Strengthening nonrandomized studies of health communication strategies for HIV prevention.

BACKGROUND: There is growing interest in impact evaluations of health communication (HC) interventions for HIV prevention. Although cluster randomized trials may be optimal in terms of internal validity, they are often unfeasible for political, practical, or ethical reasons. However, a common alternative, the observational study of individuals who do and do not self-report HC intervention exposure, is prone to bias by confounding. Cluster-level quasi-experimental study designs offer promising alternatives to these extremes. METHODS: We identified common rollout strategies for HC initiatives. We mapped these scenarios against established quasi-experimental evaluation designs. We identified key issues for implementers and evaluators if these designs are to be more frequently adopted in HC intervention evaluations with high internal validity. RESULTS: Stronger evaluations will document the planned intervention components in advance of delivery and will implement interventions in clusters according to a predefined systematic allocation plan. We identify 4 types of allocation plan and their associated designs. Where some places get the HC intervention, whereas others do not, a nonrandomized controlled study may be feasible. Where HC is introduced everywhere at a defined point in time, an interrupted time series may be appropriate. Where the HC intervention is introduced in phases, a nonrandomized phased implementation or stepped-wedge design may be used. Finally, where there is variation in strength of implementation of HC, a nonrandomized, dose-response study can be planned. DISCUSSION: Our framework will assist teams planning such evaluations by identifying critical decisions for the implementers and for the evaluators of HC interventions

Competition is not necessarily a barrier to community mobilisation among sex workers: an intervention planning assessment from Zimbabwe.

BACKGROUND: Community mobilization among female sex workers (SWs) is recognized as an effective strategy to empower SWs and increase their uptake of health services. Activities focus on increasing social cohesion between SWs by building trust, strengthening networks, and encouraging shared efforts for mutual gain. Several studies, however, suggest that high levels of interpersonal competition between SWs can pose a barrier to collective action and support. We conducted a study to examine levels of perceived competition between SWs in Mutare, Hwange and Victoria Falls in Zimbabwe in order to inform development of a community-based intervention for HIV prevention and treatment. This paper focuses on our qualitative findings and their implications for the design of HIV programming in the Zimbabwean context. METHODS: Following a respondent driven sampling (RDS) survey, we explored issues related to social cohesion amongst SWs in Mutare, Hwange and Victoria Falls through in-depth interviews conducted with 22 SWs. Interviews examined dynamics of SWs' relationships and extent of social support, and were analyzed using thematic content analysis using the constant comparative method. Findings are contextualised against descriptive data extracted from the survey, which was analysed using Stata 12, adjusting for RDS. RESULTS: Across all sites, women described protecting each other at night, advising each other about violent or non-paying clients, and paying fines for each other following arrest. In Mutare, women gave additional examples, including physically attacking problem clients, treatment adherence support and shared saving schemes. However, interviews also highlighted fierce competition between women and deep mistrust. This reflects the reported mix of competition and support from the survey of 836 women (Mutare n = 370, Hwange n = 237, Victoria Falls n = 229). In Mutare, 92.8 % of SWs agreed there was a lot of competition; 87.9 % reported that SWs support each other. This contrasted with Victoria Falls and Hwange where fewer agreed there was competition between SWs (70.5 % and 78.0 %), but also fewer reported that SWs support each other at work (55.2 % and 51.2 %). CONCLUSIONS: Women reported being most likely to support each other when confronted with serious danger but maintained high levels of competition for clients, suggesting competition at work does not represent a barrier to support. Examples of practical assistance between SWs provide entry points for our planned community mobilization activities, which aim to broaden trust and support among SWs while acknowledging their professional competition

Re-analysis of health and educational impacts of a school-based deworming programme in western Kenya: a pure replication.

BACKGROUND: Helminth (worm) infections cause morbidity among poor communities worldwide. An influential study conducted in Kenya in 1998-99 reported that a school-based drug-and-educational intervention had benefits regarding worm infections and school attendance. Effects were seen among children treated with deworming drugs, untreated children in intervention schools and children in nearby non-intervention schools. Combining these effects, the intervention was reported to increase school attendance by 7.5% in treated children. Effects on other outcomes (worm infections, anaemia, nutritional status and examination performance) were also investigated. METHODS: In this pure replication, we used data provided by the original authors to re-analyse the study according to their methods. We compared these results against those presented in the original paper. RESULTS: Although most results were reproduced as originally reported, we identified discrepancies of several types between the original findings and re-analysis. For worm infections, re-analysis showed reductions similar to those originally reported. For anaemia prevalence, in contrast to the original findings, re-analysis found no evidence of benefit. For nutritional status, both original findings and re-analysis described modest evidence for a small improvement. For school attendance, re-analysis showed benefits similar to those originally found in intervention schools for both children who did and those who did not receive deworming drugs. However, after correction of coding errors, there was little evidence of an indirect effect on school attendance among children in schools close to intervention schools. Combining these effects gave a total increase in attendance of 3.9% among treated children, which was no longer statistically significant. As in the original results, re-analysis found no effect of the intervention on examination performance. CONCLUSIONS: Re-applying analytical approaches originally used, but correcting various errors, we found little evidence for some previously-reported indirect effects of a deworming intervention. Effects on worm infections, nutritional status, examination performance and school attendance on children in intervention schools were largely unchanged

Re-analysis of health and educational impacts of a school-based deworming programme in western Kenya: a statistical replication of a cluster quasi-randomized stepped-wedge trial.

INTRODUCTION: Helminth (worm) infections cause morbidity among poor communities worldwide. An influential study conducted in Kenya in 1998-99 reported that a school-based drug-and-educational intervention had benefits for worm infections and school attendance. METHODS: In this statistical replication, we re-analysed data from this cluster quasi-randomized stepped-wedge trial, specifying two co-primary outcomes: school attendance and examination performance. We estimated intention-to-treat effects using year-stratified cluster-summary analysis and observation-level random-effects regression, and combined both years with a random-effects model accounting for year. The participants were not blinded to allocation status, and other interventions were concurrently conducted in a sub-set of schools. A protocol guiding outcome data collection was not available. RESULTS: Quasi-randomization resulted in three similar groups of 25 schools. There was a substantial amount of missing data. In year-stratified cluster-summary analysis, there was no clear evidence for improvement in either school attendance or examination performance. In year-stratified regression models, there was some evidence of improvement in school attendance [adjusted odds ratios (aOR): year 1: 1.48, 95% confidence interval (CI) 0.88-2.52, P = 0.147; year 2: 1.23, 95% CI 1.01-1.51, P = 0.044], but not examination performance (adjusted differences: year 1: -0.135, 95% CI -0.323-0.054, P = 0.161; year 2: -0.017, 95% CI -0.201-0.166, P = 0.854). When both years were combined, there was strong evidence of an effect on attendance (aOR 1.82, 95% CI 1.74-1.91, P < 0.001), but not examination performance (adjusted difference -0.121, 95% CI -0.293-0.052, P = 0.169). CONCLUSIONS: The evidence supporting an improvement in school attendance differed by analysis method. This, and various other important limitations of the data, caution against over-interpretation of the results. We find that the study provides some evidence, but with high risk of bias, that a school-based drug-treatment and health-education intervention improved school attendance and no evidence of effect on examination performance

Disability-inclusive COVID-19 response: What it is, why it is important and what we can learn from the United Kingdom's response.

All too often, disabled people are left behind in emergencies, and this is a risk in the ongoing COVID-19 pandemic. This is an important issue, as globally there are approximately one billion people with disabilities. This number includes one in three people aged over 60, who are the group at greatest risk from COVID-19. The COVID-19 pandemic in the UK has highlighted additional difficulties that disabled people may face. Complying with preventative measures, like social distancing, can be challenging, particular for people who rely on carers. Disabled people may also be at greater risk of morbidity and mortality if they contract the virus, yet in danger of being de-prioritised for care. Many people with disabilities have ongoing healthcare needs, and these need to still be supported during the pandemic. Furthermore, people may become newly disabled as a result of the pandemic, and therefore require appropriate care. Good practice examples have emerged for meeting these challenges, such as guidance for healthcare professionals on treating people with dementia, but these need to be scaled up further and adapted for other settings. In conclusion, it is clear that a disability-inclusive COVID-19 response is needed, both in the UK and as the pandemic unfolds globally. This response will require inclusion of disability measures within data collection, consulting with disabled people, and tailoring responses to be appropriate for this group

Living with COVID-19 and preparing for future pandemics: revisiting lessons from the HIV pandemic

In April, 2020, just months into the COVID-19 pandemic, an international group of public health researchers published three lessons learned from the HIV pandemic for the response to COVID-19, which were to: anticipate health inequalities, create an enabling environment to support behavioural change, and engage a multidisciplinary effort. We revisit these lessons in light of more than 2 years’ experience with the COVID-19 pandemic. With specific examples, we detail how inequalities have played out within and between countries, highlight factors that support or impede the creation of enabling environments, and note ongoing issues with the scarcity of integrated science and health system approaches. We argue that to better apply lessons learned as the COVID-19 pandemic matures and other infectious disease outbreaks emerge, it will be imperative to create dialogue among polarised perspectives, identify shared priorities, and draw on multidisciplinary evidence

Association between disability status and health care utilisation for common childhood illnesses in 10 countries in sub-Saharan Africa: a cross-sectional study in the Multiple Indicator Cluster Survey.

BACKGROUND: Approximately 70 million children in sub-Saharan Africa (SSA) are disabled, yet little is known about the prevalence of and care-seeking patterns for common childhood illnesses, such as acute respiratory infection (ARI), diarrhoea, and fever. METHODS: Data were from 10 SSA countries with data available from 2017 to 2020 in the UNICEF-supported Multiple Indicator Cluster Survey (MICS) online repository. Children aged 2-4 years who completed the child functioning module were included. Using logistic regression, we examined the association between disability and ARI, diarrhoea and fever in the past two weeks and care-seeking behaviour for these illnesses. Using multinomial logistic regression, we examined the association between disability and the type of health care providers from which caregivers sought care. FINDINGS: There were 51,901 children included. Overall, there were small absolute differences in illnesses between disabled and non-disabled children. However, there was evidence disabled children had a greater odds of ARI (aOR = 1.33, 95% C.I 1.16-1.52), diarrhoea (aOR = 1.27, 95% C.I. 1.12-1.44), and fever (aOR = 1.19 95% CI 1.06-1.35) compared to non-disabled children. There was no evidence that caregivers of disabled children had a greater odds of seeking care for ARI (aOR = 0.90, 95% C.I 0.69-1.19), diarrhoea (aOR = 1.06, 95% C.I. 0.84-1.34), and fever (aOR = 1.07, 95% C.I 0.88-1.30) compared to caregivers of non-disabled children. Caregivers of disabled children had a higher odds of seeking care from a trained health worker for ARI (aOR = 1.76, 95% C.I. 1.25-2.47) and fever (aOR = 1.49, 95% C.I. 1.03-2.14) or non-health professional (aOR = 1.89, 95% C.I. 1.19-2.98) for ARI than from an unspecified health facility worker compared to caregivers of non-disabled children, but no associations were not seen for diarrhoea. INTERPRETATION: While the data showed relatively small absolute differences, disability was associated with ARI, diarrhoea and fever and caregivers of disabled children sought care from trained health workers for ARI and fever more than non-disabled children. The overall small absolute differences show closing gaps in illness and access to care may be possible, but highlights that more research on illness severity, care quality, and outcomes should be conducted to further assess health inequities for disabled children. FUNDING: SR receives funding from the Rhodes Trust

The effect of mobility on HIV-related healthcare access and use for female sex workers: A systematic review.

Female sex workers (FSW) experience a high HIV burden and are often mobile. FSW access to HIV-related healthcare is essential for equitable welfare and to reduce new HIV infections. We systematically reviewed the literature on mobility and HIV-related healthcare access and use among FSW. Outcome measures included: HIV/STI testing, STI treatment, PrEP (initiation or adherence), and ART (initiation or adherence). We summarised the results with a narrative synthesis. From 7417 non-duplicated citations, nine studies from Canada (3), Guatamala, Honduras (2), India, South Africa, and Vietnam were included. Only one of the studies was designed to address mobility and healthcare access, and only six reported adjusted effect estimates. Mobility was measured over four time-frames (from 'current' to 'ever'), as having lived or worked elsewhere or in another town/province/country. Three studies from Canada, Guatemala, and India found mobility associated with increased odds of poor initial access to healthcare (adjusted odds ratios (AOR) from 1.33, 95% CI 1.02, 1.75, to 2.27, 95% CI 1.09, 4.76), and one from Vietnam found no association (odds ratio (OR): 0.92, 95% CI 0.65, 1.28). The study from South Africa found no association with initiating ART (risk ratio: 0.86, 95% CI 0.65, 1.14). Two studies from Canada and Honduras found increased odds of ART interruption (AOR 2.74, 95% CI 0.89, 8.42; 5.19, 95% CI 1.38, 19.56), while two other studies from Canada and Honduras found no association with detectable viral load (OR 0.84, 95% CI 0.08, 8.33; AOR 0.79, 95% CI 0.41, 1.69). We found that mobility is associated with reduced initial healthcare access and interruption of ART, consistent with literature from the general population. Discordance between effects on adherence and viral load may be due to measurement of mobility. Future research should carefully construct measures of mobility and consider a range of HIV-related healthcare outcomes

A focus on disability is necessary to achieve HIV epidemic control.

Provision of inclusive services and reaching marginalised groups are crucial to achieving the UNAIDS 95-95-95 targets by 2030. However, people with disabilities are often left behind. This gap in HIV care provision is important because more than 1 billion people worldwide have disabilities, including a quarter of people living with HIV. The association between HIV and disability is bidirectional: HIV can cause a range of physical, sensory, and cognitive impairments and people with disabilities are at higher risk of acquiring HIV. People with disabilities often have lower levels of access and adherence to HIV treatment due to barriers with regard to the provision of services (eg, inadequate knowledge among health-care workers and inaccessibility of facilities) and the demand for services (eg, absence of autonomy and awareness of people with disabilities of HIV care needs and service availability). Ultimately, these barriers arise from failures at the system level, including poor governance, leadership, financing, and paucity of data