Decolonising global health research: Shifting power for transformative change

Recent debates on decolonizing global health have spurred interest in addressing the power asymmetries and knowledge hierarchies that sustain colonial ideas and relationships in global health research. This paper applies three intersecting dimensions of colonialism (colonialism within global health; colonisation of global health; and colonialism through global health) to develop a broader and more structural understanding of the policies and actions needed to decolonise global health research. It argues that existing guidelines and checklists designed to make global health research more equitable do not adequately address the underlying power asymmetries and biases that prevail across the global health research ecosystem. Beyond encouraging fairer partnerships within individual research projects, this paper calls for more emphasis on shifting the balance of decision-making power, redistributing resources, and holding research funders and other power-holders accountable to the places and peoples involved in and impacted by global health research.

Developing an agenda for the decolonization of global health

Colonialism, which involves the systemic domination of lands, markets, peoples, assets, cultures or political institutions to exploit, misappropriate and extract wealth and resources, affects health in many ways. In recent years, interest has grown in the decolonization of global health with a focus on correcting power imbalances between high-income and low-income countries and on challenging ideas and values of some wealthy countries that shape the practice of global health. We argue that decolonization of global health must also address the relationship between global health actors and contemporary forms of colonialism, in particular the current forms of corporate and financialized colonialism that operate through globalized systems of wealth extraction and profiteering. We present a three-part agenda for action that can be taken to decolonize global health. The first part relates to the power asymmetries that exist between global health actors from high-income and historically privileged countries and their counterparts in low-income and marginalized settings. The second part concerns the colonization of the structures and systems of global health governance itself. The third part addresses how colonialism occurs through the global health system. Addressing all forms of colonialism calls for a political and economic anticolonialism as well as social decolonization aimed at ensuring greater national, racial, cultural and knowledge diversity within the structures of global health.

Integrating human rights into sexual and reproductive health research: moving beyond the rhetoric, what will it take to get us there?

The integration of human rights principles in sexual and reproductive health (SRH) research is often recognised to be of value. Good examples abound but lack of clarity persists as to what defines rights-inclusive SRH research. To help move the field forward, this article seeks to explore how key stakeholders responsible for funding and supporting rights in SRH research understand the strengths and weaknesses of what is being done and where, and begins to catalogue potential tools and actions for the future. Interviews with a range of key stakeholders including international civil servants, donors and researchers committed to and supportive of integrating rights into SRH research were conducted and analysed. Interviews confirmed important differences in what is understood to be SRH rights-oriented research and what it can accomplish. General barriers include lack of understanding about the importance of rights; lack of clarity as to the best approach to integration; fear of adding more work with little added benefit; as well as the lack of methodological guidance or published research methodologies that integrate rights. Suggestions include the development of a comprehensive checklist for each phase of research from developing a research statement through ultimately to publication; development of training modules and workshops; inclusion of rights in curricula; changes in journal requirements; and agreement among key funding sources to mandate the integration of rights principles in research proposals they receive. As a next step, cataloguing issues and concerns at local levels can help move the integration of human rights in SRH research from rhetoric to reality.

Inclusion of human rights in sexual and reproductive health programming: Facilitators and barriers to implementation

The need to prioritise those furthest behind is well understood in global health circles, and how human rights norms and standards can help often touted. As rights concerns are particularly recognised in sexual and reproductive health (SRH) programming, as part of a larger exercise, a review was conducted to identify documented barriers and facilitators to implementation. Given the role global guidance plays in implementing rights-based approaches to SRH, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) guidelines, tools, recommendations and guidance that include the explicit mention of human rights principles served as the basis for this exercise. This was followed by an extensive review of the literature. Sources reviewed confirmed barriers include not only broad structural, policy and health systems barriers but financial, staffing and time constraints, as well as lack of understanding of concretely how to include human rights in these efforts. Facilitators include the existence of human rights champions, leadership, strong civil society participation, training, and funding made available specifically for implementation. Investment in indicators and documentation sensitive to human rights is warranted in sexual and reproductive health, as well as other health topics, to best serve populations who need them most.

Necessary but not sufficient: a scoping review of legal accountability for sexual and reproductive health in low-income and middle-income countries

Background

This paper is a scoping review of the impact of legal accountability efforts for sexual and reproductive health and rights (SRHR), exploring the links between legal accountability strategies and changes in the desired SRHR outcomes.

Methods

We defined legal accountability as use of the judicial system following state failure to respect, protect or fulfil SRHR as enshrined in national law, as well as individuals’ or the state’s use of criminal law mechanisms to prevent unwanted behaviour and to provide remedy. We undertook a keyword search in PubMed, Scopus and LexisNexis and then consulted a group of experts to provide guidance regarding further peer-reviewed and grey literature, yielding a total of 191 articles.

Results

The majority of the empirical, peer-reviewed articles identified were regarding abortion law and abortion care availability, followed by violence against women. Most of these articles explore the gaps between law and practice. We identified seven key factors that shape the efficacy of legal accountability efforts, including the ways a law or court decision is formulated, access to courts, the (dis)advantages of criminal law in the given context, cultural norms, politics, state capacity and resources and the potential for further litigation. Many articles explained that use of the judiciary may be necessary to effect change and that the act of claiming rights can empower, but that legal avenues for change can be imperfect tools for justice.

Conclusions

Legal accountability can be effective as part of a broader, long-term strategy, with due attention to context.

Gender-transformative programming with men and boys to improve sexual and reproductive health and rights: a systematic review of intervention studies

Background

Global health organisations advocate gender-transformative programming (which challenges gender inequalities) with men and boys to improve sexual and reproductive health and rights (SRHR) for all. We systematically review evidence for this approach.

Methods

We previously reported an evidence-and-gap map (http://srhr.org/masculinities/wbincome/) and systematic review of reviews of experimental intervention studies engaging men/boys in SRHR, identified through a Campbell Collaboration published protocol (https://doi.org/10.1002/CL2.203) without language restrictions between January 2007 and July 2018. Records for the current review of intervention studies were retrieved from those systematic reviews containing one or more gender-transformative intervention studies engaging men/boys. Data were extracted for intervention studies relating to each of the World Health Organization (WHO) SRHR outcomes. Promising programming characteristics, as well as underused strategies, were analysed with reference to the WHO definition of gender-transformative programming and an established behaviour change model, the COM-B model. Risk of bias was assessed using Cochrane Risk of Bias tools, RoB V.2.0 and Risk of Bias In Non-randomised Studies of Interventions.

Findings

From 509 eligible records, we synthesised 68 studies comprising 36 randomised controlled trials, n=56 417 participants, and 32 quasi-experimental studies, n=25 554 participants. Promising programming characteristics include: multicomponent activities of education, persuasion, modelling and enablement; multilevel programming that mobilises wider communities; targeting both men and women; and programmes of longer duration than three months. Six of the seven interventions evaluated more than once show efficacy. However, we identified a significant risk of bias in the overall available evidence. Important gaps in evidence relate to safe abortion and SRHR during disease outbreaks.

Conclusion

It is widely acknowledged by global organisations that the question is no longer whether to include boys and men in SRHR but how to do so in ways that promote gender equality and health for all and are scientifically rigorous. This paper provides an evidence base to take this agenda for programming and research forward.

From words to actions: systematic review of interventions to promote sexual and reproductive health of persons with disabilities in low- and middle-income countries

Introduction

Persons with disabilities have the same sexual and reproductive health and rights (SRHR) as non-disabled persons. Yet they face numerous barriers in their access to sexual and reproductive health services and their rights are often not met. Evidence on SRHR for persons with disabilities is sparse, particularly evaluations of interventions demonstrating ‘what works.’ This systematic review assessed interventions to promote SRHR for persons with disabilities in low- and middle-income countries.

Methods

We searched for qualitative, quantitative or mixed method observational studies representing primary research, published between 2010 and 2019, using MEDLINE, Embase, PubMed, Global Health and CINAHL Plus. Search strings were compiled for different elements of SRHR and for all forms of disability. 24,919 records were screened, leading to over 380 relevant papers, most of which were descriptive, focussing on needs and barriers to SRHR needs being fulfilled. Of the 33 full-text articles assessed for eligibility, 18 were included in the synthesis. All included studies were assessed for bias and quality of evidence, using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) and RATS (relevance, appropriateness, transparency andsoundness) tools. Among the 16 interventions (from 18 articles), 25% had low risk of bias, 31% had moderate risk of bias and 44% had high risk of bias. Data analysis used narrative synthesis; a method suited for systematic reviews with heterogeneous studies. We used Levesque healthcare access model to analyse the focus of interventions.

Results

11 interventions were from upper middle-income settings; two from lower-income settings; only one operated in rural areas. Interventions addressed intellectual impairment (6), visual impairment (6), hearing impairment (4), mental health conditions (2) and physical impairments (2). Most interventions (15/16) focus on information provision and awareness raising. We could not identify any intervention promoting access to maternal health, family planning and contraception, or safe abortion for people with disabilities.

Conclusion

This systematic review has highlighted stark gaps in evidence. More rigorous evaluations are needed.

When accountability meets power: realizing sexual and reproductive health and rights

This paper addresses a critical concern in realizing sexual and reproductive health and rights through policies and programs - the relationship between power and accountability. We examine accountability strategies for sexual and reproductive health and rights through the lens of power so that we might better understand and assess their actual working. Power often derives from deep structural inequalities, but also seeps into norms and beliefs, into what we 'know' as truth, and what we believe about the world and about ourselves within it. Power legitimizes hierarchy and authority, and manufactures consent. Its capillary action causes it to spread into every corner and social extremity, but also sets up the possibility of challenge and contestation.Using illustrative examples, we show that in some contexts accountability strategies may confront and transform adverse power relationships. In other contexts, power relations may be more resistant to change, giving rise to contestation, accommodation, negotiation or even subversion of the goals of accountability strategies. This raises an important question about measurement. How is one to assess the achievements of accountability strategies, given the shifting sands on which they are implemented?We argue that power-focused realist evaluations are needed that address four sets of questions about: i) the dimensions and sources of power that an accountability strategy confronts; ii) how power is built into the artefacts of the strategy - its objectives, rules, procedures, financing methods inter alia; iii) what incentives, disincentives and norms for behavior are set up by the interplay of the above; and iv) their consequences for the outcomes of the accountability strategy. We illustrate this approach through examples of performance, social and legal accountability strategies.

Operationalizing a Human Rights-Based Approach to Address Mistreatment against Women during Childbirth

A growing body of evidence reveals that the mistreatment of pregnant women during facility-based childbirth is occurring across the globe. As human rights bodies have increasingly recognized, numerous human rights are implicated in the context of mistreatment of women in childbirth, including the rights to be free from torture and other ill-treatment, privacy, health, non-discrimination, and equality. This paper builds on a previous paper published in this journal by Rajat Khosla, Christina Zampas, and others, and the new body of evidence describing the types of mistreatment that occur during childbirth, to unpack the drivers of the mistreatment of women during childbirth and how they are understood and addressed within human rights. Tracing recent developments, it examines how the United Nations Special Rapporteur on violence against women and the Parliamentary Assembly of the Council of Europe have addressed this issue. Understanding the drivers and human rights dimensions of the mistreatment of women during childbirth can contribute to accelerating progress toward universal health coverage, including access to reproductive health services, as mistreatment is a key barrier to women's access to such services. The article concludes by offering guidance to states on a human rights-based approach to addressing mistreatment against women during facility-based childbirth.

Accountability strategies for sexual and reproductive health and reproductive rights in humanitarian settings: a scoping review

Background

Many of the 35 million women and girls aged 15–49 requiring humanitarian assistance have inadequate access to the sexual and reproductive health (SRH) services to which they are entitled. Ensuring accountability is critical to realizing their SRH and reproductive rights (RR).

Objectives

This scoping review examines the extent and nature of existing evidence on accountability strategies for SRH in humanitarian settings in different geographical scopes/contexts, and contextualizes these findings in the larger thematic literature. This review seeks to answer the following questions: What accountability strategies are employed to address the availability, accessibility, acceptability, and quality of SRH in humanitarian settings? What do we know about the successes and challenges of the given strategies? What are the implications for practice?

Methods

We consulted public health, social science, and legal databases including SCOPUS, PubMed, ProQuest, and LexisNexis for peer-reviewed articles, as well as Google Advanced search for grey literature; the search was conducted in March 2019. We searched for relevant articles and documents relating to accountability, humanitarian, and SRH and/or RR. To identify key challenges not reflected in the literature and additional grey literature, 18 key informants from international NGOs, local government bodies, academia, and donor agencies were interviewed from March–June 2019.

Results

A total of 209 papers and documents were identified via our literature searches and interviews for review. We identified three categories of approaches to accountability in our background reading, and we then applied these to the papers reviewed a priori. We created a fourth category based on our findings. The categories include: (1) humanitarian principles, codes of conduct, and legal instruments; (2) technical, performance, and impact standards; (3) efforts to solicit and address the rights and needs of the affected populations, or “listening and responding,” and, (4) accountability demands made by affected populations themselves. Almost all papers identified referred to challenges to realizing accountability in humanitarian contexts. There are promising accountability approaches – some specific to SRH and some not - such as open-ended feedback from affected populations, quality improvement, and practical application of standards. Reflecting a largely top down orientation, papers concentrate on accountability mechanisms within humanitarian work, with much less focus on supporting affected populations to deepen their understanding of structural causes of their position, understand their entitlements, or access justice.

Conclusion

In the last 20 years, there has been increasing standard and guideline development and program experiences related to accountability in humanitarian settings. Yet, the emphasis is on tools or mechanisms for accountability with less attention to changing norms regarding SRH and RR within affected communities, and to a lesser extent, among implementers of humanitarian programs or to institutionalizing community participation.

Building a transformative agenda for accountability in SRHR: lessons learned from SRHR and accountability literatures

Global strategies and commitments for sexual and reproductive health and rights (SRHR) underscore the need to strengthen rights-based accountability processes. Yet there are gaps between these ambitious SRHR rights frameworks and the constrained socio-political lived realities within which these frameworks are implemented. This paper addresses these gaps by reviewing the evidence on the dynamics and concerns related to operationalising accountability in the context of SRHR. It is based on a secondary analysis of a systematic review that examined the published evidence on SRHR and accountability and also draws on the broader literature on accountability for health. Key themes include the political and ideological context, enhancing community voice and health system responsiveness, and recognising the complexity of health systems. While there is a range of accountability relationships that can be leveraged in the health system, the characteristics specific to SRHR need to be considered as they colour the capabilities and conditions in which accountability efforts occur.

Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews

OBJECTIVES

Working with men/boys, in addition to women/girls, through gender-transformative programming that challenges gender inequalities is recognised as important for improving sexual and reproductive health and rights (SRHR) for all. The aim of this paper was to generate an interactive evidence and gap map (EGM) of the total review evidence on interventions engaging men/boys across the full range of WHO SRHR outcomes and report a systematic review of the quantity, quality and effect of gender-transformative interventions with men/boys to improve SRHR for all.

METHODS

For this EGM and systematic review, academic and non-academic databases (CINAHL, Medline, PsycINFO, Social Science Citation Index-expanded, Cochrane Library, Campbell Collaboration, Embase, Global Health Library and Scopus) were searched using terms related to SRHR, males/masculinities, systematic reviews and trials (January 2007-July 2018) with no language restrictions for review articles of SRHR interventions engaging men/boys. Data were extracted from included reviews, and AMSTAR2 was used to assess quality. Outcomes were based on WHO reproductive health strategy.

RESULTS

From the 3658 non-duplicate records screened, the total systematic reviews of interventions engaging men/boys in SRHR was mapped through an EGM (n=462 reviews) showing that such interventions were relatively evenly spread across low-income (24.5%), middle-income (37.8%) and high-income countries (37.8%). The proportion of reviews that included gender-transformative interventions engaging men/boys was low (8.4%, 39/462), the majority was in relation to violence against women/girls (n=18/39, 46.2%) and conducted in lower and middle-income countries (n=25/39, 64%). Reviews of gender-transformative interventions were generally low/critically low quality (n=34/39, 97.1%), and findings inconclusive (n=23/39, 59%), but 38.5% (n=15/39) found positive results.

CONCLUSION

Research and programming must be strengthened in engagement of men/boys; it should be intentional in promoting a gender-transformative approach, explicit in the intervention logic models, with more robust experimental designs and measures, and supported with qualitative evaluations.

Lenses and levels: the why, what and how of measuring health system drivers of women's, children's and adolescents' health with a governance focus

Health systems are critical for health outcomes as they underpin intervention coverage and quality, promote users’ rights and intervene on the social determinants of health. Governance is essential for health system endeavours as it mobilises and coordinates a multiplicity of actors and interests to realise common goals. The inherently social, political and contextualised nature of governance, and health systems more broadly, has implications for measurement, including how the health of women, children and adolescents health is viewed and assessed, and for whom. Three common lenses, each with their own views of power dynamics in policy and programme implementation, include a service delivery lens aimed at scaling effective interventions, a societal lens oriented to empowering people with rights to effect change and a systems lens concerned with creating enabling environments for adaptive learning. We illustrate the implications of each lens for the why, what and how of measuring health system drivers across micro, meso and macro health systems levels, through three examples (digital health, maternal and perinatal death surveillance and review, and multisectoral action for adolescent health). Appreciating these underpinnings of measuring health systems and governance drivers of the health of women, children and adolescents is essential for a holistic learning and action agenda that engages a wider range of stakeholders, which includes, but also goes beyond, indicator-based measurement. Without a broadening of approaches to measurement and the types of research partnerships involved, continued investments in the health of women, children and adolescents will fall short.

Correction: Broadening understanding of accountability ecosystems in sexual and reproductive health and rights: A systematic review

[This corrects the article DOI: 10.1371/journal.pone.0196788.].

Evaluating the effectiveness of sexual and reproductive health services during humanitarian crises: A systematic review

BACKGROUND

An estimated 32 million women and girls of reproductive age living in emergency situations, all of whom require sexual and reproductive health (SRH) information and services. This systematic review assessed the effect of SRH interventions, including the Minimum Initial Service Package (MISP) on a range of health outcomes from the onset of emergencies.

METHODS AND FINDINGS

We searched EMBASE, Global Health, MEDLINE and PsychINFO databases from January 1, 1980 to April 10, 2017. This review was registered with the PROSPERO database with identifier number CRD42017082102. We found 29 studies meet the inclusion criteria. We found high quality evidence to support the effectiveness of specific SRH interventions, such as home visits and peer-led educational and counselling, training of lower-level health care providers, community health workers (CHWs) to promote SRH services, a three-tiered network of health workers providing reproductive and maternal health services, integration of HIV and SRH services, and men's discussion groups for reducing intimate partner violence. We found moderate quality evidence to support transport-based referral systems, community-based SRH education, CHW delivery of injectable contraceptives, wider literacy programmes, and birth preparedness interventions. No studies reported interventions related to fistulae, and only one study focused on abortion services.

CONCLUSIONS

Despite increased attention to SRH in humanitarian crises, the sector has made little progress in advancing the evidence base for the effectiveness of SRH interventions, including the MISP, in crisis settings. A greater quantity and quality of more timely research is needed to ascertain the effectiveness of delivering SRH interventions in a variety of humanitarian crises.

Correction to: Harmonizing national abortion and pregnancy prevention laws and policies for sexual violence survivors with the Maputo Protocol: proceedings of a 2016 regional technical meeting in sub-Saharan Africa

[This corrects the article DOI: 10.1186/s12919-018-0101-5.].

Broadening understanding of accountability ecosystems in sexual and reproductive health and rights: A systematic review

BACKGROUND

Accountability for ensuring sexual and reproductive health and rights is increasingly receiving global attention. Less attention has been paid to accountability mechanisms for sexual and reproductive health and rights at national and sub-national level, the focus of this systematic review.

METHODS

We searched for peer-reviewed literature using accountability, sexual and reproductive health, human rights and accountability instrument search terms across three electronic databases, covering public health, social sciences and legal studies. The search yielded 1906 articles, 40 of which met the inclusion and exclusion criteria (articles on low and middle-income countries in English, Spanish, French and Portuguese published from 1994 and October 2016) defined by a peer reviewed protocol.

RESULTS

Studies were analyzed thematically and through frequencies where appropriate. They were drawn from 41 low- and middle-income countries, with just over half of the publications from the public health literature, 13 from legal studies and the remaining six from social science literature. Accountability was discussed in five health areas: maternal, neonatal and child health services, HIV services, gender-based violence, lesbian/gay/bisexual/transgender access and access to reproductive health care in general. We identified three main groupings of accountability strategies: performance, social and legal accountability.

CONCLUSION

The review identified an increasing trend in the publication of accountability initiatives in Sexual and Reproductive Health and Rights (SRHR). The review points towards a complex 'accountability ecosystem' with multiple actors with a range of roles, responsibilities and interactions across levels from the transnational to the local. These accountability strategies are not mutually exclusive, but they do change the terms of engagement between the actors involved. The publications provide little insight on the connections between these accountability strategies and on the contextual conditions for the successful implementation of the accountability interventions. Obtaining a more nuanced understanding of various underpinnings of a successful approach to accountability at national and sub national levels is essential.

A long way to go: a systematic review to assess the utilisation of sexual and reproductive health services during humanitarian crises

INTRODUCTION

Women and girls are affected significantly in both sudden and slow-onset emergencies, and face multiple sexual and reproductive health (SRH) challenges in humanitarian crises contexts. There are an estimated 26 million women and girls of reproductive age living in humanitarian crises settings, all of whom need access to SRH information and services. This systematic review aimed to assess the utilisation of services of SRH interventions from the onset of emergencies in low- and middle-income countries.

METHODS

We searched for both quantitative and qualitative studies in peer-reviewed journals across the following four databases: EMBASE, Global Health, MEDLINE and PsychINFO from 1 January 1980 to 10 April 2017. Primary outcomes of interest included self-reported use and/or confirmed use of the Minimum Initial Service Package services and abortion services. Two authors independently extracted and analysed data from published papers on the effect of SRH interventions on a range of SRH care utilisation outcomes from the onset of emergencies, and used a narrative synthesis approach.

RESULTS

Of the 2404 identified citations, 23 studies met the inclusion criteria. 52.1% of the studies (n=12) used quasi-experimental study designs, which provided some statistical measure of difference between intervention and outcome. 39.1% of the studies (n=9) selected were graded as high quality, 39.1% moderate quality (n=9) and 17.4% low quality (n=4). Evidence of effectiveness in increasing service utilisation was available for the following interventions: peer-led and interpersonal education and mass media campaigns, community-based programming and three-tiered network of community-based reproductive and maternal health providers.

CONCLUSIONS

Despite increased attention to SRH service provision in humanitarian crises settings, the evidence base is still very limited. More implementation research is required to identify interventions to increase utilisation of SRH services in diverse humanitarian crises settings and populations.

A novel methodology for strengthening human rights based monitoring in public health: Family planning indicators as an illustrative example

Objective

The last few years have seen a rise in the number of global and national initiatives that seek to incorporate human rights into public health practice. Nonetheless, a lack of clarity persists regarding the most appropriate indicators to monitor rights concerns in these efforts. The objective of this work was to develop a systematic methodology for use in determining the extent to which indicators commonly used in public health capture human rights concerns, using contraceptive services and programmes as a case study.

Methods

The approach used to identify, evaluate, select and review indicators for their human rights sensitivity built on processes undertaken in previous work led by the World Health Organization (WHO). With advice from an expert advisory group, an analytic framework was developed to identify and evaluate quantitative, qualitative, and policy indicators in relation to contraception for their sensitivity to human rights. To test the framework’s validity, indicators were reviewed to determine their feasibility to provide human rights analysis with attention to specific rights principles and standards.

Findings

This exercise resulted in the identification of indicators that could be used to monitor human rights concerns as well as key gaps where additional indicators are required. While indicators generally used to monitor contraception programmes have some degree of sensitivity to human rights, breadth and depth are lacking.

Conclusion

The proposed methodology can be useful to practitioners, researchers, and policy makers working in any area of health who are interested in monitoring and evaluating attention to human rights in commonly used health indicators.

Gender equality and human rights approaches to female genital mutilation: a review of international human rights norms and standards

Two hundred million girls and women in the world are estimated to have undergone female genital mutilation (FGM), and another 15 million girls are at risk of experiencing it by 2020 in high prevalence countries (UNICEF, 2016. Female genital mutilation/cutting: a global concern. 2016). Despite decades of concerted efforts to eradicate or abandon the practice, and the increased need for clear guidance on the treatment and care of women who have undergone FGM, present efforts have not yet been able to effectively curb the number of women and girls subjected to this practice (UNICEF. Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change. 2013), nor are they sufficient to respond to health needs of millions of women and girls living with FGM. International efforts to address FGM have thus far focused primarily on preventing the practice, with less attention to treating associated health complications, caring for survivors, and engaging health care providers as key stakeholders. Recognizing this imperative, WHO developed guidelines on management of health complications of FGM. In this paper, based on foundational research for the development of WHO’s guidelines, we situate the practice of FGM as a rights violation in the context of international and national policy and efforts, and explore the role of health providers in upholding health-related human rights of women at girls who are survivors, or who are at risk. Findings are based on a literature review of relevant international human rights treaties and UN Treaty Monitoring Bodies.

A pilot Project Exploring the Utility and Acceptability of a Socially-assistive Robot in an Assessment Unit for People with Neuropsychiatric Symptoms

Objectives

Socially-assistive robots have been used with older adults with cognitive impairment in residential care, and found to improve mood and well-being. However, there is little known about the potential benefits in adults with other neuropsychiatric symptoms.

Aims

The aim of this project was explore the utility and acceptability of a socially-assistive robot in engaging adults with a variety of neuropsychiatric symptoms.

Methods

Betty, a socially-assistive robot was installed in a unit which specialises in the assessment and diagnosis of adults presenting with neuropsychiatric symptoms. She is 39 cm tall, has a baby-face appearance and has the ability to engage individuals through personalised services which can be programmed according to individuals’ preferences. These include singing songs and playing games. Training for the nursing staff who were responsible for incorporating Betty into the unit activities was provided. The frequency, duration and type of activity which Betty was involved in was recorded. Patients admitted who could provide informed consent were able to be included in the project. These participants completed pre- and post-questionnaires.

Results

Eight patients (mean age 54.4 years, SD 13.6) who had diagnoses ranging from depression and schizophrenia participated. Types of activities included singing songs, playing Bingo and reading the news. Participants reported that they were comfortable with Betty and did not feel concerned in her presence. They enjoyed interacting with her.

Conclusions

This pilot project demonstrated that participants found Betty to be acceptable and she was useful in engaging them in activities. Future directions would involve larger sample sizes and different settings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

How Are Gender Equality and Human Rights Interventions Included in Sexual and Reproductive Health Programmes and Policies: A Systematic Review of Existing Research Foci and Gaps

The importance of promoting gender equality and human rights in sexual and reproductive health (SRH) programmes and policies has been affirmed in numerous international and regional agreements, most recently the 2030 Agenda for Sustainable Development. Given the critical role of research to determine what works, we aimed to identify research gaps as part of a broader priority setting exercise on integrating gender equality and human rights approaches in SRH programmes and policies. A systematic literature review of reviews was conducted to examine the question: what do we know about how research in the context of SRH programmes and policies has addressed gender equality and human rights and what are the current gaps in research. We searched three databases for reviews that addressed the research question, were published between 1994–2014, and met methodological standards for systematic reviews, qualitative meta-syntheses and other reviews of relevance to the research question. Additional grey literature was identified based on expert input. Articles were appraised by the primary author and examined by an expert panel. An abstraction and thematic analysis process was used to synthesize findings. Of the 3,073 abstracts identified, 56 articles were reviewed in full and 23 were included along with 10 from the grey literature. The majority focused on interventions addressing gender inequalities; very few reviews explicitly included human rights based interventions. Across both topics, weak study designs and use of intermediate outcome measures limited evidence quality. Further, there was limited evidence on interventions that addressed marginalized groups. Better quality studies, longer-term indicators, and measurement of unintended consequences are needed to better understand the impact of these types of interventions on SRH outcomes. Further efforts are needed to cover research on gender equality and human rights issues as they pertain to a broader set of SRH topics and populations.

International Human Rights and the Mistreatment of Women During Childbirth

International human rights bodies have played a critical role in codifying, setting standards, and monitoring human rights violations in the context of sexual and reproductive health and rights. In recent years, these institutions have developed and applied human rights standards in the more particular context of maternal mortality and morbidity, and have increasingly recognized a critical human rights issue in the provision and experience of care during and after pregnancy, including during childbirth. However, the international human rights standards on mistreatment during facility-based childbirth remain, in an early stage of development, focused largely on a discrete subset of experiences, such as forced sterilization and lack of access to emergency obstetric care. As a consequence, the range of mistreatment that women may experience has not been adequately addressed or analyzed under international human rights law. Identifying human rights norms and standards related to the full range of documented mistreatment is thus a first step towards addressing violations of human rights during facility-based childbirth, ensuring respectful and humane treatment, and developing a program of work to improve the overall quality of maternal care. This article reviews international human rights standards related to the mistreatment of women during childbirth in facility settings under regional and international human rights law and lays out an agenda for further research and action.