UMass Boston

Global Health and Development

Development as Freedom


Our work includes an inquiry into social conditions and structural factors that underpin health inequities including disparities in health that are unjust, avoidable, and systematically associated with social disadvantage that is frequent, substantial, and persistent (see Braveman & Gruskin, 2003; Whitehead, 1992).  Our team is  commited to research coupled with action. Our aim is to understand these conditions and marshal the evidence base in order to engage policy, as well as institutional and systems’ levers to advance and improve people's health and human development.

Led by Principal Senior Faculty Fellow: Courtenay Sprague, the ultimate goal of our work is to aid people in constructing lives they have reason to value, in line with Amartya Sen’s conception of development as freedom and flourishing (Sen 1999). Projects and themes include:

‘Being Blessed’: Meanings and Aspirations Attached to the Practice of Transactional Sex in KwaZulu-Natal, South Africa

Research Team: Gavin George, Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal (UKZN), Z Nana Nxumalo (HEARD UKZN), Leah Junck (HEARD UKZN) and Courtenay Sprague

Themes: Gender, health and sexuality; sexual risk and HIV risk behaviors; HIV risk environment and prevention; gender as a structural health determinant.

Description: This research engages with the dynamics of transactional sex and the influence of these sexual relationships on young women’s identities, which can inform subsequent HIV prevention efforts within the South African context. Transactional sex is a common practice in different regions of the African continent (Zembe et al., 2013) and refers to the practice of engaging in sex in exchange for gifts (Leclerc-Madlala, 2008). The exchange is neither explicit nor upfront and understandings over the nature of exchange fall outside local and Western notions of commercial sex work (Hunter 2002). Relationships may be characterized by large age and wealth differences or power imbalances. They influence young women and men’s sexual experiences and their ability to negotiate the circumstances of those encounters (Kaufman & Stavrou, 2004). Relationships involving ‘blessings’ are both, material and meaningful in complex ways (Hunter 2002), and the newest types of relationships are predicated on social media that allow men to advertise for women and women to seek 'Blessers'. In this qualitative research study, we investigate the nature and extent of these relationships, and how women enact and view their own agency in such partnerships, also considering the implications for women to contract HIV in this high HIV prevalence setting.

Regional Governance and Migrant Health (Southern Africa)

Research Team: Theresa Sommers, Jo Vearey, Courtenay Sprague

Themes: Role of civil society organizations in governance; governance mechanisms and policy; urban health; city governance.

Description: This project explores key linkages between migration, health and local-regional systems of governance in South Africa. This collaboration between ACMS (Wits, South Africa) and the University of Massachusetts Boston (US) is exploring the role of civil society networks in addressing migrant health issues throughout South Africa, the dynamic issues around access to health care services for migrants in Johannesburg, and the ways in which migration affects health for youth migrants living in South Africa. We work with practitioners and other colleagues in the field, particularly civil society, local government, and regional and international organizations, including the International Organization for Migration (IOM) South Africa office.

Publications: Vearey, Joanna, Kirsten Thomas, Theresa E. Sommers & Courtenay Sprague. 2017. Commentary: Analysing Local-Level Responses to Migration and Urban Health in Hillbrow: The Johannesburg Migrant Health Forum. BMC Public Health 17(suppl 3): 89-93.

Exclusive Breastfeeding: Safe Infant Feeding for Women with HIV in South Africa to Prevent New HIV Infections in Children under the Revised WHO 2010 Guidelines

Research Team: Courtenay Sprague, Viv Black (Wits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa), Shelley Brown, Di Cooper and Hanani Tabane (University of the Western Cape) and Sumaya Mall (Wits University)

Themes: Women’s health; child health; LMIC health systems; patient-provider encounters.

Description: HIV is the leading cause of death in women of reproductive age (15 to 44 years), globally, followed by maternal mortality (WHO, 2013). HIV is also a leading cause of death in children in high HIV prevalence settings (UNAIDS, 2013). Pregnancy, labor, delivery and breastfeeding are modes of mother to child HIV transmission (MTCT) (UNAIDS, 1998). Key to preventing MTCT is ensuring safe infant feeding. New 2010 guidelines issued by WHO recommend six months of exclusive breastfeeding (EBF) + lifelong cART, based on evidence of child malnourishment, stunting and other effects on child health and survival by use of milk replacements or substitutes (Black et al, 2008; Taha et al, 2006). The new policy presents a major policy shift for countries that previously employed formula feeding programs for HIV positive mothers. Whether EBF benefits for child survival and prevention of HIV acquisition will be realized in those LMICs adopting this approach will depend on the health behaviors of HIV positive mothers within their social-economic environments and constraints, social support and clear guidance from health providers. South Africa offers a case study. This research aims to document, identify and better understand the challenges of safe infant feeding – socio-cultural, individual and health care/health systems – for South African women. We will draw out the implications for clinical service delivery, training of health personnel and health policy in South Africa, while identifying the relevance for other high HIV prevalence settings, as appropriate.

Publications: Sprague, Courtenay, Hannah Fraley & Vivian Black. 2016. Constraints to Practicing Exclusive Breastfeeding for HIV Positive South African Women. In: Breastfeeding, Social Justice and Equity: Reflecting, Reclaiming, Re-visioning. Paige Hall Smith, Miriam Labbok & BE Chambers, eds. Amarillo (TX): Praeclarus Press.

Presentations: Sprague, Courtenay, Hannah Fraley, Heather McKay and Vivian Black. 2015. How feasible is exclusive breastfeeding for women in high HIV prevalence settings? Results of a systematic review of literature on infant feeding practices in South Africa. 7th South Africa AIDS Conference, Durban, 10 June.

Sprague, Courtenay, Hannah Fraley & Vivian Black. 2015. Breastfeeding challenges in social context for South African women with HIV. 10th Breastfeeding and Feminism International Conference. University of North Carolina-Chapel Hill School of Public Health, 20 March.

Justice-Involved Women Living with HIV (US South)

Research Team: Courtenay Sprague, Michael Scanlon, Bharathi Radhakrishnan, Shelley Brown, Theresa Sommers and David Pantalone

Themes: Social patterning of ill health; linkage to and continuous engagement in HIV Care in prison settings; post-release adjustment.

Description: To date, we have explored three lines of inquiry that intersect in the study population. It is possible to view these on a timeline (as we have conceived them), using a life course approach: from the early environment that shapes vulnerability, exposure and HIV/incarceration risk (in childhood/adolescence) and their psychosocial histories and pathways into jail/prison (in adolescence and early adulthood); to access to HIV care during incarceration, in order to address their physical health needs; and then post-release services via mental health treatment, substance rehabilitation and social support (continuing in adulthood as women age with HIV) to facilitate post-release adjustment.

I. The HIV Risk Environment (family and social settings). Women involved with the US criminal justice system (‘justice-involved’), particularly those in the US South (17 states), are a hidden, understudied population who experience poor health, high barriers to HIV care, difficulties with adherence when they do access cART, and poor HIV outcomes (e.g., sub-optimal viral suppression, lack of adherence, and higher risk of death). The numbers of justice-involved women (comprising 7% of the total), while small compared to men, have increased sharply—700% from 1980 to 2014—and at twice the rate of men (Kelly et al., 2014). Notably, there has been insufficient atten­tion to the substance use and poor mental health underpinning the growth in the incarcerated population of women and their relation to women’s increasing risk of HIV infection. While there is a large literature on the health of justice-involved women, including HIV in women in prison, little work to date has explored the psychosocial histories of this population in relation to their HIV risk environment in social context (within family and social settings) in some of the worst affected Southern states. Gender-based aspects of this problem and responses have been called for, particularly, in research and accompanying interventions.

Our focus is on exploring risk factors, behaviors and psychosocial histories in this population, including experiences of early abuse, violence and trauma, which affect their health profiles, risk of incarceration and of acquiring HIV. Extremely adverse life histories affect this population’s ability to link to HIV care and to adhere to cART (see Sprague, Radhakrishnan et al., 2017).

II. Timely Linkage to HIV Care (prison and jail settings). US prisons are venues where health care is constitutionally mandated. This generates what we have termed the HIV prison paradox (see Sprague, Scanlon et al., 2016), where prisons, regularly depicted as unhealthy environments, are recognized as offering perhaps the greatest opportunity for justice-involved populations, women and men, to initiate stable cART, due to the instability that characterizes their lives. Although researchers have recognized prison as a site for HIV service linkage, due to the variability across U.S. states, there is no systematic picture of the correctional population’s engagement and retention in HIV care in correctional settings (for men or women) (Beckwith et al., 2010). Rather, there is a patchwork of studies conducted in different states, and justice-involved populations typically struggle to link to and be retained in continuous HIV care, moving frequently between community and jail/prison settings.

Through this second line of inquiry we investigate participants’ self-reported experiences accessing HIV services in jail, prison, and post-release, while tracking patterns of HIV care access, linkage, and lapses (Sprague, Scanlon et al., 2016).

III. Achieving Post-Release Adjustment (community settings). The third line is understanding how successful post-release adjustment can be achieved along with improved mental and physical health (Pantalone et al., under review).

Key approaches and findings to date: We have used interdisciplinary approaches—from public health, to health sociology and clinical psychology—to investigate this problem. A life course narrative approach, together with in-depth interviews, has guided our design and methods (discussed in Sprague, Scanlon & Pantalone, 2017). The findings have illuminated the role played by early risk factors, present in childhood and adolescence for this population, including experiences of sexual abuse, in this social context of the Deep South. Subsequent trauma followed, which went undiagnosed and untreated, for the majority of the participants. In adolescence, risk factors and behaviors (such as drug taking, unlawful activity and unsafe sex) were established. Instead of HIV risk being reduced as participants left the family setting and moved into social settings, which might have disrupted risk patterns, women instead relied on substance use for coping (primarily crack cocaine), partaking in unlawful activity to gain access to substances. Their negative risk behaviors for both HIV and incarceration thus increased (rather than decreasing). Women’s significant underlying psychosocial problems seemed to be motivating their HIV and incarceration risk behaviors, notably their dependence on substances (see Sprague, Radhakrishnan, Brown, Sommers & Pantalone, 2017: link below); this drove their drug-related offenses, resulting in cyclical incarceration.

The findings have also cast light on the role of prison settings for optimizing HIV care, psychological and social support for this population, through potential points of intervention. We found these could be better maximized at distinct stages in the care continuum to protect and promote women’s health: (a) on entry: providing counseling, together with HIV testing. This is a key moment to inform women about the critical importance of prevention, the benefits of HIV treatment, and how to access cART (Mugavero et al., 2013); (b) during incarceration: rapid and consistent treatment initiation to facilitate their timely linkage to HIV care; (c) during discharge planning: to identify community-based HIV services, encompassing: substance rehabilitation, safe housing, and mental health services to address women’s unmet health needs: creating an opportunity for the health transitions between correctional and community settings to be bridged, in keeping with CDC guidelines (2012; Iroh et al., 2015); and (d) post-release: linking women to clinics and social services through partnerships between corrections departments and local CBOs (trusted by justice-involved women) needs to take place to ensure a transition to communities, facilitate engagement and improve adherence in continuous HIV care (see Sprague, Scanlon, Radhakrishnan & Pantalone, 2016). The fourth article under review (Pantalone et al., 2018) captures our findings related to post-release adjustment in this population.

Publications: Sprague, Courtenay, Bharathi Radhakrishnan, Shelley M. Brown, Theresa E. Sommers & David W. Pantalone. 2017. Southern Women at Risk: Narratives of Familial and Social HIV Risk in Justice-Involved U.S. Women in Alabama. Violence & Victims 32 (4): 1-26. doi: 10.1891/0886-6708.VV-D-16-00077.

Sprague, Courtenay, Michael L. Scanlon & David W. Pantalone. 2017. Qualitative Methods to Advance Research on Health Inequities among Previously Incarcerated Women Living with HIV in Alabama. Health Education & Behavior 44 (5): 716-727.

Sprague, Courtenay, Michael L. Scanlon, Bharathi Radhakrishnan & David W. Pantalone. 2016. The HIV Prison Paradox: Agency and HIV-Positive Women’s Experiences in Jail and Prison in Alabama. Qualitative Health Research 27(10): 1427-1444.

Presentations: Sprague, Courtenay, Michael L. Scanlon, Bharathi Radhakrishnan & David W. Pantalone. 2016. "Women's Experiences of HIV Testing, Counselling and Care in Jail and Prison in the Deep South: An Exploratory Qualitative Study among Women with Histories of Violence and Substance Dependence” XXI International AIDS Conference, Durban, South Africa, 21 July.

Pantalone, David W., Bharathi Radhakrishnan, Shelley Brown & Courtenay Sprague. 2016. Unmet Mental Health and Social Service Needs of Formerly Incarcerated Women with HIV Living in the Deep South. XXI International AIDS Conference, Durban, South Africa, 21 July.

Brown, Shelley, Courtenay Sprague & David W Pantalone. 2015. Mental health and post-release adjustment in formerly incarcerated women with HIV. Correctional Healthcare Conference, Boston, 19 March.

Sprague, Courtenay, Theresa E. Sommers, Bharathi Radhakrishnan, Shelley Brown & David W Pantalone. 2015. Early Trauma in the Chain of Risk Cascade for Re-offending Women with Post-Traumatic Stress Disorder and HIV in Alabama. Sexual Violence Research Initiative 4th International Conference. Stellenbosch, South Africa, 16 September.

HIV Care Linkage, Retention in HIV Care for Low-Income Populations in Alabama and Mississippi

Research Team: Courtenay Sprague, Sara Simon, Shelley Brown, Deborah Konkle-Parker (University of Mississippi Medical Center, Jackson, Mississippi)

Themes: Social/structural determinants of HIV care access and retention; HIV stigma and discrimination; role of AIDS service organizations and health care practitioners; health inequities; national health care policy.

Description: This study is an adjunct to a previous study in Alabama (Sprague & Simon, 2014), which documented delayed HIV care in low-income people on the AIDS Drug Assistance Program in two sites in Alabama (Tuscaloosa and Birmingham). This project builds on the previous study, by exploring the problem of delayed HIV care linkage and retention in Mississippi. Two locations in Mississippi comprise the study sites: the urban center of Jackson and the rural Delta. The study population comprises low-income people with HIV. Overlapping themes, including poor retention of people with HIV in care, poorer health outcomes for racial/ethnic minority groups living with HIV, and the correlates of increasing rates of HIV in the southern US and high-risk behaviors, drive the research. The purpose is to explore how to identify, reach and retain individuals with HIV in continuous HIV care more effectively in the South, particularly low-income, socially marginalized populations. The study also seeks to explore the level of “social infrastructure” to support people living with HIV in care, and similarities and differences in Mississippi and Alabama. The aims of the overall project are to enhance understanding needs in the South related to HIV care engagement (linkage) and retention to ensure optimal HIV and health outcomes for people living with HIV, to reduce health inequities in this population, in line with the national US Strategy on HIV and AIDS.

Publications: Sprague, Courtenay and Sara Simon. 2014. Understanding HIV Care Delays in the US South and the Role of the Social-Level in HIV Care Engagement/Retention: A Qualitative Study. International Journal for Equity in Health 2014 13(28): 1-14.

Simon, Sara and Courtenay Sprague. 2014. Social Actors Fight the Rising Tide of HIV in US Southern Poor. Boston: Center for Peace Democracy & Development.

Presentations: Sprague, Courtenay and Sara Simon. 2013. HIV and AIDS in the US South: Results from Research Findings in Two Sites in Alabama. HIV Stakeholder Meeting, AIDS Alabama, Birmingham, Alabama, 18 March.

Women in South Africa Living with or at Risk of HIV who Experience IPV

Research Team: Courtenay Sprague, Abigail Hatcher (Wits Reproductive Health & HIV Institute & School of Public Health, University of the Witwatersrand, South Africa), Nataly Woollett (Wits Reproductive Health & HIV Institute), Jane Parpart, Shelley Brown, Theresa Sommers, Vivian Black (Wits Reproductive Health & HIV Institute and School of Medicine)


Description: While maternal mortality has declined by 45% since 1990 across many settings, globally, maternal deaths have remained disproportionately high in sub-Saharan Africa (World Health Organization [WHO] 2014). In South and Southern Africa, women’s health outcomes in terms of maternal mortality and life expectancy are particularly poor, relative to women in many other settings, globally (WHO, 2014). In South Africa, HIV has contributed to an estimated 40% of maternal and child mortality and life expectancy is just 64 years; this is due primarily to HIV (South Africa Every Death Counts Writing Group 2008; WHO, 2014). HIV prevalence is 23–43% in South African women of reproductive age (18–44 years), and has remained elevated over the last decade (Shisana et al., 2014). Intimate partner violence (IPV) is an important correlate of HIV risk for South African women (Dunkle & Decker 2013). An estimated 31% to 55% of women have experienced IPV in South Africa (Dunkle et al., 2004; Gass et al., 2010). The negative health consequences of such violence have been well established: spanning extensive injuries, chronic pain, increased risks of sexually transmitted infections, including HIV, severe mental health consequences, suicide and homicide (Ellsberg et al., 2008). IPV risk and HIV risk are influenced by gender norms, or the beliefs and actions that define relations (with a focus on relations between men and women in the heterosexual HIV epidemic in South Africa) (Gibbs et al., 2015; Jewkes et al., 2011). Relationship power, control and infidelity by male partners have been identified as factors enabling intimate partner violence and HIV acquisition in women (Dunkle et al., 2004).

Health providers have long been in a position to influence the health beliefs and behaviors of women patients through their structured daily encounters with them. Nurses have played a leading role in health care delivery in South Africa and are well-placed to influence women’s health and wellbeing, including abused women (Marks, 1994). Indeed, research indicates that women who experience IPV in South Africa (like other settings) seek health care from the public health system more frequently than women who have not been abused; this includes women who are HIV positive, who access free HIV care in the South African public health system, particularly during the perinatal period, through prenatal (antenatal) and postnatal care (Gass et al., 2010; WHO, 2013). Recent guidelines have been issued by the US and the WHO on IPV screening in health settings recommending minimum standards. There has been little published research on health provider perceptions of IPV in their female patients in this high-HIV prevalence setting of South Africa, however (Joyner & Mash, 2012; Kim & Motsei, 2002). Health system responses to IPV in South Africa and in other low and middle income countries (LMICs), are thus poorly understood.

Key approaches and findings to date: We have employed agency as a conceptual lens; qualitative research methods; legal analyses; and interdisciplinary approaches that combine public health, medicine, sociology, psychology and law—have assisted in deepening our research insights.

Health Providers - Contesting Gender Norms and Hierarchies. We found that the health behaviors of women patients, as reported by health providers, were predicated on sociocultural norms of submission to men’s authority and economic dependence on their partners. Health provider respondents described how men’s preferences and health decision-making in clinics affected their (women) patients’ health.

Adverse gender norms and gender inequalities affected women’s opportunities to be healthy (e.g., by limiting their ability to insist on condom use, refuse sex and take HIV medicine), contributing to HIV risk and undermining effective HIV management in this context. Some providers, seeking to deliver a standard of quality health care to their female patients, demonstrated a willingness to challenge patriarchal gender relations. Findings shed light on how socially-sanctioned gender norms, intimate partner violence and HIV are synergistic, also reaffirming the need for integrated HIV-intimate partner violence responses in multi-sector national strategic plans. Health providers’ intimate knowledge of the lived experiences of female patients with intimate partner violence and/or HIV deepens understanding of how adverse gender norms generate health risks for women in ways that inform policy and clinical practice in South Africa and other high-HIV prevalence settings (see Sprague, Hatcher, Woollett & Black, 2015).

Institutional Agency. We found that the South African health system is serving as a form of institutional agency, a concept which has been given little attention in the public health, health systems or health sociology literature to date. We posit that nurses can serve as important agentic actors in public health systems in LMICs by assisting patients to address IPV, even in the absence of targeted training and guidelines. However, to ensure the health and well-being of women experiencing IPV, nurses should be supported by the health sector to respond skillfully to patients and to safely process their own experiences of violence, through the development of guidelines and the delivery of training to health providers, in line with WHO’s recommendations. In Woolman and Sprague, we found this to be an important gap and a violation of the Domestic Violence Act of 1998 (see Woolman & Sprague, 2015; Sprague, Woollett, et al., 2016).

Publications: Sprague, Courtenay, Nataly Woollett, Jane Parpart, Abigail Hatcher, Theresa E. Sommers, Shelley Brown and Vivian Black. 2016. When Nurses are Also Patients: Intimate Partner Violence and the Health System as an Enabler of Women’s Health and Institutional Agency in Johannesburg. Global Public Health 11 (1-2): 169-183.

Sprague, Courtenay, Abigail M. Hatcher, Nataly Woollett, Theresa E. Sommers and Vivian Black. 2015. “They can’t report abuse; they can’t move out. They are at the mercy of these men,” Exploring Connections between Intimate Partner Violence, Gender and HIV in South African Clinical Settings. Culture, Health & Sexuality 18(5): 567-81.

Sprague, Courtenay, Abigail Hatcher, Nataly Woollett, Vivian Black. 2015. How Nurses in Johannesburg Address Intimate Partner Violence in Female Patients: Understanding IPV Responses in Low and Middle-Income Country Health Systems. Journal of Interpersonal Violence 32(11): 1591-1619.

Woolman, Stu and Courtenay Sprague. 2015. Nowhere to Run, Nowhere to Hide: The Absence of Public Policy as to How Health Care Professionals Should Address Intimate Partner Violence Constitutes a Breach of the Rights to Health and Bodily Integrity Under the South African Constitution. Cardozo Journal of Law & Gender 22(1): 29-74.

Presentations: Sprague, Courtenay, Nataly Woollett, Jane Parpart, Abigail Hatcher, Theresa E. Sommers, Shelley Brown & Vivian Black. 2014. Intimate Partner Violence in Marginalised Settings: Re-theorising Agency for Global Public Health. Workshop on Agency for Women with IPV in Marginalised Settings. London School of Economics & Political Science (UK), 24-25 March.

Sprague, Courtenay, Abigail Hatcher, Nataly Woollett & Vivian Black. 2015. Inconsistent but Determined: How Nurses in Johannesburg Address Intimate Partner Violence. 7th South Africa AIDS Conference, Durban, 11 June.