Opportunities, challenges and countervailing narratives: Exploring men’s gendered involvement in contraception and family planning in Southern Malawi

Malawi faces challenges regarding increasing its contraceptive use and advancing women’s empowerment. Male involvement, and use of male methods, remain low in Southern Malawi, and little is known about how men’s gendered understandings, attitudes, norms and behaviours influence their approach to contraception and family planning. This study focuses on male involvement to inform a more supportive and equitable environment for the use of contraception. A mixed methods community-based design was employed in urban Blantyre and rural Chiradzulu, including a household survey with 417 men, in-depth interviews with 40 men, six focus group discussions with men and women, 38 interviews with health providers and key stakeholders, secondary male client data and observational techniques. Bivariate and multivariate analyses were carried out, with thematic analysis of qualitative data, before data integration. Analysis was informed by Raewyn Connell's theory of hegemonic masculinities. Gender and contraception were conceptualised and operationalised as female-only. Unmarried men reported greater odds of contraceptive use, using male condoms with their partners, while married men relied exclusively on their wives’ methods. Men reported overall inconsistent condom use and objections to male and female methods, alongside gendered understandings and misconceptions of family planning and contraception. Men’s support for gender equality was associated with increased method use. Men predominately desired to control contraceptive communication flows and decision-making, while women were primarily responsible for preventing pregnancy. Norms of male fertility, breadwinner masculinities, male stoicism, virility, sexual pleasure, multiple sexual partners and ownership of women’s sexuality influenced male involvement in complex and countervailing ways. The health system and government had a limited focus on male involvement and reinforced male hegemony. Programmes and policies require a greater understanding of how the social production of gender and contraception, the enforcement of hegemonic masculinities, and men’s performance of gender norms influence male involvement and undermine women’s reproductive autonomy

Embedding online patient record access in UK primary care: a survey of stakeholder experiences

Summary Objectives To explore the integration of online patient Record Access within UK Primary Care, its perceived impacts on workload and service quality, and barriers to implementation. Design Mixed format survey of clinicians, administrators and patients. Telephone interviews with non-users. Setting Primary care centres within NHS England that had offered online record access for the preceding year. Participants Of the 57 practices initially agreeing to pilot the system, 32 had adopted it and 16 of these returned questionnaires. The 42 individual respondents included 14 practice managers, 15 clinicians and 13 patients. Follow-up interviews were conducted with one participant from 15 of the 25 non-adopter practices. Results Most professionals believed that the system is easy to integrate within primary care; while most patients found it easy to integrate within their daily lives. Professionals perceived no increase in the volume of patient queries or clinical consultations as a result of Record Access; indeed some believed that these had decreased. Most clinicians and patients believed that the service had improved mutual trust, communication, patients’ health knowledge and health behaviour. Inhibiting factors included concerns about security, liability and resource requirements. Non-adoption was most frequently attributed to competing priorities, rather than negative beliefs about the service. Conclusions Record access has an important role to play in supporting patient-focused healthcare policies in the UK and may be easily accommodated within existing services. Additional materials to facilitate patient recruitment, inform system set-up processes, and assure clinicians of their legal position are likely to encourage more widespread adoption. </jats:sec

Lessons learned from engaging men in sexual and reproductive health as clients, partners and advocates of change in the Hoima district of Uganda.

This study examined the impact of a three-year intervention project conducted in the Hoima district of Uganda, which sought to engage men in sexual and reproductive health as clients, equal partners and advocates of change. Structured surveys with 164 self-reported heterosexual men aged 18-54 years were used to assess knowledge and attitudes towards sexual and reproductive health. Data from these were analysed using Stata and SPSS. Additionally, five focus groups were conducted with the female partners and male beneficiaries of the project and with project peer educators. Four interviews were conducted with project staff and male beneficiaries. Data from these and the focus groups were analysed using a thematic approach. Following the intervention, a significantly greater number of men accessed, and supported their partners in accessing sexual health services services, had gained sexual and reproductive health awareness, reported sharing domestic duties and contraceptive decision-making, and displayed a decreased tolerance for domestic violence. It was more difficult to assess men's involvement and behaviours as advocates of change, which sheds light on the complexities of a gender transformative project and the importance of evaluating such projects from both men's and their partners' perspectives and at different levels of the male involvement model in sexual and reproductive health

Giving patients online access to their electronic primary care record: experiences and perceptions of practice staff and service users

The Record Access Collaborative is a voluntary network of clinicians, academics, industry representatives and policymakers interested in emerging Personal Health Record technologies and their impacts on patients and health service providers. This study was commissioned by the Collaborative to explore stakeholders’ experiences with and perceptions of a system that allows patients to access their detailed primary care record online. The specific aims of the analysis were to help understand: 1) How health centres have integrated Record Access into their working practices and its acceptability to providers and recipients of the service 2) How Record Access has influenced clinician behaviour, staff time or workflow, patient self-care and patient-provider relations. 3) The barriers encountered during implementation and any training or support needs that should be addressed 4) Features of the system, or its operational procedures, that may require modification or clarification. This study found overall support amongst clinicians, practice managers and patients for online Record Access. The experience gained from practices participating in this study suggests that Record Access is easy to set up and manage and has few implications for clinical workflow. All three groups articulated benefits that this service will bring to the working practice of health centres, to the health and empowerment of patients, and to the relationships between patients and the health system. At the same time, the study pointed to a number of barriers, uncertainties and areas of improvement that should be addressed before wider deployment. Record access clearly has an important role to play in supporting a more patient focused health system and these findings provide a useful road map for the successful expansion and roll-out of these services

The HIV Blind Spot: Men and HIV Testing, Treatment and Care in Sub?Saharan Africa

Evidence shows that men are significantly underrepresented in HIV and AIDS testing and treatment services – both in sub?Saharan Africa and globally. HIV policies within sub?Saharan Africa also have insufficient focus on ensuring national HIV responses encourage men to test, access anti?retroviral treatment and support the disproportionate burden of HIV care on women. Addressing these challenges is important for everyone's sake and must be approached within a context of addressing power differentials between men and women at all levels. This includes challenging the broader patriarchal power structures in which gender plays out, such as the assumption that care work is ‘women's work’ and therefore less valued, and the rigidity of gender norms that encourage men to participate in risk?taking behaviours that put their life and the life of those around them in jeopardy

Treatment-seeking for tuberculosis-suggestive symptoms: a reflection on the role of human agency in the context of universal health coverage in Malawi

Tuberculosis (TB) is highly infectious and one of the leading killers globally. Several studies from sub-Saharan Africa highlight health systems challenges that affect ability to cope with existing disease burden, including TB, although most of these employ survey-type approaches. Consequently, few address community or patient perspectives and experiences. At the same time, understanding of the mechanisms by which the health systems challenges translate into seeking or avoidance of formal health care remains limited. This paper applies the notion of human agency to examine the ways people who have symptoms suggestive of TB respond to and deal with the symptoms vis-à-vis major challenges inherent within health delivery systems. Empirical data were drawn from a qualitative study exploring the ways in which notions of masculinity affect engagement with care, including men's well-documented tendency to delay in seeking care for TB symptoms. The study was carried out in three high-density locales of urban Blantyre, Malawi. Data were collected in March 2011 -March 2012 using focus group discussions, of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers; and in-depth interviews with 20 TB patients (female = 14) and 20 un-investigated chronic coughers (female = eight). The research process employed a modified version of grounded theory. Data were coded using a coding scheme that was initially generated from the study aims and subsequently progressively amended to incorporate concepts emerging during the analysis. Coded data were retrieved, re-read, and broken down and reconnected iteratively to generate themes. A myriad of problems were described for health systems at the primary health care level, centring largely on shortages of resources (human, equipment, and drugs) and unprofessional conduct by health care providers. Participants consistently pointed out how the problems could drive patients from promptly reporting symptoms at primary healthcare centres. The accounts suggest that in responding to illness symptoms including those suggestive of TB, patients navigate their options taking into cognisance past and current experiences with formal health systems. Understanding and factoring in the mediating role of such 'agency' is critical when implementing efforts to promote timely response to TB-suggestive symptoms

Kailo: a systemic approach to addressing the social determinants of young people’s mental health and wellbeing at the local level [version 1; peer review: awaiting peer review]

The mental health and wellbeing of children and young people is deteriorating. It is increasingly recognised that mental health is a systemic issue, with a wide range of contributing and interacting factors. However, the vast majority of attention and resources are focused on the identification and treatment of mental health disorders, with relatively scant attention on the social determinants of mental health and wellbeing and investment in preventative approaches. Furthermore, there is little attention on how the social determinants manifest or may be influenced at the local level, impeding the design of contextually nuanced preventative approaches. This paper describes a major research and design initiative called Kailo that aims to support the design and implementation of local and contextually nuanced preventative strategies to improve children's and young people’s mental health and wellbeing. The Kailo Framework involves structured engagement with a wide range of local partners and stakeholders - including young people, community partners, practitioners and local system leaders - to better understand local systemic influences and support programmes of youth-centred and evidence-informed co-design, prototyping and testing. It is hypothesised that integrating different sources of knowledge, experience, insight and evidence will result in better embedded, more sustainable and more impactful strategies that address the social determinants of young people’s mental health and wellbeing at the local level

Movements of Diadromous Fish in Large Unregulated Tropical Rivers Inferred from Geochemical Tracers

Patterns of migration and habitat use in diadromous fishes can be highly variable among individuals. Most investigations into diadromous movement patterns have been restricted to populations in regulated rivers, and little information exists for those in unregulated catchments. We quantified movements of migratory barramundi Lates calcarifer (Bloch) in two large unregulated rivers in northern Australia using both elemental (Sr/Ba) and isotope (87Sr/86Sr) ratios in aragonitic ear stones, or otoliths. Chemical life history profiles indicated significant individual variation in habitat use, particularly among chemically distinct freshwater habitats within a catchment. A global zoning algorithm was used to quantify distinct changes in chemical signatures across profiles. This algorithm identified between 2 and 6 distinct chemical habitats in individual profiles, indicating variable movement among habitats. Profiles of 87Sr/86Sr ratios were notably distinct among individuals, with highly radiogenic values recorded in some otoliths. This variation suggested that fish made full use of habitats across the entire catchment basin. Our results show that unrestricted movement among freshwater habitats is an important component of diadromous life histories for populations in unregulated systems