Integrating Social Determinants in Decision-Making Processes for Health: Insights from Conceptual Frameworks-the 3-D Commission

The inclusion of social determinants of health offers a more comprehensive lens to fully appreciate and effectively address health. However, decision-makers across sectors still struggle to appropriately recognise and act upon these determinants, as illustrated by the ongoing COVID-19 pandemic. Consequently, improving the health of populations remains challenging. This paper seeks to draw insights from the literature to better understand decision-making processes affecting health and the potential to integrate data on social determinants. We summarised commonly cited conceptual approaches across all stages of the policy process, from agenda-setting to evaluation. Nine conceptual approaches were identified, including two frameworks, two models and five theories. From across the selected literature, it became clear that the context, the actors and the type of the health issue are critical variables in decision-making for health, a process that by nature is a dynamic and adaptable one. The majority of these conceptual approaches implicitly suggest a possible role for data on social determinants of health in decision-making. We suggest two main avenues to make the link more explicit: the use of data in giving health problems the appropriate visibility and credibility they require and the use of social determinants of health as a broader framing to more effectively attract the attention of a diverse group of decision-makers with the power to allocate resources. Social determinants of health present opportunities for decision-making, which can target modifiable factors influencing health-i.e. interventions to improve or reduce risks to population health. Future work is needed to build on this review and propose an improved, people-centred and evidence-informed decision-making tool that strongly and explicitly integrates data on social determinants of health.

Clinical nursing and midwifery education in the pandemic age

The COVID‐19 pandemic has disrupted clinical nursing and midwifery education. This disruption has long‐term implications for the nursing and midwifery workforce and for future healthcare responses to pandemics. Solutions may include enhanced partnerships between schools of nursing and midwifery and health service providers and including schools of nursing and midwifery in preparedness planning. These suggestions notwithstanding, we call upon national and international nursing and midwifery bodies to study how to further the clinical education of nurses and midwives during pandemics and other times of crisis.

Towards a definition of orphaned and vulnerable children

The HIV epidemic presents challenges including orphans and a large mass of children rendered vulnerable by the epidemic and other societal forces. Focus on orphaned and vulnerable children (OVC) is important, but needs accurate definition. Twelve focus group interviews of service providers, leaders in these communities, OVC and their caretakers were conducted at six project sites across Botswana, South Africa and Zimbabwe to extend this definition. The loss of a parent through death or desertion is an important aspect of vulnerability. Additional factors leading to vulnerability included severe chronic illness of a parent or caregiver, poverty, hunger, lack of access to services, inadequate clothing or shelter, overcrowding, deficient caretakers, and factors specific to the child, including disability, direct experience of physical or sexual violence, or severe chronic illness. Important questions raised in this research include the long-term implications for the child and community, and the contribution of culture systems.

A population-based study on alcohol and high-risk sexual behaviors in Botswana

BACKGROUND

In Botswana, an estimated 24% of adults ages 15-49 years are infected with HIV. While alcohol use is strongly associated with HIV infection in Africa, few population-based studies have characterized the association of alcohol use with specific high-risk sexual behaviors.

METHODS AND FINDINGS

We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana using a stratified two-stage probability sample design. Multivariate logistic regression was used to assess correlates of heavy alcohol consumption (>14 drinks/week for women, and >21 drinks/week for men) as a dependent variable. We also assessed gender-specific associations between alcohol use as a primary independent variable (categorized as none, moderate, problem and heavy drinking) and several risky sex outcomes including: (a) having unprotected sex with a nonmonogamous partner; (b) having multiple sexual partners; and (c) paying for or selling sex in exchange for money or other resources. Criteria for heavy drinking were met by 31% of men and 17% of women. Adjusted correlates of heavy alcohol use included male gender, intergenerational relationships (age gap > or =10 y), higher education, and living with a sexual partner. Among men, heavy alcohol use was associated with higher odds of all risky sex outcomes examined, including unprotected sex (AOR = 3.48; 95% confidence interval [CI], 1.65 to 7.32), multiple partners (AOR = 3.08; 95% CI, 1.95 to 4.87), and paying for sex (AOR = 3.65; 95% CI, 2.58 to 12.37). Similarly, among women, heavy alcohol consumption was associated with higher odds of unprotected sex (AOR = 3.28; 95% CI, 1.71 to 6.28), multiple partners (AOR = 3.05; 95% CI, 1.83 to 5.07), and selling sex (AOR = 8.50; 95% CI, 3.41 to 21.18). A dose-response relationship was seen between alcohol use and risky sexual behaviors, with moderate drinkers at lower risk than both problem and heavy drinkers.

CONCLUSIONS

Alcohol use is associated with multiple risks for HIV transmission among both men and women. The findings of this study underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.

Routine HIV testing in Botswana: a population-based study on attitudes, practices, and human rights concerns

BACKGROUND

The Botswana government recently implemented a policy of routine or "opt-out" HIV testing in response to the high prevalence of HIV infection, estimated at 37% of adults.

METHODS AND FINDINGS

We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana to assess knowledge of and attitudes toward routine testing, correlates of HIV testing, and barriers and facilitators to testing, 11 months after the introduction of this policy. Most participants (81%) reported being extremely or very much in favor of routine testing. The majority believed that this policy would decrease barriers to testing (89%), HIV-related stigma (60%), and violence toward women (55%), and would increase access to antiretroviral treatment (93%). At the same time, 43% of participants believed that routine testing would lead people to avoid going to the doctor for fear of testing, and 14% believed that this policy could increase gender-based violence related to testing. The prevalence of self-reported HIV testing was 48%. Adjusted correlates of testing included female gender (AOR = 1.5, 95% CI = 1.1-1.9), higher education (AOR = 2.0, 95% CI = 1.5-2.7), more frequent healthcare visits (AOR = 1.9, 95% CI = 1.3-2.7), perceived access to HIV testing (AOR = 1.6, 95% CI = 1.1-2.5), and inconsistent condom use (AOR = 1.6, 95% CI = 1.2-2.1). Individuals with stigmatizing attitudes toward people living with HIV and AIDS were less likely to have been tested for HIV/AIDS (AOR = 0.7, 95% CI = 0.5-0.9) or to have heard of routine testing (AOR = 0.59, 95% CI = 0.45-0.76). While experiences with voluntary and routine testing overall were positive, 68% felt that they could not refuse the HIV test. Key barriers to testing included fear of learning one's status (49%), lack of perceived HIV risk (43%), and fear of having to change sexual practices with a positive HIV test (33%).

CONCLUSIONS

Routine testing appears to be widely supported and may reduce barriers to testing in Botswana. As routine testing is adopted elsewhere, measures should be implemented to assure true informed consent and human rights safeguards, including protection from HIV-related discrimination and protection of women against partner violence related to testing.

IMPACT OF PEER GROUP EDUCATION ON HIV PREVENTION AMONG WOMEN IN BOTSWANA

A peer group HIV prevention intervention based on social-cognitive learning theory, gender inequality, and the primary health care model for community-based health promotion was developed for more than 300 urban employed women in Botswana. All women volunteered to participate in the intervention. To control for self-selection, matched workplaces were assigned to the intervention group or to the delayed control group. Compared with women in the delayed control group, women in the intervention group had significantly higher postintervention levels of knowledge of HIV transmission, sexually transmitted diseases (STDs), and HIV prevention behaviors; positive condom attitudes and confidence in condom use; personal safer sex behaviors; and positive attitudes toward persons living with HIV/AIDS and community HIV/AIDS-related activities. The peer group leaders have sustained the program for more than 5 years after the end of research funding. Peer groups are a low-cost and sustainable intervention that can change HIV prevention knowledge, attitudes, and behaviors for ordinary urban employed women in sub-Saharan Africa.

Aids and the elderly Tswana: the concept of pollution and consequences for AIDS prevention

A study of elderly people in a village in southern Botswana is presented in this article. An argument is made for more in depth understanding of the role of elderly people in relation to the HIV/AIDS epidemic. It is demonstrated how Tswana indigenous medical ideology is behaviourally expressed in ways that identify elderly people as a group that may be at risk of catching and spreading HIV/AIDS. Through their position as respected members of the community, elderly people may also be a resource group in the struggle for AIDS prevention.

Home-based care in Botswana: experiences of older women and young girls

In this exploratory and descriptive study we investigated the experiences of and impact on young girls and older women caring for family members living with HIV/AIDS and other chronic and terminal illnesses at home in three districts of Botswana. Using qualitative research methods, we conducted 70 interviews with family caregivers and key informants such as community home-based care (CHBC) team members and government officials. Older women reported feeling overwhelmed with the magnitude and multiplicity of tasks they had to perform. They reported feeling exhausted, malnourished, depressed, and often neglectful of their own health. Young girls often missed school and they were sexually and physically abused, sexually exploited, and depressed. In addition, these caregivers experienced poverty, social isolation, stigma, psychological distress, and a lack of basic caregiving education. We made recommendations to improve services and care to the CHBC teams and to the national government.