Social and structural determinants of health are often spatially bound, limiting access to resources that influence health. Where people go and their interactions shape and are shaped by intersectional stigma, with profound potential impacts on health. Yet, further research is needed to understand how place intersects with intersectional stigma to affect people's daily lives and health. To inform place-based HIV prevention and care interventions in Baltimore, we conducted 20 in-depth interviews with Black sexual minoritized men. Interviews explored interrelationships between place, social relationships, intersectional stigma, life priorities, and health, and were audio-recorded and transcribed for analysis. Data were coded and thematically analyzed using a hybrid approach to identify emergent themes. Findings suggested an interplay between place-including material characteristics, spatially bounded social interactions, and symbolic meanings attached to different places-and their intersectional identities as Black sexual minoritized men. Place interacted with people's race/ethnicity, sexuality, and other social locations to affect whether participants felt welcome or uncomfortable, safe or under surveillance. Participants perceived the physical characteristics of places to affect health and well-being in positive and negative ways, through feelings of calmness or stress or access to food, transportation, housing, or health services. Access to healthcare and social services was clustered spatially and socially. Future research and interventions can (1) identify accessible places where people with intersectional identities feel welcome, comfortable, and safe; (2) address the spatial aspects of intersectional stigma; (3) prioritize belonging; and (4) couple structural, place-based interventions with individual-level interventions that support people in their daily lives.

Depression and anxiety symptoms are associated with increased unmet need for family planning (FP) postpartum, yet solutions promoting the integration of mental health into FP service settings remain scarce. The aims of this study were to quantitatively examine the immediate and longer term effects of participation in a group-based cognitive behavioral therapy (CBT) intervention called Mothers Time on (1) symptoms of depression and anxiety, (2) the use of a modern family planning method, and (3) intermediate FP-related factors among postpartum women in Ethiopia. Building from lessons learned during a feasibility study, we implemented a cluster randomized controlled design, with structured interviews delivered before (baseline), immediately following (endline), and fourxst months after implementation of the intervention (follow-up). A total of 302 postpartum women were recruited from 10 health clusters in northwest Ethiopia. In comparison to control clusters where participants received standard of care, intervention clusters showed significantly greater reductions in symptoms for both depression and anxiety from baseline to follow-up. Modern FP use also increased significantly more in intervention clusters as compared to control clusters from baseline to follow-up. Results suggest that more holistic FP services that consider postpartum mental health can both reduce postpartum depression and anxiety and support women in fulfilling their reproductive intentions.

Community Health Workers (CHWs) have an extensive involvement in augmenting service capacities in primary care settings. This study sheds light on the unique experiences of CHWs as they navigate barriers and enablers in the Philippine healthcare setting through their journey for professionalization. This study aims to: (1) Describe the roles assumed by CHWs in rural and remote municipalities in the Philippines; and (2) Identify the multi-level barriers and enablers CHWs perceive to influence their performance of these roles. From June to July 2023, the Philippine Primary Care Studies parent program piloted a study on a clinical decision support tool for CHWs, involving 34 CHWs across six focus group discussions. The interviews also touched upon the roles of CHWs and the factors influencing their performance within their local health settings in-depth. A mixed inductive/deductive approach was used to investigate this subset of the FGD data. CHWs assume diverse roles that often surpass health service provision. While their roles were crucial, CHWs described being positioned against a volatile political landscape fraught with material insecurity. They utilized their individual and interpersonal capacities to overcome situational limitations and were augmented with organizational level interventions like improved network connectivity, training, or expanded access to clinical decision-support tools. Amidst resource scarcity, CHWs demonstrated remarkable resilience through their own ingenuity and by maximizing support from their social networks. While their commitment is an asset to the health workforce, support from national policymakers and local governments units are crucial to ensure CHWs remain protected against systemic exploitation. Ensuring accountability and stronger implementation of pre-existing laws to ultimately recognize the role of CHWs are an essential way to support CHWs and improve community health.

OBJECTIVE:This study explores the relationship between pregnancy intentions and maternal health behaviours. DESIGN AND SETTING:Secondary data analysis of recent (2018-2023), cross-sectional demographic and health surveys from 18 sub-Saharan African countries. POPULATION:Survey respondents were women aged 15-49 years old with a child less than a year old who responded to survey questions about their pregnancy intentions for that child (N = 39 936). METHODS:Logistic regressions and meta-analysis using fixed effects explored the relationship between pregnancy intentions and maternal health behaviours across study countries adjusting for sociodemographic and contextual variables. MEASURES:Pregnancy intentions were defined as intended versus unintended. Maternal health behaviours included (i) early ANC, (ii) 4+ ANC contacts (ANC4+), (iii) 3+ doses of intermittent preventive treatment of malaria in pregnancy (IPTp3+), (iv) Mosquito net use in pregnancy, (v) receipt of tetanus toxoid and (vi) immediate breastfeeding. RESULTS:Overall, 25% of women did not want their index pregnancy (ranging from 13% in Burkina Faso to 49% in Gabon). Unintended pregnancies were associated with reduced odds of early ANC (aOR: 0.68, 95% CI: 0.63, 0.73), ANC4+ (AOR: 0.70; 95% CI: 0.65, 0.75), IPTp3+ (AOR: 0.87; 95% CI: 0.81, 0.94), receiving tetanus toxoid (AOR: 0.74; 95% CI: 0.68, 0.80) and immediate breastfeeding (AOR: 0.83; 95% CI: 0.80, 0.87). CONCLUSIONS:Study findings corroborate the role of reproductive health agency and pregnancy preparedness in optimising maternal health behaviours and subsequent outcomes. Integration of reproductive health services, malaria service delivery and social and behaviour change interventions can help to improve pregnancy outcomes.

BACKGROUND:Residential mobility, or a change in residence, can influence health care utilization and outcomes. Health systems can leverage their patients' residential addresses stored in their electronic health records (EHRs) to better understand the relationships among patients' residences, mobility, and health. The Veteran Health Administration (VHA), with a unique nationwide network of health care systems and integrated EHR, holds greater potential for examining these relationships. METHODS:We conducted a cross-sectional analysis to examine the association of sociodemographics, clinical conditions, and residential mobility. We defined residential mobility by the number of VHA EHR residential addresses identified for each patient in a 1-year period (1/1-12/31/2018), with 2 different addresses indicating one move. We used generalized logistic regression to model the relationship between a priori selected correlates and residential mobility as a multinomial outcome (0, 1, ≥2 moves). RESULTS:In our sample, 84.4% (n=3,803,475) veterans had no move, 13.0% (n=587,765) had 1 move, and 2.6% (n=117,680) had ≥2 moves. In the multivariable analyses, women had greater odds of moving [aOR=1.11 (95% CI: 1.10,1.12) 1 move; 1.27 (1.25,1.30) ≥2 moves] than men. Veterans with substance use disorders also had greater odds of moving [aOR=1.26 (1.24,1.28) 1 move; 1.77 (1.72,1.81) ≥2 moves]. DISCUSSION:Our study suggests about 16% of veterans seen at VHA had at least 1 residential move in 2018. VHA data can be a resource to examine relationships between place, residential mobility, and health.

Understanding everyday conversations about climate change may provide insights into framing the issue to promote climate change action. As part of a longitudinal online study in the US launched in June 2021, 805 respondents were asked if they had discussed climate change with a friend or family member in the prior month; if not, why not, and if yes, they were asked to delineate the conversation topic. Concurrent mixed methods were used to analyze the data. The majority (62.6%) of respondents reported not having a conversation about climate change in the prior month. Among those who indicated that they had discussed climate change, five themes were identified from the conversation topics, with many having reported discussing the impact of climate change on weather patterns. Very few discussed actions to address climate change, and most of these discussions focused on individual-level behaviors rather than collective actions. Among participants who had not recently discussed climate change, the most prevalent theme was that it was not a priority or an issue they cared about. Results suggest that conversations may not lead to collective actions and that policymakers and environmental organizations should provide guidance on effectively channeling climate change concerns into action.

Female sex workers (FSW) are highly mobile, which may result in reduced access to and use of health services and increased risk for poor health outcomes, particularly for those living with HIV. Mobility includes spatial, temporal, and social elements that are not fully captured by quantitative measures. We conducted two rounds of in-depth interviews with FSW living with HIV in Iringa, Tanzania (n = 20), and Santo Domingo, Dominican Republic (n = 20), to describe mobility experiences and compare mobility narratives across settings. We integrated a thematic analysis of all interviews with a narrative analysis of a subset of 10 information-rich interviews (five in each country) with women who had recently traveled, for sex work or another reason, outside of their hometown. Across narratives, FSW living with HIV traveled locally or to seasonal destinations, for short and long periods. Social factors influencing mobility included economic drivers; risk of arrest, harassment, or violence; anonymity and/or familiarity; social relationships; and clients’ mobility. Spatial, temporal, and social factors intersected in unique ways in FSW’s mobility experiences, yet distinct mobility typologies were evident across settings and destinations. Together, mobility narratives of FSW living with HIV can inform quantitative research on mobility typologies in Tanzania, the Dominican Republic, and elsewhere. With the potential for economic circumstances, climate change, and other emergencies to increase people’s mobility around the world, researchers and practitioners can learn from the lived experiences of FSW to inform whether and how to tailor and improve the accessibility of HIV care and treatment interventions based on spatial, temporal, and social characteristics of mobility.

IntroductionThis study investigated the clustering of health behaviors among US active duty servicemembers (ADSM) into risk profiles and explored the association between these profiles with ADSM sociodemographic characteristics and mental health status.MethodsThis study utilized secondary data from the 2018 Health Related Behaviors Survey (HRBS), a Department of Defense (DoD) self-administered online survey. Health behaviors included physical activity, screen use, sleep habits, tobacco/substance use, alcohol drinking, preventive health care seeking and condom use at last sex/having multiple sexual partners. Past-year mental health status was measured using the Kessler Screening Scale for Psychological Distress (K6). Latent class analysis (LCA) on health behaviors was used to cluster ADSMs into risk profiles. Multivariable logistic model was used to examine whether ADSM characteristics and mental health status were associated with ADSMs' risk profiles.ResultsThe LCA identified a four-class model that clustered ADSMs into the following sub-groups: (1) Risk Inclined (14.4%), (2) High Screen Users (51.1%), (3) Poor Sleepers (23.9%) and (4) Risk Averse (10.6). Over a tenth (16.4%) of ADSMs were categorized as having serious psychological distress. Being male, younger, less educated, in the Army, Marine Corps or Navy were associated with higher odds of being Risk Inclined (AOR ranging from 1.26 to 2.42). Compared to the reference group of Risk Adverse ADSMs, those categorized as Risk Inclined (AOR: 8.30; 95% CI: 5.16–13.36), High Screen Users (AOR: 2.44; 95% CI: 1.56–3.82) and Poor Sleepers (AOR: 5.26; 95% CI: 3.38–8.19) had significantly higher odds of having serious psychological distress.DiscussionStudy findings suggest opportunities to tailor behavioral and health promotion interventions for each of the distinct risk profiles. For example, ADSM described as Risk Inclined may benefit from preventive mental health services. Solutions for ADSM described as Poor Sleepers may include education on sleep hygiene; instituting duty schedules; and shifting military cultural norms to promote sleep hygiene as a pathway to optimal performance and thus military readiness. ADSM with low-risk behavior profiles such as those described as Risk Averse may prove beneficial in the roll-out of interventions as they act as peer-educators or mentors.

Background Mobility is a key social determinant of health for female sex workers (FSWs). While extant research has focused on the adverse effects of mobility for FSWs, there are very few studies that have examined the multiple ways in which mobility may impact the lives of these mobile women from their perspective. This qualitative study aims to fill this gap by exploring how mobility impacts the lives, livelihoods, and HIV care and treatment from the perspectives of women living with HIV in two epidemic settings, the Dominican Republic and Tanzania. Methods We conducted two rounds of in-depth interviews with 12 Dominican women and 12 Tanzanian women who were 18 years plus, had an HIV-positive diagnosis, and reported having exchanged sex for money in the last month. We utilized thematic analysis with a focus on intra- and intercomparisons to observe patterns within and across the two contexts. Results We identified a salient pattern of three thematic “mobility paradoxes,” which related to both disruptors and benefits of sex work mobility: (1) uncertainty versus autonomy: while sex work mobility often took place in contexts of vulnerability, which often led to women experiencing violence, it simultaneously benefitted women by allowing them to choose where they stayed and make plans on their terms; (2) financial insecurity versus profitability: although participants sometimes made less money than expected when they traveled for sex work, there was a powerful economic benefit for mobile women as it increased their likelihood of profitability; and (3) disorder and interruptions versus strategy and social support in HIV care and treatment: participants reported that they were sometimes inconsistent with their HIV appointments and medications when they traveled for sex work. On the other hand, mobility contributed to participants often becoming more strategic and creative in their HIV care and treatment and relying on one another for support. Conclusions Findings indicate that sex work mobility is a nuanced, complex, and paradoxical phenomenon. Implications include the development of strengths-based and community empowerment mobile health initiatives tailored to mitigate disruptors of mobility while maximizing benefits for this population.

It is unclear if there are any differences in the ways men and women perceive partner support in the context of family planning. The USAID-funded Social and Behavior Change Activity (SBCA) in Uganda explored male versus female priorities in the decision-making considerations and preferred measures of partner support related to family planning. Data were from a cross -sectional nationally representative telephone survey of 1177 men and women aged 18-49 years old in sexual partnerships. Key measures included current family planning use (Are you or your partner currently doing anything to prevent or delay becoming pregnant?); family planning decision-making considerations (In your experience, which of the following are the three most important considerations as you make family planning decisions?); and preferred partner support (What level of involvement would you like to see from your partner in your family planning decisions?). Multivariable logistic regressions explored factors associated with decision-making priorities and preferred partner support, adjusting for sociodemographic confounders. Two-thirds (66%) of men and women wanted a high level of involvement from their partner, which was associated with higher odds of using family planning (aOR: 2.46, 95% CI: 1.87-3.24). Specific ways partners could be involved included accompanying them to health services (39%), permitting them to get family planning services (26%), and jointly discussing family planning options (23%). Of note, more women wanted their partner to accompany them (45%) than men (33%) while more men (29%) wanted to jointly discuss options than women (15%). Social and behavior change interventions should operationalize partner support differently for men and women. Study findings were used to implement a health campaign that explicitly encouraged partner dialogue and support across the various life stages; empowering women with knowledge and skills to have honest conversations with their partners about birth spacing and timing.

Background High meat consumption negatively impacts human and planetary health. Meatless Monday (MM) is a widely known public health initiative that promotes healthy and sustainable diets by encouraging people to eliminate meat for one day each week. Objectives This study investigated whether exposure to MM, through practicing MM and receiving the MM e-newsletter, is associated with reduced meat intake on days other than Mondays. Methods This cross-sectional study analyzed survey responses from MM e-newsletter subscribers (n = 1172). Using logistic regression analysis, we investigated the relationship between practicing MM and additional changes in meat intake, including eliminating meat on more than one day per week, eliminating meat entirely, and incorporating more meatless recipes at home and when eating out. We also examined the relationship between the duration of time receiving the MM e-newsletter and meat consumption. Results Participants who reported practicing MM were 15 times more likely to eliminate meat more than one day per week compared to non-practicers (Adjusted Odds Ratio (aOR) = 15.1, 95CI 6.4 to 36.0, p < 0.001), three times more likely to eliminate meat entirely (aOR = 2.8, 95CI 1.3 to 6.0, p = 0.009), five times more likely to incorporate more meatless recipes at home (aOR = 4.9, 95CI 1.2 to 19.3, p = 0.024), and three times more likely to order more meatless meals when eating out (aOR = 3.1, 95CI 1.4 to 6.8, p = 0.007), respectively. Furthermore, participants who subscribed to the MM e-newsletter for longer were significantly more likely to eliminate meat more than one day per week or from their diet entirely. Conclusions MM could be used as part of a multi-pronged strategy to promote healthy and sustainable diets, offering a small-step approach that may lead to beneficial dietary changes for both people and the planet.

Communicating about actions to address climate change is critical to mobilize collective actions, and enact policies for climate change mitigation (prevention) and adaptation to climate change. The current study assessed factors associated with climate change action (CCA) communications in the US. Respondents were recruited through Prolific, an online survey research platform. The sample was restricted to the 599 respondents who reported that the issue of climate change was extremely or very important to them. Key outcome variables included (1) talking to family/friends about CCA, (2) texting/emailing family/friends about CCA, and (3) posting or sharing a post on social media about CCA. Multinomial logistic regression models examined correlates of CCA communications. Descriptive and injunctive social norms, barriers to CCA, and climate change distress were consistently significantly associated with engaging in the three CCA communication modalities in the prior month compared to never. This study's results suggest that talking with peers is the most common form of CCA communication, and is associated with social norms and distinct barriers to CCA. Organizations that address climate change should consider utilizing dialogical approaches to shift social norms related to CCA, and foster CCA communications and address barriers to CCA.

Objectives Early and adequate antenatal care (ANC) has been shown to reduce maternal morbidity and mortality globally. Increasing evidence suggests that women’s economic empowerment (WEE) is a critical factor that may influence uptake of ANC during pregnancy. However, existing literature lacks a comprehensive synthesis of studies on WEE interventions and their effects on ANC outcomes. This systematic review analyses WEE interventions at the household, community and national levels and their effects on ANC outcomes in low-income and middle-income countries, where the majority of maternal deaths occur. Methods Six electronic databases were systematically searched as well as 19 websites of relevant organisations. Studies published in English and after 2010 were included. Results Following abstract and full-text review, 37 studies were included in this review. Seven studies used an experimental study design, 26 studies used a quasi-experimental study design, 1 study used an observational design and 1 study was a systematic review with meta-analysis. Thirty-one included studies evaluated a household-level intervention, and six studies evaluated a community-level intervention. No included studies examined a national-level intervention. Conclusion Most included studies on household-level and community-level interventions found a positive association between the intervention and the number of ANC visits women received. This review emphasises the need for more WEE interventions that empower women at the national level, for the expansion of the definition of WEE to be more inclusive of the multidimensionality of WEE interventions and the social determinants of health, and the standardisation of ANC outcome measurement globally.

Objectives: In Nepal, where increasing numbers of married couples live apart due to migration, progress in reducing unmet need for family planning (UMN) is stagnant. This study aims to identify spatial patterns of UMN of married women and spousal separation in Nepal and explore associations between UMN and spousal separation at individual- and district-levels. Methods: We used 2016 Nepal Demographic and Health Surveys data to conduct spatial and multilevel logistic analyses. Results: This study shows evidence of similar geographical patterns in UMN of married women and spousal separation. At the individual level, women living with their spouses had 88% (aOR = 0.12, 95% CI 0.11-0.13) decreased odds of experiencing UMN compared to those living apart from their spouses. While not statistically significant, increasing odds of UMN were observed with higher prevalence of spousal separation at the district level. Conclusion: This study contributes to the existing literature by showing similar geographical patterns of UMN and spousal separation across Nepal and demonstrating both individual and contextual effects of spousal separation on UMN among married women. Theoretical and policy implications are discussed.

Attitudes and behaviors related to the COVID-19 pandemic and the climate change crisis might be driven by similar political beliefs and attitudes. The current study used a neo-Gramsci perspective to examine how political attitudes may be linked to COVID-19 prevention and climate change attitudes and behaviors. A longitudinal online survey in the US assessed climate change and COVID-19 attitudes and behaviors, and wave 7 (2021) data were used to predict outcomes at wave 8 (2022) among 572 respondents. There were significant correlations among the variables of political ideology, climate change concerns, COVID-19 vaccine hesitancy, COVID-19 skepticism, COVID-19 vaccine as a personal choice, COVID-19 conspiracy, political correctness, percent of Republican friends, and dislike of the Democratic Party. In the multivariate models, COVID-19 vaccination as a personal choice was significantly associated with the four outcomes: vaccination status, climate change actions, vaccine hesitancy, and climate change concerns. COVID-19 skepticism was significantly associated with vaccination status, vaccine hesitancy, and climate change concerns. These findings suggest that there are similar drivers of COVID-19 prevention and climate change attitudes and behaviors, and interventions need to be tailored to target individual-level and societal-level factors.

Background: While considerable research has explored associations between gender norms and various sexual and reproductive health behaviors (SRH) with the aim of informing programs, no studies have examined whether couple concordance on specific gender norms is associated with both contraceptive use and reduced intimate partner violence (IPV) experience.Methods: This study relies on analysis of Demographic and Health Survey (DHS) couples' datasets from Mali, Nigeria, Nepal, Pakistan, Tanzania, and Zambia that were collected in/after 2015 and include the DHS Domestic Violence Module for female respondents. To examine the associations between couple concordance regarding household decision-making or justification of violence (wife beating) and women's use of modern contraceptives or experience of violence, bivariate and multivariate logistic regression models were fit using Stata15.Results: Joint decision-making about large household purchases was significantly positively associated with modern contraceptive use in all study countries as well as with reduced odds of IPV experience in adjusted models in Tanzania and Zambia. In Nigeria, women's justification for violence was negatively associated with contraceptive use. Across settings, women in couples where both justified violence had significantly increased odds of reporting IPV experience.Conclusions: The evidence suggests that family planning programs should support joint decision-making as it was positively associated with contraceptive use across the six countries and is a proxy for shared economic power within the household. IPV reduction and prevention programs should also consider encouraging joint decision-making given the correlations found in two settings. Programs should enable participants to interrogate attitudes regarding justifying violence against female partners and propose approaches to avoid IPV. Finally, husbands' alcohol consumption, a strong predictor of IPV experience, has too long been overlooked.

Residential mobility remains an underexplored yet critical construct that may influence the risk of violence among women who exchange sex. This study examined the longitudinal relationship between residential mobility and experience of client-perpetrated physical or sexual violence among women who exchange sex in Baltimore, Maryland. Participants were at least at 18 years of age, were cisgender women, reported having engaged in transactional sex three or more times within the last 3 months, and were willing to be contacted for 6-, 12-, and 18-month follow-up visits. Analyses of responses from 370 women who exchange sex participating in at least one study visit were conducted. Unadjusted and adjusted Poisson regression models of the association over time between residential mobility and recent experience of physical or sexual violence were fit. Generalized estimating equations with an exchangeable correlation structure and robust variance estimation were used to account for clustering of participants' responses over time. Findings demonstrated that those who had lived in at least four places in the past 6 months had a 39% increased risk of client-perpetrated physical violence (aRR: 1.39; 95% CI: 1.07-1.80; p < .05) and a 63% increased risk of sexual violence (aRR: 1.63; 95% CI: 1.14-2.32; p < .01) compared to their less-mobile counterparts. These findings provide necessary evidence of correlations over time between residential mobility and experience of client-perpetrated violence among women who exchange sex. Strengthening our understanding of how residential mobility intersects with violence is critical for the development of public health interventions that are relevant to women's lives and needs. Future interventions should explore including residential mobility, a critical pillar of housing instability, with efforts to address client-perpetrated violence.

The authorization of several high-efficacy vaccines for use against the novel SARS-CoV2 virus signals a transition in the global COVID-19 response. Vaccine acceptance is critical for pandemic control and has a variety of context- specific drivers that operate at the individual, group, and sociopolitical levels. Social and behavior change interventions can influence individual knowledge, attitudes, and intentions as well as community norms to facilitate widespread vaccine uptake. While considerable research has been done to explore vaccine confidence in high-income populations as well as with respect to childhood vaccinations, much work remains to be done in understanding attitudes and intentions in low and middle income countries for adult or novel vaccines. We conducted in-depth interviews with individuals who had recovered from COVID-19 (n = 8), people who had lost a family member to COVID-19 (n = 4), and health providers (n = 17). We also conducted focus group discussions with members of the general population (n = 24 groups) to explore social norms and community perceptions related to COVID-19, including prevention behaviors, stigma, and vaccines. Researchers collected data in Abidjan, Côte d'Ivoire, in November 2020. In considering whether to accept a future COVID-19 vaccine or not, individuals in the study weighed perceived risk of the vaccine against the severity of the disease. Perceived severity of rumored side effects or safety issues of vaccines were also a factor. Convenience was a secondary, albeit also important, consideration. While concerns about vaccine safety tended to produce an expressed intention to delay vaccination, conspiracy theories about those developing and promoting vaccines and their motives led people to say they would opt out entirely. Behavior change interventions must raise awareness and address misunderstandings about the purpose of vaccines, transparently communicate about vaccine safety and development processes, and engage trusted influencers to build an enabling environment for COVID-19 vaccine roll out.

While vaccines are now authorized for use against the SARS-CoV2 virus, they remain inaccessible for much of the world and widespread hesitancy persists. Ending the COVID-19 pandemic depends on continued prevention behaviors such as mask wearing, distancing, hand hygiene, and limiting large gatherings. Research in low- and middle-income countries has focused on the prevalence of adherence and demographic determinants, but there is a need for a nuanced understanding of why people do or do not practice a given prevention behavior. The Breakthrough ACTION project led by Johns Hopkins Center for Communication Programs conducted a qualitative study in November 2020 in Côte d’Ivoire to explore people’s experience with and perceptions of the COVID-19 pandemic. We conducted 24 focus group discussions and 29 in-depth interviews with members of the general population and health providers. This analysis explores barriers and facilitators to seven recommended prevention behaviors with a particular focus on response efficacy, self-efficacy, and social norms. We found these constructs to be salient for participants who generally felt that the behaviors were useful for preventing COVID-19 but were difficult to practice for a variety of reasons. The perception that COVID-19 prevention behaviors were anti-social emerged as a key theme. Behavior change interventions must reframe the recommended behaviors as pro-social, while making them very easy to practice by removing social and structural barriers such as the expense or inaccessibility of masks and hand sanitizer.

Lack of trust in the health care system can serve as a barrier to service utilization, especially in pandemic and postemergency settings. Although previous research has identified domains of trust that contribute to individuals' trust in the health system, little research exists from low- and middle-income countries, particularly during and after infectious disease outbreaks. The current study-conducted to inform activities for a post-Ebola program-explored perceptions and experiences of health care provision in post-Ebola Guinea, with particular attention to trust. Researchers conducted in-depth interviews with health workers (n=15) and mothers of young children (n=29) along with 12 focus group discussions with grandmothers of young children and 12 with male heads of household. The study occurred in Basse Guinée and Guinée Forestière-2 areas hardest hit by Ebola. Respondents identified a breach of trust during the epidemic, with several domains emerging as relevant for renewed trust and care-seeking practices. At the core of a trusting client-provider relationship was the inherent belief that providers had an intrinsic duty to treat clients well. From there, perceived provider competence, the hospitality at the facility, provider empathy, transparency about costs, and commitment to confidentiality emerged as relevant influences on participant trust in providers. Community members and providers expressed similar viewpoints regarding trust and discussed the role of open communication and community mobilization in rebuilding trust. Study findings informed a variety of program activities, including the development of campaign messages and interpersonal communication trainings for health workers. This study provides valuable insight about some underlying components of trust that can provide key leverage points to rebuild trust and promote care seeking in postemergency settings. This insight is informing program activities in the current Ebola response in Guinea and could be useful in other crises, such as the global coronavirus disease (COVID-19) pandemic.