Influence of mhealth interventions on gender relations in developing countries: a systematic literature review

INTRODUCTION: Research has shown that mHealth initiatives, or health programs enhanced by mobile phone technologies, can foster women’s empowerment. Yet, there is growing concern that mobile-based programs geared towards women may exacerbate gender inequalities. METHODS: A systematic literature review was conducted to examine the empirical evidence of changes in men and women’s interactions as a result of mHealth interventions. To be eligible, studies had to have been published in English from 2002 to 2012, conducted in a developing country, included an evaluation of a mobile health intervention, and presented findings on resultant dynamics between women and men. The search strategy comprised four electronic bibliographic databases in addition to a manual review of the reference lists of relevant articles and a review of organizational websites and journals with recent mHealth publications. The methodological rigor of selected studies was appraised by two independent reviewers who also abstracted data on the study’s characteristics. Iterative thematic analyses were used to synthesize findings relating to gender-transformative and non-transformative experiences. RESULTS: Out of the 173 articles retrieved for review, seven articles met the inclusion criteria and were retained in the final analysis. Most mHealth interventions were SMS-based and conducted in sub-Saharan Africa on topics relating to HIV/AIDS, sexual and reproductive health, health-based microenterprise, and non-communicable diseases. Several methodological limitations were identified among eligible quantitative and qualitative studies. The current literature suggests that mobile phone programs can influence gender relations in meaningfully positive ways by providing new modes for couple’s health communication and cooperation and by enabling greater male participation in health areas typically targeted towards women. MHealth initiatives also increased women’s decision-making, social status, and access to health resources. However, programmatic experiences by design may inadvertently reinforce the digital divide, and perpetuate existing gender-based power imbalances. Domestic disputes and lack of spousal approval additionally hampered women’s participation. CONCLUSION: Efforts to scale-up health interventions enhanced by mobile technologies should consider the implementation and evaluation imperative of ensuring that mHealth programs transform rather than reinforce gender inequalities. The evidence base on the effect of mHealth interventions on gender relations is weak, and rigorous research is urgently needed

Systematic review of mobile health behavioural interventions to improve uptake of HIV testing for vulnerable and key populations

This systematic narrative review examined the empirical evidence on the effectiveness of mobile health (mHealth) behavioral interventions designed to increase uptake of HIV testing among vulnerable and key populations

Community-Led Response to Address Economic Vulnerability due to COVID-19 with, for, and by Transgender Women of Color: A Qualitative Pilot Evaluation

PURPOSE: Intersectional stigma fuels inequities among transgender women of color, which have been exacerbated by coronavirus disease 2019 (COVID-19). This study evaluated a community-led emergency assistance program for transgender women of color. METHODS: We conducted a pilot program evaluation (n=8). RESULTS: Retention was 87.5% over the follow-up. Funds were primarily used for bills, food, and housing. Requesting and receiving funds was described as somewhat to extremely easy. Participants identified the need for economic empowerment components in future programming, specifically gender affirmation, skill-building for education and employment, and entrepreneurial opportunities. CONCLUSION: Findings highlight the need to invest in community-led strategies to address inequities experienced by transgender women of color

I expected little, although I learned a lot : Perceived benefits of participating in HIV risk reduction sessions among women engaged in sex work in Uganda

BACKGROUND: The global HIV burden remains a public health concern. Women engaged in sex work (WESW) are at higher risk of acquiring HIV compared to the general adult population. Uganda reports high rates of HIV prevalence among WESW. While WESW in Uganda have long been the subject of surveillance studies, they have not been targeted by theory-informed HIV prevention intervention approaches. In this study, we explored the perceived benefits of an evidence-based HIV risk reduction intervention that was implemented as part of a combination intervention tested in a clinical trial in Uganda. METHODS: As part of a larger randomized clinical trial, we conducted semi-structured in-depth interviews with 20 WESW selected using a stratified purposive sampling. All interviews were conducted in Luganda, language spoken in the study area, and audio-recorded. They were transcribed verbatim and translated to English. Thematic analysis was used to analyze the data. RESULTS: WESW\u27s narratives focused on: (1) condom use; (2) alcohol/drug consumption; (3) PrEP use; (4) handling customers; and (5) massaging customers. WESW agreed that male condom was one of the important learning points for them and planned to continue using them while female condoms were received with mixed reactions. Many women appreciated receiving information about the risks of consuming alcohol and drugs, and discussed how they reduced/ eliminated their consumption. PrEP information was appreciated though identified by fewer WESW. Handling a client was discussed as a helpful strategy for safer sex through improved ability to convince customers to use condoms or avoiding sex. Massaging was also beneficial to avoid penetrative sex, but similar to female condom, massaging also yielded mixed perceptions. CONCLUSION: WESW found the intervention beneficial and described ways in which it improved their ability to engage in safer sex and stay healthy. The fact that WESW identified other strategies beyond condom use as helpful underlines the importance of adopting a comprehensive approach to behavioral interventions targeting HIV prevention even when combined with other interventions. Additionally, WESW\u27s narratives suggest that incorporating the tenets of social cognitive theory and harm reduction approaches in HIV prevention among this population can result in risk behavior change

Economic Abuse and Care-seeking Practices for HIV and Financial Support Services in Women Employed by Sex Work: A Cross-Sectional Baseline Assessment of a Clinical Trial Cohort in Uganda

Economic hardship is a driver of entry into sex work, which is associated with high HIV risk. Yet, little is known about economic abuse in women employed by sex work (WESW) and its relationship to uptake of HIV prevention and financial support services. This study used cross-sectional baseline data from a multisite, longitudinal clinical trial that tests the efficacy of adding economic empowerment to traditional HIV risk reduction education on HIV incidence in 542 WESW. Mixed effects logistic and linear regressions were used to examine associations in reported economic abuse by demographic characteristics, sexual behaviors, HIV care-seeking, and financial care-seeking. Mean age was 31.4 years. Most WESW were unmarried (74%) and had less than primary school education (64%). 48% had savings, and 72% had debt. 93% reported at least one economic abuse incident. Common incidents included being forced to ask for money (80%), having financial information kept from them (61%), and being forced to disclose how money was spent (56%). WESW also reported partners/relatives spending money needed for bills (45%), not paying bills (38%), threatening them to quit their job(s) (38%), and using physical violence when earning income (24%). Married/partnered WESW (OR = 2.68, 95% CI:1.60–4.48), those with debt (OR = 1.70, 95% CI:1.04–2.77), and those with sex-work bosses (OR = 1.90, 95% CI:1.07–3.38) had higher economic abuse. Condomless sex (β = +4.43, p < .05) was higher among WESW experiencing economic abuse, who also had lower odds of initiating PrEP (OR = .39, 95% CI:.17–.89). WESW experiencing economic abuse were also more likely to ask for cash among relatives (OR = 2.36, 95% CI:1.13–4.94) or banks (OR = 2.12, 95% CI:1.11–4.03). The high prevalence of HIV and economic abuse in WESW underscores the importance of integrating financial empowerment in HIV risk reduction interventions for WESW, including education about economic abuse and strategies to address it. Programs focusing on violence against women should also consider economic barriers to accessing HIV prevention services

Qualitative Assessment of the Feasibility, Usability, and Acceptability of a Mobile Client Data App for Community-Based Maternal, Neonatal, and Child Care in Rural Ghana

Mobile phone applications may enhance the delivery of critical health services and the accuracy of health service data. Yet, the opinions and experiences of frontline health workers on using mobile apps to track pregnant and recently delivered women are underreported. This evaluation qualitatively assessed the feasibility, usability, and acceptability of a mobile Client Data App for maternal, neonatal, and child client data management by community health nurses (CHNs) in rural Ghana. The mobile app enabled CHNs to enter, summarize, and query client data. It also sent visit reminders for clients and provided a mechanism to report level of care to district officers. Fourteen interviews and two focus groups with CHNs, midwives, and district health officers were conducted, coded, and thematically analyzed. Results indicated that the app was easily integrated into care, improved CHN productivity, and was acceptable due to its capacity to facilitate client follow-up, data reporting, and decision-making. However, the feasibility and usability of the app were hindered by high client volumes, staff shortages, and software and device challenges. Successful integration of mobile client data apps for frontline health workers in rural and resource-poor settings requires real-time monitoring, program investments, and targeted changes in human resources

Examining Cash Expenditures and Associated HIV-Related Behaviors Using Financial Diaries in Women Employed by Sex Work in Rural Uganda: Findings from the Kyaterekera Study

Background: Women employed by sex work (WESW) have a high risk of human immunodeficiency virus (HIV) infection and experience economic barriers in accessing care. However, few studies have described their financial lives and the relationship between expenditures and HIVrelated behaviors. Methods: This exploratory study used financial diaries to collect expenditure and income data from WESW in Uganda over 6 months. Data were collected as part of a larger trial that tested the efficacy of an HIV prevention intervention method. Descriptive statistics were used to quantify women’s income, relative expenditures, and negative cash balances. Bivariate and multivariate logistic regressions were used to examine the odds of sexual risk behavior or use of HIV medications for several cash scenarios. Results: A total of 163 WESW were enrolled; the participants mean age was 32 years old. Sex work was the sole source of employment for most WESW (99%); their average monthly income was $62.32. Food accounted for the highest proportion of spending (44%) followed by sex work (20%) and housing expenditures (11%). WESW spent the least on health care (5%). Expenditures accounted for a large but variable proportion of these women’s income (56% to 101%). Most WESW (74%) experienced a negative cash balance. Some also reported high sex work (28%), health care (24%), and education (28%) costs. The prevalence of condomless sex (77%) and sex with drugs/alcohol (70%) was high compared to use of ART/PrEP (Antiretroviral therapy/Pre-exposure prophylaxis) medications (45%). Women’s cash expenditures were not statistically significantly associated with HIV-related behaviors. However, the exploratory study observed a consistent null trend of lower odds of condomless sex (adjusted odds ratio (AOR) = 0.70, 95% confidence interval (CI): 0.28–1.70), sex with drugs/alcohol (AOR = 0.93, 95% CI: 0.42–2.05), and use of ART/PrEP (AOR = 0.80, 95% CI: 0.39–1.67) among women who experienced a negative cash balance versus those who did not. Similar trends were observed for other cash scenarios. Conclusion: Financial diaries are a feasible tool to assess the economic lives of vulnerable women. Despite having paid work, most WESW encountered a myriad of financial challenges with limited spending on HIV prevention. Financial protections and additional income-generating activities may improve their status. More robust research is needed to understand the potentially complex relationship between income, expenditures, and HIV risk among vulnerable sex workers

Conducting high-frequency data collection in low-resource settings: Lessons from a financial diary study among women engaged in sex work in Uganda

Poverty and economic insecurity are driving forces in entering sex work among women in low resource areas. This increases their risk for HIV by influencing the decision-making process for high-risk beha­ viors. Few studies have examined the financial behaviors and capa­ cities of women engaged in sex work (WESW). This paper describes the methodology used in a financial diary study aimed at characterizing women’s spending patterns within a larger prevention intervention trial among WESW in Uganda. From June 2019 to March 2020, a subsample of 150 women randomized to the combination HIV pre­ vention and economic empowerment treatment was asked to com­ plete financial diaries to monitor daily expenditures in real time. Two hundred and forty financial diaries were distributed to study partici­ pants during the financial literacy sessions at eight sites. A total of 26,919 expense entries were recorded over 6 months. Sex-workrelated expenses comprised approximately 20.01% of the total. The process of obtaining quality and consistent data was challenging due to the transient and stigmatized nature of sex work coupled with women’s varying levels of education. Frequent check-ins, using peer support, code word or visuals, and a shorter time frame would allow for a more accurate collection of high-frequency data. Moreover, the ability of women to complete the financial diaries despite numerous challenges speaks to their potential value as a data collection tool, and also as an organizing tool for finances

Prevalence and Correlates of Knowledge of Male Partner HIV Testing and Serostatus Among African-American Women Living in High Poverty, High HIV Prevalence Communities (HPTN 064)

Knowledge of sexual partners' HIV infection can reduce risky sexual behaviors. Yet, there are no published studies to-date examining prevalence and characteristics associated with knowledge among African-American women living in high poverty communities disproportionately affected by HIV. Using the HIV Prevention Trial Network's (HPTN) 064 Study data, multivariable logistic regression was used to examine individual, partner, and partnership-level determinants of women's knowledge (n=1,768 women). Results showed that women's demographic characteristics alone did not account for the variation in serostatus awareness. Rather, lower knowledge of partner serostatus was associated with having two or more sex partners (OR=0.49, 95%CI: 0.37-0.65), food insecurity (OR=0.68, 95%CI: 0.49-0.94), partner age>35 (OR=0.68, 95%CI: 0.49-0.94), and partner concurrency (OR=0.63, 95%CI: 0.49-0.83). Access to financial support (OR=1.42, 95%CI: 1.05-1.92) and coresidence (OR=1.43, 95%CI: 1.05-1.95) were associated with higher knowledge of partner serostatus. HIV prevention efforts addressing African-American women's vulnerabilities should employ integrated behavioral, economic, and empowerment approaches

Economic Resources and HIV Preventive Behaviors Among School-Enrolled Young Women in Rural South Africa (HPTN 068)

Individual economic resources may have greater influence on school-enrolled young women's sexual decision-making than household wealth measures. However, few studies have investigated the effects of personal income, employment, and other financial assets on young women's sexual behaviors. Using baseline data from the HIV Prevention Trials Network (HPTN) 068 study, we examined the association of ever having sex and adopting sexually-protective practices with individual-level economic resources among school-enrolled women, aged 13-20 years (n=2,533). Age-adjusted results showed that among all women employment was associated with ever having sex (OR=1.56, 95%CI:1.28-1.90). Among sexually-experienced women, paid work was associated with changes in partner selection practices (OR=2.38, 95%CI:1.58-3.58) and periodic sexual abstinence to avoid HIV (OR=1.71,95%CI:1.07-2.75). Having money to spend on oneself was associated with reducing the number of sexual partners (OR=1.94, 95%CI:1.08-3.46), discussing HIV testing (OR=2.15, 95%CI:1.13-4.06), and discussing condom use (OR=1.99, 95%CI:1.04-3.80). Having a bank account was associated with condom use (OR=1.49, 95%CI:1.01-2.19). Economic hardship was positively associated with ever having sex, but not with sexually-protective behaviors. Maximizing women's individual economic resources may complement future prevention initiatives