Balancing the uncertain and unpredictable nature of possible zoonotic disease transmission with the value placed on animals: Findings from a qualitative study in Guinea.

Zoonoses, or diseases that pass between animals and humans, represent a major threat to global health and global economies. In Guinea, zoonotic diseases (e.g. rabies, Lassa fever) have been at the forefront due to recent outbreaks and government priorities. Much like many other diseases, zoonotic disease prevention demands a thorough and culturally nuanced understanding of the factors that influence preventive behaviors. To gain this knowledge and enhance risk communication for priority zoonotic diseases, this qualitative study conducted focus group discussions, in-depth interviews, and observations in three Guinean prefectures. Study participants included individuals who interact with animals or influence human-animal interactions, (e.g., veterinarians, local leaders, human health providers, butchers, hunters, general population). A total of 229 individuals participated in the study. Data analysis, which combined deductive and inductive coding, found that although individuals generally had basic knowledge about zoonotic diseases, a gap existed between knowledge and practice. In exploring possible reasons behind this gap, several key themes arose, the two most novel being the focus of this paper. First, participants described living in an uncertain world where they lack control over the behaviors of others. Many participants described uncertainty over the vaccine status of stray dogs or even those of their neighbors, making them feel powerless over rabies. Second, animals serve as a main source of livelihood (income, investment, or savings) for individuals. The value placed on livestock may, in turn, drive and impede prevention behaviors such as vaccinating animals or avoiding the sale of unsafe meat. Given that the Guinean government's list of priority zoonotic diseases continues to evolve, the need to discover ways to effectively promote multiple related prevention behaviors remains pertinent. The insights from this study can inform existing and future programs for the prevention, control, and surveillance of zoonotic disease in Guinea and other similar countries.

Findings and Implications From an Evaluation of the Gold Star Campaign in Post-Ebola Guinea: The Role of Gender and Education.

In post-Ebola Guinea, the Health Communication Capacity Collaborative (HC3) project worked to rebuild trust in the health system and increase the utilization of reproductive, maternal, neonatal, and child health services. Core to HC3 Guinea was the promotion of quality local health centers through the Gold Star campaign (2016-2017). The current study aimed to determine the relationship between campaign exposure and attitudes/intentions regarding local health centers, to inform communication efforts in future epidemics. Between June-July 2017, HC3 Guinea conducted a telephone survey with men (n=1,000) and women (n=2,000) aged 18-49 years. Multivariate regression analyses estimated the association between campaign exposure and attitudinal/intention outcomes for the overall sample as well as for gender- and education-stratified samples.Survey results indicated that more than 30% of the sample recalled either the campaign (32.5%) or logo (37.6%). Statistically significant associations existed between exposure and various attitudinal outcomes. For example, regardless of gender/level of education, campaign recall was strongly associated with agreeing that the local health center improved in the last 6 months. Given that the campaign itself was short in duration, it is encouraging that attitudes changed with campaign exposure. Although a greater percentage of women than men held positive attitudes about health facilities, men seemed more influenced by campaign exposure.The current study provides evidence that mass media campaigns can help rebuild trust in health care facilities after an epidemic. Study findings also stress the value of conducting stratified analyses by important demographic characteristics (e.g., gender, education). Stratified analyses can help identify meaningful differences and better tailor health promotion activities and achieve greater success. The recent recurrence of Ebola in Guinea has resulted in renewed discussions about ways to incorporate these evaluation findings into current programming, including exploring ways to address gender considerations in message design and overall program strategy.

The Salience of Trust to the Client-Provider Relationship in Post-Ebola Guinea: Findings From a Qualitative Study.

Lack of trust in the health care system can serve as a barrier to service utilization, especially in pandemic and postemergency settings. Although previous research has identified domains of trust that contribute to individuals' trust in the health system, little research exists from low- and middle-income countries, particularly during and after infectious disease outbreaks. The current study-conducted to inform activities for a post-Ebola program-explored perceptions and experiences of health care provision in post-Ebola Guinea, with particular attention to trust. Researchers conducted in-depth interviews with health workers (n=15) and mothers of young children (n=29) along with 12 focus group discussions with grandmothers of young children and 12 with male heads of household. The study occurred in Basse Guinée and Guinée Forestière-2 areas hardest hit by Ebola. Respondents identified a breach of trust during the epidemic, with several domains emerging as relevant for renewed trust and care-seeking practices. At the core of a trusting client-provider relationship was the inherent belief that providers had an intrinsic duty to treat clients well. From there, perceived provider competence, the hospitality at the facility, provider empathy, transparency about costs, and commitment to confidentiality emerged as relevant influences on participant trust in providers. Community members and providers expressed similar viewpoints regarding trust and discussed the role of open communication and community mobilization in rebuilding trust. Study findings informed a variety of program activities, including the development of campaign messages and interpersonal communication trainings for health workers. This study provides valuable insight about some underlying components of trust that can provide key leverage points to rebuild trust and promote care seeking in postemergency settings. This insight is informing program activities in the current Ebola response in Guinea and could be useful in other crises, such as the global coronavirus disease (COVID-19) pandemic.

'I can't leave everything in the hands of my husband': Economic constraints and gender roles in care-seeking in post-Ebola Guinea.

The 2014-2016 Ebola epidemic in West Africa had enduring effects on health systems and healthcare utilisation. This study explores the intersection of economic constraints and gender roles in Guinea to understand delays in care-seeking post-Ebola. In-depth interviews (n = 45) and focus group discussions (n = 24) were conducted with mothers, male heads of household, grandmothers, and health workers in rural and urban areas in Basse-Guinée and Guinée Forestière. A thematic analysis identified salient themes related to gender and economic constraints on health care-seeking. Participants, particularly men, emphasised the high cost of seeking care, which led to delays as women secured funds. Men's engagement in care-seeking included providing funds and permission, picking up medication, and giving appointment reminders. As principal actors when 'navigating' the healthcare system, women were intimately involved in economic decisions and responsible for securing funds for services - even when lacking direct financial control. Essentialist descriptions of men as 'providers' and women as 'navigators', therefore, masked nuances in care-seeking and economic responsibilities. Programmes must acknowledge men's engagement in care-seeking and address both the economic barriers women face when seeking care and their economic roles. Greater attention to the complex intersection of economic constraints and gender roles could address care-seeking delays.

Evaluating capacity strengthening for social and behavior change communication: a systematic review.

International social and behavior change communication (SBCC) programs often include capacity strengthening (CS). Quality evaluations of CS can help justify investing in these activities and guide the design of future CS activities. To inform and improve future CS efforts, a comprehensive examination of ways in which activities aimed at strengthening capacity for improved SBCC are assessed is needed. Unfortunately, systematic literature reviews about the assessment of CS activities in SBCC programs are rare. This systematic review helped fill this gap and explored ways in which CS interventions for improved SBCC in low- and middle-income countries (LMICs) evaluated their success. A search of electronic research databases yielded a total of 1033 potentially eligible publications. Reviewers identified 19 eligible publications that assessed the effects of activities for improved SBCC capacity. Reviewers identified seven findings, including the fact that evaluating CS for improved SBCC is rare, with only three publications having focused exclusively on evaluating SBCC capacity. This current review also identified several shortcomings around the quality of writing as well as sufficient detail to support certain claims and conclusions, especially around issues of sustainability. Until quality evaluations of CS activities are better documented, future CS activities for SBCC will find it difficult to identify effective CS approaches and demonstrate their contribution to improved SBCC in LMICs. The review discusses several implications and offers practical recommendations regarding ways to improve the evaluation of CS activities in SBCC.

A qualitative study of community perspectives surrounding cleaning practices in the context of Zika prevention in El Salvador: implications for community-based Aedes aegypti control.

BACKGROUND: In El Salvador, Aedes aegypti mosquitoes transmitting Zika and other arboviruses use water storage containers as important oviposition sites. Promotion of water storage container cleaning is a key element of prevention programs. We explored community perceptions surrounding cleaning practices among pregnant women, male partners of pregnant women, and women likely to become pregnant. METHODS: Researchers conducted 11 focus groups and 12 in-depth interviews which included individual elicitations of Zika prevention measures practiced in the community. Focus group participants rated 18 images depicting Zika-related behaviors according to effectiveness and feasibility in the community context, discussed influencing determinants, voted on community intentions to perform prevention behaviors, and performed washbasin cleaning simulations. In-depth interviews with male partners of pregnant women used projective techniques with images to explore their perceptions on a subset of Zika prevention behaviors. RESULTS: General cleaning of the home, to ensure a healthy environment, was a strong community norm. In this context, participants gave water storage container cleaning a high rating, for both its effectiveness and feasibility. Participants were convinced that they cleaned their water storage containers effectively against Zika, but their actual skills were inadequate to destroy Aedes aegypti eggs. A further constraint was the schedule of water availability. Even during pregnancy, male partners rarely cleaned water storage containers because water became available in homes when they were at work. Furthermore, prevailing gender norms did not foster male participation in domestic cleaning activities. Despite these factors, many men were willing to provide substantial support with cleaning when their partners were pregnant, in order to protect their family. CONCLUSIONS: Behavior change programs for the prevention of Zika and other arboviruses need to improve community members' mosquito egg destruction skills rather than perpetuate the promotion of non-specific cleaning in and around the home as effective. Egg elimination must be clearly identified as the objective of water storage container maintenance and programs should highlight the effective techniques to achieve this goal. In addition, programs must build the skills of family members who support pregnant women to maintain the frequency of effective egg destruction in all water storage containers of the home.

The role of gender in Zika prevention behaviors in the Dominican Republic: Findings and programmatic implications from a qualitative study.

BACKGROUND: Zika remains an epidemiological threat in Latin America, including the Dominican Republic. Although transmitted by the same mosquito as Dengue and Chikungunya, Zika is unique in the potentially harmful consequences for babies born to women infected during pregnancy. Experts highlight the feminization of Zika, in terms of burden of disease and women's caregiving responsibilities. Understanding gender's role in Zika prevention, therefore, is key to strengthening current and future programs. METHODOLOGY/PRINCIPAL FINDINGS: This qualitative study, comprised of 12 focus group discussions and eight in-depth interviews, explored gender's role in Zika among pregnant and non-pregnant women as well as male partners of pregnant women in the Dominican Republic. Topics included perceptions about Zika and perceived feasibility and effectiveness of prevention behaviors (e.g. cleaning water storage containers, using condoms during pregnancy). Researchers applied grounded theory through a process of deductive coding-classifying data around predetermined categories-followed by inductive coding-identifying themes that emerged from coded data. Study findings uncovered three ways in which gender may influence Zika prevention. First, women are largely responsible for household chores-including cleaning water storage containers-with men as assistants. Second, men described their role in the family as the protector. Finally, men and women believed that partners would perceive suggesting condom use or abstinence during pregnancy as a sign of infidelity. CONCLUSIONS: Current/future Zika programs should address knowledge gaps, especially around water storage cleaning techniques and sexual transmission. Programs should also integrate gender into programming in culturally-relevant ways that avoid reinforcing stereotypes. Furthermore, programs should tailor activities for men, women, as well as the couple. In the end, integrating gender in a way that is mindful of the local context while not exploiting existing gender roles is critical for preventing Zika and similar mosquito-borne diseases, both in the Dominican Republic and throughout the region.

Effects on Career Development From Sharing One's Story: Young Professionals' Experiences With Family Planning Voices.

Supporting the development of young family planning professionals is key to fostering communities of practitioners that can help countries achieve family planning goals. The Family Planning Voices (FP Voices) storytelling initiative, created by The Knowledge for Health Project and Family Planning 2020, documents stories from people around the world who are passionate about family planning. This qualitative evaluation used in-depth interviews (n = 11) with young professionals (ages 18-30) to uncover the effects of sharing their story with FP Voices. Participants came from 10 countries in one of three regions, Latin America (n = 2), South Asia (n = 2), and Africa (n = 7). Findings highlight that sharing one's story with FP Voices served as a professional development opportunity and instilled confidence and pride among young professionals. Additionally, participants linked access to a professional headshot and the experience of participating in an interview to their professional development. Participants often discussed the recognition they gained from sharing their story and the resulting increase in professional connections and opportunities. Participants hoped that their stories would inspire and encourage others and support recognition of the value of young professionals to the larger family planning field. In sum, storytelling initiatives like FP Voices can motivate and create community and opportunity among young professionals.

How Do African-American Caregivers Navigate a Food Desert to Feed Their Children? A Photovoice Narrative.

OBJECTIVES: To determine how African-American caregivers living in a food desert navigate neighborhood resources to procure foods for their children and to identify actions to improve those resources. DESIGN: Using the Photovoice approach, we conducted two sets of individual in-depth interviews with 16 African-American primary caregivers of children (total of 32 interviews) and one culminating workshop (n=10 participants). Data were systematically analyzed according to the Social Ecological Framework to evaluate the role of different environments in shaping individual decisions. SETTING: Urban, low-income and geographically marginalized neighborhoods. RESULTS: Despite the challenges of living in a food desert, caregivers perceived that they were providing the foods that they wanted for their children. These perceptions were based on their own health concerns, food customs, time and convenience, and responses to their children's food preferences. Caregivers were resourceful in how they procured these foods, searching for quality and better-priced foods. They relied on their friends, family, and local/national programs to mitigate the challenges of the food desert. Caregivers were interested in taking action to improve the underlying determinants of food access and choice (eg, affordable housing, job training, nutrition knowledge, food shopping experience). CONCLUSION: These African-American caregivers procured foods they thought were best for their children by relying on their strong social relationships and national and local food programs to navigate the food desert. Public health nutrition interventions that aim to reduce diet-related disparities should look beyond the presence or absence of supermarkets in food deserts to address multisectoral determinants of access while shaping food choices.

A Framework for Health Communication Across the HIV Treatment Continuum.

BACKGROUND: As test and treat rolls out, effective interventions are needed to address the determinants of outcomes across the HIV treatment continuum and ensure that people infected with HIV are promptly tested, initiate treatment early, adhere to treatment, and are virally suppressed. Communication approaches offer viable options for promoting relevant behaviors across the continuum. CONCEPTUAL FRAMEWORK: This article introduces a conceptual framework, which can guide the development of effective health communication interventions and activities that aim to impact behaviors across the HIV treatment continuum in low- and medium-income countries. The framework includes HIV testing and counseling, linkage to care, retention in pre-antiretroviral therapy and antiretroviral therapy initiation in one single-stage linkage to care and treatment, and adherence for viral suppression. The determinants of behaviors vary across the continuum and include both facilitators and barriers with communication interventions designed to focus on specific determinants presented in the model. At each stage, relevant determinants occur at the various levels of the social-ecological model: intrapersonal, interpersonal, health services, community, and policy. Effective health communication interventions have mainly relied on mHealth, interpersonal communication through service providers and peers, community support groups, and treatment supporters. DISCUSSION: The conceptual framework and evidence presented highlight areas across the continuum where health communication can significantly impact treatment outcomes to reach the 90-90-90 goals by strategically addressing key behavioral determinants. As test and treat rolls out, multifaceted health communication approaches will be critical.

Waking Up the Mind: Qualitative Study Findings About the Process Through Which Programs Combining Income Generation and Health Education Can Empower Indigenous Guatemalan Women.

We explored the process through which two income-generation programs that include health education empower indigenous Guatemalan women artisans. Both artisans (n = 44) and program staff (n = 11) participated in semistructured interviews. Respondents expressed that women gained support about personal issues and experienced an awakening of the mind (despertar la mente). Through active participation, women's fear of strangers and speaking in public decreased. Women also gained mobility, awareness of their rights as women, and self-confidence from earning and managing their own income. Given our findings, we suggest that programs combining income generation and health education have the potential to empower women.

#ec: Findings and implications from a quantitative content analysis of tweets about emergency contraception.

Twitter, a popular social media, helps users around the world quickly share and receive information. The way in which Twitter frames health issues - especially controversial issues like emergency contraception (EC) - can influence public opinion. The current study analyzed all English-language EC-related tweets from March 2011 (n = 3535). Variables measured user characteristics (e.g. gender), content (e.g. news, humor), Twitter-specific strategy (e.g. retweet), and certain time periods (e.g. weekends). The analysis applied chi-square and regression analyses to the variables. Tweets most frequently focused on content related to news (27.27%), accessing EC (27.27%), and humor (25.63%). Among tweets that were shared, however, the most common content included humor, followed by personal/vicarious experience. Although only 5.54% of shared tweets mentioned promiscuity, this content category had the strongest odds for being shared (OR = 1.51; p = 0.031). The tweet content with lowest odds of being shared were side effects (OR = 0.24; p < 0.001), drug safety (OR = 0.44; p < 0.001), and news (OR = 0.44; p < 0.001). Tweets with the greatest odds of having been sent on a weekend sought advice (OR = 1.94; p = 0.012), addressed personal or vicarious experience (OR = 1.91; p < 0.001), or contained humor (OR = 1.56; p < 0.001). Similar patterns occurred in tweets sent around St. Patrick's Day. Only a few differences were found in the ways in which male and female individuals discussed EC on Twitter. In particular, when compared to males, females mentioned birth control (p = 0.002), EC side effects (p = 0.024), and issues related to responsibility (p = 0.003) more often than expected. Study findings offer timely and practical suggestions for public health professionals wanting to communicate about EC via Twitter.

Reaching the global community during disasters: findings from a content analysis of the organizational use of Twitter after the 2010 Haiti earthquake.

Social networking sites provide virtual environments in which individuals and organizations exchange real-time information on a multitude of topics, including health promotion and disease prevention. The January 2010 earthquake in Haiti has been posited as a turning point in the way in which organizations use social media, such as Twitter, for crisis communication. The purpose of this content analysis was to explore whether organizations' use of Twitter changed after the 2010 Haiti earthquake. A team of 13 coders analyzed all English-language tweets (N = 2,616) during the 3 months before and post earthquake from 6 leading organizations in the Haiti disaster relief efforts. Study findings indicate that the ways in which organizations used Twitter changed over time. Chi-square analyses demonstrated that organizations decreased in their use of certain strategies to disseminate information through Twitter, such as the use of links. Organizations did not change in their use of techniques to involve users (e.g., retweet, call to action), with the exception of using tweets as a fundraising mechanism. Study findings highlight missed opportunities among organizations to maximize Twitter in order to encourage more interactive and immediate communication with the global community.

Informing the scaling up of voluntary medical male circumcision efforts through the use of theory of reasoned action: survey findings among uncircumcised young men in Swaziland.

Assessing predictors of intention to circumcise can help to identify effective strategies for increasing uptake of voluntary medical male circumcision (VMMC). Grounded in the theory of reasoned action (TRA), the current study of uncircumcised males ages 13-29 in Swaziland (N = 1,257) employed multivariate logistic regression to determine predictors of VMMC intention. The strongest predictors were strongly disagreeing/disagreeing that sex was more painful for a circumcised man (odds ratio [OR] = 4.37; p = < .007), a Christian man should not get circumcised (OR = 2.47; p < .001), and circumcision makes penetration more painful and difficult (OR = 2.44; p = .007). Several beliefs about enhanced sexual performance, normative beliefs (parents, sexual partner, and friends), and non-TRA-related factors (e.g., importance of plowing season to daily schedule) were also statistically significant predictors. TRA proved a useful theory to explore young men's intention to circumcise and can help inform interventions aimed at increasing uptake of VMMC.

'By seeing with our own eyes, it can remain in our mind': qualitative evaluation findings suggest the ability of participatory video to reduce gender-based violence in conflict-affected settings.

Gender-based violence is pervasive and poses unique challenges in conflict-affected settings, with women and girls particularly vulnerable to its sequelae. Furthermore, widespread stigmatization of gender-based violence promotes silence among survivors and families, inhibiting access to services. Little evidence exists regarding effective gender-based violence prevention interventions in these settings. Through Our Eyes, a multi-year participatory video project, addressed gender-based violence by stimulating community dialogue and action in post-conflict settings in South Sudan, Uganda, Thailand, Liberia and Rwanda. The present qualitative analysis of project evaluation data included transcripts from 18 focus group discussions (n = 125) and key informant interviews (n = 76). Study participants included project team members, representatives from partner agencies, service providers and community members who either participated in video production or attended video screenings. Study findings revealed that the video project contributed to a growing awareness of women's rights and gender equality. The community dialogue helped to begin dismantling the culture of silence gender-based violence, encouraging survivors to access health and law enforcement services. Furthermore, both men and women reported attitude and behavioral changes related to topics such as wife beating, gender-based violence reporting and girls' education. Health education professionals should employ participatory video to address gender-based violence within conflict-affected settings.

"It depends on your pocket:" findings from a qualitative study in Uganda exploring women's and health care providers' perspectives on family planning.

An unmet need for family planning among Ugandan women remains. Our research team conducted qualitative research to identify Ugandan perspectives about family planning. We facilitated interviews with Ugandan women and health care providers. Using grounded theory, our team analyzed the data to identify themes from the transcripts. The researchers identified the cross-cutting theme as the influence of money on women and health care providers. Although affordability and accessibility were recognized as determinants of ensuring family planning uptake, we found that money impacts the decision making via additional mechanisms. For women, monetary concerns associated with assuring family needs were prioritized. For health care providers, they discussed that money created barriers as well as incentives to family planning service provisions.

Effectiveness of mHealth behavior change communication interventions in developing countries: a systematic review of the literature.

Mobile health (mHealth) technologies and telecommunication have rapidly been integrated into the health care delivery system, particularly in developing countries. Resources have been allocated to developing mHealth interventions, including those that use mobile technology for behavior change communication (BCC). Although the majority of mobile phone users worldwide live in the developing world, most research evaluating BCC mHealth interventions has taken place in developed countries. The purpose of this study was to conduct a systematic review of the literature to determine how much evidence currently exists for mHealth BCC interventions. In addition to analyzing available research for methodological rigor and strength of evidence, the authors assessed interventions for quality, applying a set of 9 standards recommended by mHealth experts. The authors reviewed 44 articles; 16 (36%) reported evaluation data from BCC mHealth interventions in a developing country. The majority of BCC mHealth interventions were implemented in Africa (n = 10) and Asia (n = 4). HIV/AIDS (n = 10) and family planning/pregnancy (n = 4) were the health topics most frequently addressed by interventions. Studies did not consistently demonstrate significant effects of exposure to BCC mHealth interventions on the intended audience. The majority of publications (n = 12) described interventions that used two-way communication in their message delivery design. Although most publications described interventions that conducted formative research about the intended audience (n = 10), less than half (n = 6) described targeting or tailoring the content. Although mHealth is viewed as a promising tool with the ability to foster behavior change, more evaluations of current interventions need to be conducted to establish stronger evidence.

Disconnect between discourse and behavior regarding concurrent sexual partnerships and condom use: findings from a qualitative study among youth in Malawi.

The practice of concurrent sexual partnerships (CP) is posited to be a contributor to the elevated risk of HIV transmission among youth in Malawi. The lens through which Malawian youth conceptualize the practices of CP and condom use has yet to be fully explored. The current study--a secondary data analysis of semi-structured in-depth interviews (n = 19) with Malawian youth aged 18 to 22 years--addresses this gap. Participants were interviewed about their sexual relationships and behavior, as well as their perceptions and knowledge regarding condom use and CP. In order to ensure that youth engaged in CP were oversampled, the recruitment process asked potential respondents to self-identify whether they currently participated in CP. Of the total sample (n = 19), 13 self-identified as currently engaging in CP. Data were analyzed using a grounded theory approach. This qualitative study highlights a disconnect between the high level of knowledge youth exhibit about HIV prevention methods and their actual reported condom use and CP behaviors. While some youth claimed to use condoms, their discourse demonstrated fluidity in that use changed over time, or interest in changing behavior was expressed, or was inconsistent between partnerships. The disconnect between knowledge of the consequences of risky sexual behavior and actual behavior was most evident among inconsistent condom users engaged in CP. This finding indicates knowledge alone has a limited role in the adoption of lower risk behaviors such as condom use and reduction of CP among youth. Moreover, findings from this study can inform HIV prevention programs operating in Malawi and the sub-Saharan Africa region by enabling them to provide tailored, more persuasive health promotion and prevention messaging.