Type 1 diabetes care delivery in Yaoundé, Cameroon: Social and political representations.

BACKGROUND:  Increasing chronic diseases challenges the health systems of low- and middle-income countries, including Cameroon. Type 1 diabetes (T1D), among the most common chronic diseases in children, poses particular care delivery challenges. AIM:  We examined social representations of patients' roles and implementation of T1D care among political decision-makers, healthcare providers and patients within families. SETTING:  The study was conducted in Yaoundé, Cameroon. METHODS:  Eighty-two individuals were included in the study. The authors conducted semi-structured interviews with policy makers (n = 5), healthcare professionals (n = 7) and patients 'parents (n = 20). Questionnaires were administered to paediatric patients with T1D (n = 50). The authors also observed care delivery at a referral hospital and at a T1D-focused non-governmental organisation over 15 days. Data were analysed using thematic content analysis and descriptive statistics. RESULTS:  Cameroonian health policy portrays patients with T1D as passive recipients of care. While many practitioners recognised the complex social and economic determinants of adherence to T1D care, in practice interactions focused on specific biomedical issues and offered brief guidance. Cultural barriers and policy implementation challenges prevent patients and their families from being fully active participants in care. Parents and children prefer an ongoing relationship with a single clinician and interactions with other patients and families. CONCLUSION:  Patients and families mobilise experience and lay knowledge to complement biomedical knowledge, but top-down policy and clinical practice limit their active engagement in T1D care.Contribution: Children with T1D and their families, policy makers, healthcare professionals, and civil society have new opportunities to contribute to person-centred care, as advocated by the Sustainable Development Goals.

One Health communication channels: a qualitative case study of swine influenza in Canada in 2020.

BACKGROUND: With increased attention to the importance of integrating the One Health approach into zoonotic disease surveillance and response, a greater understanding of the mechanisms to support effective communication and information sharing across animal and human health sectors is needed. The objectives of this qualitative case study were to describe the communication channels used between human and animal health stakeholders and to identify the elements that have enabled the integration of the One Health approach. METHODS: We combined documentary research with interviews with fifteen stakeholders to map the communication channels used in human and swine influenza surveillance in Alberta, Canada, as well as in the response to a human case of H1N2v in 2020. A thematic analysis of the interviews was also used to identify the barriers and facilitators to communication among stakeholders from the animal and human health sectors. RESULTS: When a human case of swine influenza emerged, the response led by the provincial Chief Medical Officer of Health involved players at various levels of government and in the human and animal health sectors. The collaboration of public and animal health laboratories and of the swine sector, in addition to the information available through the surveillance systems in place, was swift and effective. Elements identified as enabling smooth communication between the human and animal health systems included preexisting relationships between the various stakeholders, a relationship of trust between them (e.g., the swine sector and their perception of government structures), the presence of stakeholders acting as permanent liaisons between the ministries of health and agriculture, and stakeholders' understanding of the importance of the One Health approach. CONCLUSIONS: Information flows through formal and informal channels and both structural and relational features that can support rapid and effective communication in infectious disease surveillance and outbreak response.

Integrated health system intervention aimed at reducing type 2 diabetes risk in women after gestational diabetes in South Africa (IINDIAGO): a randomised controlled trial protocol.

INTRODUCTION: South Africa has a high prevalence of gestational diabetes mellitus (GDM; 15%) and many of these women (48%) progress to type 2 diabetes mellitus (T2DM) within 5 years post partum. A significant proportion (47%) of the women are not aware of their diabetes status after the index pregnancy, which may be in part to low postnatal diabetes screening rates. Therefore, we aim to evaluate a intervention that reduces the subsequent risk of developing T2DM among women with recent GDM. Our objectives are fourfold: (1) compare the completion of the nationally recommended 6-week postpartum oral glucose tolerance test (OGTT) between intervention and control groups; (2) compare the diabetes risk reduction between control and intervention groups at 12 months' post partum; (3) assess the process of implementation; and (4) assess the cost-effectiveness of the proposed intervention package. METHODS AND ANALYSES: Convergent parallel mixed-methods study with the main component being a pragmatic, 2-arm individually randomised controlled trial, which will be carried out at five major referral centres and up to 26 well-baby clinics in the Western Cape and Gauteng provinces of South Africa. Participants (n=370) with GDM (with no prior history of either type 1 or type 2 diabetes) will be recruited into the study at 24-36 weeks' gestational age, at which stage first data collection will take place. Subsequent data collection will take place at 6-8 weeks after delivery and again at 12 months. The primary outcome for the trial is twofold: first, the completion of the recommended 2-hour OGTT at the well-baby clinics 6-8 weeks post partum, and second, a composite diabetes risk reduction indicator at 12 months. Process evaluation will assess fidelity, acceptability, and dose of the intervention. ETHICS AND DISSEMINATION: Ethics approval has been granted from University of Cape Town (829/2016), University of the Witwatersrand, Johannesburg (M170228), University of Stellenbosch (N17/04/032) and the University of Montreal (2019-794). The results of the trial will be disseminated through publication in peer-reviewed journals and presentations to key South African Government stakeholders and health service providers. PROTOCOL VERSION: 1 December 2022 (version #2). Any protocol amendments will be communicated to investigators, Human Ethics Research Committees, trial participants, and trial registries. TRIAL REGISTRATION NUMBER: PAN African Clinical Trials Registry (https://pactr.samrc.ac.za) on 11 June 2018 (identifier PACTR201805003336174).

Challenges to the Provision of Services for Sexual and Intimate Partner Violence in Canada During the COVID-19 Pandemic: Results of a Nationwide Web-Based Survey.

The COVID-19 pandemic increased women's vulnerability to intimate partner and sexual violence (IPV/SV), as well as challenging organizations' ability to respond. This research is based on a 2021 nationwide survey about the impacts of COVID-19 on IPV/SV services across Canada. Nationwide, organizations adopted several measures to reduce the risk of COVID-19 transmission, including scaling back services, reducing or stopping their volunteers, and reducing the number of in-shelter clients. Organizations detailed several financial challenges including increased costs and cancelation of fundraising events. Organizations also reported many staffing challenges, from increased workloads to staff leaves of absence due to childcare responsibilities, mental health reasons, or contracting COVID-19. Policies ensuring adequate financial support to IPV/SV services in nonemergency times could help minimize disruption to service delivery during crisis situations.

Type 1 diabetes care delivery in Yaoundé, Cameroon: Social and political representations

Background: Increasing chronic diseases challenges the health systems of low- and middleincome countries, including Cameroon. Type 1 diabetes (T1D), among the most common chronic diseases in children, poses particular care delivery challenges. Aim: We examined social representations of patients' roles and implementation of T1D care among political decision-makers, healthcare providers and patients within families. Setting: The study was conducted in Yaoundé, Cameroon. Methods: Eighty-two individuals were included in the study. The authors conducted semistructured interviews with policy makers (n = 5), healthcare professionals (n = 7) and patients 'parents (n = 20). Questionnaires were administered to paediatric patients with T1D (n = 50). The authors also observed care delivery at a referral hospital and at a T1D-focused nongovernmental organisation over 15 days. Data were analysed using thematic content analysis and descriptive statistics. Results: Cameroonian health policy portrays patients with T1D as passive recipients of care. While many practitioners recognised the complex social and economic determinants of adherence to T1D care, in practice interactions focused on specific biomedical issues and offered brief guidance. Cultural barriers and policy implementation challenges prevent patients and their families from being fully active participants in care. Parents and children prefer an ongoing relationship with a single clinician and interactions with other patients and families. Conclusion: Patients and families mobilise experience and lay knowledge to complement biomedical knowledge, but top-down policy and clinical practice limit their active engagement in T1D care. Contribution: Children with T1D and their families, policy makers, healthcare professionals, and civil society have new opportunities to contribute to person-centred care, as advocated by the Sustainable Development Goals.

Using the COM-B model and Behaviour Change Wheel to develop a theory and evidence-based intervention for women with gestational diabetes (IINDIAGO).

BACKGROUND: In South Africa, the prevalence of gestational diabetes (GDM) is growing, concomitant with the dramatically increasing prevalence of overweight/obesity among women. There is an urgent need to develop tailored interventions to support women with GDM to mitigate pregnancy risks and to prevent progression to type 2 diabetes post-partum. The IINDIAGO study aims to develop and evaluate an intervention for disadvantaged GDM women attending three large, public-sector hospitals for antenatal care in Cape Town and Soweto, SA. This paper offers a detailed description of the development of a theory-based behaviour change intervention, prior to its preliminary testing for feasibility and efficacy in the health system. METHODS: The Behaviour Change Wheel (BCW) and the COM-B model of behaviour change were used to guide the development of the IINDIAGO intervention. This framework provides a systematic, step-by-step process, starting with a behavioural analysis of the problem and making a diagnosis of what needs to change, and then linking this to intervention functions and behaviour change techniques to bring about the desired result. Findings from primary formative research with women with GDM and healthcare providers were a key source of information for this process. RESULTS: Key objectives of our planned intervention were 1) to address women's evident need for information and psychosocial support by positioning peer counsellors and a diabetes nurse in the GDM antenatal clinic, and 2) to offer accessible and convenient post-partum screening and counselling for sustained behaviour change among women with GDM by integrating follow-up into the routine immunisation programme at the Well Baby clinic. The peer counsellors and the diabetes nurse were trained in patient-centred, motivational counselling methods. CONCLUSIONS: This paper offers a rich description and analysis of designing a complex intervention tailored to the challenging contexts of urban South Africa. The BCW was a valuable tool to use in designing our intervention and tailoring its content and format to our target population and local setting. It provided a robust and transparent theoretical foundation on which to develop our intervention, assisted us in making the hypothesised pathways for behaviour change explicit and enabled us to describe the intervention in standardised, precisely defined terms. Using such tools can contribute to improving rigour in the design of behavioural change interventions. TRIAL REGISTRATION: First registered on 20/04/2018, Pan African Clinical Trials Registry (PACTR): PACTR201805003336174.

Integrating Gestational Diabetes Screening and Care and Type 2 Diabetes Mellitus Prevention After GDM Into Community Based Primary Health Care in South Africa-Mixed Method Study.

Background: Despite high gestational diabetes mellitus (GDM) prevalence in South Africa (9.1% in 2018), its screening and management are not well integrated into routine primary health care and poorly linked to post-GDM prevention of type 2 diabetes mellitus (T2DM) in South Africa's fragmented health system. This study explored women's, health care providers' and experts' experiences and perspectives on current and potential integration of GDM screening and prevention of T2DM post-GDM within routine, community-based primary health care (PHC) services in South Africa. Methods: This study drew on the Behaviour Change Wheel (BCW) framework and used a mixed method, sequential exploratory design for data collection, analysis and interpretation. Individual semi-structured interviews were conducted with key informants (n = 5) from both national and provincial levels and health care providers (n = 18) in the public health system of the Western Cape Province. Additionally, focus group discussions (FGDs) with Community Health Workers (CHWs n = 15) working with clinics in the Western Cape province. A further four FGDs and brief individual exit interviews were conducted with women with GDM (n = 35) followed-up at a tertiary hospital: Groote Schuur Hospital (GSH). Data collection with women diagnosed and treated for GDM happened between March and August 2018.Thematic analysis was the primary analytical method with some content analysis as appropriate. Statistical analysis of quantitative data from the 35 exit interview questionnaires was conducted, and correlation with qualitative variables assessed using Cramér's V coefficient. Results: Shortage of trained staff, ill-equipped clinics, socio-economic barriers and lack of knowledge were the major reported barriers to successful integration of GDM screening and postnatal T2DM prevention. Only 43% of women reported receiving advice about all four recommendations to improve GDM and decrease T2DM risk (improve diet, reduce sugar intake, physical exercise and regularly take medication). All participants supported integrating services within routine, community-based PHC to universally screen for GDM and to prevent or delay development of T2DM after GDM. Conclusion: GDM screening and post-GDM prevention of T2DM are poorly integrated into PHC services in South Africa. Integration is desired by stakeholders (patients and providers) and may be feasible if PHC resource, training constraints and women's socio-economic barriers are addressed.

Integrated Management of Type 2 Diabetes and Gestational Diabetes in the Context of Multi-Morbidity in Africa: A Systematic Review.

Introduction: Many adults diagnosed with gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) also have other known or unknown comorbid conditions. The rising prevalence of GDM and T2DM within a broader context of multimorbidity can best be addressed through an integrated management response, instead of stand-alone programs targeting specific infectious and/or chronic diseases. Aim: To describe GDM and T2DM screening, care and cost-effectiveness outcomes in the context of multimorbidity through integrated interventions in Africa. Methods: A systematic review of all published studies was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk Of Bias in Non-randomised Studies of Interventions (ROBINS-I) was used to assess risk of bias. Data synthesis was conducted using narrative synthesis of included studies. Results: A total of 9 out of 13 included studies reported integrated diabetes mellitus (DM) screening, 7 included integrated care and 9 studies addressed cases of newly detected DM who were asymptomatic in pre-diabetes stage. Only 1 study clearly analysed cost-effectiveness in home-based care; another 5 did not evaluate cost-effectiveness but discussed potential cost benefits of an integrated approach to DM screening and care. Compared to partial integration, only 2 fully integrated interventions yielded tangible results regarding DM screening, care and early detection of cases despite many that reported barriers to its sustainability. Conclusion: Though few, integrated interventions for screening and/or care of DM in the context of multimorbidity within available resources in health systems throughout Africa exist and suggest that this approach is possible and could improve health outcomes.

Looking at COVID-19 effects on intimate partner and sexual violence organizations in Canada through a feminist political economy lens: a qualitative study.

OBJECTIVES: Intimate partner violence and sexual violence organizations such as women's shelters play a crucial role in advancing gender equality in Canada. COVID-19 has challenged how such organizations operate. This study explored how intimate partner violence and sexual violence organizations in Canada have been affected by COVID-19 and the consequences on service delivery. METHODS: We interviewed 17 frontline and management staff from intimate partner violence and sexual violence organizations and programs across Canada, and analyzed the data using thematic analysis and applying a feminist political economy lens. RESULTS: We identified the following themes: (1) Adapting; (2) Struggling financially; (3) Resourcefulness; (4) Troubles connecting; (5) Narrowing scope of work; and (6) Burden of care. CONCLUSION: A feminist political economy framework considers the gendered impact of the pandemic and related measures on the workforce. Both the pandemic and measures to control it have affected intimate partner violence and sexual violence organizations in Canada, the staff working in these organizations, and the quality of relationships between staff and clients. Intimate partner and sexual violence organizations in Canada have been chronically underfunded and their predominantly female staff underpaid, affecting their ability to meet the needs of women. The onset of COVID-19 not only worsened these issues but converged with a shift in focus to more pandemic-related tasks, further limiting the scope and reach of organizations. Whether the adaptations, innovations, and perseverance demonstrated by such organizations and staff can tip the balance in favour of more equitable policy and outcomes remains to be seen.

RéSUMé: OBJECTIFS: Les organismes de lutte contre la violence conjugale et la violence sexuelle, comme les hébergements pour femmes, jouent un rôle crucial dans la promotion de l'égalité des genres au Canada. La COVID-19 a remis en question le mode de fonctionnement de ces organisations. Cette étude a examiné la manière dont les organismes de lutte contre la violence conjugale et sexuelle au Canada ont été affectés par la COVID-19 et les conséquences sur la prestation de services. MéTHODES: Nous avons mené des entrevues avec 17 intervenantes de première ligne et membres de la direction d'organismes et de programmes de lutte contre la violence conjugale et sexuelle à travers le Canada. Les données ont été analysées à l'aide d'une analyse thématique et en appliquant une optique d'économie politique féministe. RéSULTATS: Nous avons identifié les thèmes suivants : 1) adaptation; 2) difficultés financières; 3) ingéniosité; 4) difficultés à établir des liens; 5) réduction du champ d'action; et 6) charge de travail. CONCLUSION: Un cadre d'économie politique féministe permet d'examiner l'impact genré de la pandémie et des mesures connexes sur le personnel. La pandémie a eu des répercussions sur les organismes de lutte contre la violence conjugale et la violence sexuelle au Canada, sur le personnel qui y travaille et sur la qualité des relations entre le personnel et les clients. Les organisations de lutte contre la violence ont souffert d'un sous-financement chronique et leur personnel, majoritairement féminin, a été sous-payé, ce qui a nui à leur capacité de répondre aux besoins des femmes. L'apparition du COVID-19 a non seulement aggravé ces problèmes, mais a aussi entraîné un changement d'orientation vers des tâches plus liées à la pandémie, ce qui a limité encore davantage le champ d'action des organismes. Il reste à voir si les adaptations, les innovations et la persévérance dont font preuve ces organisations et leur personnel peuvent faire pencher la balance en faveur d'une politique et de résultats plus équitables.

How are large-scale One Health initiatives targeting infectious diseases and antimicrobial resistance evaluated? A scoping review.

While One Health initiatives are gaining in popularity, it is unclear if and how they are evaluated when implementation at scale is intended. The main purpose of this scoping review was to describe how One Health initiatives targeting infectious diseases and antimicrobial resistance at a large scale are evaluated. Secondary objectives included identifying the main facilitators and barriers to the implementation and success of these initiatives, and how their impacts were assessed. Twenty-three studies evaluating One Health initiatives were eligible. Most studies included the human (n = 22) and animal (n = 15) sectors; only four included the environment sector. The types of evaluated initiative (non-exclusive) included governance (n = 5), knowledge (n = 6), protection (n = 17), promotion (n = 16), prevention (n = 9), care (n = 8), advocacy (n = 10) and capacity (n = 10). Studies used normative (n = 4) and evaluative (n = 20) approaches to assess the One Health initiatives, the latter including impact (n = 19), implementation (n = 8), and performance (n = 7) analyses. Structural and economic, social, political, communication and coordination-related factors, as well as ontological factors, were identified as both facilitators and barriers for successful One Health initiatives. These results identified a wide range of evaluation methods and indicators used to demonstrate One Health's added values, strengths, and limitations: the inherent complexity of the One Health approach leads to the use of multiple types of evaluation. The strengths and remaining gaps in the evaluation of such initiative highlight the relevance of comprehensive, mixed-method, context-sensitive evaluation frameworks to inform and support the implementation of One Health initiatives by stakeholders in different governance settings.

Service provider perspectives on how COVID-19 and pandemic restrictions have affected intimate partner and sexual violence survivors in Canada: a qualitative study.

BACKGROUND: The COVID-19 pandemic may increase risk of intimate partner and sexual violence and make relevant services less accessible. This study explored the perspectives of intimate partner and sexual violence workers across Canada on how the COVID-19 pandemic has affected the survivors with whom they work. METHODS: Using a qualitative descriptive design, we interviewed 17 management and frontline staff of organizations supporting survivors of intimate partner and sexual violence across Canada. RESULTS: We identified 4 themes that describe the impacts of COVID-19 on intimate partner and sexual violence survivors, from the perspective of service providers: (1) No escape; (2) Isolation; (3) Tough decisions; and (4) Heightened vulnerability. These narrative findings are presented first, followed by an analysis within a social determinants of health framework. Interpreting our findings against such a framework revealed a complex interplay of social determinants, notably social support, access to services, and poverty, that produced several challenges for intimate partner and sexual violence survivors during COVID-19. CONCLUSION: According to service providers, intimate partner and sexual violence survivors in Canada faced several challenges during the pandemic, including reduced ability to escape their situations, increased isolation, increasingly complex decisions, and heightened vulnerability. Our findings demonstrate the critical need to adopt a broader, more holistic approach in tackling  intimate partner and sexual violence by also addressing socioeconomic issues such as poverty and marginalization.

Disability and sexual and reproductive health service utilisation in Uganda: an intersectional analysis of demographic and health surveys between 2006 and 2016.

BACKGROUND: The United Nations through universal health coverage, including sexual and reproductive health (SRH), pledges to include all people, leaving no one behind. However, people with disabilities continue to experience multiple barriers in accessing SRH services. Studies analysing the impacts of disability in conjunction with other social identities and health determinants reveal a complex pattern in SRH service use. Framed within a larger mixed methods study conducted in Uganda, we examined how disability, among other key social determinants of health (SDH), was associated with the use of SRH services. METHODS: We analysed data from repeated cross-sectional national surveys, the Uganda Demographic and Health Surveys (DHS) of 2006, 2011, and 2016. The three outcomes of interest were antenatal care visits, HIV testing, and modern contraception use. Our main exposure of interest was the type of disability, classified according to six functional dimensions: seeing, hearing, walking/climbing steps, remembering/concentrating, communicating, and self-care. We performed descriptive and multivariable logistic regression analyses, which controlled for covariates such as survey year, sex, age, place of residence, education, and wealth index. Interaction terms between disability and other factors such as sex, education, and wealth index were explored. Regression analyses were informed by an intersectionality framework to highlight social and health disparities within groups. RESULTS: From 2006 to 2016, 15.5-18.5% of study participants lived with some form of disability. Over the same period, the overall prevalence of at least four antenatal care visits increased from 48.3 to 61.0%, while overall HIV testing prevalence rose from 30.8 to 92.4% and the overall prevalence of modern contraception use increased from 18.6 to 34.2%. The DHS year, highest education level attained, and wealth index were the most consistent determinants of SRH service utilisation. People with different types of disabilities did not have the same SRH use patterns. Interactions between disability type and wealth index were associated with neither HIV testing nor the use of modern contraception. Women who were wealthy with hearing difficulty (Odds Ratio (OR) = 0.15, 95%CI 0.03 - 0.87) or with communication difficulty (OR = 0.17, 95%CI 0.03 - 0.82) had lower odds of having had optimal antenatal care visits compared to women without disabilities who were poorer. CONCLUSION: This study provided evidence that SRH service use prevalence increased over time in Uganda and highlights the importance of studying SRH and the different disability types when examining SDH. The SDH are pivotal to the attainment of universal health coverage, including SRH services, for all people irrespective of their social identities.

Policy Implementation Challenges and Barriers to Access Sexual and Reproductive Health Services Faced By People With Disabilities: An Intersectional Analysis of Policy Actors' Perspectives in Post-Conflict Northern Uganda.

BACKGROUND: Emerging from a 20-year armed conflict, Uganda adopted several laws and policies to protect the rights of people with disabilities, including their sexual and reproductive health (SRH) rights. However, the SRH rights of people with disabilities continue to be infringed in Uganda. We explored policy actors' perceptions of existing pro-disability legislation and policy implementation, their perceptions of potential barriers experienced by people with disabilities in accessing and using SRH services in post-conflict Northern Uganda, and their recommendations on how to redress these inequities. METHODS: Through an intersectionality-informed approach, we conducted and thematically analysed 13 in-depth semi-structured interviews with macro level policy actors (national policy-makers and international and national organisations); seven focus groups (FGs) at meso level with 68 health service providers and representatives of disabled people's organisations (DPOs); and a two-day participatory workshop on disability-sensitive health service provision for 34 healthcare providers. RESULTS: We identified four main themes: (1) legislation and policy implementation was fraught with numerous technical and financial challenges, coupled with lack of prioritisation of disability issues; (2) people with disabilities experienced multiple physical, attitudinal, communication, and structural barriers to access and use SRH services; (3) the conflict was perceived to have persisting impacts on the access to services; and (4) policy actors recommended concrete solutions to reduce health inequities faced by people with disabilities. CONCLUSION: This study provides substantial evidence of the multilayered disadvantages people with disabilities face when using SRH services and the difficulty of implementing disability-focused policy in Uganda. Informed by an intersectionality approach, policy actors were able to identify concrete solutions and recommendations beyond the identification of problems. These recommendations can be acted upon in a practical road map to remove different types of barriers in the access to SRH services by people with disabilities, irrespective of their geographic location in Uganda.

How to navigate the application of ethics norms in global health research: reflections based on qualitative research conducted with people with disabilities in Uganda.

BACKGROUND: As Canadian global health researchers who conducted a qualitative study with adults with and without disabilities in Uganda, we obtained ethics approval from four institutional research ethics boards (two in Canada and two in Uganda). In Canada, research ethics boards and researchers follow the research ethics norms of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2), and the National Guidelines for Research Involving Humans as Research Participants of Uganda (NGRU) in Uganda. The preparation and implementation of this qualitative research raised specific ethical issues related to research participant privacy and the importance of availability and management of financial resources. MAIN BODY: Our field experience highlights three main issues for reflection. First, we demonstrate that, in a global health research context, methodological and logistic adjustments were necessary throughout the research implementation process to ensure the protection of study participants' privacy, especially that of people with disabilities, despite having followed the prescribed Canadian and Ugandan ethics norms. Data collection and management plans were adapted iteratively based on local realities. Second, securing financial support as a key aspect of financial management was critical to ensure privacy through disability-sensitive data collection strategies. Without adequate funding, the recruitment of research participants based on disability type, sex, and region or the hiring of local sign language interpreters would not have been possible. Third, although the TCPS2 and NGRU underscore the significance of participants' privacy, none of these normative documents clearly express this issue in the context of global health research and disability, nor broadly discuss the ethical issue related to financial availability and management. CONCLUSIONS: Conducting research in resource limited settings and with study participants with different needs calls for a nuanced and respectful implementation of research ethics in a global health context. We recommend a greater integration in both the TCPS2 and NGRU of global health research, disability, and responsible conduct of research. This integration should also be accompanied by adequate training which can further guide researchers, be they senior, junior, or students, and funding agencies.

Community views on short birth interval in Northern Uganda: a participatory grounded theory.

BACKGROUND: Short birth interval is associated with adverse perinatal, maternal, and infant outcomes, although evidence on actionable factors underlying short birth interval remains limited. We explored women and community views on short birth intervals to inform potential solutions to promote a culturally safe child spacing in Northern Uganda. METHODS: Gendered fuzzy cognitive mapping sessions (n = 21), focus group discussions (n = 12), and an administered survey questionnaire (n = 255) generated evidence on short birth intervals. Deliberative dialogues with women, their communities, and service providers suggested locally relevant actions promote culturally safe child spacing. RESULTS: Women, men, and youth have clear understandings of the benefits of adequate child spacing. This knowledge is difficult to translate into practice as women are disempowered to exercise child spacing. Women who use contraceptives without their husbands' consent risk losing financial and social assets and are likely to be subject to intra-partner violence. Women were not comfortable with available contraceptive methods and reported experiencing well-recognized side effects. They reported anxiety about the impact of contraception on the health of their future children. This fear was fed by rumors in their communities about the effects of contraceptives on congenital diseases. The women and their communities suggested a home-based sensitization program focused on improving marital relationships (spousal communication, mutual understanding, male support, intra-partner violence) and knowledge and side-effects management of contraceptives. CONCLUSIONS: The economic context, gender power dynamics, inequality, gender bias in land tenure and ownership regulations, and the limited contraceptive supply reduce women's capacity to practice child spacing.

The evidence on what increases birth spacing remains limited. This study explored community views on influences on short birth interval to promote a culturally safe child spacing in Northern Uganda. A participatory research process began by collating perspectives of causes of short birth intervals through fuzzy cognitive mapping. Focus group discussions clarified concepts emerging from the fuzzy cognitive mapping exercise. Fieldworkers administered a household survey to quantify reproductive health outcomes. In deliberative dialogue sessions involving women and their communities, shared and discussed these results and suggested potential actions to promote culturally safe child spacing. Women, men, and youth showed clear understandings of the benefits of adequate child spacing. This knowledge is difficult to translate into practice, however, as women feel they are unable to exercise child spacing. Women who use contraceptives without their husbands' consent risk losing financial and social resources and are likely to face intra-partner violence. Women were not comfortable with contraceptive methods and reported experiencing side effects. The deliberative dialogues suggested a home-based sensitization program focused on improving marital relationships (spousal communication, mutual understanding, male support, intra-partner violence) and knowledge and side-effects management of contraceptives.

Communities and service providers address access to perinatal care in postconflict Northern Uganda: socialising evidence for participatory action.

OBJECTIVES: Describe participatory codesign of interventions to improve access to perinatal care services in Northern Uganda. STUDY DESIGN: Mixed-methods participatory research to codesign increased access to perinatal care. Fuzzy cognitive mapping, focus groups and a household survey identified and documented the extent of obstructions to access. Deliberative dialogue focused stakeholder discussions of this evidence to address the obstacles to access. Most significant change stories explored the participant experience of this process. SETTING: Three parishes in Nwoya district in the Gulu region, Northern Uganda. PARTICIPANTS: Purposively sampled groups of women, men, female youth, male youth, community health workers, traditional midwives and service providers. Each of seven stakeholder categories included 5-8 participants in each of three parishes. RESULTS: Stakeholders identified several obstructions to accessing perinatal care: lack of savings in preparation for childbirth in facility costs, lack of male support and poor service provider attitudes. They suggested joining saving groups, practising saving money and income generation to address the short-term financial shortfall.They recommended increasing spousal awareness of perinatal care and they proposed improving service provider attitudes. Participants described their own improved care-seeking behaviour and patient-provider relationships as short-term gains of the codesign. CONCLUSION: Participatory service improvement is feasible and acceptable in postconflict settings like Northern Uganda. Engaging communities in identifying perinatal service delivery issues and reflecting on local evidence about these issues generate workable community-led solutions and increases trust between community members and service providers.

A qualitative meta-synthesis of facilitators and barriers to tuberculosis diagnosis and treatment in Nigeria.

BACKGROUND: Despite progress in tuberculosis (TB) control globally, TB continues to be a leading cause of death from infectious diseases, claiming 1.2 million lives in 2018; 214,000 of these deaths were due to drug resistant strains. Of the estimated 10 million cases globally in 2018, 24% were in Africa, with Nigeria and South Africa making up most of these numbers. Nigeria ranks 6th in the world for TB burden, with an estimated 4.3% multi-drug resistance in new cases. However, the country had one of the lowest case detection rates, estimated at 24% of incident cases in 2018 - well below the WHO STOP TB target of 84%. This rate highlights the need to understand contextual issues influencing tuberculosis management in Nigeria. Our synthesis was aimed at synthesizing qualitative evidence on factors influencing TB care in Nigeria. METHODS: A three-stage thematic meta-synthesis of qualitative studies was used to identify barriers and facilitators to tuberculosis case finding and treatment in Nigeria. A search of eleven databases was conducted. The date of publication was limited to 2006 to June 2020. We analyzed articles using a three-stage process, resulting in coding, descriptive subthemes and analytical themes. RESULTS: Our final synthesis of 10 articles resulted in several categories including community and family involvement, education and knowledge, attitudes and stigma, alternative care options, health system factors (including coverage and human resource), gender, and direct and indirect cost of care. These were grouped into three major themes: individual factors; interpersonal influences; and health system factors. CONCLUSION: Case finding and treatment for TB in Nigeria currently depends more on individual patients presenting voluntarily to the hospital for care, necessitating an understanding of patient behaviors towards TB diagnosis and treatment. Our synthesis has identified several related factors that shape patients' behavior towards TB management at individual, community and health system levels that can inform future interventions.

Commentary: Lessons from the COVID-19 global health response to inform TB case finding.

The coronavirus disease 2019 (COVID-19) has emerged as a serious threat to global public health, demanding urgent action and causing unprecedented worldwide change in a short space of time. This disease has devastated economies, infringed on individual freedoms, and taken an unprecedented toll on healthcare systems worldwide. As of 1 April 2020, over a million cases of COVID-19 have been reported in 204 countries and territories, resulting in more than 51,000 deaths. Yet, against the backdrop of the COVID-19 pandemic, lies an older, insidious disease with a much greater mortality. Tuberculosis (TB) is the leading cause of death by a single infectious agent and remains a potent threat to millions of people around the world. We discuss the differences between the two pandemics at present, consider the potential impact of COVID-19 on TB case management, and explore the opportunities that the COVID-19 response presents for advancing TB prevention and control now and in future.

Integrating gestational diabetes and type 2 diabetes care into primary health care: Lessons from prevention of mother-to-child transmission of HIV in South Africa - A mixed methods study.

BACKGROUND: Implementation of the programmes for the Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) into antenatal care over the last three decades could inform implementation of interventions for other health challenges such as gestational diabetes mellitus (GDM). This study assessed PMTCT outcomes, and how GDM screening, care, and type 2 diabetes (T2DM) prevention were integrated into PMTCT in Western Cape (WC), South Africa. METHODS: A convergent mixed methods and triangulation design were used. Content and thematic analysis of PMTCT-related policy documents and of 30 semi-structured interviews with HIV/PMTCT experts, health care workers and women under PMTC diagnosed with GDM complement quantitative longitudinal analysis of PMTCT implementation indicators across the WC for 2012-2017. RESULTS: Provincial PMTCT and Post Natal Care (PNC) documents emphasized the importance of PMTCT, but GDM screening and T2DM prevention were not covered. Data on women with both HIV and GDM were not available and GDM screening was not integrated into PMTCT. Women who attended HIV counselling and testing annually increased at 17.8% (95% CI: 12.9% - 22.0%), while women who delivered under PMTCT increased at 3.1% (95% CI: 0.6% - 5.9%) annually in the WC. All 30 respondents favour integrating GDM screening and T2DM prevention initiatives into PMTCT. CONCLUSION: PMTCT programmes have not yet integrated GDM care. However, Western Cape PMTCT integration experience suggests that antenatal GDM screening and post-partum initiatives for preventing or delaying T2DM can be successfully integrated into PMTCT and primary care.

Exploring the impact of a community participatory intervention on women's capability: a qualitative study in Gulu Northern Uganda.

BACKGROUND: Community participatory interventions mobilizing women of childbearing age are an effective strategy to promote maternal and child health. In 2017, we implemented this strategy in Gulu Northern Uganda. This study explored the perceived impact of this approach on women's capability. METHODS: We conducted a qualitative study based on three data collection methods: 14 in-depth individual interviews with participating women of childbearing age, five focus group discussions with female facilitators, and document analysis. We used the Sen capability approach as a conceptual framework and undertook a thematic analysis. RESULTS: Women adopted safe and healthy behaviors for themselves and their children. They were also able to respond to some of their family's financial needs. They reported a reduction in domestic violence and in mistreatment towards their children. The facilitators perceived improved communication skills, networking, self-confidence, and an increase in their social status. Nevertheless, the women still faced unfreedoms that deprived them of living the life they wanted to lead. These unfreedoms are related to their lack of access to economic opportunities and socio-cultural norms underlying gender inequalities. CONCLUSION: To expand women's freedoms, we need more collective political actions to tackle gender inequalities and need to question the values underlying women's social status.