Youth-friendly services in two rural districts of West Bengal and Jharkhand, India: definite progress, a long way to go.

It is a continuing challenge to reach rural youth in India with sexual and reproductive health services. Drawing on a large survey among 6,572 young people aged 15-24 and 264 rural health providers accessed by them in rural West Bengal and Jharkhand, we witnessed a long-awaited response to national efforts to promote birth spacing. That 31% of young, married women without children were using contraception to delay a first birth was evidence of cracks in the persistent tradition of demonstrating fertility soon after marriage. The coverage of public sector services for reproductive and sexual health is highly variable and the scope largely restricted to married women, with unmarried young women and men relying mainly on the informal private sector, and seriously underserved. Strong social norms proscribing pre-marital sexual relationships perpetuate barriers in meeting their needs. Access to contraception is affected by negative provider attitudes and reluctance to report having sex underestimates the real scale of unmet need. Yet, 30% of providers reported unmarried young women seeking abortion services. To address the needs of all rural youth, the public sector needs to expand its remit or engage with informal providers, train them to deliver youth-friendly services and give them a recognised role in abortion referral

Is scale-up of community mobilisation among sex workers really possible in complex urban environments? The case of Mumbai, India.

BACKGROUND: In the last decade, community mobilisation (CM) interventions targeting female sex workers (FSWs) have been scaled-up in India's national response to the HIV epidemic. This included the Bill and Melinda Gates Foundation's Avahan programme which adopted a business approach to plan and manage implementation at scale. With the focus of evaluation efforts on measuring effectiveness and health impacts there has been little analysis thus far of the interaction of the CM interventions with the sex work industry in complex urban environments. METHODS AND FINDINGS: Between March and July 2012 semi-structured, in-depth interviews and focus group discussions were conducted with 63 HIV intervention implementers, to explore challenges of HIV prevention among FSWs in Mumbai. A thematic analysis identified contextual factors that impact CM implementation. Large-scale interventions are not only impacted by, but were shown to shape the dynamic social context. Registration practices and programme monitoring were experienced as stigmatising, reflected in shifting client preferences towards women not disclosing as 'sex workers'. This combined with urban redevelopment and gentrification of traditional red light areas, forcing dispersal and more 'hidden' ways of solicitation, further challenging outreach and collectivisation. Participants reported that brothel owners and 'pimps' continued to restrict access to sex workers and the heterogeneous 'community' of FSWs remains fragmented with high levels of mobility. Stakeholder engagement was poor and mobilising around HIV prevention not compelling. Interventions largely failed to respond to community needs as strong target-orientation skewed activities towards those most easily measured and reported. CONCLUSION: Large-scale interventions have been impacted by and contributed to an increasingly complex sex work environment in Mumbai, challenging outreach and mobilisation efforts. Sex workers remain a vulnerable and disempowered group needing continued support and more comprehensive services

Considering risk contexts in explaining the paradoxical HIV increase among female sex workers in Mumbai and Thane, India.

BACKGROUND: The period 2006-2009 saw intensive scale-up of HIV prevention efforts and an increase in reported safer sex among brothel and street-based sex workers in Mumbai and Thane (Maharashtra, India). Yet during the same period, the prevalence of HIV increased in these groups. A better understanding of sex workers' risk environment is needed to explain this paradox. METHODS: In this qualitative study we conducted 36 individual interviews, 9 joint interviews, and 10 focus group discussions with people associated with HIV interventions between March and May 2012. RESULTS: Dramatic changes in Mumbai's urban landscape dominated participants' accounts, with dwindling sex worker numbers in traditional brothel areas attributed to urban restructuring. Gentrification and anti-trafficking efforts explained an escalation in police raids. This contributed to dispersal of sex work with the sex-trade management adapting by becoming more hidden and mobile, leading to increased vulnerability. Affordable mobile phone technology enabled independent sex workers to trade in more hidden ways and there was an increased dependence on lovers for support. The risk context has become ever more challenging, with animosity against sex work amplified since the scale up of targeted interventions. Focus on condom use with sex workers inadvertently contributed to the diversification of the sex trade as clients seek out women who are less visible. Sex workers and other marginalised women who sell sex all strictly prioritise anonymity. Power structures in the sex trade continue to pose insurmountable barriers to reaching young and new sex workers. Economic vulnerability shaped women's decisions to compromise on condom use. Surveys monitoring HIV prevalence among 'visible' street and brothel-bases sex workers are increasingly un-representative of all women selling sex and self-reported condom use is no longer a valid measure of risk reduction. CONCLUSIONS: Targeted harm reduction programmes with sex workers fail when implemented in complex urban environments that favour abolition. Increased stigmatisation and dispersal of risk can no longer be considered as unexpected. Reaching the increasing proportion of sex workers who intentionally avoid HIV prevention programmes has become the main challenge. Future evaluations need to incorporate building 'dark logic' models to predict potential harms

Contesting restrictive mobility norms among female mentors implementing a sport based programme for young girls in a Mumbai slum.

BACKGROUND: Harmful gender norms are known structural barriers to many public health and development interventions involving adolescent girls. In India, restrictions on girls' liberty to move freely in public spaces contribute to school dropout and early marriage, and negatively affect girls' health and wellbeing, from adolescence into adulthood. We report on mechanisms of change among female mentors 18 to 24 years old who contested discriminatory norms while implementing a sports-based programme for adolescent girls in a Mumbai slum. METHODS: We adopted a prospective qualitative research design. Our analysis is based on case studies derived from two rounds of face to face, in -depth interviews with 10 young women recruited to serve as mentors for the project's young female athletes. We combined both thematic and narrative analysis. RESULTS: The programme created opportunities for collective action, increasing mentors' ability to think and relate in a collectivized manner, and challenged the traditional female identity constructed for young women, which centres on domestic duties. The mentors themselves negotiated freedoms both in and outside their homes, which required careful and strategic bargaining. They changed the nature of key day-to-day social interactions with parents and brothers, as well as with neighbours, parents of their groups of athletes and men on the streets. They formed a new reference group for each other in terms of what was possible and acceptable. Demonstrating greater negotiation skills within the family helped win parents' trust in the mentor's ability to be safe in public spaces. Parents became active supporters by not giving into social sanctions of neighbours and relatives thus co-producing a new identity for their daughters as respectable young women doing 'good work'. They effectively side stepped reputational risk with their presence in public spaces becoming de-sexualised. CONCLUSIONS: Mentors contested mobility restrictions by taking risks as a group first, with collective agency an important step towards greater individual agency. This research provides important insights into addressing embedded social norms that perpetuate gender discriminatory practices and the social patterning of health inequalities

Widening cracks in patriarchy: mothers and daughters navigating gender norms in a Mumbai slum.

Inequitable gender norms can be harmful to girls' and boys' health and sexuality. Programmatic approaches that help renegotiate gendered power relationships are sorely needed. This qualitative study reveals how Parivartan, a sport-based intervention in a Mumbai informal settlement, helped families resist inequitable gender norms that limited girls' mobility in public spaces. Fifteen girl athletes were interviewed in two rounds of face-to-face in-depth interviews. Results identify the strategies girls' mothers used to support their daughters' participation in the programme when they feared their husbands' disapproval. Rather than openly confronting their husbands, mothers worked from within the patriarchal gender order, through its 'cracks', for instance initially hiding their daughters' participation from their husbands. At an appropriate moment, girls' mothers revealed to their husbands about their daughters playing sports, convincing them of the usefulness of the programme. Girls' participation profoundly and positively affected relationships between daughters, mothers and fathers. Over time, parents' trust that girls would not compromise family honour increased, eventually changing the acceptability of girls' playing sport in public in spite of the patriarchal gender order. Concluding remarks offer key implications for effective interventions, highlighting the historical nature of gender transformation processes

Supporting adolescent girls to stay in school, reduce child marriage and reduce entry into sex work as HIV risk prevention in north Karnataka, India: protocol for a cluster randomised controlled trial.

BACKGROUND: Low caste adolescent girls living in rural northern Karnataka are at increased risk of school drop-out, child marriage, and entry into sex-work, which enhances their vulnerability to HIV, early pregnancy and adverse maternal and child health outcomes. This protocol describes the evaluation of Samata, a comprehensive, multi-level intervention designed to address these structural drivers of HIV risk and vulnerability. METHODS/DESIGN: The Samata study is a cluster randomised controlled trial that will be conducted in eighty village clusters (40 intervention; 40 control) in Bijapur and Bagalkot districts in northern Karnataka. The intervention seeks to reach low caste girls and their families; adolescent boys; village communities; high school teachers and school governing committees; and local government officials. All low caste (scheduled caste/tribe) adolescent girls attending 7th standard (final year of primary school) will be recruited into the study in two consecutive waves, one year apart. Girls (n = 2100), their families (n = 2100) and school teachers (n = 650) will be interviewed at baseline and at endline. The study is designed to assess the impact of the intervention on four primary outcomes: the proportion of low caste girls who (i) enter into secondary school; (ii) complete secondary school; (iii) marry before age 15; and (iv) engage in sex before age 15. Observers assessing the outcomes will be blinded to group assignment. The primary outcome will be an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at follow-up. We will also conduct survival analyses for the following secondary outcomes: marriage, sexual debut, pregnancy and entry into sex work. Complementary monitoring and evaluation, qualitative and economic research will be used to explore and describe intervention implementation, the pathways through which change occurs, and the cost-effectiveness of the intervention. DISCUSSION: This is an innovative trial of a comprehensive intervention to improve the quality of life and reduce HIV vulnerability among marginalised girls in northern Karnataka. The findings will be of interest to programme implementers, policy makers and evaluation researchers working in the development, education, and sexual and reproductive health fields. TRIAL REGISTRATION: ClinicalTrials.Gov NCT01996241 . 16th November 2013

Examining diffusion to understand the how of SASA!, a violence against women and HIV prevention intervention in Uganda.

BACKGROUND: A growing number of complex public health interventions combine mass media with community-based "change agents" and/or mobilisation efforts acting at multiple levels. While impact evaluations are important, there is a paucity of research into the more nuanced roles intervention and social network factors may play in achieving intervention outcomes, making it difficult to understand how different aspects of the intervention worked (or did not). This study applied aspects of diffusion of innovations theory to explore how SASA!, a community mobilisation approach for preventing HIV and violence against women, diffused within intervention communities and the factors that influenced the uptake of new ideas and behaviours around intimate partner relationships and violence. METHODS: This paper is based on a qualitative study of couples living in SASA communities and secondary analysis of endline quantitative data collected as part of a cluster randomised control trial designed to evaluate the impact of the SASA! INTERVENTION: The primary trial was conducted in eight communities in Kampala, Uganda between 2007 and 2012. The secondary analysis of follow up survey data used multivariate logistic regression to examine associations between intervention exposure and interpersonal communication, and relationship change (n = 928). The qualitative study used in-depth interviews (n = 20) and framework analysis methods to explore the intervention attributes that facilitated engagement with the intervention and uptake of new ideas and behaviours in intimate relationships. RESULTS: We found communication materials and mid media channels generated awareness and knowledge, while the concurrent influence from interpersonal communication with community-based change agents and social network members more frequently facilitated changes in behaviour. The results indicate combining community mobilisation components, programme content that reflects peoples' lives and direct support through local change agents can facilitate diffusion and powerful collective change processes in communities. CONCLUSIONS: This study makes clear the value of applying diffusion of innovations theory to illuminate how complex public health intervention evaluations effect change. It also contributes to our knowledge of partner violence prevention in a low-income, urban East African context. TRIAL REGISTRATION: ClinicalTrials.gov # NCT00790959 . Registered 13th November 2008

Practice-based insights in developing and implementing a sport-based programme for girls

Parivartan Plus is a structured sports mentoring programme for girls, implemented in a Mumbai slum where social expectations around gender-appropriate behaviour and good parenting restricts girls’ mobility and visibility in public spaces. This article presents practice-based learning from developing and implementing programme theory to empower girls in achieving changes in their everyday social interactions at home and beyond. Gender and social norms theory were combined with local practical wisdom to turn main implementation challenges into opportunities. The article reflects on the strategies that gave visibility to, and achieved community endorsement for, the erosion of restrictive gender norms while ensuring community safety

Numbers, systems, people: how interactions influence integration. Insights from case studies of HIV and reproductive health services delivery in Kenya.

Drawing on rich data from the Integra evaluation of integrated HIV and reproductive-health services, we explored the interaction of systems hardware and software factors to explain why some facilities were able to implement and sustain integrated service delivery while others were not. This article draws on detailed mixed-methods data for four case-study facilities offering reproductive-health and HIV services between 2009 and 2013 in Kenya: (i) time-series client flow, tracking service uptake for 8841 clients; (ii) structured questionnaires with 24 providers; (iii) in-depth interviews with 17 providers; (iv) workload and facility data using a periodic activity review and cost-instruments; and (v) contextual data on external activities related to integration in study sites. Overall, our findings suggested that although structural factors like stock-outs, distribution of staffing and workload, rotation of staff can affect how integrated care is provided, all these factors can be influenced by staff themselves: both frontline and management. Facilities where staff displayed agency of decision making, worked as a team to share workload and had management that supported this, showed better integration delivery and staff were able to overcome some structural deficiencies to enable integrated care. Poor-performing facilities had good structural integration, but staff were unable to utilize this because they were poorly organized, unsupported or teams were dysfunctional. Conscientious objection and moralistic attitudes were also barriers.Integra has demonstrated that structural integration is not sufficient for integrated service delivery. Rather, our case studies show that in some cases excellent leadership and peer-teamwork enabled facilities to perform well despite resource shortages. The ability to provide support for staff to work flexibly to deliver integrated services and build resilient health systems to meet changing needs is particularly relevant as health systems face challenges of changing burdens of disease, climate change, epidemic outbreaks and more

Education, poverty and "purity" in the context of adolescent girls' secondary school retention and dropout: A qualitative study from Karnataka, southern India.

BACKGROUND: Gender-related norms and poverty remain important structural barriers to secondary school attendance among adolescent girls in southern India. We analyse how gender norms interact with family deprivation and dynamics to result in girls dropping out of school; we identify the main facilitators of school retention and changes to gender socialisation. METHODS: Longitudinal qualitative case studies with 36 girls were nested within a cluster randomized trial to evaluate the Samata intervention targeting adolescent girls in Bagalkote and Vijayapura districts in northern Karnataka. We used two rounds of in-depth interviews, conducted in 2014 at a time when respondents were in 8th standard at the age of 13 to 14 and sixteen months later. We combined thematic and narrative analyses. RESULTS: Our study found that poverty and socioeconomic realities at the household level strongly affect conformity with discriminatory gender practices such as restricting girls' mobility. The value placed on education by parents clearly differentiates the regular school goers from those frequently absent and others who dropped out. With active encouragement of the girls' educational and career aspirations, parents engendered the girl's agency to communicate openly both at home and at school, allowing subtle changes to gender performance while resisting the pressure of social sanctions. In contrast, where educational aspirations were weak, parents invested more intensely in enforcing correct performance of gender, prioritising her well-being by aiming to secure her future in a good marriage. Among poorer families, girls' domestic duties came at the cost of schooling with concerns about protecting her sexual purity predominating. CONCLUSIONS: In contexts where a strong gender ideology of virginity before marriage rules, subtle shifts in harmful gender practices are possible. Interventions aiming to improve education need to target the most deprived families, focussing on trust building through open communication