Sexual violence in post-conflict Sierra Leone: Obstacles to prevention responses

Although the high prevalence of sexual violence during the decade-long armed conflict in Sierra Leone has been investigated and reported on extensively, very little is known about the nature and extent of sexual violence during Sierra Leone’s post-conflict transition. The purpose of this paper was to explore narratives about the problem of sexual violence and obstacles to prevention efforts in the aftermath of war in Sierra Leone. Using a qualitative research approach, this study examines gender norms and pressures that shape gender roles, rights, responsibilities and sexual relationships in post-conflict situations. Evidence on the nature and extent of sexual violence and challenges and barriers to prevention responses were elicited through the in-depth interviews and focus group discussions with both men and women as well as key informant interviews with community leaders and service providers. Findings indicate the widespread occurrence of sexual violence that continues even in the aftermath of hostilities in Sierra Leone. The changes in economic, cultural and geopolitical spheres as well as gender inequalities in education, social and economic domains as a result of the conflict have evidently disempowered women and girls with a profound impact on their sexual and reproductive health/rights. Adequate attention should be given to the design and implementation of responses to sexual violence given the gendered nature of such violence and post-conflict contexts.Keywords: Sexual violence; post-conflict; Sierra Leone; gender; wome

Coerced first sex among adolescent girls in sub-Saharan Africa: prevalence and context.

Coercive experiences at sexual debut have been shown to be associated with other sexual risks throughout the life course. Using nationally representative surveys from 12-19 year old girls in Burkina Faso, Ghana, Malawi, and Uganda collected in 2004, we examine the prevalence of sexual coercion at sexual debut among unmarried girls and its correlates. In Malawi, 38 percent of girls said that they were "not willing at all" at their first sexual experience followed by Ghana at 30 percent, Uganda at 23 percent and Burkina Faso at 15 percent. In-depth interviews collected in 2003 with the same demographic shows that there are four primary types of sexual coercion: forced sex; pressure through money or gifts; flattery, pestering, and threatening to have sex with other girls; and passive acceptance. The article concludes with the research and policy implications of these findings.Premier rapport sexuel coercitif chez les adolescents en Afrique subsaharienne: Prévalence et contexte On a montré que les expériences coercitives au moment du premier rapport sexuel ont été liées à d'autres risques sexuels pour toute la vie. A l'aide des enquêtes à représentation nationale menée auprès des filles âgées de 12-19 ans au Burkina-Faso, au Ghana, au Malawi et en Ouganda en 2004, nous avons étudié la prévalence de la coercition sexuelle au moment du premier acte sexuel chez les filles célibataires et leurs corrélats. Au Malawi, 38% des filles ont affirmé qu'elles "ne voulaient pas du tout" au moment de leur premier expérience sexuelle, suivi par le Ghana à 30%, l'Ouganda à 23% et le Burkina-Faso à 15%. Des interviews en prodondeur recueillies en 2003 avec les mêmes données démographiques, montrent qu'il y a quatre types de coercition sexuelle: le rapport sexuel contraint; la pression à travers l'argent ou des cadeaux; la flatterie, à force d'insister et menacer d'avoir des rapports sexuels avec d'autres filles; et l'acceptation passive. L'article conclut avec les implications de la recherche et de la politique de ces résultats

What influences antibiotic sales in rural Bangladesh? A drug dispensers’ perspective

Background Antibiotic resistance poses a great threat to global health, especially in low- and middle-income countries with a high infectious disease burden and limited resources. In spite of regulations, antibiotics are sold in many settings as non-prescription medicines, resulting in inappropriate use and resistance. Objective This study aimed to investigate the current status of access and use of antibiotics in rural Bangladesh, by exploring the perspectives and sales practices of antibiotic drug dispensers. Methods We used a mixed methods approach (qualitative and quantitative). We mapped and characterized antibiotic purchasing and dispensing sites in the Matlab Health and Demographic Surveillance System catchment area. Furthermore, we investigated the volume of provision of systemic antibiotics in 10 drug outlets. We held 16 in-depth interviews with randomly selected antibiotics dispensers. Interviews explored factors associated with antibiotic selling. Responses were transcribed, coded for themes, and summarized. We used ATLAS.ti 5.2 for conducting a thematic analysis. Results A total of 301 antibiotic dispensers were identified, of whom 92% (n = 278) were private and 8% (n = 23) public. 52% (n = 155) operated informally (i.e. without legal authorization). In order to promote and survive in their business, dispensers sell antibiotics for a range of conditions without a qualified physician’s prescription. Factors that facilitate these inappropriate sales include lack of access to healthcare in the rural community, inadequate doctor: population ratio, limited dispenser knowledge, poor pharmacovigilance concerning safety of self medication, lack of enforcement of policies, financial benefits for both customers and dispensers, and high dependency on pharmaceutical companies’ information. Conclusion Dispensers in rural Bangladesh sell antibiotics inappropriately by ignoring existing national regulations. They operate the antibiotic sales without facing any legal barriers and primarily with a view to sustain their business, resulting in inappropriate sales of antibiotics to the rural community. The influence of the drug industry needs to be replaced with evidence-based, not commercially driven information. Awareness programs for antibiotic providers that promote understanding of antibiotics and antibiotic resistance through tailored interventions may be helpful in changing current antibiotic sales practices

What influences antibiotic sales in rural Bangladesh? A drug dispensers' perspective

Contains fulltext : 220033.pdf (publisher's version ) (Open Access)Background: Antibiotic resistance poses a great threat to global health, especially in low- and middle-income countries with a high infectious disease burden and limited resources. In spite of regulations, antibiotics are sold in many settings as non-prescription medicines, resulting in inappropriate use and resistance. Objective: This study aimed to investigate the current status of access and use of antibiotics in rural Bangladesh, by exploring the perspectives and sales practices of antibiotic drug dispensers. Methods: We used a mixed methods approach (qualitative and quantitative). We mapped and characterized antibiotic purchasing and dispensing sites in the Matlab Health and Demographic Surveillance System catchment area. Furthermore, we investigated the volume of provision of systemic antibiotics in 10 drug outlets. We held 16 in-depth interviews with randomly selected antibiotics dispensers. Interviews explored factors associated with antibiotic selling. Responses were transcribed, coded for themes, and summarized. We used ATLAS.ti 5.2 for conducting a thematic analysis. Results: A total of 301 antibiotic dispensers were identified, of whom 92% (n = 278) were private and 8% (n = 23) public. 52% (n = 155) operated informally (i.e. without legal authorization). In order to promote and survive in their business, dispensers sell antibiotics for a range of conditions without a qualified physician's prescription. Factors that facilitate these inappropriate sales include lack of access to healthcare in the rural community, inadequate doctor: population ratio, limited dispenser knowledge, poor pharmacovigilance concerning safety of self medication, lack of enforcement of policies, financial benefits for both customers and dispensers, and high dependency on pharmaceutical companies' information. Conclusion: Dispensers in rural Bangladesh sell antibiotics inappropriately by ignoring existing national regulations. They operate the antibiotic sales without facing any legal barriers and primarily with a view to sustain their business, resulting in inappropriate sales of antibiotics to the rural community. The influence of the drug industry needs to be replaced with evidence-based, not commercially driven information. Awareness programs for antibiotic providers that promote understanding of antibiotics and antibiotic resistance through tailored interventions may be helpful in changing current antibiotic sales practices

Community knowledge and practices regarding antibiotic use in rural Mozambique: where is the starting point for prevention of antibiotic resistance?

Background Antibiotic misuse and other types of unnecessary use of antibiotics can contribute to accelerate the process of antibiotic resistance, which is considered a global concern, mostly affecting low-and middle-income countries (LMICs). In Mozambique there is limited evidence on community knowledge and practices regarding antibiotics and antibiotic resistance. As part of the ABACUS project, this paper describes knowledge and practices of antibiotic use among the general population in the semi-rural district of Manhiça to inform evidence-based communication intervention strategies for safer antibiotic use. Methods The study was conducted in Manhiça, a semi-rural district of Southern Mozambique. Sixteen in-depth interviews and four focus group discussions (FGDs) were conducted with community members to explore lay knowledge and practices regarding antibiotics and awareness of antibiotic resistance. The qualitative data was analysed using a combination of content and thematic analysis. The SRQR guidelines for reporting qualitative studies was performed. Results Although participants did not hold any consistent knowledge of antibiotics, their visual recognition of amoxicillin (distinct red yellow capsule) was acceptable, but less so for different types and brands of antibiotics. The majority of participants were aware of the term ‘antibiotic’, yet the definition they gave was rarely backed by biomedical knowledge. Participants associated antibiotics with certain colours, shapes and health conditions. Participants reported common habits that may contribute to resistance: not buying the full course, self-medication, sharing medicines and interruption of treatment. Most had never heard of the term ‘antibiotic resistance’ but were familiar with the phenomenon. They often understood the term ‘resistance’ as treatment failure and likened ‘resistance’ to non-compliance, ineffective medication, disease resistance or to an inability of the physical body to respond to it. Conclusion There is a broad understanding of the importance of medication compliance but not specifically of antibiotic resistance. In addition, there is a recognized gap between knowledge of responsible drug compliance and actual behaviour. Future qualitative research is required to further explore what determines this behaviour. The existing ability to visually identify amoxicillin by its distinct red and yellow appearance is informative for future awareness and behavioural change campaigns that may incorporate visual aids of antibiotics

Community-level antibiotic access and use (ABACUS) in low- and middle-income countries: Finding targets for social interventions to improve appropriate antimicrobial use - an observational multi-centre study

In many low- and middle-income countries (LMICs), a poor link between antibiotic policies and practices exists. Numerous contextual factors may influence the degree of antibiotic access, appropriateness of antibiotic provision, and actual use in communities. Therefore, improving appropriateness of antibiotic use in different communities in LMICs probably requires interventions tailored to the setting of interest, accounting for cultural context. Here we present the ABACUS study (AntiBiotic ACcess and USe), which employs a unique approach and infrastructure, enabling quantitative validation, contextualization of determinants, and cross-continent comparisons of antibiotic access and use. The community infrastructure for this study is the INDEPTH-Network (International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries), which facilitates health and population research through an established health and demographic surveillance system. After an initial round of formative qualitative research with community members and antibiotic suppliers in three African and three Asian countries, household surveys will assess the appropriateness of antibiotic access, provision and use. Results from this sample will be validated against a systematically conducted inventory of suppliers. All potential antibiotic suppliers will be mapped and characterized. Subsequently, their supply of antibiotics to the community will be measured through customer exit interviews, which tend to be more reliable than bulk purchase or sales data. Discrepancies identified between reported and observed antibiotic practices will be investigated in further qualitative interviews. Amartya Sen's Capability Approach will be employed to identify the conversion factors that determine whether or not, and the extent to which appropriate provision of antibiotics may lead to appropriate access and use of antibiotics. Currently, the study is ongoing and expected to conclude by 2019. ABACUS will provide important new insights into antibiotic practices in LMICs to inform social interventions aimed at promoting optimal antibiotic use, thereby preserving antibiotic effectiveness

Community-based antibiotic access and use in six low-income and middle-income countries: a mixed-method approach

Background Antimicrobial misuse is common in low-income and middle-income countries (LMICs), and this practice is a driver of antibiotic resistance. We compared community-based antibiotic access and use practices across communities in LMICs to identify contextually specific targets for interventions to improve antibiotic use practices. Methods We did quantitative and qualitative assessments of antibiotic access and use in six LMICs across Africa (Mozambique, Ghana, and South Africa) and Asia (Bangladesh, Vietnam, and Thailand) over a 2·5-year study period (July 1, 2016–Dec 31, 2018). We did quantitative assessments of community antibiotic access and use through supplier mapping, customer exit interviews, and household surveys. These quantitative assessments were triangulated with qualitative drug supplier and consumer interviews and discussions. Findings Vietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55·2% of antibiotics dispensed without prescription), Bangladesh (45·7%), and Ghana (36·1%), but less so in Mozambique (8·0%), South Africa (1·2%), and Thailand (3·9%). Self-medication was considered to be less time consuming, cheaper, and overall, more convenient than accessing them through health-care facilities. Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia. Interpretation Contextual complexities and differences between countries with different incomes, policy frameworks, and cultural norms were revealed. These contextual differences render a single strategy inadequate and instead necessitate context-tailored, integrated intervention packages to improve antibiotic use in LMICs as part of global efforts to combat antibiotic resistance. Funding Wellcome Trust and Volkswagen Foundation