Disrupting gender norms in health systems: making the case for change

Four-year follow-up of CHARM2, an effective family planning intervention, on number and sex of births: Findings from an RCT in rural India

Background

Effective family planning interventions may have inadvertent effects on births of girls given son preference in India. We conducted 36 and 48-month follow-ups to our CHARM2 family planning study to determine long-term intervention effects on births and sex of children.

Methods

Our non-blinded two-armed cluster RCT randomized young married couples (N = 1201 couples) from 20 geographic clusters (60-61 couples per cluster) into either the CHARM2 intervention or control (referral to local care) condition. CHARM2 offers 5-session gender-synchronized family planning and gender equity counseling delivered by trained local medical providers. Data were collected at baseline in September 2018-June 2019 and then follow-ups at 9, 18, 36 and 48 months, up to September 2023. We retained 88 %-91 % of women across follow-ups with no difference in retention by treatment group. We used adjusted mixed-effects logistic regression models examining sex composition of births at each follow-up and over the total 48-month follow-up to assess differences in all births of boys and girls by treatment group. We adjusted for treatment condition, cluster, and relevant demographics in adjusted models.

Results

We saw no treatment effects on total births or boy births, but lower likelihood of a girl birth was seen at 9-month follow-up and for the total 48-month follow-up period. We found at 9-month follow-up a girl birth was less likely for intervention compared with control participants (7.1 % vs. 10.3 %, respectively, p = 0.06), and the male to female sex ratio of births born between baseline and 9-month follow-up was also significantly higher for intervention vs. comparison participants (1.50 [95 % CI 1.00-2.26] vs. 0.83 [95 % CI 0.56-1.21], p = 0.04). We conducted a sensitivity analysis to determine treatment effects on boy births and girl births over the 48-month follow-up and again found no effects on boy births, but a significantly lower likelihood of a girl birth for the intervention group (22 % vs 29 %, p = 0.03).

Conclusion

The CHARM2 family planning intervention, previously demonstrating significant effects on contraceptive use and women's reproductive agency in rural India, resulted in lower likelihood of girl births over time, suggesting that family planning programs can contribute to sex ratio imbalances if broader social changes eliminating son preference and improving value of a girl child do not occur.

Funding

National Institutes of Health, Grant R01HD084453 Bill and Melinda Gates Foundation. INV002967. The funders had no role in the design and conduct of the study, collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. [ClinicalTrials.gov Identifier: NCT03514914.].

Gender equity and COVID-19 vaccine policies for pregnant people: a global analysis

BACKGROUND

Despite increasing vaccine availability and evidence and expert recommendations to support administration, some countries maintained restrictive policies regarding COVID-19 vaccination in pregnancy throughout the pandemic. This global analysis explores the role of gender equity, country income level, and vaccine availability in predicting national policies on COVID-19 vaccine administration in pregnancy.

METHODS

Policies were collected from May 2021 to January 2023 from 224 countries/territories using publicly available information posted on national public health authority web pages. Policies were categorized into 6 types, representing different levels of permissiveness, from recommended for some or all to not recommended, and changes in national policies were captured over time. Outcomes were defined as: 1) prevalence of restrictive policies at a specific time point; 2) country-level change from restrictive policy/no position at an earlier time point to a permissive policy at a later timepoint. Simple and multivariable logistic regressions were performed to explore the association between the outcomes and potential policy predictors, including income level, mRNA vaccine availability, and the Global Gender Gap Index (GGGI).

RESULTS

Complete cross-sectional data were available for 114 countries as of June 2021, 137 countries as of October 2021, and 142 countries as of March 2022. The number of maternal immunization policies increased and became steadily more permissive between 2021 and 2022. Availability of mRNA vaccines and higher income level were associated with reduced odds of a restrictive policy at the 2021 timepoints, and higher GGGI scores were associated with reduced odds of restrictive policies at all timepoints. After adjusting for income level and mRNA vaccine availability, higher GGGI scores reduced the relative odds of a restrictive COVID-19 vaccine policy by 10% (aOR: 0.90, 95CI: 0.81, 0.99) in October 2021 and 14% (aOR: 0.86, 95%CI: 0.76, 0.97) in March 2021. Higher GGGI scores were also associated with increased odds of a policy switch from restrictive/no position in June 2021 to permissive in October 2021 (aOR: 1.12, 95%CI: 1.00, 1.24).

CONCLUSIONS

Gender inequity was associated with greater odds of a restrictive policy for use of COVID-19 vaccines in pregnancy, suggesting that gender biases may influence fair policymaking for pregnant people in pandemic preparedness and response.

Prevalence of Traditional, Complementary, and Integrative Medicine Training, Its Different Practices, and Associated Sociodemographic Factors: A Study with Brazilian Nurses

Objective: To analyze the prevalence of nurses trained in traditional, complementary, and integrative medicine (TCIM), the different practices, and associated sociodemographic factors. Methods: This quantitative, cross-sectional study was implemented online in Brazil from June 2021 to January 2022 among 1,154 nurses using a questionnaire comprising open- and closed-ended questions. The Stata IC software, version 16.0, was used in the statistical analysis. The dependent variable was training in TCIM, and the prevalence of different TCIM practices was also investigated. The independent variables included sociodemographic information. Descriptive and inferential statistical tests were performed. This study was approved by the Institutional Review Board at the Federal University of Rio Grande do Sul and was developed according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) initiative. Results: The prevalence of TCIM training was 43.50%. Most participants were women (89.49%), Brazilian (99.65%), aged 39.71 on average (SD = 10.37), and had an income of up to four times the minimum wage (52.43%). The prevalence of professionals implementing TCIM in their practice among those with training was 64.60%. They reported working up to 2 h a week (36.96%) in primary health care settings (33.40%) and providing individual consultations (78.0%). After the adjusted analysis, TCIM training appeared significantly associated with age (p < 0.001), the region where the workplace is located (p < 0.001), and income (p < 0.001). Auriculotherapy (59.96%) stood out among the TCIM practices in which nurses were trained. Conclusions: Almost half of the nurses working in Brazil have training in TCIM and sociodemographic factors such as age, region of work, and income are significantly associated with this training.

Gender disparities regarding invited speakers in paediatric dentistry congresses: Are we closing the gap?

AIM

The aim of the present cross-sectional study was to evaluate the representation of female scientists as invited speakers at two major paediatric dentistry congresses, the European Academy of Paediatric Dentistry (EAPD) and the American Academy of Pediatric Dentistry (AAPD), held between 2016 and 2023. A secondary aim was to explore association with lecture topic- or scientist-related characteristics.

METHODS

The gender of all invited speakers was identified through electronically searching of scientific programmes and abstract books of the EAPD and the AAPD Congresses held between 2016 and 2023. Variables assessed were year of the congress, the continent of origin of the invited scientist, the type of meeting (congress or interim seminar) and lecture topic.

RESULTS

A total of 462 lectures were included in the assessment and the overall representation of female scientists was 44.2%. Since 2016, yearly representation of female invited speakers exceeded in number that of male only twice, in 2021 (59.4%) and in 2023 (53.7%). For the EAPD, invited female lecturers were 41.1%, while for the AAPD Congress was 46.3%. There was equal representation of female and male speakers in seminars (50% each), although this type of meeting is solely organised by the EAPD. Pain management (62.5%), insurance (54.8%), paediatrics (55.6%) and orthodontics (52.4%) were the only thematic regions where female speakers outnumbered their male counterparts. Univariable and multivariable analyses did not reveal any overall significant association between invited speaker gender and year, congress or continent of authorship (p-value > 0.05 in all cases).

CONCLUSION

Women' voice representation at major paediatric dentistry congresses was found to improve, however, efforts for further improvement should persist to establish balanced representation.

Factors Influencing Adherence to Non-Invasive Telemedicine in Heart Failure: A Systematic Review

Background/Objectives: Telemedicine (TM) has emerged as a promising tool for improving heart failure (HF) management by allowing non-invasive, remote patient monitoring. However, patient adherence to TM plays a critical role in its effectiveness. This systematic review aims to assess adherence levels to non-invasive TM interventions and explore factors influencing compliance. Methods: This systematic review followed the PRISMA guidelines. A literature search was conducted across the PubMed, Medline, Web of Science, and Google Scholar databases to identify prospective randomized controlled trials published between January 2010 and June 2024. The inclusion criteria included studies focused on non-invasive TM in HF patients with a follow-up period longer than three months. Adherence rates were categorized as high (≥80%), moderate (60-79%), or low (<60%). Results: Of the 136 identified studies, 6 met the inclusion criteria. Three studies reported high adherence (>80%), and three moderate adherence (60-79%). Older patients (≥65 years) showed higher adherence, with two studies exceeding 85% adherence. Studies with higher female participation (>30%) reported better adherence, with two exceeding 88%. Across studies, a lack of racial diversity was especially notable, apart from a study that included a population with 69% black and 31% Hispanic participants, where adherence was 50% for ≥10 uploads over a 90-day period. Seasonal variations affected adherence, with December being the lowest (47-69%) and August the highest (>85%). Monitoring multiple health parameters correlated with better adherence (>85%) compared to single-parameter tracking (50-74%). Conclusions: TM is a promising tool for HF management, but adherence differs by age, sex, and the complexity of monitoring. To optimize TM use, standardized adherence measures and tailored strategies are needed.

Transforming partnerships through transboundary research

Research partnerships are a key entry point for addressing the asymmetries that pervade global health. However, highly competitive and fast-paced science limits the kind of innovation and transformative change needed to reduce the imbalances that undermine the independence and academic freedom of research partners. The goal of this piece is to present a transformative lens for partnerships in which participating research organisations are willing to be mutually influenced through genuine collaborative efforts. In contrast to transactional partnerships, a transformative collaboration identifies a set of goals toward which the partnership wishes to work and agrees on the process for achieving them together. First, reflexivity and awareness of positionality are needed to recognise the power relations embedded in research and how these relations may not serve all people equally. Second, solidarity and togetherness create an interconnected view that transcends differences. Third, collective reflection on how and why the desired changes will occur is needed to guide the planning of 'who will do what, how and when' to advance equity-centred actions. Finally, shared responsibility for actions and outcomes will ensure mutual trust and a productive working relationship among partners. Implementing these principles requires some partners to relinquish control and step back when necessary, others to take ownership and greater leadership, and all partners to act with solidarity, accountability and trust. These complementary attitudes underpin the success of transformative partnerships in realising the full societal value of global health research.

Is 'gender equality in health' the right goal? Exploring issues of definition and measurement

Achieving 'gender equality in health' has been advocated by many as a key goal in health globally; however, we observe this goal has been defined differently by different users. In this paper, we explore the question of how progress towards gender equality in health has been defined and measured, and how the selection of indicators and targets can influence perceptions of who in a population is suffering disadvantage. We summarise the common population health measures-such as life expectancy and risk exposure-and illustrate how each of these measures may lead to different conclusions about gender equality in health. We call for more specificity when defining and measuring gender inequality in health, and propose expanding the focus from 'gender inequalities' (comparison between genders) to also addressing 'within-gender inequities' (a focus that incorporates addressing inequities within different gender identity groups).

Scheduled couple consultations during pregnancy as a lever to increase male involvement in maternal health: results of a qualitative photovoice study in Mozambique

BACKGROUND

Men in low- and middle-income countries often play a critical role in maternal health by increasing access to and utilization of maternal health services. This photovoice study examined the experiences of men and women with scheduled couple consultations during pregnancy, supported by social mobilization activities, as a lever to increase male involvement during pregnancy and childbirth.

METHODS

The lived experiences with scheduled couple consultations were evaluated by collecting photovoice data from couples, conducting focus group discussions with health providers and in-depth interviews with women. Analysis was done by applying a thematic inductive approach.

RESULTS

Data were collected from five couples using photovoice, nine health providers by conducting focus group discussions and nine single women by conducting individual in-depth interviews. Two overall themes arose during analysis of the data: health center experiences and community norms about pregnancy. Overall, the couple consultations had a positive effect on the interest of the male partner in pregnancy and childbirth, but deep-rooted gender norms around women's roles during pregnancy persisted.

CONCLUSIONS

Implementing scheduled couple consultations at health center level, supported by social mobilization activities, is a promising strategy for stimulating active participation of male partners in maternal health.

Examining gender in alcohol research: A systematic review of gender differences in how men and women are studied in alcohol research

BACKGROUND

This systematic review examined differences in the way women and men have been studied in alcohol research over the past decade. In particular, it explored differences in methodology, discipline, country, subpopulation and age focus, to understand who is being studied and how.

METHODS

Single-gender peer-reviewed studies on alcohol consumption published between 1st January 2014 and 31st December 2023 were identified by searching Medline, PsycInfo, Scopus and CINAHL. Descriptive statistics and comparisons to Global Burden of Disease [GBD] estimates are presented to understand whether the studies' gendered focus were proportionate to the distribution of alcohol-related harms. The review was registered with PROSPERO (CRD42022359103).

RESULTS

A total of 11,235 studies were identified, with 1,267 studies included. Despite consuming more alcohol and experiencing more harms, only 44% (n=554) of single gender studies were on men. One in three studies on men were from medical disciplines, whereas studies on women were more likely to come from psychology, public health or sociology disciplines. In several countries, including Australia, the disparity in the number of studies on women compared with GBD estimates of harms from alcohol consumption were particularly pronounced.

CONCLUSIONS

The majority of single-gender studies on alcohol consumption in the last decade focused on women. There has been strong focus on men's health (medical focus), and on women's behaviour (psychology, public health and sociology focus). Researchers' choices around study foci can differentially shape public discourse, policies and clinical practice, with important implications for gender equity and treatment outcomes.

Access to maternity care: challenges and solutions for improving equity across US communities

PURPOSE OF REVIEW

Improving maternal health is a clinical and policy priority in the United States. We reviewed recent literature on access to maternity care and impacts on racial and geographic equity.

RECENT FINDINGS

New research indicates a wide range of consequences of obstetric unit closures, as well as health challenges for lower-volume obstetric units and those who travel long distances to care.

SUMMARY

As maternal mortality rates rise, maternity care access is declining in the US, especially in rural areas and communities with a higher proportion of Black, Latinx, or Indigenous residents. Lack of resources and financial strain are challenges for low-volume and Black-serving obstetric units, and targeted investments may help improve safety and access.

Individual- and community-level women's empowerment and complete use of maternal healthcare services: A multilevel analysis of 34 sub-Saharan African countries

BACKGROUND

Current literature on women's empowerment (WE) and maternal healthcare use is limited to individual-level analysis, with a focus on single components of maternal healthcare services. As gender-related community contexts may importantly shape women's ability to seek healthcare services, we examined how both individual- and community-level WE are associated with complete use of maternal healthcare services in sub-Saharan Africa (SSA).

METHODS

We analyzed Demographic and Health Surveys conducted between 2011 and 2022 across 34 SSA countries (N = 194,740 women aged 15-49 years old). Complete care was defined as utilizing four or more antenatal care contacts, facility delivery, and any postnatal care. Based on a globally validated survey-based WE index (SWPER), a composite variable was constructed for individual- and community-level WE for each domain of attitude to violence, social independence, and decision-making: low-low (reference), low-high, high-low, and high-high. Multilevel linear probability models were used adjusting for key sociodemographic factors.

RESULTS

About one-third of women (35.4%) utilized complete care. Women with high empowerment at both individual- and community-levels demonstrated the highest probability of complete care (b = 0.058; 95% CI = 0.051,0.066 for attitude to violence; b = 0.116; 95% CI = 0.108,0.124 for social independence; b = 0.070; 95% CI = 0.063,0.078 for decision-making). Women with low empowerment but living in high empowerment communities (low-high) were more likely to utilize complete care than their counterparts (high-low group), which was particularly evident in the social independence domain.

CONCLUSION

We found a strong contextual effect of WE on complete utilization of maternal healthcare services. Alongside efforts to enhance individual WE, interventions to advance gender equality at the community-level are crucial to facilitate timely access to maternal healthcare in SSA.

Sex bias consideration in healthcare machine-learning research: a systematic review in rheumatoid arthritis

OBJECTIVE

To assess the acknowledgement and mitigation of sex bias within studies using supervised machine learning (ML) for improving clinical outcomes in rheumatoid arthritis (RA).

DESIGN

A systematic review of original studies published in English between 2018 and November 2023.

DATA SOURCES

PUBMED and EMBASE databases.

STUDY SELECTION

Studies were selected based on their use of supervised ML in RA and their publication within the specified date range.

DATA EXTRACTION AND SYNTHESIS

Papers were scored on whether they reported, attempted to mitigate or successfully mitigated various types of bias: training data bias, test data bias, input variable bias, output variable bias and analysis bias. The quality of ML research in all papers was also assessed.

RESULTS

Out of 52 papers included in the review, 51 had a female skew in their study participants. However, 42 papers did not acknowledge any potential sex bias. Only three papers assessed bias in model performance by sex disaggregating their results. Potential sex bias in input variables was acknowledged in one paper, while six papers commented on sex bias in their output variables, predominantly disease activity scores. No paper attempted to mitigate any type of sex bias.

CONCLUSIONS

The findings demonstrate the need for increased promotion of inclusive and equitable ML practices in healthcare to address unchecked sex bias in ML algorithms.

PROSPERO REGISTRATION NUMBER

CRD42023431754.

"Just Treat Me Delicately": A Qualitative Exploration of What Works to Engage Australian Men in Health Care Encounters

There is growing consensus for upskilling the health care workforce on gender-responsive strategies to more effectively connect and respond to men during health care encounters. To inform health practitioner education, the primary aim of this study was to gain insights from a diverse sample of men in Australia on their experiences and expectations when engaging with health care practitioners. Thirty-two men (18-70 years, median 33) participated in eight online focus group discussions. A combined deductive and inductive thematic analysis was undertaken to reconcile their expectations with prior published approaches for practitioners to engage men in care and identify new themes. Participants desired a genuine relationship, signaled by upfront and informal communication, active listening, and enquiry. In structuring treatment, participants sought transparency and respect for autonomy. Regarding the therapeutic alliance, avoiding gender stereotyping and empathetic, sensitive, and holistic care were valued by men. These expectations for how practitioners engage with men in care were reflected in their advice for health practitioner student training and aligned with approaches published previously. Participant insights were synthesized into four outcomes, for men, of successful engagement: legitimize the relationship to build trust, create a safe space to facilitate disclosure, empower men, and assess and treat the whole man through a biopsychosocial lens. In conclusion, men seek authentic connection and a caring style that allows them to legitimize and forge an ongoing relationship with their practitioner. These outcomes of successful engagement are key to developing consumer-informed health practitioner education and competencies on gender-responsive health care for men.

'Charge what you think you're worth': a qualitative study exploring the gender pay gap in medicine and the role of price transparency

BACKGROUND

The gender pay gap in medicine is entrenched and has a negative impact on economic growth, institutional reputation and financial success, recruitment, retention and job satisfaction of female specialists and patient care. It also discourages women from entering specialist fields of medicine. In the Australian unregulated market setting, female specialists are not simply getting paid less, they are choosing to set lower fees than their male counterparts.

AIMS

We examine how implicit and explicit gender biases affect how fees are set and the potential role of price transparency in addressing the gender pay gap.

METHODS

We conducted 27 semi-structured interviews with medical specialists recruited via social media and medical society newsletters between June 2021 and March 2022. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis. Twenty surgeons and seven anaesthetists, 15 of whom identified as male and 12 as female, participated in this study. The primary outcomes and measures focused on the perspectives of surgeons and anaesthetists regarding fee-setting practices.

RESULTS

A combination of contextual and market- and gender-related factors was the source of the biases that determine fee setting. Further, information asymmetry in medicine in Australia underlies current fee-setting practices, exacerbating and entrenching false perceptions about women's skills as surgeons and anaesthetists. Women tend to internalise these biases, self-regulating their behaviours and how they set their fees.

CONCLUSION

The gender pay gap is pervasive. Greater transparency on fees and quality could be explored as a potential solution to reduce pay inequality.

'I just LOVE data': perceptions and practices of data sharing and privacy among users of the Lioness

High profile data breaches and the proliferation of self-tracking technologies generating bio-feedback data have raised concerns about data privacy and data sharing practices among users of these devices. However, our understanding of how self-trackers in sexual health populations, where the data may be sensitive, personal, and stigmatising, perceive data privacy and sharing is limited. This study combined industry consultation with a survey of users of the world's first biofeedback smart vibrator, the Lioness, that enables users to monitor and analyse their sexual response intensity and orgasm duration over time. We found users of the Lioness are motivated to self-track by both individual and altruistic goals: to learn more about their bodies, and to contribute to research that leads to better sexual health outcomes. Perceptions of data privacy and data sharing were shaped by an eagerness to collaborate with sexual health researchers to challenge traditional male-centric perspectives in biomedical research on women's sexual health, where gender plays a crucial role in defining healthcare systems and outcomes. This study extends our understanding of the non-digital aspects of self-tracking by emphasising the role of gender and inclusive healthcare advocacy in shaping perceptions of data privacy and sharing within sexual health populations.

Sex-Based Bias in Artificial Intelligence-Based Segmentation Models in Clinical Oncology

Artificial intelligence (AI) advancements have accelerated applications of imaging in clinical oncology, especially in revolutionizing the safe and accurate delivery of state-of-the-art imaging-guided radiotherapy techniques. However, concerns are growing over the potential for sex-related bias and the omission of female-specific data in multi-organ segmentation algorithm development pipelines. Opportunities exist for addressing sex-specific data as a source of bias, and improving sex inclusion to adequately inform the development of AI-based technologies to ensure their fairness, generalizability and equitable distribution. The goal of this review is to discuss the importance of biological sex for AI-based multi-organ image segmentation in routine clinical and radiation oncology; sources of sex-based bias in data generation, model building and implementation and recommendations to ensure AI equity in this rapidly evolving domain.

Evaluating Covid-19 publications for sex and gender-specific health content: A bibliometric analysis

BACKGROUND

Sex and gender are key variables which inform human health and disease. It remained unclear how sex and gender were considered, evaluated, reported, or analyzed within Covid-19 research. This article evaluates the proportion of Covid-19-related articles which highlighted sex- or gender-specific health content and examines associations with author gender.

MATERIALS AND METHODS

Article records for 134,008 publications indexed in the LitCovid database were extracted on June 1st, 2021. Metadata such as publication year, author names, and country of institutional affiliation were obtained from Elsevier's SCOPUS database by matching PubMed Identifiers (PMIDs). Only articles with matching SCOPUS records were included in the study, resulting in a final sample of 94,488 articles. First and last author gender was assigned to a subset of 71,597 articles. Article title, abstracts, and keywords were screened for sex or gender-specific health content using a text-based search strategy. Descriptive statistics and regression analyses were used to study associations between author gender and the presence or absence of sex or gender-related health content.

RESULTS

Only 4% of Covid-19-related articles highlighted sex or gender-related health content. Papers with women first authors were more likely to highlight sex or gender-related health content compared to papers with men as first authors (4.15% n = 1,339 vs 3.68%, n = 1,997) [X2 (1, n = 86,468) = 12,01, p = 0.0005]. Papers with women first and last authors had an increased probability of addressing sex or gender-related health with an odds ratio of 1.16 (95% CI 1.04 - 1.29). While there was no association between author gender and journal impact, articles which highlighted sex or gender-related health content were published in journals with higher CiteScores [Mdn = 5.0, Q1-Q3 (3.5-8.2) vs. Mdn = 4.7, Q1-Q3 (2.8-8.0)].

CONCLUSIONS

The paucity of publications to highlight sex or gender in the context of the Covid-19 pandemic is alarming. Research that focuses on the influence of sex and or gender is essential for advancing the scientific understanding of disease processes.

"Stop Gaslighting Your Patients": A Quantitative and Qualitative Analysis of User Experiences of IUDs on TikTok

STUDY OBJECTIVE

TikTok is a social media platform where patients can access and share information about intrauterine devices (IUDs). The primary objective of this study was to identify prominent themes of creators' experiences with IUDs on TikTok.

METHODS

We conducted a quantitative and qualitative assessment of eligible videos that appeared when searching for "IUD" on the TikTok platform between July 2019 and August 2022. Eligible videos contained content relevant to IUDs and were spoken and/or written in English.

RESULTS

Of the 354 videos that met inclusion criteria, the majority were created by users without healthcare expertise (77%) and mentioned personal experiences with IUDs (68%). However, videos that were educational (27%) or created by users with healthcare expertise (23%) averaged more likes and views than other video types. Common content areas included IUD insertion (45%), side effects (31%), and removal (25%). Perceived gaps in knowledge about the insertion procedure and feeling that providers did not adequately prepare patients for the procedure contributed to dissatisfaction with IUD insertion and motivated creators to share their experiences on TikTok. Video creators often relied on information that they found on TikTok to educate themselves about the IUD insertion process and expressed frustration at unacceptable levels of pain during insertion.

CONCLUSION

Healthcare providers should be aware that adolescent patients who use TikTok have likely seen videos depicting negative experiences with IUDs and be prepared to address patients' concerns, particularly regarding IUD insertion. Additionally, healthcare providers may use TikTok to educate users about IUDs.

Evaluating the impact, implementation experience and political economy of primary care networks in Kenya: protocol for a mixed methods study

BACKGROUND

Primary care networks (PCNs) are increasingly being adopted in low- and middle-income countries (LMICs) to improve the delivery of primary health care (PHC). Kenya has identified PCNs as a key reform to strengthen PHC delivery and has passed a law to guide its implementation. PCNs were piloted in two counties in Kenya in 2020 and implemented nationally in October 2023. This protocol outlines methods for a study that examines the impact, implementation experience and political economy of the PCN reform in Kenya.

METHODS

We will adopt the parallel databases variant of convergent mixed methods study design to concurrently but separately collect quantitative and qualitative data. The two strands will be mixed during data collection to refine questions, with findings triangulated during analysis and interpretation to provide a comprehensive understanding of PCN implementation. The quantitative study will use a controlled before and after study design and collect data using health facility and client exit surveys. The primary outcome measure will be the service delivery readiness of PHC facilities. We will use a random sample of 228 health facilities and 2560 clients in four currently implementing PCNs, four planning to implement and four control counties at baseline and post-implementation. We shall undertake a preliminary cross-sectional analysis of the data at baseline from October to December 2023, followed by a difference-in-difference analysis at the endline from October to December 2024 to compare the outcome differences between the intervention and control counties over a 12-month period. The qualitative study will include a cross-sectional process evaluation and political economy analysis (PEA) using document reviews and approximately 80 in-depth interviews with national and sub-national stakeholders. The process evaluation will assess the emergence of PCN reforms, the implementation experience, the mechanism of impact and how the context affects implementation and outcomes. The PEA will examine the interaction of structural factors, institutions and actors/stakeholders' interests and power relations in implementing PCNs. We will also examine the gendered effects of the PCNs, including power relations and norms, and their implications on PHC from the supply and demand sides. We shall undertake a thematic analysis of the qualitative data.

DISCUSSION

This evaluation will contribute robust evidence on the impact, implementation experience, political economy and gendered implications of PCNs in a LMIC setting, as well as guide the refining of PCN implementation in Kenya and other LMICs implementing or planning to implement PCNs to enhance their effectiveness.

Determinants of gender-equitable attitudes among adult men in a health education program: a cross-sectional study in Southern Malawi

BACKGROUND

Malawi ranks 142 out of 170 countries on the UN's Gender Inequality Index (GII). Women and men in Malawi have unequal access to and control over resources. Previous research has primarily examined gender roles and norms from a women's perspective, but few studies have investigated men's attitudes and behaviors regarding gender equality. This study fills this gap by investigating the social factors that influence attitudes towards gender-equality and exploring the association between behaviors and attitudes in south-eastern Malawi.

METHODS

A cross-sectional survey was administered to adult males during a health education program (male-friendly clinics) in four healthcare facilities from August 2022 to November 2022. The validated Gender-Equitable Men (GEM) scale, was employed to quantify men's attitudes towards gender norms. Univariate and multivariable analyses were used to identify the social determinants of and the behaviors associated with gender-equitable attitudes.

RESULTS

A total of 422 men, with a median age of 46 years (IQR = 34, 55), were included in this study. The participants reported a median score of 0.53 for gender attitudes, where 0 represents the minimum score and 1 the maximum. A higher GEM score was associated with a higher educational grade and living in an urban area. In terms of decision-making, 64% and 56% of men reported that they had the final say in matters concerning women's and children's health, respectively. Higher GEM scores were associated with joint decision-making in relation to women's (0.55 vs. 0.49; p = 0.008) and children's health (0.54 vs. 0.48; p = 0.012), and spending on food and clothing (0.56 vs. 0.49; p < 0.001). On the other hand, certain activities, such as cleaning the house (64% of men reported unequal participation), and cooking (70%) were not shared among partners. An equal or greater participation from men (70%) compared to women was reported for activities related to childcare. Men who participated in the previously mentioned tasks had higher GEM scores than those who did not.

CONCLUSIONS

The findings of this study shed light on the significant role of educational grade and living in an urban area as determinants of gender-equitable attitudes among men in south-eastern Malawi. More equitable perspectives towards gender norms were associated with being more involved in tasks typically assigned to women and in joint decision-making. Incorporating gender in research can contribute to the advancement of a more inclusive healthcare system.

One Health in Agricultural Sectors in Thailand, Lao PDR, and Vietnam: Interconnectedness Between Awareness and Socioeconomic Factors

Objective

The study aims to analyze the interconnectedness of farmers' socioeconomic factors and their awareness of the One Health framework.

Method

This study conducted a survey with 1,166 observations across Thailand, Lao, and Vietnam and employed binary logit regression for data analysis. Odds ratios were used for interpreting the results.

Results

The results indicated that certain socioeconomic factors-particularly household income, age, gender roles within the household, and household size-significantly influenced farmers' awareness and engagement with One Health literacy. Awareness levels varied across the three countries: for example, the composition of adults in Thai farming households was correlated with awareness of environmental health and infectious diseases. In Lao PDR, gender was significantly associated with awareness of animal health, while in Vietnam, it was linked to awareness of animal disease transmission.

Conclusion

These determinants contribute to the application of a more integrated One Health approach among farmers in these areas.

Community Health Agents Dismantling Gender Norms in a Machismo Society

BACKGROUND

Community health agents (CHAs) play a crucial role in healthcare delivery and can also impact societal gender norms. This study aims to understand CHAs' perceptions of gender roles and norms to identify long-term strategies for women's empowerment.

METHODS

We conducted 90-min focus group discussions (FGDs) among CHAs in Peru. FGDs illuminated women's perceptions of gender roles and how to empower women in communities.

RESULTS

In total, 53 CHAs participated across six FGDs. CHAs noted that women face significant barriers, are treated disrespectfully, and relegated to domestic roles. Ideal gender norms were described as having access to education, increasing voice, inclusion in decision-making, and independence. Changing gender norms requires that men, women, families, and communities support women's progress in society.

CONCLUSIONS

CHAs are in a unique and powerful position to drive social change. Understanding CHAs perceptions can help develop effective strategies for women's empowerment.

Enhancing brain health in the Global South through sex and gender lens

Gender inequality substantially impacts society, disproportionately disadvantaging women, especially in the Global South. This inequality correlates with brain health outcomes for women, including a higher risk of cognitive decline and dementia. This perspective highlights how sex-linked biology and gender disparities affect women's brain health in the Global South through various pathways, such as differential exposome, health behaviors, and gender biases in research and healthcare systems. Alzheimer's disease and other brain health conditions exemplify how sex-specific risk factors and gender-related health barriers interact to influence brain health. We advocate for incorporating sex/gender considerations in research, policy, and clinical practice to improve brain health interventions in the Global South. Additionally, we propose using the patient and public involvement framework to effectively tailor health strategies that address these factors.

Breaking Barriers: Ensuring Gender Neutral Care on Short Term Surgical Missions

INTRODUCTION

Gender discrimination is prevalent worldwide in medical and surgical care. In the setting of short-term surgical missions (STSMs) conducted to address the global burden of surgical disease, patient selection raises ethical considerations regarding equitable distribution of limited clinical resources. The goal of this study was to examine if equitable distribution of operative care between male and female patients occurs in STSMs.

METHODS

The International Surgical Health Initiative (ISHI) is a US based nonprofit, nongovernmental organization. Records from surgical missions to Ghana (2014-2023) and Sierra Leone (2013-2023) were analyzed to evaluate for gender equity in inguinal hernia repairs, the most common procedure performed. A control group was created from a literature review inclusive of all studies of inguinal hernia repairs that included over 500 patients and patient gender.

RESULTS

The review of 26 studies, representing 3,239,043 patients, demonstrated a gender distribution of 13% female. In Sierra Leone 246 inguinal hernia repairs were performed between 2013 and 2023. 28 (11.4%) of the hernia repairs were in females, which was not significantly different from the control group (P = 0.45). In Ghana 150 inguinal hernia repairs were performed between 2014 and 2023. 12 (8%) of the hernia repairs were in females. This was not significantly different from the control group (P = 0.07).

CONCLUSIONS

This is the first study investigating the gender equity conducted within the context of humanitarian surgical outreach. Equitable patient selection is a paramount consideration in STSMs, particularly to address gender-related disparities in surgical care.

Impact of gender-biased parental perceptions on under-immunization in Eastern Sudan: a cross-sectional study

Background

Despite global efforts, inequities in vaccine uptake remain, influenced by socioeconomic, geographic, cultural, and gender-related factors. In Eastern Sudan, gender disparities are acknowledged, particularly in livelihoods, but their impact on vaccination uptake is unclear. This study aimed to assess the effect of gender-biased parental perceptions on under-immunization among children in Kassala, Eastern Sudan.

Methods

This study was a community-based cross-sectional in rural and urban districts of Kassala locality in Kassala State, Eastern Sudan in November 2022. Data were collected from parents using a pre-tested, structured questionnaire. The Chi-square or Fisher's exact test was conducted to assess the factors associated with under-immunization among children.

Results

Data were collected from 400 parents. Our data reveal that most children were fully vaccinated with the three doses of the pentavalent vaccine (83%), while 14% were partially vaccinated. Findings showed that about one in five parents perceived male vaccination as more important than female vaccination. This parental perception of gender-based importance in vaccination was significantly associated with under-immunization among children (p-value = 0.049). Additionally, males in our study are fully vaccinated 5% more often than females. Socio-economic factors, including mothers' education and households' income level, were also significantly associated with the vaccination status of the children.

Conclusion

This study shed light on the effect of gender norms and related determinants on equitable access to vaccinations for boys and girls alike. More research is needed to gain a better understanding of the gender norms related to vaccination and their long-term impact on immunization demand and resilience in this region.

Systemic Factors Contributing to Gender Differences in Living Kidney Donation: A Systematic Review and Meta-Synthesis Using the Social-Ecological Model Lens

INTRODUCTION

The field of living kidney donation is profoundly gendered contributing to a predominance of women, mothers, and wives as living kidney donors (LKDs). Individual factors have traditionally been emphasized, and there is a limited appreciation of relational, community, and sociocultural influences in decision-making. We aimed to comprehensively capture existing evidence to examine the relative importance of these factors.

METHODS

This was a systematic review of existing literature that has explored the motivation of different genders to become LKDs. Of the 3,188 records screened, 16 studies from 13 counties were included. Data were synthesized thematically using the Social-Ecological Model lens.

RESULTS

At the individual level, themes related to intrinsic motivation; thoughtful deliberation; and attitudes, fears, and beliefs; however, evidence demonstrating differences between men and women was minimal. Greater variation between genders emerged along the relational (coercion from family/network, relationship with the intended recipient, self-sacrifice within the family unit, and stability/acceptance within family); community (economic value and geographic proximity to recipient); and sociocultural (gendered societal roles, social norms and beliefs, social privilege, and legislation and policy) dimensions. The relative importance of each factor varied by context; cultural components were inferred in each study, and economic considerations seemed to transcend the gender divide.

CONCLUSIONS

A complex interplay of factors at relational, community, and sociocultural levels influences gender roles, relations, and norms and manifests as gender disparities in living kidney donation. Our findings suggest that to address gender disparities in living donation, dismantling of deep-rooted systemic contributors to gender inequities is needed.

Psychometric evaluation of the study interest questionnaire-short form among Chinese nursing students based on classical test theory and item response theory

BACKGROUND

There is currently no dedicated measurement for assessing nursing students' study interest in China. Considering the good reliability, validity, and widespread applicability of the Study Interest Questionnaire-Short Form (SIQ-SF), the objective of this study was to validate its usage among Chinese nursing students.

METHODS

The translation and cross-cultural adaptation rigorously followed the modified Brislin model. A cross-sectional survey was conducted using the Chinese version of the SIQ-SF and convenience sampling was employed to select nursing students. The Psychometric evaluation of the Chinese version of the SIQ-SF was conducted based on Classical Test Theory and Item Response Theory.

RESULTS

A total of 1158 participants were included in the analysis. The item-level content validity index (CVI) ranged from 0.9 to 1.0, and the scale-level CVI was 0.98. In the Exploratory factor analysis, three factors with eigenvalues above 1 were identified, accounting for 62.554% of the cumulative variance. In the confirmatory factor analysis, the CMIN\DF was 5.639, the GFI was 0.953, the CFI was 0.902, and the IFI was 0.904. The Cronbach's α coefficient of the Chinese version of the SIQ-SF was 0.70. Thirty-one participants were invited to sign the scale after two weeks. The intraclass correlation coefficient was 0.784, and that of items ranged from 0.70 to 0.819. The infit MnSQ values ranged between 0.76 and 1.51, and the outfit MnSQ values ranged between 0.72 and 1.76. The point-measure correlation value ranged between 0.30 and 0.68. The item difficulty measures ranged from - 0.66 to 1.44 logit and the individual learning interest estimations ranged from - 4.22 to 4.97 logit. DIF contrast ranged from 0.00 to 0.33 logits, with all p values greater than 0.05.

CONCLUSIONS

The Chinese version of the SIQ-SF demonstrated acceptable reliability and validity among Chinese nursing students and could be used to assess nursing students' study interest in China. With the aid of this scale, teachers can gain a better understanding of nursing students' study interests, thereby maximizing their learning effects through appropriate content and methods.

A multidimensional gender analysis of health technology self-efficacy among people with Parkinson's disease

BACKGROUND

Digital health technologies (DHT) enable self-tracking of bio-behavioral states and pharmacotherapy outcomes in various diseases. However, the role of gender, encompassing social roles, expectations, and relations, is often overlooked in their adoption and use. This study addresses this issue for persons with Parkinson's disease (PD), where DHT hold promise for remote evaluations.

METHODS

We conducted a cross-sectional survey study in the Netherlands, assessing the impact of gender identity, roles, and relations on health technology self-efficacy (HTSE) and attitude (HTA). An intersectional gender analysis was applied to explore how gender intersects with education, employment, disease duration, and severity in influencing HTSE and HTA.

RESULTS

Among 313 participants (40% women), no significant correlation was found between gender identity or relations and HTSE or HTA. However, individuals with an androgynous (non-binary) gender role orientation demonstrated better HTSE and HTA. The exploratory intersectional analysis suggested that sociodemographic and clinical factors might affect the influence of gender role orientations on HTSE and HTA, indicating complex and nuanced interactions.

CONCLUSION

This study highlights the importance of investigating gender as a multidimensional variable in PD research on health technology adoption and use. Considering gender as a behavioral construct, such as through gender roles and norms, shows more significant associations with HTSE and HTA, although effect sized were generally small. The impact of gender dimensions on these outcomes can be compounded by intersecting social and disease-specific factors. Future studies should consider multiple gender dimensions and intersecting factors to fully understand their combined effects on technology uptake and use among people with PD.

Mpox virus infection in women and outbreak sex disparities: A Systematic Review and Meta-analysis

BACKGROUND

Although the recent literature indicates that mpox (monkeypox) primarily affects men, there are also multiple reports in women. Estimates of the sex distribution of mpox patients and patterns will enable a better understanding of the ongoing mpox outbreak.

METHODS

In this systematic review and meta-analysis, seven databases were searched for studies published in English up to January 4th, 2023. The proportion of women with mpox was the primary outcome. A random-effects model was fitted for the primary outcome, and a sensitivity analysis was performed to check possible outliers in the studies.

RESULTS

Here we screened 470 articles and included 60 studies for qualitative synthesis. 42 studies with 3125 women out of 47,407 confirmed cases were found suitable for meta-analysis. The pooled proportion of female patients is 17.22% (95% CI: 10.49-25.11; I2 = 98.86%). Subgroup analyses reveal higher proportion before 2022 [44.09% (42.93-46.86] than 2022 onwards [2.40% (1.17-3.98)], and in endemic countries [43.13% (37.63-48.72)] than in nonendemic countries [6.15% (2.20-11.65)].

CONCLUSIONS

There is considerable caseload (17.22%) amongst women, which must be seen in the context of a much higher proportion (44.09%) in studies prior to 2022 compared to 2.40% in the 2022 outbreak indicating an epidemiological shift. Data on disease characteristics among women with mpox disease are scarce. Further studies should focus on these aspects to better understand the disease in women and empower epidemiologists and clinicians to make evidence-based decisions for this vulnerable group.

The gender gap in outpatient care for non-communicable diseases in Mexico between 2006 and 2022

BACKGROUND

Equitable health service utilization is key to health systems' optimal performance and universal health coverage. The evidence shows that men and women use health services differently. However, current analyses have failed to explore these differences in depth and investigate how such gender disparities vary by service type. This study examined the gender gap in the use of outpatient health services by Mexican adults with non-communicable diseases (NCDs) from 2006 to 2022.

METHODS

A cross-sectional population-based analysis of data drawn from National Health and Nutrition Surveys of 2006, 2011-12, 2020, 2021, and 2022 was performed. Information was gathered from 300,878 Mexican adults aged 20 years and older who either had some form of public health insurance or were uninsured. We assessed the use of outpatient health services provided by qualified personnel for adults who reported having experienced an NCD and seeking outpatient care in the 2 weeks before the survey. Outpatient service utilization was disaggregated into four categories: non-use, use of public health services from providers not corresponding to the user's health insurance, use of public health services from providers not corresponding to the user's health insurance, and use of private services. This study reported the mean percentages (with 95% confidence intervals [95% CIs]) for each sociodemographic covariate associated with service utilization, disaggregated by gender. The percentages were reported for each survey year, the entire study period, the types of service use, and the reasons for non-use, according to the type of health problem. The gender gap in health service utilization was calculated using predictive margins by gender, type of disease, and survey year, and adjusted through a multinomial logistic regression model.

RESULTS

Overall, we found that women were less likely to fall within the "non-use" category than men during the entire study period (21.8% vs. 27.8%, P < 0.001). However, when taking into account the estimated gender gap measured by incremental probability and comparing health needs caused by NCDs against other conditions, compared with women, men had a 7.4% lower incremental likelihood of falling within the non-use category (P < 0.001), were 10.8% more likely to use services from providers corresponding to their health insurance (P < 0.001), and showed a 12% lower incremental probability of using private services (P < 0.001). Except for the gap in private service utilization, which tended to shrink, the others remained stable throughout the period analyzed.

CONCLUSION

Over 16 years of outpatient service utilization by Mexican adults requiring care for NCDs has been characterized by the existence of gender inequalities. Women are more likely either not to receive care or resort to using private outpatient services, often resulting in catastrophic out-of-pocket expenses for them and their families. Such inequalities are exacerbated by the segmented structure of the Mexican health system, which provides health insurance conditional on formal employment participation. These findings should be considered as a key factor in reorienting NCD health policies and programs from a gender perspective.

Association between sexual violence and depression is mediated by perceived social support among female university students in the kingdom of Eswatini

BACKGROUND

Gender-based violence is a tool that primarily functions to maintain gendered power hierarchies. Manifestations of gender-based violence, sexual assault and street harassment have been shown to have significant effects on mental wellbeing in the global North, however there is little research centering the experiences and consequences of gendered harassment in the Africa region.

METHODS

We analyzed a cross-sectional random sample of 372 women attending a major university in Eswatini in 2017 to measure the prevalence of street harassment among female university students and assess the relationship between experiences of sexual assault, sexualized street harassment, and mental health outcomes in this population.

RESULTS

We found that in the previous 12 months, women reported experiencing high levels of sexual assault (20%), street harassment (90%), and depression (38%). Lifetime sexual assault, past 12 months sexual assault, and street harassment were all significantly associated with symptoms of depression. We created a structural model to test hypothesized causal pathways between street harassment, previous experiences of sexual assault, and symptoms of depression, with social support as a potential mediator. We found that a history of sexual violence significantly mediated the association between street harassment and depression, and that social support mediated a large proportion of the association between both forms of gender-based violence and depression.

CONCLUSION

Sexualized street harassment is associated with increased depressive symptomology for nearly all women, however the effects are especially pronounced for women who have previous experiences of sexual violence. Sexualized street harassment functions as a tool to maintain gendered power hierarchies by reminding women of ongoing threat of sexual violence even in public spaces. Social support and solidarity among women is a potentially important source of resiliency against the physical and mental harms of all forms of gender based violence.

COVID-19 vaccine uptake in individuals with functional difficulty, disability, and comorbid conditions: insights from a national survey in Bangladesh

BACKGROUND

COVID-19 vaccine uptake among individuals with disabilities is crucial for safeguarding their health and well-being. However, the extent of vaccine uptake among this group remains largely unknown in low- and middle-income countries. This study aims to assess the COVID-19 vaccine uptake among persons with functional difficulty, disability and/or comorbidity in Bangladesh and their associated factors.

METHODS

Data from 9,370 respondents extracted from the 2021 National Household Survey on Persons with Disability were analysed. The outcome variable was the uptake of at least one dose of the COVID-19 vaccine (yes, no). Key explanatory variables included the presence of disability (yes, no), comorbidity (yes, no), and both comorbidity and disability (yes, no) among persons with functional difficulty. The relationship between the outcome and explanatory variables was determined using mixed-effects multilevel logistic regressions adjusted for covariates.

RESULTS

The overall uptake of at least one dose of the COVID-19 vaccine among persons with functional difficulty was 57.37%, among persons with functional difficulty and disability was 48.63% and among persons with functional difficulty and single (57.85%) or multi-comorbidity (60.37%). Compared to the respondents with functional difficulty only, the adjusted odds ratio (aOR) of not receiving any dose of the COVID-19 vaccine for individuals with both functional difficulty and disability was 1.37 (95% CI, 1.22-1.53), and for individuals with functional difficulty, disability and one or more comorbid conditions was 1.30 (95% CI, 1.15-1.47). The aOR of receiving at least one dose of the COVID-19 vaccine among individuals with functional difficulty and one or more comorbid conditions was significantly higher than among those with functional difficulty only.

CONCLUSION

In Bangladesh, COVID-19 vaccine uptake was relatively low among individuals with disabilities. The existing COVID-19 vaccine rollout programs and similar future programs should prioritise individuals with disabilities and include targeted strategies to reach them.

Promoting gender equity in a home visits programme: a qualitative study in Northern Nigeria

BACKGROUND

Gender inequities remain critical determinants influencing maternal health. Harmful gender norms and gender-based violence adversely affect maternal health. Gendered division of labour, lack of access to and control of resources, and limited women's decision-making autonomy impede women's access to maternal healthcare services. We undertook a cluster randomized controlled trial of universal home visits to pregnant women and their spouses in one local government area in Bauchi State, North-Eastern Nigeria. The trial demonstrated a significant improvement in maternal and child health outcomes and male knowledge, attitudes and behaviours. This paper qualitatively evaluates gender equity in the home visits programme.

METHODS

The research team explored participants' views about gender equity in the home visits programme. We conducted nine key informant interviews with policymakers and 14 gender and age-stratified focus group discussions with men and women from visited households, with women and men home visitors and supervisors, and with men and women community leaders. Analysis used an adapted conceptual framework exploring gender equity in mainstream health. A deductive thematic analysis of interviews and focus group reports looked for patterns and meanings.

RESULTS

All respondents considered the home visits programme to have a positive impact on gender equity, as they perceived gender equity. Visited women and men and home visitors reported increased male support for household chores, with men doing heavy work traditionally pre-assigned to women. Men increased their support for women's maternal health by paying for healthcare and providing nutritious food. Households and community members confirmed that women no longer needed their spouses' permission to use health services for their own healthcare. Households and home visitors reported an improvement in spousal communication. They perceived a significant reduction in domestic violence, which they attributed to the changing attitudes of both women and men due to the home visits. All stakeholder groups stressed the importance of engaging male spouses in the home visits programme.

CONCLUSION

The home visits programme, as implemented, contributed to gender equity.

Effect of male partners' involvement and support on reproductive, maternal and child health and well-being in East Africa: A scoping review

Background and Aims

East African countries have high rates of maternal and child mortality and morbidity. Studies have shown that the involvement of male partners in reproductive health can benefit maternal and child health (MCH). This scoping review aims to provide an overview of the evidence across East Africa that describes male partner involvement and its effect on maternal, reproductive, and child well-being.

Methods

Ten databases were searched to identify quantitative data on male's involvement in East Africa. Studies reporting qualitative data, "intention to use" data or only reporting on male partner's education or economic status were excluded. Studies were organized into five a priori categories: antenatal care (ANC), human immunodeficiency virus, breastfeeding, family planning, and intimate partner violence with further categories developed based on studies included.

Results

A total of 2787 records were identified; 644 full texts were reviewed, and 96 studies were included in this review. Data were reported on 118,967 mothers/pregnant women and 15,361 male partners. Most of the studies (n = 83) were reported from four countries Ethiopia (n = 49), Kenya (n = 14), Tanzania (n = 12) and Uganda (n = 10). The evidence indicates that male partner involvement and support is associated with improved reproductive, MCH across a wide range of outcomes. However, the studies were heterogeneous, using diverse exposure and outcome measures. Also, male partners' lack of practical and emotional support, and engagement in violent behaviors towards partners, were associated with profound negative impacts on MCH and well-being.

Conclusions

The body of evidence, although heterogeneous, provides compelling support for male involvement in reproductive health programs designed to support MCH. To advance research in this field, an agreement is needed on a measure of male partner "involvement." To optimize benefits of male partners' involvement, developing core outcome sets and regional coordination are recommended.

Pathways to leadership: what accounts for women's (in)equitable career paths in the health sectors in India and Kenya? A scoping review

OBJECTIVES

We aimed to capture evidence on enablers and barriers to improving equal opportunity and effective organisational interventions that can advance women's leadership in India and Kenya's health sectors.

METHODS

We systematically searched JSTOR, PubMed, SCOPUS and Web of Science databases, reference lists of selected articles and Google Scholar using string searches. We included studies that were published in English from 2000 to 2022 in peer-reviewed journals or grey literature, focused on paid, formal health professionals in India or Kenya, described factors relating to women's representation/leadership.

RESULTS

We identified 26 studies, 15 from India and 11 from Kenya. From each country, seven studies focused on nursing. Participants included women and men health sector workers. Seven studies used mixed methods, 11 were qualitative, 5 were quantitative and 3 were commentaries. Factors influencing women's career progression at individual/interpersonal levels included family support, personal attributes (knowledge/skills) and material resources. Factors at the organisational level included capacity strengthening, networking, organisational policies, gender quotas, work culture and relationships, flexibility, and work burden. Nursing studies identified verbal/sexual harassment and professional hierarchies as barriers to career progression. Structural barriers included a lack of infrastructure (training institutes and acceptable working environments). Normative themes included occupational segregation by gender (particularly in nursing), unpaid care work burden for women and gender norms. Studies of interventions to improve women's career progression and sex-disaggregated workforce data in India or Kenya were limited, especially on leadership within career pathways. The evidence focuses on enablers and barriers at work, rather than on organisations/systems to support women's leadership or address gender norms.

CONCLUSIONS

Women in India and Kenya's health sectors face multiple impediments in their careers, which impact their advancement to leadership. This calls for gender-transformative interventions to tackle discrimination/harassment, provide targeted training/mentorship, better parental leave/benefits, flexible/remote working, family/coworker support and equal-opportunity policies/legislation.

Empowering women as enablers in public health: A quantitative-qualitative systematic review of the gender-transformative approach

Women are expected to take on multiple roles as caregivers and health care providers, but they are still often perceived as victims or beneficiaries rather than enablers. We aimed to explore women's empowerment and gender equality in public health systems and identify proactive enablers that can be incorporated into projects. A systematic review of peer-reviewed literature as well as text analysis were conducted to examine changes in perceptions of women's roles in public health projects. The authors conducted a quantitative analysis of the collected article titles, which revealed a shift in research from identifying risk factors to exploring women's autonomy in health promotion. However, our qualitative review of the articles showed that previous gender-related projects used a gender-sensitive approach that perpetuated the view of women as victims or beneficiaries rather than enablers. The concept of proactive enablers in all aspects of project planning and implementation ensures that women's roles are fully recognized and valued.

Early Impressions and Adoption of the AtriAmp for Managing Arrhythmias Following Congenital Heart Surgery

AtriAmp is a new medical device that displays a continuous real-time atrial electrogram on telemetry using temporary atrial pacing leads. Our objective was to evaluate early adoption of this device into patient care within our pediatric intensive care unit (PICU). This is a qualitative study using inductive analysis of semi-structured interviews to identify dominant themes. The study was conducted in a single-center, tertiary, academic 21-bed mixed PICU. The subjects were PICU multidisciplinary team members (Pediatric Cardiac Intensivists, PICU Nurse Practitioners, PICU nurses and Pediatric Cardiologists) who were early adopters of the AtriAmp (n = 14). Three prominent themes emerged: (1) Accelerated time from arrhythmia event to diagnosis and treatment; (2) Increased confidence in the accuracy of providers' arrhythmia diagnosis; and (3) Improvement in the ability to educate providers about post-operative arrhythmias. Providers also noted some learning curves, but none compromised medical care or clinical workflow. Insights from early adopters of AtriAmp signal the need for simplicity and fidelity in new PICU technologies. Our research suggests that such technologies can be pivotal to the support and growth of multi-disciplinary teams, even among those who do not participate in early implementation. Further research is needed to understand when and why novel technology adoption becomes widespread in high-stakes settings.

Active listening, shared decision-making and participation in care among older women and primary care nurses: a critical discourse analysis approach from a gender perspective

BACKGROUND

Nursing care for older women represent a challenge worldwide due to its characteristics. When communication is impaired between primary care nurses and older women living alone, an imbalance in power relations occurs. The main objective of this study is to analyse the power relations between older women and primary care nurses in situations of active listening, shared decision-making and participation in care.

METHODS

We developed a qualitative study in southern Spain using a discursive and gender approach. We used purposeful sampling to interview older women who lived alone and received home nursing care. Simultaneously, we conducted focus groups with primary care nurses who provided home care to older women. A linguistic analysis of the transcripts was carried out.

RESULTS

Nine semi-structured face-to-face interviews were conducted with older women who lived alone and two face-to-face focus groups with four primary care nurses in each. The discourse of the participants demonstrated an imbalance in power relations. Influenced by work overload, active listening was considered a privilege in primary care nurses´ discourse. Regarding shared decision-making, older women´s discourses revealed "mirages" of real situations where they thought they were deciding. Participation in care was difficult since older women saw themselves as a nuisance in nurses´ presence, and primary care nurses did not facilitate older women's engagement. Older women weren´t considered when organising home visits and had interiorised a subordinated feeling. Similarly, a strict sense of identity made primary care nurses feel powerful in their relationships with older women.

CONCLUSIONS

The discourse of older women represented them as victims of a hostile panorama whilst they were sometimes satisfied with the deficient care received. The discourse of primary care nurses used more discursive strategies to represent themselves as professionals committed to caring. However, it also revealed deficiencies in care, discriminatory elements, and feelings of being limited by their working conditions. Active listening to older women and engagement in decision-making readjust empower the older women. Attending to the needs and concerns of primary care nurses could recalibrate the power imbalance between them and healthcare organisations.

Intrahousehold food allocation social norms and food taboos in rural Ethiopia: The case of adolescent girls

Background

In low-income countries, social norms play a significant role in intrahousehold food allocation practices. These norms can sometimes lead to discrimination against specific groups, posing a public health concern. This study focuses on the social norm surrounding food allocation within households and food taboos affecting adolescent girls in rural Ethiopia.

Method

A qualitative study was conducted using vignettes as prompts for 20 focus group discussions and 32 in-depth interviews. The vignettes were tailored to the local context. Participants were chosen purposefully, and data were collected in a comfortable setting. All sessions were recorded and transcribed verbatim. Data analysis was done using Open Code qualitative analysis software with a thematic framework approach.

Findings

In the community, adolescent girls were expected to eat after serving the male family members. Those who did not follow this expectation faced sanctions such as being labeled as disrespectful and could even be insulted or beaten by their spouses and siblings. However, there were some exceptions to this rule, such as when girls were giving birth, breastfeeding, sick, or when male family members were traveling. Certain foods were also prohibited for adolescent girls, including spicy foods like chili, animal products such as meat and milk, and nuts. These foods were believed to increase girls' sexual desire, potentially leading them to engage in premarital or extramarital sex. Additionally, eating outside of the house was not considered appropriate behavior for adolescent girls in this community.

Conclusion

In many households, social norms dictate that adolescent girls are not given enough food or are denied essential nutrients for their health. It is important to challenge these norms to ensure fair food distribution within households and support the healthy development of adolescent girls.

The EMERGE framework to measure empowerment for health and development

RATIONALE

Women's empowerment is a UN Sustainable Development Goal and a focus of global health and development but survey measures and data on gender empowerment remain weak. Existing indicators are often disconnected from theory; stronger operationalization is needed.

OBJECTIVE

We present the EMERGE Framework to Measure Empowerment, a framework to strengthen empowerment measures for global health and development.

METHOD

We initiated development of this framework in 2016 as part of EMERGE - an initiative designed to build the science of survey research and availability of high-quality survey measures and data on gender empowerment. The framework is guided by existing theories of empowerment, evidence, and expert input. We apply this framework to understand women's empowerment in family planning (FP) via review of state of the field measures.

RESULTS

Our framework offers concrete measurable constructs to assess critical consciousness and choice, agency and backlash, and goal achievement as the empowerment process, recognizing its operation at multiple levels-from the individual to the collective. Internal attributes, social norms, and external contexts and resources create facilitators or barriers to the empowerment process. Review of best evidence FP measures assessing empowerment constructs, social norms, and key influencers (e.g., partners and providers) show a strong landscape of measures, including those with women, partners, and providers, but they are limited in assessing translation of choice to agency to achievement of women's self-determined fertility or contraceptive goals, instead relying on assumption of contraceptive use as the goal. We see no measures on collective empowerment toward women's reproductive choice and rights.

CONCLUSION

The EMERGE Framework can guide development and analysis of survey measures on empowerment and is needed as the current state of the field shows limited coverage of empowerment constructs even in areas which have received more study, such as family planning.

Examining the association between men's gender equitable attitudes and contraceptive outcomes in rural Maharashtra, India

Background

Previous literature suggests that men reporting more gender-equitable attitudes are more likely to use condoms, but there is a paucity of data evaluating whether these attitudes are associated with contraceptive communication and use. The objective of this study is to test the hypothesis that men reporting more gender-equitable attitudes will be more likely to (a) engage in contraceptive communication with their wives and (b) that they and/or their wives will be more likely to use all forms of family planning, compared to men with less equitable attitudes.

Methods

Using cross-sectional dyadic survey data from young married couples from rural Maharashtra, India (N = 989), we assessed the associations between men's gender role attitudes and a) spousal contraceptive communication and b) contraceptive use by type (none, traditional, condoms, pills, or IUD). The contraceptive use outcome is based on wives' report. We assessed these associations via bivariate t-test (communication outcome) or ANOVA test (contraceptive type outcome), as well as unadjusted and adjusted logistic (communication outcome) and multinomial logistic (contraceptive type outcome) regression models. Adjusted models included sociodemographic factors selected a priori based on established associations with gender-equitable attitudes and/or our assessed outcomes.

Findings

Men with more gender-equitable attitudes were more likely to discuss family planning with their wives (AOR = 1·05, 95%CI 1·03-1·07, p < 0·001) and to use condoms (ARRR = 1·03, 95%CI 1·00-1·06, p = 0·07). There was no association between gender-equitable attitudes and use of other types of contraception.

Interpretation

While gender-equitable attitudes among men may facilitate condom use and family planning communication in marriage, they do not appear to be linked with greater likelihood of use of more effective types of contraceptive use. This suggests that males supportive of gender equity may take greater responsibility for family planning vis a vis a less effective contraceptive, condoms, in the absence of more effective short-acting contraceptives for men.

Funding

The National Institutes of Health [Grant number 5R01HD084453-01A1] and the Bill & Melinda Gates Foundation, Seattle, WA [grant number INV-002967].

Sex-based differences in TB treatment compliance: A mediating factor for sputum conversion among newly diagnosed pulmonary TB patients in Chennai, South India

BACKGROUND

Tuberculosis (TB) remains a global health concern, particularly in India, which carries a significant portion of the global burden. The role of sex as a determinant of health is increasingly recognized, impacting various aspects of TB, including treatment compliance and outcomes. This study aimed to determine the mediating role of treatment compliance in the relationship between sex and sputum conversion in newly diagnosed pulmonary TB patients in Chennai, South India.

METHODS

We conducted a retrospective cohort study among patients newly diagnosed for TB at ESIC Medical College & PGIMSR between April 2020 and April 2022. A causal mediation analysis was performed to identify the direct and indirect effects of sex on sputum conversion via the mediator, treatment compliance. We employed logistic regression models and the "paramed" package for the analysis, with bootstrapping technique for examining the significance of indirect and direct effects.

RESULTS

The Marginal Total Effect (MTE) suggested that females were more likely to have sputum positivity compared to males (OR: 6.77; p = 0.003). Direct effect of being female increased the odds of sputum positivity at the end of the intensive phase (OR: 3.42; p = 0.03). The indirect effect of being female via treatment compliance significantly increased the odds of sputum positivity at the end of the intensive phase (OR: 1.98; p = 0.03).

CONCLUSION

The study provides evidence that treatment compliance significantly mediates the relationship between sex and sputum conversion in TB patients, highlighting the necessity to consider gendered dimensions of health in TB control strategies.

The Female Global Scholars Program: A mixed-methods evaluation of a novel intervention to promote the retention and advancement of women in global health research

Fewer than 25% of global health leadership positions worldwide are held by women, adversely impacting women's health and widening gendered health disparities. The Female Global Scholars (FGS) Program, established in 2018 at Weill Cornell Medicine, is a two-year hybrid training and peer-mentorship program that promotes the retention and advancement of early-career female investigators conducting health research in low- and middle-income countries (LMICs). The purpose of this study is to determine the impact of the FGS Program on individual career advancement, academic productivity, and research self-efficacy. This mixed-methods study followed an explanatory sequential design. Participants completed an electronic survey collecting information on demographics, academic milestones, and research skill competency. Survey data were descriptively analyzed using R (Version 1.4.1106). In-depth interviews explored perceptions of the impact of the FGS Program on career development. The authors independently reviewed and thematically analyzed de-identified transcripts using NVivo (Version 13). In June 2022, twelve participants completed the survey. The median age was 40 years; 90% carried an MD, PhD, or other post-graduate degree. Since joining the FGS Program, respondents achieved a combined total of eight awarded grants, five academic promotions, 12 oral scientific presentations and 35 first-author peer-reviewed publications. Thematic analysis identified four overarching themes: gaining confidence through mimicry; improved self-efficacy to address gendered challenges; real-world application of scientific and career development skills; and building multi-disciplinary communities in a protected female-only space. We demonstrate that this low-cost training and mentorship program successfully addresses critical barriers that impede women's advancement in global health research. Our data may inform the adaptation of this initiative across other academic institutions.

Female Attendings in University Clinics of Surgery in Germany: A Scoping Analysis of an Ongoing Disparity

INTRODUCTION

 Gender-based discrimination, particularly in healthcare, affects women's roles and opportunities, including in surgery where they remain underrepresented in leadership positions. The extent to which such discrimination is prevalent in attending positions is unclear.

METHODS

 The publicly available records of 48 universities and university-associated hospitals in Germany were extracted to quantify gender ratios among attending surgeons and head surgeons in the fields of visceral, vascular, cardiac, thoracic, pediatric, orofacial, neuro-, trauma, and plastic surgery. Statistical analysis, including Chi-Square tests and Student's t-test, was used to analyze the data.

RESULTS

 Among the 367 department heads, 353 (96.2%) were male and 14 (3.8%) were female. Among the 2,366 attendings, 1,854 (78.4%) were men and 512 (21.6%) were women. These differences were significant (χ²=64.95, p<0.001, odds ratio=0.14, 95% confidence interval=0.08-0.25). Departments being led by a female department head were not more likely to employ female attendings (χ²=0.379, p=0.538, odds ratio=1.17, 95% confidence interval=0.70-1.96).

CONCLUSION

 German surgical departments in University Hospitals have significant gender disparities, with women underrepresented at higher levels. This may negatively affect patient outcomes. To tackle the problem, further research is needed to fully understand the issue.

A mixed methods study examining the impact of primary health care financing transitions on facility functioning and service delivery in Kenya: a study protocol

Background

Kenya has experienced several health financing changes that have implications for financing primary healthcare (PHC). These include transitions from funding by two key donors (the World Bank and the Danish International Development Agency (DANIDA)) and the abolishment of conditional grants that were earmarked for financing primary healthcare facilities. This protocol lays out study plans to evaluate the impact and implementation experience of these financing changes on PHC facility functioning and service delivery in Kenya.

Methods/design

A sequential mixed methods design will be applied to address our research objectives. Firstly, we will perform a document review to understand the evolution of policy changes understudy. Second, we will conduct an interrupted time series analysis across all 47 counties in Kenya to assess these financing changes' impact on health service utilization in all public primary healthcare facilities (level 2 and 3 facilities). Data for this analysis will be obtained from the Kenya Health Information System (KHIS). Third, we will carry out in-depth interviews with health financing stakeholders at the national, county, and health facility levels to examine their perceptions of the experiences with these changes in health financing.

Discussion

This mixed methods study will contribute to evidence on the sustainability of financing primary healthcare in low and middle-income countries facing financing changes and donor transitions.

A roadmap to SDGs-emergence of technological innovation and infrastructure development for social progress and mobility

The goal of this study was to conduct a thorough investigation on understanding how infrastructure growth and technological innovation affect social mobility and the Sustainable Development Goals (SDGs). This study aimed to illuminate the underlying mechanisms by exploring the mediating function of psychological empowerment and the moderating impact of community satisfaction. The study carefully chose a sizeable sample of 370 connected to the mega project CPEC. Data collection was carried out using a questionnaire-based approach. Notably, the study confirmed the large and favorable influence of technical innovation and infrastructural development on both the SDGs-13 (climate change) and social mobility. Furthermore, this study provided light on the critical function of environmental impacts identifying it as an important mediating mechanism that magnifies the effects of innovation and infrastructure on long-term development outcomes. It gives decision-makers in government, business, international organizations, and local communities useful information by offering empirical data and insights. This study offers a novel perspective and explores the relationship between infrastructure growth, technological innovation, social mobility, and SDGs-13-climate change. It uncovers the pivotal roles of psychological empowerment and community satisfaction, offering fresh insights into global development strategies influencing SDGs.

"I am the doctor": gender-based bias within the clinical practice of emergency medicine in Canada-a thematic analysis of physician and trainee interview data

OBJECTIVES

While women comprise about half of current Canadian medical students and physicians, only 31% of emergency medicine physicians identify as women and women trainees are less likely to express interest in emergency medicine compared to men. Gender-based bias continues to negatively impact the career choice, progress, and well-being of women physicians/trainees. Although instances of gender-based bias are well documented within other medical specialties, there remains a gap in the literature addressing the role of gender specific to the Canadian emergency medicine clinical environment.

METHODS

Using a qualitative study with a thematic analytical approach, participants were purposively and snowball sampled from a cross-section of centers across Canada and included emergency medicine attending physicians and trainees. A thematic analysis using an inductive and deductive approach was undertaken. All data were double coded to improve study trustworthiness. Descriptive statistics were used to characterize the study population.

RESULTS

Thirty-four individuals (17 woman-identifying and 17 man-identifying) from 10 different institutions across 4 provinces in Canada participated in the study. Six themes were identified: (1) women experience gender bias in the form of microaggressions; (2) women experience imposter syndrome and question their role in the clinical setting; (3) more women provide patient care to women patients and vulnerable populations; (4) gender-related challenges with family planning and home responsibilities affect work-life balance; (5) allyship and sponsorship are important for the support and development of women physicians and trainees; and (6) women value discussing shared experiences with other women to debrief situations, find mentorship, and share advice.

CONCLUSIONS

Gender inequity in emergency medicine affects women-identifying providers at all levels of training across Canada. Described experiences support several avenues to implement change against perceived gender bias that is focused on education, policy, and supportive spaces. We encourage institutions to consider these recommendations to achieve gender-equitable conditions in emergency medicine across Canada.