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BackgroundCultural safety encourages practitioners to examine how their own culture shapes their clinical practice and to respect their patients’ worldviews. Lack of cultural safety in health care is linked to stigma and discrimination toward culturally diverse patients. Training in cultural safety poses considerable challenges. It is an unappealing subject for medical students and requires behavioral changes in their clinical practice. Game jams—collaborative workshops to create and play games—have recently shown effectiveness and engaging potential in university-level education. ObjectiveThe trial aims to determine if medical students’ participation in a game jam to design an educational game on cultural safety is more effective than a standard lesson on cultural safety in terms of change in the students’ self-reported intended patient-oriented behavior. MethodsA parallel-group, 2-arm randomized controlled trial with a 1:1 allocation ratio will randomize 340 medical students and 60 medical interns (n=400) at the Faculty of Medicine at La Sabana University, Colombia (170 students and 30 medical interns to each arm). The intervention group will participate in an 8-hour game jam comprising (1) a preliminary lecture on cultural safety and game design, (2) a game building session where groups of students will create educational games about cultural safety, and (3) a play-test session in which students will play and learn from each other’s games. The control group will receive a standard lesson, including a 2-hour lecture on cultural safety, followed by a 6-hour workshop to create posters about cultural safety. Web-based self-administered 30-item Likert-type questionnaires will assess cultural safety self-reported intended behavior before, immediately after, and 6 months after the intervention. An intention-to-treat approach will use a t-test with 95% CIs to determine the significance of the effect of the intervention, including within- and between-group comparisons. The qualitative most significant change technique will explore the impact of the intervention on the clinical experience of the students. ResultsStudy enrollment began in July 2019. A total of 531 students completed the baseline survey and were randomized. Data collection is expected to be complete by July 2020, and results are expected in October 2020. The study was approved by the institutional review board of the Faculty of Medicine at McGill University (May 31, 2017) and by the Subcommittee for Research of the Faculty of Medicine at La Sabana University (approval number 445). ConclusionsThe research will develop participatory methods in game-based learning co-design that might be relevant to other subjects. Ultimately, it should foster improved cultural safety skills for medical students, improve the quality of health services for diverse cultural groups, and contribute to enhanced population health. Game learning may provide an innovative solution to a long-standing and neglected problem in medical education, helping to meet the educational expectations and needs of millennial medical students. Trial RegistrationISRCTN Registry ISRCTN14261595; http://www.controlled-trials.com/ISRCTN14261595

A recurring issue in intercultural research is whose knowledge informs conceptualization and design of projects or interventions. Fuzzy cognitive mapping uses arrows and weights to represent stakeholder knowledge on causal relationships and can generate composite theories to inform research and action. Cognitive mapping is accessible across different cultures, but participant weighting is not always straightforward. We describe a procedure to combine and condense maps from different stakeholders and an alternative operator-independent weighting procedure adapted from Harris's discourse analysis.

Dengue vector entomological indices are widely used to monitor vector density and disease control activities. But the value of these indices as predictors of dengue infection is not established. We used data from the impact assessment of a trial of community mobilization for dengue prevention (Camino Verde) to examine the associations between vector indices and evidence of dengue infection and their value for predicting dengue infection levels. In 150 clusters in Mexico and Nicaragua, two entomological surveys, three months apart, allowed calculation of the mean Container Index, Breteau index, Pupae per Household Index, and Pupae per Container Index across the two surveys. We measured recent dengue virus infection in children, indicated by a doubling of dengue antibodies in paired saliva samples over the three-month period. We examined the associations between each of the vector indices and evidence of dengue infection at household level and at cluster level, accounting for trial intervention status. To examine the predictive value for dengue infection, we constructed receiver operating characteristic (ROC) curves at household and cluster level, considering the four vector indices as continuous variables, and calculated the positive and negative likelihood ratios for different levels of the indices. None of the vector indices was associated with recent dengue infection at household level. The Breteau Index was associated with recent infection at cluster level (Odds ratio 1.36, 95% confidence interval 1.14-1.61). The ROC curve confirmed the weak predictive value for dengue infection of the Breteau Index at cluster level. Other indices showed no predictive value. Conventional vector indices were not useful in predicting dengue infection in Mexico and Nicaragua. The findings are compatible with the idea of sources of infection outside the household which were tackled by community action in the Camino Verde trial.

In Bauchi State, northern Nigeria, communities recognise short birth interval (kunika in the Hausa language) as harmful, but family planning is a sensitive topic. This paper describes the development of a culturally safe way to communicate about kunika in a conservative Muslim setting. The objective was to co-design culturally safe communication material, based on local knowledge about short birth interval, to share with women and men in households. Six community co-design groups of women and six of men (total 96 participants) reviewed summaries of their previously created maps of perceived local causes of kunika, categorised as frequent sex, family dynamics and non-use of contraception. They advised how these causes could be discussed effectively and acceptably with women and their husbands in households and suggested storylines for three short video docudramas about the prevention of kunika. The research team created the docudramas with a local producer and fieldworkers piloted their use in households. The design groups advised that communication materials should focus on child spacing rather than on limitation of family size. Even sensitive issues could be covered. People would not change their sexual behaviour but could be advised to use contraceptives to prevent kunika. The groups approved the final videos and six focus groups of visited women and men reported they were acceptable and helpful. Community co-design of communication about kunika was feasible and led to videos about a sensitive topic that were acceptable to ordinary men and women in communities in Bauchi. [ABSTRACT FROM AUTHOR]

Introduction: Socialprotection programmes are considered HIV-sensitive when addressing risk, vulnerability or impact of HIV infection. Socio-economic interventions, like livelihood and employability programmes, address HIV vulnerabilities like poverty and gender inequality. We explored the HIV-sensitivity of socio-economic interventions for unemployed and out-of-school young women aged 15 to 30 years, in Fast and Southern Africa, a key population for HIV infection. Methods: We conducted a systematic review using a narrative synthesis method and the Mixed Methods AppraisalTool for quality appraisal. Interventions of interest were work skills training, microfinance, and employment support. Outcomes of interest were socio-economic outcomes (income, assets, savings, skills, (self-) employment) and HIV-related outcomes (behaviouraland biological). We searched published and grey literature (January 2005 to November 2019; English/French) in MFDLINF, Scopus, Web of Science and websites of relevant internationalorganizations. Results: We screened 3870 titles and abstracts and 188 full-text papers to retain 18 papers, representing 12 projects. Projects offered different combinations of HIV-sensitive socialprotection programmes, complemented with mentors, safe space and training (HIV, reproductive health and gender training). All 12 projects offered work skills training to improve life and business skills. Six offered formal(n = 2) or informal(n = 5) livelihood training. Fleven projects offered microfinance, including microgrants (n = 7), microcredit (n = 6) and savings (n = 4). One project offered employment support in the form of apprenticeships. In general, microgrants, savings, business and life skills contributed improved socio-economic and HIV-related outcomes. Most livelihood training contributed positive socio-economic outcomes, but only two projects showed improved HIV-related outcomes. Microcredit contributed little to either outcome. Programmes were effective when (i) sensitive to beneficiaries' age, needs, interests and economic vulnerability; (ii) adapted to local-implementation contexts; and (iii) included life skills. Programme delivery through mentorship and safe space increased social capital and may be critical to improve the HIV-sensitivity of socio-economic programmes. Conclusions: A wide variety of livelihood and employability programmes were leveraged to achieve improved socio-economic and HIV-related outcomes among unemployed and out-of-school young women. To be HIV-sensitive, programmes should be designed around their interests, needs and vulnerability, adapted to local implementation contexts, and include life skills. Fmployment support received little attention in this literature. Keywords: adolescent girls and young women; Africa region; HIV prevention; social support; structural drivers; structural interventions, 1 | INTRODUCTION In 2018, East and Southern Africa represented nearly one half of global human immunodeficiency virus (HIV) incident cases [1]. Adolescent girls and young women (AGYW) aged 15 [...]

Background: Socio-economically disadvantaged women have poor maternal health outcomes. Maternal health interventions often fail to reach those who need them most and may exacerbate inequalities. In Bauchi State, Nigeria, a recent cluster randomised controlled trial (CRCT) showed an impressive impact on maternal health outcomes of universal home visits to pregnant women and their spouses. The home visitors shared evidence about local risk factors actionable by households themselves and the program included specific efforts to ensure all households in the intervention areas received visits. Purpose: To examine equity of the intervention implementation and its pro-equity impact. Research design and study sample: The overall study was a CRCT in a stepped wedge design, examining outcomes among 15,912 pregnant women. Analysis: We examined coverage of the home visits (three or more visits) and their impact on maternal health outcomes according to equity factors at community, household, and individual levels. Results: Disadvantaged pregnant women (living in rural communities, from the poorest households, and without education) were as likely as those less disadvantaged to receive three or more visits. Improvements in maternal knowledge of danger signs and spousal communication, and reductions in heavy work, pregnancy complications, and post-natal sepsis were significantly greater among disadvantaged women according to the same equity factors. Conclusions: The universal home visits had equitable coverage, reaching all pregnant women, including those who do not access facility-based services, and had an important pro-equity impact on maternal health. [ABSTRACT FROM AUTHOR]

A 2017 randomised controlled trial in Guerrero State, Mexico, showed supporting Indigenous traditional midwives on their own terms improved traditional childbirths without inferior maternal health outcomes. This narrative evaluation complements the trial to document participant experience of safer birth in cultural safety, transformative dynamics and implementation issues of the intervention. Stories came from 26 traditional midwives, 28 apprentices, 12 intercultural brokers and 20 Indigenous women who experienced the intervention. Their accounts indicate the intervention revitalised traditional midwifery and consolidated local skills through traditional midwife apprentices and intercultural brokers to support safe birth. According to the stories, communities reintroduced traditional perinatal care and reported positive health impacts for mothers, children, and other adults, which contributed to early collaboration with official health services. Challenges included remuneration and disinterest of younger apprentices and brokers. The intervention seems to have improved interaction between traditional and Western services, setting the stage for further intercultural dialogue. [ABSTRACT FROM AUTHOR]

Violence against young women (VAW) and suicide among young men are serious concerns in Botswana and elsewhere. We examined the overlap in locally perceived causes of these two forms of violence in Botswana using the results from separate studies that used fuzzy cognitive mapping (FCM) to explore perceived causes of the two outcomes. FCM depicts perceived causes of an outcome and their links to the outcome and each other, with weights denoting the perceived strength of each link. The two studies engaged groups of young women, young men, older women, and older men in rural communities. We grouped related concepts into broader categories, then combined category maps for each outcome into a single map including both forms of violence. Based on social network analysis, we calculated the out-degree centrality of each category indicating its influence within the network. Intervention soft-modelling explored the effects of removing individual categories on suicide and VAW. Of 24 causal categories in the combined map, six were shared between both outcomes, 10 were for suicide only, and seven were for VAW only. The six shared categories accounted for 60% of cumulative influence of all categories in the combined map. The three most influential shared categories were financial difficulties, conflict in relationships, and parenting and family issues. Based on local perceptions, avoiding conflict in relationships could reduce suicide by 4.8% and VAW by 18.5%. Eliminating parenting and family issues could reduce suicide by 3% and VAW by 5.4%. Preventing financial difficulties could reduce suicide by 9.3% and VAW by 2.9%. The findings support the idea that some interventions might reduce both personal and interpersonal violence among youth. Analysis of stakeholder perceived causes and soft-modelling of potential interventions could inform community-led co-design of strategies to reduce youth suicide and violence against young women in Botswana. [ABSTRACT FROM AUTHOR]

Suicide is common in Botswana, particularly among young men. Fuzzy cognitive mapping (FCM) can support participatory research by depicting local stakeholder knowledge about causes of health outcomes. This study used FCM to explore local perceptions about causes of suicide among young men in rural communities close to the capital, Gaborone. In nine sessions, groups of young men, young women, older men, and older women separately mapped their knowledge of factors related to suicide among young men (46 people in total). Two trained facilitators, fluent in the local language, led the group sessions. The maps depicted risk and protective factors as nodes connected by arrows to show causal relationships. Participants also ranked the strength of each link on a scale of one (weakest) to five (strongest). Fuzzy transitive closure calculated the maximum influence of each factor, taking into account all other influences on the map. We combined maps by different stakeholders and grouped the 130 unique factors across the maps into 17 broader categories which emerged from an inductive thematic analysis of all the node labels. Financial difficulties, relationship problems, and family issues were the strongest categories of perceived causes of suicide by young men. Mental health problems played an intermediary role between more distal causes and suicide. There were differences in maps of different gender and age groups, but the strongest influences were consistent across groups. Young women, but not young men, identified men's lack of self-esteem as a strong cause of suicide. The FCM findings offer a starting point for community discussions to seek local solutions to youth suicide. [ABSTRACT FROM AUTHOR]

Violence against young women is a problem worldwide. Understanding its causes in a particular setting can inform context-specific interventions. We used Fuzzy cognitive mapping (FCM), a visual method for collating local knowledge about causes of health outcomes, to explore community views of factors that cause or prevent violence against young women in rural communities in southeast Botswana. In three communities, groups of young men, young women, older men, and older women built maps (68 participants and 12 maps in total) of factors they believed increased or decreased the risk of violence against young women. Trained local facilitators guided group sessions, drawing the reported factors as nodes linked by weighted arrows indicating the direction and strength of causal relationships among factors. Fuzzy transitive closure calculated the influence of each factor on others, considering direct and indirect connections. We combined maps by groups of stakeholders and condensed individual factors into categories which emerged from an inductive thematic analysis. The categories labelled conflict in relationships and parenting and family issues had the strongest influences on increasing violence across all maps. These categories were also common intermediaries between other causal categories and violence. The categories labelled women being disrespectful or uncooperative and transactional and intergenerational sex were the third and fourth strongest risk categories overall. Prominent protective concepts included a stronger legal framework and strengthening the role of local traditional leadership, with greater prominence on the maps of older participants. The most influential risk and protective categories were consistent across young men, young women, older men, and older women. FCM was feasible and acceptable with different stakeholders in Botswana. Fuzzy cognitive maps can inform community discussions, for example, of conflictive gender norms, family dynamics or healthier relationships, and are useful to build theories on how to act on the causes of violence against young women. [ABSTRACT FROM AUTHOR]

Background: Transferring pregnant women out of their communities for childbirth continues to affect Inuit women living in Nunavik—Inuit territory in Northern Quebec. With estimates of maternal evacuation rates in the region between 14% and 33%, we examine how to support culturally safe birth for Inuit families when birth must take place away from home. Methods: A participatory research approach explored perceptions of Inuit families and their perinatal healthcare providers in Montreal for culturally safe birth, or "birth in a good way" in the context of evacuation, using fuzzy cognitive mapping. We used thematic analysis, fuzzy transitive closure, and an application of Harris' discourse analysis to analyze the maps and synthesize the findings into policy and practice recommendations. Results: Eighteen maps authored by 8 Inuit and 24 service providers in Montreal generated 17 recommendations related to culturally safe birth in the context of evacuation. Family presence, financial assistance, patient and family engagement, and staff training featured prominently in participant visions. Participants also highlighted the need for culturally adapted services, with provision of traditional foods and the presence of Inuit perinatal care providers. Stakeholder engagement in the research resulted in dissemination of the findings to Inuit national organizations and implementation of several immediate improvements in the cultural safety of flyout births to Montreal. Conclusions: The findings point toward the need for culturally adapted, family‐centered, and Inuit‐led services to support birth that is as culturally safe as possible when evacuation is indicated. Application of these recommendations has the potential to benefit Inuit maternal, infant, and family wellness. [ABSTRACT FROM AUTHOR]