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Nutrition-sensitive agriculture programs hold substantial promise for improving access to nutritious food in contexts like rural Nepal. Yet, implementing such programs in geographically and culturally diverse settings can be challenging. To better understand the contextual factors that influence the ability of program participants to benefit from agriculture-nutrition interventions, we qualitatively examined the implementation of Helen Keller International’s Homestead Food Production program (HFP) in far-western Nepal. Data collection consisted of shadowing program staff for three months, interviewing program participants (n = 31) and staff (n = 10), and conducting three focus-group discussions with female community health volunteers (n = 28). An integrated food and nutrition system framework guided thematic analysis. Participants demonstrated high levels of knowledge about the program’s nutrition messages and expressed interest in and motivation to engage in the HFP program. However, access to water, land, and time determined the extent to which their full participation in the program was feasible. Factors within the biophysical and sociocultural environments interacted to influence access to these crucial resources. Some program participants and staff provided examples of ways in which they overcame these contextual constraints. These included investing in micro-irrigation equipment, arranging land-sharing agreements, and demonstrating more equitable gender norms. Successfully implementing nutrition-sensitive agriculture requires addressing context-specific structural barriers, particularly when aiming to benefit the most vulnerable. Long-term solutions to the barriers faced by the most marginalized households will require broad structural changes. However, problem-solving strategies used by program participants and staff also point towards immediate actions that programs can take to expand the potential for marginalized households to fully participate.

Amid widespread labor migration in Nepal, spousal separation may affect partner communication about intimate topics like family planning. We examined the association between spousal migration exper...

Couple communication and joint decision-making are widely recommended in the family planning and reproductive health literature as vital aspects of fertility management. Yet, most studies continue to rely on women’s reports to measure couple concordance. Moreover, the association between communication and decision-making is often assumed and very rarely studied. Arguably, associations between dyadic communication and shared decision-making constitute a missing link in our understanding of how communication affects fertility-related practices. Informed by Carey’s notions of transmission and ritual communication, this study sought to address those gaps with two complementary studies in Nepal: a qualitative study of married men and women and a quantitative study of 737 couples. To assess spousal concordance on matters of family planning-related communication and decision-making in the quantitative study, responses from the couple were compared for each question of interest and matched responses were classified as concordant. Quantitative results found that more than one-third of couples reported spousal communication on all measured family planning-related topics. Nearly, 87% of couples reported joint decision-making on both family planning use and method type. Partner communication was significantly and positively associated with concordant family planning decision-making in both bivariate and multivariate models. Couples communicating about three family planning topics had more than twice the odds of concordant family planning decision-making than did those not reporting such communication. The qualitative findings provided insights into discordant as well as concordant interactions, revealing that decision-making, even when concordant, is not necessarily linear and is often complex.

This study assessed associations between depression and urban/rural residence from a life-course perspective within African settings. Data on Ghanaian and South African adults aged 50 years and older were taken from wave 1 of the World Health Organization Study on Global Ageing and Adult Health (SAGE). Neither urbanicity of childhood nor adulthood residence was associated with later-life depression in either country. Significant differences were also not observed for residence changes over the life course, but there were trends in the data suggestive of higher depression prevalence in Ghanaian recent rural-urban migrants and lower prevalence among South African recent urban-rural migrants.

Background Conceptualizing gender dynamics and ways of bridging entrenched gender roles will contribute to better health promotion, policy and planning. Such processes are explored in relation to malaria in Mozambique. Methods A multi-method, qualitative study using focus group discussions (FGDs) and in-depth interviews (IDIs) explored the perspectives of community members, leaders and stakeholders on malaria. The study was conducted in Nampula Province, in an intervention district for the Tchova Tchova Stop Malaria (TTSM) gender-sensitive community dialogues, and in a non-intervention district. Results Participants (n = 106) took part in six FGDs and five IDIs in each district. Those exposed to TTSM commonly stated that the programme influenced more equalitarian gender roles, attitudes and uptake of protective malaria-related practices. These positive changes occurred within the context of an observed, gendered decision-making matrix, which aligns inward- or outward-facing decisions with malaria prevention or treatment. Decisions more dependent on male or elder sanctioning at community level are outward-facing decisions, while decisions falling within women’s domain at household level are inward-facing decisions. Related to prevention, using bed nets was largely an inward-facing prevention decision for women, who were generally tasked with hanging, washing and making nets usable. Net purchase and appropriation for malaria prevention (rather than for instance for fishing) was men’s prerogative. Regular net use was associated with sleeping together more regularly, bringing couples closer. Attending antenatal care to access intermittent preventive treatment during pregnancy was often an outward-facing prevention decision, under the purview of older, influential women and ultimately needing sanctioning by men. With respect to seeking care for malaria symptoms, women typically sought help from traditional healers first. This inward-facing treatment decision was within their control, in contrast to the frequently transport-dependent, outward-facing decision to attend a health facility. Sharing decisions was described as a feature of a “harmonious household,” something that was said to be encouraged by the TTSM intervention and that was both lived and aspirational. Conclusions TTSM community dialogues helped communication on both interpersonal (couple) and community levels, ultimately encouraging malaria-related behaviours. Leveraging ways of bringing men and women together to share decision making will improve malaria intervention success.

Limited attention has been given to the effects of labour migration on the reproductive lives of women 'left behind' as their partners travel for work. Drawing on two rounds of qualitative interviews with 20 women in the central hill region of Nepal, this paper examines how global economic processes that lead Nepali men to travel for work also affect women's reproductive work, including childrearing and reproductive decision-making. Women understood their husband's migration to engage in the wage economy as a response to both immediate and long-term goals for their children and family. As a result, such productive work was intrinsically linked to reproductive work. Men's migration patterns played a pivotal role in reinforcing women's immediate childrearing roles and affecting whether and when women used a contraceptive method and what methods they considered. During periods of spousal migration, women's reproductive lives became targets of gossip and rumours as their intimate and reproductive practices and use of remittances were socially monitored. This complex understanding of women's lived experiences at the nexus of (re)productive work and labour migration can be practically applied to address the reproductive health needs of women with migrant spouses in Nepal.

Suaahara, a nutrition-enhancement program in Nepal, conducted participatory community theater (CT) dramas with the goal of improving nutrition-related practices. To evaluate CT, a pre/posttest with randomized intervention and matched control sites was used. Dramas were conducted in Nawalparasi, Bajhang, and Sindhupalchowk Districts to represent the mountain, hill, and terai/plains regions. Within each study district, two intervention sites were randomly selected and two matched comparison sites were identified for inclusion in the study. At both baseline and endline, 600 individuals aged 18-59 (100 men and 100 women/district × 3 districts) were interviewed in the control sites and 600 in the intervention sites (1200 total respondents). Multivariate logistic analysis controlling for background characteristics found that CT attendance was significantly and positively associated with improved nutrition-related knowledge (adjusted odds ratio ratio [aORR] 10.2, p 0.001) and communication (aORR 2.4, p 0.001), hand washing after cleaning a defecating child (aORR 1.49, p 0.05), feeding children eggs (aORR 1.83, p 0.01), and feeding children meat and/or fish (aORR 2.10, p 0.01). This is the first study to rely on a pre/post matched intervention-control design to assess CT effects in a low-income setting. By testing the "difference-in-differences"-or the difference between intervention groups at baseline and endline minus that between controls at baseline and endline-the argument that the effects can be causally attributed to the intervention itself is strengthened. These findings support the continued and expanded use of CT to improve nutrition-related knowledge, communication, efficacy, and feeding practices as a valuable community-based, public health approach.

Background The extent of coronary disease affects clinical outcomes and may predict the effectiveness of coronary revascularization with either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score quantifies the extent of coronary disease. Objectives This study sought to determine whether SYNTAX scores predicted outcomes and the effectiveness of coronary revascularization compared with medical therapy in the BARI-2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. Methods Baseline SYNTAX scores were retrospectively calculated for BARI-2D patients without prior revascularization (N = 1,550) by angiographic laboratory investigators masked to patient characteristics and outcomes. The primary outcome was major cardiovascular events (a composite of death, myocardial infarction, and stroke) over 5 years. Results A mid/high SYNTAX score (≥23) was associated with a higher risk of major cardiovascular events (hazard ratio: 1.36, confidence interval: 1.07 to 1.75, p = 0.01). Patients in the CABG stratum had significantly higher SYNTAX scores: 36% had mid/high SYNTAX scores compared with 13% in the PCI stratum (p Conclusions Among patients with diabetes and stable ischemic heart disease, higher SYNTAX scores predict higher rates of major cardiovascular events and were associated with more favorable outcomes of revascularization compared with medical therapy among patients suitable for CABG. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes; NCT00006305)

Communication between Nepali women and their migrating spouses affects the transregional or transnational social fields of women "left behind" and may have implications for their reproductive health. We explored women's interactions with their absent spouses using data gathered from qualitative interviews. Conversations with migrant husbands were frequent, organized around husbands' schedules, and focused on children's needs and expenses. Couple power dynamics were challenged and reinforced in such conversations. Communication about family planning and childbearing was often delayed until the husband's return. In an increasingly mobile world, encouraging partner communication should be integral to reproductive health programs working with migrant couples.

Female sex workers (FSWs) in sub-Saharan Africa are disproportionately affected by HIV and gender-based violence (GBV). Substance use overlaps with these co-occurring epidemics to further increase FSWs’ risk for negative health outcomes. We explored the relationship between substance use, GBV, and consistent condom use utilizing baseline data from a cohort of 496 FSWs in Tanzania. Results demonstrate high levels of alcohol use and GBV, and low levels of consistent condom use. Frequent intoxication during sex work was associated with increased odds of recent GBV (aOR: 1.64, 95% CI: 1.07, 2.49; p-value: 0.02) and reduced odds of consistent condom use with clients (aOR: 0.58, 95% CI: 0.37, 0.92; p-value: 0.02). We adapt the Risk Environment Framework to contextualize our findings in the social and structural context and to gain insight into intervention approaches to address the intersecting challenges of substance use, GBV, and HIV among FSWs in Tanzania and similar settings.

OBJECTIVES: As the primary cause of disability worldwide, depression is a significant contributor to global morbidity and mortality and often disproportionately affects older adults. Several studies have demonstrated a link between urban residence and depression, but few studies have examined this association among older adult populations, and even fewer have studied it within an African context. Given that African societies are aging and urbanizing at rapid rates, this study aimed to assess the relationship between urbanicity and depression within older adult populations in two African countries. METHOD: Data were drawn from the Ghana and South Africa samples of the World Health Organization Study on Global AGEing and Adult Health (SAGE) wave 1 (2007–2008). Depression over the past 12 months was measured using self-reported treatment and depressive symptoms based on ICD-10 criteria in 4,209 Ghanaian and 3,148 South African adults aged 50 years and older residing in their current location for over one year. RESULTS: The 12-month prevalence of depression was 7.5% and 4.0% in Ghana and South Africa, respectively; 41.1% and 65.6%, respectively, lived in urban areas. Comparing urban to rural residents, the adjusted odds ratio (OR) for depression in multivariable analysis was 1.13 (95% CI: 0.71–1.79) in South Africa and 0.85 (95% CI: 0.55–1.31) in Ghana. CONCLUSION: Results do not support a significant urban-rural difference in 12-month depression among Ghanaian or South African SAGE participants. Mental health resources in rural areas should therefore be enhanced in these countries for more equitable distributions between the two settings given similar need.

Female sex workers experience high rates of gender-based violence and HIV. Alcohol has been shown to facilitate women's risk of both gender-based violence and HIV; however, little research has explored how aspects of the sex work environment shape this risk. Drawing on structuration theory, this study explored how social conduct is patterned across time and space within the sex work environment to influence alcohol consumption, gender-based violence and HIV risk among female sex workers. Qualitative in-depth interviews were conducted with 24 female sex workers enrolled in an ongoing community randomised controlled trial of a combination HIV prevention intervention in Iringa, Tanzania. Data were analysed using both inductive and deductive approaches. Findings reveal how routine interactions between female sex workers and their clients occur at three moments of time and space during the sex exchange process to facilitate alcohol consumption and increase women's risk of gender-based violence and HIV. Findings also highlight how sex workers utilise collective agency to address aspects of the sex work environment that place them at risk of alcohol abuse, gender-based violence and HIV. Implications for future interventions to prevent gender-based violence and HIV among female sex workers in Tanzania and similar contexts are discussed.

Girls are vulnerable to HIV in part because the social systems in which they live have failed to protect them. This study evaluates a program aimed at making schools safe for girl learners in order to reduce girls’ vulnerability to HIV in Botswana, Malawi, and Mozambique. In addition to an extensive process evaluation with school personnel program participants, program facilitators, and community members, a cross-sectional post-intervention survey was conducted among adolescent girls in the three countries. The total sample size was 1249 adolescent girls (ages 11–18). Bivariate and multilevel, multivariate analyses were conducted to assess the association between school participation in the intervention and a decrease in teachers offering sex in exchange for academic favors. In Botswana, girls who attended an intervention school, as compared to girls who attended a non-intervention school, were significantly more likely to report a reduction in teachers offering sex in exchange for favors. Communication interventions that both challenge and empower school personnel to create safer environments for schoolgirls can have positive effects, particularly in settings with sufficient resources to support change.

Past research documents multiple factors associated with girls' susceptibility to human immunodeficiency virus transmission; yet a literature review found no systematic approach to measure vulnerability. This study characterized, developed and tested a set of indicators to measure girls' vulnerability, resulting in the vulnerable girls index (VGI). A quasi- experimental, separate-sample pre-/post-test design was used to test the index. Adolescent girls were randomly drawn for the pre-test (2277 respondents) and post-test (1418 respondents) from 16 purposively selected communities in Botswana, Malawi and Mozambique. The higher the VGI score-or the more vulnerable the girl-the more likely she was to report premarital sexual experience across the three countries and the more likely she was to report low agency to insist upon condom use in Botswana and Mozambique. The VGI can be used to assess girls' vulnerability levels across time and space for policy and programme planning purposes, and as part of programme evaluations.

Girls are vulnerable to HIV in part because the social systems in which they live have failed to support and protect them. The goal of this research was to develop a viable supportive community index and test its association with intermediate variables associated with HIV risk across 16 communities in Botswana, Malawi, and Mozambique. This cross-sectional survey with separate samples randomly drawn in each country (2010) yielded a total sample of 1,418 adolescent girls (aged 11–18). Multilevel, multivariate logistic regression, while controlling for vulnerability, age, religion, and residence, found that an increase in supportive community index is positively associated with the odds of indicating improved community support for girls and with the confidence to refuse unwanted sex with a boyfriend across the three countries, as well as with self-efficacy to insist on condom use in Botswana and Mozambique. Program implementers and decision makers alike can use the supportive community index to identify and measure structural factors associated with girls’ vulnerability to HIV/AIDS; this will potentially contribute to judicious decision making regarding resource allocation to enhance community-level, protective factors for adolescent girls.

In sub-Saharan Africa, girls are several times more likely to be infected with HIV than are boys of the same age and young people aged 15–24 years represent more than half of all new infections. An extensive literature review augmented by formative research conducted in Botswana, Malawi and Mozambique reveals that although individual sexual behaviors heighten risk, a complex interaction of structural factors outside of girls’ control is fueling the epidemic. Guided by the understanding that individuals are influenced by a system of socio-cultural relationships – families, social networks, communities and nations – the Go Girls! (GG) Program incorporated a social ecological approach to prevent HIV. Eight multifaceted interventions were designed and implemented to simultaneously reach communities, leaders, teachers, parents/guardians and young people themselves. This chapter highlights evidence that, despite a short implementation period of 10 months or less, positive effects were extended to girls when adults in their communities worked together to create a more enabling environment for their health, well-being and HIV prevention.

BACKGROUND In developing countries, breast cancer is generally diagnosed late. Two companion quantitative studies found that health system shortages were a major cause of delayed diagnosis together with poor health literacy. Yet, patients' perceptions regarding the delays were missing. OBJECTIVE We conducted a qualitative study to deepen our understanding of women's experiences with diagnosis and treatment delays and highlight nuances not identifiable in the quantitative studies. INTERVENTIONS/METHODS Fifteen women recruited from the quantitative study were interviewed. Information on diagnosis/treatment delays collected in the quantitative study constituted the basis for the selection of participants, the aim being to ensure a maximum of variability in the types of delays. RESULTS In addition to women's health literacy challenges, which likely resulted from the interactions of individual, interpersonal, and systemic factors, barriers attributable to healthcare system weaknesses and financial constraints were revealed to be key factors. CONCLUSIONS To reduce late-stage diagnosis, tackling women's "lack of breast cancer awareness" is far from sufficient. Although the majority of health professionals are not in a position to address structural and policy barriers, it is nonetheless important for them to be cognizant of these barriers so that they can better advise and guide their patients. IMPLICATIONS FOR PRACTICE Our study aimed to provide a deeper understanding of the social, cultural, and structural barriers patients face in Egypt. Such knowledge should help nurses and other health professionals develop a nonjudgmental, compassionate, and perceptive approach to care.

Addressing community-level factors (CLFs) is integral to the ongoing effort to design multilevel, effective, and sustainable interventions to address each element of the HIV/AIDS treatment cascade. This review, the first critical review of this topic, identified 100 articles that (1) assessed CLFs in relation to the HIV/AIDS treatment cascade, (2) had been peer-reviewed, and (3) were based on studies conducted in low- or middle-income countries. Social support and social networks, cultural norms, gender norms, and stigma were the key CLFs associated with treatment and care. This extensive review found only 5 evaluations of interventions designed to affect CLFs, reflecting a major gap in the literature. All were communication interventions designed to create a more positive environment for HIV testing and access to treatment and care, thus pointing to some of the potential extraindividual effects of communication interventions. The qualitative data are rich and vital for understanding the context; yet, more quantitative analysis to provide evidence regarding the distribution of these factors is essential, as only 19 of the studies were quantitative. There is a pressing need to (1) collect community-level data, (2) validate social and gender norm scales, and (3) better use available data regarding social norms, gender norms, and other CLFs. These data could be aggregated at the cluster, neighborhood, or community levels and incorporated into multilevel analysis to help clarify the pathways to enhanced outcomes across the treatment cascade and thereby mitigate HIV sequelae.

IntroductionResearch has demonstrated benefits of social capital on depression, but variations in this relationship by geographic characteristics such as urbanicity have rarely been investigated.MethodsUsing survey data on 4,209 Ghanaian and 3,148 South African adults aged 50 and above from the World Health Organization (WHO) Study on Global AGEing and Adult Health (SAGE), exploratory and confirmatory factor analyses were conducted to extract dimensions of social capital from survey items. Structural equation models with the extracted factors were then used to estimate the associations between social capital and depression in each sample and assess differences between urban and rural settings with measurement and structural invariance tests.ResultsFactor analyses suggested three dimensions of social capital representing community engagement, sociability, and trust. Urbanicity did not substantially modify the effects of social capital on depression in either setting, but urban-rural differences in the measurement and level of social capital were observed. Urban Ghanaian older adults were less socially integrated and trusting than older rural residents (standardized mean difference: -0.28, -0.24, and -0.38 for community engagement, sociability, and trust, respectively) while urban South African older adults appeared less engaged in community activities but significantly more trusting and socially active informally than older rural residents (standardized mean difference: -0.33, 0.30, and 0.17 for community engagement, sociability, and trust, respectively). Moreover, while trust was associated with a lower risk of depression in South Africa overall, sociability and trust were associated with an increased risk of depression in Ghana.ConclusionsResults indicate that the composition and average levels of social capital differ between urban and rural older adult residents in Ghana and South Africa although urban-rural differences in the strength of the association between social capital and depression were not substantial. Furthermore, the associations between social capital and depression are context-specific and are not uniformly beneficial.

This study is an evaluation of a psychosocial intervention involving child and adolescent survivors of the 2008 Sichuan China earthquake. Sociodemographics, earthquake-related risk exposure, resilience using the Connor-Davidson Resilience Scale, and posttraumatic stress disorder (PTSD) using the UCLA-PTSD Index were collected from 1,988 intervention participants and 2,132 controls. Mean resilience scores and the odds of PTSD did not vary between groups. The independent factors for risk and resilience and the dependent variable, PTSD, in the measurement models between control and intervention groups were equivalent. The structural model of risk and 2 resilience factors on PTSD was examined and found to be unequivalent between groups. In contrast to controls, risk exposure (B = −0.32, p Language: en

In Irbid, Jordan, a combination of community outreach, using home visits, plays, women's groups, and religious leaders, and improved client-provider counseling based on the “Consult and Choose” approach increased family planning demand and client satisfaction. Service statistic trends suggest increased contraceptive use., Background: High levels of unmet need for family planning and high contraceptive discontinuation rates persist in Jordan, prompting the Jordan Health Communication Partnership (JHCP) to initiate a client-centered family planning service program called “Consult and Choose” (CC), together with community-based activities to encourage women with unmet need to visit health centers. Methods: We held exit interviews with 461 family planning clients between November–December 2011 to assess, from the clients' perspective, whether trained providers followed the CC protocol and used the CC tools, as well as to measure client satisfaction. We also tracked referral card information from community-based activities to health centers and examined service statistics to explore trends in family planning use. Results: On average, clients reported that providers performed 5.6 of the 7 steps outlined in the CC protocol. Nearly 83% of respondents were very satisfied with their clinic visits. Logistic regression analysis found that the odds of being “very satisfied” increases by 20% with each additional counseling protocol step performed and by 70% with each increase in the number of CC materials used. Between June 2011 and August 2012, 14,490 referral cards from community-based activities were collected in health centers, 59% of which were for family planning services. Service statistic trends indicate an increase in the number of new family planning users and in couple-years of protection after starting the CC program. Conclusions: Implementation of the CC program at health centers nationally, in tandem with community-based interventions, could play a key role in attaining Jordan's goal of reducing its total fertility rate to 2.1 by 2030. Although this initiative would likely be replicated most readily in other middle-income countries, lower-resource countries could also adapt the tested CC approach.

The burden of undernutrition in South Asia is greater than anywhere else. Policies and programmatic efforts increasingly address health and non‐health determinants of undernutrition. In Nepal, one large‐scale integrated nutrition program, Suaahara, aimed to reduce undernutrition among women and children in the 1,000‐day period, while simultaneously addressing inequities. In this study, we use household‐level process evaluation data (N = 480) to assess levels of exposure to program inputs and levels of knowledge and practices related to health, nutrition, and water, sanitation, and hygiene (WASH). We also assess Suaahara's effect on the differences between disadvantaged (DAG) and non‐disadvantaged households in exposure, knowledge, and practice indicators. All regression models were adjusted for potential confounders at the child‐, maternal‐, and household levels, as well as clustering. We found a higher prevalence of almost all exposure and knowledge indicators and some practice indicators in Suaahara areas versus comparison areas. A higher proportion of DAG households in Suaahara areas reported exposure, were knowledgeable, and practiced optimal behaviors related to nearly all maternal and child health, nutrition, and WASH indicators than DAG households in non‐Suaahara areas and sometimes even than non‐DAG households in Suaahara areas. Moreover, differences in some of these indicators between DAG and non‐DAG households were significantly smaller in Suaahara areas than in comparison areas. These results indicate that large‐scale integrated interventions can influence nutrition‐related knowledge and practices, while simultaneously reducing inequities.

In sub-Saharan Africa, adolescent girls are three to four times more likely than adolescent boys to be living with HIV/AIDS. A literature review revealed only four studies that had examined HIV vulnerability from the perspective of community members. None of the studies focused specifically on adolescent girls. To fill this gap, in 2008 12 focus group discussions were held in selected peri-urban and rural sites in Botswana, 12 in Malawi, and 11 in Mozambique to identify factors that render girls vulnerable to HIV infection from the community members’ perspective. The preponderance of comments identified structural factors – insufficient economic, educational, socio-cultural, and legal support for adolescent girls – as the root causes of girls’ vulnerability to HIV through exposure to unprotected sexual relationships, primarily relationships that are transactional and age-disparate. Community members explicitly called for policies and interventions to strengthen cultural, economic, educational, and legal structures to protect girls, recognized community members’ responsibility to take action, and requested programs to enhance adult–child communication, thus revealing an understanding that girls’ vulnerability is multi-level and multi-faceted, so must be addressed through a comprehensive approach to HIV prevention.

African Transformation (AT) is a community development program informed by James Carey's notion of ritual communication and Paulo Freire's theory of critical pedagogy. AT features video portraits of ordinary people in Tanzania, Uganda, and Zambia who have overcome gender-based obstacles to better their lives. In Uganda, women and men gathered to interrogate common beliefs and explore actions they could take in light of the real-life stories portrayed in the videos. We hypothesized that individuals who participated in the program would be more likely than nonparticipants to express high levels of self-efficacy, espouse equitable gender norms, and report high levels of agency. Multivariate regression analysis, controlling for socioeconomic characteristics, confirmed that hypothesis.

Summary Background Families have been shown to be dissatisfied with the frequency of doctor communication in the Critical Care setting. Discussions with families are often conducted in an ad-hoc fashion. We hypothesised that the offer of a formal daily weekday clinic for the relatives of Critical Care patients would increase the relatives’ satisfaction. Methods All patients admitted to a 12-bedded Critical Care Unit over a 6-month period in a 480-bed hospital in the East of England were included in the study. The design was a time-interrupted prospective trial assessing the impact of an offered relatives’ clinic on the satisfaction of the next-of-kin. Satisfaction was assessed 4 weeks following discharge from the Critical Care Unit by mail survey using the validated Critical Care Family Satisfaction Survey (1–5 scoring scale). Results Three hundred twenty-one patients met inclusion criteria. Survey return rate was 46%. The control and intervention groups were similar in size and demographics. Mean satisfaction of the control group was 4.50, and that of the intervention group was 4.55 (p = 0.35). Conclusion Offering a relatives’ clinic does not significantly improve the satisfaction of the next-of-kin in this setting. Other means of improving satisfaction have been highlighted as a result of the study.

Background: Children and adolescents are among the most vulnerable groups affected by natural and man-made disaster. To better understand research and practice concerning mental health and psychosocial support efforts in humanitarian settings, the authors conducted a comprehensive review of all intervention programmes within the past decade that universally targeted children and adolescents who were exposed to a natural and/or man-made disaster.Methods: We searched PubMed, PsychINFO, Cochrane Library and CINAHL for mental health and psychosocial interventions (MHPSS) involving children and adolescents. A total of 11 studies, 4 from natural disasters and 7 from conflict-affected areas met the inclusion criteria. Effect sizes were calculated using a random effects model for studies in post-natural disaster and war/terrorist-affected settings separately.Results: The weighted mean effect sizes for interventions in both settings were statistically significant: −0.308, 95% CI = −0.54– −0.07, z = −2.58, p = 0.010 after a natural disaster, and −0.514, 95% CI = −0.80 to −0.23, z = −3.57, p < 0.001 in conflict areas. This indicates that MHPSS interventions in both disaster settings resulted in a reduction in PTSD symptoms compared to the control.Conclusions: This review suggests that school-based, universal programmes that are conducted by teachers or local paraprofessionals are effective in reducing PTSD symptoms in children and adolescents. The few studies meeting the inclusion criteria of this study demonstrate the need for further expansion of statistical methods and study designs to test for the effects of interventions in challenging humanitarian settings.

Comprehension of health materials and messages is a necessary, though not sufficient, condition for the development of health literacy; in the case of print materials, reading comprehension is elemental. Assessments of the population's ability to read and comprehend written materials are complex and highly salient in multilingual countries, such as Zambia, particularly when an excolonial language is but one of multiple official languages. Yet no study has contrasted adult Zambians' reading comprehension of health materials in the major Zambian languages with comparable English-language materials. This article reports the results of a survey of 2,009 literate Zambian adults who were tested for reading comprehension of health materials written at fourth- and eighth-grade levels. The analysis found that respondents who had not gone beyond primary school scored significantly higher on Zambian- than on English-language reading comprehension tests. Respondents with at least an eighth-grade education scored equally well or better on English-language compared with Zambian-language tests. Overall, respondents were more likely to pass the grade-four than the grade-eight reading comprehension tests. In the multilingual context of Zambia it is vital to produce health communication print materials written at or near a grade-four readability level in English and, when warranted, in appropriate Zambian languages.

We sought to determine the effectiveness of uncovered stents with aneurysm transstent coil embolization compared with endografts for percutaneous abdominal aortic aneurysm (AAA) repair. Thirty-six patients with AAA considered inoperable underwent endovascular repair using the Ancure bifurcated endograft or overlapping uncovered stents with transstent coil embolization. Procedural success, outcomes, serial aneurysm size, aneurysm blood flow, and growth ratios were compared between groups. One patient in each group died due to the procedure and two patients in the endograft cohort required acute surgical repair. After 2.0 ± 0.8 years of follow-up, three patients required endograft placement, four surgical repair, three had AAA rupture, with two AAA-related deaths in the uncovered stent group. No late deaths or surgical conversion occurred in the endograft group. The primary AAA flow exclusion and aneurysm expansion rate and growth were superior in the endograft group and during follow-up. In high-risk patients with AAA, the use of endografts was superior compared to uncovered stents with transstent coil embolization for endovascular repair. Catheter Cardiovasc Interv 2005;64:283–290. © 2005 Wiley-Liss, Inc.

Background.Research has shown less aggressive treatment and poorer control of cardiovascular disease (CVD) risk factors in women than men.Methods.We analyzed sex differences in pharmacotherapy strategies and attainment of goals for hemoglobin A1c (HbA1c), blood pressure (BP), and low density lipoprotein cholesterol (LDL-C) in patients with type 2 diabetes and established coronary artery disease enrolled into the BARI 2D trial.Results.Similar numbers of drugs were prescribed in both women and men. Women were less frequent on metformin or sulfonylurea and more likely to take insulin and to be on higher doses of hydroxymethylglutaryl-CoA reductase inhibitors (statins) than men. After adjusting for baseline differences and treatment prescribed, women were less likely to achieve goals for HbA1c (OR = 0.71, 95% CI 0.57, 0.88) and LDL-C (OR = 0.64, 95% CI 0.53, 0.78). More antihypertensives were prescribed to women, and yet BP ≤ 130/80 mmHg did not differ by sex.Conclusions.Women entering the BARI 2D trial were as aggressively treated with drugs as men. Despite equivalent treatment, women less frequently met targets for HbA1c and LDL-C. Our findings suggest that there may be sex differences in response to drug therapies used to treat diabetes, hypertension, and hyperlipidemia.

This study is an evaluation of a psychosocial intervention involving child and adolescent survivors of the 2008 Sichuan China earthquake. Sociodemographics, earthquake-related risk exposure, resilience using the Connor-Davidson Resilience Scale, and posttraumatic stress disorder (PTSD) using the UCLA-PTSD Index were collected from 1,988 intervention participants and 2,132 controls. Mean resilience scores and the odds of PTSD did not vary between groups. The independent factors for risk and resilience and the dependent variable, PTSD, in the measurement models between control and intervention groups were equivalent. The structural model of risk and 2 resilience factors on PTSD was examined and found to be unequivalent between groups. In contrast to controls, risk exposure (B = −0.32, p.001) in the intervention group was negatively associated with PTSD. Rational thinking (B = −0.48, p.001), a resilience factor, was more negatively associated with PTSD in the intervention group. The second resilience factor explored, self-awareness, was positively associated with PTSD in both groups (B = 0.46 for controls, p.001, and B = 0.69 for intervention, p.001). Results highlight the need for more cross-cultural research in resilience theory to develop culturally appropriate interventions and evaluation measures.

Background The 2008 Sichuan earthquake in China destroyed towns and village, displaced over a million people and caused thousands of deaths. There is a need to understand how children and adolescents are able to bounce back after this distressing event. This study conducts a psychometric assessment of the Connor–Davidson Resilience Scale (CD-RISC) and the measure's validity among children and adolescent survivors in order to identify the factors associated with resilience in this socio-cultural setting. Methods Translated and culturally verified versions of the CD-RISC, UCLA-PTSD Index and Birleson Self-rating Depression Scale were used to collect data from 2132 children and adolescents located in post-disaster areas 1 year after the event. Results Through exploratory factor analysis, a 2-factor model was found and defined by Chinese scholars as Rational Thinking and Self-Awareness. Internal consistency of total CD-RISC was 0.86, 0.91 for Rational Thinking and 0.74 for Self-Awareness. Convergent validity between items ranged from 0.17–0.69 and 0.12–0.20 to the total score. Items related to post-traumatic stress disorder loaded separately than CD-RISC items, demonstrating discriminant validity. Conclusions Our findings demonstrate that resilience may be understood and manifested dissimilarly in different socio-cultural settings. This study confirms the applicability of the CD-RISC scale to Chinese children and adolescent earthquake survivors, and adds to the richness of resilience research cross-culturally.

This three-phase study characterized, validated, and applied community capacity domains in a health communication project evaluation in Zambia. Phase I explored community capacity domains from community members' perspectives (16 focus groups, 14 in-depth interviews, 4 sites. These were validated in Phase II with 720 randomly selected adults. The validated domains were incorporated into a program evaluation survey (2,462 adult women, 2,354 adult men; October 2009). The results indicated that the intervention had direct effects on community capacity; enhanced capacity was then associated with having taken community action for health. Finally, community capacity mediated by community action and controlling for confounders, had a significant effect on women's contraceptive use, children's bed net use, and HIV testing. The results indicate that building community capacity served as a means to an end—improved health behaviors and reported collective action for health—and an end-in-itself, both of which are essential to overall wellbeing.

The Bard Atherectomy Catheter is a new rotational atherectomy device that consists of a flexible, hollow, thin-walled cutting catheter that, while rotated at 1,500 revolutions per minute, is advanced across the lesion over a special spiral guidewire system. We report the initial clinical experience with this device in 20 peripheral lesions in ten patients. The majority of patients were treated for limb salvage. All lesions were successfully intervened on by atherectomy followed by adjunctive balloon angioplasty. A reduction to less than 50% stenosis was achieved in 13 of the 20 lesions (65%) after atherectomy but in all 20 lesions (100%) after adjunctive angioplasty for all lesions and stenting for dissections in two. Baseline minimal lesion lumen diameter was 0.8 ± 0.7 mm with a reference vessel diameter of 4.2 ± 1.7 mm (75 ± 21% stenosis). The lumen improved to 2.0 ± 0.8 mm (45 ± 19% stenosis) (P < 0.001) following atherectomy and to 3.9 ± 1.9 mm (13 ± 16% stenosis) (P < 0.001) after adjunctive angioplasty. The average weight of removed atheroma was 45 ± 58 mg. All ten patients had initial improvement in symptoms. At 6 months follow-up there was persistent improvement in eight patients and two subjects had undergone amputations. Our early clinical experience with this low profile, flexible atherectomy device, that enables extraction of a large amount of atheroma, suggests that it will become a valuable addition to current atherectomy technologies in small- and medium-sized vessels. The value of this device in coronary vessels is under investigation. © 1996 Wiley-Liss, Inc.

Girls are vulnerable to HIV in part because the social systems in which they live have failed to protect them. This study evaluates a program aimed at strengthening adult-child relationships to reduce girls' vulnerability to HIV in Botswana, Malawi, and Mozambique. In addition to an extensive process evaluation, a cross-sectional post-intervention survey was conducted in the three countries. The total sample size was 1418 adolescent girls (ages 11-18). Bivariate and multilevel, multivariate analyses were conducted to assess the association between adult program exposure and adult-child relationship improvement. In Botswana, Malawi, and Mozambique, girls whose mothers and fathers participated in the program, as compared to those whose parents did not participate in the program, were significantly more likely to report that their relationships with their parents had improved. Research has shown the important role that adults can play in the mitigation of youth risk taking behavior.

Although some cultural practices have been identified as a determinant of HIV transmission, research investigating how specific practices affect HIV risk is lacking. In Malawi, initiation rites, in which young people attend ceremonies around the time of puberty, have received little attention. In this qualitative study, we explored whether communities in southern Malawi perceive initiation rites to be an HIV risk factor for girls. Twelve focus group discussions were held with adolescents and adults in a rural community of Thyolo district and a peri-urban community of Mangochi district. Community members observed that certain aspects of traditional initiation rites propel girls into sexual roles expected of adulthood, without facilitating their adaption to the emerging landscape of HIV, thereby increasing HIV risk. HIV prevention programming needs to address the role of initiation rites in adolescent girls' vulnerability to HIV and help young girls navigate the conflicting messages they receive from a wide range of channels about expected sexual behavior.

Purpose The purpose of this study was to evaluate phase I of a theoretically informed media campaign designed by youth in Zambia to encourage their peers to adopt risk-reduction practices to protect themselves from sexually transmitted infections and human immunodeficiency virus (HIV). The Helping Each other Act Responsibly Together (HEART) campaign conveys information for young people ages 13 to 19 years about sexually transmitted infections, HIV, and acquired immune deficiency syndrome transmission and prevention, and promotes abstinence, a return to abstinence, or consistent condom use as viable risk-reduction practices. Methods Separate sample baseline and follow-up designs were used to evaluate phase I of the HEART campaign among adolescents aged 13 to 19 years. The 1999 baseline survey had a sample of 368 male and 533 female adolescents; the 2000 follow-up survey comprised 496 male and 660 female adolescents. Results Controlling for age, sex, educational attainment, and urban or rural residence, logistic regression analyses demonstrated that, compared with nonviewers, campaign viewers were 1.61 times more likely to report primary or secondary abstinence and 2.38 times more likely to have ever used a condom. The odds ratio of condom use during last sex was 2.1 for respondents who recalled at least 3 television spot advertisements compared with other respondents. Conclusions The positive correlations between HEART campaign viewership and HIV risk-reduction practices demonstrate that mediated messages can influence adolescents. The HEART campaign is among a range of programs in Zambia designed to enable young people to protect their reproductive health. Future research should capture the independent as well as the synergistic effects of multiple campaigns and interventions.

Results: Eighty percent of men, 86% of women, 82% of male religious leaders and 98% of female religious leaders believe that family planning is in keeping with the tenets of Islam. Among religious leaders, 36% reported that they had preached about family planning in the year preceding the survey. Seventy-five percent of women and 62% of men in the general public said that they had spoken about family planning with their spouse, and 9% and 17%, respectively, reported having spoken with a religious leader On a scale of 0- 10 measuring agreement with statements regarding the benefits of family planning (with 10 being complete agreement), women averaged 9.4 and men 8.8, while male religious leaders averaged 6.5 and female religious leaders 7.2. Among the general public, 74 % of women and 58% of men said that deciding to practice contraception is a ]oint decision between husband and wife. About 90% of religious leaders agreed or agreed strongly with the statement that contraceptive decisions should be made jointly by husband and wife. Women were significantly more likely than men to believe that specific contraceptive methods are permitted under Islam, and male religious leaders were more likely than were men in the general population to find specific methods acceptable. Only 26% of men cited interpersonal communication as a source of family planning information, compared with 66% of women, 73% of male reilgious leaders and 89% of female religious leaders. Almost threequarters of men and women said they want to know more about family planning. Conclusion: Although Islamic religious leaders in Jordon cite different reasons than the general public to justify the use of contraceptives, they are as likely as others in the population to approve of family planning. International Family Planning Perspectives, 2000, 26(3):110-117 & 136 M v Xuslim religious leaders are often assumed to hold more conservative attitudes than the general population about family planning, yet a review of the literature finds no research that has specifically compared the two groups. Indeed, Muslim religious leaders' stance toward family planning is often misinterpreted. While they can be expected to refer to religious texts for guidance as they seek to interpret the acceptability of new ideas, religious leaders may prove no more opposed than other members of society to innovation, unless a new idea is perceived to contravene religious tenets. Muslim religious leaders in Jordan, who as members of social networks are intimately involved in the everyday lives of their congregations, probably share ways of thinking that are prevalent within their community. A social group can be expected to have a single worldview, yet the

ObjectiveTo assess the effect of a training program designed to enhance the role of Muslim religious leaders (RLs) in promoting family welfare, including reproductive health generally and family planning more specifically.MethodsA panel study design was utilized; 136 and 115 RLs completed the self-administered questionnaires at baseline (pre-training) and endline (6months post-training), respectively. Scales were generated to assess RLs’ knowledge of the number of family-planning methods deemed to be acceptable according to Islamic teachings (9 methods, Cronbach α=0.85), attitudes toward family planning (7 statements, Cronbach α=0.67), and preaching and/or counseling on family-planning topics (7 topics, Cronbach α=0.85).ResultsLinear regressions controlling for sex, age, and educational attainment showed that, on average, RLs cited more methods deemed acceptable according to Islamic teachings (β=1.381; P