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Background Disrespect and abuse (D & A) during labor and delivery are important issues correlated with human rights, equity, and public health that also affect women’s decisions to deliver in facilities, which provide appropriate management of maternal and neonatal complications. Little is known about interventions aimed at lowering the frequency of disrespectful and abusive behaviors. Methods Between 2011 and 2014, a pre-and-post study measured D & A levels in a three-tiered intervention at 13 facilities in Kenya under the Heshima project. The intervention involved working with policymakers to encourage greater focus on D & A, training providers on respectful maternity care, and strengthening linkages between the facility and community for accountability and governance. At participating facilities, postpartum women were approached at discharge and asked to participate in the study; those who consented were administered a questionnaire on D & A in general as well as six typologies, including physical and verbal abuse, violations of confidentiality and privacy, detainment for non-payment, and abandonment. Observation of provider-patient interaction during labor was also conducted in the same facilities. In both exit interview and observational studies, multivariate analyses of risk factors for D & A controlled for differences in socio-demographic and facility characteristics between baseline and endline surveys. Results Overall D & A decreased from 20–13 % ( p < 0.004) and among four of the six typologies D & A decreased from 40–50 %. Night shift deliveries were associated with greater verbal and physical abuse. Patient and infant detainment declined dramatically from 8.0–0.8 %, though this was partially attributable to the 2013 national free delivery care policy. Conclusion Although a number of contextual factors may have influenced these findings, the magnitude and consistency of the observed decreases suggest that the multi-component intervention may have the potential to reduce the frequency of D & A. Greater efforts are needed to develop stronger evaluation methods for assessing D & A in other settings.

Despite ongoing recommendations to increase male engagement and gender-equity (GE) counseling in family planning (FP) services, few such programs have been implemented and rigorously evaluated. This study evaluates the impact of CHARM, a three-session GE+FP counseling intervention delivered by male health care providers to married men, alone (sessions 1&2) and with their wives (session 3) in India. A two-armed cluster randomized controlled trial was conducted with young married couples (N = 1081 couples) recruited from 50 geographic clusters (25 clusters randomized to CHARM and a control condition, respectively) in rural Maharashtra, India. Couples were surveyed on demographics, contraceptive behaviors, and intimate partner violence (IPV) attitudes and behaviors at baseline and 9 &18-month follow-ups, with pregnancy testing at baseline and 18-month follow-up. Outcome effects on contraceptive use and incident pregnancy, and secondarily, on contraceptive communication and men's IPV attitudes and behaviors, were assessed using logistic generalized linear mixed models. Most men recruited from CHARM communities (91.3%) received at least one CHARM intervention session; 52.5% received the couple's session with their wife. Findings document that women from the CHARM condition, relative to controls, were more likely to report contraceptive communication at 9-month follow-up (AOR = 1.77, p = 0.04) and modern contraceptive use at 9 and 18-month follow-ups (AORs = 1.57-1.58, p = 0.05), and they were less likely to report sexual IPV at 18-month follow-up (AOR = 0.48, p = 0.01). Men in the CHARM condition were less likely than those in the control clusters to report attitudes accepting of sexual IPV at 9-month (AOR = 0.64, p = 0.03) and 18-month (AOR = 0.51, p = 0.004) follow-up, and attitudes accepting of physical IPV at 18-month follow-up (AOR = 0.64, p = 0.02). No significant effect on pregnancy was seen. Findings demonstrate that men can be engaged in FP programming in rural India, and that such an approach inclusive of GE counseling can improve contraceptive practices and reduce sexual IPV in married couples. ClinicalTrials.gov NCT01593943.

Financial hardship in childhood cancer contributes to poor health outcomes and global disparities in survival, but the extent of the financial burden on families is not yet fully understood. We systematically reviewed financial hardship prevalence and individual components characterising financial hardship across six domains (medical, non-medical, and indirect costs, financial strategies, psychosocial responses, and behavioural responses) and compared characteristics across country income levels using an established theory of human needs. We included 123 studies with data spanning 47 countries. Extensive heterogeneity in study methodologies and measures resulted in incomparable prevalence estimates and limited analysis. Components characterising financial hardship spanned the six domains and showed variation across country income contexts, yet a synthesis of existing literature cannot establish whether these are true differences in characterisation or burden. Our findings emphasise a crucial need to implement a data-driven methodological framework with validated measures to inform effective policies and interventions to address financial hardship in childhood cancer.

Many social determinants that are outside an individual's control affect their exposure to cancer risk factors and access to high-quality care. There is increasing recognition that national cancer control plans are fundamental tools to address cancer burden and promote equitable care. To investigate how policies in the WHO region of the Americas promote equity in cancer care, we evaluated 46 cancer-related health plans covering 34 countries. We analysed and coded the text of the documents according to 40 indicators and three dimensions (context, equity, and governance). Our results suggest that equity is not sufficiently integrated in national cancer control plans in the region. 17 documents defined inequity as a problem mainly related to difficulties in the access to care. Although 25 countries had designed equitable interventions, none had dedicated a budget for their implementation. Countries still need to translate their expressed concern with equity in health into funded, targeted interventions that accompany patients throughout the entire cancer care continuum.

Background The existing literature on the intersection between women's reports of spousal intimate partner violence (IPV) and contraceptive use in South Asia is conflicted. Results vary based on method of contraception use and form of violence (physical or sexual), and few examine the relationship between IPV and various methods of modern spacing contraceptive (MSC) use. This study examines associations between IPV and MSC use among a sample of married, not-currently pregnant couples in rural Maharashtra, India (n=861). Multinomial logistic regression models assessed wives' physical and sexual IPV victimisation (for the past 6-months) in relation to the wives' past 3-month MSC use (categorised as condom use, other MSCs [oral pills, Intrauterine device (IUD)] and no MSCs). In terms of violence, 9% (n=78) and 4% (n=34) of wives reported recent physical and sexual IPV victimisation, respectively. The majority (72%; n=621) did not use any MSC method in the past 3 months; 14% (n=119) reported recent condom use, and the same proportion reported other MSC use. Recent physical IPV was associated with increased likelihood of recent condom use (AOR: 2.46, 95% CI: 1.20, 5.04), and recent sexual IPV was associated with increased likelihood of recent use of other MSC (AOR: 3.27, 95% CI: 1.24, 8.56). These findings reinforce the need for integration of counselling around IPV prevention and intervention programming into existing family planning services targeting married couples in rural Maharashtra, India.

Background Promoting respect and dignity is a key component of providing quality care during facility-based childbirth and is becoming a critical indicator of maternal health care. Providing quality care requires essential skills and attitudes from healthcare providers, as their role is central to optimizing interventions in maternity settings. Methods In 13 facilities in Kenya we conducted a mixed methods, pre-post study design to assess health providers’ perspectives of a multi-component intervention (the Heshima project), which aimed to mitigate aspects of disrespect and abuse during facility-based childbirth. Providers working in maternity units at study facilities were interviewed using a two-part quantitative questionnaire: an interviewer-guided section on knowledge and practice, and a self-administered section focusing on intrinsic value systems and perceptions. Eleven distinct composite scores were created on client rights and care, provider emotional wellbeing, and work environments. Bivariate analyses compared pre- and post-scores. Qualitative in-depth interviews focused on underlying factors that affected provider attitudes and behaviors including the complexities of service delivery, and perceptions of the Heshima interventions. Results Composite scales were developed on provider knowledge of client rights (Chronbach α = 0.70), client-centered care (α = 0.80), and HIV care (α = 0.81); providers’ emotional health (α = 0.76) and working relationships (α = 0.88); and provider perceptions of management (α = 0.93), job fairness (α = 0.68), supervision (α = 0.84), promotion (α = 0.83), health systems (α = 0.85), and work environment (α = 0.85). Comparison of baseline and endline individual item scores and composite scores showed that provider knowledge of client rights and practice of a rights-based approach, treatment of clients living with HIV, and client-centered care during labor, delivery, and postnatal periods improved ( p  < 0.001). Changes in emotional health, perceptions of management, job fairness, supervision, and promotion seen in composite scores did not directly align with changes in item-specific responses. Qualitative data reveal health system challenges limit the translation of providers’ positive attitudes and behaviors into implementation of a rights-based approach to maternity care. Conclusion Behavior change interventions, central to promoting respectful care, are feasible to implement, as seen in the Heshima experience, but require sustained interaction with health systems where providers practice. Provider emotional health has the potential to drive (mis)treatment and affect women’s care.

Measuring mistreatment and quality of care during childbirth is important in promoting respectful maternity care. We describe these dimensions throughout the birthing process from admission, delivery and immediate postpartum care. We observed 677 client-provider interactions and conducted 13 facility assessments in Kenya. We used descriptive statistics and logistic regression model to illustrate how mistreatment and clinical process of care vary through the birthing process. During admission, the prevalence of verbal abuse was 18%, lack of informed consent 59%, and lack of privacy 67%. Women with higher parity were more likely to be verbally abused [AOR: 1.69; (95% CI 1.03,2.77)]. During delivery, low levels of verbal and physical abuse were observed, but lack of privacy and unhygienic practices were prevalent during delivery and postpartum (>65%). Women were less likely to be verbally abused [AOR: 0.88 (95% CI 0.78, 0.99)] or experience unhygienic practices, [AOR: 0.87 (95% CI 0.78, 0.97)] in better-equipped facilities. During admission, providers were observed creating rapport (52%), taking medical history (82%), conducting physical assessments (5%). Women's likelihood to receive a physical assessment increased with higher infrastructural scores during admission [AOR: 2.52; (95% CI 2.03, 3.21)] and immediately postpartum [AOR 2.18; (95% CI 1.24, 3.82)]. Night-time deliveries were associated with lower likelihood of physical assessment and rapport creation [AOR; 0.58; (95% CI 0.41,0.86)]. The variability of mistreatment and clinical quality of maternity along the birthing process suggests health system drivers that influence provider behaviour and health facility environment should be considered for quality improvement and reduction of mistreatment.

Financial hardship in childhood cancer contributes to poor health outcomes and global disparities in survival, yet the extent of the burden for families is not fully understood. We systematically reviewed financial hardship prevalence and individual components characterizing financial hardship across six domains (medical, non-medical, and indirect costs, financial strategies, psychosocial responses, behavioral responses) and compared characterization across country income levels utilizing an established theory of human needs. We included 123 studies with data spanning 47 countries. Extensive heterogeneity in study methodologies and measures resulted in incomparable prevalence estimates and limited analysis. Components characterizing financial hardship spanned the six domains and demonstrated variation across country income contexts, yet synthesis of existing literature cannot determine if these are true differences in characterization or burden. Our findings emphasize a critical need to establish a data-driven methodological framework with validated measures, to inform effective policies and interventions to address financial hardship in childhood cancer.

We assess the effect of CHARM, a gender equity and family planning counseling intervention for husbands in rural India, on men's gender ideology. We used a two-armed cluster randomized control trial design and collected survey data from husbands (n=1081) at baseline, 9 months, and 18 months. We used a continuous measure of support for gender equity and a dichotomous measure of equitable attitudes toward women's role in household decision-making. To assess differences on these outcomes, we used generalized linear mixed models. After controlling for socio-demographic factors, men who received the CHARM intervention were significantly more likely than men in the control group to have equitable attitudes toward household decision-making at 9-months follow-up; there was a non-significant difference between the groups for the measure of supportfor gender equity For household decision-making, differences were not sustained at 18-months follow-up. Given the role of husbands' gender ideology in women s contraceptive use, the CHARM intervention represents a promising approach for challenging root causes of women's unmet need for contraception.

A dearth of empirical research exists on female sex workers in Central America who begin selling sex under age 18. Data were collected from adult female sex workers (N = 1216) sampled using census and modified time-location sampling in three urban centers of Guatemala. In adjusted analyses, female sex workers who entered the sex trade under age 16 years were more likely to be HIV positive (AOR = 4.6, 95% CI 1.6, 13.2), have not received HIV education in their first year of sex trade (AOR = 2.8, 95% CI 1.5, 5.5), have experienced violence to force commercial sex (AOR = 4.6, 95% CI 2.2, 9.8) and have not used condoms in their first month (AOR = 2.8, 95% CI 1.3, 6.1) , relative to those who entered as adults. An interaction between age at entry and foreign migration at entry was found for HIV risk. Efforts to prevent adolescent sex trade entry are needed and may also help to reduce HIV rates in Guatemala.