Reliability of the Marlowe-Crowne social desirability scale in Ethiopia, Kenya, Mozambique, and Uganda

A good egg: An evaluation of a social and behavior change communication campaign to increase egg consumption among children in Rwanda

Childhood malnutrition, which is endemic in rural areas of low-income countries, leads to a host of deleterious outcomes such as poor cognitive development, low educational attainment and lower lifetime wages. Promoting the consumption of eggs among young children has emerged as a promising strategy to combat childhood malnutrition, though pathways to scale remain unclear. In this paper, we evaluate the impact of a social and behaviour change communication (SBCC) campaign combined with a program in which rural families purchased chickens on credit (poultry + SBCC; n = 769) relative to an arm in which families only received the poultry intervention (poultry only; n = 750), using a difference-in-difference estimation strategy with propensity score matching. The SBCC consisted of radio messages, in-person training, text message reminders and posters. We found a relatively modest but statistically significant increase in the number of times per week respondents in the poultry + SBCC arm reported feeding eggs to children of 0.28 (p = 0.02) compared to the poultry-only arm. The increase in egg feeding, however, was more pronounced for boys (0.42, p < 0.01) than for girls (0.14, p = 0.26). In addition, the campaign increased egg feeding more for those who were already feeding eggs to children (0.63, p < 0.01) than those who were not engaging in those practices at baseline (0.26, p < 0.01). However, the difference in these differences was not statistically significant. Future campaigns should ensure higher saturation of messaging and include specific messaging around the importance of feeding girls as well as boys. Campaigns seeking to scale up egg feeding quickly could potentially target the easier-to-reach segment of caregivers who already occasionally feed eggs to children though these might not be the neediest group.

Culturally-informed adaptation and psychometric properties of the Cataldo Cancer Stigma Scale in Northern Tanzania

BACKGROUND

Cancer-related stigma impacts patients' emotional health, care engagement, and cancer outcomes, but few measures of cancer stigma exist. We culturally adapted and assessed psychometric properties of the Cataldo Cancer Stigma Scale (CCSS) in Tanzania.

METHODS

We administered the CCSS short version (21 items), plus 12 locally-derived items, to 146 adult cancer patients. We conducted exploratory factor analysis, examined internal consistency/reliability, and assessed convergent validity with relevant measures.

RESULTS

We identified a 17-item cancer stigma scale with strong psychometric properties and four subscales: enacted stigma, shame and blame, internalized stigma, and disclosure concerns. Stigma was rare except for disclosure concerns. Stigma was positively associated with depression and anxiety and negatively associated with social support, quality of life, and illness acceptance.

CONCLUSIONS

The scale provides valid, culturally-informed measurement of cancer stigma in Tanzania. Future studies should assess associations with care engagement, which will inform interventions to reduce stigma and improve outcomes.

How does social desirability bias influence survey-based estimates of the use of antenatal care in rural Nepal? A validation study

OBJECTIVES

Social desirability bias is often speculated to influence survey responses but seldom studied in healthcare. The objective was to explore whether social desirability scores (SDS) or the presence of interview observers is associated with inaccurate recall and overestimation of antenatal care (ANC) services.

DESIGN

Longitudinal validation study comparing recalled receipt of ANC services and nutrition components of ANC against direct observations of care. An adapted short form Marlowe-Crowne questionnaire was used to generate an SDS, and the presence of interview observers was treated as a separate exposure. We assessed accuracy and overestimation of recalled receipt of ANC services against observed receipt using log-binomial regression, adjusting for age, education, first-pregnancy and socioeconomic status.

SETTING

Rural Southern Nepal with recruitment from five government health posts.

PARTICIPANTS

401 pregnant women.

RESULTS

Social desirability scores did not significantly predict accuracy or overestimation of most types of ANC care except counselling on nausea. Higher SDS was associated with more accurate recall (adjusted RR, aRR 1.08 (95% CI 1.03, 1.12)) and less overestimation (aRR 0.85 (0.80, 0.91)). The presence of mothers-in-law or husbands during interviews was associated with greater overestimation of the number of ANC visits received by more than three visits (aRR 2.07 (1.11, 3.84)) and (aRR 4.19 (2.17, 8.10)), respectively. Those interviewed with friends present tended to overestimate the receipt of counselling on nausea, avoiding alcohol and not smoking.

CONCLUSION

The presence of observers can lead to overestimation of the receipt of ANC care and support the conduct of interviews in private settings despite challenges of doing so in village contexts. Findings that the SDS did not predict the accuracy of most types of ANC care might reflect a reality that such questions may not be sensitive from a social-norms perspective. Additional local adaptation of SDS is recommended.

A Mixed Methods Exploration of the Role of Participation in a Nutrition-Sensitive Agroecology Intervention in Rural Tanzania

Background

Participation is key to the successful implementation of nutrition-related interventions, but it has been relatively overlooked.

Objective

We sought to describe participation intensity among smallholder farmers in a randomized nutrition-sensitive agroecology study in rural Tanzania. We explored the association between baseline characteristics and overall participation intensity (quantitatively at the individual level and qualitatively at the group level), the association of participation intensity with 2 process indicators, and the association between participation intensity and key study outcomes.

Methods

Data came from 7 rounds of surveys with 295 women and 267 men across 29 months and 2 rounds of semi-structured interviews with the 20 "mentor farmers" who delivered the intervention. Participation intensity was based on the number of months of attendance at village-level project meetings or household visits (range: 0-29). Multivariable models of participation were built.

Results

Women and men participated for 17.5 ± 7.2 and 13.6 ± 8.3 months, respectively. Participation intensity followed 1 latent trajectory: initially low, with a sharp increase after month 7, and plateaued after the first year. At baseline, higher participation intensity was associated with older age, higher education, level of women's empowerment, being in the middle quintile of wealth, and qualitatively, village residence. Higher participation intensity was associated with 2 process indicators - better recall of topics discussed during meetings and greater knowledge about key agroecological methods. High participation intensity was positively associated with increased use of sustainable agricultural practices among all participants, and among women, with husband's involvement in household tasks and child's dietary diversity score.

Conclusions

Participation intensity covaried with key study outcomes, suggesting the value of increased attention to implementation in nutrition-related programs for providing insights into drivers of impact. We hope that investigations of participation, including participation intensity, will become more widespread so that intervention impacts, or lack thereof, can be better understood.

Unhealthy Alcohol Use Is Associated With Suboptimal Adherence to Isoniazid Preventive Therapy in Persons With HIV in Southwestern Uganda

BACKGROUND

Unhealthy alcohol use is associated with increased progression to tuberculosis (TB) disease, but its effect on adherence to isoniazid (INH) preventive therapy is not known.

METHODS

This was a prospective study of persons with HIV with latent TB in southwestern Uganda reporting any current (previous 3 months) alcohol use or no alcohol consumption in the previous year (2:1 ratio). All received INH. We defined suboptimal adherence as <90% of days with at least 1 Medication Event Monitoring System cap opening, over the previous 90 days. Alcohol use was categorized as follows: none: no self-report and phosphatidylethanol (PEth) <8 ng/mL; moderate: Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) 1-2 (women) or 1-3 (men) and/or PEth 8 ≥ 50 ng/mL; and unhealthy: AUDIT-C ≥3 (women) or ≥4 (men) and/or PEth ≥50 ng/mL. We used generalized estimating equation logistic regression analyses to assess the association between the level of alcohol use and suboptimal INH adherence.

RESULTS

Three hundred two persons were enrolled; 279 were on INH for 3 or more months. The prevalence of suboptimal INH adherence was 31.3% at 3 months and 43.9% at 6 months. The odds of suboptimal INH adherence were higher for unhealthy (adjusted odds ratio, 2.78; 95% confidence interval: 1.62 to 4.76) and moderate (adjusted odds ratio, 1.59; 95% confidence interval: 0.94 to 2.71) compared with no alcohol consumption.

CONCLUSIONS

Suboptimal adherence to INH at 3 and 6 months was high among prospective study of persons with HIV and associated with unhealthy alcohol use. Adherence support and alcohol reduction strategies are needed for this group at high risk for active TB.

The Efficacy of a Smartphone Game to Prevent HIV Among Young Africans: Protocol for a Randomized Controlled Trial in the Context of COVID-19

BACKGROUND

Adolescents contribute slightly less than one-third of all new HIV infections in sub-Saharan Africa. There is a need for more effective intervention approaches to help young adolescents safely navigate through adolescence and into adulthood. We are assessing the efficacy of Tumaini, a smartphone game designed to prevent HIV among young Africans. Against the background of COVID-19, meaningful alteration of the research protocol was necessary to ensure successful implementation and retention of the study participants in ongoing research.

OBJECTIVE

The objective of our protocol is to determine (1) if Tumaini delays sexual debut and increases condom use at first sex and (2) whether it influences behavioral mediators of early and unprotected sex.

METHODS

Participants were recruited from Kisumu County in Western Kenya. This study is a 2-arm, individual-randomized controlled trial that enrolled 1004 adolescents aged between 12 years and 15 years. The intervention arm participants are playing Tumaini, while the control arm is provided with Brainilis, a commercially available control game. The study period will last 45 months. At baseline, participants in both arms completed a baseline survey and biological testing for HIV and herpes simplex virus, type 2 (HSV-2); participants will have annual game play periods in years 1-3. They will also complete a total of 12 follow-up surveys. At endline, repeat biological testing will be conducted. Protocol adaptations were necessitated by the COVID-19 pandemic and implemented in accordance with local public health guidelines.

RESULTS

Participants were enrolled between October 2020 and November 2020. We plan to complete study procedures in September 2024. The enrolled participant sample was 50.1% (499/996) female and had a mean age of 14.0 (SD 0.6) years.

CONCLUSIONS

This ongoing research demonstrates that, with appropriate revisions to planned protocol activities guided by the need to maintain study integrity, protect both study participants and staff, and adhere to institutional review board and local health authority guidelines, human subject research is possible in the context of a global pandemic. If the trial demonstrates efficacy, Tumaini would provide an alternative, remote means of delivering age-appropriate education to adolescents on safer sex, HIV prevention, and effective life skills on a highly scalable, low-cost, and culturally adaptable platform.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04437667; https://clinicaltrials.gov/ct2/show/NCT04437667.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35117.

Post-traumatic stress disorder among persons with HIV who engage in heavy alcohol consumption in southwestern Uganda

BACKGROUND

We aimed to describe the prevalence of PTSD symptoms and its associated factors in persons living with HIV (PLWH) in Uganda who engage in heavy alcohol use.

METHODS

We analyzed baseline data from the Drinkers Intervention to Prevent Tuberculosis study which enrolls PLWH with latent tuberculosis who engage in heavy alcohol consumption. Using the primary care Post Traumatic Stress Disorder (PTSD) screening scale from the DSM-5 (PC-PTSD-5), probable PTSD was defined as reporting ≥3 of 5 assessed symptoms. We conducted the Alcohol Use Disorders Identification Test-Consumption and assessed demographics, smoking, symptoms of depression, and spirituality/religiosity.

RESULTS

Of 421 participants enrolled from 2018 through 2020, the majority (68.2%) were male, median age was 40 years (interquartile range [IQR]: 32-47), and median AUDIT-C score was 6 [IQR: 4-8]. Half (50.1%) of the participants reported ever experiencing a traumatic event, and 20.7% reported ≥3 symptoms of PTSD. The most commonly reported PTSD symptoms in the past 1 month in the entire sample were avoidance (28.3%), nightmares (27.3%), and being constantly on guard (21.6%). In multivariable logistic regression analyses, level of alcohol use was not associated with probable PTSD (adjusted odds ratio [AOR] for each AUDIT-C point: (1.02; 95% CI: 0.92-1.14; p = 0.69); however, lifetime smoking (AOR 1.89; 95% CI: 1.10-3.24) and reporting symptoms of depression (AOR 1.89; 95% CI: 1.04-3.44) were independently associated with probable PTSD.

CONCLUSIONS AND RECOMMENDATIONS

A history of traumatic events and probable PTSD were frequently reported among persons who engage in heavy drinking, living with HIV in Uganda. Level of alcohol use was not associated with probable PTSD in this sample of PLWH with heavy alcohol use, however other behavioral and mental health factors were associated with probable PTSD. These data highlight the high prevalence of PTSD in this group, and the need for screening and interventions for PTSD and mental health problems.

Correlation between moral courage score and social desirability score of the medical residents and fellows in Argentina

PURPOSE

Moral courage is the conviction to take action on one's ethical beliefs despite the risk of adverse consequences.. It aimed to evaluate the correlation between social desirability score and moral courage scores of medical residents and fellows, and to explore gender and specialty-based differences of moral courage scores.

METHODS

In April 2018, the Moral Courage Scale for Physicians (MCSP), the Professional Moral Courage (PMC) scale and the Marlowe-Crowne scale to measure social desirability were administered to 87 medical residents from Hospital Alemán of Buenos Aires, Argentina.

RESULTS

Cronbach's alpha coefficients were 0.78, 0.74 and 0.81 for the Marlowe-Crowne, MCSP and PMC scales, respectively. Correlation analysis showed that moral courage scores were poorly correlated with social desirability scores, while both moral courage scales were highly correlated with each other. Physicians who were training in a surgical specialty showed lower moral courage scores than nonsurgical specialty trainees, and male from any specialty tended to have lower moral courage scores than females. Particularly, individuals performing a surgical specialty ranked lower when assessing "multiple values", "endurance of threats", and "going beyond compliance" dimensions from PMC scale. Male individuals tended to rank lower than females on "multiple values", "moral goals" and "endurance of threats" dimensions.

CONCLUSION

There was a poor correlation between two validated moral courage scores and social desirability score of the medical residents and fellows in Argentina. Conversely, both moral courage tools showed a good correlation and concordance between them, making these scales reasonably interchangeable.

Social Desirability Bias Impacts Self-Reported Alcohol Use Among Persons With HIV in Uganda

BACKGROUND

Self-report is widely used to assess alcohol use in research and clinical practice, but may be subject to social desirability bias. We aimed to determine if social desirability impacts self-reported alcohol use.

METHODS

Among 751 human immunodeficiency virus (HIV)-infected patients from a clinic in southwestern Uganda, we measured social desirability using the Marlowe-Crowne Social Desirability Scale (SDS) Short Form C, self-reported alcohol use (prior 3 months) Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), and phosphatidylethanol (PEth), a biomarker of prior 3 weeks' drinking. We conducted multiple regression analyses to assess the relationship between SDS score (low, medium, and high levels) and (i) any self-reported recent alcohol use, among those who were PEth-positive (≥8 ng/ml), and (ii) continuous AUDIT-C score, among those reporting any recent alcohol use. We controlled for PEth level, age, gender, education, economic assets, marital status, religion, spirituality/religiosity, social support, and study cohort.

RESULTS

Of 751 participants, 59% were women; the median age was 31 years (interquartile range [IQR]: 26 to 39). Median SDS score was 9 (IQR: 4 to 10). Two-thirds (62%) self-reported any recent alcohol use; median AUDIT-C was 1 (IQR: 0 to 4). Among those who were PEth-positive (57%), 13% reported no recent alcohol use. Those with the highest SDS tertile had decreased odds of reporting any recent alcohol use compared to the lowest tertile, but the association did not reach statistical significance in multivariable analyses (adjusted odds ratio 0.55 [95% confidence interval (CI): 0.25, 1.23]). Among participants self-reporting recent alcohol use, SDS level was negatively associated with AUDIT-C scores (adjusted β: -0.70 [95% CI: -1.19, -0.21] for medium vs. low SDS and -1.42 [95% CI: -2.05, -0.78] for high vs. low SDS).

CONCLUSIONS

While use of objective measures (e.g., alcohol biomarkers) is desirable for measuring alcohol use, SDS scores may be used to adjust self-reported drinking levels by participants' level of social desirability in HIV research studies.

Biomarker-Measured Unhealthy Alcohol Use in Relation to CD4 Count Among Individuals Starting ART in Sub-Saharan Africa

Individuals are initiating antiretroviral therapy (ART) at earlier HIV disease stages. Unhealthy alcohol use is a known barrier to successful HIV treatment outcomes, yet it is unclear whether the problem varies by disease stage. We measured alcohol use with an objective biomarker (phosphatidylethanol [PEth]), comparing individuals (n = 401) with early (CD4 > 350 cells/mL, WHO Stage 1) versus late (CD4 < 200 cells/mL) ART initiation in HIV care in Uganda and South Africa (SA). We examined the association between CD4 count and biomarker results using multivariable regression modeling, and compared PEth results to self-report to assess underreporting. Overall, 32.2% (n = 129) had unhealthy alcohol use (PEth ≥ 50 ng/ml). Early ART initiation was significantly associated with unhealthy alcohol use in Uganda (AOR 2.65; 95% CI: 1.05–6.72), but not SA (AOR 1.00; 95% CI: 0.46–2.17). In Uganda, 23.2% underreported unhealthy alcohol use versus 11.6% in SA (χ² = 9.30; p < 0.01). Addressing unhealthy alcohol use is important as patients initiate ART earlier, yet challenging due to underreporting.

Recreational ART use among individuals living with HIV/AIDS in South Africa: Examining longitudinal ART initiation and viral suppression

BACKGROUND

South Africa has the highest number of people living with HIV (PLWH) and one of the largest antiretroviral therapy (ART) programs globally. High rates of substance use comorbidity exist, including speculation of recreational ART use (i.e., mixing ART with other illicit drugs). Recreational ART use may affect viral load among PLWH due to ART nonadherence and/or viral resistance; however, prior quantitative research has not examined rates of recreational ART use, nor associations with HIV treatment outcomes longitudinally.

METHODS

Data were drawn from a prospective, observational cohort study (n = 500) of ART-eligible adults recruited from two HIV voluntary counseling and testing centers in Cape Town, and Johannesburg, South Africa. Multiple logistic regression models assessed recreational ART use as a predictor of ART initiation over six months and viral load suppression over nine months, above and beyond other substance use (binge drinking and illicit drug use).

RESULTS

Approximately 5% (n = 24) reported recreational ART use, which was less frequent in Cape Town compared to Johannesburg (AOR = 0.025; 95%CI: 0.003-0.19; p < 0.001). Recreational ART use was not significantly associated with ART initiation or viral suppression. Other substance use, but not recreational ART use, was significantly associated with lower odds of ART initiation (AOR = 0.54; 95%CI: 0.33-0.87; p = .01) and viral suppression (AOR = 0.47; 95%CI: 0.25-0.89; p = .02).

CONCLUSIONS

Recreational ART use was infrequent and not uniquely associated with ART initiation or viral suppression. Findings suggest that comorbid use of other substances is ultimately what may make recreational ART use problematic for ongoing engagement in care and viral suppression.

Psychometric properties and reliability of the Assessment Screen to Identify Survivors Toolkit for Gender Based Violence (ASIST-GBV): results from humanitarian settings in Ethiopia and Colombia

Background

Refugees and internally displaced persons who are affected by armed-conflict are at increased vulnerability to some forms of sexual violence or other types of gender-based violence. A validated, brief and easy-to-administer screening tool will help service providers identify GBV survivors and refer them to appropriate GBV services. To date, no such GBV screening tool exists. We developed the 7-item ASIST-GBV screening tool from qualitative research that included individual interviews and focus groups with GBV refugee and IDP survivors. This study presents the psychometric properties of the ASIST-GBV with female refugees living in Ethiopia and IDPs in Colombia.

Methods

Several strategies were used to validate ASIST-GBV, including a 3 month implementation to validate the brief screening tool with women/girls seeking health services, aged ≥15 years in Ethiopia (N = 487) and female IDPs aged ≥ 18 years in Colombia (N = 511).

Results

High proportions of women screened positive for past-year GBV according to the ASIST-GBV: 50.6 % in Ethiopia and 63.4 % in Colombia. The factor analysis identified a single dimension, meaning that all items loaded on the single factor. Cronbach’s α = 0.77. A 2-parameter logistic IRT model was used for estimating the precision and discriminating power of each item. Item difficulty varied across the continuum of GBV experiences in the following order (lowest to highest): threats of violence (0.690), physical violence (1.28), forced sex (2.49), coercive sex for survival (2.25), forced marriage (3.51), and forced pregnancy (6.33). Discrimination results showed that forced pregnancy was the item with the strongest ability to discriminate between different levels of GBV. Physical violence and forced sex also have higher levels of discrimination with threats of violence discriminating among women at the low end of the GBV continuum and coercive sex for survival among women at the mid-range of the continuum.

Conclusion

The findings demonstrate that the ASIST-GBV has strong psychometric properties and good reliability. The tool can be used to screen and identify female GBV survivors confidentially and efficiently among IDPs in Colombia and refugees in Ethiopia. Early identification of GBV survivors can enable safety planning, early referral for treatment, and psychosocial support to prevent long-term harmful consequence of GBV.

Over-Reporting in Handwashing Self-Reports: Potential Explanatory Factors and Alternative Measurements

Handwashing interventions are a priority in development and emergency aid programs. Evaluation of these interventions is essential to assess the effectiveness of programs; however, measuring handwashing is quite difficult. Although observations are considered valid, they are time-consuming and cost-ineffective; self-reports are highly efficient but considered invalid because desirable behaviour tends to be over-reported. Socially desirable responding has been claimed to be the main cause of inflated self-reports, but its underlying factors and mechanisms are understudied. The present study investigated socially desirable responding and additional potential explanatory factors for over-reported handwashing to identify indications for measures which mitigate over-reporting. Additionally, a script-based covert recall, an alternative interview question intended to mitigate recall errors and socially desirable responding, was developed and tested. Cross-sectional data collection was conducted in the Borena Zone, Ethiopia, through 2.5-hour observations and 1-hour interviews with the primary caregivers in households. A total sample of N = 554 was surveyed. Data were analysed with correlation and multiple regression analyses and dependent t-tests. Over-reporting of handwashing was associated with factors assumed to be involved in (1) socially desirable responding, (2) encoding and recall of information, and (3) dissonance processes. The latter two factor groups explained over-reported handwashing beyond socially desirable responding. The alternative interview question—script-based covert recall—reduced over-reporting compared to conventional self-reports. Although the difficulties involved in measuring handwashing by self-reports and observations are widely known, the present study is the first to investigate the factors which explain over-reporting of handwashing. This research contributes to the limited evidence base on a highly important subject: how to evaluate handwashing interventions efficiently and accurately.

The science of being a study participant: FEM-PrEP participants' explanations for overreporting adherence to the study pills and for the whereabouts of unused pills

BACKGROUND

FEM-PrEP was unable to determine whether once-daily, oral emtricitabine/tenofovir disoproxil fumarate reduces the risk of HIV acquisition among women because of low adherence. Self-reported adherence was high, and pill-count data suggested good adherence. Yet, drug concentrations revealed limited pill use. We conducted a follow-up study with former participants in Bondo, Kenya, and Pretoria, South Africa, to understand factors that had influenced overreporting of adherence and to learn the whereabouts of unused pills.

METHODS

Qualitative, semistructured interviews were conducted with 88 participants, and quantitative, audio computer-assisted self-interviews were conducted with 224 participants. We used thematic analysis and descriptive statistics to analyze the qualitative and quantitative data, respectively.

RESULTS

In audio computer-assisted self-interviews, 31% (n = 70) said they had overreported adherence; the main reason was the belief that nonadherence would result in trial termination (69%, n = 48). A considerable percentage (35%, n = 78) acknowledged discarding unused pills. Few acknowledged giving their pills to someone else (4%, n = 10), and even fewer acknowledged giving them to someone with HIV (2%, n = 5). Many participants in the semistructured interviews said other participants had counted and removed pills from their bottles to appear adherent.

CONCLUSIONS

Despite repeated messages that nonadherence would not upset staff, participants acknowledged several perceived negative consequences of reporting nonadherence, which made it difficult to report accurately. Uneasiness continued in the follow-up study, as many said they had not overreported during the trial. Efforts to improve self-reported measures should include identifying alternative methods for creating supportive environments that allow participants to feel comfortable reporting actual adherence.

Measurement of delayed bathing and early initiation of breastfeeding: a cross-sectional survey exploring experiences of data collectors in Ethiopia

Background

Delayed bathing and early initiation of breastfeeding are among the essential interventions recommended to save newborn lives. Although survey coverage reports are key to monitoring these interventions, few studies investigated whether such reports accurately reflect the proportion of mothers and children who received these interventions. In order to gather accurate data, guidance on how to interview and probe mothers is provided. In this study, we investigated experiences of data collectors when asking mothers survey questions that assessed delayed bathing and early initiation of breastfeeding.

Methods

In November 2013, using a self-administered semi-structured questionnaire, we interviewed data collectors who had taken part in a population-based newborn health household survey in Ethiopia during October-November 2013. A total of 130 out of 160 invited data collectors completed and returned the self-administered questionnaire. Descriptive statistics were used to analyse quantitative data using SPSS software version 19. Qualitative data showing the variety of probes used by data collectors was analysed by listing, screening to identify common themes, and grouping by category.

Results

Most data collectors reported that, in their opinion, mothers were able to understand the meaning of the question about newborn bathing (n = 102, 79%) and breastfeeding initiation (n = 106, 82%) without the need for probes. However, fewer mothers were able to recall the event for either newborn behaviours and describe it in minutes, hours or days without the need for probes. Overall, only 26% (n = 34) and 34 % (n = 44) of all data collectors reported that they did not need any probing for the questions related to newborn bathing and breastfeeding initiation questions, respectively. We identified a variety of probes used by data collectors and present examples.

Conclusion

Considerable probing was necessary to facilitate maternal recall of the events and approximate their responses of time regardless of mothers’ age, level of education and parity. This could potentially lead to inaccurate coverage reports due to subjective and inconsistent interpretation of the indicators. Therefore, we recommend inclusion of standard probes or follow-on questions to the existing survey tools assessing the two indicators. Data collectors also require further guidance in using appropriate probes to gather accurate maternal responses.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0350-7) contains supplementary material, which is available to authorized users.

Measurement of breastfeeding initiation: Ethiopian mothers' perception about survey questions assessing early initiation of breastfeeding

BACKGROUND

Although breastfeeding is almost universal in Ethiopia, only 52% newborns benefited from early initiation in 2011. Early initiation is one of the recommended interventions for saving newborn lives but its potential seems not yet realized for Ethiopian newborns and there is a need for continued efforts to increase coverage. To do so, it is also relevant to focus on consistent and accurate reporting of coverage in early initiation. WHO recommends the question "how long after birth did you first put [name] to the breast?" in order to assess coverage in early initiation. It is designed to measure the time after birth when the mother attempted to initiate breastfeeding regardless of whether breast milk had arrived or not. However, it is unclear how mothers perceive this question and what their responses of time refer to. In this study, we assessed Ethiopian mothers' perception about the question assessing early initiation.

METHODS

Cognitive interviews were conducted between April and May 2013 with eligible mothers in Basona and Debrebirhan woredas (districts), 120 km away from Addis Ababa, Ethiopia.

RESULTS

A total of 49 mothers, most from Basona (n = 36) and the rest from Debrebirhan woredas (n = 13) were interviewed. No probes or follow on questions were required for mothers to understand what the WHO recommended question was about. However, further probing was needed to ascertain what maternal responses of time refer to. Accordingly, mothers' response about the timing of early initiation was related to the first time the newborn received breast milk rather than their first attempt to initiate breastfeeding. In addition, considerable probing was required to approximate and code responses of time based on the WHO coding format because some mothers were unable to assess time in minutes or hours.

CONCLUSION

The existing question is not adequate to identify intended attempts of mothers to initiate breastfeeding. We recommend revising the question as "how long after birth did you first put [name] to the breast even if your breast milk did not arrive yet?" Standard probes or follow on questions are required to avoid subjective interpretation of the indicator.

The Prevalence of Sexual Violence among Female Refugees in Complex Humanitarian Emergencies: a Systematic Review and Meta-analysis

Importance: Refugees and internally displaced persons are highly vulnerable to sexual violence during conflict and subsequent displacement. However, accurate estimates of the prevalence of sexual violence among in these populations remain uncertain. Objective: Our objective was to estimate the prevalence of sexual violence among refugees and displaced persons in complex humanitarian emergencies. Data Source: We conducted systematic review of relevant literature in multiple databases (EMBASE, CINAHL, and MEDLINE) through February 2013 to identify studies. We also reviewed reference lists of included articles to identify any missing sources. Study Selection: Inclusion criteria required identification of sexual violence among refugees and internally displaced persons or those displaced by conflict in complex humanitarian settings. Studies were excluded if they did not provide female sexual violence prevalence, or that included only single case reports, anecdotes, and those that focused on displacement associated with natural disasters. After a review of 1175 citations 19 unique studies were selected. Data Extraction: Two reviewers worked independently to identify final selection and a third reviewer adjudicated any differences. Descriptive and quantitative information was extracted; prevalence estimates were synthesized. Heterogeneity was assessed using I2. Main Outcomes: The main outcome of interest was sexual violence among female refugees and internally displaced persons in complex humanitarian settings. Results: The prevalence of sexual violence was estimated at 21.4% (95% CI, 14.9-28.7; I2=98.3%), using a random effects model. Statistical heterogeneity was noted with studies using probability sampling designs reporting lower prevalence of sexual violence (21.0%, 95% CI, 13.2-30.1; I2=98.6%), compared to lower quality studies (21.7%, 95% CI, 11.5-34.2; I2=97.4%). We could not rule out the presence of publication bias. Conclusions: The findings suggest that approximately one in five refugees or displaced women in complex humanitarian settings experienced sexual violence. However, this is likely an underestimation of the true prevalence given the multiple existing barriers associated with disclosure. The long-term health and social consequences of sexual violence for women and their families necessitate strategies to improve identification of survivors of sexual violence and increase prevention and response interventions in these complex settings.

Quality of life, social desirability and their relationship in opium addicted persons in southeast of Iran

Background and Aim:

Addiction leads to many problems which may adversely affect addicted people, their families and impose health care agencies with many challenges. This study aimed to examined quality of life (QoL), social desirability and their relationship among opium addicted persons in southeast of Iran.

Material and Methods:

In a cross-sectional study conducted from September 2012 to January 2013, 123 addicted people were studied. Date collection tools were; checklist of demographic data, Iranian version of the 36-item short form QoL (SF-36) and Marlowe-Crowne Social Desirability Scale (MC-SDS).

Results:

While mean score of QoL was 60.4±29.5, mean score of social desirability were 14.2±3.7. Low, moderate and high levels of social desirability were observed in 4.9%, 90.2% and 4.9% of participants, respectively. Pearson’s correlation were not significant between mean score of social desirability and mean score of QoL (p=0.969, r=0.004).

Conclusion:

Addicted participants of present study showed a moderate level of QoL and social desirability, without any significant relationship between QoL and social desirability. Further research is suggested in addicts with social and cultural differences.

Effects of home-based voluntary counselling and testing on HIV-related stigma: findings from a cluster-randomized trial in Zambia

HIV-related stigma continues to be a prominent barrier to testing, treatment and care. However, few studies have investigated changes in stigma over time and the factors contributing to these changes, and there is no evidence of the impact of HIV testing and counselling on stigma. This study was nested within a pair-matched cluster-randomized trial on the acceptance of home-based voluntary HIV counselling and testing conducted in a rural district in Zambia between 2009 and 2011, and investigated changes in stigma over time and the impact of HIV testing and counselling on stigma. Data from a baseline survey (n = 1500) and a follow-up survey (n = 1107) were used to evaluate changes in stigma. There was an overall reduction of seven per cent in stigma from baseline to follow-up. This was mainly due to a reduction in individual stigmatizing attitudes but not in perceived stigma. The reduction did not differ between the trial arms (β = -0.22, p = 0.423). Being tested for HIV was associated with a reduction in stigma (β = -0.57, p = 0.030), and there was a trend towards home-based Voluntary Counselling and Testing having a larger impact on stigma than other testing approaches (β = -0.78, p = 0.080 vs. β = -0.37, p = 0.551), possibly explained by a strong focus on counselling and the safe environment of the home. The reduction observed in both arms may give reason to be optimistic as it may have consequences for disclosure, treatment access and adherence. Yet, the change in stigma may have been affected by social desirability bias, as extensive community mobilization was carried out in both arms. The study underscores the challenges in measuring and monitoring HIV-related stigma. Adjustment for social desirability bias and inclusion of qualitative methods are recommended for further studies on the impact of HIV testing on stigma.