Sexual health policies and youth: a case study of the Maldives

This research examines sexual health (SH) policies and experiences of youth, using the Maldives as a case study. Youth SH is a controversial and under-researched issue in The Maldives, an Islamic state where premarital sexual activity is a punishable offence. This thesis addresses the question: To what extent, and why is there a mismatch between official Maldivian SH policies, services and data and the lived experiences of youth in Maldives? It is a mixed methods study involving four research methods and sets of data: i) qualitative in-depth interviews (n=61) with youth aged 18-24 years from three sites within the Maldives; ii) key informant interviews (n=17) with policy actors and service providers; iii) a web-based quantitative survey of Maldivian youth (n=480); and iv) secondary analysis of the Maldives DHS 2009. There are four main findings from this research, three of which are substantive, and one of which is methodological. Sociocultural and religious factors heavily influenced policymaking, service provision and youth experiences. Contrary to most theocratic states, the SH policymaking process in the Maldives is shaped by policy actors and institutions whose strengths have more sociocultural basis than religious expertise. Whilst published official data and original secondary analyses of the MDHS suggest that premarital sexual activity among youth is very limited; this thesis finds extensive reporting of sexual activity. This contrast was also reflected in youth’s knowledge of STIs- where official data displayed a higher level of awareness than found through in-depth interviews and the web-based survey- and their experience of unwanted pregnancies and abortions, which appear to be under-reported in official data. Analyses of the web-based survey using the same questions as the DHS show significantly higher levels of reporting of sexual activity, showing a strong modality effect on survey response. Results from the web-based survey demonstrated that if sociocultural factors were removed from questionnaire design (e.g. censorship of certain issues) and administration (e.g., privacy and anonymity- difficult to achieve in small island communities typical of the Maldives); it is possible to improve response rates and quality of the data. Finally, this thesis highlights two key characteristics of the relationship between SH policy, services, data and youth experiences in the Maldives. Firstly, youth SH experiences appear to be disconnected from SH policies, services and data. Secondly, there is a mutually reinforcing relationship between official SH data and policies, where restrictive policies dictate the type and extent of data that may be collected, which then reinforce justifications for the current restrictive policies and limited services. Policy implications of this research include identifying and addressing the links between SH policymaking and religious and sociocultural factors, and addressing the subsequent effect on SH policy and services for youth

To be young, unmarried, rural, and female: intersections of sexual and reproductive health and rights in the Maldives.

This paper explores sexual and reproductive health and rights (SRHR) among young people, identifying intersecting factors that create inequities in access to services, health-seeking behaviour, and ultimately health outcomes. Based on qualitative interviews with young people in the Maldives, it demonstrates how these intersectional experiences are contrary to what is often assumed in official data, policies, and services. Three factors were found to shape young people's experiences: marital status, gender, and urban/rural differences. Non-marital sexual activity is illegal in the Maldives, but it is somewhat expected of unmarried men, while unmarried women are stigmatised for being sexually active. Although access to SRH services is restricted for all unmarried people, young women face additional difficulties, as the risk of being exposed is much greater in small island communities. Maldivian island communities are extremely small and characterised by an inward-looking culture that exerts considerable social pressure, particularly on unmarried women. For an unmarried woman, being known to be sexually active, or worse, pregnant outside of marriage, has severe social consequences including stigma and isolation from the community, and their own family. This concern is more prevalent among rural young women, as they live in smaller communities where stigma is inescapable. The need to avoid public scrutiny and humiliation contributes to making unsafe abortion a common solution for many unintended pregnancies. Failure to acknowledge these intersecting factors in SRHR experience and access has led to inequities among an already overlooked population, shaping their experiences, knowledge, health-seeking behaviour, and health outcomes

No One Left Behind? Comparing Poverty and Deprivation between People with and without Disabilities in the Maldives

The 2030 Sustainable Development Goals call for the disaggregation of all indicators by disability and other characteristics so as to “leave no one behind” from development progress. Data on disability, however, is acknowledged to be lacking, which is essential for informing policy and planning. Consequently, this study estimates the prevalence of disability in the Maldives and compares indicators of poverty and living conditions between people with and without disabilities, using nationally-representative, population-based data (n = 5363). The prevalence of disability was estimated at 6.8%. Overall, this research finds that people with disabilities are at risk of being left behind from progress across multiple Sustainable Development Goal domains, including in combatting income poverty, food insecurity and exclusion from health, education, work and social participation, and vulnerability to violence. Further, amongst people with disabilities, people with cognitive and mental health impairments, people living outside the capital, Male’, and children and working-age adults tend to face the highest levels of deprivation.</jats:p

Disability and mental health among Syrian refugees in Sultanbeyli, Istanbul: 2019 Survey Report

Evidence suggests that refugee populations are at an increased risk of disability, especially mental health issues. There is, however, insufficient data regarding the prevalence and lived experience of Syrian refugees with disabilities in Istanbul. This study aims to provide reliable data on disability and mental health, with which to inform service provision, policy, and advocacy

Impact evaluation of the Disability Allowance in the Maldives: Policy Brief

This policy brief is based on findings of a 3ie-supported impact evaluation of the Disability Allowance in the Maldives. This study used a nationally representative, population-based survey of disability in the Maldives, combined with a mixed-methods, quasi-experimental evaluation to assess access to the Disability Allowance and the impact of the Disability Allowance on poverty, health, well-being and social participation. This study found 6.7% of people are living with a disability in the Maldives, of whom 25.5% were receiving the Disability Allowance (programme coverage). Overall, the Disability Allowance had a minimal impact. No impact was found on poverty, well-being and social participation. However, receiving the Disability Allowance was linked to a modest positive impact in health. Access to the Disability Allowance could be improved by streamlining and decentralising the application process, amending the cumbersome requirements for gathering medical documentation of impairments and raising awareness on the application process, including eligibility requirements. The impact of the Disability Allowance may be improved by raising the benefit level, strengthening referrals to linked services and through broader, cross-sector disability-inclusive policy and planning

From words to actions: systematic review of interventions to promote sexual and reproductive health of persons with disabilities in low- and middle-income countries.

INTRODUCTION: Persons with disabilities have the same sexual and reproductive health and rights (SRHR) as non-disabled persons. Yet they face numerous barriers in their access to sexual and reproductive health services and their rights are often not met. Evidence on SRHR for persons with disabilities is sparse, particularly evaluations of interventions demonstrating 'what works.' This systematic review assessed interventions to promote SRHR for persons with disabilities in low- and middle-income countries. METHODS: We searched for qualitative, quantitative or mixed method observational studies representing primary research, published between 2010 and 2019, using MEDLINE, Embase, PubMed, Global Health and CINAHL Plus. Search strings were compiled for different elements of SRHR and for all forms of disability. 24,919 records were screened, leading to over 380 relevant papers, most of which were descriptive, focussing on needs and barriers to SRHR needs being fulfilled. Of the 33 full-text articles assessed for eligibility, 18 were included in the synthesis. All included studies were assessed for bias and quality of evidence, using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) and RATS (relevance, appropriateness, transparency andsoundness) tools. Among the 16 interventions (from 18 articles), 25% had low risk of bias, 31% had moderate risk of bias and 44% had high risk of bias. Data analysis used narrative synthesis; a method suited for systematic reviews with heterogeneous studies. We used Levesque healthcare access model to analyse the focus of interventions. RESULTS: 11 interventions were from upper middle-income settings; two from lower-income settings; only one operated in rural areas. Interventions addressed intellectual impairment (6), visual impairment (6), hearing impairment (4), mental health conditions (2) and physical impairments (2). Most interventions (15/16) focus on information provision and awareness raising. We could not identify any intervention promoting access to maternal health, family planning and contraception, or safe abortion for people with disabilities. CONCLUSION: This systematic review has highlighted stark gaps in evidence. More rigorous evaluations are needed

Disabled people and the impact of COVID-19: four urgent messages for the government

Tom Shakespeare, Nicholas Watson, Richard Brunner, Jane Cullingworth, Shaffa Hameed, Charlotte Pearson, Nathaniel Scherer and Veronika Reichenberger report on in-depth qualitative interviews conducted with 69 disabled people in England and Scotland, and with 28 key informants from infrastructure organisations in the voluntary and statutory sectors, about the impact of COVID-19, and measures taken to control it. They discuss the dislocations it has caused in everyday life; the failures of social care; the use of new technologies; and participants’ views on leadership and communication

Assessing the capacity of primary health care facilities in Nigeria to deliver eye health promotion: Results of a mixed-methods feasibility study.

Over 25 million people in sub-Saharan Africa are blind or visually impaired, the majority from avoidable causes. Health promotion and disease prevention are important strategies for eye health, through good governance, health literacy and increasing access to eye care services. To increase equity in access for eyecare services, the World Health Organization Africa Region developed a package of interventions for primary eye care, which includes health promotion. The aim of this study was to assess the capacity of the primary healthcare system to deliver health promotion for eye care in Nigeria. Mixed methods were used during a survey of 48 government-owned primary health care facilities in Anambra state, Nigeria: interviews with district health supervisors, facility staff and village health workers, and a desk review of policy documents for primary health care and eye care in Nigeria. Findings were benchmarked against the capacities needed to deliver health promotion agreed through a Delphi exercise and were analysed using the World Health Organization’s health system building blocks. Eye health promotion policies exist but are fragmented across different national health policies. Health promotion activities focussed on “mobilising” community members to access care provided in facilities, particularly for women of childbearing age and young children, and health education was limited. Only one in ten facilities engaged the elderly and a fifth delivered health promotion for eye care. Health promotion activities were supervised in 43.2% of facilities and transport to remote areas was limited. A robust eye health promotion strategy needs to be included in the National Eye Health Policy. The scope of existing health promotion will need to expand to include eye conditions and different age groups. Increasing eye health literacy should be emphasized. Governance, training health workers in eye health promotion, educational materials, and transport to visit communities will also be needed

Disabled people and COVID-19: four urgent messages for the government

Tom Shakespeare (LSHTM), Nicholas Watson, Richard Brunner, Jane Cullingworth (University of Glasgow), Shaffa Hameed (LSHTM), Charlotte Pearson (University of Glasgow), Nathaniel Scherer and Veronika Reichenberger (LSHTM) report on in-depth qualitative interviews conducted with 69 disabled people in England and Scotland, and with 28 key informants from infrastructure organisations in the voluntary and statutory sectors, about the impact of COVID-19, and measures taken to control it. They discuss the dislocations it has caused in everyday life; the failures of social care; the use of new technologies; and participants’ views on leadership and communication