No one left behind: Using mixed-methods research to identify and learn from socially marginalised adolescents in low- and middle-income countries

This article describes the mixed-methods approach used by the Gender and Adolescence: Global Evidence (GAGE) research programme. It discusses how qualitative and quantitative methods can be used both in isolation and combined to learn about the lives of adolescents in low- and middle-income countries (LMICs), focusing on the methodological and ethical approaches used to reach socially marginalised adolescents (including adolescents with disabilities, adolescents not in school, adolescent refugees, adolescents living in urban slums, adolescents who married as children, and adolescent mothers). We reflect on the implementation of the GAGE conceptual framework, discussing its strengths and weaknesses, and the challenges to promoting inclusive and genuinely mixed-methods research practices. While these methods have been adapted in the countries where research was undertaken, the conceptual framework provides a common methodological approach, utilising an intersectional lens. We show how mixed-methods approaches can contribute to the knowledge base on research with socially marginalised adolescent girls and boys globally, serving as an important resource for future research with young people in LMICs

“Sometimes they used to whisper in our ears”: health care workers’ perceptions of the effects of abortion legalization in Nepal

BACKGROUND: Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers’ views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care. METHODS: To complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data. RESULTS: Overall, participants had positive views of abortion legalization – many believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment. CONCLUSIONS: Providers were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications

Suffering in silence: consequences of sexual violence within marriage among young women in Nepal

<p>Abstract</p> <p>Background</p> <p>Despite the grave consequences of sexual violence, and it's persistence both within and outside marriages, this subject has received relatively little attention from researchers, policy makers, and programme managers in Nepal. This paper explores the definition of sexual violence and its various forms and consequences as reported by young married women in Nepal. In addition, it describes the coping mechanisms used by young married women to avoid sexual violence perpetrated against them by their husbands.</p> <p>Methods</p> <p>This paper analyzes data collected during the qualitative study on "Sexual violence among young couples in Nepal", conducted amongst two major ethnic groups - Brahmin/Chhetri and Tharu - between 2006 and 2007. The data is comprised of 39 free-lists and 15 in-depth case histories with married women aged 15-24 years. The average rank and Smith's Salience were calculated from the free-listing data. The thematic analysis approach was used for the analysis of information from the case histories.</p> <p>Results</p> <p>Approximately three-quarters (74%) of the young women mentioned 'sex against one's wishes' as sexual violence within marriage (SVWM). Sixty-two percent of respondents described 'forced sex during illness' and 'forced sex after consumption of alcohol' as SVWM. About half of young women (48.7%) who participated in the free-listing exercise reported having experienced SVWM. The types of SVWM ranged from unwanted sexual touch to forced sex. Backache, headache, lower abdominal pain, vaginal bleeding and thoughts of suicide were the most commonly reported negative physical and psychological health consequences of SVWM. Women reported various coping strategies including 'trying to convince husbands', 'sleeping in a separate room', 'visiting maternal home', 'waking up the children', and 'using pretexts such as being ill or menstruating', to avoid SVWM. However, in most cases, women reported that these coping strategies were unsuccessful. Almost all women experiencing SVWM were socially isolated and did not turn to institutions, relatives or friends for advice and support.</p> <p>Conclusions</p> <p>Sexual violence within marriage is common in Nepal. Findings provide circumstantial evidence of links between sexual violence and negative general and reproductive health outcomes for women. Various actions are required to prevent SVWM and provide immediate support to the victims.</p

Savannahs of Asia: Antiquity, biogeography, and an uncertain future

The savannahs of Asia remain locally unrecognized as distinctive ecosystems, and continue to be viewed as degraded forests or seasonally dry tropical forests. These colonial-era legacies are problematic, because they fail to recognize the unique diversity of Asian savannahs and the critical roles of fire and herbivory in maintaining ecosystem health and diversity. In this review, we show that: the palaeo-historical evidence suggests that the savannahs of Asia have existed for at least 1 million years, long before widespread landscape modification by humans; savannah regions across Asia have levels of C4 grass endemism and diversity that are consistent with area-based expectations for non-Asian savannahs; there are at least three distinct Asian savannah communities, namely deciduous broadleaf savannahs, deciduous fine-leafed and spiny savannahs and evergreen pine savannahs, with distinct functional ecologies consistent with fire- and herbivory-driven community assembly. Via an analysis of savannah climate domains on other continents, we map the potential extent of savannahs across Asia. We find that the climates of African savannahs provide the closest analogues for those of Asian deciduous savannahs, but that Asian pine savannahs occur in climates different to any of the savannahs in the southern continents. Finally, we review major threats to the persistence of savannahs in Asia, including the mismanagement of fire and herbivory, alien woody encroachment, afforestation policies and future climate uncertainty associated with the changing Asian monsoon. Research agendas that target these issues are urgently needed to manage and conserve these ecosystems. This article is part of the themed issue ‘Tropical grassy biomes: linking ecology, human use and conservation’

Lessons and implications from a mass immunization campaign in squatter settlements of Karachi, Pakistan: an experience from a cluster-randomized double-blinded vaccine trial [NCT00125047]

OBJECTIVE: To determine the safety and logistic feasibility of a mass immunization strategy outside the local immunization program in the pediatric population of urban squatter settlements in Karachi, Pakistan. METHODS: A cluster-randomized double blind preventive trial was launched in August 2003 in 60 geographic clusters covering 21,059 children ages 2 to 16 years. After consent was obtained from parents or guardians, eligible children were immunized parenterally at vaccination posts in each cluster with Vi polysaccharide or hepatitis A vaccine. Safety, logistics, and standards were monitored and documented. RESULTS: The vaccine coverage of the population was 74% and was higher in those under age 10 years. No life-threatening serious adverse events were reported. Adverse events occurred in less than 1% of all vaccine recipients and the main reactions reported were fever and local pain. The proportion of adverse events in Vi polysaccharide and hepatitis A recipients will not be known until the end of the trial when the code is broken. Throughout the vaccination campaign safe injection practices were maintained and the cold chain was not interrupted. Mass vaccination in slums had good acceptance. Because populations in such areas are highly mobile, settlement conditions could affect coverage. Systemic reactions were uncommon and local reactions were mild and transient. Close community involvement was pivotal for information dissemination and immunization coverage. CONCLUSION: This vaccine strategy described together with other information that will soon be available in the area (cost/effectiveness, vaccine delivery costs, etc) will make typhoid fever control become a reality in the near future

Mapping disparities in education across low- and middle-income countries

Analyses of the proportions of individuals who have completed key levels of schooling across all low- and middle-income countries from 2000 to 2017 reveal inequalities across countries as well as within populations. Educational attainment is an important social determinant of maternal, newborn, and child health(1-3). As a tool for promoting gender equity, it has gained increasing traction in popular media, international aid strategies, and global agenda-setting(4-6). The global health agenda is increasingly focused on evidence of precision public health, which illustrates the subnational distribution of disease and illness(7,8); however, an agenda focused on future equity must integrate comparable evidence on the distribution of social determinants of health(9-11). Here we expand on the available precision SDG evidence by estimating the subnational distribution of educational attainment, including the proportions of individuals who have completed key levels of schooling, across all low- and middle-income countries from 2000 to 2017. Previous analyses have focused on geographical disparities in average attainment across Africa or for specific countries, but-to our knowledge-no analysis has examined the subnational proportions of individuals who completed specific levels of education across all low- and middle-income countries(12-14). By geolocating subnational data for more than 184 million person-years across 528 data sources, we precisely identify inequalities across geography as well as within populations.Peer reviewe

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2—to end preventable child deaths by 2030—we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000–2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations

Estimating global injuries morbidity and mortality : methods and data used in the Global Burden of Disease 2017 study

Background While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. Methods In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. Results GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. Conclusions GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.Peer reviewe