Newsletter February 2018

15th of February, 2018

EVENTS

Cervical cancer prevention
A cross-sectional study on knowledge and practices of general practitioners at district hospitals towards cervical cancer prevention in Burundi.
Well-organized screening and treatment programmes are effective to prevent Invasive Cervical Cancer (ICC) in LMICs. To achieve this, the World Health Organization (WHO) recommends the involvement of existing health personnel in casu doctors, nurses, midwives in ICC prevention. A necessary precondition is that health personnel have appropriate knowledge about ICC. Therefore, to inform policy makers and training institutions in Burundi, the authors documented the knowledge and practices of general practitioners (GPs) at district hospital level towards ICC control.
A descriptive cross-sectional survey was conducted from February to April, 2015 among all GPs working in government district hospitals. A structured questionnaire and a scoring system were used to assess knowledge and practices of GPs.
The participation rate was 58.2%. Majority of GPs (76.3%) had appropriate knowledge (score > 70%) on cervical cancer disease; but some risk factors were less well known as smoking and the 2 most important oncogenic HPV. Only 8.4% of the participants had appropriate knowledge on ICC prevention: 55% of the participants were aware that HPV vaccination exists and 48.1% knew cryotherapy as a treatment method for CIN. Further, 15.3% was aware of VIA as a screening method. The majority of the participants (87%) never or rarely propose screening tests to their clients. Only 2 participants (1.5%) have already performed VIA/VILI. Wrong thoughts were also reported: 39.7% thought that CIN could be treated with radiotherapy; 3.1% thought that X-ray is a screening method.
The authors conclude that Burundian GPs have a very low knowledge level about ICC prevention, screening and treatment. Suboptimal practices and wrong thoughts related to ICC screening and treatments have also been documented. They therefore recommend an adequate pre- and in-service training of GPs and most probably nurses on ICC control before setting up any public health intervention on ICC control.
Ndizeye, Z., Broeck, D. V., Vermandere, H., Bogers, J. P., & Van Geertruyden, J. P. (2018). Knowledge and practices of general practitioners at district hospitals towards cervical cancer prevention in Burundi, 2015: a cross-sectional study. Globalization and Health, 14(1), 4.?

Contraceptive use in Kenya
Results from a cross-sectional household survey on pattern and determinants of contraceptive usage among women of reproductive age from the Digo community residing in Kwale, Kenya.
Contraceptive usage has been associated with improved maternal and child health (MCH) outcomes. Despite significant resources being allocated to programs, there has been sub-optimal uptake of contraception, especially in the developing world. It is important therefore, to granulate factors that determine uptake and utilization of contraceptive services so as to inform effective programming. A cross-sectional survey was conducted between March and December 2015 among women of reproductive age (WRA) from the Digo community residing in Kwale County, Kenya. The study aimed to describe the pattern and determinants of contraceptive usage in this population. Respondents were selected using stratified, systematic sampling and completed a household sexual and reproductive health (SRH) questionnaire. The researchers interviewed 745 respondents from 15 villages in 2 out of 4 sub-counties of Kwale. Their median (interquartile range, IQR) age was 29 (23-37) years. 568 (76%) reported being currently in a marital union. Among these, 308 (54%) were using a contraceptive method. The total unmet need, unmet need for spacing and for limiting was 16%, 8% and 8%, respectively. Determinants of contraceptive usage were education; having children; having attended antenatal care (ANC) at last delivery as well as intention to stop or delay future birth. The authors conclude that to further improve uptake and utilization of contraception in this setting, programs should address demand-side factors including ensuring female educational attainment as well as promotion of ANC and skilled birth attendance.
Mochache V, Lakhani A, El-Busaidy H, Temmerman M, Gichangi P. Pattern and determinants of contraceptive usage among women of reproductive age from the Digo community residing in Kwale, Kenya: results from a cross-sectional household survey. BMC Womens Health. 2018 Jan 8;18(1):10. doi: 10.1186/s12905-017-0497-5.

'The co-authors of pregnancy’
Leveraging men's sense of responsibility and other factors for male involvement in antenatal services in Kinshasa, DRC.
Despite efforts to improve male involvement, few male partners typically attend antenatal care (ANC). Male involvement in ANC and interventions to prevent mother-to-child HIV transmission have been demonstrated to be beneficial for the HIV-positive mother and her child. This study aimed to explore factors influencing partner attendance and highlight interventions with potential to improve MI within a Congolese context. This was an exploratory, qualitative study conducted in two urban and two semi-urban catchment areas of Kinshasa, DRC in June-September 2016. Two women-only and two men-only focus group discussions (FGDs) were held; participants were recruited from ANC clinics and surrounding communities. Key informants purposively selected from health facility leadership and central government were also interviewed. Guide topics included MI barriers and facilitators, experiences with couples' ANC attendance and perceptions of MI interventions and how to improve them. Data from FGDs and interviews were analysed to determine three interventions that best addressed the identified MI facilitators and barriers. These interventions were explored further through dialogues held with representatives from community organizations. This study included 17 female and 18 male FGD participants, 3 key informants and 21 community dialogue participants. Receipt of clinic staff advice was the most commonly-reported factor facilitating male attendance. No time off work was the most commonly-reported barrier. Only men identified responsibility, referring to themselves as "authors of the pregnancy," and wanting to be tested for HIV as facilitators. The most promising interventions perceived by FGD and interview participants were male partner invitation letters, couple- and male-friendly improvements to ANC, and expert peer-to-peer outreach. Community dialogue participants provided further detail on these approaches, such as invitation letter content and counseling messages targeting men attending ANC.
Common themes regarding male involvement in ANC that emerged from this study included men's need to understand how the pregnancy is progressing and how best to care for their female partners and unborn children, and ANC settings that were misaligned to the needs of men and couples. Interventions at the individual, facility and community levels were discussed that could result in improvements to male attendance at pregnancy-related services.
Gill MM, Ditekemena J, Loando A, Ilunga V, Temmerman M, Fwamba F. ‘The co-authors of pregnancy’: leveraging men's sense of responsibility and other factors for male involvement in antenatal services in Kinshasa, DRC. BMC Pregnancy Childbirth. 2017 Dec 6;17(1):409. doi: 10.1186/s12884-017-1587-y.

Improving health and reducing poverty
Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition.
The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.
Jamison DT et al. Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition. Lancet. 2017 Nov 24. pii: S0140-6736(17)32906-9. doi: 10.1016/S0140-6736(17)32906-9. [Epub ahead of print] Review.

Medical abortion
Access to essential medicines for medical abortion as a core obligation.
WHO has a pivotal role to play as the leading international agency promoting good practices in health and human rights. In 2005, mifepristone and misoprostol were added to WHO’s Model List of Essential Medicines for combined use to terminate unwanted pregnancies. However, these drugs were considered ‘complementary’ and qualified for use when in line with national legislation and where ‘culturally acceptable’.
This article argues that these qualifications, while perhaps appropriate at the time, must now be removed. First, compelling medical evidence justifies their reclassification as a ‘core’ essential medicine. Second, continuing to subjugate essential medicines for medical abortion to domestic law and cultural practices is incoherent with today’s human rights standards in which universal access to these medicines is an inextricable part of the right to sexual and reproductive health, which should be supported and realised through domestic legislation.
This article shows that removing such limitations will align WHO’s Model List of Essential Medicines with the mounting scientific evidence, human rights standards, and its own more recently developed policy guidance. This measure will send a strong normative message to governments that these medicines should be readily available in a functioning and human-rights-abiding health system.
Katrina Perehudoff, Lucía Berro Pizzarossa and Jelle Stekelenburg. Realising the right to sexual and reproductive health: access to essential medicines for medical abortion as a core obligation. BMC International Health and Human Rights 2018. https://doi.org/10.1186/s12914-018-0140-z

HIV testing of MSM in Myanmar
A cross-sectional study on factors associated with HIV testing among young men who have sex with men in Myanmar.
In Myanmar, men who have sex with men (MSM) experience high risk of HIV infection. However, access to HIV testing and prevention services remains a challenge among this marginalized population. The objective of this study was to estimate population prevalence and correlates of prior HIV testing among young MSM (YMSM) and informs the development of HIV testing and intervention programmes that respond to the specific needs of this population.
Five hundred and eighty-five YMSM aged 18 to 24 years were recruited using respondent-driven sampling (RDS) in a cross-sectional survey conducted in six townships of Myanmar. RDS-adjusted population estimates were calculated to estimate prevalence of HIV testing; RDS-weighted logistic regression was used to examine correlates of HIV testing in the past 6 months and in a lifetime. There were 12 participants who reported receiving a HIV-positive test; of those, five were tested in the past 6 months. The RDS-weighted prevalence estimates of lifetime (any prior) HIV testing was 60.6% and of recent (≤ 6 months) HIV testing was 50.1%. In multivariable analysis, sexual identity was associated with lifetime but not recent HIV testing. Lifetime and recent HIV testing were associated with having three or more male sexual partners in the past 12 months, having good HIV-related knowledge, reporting high HIV testing self-efficacy and having access to and use of non-HIV health-related services in the past 12 months respectively.
The authors conclude that HIV testing coverage among YMSM aged 18 to 24 years old in Myanmar is still suboptimal. Integrated HIV testing and prevention services in existing health service provision systems with tailored HIV information and education programmes targeting YMSM to improve HIV-related knowledge and self-efficacy may help to promote regular HIV testing behaviour and contribute to sustainable control of the HIV epidemic among this marginalized population in Myanmar.
Pham MD, Aung PP, Paing AK, Pasricha N, Agius PA, Tun W, Bajracharya A, Luchters S. Factors associated with HIV testing among young men who have sex with men in Myanmar: a cross-sectional study. Journal of the International AIDS Society. 2017 Nov;20(3).

SRHR and drugs
A qualitative study on sexual and reproductive health of women who use drugs in Delhi, India.
This study aimed to explore contextual factors that increase vulnerabilities to negative sexual and reproductive health (SRH) outcomes and possible differences in SRH-related behaviours and the needs of women who use drugs (WUD) through non-injecting and injecting routes. Semi-structured in-depth interviews were conducted with twenty women who injected drugs in the past 3 months and 28 women who reported using drugs through non-injecting routes in the past 1 month.
Study findings illustrate that WUD were sexually active and had multiple sex partners including clients of sex work. Transient relationships were reported and many participants engaged in unsafe sex. Factors which affected safe sex behaviours included: gender power imbalance, limited agency for decision-making, lack of accurate information for correct self-risk assessment, and being under the influence of drugs. Despite high awareness, low and inconsistent contraceptive use was reported. Some participants were coerced to conceive while a few others reported their inability to conceive. Violence was a key determinant for SRH outcomes. Perception of certain adverse health outcomes (such as infertility) to be 'common and expected among WUD' influenced access to healthcare. Further, healthcare providers' stigmatising attitudes and lack of women-centric services deterred women from uptake of healthcare services.
Findings highlight that SRH-related behaviours and needs of this group are a complex interplay of multiple determinants which need to be addressed at all levels: individual, family, community and institutional. It is imperative to roll out a 'one-stop-shop' for a comprehensive package of health services. Expansion of existing drop-in-centres could be considered for setting-up community-based women-centric services with appropriate linkage to drug dependence treatment and reproductive health services.
Sharma V, Sarna A, Tun W, Saraswati LR, Thior I, Madan I, Luchters S. Women and substance use: a qualitative study on sexual and reproductive health of women who use drugs in Delhi, India. BMJ Open. 2017 Nov 19;7(11);7:e018530

Twin pregnancy
Findings from 60 low- and middle-income countries on early neonatal mortality in twin pregnancy.
Around the world, the incidence of multiple pregnancies reaches its peak in the Central African countries and often represents an increased risk of death for women and children because of higher rates of obstetrical complications and poor management skills in those countries. The authors sought to assess the association between twins and early neonatal mortality compared with singleton pregnancies. They also assessed the role of skilled birth attendant and mode of delivery on early neonatal mortality in twin pregnancies.
A secondary analysis was conducted of individual level data from 60 nationally-representative Demographic and Health Surveys including 521 867 singleton and 14 312 twin births. The occurrence of deaths was investigated within the first week of life in twins compared to singletons and the effect of place and attendance at birth; also, the role of caesarean sections against vaginal births was examined, globally and after countries stratification per caesarean sections rates. A multi-level logistic regression was used accounting for homogeneity within country, and homogeneity within twin pairs.
Early neonatal mortality among twins was significantly higher when compared to singleton neonates in these 60 countries. Early neonatal mortality was also higher among twins than singletons when adjusting for birth weight in a subgroup analysis of those countries with data on birth weight (n = 20; less than 20% of missing values). For countries with high rates (>15%) of caesarean sections (CS), twins delivered vaginally in health facility had a statistically significant increased risk of early neonatal mortality compared to twins delivered through caesarean sections. Home twin births without SBA was associated with increased mortality compared with delivering at home with SBA and with vaginal birth in health facility.
The authors conclude that institutional deliveries and increased access of caesarean sections may be considered for twin pregnancies in low- and middle- income countries to decrease early adverse neonatal outcomes. Bellizzi S, Sobel H, Betran AP, Temmerman M. Early neonatal mortality in twin pregnancy: Findings from 60 low- and middle-income countries. J Glob Health. 2018 Jun;8(1):010404. doi: 10.7189/jogh.08.010404.

Violence and sexual orientation
A systematic review on violence motivated by perception of sexual orientation and gender identity.
The review aimed to assess the prevalence of physical and sexual violence motivated by perception of sexual orientation and gender identity in sexual and gender minorities.
Nine databases without language restrictions were searched for peer-reviewed and grey literature published from 2000 to April 2016. Studies with more than 50 participants that measured the prevalence of physical and sexual violence perceived as being motivated by sexual orientation and gender identity or gender expression were included. Intimate partner violence and self-harm were excluded. Due to heterogeneity and the absence of confidence intervals in most studies, no meta-analysis was made.
76 articles from 50 countries were included. These covered 74 studies conducted between 1995 and 2014, including a total of 202 607 sexual and gender minority participants. The quality of data was relatively poor due to a lack of standardized measures and sometimes small and non-randomized samples. In studies where all sexual and gender minorities were analysed as one population, the prevalence of physical and sexual violence ranged from 6% (in a study including 240 people) to 25% (49/196 people) and 5.6% (28/504) to 11.4% (55/484), respectively. For transgender people the prevalence ranged from 11.8% (of a subsample of 34 people) to 68.2% (75/110) and 7.0% (in a study including 255 people) to 49.1% (54/110).
The authors conclude that more data are needed on the prevalence, risk factors and consequences of physical and sexual violence motivated by sexual orientation and gender identity in different geographical and cultural settings. National violence prevention policies and interventions should include sexual and gender minorities.
Blondeel K, de Vasconcelos S, García-Moreno C, Stephenson R, Temmerman M, Toskin I. Violence motivated by perception of sexual orientation and gender identity: a systematic review. Bull World Health Organ. 2018 Jan 1;96(1):29-41L. doi: 10.2471/BLT.17.197251. Epub 2017 Nov 23. Review.

Countdown to 2030
Tracking progress towards universal coverage for reproductive, maternal, newborn, and child health.
Building upon the successes of Countdown to 2015, Countdown to 2030 aims to support the monitoring and measurement of women's, children's, and adolescents' health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Such accelerations are only possible with a rapid scale-up of effective interventions to all population groups within countries (particularly in countries with the highest mortality and in those affected by conflict), supported by improvements in underlying socioeconomic conditions, including women's empowerment. Three main conclusions emerge from an analysis of intervention coverage, equity, and drivers of reproductive, maternal, newborn, and child health (RMNCH) in the 81 Countdown countries. First, even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes. Second, within-country inequalities in intervention coverage are reducing in most countries (and are now almost non-existent in a few countries), but the pace is too slow. Third, health-sector (eg, weak country health systems) and non-health-sector drivers (eg, conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision making and accountability. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.
Boerma T, Requejo J, Victora CG, Amouzou A, George A, Agyepong I, Barroso C, Barros AJD, Bhutta ZA, Black RE, Borghi J, Buse K, Aguirre LC, Chopra M, Chou D, Chu Y, Claeson M, Daelmans B, Davis A, DeJong J, Diaz T, El Arifeen S, Ewerling F, Fox M, Gillespie S, Grove J, Guenther T, Haakenstad A, Hosseinpoor AR, Hounton S, Huicho L, Jacobs T, Jiwani S, Keita Y, Khosla R, Kruk ME, Kuo T, Kyobutungi C, Langer A, Lawn JE, Leslie H, Liang M, Maliqi B, Manu A, Masanja H, Marchant T, Menon P, Moran AC, Mujica OJ, Nambiar D, Ohiri K, Park LA, Patton GC, Peterson S, Piwoz E, Rasanathan K, Raj A, Ronsmans C, Saad-Haddad G, Sabin ML, Sanders D, Sawyer SM, da Silva ICM, Singh NS, Somers K, Spiegel P, Tappis H, Temmerman M, Vaz LME, Ved RR, Vidaletti LP, Waiswa P, Wehrmeister FC, Weiss W, You D, Zaidi S.Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Countdown to 2030 Collaboration. Lancet. 2018 Jan 30. pii: S0140-6736(18)30104-1. doi: 10.1016/S0140-6736(18)30104-1. [Epub ahead of print] Review.