[Show abstract][Hide abstract] ABSTRACT: Transactional sex is associated with increased risk of HIV and gender based violence in southern Africa and around the world. However the typical quantitative operationalization, "the exchange of gifts or money for sex," can be at odds with a wide array of relationship types and motivations described in qualitative explorations. To build on the strengths of both qualitative and quantitative research streams, we used cultural consensus models to identify distinct models of transactional sex in Swaziland. The process allowed us to build and validate emic scales of transactional sex, while identifying key informants for qualitative interviews within each model to contextualize women's experiences and risk perceptions. We used logistic and multinomial logistic regression models to measure associations with condom use and social status outcomes. Fieldwork was conducted between November 2013 and December 2014 in the Hhohho and Manzini regions. We identified three distinct models of transactional sex in Swaziland based on 124 Swazi women's emic valuation of what they hoped to receive in exchange for sex with their partners. In a clinic-based survey (n = 406), consensus model scales were more sensitive to condom use than the etic definition. Model consonance had distinct effects on social status for the three different models. Transactional sex is better measured as an emic spectrum of expectations within a relationship, rather than an etic binary relationship type. Cultural consensus models allowed us to blend qualitative and quantitative approaches to create an emicly valid quantitative scale grounded in qualitative context.
Full-text · Article · Nov 2015 · Social Science [?] Medicine
[Show abstract][Hide abstract] ABSTRACT: To estimate the absolute wealth of households using data from demographic and health surveys.
We developed a new metric, the absolute wealth estimate, based on the rank of each surveyed household according to its material assets and the assumed shape of the distribution of wealth among surveyed households. Using data from 156 demographic and health surveys in 66 countries, we calculated absolute wealth estimates for households. We validated the method by comparing the proportion of households defined as poor using our estimates with published World Bank poverty headcounts. We also compared the accuracy of absolute versus relative wealth estimates for the prediction of anthropometric measures.
The median absolute wealth estimates of 1 403 186 households were 2056 international dollars per capita (interquartile range: 723-6103). The proportion of poor households based on absolute wealth estimates were strongly correlated with World Bank estimates of populations living on less than 2.00 United States dollars per capita per day (R(2) = 0.84). Absolute wealth estimates were better predictors of anthropometric measures than relative wealth indexes.
Absolute wealth estimates provide new opportunities for comparative research to assess the effects of economic resources on health and human capital, as well as the long-term health consequences of economic change and inequality.
Full-text · Article · Jul 2015 · Bulletin of the World Health Organisation
[Show abstract][Hide abstract] ABSTRACT: Contemporary human populations conform to ecogeographic predictions that animals will become more compact in cooler climates and less compact in warmer ones. However, it remains unclear to what extent this pattern reflects plastic responses to current environments or genetic differences among populations. Analyzing anthropometric surveys of 232,684 children and adults from across 80 ethnolinguistic groups in sub-Saharan Africa, Asia and the Americas, we confirm that body surface-to-volume correlates with contemporary temperature at magnitudes found in more latitudinally diverse samples (Adj. R2 = 0.14-0.28). However, far more variation in body surface-to-volume is attributable to genetic population structure (Adj. R2 = 0.50-0.74). Moreover, genetic population structure accounts for nearly all of the observed relationship between contemporary temperature and body surface-to-volume among children and adults. Indeed, after controlling for population structure, contemporary temperature accounts for no more than 4% of the variance in body form in these groups. This effect of genetic affinity on body form is also independent of other ecological variables, such as dominant mode of subsistence and household wealth per capita. These findings suggest that the observed fit of human body surface-to-volume with current climate in this sample reflects relatively large effects of existing genetic population structure of contemporary humans compared to plastic response to current environments.
[Show abstract][Hide abstract] ABSTRACT: Food insecurity has traditionally been characterized as a driver of health disparities because of its potential impacts on nutritional status. Food, however, has important social and cultural valences that make it much more than a nutritional vehicle. Recent research that is sensitive to the social meanings of food has drawn attention to the complex and far-reaching mental and social health effects of food insecurity. In this article, we outline several theoretical pathways linking food insecurity to reduced physical and mental well-being, and then present results of a preliminary study in rural Brazil designed to test the relative importance of each of these pathways. Our results tentatively suggest that in this context, food insecurity is closely related to both mental and physical health disparities, but the pathways connecting food insecurity and mental health remain somewhat unclear. We present lessons learned and propose a set of research steps to further address the relationships between the social meaning of food and mental health.
[Show abstract][Hide abstract] ABSTRACT: Task shifting in response to the health workforce shortage has resulted in community-based health workers taking on increasing responsibility. Community health workers are expected to work collaboratively, though they are often a heterogeneous group with a wide range of training and experience. Interpersonal relationships are at the very core of effective teamwork, yet relational variables have seldom been the focus of health systems research in low resource, rural settings. This article helps fill this knowledge gap by exploring the dyadic level, or relational, characteristics of community maternal and newborn health workers and the individual and collective influence of these characteristics on interaction patterns. Network data were collected from community health workers (N ¼ 194) in seven rural kebeles of Amhara region, Ethiopia from November 2011 to January 2012. Multiple Regression Quadratic Assignment Procedure was used to fit regression models for frequency of work interactions, a proxy for teamwork. Strong and consistent evidence was found in support of Trust and Past training together as important relational factors for work interactions; less consistent evidence was found across sites in support of Homophily, Distance and Shared motivations. Our findings also point to a typology of network structure across sites, where one set of networks was characterized by denser and stronger health worker ties relative to their counterparts. Our results suggest that the development of interventions that promote trust and incorporate cross-cadre training is an important step in encouraging collective action. Moreover, assessing the structure of health worker networks may be an effective means of evaluating health systems strengthening efforts in rural, low-resource settings.
Full-text · Article · Oct 2014 · Health Policy and Planning
[Show abstract][Hide abstract] ABSTRACT: Worldwide, a shortage of skilled health workers has prompted a shift toward community-based health workers taking on greater responsibility in the provision of select maternal and newborn health services. Research in mid- and high-income settings suggests that coworker collaboration increases productivity and performance. A major gap in this research, however, is the exploration of factors that influence teamwork among diverse community health worker cadres in rural, low-resource settings. The purpose of this study is to examine how sociodemographic and structural factors shape teamwork among community-based maternal and newborn health workers in Ethiopia.
A cross-sectional survey was conducted with health extension workers, community health development agents, and traditional birth attendants in 3 districts of the West Gojam Zone in the Amhara region of Ethiopia. Communities were randomly selected from Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) sites; health worker participants were recruited using a snowball sampling strategy. Fractional logit modeling and average marginal effects analyses were carried out to identify the influential factors for frequency of work interactions with each cadre.
One hundred and ninety-four health workers participated in the study. A core set of factors-trust in coworkers, gender, and cadre-were influential for teamwork across groups. Greater geographic distance and perception of self-interested motivations were barriers to interactions with health extension workers, while greater food insecurity (a proxy for wealth) was associated with increased interactions with traditional birth attendants.
Interventions that promote trust and gender sensitivity and improve perceptions of health worker motivations may help bridge the gap in health services delivery between low- and high-resource settings. Inter-cadre training may be one mechanism to increase trust and respect among diverse health workers, thereby increasing collaboration. Large-scale, longitudinal research is needed to understand how changes in trust, gender norms, and perceptions of motivations influence teamwork over time.
Full-text · Article · Mar 2014 · Journal of midwifery & women's health
[Show abstract][Hide abstract] ABSTRACT: Insecure access to food and water are experienced by millions of people around the world. Not only does insecure access to food and water represent a violation of basic human rights, it is a major threat to the physical and mental health of individuals and communities. There is, therefore, great need for tools to identify those who are food and water insecure and the severity of their insecurity. We argue here that measures of food and water insecurity must not only reflect biological requirements but also the biocultural nature of food and water needs. In this paper, we present case studies from Tanzania and Bolivia that detail the steps used to adapt or create experience-based measures and validate these measures using a suite of established approaches. We also show that, by broadening our understanding of insecurity to include respondents' experiences, the full range of health impacts-including psychosocial stress and mental health-become apparent. We conclude by noting limitations of the biocultural approach and offer suggestions for future research.
Full-text · Article · Dec 2013 · Human organization
[Show abstract][Hide abstract] ABSTRACT: This paper explores the expected outcome of maternal nutritional "buffering," namely that children's diets will be more adequate than mothers' diets under conditions of food scarcity. Data on Amazonian mothers and their children, household demography and economics and direct, weighed measures of household food availability and dietary intakes of mother-child pairs were collected from 51 households to address the following research questions: (1) is there evidence of food scarcity in this setting?; (2) are there differences in energy and protein adequacy between children and their mothers?; and, (3) which individual and household-level factors are associated with these mother-child differences in energy and protein adequacy? In this context of food scarcity, we found that the majority of children had more adequate energy (p < 0.001) and protein (p < 0.001) intakes than their mothers. Multivariate OLS regression models showed that of the individual-level factors, child age and height-for-age were negatively associated with maternal-child energy and protein inequalities while maternal reproductive status (lactation) was positively associated with energy inequality. While there were no gender differences in dietary adequacy among children, boys had a larger advantage over their mothers in terms of protein adequacy than girls. Household food availability was related to maternal-child energy and protein inequalities in a curvilinear fashion with the lowest inequalities found in households with extremely low food availability and those with adequate food resources. This is the first study to quantify maternal-child dietary inequalities in a setting of food scarcity and demonstrates the importance of the household context and individual characteristics in understanding the degree to which mothers protect their children from resource scarcity.
Full-text · Article · Nov 2013 · Social Science [?] Medicine
[Show abstract][Hide abstract] ABSTRACT: Research on trust, and its influence on teamwork, among health workers in low-resource settings has been understudied. We, therefore, undertook a formative study of trust among three diverse cadres of frontline health workers in Amhara region, Ethiopia. We aimed to develop a comprehensive description of trust in this setting and generate a tool to measure levels of trust within and between cadres. In-depth interviews with 30 frontline workers uncovered a core set of items that seem to define trust in this setting (character/ability/communication), including novel conceptualizations (oneness). Twenty-five items developed from formative data were pilot tested with 92 health workers. The final 10-item scale exhibited strong internal consistency across cadres (alpha>0.83).
In support of criterion validity, the scale was positively associated with the sense-of-team scale (p<0.001) and accounted for greater variance in health workers’ sense-of-team (Adj.R2 =0.67) than did a composite of single trust items (Adj.R2=0.28). For contrasting group validity, respondents had greater within-group agreement compared to between-group agreement on trust items and displayed higher competence in answering questions about their own cadre. Results demonstrate that the Rural Health Worker Trust Scale can be validly and reliably used to measure trust among diverse cadres. The scale may be used to develop and evaluate trust-building
interventions that aim to encourage and sustain collaboration among heterogeneous frontline workers.
Full-text · Article · Sep 2013 · Human organization
[Show abstract][Hide abstract] ABSTRACT: Although many studies showed that adolescent food insecurity is a pervasive phenomenon in Southwest Ethiopia, its effect on the linear growth of adolescents has not been documented so far. This study therefore aimed to longitudinally examine the association between food insecurity and linear growth among adolescents.
Methods: Data for this study were obtained from a longitudinal survey of adolescents conducted in Jimma Zone, which followed an initial sample of 2084 randomly selected adolescents aged 13-17 years. We used linear mixed effects model for 1431 adolescents who were interviewed in three survey rounds one year apart to compare the effect of food insecurity on linear growth of adolescents.
Results: Overall, 15.9% of the girls and 12.2% of the boys (P=0.018) were food insecure both at baseline and on the year 1 survey, while 5.5% of the girls and 4.4% of the boys (P=0.331) were food insecure in all the three rounds of the survey. In general, a significantly higher proportion of girls (40%) experienced food insecurity at least in one of the survey rounds compared with boys (36.6%) (P=0.045).
The trend of food insecurity showed a very sharp increase over the follow period from the baseline 20.5% to 48.4% on the year 1 survey, which again came down to 27.1% during the year 2 survey.
In the linear mixed effects model, after adjusting for other covariates, the mean height of food insecure girls was shorter by 0.87 cm (P
Full-text · Article · May 2013 · Nutrition Journal
[Show abstract][Hide abstract] ABSTRACT: We are delighted that our article has stimulated novel analyses regarding the relationship between food insecurity and well-being. Theall et al. describe how there were no significant associations found between food security and inflammation among a younger age group (adolescents aged 12-17 years) of the National Health and Nutrition Examination Survey study population 1999-2006 that we used to investigate these relationships in adults (aged ≥ 18 years). (Am J Public Health. Published online ahead of print January 17, 2013: e1. doi:10.2105/AJPH.2012.301187).
No preview · Article · Jan 2013 · American Journal of Public Health
[Show abstract][Hide abstract] ABSTRACT: This article draws on qualitative and quantitative research to examine the relationship between the consumption of khat, symptoms of depression and anxiety and the experience of time among young men in urban Ethiopia. Young men claim that khat, a mild stimulant, both causes and alleviates symptoms of depression and anxiety. However, our quantitative data indicate that there is not a direct relationship between khat and symptoms of depression and anxiety. We analyze this apparent contradiction in terms of young men's experiences of time. Long-term ethnographic research indicates that khat consumption and mental distress have a close relationship with young men's temporal problems. In a context of high urban unemployment, young men struggle to negotiate overabundant amounts of unstructured time in the present and place themselves within a narrative in which they are progressing toward future aspirations. These temporal struggles generate symptoms of depression and anxiety. For young men, khat consumption functions to reposition them in relation to time, both in the present and the future. Ultimately, we argue that the relationship between khat and time has implications for the economic issues that underlie young people's symptoms of depression and anxiety.
No preview · Article · Nov 2012 · Culture Medicine and Psychiatry
[Show abstract][Hide abstract] ABSTRACT: We thank Dodge for highlighting the potential environmental factors that may impact food insecurity upstream of the mechanistic pathway between food insecurity and health. Our work demonstrated that food insecurity is associated with C-reactive protein, a marker of inflammation associated with chronic health conditions such as diabetes, hyperlipidemia, and cardiovascular disease. In our exploratory study, we focused primarily on associations at the individual and household level between socioeconomic conditions and biological processes such as nutritional deficiencies, susceptibility to infection, and increased inflammation. (Am J Public Health. Published online ahead of print November 15, 2012: e1. doi:10.2105/AJPH.2012.301099).
No preview · Article · Nov 2012 · American Journal of Public Health
[Show abstract][Hide abstract] ABSTRACT: Food insecurity is common among HIV-infected populations in resource-rich and resource-poor countries. We hypothesized that food insecurity would be associated with risky sexual behaviors. We examined this hypothesis among all sexually active participants (n = 154) in the Research on Access to Care in the Homeless (REACH) cohort in San Francisco. The outcomes were unprotected vaginal or anal sex and multiple sexual partners during the prior 90 days. Associations were examined using repeated measures multivariable logistic regression analyses. Food insecurity was independently associated with unprotected sexual activity (AOR = 2.01 for each five point increase in HFIAS scale, 95 % CI 1.31-3.10) and multiple sexual partners (AOR = 1.54 for each five-point increase in HFIAS scale, 95 % CI 1.05-2.29). Food insecurity is a risk factor for unprotected sexual activity and multiple sexual partners among homeless and marginally housed HIV-infected individuals in San Francisco. Measures to alleviate food insecurity may play a role in decreasing secondary HIV transmission.
Full-text · Article · Oct 2012 · AIDS and Behavior