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Forbidden Narratives: Critical Autobiography as Social Science explores overlapping layers of voices and stories that convey the social relations of psychiatric survivor participation within a community mental health service system. It is written from the perspective of a woman who, in the course of working with the survivor movement, had a physical and emotional breakdown. Ironically, the author found herself personally confronted with issues she typically dealt with only from a distance: as a mental health professional, a researcher, and an activist.The author of this volume writes herself i

Forbidden Narratives: Critical Autobiography as Social Science explores overlapping layers of voices and stories that convey the social relations of psychiatric survivor participation within a community mental health service system. It is written from the perspective of a woman who, in the course of working with the survivor movement, had a physical and emotional breakdown. Ironically, the author found herself personally confronted with issues she typically dealt with only from a distance: as a mental health professional, a researcher, and an activist. The author of this volume wri.

The last comprehensive literature review to examine the effectiveness of family planning (FP) services in delivering STI and HIV prevention and care was published in 2000. This review updates that report by examining evidence of the impact of integrating any component of STI or HIV prevention, care, and treatment into a family planning setting in developing countries. Forty‐four reports were identified from a comprehensive search of published databases and "grey literature." The weight of evidence demonstrates that integrated services can have a positive impact on client satisfaction, improve access to component services, and reduce clinic‐based HIV‐related stigma, and that they are cost‐effective. Evidence of FP services reaching men and adolescents and of their impact on health outcomes is inconclusive. Several studies found that providers frequently miss opportunities to integrate care and that the capacity to maintain the quality of care is also influenced by many programmatic challenges. The range of experiences indicates that managers need to determine appropriate health‐care service‐delivery models based on a consideration of epidemiological, structural, and health‐systems factors.

This article describes how researchers from a longitudinal study of early childhood service systems generated a visual representation of transinstitutionalization that could facilitate dialogue for change with a variety of audiences. Comprised of seven portable banners, the photo essay that we constructed features snapshots of documents and/or material objects brought forward by mothers, grandmothers, fathers and foster parents in the course of research interviews. Working the theme of tensions in disabled childhoods, we assembled the collection to produce sharp contrasts between the generalizing effects that institutional involvement has on disabled children, and the particular lives that they live out at home with family members. Proceeding banner by banner, the article reveals the "thinking through" that we did to produce the photo essay, and our hopes for informing action on a systemic relation whereby parents are held responsible for producing 'normal' children.

AbstractWe undertook a systematic review to assess 1) the level and quality of pharmacy and drug shop provision of medical abortion (MA) in low‐ and middle‐income countries (LMICs) and 2) interventions to improve quality of provision. We used standardized terms to search six databases for peer‐reviewed and grey literature. We double‐extracted data using a standardized template, and double‐graded studies for methodological quality. We identified 22 studies from 16 countries reporting on level and quality of MA provision through pharmacies and drug sellers, and three intervention studies. Despite widespread awareness and provision of MA drugs, even in legally restricted contexts, most studies found that pharmacy workers and drug sellers had poor knowledge of effective regimens. Evidence on interventions to improve pharmacy and drug shop provision of MA was limited and generally low quality, but indicated that training could be effective in improving knowledge. Programmatic attention should focus on the development and rigorous evaluation of innovative interventions to improve women's access to information about MA self‐management in low‐and middle‐income countries.

Context: Despite liberal abortion laws, safe abortion access in Zambia is impeded by limited legal awareness, lack of services, and restrictive clinical policies. As in many countries with restricted abortion access, women frequently seek abortions informally from pharmacies.Methods: We conducted 16 in‐depth interviews in 2019 to understand the experiences and motivations of pharmacy workers who sell medication abortion (MA) drugs in Lusaka.Results: We found that pharmacy staff reluctantly assume a gatekeeper role for MA due to competing pressures from clients and from regulatory constraints. Pharmacy staff often decide to provide MA, motivated by their duty of care and desire to help clients, as well as financial interests. However, pharmacy workers' motivation to protect themselves from legal and business risk perpetuates inequalities in abortion access, as pharmacy workers improvise additional eligibility criteria based on personal risk and values such as age, partner approval, reason for abortion, and level of desperation.Conclusion: These findings highlight how pharmacy staff informally determine women's abortion access when laws and policies prevent comprehensive access to safe abortion. Reform of clinical guidelines, public education, strengthened public sector availability, task sharing, and improved access to prescription services are needed to ensure women can legally access safe abortion.

This paper describes a community event organized in response to the appropriation and overreliance on the psychiatric patient "personal story" within mental health organizations. The sharing of experiences through stories by individuals who self-identify as having "lived experience" has been central to the history of organizing for change in and outside of the psychiatric system. However, in the last decade, personal stories have increasingly been used by the psychiatric system to bolster research, education, and fundraising interests. We explore how personal stories from consumer/survivors have been harnessed by mental health organizations to further their interests and in so doing have shifted these narrations from "agents of change" towards one of "disability tourism" or "patient porn." We mark the ethical dilemmas of narrative cooptation and consumption, and query how stories of resistance can be reclaimed not as personal recovery narratives but rather as a tool for socio-political change.

IntroductionIntegrating HIV with primary health services has the potential to reduce HIV‐related stigma through delivering care in settings disassociated with HIV. This study investigated the relationship between integrated care and felt stigma. The study design was a comparative case study of four models of HIV care in Swaziland, ranging from fully integrated to fully stand‐alone HIV care.MethodsAn exit survey (N=602) measured differences in felt stigma across model of care; the primary outcome "perception of HIV status exposure through clinic attendance" was analyzed using multivariable logistic regression. In‐depth interviews (N=22) explored whether and how measured differences in stigma experiences were related to service integration.ResultsThere were significant differences in perceived status exposure across models of care. After adjustment for potential confounding between sites, those at a partially integrated site and a partially stand‐alone site had greater odds of perceived status exposure than those at the fully stand‐alone site (aOR 3.33, 95% CI 1.98–5.60; and aOR 11.84, 95% CI 6.89–20.36, respectively). There was no difference between the fully stand‐alone and the fully integrated clinic. Qualitative data suggested that many clients at HIV‐only sites felt greater confidentiality knowing that those around them were positive, and support was gained from other HIV care clients. Confidentiality was maintained in various ways, even in stand‐alone sites, through separate waiting areas for HIV testing and HIV treatment, and careful clinic and room labelling.ConclusionsThe relationship between model of care and stigma was complex, and the hypothesis that stigma is higher at stand‐alone sites did not hold true in this high prevalence setting. Policy‐makers should ensure that service integration does not increase stigma, in particular within partially integrated models of care.

OBJECTIVE: Maternal and child health (MCH) care may provide an entry point for HIV services in high HIV-prevalence settings. Our objective was to assess integration of HIV with MCH services in public sector facilities in Swaziland. DESIGN: In 2009, 2010 and 2012, client flow assessments (CFAs) were conducted over 5 days in the MCH units of eight government facilities, purposively selected as intervention or comparison sites. PARTICIPANTS: 8263 MCH visits with female clients were tracked: 3261 in 2009, 2086 in 2010 and 2916 in 2012. INTERVENTION: Activities and resources to strengthen integration of HIV services into postnatal care (PNC), 2009-2010. MAIN OUTCOME MEASURES: The proportion of all visits in which an HIV/sexually transmitted infection (STI) testing, counselling or treatment was received together with an MCH service; the proportion of all visits in which a client receives HIV counselling. RESULTS: Across facilities, the proportion of visits in which HIV/STI and MCH services were received varied considerably, for example, from 9% to 49% in 2009. HIV/STI services were integrated most frequently with child health (CH), antenatal care (ANC) and family planning (FP)-the most common reasons for women's attendance-and least often with PNC and cervical screening (CS). There was no meaningful difference in integration over time by design group and considerable heterogeneity across facilities. Receipt of integrated services increased in one intervention and two comparison facilities, where HIV counselling also rose, and fell in one intervention and two comparison facilities. CONCLUSIONS: Provision of HIV/STI services with MCH care occurred at all facilities, yet relatively few women receive integrated services. Increases in integration were driven by increases in HIV counselling, while sharp declines in some facilities indicate that integration is difficult to sustain. Opportunities for intensifying HIV integration lie with ANC, CH and FP, while HIV-PNC integration will remain limited until more women attend PNC. TRIAL REGISTRATION NUMBER: Current Controlled Trials NCT01694862.

AbstractTask sharing is a strategy with potential to increase access to effective modern contraceptive methods. This study examines whether community health extension workers (CHEWs) can insert contraceptive implants to the same safety and quality standards as nurse/midwives. We analyze data from 7,691 clients of CHEWs and nurse/midwives who participated in a noninferiority study conducted in Kaduna and Ondo States, Nigeria. Adverse events (AEs) following implant insertions were compared. On the day of insertion AEs were similar among CHEW and nurse/midwife clients—0.5 percent and 0.4 percent, adjusted odds ratio (aOR) 0.92 (95 percent CI 0.38–2.23)—but noninferiority could not be established. At follow‐up 6.6 percent of CHEW clients and 2.1 percent of nurse/midwife clients experienced AEs. There was strong evidence of effect modification by State. In the final adjusted model, odds of AEs for CHEW clients in Kaduna was 3.34 (95 percent CI 1.53–7.33) compared to nurse/midwife clients, and 0.72 (95 percent CI 0.19–2.72]) in Ondo. Noninferiority could not be established in either State. Implant expulsions were higher among CHEW clients (142/2987) compared to nurse/midwives (40/3517). Results show the feasibility of training CHEWs to deliver implants in remote rural settings but attention must be given to provider selection, training, supervision, and follow‐up to ensure safety and quality of provision.

The impact of integrated reproductive health and HIV services on HIV testing and counseling (HTC) uptake was assessed among 882 Kenyan family planning clients using a nonrandomized cohort design within six intervention and six "comparison" facilities. The effect of integration on HTC goals (two tests over two years) was assessed using conditional logistic regression to test four "integration" exposures: a training and reorganization intervention; receipt of reproductive health and HIV services at recruitment; a functional measure of facility integration at recruitment; and a woman's cumulative exposure to functionally integrated care across different facilities over time. While recent receipt of HTC increased rapidly at intervention facilities, achievement of HTC goals was higher at comparison facilities. Only high cumulative exposure to integrated care over two years had a significant effect on HTC goals after adjustment (aOR 2.94, 95%CI 1.73‐4.98), and programs should therefore make efforts to roll out integrated services to ensure repeated contact over time.