Access to energy is essential for resilient health systems; however, strengthening energy infrastructure in rural health facilities remains a challenge. In 2015–19, ‘Powering Healthcare’ deployed solar energy solutions to off-grid rural health facilities in Ghana and Uganda to improve the availability of maternal and child health services. To explore the links between health facility electrification and service availability and use, the World Health Organization (WHO), in partnership with Dodowa Health Research Centre and Makerere University School of Public Health, carried out an implementation research study. The objectives of this study were to (1) capture changes in service availability and readiness, (2) describe changes in community satisfaction and use and (3) examine the implementation factors of sustainable electrification that affect these changes. Data were collected through interviews with over 100 key informants, focus group discussions with over 800 community members and health facility assessment checklist adapted from the WHO’s Service Availability and Readiness Assessment tool. Implementation factors were organized using Normalization Process Theory constructs. The study found that access to energy is associated with increased availability of health services, access to communication technologies, appropriate storage of vaccines and medicines, enhanced health worker motivation and increased community satisfaction. Implementation factors associated with improved outcomes include stakeholder engagement activities to promote internalization, provision of materials and information to encourage participation, and establishment of relationships to support integration. Barriers to achieving outcomes are primarily health systems challenges—such as drug stockouts, lack of transportation and poor amenities—that continue to affect service availability, readiness and use, even where access to energy is available. However, through appropriate implementation and integration of sustainable electrification, strengthened energy infrastructure can be leveraged to catalyze investment in other components of functioning health systems. Improving access to energy in health facilities is, therefore, necessary but not sufficient for strengthening health systems. Improved energy access in rural health facilities is associated with increased availability of services (particularly at night), appropriate storage of vaccines and medicines, and health workers’ self-assessed ability to carry out maternal and child health-related tasks.Availability of sustainable energy in rural health facilities is associated with improved community satisfaction of available health services.Early and continuous engagement of stakeholders at the national, regional and local levels is required to ensure the suitable installation of energy infrastructure, community buy-in and participation, positive knock-on effects, and sustainability.Improving access to energy in health facilities is necessary, but not sufficient, for strengthening health systems and can support the strengthening of other health system components such as workforce retention, access to medicines and availability of essential equipment.Many primary healthcare facilities in low- and middle-income countries do not have adequate access to electricity. A 2013 review of nationally representative data in 11 countries in sub-Saharan Africa found that, on average, one in four healthcare facilities did not have energy access  Service Availability and Readiness Assessment (SARA) tool identifies access to energy as a core requirement of functional health facilities, essential for the operation of basic amenities, including lighting, refrigeration, sterilization, ventilation, communications and computer systems . It is aDespite these benefits, strengthening energy infrastructure in rural areas remains a challenge due to the lack of planning, maintenance, community participation, sustainable financing and institutional adaptability . ImproveIn 2015–19, the United Nations Foundation (UNF), with funding from the UK Department for International Development, supported the ‘Powering Healthcare’ programme in deploying solar energy solutions to rural health facilities in Ghana and Uganda. The intervention was implemented under the auspices of ‘Energy for Women’s and Children’s Health’ and sought to enhance access to reliable electricity for the delivery of maternal and child health services. To ensure the successful implementation and sustainability of the project, Powering Healthcare and UNF engaged multiple local and international partners across both the health and energy sectors.At the national levels, implementation partners included: All in Trade Ltd. in Uganda and Power World Ltd. in Ghana—both supported by the Solar Electric Light Fund. African Solar Designs Ltd., a Kenya-based renewable energy company, provided an initial needs assessment that informed the intervention. Ghana’s Ministry of Energy and Uganda’s Rural Electrification Agency were consulted and engaged in ensuring alignment with current and future government-led electrification plans. Stakeholders at different levels of the health system were engaged through Ghana Health Service and Uganda’s Ministry of Health to define service delivery needs and support the integration of energy infrastructure in health facilities.Electricity needs can be categorized into ambient lighting , task  and security (outdoor lighting for safety) ,b. AfricPowering Healthcare and UNF aimed to avoid these pitfalls through following recommendations made in the needs assessments and by national partners. They planned the installation of solar photovoltaic systems based on anticipated future energy load requirements rather than limiting system capacities to current needs, allowing for further potential investment in health facility capabilities. They planned community and stakeholder engagement activities targeted to different stakeholder groups and at various stages of implementation. And they worked with national implementers who have the skills and expertise necessary to monitor and maintain solar photovoltaic systems remotely. In doing all this, the goal of the intervention was the sustainable implementation of reliable energy infrastructure in rural health facilities to improve the delivery of maternal and child health services.For the intervention to achieve its goal, the integration of solar photovoltaic systems (electricity) into the daily operations and contexts of rural health facilities and the adoption of energy-dependent equipment are critical. Therefore, to understand the outcomes of the intervention, the implementation factors affecting the integration and adoption of energy capabilities must also be examined. To study the outcomes and implementation of Powering Healthcare’s approach to solar electrification of rural health facilities, UNF partnered with the WHO’s Alliance for Health Policy and Systems Research and the Department of Public Health, Environmental, and Social determinants of health. The objectives of the study wereTo explore changes in service availability and readiness following solar electrification of rural health facilities;To describe whether electrification of health facilities affects demand for, utilization of and satisfaction with maternal and child health services; andTo examine the effect of implementation factors on the adoption and integration of improved energy capabilities and their roles in achieving service availability, readiness and use outcomes.Seventy-nine percent of the general Ghanaian population has access to electricity, with regional and geographical variations . That isDuring a needs assessment to inform the selection of health facilities for electrification, African Solar Designs carried out 75 audits in six regions across Ghana, 87% of which were on CHPS compounds . They asUganda has one of the lowest electricity consumption rates in Africa, with the electrification rate at 27% nationally and 18% in rural areas where ∼83.6% of the population resides . In 2012Health governance in Uganda is decentralized and split across national and district levels. Health centre I represents the village level, offering preventative and health promotion services . Health During the needs assessment conducted in Uganda, African Solar Designs consulted 100 health facilities—48% of which were health centre II and 42% health centre III—to assess energy demand and supply . Based on the audit, priority was given to facilities that were off-grid and government-operated to ensure ownership and sustainability, located in priority districts with large populations, and providing maternal and child health services . Thirty-The theory of change for the intervention asserts that the availability of reliable electricity would improve the availability, readinessTo describe changes in community demand, use and satisfaction (objective 2), health facility records on attendance and focus group discussions (FGDs) around user perceptions and satisfaction with health facility infrastructure and service delivery were used.Finally, Normalization Process Theory (NPT) constructs were applied to examine the role of implementation factors in the adoption and integration of improved energy capabilities and their role in whether (or not) changes to service availability, readiness and use take place (objective 3). NPT is concerned with implementation , embedding (when behaviours and use become routine) and integration  . NPT posThis was a multi-country case study using mixed qualitative and quantitative methods to study the outcomes and implementation process of a rural health facility electrification programme 1-year post-installation. The in-country study was carried out by local research teams at Makerere University School of Public Health in Uganda and Dodowa Health Research Centre in Ghana. Research teams included research assistants, translators with research training for local languages and principal investigators. Research teams were not connected to the villages in which the research was conducted and had no source of pre-existing bias. Methods of data collection included key informant interviews, FGDs, administration of a health facility checklist, a review of facility records and administration of semi-structured questionnaire interviews. All data collection tools were tested during a training workshop in both Uganda and Ghana for the research assistants. Suggested prompts, based on NPT constructs, were included in semi-structured interviews. All interviews and FGDs were audio-recorded and supplemented by hand-written notes. In Uganda, from the 36 health facilities electrified, a randomly selected group of 25 Health facilities in the Kyegegwa, Kabarole, Kyenjojo, Kamwenge, Ibanda, Sheema, Bushenyi and Mitooma districts were included for study. These were selected using computer-generated identification numbers for each facility and random sampling. In Ghana, all 26 electrified primary health facilities—categorized as CHPS compounds—were included in the study.In both countries, community members included in the FGDs were selected using convenience and snowball sampling. Selection criteria for FGD discussants included: a pregnant or postnatal woman and/or caregiver of a child under the age of 5, who had sought maternal and child health services from the selected healthcare facility within a year, and living within 5 km of the facility. Participants were identified and recruited during antenatal care visit days at the health facilities, through referral from community members, and through self-selection. FGDs were conducted in a private setting and spanned an average of 1 h. All available health workers were recruited for semi-structured interviews lasting 1–1.5 h and taking place in a private room at the health facility. Health facility checklists were completed through observation and with input from health workers. Key informants were purposively sampled based on their roles and connections with the implementation of the project. They included district and local leaders, ministry staff, engineers and implementing partners. Interviews spanned ∼1 h and were conducted in person for most participants except those not living in the countries in which the study took place. Different individuals were sampled at baseline and endline due to the turnover of key informants and availability of community members; however, the stakeholder groups from which they were sampled remained consistent.In Uganda, a total of 432 and 500 community members seeking maternal and child health services participated in 25 FGDs at baseline and endline phases of the study, respectively. A total of 25 healthcare providers—one available at each facility—were interviewed using the semi-structured questionnaire, and 50 key informant interviews were conducted at baseline and endline. In Ghana, a total of 488 and 399 community members seeking maternal and child health services participated in 29 FGDs at baseline and endline phases of the study, respectively. A total of 45 and 36 health workers were available for interviews at baseline and endline phases, respectively, and 22 key informant interviews were conducted.Quantitative data  were analysed using STATA 14. Qualitative data  were analysed using the thematic content analysis. All FGDs and key informant interviews were transcribed verbatim and analysed using ATLAS.ti.8.0. Two research team members read the transcripts several times and independently developed codebooks using elements of service availability, readiness, use, satisfaction and NPT constructs described above to guide the process. The members discussed any issues and agreed on a final codebook. The transcripts were coded and categorized into emerging themes and sub-themes. Preliminary results were discussed with multiple stakeholders, and final analysis was reviewed and refined based on feedback from these discussions.The baseline health facility assessment in Ghana painted a picture of understaffed facilities with low capacity for delivering maternal and child health due to a lack of amenities, communication tools and equipment such as vaccine refrigerators and foetal dopplers. Only 2 out of the 26 facilities provided services 24 h a day for 7 days. Only 6 facilities had a midwife on staff, though 12 provided delivery services.In Uganda, the baseline assessment showed a similar staffing situation; however, more midwives were available than in Ghana, and clinical officers were also posted at health centres II and III as these operate differently to Ghana’s CHPS, which are more reliant on community health nurses. In Uganda, there were slightly higher readiness capabilities as more facilities had access to some form of electricity, albeit unreliable, as well as equipment such as vaccine refrigerators and autoclaves.Administration of the health facility checklist in Ghana revealed statistically significant changes in the availability of 24-h emergency services, access to a mobile communication device supported by the facility, access to a reliable source of electricity with no interruptions and availability of energy-dependent equipment such as vaccine refrigerators see . In UganSemi-structured interviews with health workers and FGDs with community members revealed potential for upcoming changes to service availability and readiness. For example, study teams in both countries noted plans by community members and by local decision-makers to build additional structures, including operating theatres, wells and housing for health facility staff  of those interviewed shared that since electrification, they have had adequate lighting to conduct tasks in the maternity department both during the day and at night—a change from 1 (2%) expressing the same at baseline see . In UganEmergent themes from health worker interviews, key informant interviews with district leaders, and FGDs with community members include changes in access to health workers, improvements in the quality of care they can deliver and an enhanced overall quality of life for staff. Health workers frequently reflected on improvements to their living situation. District leaders emphasized improved health worker perceptions towards being posted at newly electrified health facilities as well as full-time accessibility of health workers within the villages  of 488 community members claimed they were satisfied at baseline while 378 (94.7%) of 399 said the same at endline. In Uganda, 147 (34.0%) of 432 community members claimed they were satisfied at baseline, while 477 (95.4%) of 500 said the same at endline.Emergent themes around the satisfaction of community members with health facilities include use of the health facility at night, improved perceptions around safety, cleanliness and quality of care and a minor theme around pride and trust towards the health facility as a result of its improved infrastructure . This process was successful in mitigating design flaws that may have been more difficult to correct later. It also allowed implementers to better understand community expectations so that they could clarify their messaging during check-in visits.A major limitation of the study is that the period of observation post-implementation was too short at 1 year to demonstrate real change in outcomes and impact as it will take time for service delivery norms and community perceptions to change. In addition, many factors contribute to changing health outcomes, and energy is just one. The facilities selected were often lacking in many of the other elements of a strong health system, so it was difficult to measure and observe technical aspects of service delivery where necessary resources and technical equipment were unavailable.This study demonstrates that solar electrification of health facilities can be successfully implemented to achieve positive outcomes in service availability, community satisfaction and health facility readiness—specifically, communication capabilities, appropriate storage of vaccines and medicines and health worker motivation. The health system barriers identified in the study—such as drug stockouts, lack of transportation, limited human resources and poor amenities—demonstrate that improving access to energy is necessary but not sufficient for strengthening health systems. Through appropriate implementation and integration, energy infrastructure can be leveraged to stimulate ownership and investment in strengthening other components of well-functioning health systems. Implementation factors associated with improved outcomes include stakeholder engagement activities to promote the internalization of project aims (sense-making), provision of materials and information to encourage active participation (cognitive participation), and establishment of relationships to support integration and sustainment (collective action and reflexive monitoring).Future research studies could explore the impact of solar electrification on more technical aspects of care provision, including the use of specific equipment, the load required and training needs. This can facilitate service-specific energy needs assessments. Furthermore, cost-effectiveness evaluations of sustainable energy solutions are worth pursuing to provide insight into the financing implications of implementing similar interventions and negotiating purchasing, installation and maintenance, roles across sectors.This study has explored one comprehensive approach for bringing reliable energy supply to remote health facilities. The lessons learned here can help other governments, implementers and donors in designing similar interventions to strengthen health systems.


This special issue of Addiction Science & Clinical Practice, “Addiction treatment access and utilization among criminal justice involved populations”, presents a series of articles on substance use disorder treatment access and utilization by people who have contact with the criminal justice system . Despite the high prevalence of substance use disorders among people who experience these settings, evidence-based treatment for substance use disorders may be unavailable and/or care may be fragmented during transitions between settings. Articles in this special issue address several gaps in the literature and present a conceptual model of opioid overdose risk, the results of a randomized controlled trial to increase treatment uptake and retention during and after incarceration, descriptions of barriers to treatment after release from incarceration, and data from nationally representative surveys of substance use disorders and treatment use among people who have been involved in the criminal justice system. Importantly, the voices of people with lived experience in the criminal justice system were incorporated in two manuscripts. Together these articles advance our understanding of how to improve care coordination and expansion of services across systems and organizations to prevent overdose, improve treatment utilization, and ultimately, improve health outcomes among criminal justice involved populations in the United States who have substance use disorders or use substances. Adults in the United States (US) in jails, prisons, or courts have a high prevalence of substance use disorders , 2 and aAn estimated 58% of adults in US prisons and 63% in US jails have a substance use disorder, and 40% were using drugs at the time of committing the offense for which they were incarcerated . DespiteAddiction Science & Clinical Practice, “Addiction treatment access and utilization among criminal justice involved populations”, includes 10 articles that address substance use disorder treatment across criminal justice contexts, including prison, jails, and courts. We aimed to fill eight knowledge gaps among criminal justice involved populations: (1) Models for providing effective substance use disorder treatment and harm reduction; (2) Treatment and care coordination during the transition from incarceration to community settings; (3) The impact of criminal justice laws on substance use behavior, substance-related outcomes, and access to treatment and other services; (4) Overdose prevention; (5) Mental health and medical co-morbidities and their impact on substance use disorder treatment; (6) Health disparities in access to and utilization of substance use disorder treatment; (7) Patient-centered or technologically supported interventions to improve access to and utilization of effective substance use disorder treatment; and (8) Implementation approaches to increase uptake of evidence-based prevention and treatment practices. While more work is needed, the manuscripts in this special issue begin to inform some knowledge gaps, including models for providing effective substance use disorder treatment and harm reduction, treatment and care coordination during the transition from incarceration to the community, overdose prevention, and health disparities in access to and utilization of substance use disorder treatment.This special issue of Joudrey and colleagues contributed a novel conceptual model—The Post-Release Opioid-Related Overdose Risk Model—to guide an understanding of opioid-related overdose mortality after jail or prison release . The modSeveral articles in the special issue support aspects of Joudrey et al.’s conceptual model. They describe intervention programs and support services for patients with substance use disorders who were incarcerated or recently exited incarceration, including specific groups such as women. Two randomized controlled trials in the special issue focus on people incarcerated in prison. These studies aim to improve treatment initiation during incarceration and increase treatment continuation after release to the community. Ramsey et al.  present Two studies on the Transitions Clinic Network, comprised of 19 medical clinics scattered across the United States that treat formerly incarcerated individuals, provide a model to support healthcare access and utilization among people exiting prison. Chamberlain et al.  applied Mixed methods and qualitative studies identified barriers to substance use disorder treatment access and utilization, which can inform intervention program design to address specific treatment needs of incarcerated populations. Using surveys of people exiting jails, Owens et al.  quantifiFinally, three large nationally representative studies examined substance use and treatment among people with an incarceration history. Winkelman et al.  used NatWhile the array of articles in this special issue begin to address some important gaps in the literature, many gaps remain. Patient perspectives on substance use disorder treatment access and utilization is relatively understudied . Two artThere is a dearth of literature on criminal justice systems and substance use disorder treatment by country and criminal justice settings. Substance use treatment for criminal justice populations can vary widely by country, as well as within countries, and there may be existing international models that could inform the US research and treatment communities. The research in this issue primarily focuses on formerly incarcerated populations, but treatment for people on probation, parole, in jail, and in prison is also important. Studies that examine different treatments that are delivered (or not) in incarceration settings will inform the provision of care to correctional populations. Studies of other criminal justice contexts, such as law enforcement interactions and court systems, are also needed. Although there have been studies of drug courts , the delTo address these gaps, the methodology used in studies on substance use disorder treatment of criminal justice populations could be improved. For example, definitions of criminal justice involvement vary across studies such that work to standardize a definition is needed. Broadly, the use and elaboration of conceptual models, such as the one initiated by Joudrey et al.  are needThe prevalence of substance use disorders is high among people with a criminal justice history , but evi


Among young first-time mothers, participation in a comprehensive, community-based program led to a 3-fold increase in voluntary modern contraceptive use and other positive changes. These results demonstrate the importance of investing in interventions for this youth population that ideally address a range of priorities across the first-time parent lifestage. We implemented and evaluated a program to improve child spacing, modern contraceptive use, and related gender outcomes among first-time parents in Cross River State, Nigeria.Contraceptive awareness, attitudes, and couples’ communication increased significantly from baseline to endline.After controlling for significant factors related to family planning use, first-time mothers were 3.3 times more likely and male partners 3.7 times more likely to be using a modern contraceptive method at endline. Most first-time mothers and their partners preferred the contraceptive implant, and a smaller percentage chose the injectable.This experience suggests that local and state governments can adapt and scale up 3 essential program elements:Ensure the availability of modern contraceptive methods through local health facilitiesUse community-based health workers to conduct home visits with first-time parents to provide tailored health information and referrals, as well as build linkages with the formal health sectorInclude activities that address gender norms and couple dynamics to foster better alignment, communication, and joint action on reproductive issues  Reproductive health programs for youth have largely overlooked first-time parents (FTPs)—defined as young women younger than 25 years old who are pregnant or already have 1 child, and their partners. To address this gap, we implemented and evaluated a program to improve child spacing, modern contraceptive use, and related gender outcomes among FTPs in Cross River State (CRS), Nigeria. This paper examines the effectiveness of FTP interventions in improving voluntary uptake of contraception.We conducted small group sessions and home visits with FTPs from May to August 2018 in 2 local government areas of CRS. A pretest–posttest study examined the effectiveness of these interventions regarding healthy timing and spacing of pregnancy/family planning knowledge, attitudes, intentions, communication, decision making, and contraceptive use. We performed a bivariate analysis and logistic binomial regression to confirm change over time in the primary study outcome, current use of a modern method of contraception. We also performed analysis of demographic characteristics and secondary outcomes .P<.000), and from 44% to 81% among partners (P<.000). After controlling for significant factors related to family planning use, FTMs were 3.3 times more likely (P<.001) and partners 3.7 times more likely (P<.000) to be using a modern contraceptive method at endline.We interviewed 338 participating first-time mothers (FTMs) and 224 participating partners at baseline and endline. Important indicators of contraceptive awareness, attitudes, and couples’ communication increased significantly from baseline to endline. Voluntary current modern contraceptive use increased from 26% to 79% among nonpregnant FTMs (Program participation was associated with significant improvements in voluntary uptake of modern contraceptive methods and multiple secondary outcomes. Even within a short timeframe, this intensive, multi-intervention effort achieved significant advancements across healthy timing and spacing of pregnancy and family planning outcomes for this vulnerable youth population. As of May 2017, available national- and state-level data showed that sexual activity and motherhood began early. In CRS, 18% of adolescent girls aged 15–19 years have started childbearing.–,,As noted in a 2007 literature review by the World Health Organization–,Adolescent and young mothers also face critical barriers  in seeking health care and services.,In addition, adolescents and young women themselves have their own biases and misinformation about the risks and potential side effects of contraception, such as infertility, permanent damage to reproductive organs, infections, or cancer.First-time parents (FTPs)—defined as young women under age 25 who are pregnant or already have 1 child, and their partners—have largely been overlooked in reproductive health programs for youth. A 2014 review of global data showed that many first-time mothers (FTMs) are at increased risk of poor pregnancy, delivery, and child health outcomes, a situation compounded by multiple factors that limit their access to timely health information and services.First-time parents have largely been overlooked in reproductive health programs for youth.To address this gap in CRS, the Evidence to Action (E2A) Project, a global family planning project funded by United States Agency for International Development, and Pathfinder International/Nigeria launched a program to improve child spacing, voluntary contraceptive use, and related gender outcomes among FTMs and their male partners. Implemented through the Saving Mothers, Giving Life (SMGL) Initiative, and in partnership with the CRS Ministry of Health, the program focused on increasing access to HTSP and family planning information and services, as well as addressing the underlying social and gender factors that influence family planning communication, decision making, and action for FTMs and their male partners. The program applied both a life course and a socioecological lens to determine the appropriate content and structure of interventions with young FTMs, their husbands/partners, other key influencers, and the broader community.This article examines the effectiveness of community-based FTP interventions in improving FTPs’ demand for HTSP and their voluntary uptake of contraception through analysis of key indicators obtained from the baseline and endline survey results among program participants. These indicators, which were part of the initial conceptual model and reflect program content on HTSP and family planning, include intentions to space the next birth by at least 3 years; awareness of 3 or more modern contraceptive methods; belief that contraception will “spoil” or harm one’s reproductive organs, perceived approval from a male partner for a female partner to use contraception, recent partner communication about contraceptive use, perceived joint decision making about using a method of contraception, and finally, current voluntary use of a modern method of contraception.From 2014 to 2019, E2A and Pathfinder International worked closely with the CRS Ministry of Health and other partners to decrease the maternal mortality ratio and neonatal mortality rate and increase contraceptive use across the state through the SMGL Initiative. Using a systems approach, SMGL strengthened state, facility, and community networks to address the 3 delays that contribute to maternal mortality  and increase access to comprehensive family planning services, including long-acting reversible contraceptives, in 108 facilities in all 18 LGAs of CRS. Although the SMGL Initiative achieved reductions in facility neonatal mortality rate and facility maternal mortality ratio, the project team noted a persistent gap in reaching young women and mothers with family planning services at the community level, including those at risk of early childbearing and rapid repeat pregnancies.The SMGL Initiative noted a persistent gap in reaching young women and mothers, including those at risk of early childbearing and rapid repeat pregnancies.Informed by evidence from formative research conducted with FTPs in 2017 ,9 E2A deBOX 1Evidence to Action Project Formative Research Findings in Cross River State NigeriaNearly all FTMs and male partners agreed that birth spacing is beneficial for the mother, infant, and family, and could name at least one benefit of child spacing.Most FTMs and male partners could name or describe at least one modern family planning method, but did not know how to use any of the methods.Some FTPs were not sure whether family planning was safe and were concerned that its use might “spoil the womb,” thereby negatively affecting a woman’s future fertility. Married FTMs generally thought family planning was safe and beneficial, while unmarried FTMs  were less likely to believe that family planning is safe for young mothers to space their children.Several men mentioned that they prefer “the local method” of spacing (extended postpartum abstinence), and a few men mentioned that family planning is only appropriate for women who have finished childbearing or for women in school so that they can “concentrate on their studies.” Despite this apprehension about the safety of family planning, most reported that they would approve of their wives/partners using family planning if they wanted to do so to space their births.Evidence to Action conducted formative research with first-time mothers (FTMs), male partners, mothers of FTMs, and other respondents in Cross River State, Nigeria, in May 2017. The following key findings informed the design of the new first-time parent (FTP) componentThe formative research findings pointed to limited awareness and use of family planning services and a need to increase awareness across study sites. Recommendations also included provision of accurate and comprehensive information on family planning methods, providing effective counseling on family planning methods and services, and encouraging spousal communication to improve family planning decision making and uptake. The findings also noted young women’s/mothers’ limited use of health facilities, highlighting the need for community-based approaches that reach young people and link them to the larger health system.naira, or approximately US$55 at the time of the intervention) and transport allowance  to conduct activities. CVs were trained by project and CBO staff on priority health issues, including danger signs and 3 delays during pregnancy, HTSP and family planning, exclusive breastfeeding, positive parenting, and gender norms and barriers to accessing services. Trainings also stressed communication and facilitation skills, as well as project roles and responsibilities . CVs participated in implementing all elements of the FTP component and were the linchpin between different activities, especially in connecting FTPs and communities with health facilities. Field activities were closely monitored by project and CBO staff attending project activities to observe progress, provide supportive supervision, and assist with any troubleshooting. Three FTP interventions—FTM peer groups, small groups with husbands/partners, and home visits by CVs—were particularly important for improving family planning–related knowledge, attitudes, gender dynamics, and actions and for increasing access to family planning services.FTP interventions included peer group sessions with FTMs; small group sessions with the husbands/partners of peer group members; small group sessions with older women, typically the mothers or mothers-in-law of peer group members; home visits by Greater Hands Foundation community volunteers (CVs); community sensitization; and ongoing family planning service delivery at facilities and through mobile outreach. While the Greater Hands Foundation had already been active in these communities through SMGL, new FTP activities required increased CV capacity and engagement. E2A worked with the foundation to recruit 25 certified, but not yet employed, community health extension workers (CHEWs), a health worker cadre with 2–3 years of training and typically based in peripheral health facilities. Recruited CHEWs lived in FTP intervention communities and were awaiting their official Ministry of Health posting. These CHEWs (21 women and 4 men) served as CVs dedicated to reaching FTPs and received a monthly stipend  Peer Groups, Cross River State NigeriaHealthy timing and spacing of pregnancyProblem solving in intimate relationshipsLife aspirationsContraceptive methods: implants, injectables, oral contraceptive pills, condoms, emergency contraceptionGender normsCommunication and decision making among couplesDesired family sizeGender-based and intimate partner violenceExclusive breastfeedingPositive parentingEvidence to Action (E2A) adapted 12 activity cards from a toolkit developed by the Gender Roles, Equality, and Transformations (GREAT) project, led by the Institute for Reproductive Health of Georgetown University and implemented by Pathfinder International and Save the Children in Northern Uganda.The FTP program prioritized a structured intervention with the male partners of FTM peer group members, given their influence over health decisions, including family planning use, and their own needs. By design, the male partner intervention began after the FTM peer groups, giving FTMs time to determine if they wanted to include their husband/partners. Once identified by the FTMs, CVs and “male motivators” (the partners of FTM peer group leaders) invited husbands/male partners to the small groups. This peer-to-peer approach worked well, as men were comfortable discussing the proposed activity with other men and also appreciated knowing someone who would be in the group. In total, 20 male partner groups formed in July 2018, engaging 241 men, against a target of 200, in 6 weekly sessions. These sessions explored similar health- and gender-related topics as the FTM peer groups, including HTSP, modern contraceptive methods, gender norms/roles, fatherhood, and healthy relationships. Both male and female CVs led these sessions, as their status as community resource persons helped overcome any inhibitions felt by male participants. Almost all men (231 of 241) attended the full set of sessions.Under SMGL, CVs conducted home visits during pregnancy, immediately after delivery, and 6 weeks postpartum to support maternal and infant health outcomes. The FTP component supported home visits further into the extended postpartum period for FTM peer group members. CV visits focused primarily on HTSP/family planning information, counseling, and referral services, but also addressed other pre- or postnatal issues as relevant. CVs conducted 4–6 home visits with each peer group member from May to August 2018, often at the request of the FTM or male partner, or in follow-up to an earlier conversation or referral. As much as possible, CVs made an effort to engage male partners, older women, and other household members, and often helped to address different or conflicting perspectives on possible health actions. Home visits accounted for the majority of family planning referrals given and completed. The multiple points of contact over the 4-month intervention period proved instrumental in building FTPs’ trust and confidence in CVs and, importantly, creating linkages with the broader health system.This evaluation employed a quantitative pretest-posttest design with program participants to evaluate outcomes related to knowledge, attitudes, and behaviors on family planning and HTSP, exclusive breastfeeding, child development and parenting, and gender-equitable relationships between FTMs and their male partners. All data collection tools were piloted for suitability, reliability, coherence, and clarity; corrections were made as needed. Baseline and endline structured interviews were carried out using precoded questionnaires administered to FTMs and their male partners who were members/participants of intervention groups , before and after participation in these groups.The evaluation focused on knowledge, attitudes, and behaviors on family planning and HTSP, exclusive breastfeeding, child development and parenting, and gender-equitable relationships.P<.05 level of significance with a design effect of 2.0. A 2-stage  cluster sampling scheme was used to sample FTM respondents. The research team proportionately allocated the FTM sample (N=300) among each of the 2 LGAs based on the total number of participants and peer groups in each LGA. The study team randomly sampled respondents at both baseline and again at endline from the same 32 FTM peer groups. Due to the smaller size of the male partner program, a research team interviewed all male partners participating in the program from each of the 20 male partner groups at baseline and endline. The final achieved sample size was 338 FTMs at baseline, 339 FTMs at endline, 245 male partners at baseline, and 225 male partners at endline  from an assumed baseline value of or near zero. This would yield a sample detecting a significant difference from baseline to endline at the  endline .The study protocol and other required documents were submitted to the Government of CRS of Nigeria Health Research Ethics Committee (CRS-HREC) in Calabar, Nigeria, and to PATH’s research determination committee (RDC) in the United States in late 2017. E2A and Pathfinder International received approval to proceed with the research from the CRS-HREC on March 2, 2018. On February 26, 2018, PATH’s RDC approved the application and determined it to be “not research,” therefore obviating the need for any additional U.S.-based institutional review board review, including PATH/US institutional review board.Baseline data collection took place May 9–18, 2018, for FTMs and July 9–15, 2018, for male partners, and endline data collection for both FTMs and male partners took place from August 20 to September 2, 2018. At baseline, interviews took place during the initial group activities; a trained research team conducted private, one-on-one interviews with recruited FTMs and male partners/fathers who agreed to enroll in their respective group-based activities and consented to participate in the study. At endline, participants were recruited for private one-on-one interviews at the conclusion of the final group session. The research team of field-based staff conducted face-to-face structured interviews using standardized, precoded questionnaires at both baseline and endline. For all interviews, participants received a summary of the study and were requested to sign a consent form (with provisions for thumbprint signatures). Signed consent was obtained and a copy given to participants. Interviews were conducted in either English or Pidgin language.The research team collected data using Android-based mobile phones with the Open Data Kit application. The mobile phone data entry application included built-in consistency checks and skips. The research team uploaded the dataset to a platform storage server, where it was monitored centrally during the period of field data collection. The team then downloaded the dataset to Excel and cleaned, labeled, and checked it for inconsistencies.SPSS Version 22 was used to perform a descriptive data analysis, using simple frequencies and bivariate analyses. Based on the sampling scheme, the baseline and endline FTM samples (which were randomly generated at both times) were treated as independent samples, and the male partner samples were treated as nonindependent repeated measures. Although FTMs were randomly recruited at baseline and endline, the peer groups to which they belonged were the same at baseline and endline. Therefore, the authors of this study conducted a post hoc analysis of independence between the 2 FTM samples and determined that about 75% of the sample at baseline was included again at endline. A sensitivity test was therefore conducted with only the repeated measures subset to confirm the robustness of the analysis and the statistical significance of the FTM findings. All statistical comparisons of the FTM data presented in this paper were reanalyzed as repeated measures using McNemar’s test of significance for categorical data and the paired t-test for continuous data, both with and without complex sampling (based on 2-stage cluster sampling), using the subsample of participants measured at both baseline and endline. Significance levels of these findings did not vary from the analysis of independent samples. Therefore, 1-tailed Pearson chi-square tests for categorical data and analysis of variance F-tests for continuous data were used to present the statistical significance of differences between baseline and endline and other variables of interest among FTMs. In addition, a logistic regression analysis of current use of modern contraceptive methods by FTMs was also performed to determine if a significant change took place over the course of the interventions in the uptake of contraception after controlling for key demographic variables, partner characteristics, couple communication, and attitudes.A different analytical approach was used for the male partner sample, as it was a census of all program participants (and thus the samples were not independent). The unmatched sample was dropped (n=21), and the McNemar’s test and paired t-test were used to present statistical differences at baseline and endline using the matched sample (n=224). In addition, all statistical comparisons of the male partner data presented in this paper were analyzed using these tests with and without complex sampling (based on 2-stage cluster sampling). Significance levels of these findings did not change based on adjusting for 2-stage cluster sampling, remaining highly significant.The baseline and endline survey data provided useful information about the characteristics of FTMs and a subset of their male partners who joined and stayed engaged in interventions. While some recruitment inclusion criteria were set for FTM peer group members  and their male partners (identified and nominated by interested/willing FTM participants), activities were otherwise open to FTMs and male partners who wanted to participate. At baseline, most FTMs reported that they were not married/living with their partner , and 68% of a subset of nominated male partners (N=245) reported that they were either married or living with their partner. The majority of FTM participants (86%) had 1 child with a mean age of 6.9 months at baseline, with another 14% pregnant with their first child. The data also show that most (90%) male partners enrolled in the program were also first-time fathers. A majority of both FTMs and male partners who participated in the FTM program reported completing a secondary or higher level of education. Although most (85%) male partners reported being currently employed at baseline, only about one-third of FTMs (36%) reported working at baseline, likely due to their recent pregnancy and delivery.Between baseline and endline, FTMs had a few significant differences in some of these variables. FTMs at endline were slightly older (21.1 years of age) than at baseline (20.6 years of age), as were their babies, largely due to the 4-month interval between data collection efforts for FTMs.  In addition, by endline, FTMs were more likely to be in union or married and were more likely to be working to earn money than at baseline. As expected, no significant differences were noted among male partners from baseline to endline with respect to these key demographic variables.P<.000, Pearson chi square) and 88% of male partners preferred no more children or to wait 3 years or longer . Importantly, an alignment in birth spacing intentions generally occurred for both FTMs and male partners.One of the key messages of the FTP interventions was to encourage a spacing gap of 3 years or more between births. One of the key messages of the FTP interventions was to encourage a spacing gap of 3 years or more between births.P<.000, Pearson chi-square), and among male partners from 38% at baseline to 75% at endline .The FTM and male partner interventions emphasized knowledge and use of postpartum contraception. Knowledge of modern contraceptive methods increased over the course of the interventions, with the percentage of FTMs and male partners who could spontaneously recall at least 3 modern methods increasing significantly see . The perP<.000, Pearson chi-square) and 7% of male partners held this belief .A key finding from formative research conducted prior to the FTP interventions was that many FTMs and their male partners believed that using contraception can damage a woman’s reproductive organs and create difficulties in conceiving or can even cause permanent sterility after discontinuation. Thus, most believed that it is best for a woman to use contraception for limiting fertility only after achieving one’s desired family size. Correcting this misconception was an area of focus throughout the interventions. P<.000, Pearson chi-square test) at endline .Husband’s or partner’s approval for using a method of contraception  may be a critical factor in facilitating an FTM who is married or in union to accept and use contraception. FTMs were asked if they thought that their husband/partner would approve if they wanted to use a method of contraception to space their next child, and male partners were asked if they themselves would approve of their wife/partner using a method of family planning, as well as whether or not they would give her money to seek family planning services. At baseline, only about two-thirds (67%) of the FTM participants thought that their partner would approve of their use of family planning to space their next child, which increased significantly to 80%  and increased significantly among male partners from 69% to 91% . Discussions among FTMs and male partners with other influential people also increased from baseline to endline (data not shown), from 28% to 55% for FTMs (P<.000) and from 17% to 42% for male partners . When asked with whom they discussed family planning in the past 3 months, FTMs were most likely to report discussing family planning with a mother (43%), sister (34%), or friend (51%) at endline ; male partners were most likely to discuss family planning with a friend (73%) or a brother (21%) at endline .Having discussions with one’s partner or other influential people is often associated with interest in and voluntary use of family planning. The FTP interventions included activities and discussion around partner communication on family planning and birth spacing. Having discussions with one’s partner or other influential people is often associated with interest in and voluntary use of family planning.P<.000, Pearson chi-square) of FTMs and 99%  of male partners agreed that using family planning should be a joint decision. Perhaps even more important, relatively few FTMs reported that husbands/partners were the primary decision maker about family planning, suggesting that contraceptive use was largely voluntary for these young women.Both FTMs and male partners were asked at baseline and endline about decision-making responsibility for using family planning (data not shown). The percentage of FTMs and male partners who reported that they should decide together to use family planning was high even at baseline: 82% (N=338) of FTMs and 88% (n=224) of male partners agreed that using family planning should be a joint decision before the intervention. However, this percentage significantly increased for both participant groups by endline; by the end of the intervention, 96% , and from 44% to 81% (n=200) among male partners . Importantly, other positive changes in family planning knowledge, attitudes, communication, and decision making all support the overall increase in informed, voluntary contraceptive use by FTP participants.The key objective of the FTP interventions was to increase current voluntary use of a modern contraceptive method. P<.001) with adjusted odds ratios of 3.3 for FTMs and 3.7 for male partners. This means that modern contraceptive uptake significantly increased from baseline to endline for both groups of participants. In other words, after controlling for hypothesized predictors of family planning use, including demographic factors  and all attitudes related to family planning use presented in this report , FTMs were approximately 3 times more likely and male partners nearly 4 times more likely to be using a modern family planning method at endline, compared with baseline.A logistic regression analysis was also performed to confirm the bivariate findings above, predicting current use of any modern family planning method  among both FTMs and male partners . All relevant demographic variables were included in the model, as well as attitudes toward family planning, couples’ discussions about family planning, perceived partner approval and joint decision making for family planning, as well as a variable representing the survey wave . This analysis revealed that for both FTMs and male partners, survey wave was highly significant . Importantly, use of implants aligns with the overall spacing intentions (majority reported 3 or more years) indicated by both FTMs and male partners at endline.This article has highlighted selected results of a program designed to address some of the critical barriers faced by young FTMs and their male partners in using family planning to space their second and subsequent children. Implemented by local organizations and resource persons, the interventions aimed to increase HTSP awareness and intentions, build awareness of modern contraceptive methods, dispel key myths and misperceptions about family planning, address gender norms and barriers, increase social and partner support for family planning use, and provide referrals and facility linkages for obtaining specific contraceptive methods. We examined key HTSP and family planning indicators among participating FTMs and their male partners to determine if they successfully changed attitudes and behaviors related to birth spacing and voluntary contraceptive use over the course of the program.This intervention evaluation included a coordinated baseline and endline questionnaire among a scientific and robust sample of FTM participants and a census of male participants using a trained team of interviewers and digital mobile data collection tools. The results show that the interventions attracted and retained a diverse range of FTMs and male partners  and was successful in improving birth spacing intentions and current use of contraceptive methods from baseline to endline, even after controlling for key sociodemographic and attitudinal variables. Important indicators of contraceptive awareness, attitudes, and couples’ communication increased significantly from baseline to endline, and also significantly predicted current use of a modern contraceptive method over the course of the intervention. Along with overall increased contraceptive uptake, FTMs and their partners chose to use more effective and/or long-acting methods (injectables and implants), perhaps reflecting, in part, their longer birth spacing preferences, interest in a newly introduced method (implant), as well as the recent increased availability of these contraceptives locally.The interventions were successful in improving birth spacing intentions and current use of contraceptive methods from baseline to endline.These positive findings should be interpreted with several limitations in mind. This study relied on self-reported information gathered during face-to-face interviews, subject to both courtesy and recall bias. This bias was minimized through training of interviewers and design of the questionnaire. Another limitation is related to the possibility that other family planning activities took place in CRS, Nigeria, in the same or nearby geographic areas, which also may have resulted in increased health knowledge and behaviors including a high level of family planning uptake by program participants; however, Pathfinder International’s CRS program staff reported that no other family planning-related partner activities had taken place concurrently in Ikom or Obubra LGAs. In addition, participants might have changed between the pretest and the posttest regardless of the interventions because they are maturing and learning, especially as parents of young infants. This limitation was minimized by ensuring that baseline and endline data collection coincided tightly with program implementation. A final limitation is related to the self-selection of program participants and propensity of more empowered individuals  to participate. While it is highly likely that participants had some propensity toward the information and messages received during the program, baseline attitudes and knowledge were consistent with findings from the formative research (described previously).While previous E2A FTP projects primarily focused on activities with FTMs related to HTSP/family planning, the interventions in CRS engaged male partners more systematically. We included group activities with a subset of nominated male partners of FTM peer group members to address gender norms, increase male engagement in HTSP and family planning, and promote couple communication and joint decision making. Specific activities were included to generate evidence on both the implementation experience and on health and family planning outcomes for FTMs and their male partners emerging from this programming effort. Importantly, endline results show that FTMs and their partners were generally aligned on key family planning attitudes and birth spacing intentions, which may have facilitated increased contraceptive use and method choice. These results suggest that couple-oriented interventions or joint activities can work well—even in a context in which many FTPs are not in formal unions or necessarily living in the same household.Our experience in CRS suggests that FTMs and male partners may be particularly open to HTSP and family planning use because they face the practical and financial realities of raising a child. Community-based resources like CBOs, CVs , peer leaders, and others provided FTPs with tailored and timely access to information and services, as well as linkages with health facilities critical to ensuring access to a full range of needed services. Many FTMs do not routinely access health facilities or may not be ready to consider family planning options when they do. Therefore, such approaches may work better than only integrating family planning into clinic-based services , especially where there are inequities in access to and use of health care by young FTMs.While our project included multiple interventions focused on FTPs, all activities were implemented over a 4-month period through existing health facilities and a local CBO, using trained and certified (but not yet employed) CHEWs. Several elements, such as home visits, community outreach, and the provision of modern contraceptive methods, were already included within the general mandate of the primary health care system. Building on existing community- and facility-based resources to identify and reach FTPs with tailored activities generated compelling results and provided a model that can be adapted based on available resources and scaled-up across the state.The E2A experience in CRS shows that tailored interventions with FTPs can achieve important HTSP and family planning results within a relatively short time frame. FTMs and partners are coping with multiple challenges as new parents and are receptive to information and options that allow them to delay subsequent births. The emerging high demand for family planning across diverse FTMs and partners—especially for more effective and longer-acting contraceptive methods—underscores the importance of engaging FTPs during this critical moment in their reproductive lives. In particular, the CRS experience suggests 3 essential program elements: (1) ensuring the availability of modern contraceptive methods  through local health facilities; (2) using locally based resource persons or community-based health workers to conduct home visits with FTPs to provide tailored health information and referrals, as well as build linkages with the formal health sector; and (3) using activities that address gender norms and couple dynamics to foster better alignment, communication, and joint action on reproductive issues. All activities can be implemented through locally based resource persons, who are best positioned to identify and reach young FTPs of different characteristics and situations. The results that can be achieved, along with high levels of engagement from FTPs, demonstrate the importance of investing in these types of interventions, ideally addressing all priorities for family planning, reproductive health, and maternal, neonatal, and child health across the FTP lifestage, from pregnancy through the postpartum period.


This paper presents an empirically grounded call for a more nuanced engagement and situatedness with placial characteristics within a spatial epidemiology frame. By using qualitative data collected through interviews and observation to parameterise standard and spatial regression models, and through a critical interpretation of their results, we present initial inroads for a situated spatial epidemiology and an analytical framework for health/medical geographers to iteratively engage with data, modelling, and the context of both the subject and process of analysis. In this study, we explore the socioeconomic factors that influence homicide rates in the Brazilian state of Alagoas from a critical public health perspective. Informed by field observation and interviews with 24 youths in low-income neighbourhoods and prisons in Alagoas, we derive and critically reflect on three regression models to predict municipal homicide rates from 2016–2020. The model results indicate significant effects for the male population, persons without elementary school completion, households with reported income, divorced persons, households without piped water, and persons working outside their home municipality. These results are situated in the broader socioeconomic context, trajectories, and cycles of inequality in the study area and underscore the need for integrative and contextually engaged mixed method study design in spatial epidemiology. Immense increases in computational capability, data availability, methodological sophistication, and ease-of-implementation have facilitated rapid growth in the number of studies under the broad umbrella of applied spatial epidemiology. Studies range from mapping and visually evaluating point patterns of disease to geographical correlation studies and multivariate analysis using complex Bayesian spatiotemporal lag models and spatially aware artificial intelligence . The devIn contrast to epidemiology as a global/public health practice, in which individual case-level analysis, fieldwork, and social, political, economic, and cultural contexts play a significant role, spatial epidemiology within academic spheres tends to direct more focus towards the analyst-level. Concretely, this tendency has positioned the practice of applied spatial epidemiology research as a spatial variant of public health epidemiology , wherebyDrawing on previous efforts to integrate qualitatively/critically-informed conceptualisations of place in spatial epidemiological analysis ,7,8, thiIn 1996, the World Health Organisation passed Resolution WHA-49.25, in which interpersonal violence was framed as a leading public health problem worldwide. The most recent United Nations Global Study on Homicide estimates that 465,000 persons were victims of homicide in the year 2017, of which 64,078 were reported in Brazil alone , with 18The majority of homicides in Alagoas occur in the capital city of Maceió, one of 102 municipalities in the state. The structure of the city uniquely features many wealthy neighbourhoods directly adjacent to impoverished/less affluent areas, known as favelas (unplanned hillside settlements), grotas , deprived bairros (un/planned urban neighbourhoods), and conjuntos habitacionais  . FavelasThe physical infrastructure of informal settlements is often insufficient for the needs of residents. The buildings are multifunctional in design in order to meet both occupational and domestic needs , but theThe relationship between socioeconomic deprivation and violence has been intensively studied in a health/medical geographical context in recent decades, with the wide majority of analyses indicating a strong positive covariance between socioeconomic deprivation and interpersonal violence, i.e., that counts and rates of violence tend to be higher in more deprived countries , regionsIn the Brazilian context, socioeconomic conditions are known to play a significant role in violence incidence . SocioecIn previous spatial epidemiological studies of violence, it has been demonstrated that income measures, (un)employment, and educational attainment can function as useful predictor variables ,22, inclThe role of educational attainment is well understood to be a vital element in the linkages between socioeconomic deprivation and violence . The impIn the Brazilian context, sex/gender also appear to exhibit a significant role in violence and homicide. The observed demographic involved in violence and homicide, both as perpetrator and victim, is disproportionately young and poor, self-identifies as black and male, has little or no access to education, and inhabits spaces of extreme wealth inequality, dominance of informal economies, and a high concentration of organized crime ,25,26,28However, Brazilian women experience very high rates of violence, often occurring within the household or from an intimate male partner. The rates of femicide in Maceió  are more than double the national average (4.8) . These rThis study features two distinct objectives: (i) to provide an initial exploration of the utility of local knowledge for informing and situating the practice of spatial epidemiological analysis in an applied research sphere, and; (ii) to test for aspatial and spatial associations between area-level socioeconomic deprivation and homicide through a public health lens.The empirical methods for this analysis were conducted in three phases: (i) a snowball review of the studies on violence and socioeconomic deprivation was conducted and qualitative data were collected via transcribed interviews and participant/field observation; (ii) based on the results of the first phase, we selected candidate variables from the Brazilian census and acquired homicide data at the municipal scale in Alagoas. These variables were entered into an aspatial linear regression model, a spatial lag model, and a spatial error model to identify socioeconomic correlates with homicide rates, and (iii) model results were contextualised using local expert knowledge and interview/observation findings. A snowball literature review was conducted from September 2019 until April 2020, during which academic and non-academic sources in English and Portuguese were collected and assessed for their thematic suitability. A total of 171 sources were indexed. Contextual information specific to Brazil, Alagoas, interpersonal violence, homicide, and socioeconomic/built environments was recorded and categorised heuristically to derive (a) an adequate depth of background information to the point of saturation and (b) a list of candidate socioeconomic criteria suitable for modelling homicide rates in the study area.Interview data and participant/field observation were drawn from fieldwork conducted by the second author in Alagoas during two data collection periods in 2013 and 2016, during which time the author conducted site/participant observation and 24 semi-structured interviews with local youths involved in violence and additional interviews and discussions with their family and community members, persons employed in the legal system, and other experts and community stakeholders. All participants provided informed consent and were anonymised for transcription. Data were collected in low-income communities across Macieó, in all correctional facilities for youths and adults in Macieó, and whilst travelling through the city with youths and community members. Following data collection, interviews were transcribed using 129 subject-derived codes and analysed using the QDA software package, and field observations/photographs were categorised and used to supplement and contextualise the results of the qualitative analysis. More detail on the data collection and analysis is provided by Moura de Souza [n = 101 during the study period) were acquired from the publicly accessible data portal of the Public Security Secretariat of the State of Alagoas (SESP). All recorded homicide records were downloaded with victim age, sex, date and time of death, municipality of residence, and cause of death (by ICD-10 group). Homicides were considered to be all cases with ICD codes X85–Y09 inclusive. The number of homicides was recalculated into an average crude rate per 100,000 life-years, based on each municipality’s number of homicides and its official estimated population for each year in the study period.Homicide data from January 2016 to February 2020 (inclusive) for every municipality in Alagoas , the federal agency responsible for the decennary national census. A total of 167 census indicators across all socioeconomic categories were collected and random samples were drawn and checked for errors against figures published by IBGE to ensure data fidelity; no data for the selected indicators were missing or featured erroneous or implausible values. Variables were thematically categorised manually  and each category was examined and deliberated independent of the others. The deliberation phase was conducted amongst the authorship through eleven meetings and frequent informal discussions from February to August 2020, during which each category of interest was discussed in the context of the qualitative data, and linkages to interview results were made. For example, the prevalence of legal household piped water as a means of delineating spaces of urban poverty emerged through field visits and interviews with residents of grotas and favelas in Macieó. After a further filtering stage, during which excessively precise variables were manually removed from the categories , a list of 93 variables remained. In the next phase, the results of the qualitative analysis were linked to potential explanatory variables using hand-drawn mind maps and a simple Likert scale to represent suitability in Microsoft Excel, where a variable’s score out of ten represented its heuristically-assessed suitability as determined by the first two authors and the final author. The most prevalent or central variables from the mind maps and the highest-scoring variables from the Likert ranking were then independently evaluated for their suitability for modelling through further discussions in light of the results of qualitative data collection, resulting in 31 candidate explanatory variables, which were entered into preliminary linear regression models using a stepwise parameterisation to explore effects and familiarise the authors with patterns in the data. Further discussion with the two co-authors from Alagoas and the removal of variables exhibiting excessive multicollinearity resulted in a further reduction to six final predictor variables: male population, persons without elementary school completion, households with reported income, divorced persons, number of persons whose place of employment is outside their municipality of residence, and households without piped water. The selected predictors were then standardised by resident population or number of households where appropriate and mapped by municipality using the software package QGIS (v.3.10.4). Manual data validation and correction was conducted prior to modelling and no transformations were necessary.Modelling and mapping were conducted using R (v.1.3) and GeoDA (v.1.14). This study used ordinary least squares (OLS) regression to assess bivariate and multivariable linear relationships between the six selected socioeconomic predictors and crude homicide rates. Despite the relatively restrictive model assumptions compared to semiparametric approaches, we selected OLS for interpretability and conceptual simplicity in order to improve accessibility for a broader multidisciplinary audience. Bivariate and multivariable preliminary models using the qualitatively-informed selection of candidate variables were run to assess fit and multicollinearity and overfitting, and experimental dummy variables were included for the major cities of Macieó and Arapiraca, based on evidence that the unique socioeconomic, cultural, and built environment structures of these sites may exhibit differences with the remainder of the study area. Similar experimentation was conducted with population density as a standalone parameter and interaction term. These exhibited small, insignificant effect sizes and were therefore excluded from the final model. Model fit and residuals were visually assessed by plotting and interpreting residuals and statistically assessed using Jarque–Bera, Koenker–Basset, and Breusch–Pagan tests. The spatial autocorrelation of residuals was tested using Moran’s I with a contiguity neighbourhood definition and threshold selection. In addition to the OLS model, we ran two common variants that are able to account for spatial effects: spatial lag and spatial error. A spatial lag model is a geographical variant of OLS where independent variables are assumed to exhibit a given degree of effect on the dependent variable of neighbouring areas, thereby improving estimates that would otherwise be unreliable due to clustering effects. In contrast, a spatial error model is a geographical variant of OLS in which spatial effects are estimated using the error terms, rather than in the predictor variables themselves, thereby allowing unspecified spatial effects to be modelled; spatial error model coefficients therefore reflect unknown spatial effects. Both spatially weighted models used a first-order queen contiguity definition for their spatial weight matrices, selected heuristically based on discussions with local experts and tested in preliminary sensitivity analyses. Field observation in low-income communities, whether planned (conjuntos habiatcionais), semi-planned (bairros), or unplanned (favelas and grotas), yielded strong similarities in the socioeconomic situations, settings, and trajectories of their residents, despite significant differences in their respective built environments. These sites feature informal markets and concentrations of open-air bocas (“mouths”), locations where illicit drugs (predominantly crack cocaine and cannabis) are sold by male youths associated with organised crime groups, known in Brazil as facções.The youths interviewed described their experiences within the socioeconomic and legal structures of Alagoas similarly, including: an insufficient living environment, e.g., poor/no sanitation in the household, small living spaces with minimal privacy, and a dense and polluted neighbourhood environment; low access to schools due to excessive travel distance, poor quality of education, and/or classes not held due to a dearth of teaching staff ; a lack of professional development, apprenticeships, and legal employment opportunities, and; familial factors often also play a significant role, e.g., single-mother households and weak parental control. These factors were directly linked to criminal and  violent activity, as the participants described a search for accessible means to improve their individual, family, and community socioeconomic conditions.Only two of the twenty-four participants had any formal work experience, and many described a point at which they transitioned from informal employment to criminal means of earning. The participants indicated that the sale of ~50 g of cocaine per week would earn them double the average adult income in their community, which despite the risk of arrest or violence, enables them to financially contribute to their families and purchase socially important status symbols. A sense of excitement, belonging, and social cohesion were also cited as motivations for involvement in criminal activity.In addition to drug trafficking, robbery emerged as a common means of acquiring wealth amongst the participants. Unwritten codes generally forbid robbery within one’s own neighbourhood, so many persons travel via public transport or motorcycle to surrounding areas to commit robbery, thereby spatially disconnecting the criminal act and site of potential violence from one’s place of residence.A total of 6705 homicides were recorded for the study period. As shown in As shown in p-value.Model coefficients are shown in 2 > 0.62) and no significant multicollinearity among predictors. The OLS model residuals were normally distributed and featured a slight positive skew (Jarque–Bera (df = 2) = 8.43) and homoscedasticity (Koenker–Bassett (df = 8) = 8.46, p = 0.39). The spatial lag model exhibited a near-normal distribution of residuals and homoscedasticity (Breusch–Pagan (df = 8) = 9.5), and a likelihood ratio (df = 1) of 11.01 indicates some remaining spatial effects. The spatial error model also exhibited homoscedasticity (Breusch–Pagan (df = 8) = 12.96) and a likelihood ratio (df = 1) of 1.12 indicates no significant spatial effects remaining. The spatial error model showed a slight increase in performance over the aspatial OLS and spatial lag models, and similar coefficients to those in the aspatial OLS indicate robustness, while the improved model fit (R2 = 0.66) indicates that accounting for spatial effects may have contributed to improved parameter estimates, although this result is not confirmed in our study design. Distinct spatial clustering of residuals for all three models is evident in All three models exhibited moderate fit  and the landmark decision of the constitutional Maria da Penha Law (MPL) that established women’s support services and stricter punishment for perpetrators, the problem persists . The larThe interview results demonstrated a strong association between youth violence and organised crime in Alagoas, as documented in more detail ,26. CrimBrazil is facing an increasingly serious threat from its two major criminal organizations: the First Capital Command , and Red Command (Comando Vermelho). Factions within these groups are becoming more involved in the international drug trade and continue to operate extortion and kidnapping rings locally. These groups have become dispersed into rural areas since the 2014 World Cup and the 2016 Rio Olympics, a trend that matches with the rates of homicide. Large cities such as São Paulo and Rio de Janeiro have begun to see a decrease in homicide rates whereas lower population areas, like Alagoas, have been seeing an increase in homicide rates. This increase in Alagoas and other areas suggests that homicide is closely linked to the presence of criminal organizations and their involvement in the international drug trade. According to an eyewitness account, shoot-outs between police and members of criminal groups are common . OrganizStudies examining police activity in Brazil have shown that police forces disproportionately target young African-Brazilian males from socioeconomically deprived areas . In addiCorruption in Brazilian law enforcement is common, as officers often take bribes from donos, who are local leaders in the drug trade . In 2017This applied study sought to serve as an experimental interdisciplinary spatial epidemiological analysis, the process of which yields several key points for reflection and developing a research agenda. Many factors embedded in the research process itself provide challenges for moving towards a more situated and integrative spatial epidemiology; in this study, we sought to establish common ground between a diversity of academic backgrounds amongst the authorship , a wide range of professional experience , the multilingual nature of this study , and varying degrees of experience with the study area, victims, perpetrators, and local stakeholders. These are common challenges that underscore the necessity for situating both the researchers and the research process itself and to report accordingly, despite a scientific preference for dissociation in quantitative science . Indeed,n = 101) may explain the instability in parameter estimates.An important limitation concerns the process by which candidate variables were selected based on the qualitative data analysis; the authors elected to conduct this step through open discussion, deliberation, and consensus amongst the authorship, rather than adopting a more methodologically strict qualitative approach. This flexibility allowed the authors’ understanding of the study area to play a role in the process, but a coding and weighted frequency analysis, for example, may have yielded similar results. Future research should compare approaches to this step in order to develop best-practice guidelines. Interestingly, several variables that were heuristically selected through group deliberation did not emerge as significant in the preliminary models after controlling for all covariates included in the final model: household income measures, health indicators, households without a phone, number of bedrooms, school attendance rate, and unemployment rate. However, the small number of municipalities . This is perhaps best exemplified in the case of Macieó, whose municipal boundaries extend well into the rural periphery. Therefore, the homicide and census data for Macieó do not reflect the reality of homicide and socioeconomic deprivation across its entire area, and a finer-resolution analysis would be preferred, were we able to acquire more precise homicide data.More broadly, the use of precisely-defined census variables constrains the dimensionality of socioeconomic deprivation they represent, and prevents modelling of individual-level intersectional deprivation, e.g., as cross-tabulated variables such as number of lone-parent families with no piped water and no primary school completion. Similarly, the use of reported homicide rates to describe the broader burden of violence induces several significant limitations. Many cases of non-fatal familial/domestic/intimate partner violence are not reported, and the distribution of these incidents is likely underrepresented and dependent on local community-level sociocultural contexts. Other forms of non-lethal violence are not included in the dataset, and therefore the results may exhibit a bias towards more lethal trajectories, such as the drug trade, robbery, and inter-gang conflict.This study explores the initial steps towards informing and situating an applied spatial epidemiological analysis through the use of qualitative contextual information and local knowledge. The use of interviews, field/participant observation, and local expert knowledge enabled the parameterisation of regression models that indicated significant associations between homicide rates and six selected socioeconomic variables at the municipal scale in Alagoas, Brazil. The proportion of male population, population without primary school completion, and the divorce rate were positively correlated with homicide rates, while the proportion of houses with reported income, houses without running water, and commuter populations were negatively correlated with homicide rates. The authors favoured a public health approach to the problem of interpersonal violence with a contextual focus on the underlying trajectories and cycles embedded in Brazil’s social systems. We found that wealth inequality, education, and criminal activity are closely intertwined and have strong ties to homicide, especially for the demographic of young men. Wealth inequality and both real and perceived lack of social mobility influence future potential for violence and homicide. Employment opportunities and economic policies that reduce wealth disparities are valuable for decreasing violence and homicide, and they should be adjusted to accommodate the higher costs of living in urban areas. This will increase equity and accessibility of opportunities and services for those who would otherwise have to turn to informal or illegal labour. Multiple sources agree that the law enforcement structures play a significant role in violence, and other current studies are presently investigating these linkages and processes in depth, with a focus on policing tactics and systemic corruption. We found that a lack of access to education is tied to inequality and criminal activity and serves as a gateway into a violent lifestyle. These factors do not directly contribute to homicide on their own, but rather act as a complex interrelated network of actants that create the social-built environment experienced in Alagoas. Altogether, this study evidences that poverty alone is not an adequate predictor of violence and homicide, and instead multiple socioeconomic deprivation factors and the social-built environment should be the focus of future research. We therefore assert the need for more contextually engaged and interdisciplinary methodologies in applied spatial epidemiological violence research and the importance of embedded and locally informed interpretations of modelling results when moving towards violence prevention policy.