ArticleLiterature Review

Understanding gender inequities in antimicrobial resistance: role of biology, behaviour and gender norms

BMJ Group
BMJ Global Health
Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Antimicrobial resistance (AMR) poses a critical public health threat, with gendered implications that are often overlooked. Key drivers of bacterial AMR include the misuse of antibiotics, inadequate water, sanitation and hygiene infrastructure and poor infection control practices. Persistent gender discrimination exacerbates these issues, resulting in disparities in healthcare access and outcomes. This review explores how biological, sociocultural and behavioural factors contribute to the differential incidence of AMR in women. We present a conceptual framework to understand how gender norms influence antibiotic use and AMR. Differences in infection susceptibility, health-seeking behaviours, the ability to access and afford essential antibiotics and quality healthcare and appropriate diagnosis and management by healthcare providers across genders highlight the necessity for gender-sensitive approaches. Addressing gender dynamics within the health workforce and fostering inclusive policies is crucial for effectively mitigating AMR. Integrating intersectional and life course approaches into AMR mitigation strategies is essential to manage the changing health needs of women and other vulnerable groups.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Different sexes and genders experience differentiated risks of acquiring infections, including drug-resistant infections, and of becoming ill. Different genders also have different health-seeking behaviours that shape their likelihood of having access to and appropriately using and administering antimicrobials. Consequently, they are distinctly affected by antimicrobial resistance (AMR). As such, it is crucial to incorporate perspectives on sex and gender in the study of both AMR and antimicrobial use in order to present a full picture of AMR's drivers and impact. An intersectional approach to understanding gender and AMR can display how gender and other components 'intersect' to shape the experiences of individuals and groups affected by AMR. However, there are insufficient data on the burden of AMR disaggregated by gender and other socio-economic characteristics, and where available, it is fragmented. For example, to date, the best estimate of the global burden of bacterial AMR published in The Lancet does not consider gender or other social stratifiers in its analysis. To address this evidence gap, we undertook a scoping review to examine how sex and gender compounded by other axes of marginalization influence one's vulnerability and exposure to AMR as well as one's access to and use of antimicrobials. We undertook a gendered analysis of AMR, using intersectionality as a concept to help us understand the multiple and overlapping ways in which different people experience exposure vulnerability to AMR. This approach is crucial in informing a more nuanced view of the burden and drivers of AMR. The intersectional gender lens should be taken into account in AMR surveillance, antimicrobial stewardship, infection prevention and control and public and professional awareness efforts, both donor and government funded, as well as national and international policies and programmes tackling AMR such as through national action plans.
Article
Full-text available
At the 2015 World Health Assembly, UN member states adopted a resolution that committed to the development of national action plans (NAPs) for antimicrobial resistance (AMR). The political determination to commit to NAPs and the availability of robust governance structures to assure sustainable translation of the identified NAP objectives from policy to practice remain major barriers to progress. Inter-country variability in economic and political resilience and resource constraints could be fundamental barriers to progressing AMR NAPs. Although there have been regional and global analyses of NAPs from a One Health and policy perspective, a global assessment of the NAP objectives targeting antimicrobial use in human populations is needed. In this Health Policy, we report a systematic evidence synthesis of existing NAPs that are aimed at tackling AMR in human populations. We find marked gaps and variability in maturity of NAP development and operationalisation across the domains of: (1) policy and strategic planning; (2) medicines management and prescribing systems; (3) technology for optimised antimicrobial prescribing; (4) context, culture, and behaviours; (5) operational delivery and monitoring; and (6) patient and public engagement and involvement. The gaps identified in these domains highlight opportunities to facilitate sustainable delivery and operationalisation of NAPs. The findings from this analysis can be used at country, regional, and global levels to identify AMR-related priorities that are relevant to infrastructure needs and contexts.
Article
Full-text available
Introduction: Few studies have reported antibiotic purchases from retail drug shops in relation to gender in low and middle-income countries (LMICs). Using a One Health approach, we aimed to examine gender dimensions of antibiotic purchases for humans and animals and use of prescriptions in retail drug shops in Bangladesh. Methods: We conducted customer observations in 20 drug shops in one rural and one urban area. Customer gender, antibiotic purchases, and prescription use were recorded during a four-hour observation (2 sessions of 2 hours) in each shop. We included drug shops selling human medicine (n = 15); animal medicine (n = 3), and shops selling both human and animal medicine (n = 2). Results: Of 582 observations, 31.6% of drug shop customers were women. Women comprised almost half of customers (47.1%) in urban drug shops but only 17.2% of customers in rural drug shops (p < 0.001). Antibiotic purchases were more common in urban than rural shops (21.6% versus 12.2% of all transactions, p = 0.003). Only a quarter (26.0%) of customers who purchased antibiotics used a prescription. Prescription use for antibiotics was more likely among women than men (odds ratio (OR) = 4.04, 95% CI 1.55, 10.55) and more likely among urban compared to rural customers (OR = 4.31 95% CI 1.34, 13.84). After adjusting for urban-rural locality, women remained more likely to use a prescription than men (adjusted OR = 3.38, 95% CI 1.26, 9.09) but this was in part due to antibiotics bought by men for animals without prescription. Customers in drug shops selling animal medicine had the lowest use of prescriptions for antibiotics (4.8% of antibiotic purchases). Conclusion: This study found that nearly three-quarters of all antibiotics sold were without prescription, including antibiotics on the list of critically important antimicrobials for human medicine. Men attending drug shops were more likely to purchase antibiotics without a prescription compared to women, while women customers were underrepresented in rural drug shops. Antibiotic stewardship initiatives in the community need to consider gender and urban-rural dimensions of drug shop uptake and prescription use for antibiotics in both human and animal medicine. Such initiatives could strengthen National Action Plans.
Article
Full-text available
Neisseria gonorrhoeae has become a significant global public health problem due to growing infection rates and antibiotic resistance development. In 2012, N. gonorrhoeae positive samples isolated from Southeast Asia were reported to be the first strains showing resistance to all first-line antibiotics. To date, N. gonorrhoeae’s antimicrobial resistance has since been identified against a wide range of antimicrobial drugs globally. Hence, the World Health Organization (WHO) listed N. gonorrhoeae’s drug resistance as high-priority, necessitating novel therapy development. The persistence of N. gonorrhoeae infections globally underlines the need to better understand the molecular basis of N. gonorrhoeae infection, growing antibiotic resistance, and treatment difficulties in underdeveloped countries. Historically, Africa has had minimal or rudimentary N. gonorrhoeae monitoring systems, and while antimicrobial-resistant N. gonorrhoeae is known to exist, the degree of resistance is unknown. This review looks at the gender-related symptomatic gonorrhoeae disease and provides an overview of the essential bacterial factors for the different stages of pathogenesis, including transmission, immune evasion, and antibiotic resistance. Finally, we deliberate on how molecular epidemiological studies have informed our current understanding of sexual networks in the Sub-Saharan region.
Article
Full-text available
Background Globally, antimicrobial resistance (AMR) restricted the armamentarium of the health care providers against infectious diseases, mainly due to the emergence of multidrug resistant. This review is aimed at providing contemporary bacterial profile and antimicrobial resistance pattern among pregnant women with significant bacteriuria. Methods Electronic biomedical databases and indexing services such as PubMed/MEDLINE, Web of Science, EMBASE and Google Scholar were searched. Original records of research articles, available online from 2008 to 2021, addressing the prevalence of significant bacteriuria and AMR pattern among pregnant women and written in English were identified and screened. The relevant data were extracted from included studies using a format prepared in Microsoft Excel and exported to STATA 14.0 software for the outcome measure analyses and subgrouping. Results The data of 5894 urine samples from 20 included studies conducted in 8 regions of the country were pooled. The overall pooled estimate of bacteriuria was 15% (95% CI 13–17%, I² = 77.94%, p < 0.001) with substantial heterogeneity. The pooled estimate of Escherichia coli recovered from isolates of 896 urine samples was 41% (95% CI 38–45%) followed by coagulase-negative Staphylococci, 22% (95% CI 18–26%), Staphylococcus aureus, 15% (95% CI 12–18%), Staphylococcus saprophytic, 12% (95% CI 6–18%) Proteus mirabilis, 7% (95% CI 4–10%), Enterococcus species, 6% (0–12%), Pseudomonas aeruginosa, 4% (2–6%), Citrobacter species, 4% (95% CI 2–4%), Group B streptococcus, 3% (1–5%), and Enterobacter species, 2% (1–4%). Multidrug resistance proportions of E. coli, Klebsiella species, Staphylococcus aureus and Coagulase negative staphylococci, 83% (95% CI 76–91%), 78% (95% CI 66–90%), 89% (95% CI 83–96%), and 78% (95% CI 67–88%), respectively. Conclusion The result of current review revealed the occurrence of substantial bacteriuria among pregnant women in Ethiopia. Resistance among common bacteria (E. coli, Klebsiella species, Staphylococci species) causing UTIs in pregnant women is widespread to commonly used antibiotics. The high rate of drug resistance in turn warrants the need for regular epidemiological surveillance of antibiotic resistance and implementation of an efficient infection control and stewardship program.
Article
Full-text available
Background: Despite the fact that every girl has to deal with menstrual hygiene, there is a lack of awareness about the process of menstruation and proper menstrual hygiene among adolescent girls, especially from tribal backgrounds. Aim: The aim of the study was to assess the knowledge and practices related to menstruation among tribal (Munda) adolescent girls. Materials and methods: This was a community-based cross-sectional study. The sample for the study consisted of 150 girls belonging to Munda tribe in the age group of 13-18 years, recruited by purposive sampling from various schools of Khunti district of Jharkhand state. Interview guide was predeveloped, validated, and used to study the knowledge and practices related to menstruation among adolescent girls. The data were collected by a personal interview of the study subjects. Results: The mean age of menarche of the study subjects was 14.1 years. It was evident that only 48.67% of the participants were aware about menstruation before menarche and the most important source of the information about menstruation for them was their friends (53.33%) followed by mothers. Conclusions: Knowledge about menstruation is poor among tribal adolescent girls and practices included various myths and misconceptions.
Article
Full-text available
Background Maternal sepsis and other maternal infections (MSMI) have considerable impacts on women’s and neonatal health, but data on the global burden and trends of MSMI are limited. Comprehensive knowledge of the burden and trend patterns of MSMI is important to allocate resources, facilitate the establishment of tailored prevention strategies and implement effective clinical treatment measures. Methods Based on data from the Global Burden of Disease database, we analysed the global burden of MSMI by the incidence, death, disability-adjusted life year (DALY) and maternal mortality ratio (MMR) in the last 30 years. Then, the trends of MSMI were assessed by the estimated annual percentage change (EAPC) of MMR as well as the age-standardized rate (ASR) of incidence, death and DALY. Moreover, we determined the effect of sociodemographic index (SDI) on MSMI epidemiological parameters. Results Although incident cases almost stabilized from 1990 to 2015, the ASR of incidence, death, DALY and MMR steadily decreased globally from 1990 to 2019. The burden of MSMI was the highest in the low SDI region with the fastest downward trends. MSMI is still one of the most important causes of maternal death in the developed world. Substantial diversity of disease burden and trends occurred in different regions and individual countries, most of which had reduced burden and downward trends. The MMR and ASR were negatively correlated with corresponding SDI value in 2019 in 204 countries/territories and 21 regions. Conclusion These findings highlight significant improvement in MSMI care in the past three decades, particularly in the low and low-middle SDI regions. However, the increased burden and upward trends of MSMI in a few countries and regions are raising concern, which poses a serious challenge to maternal health. More tailored prevention measures and additional resources for maternal health are urgently needed to resolve this problem.
Article
Full-text available
One of the key drivers of antibiotic resistance (ABR) and drug-resistant bacterial infections is the misuse and overuse of antibiotics in human populations. Infection management and antibiotic decision-making are multifactorial, complex processes influenced by context and involving many actors. Social constructs including race, ethnicity, gender identity and cultural and religious practices as well as migration status and geography influence health. Infection and ABR are also affected by these external drivers in individuals and populations leading to stratified health outcomes. These drivers compromise the capacity and resources of healthcare services already over-burdened with drug-resistant infections. In this review we consider the current evidence and call for a need to broaden the study of culture and power dynamics in healthcare through investigation of relative power, hierarchies and sociocultural constructs including structures, race, caste, social class and gender identity as predictors of health-providing and health-seeking behaviours. This approach will facilitate a more sustainable means of addressing the threat of ABR and identify vulnerable groups ensuring greater inclusivity in decision-making. At an individual level, investigating how social constructs and gender hierarchies impact clinical team interactions, communication and decision-making in infection management and the role of the patient and carers will support better engagement to optimize behaviours. How people of different race, class and gender identity seek, experience and provide healthcare for bacterial infections and use antibiotics needs to be better understood in order to facilitate inclusivity of marginalized groups in decision-making and policy.
Article
Full-text available
Introduction. Globally, there is a growing concern over antimicrobial resistance (AMR) which is currently estimated to account for more than 700,000 deaths per year worldwide. AMR undermines the management of infectious diseases in general especially in pregnancy where significant bacteriuria continues to be a serious cause of maternal and perinatal morbidity and mortality. We therefore aimed to determine the prevalence of AMR and the associated factors among pregnant women with urinary tract infections (UTIs) attending antenatal clinic at a selected hospital in Lusaka, Zambia. Methods. This was a hospital-based, cross-sectional study conducted between November 2018 and May 2019. Interviewer-administered questionnaire was used to assess the sociodemographic characteristics and behavioural characteristics. Laboratory tests were also conducted. Descriptive statistics of study participants were used to describe the characteristics of the respondents. Chi-square was used to assess the association between categorical variables. The logistic regression analysis was carried out to generate the adjusted odds ratio with 95% confidence interval. Results. Overall (n = 203), the prevalence of UTI was 60% (95% CI: 53.3%–66.7%). The most isolated bacteria were E. coli (59%) and Klebsiella (21%). The prevalence of AMR was found to be 53% (95% CI: 46.1%–59.8%). The drugs highly resistant to antimicrobials were nalidixic acid (88.3%), ampicillin (77.8%), and norfloxacin (58.5%), while the least resistant drug was chloramphenicol (20%). There were no important significant predictors to AMR among pregnant women observed in this study. Conclusion. We found high burden of AMR closely linked to observe high prevalence of UTI suggested in this small population. This suggests a need to develop integrated surveillance systems that aim for early and regular screening of pregnant women for UTI as well as concurrent determination of antibiotic susceptibility patterns. This is important to prevent complications that may endanger maternal and fetal health outcomes. Furthermore, further research is needed to explore reasons for this high prevalence of AMR including examining possible attribution to the misuse of drugs so as to inform, enforce, or adjust the prescription-only policies and enforce antimicrobial stewardship programs. 1. Introduction It is estimated that, about 150 million people worldwide are diagnosed with urinary tract infections (UTIs) [1]. Urinary tract infections are among the most common bacterial infections encountered by both the general community and in hospitals, ranking the second commonest infection after respiratory infections [2]. In poor-resourced and tropical countries, UTIs are still the major source of morbidity and death [3] with an estimated annual global incidence of at least 250 million in developing countries [4]. Women are more susceptible to UTI when compared to men, and this is largely due to short urethra, absence of prostatic secretion, pregnancy, and easy contamination of the urinary tract with faecal flora [5]. About 50% of women will suffer from at least one urinary tract infection (UTI) during their adult life including during pregnancy. There are many different pathogenic microorganisms (bacteria, fungi, protozoa, and viruses) which cause UTIs among pregnant women. Among the bacterial pathogens, E. coli and other Enterobacteriaceae are the most and account approximately 75% of the isolates [4]. Antibiotics are among the most commonly used medications to treat UTIs globally and are of enormous importance to global health. Despite their importance, the sustained effectiveness of antibiotics is endangered by the development of resistance. The excessive and unnecessary use of antibiotics has been the main cause of antibiotic resistance [6]. Internationally, there is a growing concern over antimicrobial resistance (AMR) which is currently estimated to account for more than 700,000 deaths per year worldwide [7]. Antimicrobial resistance is a broad term that includes resistance to all antimicrobial agents. Antimicrobial resistance results in the therapeutic failure of standard treatment and longer duration of treatment, leading to an increased risk in the spread of infections [8]. One of the important risk factors for antibiotic resistance is the abuse of antibiotics by the public [9], while some studies have also reported that some pregnant women are ignorant of the management of common infections which results in AMR [10]. In Zambia, like many other countries, there is emerging evidence of AMR in several pathogens [11–13]. Despite the large number of antimicrobial agents available, UTIs have remained a significant problem among pregnant women in Zambia [14], particularly in Lusaka. Yet, evidence on the prevalence of AMR among pregnant women and the associated factors is limited. It is against this background that the study was carried out to determine the prevalence of AMR and associated factors among pregnant women with UTI and attending antenatal clinic at a selected university teaching hospital in Lusaka, Zambia. 2. Methods 2.1. Study Setting and Period A hospital-based cross-sectional study based on quantitative approach was conducted from November 2018 to May 2019. The study was conducted at Levy Mwanawasa University Teaching Hospital, located in Lusaka, the capital city of Zambia. The selected teaching hospital serves as a referral centre with a total catchment population of approximately 800,000 in- and outpatients. 2.2. Study Participants and Sampling This study focused on all pregnant women who were attending antenatal clinic at Levy Mwanawasa University Teaching Hospital. All pregnant women aged 18 years and above, attending antenatal clinic within the data collection period, were targeted for the study, and they were hence purposely selected. Participants consenting to participate in the study were included in the study. We excluded pregnant women who were on antimicrobial therapy for UTI two weeks prior to selection and who provided inadequate urine samples (less than 10 ml urine), whose urine specimens were collected more than 2 hours before receipt for laboratory diagnosis, with specimens submitted in leaking or dirty unsterile containers and specimens revealing growth of more than two types of bacteria on culture. 2.3. Study Design This was a hospital-based, cross-sectional study conducted between November 2018 and May 2019. Interviewer-administered questionnaire was used to assess the sociodemographic characteristics and lifestyle data. Laboratory tests were also conducted. Descriptive statistics of study participants were used to describe the characteristics of the respondents. Chi-square was used to assess the association between categorical variables. The logistic regression analysis was carried out to generate the adjusted odds ratio with 95% confidence interval. 2.4. Sample Size The sample size was determined by using the single size population proportion formula with an assumption of 14% prevalence of antimicrobial resistance, from a study by Behailu Deres et al. [14]. Therefore, for 0.14, , 1.96 Z, 95% CI, a = 0.05, and a 10% nonresponse rate, a sample size of 203 participants was determined. A convenient sampling technique was used to enroll consecutive pregnant women attending antenatal care in the hospital during the study period. Patients who tested positive for UTIs were recruited until the expected number of participants of the study sample was attained. The main outcome variable was antimicrobial resistance, in pregnant women, a binary variable. Independent variables included sociodemographic characteristics (age, marital status, residence, education level, and monthly income) and clinical characteristics (HIV status, history of urinary tract infection, and trimester). 2.5. Laboratory Procedures Urine specimens were inoculated onto CLED (cysteine-lactose-electrolyte-deficient agar) and MacConkey’s and blood agar plates (OXOID, Ltd, Basingstoke, UK) by using the streak method following the standard microbiological procedures. The plates were incubated at 37°C for 24 hours and then examined for significant growth. Diagnosis of UTI was based on the presence of ≥10⁵ colony-forming units per millilitre of midstream urine of one or two types of bacterial species. Specimens with more than two types of bacteria species were regarded as contamination, and sample collection was repeated. The identification of bacteria isolate was done using biochemical tests. Antimicrobial susceptibility testing was performed for the bacterial isolates identified from urine cultures with significant growth by using the Kirby–Bauer disk diffusion method on Mueller–Hinton agar (Oxoid Ltd, Basingstoke, UK) according to the criteria set by the Clinical and Laboratory Standards Institute [15, 16] to determine the susceptibility patterns of the commonly used antibiotics. The procedure for antimicrobial susceptibility testing was as follows. In brief, 4–6 morphologically identical colonies of bacteria from pure cultures were collected with an inoculating loop, transferred into a tube containing 5 mL of nutrient broth, then mixed gently until a homogenous suspension was formed, and incubated at 37°C for 3–5 hours until the turbidity of the suspension became adjusted to the density of 0.5 McFarland standards, which yields a uniform suspension containing 105–106 cells/mL. Using a sterile nontoxic dry cotton swab, the sample of the standardized inoculums (turbidity was adjusted to obtain confluent growth) were taken and streaked on the entire surface of the dried Mueller–Hinton agar plate three times, turning the plate at 60° angle between each streaking to ensure even distribution. The inoculum was allowed to dry for 5–15 minutes with the lid in place. Using standard antibiotic disks (Oxoid) containing nalidixic acid (30 μg), nitrofurantoin (300 μg), norfloxacin (10 μg), chloramphenicol (30 μg), co-trimoxazole (25 μg), cefotaxime (30 μg), penicillin (10 μg)), gentamicin (10 μg)), erythromycin (15 μg)), ciprofloxacin (5 μg), ampicillin (10 μg)), and vancomycin (30 μg) were dispensed onto well-labelled inoculated MHA plates using the disc dispenser. Sterile antibiotic disks used were based on their availability at the laboratory at the time of the study. The plates were allowed to stand for few minutes and were incubated at 37°C for 24 hours within 15 minutes of applying. Antibiotic sensitivity was checked by measuring the zone of inhibition (zone of clearance) from the back of the plate to the nearest mm using a ruler or caliper. Sterile zone of inhibitions was recorded and used to establish if the bacterial isolates were resistant, intermediate, and susceptible using reference books and WHONET. Bacteria were reported as sensitive (S), intermediate (I), or resistant (R) to each of the antibiotics used in the test. 2.6. Data Processing, Quality Control, and Analysis Data were collected by face-to-face interviews using a standard questionnaire to collect sociodemographic and lifestyle data from the participants. The questionnaire was designed in English and translated to Nyanja, a commonly used local language in Lusaka. The tool was pretested for validation. Upon completion of the interview, the participants were sent to the hospital laboratory with a request form. Instructions were given to them by a trained medical laboratory personnel on how to collect the urine specimen. Participants were advised to place 10–20 mL clean-catch midstream urine specimen into a sterile screw-capped, wide-mouthed, sterile disposable plastic container after signing the consent form [15]. Each sample bottle was labelled with date and time of collection and then immediately sent to the microbiology department for microscopy, culture, and antimicrobial susceptibility. A unique sample number was linked to the participant`s questionnaire which was in turn linked to confidential patient information. Data collected were verified for completeness and were double-entered into the excel spreadsheet to ensure accuracy and reliability. Culture and biochemical tests were performed by a laboratory scientist using the standard operating procedures to ensure quality results. The American Type Culture Collection (ATCC) reference strains such as Escherichia coli (ATCC-25922), Staphylococcus aureus (ATCC-25923), and Pseudomonas aeruginosa (ATCC-27853) were used as quality control parameters of laboratory tests. The culture results from the samples collected were used to calculate prevalence of UTI, to characterize the type of microbial growth (isolates), and to test for antimicrobial susceptibility test. The data generated from the questionnaires were entered and checked for completeness, consistency, and accuracy and then entered into an Excel spreadsheet. After manual verification and cleaning, the data processing and statistical analysis was performed using STATA software version 14.0 (Stata™ Corporation, Texas, USA). Basic descriptive statistics (proportions and means) of study participants were used to describe the characteristics of the variables of respondents. Categorical variables were summarized in the form of numbers and percentages and presented in table format. Continuous variables such as age were assessed for normality assumptions using Q-Q plots. Statistics such as means and their respective standard deviations were reported. Chi-square test was used to assess statistical differences between categorical variables with significance level set at and 95% confidence interval. Bivariate analysis was applied, and all the variables with a value less than 0.05 were then entered into the logistic regression model to generate the adjusted odds ratio with 95% confidence interval. A value less than 0.05 () was considered statistically significant. 2.7. Ethical Consideration This study obtained ethical approval from the University of Zambia Biomedical Research Ethics Committee (UNZABREC) (reference number: 002-09-18). Authority to conduct the study was also obtained from the National Health Research Authority in Zambia. We received written informed consent from the study participants. Confidentiality was maintained by omitting personal identifiers. Privacy was also maintained. 3. Results 3.1. Participant Description A total of 203 pregnant women were included in this study. As shown in Table 1, most of the pregnant women were married with a proportion of 80. 9% (165/206). A majority of the study participants were in the age range of 25 to 29 years and 30 to 34 (59% and 28.8%) respectively. Most of these women came from low-cost areas (areas with high population density and low cost of living) having a proportion of 68.2% (131/206), and 52% (102/202) of the women had secondary education as the highest level of education achieved. Approximately 61% (125/202) of the women had a history of previous urinary tract infection, and half of them (50%) were in their second trimester. Characteristics Total (n = 203) Patients (n) Percentage (%) Marital status Single 36 17.6 Married 163 80.9 Separated 1 0.4 Widowed 1 0.4 Divorced 2 1.0 Age in years Less than 20 9 4.3 20 to 24 43 20.0 25 to 29 59 28.8 30 to 34 59 28.8 35 to 39 24 12.7 40 and above 9 4.4 Residence High cost 15 7.8 Low cost 131 68.2 Medium cost 46 23.0 Education level Primary 28 14.3 Secondary 102 52.0 Tertiary 66 33.7 Monthly income (USD) No income 48 23.4 10.1 to 15 42 20.5 15.1 to 20 26 12.7 20.1 to 30 50 24.4 Above 30 39 19.0 HIV status Reactive 74 36.8 Nonreactive 127 63.2 History of urinary tract infection Yes 125 61.0 No 78 39.0 Pregnancy trimester First 19 10.8 Second 88 50.0 Third 69 39.2
Article
Full-text available
Urinary tract infections (UTIs) are associated with negative pregnancy outcomes and are treated with antibiotics. Although beneficial, antibiotic use causes antimicrobial resistance (AMR), and therefore their use needs to be carefully balanced. Antimicrobial guidelines are developed to facilitate appropriate prescribing of antibiotics. This study assessed antibiotic prescribing for UTIs in pregnancy against the National Institute for Health and Care Excellence (NICE) guideline NG109. Fifty antibiotic prescribing records dated from 1st October 2018 to 1st July 2019 were identified from three London-based GP practices. The results show that a mid-stream sample of urine, which is important for the review and tailoring of antibiotic treatment, was collected in 77.6% of cases. Prescribing the first-line antibiotic is important for adequate treatment and good antimicrobial stewardship and results show that 44% of prescriptions were for the first-choice antibiotic. Most prescriptions (56%) were for a second-line or non-recommended antibiotic. Providing self-care advice is key to empowering pregnant women in managing their own health but only 16% of records documented provision of self-care advice. This study highlights important areas of concern in the management of UTIs in pregnancy. However, due to the retrospective design, future work is needed to evaluate the role of AMR in the prescriber's treatment decision-making process.
Article
Full-text available
Men whose sexual behaviors place them at risk of HIV often exhibit a "cluster" of behaviors, including alcohol misuse and violence against women. Called the "Substance Abuse, Violence and AIDS (SAVA) syndemic," this intersecting set of issues is poorly understood among heterosexual men in sub-Saharan Africa. We aim to determine cross-sectional associations between men's use of alcohol, violence, and HIV risk behaviors using a gendered syndemics lens. We conducted a baseline survey with men in an informal, peri-urban settlement near Johannesburg (Jan-Aug 2016). Audio-assisted, self-completed questionnaires measured an index of risky sex (inconsistent condom use, multiple partnerships, transactional sex), recent violence against women (Multicountry Study instrument), alcohol misuse (Alcohol Use Disorders Tool), and gender attitudes (Gender Equitable Men's Scale). We used logistic regression to test for syndemic interaction on multiplicative and additive scales and structural equation modeling to test assumptions around serially causal epidemics. Of 2454 men, 91.8% reported one or more types of risky sex. A majority of participants reported one or more SAVA conditions (1783, 71.6%). After controlling for socio-demographics, higher scores on the risky sex index were independently predicted by men's recent violence use, problem drinking, and inequitable gender views. Those men reporting all three SAVA conditions had more than 12-fold greater odds of risky sex compared to counterparts reporting no syndemic conditions. Each two-way interaction of alcohol use, gender inequitable views, and IPV perpetration was associated with a relative increase in risky sex on either a multiplicative or additive scale. A structural equation model illustrated that gender norms predict violence, which in turn predict alcohol misuse, increasing both IPV perpetration and risky sex. These data are consistent with a syndemic model of HIV risk among heterosexual men. Targeting intersections between syndemic conditions may help prevent HIV among heterosexual men in peri-urban African settings.
Article
Full-text available
Introduction Unsafe abortion is a preventable cause of maternal mortality. While studies report high number of abortions in India, the population-level rates of unsafe abortion and their risk factors are not well understood. Our objective was to analyse the rates of and risk factors for unsafe abortion and abortion-related maternal death in India. Methods We conducted a secondary analysis of data from 1 876 462 pregnant women aged 15–58 years from nine states in the Indian Annual Health Survey (2010–2013). We calculated the rate of unsafe abortion and abortion-related mortality with 95% CI. Multivariable logistic regression models examined the associations of sociodemographic characteristics, health seeking behaviours and family planning with unsafe abortion and abortion-related mortality. Results There were 89 447 abortions among 1 876 462 pregnant women in 2007–2011 (4.8%; 95% CI 4.8 to 4.9). Of these, 58 266 were classified as unsafe (67.1%; 95% CI 66.7 to 67.5). There were 253 abortion-related maternal deaths (0.3%; 95% CI 0.2 to 0.3). Factors associated with unsafe abortion: maternal age 20–24 years (adjusted OR (aOR): 1.13; 95% CI 1.09 to 1.18), illiteracy (aOR: 1.48; 95% CI 1.39 to 1.59), rural residence (aOR: 1.26; 95% CI 1.21 to 1.32), Muslim religion (aOR: 1.16; 95% CI 1.12 to 1.22), Schedule caste social group (aOR: 1.08; 95% CI 1.04 to 1.12), poorest asset quintile (aOR: 1.45; 95% CI 1.38 to 1.53), antenatal care (aOR: 0.69; 95% CI 0.67 to 0.72), no surviving children (aOR: 1.30; 95% CI 1.16 to 1.46), all surviving children being female (aOR: 1.12; 95% CI 1.07 to 1.17), use of family planning methods (aOR: 0.69; 95% CI 0.66 to 0.71). Factors associated with abortion-related deaths: maternal age 15–19 (aOR: 7.79; 95% CI 2.73 to 22.23), rural residence (aOR: 3.28; 95% CI 1.76 to 6.11), Schedule tribe social group (aOR: 4.06; 95% CI 1.39 to 11.87). Conclusion Despite abortion being legal, the high estimated prevalence of unsafe abortion demonstrates a major public health problem in India. Socioeconomic vulnerability and inadequate access to healthcare services combine to leave large numbers of women at risk of unsafe abortion and abortion-related death.
Article
Full-text available
Background Patient gender as well as doctor gender are known to affect doctor-patient interaction during a medical consultation. It is however not known whether an interaction of gender influences antibiotic prescribing. This study examined GP’s prescribing behavior of antibiotics at the first presentation of patients with sore throat symptoms in primary care. We investigated whether GP gender, patient gender and gender concordance have an effect on the GP’s prescribing behavior of antibiotics in protocolled and non-protocolled diagnoses. Methods We analyzed electronic health record data of 11,285 GP practice consultations in the Netherlands in 2013 extracted from the Nivel Primary Care Database. Our primary outcome was the prescription of antibiotics for throat symptoms. Sore throat symptoms were split up in ‘protocolled diagnoses’ and ‘non-protocolled diagnoses’. The association between gender concordance and antibiotic prescription was estimated with multilevel regression models that controlled for patient age and comorbidity. Results Antibiotic prescription was found to be lower among female GPs (OR 0.88, CI 95% 0.67–1.09; p = .265) and female patients (OR 0.93, 95% 0.84–1.02; p = .142), but observed differences were not statistically significant. The difference in prescription rates by gender concordance were small and not statistically significant in non-protocolled consultations (OR 0.92, OR 95% CI: 0.83–1.01; p = .099), protocolled consultations (OR 1.00, OR 95% CI: 0.68–1.32; p = .996) and all GP practice consultations together (OR 0.92, OR 95% CI: 0.82–1.02; p = .118). Within the female GP group, however, gender concordance was associated with reduced prescribing of antibiotics (OR 0.85, OR 95% CI: 0.72–0.99; p = 0.034). Conclusions In this study, female GPs prescribed antibiotics less often than male GPs, especially in consultation with female patients. This study shows that, in spite of clinical guidelines, gender interaction may influence the prescription of antibiotics with sore throat symptoms.
Article
Full-text available
Background: The extent to which reproductive tract infections (RTIs) are associated with poor menstrual hygiene management (MHM) practices has not been extensively studied. We aimed to determine whether poor menstrual hygiene practices were associated with three common infections of the lower reproductive tract; Bacterial vaginosis (BV), Candida, and Trichomonas vaginalis (TV). Methods: Non-pregnant women of reproductive age (18-45 years) and attending one of two hospitals in Odisha, India, between April 2015 and February 2016 were recruited for the study. A standardized questionnaire was used to collect information on: MHM practices, clinical symptoms for the three infections, and socio-economic and demographic information. Specimens from posterior vaginal fornix were collected using swabs for diagnosis of BV, Candida and TV infection. Results: A total of 558 women were recruited for the study of whom 62.4% were diagnosed with at least one of the three tested infections and 52% presented with one or more RTI symptoms. BV was the most prevalent infection (41%), followed by Candida infection (34%) and TV infection (5.6%). After adjustment for potentially confounding factors, women diagnosed with Candida infection were more likely to use reusable absorbent material (aPRR = 1.54, 95%CI 1.2-2.0) and practice lower frequency of personal washing (aPRR = 1.34, 95%CI 1.07-1.7). Women with BV were more likely to practice personal washing less frequently (aPRR = 1.25, 95%CI 1.0-1.5), change absorbent material outside a toilet facility (aPRR = 1.21, 95%CI 1.0-1.48) whilst a higher frequency of absorbent material changing was protective (aPRR = 0.56, 95%CI 0.4-0.75). No studied factors were found to be associated with TV infection. In addition, among women reusing absorbent material, Candida but not BV or TV - infection was more frequent who dried their pads inside their houses and who stored the cloth hidden in the toilet compartment. Conclusion: The results of our study add to growing number of studies which demonstrate a strong and consistent association between poor menstrual hygiene practices and higher prevalence of lower RTIs.
Article
Full-text available
Men living with HIV/AIDS in sub-Saharan Africa are less likely to test for HIV than women. We conducted a scoping review in May of 2016 to identify how masculine norms influence men’s HIV testing in sub-Saharan Africa. Our review yielded a total of 13 qualitative studies from 8 countries. Masculine norms create both barriers and facilitators to HIV testing. Barriers included emotional inexpression, gendered communication, social pressures to be strong and self-reliant, and the fear that an HIV positive result would threaten traditional social roles (i.e., husband, father, provider, worker) and reduce sexual success with women. Facilitators included perceptions that HIV testing could restore masculinity through regained physical strength and the ability to re-assume the provider role after accessing treatment. Across sub-Saharan Africa, masculinity appears to play an important role in men’s decision to test for HIV and further research and interventions are needed to address this link.
Article
Full-text available
Background: Empirical evidence shows that the relationship between health-seeking behaviour and diverse gender elements, such as gendered social status, social control, ideology, gender process, marital status and procreative status, changes across settings. Given the high relevance of social settings, this paper intends to explore how gender elements interact with health-seeking practices among men and women residing in an Indian urban slum, in consideration of the unique socio-cultural context that characterises India's slums. Methods: The study was conducted in Sahid Smriti Colony, a peri-urban slum of Kolkata, India. The referral technique was used for selecting participants, as people in the study area were not very comfortable in discussing their health issues and health-seeking behaviours. The final sample included 66 participants, 34 men and 32 women. Data was collected through individual face-to-face in-depth interviews with a semi-structured questionnaire. Results: The data analysis shows six categories of reasons underlying women's preferences for informal healers, which are presented in the form of the following themes: cultural competency of care, easy communication, gender-induced affordability, avoidance of social stigma and labelling, living with the burden of cultural expectations and geographical and cognitive distance of formal health care. In case of men ease of access, quality of treatment and expected outcome of therapies are the three themes that emerged as the reasons behind their preferences for formal care. Conclusion: Our results suggest that both men and women utilise formal and informal care, but with different motives and expectations, leading to contrasting health-seeking outcomes. These gender-induced contrasts relate to a preference for socio-cultural (women) versus technological (men) therapies and long (women) versus fast (men) treatment, and are linked to their different societal and familial roles. The role of women in following and maintaining socio-cultural norms leads them to focus on care that involves long discussions mixed with socio-cultural traits that help avoid economic and social sanctions, while the role of men as bread earners requires them to look for care that ensures a fast and complete recovery so as to avoid financial pressures.
Article
Full-text available
This commentary examines how specific sustainable development goals (SDGs) are affected by antimicrobial resistance and suggests how the issue can be better integrated into international policy processes. Moving beyond the importance of effective antibiotics for the treatment of acute infections and health care generally, we discuss how antimicrobial resistance also impacts on environmental, social, and economic targets in the SDG framework. The paper stresses the need for greater international collaboration and accountability distribution, and suggests steps towards a broader engagement of countries and United Nations agencies to foster global intersectoral action on antimicrobial resistance.
Article
Full-text available
Autonomy is considered essential for decision-making in a range of health care situations, from health care seeking and utilization to choosing among treatment options. Evidence suggests that women in developing or low-income countries often have limited autonomy and control over their health decisions. A review of the published empirical literature to identify definitions and methods used to measure women’s autonomy in developing countries describe the relationship between women’s autonomy and their health care decision-making, and identify sociodemographic factors that influence women’s autonomy and decision-making regarding health care was carried out. An integrated literature review using two databases (PubMed and Scopus) was performed. Inclusion criteria were 1) publication in English; 2) original articles; 3) investigations on women’s decision-making autonomy for health and health care utilization; and 4) developing country context. Seventeen articles met inclusion criteria, including eleven from South Asia, five from Africa, and one from Central Asia. Most studies used a definition of autonomy that included independence for women to make their own choices and decisions. Study methods differed in that many used study-specific measures, while others used a set of standardized questions from their countries’ national health surveys. Most studies examined women’s autonomy in the context of reproductive health, while neglecting other types of health care utilized by women. Several studies found that factors, including age, education, and income, affect women’s health care decision-making autonomy. Gaps in existing literature regarding women’s autonomy and health care utilization include gaps in the areas of health care that have been measured, the influence of sex roles and social support, and the use of qualitative studies to provide context and nuance.
Article
Full-text available
Background: Caesarean section (CS) rates continue to evoke worldwide concern because of their steady increase, lack of consensus on the appropriate CS rate and the associated additional short- and long-term risks and costs. We present the latest CS rates and trends over the last 24 years. Methods: We collected nationally-representative data on CS rates between 1990 to 2014 and calculated regional and subregional weighted averages. We conducted a longitudinal analysis calculating differences in CS rates as absolute change and as the average annual rate of increase (AARI). Results: According to the latest data from 150 countries, currently 18.6% of all births occur by CS, ranging from 6% to 27.2% in the least and most developed regions, respectively. Latin America and the Caribbean region has the highest CS rates (40.5%), followed by Northern America (32.3%), Oceania (31.1%), Europe (25%), Asia (19.2%) and Africa (7.3%). Based on the data from 121 countries, the trend analysis showed that between 1990 and 2014, the global average CS rate increased 12.4% (from 6.7% to 19.1%) with an average annual rate of increase of 4.4%. The largest absolute increases occurred in Latin America and the Caribbean (19.4%, from 22.8% to 42.2%), followed by Asia (15.1%, from 4.4% to 19.5%), Oceania (14.1%, from 18.5% to 32.6%), Europe (13.8%, from 11.2% to 25%), Northern America (10%, from 22.3% to 32.3%) and Africa (4.5%, from 2.9% to 7.4%). Asia and Northern America were the regions with the highest and lowest average annual rate of increase (6.4% and 1.6%, respectively). Conclusion: The use of CS worldwide has increased to unprecedented levels although the gap between higher- and lower-resource settings remains. The information presented is essential to inform policy and global and regional strategies aimed at optimizing the use of CS.
Article
Full-text available
Numerous studies have documented a relationship between masculine norms and men's HIV-related sexual behaviors, but intervening upon this relationship requires a nuanced understanding of the specific aspects of masculine norms that shape men's sexual behaviors. We integrate theories on masculinities with empirical HIV research to identify specific dimensions of masculine norms that influence men's HIV-related sexual behaviors. We identify three major dimensions of masculine norms that shape men's sexual behavior: (1) uncontrollable male sex drive, (2) capacity to perform sexually, and (3) power over others. While the existing literature does help explain the relationship between masculine norms and men's sexual behaviors several gaps remain including: a recognition of context-specific masculinities, an interrogation of the positive influences of masculinity, adoption of an intersectional approach, assessment of changes in norms and behaviors over time, and rigorous evaluations of gender-transformative approaches. Addressing these gaps in future research may optimize prevention efforts.
Article
Full-text available
Menstrual hygiene management (MHM) practices vary worldwide and depend on the indi-vidual's socioeconomic status, personal preferences, local traditions and beliefs, and access to water and sanitation resources. MHM practices can be particularly unhygienic and inconvenient for girls and women in poorer settings. Little is known about whether unhygienic MHM practices increase a woman's exposure to urogenital infections, such as bacterial vaginosis (BV) and urinary tract infection (UTI). This study aimed to determine the association of MHM practices with urogenital infections, controlling for environmental drivers. A hospital-based case-control study was conducted on 486 women at Odisha, India. Cases and controls were recruited using a syndromic approach. Vaginal swabs were collected from all the participants and tested for BV status using Amsel's criteria. Urine samples were cultured to assess UTI status. Socioeconomic status, clinical symptoms and reproductive history, and MHM and water and sanitation practices were obtained by stan-dardised questionnaire. A total of 486 women were recruited to the study, 228 symptomatic cases and 258 asymptomatic controls. Women who used reusable absorbent pads were more likely to have symptoms of urogenital infection (AdjOR=2.3, 95%CI1.5-3.4) or to be diagnosed with at least one urogenital infection (BV or UTI) (AdjOR=2.8, 95%CI1.7-4.5), than women using disposable pads. Increased wealth and space for personal hygiene in the household were protective for BV (AdjOR=0.5, 95%CI0.3-0.9 and AdjOR=0.6, 95% CI0.3-0.9 respectively). Lower education of the participants was the only factor associated with UTI after adjusting for all the confounders (AdjOR=3.1, 95%CI1.2-7.9). Interventions that ensure women have access to private facilities with water for MHM and that educate women about safer, low-cost MHM materials could reduce urogenital disease among women. Further studies of the effects of specific practices for managing hygienically
Article
Full-text available
Protecting women’s sexual freedom has evolved as a modern value through a long process of social, economic, and institutional changes brought about by the ascend of human rights principles and societal engagements such as the feminist movement. We suggest that the concept of sexual freedom accommodates a more encompassing expression of the simultaneous demand for all aspects of personal, socioeconomic, and political resources related to the pursuit of women’s well-being. The purpose of this study is to develop a construct of women’s sexual freedom in the Mexican context. The data are from the National Survey on the Dynamics of Households Relationships, 2011. We use exploratory and confirmatory factor analysis to model women’s sexual freedom and test for invariance between working and non-working women. Results indicate that women’s sexual freedom consists of four factors: reproductive rights, physical intimate partner violence, sexual intimate partner violence, and violence inflicted by others.
Article
Full-text available
Background: Data for the causes of maternal deaths are needed to inform policies to improve maternal health. We developed and analysed global, regional, and subregional estimates of the causes of maternal death during 2003-09, with a novel method, updating the previous WHO systematic review. Methods: We searched specialised and general bibliographic databases for articles published between between Jan 1, 2003, and Dec 31, 2012, for research data, with no language restrictions, and the WHO mortality database for vital registration data. On the basis of prespecified inclusion criteria, we analysed causes of maternal death from datasets. We aggregated country level estimates to report estimates of causes of death by Millennium Development Goal regions and worldwide, for main and subcauses of death categories with a Bayesian hierarchical model. Findings: We identified 23 eligible studies (published 2003-12). We included 417 datasets from 115 countries comprising 60 799 deaths in the analysis. About 73% (1 771 000 of 2 443 000) of all maternal deaths between 2003 and 2009 were due to direct obstetric causes and deaths due to indirect causes accounted for 27·5% (672 000, 95% UI 19·7-37·5) of all deaths. Haemorrhage accounted for 27·1% (661 000, 19·9-36·2), hypertensive disorders 14·0% (343 000, 11·1-17·4), and sepsis 10·7% (261 000, 5·9-18·6) of maternal deaths. The rest of deaths were due to abortion (7·9% [193 000], 4·7-13·2), embolism (3·2% [78 000], 1·8-5·5), and all other direct causes of death (9·6% [235 000], 6·5-14·3). Regional estimates varied substantially. Interpretation: Between 2003 and 2009, haemorrhage, hypertensive disorders, and sepsis were responsible for more than half of maternal deaths worldwide. More than a quarter of deaths were attributable to indirect causes. These analyses should inform the prioritisation of health policies, programmes, and funding to reduce maternal deaths at regional and global levels. Further efforts are needed to improve the availability and quality of data related to maternal mortality.
Article
Full-text available
Background: Self-medication with antibiotics is an important factor contributing to the development of bacterial antibiotic resistance. The purpose of this study was to evaluate the prevalence of self-medication with antibiotics for the treatment of menstrual symptoms among university women in Southwest Nigeria. Methods: A cross-sectional survey was administered to female undergraduate and graduate students (n = 706) at four universities in Southwest Nigeria in 2008. The universities were selected by convenience and the study samples within each university were randomly selected cluster samples. The survey was self-administered and included questions pertaining to menstrual symptoms, analgesic and antibiotic use patterns, and demographics. Data were analyzed using descriptive statistics and logistic regression. Results: The response rate was 95.4%. Eighty-six percent (95% CI: 83-88%) of participants experienced menstrual symptoms, and 39% (95% CI: 36-43%) reported using analgesics to treat them. Overall, 24% (95% CI: 21-27%) of participants reported self-medicated use of antibiotics to treat the following menstrual symptoms: cramps, bloating, heavy bleeding, headaches, pimples/acne, moodiness, tender breasts, backache, joint and muscle pain. Factors associated with this usage were: lower levels of education (Odds Ratio (OR): 2.8, 95% CI: 1.1-7.1, p-value: 0.03); non-science major (OR: 1.58, 95% CI: 1.03-2.50, p-value: 0.04); usage of analgesics (OR: 3.17, 95% CI: 2.07-4.86, p-value: <0.001); and mild to extreme heavy bleeding (OR: 1.64, 95% CI: 1.01-2.67, p-value: 0.05) and pimples/acne (OR: 1.57, 95% CI: 0.98-2.54, p-value: 0.06). Ampicillin, tetracycline, ciprofloxacin and metronidazole were used to treat the most symptoms. Doctors or nurses (6%, 95% CI: 4-7%), friends (6%, 95% CI: 4-7%) and family members (7%, 95% CI: 5-8%) were most likely to recommend the use of antibiotics for menstrual symptoms, while these drugs were most often obtained from local chemists or pharmacists (10.2%, 95% CI: 8-12%). Conclusions: This is the first formal study to report that approximately 1 out of 4 university women surveyed in Southwest Nigeria self-medicate with antibiotics to treat menstrual symptoms. This practice could provide monthly, low-dose exposures to antibiotics among users. Further studies are necessary to evaluate the impacts of self-medication on student health.
Article
Full-text available
Excessive alcohol consumption predisposes the host to a wide range of infectious complications, particularly pulmonary infections. Factors that contribute to the development of pulmonary infections in alcohol-abusing patients include dysfunction of the protective barriers in the respiratory tract, aspiration of oropharyngeal contents, nutritional deficiencies, liver disease, and impairment of host defense mechanisms. This review discusses the complex host-pathogen interactions in the airways with an emphasis on how alcohol consumption adversely affects these mechanisms and predisposes the host to infections. Potential immunomodulatory strategies for enhancing host defense function in alcohol-consuming patients are also discussed.
Article
Full-text available
Women requesting abortion are at increased risk of developing RTI complications. However, RTI control in many resource-poor countries including Vietnam have been faced with logistical and methodological problems due to lack of standardized definitions of RTIs, lack of well-validated diagnostic criteria, lack of accurate laboratory tests, and lack of diagnostic equipment and skills. This article investigates the prevalence of RTIs among Vietnamese abortion-seeking women, to evaluate the available diagnostic techniques, and to assess antibiotic resistance among aetiological agents of RTI. The study was conducted in Phu-San hospital (PSH) from December 2003 through April 2004 among 748 abortion clients. A structured questionnaire was used to collect data on socio-economic and reproductive characteristics. Specimens were collected for laboratory analyses of chlamydia, gonorrhoea, trichomoniasis, vaginal candidiasis (VC), bacterial vaginosis (BV) and syphilis. To assess the validity of the obtained results, the study was repeated among 100 women and the duplicate samples were analysed at PSH and Copenhagen University Hospital (CUH). In all 54% of the women were diagnosed as having an RTI, including 3.3% with sexually transmitted infections. Endogenous infections were most prevalent (VC 34% and BV 12%) followed by chlamydia (1.3%) and trichomoniasis (0.7%). The sensitivity of culture for VC and BV was 30% and 88%, respectively, when tests in PSH were measured against tests in CUH. Antibiotic resistance was common among bacterial isolates. RTIs are common among women seeking abortion. The presence of RTIs is associated with an increased risk of developing iatrogenic infections, routine administration of prophylactic antibiotic to all women undergoing abortion should be considered. However, the choice of routine prophylactic antibiotics should be based on relevant surveillance data of antibiotic resistance. Moreover, since the accuracy of diagnosis is doubtful and to address the problem of under-diagnosed and treated RTIs new investment in diagnostic facilities with simple performed microscopy or improved rapid tests should also be taken into consideration.
Article
Antibiotics have substantially improved life expectancy in past decades through direct control or prevention of infections. However, emerging antibiotic resistance and lack of access to effective antibiotics have significantly increased the death toll from infectious diseases, making it one of the biggest threats to global health. Addressing the antibiotic crisis to meet future needs require considerable investment in both research and development along with ensuring a viable marketplace to encourage innovation. Fortunately, there has been some improvement in the number of antibiotics approved or in different phases of development through collective global efforts. However, the universal access to these essential novel and generic antibiotics, especially in low- and middle-income countries (LMICs), is challenged by poor economic incentives, regulatory hurdles and poor health infrastructure. Recently, the agenda of securing and expanding access has gained global attention. Several mechanisms are now being proposed and implemented to improve access to essential antibiotics. This review provides an insight into the major barriers to antibiotic access as well as the models proposed and implemented to mitigate accessibility issues. These models include but are not limited to market entry rewards, subscription models and transferable exclusivity vouchers. Further, global access programmes including, Global Antibiotic Research and Development Partnership, Antimicrobial Resistance Action Fund and SECURE Platform are discussed. We also propose the way forward for improving access in LMICs with suggested measures to improve access to generic and novel antibiotics.
Chapter
The effectiveness of antibiotics is getting increasingly outweighed by antimicrobial resistance (AMR) arising from indiscriminate antibiotic use in humans and livestock. If AMR remains unchecked, by 2050, it will adversely affect ten million lives annually and trigger economic losses surmounting those faced in 2008 global economic crisis. According to WHO analysis, over 50% of all medicines, including antibiotics, are unnecessarily prescribed and used. The adverse effects of antibiotics in pregnancy are less researched due to the vulnerability of this stage of the lifecycle. However, their use in pregnancy is not uncommon. The main conditions for which antibiotics are misused in pregnancy include prophylaxis in cesarean section and operational vaginal delivery, prevention of neonatal streptococcal sepsis, prevention of preterm birth, chorioamnionitis, urinary tract and genital infections. Inappropriate use of antibiotics during pregnancy has short- and long-term consequences, the latter less investigated. Antibiotic use in pregnancy is known to alter mother’s and neonate’s microbiome affecting immune and metabolic functions later in life. Negative effects such as neurologic disorders, obesity, asthma, allergy and infections during childhood, and AMR in children, resulting from inappropriate use of antibiotics in pregnancy, have been observed in several research. One critical step in improving the correct usage of antibiotics and other medication in general and among pregnant women is to integrate rational antibiotic use in medical undergraduate training. This along with rigorous implementation of antimicrobial stewardship program in all health facilities and other strategic objectives of the National Action Plan on AMR has the potential to optimize the use of antibiotics in pregnancy and other stages of the lifecycle.KeywordsAntimicrobial resistanceAntibiotic stewardship programInfection preventionPregnancyRational use of antibiotics
Article
This paper evaluates an intervention in India that engaged adolescent girls and boys in classroom discussions about gender equality for two years, aiming to reduce their support for societal norms that restrict women's and girls' opportunities. Using a randomized controlled trial, we find that the program made attitudes more supportive of gender equality by 0.18 standard deviations, or, equivalently, converted 16 percent of regressive attitudes. When we resurveyed study participants two years after the intervention had ended, the effects had persisted. The program also led to more gender-equal self-reported behavior, and we find weak evidence that it affected two revealed-preference measures. (JEL D63, D91, I21, J13, J16, 012)
Article
Despite global commitments to achieving gender equality and improving health and wellbeing for all, quantitative data and methods to precisely estimate the effect of gender norms on health inequities are underdeveloped. Nonetheless, existing global, national, and subnational data provide some key opportunities for testing associations between gender norms and health. Using innovative approaches to analysing proxies for gender norms, we generated evidence that gender norms impact the health of women and men across life stages, health sectors, and world regions. Six case studies showed that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be contextspecific, demanding care when designing effective gender-transformative health policies and programmes. Limitations of survey-based data are described that resulted in missed opportunities for investigating certain populations and domains. Recommendations for optimising and advancing research on the health impacts of gender norms are made.
Article
Gender is not accurately captured by the traditional male and female dichotomy of sex. Instead, it is a complex social system that structures the life experience of all human beings. This paper, the first in a Series of five papers, investigates the relationships between gender inequality, restrictive gender norms, and health and wellbeing. Building upon past work, we offer a consolidated conceptual framework that shows how individuals born biologically male or female develop into gendered beings, and how sexism and patriarchy intersect with other forms of discrimination, such as racism, classism, and homophobia, to structure pathways to poor health. We discuss the ample evidence showing the far-reaching consequences of these pathways, including how gender inequality and restrictive gender norms impact health through differential exposures, health-related behaviours and access to care, as well as how gender-biased health research and health-care systems reinforce and reproduce gender inequalities, with serious implications for health. The cumulative consequences of structured disadvantage, mediated through discriminatory laws, policies, and institutions, as well as diet, stress, substance use, and environmental toxins, have triggered important discussions about the role of social injustice in the creation and maintenance of health inequities, especially along racial and socioeconomic lines. This Series paper raises the parallel question of whether discrimination based on gender likewise becomes embodied, with negative consequences for health. For decades, advocates have worked to eliminate gender discrimination in global health, with only modest success. A new plan and new political commitment are needed if these global health aspirations and the wider Sustainable Development Goals of the UN are to be achieved.
Article
Males and females differ in their immunological responses to foreign and self-antigens and show distinctions in innate and adaptive immune responses. Certain immunological sex differences are present throughout life, whereas others are only apparent after puberty and before reproductive senescence, suggesting that both genes and hormones are involved. Furthermore, early environmental exposures influence the microbiome and have sex-dependent effects on immune function. Importantly, these sex-based immunological differences contribute to variations in the incidence of autoimmune diseases and malignancies, susceptibility to infectious diseases and responses to vaccines in males and females. Here, we discuss these differences and emphasize that sex is a biological variable that should be considered in immunological studies.
Article
Objectives: Determinants of inappropriate antibiotic prescription in the community are not clearly defined. The objective of this study was to perform a systematic review and meta-analysis evaluating gender differences in antibiotic prescribing in primary care. Methods: All studies analysing antibiotic prescription in primary care were eligible. PubMed and MEDLINE entries with publication dates from 1976 until December 2013 were searched. The primary outcomes were the incidence rate ratio (IRR) (measured as DDD/1000 inhabitants/day) and the prevalence rate ratio (PRR) (measured as prevalence rate/1000 inhabitants) of antimicrobial prescription, stratified by gender, age and antibiotic class. Random-effects estimates of the IRR and PRR and standard deviations were calculated. Results: Overall, 576 articles were reviewed. Eleven studies, comprising a total of 44 333 839 individuals, were included. The studies used data from prospective national (five studies) or regional (six studies) surveillance of community pharmacy, insurance or national healthcare systems. Women were 27% (PRR 1.27 ± 0.12) more likely than men to receive an antibiotic prescription in their lifetimes. The amount of antibiotics prescribed to women was 36% (IRR 1.36 ± 0.11) higher than that prescribed for men in the 16 to 34 years age group and 40% (IRR 1.40 ± 0.03) greater in the 35 to 54 years age group. In particular, the amounts of cephalosporins and macrolides prescribed to women were 44% (IRR 1.44 ± 0.30) and 32% (IRR 1.32 ± 0.15) higher, respectively, than those prescribed for men. Conclusions: This meta-analysis shows that women in the 16 to 54 years age group receive a significantly higher number of prescriptions of cephalosporins and macrolides in primary care than men do. Prospective studies are needed to address reasons for gender inequality in prescription and to determine whether a difference in adverse events, including resistance development, also occurs.
Article
Urinary tract infection (UTI) constitutes a major health problem in pregnant women due to their relatively short urethra, which promotes the ascending of the pathogens to the bladder, urethra and the kidneys. It is also more common in pregnant women due to the anatomical and physiological changes that occur during pregnancy. Aim: To determine the incidence of Urinary Tract Infections and the antimicrobial susceptibility of the microbial isolates from the urine samples of pregnant women prior to treatment. Methods: Fifty (50) mid stream urine (MSU) samples were collected and analyzed using standard Microbiological Techniques, and the antimicrobial sensitivity tests determined using Kirby Bauer disc diffusion techniques. Results: Of the 50 urine samples obtained from pregnant women, 3 different microbes were isolated indicating 28%. Staphylococcus aureus 18%, Escherichia coli 8%, Candida albicans 4%; and a 2% co-infection of Candida albicans and Staphylococcus aureus. Staphylococcus aureus and Escherichia coli were highly sensitive to Ciprofloxacin, Ofloxacin (Cilox), Paflacin and Cephalosporine. Conclusion: Undetected and untreated urinary tract infection in pregnancy leads to discomfort associated with abdominal pains, itching, vaginal discharge and dysuria which may lead to more serious medical complications. Keywords: Microbial isolates; pregnant women; anti-microbial susceptibility; microbiological techniques; Disc diffusion.
Article
Chronic alcohol abuse exacts a major social and medical toll in the United States and other Western countries. One of the least appreciated medical complications of alcohol abuse is altered immune regulation leading to immunodeficiency and autoimmunity. The consequences of the immunodeficiency include increased susceptibility to bacterial pneumonia, tuberculosis, and other infectious diseases. In addition, the chronic alcoholic often has circulating autoantibodies, and recent investigations indicate that the most destructive complications of alcoholism, such as liver disease and liver failure, may have a component of autoimmunity. Current research on altered cytokine balance produced by alcohol is leading to new insights on the regulation of the immune system in the chronic alcoholic. There is also recent development of exciting new techniques designed to improve or restore immune function by manipulation of cytokine balance. Although much remains to be learned, both in the abnormalities produced by alcohol and in the techniques to reverse those abnormalities, current progress reflects a rapidly improving understanding of the basic immune disorders of the alcoholic.
Article
To examine inappropriate antibiotic prescribing for acute respiratory tract infections (RTIs) in ambulatory care to help target antimicrobial stewardship interventions. Design and Setting Retrospective analysis of RTI visits within general internal medicine (GIM) and family medicine (FM) ambulatory practices at an inner-city academic medical center from 2008 to 2010. Patient, physician, and practice characteristics were analyzed using multivariable logistic regression to determine factors predictive of inappropriate prescribing; physicians in the highest and lowest antibiotic-prescribing quartiles were compared using χ2 analysis. Visits with FM providers, female gender, and self-reported race/ethnicity as white or Hispanic were significantly associated with inappropriate antibiotic prescribing. Physicians in the lowest quartile prescribed antibiotics for 5%-28% (mean, 21%) of RTI visits; physicians in the highest quartile prescribed antibiotics for 54%-85% (mean, 65%) of RTI visits. High prescribers had fewer African-American patients and more patients who were younger and privately insured. High prescribers had more patients with chronic lung disease. A GIM practice pod with a low prescriber was 3.0 times more likely to have a second low prescriber than other practice pods, whereas pods with a high prescriber were 1.3 times more likely to have a second high prescriber. Medical specialty was the only physician factor predictive of inappropriate prescribing when patient gender, race, and comorbidities were taken into account. Possible disparities in care need further study. Stewardship education in medical school, enlisting low prescribers as physician leaders, and targeting interventions to the highest prescribers might be more effective approaches to antimicrobial stewardship. Infect Control Hosp Epidemiol 2014;00(0): 1-7.
Article
The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Similarities with climate change are evident. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally. Antibiotics paved the way for unprecedented medical and societal developments, and are today indispensible in all health systems. Achievements in modern medicine, such as major surgery, organ transplantation, treatment of preterm babies, and cancer chemotherapy, which we today take for granted, would not be possible without access to effective treatment for bacterial infections. Within just a few years, we might be faced with dire setbacks, medically, socially, and economically, unless real and unprecedented global coordinated actions are immediately taken. Here, we describe the global situation of antibiotic resistance, its major causes and consequences, and identify key areas in which action is urgently needed.
Article
Infectious diseases and especially diarrheal diseases have been noted to have an adverse effect on the growth of underprivileged children in developing countries. Diarrheal diseases have been estimated to account for 10-80% of growth retardation in the first few years of life, with the magnitude of effect possibly modified by other factors, such as the adequacy and source of dietary intake, treatment and feeding practices during and following illness and the opportunity for catch-up growth after illness. In the only study in which infectious diseases and routine dietary intake have been evaluated simultaneously, inadequate dietary intake rather than infectious diseases, was found to have the predominant role in growth faltering. Although reduction in infectious diseases is desirable for many reasons, the relative feasibility and cost of this approach to improve nutritional status must be compared with more direct nutrition interventions.
Article
The percentage of faecal samples containing resistant Echerichia coli and the proportion of resistant faecal E. coli were determined in three poultry populations: broilers and turkeys commonly given antibiotics, and laying hens treated with antibiotics relatively infrequently. Faecal samples of five human populations were also examined: turkey farmers, broiler farmers, laying-hen farmers, broiler slaughterers and turkey slaughterers. The MICs of antibiotics commonly used in poultry medicine were also determined. Ciprofloxacin-resistant isolates from these eight populations and from turkey meat were genotyped by pulsed-field gel electrophoresis (PFGE) after SmaI digestion. The proportion of samples containing resistant E. coli and the percentages of resistant E. coli were significantly higher in turkeys and broilers than in the laying-hen population. Resistance to nearly all antibiotics in faecal E. coli of turkey and broiler farmers, and of turkey and broiler slaughterers, was higher than in laying-hen farmers. Multiresistant isolates were common in turkey and broiler farmers but absent in laying-hen farmers. The same resistance patterns were found in turkeys, turkey farmers and turkey slaughterers and in broiler, broiler farmers and broiler slaughterers. The PFGE patterns of the isolates from the eight populations were quite heterogeneous, but E. coli with an identical PFGE pattern were isolated at two farms from a turkey and the farmer, and also from a broiler and a broiler farmer from different farms. Moreover, three E. coli isolates from turkey meat were identical to faecal isolates from turkeys. The results of this study strongly indicate that transmission of resistant clones and resistance plasmids of E. coli from poultry to humans commonly occurs.
Article
This article examines the role of the sex composition of surviving older siblings on gender differences in childhood nutrition and immunization, using data from the National Family Health Survey, India (1992-1993). Logit and ordered logit models were used for severe stunting and immunization, respectively. The results show selective neglect of children with certain sex and birth-order combinations that operate differentially for girls and boys. Both girls and boys who were born after multiple same-sex siblings experience poor outcomes, suggesting that parents want some balance in sex composition. However, the preference for sons persists, and boys who were born after multiple daughters have the best possible outcomes.
Article
This study was conducted to identify reasons why women had unprotected intercourse that led to an unintended pregnancy. As part of the Pregnancy Risk Assessment Monitoring System (PRAMS) survey, women with a recent unintended viable pregnancy were asked after the birth why they had not used birth control. Of 7856 respondents, 33% felt they could not get pregnant at the time of conception, 30% did not really mind if they got pregnant, 22% stated their partner did not want to use contraception, 16% cited side effects, 10% felt they or their partner were sterile, 10% cited access problems and 18% selected "other." Latent class analysis showed seven patterns of response, each identifying strongly with a single reason. Almost half of women with viable unintended pregnancies ending in a birth felt they could not/would not get pregnant at the time of conception. Most women identified with a single reason for having unprotected intercourse.
Article
When choosing a contraception method, women base their decisions on their subjective expectations about the realizations of method-related outcomes. Examples of outcomes include getting pregnant and contracting a sexually transmitted disease (STD). I combine innovative data on probabilistic expectations with observed contraceptive choices to estimate a random utility model of birth control choice. The availability of expectations data is essential to identify preferences from beliefs. Effectiveness, protection against STDs, and partner's disapproval are found to be the most important factors in the decision process. The elicited expectations and inferred preference parameters are used to simulate the impact of various policies. Copyright © 2008 the Economics Department of the University of Pennsylvania and the Osaka University Institute of Social and Economic Research Association.