BMC International Health and Human Rights is an open access journal publishing original peer-reviewed research articles in relation to health and disease in developing and transitional countries, as well as all issues relating to the impact of health policies, programs and practices on human rights. BMC International Health and Human Rights is indexed/tracked/covered by PubMed, CAS, Scopus, EMBASE and Google Scholar.

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  • Experiences of gender-based violence among female sex workers, men who have sex with men, and transgender women in Latin America and the Caribbean: a qualitative study to inform HIV programming

    Emily Evens; Michele Lanham; Karin Santi; Juana Cooke; Kathleen Ridgeway; Giuliana Morales; Caleb Parker; Claire Brennan; Marjan de Bruin; Pavel Chladni Desrosiers; et al. (BMC, 2019-03-01)
    Abstract Background Female sex workers, MSM, and transgender women—collectively referred to as key populations (KPs)—are disproportionately affected by gender-based violence (GBV) and HIV, yet little is known about the violence they face, its gender-based origins, and responses to GBV. The purpose of this study was to understand the nature and consequences of GBV experienced, to inform HIV policies and programming and to help protect KPs’ human rights. Methods Using a participatory approach, FSWs, MSM, and transgender women in Barbados, El Salvador, Trinidad and Tobago, and Haiti conducted 278 structured interviews with peers to understand their experiences of and responses to GBV. Responses to open-ended questions were coded in NVivo and analyzed using an applied thematic analysis. Results Nearly all participants experienced some form of GBV. Emotional and economic GBV were the most commonly reported but approximately three-quarters of participants reported sexual and physical GBV and other human rights violations. The most common settings for GBV were at home, locations where sex work took place such as brothels, bars and on the street; public spaces such as parks, streets and public transport, health care centers, police stations and—for transgender women and MSM—religious settings and schools. The most common perpetrators of violence included: family, friends, peers and neighbors, strangers, intimate partners, sex work clients and other sex workers, health care workers, police, religious leaders and teachers. Consequences included emotional, physical, and sexual trauma; lack of access to legal, health, and other social services; and loss of income, employment, housing, and educational opportunities. Though many participants disclosed experiences of GBV to friends, colleagues and family, they rarely sought services following violence. Furthermore, less than a quarter of participants believed that GBV put them at risk of HIV. Conclusions Our study found that across the four study countries, FSWs, MSM, and transgender women experienced GBV from state and non-state actors throughout their lives, and much of this violence was directly connected to rigid and harmful gender norms. Through coordinated interventions that address both HIV and GBV, this region has the opportunity to reduce the national burden of HIV while also promoting key populations’ human rights.
  • HIV prevalence, risky behaviors, and discrimination experiences among transgender women in Cambodia: descriptive findings from a national integrated biological and behavioral survey

    Siyan Yi; Chanrith Ngin; Sovannary Tuot; Pheak Chhoun; Srean Chhim; Khuondyla Pal; Phalkun Mun; Gitau Mburu (BioMed Central, 2017-05-01)
    Abstract Background Transgender people are disproportionately affected by HIV. Despite their high vulnerability to HIV, lack of adequate epidemiological and surveillance data related to this population in many countries prevents provision of appropriate services. This paper summarizes descriptive findings from a national integrated biological and behavioral survey and discusses policy implications of the findings on HIV prevention among transgender women in Cambodia. Methods This cross-sectional study was conducted between December 2015 and February 2016. Participants were recruited from 20 sites in the capital city and 12 provinces of Cambodia using Respondent Driven Sampling (RDS) method. Behavioral data were collected through structured questionnaire interviews, and rapid finger-prick HIV testing was performed. Descriptive data analyses were conducted using STATA. Results This study included 1,375 transgender women with a mean age of 25.9 years (SD = 7.1). The overall prevalence of HIV was 5.9%. The prevalence of HIV was significantly higher among urban participants compared to their rural counterparts (6.5 vs. 2.6%, p = 0.02). Almost one in five (19.6%) had never been tested for HIV prior to the study. Overall, 45.0% reported ever using gender affirming hormones. More than one-third (39.1%) reported not using condoms in their last sex, 29.8% had engaged in sex in exchange for money/gifts, and 14.0% reported that they had experienced at least one symptom of sexually transmitted infections (STI) in the past year. About one in ten (10.1%) reported having used some form of amphetamine-type stimulant drugs, while 6.5% reported having sex during or after using illicit drugs. A significant number of participants experienced sexual abuse (39.2%), losing a job (24.3%), or physical abuse (23.6%) because of their transgender identity. In addition, 82.9 and 88.9% would be willing to use the HIV self-test and pre-exposure prophylaxis (PrEP), respectively, if they become available. Conclusions The high prevalence of HIV, STI, and related risk behaviors among transgender women in Cambodia is of great concern, suggesting an urgent need to further expand tailored prevention interventions for this key population focusing on individual, social, and structural drivers of HIV. HIV self-test and PrEP should be explored as a priority.
  • Bibliometric analysis of peer-reviewed literature in transgender health (1900 – 2017)

    Waleed M. Sweileh (BMC, 2018-03-01)
    Abstract Background Transgender community is marginalized and under-researched. Analysis of peer-reviewed literature in transgender health is needed to better understand health needs and human rights of transgender people. Therefore, the aim of this study was to analyze global research activity in transgender health published in peer-reviewed journals. Methods Peer-reviewed documents in transgender health were retrieved using Scopus database. VOSviewer was used to map frequently encountered author keywords while ArcGIS 10.1 was used to map the geographical distribution of the retrieved documents. Most active countries, institutions, and authors were presented. The study period was set from 1900 to 2017. Results In total, 5772 peer-reviewed documents were obtained. English (5008; 86.8%) was the most frequently encountered language. A dramatic increase in the number of publications was seen in the last decade. The retrieved documents had an average of 12.1 citations per document and h-index of 92. Most frequently encountered author keywords were Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), mental health, and discrimination. Authors from 80 different countries contributed to publishing the retrieved documents. Publications originated mainly from Northern America, certain European countries, Australia, and Brazil. Professor Gooren, L.J.G. was the most active author in this field with 104 (1.88%) publications. Top active authors were in the fields of endocrinology, plastic surgery, psychiatry/psychology, public health, and sexology. Five of the top ten active authors were from the USA, three were from the Netherlands, and two were from Belgium. The most active institution was the VU University Medical Center (Netherlands) (184; 3.2%) followed by the University of California, San Francisco (USA) (157; 2.7%). The International Journal of Transgenderism was most active (284; 4.9%) in publishing articles in transgender health. However, documents published in the American Journal of Public Health had the highest impact with 53.5 citations per article. Conclusion There was a noticeable growth of research in transgender health in the last decade. Researchers from different world regions need to get involved in health and human rights research of transgender community.
  • Sexual violence against female university students in Ethiopia

    Yohannes Mehretie Adinew; Mihiret Abreham Hagos (BioMed Central, 2017-07-01)
    Abstract Background Though many women are suffering the consequences of sexual violence, only few victims speak out as it is sensitive and prone to stigma. This lack of data made it difficult to get full picture of the problem and design proper interventions. Thus, the aim of this study was to assess the prevalence and factors associated with sexual violence among female students of Wolaita Sodo University, south Ethiopia. Methods Institution based cross-sectional study was conducted among 462 regular female Wolaita Sodo University students on April 7/2015. Participants were selected by simple random sampling. Data were collected by self-administered questionnaire. Data entry and analysis was done by EPI info and SPSS statistical packages respectively. Descriptive statistics were done. Moreover, bivariate and multivariate analyses were also carried out to identify predictors of sexual violence. Result The age of respondents ranged from 18 to 26 years. Lifetime sexual violence was found to be 45.4%. However, 36.1% and 24.4% of respondents reported experiencing sexual violence since entering university and in the current academic year respectively. Life time sexual violence was positively associated with witnessing inter-parental violence as a child, rural childhood residence, having regular boyfriend, alcohol consumption and having friends who drink regularly; while it was negatively associated with discussing sexual issues with parents. Conclusion Sexual violence is a common phenomenon among the students. More detailed research has to be conducted to develop prevention and intervention strategies.
  • Health and legal literacy for migrants: twinned strands woven in the cloth of social justice and the human right to health care

    Bilkis Vissandjée; Wendy E. Short; Karine Bates (BioMed Central, 2017-04-01)
    Abstract Background Based on an analysis of published literature, this paper provides an over-view of the challenges associated with delivering on the right to access quality health care for international migrants to industrialized countries, and asks which group of professionals is best equipped to provide services that increase health and legal literacy. Both rights and challenges are approached from a social justice perspective with the aim of identifying opportunities to promote greater health equity. That is, to go beyond the legal dictates enshrined in principles of equality, and target as an ethical imperative a situation where all migrants receive the particular assistance they need to overcome the barriers that inhibit their equitable access to health care. This assistance is especially important for migrant groups that are further disadvantaged by differing cultural constructions of gender. Viewing the topic from this perspective makes evident a gap in both research literature and policy. The review has found that while health literacy is debated and enshrined as a policy objective, and consideration is given to improving legal literacy as a means of challenging social injustice in developing nations, however, no discussion has been identified that considers assisting migrants to gain legal literacy as a step toward achieving not only health literacy and improved health outcomes, but critical participation as members of their adoptive society. Conclusion Increasing migrant health literacy, amalgamated with legal literacy, aids migrants to better access their human right to appropriate care, which in turn demonstrably assists in increasing social engagement, citizenship and productivity. However what is not evident in the literature, is which bureaucratic or societal group holds responsibility for assisting migrants to develop critical citizenship literacy skills. This paper proposes that a debate is required to determine both who is best placed to provide services that increase health and legal literacy, and how they should be resourced, trained and equipped.
  • Scrambling for access: availability, accessibility, acceptability and quality of healthcare for lesbian, gay, bisexual and transgender people in South Africa

    Alex Müller (BioMed Central, 2017-05-01)
    Abstract Background Sexual orientation and gender identity are social determinants of health for people identifying as lesbian, gay, bisexual and transgender (LGBT), and health disparities among sexual and gender minority populations are increasingly well understood. Although the South African constitution guarantees sexual and gender minority people the right to non-discrimination and the right to access to healthcare, homo- and transphobia in society abound. Little is known about LGBT people’s healthcare experiences in South Africa, but anecdotal evidence suggests significant barriers to accessing care. Using the framework of the UN International Covenant on Economic, Social and Cultural Rights General Comment 14, this study analyses the experiences of LGBT health service users using South African public sector healthcare, including access to HIV counselling, testing and treatment. Methods A qualitative study comprised of 16 semi-structured interviews and two focus group discussions with LGBT health service users, and 14 individual interviews with representatives of LGBT organisations. Data were thematically analysed within the framework of the UN International Covenant on Economic, Social and Cultural Rights General Comment 14, focusing on availability, accessibility, acceptability and quality of care. Results All interviewees reported experiences of discrimination by healthcare providers based on their sexual orientation and/or gender identity. Participants recounted violations of all four elements of the UN General Comment 14: 1) Availability: Lack of public health facilities and services, both for general and LGBT-specific concerns; 2) Accessibility: Healthcare providers' refusal to provide care to LGBT patients; 3) Acceptability: Articulation of moral judgment and disapproval of LGBT patients’ identity, and forced subjection of patients to religious practices; 4) Quality: Lack of knowledge about LGBT identities and health needs, leading to poor-quality care. Participants had delayed or avoided seeking healthcare in the past, and none had sought out accountability or complaint mechanisms within the health system. Conclusion Sexual orientation and gender identity are important categories of analysis for health equity, and lead to disparities in all four dimensions of healthcare access as defined by General Comment 14. Discriminatory and prejudicial attitudes by healthcare providers, combined with a lack of competency and knowledge are key reasons for these disparities in South Africa.
  • HIV testing and care in Burkina Faso, Kenya, Malawi and Uganda: ethics on the ground

    Obermeyer Carla Makhlouf; Bott Sarah; Bayer Ron; Desclaux Alice; Baggaley Rachel (BioMed Central, 2013-01-01)
    <p>Abstract</p> <p>Background</p> <p>The ethical discourse about HIV testing has undergone a profound transformation in recent years. The greater availability of antiretroviral therapy (ART) has led to a global scaling up of HIV testing and counseling as a gateway to prevention, treatment and care. In response, critics raised important ethical questions, including: How do different testing policies and practices undermine or strengthen informed consent and medical confidentiality? How well do different modalities of testing provide benefits that outweigh risks of harm? To what degree do current testing policies and programs provide equitable access to HIV services? And finally, what lessons have been learned from the field about how to improve the delivery of HIV services to achieve public health objectives and protections for human rights? This article reviews the empirical evidence that has emerged to answer these questions, from four sub-Saharan African countries, namely: Burkina Faso, Kenya, Malawi and Uganda.</p> <p>Discussion</p> <p>Expanding access to treatment and prevention in these four countries has made the biomedical benefits of HIV testing increasingly clear. But serious challenges remain with regard to protecting human rights, informed consent and ensuring linkages to care. Policy makers and practitioners are grappling with difficult ethical issues, including how to protect confidentiality, how to strengthen linkages to care, and how to provide equitable access to services, especially for most at risk populations, including men who have sex with men.</p> <p>Summary</p> <p>The most salient policy questions about HIV testing in these countries no longer address <it>whether</it> to scale up routine PITC (and other strategies), but <it>how.</it> Instead, individuals, health care providers and policy makers are struggling with a host of difficult ethical questions about how to protect rights, maximize benefits, and mitigate risks in the face of resource scarcity.</p>
  • Household exposure to violence and human rights violations in western Bangladesh (II): history of torture and other traumatic experience of violence and functional assessment of victims

    Biswas Shuvodwip; Modvig Jens; Masum Saber-ud-Daula; Wang Shr-Jie; Haque Mohammad (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>Organised crime and political violence (OPV) and human rights violations have marred Bangladesh history since 1971. Little is known about the consequences for the oppressed population. This study describes the patterns of OPV and human rights violations in a disturbed area of Bangladesh and assesses the physical, emotional and social functioning of victims.</p> <p>Methods</p> <p>A total of 236 of selected participants in a household survey in Meherpur district were recruited for a detailed study. Interviews and physical examinations were used to obtain information about history of torture and other cruel, inhuman or degrading treatment or punishment (TCIDTP), and about injuries, pain frequency and intensity. Handgrip strength and standing balance performance were measured. The "WHO-5 Well-being" scale was used to assess the subjective emotional well-being of study participants.</p> <p>Results</p> <p>The majority of the reported cases of TCIDTP occurred in 2000-2008, 51% of incidents occurred during winter; 32.0% between 20:00 and midnight. Police involvement was reported in 75% of cases. Incidents took place at victims' homes (46.7%), or at the police station, military camp, in custody or in prison (21.9%). Participants experienced 1-10 TCIDTP methods and reported 0-6 injury locations on their bodies; 77.5% reported having at least two injuries. Less than half of the participants were able to stand on one leg for 30 seconds. Only 7.5% of males aged 25-44 had handgrip strength in both hands exceeding average values for healthy people at the same age. Over 85% of participants scored low (&lt;13) on the 25-point "WHO-5 Well-being" scale. The number of years since the TCIDTP event, pain frequency, the need to quit a job to take care of an injured family member, political involvement, personal conflicts and the fear of neighbourhood violence strongly affected emotional well-being. Good emotional well-being correlated with increased political and social participation.</p> <p>Conclusion</p> <p>A detailed picture of characteristics of the victimisation is presented. The participants showed poor emotional well-being and reduced physical capacity. The results indicated that the simple and rapid method of assessment used here is a promising tool that could be used to monitor the quality and outcome of rehabilitation.</p>
  • Household exposure to violence and human rights violations in western Bangladesh (I): prevalence, risk factors and consequences

    Wang Shr-Jie; Modvig Jens; Montgomery Edith (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>The ruling parties in Bangladesh have systematically used violence against political opponents and criminals. It is essential to 1) determine the magnitude and burden of organised crime and political violence (OPV) and human rights violations in the affected community, and to 2) identify the risk factors and key indicators for developing effective health intervention and prevention measures.</p> <p>Methods</p> <p>The population-based study consisted of two parts: a household survey and OPV screening at mobile clinics (presented in Part II). A cross-sectional, multistage cluster household survey was conducted in the Meherpur district in February-March 2008; 22 clusters with a sample size of 1,101 households (population of 4,870) were selected.</p> <p>Results</p> <p>Around 83% of households reported being exposed to at least two categories of OPV or human rights violations: 29% reported that the family members had been arrested or detained; 31% reported torture or other cruel, inhuman or degrading treatment or punishment. Crude mortality rate was 17.9/1,000 and under 5 mortality rate was 75/1,000. The annual injury rate was 36%, lifetime experience of violence-related injury was 50%, and pain experience within 2 weeks was reported by 57%. Over 80% of the population over 35 years old complained of pain. High prevalence of injury, lifetime experience of OPV-related injury and pain complaints are related to the level of exposure to OPV and human rights violations. A financial burden was imposed on families with an injured person. A geographical variation was revealed regarding reports of torture and lifetime experience of violence-related injury. A combination of individual, relational, community and societal factors, including variables such as political party affiliation, conflict with other families, household income and residential area, affected the risk of victimisation in the household. The odds ratio for reporting extrajudicial execution of a family member was 9.22 for Awami League supporters, 9.15 for Bangladesh Nationalist Party supporters; and 3.97 for Jamaat-e-Islami Party supporters compared with families with no political involvement.</p> <p>Conclusion</p> <p>The level of violence and human rights violations is high. The affected population suffers from violence-related injuries and traumas, which could be a factor contributing to poverty. Victimisation is not random.</p>
  • The forsaken mental health of the Indigenous Peoples - a moral case of outrageous exclusion in Latin America

    Incayawar Mario; Maldonado-Bouchard Sioui (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>Mental health is neglected in most parts of the world. For the Indigenous Peoples of Latin America, the plight is even more severe as there are no specific mental health services designed for them altogether. Given the high importance of mental health for general health, the status quo is unacceptable. Lack of research on the subject of Indigenous Peoples' mental health means that statistics are virtually unavailable. To illustrate their mental health status, one can nonetheless point to the high rates of poverty and extreme poverty in their communities, overcrowded housing, illiteracy, and lack of basic sanitary services such as water, electricity and sewage. At the dawn of the XXI century, they remain poor, powerless, and voiceless. They remain severely excluded from mainstream society despite being the first inhabitants of this continent and being an estimated of 48 million people. This paper comments, specifically, on the limited impact of the Pan American Health Organization's mental health initiative on the Indigenous Peoples of Latin America.</p> <p>Discussion</p> <p>The Pan American Health Organization's sponsored workshop "Programas y Servicios de Salud Mental en Communidades Ind&#237;genas" [Mental Health Programs and Services for the Indigenous Communities] in the city of Santa Cruz, Bolivia on July16 - 18, 1998, appeared promising. However, eleven years later, no specific mental health program has been designed nor developed for the Indigenous Peoples in Latin America. This paper makes four specific recommendations for improvements in the approach of the Pan American Health Organization: (1) focus activities on what can be done; (2) build partnerships with the Indigenous Peoples; (3) consider traditional healers as essential partners in any mental health effort; and (4) conduct basic research on the mental health status of the Indigenous Peoples prior to the programming of any mental health service.</p> <p>Summary</p> <p>The persistent neglect of the Indigenous Peoples' mental health in Latin America raises serious concerns of moral and human rights violations. Since the Pan American Health Organization' Health of the Indigenous Peoples Initiative 16 years ago, no mental health service designed for them has yet been created.</p>
  • Measuring the health impact of human rights violations related to Australian asylum policies and practices: a mixed methods study

    Markovic Milica; Johnston Vanessa; Mulholland Kim; Allotey Pascale (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>Human rights violations have adverse consequences for health. However, to date, there remains little empirical evidence documenting this association, beyond the obvious physical and psychological effects of torture. The primary aim of this study was to investigate whether Australian asylum policies and practices, which arguably violate human rights, are associated with adverse health outcomes.</p> <p>Methods</p> <p>We designed a mixed methods study to address the study aim. A cross-sectional survey was conducted with 71 Iraqi Temporary Protection Visa (TPV) refugees and 60 Iraqi Permanent Humanitarian Visa (PHV) refugees, residing in Melbourne, Australia. Prior to a recent policy amendment, TPV refugees were only given temporary residency status and had restricted access to a range of government funded benefits and services that permanent refugees are automatically entitled to. The quantitative results were triangulated with semi-structured interviews with TPV refugees and service providers. The main outcome measures were self-reported physical and psychological health. Standardised self-report instruments, validated in an Arabic population, were used to measure health and wellbeing outcomes.</p> <p>Results</p> <p>Forty-six percent of TPV refugees compared with 25% of PHV refugees reported symptoms consistent with a diagnosis of clinical depression (p = 0.003). After controlling for the effects of age, gender and marital status, TPV status made a statistically significant contribution to psychological distress (B = 0.5, 95% CI 0.3 to 0.71, p &#8804; 0.001) amongst Iraqi refugees. Qualitative data revealed that TPV refugees generally felt socially isolated and lacking in control over their life circumstances, because of their experiences in detention and on a temporary visa. This sense of powerlessness and, for some, an implicit awareness they were being denied basic human rights, culminated in a strong sense of injustice.</p> <p>Conclusion</p> <p>Government asylum policies and practices violating human rights norms are associated with demonstrable psychological health impacts. This link between policy, rights violations and health outcomes offers a framework for addressing the impact of socio-political structures on health.</p>
  • "Just like fever": a qualitative study on the impact of antiretroviral provision on the normalisation of HIV in rural Tanzania and its implications for prevention

    Urassa Mark; Roura Maria; Zaba Basia; Wringe Alison; Nhandi Benjamin; Busza Joanna; Mbata Doris (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>Once effective therapy for a previously untreatable condition is made available, a normalisation of the disease often occurs. As part of a broader initiative to monitor the implementation of the national antiretroviral therapy (ART) programme, this qualitative study investigated the impact of ART availability on perceptions of HIV in a rural ward of North Tanzania and its implications for prevention.</p> <p>Methods</p> <p>A mix of qualitative methods was used including semi-structured interviews with 53 ART clinic clients and service providers. Four group activities were conducted with persons living with HIV. Data were analyzed using the qualitative software package NVIVO-7.</p> <p>Results</p> <p>People on ART often reported feeling increasingly comfortable with their status reflecting a certain "normalization" of the disease. This was attributed to seeing other people affected by HIV, regaining physical health, returning to productive activities and receiving emotional support from health service providers. Overcoming internalized feelings of shame facilitated disclosure of HIV status, helped to sustain treatment, and stimulated VCT uptake. However "blaming" stigma - where people living with HIV were considered responsible for acquiring a "moral disease" - persisted in the community and anticipating it was a key barrier to disclosure and VCT uptake. Attributing HIV symptoms to witchcraft seemed an effective mechanism to transfer "blame" from the family unit to an external force but could lead to treatment interruption.</p> <p>Conclusion</p> <p>As long as an HIV diagnosis continues to have moral connotations, a de-stigmatisation of HIV paralleling that occurring with diseases like cancer is unlikely to occur. Maximizing synergies between HIV treatment and prevention requires an enabling environment for HIV status disclosure, treatment continuation, and safer sexual behaviours. Local leaders should be informed and sensitised and communities mobilised to address the blame-dimension of HIV stigma.</p>
  • Economic burden of diabetes mellitus in the WHO African region

    Sambo Hama; Sambo Luis; Barry Saidou; Kirigia Joses (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>In 2000, the prevalence of diabetes among the 46 countries of the WHO African Region was estimated at 7.02 million people. Evidence from North America, Europe, Asia, Latin America and the Caribbean indicates that diabetes exerts a heavy health and economic burden on society. Unfortunately, there is a dearth of such evidence in the WHO African Region. The objective of this study was to estimate the economic burden associated with diabetes mellitus in the countries in the African Region.</p> <p>Methods</p> <p>Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health systems and the families in directly addressing the problem; and (b) the indirect costs, i.e. the losses in productivity attributable to premature mortality, permanent disability and temporary disability caused by the disease. Prevalence estimates of diabetes for the year 2000 were used to calculate direct and indirect costs of diabetes mellitus. A discount rate of 3% was used to convert future earnings lost into their present values. The economic burden analysis was done for three groups of countries, i.e. 6 countries whose gross national income (GNI) per capita was greater than 8000 international dollars (i.e. in purchasing power parity), 6 countries with Int$2000&#8211;7999 and 33 countries with less than Int$2000. GNI for Zimbabwe was missing.</p> <p>Results</p> <p>The 7.02 million cases of diabetes recorded by countries of the African Region in 2000 resulted in a total economic loss of Int$25.51 billion (PPP). Approximately 43.65%, 10.03% and 46.32% of that loss was incurred by groups 1, 2 and 3 countries, respectively. This translated into grand total economic loss of Int$11,431.6, Int$4,770.6 and Int$ 2,144.3 per diabetes case per year in the three groups respectively.</p> <p>Conclusion</p> <p>In spite of data limitations, the estimates reported here show that diabetes imposes a substantial economic burden on countries of the WHO African Region. That heavy burden underscores the urgent need for increased investments in the prevention and management of diabetes.</p>
  • Developing a health and human rights training program for french speaking Africa: lessons learned, from needs assessment to a pilot program

    Klohn Axel; Freigburghaus Franziska; Zesiger V&#233;ronique; Mpinga Emmanuel; Chastonay Philippe (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>The importance of human rights education has widely been recognized as one of the strategies for their protection and promotion of health. Yet training programs have not always taken into account neither local needs, nor public health relevance, nor pedagogical efficacy.</p> <p>The objectives of our study were to assess, in a participative way, educational needs in the field of health and human rights among potential trainees in six French-speaking African countries and to test the feasibility of a training program through a pilot test. Ultimately the project aims to implement <it>a health and human rights training program most appropriate to the African context</it>.</p> <p>Methods</p> <p><it>Needs assessment </it>was done according to four approaches: Revue of available data on health and human rights in the targeted countries; Country visits by one of the authors meeting key institutions; Focus group discussions with key-informants in each country; A questionnaire-based study targeting health professionals and human rights activists.</p> <p><it>Pilot training program</it>: an interactive e-learning pilot program was developed integrating training needs expressed by partner institutions and potential trainees.</p> <p>Results</p> <p>Needs assessment showed high public health and human rights challenges that the target countries have to face. It also showed precise demands of partner institutions in regard to a health and human rights training program. It further allowed defining training objectives and core competencies useful to potential employers and future students as well as specific training contents.</p> <p>A pilot program allowed testing the motivation of students, the feasibility of an interactive educational approach and identifying potential difficulties.</p> <p>Conclusion</p> <p>In combining various approaches our study was able to show that training needs concentrate around tools allowing the identification of basic human rights violations in the health system, the analysis of their causes and coordinated responses through specific intervention projects.</p>
  • Stakeholder perceptions of mental health stigma and poverty in Uganda

    Kizza Dorothy; Ssebunnya Joshua; Lund Crick; Okello Elialilia; Kigozi Fred (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>World wide, there is plentiful evidence regarding the role of stigma in mental illness, as well as the association between poverty and mental illness. The experiences of stigma catalyzed by poverty revolve around experiences of devaluation, exclusion, and disadvantage. Although the relationship between poverty, stigma and mental illness has been documented in high income countries, little has been written on this relationship in low and middle income countries.</p> <p>The paper describes the opinions of a range of mental health stakeholders regarding poverty, stigma, mental illness and their relationship in the Ugandan context, as part of a wider study, aimed at exploring policy interventions required to address the vicious cycle of mental ill-health and poverty.</p> <p>Methods</p> <p>Semi-structured interviews and focus group discussions (FGDs) were conducted with purposefully selected mental health stakeholders from various sectors. The interviews and FGDs were audio-recorded, and transcriptions were coded on the basis of a pre-determined coding frame. Thematic analysis of the data was conducted using NVivo7, adopting a framework analysis approach.</p> <p>Results</p> <p>Most participants identified a reciprocal relationship between poverty and mental illness. The stigma attached to mental illness was perceived as a common phenomenon, mostly associated with local belief systems regarding the causes of mental illness. Stigma associated with both poverty and mental illness serves to reinforce the vicious cycle of poverty and mental ill-health. Most participants emphasized a relationship between poverty and internalized stigma among people with mental illness in Uganda.</p> <p>Conclusion</p> <p>According to a range of mental health stakeholders in Uganda, there is a strong interrelationship between poverty, stigma and mental illness. These findings re-affirm the need to recognize material resources as a central element in the fight against stigma of mental illness, and the importance of stigma reduction programmes in protecting the mentally ill from social isolation, particularly in conditions of poverty.</p>
  • A taxonomy of dignity: a grounded theory study

    Jacobson Nora (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>This paper has its origins in Jonathan Mann's insight that the experience of dignity may explain the reciprocal relationships between health and human rights. It follows his call for a taxonomy of dignity: "a coherent vocabulary and framework to characterize dignity."</p> <p>Methods</p> <p>Grounded theory procedures were use to analyze literature pertaining to dignity and to conduct and analyze 64 semi-structured interviews with persons marginalized by their health or social status, individuals who provide health or social services to these populations, and people working in the field of health and human rights.</p> <p>Results</p> <p>The taxonomy presented identifies two main forms of dignity&#8211;human dignity and social dignity&#8211;and describes several elements of these forms, including the social processes that violate or promote them, the conditions under which such violations and promotions occur, the objects of violation and promotion, and the consequences of dignity violation. Together, these forms and elements point to a theory of dignity as a quality of individuals and collectives that is constituted through interaction and interpretation and structured by conditions pertaining to actors, relationships, settings, and the broader social order.</p> <p>Conclusion</p> <p>The taxonomy has several implications for work in health and human rights. It suggests a map to possible points of intervention and provides a language in which to talk about dignity.</p>
  • Mental health of returnees: refugees in Germany prior to their state-sponsored repatriation

    Elbert Thomas; Wiens Ulrike; von Lersner Ulrike; Neuner Frank (BioMed Central, 2008)
    <p>Abstract</p> <p>Background</p> <p>Many refugees live for years in exile. The combination of stress in the host country, together with long-term effects resulting from traumatic stress usually experienced in the home country may affect mental health. Little is known, to what extent these and other factors promote or stall the willingness to return to the country of origin. Here, we investigate, as an example, refugees who will return to their country of origin after having lived in exile in Germany for some 11 years.</p> <p>Objective</p> <p>What is the mental health status of returnees before the actual return who have been living in exile for an extended period? We also asked, what are the current living conditions in Germany and what are the motives for and reasons against a voluntary return to the country of origin?</p> <p>Methods</p> <p>Forty-seven participants of programs for assisted voluntarreturn were interviewed about their present living situation, their view regarding their home country and voluntary return. These findings were compared to a group of 53 refugees who had decided to remain in Germany (stayers). Participants were recruited by means of advertisements posted in refugee centres, language schools, at doctors' offices and in organisations involved in the management of voluntary return in Germany. The prevalence of psychiatric disorders among respondents was tested using the structured interview M.I.N.I. The Posttraumatic Stress Diagnostic Scale (PDS) was used to assess PTSD in more detail and EUROHIS was applied to measure the subjective quality of life of participants.</p> <p>Results</p> <p>We found a prevalence rate of 44% psychiatric disorders in the group of returnees and a rate of 78% in the group of stayers. We also recorded substantial correlations between the living situation in Germany, disposition to return and mental health. In almost two thirds of the participants the decision to return was not voluntary but strongly influenced by immigration authorities. The most important reason for participants to opt for a stay in Germany were their children, who have been born and raised in Germany.</p> <p>Conclusion</p> <p>Psychological strains among the study participants were very high. Traumatic stress, experienced during war and refuge, has left the victims vulnerable and not well equipped to cope with post-migration stressors in exile. It is noteworthy that the majority returned under pressure of the immigration authorities. The fear of an uncertain future after the return was substantial. These factors should be taken into account in programs designed to assist returnees, including those that offer support after return to the country of origin.</p>
  • A multilevel analysis of effect of neighbourhood and individual wealth status on sexual behaviour among women: evidence from Nigeria 2003 Demographic and Health Survey

    Uthman Olalekan; Kongnyuy Eugene (BioMed Central, 2008)
    <p>Abstract</p> <p>Background</p> <p>Nigeria is home to more people living with HIV than any other country in the world, except South Africa and India &#8211; where an estimated 2.9 million [1.7 million &#8211; 4.2 million] people were living with the virus in 2005. Women bear the greatest burden of frequent high-risk pregnancies, raising large families, and increasingly, the AIDS epidemic. Thus, there is a need for better understanding of the determinants of high risk sexual behaviour among women. In this study, we examined factors associated with extra-marital sex among women in Nigeria and investigated how much variation in reported extra-marital sex can be attributed to individual-, and community-level factors.</p> <p>Methods</p> <p>We analyzed data from 6362 sexually active women aged 15 &#8211; 49 years who participated in the Nigeria 2003 Demographic and Health Survey using multilevel logistic regression models. Results are presented as odds ratio with 95% confidence interval.</p> <p>Results</p> <p>Independent of other factors, compared to women aged 15&#8211;24 years, those 25 &#8211; 34 years (odds ratio [OR] 0.59; 95% CI: 0.44 &#8211; 0.79) and 35 years or older (OR 0.36; 95% CI: 0.24 &#8211; 0.54) were less likely to have reported multiple concurrent sex partners in the last 12 years. As expected, women currently or formerly married were less likely to have reported multiple concurrent sex partners than women never married. Women who drank alcohol in the last three months were more likely to have reported multiple concurrent sex partners. Compared to women from richest household, women from poorest and middle household were 83% and 51% more likely to multiple concurrent sex partners in the last 12 month respectively. After individual compositional and contextual factors, community wealth status was statistically significant with sexual behaviour.</p> <p>Conclusion</p> <p>The study has demonstrated that individual and community wealth status are independent predictors of women's sexual behaviour, and that there is significant neighbourhood variation in odds of multiple concurrent sex partners, even after controlling for effects of both individual- and community-level characteristics. Scholars trying to understand variation individual high risk sexual behaviour should pay attention to the characteristics of both individuals and places of residence.</p>
  • HIV/AIDS awareness and risk behavior among students in Semey, Kazakhstan: a cross-sectional survey

    Urazalin Marat; Andersson Rune; Stockfelt Leo; Ahlm Clas; Hansson Marit (BioMed Central, 2008)
    <p>Abstract</p> <p>Background</p> <p>Until recently, young people in Kazakhstan have been only moderately affected by the global HIV epidemic. Today, however, the HIV epidemic in Central Asia is one of the most rapidly increasing epidemics in the world. It is mainly concentrated to vulnerable groups such as intravenous drug users, sex workers, the purchasers of sexual services and the financially marginalized. Young, sexually active people may however be the gateway for the epidemic to the general population, and knowledge about their attitudes and behavior is therefore important in planning preventive measures.</p> <p>Methods</p> <p>To gather information about young students and their attitudes and knowledge about HIV/AIDS, we collected 600 structured questionnaires and made 23 semi-structured interviews among three groups of students. Response rate was 99%.</p> <p>Results</p> <p>Almost 99% of the respondents had heard of HIV/AIDS, and 89% could identify ways to protect oneself against sexually transmitted HIV/AIDS. The main routes of transmission, sexual contact without condom and intravenous drug use, were both identified by 97% of the students. Twenty-five percent of the female students and 75% of the male students had had one or more sexual partners. More than 30% of the young men had purchased sex, and homosexuality was widely stigmatized.</p> <p>Conclusion</p> <p>Risks for the spread of HIV/AIDS among young people in Kazakhstan include prostitution as well as stigmatization of the HIV positive and of homosexuals. Protective factors are good knowledge about risks and protection, and opportunities to talk and gather information about sexuality and HIV/AIDS.</p>
  • Awareness of health effects of cooking smoke among women in the Gondar Region of Ethiopia: a pilot survey

    Silverman M; Edelstein M; Asres G; Kulkarni N; Pitchforth E (BioMed Central, 2008)
    <p>Abstract</p> <p>Background</p> <p>The burning of biomass fuels results in exposure to high levels of indoor air pollution, with consequent health effects. Possible interventions to reduce the exposure include changing cooking practices and introduction of smoke-free stoves supported by health education. Social, cultural and financial constraints are major challenges to implementation and success of interventions. The objective of this study is to determine awareness of women in Gondar, Ethiopia to the harmful health effects of cooking smoke and to assess their willingness to change cooking practices.</p> <p>Methods</p> <p>We used a single, administered questionnaire which included questions on household circumstances, general health, awareness of health impact of cooking smoke and willingness to change. We interviewed 15 women from each of rural, urban-traditional and middle class backgrounds.</p> <p>Results</p> <p>Eighty percent of rural women cooked indoors using biomass fuel with no ventilation. Rural women reported two to three times more respiratory disease in their children and in themselves compared to the other two groups. Although aware of the negative effect of smoke on their own health, only 20% of participants realised it caused problems in children, and 13% thought it was a cause for concern. Once aware of adverse effects, women were willing to change cooking practices but were unable to afford cleaner fuels or improved stoves.</p> <p>Conclusion</p> <p>Increasing the awareness of the health-effects of indoor biomass cooking smoke may be the first step in implementing a programme to reduce exposure.</p>

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