Purpose: Mobile technology is increasingly being used to widen access to and support the delivery of public health interventions. Human immunodeficiency viruses (HIV) self-testing (HIVST) enables individuals to have autonomy. We evaluated the feasibility of a novel application called ITHAKA to support HIVST among youth aged 16-24 years in Zimbabwe.Methods: This study was nested within a trial of community-based delivery of integrated HIV and sexual and reproductive health services called CHIEDZA. Youth accessing CHIEDZA were offered provider-delivered HIV testing or HIVST supported by ITHAKA, either on a tablet on-site at a community centre or on their mobile phone off-site. ITHAKA incorporated pre and post-test counselling, and instructions for conducting the test and the appropriate actions to take depending on test result, including reporting HIV test results to health providers. The outcome was completion of the testing journey. Semistructured interviews with CHIEDZA providers explored the perceptions of and experiences with the application.Results: Between April and September 2019, of the 2,181 youth who accepted HIV testing in CHIEDZA, 128 (5.8%) initiated HIVST (the remainder opting for provider-delivered testing) using ITHAKA. Nearly all who performed HIVST on-site (108/109 (99.1%)) compared to only 9/19 (47.4%) who tested off-site completed their testing journey. Low digital literacy, lack of agency, erratic network coverage, lack of dedicated phone ownership, the limited functionality of smartphones challenged implementation of ITHAKA.Discussion: Digitally supported HIVST had low uptake among youth. The feasibility and usability of digital interventions should be carefully assessed before implementation, paying careful attention to digital literacy, network availability, and access to devices.

Purpose The ways family members engage and communicate with each other has significant impacts on well-being and coping strategies in the face of adversity, but there is a dearth of studies examining family functioning programming in humanitarian settings, particularly programs that incorporate a gender lens and engage multiple family members and genders. This study evaluates the Sibling Support for Adolescent Girls in Emergencies (SSAGE) intervention to understand the impact of gender transformative family programming on family functioning. Methods The 12-week SSAGE program engaged adolescent girls, their adolescent brothers, and their caregivers in Northeast Nigeria in synchronous sessions stratified by gender and age, with curricula exploring topics including gender-based violence, healthy relationships, and positive parenting. The two-week, post-intervention qualitative evaluation consisted of key informant and paired interviews, participatory research activities, focus group discussions, and in-depth interviews with 90 program participants and 12 program staff/mentors to understand the intervention’s impact on attitudes and behaviors around family gender roles. Results Findings revealed improved communication within families, bolstered by mentors’ encouragement to discuss program topics within households, and caregivers’ and siblings’ shift toward the use of healthier, non-corporal behavior control methods. Families described how the intervention promoted conversations around gendered issues including early marriage, education, employment, and puberty. Results This study builds the evidence base for gender transformative family functioning programming in humanitarian contexts. Practitioners should work to ensure safety of women and girls in future programming, particularly by focusing on communication skills and promoting gender norms change both within households and the community.

Household violence poses a significant threat to the physical and mental health of adolescent girls. In conflict-affected communities, increased stresses to safety, security, health, and livelihoods may heighten this risk. While it is widely evidenced that the caregiver-child relationship can increase or protect against girls’ risk of violence, less is known about the role of male siblings. Sibling Support for Adolescent Girls in Emergencies (SSAGE) used whole-family support programming to synchronously engage adolescent girls, their male siblings, and their caregivers in conflict-affected communities in Jordan and Niger, using gender-transformative approaches to explore the impacts of gender norms, power, and violence and encourage support and emotional connection. We conducted qualitative research activities, including focus group discussions, participatory group activities, and in-depth, paired, and key informant interviews with 469 SSAGE participants and program facilitators to explore SSAGE’s impact on the male-female sibling dyad in both settings. The multi-stakeholder team used a collaborative thematic analysis approach to identify emergent themes. Findings suggest that the inclusion of male siblings in family strengthening programs may have a positive impact on factors related to girls’ protection, with research participants discussing decreased perpetration of physical and verbal violence by male siblings, increased equity in household labor between siblings, and improved trust and mutual support among siblings. These changes were facilitated by improved communication and interrogation of positive gender identities. In humanitarian settings, interventions that support more gender-transformative, egalitarian, and emotionally effective relationships between male-female siblings can work towards improving girls’ protective assets. More research on the impact of this relationship on girls’ experience of immediate and long-term experience of violence is needed. In settings where gender power dynamics among male-female siblings are less salient, other relationship dyads should be explored.

While family functioning interventions show promise for improving adolescent girls' well-being in humanitarian contexts, few programs employ a gender-transformative approach to maximize benefits for adolescent girls. This paper presents findings from a mixed-methods pilot evaluation of a whole-family, gender-transformative intervention conducted with Syrian refugee families in Jordan. The Siblings Support of Adolescent Girls in Emergencies program was implemented with 60 Syrian refugee households in Azraq and Za'atari camps in Jordan. A quantitative survey was administered to 18 households at baseline and endline, and researchers conducted qualitative interviews and focus group discussions with caregivers, paired interviews and participatory discussions with adolescents, and key informant interviews with program mentors. Paired t-tests revealed statistically significant improvements in mental distress, resilience, and gender equitable attitudes in the full sample and for girls only and marginally significant improvements in family functioning. Qualitative findings revealed improvements in four domains of girls' well-being-self-efficacy, self-confidence, pro-social behavior, and mental health-through three primary pathways: family members' increased gender equitable attitudes, healthier intrahousehold communication, and greater affective involvement. Findings from this mixed-methods evaluation point to the potential value in merging gender-transformative and whole-family approaches in humanitarian programming to maximize positive impacts for adolescent girls.

Background Household violence is one of the most prevalent forms of gender-based violence faced by adolescent girls in humanitarian settings. A growing evidence base demonstrates the extent to which multiple forms of familial violence, including intimate partner violence, violence against children, and sibling violence overlap in the same households. However, existing evidence of family support programming that effectively reduces violence against girls by addressing intersecting forms of household violence are limited, particularly in the Global South. Through a qualitative implementation evaluation informed by a grounded theoretical approach, we explored the perceived impact of a gender transformative, whole-family support intervention aimed at building adolescent girls’ protective assets against violence, among program participants in two communities of internally displaced people Maiduguri, Borno State, Northeast Nigeria. Methods We conducted six in-depth interviews and six focus group discussions with adult caregivers; six participatory activities and four paired interviews with adolescent girls and boys; and 12 key informant interviews with program staff. Criterion sampling was used to recruit 21 male caregivers, 21 female caregivers, 23 adolescent boys, and 21 adolescent girls; purposive sampling was used to recruit 12 program staff to participate in qualitative research activities. We audio recorded, translated, and transcribed all interviews. In a collaborative coding process, a multi-stakeholder team used applied thematic analysis in Dedoose to identify emergent themes in the data. Results Participants reported a decreased tolerance for and perpetration of violence against girls at the household level, and endorsed their right to protection from violence at the community level. However, alongside these self-reported changes in attitude and behavior, aspects of normative, patriarchal norms governing the treatment of adolescent girls were maintained by participants. Conclusions This study builds the evidence base for gender transformative, whole-family support programming and its impact on preventing violence against adolescent girls in humanitarian emergencies. Situating our findings in a feminist analysis of violence, this study calls attention to the complexity of gender norms change programming amongst families in conflict-affected settings, and highlights the need for programming which holistically addresses the relational, community, and structural drivers of violence against girls in emergencies.

PURPOSE:HIV self-testing allows youth to access testing outside of healthcare facilities. We investigated the feasibility of peer distribution of HIV self-testing (HIVST) kits to youth aged 16-24 years and examined the factors associated with testing off-site rather than at distribution points. METHODS:From July 2019 to March 2020, HIVST kits were distributed on 12 tertiary education campuses throughout Zimbabwe. Participants chose to test at the HIVST distribution point or off-site. Factors associated with choosing to test off-site and factors associated with reporting a self-test result for those who tested off-site were investigated using logistic regression. RESULTS:In total, 5,351 participants received an HIVST kit, over 129 days, of whom 3,319 (62%) tested off-site. The median age of recipients was 21 years (interquartile range 20-23); 64% were female. Overall, 2,933 (55%) returned results, 23 (1%) of which were reactive. Being female (adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI] 1.03-1.31), living on campus (aOR 1.24, 95% CI 1.09-1.40), used a condom at last sex (aOR 1.44, 95% CI 1.26-1.65), and previous knowledge of HIVST (aOR 1.22, 95% CI 1.09-1.37) were associated with off-site testing. Attending a vocational college and teachers training college compared to a university was associated with choosing to return results for those who tested off-site (OR 2.40, 95% CI 1.65-3.48, p < .001). DISCUSSION:HIVST distribution is an effective method of reaching a large number of youth over a short period of time. Efforts to increase awareness and roll out of HIVST on campuses should be coupled with support for linkage to HIV prevention and treatment services.

Background Targeted HIV testing strategies are needed to reach remaining undiagnosed people living with HIV and achieve the UNAIDS’ 95-95-95 goals for 2030. HIV self-testing (HIVST) can increase uptake of HIV testing among young people, but user perspectives on novel distribution methods are uncertain. We assess the acceptability, perceived challenges, and recommendations of young adult lay counselor-led campus-based HIVST delivery among tertiary school students aged 18–24 years in Zimbabwe. Methods We purposively sampled participants from an intervention involving campus-based HIVST using lay workers for distribution. We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) among young adults from 10 universities and colleges in Zimbabwe who: (1) self-tested on campus; (2) self-tested off campus; and (3) opted not to self-test. We audio recorded and transcribed all interviews. Using applied thematic analysis, two investigators identified emergent themes and independently coded transcripts, achieving high inter-coder agreement. Results Of the 52 young adults (53.8% male, 46.1% female) interviewed through 26 IDIs and four FGDs, most IDI participants (19/26, 73%) favored campus-based HIVST, describing it as a more autonomous, convenient, and socially acceptable experience than other facility or community-based HIV testing services. Despite general acceptability, participants identified challenges with this delivery model, including: perceived social coercion, insufficient privacy and access to post-test counseling. These challenges influenced some participants to opt against self-testing (6/52, 11.5%). Recommendations for improved implementation included integrating secondary distribution of test kits and increased HIV counseling options into campus-based programs. Conclusions Barriers to HIV testing among young people are numerous and complex. As the number of new HIV infections among youth continue to grow worldwide, targeted strategies and youth friendly approaches that increase access to testing are needed to close the diagnostic coverage gap. This is the first study to describe young adult acceptance of campus-based delivery of HIVST by lay counselors in Zimbabwe.

Global injury research and policy too often fail to acknowledge the need for gender-sensitive approaches in their efforts to effectively reduce the detrimental burden of traumatic road injuries. A case example from Bangladesh demonstrates the distinct challenges females face and how addressing those are critical to achieving global health equity.

### Summary box The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak has grinded the world economy to a halt and upended health systems across the globe, contributing to disruptions in routine health services and skyrocketing rates of death.1 Against this backdrop, the pandemic highlights with renewed clarity the way structural violence operates both within and between countries. Defined as the discriminatory social arrangement that, when encoded into laws, policies and norms, unduly privileges some social groups while harming others, this concept broadens our thinking about drivers of disease.2 While the manifestation of inequity in each country or region is bound up in the local-to-global interface of historical, economical, social and political forces, COVID-19 disproportionately affects the world’s marginalised, from Black, Indigenous and People of Color (BIPOC) communities in North America to migrant workers in Singapore. …