home.Discussion:Women who had decision-making freedom in their parental home carried this ability with them into marriage in their new home and were better able to negotiate about their fertility.