Co-development of online violence against women and girls prevention interventions with school-going adolescents

Background: Violence against women and girls (VAWG)amongst adolescents remains a global public health problem. Globally, an estimated 24 per cent of girls aged 15-19 are reported to have experienced VAWG before the age of 20. Experience of VAWG has far reaching health and educational consequences. Thus, the prevention of VAWG needs to be a priority. In recent years, there has been an increase in web-based or online violence prevention interventions. However, these interventions are either secondary prevention interventions, or primary prevention interventions, focused on emergency or protective solutions. Current evidence indicates that group-based participatory violence prevention interventions are an important approach to the primary prevention of VAWG but there remains a gap in understanding if these interventions can be delivered online. Further, it remains unclear if co-development of group-based participatory violence prevention interventions with young people – which has been proposed to enhance contextualisation of interventions – can occur online. Goal and specific objectives: This study aimed to explore and understand the feasibility of co-developing an online group-based participatory VAWG prevention intervention for adolescents. The specific objectives of this study were (i) from the perspective of experts understand the feasibility, acceptability and challenges of a group-based participatory VAWG prevention intervention developed and delivered online, (ii) from the perspective of adolescents, understand the feasibility, acceptability and challenges of a group-based participatory VAWG prevention intervention developed and delivered online and (iii) Undertake an online co-development process of an online group-based participatory VAWG prevention intervention with adolescents. ix Methods: This qualitative study was conducted in Gqeberha (formerly known as Port Elizabeth), in the Nelson Mandela Bay municipality, Eastern Cape Province of South Africa. The study was guided by the intervention development framework: 6 Essential Steps for Quality Intervention Development (6SQuID). Data were collected online using in-depth semi-structured interviews, with 20 experts sampled through convenience and snowball strategies and 18 purposively sampled adolescents, to achieve objectives one and two. This was then followed by a co-development process with high school-going adolescents (ages 18- 19 years) to achieve objective three. In the co-development process, the candidate worked with a small group of adolescents (four adolescents) for five sessions online, over a period of two weeks. In these sessions, the co-development team engaged in discussions on sexual violence, which resulted in creation of a problem tree and populated a theory of change table. Data were transcribed in English, verbatim and analysed using thematic network analyses. Findings: Findings for the first objective about understanding from the perspective of experts the feasibility, acceptability and challenges of a group-based participatory VAWG prevention intervention developed and delivered online, showed experts identified several opportunities for these. Specifically, experts identified the potential of bringing these interventions to scale, which has been a challenge for in-person interventions, as well as accessing hard to reach groups, such as people in conflict settings, those on the move and people with limited mobility. However, experts felt there were many complex questions in the development of an online VAWG prevention intervention that needed resolving. Some of the challenges raised by experts included concerns of achieving privacy, trust, and safety online, which are central to achieving transformative communication. Experts also struggled to grapple with how a sense of community could be achieved online. There were also concerns amongst experts about material challenges such as access to devices, access to data and poor connectivity. x Interestingly, younger experts were more open to online participatory interventions than the more experienced experts. Findings for objective two “from the perspective of adolescents, understand the feasibility, acceptability and challenges of a group-based participatory VAWG prevention intervention developed and delivered online”, young people reported they were keen and open to the idea of online group-based participatory VAWG prevention interventions. They discussed how they enjoyed engaging in online groups and often experienced a sense of belonging in these groups. Yet, like the experts, school-going adolescents were concerned about safety, privacy, and trust in online groups. These concerns shaped adolescents’ willingness to disclose sensitive information online and ability to engage in open dialogue. Concern over privacy, trust and safety online also influenced adolescents’ choices over which apps to engage with, and with whom. Young people were active in thinking through and addressing how they dealt with safety, privacy and trust issues online. The third objective was “to undertake an online co-development process of an online group-based participatory VAWG prevention intervention with adolescents”, which was done over two weeks. A range of positive outcomes were identified. Firstly, young people enjoyed the level of autonomy and their depth of involvement in the process. They had come into the process anticipating being lectured to and were pleasantly surprised to find that their role was central, and they would drive the process. Secondly, adolescents were eager to be involved and appreciated being ‘heard’. This allowed for a more extensive exploration of their understanding on the topic, and development of the intervention activities that emerged. Thirdly, young people found it easy to build rapport online, both amongst each other, and with the facilitator, which made communication in the group easier. Importantly, this group of adolescents had their own laptops, or cell phones to use, and the project provided data for the young people to participate. However, there were also challenges to the process of coxi development. The central challenge was that young people and facilitator often slipped into a form of teacher-learner communication, driven by their prior histories of didactic education, which led the adolescents to ‘fearing’ to give ‘wrong’ responses. The facilitator also struggled on how to maintain adolescents’ autonomy of thought, while also incorporating ‘scientific evidence’ in the emerging intervention activities. Furthermore, the more talkative school-going adolescents took the centre stage in the discussions, with the quieter ones remaining quiet. Conclusions: The findings of this study showed that the feasibility of taking group-based participatory interventions online are possible, but this is shaped by a complex set of factors, that impact on the possibilities for transformative communication, and on the creation of safe social spaces – such as trust, privacy, safety. The central question is whether the theoretical constructs of transformative communication and safe social spaces are achievable online. A significant step in moving towards enabling transformative communication online will be addressing the issues of privacy, safety and trust. Careful training of facilitators around skills to facilitate group-based participatory VAWG prevention interventions online is also recommended. The complexities of delivering online participatory interventions require careful consideration, and this needs to be developed and thought about in conjunction with school-going adolescents (the target group), to ensure that interventions resonate with their needs and requirements. Future directions in this research field are provided.Thesis (PhD) -- Faculty of Health Sciences, 202

Co-development of online violence against women and girls prevention interventions with school-going adolescents

Background: Violence against women and girls (VAWG)amongst adolescents remains a global public health problem. Globally, an estimated 24 per cent of girls aged 15-19 are reported to have experienced VAWG before the age of 20. Experience of VAWG has far reaching health and educational consequences. Thus, the prevention of VAWG needs to be a priority. In recent years, there has been an increase in web-based or online violence prevention interventions. However, these interventions are either secondary prevention interventions, or primary prevention interventions, focused on emergency or protective solutions. Current evidence indicates that group-based participatory violence prevention interventions are an important approach to the primary prevention of VAWG but there remains a gap in understanding if these interventions can be delivered online. Further, it remains unclear if co-development of group-based participatory violence prevention interventions with young people – which has been proposed to enhance contextualisation of interventions – can occur online. Goal and specific objectives: This study aimed to explore and understand the feasibility of co-developing an online group-based participatory VAWG prevention intervention for adolescents. The specific objectives of this study were (i) from the perspective of experts understand the feasibility, acceptability and challenges of a group-based participatory VAWG prevention intervention developed and delivered online, (ii) from the perspective of adolescents, understand the feasibility, acceptability and challenges of a group-based participatory VAWG prevention intervention developed and delivered online and (iii) Undertake an online co-development process of an online group-based participatory VAWG prevention intervention with adolescents. ix Methods: This qualitative study was conducted in Gqeberha (formerly known as Port Elizabeth), in the Nelson Mandela Bay municipality, Eastern Cape Province of South Africa. The study was guided by the intervention development framework: 6 Essential Steps for Quality Intervention Development (6SQuID). Data were collected online using in-depth semi-structured interviews, with 20 experts sampled through convenience and snowball strategies and 18 purposively sampled adolescents, to achieve objectives one and two. This was then followed by a co-development process with high school-going adolescents (ages 18- 19 years) to achieve objective three. In the co-development process, the candidate worked with a small group of adolescents (four adolescents) for five sessions online, over a period of two weeks. In these sessions, the co-development team engaged in discussions on sexual violence, which resulted in creation of a problem tree and populated a theory of change table. Data were transcribed in English, verbatim and analysed using thematic network analyses. Findings: Findings for the first objective about understanding from the perspective of experts the feasibility, acceptability and challenges of a group-based participatory VAWG prevention intervention developed and delivered online, showed experts identified several opportunities for these. Specifically, experts identified the potential of bringing these interventions to scale, which has been a challenge for in-person interventions, as well as accessing hard to reach groups, such as people in conflict settings, those on the move and people with limited mobility. However, experts felt there were many complex questions in the development of an online VAWG prevention intervention that needed resolving. Some of the challenges raised by experts included concerns of achieving privacy, trust, and safety online, which are central to achieving transformative communication. Experts also struggled to grapple with how a sense of community could be achieved online. There were also concerns amongst experts about material challenges such as access to devices, access to data and poor connectivity. x Interestingly, younger experts were more open to online participatory interventions than the more experienced experts. Findings for objective two “from the perspective of adolescents, understand the feasibility, acceptability and challenges of a group-based participatory VAWG prevention intervention developed and delivered online”, young people reported they were keen and open to the idea of online group-based participatory VAWG prevention interventions. They discussed how they enjoyed engaging in online groups and often experienced a sense of belonging in these groups. Yet, like the experts, school-going adolescents were concerned about safety, privacy, and trust in online groups. These concerns shaped adolescents’ willingness to disclose sensitive information online and ability to engage in open dialogue. Concern over privacy, trust and safety online also influenced adolescents’ choices over which apps to engage with, and with whom. Young people were active in thinking through and addressing how they dealt with safety, privacy and trust issues online. The third objective was “to undertake an online co-development process of an online group-based participatory VAWG prevention intervention with adolescents”, which was done over two weeks. A range of positive outcomes were identified. Firstly, young people enjoyed the level of autonomy and their depth of involvement in the process. They had come into the process anticipating being lectured to and were pleasantly surprised to find that their role was central, and they would drive the process. Secondly, adolescents were eager to be involved and appreciated being ‘heard’. This allowed for a more extensive exploration of their understanding on the topic, and development of the intervention activities that emerged. Thirdly, young people found it easy to build rapport online, both amongst each other, and with the facilitator, which made communication in the group easier. Importantly, this group of adolescents had their own laptops, or cell phones to use, and the project provided data for the young people to participate. However, there were also challenges to the process of coxi development. The central challenge was that young people and facilitator often slipped into a form of teacher-learner communication, driven by their prior histories of didactic education, which led the adolescents to ‘fearing’ to give ‘wrong’ responses. The facilitator also struggled on how to maintain adolescents’ autonomy of thought, while also incorporating ‘scientific evidence’ in the emerging intervention activities. Furthermore, the more talkative school-going adolescents took the centre stage in the discussions, with the quieter ones remaining quiet. Conclusions: The findings of this study showed that the feasibility of taking group-based participatory interventions online are possible, but this is shaped by a complex set of factors, that impact on the possibilities for transformative communication, and on the creation of safe social spaces – such as trust, privacy, safety. The central question is whether the theoretical constructs of transformative communication and safe social spaces are achievable online. A significant step in moving towards enabling transformative communication online will be addressing the issues of privacy, safety and trust. Careful training of facilitators around skills to facilitate group-based participatory VAWG prevention interventions online is also recommended. The complexities of delivering online participatory interventions require careful consideration, and this needs to be developed and thought about in conjunction with school-going adolescents (the target group), to ensure that interventions resonate with their needs and requirements. Future directions in this research field are provided.Thesis (PhD) -- Faculty of Health Sciences, 202

The relationship between attribution style, rural vs urban status and traumatic stress severity in Kiambu and Nyeri counties, Kenya

Traumatic exposure and posttraumatic stress in Kenya is a common experience. Despite this prevalence, an investigation of the dynamic influence of variables (such as cultural differences) on posttraumatic stress has received little attention in the country. This means that a relatively narrow understanding of traumatic stress exists in the Kenyan context. This study therefore investigated the relationship between attribution style, rural vs. urban status and posttraumatic stress severity. The exploration and description of these relationships contributed to creating a more nuanced understanding of traumatic stress. Such a nuanced understanding would be useful to a variety of fields of practice. The study utilised a sample from a rural and urban area of Kenya. A purposive convenience sample of 178 rural and 176 urban individuals was used. The study employed a biographical questionnaire and 2 quantitative measures, namely, the Attribution Style Questionnaire (ASQ) and the PTSD Checklist for DSM-5 (PCL-5). Descriptive and inferential statistics were used to analyse the data. Results indicated that posttraumatic stress severity in the urban area was significantly higher than in the rural area. The urban sample was significantly more likely to attribute negative events to internal (rather than external) and specific (rather than global) causes than the rural sample. A regression analysis showed that a negative internal attribution style and educational level had a significant relationship with posttraumatic stress severity

The genetic basis of endometriosis and comorbidity with other pain and inflammatory conditions

Endometriosis is a common condition associated with debilitating pelvic pain and infertility. A genome-wide association study meta-analysis, including 60,674 cases and 701,926 controls of European and East Asian descent, identified 42 genome-wide significant loci comprising 49 distinct association signals. Effect sizes were largest for stage 3/4 disease, driven by ovarian endometriosis. Identified signals explained up to 5.01% of disease variance and regulated expression or methylation of genes in endometrium and blood, many of which were associated with pain perception/maintenance (SRP14/BMF, GDAP1, MLLT10, BSN and NGF). We observed significant genetic correlations between endometriosis and 11 pain conditions, including migraine, back and multisite chronic pain (MCP), as well as inflammatory conditions, including asthma and osteoarthritis. Multitrait genetic analyses identified substantial sharing of variants associated with endometriosis and MCP/migraine. Targeted investigations of genetically regulated mechanisms shared between endometriosis and other pain conditions are needed to aid the development of new treatments and facilitate early symptomatic intervention

The genetic basis of endometriosis and comorbidity with other pain and inflammatory conditions

Endometriosis is a common condition associated with debilitating pelvic pain and infertility. A genome-wide association study meta-analysis, including 60,674 cases and 701,926 controls of European and East Asian descent, identified 42 genome-wide significant loci comprising 49 distinct association signals. Effect sizes were largest for stage 3/4 disease, driven by ovarian endometriosis. Identified signals explained up to 5.01% of disease variance and regulated expression or methylation of genes in endometrium and blood, many of which were associated with pain perception/maintenance (SRP14/BMF, GDAP1, MLLT10, BSN and NGF). We observed significant genetic correlations between endometriosis and 11 pain conditions, including migraine, back and multisite chronic pain (MCP), as well as inflammatory conditions, including asthma and osteoarthritis. Multitrait genetic analyses identified substantial sharing of variants associated with endometriosis and MCP/migraine. Targeted investigations of genetically regulated mechanisms shared between endometriosis and other pain conditions are needed to aid the development of new treatments and facilitate early symptomatic intervention

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

How Social Contexts May Shape Online Participatory Violence Prevention Interventions for Youth? Views of Researchers and Practitioners

There is increasing interest in the possibility of delivering violence prevention interventions online. This interest has been intensified by the &lsquo;stay at home&rsquo; mandates brought about by COVID-19, which has pushed violence prevention practitioners to find innovative ways to deliver violence prevention interventions during the pandemic. Our study sought to understand the ways in which social contexts may enhance or impede participatory interventions for youth online. We conducted 20 in-depth interviews with researchers and practitioners based in various parts of the world. Data were analysed using thematic network analysis. Results indicated that online participatory violence prevention interventions may on the one hand be undermined by material factors such as access to devices, familiarity with technology, Internet infrastructure, and recruitment strategies. On the other hand, young people&rsquo;s preference for online engagement, the ability to reach those less inclined to take part in in-person interventions, and the potential for continued engagement in cases of participants on the move were raised. Online group-based participatory violence interventions are crucial for situations when in-person meeting may not be possible. We present initial thoughts on how social contexts might impact the occurrence of these interventions online. More evidence is needed to help us understand how the social contexts can shape the outcomes of online participatory violence prevention interventions

Learners’ viewpoints on the possibilities and limitations imposed by social contexts on online group-based participatory interventions to address violence

Intimate partner violence (IPV) is a global public health concern amongst young people. Consequently, prevention efforts in the form of participatory interventions have been implemented, mainly in face-to-face settings. However, in recent years, there has been a growing interest to deliver participatory IPV prevention interventions online, and this has been exacerbated by COVID-19 imposed limitations. There remain concerns, however, about the impact social contexts may have on transformative communication in participatory interventions online. We conducted semi-structured interviews with 18 learners (14–19 years) from Eastern Cape province, South Africa, to understand the possibilities and limitations that social contexts impose on online participatory IPV prevention interventions. Access to devices, reliable internet, and privacy in homes provided opportunities for online IPV prevention interventions, while limited privacy, safety, concentration, and familiarity with some apps online challenged young people’s interest in online IPV prevention interventions. We also found that young people’s greatest concern was around achieving trust, privacy and safety online. More evidence is needed on how trust, privacy, and safety, supportive of transformative communication, can be achieved online. Further, young people are active and strategic in their engagements online and their potential to generate creative relevant solutions to address these challenges is highlighted

Impact of Covid-19 Pandemic on Food Consumption Pattern in the Population of Nairobi, Kenya

The COVID-19 pandemic has had an impact on food systems globally especially due to its containment measures and this has disrupted food consumption patterns among individuals. The study compared food consumption patterns and diet quality before and upon the onset of the COVID-19 pandemic in urban households in Nairobi City, Kenya. The investigation was cross-sectional in nature with 1460 respondents, conducted between May-June 2020.&nbsp; The survey link was disseminated to respondents using online platforms namely WhatsApp, Twitter, Facebook and emails. A seven-day food frequency questionnaire was incorporated that sought what they consumed 7-days before and 7-days after the onset of the COVID-19 pandemic.&nbsp; Descriptive statistics and Chi-square tests were used to determine the association among variables. A 95% confidence interval was adopted. The respondents were 1460 in total, a majority (52.7%) being women with a mean age of 49 years, most (58%) were employed and 96% had a college/ university education. There was an increase in the intake of cereals from 62.3% to 72.6%, a decline in consumption of sugar from 42.5% to 30.8% and dairy products from 70.5% to 58.9% amid the COVID-19 pandemic. In addition, there was a rise in the intake of fruits and vegetables among respondents from 56.2% to 66.4% and a decrease in consumption of meat, poultry, fish, and eggs from 30.1% to 25.3% amid the covid-19 pandemic. This inquiry observed a significant association between intake of fats and oils with respondents’ occupation (p=0.011), income (p= 0.003) and age (p&lt;0.001). The majority (67.1%) of the participants reported an improvement in food hygiene practices while intake of fresh foods deteriorated (50%). The study showed that the COVID-19 pandemic skewed consumption of healthy diets which may influence body immunity hence the ability to suppress SARS-CoV-2 infection.&nbsp