Newsletter January 2013

ICRH Research Internship Programme

ICRH offers research internship opportunities to postgraduates considering a career in repro­ductive health research.

The programme aims at exposing junior researchers to the various aspects of research with a focus on themes such as sexually transmitted infections, maternal and child health, sexual violence and family planning. The programme starts with a 4-6 months internship at the ICRH-Ghent o?ce, located at the Faculty of Medicine and Health Sciences of Ghent University. Following the internship at ICRH-Ghent, the intern will have the opportunity to experience the implementation of ?eld research in one of ICRH’s sister-organizations in Kenya (ICRH-K) or Mozambique (ICRH-M). The stay in Kenya or Mozambique will last for 6 to 8 months.

More information:  http://www.icrh.org/news/icrh-research-internship-programme

PROJECTS

Revamping family planning amongst female sex workers in Kenya

ICRH Kenya in collaboration with UNFPA is implementing a project addressing the sexual and reproductive health needs and promoting behaviour change among FSW in the Kilifi district.

The number of self-identified female sex workers (FSW) in Kilifi is estimated at 7,346, the majority (75%) of them operating within Mtwapa town. FSW are faced with various challenges including Sexual and gender based violence, unplanned pregnancies, stigma and discrimination.

Kenya re-launched the Family Planning (FP) Campaign in February 2012 and this was an opportunity to reach FSWs in Kilifi with innovative methods. ICRH Kenya  partnered with the Minitry of Health and carried out a family planning training for 70 FSW peer educators. After the training with the help of the District Reproductive Health Nurse, 23 (33%) peer educators were identified as being competent to distribute pills to their fellow FSW in the community.

A massive FP outreach was then conducted in Mtwapa and Kilifi town targeting FSW and using the peer educators identified above together with clinical officers  to sensitise, educate and distribute FP methods. These outreaches were very successful. 548 females received pills from the FSW peer educators. The clinical officers were able to provide deprovera to 135 females while referring 15 for implants, 7 for IUCDs and 2 for tubal ligation. The results show that only 10% of the estimated population was reached within two days. The use of FSW as community distributors is innovative and has the potential to successfully reach more FSW with this vital service and reduce the number of unplanned pregnancies amongst this group.Sustainabillity is also ensured as the MOH officials are involved in the provision of FP commodities and monitoring their distribution.

More information: janet.musimbi@icrk.org

MOMI project in Kenya

The year 2012 saw a bustle of activities for the missed opportunities in maternal and infant health (MOMI) project in Kwale District, Kenya.

This five year project which began in 2011 is aimed at improving postpartum care one year after delivery. It is currently being implemented in four African countries namely Burkina Faso, Mozambique, Kenya and Malawi.

The year began with the collection of baseline data looking at community and facility capacity, current key maternal and child health indicators plus analysis of maternal, newborn and child health policies on postpartum care. Results from this activity showed that while national policy on postpartum care in Kenya was comprehensively addressed, implementation at facility level in Kwale district was a challenge. Data from health facilities showed that only 32.7% of women accessed care compared to 71.7% of newborns receiving immunization against tuberculosis (BCG). The baseline results from the four countries were shared during the Integration for Impact Conference 2012 held in Nairobi, Kenya.

The highlight of activities for the project was the formation of the policy advisory board (PAB) whose primary function is to bridge the gap between research and policy. In Kwale district members include provincial directors for the health ministries, the District Medical Officer of Health, partners and community representatives. We have managed to conduct two meetings this year where members discussed the board’s terms of reference, baseline results and proposed interventions for the next phase of the project.

The focus for 2013 will be the implementation of interventions which will run for the next two years. This will be followed by evaluation and cross country analysis of the interventions before closing the research in February 2016.

More information: Christine.katingima@icrhk.org

Reducing HIV/STI risk for female sex workers and men who have sex with men in Coast Province

ICRH Kenya in partnership with the Ministry of Health and with support from APHIA PLUS is implementing a program aimed at contributing to increased access to Reproductive health services among female sex workers (FSW) and men who have sex with men (MSM) in Coast province.

The interventions are implemented in line with National guidelines for HIV/STI programs for MARPs groups focusing on behavioural component, biomedical component and structural component.

The biomedical interventions are primarily implemented through drop-in service centres (DISCs) and through moonlight outreaches. The services provided to the sub population at the DISCs and outreaches included HIV testing and counselling, sexually transmitted infections screening and treatment and family planning. Referrals are done for reproductive health services not provided within the program to Ministry of Health facilities and other stake holders in the community. The behavioural component focuses on peer education sessions, risk assessment and risk reduction counselling as well as alcohol and drug reduction counselling. Peer education sessions are carried out by peer educators who have been grouped into eight FSW sites and three MSM sites. The structural component entails condom and lubricant promotion and distribution. This involves distribution of both male and female condoms during peer education sessions and to the target population hotspots.

In 2012, cervical cancer screening (CCS) was also introduced to the FSW DISCs and there has been an increase in uptake of the service over the months.  For sustainability purposes, the peer education groups were encouraged to register as community based organizations (CBOs). Some of these CBOs have been able to solicit funds to carry out activities in the community like creating awareness on the importance of CCS amongst their peers. Others have started income generating projects such as making soap and hair shampoo for sale. There was also an additional strategy for condom distribution which involved providing male and female condoms at night to FSW who are mainly street based. The condoms were distributed along the streets close to FSW hotspots with the aim of promoting safe sex practices and ensuring consistent supply of condoms to the street based FSW.

More information: Jackline@icrhk.org and janet@icrhk.org

ICRH Mozambique assesses determinants for access and use of maternity waiting homes 

With a rate of 408/100.000 live births, maternal mortality continues being one of the major public health concerns in Mozambique. Despite improved access to health services in general, coverage and access to obstetric care does still not to cover the need.

Preliminary data from the Demographic and Health Survey (DHS 2011) show that the antenatal care by a health professional increased from 85% in 2003 to 91% in 2011. The coverage of institutional deliveries increased from 48% in 2003 (81% in urban areas and 34% in rural areas) to 54% in 2011 (80% in urban areas and 44% in rural area).

In 2003, of the births that occur at home, only 11% were assisted by trained traditional midwives, 41% were aided by another type of untrained professional, and the rest were unaided or/took place alone.  Uterine rupture, hemorrhage during and after delivery, puerperal sepsis and eclampsia represent 75% of the direct causes of maternal mortality in the country. Difficulties in access to obstetric care contributes indirectly to maternal deaths. The theoretical ratio of action of a health unity is 16 km, but in rural area distances to reach the nearest health unit can be more than 30 km and it can take pregnant women several days of walking.

In order to reduce and/or eliminate barriers for access to obstetric care and improve the institutional deliveries, particularly in rural area, in 2009 the MOH approved the Strategy for having waiting homes for pregnant women at all health units with maternities.

The Strategy aims to reduce maternal and child morbidity and mortality by improving access to diagnosis and treatment of obstetric complications. This presupposes the extension and accreditation of a greater number of health facilities able to offer Emergency Obstetric Care (EOC), whether Basic (BEOC) or Complete (CEOC), as well as a good communication and referral system, including transport between health posts, health centers and hospitals. Since the adoption of this strategy, little has been documented in the country about the challenges, success factors and impact of its implementation.

ICRH Mozambique in collaboration with the Ministry of Health and financially supported by UNFPA is conducting a qualitative study in Inhambane, Tete and Cabo Delgado provinces to assess the determinants for access and use of the waiting homes. It includes interviews with women staying at waiting homes, exit interviews with women at antenatal consultation, health professionals in charge of waiting homes, community group discussions with women and community leaders. Data have been collected in Inhambane.  The study will generate information that can be useful to better guide the implementation process of the strategy in other parts of the country.

More information: Gilda Gondola,  icrh.research@tdm.co.mz

Subscript photo: Gilda conducting community focus group with women
Photo taken by Sérgio Uqueio

 ICRH PEOPLE

Gorik Ooms

From January on, Gorik Ooms works part-time at ICRH as Hélène De Beir Research Fellow.

Gorik graduated as lawyer from the University of Leuven in 1989 and started working with Doctors Without Borders in 1990. From August 2004 until May 2008 he was the Executive Director of Doctors Without Borders in Belgium. In March 2008, promoted by Prof. Marleen Temmerman, Gorik obtained his doctoral degree in Medical Sciences from the University of Ghent for his thesis on the subject: “The right to health and the sustainability of healthcare: Why a new global health aid paradigm is needed.” He joined the Department of Public Health at the Institute of Tropical Medicine, then was appointed as Global Justice Fellow at the Whitney and Betty MacMillan Center for International and Area Studies at Yale, Visiting Professor at the Yale School of Public Health for the 2009-2010 academic year, and Adjunct Professor at Georgetown Law since 2010.

At ICRH, Gorik will focus on on research in the field of (among others) improving access to sexual and reproductive health services and emergency obstetrics care.

More information: Gorik.ooms@ugent.be

Inge Tency

After having worked almost 10 years for Ghent University, Inge left ICRH to take up a job as lecturer in a midwifery school.

Inge, midwife and master in medical social sciences, has been working at the faculty of Medicine since 2003 and joined the department of Obstetrics and Gynaecology in 2005 as scientific staff member. Her PhD research was related to infection and preterm birth. In January 2013, she started working as lecturer in a midwifery school, KAHO Sint Lieven (Sint-Niklaas, Belgium).

PUBLICATIONS

MOMI findings published in the Lancet

MOMI stands for Missed Opportunities in Maternal and Infant Health, and is an ICRH coordinated project that aims at reducing maternal and new-born mortality and morbidity in the year after childbirth through combined facility- and community-based interventions.

Within the context of the World Health Summit in October 2012 the Lancet issued a call for abstracts under the title "New Voices in Global Health", with a view to report important research, policy, and advocacy initiatives in global health. In total 169 abstracts were submitted from 46 countries in six continents. Through a peer review and selection process, eight abstracts were chosen for oral presentation and 12 for poster presentation at the Summit. The abstract submitted by the MOMI consortium was one of them. The abstract reflects on the main findings from a comparative policy review on postpartum care in four African countries (Burkina Faso, Kenya, Malawi and Mozambique) and how we can learn - among others - from policy implementation failures at district and service delivery levels in order to design effective and sustainable interventions to improve postpartum care in the four districts of the MOMI project. The list of context-specific interventions is about to be defined and the interventions will be set up soon. The abstract can be found here:

http://www.momiproject.eu/media/8134/whs_berlin_october_2012_sue_mann_et_al.pdf

Female sex workers in South Africa

A cross-sectional survey on Migration Status, Work Conditions and Health Utilization of Female Sex Workers in Three South African Cities.

Intersections between migration and sex work are underexplored in southern Africa, a region with high internal and cross-border population mobility, and HIV prevalence. Sex work often constitutes an important livelihood activity for migrant women. In 2010, sex workers trained as interviewers conducted cross-sectional surveys with 1,653 female sex workers in Johannesburg (Hillbrow and Sandton), Rustenburg and Cape Town. Most (85.3 %) sex workers were migrants (1396/1636): 39.0 % (638/1636) internal and 46.3 % (758/1636) cross-border. Cross-border migrants had higher education levels, predominately worked part-time, mainly at indoor venues, and earned more per client than other groups. They, however, had 41 % lower health service contact (adjusted odds ratio = 0.59; 95 % confidence interval = 0.40-0.86) and less frequent condom use than non-migrants. Police interaction was similar. Cross-border migrants appear more tenacious in certain aspects of sex work, but require increased health service contact. Migrant-sensitive, sex work-specific health care and health education are needed.

Richter M, Chersich MF, Vearey J, Sartorius B, Temmerman M, Luchters S. Migration Status, Work Conditions and Health Utilization of Female Sex Workers in Three South African Cities. J Immigr Minor Health. 2012 Dec 13. [Epub ahead of print]

Anal intercourse by male sex workers in Kenya

An investigation of self-reported heterosexual anal intercourse in Mombasa, Kenya found that male sex workers who sell sex to men also engage in anal intercourse with women.

Male sex workers selling sex to men were invited to participate in surveys undertaken in 2006 and 2008. A structured questionnaire administered by trained interviewers was used to collect information on socio-demographic characteristics, sexual behaviors, HIV and STI knowledge, and health service usage. Data were analyzed through descriptive and inferential statistics. Bivariate logistic regression, after controlling for year of survey, was used to identify socio-demographic characteristics associated with heterosexual anal intercourse.

From a sample of 867 male sex workers, 297 men had sex with a woman during the previous 30 days - of whom 45% did so with a female client and 86% with a non-paying female partner. Within these groups, 66% and 43% of male sex workers had anal intercourse with a female client and non-paying partner respectively. Factors associated with reporting recent heterosexual anal intercourse in bivariate logistic regression after controlling for year of survey participation were being Muslim, ever or currently married, living with wife only, living with a female partner only, living with more than one sexual partner, self-identifying as basha/king/bisexual, having one's own children, and lower education.

The authors conclude that further investigation among women in Mombasa is needed to understand heterosexual anal sex practices, and how HIV programming may respond.

Mannava P, Geibel S, King'ola N, Temmerman M, Luchters S. Male sex workers who sell sex to men also engage in anal intercourse with women: evidence from mombasa, kenya. PLoS One. 2013;8(1):e52547. doi: 10.1371/journal.pone.0052547. Epub 2013 Jan 2.

Adolescent sex workers in Kunming, China

A cross-sectional survey among female sex workers found low levels of consistent condom use and high STI prevalence.

A cross-sectional survey was conducted in 2010. Using snowball and convenience sampling, self-identified FSWs were recruited from four urban areas in Kunming. Women consenting to participate were administered a semi-structured questionnaire by trained interviewers identified from local peer-support organisations. Following interview, a gynaecological examination and biological sampling to identify potential STIs were undertaken. Descriptive and multivariable logistic regression analyses were performed.

Adolescent FSWs had a mean age of 18.2 years and reported numerous non-paying sexual partners with very low rate of consistent condom use (22.2%). Half (50.3%) of the respondents had sex while feeling drunk at least once in the past week, of whom 56.4% did not use condom protection. STI prevalence was high overall (30.4%) among this group. Younger age, early sexual debut, being isolated from schools and family, short duration in sex work, and use of illicit drugs were found to be strong predictors for unprotected sex and presence of an STI. Conversely, having access to condom promotion, free HIV counselling and testing, and peer education were associated with less unprotected sex. The majority reported a need for health knowledge, free condoms and low-cost STI diagnosis and treatment.

The authors conclude that there is an urgent need to improve coverage, accessibility and efficiency of existing interventions targeting adolescent FSWs.

Zhang XD, Temmerman M, Li Y, Luo W, Luchters S. Vulnerabilities, health needs and predictors of high-risk sexual behaviour among female adolescent sex workers in Kunming, China. Sex Transm Infect. 2012 Dec 8. [Epub ahead of print]

Reproductive health interventions for adolescents in Latin America

This article describes the development, implementation and evaluation design of the community-embedded reproductive health care for adolescents (CERCA) study in three Latin American cities: Cochabamba (Bolivia), Cuenca (Ecuador) and Managua (Nicaragua).

Adolescents in Latin America are at high risk for unwanted and unplanned pregnancies, which often result in unsafe abortions or poor maternal health outcomes. Both young men and women in the region face an increased risk of sexually transmitted infections due to inadequate sexual and reproductive health information, services and counselling. To date, many adolescent health programmes have targeted a single determinant of sexual and reproductive health. However, recent evidence suggests that the complexity of sexual and reproductive health issues demands an equally multi-layered and comprehensive approach.
Project CERCA's research methodology builds on existing methodological frameworks, namely: action research, community based participatory research and intervention-mapping. The interventions in each country address distinct target groups (adolescents, parents, local authorities and health providers) and seek improvement of the following sexual health behaviours: communication about sexuality, sexual and reproductive health information-seeking, access to sexual and reproductive health care and safe sexual relationships. In Managua, a randomised controlled study was implemented, and in Cochabamba and Cuenca a non-randomised controlled study was set up to evaluate the effectiveness of Project CERCA interventions, in addition to a process evaluation.
This research will result in a methodological framework that will contribute to the improved design and implementation of future adolescent sexual and reproductive health interventions.

Decat P, Nelson E, De Meyer S, Jaruseviciene L, Orozco M, Segura Z, Gorter A, Vega B, Cordova K, Maes L, Temmerman M, Leye E, Degomme O. Community embedded reproductive health interventions for adolescents in Latin America: development and evaluation of a complex multi-centre intervention. BMC Public Health. 2013 Jan 14;13(1):31.
The article can be downloaded at: http://www.biomedcentral.com/1471-2458/13/31/abstract