Literacy and healthcare-seeking among women with low educational attainment: analysis of cross-sectional data from the 2011 Nepal Demographic and Health Survey

Effect of Schooling on Anemia and Nutritional Status Among Women: A Natural Experiment in Ethiopia

This study estimates the effect of length of schooling on anemia and nutritional status and evaluates the cost-effectiveness of primary schooling as an anemia intervention for women of childbearing age in Ethiopia. In 1994-1995, Ethiopia abolished primary school tuition fees and embarked on a large-scale educational investment program, which increased primary school enrollment and retention. An instrumented regression-discontinuity design was used to examine the effect on anemia risk and body mass index (BMI) of an increase in length of schooling resulting from the reforms, as a natural experiment. Anemia and BMI biomarkers and demographic data for 13,984 women were obtained from the 2011 and 2016 Ethiopia Demographic and Health Surveys, with the 2019 Mini Demographic and Health Survey used for robustness checks. Results indicate that each additional year of schooling reduced anemia risk by 3 percentage points (9.2%-11.2% reduction) and increased BMI (weight (kg)/height (m)2) by 0.26-0.42. Primary education was cost-effective-based on World Health Organization cost-effectiveness thresholds-as an anemia intervention, with a cost per anemia case averted of US$1,654. The findings suggest that investment in education reduces anemia risk later in life.

Delay in accessing definitive care for patients with microbial keratitis in Nepal

Background

The aim of this study was to describe the health-seeking journey for patients with microbial keratitis (MK) in Nepal and identify factors associated with delay.

Methods

Prospective cohort study where MK patients attending a large, tertiary-referral eye hospital in south-eastern Nepal between June 2019 and November 2020 were recruited. We collected demographic details, clinical history, and examination findings. Care-seeking journey details were captured including places attended, number of journeys, time from symptom onset, and costs. We compared "direct" with "indirect" presenters, analyzing for predictors of delay.

Results

We enrolled 643 patients with MK. The majority (96%) self-referred. "Direct" attenders accounted for only 23.6% (152/643) of patients, the majority of "indirect" patients initially presented to a pharmacy (255/491). Over half (328/643) of all cases presented after at least 7 days. The total cost of care increased with increasing numbers of facilities visited (p < 0.001). Those living furthest away were least likely to present directly (p < 0.001). Factors independently associated with delayed presentation included distance >50 km from the eye hospital [aOR 5.760 (95% CI 1.829-18.14, p = 0.003)], previous antifungal use [aOR 4.706 (95% CI 3.139-5.360)], and two or more previous journeys [aOR 1.442 (95% CI 1.111-3.255)].

Conclusions

Most patients visited at least one facility prior to our institution, with time to presentation and costs increasing with the number of prior journeys. Distance to the eye hospital is a significant barrier to prompt, direct presentation. Based on these findings, improving access to eye care services, strengthening referral networks and encouraging early appropriate treatment are recommended to reduce delay, ultimately improving clinical outcomes.

The prevalence of sexual dysfunction among postpartum women on the East Coast of Malaysia

Objective

Sexual health is a key component of the overall health and quality of life of both men and women. Sexual dysfunction is a common condition, but it lacks professional recognition. This study aims to determine the prevalence and types of sexual dysfunctions among postpartum women in primary care clinics and their associated factors in a Malaysian cohort.

Method

In this cross-sectional study, we recruited 420 women from nine primary care clinics in Kuantan, Pahang, Malaysia. All participants had given livebirths within six weeks to six months and had attended either a postnatal or a well-child clinic at a government primary care clinic. The assessment of female sexual dysfunction (FSD) was done using a validated Malay version of the female sexual function index (MVFSFI). Data were statistically analysed using appropriate methods.

Results

More than one-third (35.5%) of women had postpartum sexual dysfunction. The most common types were lubrication disorder 85.6% (n = 113), followed by loss of desire 69.7% (n = 92) and pain disorders 62.9% (n = 83). Satisfaction disorder 7.3% (n = 27), orgasmic disorder 9.7% (n = 56) and arousal disorder 11.0% (n = 41) were less common sexual problems. The independent associated factors for FSD were high education level (adjusted odd ratio = 1.717, 95% CI 1.036–2.844; p < 0.05) and usage of hormonal contraception (adjusted odd ratio = 0.582, 95% CI 0.355–0.954; p < 0.05).

Conclusion

This study showed a high prevalence of postpartum sexual dysfunction in Kuantan, Pahang, Malaysia. The most common type of sexual dysfunction was lubrication disorder. Efforts at increasing awareness in healthcare professionals should be made.

Sociodemographic correlates of antenatal care visits in Nepal: results from Nepal Demographic and Health Survey 2016

Background

Good quality antenatal care visits are crucial to reduce maternal mortality and improve overall maternal and neonatal health outcomes. A previous study on antenatal care visits analyzed the nationally representative data of 2011; however, no studies have been conducted recently in Nepal. Therefore, we analyzed the sociodemographic correlates of the frequency and quality of antenatal care among Nepalese women from the nationally representative data of 2016.

Methods

We analyzed data obtained from the Nepal Demography Health Survey (2016) on antenatal care for 2761 women who had one or more births in the past three years. Our study defined ‘good quality antenatal care’ as at least a 75% score on a composite metric which was obtained by adding the weighted scores assigned to the twelve recommended components of antenatal care. We analyzed the factors associated with the frequency and quality of antenatal care by using multiple Poisson regression and multiple logistic regression.

Results

While 70% of the Nepalese women surveyed had at least four antenatal care visits, only 21% of these women received good-quality antenatal care. We found that the educated women (APR: 1.12; CI: 1.05–1.19) and the women of rich wealth index (APR: 1.27; CI: 1.18–1.37) were more likely to receive a higher number of antenatal visits. In contrast, women living in rural areas (APR: 0.92; CI: 0.87–0.98), and those who had more than two children (APR: 0.88; CI: 0.83–0.93) were less likely to receive a higher number of antenatal visits. Regarding the quality of antenatal care, educated women (AOR: 1.51; CI: 1.09–2.08), women who had educated husbands (AOR: 2.11; CI: 1.38–3.22), women of rich wealth index (AOR: 1.58; CI: 1.13–2.20) and women who had intended pregnancy (APR: 1.69; CI: 1.23–2.34), were more likely to receive good-quality antenatal care.

Conclusions

Observing a wide variation in the coverage of different components of antenatal care, concerned stakeholders could tailor the interventions by focusing on components with lower use. Because we found an association of myriad sociodemographic factors with the frequency and quality of antenatal care, targeted interventions are necessary.

Individual and community level factors associated with anemia among lactating mothers in Ethiopia using data from Ethiopian demographic and health survey, 2016; a multilevel analysis

BACKGROUND

Maternal anemia is a worldwide public health problem especially in developing countries including Ethiopia. The anemia burden among lactating mothers was higher in Africa particularly in Ethiopia, and scant attention was paid. To date, there is limited evidence on community level determinants of anemia among lactating mothers in Ethiopia. This study, therefore, aimed to assess the prevalence and factors associated with anemia among lactating mothers in Ethiopia.

METHODS

Secondary data analysis was employed using the 2016 Ethiopian Demographic and Health Survey. A total weighted sample of 4658 lactating women was included. A multilevel logistic regression model was used to identify individual and community level determinants of anemia during lactation. Finally, the adjusted odds ratio with a 95% confidence interval was reported.

RESULTS

The overall prevalence of anemia was 28.3% (95% CI; 26.7, 30.0) with the higher regional prevalence in Somali (68.3%) and Afar (47.2%) regions. Current modern contraceptive use [AOR = 0.71; 95% CI: 0.58, 0.87], Poorer [AOR = 0.77; 95% CI: 0.61, 0.98], middle [AOR = 0.74; 95% CI: 0.56, 0.97], rich [AOR = 0.64; 95% CI: 0.46, 0.85], and richest [AOR = 0.66; 95% CI: 0.43, 0.98] wealth index, being working within the 12 months preceding the survey [AOR = 0.77; 95% CI: 0.64, 0.92], and taking iron during pregnancy [AOR = 0.82; 95% CI: 0.68, 0.98] were associated with lower odds of anemia. Whereas, being female household head [AOR = 1.22; 95% CI: 1.01, 1.49], having two births [AOR = 1.27; 95% CI: 1.04, 1.55] and three to four births [AOR = 1.53; 95% CI: 1.14, 2.06] within 5 years, and higher community illiteracy level [AOR = 1.06; 95% CI: 1.06, 1.70] were associated with the increased odds of anemia during lactation.

CONCLUSION

In this study the prevalence of anemia among lactating mothers was high. It was affected by both individual and community level factors. Therefore, focusing on family planning services especially on modern contraceptive methods, iron supplementation during pregnancy, child spacing, and improving community literacy could decrease anemia during lactation.

Healthcare accessibility in the rural plains (terai) of Nepal: physical factors and associated attitudes of the local population

BACKGROUND

While access to healthcare has been a focus of international development, populations around the world continue to lack proper access to care. Identifying at-risk demographic groups can help advance efforts both regionally and internationally. There are only a small number of studies that previously have assessed physical barriers and attitudes in Nepal.

METHODS

This study assessed the factors and attitudes associated with healthcare accessibility in a rural population outside of Lumbini, Nepal. This descriptive cross-sectional study used a volunteer-sampling approach to collect 585 questionnaire responses from the area formerly known as the Madhuwani Village Development Committee.

RESULTS

The study found that the population was more likely to access private care than public, and reported longer times to access a hospital than the national average. Across almost all findings, those with lower than a secondary education had significantly larger barriers, lower satisfaction and higher reported difficulty in accessing healthcare. Females were shown to have significantly larger transportation barriers in accessing care and lower satisfaction compared with males.

CONCLUSIONS

Results identify women and the less-educated as having larger barriers to accessing healthcare. Further research should focus on how inequities in access affect health outcomes among these identified vulnerable groups.

Presenting complaints and mortality in a cohort of 22 000 adult emergency patients at a local hospital in Nepal

Background

There is a need to develop sustainable emergency health care systems in low-resource settings, but data that analyses emergency health care needs in these settings are scarce. We aimed at assessing presenting complaints (PCs) and post-discharge mortality in a large emergency department population in Nepal.

Methods

Characteristics of adult patients who entered the emergency department (ED) in a hospital in Nepal were prospectively recorded in the local emergency registry from September 2013 until December 2016. To assess post-ED mortality, patient households were followed-up by telephone interviews at 90 days.

Results

In 21892 included adults, the major PC categories were injuries (29%), abdominal complaints (23%), and infections (16%). Median age was 40 years and sex distribution was balanced. Among 3793 patients followed at 90 days, 8% had died. For respiratory and cardiovascular PCs, 90-day mortality were 25% and 23%. The highest mortality was in individuals with known chronic lung disease, in this group 32% had died by 90 days of ED discharge, regardless of PC. In women, illiteracy compared to literacy (adjusted odds ratio (aOR) = 7.0, 95% confidence interval (CI) = 2.1-23.6) and being both exposed to tobacco-smoking and traditional cooking stove compared to no smoke (aOR = 2.8, 95% CI = 1.6-4.9) were associated with mortality. The mortality was much higher among family-initiated discharged patients (17%, aOR = 5.4, 95% CI = 3.3-8.9) compared to doctor-initiated discharged (3%).

Conclusions

Our report suggests that nearly one in ten patients seeking emergency health care died within 90 days. This finding is alarming and novel. Post-discharge studies need to be replicated and appropriate follow-up programs in low-resource settings where primary health care is underdeveloped are urgently needed.

Healthcare access for refugee women with limited literacy: layers of disadvantage

Background

Record numbers of people, across the world, are forced to be displaced because of conflict or other violations of their human rights, thus becoming refugees. Often, refugees not only have a higher burden of disease but also compromised access to healthcare, as they face many barriers, such as limited knowledge of the local language. However, there is very limited knowledge on the lived experiences of this population. Moreover, the strategies people might develop in their efforts to access healthcare have not been explored in depth, despite their value in establishing peer- support, community based programs.

Methods

In this article, we present the findings of a study aiming to explore the lived experiences of accessing healthcare in the greater Vancouver area for recently-arrived, government-assisted refugee women, who were non-literate and non-English-speaking when they arrived in the country. We carried out sixteen semi-structured interviews with eight refugee women, guided by descriptive phenomenology.

Results

The findings highlight the intersection of limited knowledge of the local language with low literacy, gender, and refugee status and how it impacts women’s access to healthcare, leading to added layers of disadvantage. We discuss three themes: (1) Dependence, often leading to compromised choice and lack of autonomy, (2) Isolation, manifesting as fear in navigating the healthcare system, rejection, or shame for a perceived inadequacy, and (3) Resourcefulness in finding ways to access healthcare.

Discussion

We propose that a greater understanding of the intersections of gender, low literacy, and refugee status can guide healthcare workers and policy makers in improving services for this population. Furthermore, It is important to enable seldom-heard, hard to reach populations and facilitate their participation in research in order to understand how vectors of disadvantage intersect.

Prediction of Adequate Prenatal Care Utilization Based on the Extended Parallel Process Model

Background:

Pregnancy complications are one of the major public health concerns. One of the main causes of preventable complications is the absence of or inadequate provision of prenatal care. The present study was conducted to investigate whether Extended Parallel Process Model’s constructs can predict the utilization of prenatal care services.

Methods:

The present longitudinal prospective study was conducted on 192 pregnant women selected through the multi-stage sampling of health facilities in Qeshm, Hormozgan province, from April to June 2015. Participants were followed up from the first half of pregnancy until their childbirth to assess adequate or inadequate/non-utilization of prenatal care services. Data were collected using the structured Risk Behavior Diagnosis Scale. The analysis of the data was carried out in SPSS-22 using one-way ANOVA, linear regression and logistic regression analysis. The level of significance was set at 0.05.

Results:

Totally, 178 pregnant women with a mean age of 25.31±5.42 completed the study. Perceived self-efficacy (OR=25.23; P<0.001) and perceived susceptibility (OR=0.048; P<0.001) were two predictors of the intention to utilize prenatal care. Husband’s occupation in the labor market (OR=0.43; P=0.02), unwanted pregnancy (OR=0.352; P<0.001), and the need to care for the minors or elderly at home (OR=0.35; P=0.045) were associated with lower odds of receiving prenatal care.

Conclusion:

The model showed that when perceived efficacy of the prenatal care services overcame the perceived threat, the likelihood of prenatal care usage will increase. This study identified some modifiable factors associated with prenatal care usage by women, providing key targets for appropriate clinical interventions.

Knowledge and awareness of human papillomavirus (HPV), cervical cancer and HPV vaccine among women in two distinct Nepali communities

BACKGROUND

This study assessed human papillomavirus (HPV), cervical cancer, and HPV vaccine knowledge and awareness among women in two sub-populations in Nepal - Khokana, a traditional Newari village in the Lalitpur District about eight kilometers south of Kathmandu, and Sanphebagar, a village development committee within Achham District in rural Far-Western Nepal.

METHODS

Study participants were recruited during health camps conducted by Nepal Fertility Care Center, a Nepali non-governmental organization. Experienced staff administered a Nepali language survey instrument that included questions on socio-demographics, reproductive health and knowledge on HPV, cervical cancer, and the HPV vaccine.

RESULTS

Of the 749 participants, 387 (51.7%) were from Khokana and 362 (48.3%) were from Sanphebagar. Overall, 53.3% (n=372) of women were aware of cervical cancer with a significant difference between Khokana and Sanphebagar (63.3% vs 43.0%; p=0.001). Overall, 15.4% (n=107) of women had heard of HPV and 32% (n=34) of these women reported having heard of the HPV vaccine. If freely available, 77.5% of the women reported willingness to have their children vaccinated against HPV. Factors associated with cervical cancer awareness included knowledge of HPV (Khokana: Odds Ratio (OR)=24.5; (95% Confidence Interval (CI): 3.1-190.2, Sanphebagar: OR=14.8; 95% CI: 3.7-58.4)) and sexually transmitted infections (Khokana: OR=6.18; 95% CI: 3.1-12.4; Sanphebagar: OR=17.0; 95% CI: 7.3- 39.7) among other risk factors.

CONCLUSIONS

Knowledge and awareness of HPV, cervical cancer, and the HPV vaccine remains low among women in Khokana and Sanphebagar. Acceptance of a freely available HPV vaccine for children was high, indicating potentially high uptake rates in these communities.