Exploring the Feasibility of Service Integration in a Low-Income Setting: A Mixed Methods Investigation into Different Models of Reproductive Health and HIV Care in Swaziland.

Integrating reproductive health (RH) with HIV care is a policy priority in high HIV prevalence settings, despite doubts surrounding its feasibility and varying evidence of effects on health outcomes. The process and outcomes of integrated RH-HIV care were investigated in Swaziland, through a comparative case study of four service models, ranging from fully integrated to fully stand-alone HIV services, selected purposively within one town. A client exit survey (n=602) measured integrated care received and unmet family planning (FP) needs. Descriptive statistics were used to assess the degree of integration per clinic and client demand for services. Logistic regression modelling was used to test the hypothesis that clients at more integrated sites had lower unmet FP needs than clients in a stand-alone site. Qualitative methods included in-depth interviews with clients and providers to explore contextual factors influencing the feasibility of integrated RH-HIV care delivery; data were analysed thematically, combining deductive and inductive approaches. Results demonstrated that clinic models were not as integrated in practice as had been claimed. Fragmentation of HIV care was common. Services accessed per provider were no higher at the more integrated clinics compared to stand-alone models (p>0.05), despite reported demand. While women at more integrated sites received more FP and pregnancy counselling than stand-alone models, they received condoms (a method of choice) less often, and there was no statistical evidence of difference in unmet FP needs by model of care. Multiple contextual factors influenced integration practices, including provider de-skilling within sub-specialist roles; norms of task-oriented routinised HIV care; perceptions of heavy client loads; imbalanced client-provider interactions hindering articulation of RH needs; and provider motivation challenges. Thus, despite institutional support, factors related to the social context of care inhibited provision of fully integrated RH-HIV services in these clinics. Programmes should move beyond simplistic training and equipment provision if integrated care interventions are to be sustained

The DRUID study: racism and self-assessed health status in an indigenous population

BackgroundThere is now considerable evidence from around the world that racism is associated with both mental and physical ill-health. However, little is known about the mediating factors between racism and ill-health. This paper investigates relationships between racism and self-assessed mental and physical health among Indigenous Australians as well as potential mediators of these relationships.MethodsA total of 164 adults in the Darwin Region Urban Indigenous Diabetes (DRUID) study completed a validated instrument assessing interpersonal racism and a separate item on discrimination-related stress. Self-assessed health status was measured using the SF-12. Stress, optimism, lack of control, social connections, cultural identity and reactions/responses to interpersonal racism were considered as mediators and moderators of the relationship between racism/discrimination and self-assessed health status.ResultsAfter adjusting for socio-demographic factors, interpersonal racism was significantly associated with the SF-12 mental (but not the physical) health component. Stress, lack of control and feeling powerless as a reaction to racism emerged as significant mediators of the relationship between racism and general mental health. Similar findings emerged for discrimination-related stress.ConclusionsRacism/discrimination is significantly associated with poor general mental health among this indigenous population. The mediating factors between racism and mental health identified in this study suggest new approaches to ameliorating the detrimental effects of racism on health. In particular, the importance of reducing racism-related stress, enhancing general levels of mastery, and minimising negative social connections in order to ameliorate the negative consequences of racism

Behavioral Health Theories, Equity, and Disparities in Global Health : A Basic Process Model

Lack of participation in health-promoting behaviors and participation in behaviors that contribute to health risks have been linked to health disparities observed among individuals from disadvantaged backgrounds. This chapter presents a basic process model to summarize the effects of socio-structural variables linked to health disparities – socioeconomic status, education, health literacy, ethnicity, and religiosity – on individuals’ beliefs and cognitions that determine behavior. Socio-structural characteristics were proposed to have a pervasive effect on individuals’ beliefs and other constructs from social cognition theories which impact their decisions to participate in prospective health behaviors and influence their health outcomes. The model provides a mechanistic explanation for health disparities among individuals from disadvantaged groups. A series of illustrative examples are presented of the application of the proposed model as a means to explain how characteristics linked to disadvantage relate to participation in health behaviors and outcomes via potentially modifiable mediating beliefs and social cognition constructs. Efforts to develop interventions targeting these modifiable beliefs will contribute to the enhancement of long-term global health and illness prevention.peerReviewe

Mindsets about malleability and intergroup relations

We live in a world rife with unwanted intergroup bias. Is this inevitable, or can it be changed? Recent research suggests that people’s perspectives on this question may determine which reality emerges, one in which intergroup relations come to be improved over time, or one in which they are continually marked by intergroup divisions and bias. This chapter reviews the body of research on mindsets about malleability and stereotyping, prejudice, and discrimination both from the perspective of perceivers (who exhibit bias) and targets (who experience bias). Given the evidence showing the importance of mindsets about malleability for the production of bias, people’s responses to it, and real-world intergroup reconciliation, we advocate an approach to the study of intergroup relations that considers people’s lay theories about malleability. Throughout, we discuss the implications and open questions that arise from this theoretical perspective