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Faysal S, Penn-Kekana L, Day LT, Tripathi V, Khan F, Stafford R, Levin K, Campbell O, Filippi V. Counseling, informed consent, and debriefing for cesarean section in sub-Saharan Africa: A scoping review. Int J Gynaecol Obstet 2024; 165:43-58. [PMID: 37698080 DOI: 10.1002/ijgo.15079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Counseling as part of the informed consent process is a prerequisite for cesarean section (CS). Postnatal debriefing allows women to explore their CS with their healthcare providers (HCPs). OBJECTIVES To describe the practices and experiences of counseling and debriefing, the barriers and facilitators to informed consent for CS; and to document the effectiveness of the interventions used to improve informed consent found in the peer-reviewed literature. SEARCH STRATEGY The databases searched were PubMed, EMBASE, PsycINFO, Africa-wide information, African Index Medicus, IMSEAR and LILACS. SELECTION CRITERIA English-language papers focusing on consent for CS, published between 2011 and 2022, and assessed to be of medium to high quality were included. DATA COLLECTION AND ANALYSIS A narrative synthesis was conducted using Beauchamp and Childress's elements of informed consent as a framework. MAIN RESULTS Among the 21 included studies reporting on consent for CS, 12 papers reported on counseling for CS, while only one reported on debriefing. Barriers were identified at the service, woman, provider, and societal levels. Facilitators all operated at the provider level and interventions operated at the service or provider levels. CONCLUSIONS There is a paucity of research on informed consent, counseling, and debriefing for CS in sub-Saharan Africa.
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Affiliation(s)
- Sumeya Faysal
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Loveday Penn-Kekana
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Louise-Tina Day
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Farhad Khan
- EngenderHealth, Washington, District of Columbia, USA
| | | | - Karen Levin
- EngenderHealth, Washington, District of Columbia, USA
| | - Oona Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Veronique Filippi
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Reichenberger V, Corona AP, Ramos VD, Shakespeare T, Hameed S, Penn-Kekana L, Kuper H. Access to primary healthcare services for adults with disabilities in Latin America and the Caribbean: a review and meta-synthesis of qualitative studies. Disabil Rehabil 2024:1-10. [PMID: 38433528 DOI: 10.1080/09638288.2024.2320268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE This review and meta-synthesis of qualitative studies aims to provide an overview of qualitative evidence on primary healthcare access of people with disability in Latin America and the Caribbean, as well as to identify barriers that exist in this region. METHODS Six databases were searched for studies from 2000 to 2022. 34 qualitative studies were identified. RESULTS Barriers exist on both demand and supply sides. The thematic synthesis process generated three broad overarching analytical themes, which authors have related to Levesque et al.'s aspects of "ability to perceive," "availability, accommodation and ability to reach" and "appropriateness and ability to engage." Access to information and health literacy are compromised due to a lack of tailored health education materials. Barriers in the urban environment, including inadequate transportation, and insufficient healthcare facility accessibility create challenges for people with disabilities to reach healthcare facilities independently. Attitudinal barriers contribute to suboptimal care experiences. CONCLUSION People with disabilities face several barriers in accessing healthcare. Lack of healthcare provider training, inappropriate urban infrastructure, lack of accessible transport and inaccessibility in healthcare centers are barriers that need to be addressed. With these actions, people with disabilities will be closer to having their rights met.
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Affiliation(s)
- Veronika Reichenberger
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, UK
| | - Ana Paula Corona
- Department of Hearing and Speech Sciences, Multidisciplinary Institute of Rehabilitation and Health, Federal University of Bahia, Salvador, Brazil
| | - Vinicius Delgado Ramos
- Instituto de Medicina Fisica e Reabilitacao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Tom Shakespeare
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, UK
| | - Shaffa Hameed
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, UK
| | - Loveday Penn-Kekana
- Epidemiology and Public Health, Maternal and Neonatal Health Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Hannah Kuper
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, UK
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Mbuo M, Okello I, Penn-Kekana L, Willcox M, Portela A, Palestra F, Mathai M. Community engagement in maternal and perinatal death surveillance and response (MPDSR): Realist review protocol. Wellcome Open Res 2023; 8:117. [PMID: 37654740 PMCID: PMC10465996 DOI: 10.12688/wellcomeopenres.18844.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 09/02/2023] Open
Abstract
Background: While there has been a decline in maternal and perinatal mortality, deaths remain high in sub-Saharan Africa and Asia. With the sustainable development goals (SDGs) targets to reduce maternal and perinatal mortality, more needs to be done to accelerate progress and improve survival. Maternal and perinatal death surveillance and response (MPDSR) is a strategy to identify the clinical and social circumstances that contribute to maternal and perinatal deaths. Through MPDSR, an active surveillance and response cycle is established by bringing together different stakeholders to review and address these social and clinical factors. Community engagement in MPDSR provides a strong basis for collective action to address social factors and quality of care issues that contribute to maternal and perinatal deaths. Studies have shown that community members can support identification and reporting of maternal and/or perinatal deaths. Skilled care at birth has been increasing globally, but there are still gaps in quality of care. Through MPDSR, community members can collaborate with health workers to improve quality of care. But we do not know how community engagement in MPDSR works in practice; for whom it works and what aspects work (or do not work) and why. This realist review answers the question: which strategies of community engagement in MPDSR produce which outcomes in which contexts? Methods : For this realist review, we will identify published and grey literature by searching relevant databases for articles. We will include papers published from 2004 in all languages and from all countries. We have set up an advisory group drawn from academia, international organizations, and practitioners of both MPDSR and community engagement to guide the process. Conclusion: This protocol and the subsequent realist review will use theoretical approaches from the community engagement literature to generate theory on community engagement in MPDSR. Prospero registration number: CRD42022345216.
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Affiliation(s)
- Mary Mbuo
- Public health, Environments and Society, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Immaculate Okello
- Primary Care Research Centre , Aldermoor Health Centre, University of Southampton, Southhampton, UK
| | - Loveday Penn-Kekana
- Public health, Environments and Society, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Merlin Willcox
- Primary Care Research Centre , Aldermoor Health Centre, University of Southampton, Southhampton, UK
| | - Anayda Portela
- Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Francesca Palestra
- Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Matthews Mathai
- Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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van Braam EJ, McRae DN, Portela AG, Stekelenburg J, Penn-Kekana L. Stakeholders' perspectives on the acceptability and feasibility of maternity waiting homes: a qualitative synthesis. Reprod Health 2023; 20:101. [PMID: 37407983 PMCID: PMC10324180 DOI: 10.1186/s12978-023-01615-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/25/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Maternity waiting homes (MHWs) are recommended to help bridge the geographical gap to accessing maternity services. This study aimed to provide an analysis of stakeholders' perspectives (women, families, communities and health workers) on the acceptability and feasibility of MWHs. METHODS A qualitative evidence synthesis was conducted. Studies that were published between January 1990 and July 2020, containing qualitative data on the perspectives of the stakeholder groups were included. A combination of inductive and deductive coding and thematic synthesis was used to capture the main perspectives in a thematic framework. RESULTS Out of 4,532 papers that were found in the initial search, a total of 38 studies were included for the thematic analysis. Six themes emerged: (1) individual factors, such as perceived benefits, awareness and knowledge of the MWH; (2) interpersonal factors and domestic responsibilities, such as household and childcare responsibilities, decision-making processes and social support; (3) MWH characteristics, such as basic services and food provision, state of MWH infrastructure; (4) financial and geographical accessibility, such as transport availability, costs for MWH attendance and loss of income opportunity; (5) perceived quality of care in the MWH and the adjacent health facility, including regular check-ups by health workers and respectful care; and (6) Organization and advocacy, for example funding, community engagement, governmental involvement. The decision-making process of women and their families for using an MWH involves balancing out the gains and losses, associated with all six themes. CONCLUSION This systematic synthesis of qualitative literature provides in-depth insights of interrelating factors that influence acceptability and feasibility of MWHs according to different stakeholders. The findings highlight the potential of MWHs as important links in the maternal and neonatal health (MNH) care delivery system. The complexity and scope of these determinants of utilization underlines the need for MWH implementation strategy to be guided by context. Better documentation of MWH implementation, is needed to understand which type of MWH is most effective in which setting, and to ensure that those who most need the MWH will use it and receive quality services. These results can be of interest for stakeholders, implementers of health interventions, and governmental parties that are responsible for MNH policy development to implement acceptable and feasible MWHs that provide the greatest benefits for its users. Trial registration Systematic review registration number: PROSPERO 2020, CRD42020192219.
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Affiliation(s)
| | - Daphne N McRae
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Anayda G Portela
- Department of Maternal, Newborn, Child, and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health Unit, University Medical Centre Groningen/University of Groningen, Groningen, The Netherlands
- Department Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, The Netherlands
| | - Loveday Penn-Kekana
- Department of Maternal Health and Health Systems, London School of Hygiene and Tropical Medicine, London, UK
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Mohan S, Chaudhry M, McCarthy O, Jarhyan P, Calvert C, Jindal D, Shakya R, Radovich E, Kondal D, Penn-Kekana L, Basany K, Roy A, Tandon N, Shrestha A, Shrestha A, Karmacharya B, Cairns J, Perel P, Campbell OMR, Prabhakaran D. A cluster randomized controlled trial of an electronic decision-support system to enhance antenatal care services in pregnancy at primary healthcare level in Telangana, India: trial protocol. BMC Pregnancy Childbirth 2023; 23:72. [PMID: 36703109 PMCID: PMC9878774 DOI: 10.1186/s12884-022-05249-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/24/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND India contributes 15% of the total global maternal mortality burden. An increasing proportion of these deaths are due to Pregnancy Induced Hypertension (PIH), Gestational Diabetes Mellitus (GDM), and anaemia. This study aims to evaluate the effectiveness of a tablet-based electronic decision-support system (EDSS) to enhance routine antenatal care (ANC) and improve the screening and management of PIH, GDM, and anaemia in pregnancy in primary healthcare facilities of Telangana, India. The EDSS will work at two levels of primary health facilities and is customized for three cadres of healthcare providers - Auxiliary Nurse Midwifes (ANMs), staff nurses, and physicians (Medical Officers). METHODS This will be a cluster randomized controlled trial involving 66 clusters with a total of 1320 women in both the intervention and control arms. Each cluster will include three health facilities-one Primary Health Centre (PHC) and two linked sub-centers (SC). In the facilities under the intervention arm, ANMs, staff nurses, and Medical Officers will use the EDSS while providing ANC for all pregnant women. Facilities in the control arm will continue to provide ANC services using the existing standard of care in Telangana. The primary outcome is ANC quality, measured as provision of a composite of four selected ANC components (measurement of blood pressure, blood glucose, hemoglobin levels, and conducting a urinary dipstick test) by the healthcare providers per visit, observed over two visits. Trained field research staff will collect outcome data via an observation checklist. DISCUSSION To our knowledge, this is the first trial in India to evaluate an EDSS, targeted to enhance the quality of ANC and improve the screening and management of PIH, GDM, and anaemia, for multiple levels of health facilities and several cadres of healthcare providers. If effective, insights from the trial on the feasibility and cost of implementing the EDSS can inform potential national scale-up. Lessons learned from this trial will also inform recommendations for designing and upscaling similar mHealth interventions in other low and middle-income countries. TRIAL REGISTRATION CLINICALTRIALS gov, NCT03700034, registered 9 Oct 2018, https://www. CLINICALTRIALS gov/ct2/show/NCT03700034 CTRI, CTRI/2019/01/016857, registered on 3 Mar 2019, http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=28627&EncHid=&modid=&compid=%27,%2728627det%27.
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Affiliation(s)
- Sailesh Mohan
- grid.415361.40000 0004 1761 0198Public Health Foundation of India (PHFI), Plot 47, Sector 44, Gurugram, Haryana 122002 India ,grid.417995.70000 0004 0512 7879Centre for Chronic Disease Control (CCDC), Safdarjung Development Area, C-1/52, Second Floor, Delhi, 110016 India
| | - Monica Chaudhry
- grid.415361.40000 0004 1761 0198Public Health Foundation of India (PHFI), Plot 47, Sector 44, Gurugram, Haryana 122002 India
| | - Ona McCarthy
- grid.8991.90000 0004 0425 469X London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Prashant Jarhyan
- grid.415361.40000 0004 1761 0198Public Health Foundation of India (PHFI), Plot 47, Sector 44, Gurugram, Haryana 122002 India
| | - Clara Calvert
- grid.8991.90000 0004 0425 469X London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK ,grid.4305.20000 0004 1936 7988Old Medical School, Usher Institute, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | - Devraj Jindal
- grid.417995.70000 0004 0512 7879Centre for Chronic Disease Control (CCDC), Safdarjung Development Area, C-1/52, Second Floor, Delhi, 110016 India
| | - Rajani Shakya
- grid.429382.60000 0001 0680 7778Dhulikhel Hospital, Kathmandu University, JG8X+P54, Dhulikhel, 45200 Nepal
| | - Emma Radovich
- grid.8991.90000 0004 0425 469X London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Dimple Kondal
- grid.415361.40000 0004 1761 0198Public Health Foundation of India (PHFI), Plot 47, Sector 44, Gurugram, Haryana 122002 India
| | - Loveday Penn-Kekana
- grid.8991.90000 0004 0425 469X London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Kalpana Basany
- grid.501907.a0000 0004 1792 1113SHARE (Sci Health Allied Res Education), MediCiti Institute of Medical Sciences Campus, Medchal-Malkajgiri, Hyderabad, Telangana 501401 India
| | - Ambuj Roy
- grid.413618.90000 0004 1767 6103All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, New Delhi, Delhi, 110029 India
| | - Nikhil Tandon
- grid.413618.90000 0004 1767 6103All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, New Delhi, Delhi, 110029 India
| | - Abha Shrestha
- grid.429382.60000 0001 0680 7778Dhulikhel Hospital, Kathmandu University, JG8X+P54, Dhulikhel, 45200 Nepal
| | - Abha Shrestha
- grid.429382.60000 0001 0680 7778Dhulikhel Hospital, Kathmandu University, JG8X+P54, Dhulikhel, 45200 Nepal
| | - Biraj Karmacharya
- grid.429382.60000 0001 0680 7778Dhulikhel Hospital, Kathmandu University, JG8X+P54, Dhulikhel, 45200 Nepal
| | - John Cairns
- grid.8991.90000 0004 0425 469X London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Pablo Perel
- grid.8991.90000 0004 0425 469X London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Oona M. R. Campbell
- grid.8991.90000 0004 0425 469X London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Dorairaj Prabhakaran
- grid.415361.40000 0004 1761 0198Public Health Foundation of India (PHFI), Plot 47, Sector 44, Gurugram, Haryana 122002 India ,grid.417995.70000 0004 0512 7879Centre for Chronic Disease Control (CCDC), Safdarjung Development Area, C-1/52, Second Floor, Delhi, 110016 India ,grid.8991.90000 0004 0425 469X London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
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Radovich E, Chaudhry M, Penn-Kekana L, Raju KRK, Mishra A, Vallabhuni R, Jarhyan P, Mohan S, Prabhakaran D, Campbell OMR, Calvert C. Measuring the quality of antenatal care in a context of high utilisation: evidence from Telangana, India. BMC Pregnancy Childbirth 2022; 22:876. [PMID: 36434534 PMCID: PMC9700993 DOI: 10.1186/s12884-022-05200-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/09/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Antenatal care coverage has dramatically increased in many low-and middle-income settings, including in the state of Telangana, India. However, there is increasing evidence of shortfalls in the quality of care women receive during their pregnancies. This study aims to examine dimensions of antenatal care quality in Telangana, India using four primary and secondary data sources. METHODS Data from two secondary statewide data sources (National Family Health Survey (NFHS-5), 2019-21; Health Management Information System (HMIS), 2019-20) and two primary data sources (a facility survey in 19 primary health centres and sub-centres in selected districts of Telangana; and observations of 36 antenatal care consultations at these facilities) were descriptively analysed. RESULTS NFHS-5 data showed about 73% of women in Telangana received all six assessed antenatal care components during pregnancy. HMIS data showed high coverage of antenatal care visits but differences in levels of screening, with high coverage of haemoglobin tests for anaemia but low coverage of testing for gestational diabetes and syphilis. The facility survey found missing equipment for several key antenatal care services. Antenatal care observations found blood pressure measurement and physical examinations had high coverage and were generally performed correctly. There were substantial deficiencies in symptom checking and communication between the woman and provider. Women were asked if they had any questions in 22% of consultations. Only one woman was asked about her mental health. Counselling of women on at least one of the ten items relating to birth preparedness and on at least one of six danger signs occurred in 58% and 36% of consultations, respectively. CONCLUSION Despite high coverage of antenatal care services and some essential maternal and foetal assessments, substantial quality gaps remained, particularly in communication between healthcare providers and pregnant women and in availability of key services. Progress towards achieving high quality in both content and experience of antenatal care requires addressing service gaps and developing better measures to capture and improve women's experiences of care.
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Affiliation(s)
- Emma Radovich
- grid.8991.90000 0004 0425 469XFaculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Monica Chaudhry
- grid.415361.40000 0004 1761 0198Public Health Foundation of India, Gurgaon, India
| | - Loveday Penn-Kekana
- grid.8991.90000 0004 0425 469XFaculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Aparajita Mishra
- grid.415361.40000 0004 1761 0198Public Health Foundation of India, Gurgaon, India ,grid.415361.40000 0004 1761 0198Indian Institute of Public Health, Hyderabad (IIPHH), Hyderabad, India
| | - Ramya Vallabhuni
- grid.415361.40000 0004 1761 0198Public Health Foundation of India, Gurgaon, India
| | - Prashant Jarhyan
- grid.415361.40000 0004 1761 0198Public Health Foundation of India, Gurgaon, India
| | - Sailesh Mohan
- grid.415361.40000 0004 1761 0198Public Health Foundation of India, Gurgaon, India
| | - Dorairaj Prabhakaran
- grid.415361.40000 0004 1761 0198Public Health Foundation of India, Gurgaon, India
| | - Oona M. R. Campbell
- grid.8991.90000 0004 0425 469XFaculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Clara Calvert
- grid.8991.90000 0004 0425 469XFaculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK ,grid.4305.20000 0004 1936 7988Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
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Reichenberger V, Smythe T, Hameed S, Rubiano Perea LC, Shakespeare T, Penn-Kekana L, Kuper H. Participatory Visual Methods with caregivers of children with Congenital Zika Syndrome in Colombia: A case study. Wellcome Open Res 2022; 7:107. [PMID: 37928610 PMCID: PMC10620479 DOI: 10.12688/wellcomeopenres.17529.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/07/2023] Open
Abstract
Background: This study explores the acceptability and feasibility of the use of two different Participatory Visual Methods (Participatory Video and Digital Storytelling) in gathering information on the experiences and perspectives of carers of children with Congenital Zika Syndrome within Colombia. Methods: Participatory Video was used to assess the impact of the Juntos parent-support intervention in the lives of carers, and Digital Storytelling was used to explore the healthcare access for these children. In-depth interviews were conducted to probe participants on their views of these methods. Results: One Participatory Video was produced and four Digital Stories. Of the initial eight caregivers who took part in the Participatory Video process, four completed both the Digital Storytelling process and an in-depth interview about their experiences. The main factors shaping participants' experiences related to the skills learned in making the videos, the feeling of collectiveness and the control over the processes. Conclusions: Women with children with Congenital Zika Syndrome have reported feeling marginalised and misunderstood in daily life. This case study found that Participatory Visual Methods is acceptable and feasible. Moreover, these approaches can support groups in different aspects, such as providing a space to share their stories creatively, hear others in similar situations as them and increase the feeling of community.
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Affiliation(s)
- Veronika Reichenberger
- International Centre for Evidence in Disability, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Tracey Smythe
- International Centre for Evidence in Disability, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Shaffa Hameed
- International Centre for Evidence in Disability, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Tom Shakespeare
- International Centre for Evidence in Disability, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Loveday Penn-Kekana
- Department of Public Health and Policy, Health Policy Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Hannah Kuper
- International Centre for Evidence in Disability, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Lyra TM, Veloso de Albuquerque MS, Santos de Oliveira R, Morais Duarte Miranda G, Andréa de Oliveira M, Eduarda Carvalho M, Fernandes Santos H, Penn-Kekana L, Kuper H. The National Health Policy for People with Disabilities in Brazil: An Analysis of the Content, Context and the Performance of Social Actors. Health Policy Plan 2022; 37:1086-1097. [PMID: 35771660 PMCID: PMC9557334 DOI: 10.1093/heapol/czac051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 06/09/2022] [Accepted: 06/29/2022] [Indexed: 11/30/2022] Open
Abstract
The purpose of this article is to analyse the circumstances in which the National Health Policy for Persons with Disabilities (PNSPCD) came into place in 2002 and the factors supporting or impeding its implementation from 2002 to 2018. The analysis was based on the Comprehensive Policy Analysis Model proposed by Walt and Gilson and focussed on understanding the context, process, content and actors involved in the formulation and implementation of the Policy. Data were obtained from two sources: document analysis of the key relevant documents and seven key informant interviews. Content analysis was undertaken using the Condensation of Meanings technique. The research demonstrates that the development and implementation of PNSPCD is marked by advances and retreats, determined, above all, by national and international macro-political decisions. The policy was formulated during Fernando Henrique’s governments, under pressure from social movements and the international agenda and constituted a breakthrough for the rights of persons with disabilities. However, progress on implementation only took place under subsequent centre-left governments with the establishment of a care network for people with disabilities and a defined specific budget. These developments resulted from the mobilization of social movements, the ratification of the United Nations Convention on the rights of people with disabilities and the adherence of these governments to the human rights agenda. The coming to power of ultra-right governments triggered fiscal austerity, a setback in the implementation of the care network and a weakening in the content of various social policies related to the care of people with disabilities. During this era, the political approach changed, with the attempt to evade the role of the State, and the perspective of guaranteeing social rights. Undoubtedly, the neoliberal offensive on social policies, especially the Unified Health System, is the main obstacle to the effective implementation of the PNPCD in Brazil.
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Affiliation(s)
- Tereza Maciel Lyra
- Aggeu Magalhães Institute, FIOCRUZ/PE, Av. Professor Moraes Rego, s/n - Campus da UFPE, Cidade Universitária, Recife, PE 50.740-465, Brazil
| | - Maria Socorro Veloso de Albuquerque
- Center for Medical Sciences, Federal University of Pernambuco, Av. da Engenharia, s/n, Bloco "D", 1º Andar - Cidade Universitária, Recife, PE 50.740-600
| | - Raquel Santos de Oliveira
- Center for Medical Sciences, Federal University of Pernambuco, Av. da Engenharia, s/n, Bloco "D", 1º Andar - Cidade Universitária, Recife, PE 50.740-600
| | - Gabriella Morais Duarte Miranda
- Center for Medical Sciences, Federal University of Pernambuco, Av. da Engenharia, s/n, Bloco "D", 1º Andar - Cidade Universitária, Recife, PE 50.740-600
| | - Márcia Andréa de Oliveira
- Medical Sciences College, University of Pernambuco, Av. Gov. Agamenon Magalhães - Santo Amaro, Recife, PE 50.100-010
| | - Maria Eduarda Carvalho
- Aggeu Magalhães Institute, FIOCRUZ/PE, Av. Professor Moraes Rego, s/n - Campus da UFPE, Cidade Universitária, Recife, PE 50.740-465, Brazil
| | - Helena Fernandes Santos
- Center for Philosophy and Human Sciences, Federal University of Pernambuco, Av. Prof. Moraes Rego, 1235 - Cidade Universitária, Recife, PE 50670-901
| | - Loveday Penn-Kekana
- Epidemiology and Public Health, Maternal and Neonatal Health Group, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Hannah Kuper
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Reichenberger V, Smythe T, Hameed S, Rubiano Perea LC, Shakespeare T, Penn-Kekana L, Kuper H. Participatory Visual Methods with caregivers of children with Congenital Zika Syndrome in Colombia: A case study. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17529.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: This study explores the acceptability and feasibility of the use of two different Participatory Visual Methods (Participatory Video and Digital Storytelling) in gathering information on the experiences and perspectives of carers of children with Congenital Zika Syndrome within Colombia. Methods: Participatory Video was used to assess the impact of the Juntos parent-support intervention in the lives of carers, and Digital Storytelling was used to explore the healthcare access for these children. In-depth interviews were conducted to probe participants on their views of these methods. Results: One Participatory Video was produced and four Digital Stories. Of the initial eight caregivers who took part in the Participatory Video process, four completed both the Digital Storytelling process and an in-depth interview about their experiences. The main factors shaping participants’ experiences related to the skills learned in making the videos, the feeling of collectiveness and the control over the processes. Conclusion: Women with children with Congenital Zika Syndrome have reported feeling marginalised and misunderstood in daily life. This case study found that Participatory Visual Methods is acceptable and feasible. Moreover, these approaches can support groups in different aspects, such as providing a space to share their stories creatively, hear others in similar situations as them and increase the feeling of community.
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10
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da Cunha MAO, Santos HF, de Carvalho MEL, Miranda GMD, de Albuquerque MDSV, de Oliveira RS, de Albuquerque AFC, Penn-Kekana L, Kuper H, Lyra TM. Health Care for People with Disabilities in the Unified Health System in Brazil: A Scoping Review. Int J Environ Res Public Health 2022; 19:1472. [PMID: 35162497 PMCID: PMC8834994 DOI: 10.3390/ijerph19031472] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 12/10/2022]
Abstract
People with disabilities have greater need for healthcare on average, but often face barriers when accessing these services. The Brazilian government launched the National Health Policy for People with Disabilities (PNSPD) in 2002 to address this inequality. PNSPD has six areas of focus: quality of life, impairment prevention, comprehensive health care, organization and functioning of health services, information mechanisms, and training of human resources. The aim of this article was to undertake a scoping review to assess the evidence on the experience of people with disabilities in Brazil with respect to the six themes of the PNSPD. The scoping review included articles published between 2002 and 2019, from four electronic databases: PUBMED/MEDLINE, LILACS, Science Direct, and Scielo. In total, 8076 articles were identified, and after review of titles, abstracts, and full texts by two independent reviewers, 98 were deemed eligible for inclusion. The evidence was relatively limited in availability and scope. However, it consistently showed large gaps in delivery of healthcare to people with disabilities across the six dimensions considered. There was lack of actions aimed at promoting quality of life; insufficient professional training about disability; little evidence on the health profile of people with disabilities; large gaps in the availability of care due to widespread physical, informational, and attitudinal barriers; and poor distribution of the supply and integration of services. In conclusion, the policy framework in Brazil is supportive of the inclusion of people with disabilities in health services; however, large inequalities remain due to poor implementation of the policy into practice.
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Affiliation(s)
| | | | | | - Gabriella Morais Duarte Miranda
- Academic Area of Public Health, Center for Medical Sciences, Federal University of Pernambuco, Recife 50070-460, Brazil; (G.M.D.M.); or (M.d.S.V.d.A.); (R.S.d.O.)
- Department of Collective Health, Aggeu Magalhães Institute, FIOCRUZ, Recife 50670-420, Brazil;
| | - Maria do Socorro Veloso de Albuquerque
- Academic Area of Public Health, Center for Medical Sciences, Federal University of Pernambuco, Recife 50070-460, Brazil; (G.M.D.M.); or (M.d.S.V.d.A.); (R.S.d.O.)
- Department of Collective Health, Aggeu Magalhães Institute, FIOCRUZ, Recife 50670-420, Brazil;
| | - Raquel Santos de Oliveira
- Academic Area of Public Health, Center for Medical Sciences, Federal University of Pernambuco, Recife 50070-460, Brazil; (G.M.D.M.); or (M.d.S.V.d.A.); (R.S.d.O.)
| | | | - Loveday Penn-Kekana
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
| | - Hannah Kuper
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
| | - Tereza Maciel Lyra
- Department of Collective Health, Aggeu Magalhães Institute, FIOCRUZ, Recife 50670-420, Brazil;
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11
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Sivaram S, Singh S, Penn-Kekana L. Understanding the role of female sterilisation in Indian family planning through qualitative analysis: perspectives from above and below. Sex Reprod Health Matters 2022; 29:2080166. [PMID: 35723228 PMCID: PMC9225727 DOI: 10.1080/26410397.2022.2080166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Since the 1990s, the global approach to family planning has undergone fundamental transformations from population control to addressing reproductive health and rights. The Indian family planning programme has also transitioned from being vertical, target-oriented, and clinic-based to a supposedly target-free, choice-based programme that champions reproductive rights. Despite contraceptive choices being offered and voluntary adoption encouraged, there is a heavy reliance on female sterilisation. Community health workers, known as ASHAs, are responsible for on-ground implementation of family planning policies and are incentivised to promote sterilisation as well as other methods. This study explored perspectives to understand of the role of female sterilisation in Indian family planning and whether policy is reflected in implementation. Secondary ethnographic data from Rajasthan, which included twenty interviews and five group discussions, were used to understand the perspectives of ASHAs. Primary data included five key informant interviews to understand the perspectives of experts nationally. Data were analysed thematically with a combination of deductive and inductive coding. Themes that emerged included choice, population control and coercion, family planning targets, quality and experience of services, historical factors and social norms. Despite the official policy shift, there appears to be narrow implementation which is still target-driven, relies heavily on female sterilisation, while negotiating between achieving population stabilisation and upholding reproductive rights. There is a need to emphasise spacing methods, ensure a rights- and choice-based approach and encourage male participation in reproductive health decisions.
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Affiliation(s)
- Sharmada Sivaram
- MSc. Student, London School of Hygiene & Tropical Medicine, London, UK
| | - Sunita Singh
- Consultant, London School of Hygiene & Tropical Medicine, London, UK
| | - Loveday Penn-Kekana
- Assistant Professor, Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
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12
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Zhang H, Liu X, Penn-Kekana L, Ronsmans C. A systematic review of the profile and density of the maternal and child health workforce in China. Hum Resour Health 2021; 19:125. [PMID: 34627289 PMCID: PMC8501553 DOI: 10.1186/s12960-021-00662-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND To track progress in maternal and child health (MCH), understanding the health workforce is important. This study seeks to systematically review evidence on the profile and density of MCH workers in China. METHODS We searched 6 English and 2 Chinese databases for studies published between 1 October 1949 and 20 July 2020. We included studies that reported on the level of education or the certification status of all the MCH workers in one or more health facilities and studies reporting the density of MCH workers per 100 000 population or per 1000 births. MCH workers were defined as those who provided MCH services in mainland China and had been trained formally or informally. RESULTS Meta-analysis of 35 studies found that only two-thirds of obstetricians and paediatricians (67%, 95% CI: 59.6-74.3%) had a bachelor or higher degree. This proportion was lower in primary-level facilities (28% (1.5-53.9%)). For nurses involved in MCH care the proportions with a bachelor or higher degree were lower (20.0% (12.0-30.0%) in any health facility and 1% (0.0-5.0%) in primary care facilities). Based on 18 studies, the average density of MCH doctors and nurses was 11.8 (95% CI: 7.5-16.2) and 11.4 (7.6-15.2) per 100 000 population, respectively. The average density of obstetricians was 9.0 (7.9-10.2) per 1000 births and that of obstetric nurses 16.0 (14.8-17.2) per 1000 births. The density of MCH workers is much higher than what has been recommended internationally (three doctors and 20 midwives per 3600 births). CONCLUSIONS Our review suggests that the high density of MCH workers in China is achieved through a mix of workers with high and low educational profiles. Many workers labelled as "obstetricians" or "paediatrician" have lower qualifications than expected. China compensates for these low educational levels through task-shifting, in-service training and supervision.
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Affiliation(s)
- Huan Zhang
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, WC1E 7HT, London, United Kingdom.
| | - Xiaoyun Liu
- Peking University China Centre for Health Development Studies, Beijing, China
| | - Loveday Penn-Kekana
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, WC1E 7HT, London, United Kingdom
| | - Carine Ronsmans
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, WC1E 7HT, London, United Kingdom
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13
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Lange IL, Nalwadda CK, Kiguli J, Penn-Kekana L. The Ambiguity Imperative: "Success" in a Maternal Health Program in Uganda. Med Anthropol 2021; 40:458-472. [PMID: 34106797 DOI: 10.1080/01459740.2021.1922901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Global health programs are compelled to demonstrate impact on their target populations. We study an example of social franchising - a popular healthcare delivery model in low/middle-income countries - in the Ugandan private maternal health sector. The discrepancies between the program's official profile and its actual operation reveal the franchise responded to its beneficiaries, but in a way incoherent with typical evidence production on social franchises, which privileges simple narratives blurring the details of program enactment. Building on concepts of not-knowing and the production of success, we consider the implications of an imperative to maintain ambiguity in global health programming and academia.
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Affiliation(s)
- Isabelle L Lange
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Christine Kayemba Nalwadda
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Juliet Kiguli
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Loveday Penn-Kekana
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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14
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Gurung R, Ruysen H, Sunny AK, Day LT, Penn-Kekana L, Målqvist M, Ghimire B, Singh D, Basnet O, Sharma S, Shaver T, Moran AC, Lawn JE, Kc A. Respectful maternal and newborn care: measurement in one EN-BIRTH study hospital in Nepal. BMC Pregnancy Childbirth 2021; 21:228. [PMID: 33765971 PMCID: PMC7995692 DOI: 10.1186/s12884-020-03516-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Respectful maternal and newborn care (RMNC) is an important component of high-quality care but progress is impeded by critical measurement gaps for women and newborns. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study was an observational study with mixed methods assessing measurement validity for coverage and quality of maternal and newborn indicators. This paper reports results regarding the measurement of respectful care for women and newborns. METHODS At one EN-BIRTH study site in Pokhara, Nepal, we included additional questions during exit-survey interviews with women about their experiences (July 2017-July 2018). The questionnaire was based on seven mistreatment typologies: Physical; Sexual; or Verbal abuse; Stigma/discrimination; Failure to meet professional standards of care; Poor rapport between women and providers; and Health care denied due to inability to pay. We calculated associations between these typologies and potential determinants of health - ethnicity, age, sex, mode of birth - as possible predictors for reporting poor care. RESULTS Among 4296 women interviewed, none reported physical, sexual, or verbal abuse. 15.7% of women were dissatisfied with privacy, and 13.0% of women reported their birth experience did not meet their religious and cultural needs. In descriptive analysis, adjusted odds ratios and multivariate analysis showed primiparous women were less likely to report respectful care (β = 0.23, p-value < 0.0001). Women from Madeshi (a disadvantaged ethnic group) were more likely to report poor care (β = - 0.34; p-value 0.037) than women identifying as Chettri/Brahmin. Women who had caesarean section were less likely to report poor care during childbirth (β = - 0.42; p-value < 0.0001) than women with a vaginal birth. However, babies born by caesarean had a 98% decrease in the odds (aOR = 0.02, 95% CI, 0.01-0.05) of receiving skin-to-skin contact than those with vaginal births. CONCLUSIONS Measurement of respectful care at exit interview after hospital birth is challenging, and women generally reported 100% respectful care for themselves and their baby. Specific questions, with stratification by mode of birth, women's age and ethnicity, are important to identify those mistreated during care and to prioritise action. More research is needed to develop evidence-based measures to track experience of care, including zero separation for the mother-newborn pair, and to improve monitoring.
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Affiliation(s)
- Rejina Gurung
- Research Division, Golden Community, Lalitpur, Nepal
| | - Harriet Ruysen
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | | | - Louise T Day
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Loveday Penn-Kekana
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Mats Målqvist
- Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, Sweden
| | | | - Dela Singh
- Ministry of Health and Population, Kathmandu, Nepal
| | - Omkar Basnet
- Research Division, Golden Community, Lalitpur, Nepal
| | | | | | - Allisyn C Moran
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, WHO, Geneva, Switzerland
| | - Joy E Lawn
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, Sweden.
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15
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Brotherton H, Daly M, Johm P, Jarju B, Schellenberg J, Penn-Kekana L, Lawn JE. "We All Join Hands": Perceptions of the Kangaroo Method Among Female Relatives of Newborns in The Gambia. Qual Health Res 2021; 31:665-676. [PMID: 33292063 PMCID: PMC7882999 DOI: 10.1177/1049732320976365] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Family support is essential for kangaroo mother care (KMC), but there is limited research regarding perceptions of female relatives, and none published from West African contexts. In-depth interviews were conducted from July to August 2017 with a purposive sample of 11 female relatives of preterm neonates admitted to The Gambia's referral hospital. Data were coded in NVivo 11, and thematic analysis was conducted applying an inductive framework. Female relatives were willing to support mothers by providing KMC and assisting with domestic chores and agricultural labor. Three themes were identified: (a) collective family responsibility for newborn care, with elder relatives being key decision makers, (b) balance between maintaining traditional practices and acceptance of KMC as a medical innovation, and (c) gendered expectations of women's responsibilities postnatally. Female relatives are influential stakeholders and could play important roles in KMC programs, encourage community ownership, and contribute to improved outcomes for vulnerable newborns.
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Affiliation(s)
- Helen Brotherton
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
- Helen Brotherton, Maternal Adolescent Reproductive & Child Health (MARCH) Centre, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
| | - Maura Daly
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Penda Johm
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Bintou Jarju
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
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16
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de Barra M, Gon G, Woodd S, Graham WJ, de Bruin M, Kahabuka C, Williams AJ, Konate K, Ali SM, Said R, Penn-Kekana L. Understanding infection prevention behaviour in maternity wards: A mixed-methods analysis of hand hygiene in Zanzibar. Soc Sci Med 2021; 272:113543. [PMID: 33578309 PMCID: PMC7938378 DOI: 10.1016/j.socscimed.2020.113543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/16/2022]
Abstract
RATIONALE Although women in low- and middle-income countries are increasingly encouraged to give birth at facilities, healthcare-associated infection of both the mother and newborn remain common. An important cause of infection is poor hand hygiene. There is a need to understand how environmental, behavioural, and organisational factors influence hygiene practice. OBJECTIVE To understand variations between facilities and between people in hygiene behaviour and to explore potential intervention targets in four labour wards in Zanzibar. METHODS Site visits including observation of deliveries and of day-to-day workings of the facilities. Thirty-three semi-structured interviews, totalling more than 46 hours, with birth attendants, orderlies, managerial staff and mothers. Transcribed interviews and observation notes were read and coded by two authors. Themes were developed and analysed in light of existing research. RESULTS The physical preconditions for hand hygiene were met more regularly in the two highvolume facilities, where soap, water, gloves were almost always available. However, in all of the facilities, hand hygiene appeared impeded by poor ergonomics, like, for example, physical distance between water taps, gloves, or delivery beds. Recontamination of gloved hands following good hand hygiene was commonly observed, a pattern that the birth attendants attributed to high and unpredictable workload and equipment shortages. Interviews and focus groups suggested that birth attendants typically understood when and why hand hygiene should be implemented, and that they were aware of low handwashing rates among co-workers. In poorer performing facilities, managers were less inclined to visit wards and more likely to perceive hand hygiene as beyond their influence. CONCLUSIONS Observations and interviews suggest improvements in the ergonomic design of delivery rooms, including convenient availability of sinks, soap, hand gel, hand towels and gloves, may be a low-cost way to reduce the infection burden from poor hand hygiene.
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Affiliation(s)
| | - Giorgia Gon
- London School of Hygiene and Tropical Medicine, UK
| | | | - Wendy J Graham
- University of Aberdeen, UK; London School of Hygiene and Tropical Medicine, UK
| | - Marijn de Bruin
- University of Aberdeen, UK; IQ Healthcare, Radboud University Medical Centre, the Netherlands
| | | | | | | | - Said M Ali
- Public Health Laboratory Ivo de Carneri, Zanzibar
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17
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Gon G, Kabanywanyi AM, Blinkhoff P, Cousens S, Dancer SJ, Graham WJ, Hokororo J, Manzi F, Marchant T, Mkoka D, Morrison E, Mswata S, Oza S, Penn-Kekana L, Sedekia Y, Virgo S, Woodd S, Aiken AM. The Clean pilot study: evaluation of an environmental hygiene intervention bundle in three Tanzanian hospitals. Antimicrob Resist Infect Control 2021; 10:8. [PMID: 33413647 PMCID: PMC7789081 DOI: 10.1186/s13756-020-00866-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 11/25/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Healthcare associated infections (HAI) are estimated to affect up to 15% of hospital inpatients in low-income countries (LICs). A critical but often neglected aspect of HAI prevention is basic environmental hygiene, particularly surface cleaning and linen management. TEACH CLEAN is an educational intervention aimed at improving environmental hygiene. We evaluated the effectiveness of this intervention in a pilot study in three high-volume maternity and newborn units in Dar es Salaam, Tanzania. METHODS This study design prospectively evaluated the intervention as a whole, and offered a before-and-after comparison of the impact of the main training. We measured changes in microbiological cleanliness [Aerobic Colony Counts (ACC) and presence of Staphylococcus aureus] using dipslides, and physical cleaning action using gel dots. These were analysed with descriptive statistics and logistic regression models. We used qualitative (focus group discussions, in-depth interviews, and semi-structured observation) and quantitative (observation checklist) tools to measure why and how the intervention worked. We describe these findings across the themes of adaptation, fidelity, dose, reach and context. RESULTS Microbiological cleanliness improved during the study period (ACC pre-training: 19%; post-training: 41%). The odds of cleanliness increased on average by 1.33 weekly during the pre-training period (CI = 1.11-1.60), and by 1.08 (CI = 1.03-1.13) during the post-training period. Cleaning action improved only in the pre-training period. Detection of S. aureus on hospital surfaces did not change substantially. The intervention was well received and considered feasible in this context. The major pitfalls in the implementation were the limited number of training sessions at the hospital level and the lack of supportive supervision. A systems barrier to implementation was lack of regular cleaning supplies. CONCLUSIONS The evaluation suggests that improvements in microbiological cleanliness are possible using this intervention and can be sustained. Improved microbiological cleanliness is a key step on the pathway to infection prevention in hospitals. Future research should assess whether this bundle is cost-effective in reducing bacterial and viral transmission and infection using a rigorous study design.
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Affiliation(s)
- Giorgia Gon
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Petri Blinkhoff
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Simon Cousens
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephanie J Dancer
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, UK
- Department of Microbiology, Hairmyres Hospital, Glasgow, UK
| | - Wendy J Graham
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Joseph Hokororo
- Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Fatuma Manzi
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Dar es Salaam, Tanzania
| | - Dickson Mkoka
- School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Sarah Mswata
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Shefali Oza
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Loveday Penn-Kekana
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Susannah Woodd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Alexander M Aiken
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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18
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Simas C, Penn-Kekana L, Kuper H, Lyra TM, Moreira MEL, de Albuquerque MDSV, de Araújo TVB, de Melo APL, Figueira Mendes CH, Nunes Moreira MC, Ferreira do Nascimento MA, Pimentel C, Pinto M, Valongueiro S, Larson H. Hope and trust in times of Zika: the views of caregivers and healthcare workers at the forefront of the epidemic in Brazil. Health Policy Plan 2020; 35:953-961. [PMID: 32681164 PMCID: PMC7553755 DOI: 10.1093/heapol/czaa042] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 12/16/2022] Open
Abstract
This article investigates how hope and trust played out for two groups at the forefront of the Zika epidemic: caregivers of children with congenital Zika syndrome and healthcare workers. We conducted 76 in-depth interviews with members of both groups to examine hope and trust in clinical settings, as well as trust in public institutions, in the health system and in the government of Brazil. During and after the Zika epidemic, hope and trust were important to manage uncertainty and risk, given the lack of scientific evidence about the neurological consequences of Zika virus infection. The capacity of healthcare workers and caregivers to trust and to co-create hope seems to have allowed relationships to develop that cushioned social impacts, reinforced adherence to therapeutics and enabled information flow. Hope facilitated parents to trust healthcare workers and interventions. Hope and trust appeared to be central in the establishment of support networks for caregivers. At the same time, mistrust in the government and state institutions may have allowed rumours and alternative explanations about Zika to spread. It may also have strengthened activism in mother's associations, which seemed to have both positive and negative implications for healthcare service delivery. The findings also point to distrust in international health actors and global health agenda, which can impact community engagement in future outbreak responses in Brazil and other countries in Latin America.
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Affiliation(s)
- Clarissa Simas
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel St, London WC1E 7HT, UK
| | - Loveday Penn-Kekana
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel St, London WC1E 7HT, UK
| | - Hannah Kuper
- International Centre for Evidence in Disability, Clinical Research Department, London School of Hygiene & Tropical Medicine, Keppel St, London WC1E 7HT, UK
| | - Tereza Maciel Lyra
- Fundação Oswaldo Cruz, Instituto Aggeu Magalhães/Fiocruz, Avenida Professor Moraes Rêgo, S/N Cidade Universitária. CEP 50740-465, Recife, PE, Brasil
- Department of Social Medicine, Faculty of Medicine, Federal University of Pernambuco, Avenida da Engenharia, S/N, Bloco D, 1º Andar, Cidade Universitária. CEP: 50.740-600 Recife, PE, Brazil
| | - Maria Elisabeth Lopes Moreira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira/Fiocruz, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ 20021-140, Brazil
| | - Maria do Socorro Veloso de Albuquerque
- Postgraduate Programme in public Health, Center of Medical Sciences, Federal University of Pernambuco. Avenida Professor Moraes Rêgo, S/N Hospital das Clínicas, Bloco E, 4o.andar. Cidade Unitersitária, CEP 50.670-901, Recife -PE, Brazil
| | - Thália Velho Barreto de Araújo
- Postgraduate Programme in Public Health, Center of Medical Sciences, Federal University of Pernambuco, Avenida Professor Moraes Rêgo, S/N Hospital das Clínicas, Bloco E - 4º Andar, Cidade Universitária, CEP: 50.670-901, Recife, PE, Brazil
| | - Ana Paula Lopes de Melo
- Fundação Oswaldo Cruz, Instituto Aggeu Magalhães/Fiocruz, Avenida Professor Moraes Rêgo, S/N Cidade Universitária. CEP 50740-465, Recife, PE, Brasil
- Núcleo de Saúde Coletiva da Universidade Federal de Pernambuco R. Alto do Reservatório - Alto José Leal, Vitória de Santo Antã - PE-Brasil, 55608-250l
| | - Corina Helena Figueira Mendes
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira/Fiocruz, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ 20021-140, Brazil
| | - Martha Cristina Nunes Moreira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira/Fiocruz, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ 20021-140, Brazil
| | - Marcos Antonio Ferreira do Nascimento
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira/Fiocruz, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ 20021-140, Brazil
| | - Camila Pimentel
- Fundação Oswaldo Cruz, Instituto Aggeu Magalhães/Fiocruz, Avenida Professor Moraes Rêgo, S/N Cidade Universitária. CEP 50740-465, Recife, PE, Brasil
| | - Marcia Pinto
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira/Fiocruz, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ 20021-140, Brazil
| | - Sandra Valongueiro
- Postgraduate Programme in Public Health, Center of Medical Sciences, Federal University of Pernambuco, Avenida Professor Moraes Rêgo, S/N Hospital das Clínicas, Bloco E - 4º Andar, Cidade Universitária, CEP: 50.670-901, Recife, PE, Brazil
| | - Heidi Larson
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel St, London WC1E 7HT, UK
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19
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Graham WJ, Afolabi B, Benova L, Campbell OMR, Filippi V, Nakimuli A, Penn-Kekana L, Sharma G, Okomo U, Valongueiro S, Waiswa P, Ronsmans C. Protecting hard-won gains for mothers and newborns in low-income and middle-income countries in the face of COVID-19: call for a service safety net. BMJ Glob Health 2020; 5:e002754. [PMID: 32499220 PMCID: PMC7298807 DOI: 10.1136/bmjgh-2020-002754] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 11/03/2022] Open
Affiliation(s)
- Wendy Jane Graham
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Bosede Afolabi
- Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Akoka, Lagos, Nigeria
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | | | - Veronique Filippi
- Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Annettee Nakimuli
- Obstetrics and Gynecology, Makerere University and Mulago National Referral Hospital, Kampala, Uganda
| | - Loveday Penn-Kekana
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Uduak Okomo
- Vaccines and Immunity Theme, MRC Unit-Gambia, Banjul, Gambia
| | - Sandra Valongueiro
- Postgraduate Program of Public Health, Universidade Federal de Pernambuco, Recife, Brazil
| | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Carine Ronsmans
- Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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20
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Ndiaye S, Bosowski J, Tuyisenge L, Penn-Kekana L, Thorogood N, Moxon SG, Lissauer T. Parents as carers on a neonatal unit: Qualitative study of parental and staff perceptions in a low-income setting. Early Hum Dev 2020; 145:105038. [PMID: 32311647 DOI: 10.1016/j.earlhumdev.2020.105038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/28/2020] [Accepted: 03/31/2020] [Indexed: 11/12/2022]
Abstract
UNLABELLED Aim To determine parents' experiences on a neonatal unit in a low-income country, how they and staff perceive the role of parents and if parents' role as primary carers could be extended. BACKGROUND A busy, rural district hospital in Rwanda. Rwandan neonatal mortality is falling, but achieving Sustainable Development Goal target is hampered by trained staff shortage. METHODS Qualitative thematic content analysis of semi-structured interviews with 12 parents and 16 staff. RESULTS Parental concerns were around their baby's survival, stress and discharge. They were satisfied with their baby's care but feared their baby may die. Mothers described stress from remaining in hospital throughout baby's stay, providing all non-technical care including tube or breast feeds day and night, followed by kangaroo mother care until discharge. They expressed loneliness from lack of visitors, difficulty finding food and somewhere to sleep, financial worries, concern about family at home, and were desperate to be discharged. Staff focused on shortage of nurses limiting technical care, ability to educate parents and provide follow-up. Neither groups thought parents' role could be extended. CONCLUSION Staff, including senior management, were mainly focused on increasing nursing numbers. Parents' concerns were psychosocial and about coping emotionally with their baby's care and practical concerns about inpatient facilities, particularly lack of food and accommodation and absence from home. Staff preoccupation with nurse numbers made them concentrate on medical care, but parental issues identified are more likely to be provided by experienced mothers, allied health professionals, mothers' groups or community health workers.
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Affiliation(s)
- S Ndiaye
- London School of Hygiene and Tropical Medicine, London, UK
| | - J Bosowski
- London School of Hygiene and Tropical Medicine, London, UK
| | - L Tuyisenge
- University Teaching Hospital of Kigali, Rwanda
| | - L Penn-Kekana
- London School of Hygiene and Tropical Medicine, London, UK
| | - N Thorogood
- London School of Hygiene and Tropical Medicine, London, UK
| | - S G Moxon
- London School of Hygiene and Tropical Medicine, London, UK
| | - T Lissauer
- Imperial College Healthcare Trust, London, UK; University of Rwanda, Rwanda.
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21
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Passos MJ, Matta G, Lyra TM, Moreira MEL, Kuper H, Penn-Kekana L, Mendonça M. The promise and pitfalls of social science research in an emergency: lessons from studying the Zika epidemic in Brazil, 2015-2016. BMJ Glob Health 2020; 5:e002307. [PMID: 32345582 PMCID: PMC7213811 DOI: 10.1136/bmjgh-2020-002307] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 11/08/2022] Open
Abstract
Social science generates evidence necessary to control epidemics. It can help to craft appropriate public health responses, develop solutions to the epidemic impacts and improve understanding of why the epidemic occurred. Yet, there are practical constraints in undertaking this international research in a way that produces quality, ethical and appropriate data, and that values all voices and experiences, especially those of local researchers and research participants. In this paper, we reflected on the experience of undertaking social science research during the 2015/2016 Zika epidemic in Brazil. This experience was considered from the perspective of this paper's authors: three Brazilian academics, two UK academics and two mothers of children affected by congenital Zika syndrome. This group came together through the conduct of the Social and Economic Impact of Zika study, a mixed-methods social science study. The key findings highlight practical issues in the achievement of three goals: the conduct of high-quality social science in emergencies and efforts towards the decolonisation of global health in terms of levelling the power between Brazilian and UK researchers and optimising the role of patients within research. From our perspective, the information collected through social science was valuable, providing detailed insight into the programmatic needs of mothers and their affected children (eg, economic and social support and mental health services). Social science was considered a low priority within the Zika epidemic despite its potential importance. There were logistical challenges in conducting social science research, foremost of which are the difficulties in developing a trusting and balanced power relationship between the UK and Brazilian researchers in a short time frame. When these issues were overcome, each partner brought unique qualities, making the research stronger. The mothers of affected children expressed dissatisfaction with research, as they were involved in many studies which were not coordinated, and from which they did not see a benefit. In conclusion, the importance of social science in epidemics must continue to be promoted by funders. Funders can also set in place mechanisms to help equalise the power dynamics between foreign and local researchers, researchers and participants, both to promote justice and to create best quality data.
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Affiliation(s)
| | - Gustavo Matta
- Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Tereza Maciel Lyra
- Aggeu Magalhães Institute, FIOCRUZ/PE, Recife, Brazil
- Faculty of Medicine, University of Pernambuco, Recife, Brazil
| | | | - Hannah Kuper
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Loveday Penn-Kekana
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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22
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Duclos D, Cavallaro FL, Ndoye T, Faye SL, Diallo I, Lynch CA, Diallo M, Faye A, Penn-Kekana L. Critical insights on the demographic concept of "birth spacing": locating Nef in family well-being, bodies, and relationships in Senegal. Sex Reprod Health Matters 2020; 27:1581533. [PMID: 31533565 PMCID: PMC7887960 DOI: 10.1080/26410397.2019.1581533] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Birth spacing has emerged since the early 1980s as a key concept to improve maternal and child health, triggering interest in birth spacing practices in low-income countries, and drawing attention to prevailing norms in favour of long birth intervals in West Africa. In Senegal, the Wolof concept of Nef, which means having children too closely spaced in time, is morally condemned and connotes a resulting series of negative implications for family well-being. While Nef and “birth spacing” intersect in key ways, including acknowledging the health benefits of longer birth intervals, they are not translations of each other, for each is embedded in distinct broader cultural and political assumptions about social relations. Most notably, proponents of the demographic concept of birth spacing assume that the practice of using contraception after childbearing to postpone births could contribute to “empowering” women socially. In Senegal, by contrast, preventing Nef (or short birth intervals) is also viewed as strengthening family well-being by allowing women to care more fully for their family. This paper draws on policy documents and interviews to explore women's and men's understanding of Nef, and in turn critically reflect on the demographic concept of birth spacing. Our findings reinforce the relevance of the concept of birth spacing to engage with women and men around family planning services in Senegal. Accounts of the Nef taboo in Senegal also show that social norms stigmatising short birth intervals can legitimise constraints faced by women on control of their body.
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Affiliation(s)
- Diane Duclos
- Research Fellow , London School of Hygiene and Tropical Medicine , London , UK
| | | | - Tidiane Ndoye
- Senior Lecturer , University Cheikh Anta Diop , Dakar , Senegal
| | - Sylvain L Faye
- Senior Lecturer , University Cheikh Anta Diop , Dakar , Senegal
| | - Issakha Diallo
- Director , Convergence Santé pour le Développement , Dakar , Senegal
| | - Caroline A Lynch
- Assistant Professor , London School of Hygiene and Tropical Medicine , London , UK
| | - Mareme Diallo
- Researcher , University Cheikh Anta Diop , Dakar , Senegal
| | - Adama Faye
- Professor , University Cheikh Anta Diop , Dakar , Senegal
| | - Loveday Penn-Kekana
- Assistant Professor , London School of Hygiene and Tropical Medicine , London , UK
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23
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Kuper H, Lyra TM, Moreira MEL, de Albuquerque MDSV, de Araújo TVB, Fernandes S, Jofre-Bonet M, Larson H, Lopes de Melo AP, Mendes CHF, Moreira MCN, do Nascimento MAF, Penn-Kekana L, Pimentel C, Pinto M, Simas C, Valongueiro S. Social and economic impacts of congenital Zika syndrome in Brazil: Study protocol and rationale for a mixed-methods study. Wellcome Open Res 2019; 3:127. [PMID: 31667356 PMCID: PMC6807146 DOI: 10.12688/wellcomeopenres.14838.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 12/22/2022] Open
Abstract
Global concern broke out in late 2015 as thousands of children in Brazil were born with microcephaly, which was quickly linked to congenital infection with Zika virus (ZIKV). ZIKV is now known to cause a wider spectrum of severe adverse outcomes-congenital Zika syndrome (CZS)-and also milder impairments. This study aimed to explore the social and economic impacts of CZS in Brazil. Data was collected through mixed methods across two settings: Recife City and Jaboatão dos Guararapes in Pernambuco State (the epicentre of the epidemic), and the city of Rio de Janeiro (where reports of ZIKV infection and CZS were less frequent). Data was collected May 2017-January 2018. Ethical standards were adhered to throughout the research. In-depth qualitative interviews were conducted with: mothers and other carers of children with CZS (approximately 30 per setting), pregnant women (10-12 per setting), men and women of child-bearing age (16-20 per setting), and health professionals (10-12 per setting). Thematic analysis was undertaken independently by researchers from at least two research settings, and these were shared for feedback. A case-control study was undertaken to quantitatively explore social and economic differences between caregivers of a child with CZS (cases) and caregivers with an unaffected child (controls). We aimed to recruit 100 cases and 100 controls per setting, from existing studies. The primary caregiver, usually the mother, was interviewed using a structured questionnaire to collect information on: depression, anxiety, stress, social support, family quality of life, health care and social service use, and costs incurred by families. Multivariable logistic regression analyses were used to compare outcomes for cases and controls. Costs incurred as a result of CZS were estimated from the perspective of the health system, families and society. Modelling was undertaken to estimate the total economic burden of CZS from those three perspectives.
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Affiliation(s)
- Hannah Kuper
- International Centre for Evidence in Disability, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Tereza Maciel Lyra
- Aggeu Magalhães Institute, FIOCRUZ/PE, Recife, Brazil.,Faculty of Medicine, University of Pernambuco, Recife, Brazil
| | | | | | | | - Silke Fernandes
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Heidi Larson
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ana Paula Lopes de Melo
- Aggeu Magalhães Institute, FIOCRUZ/PE, Recife, Brazil.,Public Health Department, Federal University of Pernambuco, Recife, Brazil
| | | | | | | | - Loveday Penn-Kekana
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Marcia Pinto
- Fernando Figueira Maternal and Children's Institute, Rio de Janeiro, Brazil
| | - Clarissa Simas
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sandra Valongueiro
- Postgraduate Programme in Public Health, Federal University of Pernambuco, Recife, Brazil
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24
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Kuper H, Lyra TM, Moreira MEL, de Albuquerque MDSV, de Araújo TVB, Fernandes S, Jofre-Bonet M, Larson H, Lopes de Melo AP, Mendes CHF, Moreira MCN, do Nascimento MAF, Penn-Kekana L, Pimentel C, Pinto M, Simas C, Valongueiro S. Social and economic impacts of congenital Zika syndrome in Brazil: Study protocol and rationale for a mixed-methods study. Wellcome Open Res 2019; 3:127. [PMID: 31667356 DOI: 10.12688/wellcomeopenres.14838.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2018] [Indexed: 11/20/2022] Open
Abstract
Global concern broke out in late 2015 as thousands of children in Brazil were born with microcephaly, which was quickly linked to congenital infection with Zika virus (ZIKV). ZIKV is now known to cause a wider spectrum of severe adverse outcomes-congenital Zika syndrome (CZS)-and also milder impairments. This study aimed to explore the social and economic impacts of CZS in Brazil. Data was collected through mixed methods across two settings: Recife City and Jaboatão dos Guararapes in Pernambuco State (the epicentre of the epidemic), and the city of Rio de Janeiro (where reports of ZIKV infection and CZS were less frequent). Data was collected May 2017-January 2018. Ethical standards were adhered to throughout the research. In-depth qualitative interviews were conducted with: mothers and other carers of children with CZS (approximately 30 per setting), pregnant women (10-12 per setting), men and women of child-bearing age (16-20 per setting), and health professionals (10-12 per setting). Thematic analysis was undertaken independently by researchers from at least two research settings, and these were shared for feedback. A case-control study was undertaken to quantitatively explore social and economic differences between caregivers of a child with CZS (cases) and caregivers with an unaffected child (controls). We aimed to recruit 100 cases and 100 controls per setting, from existing studies. The primary caregiver, usually the mother, was interviewed using a structured questionnaire to collect information on: depression, anxiety, stress, social support, family quality of life, health care and social service use, and costs incurred by families. Multivariable logistic regression analyses were used to compare outcomes for cases and controls. Costs incurred as a result of CZS were estimated from the perspective of the health system, families and society. Modelling was undertaken to estimate the total economic burden of CZS from those three perspectives.
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Affiliation(s)
- Hannah Kuper
- International Centre for Evidence in Disability, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Tereza Maciel Lyra
- Aggeu Magalhães Institute, FIOCRUZ/PE, Recife, Brazil.,Faculty of Medicine, University of Pernambuco, Recife, Brazil
| | | | | | | | - Silke Fernandes
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Heidi Larson
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ana Paula Lopes de Melo
- Aggeu Magalhães Institute, FIOCRUZ/PE, Recife, Brazil.,Public Health Department, Federal University of Pernambuco, Recife, Brazil
| | | | | | | | - Loveday Penn-Kekana
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Marcia Pinto
- Fernando Figueira Maternal and Children's Institute, Rio de Janeiro, Brazil
| | - Clarissa Simas
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sandra Valongueiro
- Postgraduate Programme in Public Health, Federal University of Pernambuco, Recife, Brazil
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25
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Albuquerque MSV, Lyra TM, Melo APL, Valongueiro SA, Araújo TVB, Pimentel C, Moreira MCN, Mendes CHF, Nascimento M, Kuper H, Penn-Kekana L. Access to healthcare for children with Congenital Zika Syndrome in Brazil: perspectives of mothers and health professionals. Health Policy Plan 2019; 34:499-507. [PMID: 31369667 PMCID: PMC6788207 DOI: 10.1093/heapol/czz059] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2019] [Indexed: 01/03/2023] Open
Abstract
The Congenital Zika Syndrome (CZS) epidemic took place in Brazil between 2015 and 2017 and led to the emergence of at least 3194 children born with CZS. We explored access to healthcare services and activities in the Unified Health Service (Sistema Único de Saúde: SUS) from the perspective of mothers of children with CZS and professionals in the Public Healthcare Network. We carried out a qualitative, exploratory study, using semi-structured interviews, in two Brazilian states-Pernambuco, which was the epicentre of the epidemic in Brazil, and Rio de Janeiro, where the epidemic was less intense. The mothers and health professionals reported that healthcare provision was insufficient and fragmented and there were problems with follow-up care. There was a lack of co-ordination and an absence of communication between the various specialized services and between different levels of the health system. We also noted a public-private mixture in access to healthcare services, resulting from a segmented system and related to inequality of access. High reported household expenditure is an expression of the phenomenon of underfunding of the public system. The challenges that mothers and health professionals reported exposes contradictions in the health system which, although universal, does not guarantee equitable and comprehensive care. Other gaps were revealed through the outbreak. The epidemic provided visibility regarding difficulties of access for other children with disabilities determined by other causes. It also made explicit the gender inequalities that had an impact on the lives of mothers and other female caregivers, as well as an absence of the provision of care for these groups. In the face of an epidemic, the Brazilian State reproduced old fashioned forms of action-activities related to the transmitting mosquito and to prevention with an emphasis on the individual and no action related to social determinants.
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Affiliation(s)
- Maria S V Albuquerque
- Department of Social Medicine, Federal University of Pernambuco, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ, Brazil
| | - Tereza M Lyra
- Aggeu Magalhães Institute, FIOCRUZ/PE, Av. Professor Moraes Rego, s/n - Campus da UFPE, Cidade Universitária, Recife, PE, CEP:50.740-465, Brazil
- Public Health Department, Faculty of Medicine, University of Pernambuco, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ, Brazil
| | - Ana P L Melo
- Aggeu Magalhães Institute, FIOCRUZ/PE, Av. Professor Moraes Rego, s/n - Campus da UFPE, Cidade Universitária, Recife, PE, CEP:50.740-465, Brazil
- Federal University of Pernambuco, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ, Brazil
| | - Sandra A Valongueiro
- Postgraduate Programme in Public Health, Federal University of Pernambuco, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ, Brazil
| | - Thalia V B Araújo
- Postgraduate Programme in Public Health, Federal University of Pernambuco, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ, Brazil
| | - Camila Pimentel
- Aggeu Magalhães Institute, FIOCRUZ/PE, Av. Professor Moraes Rego, s/n - Campus da UFPE, Cidade Universitária, Recife, PE, CEP:50.740-465, Brazil
| | - Martha C N Moreira
- National Institute of Women, Children and Adolescents Health Fernandes Figueira/Fiocruz, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ, Brazil
| | - Corina H F Mendes
- National Institute of Women, Children and Adolescents Health Fernandes Figueira/Fiocruz, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ, Brazil
| | - Marcos Nascimento
- National Institute of Women, Children and Adolescents Health Fernandes Figueira/Fiocruz, Avenida Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ, Brazil
| | - Hannah Kuper
- Clinical Research Department, International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, Kepple Street, London, UK
| | - Loveday Penn-Kekana
- Epidemiology and Public Health, Maternal and Neonatal Health Group, London School of Hygiene & Tropical Medicine, Kepple Street, London, UK
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26
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Duclos D, Ndoye T, Faye SL, Diallo M, Penn-Kekana L. Why didn’t you write this in your diary? Or how nurses (mis)used clinic diaries to (re)claim shared reflexive spaces in Senegal. Critique of Anthropology 2019. [DOI: 10.1177/0308275x19842913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Between 2015 and 2017, we implemented the clinic diaries project as part of the qualitative component of an evaluation of a supply chain intervention for family planning in Senegal. This project combined different tools including the diaries and participatory workshops with nurses. At the intersection between writings and silences, this paper explores the role played by the clinic diaries to mediate ethnographic encounters, and the iterative nature of ‘doing fieldwork’ to produce knowledge in hierarchical health systems. This paper also reflects on the processes through which the diaries created a space where accounts of lived experiences routinely unfolding in health facilities could be shared, in the context of a health system increasingly dominated by metrics, performances and vertical reporting mechanisms. The clinic diaries research process therefore sheds light on the limits of approaching bureaucratic norms and practices as coming from the top, an approach reinforced by data reporting and coordination mechanisms in the Senegalese pyramidal health system. In contrast, the diaries suggest a role for participative ethnography to identify collegial spaces to reflect on shared experiences in and of bureaucratic spaces.
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Affiliation(s)
- Diane Duclos
- London School of Hygiene and Tropical Medicine, UK
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27
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Radovich E, Benova L, Penn-Kekana L, Wong K, Campbell OMR. 'Who assisted with the delivery of (NAME)?' Issues in estimating skilled birth attendant coverage through population-based surveys and implications for improving global tracking. BMJ Glob Health 2019; 4:e001367. [PMID: 31139455 PMCID: PMC6509598 DOI: 10.1136/bmjgh-2018-001367] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/08/2019] [Accepted: 03/26/2019] [Indexed: 11/29/2022] Open
Abstract
The percentage of live births attended by a skilled birth attendant (SBA) is a key global indicator and proxy for monitoring progress in maternal and newborn health. Yet, the discrepancy between rising SBA coverage and non-commensurate declines in maternal and neonatal mortality in many low-income and middle-income countries has brought increasing attention to the challenge of what the indicator of SBA coverage actually measures, and whether the indicator can be improved. In response to the 2018 revised definition of SBA and the push for improved measurement of progress in maternal and newborn health, this paper examines the evidence on what women can tell us about who assisted them during childbirth and methodological issues in estimating SBA coverage via population-based surveys. We present analyses based on Demographic and Health Surveys and Multiple Indicator Cluster Surveys conducted since 2015 for 23 countries. Our findings show SBA coverage can be reasonably estimated from population-based surveys in settings of high coverage, though women have difficulty reporting specific cadres. We propose improvements in how skilled cadres are classified and documented, how linkages can be made to facility-based data to examine the enabling environment and further ways data can be disaggregated to understand the complexity of delivery care. We also reflect on the limitations of what SBA coverage reveals about the quality and circumstances of childbirth care. While improvements to the indicator are possible, we call for the use of multiple indicators to inform local efforts to improve the health of women and newborns.
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Affiliation(s)
- Emma Radovich
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Loveday Penn-Kekana
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kerry Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Oona Maeve Renee Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Abstract
The notion of performance has become dominant in health programming, whether
being embodied through pay-for-performance schemes or through other incentive-based
interventions. In this article, we seek to unpack the idea of performance and performing in a
dialogical fashion between field-based evaluation findings and methodological considerations.
We draw on episodes where methodological reflections on performing ethnography
in the field of global health intersect with findings from the everyday practices of working
under performance-based contracts in the Senegalese supply chain for family planning. While
process evaluations can be used to understand contextual factors influencing the implementation
of an intervention, we as anthropologists in and of contemporary global health have an
imperative to explore and challenge categories of knowledge and practice. Making room for
new spaces of possibilities to emerge means locating anthropology within qualitative global
health research.
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Gon G, de Bruin M, de Barra M, Ali SM, Campbell OM, Graham WJ, Juma M, Nash S, Kilpatrick C, Penn-Kekana L, Virgo S, Woodd S. Hands washing, glove use, and avoiding recontamination before aseptic procedures at birth: A multicenter time-and-motion study conducted in Zanzibar. Am J Infect Control 2019; 47:149-156. [PMID: 30293743 PMCID: PMC6367567 DOI: 10.1016/j.ajic.2018.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/27/2018] [Accepted: 07/27/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Our primary objective was to assess hand hygiene (HH) compliance before aseptic procedures among birth attendants in the 10 highest-volume facilities in Zanzibar. We also examined the extent to which recontamination contributes to poor HH. Recording exact recontamination occurrences is not possible using the existing World Health Organization HH audit tool. METHODS In this time-and-motion study, 3 trained coders used WOMBATv2 software to record the hand actions of all birth attendants present in the study sites. The percentage compliance and 95% confidence intervals (CIs) for individual behaviors (hand washing/rubbing, avoiding recontamination and glove use) and for behavioral sequences during labor and delivery were calculated. RESULTS We observed 104 birth attendants and 781 HH opportunities before aseptic procedures. Compliance with hand rubbing/washing was 24.6% (95% CI, 21.6-27.8). Only 9.6% (95% CI, 7.6-11.9) of birth attendants also donned gloves and avoided recontamination. Half of the time when rubbing/washing or glove donning was performed, hands were recontaminated prior to the aseptic procedure. CONCLUSIONS In this study, HH compliance by birth attendants before aseptic procedures was poor. To our knowledge, this is the first study in a low- to middle-income country to show the large contribution to poor HH compliance from hand and glove recontamination before the procedure. Recontamination is an important driver of infection risk from poor HH. It should be understood for the purposes of improvement and therefore included in HH monitoring and interventions.
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Affiliation(s)
- Giorgia Gon
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom.
| | - Marijn de Bruin
- University of Aberdeen, Institute of Applied Health Sciences, Aberdeen, United Kingdom
| | - Mícheál de Barra
- Brunel University London, Department of Life Sciences, Uxbridge, United Kingdom
| | - Said M Ali
- Public Health Laboratory-Ivo de Carneri, Chake Chake, Pemba, Zanzibar, Tanzania
| | - Oona M Campbell
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Wendy J Graham
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Mohammed Juma
- Public Health Laboratory-Ivo de Carneri, Chake Chake, Pemba, Zanzibar, Tanzania
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Claire Kilpatrick
- Consultant, World Health Organization IPC Global Unit, Service Delivery and Safety Department, Geneva, Switzerland
| | - Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Sandra Virgo
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Susannah Woodd
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
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Sharma G, Penn-Kekana L, Halder K, Filippi V. An investigation into mistreatment of women during labour and childbirth in maternity care facilities in Uttar Pradesh, India: a mixed methods study. Reprod Health 2019; 16:7. [PMID: 30674323 PMCID: PMC6345007 DOI: 10.1186/s12978-019-0668-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/09/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To investigate the nature and context of mistreatment during labour and childbirth at public and private sector maternity facilities in Uttar Pradesh, India. METHODS This study analyses mixed-methods data obtained through systematic clinical observations and open-ended comments recorded by the observers to describe care provision for 275 mothers and their newborns at 26 hospitals in three districts of Uttar Pradesh from 26 May to 8 July 2015. We conducted a bivariate descriptive analysis of the quantitative data and used a thematic approach to analyse qualitative data. FINDINGS All women in the study encountered at least one indicator of mistreatment. There was a high prevalence of not offering birthing position choice (92%) and routine manual exploration of the uterus (80%) in facilities in both sectors. Private sector facilities performed worse than the public sector for not allowing birth companions (p = 0.02) and for perineal shaving (p = < 0.001), whereas the public sector performed worse for not ensuring adequate privacy (p = < 0.001), not informing women prior to a vaginal examination (p = 0.01) and for physical violence (p = 0.04). Prepared comments by observers provide further contextual insights into the quantitative data, and additional themes of mistreatment, such as deficiencies in infection prevention, lack of analgesia for episiotomy, informal payments and poor hygiene standards at maternity facilities were identified. CONCLUSIONS Mistreatment of women frequently occurs in both private and public sector facilities. This paper contributes to the literature on mistreatment of women during labour and childbirth at maternity facilities in India by articulating new constructs of overtreatment and under-treatment. There are five key implications of this study. First, a systematic and context-specific effort to measure mistreatment in public and private sector facilities in high burden states in India is required. Second, a training initiative to orient all maternity care personnel to the principles of respectful maternity care would be useful. Third, innovative mechanisms to improve accountability towards respectful maternity care are required. Fourth, participatory community and health system interventions to support respectful maternity care would be useful. Lastly, we note that there needs to be a long-term, sustained investment in health systems so that supportive and enabling work-environments are available to front- line health workers.
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Affiliation(s)
- Gaurav Sharma
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC 1E 7HT UK
| | - Loveday Penn-Kekana
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC 1E 7HT UK
| | - Kaveri Halder
- Deputy Manager-Research, Sambodhi Research and Communications, O-2, Lajpat Nagar-II, New Delhi, 110024 India
| | - Véronique Filippi
- Deputy Manager-Research, Sambodhi Research and Communications, O-2, Lajpat Nagar-II, New Delhi, 110024 India
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Benova L, Dennis ML, Lange IL, Campbell OMR, Waiswa P, Haemmerli M, Fernandez Y, Kerber K, Lawn JE, Santos AC, Matovu F, Macleod D, Goodman C, Penn-Kekana L, Ssengooba F, Lynch CA. Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys. BMC Health Serv Res 2018; 18:758. [PMID: 30286749 PMCID: PMC6172797 DOI: 10.1186/s12913-018-3546-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 09/17/2018] [Indexed: 11/11/2022] Open
Abstract
Background Uganda halved its maternal mortality to 343/100,000 live births between 1990 and 2015, but did not meet the Millennium Development Goal 5. Skilled, timely and good quality antenatal (ANC) and delivery care can prevent the majority of maternal/newborn deaths and stillbirths. We examine coverage, equity, sector of provision and content of ANC and delivery care between 1991 and 2011. Methods We conducted a repeated cross-sectional study using four Uganda Demographic and Health Surveys (1995, 2000, 2006 and 2011).Using the most recent live birth and adjusting for survey sampling, we estimated percentage and absolute number of births with ANC (any and 4+ visits), facility delivery, caesarean sections and complete maternal care. We assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone on the 1995 and 2011 surveys. We estimated the proportions of ANC and delivery care provided by the public and private (for-profit and not-for-profit) sectors, and compared content of ANC and delivery care between sectors. Statistical significance of differences were evaluated using chi-square tests. Results Coverage with any ANC remained high over the study period (> 90% since 2001) but was of insufficient frequency; < 50% of women who received any ANC reported 4+ visits. Facility-based delivery care increased slowly, reaching 58% in 2011. While significant inequalities in coverage by wealth, education, residence and geographic zone remained, coverage improved for all indicators among the lowest socio-economic groups of women over time. The private sector market share declined over time to 14% of ANC and 25% of delivery care in 2011. Only 10% of women with 4+ ANC visits and 13% of women delivering in facilities received all measured care components. Conclusions The Ugandan health system had to cope with more than 30,000 additional births annually between 1991 and 2011. The majority of women in Uganda accessed ANC, but this contact did not result in care of sufficient frequency, content, and continuum of care (facility delivery). Providers in both sectors require quality improvements. Achieving universal health coverage and maternal/newborn SDGs in Uganda requires prioritising poor, less educated and rural women despite competing priorities for financial and human resources. Electronic supplementary material The online version of this article (10.1186/s12913-018-3546-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lenka Benova
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
| | - Mardieh L Dennis
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Isabelle L Lange
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oona M R Campbell
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Peter Waiswa
- School of Public Health, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Manon Haemmerli
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Yolanda Fernandez
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Kate Kerber
- Saving Newborn Lives, Save the Children, 899 North Capitol Street, Suite 900, Washington, DC, 20002, USA.,Indigenous & Global Health Research Group, Department of Medicine, University of Alberta, University Terrace, 8303-112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Joy E Lawn
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Andreia Costa Santos
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Fred Matovu
- School of Economics, Makerere University Kampala, Uganda and Policy Analysis & Development Research Institute (PADRI), Kampala, Uganda
| | - David Macleod
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Freddie Ssengooba
- School of Public Health, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Caroline A Lynch
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Penn-Kekana L, Powell-Jackson T, Haemmerli M, Dutt V, Lange IL, Mahapatra A, Sharma G, Singh K, Singh S, Shukla V, Goodman C. Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India. Implement Sci 2018; 13:124. [PMID: 30249294 PMCID: PMC6154932 DOI: 10.1186/s13012-018-0813-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 09/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A prominent strategy to engage private sector health providers in low- and middle-income countries is clinical social franchising, an organisational model that applies the principles of commercial franchising for socially beneficial goals. The Matrika programme, a multi-faceted social franchise model to improve maternal health, was implemented in three districts of Uttar Pradesh, India, between 2013 and 2016. Previous research indicates that the intervention was not effective in improving the quality and coverage of maternal health services at the population level. This paper reports findings from an independent external process evaluation, conducted alongside the impact evaluation, with the aim of explaining the impact findings. It focuses on the main component of the programme, the "Sky" social franchise. METHODS We first developed a theory of change, mapping the key mechanisms through which the programme was hypothesised to have impact. We then undertook a multi-methods study, drawing on both quantitative and qualitative primary data from a wide range of sources to assess the extent of implementation and to understand mechanisms of impact and the role of contextual factors. We analysed the quantitative data descriptively to generate indicators of implementation. We undertook a thematic analysis of the qualitative data before holding reflective meetings to triangulate across data sources, synthesise evidence, and identify the main findings. Finally, we used the framework provided by the theory of change to organise and interpret our findings. RESULTS We report six key findings. First, despite the franchisor achieving its recruitment targets, the competitive nature of the market for antenatal care meant social franchise providers achieved very low market share. Second, all Sky health providers were branded but community awareness of the franchise remained low. Third, using lower-level providers and community health volunteers to encourage women to attend franchised antenatal care services was ineffective. Fourth, referral linkages were not sufficiently strong between antenatal care providers in the franchise network and delivery care providers. Fifth, Sky health providers had better knowledge and self-reported practice than comparable health providers, but overall, the evidence pointed to poor quality of care across the board. Finally, telemedicine was perceived by clients as an attractive feature, but problems in the implementation of the technology meant its effect on quality of antenatal care was likely limited. CONCLUSIONS These findings point towards the importance of designing programmes based on a strong theory of change, understanding market conditions and what patients value, and rigorously testing new technologies. The design of future social franchising programmes should take account of the challenges documented in this and other evaluations.
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Affiliation(s)
- Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Timothy Powell-Jackson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Manon Haemmerli
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Varun Dutt
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | - Isabelle L. Lange
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | | | - Gaurav Sharma
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Kultar Singh
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | | | - Vasudha Shukla
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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Haemmerli M, Santos A, Penn-Kekana L, Lange I, Matovu F, Benova L, Wong KLM, Goodman C. How equitable is social franchising? Case studies of three maternal healthcare franchises in Uganda and India. Health Policy Plan 2018; 33:411-419. [PMID: 29373681 PMCID: PMC5886275 DOI: 10.1093/heapol/czx192] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2017] [Indexed: 11/03/2022] Open
Abstract
Substantial investments have been made in clinical social franchising to improve quality of care of private facilities in low- and middle-income countries but concerns have emerged that the benefits fail to reach poorer groups. We assessed the distribution of franchise utilization and content of care by socio-economic status (SES) in three maternal healthcare social franchises in Uganda and India (Uttar Pradesh and Rajasthan). We surveyed 2179 women who had received antenatal care (ANC) and/or delivery services at franchise clinics (in Uttar Pradesh only ANC services were offered). Women were allocated to national (Uganda) or state (India) SES quintiles. Franchise users were concentrated in the higher SES quintiles in all settings. The percent in the top two quintiles was highest in Uganda (over 98% for both ANC and delivery), followed by Rajasthan (62.8% for ANC, 72.1% for delivery) and Uttar Pradesh (48.5% for ANC). The percent of clients in the lowest two quintiles was zero in Uganda, 7.1 and 3.1% for ANC and delivery, respectively, in Rajasthan and 16.3% in Uttar Pradesh. Differences in SES distribution across the programmes may reflect variation in user fees, the average SES of the national/state populations and the range of services covered. We found little variation in content of care by SES. Key factors limiting the ability of such maternal health social franchises to reach poorer groups may include the lack of suitable facilities in the poorest areas, the inability of the poorest women to afford any private sector fees and competition with free or even incentivized public sector services. Moreover, there are tensions between targeting poorer groups, and franchise objectives of improving quality and business performance and enhancing financial sustainability, meaning that middle income and poorer groups are unlikely to be reached in large numbers in the absence of additional subsidies.
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Affiliation(s)
- Manon Haemmerli
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Andreia Santos
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Loveday Penn-Kekana
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and
| | - Isabelle Lange
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and
| | - Fred Matovu
- School of Economics, Makerere University, Kampala, Uganda
| | - Lenka Benova
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and
| | - Kerry L M Wong
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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Penn-Kekana L, Pereira S, Hussein J, Bontogon H, Chersich M, Munjanja S, Portela A. Understanding the implementation of maternity waiting homes in low- and middle-income countries: a qualitative thematic synthesis. BMC Pregnancy Childbirth 2017; 17:269. [PMID: 28854880 PMCID: PMC5577673 DOI: 10.1186/s12884-017-1444-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/04/2017] [Indexed: 11/10/2022] Open
Abstract
Background Maternity waiting homes (MWHs) are accommodations located near a health facility where women can stay towards the end of pregnancy and/or after birth to enable timely access to essential childbirth care or care for complications. Although MWHs have been implemented for over four decades, different operational models exist. This secondary thematic +analysis explores factors related to their implementation. Methods A qualitative thematic analysis was conducted using 29 studies across 17 countries. The papers were identified through an existing Cochrane review and a mapping of the maternal health literature. The Supporting the Use of Research Evidence framework (SURE) guided the thematic analysis to explore the perceptions of various stakeholders and barriers and facilitators for implementation. The influence of contextual factors, the design of the MWHs, and the conditions under which they operated were examined. Results Key problems of MWH implementation included challenges in MWH maintenance and utilization by pregnant women. Poor utilization was due to lack of knowledge and acceptance of the MWH among women and communities, long distances to reach the MWH, and culturally inappropriate care. Poor MWH structures were identified by almost all studies as a major barrier, and included poor toilets and kitchens, and a lack of space for family and companions. Facilitators included reduced or removal of costs associated with using a MWH, community involvement in the design and upkeep of the MWHs, activities to raise awareness and acceptance among family and community members, and integrating culturally-appropriate practices into the provision of maternal and newborn care at the MWHs and the health facilities to which they are linked. Conclusion MWHs should not be designed as an isolated intervention but using a health systems perspective, taking account of women and community perspectives, the quality of the MWH structure and the care provided at the health facility. Careful tailoring of the MWH to women’s accommodation, social and dietary needs; low direct and indirect costs; and a functioning health system are key considerations when implementing MWH. Improved and harmonized documentation of implementation experiences would provide a better understanding of the factors that impact on successful implementation.
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Affiliation(s)
- Loveday Penn-Kekana
- School of Public Health, Faculty of Health Sciences, Centre for Health Policy/MRC Health Policy Research Group, Private Bag X3, University of the Witwatersrand, Johannesburg, 2050, Gauteng, South Africa.,Department of Infectious Disease Epidemiology, London School Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Shreya Pereira
- Department of Global Health and Development, London School Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Julia Hussein
- Immpact, Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, Scotland.
| | - Hannah Bontogon
- Department of Maternal, Newborn, Child, Adolescent Health, World Health Organization, 20, Avenue Appia, 1211, Geneva, Switzerland
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen Munjanja
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Mazowe Street, Harare, Zimbabwe
| | - Anayda Portela
- Department of Maternal, Newborn, Child, Adolescent Health, World Health Organization, 20, Avenue Appia, 1211, Geneva, Switzerland
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Chersich M, Blaauw D, Dumbaugh M, Penn-Kekana L, Thwala S, Bijlmakers L, Vargas E, Kern E, Kavanagh J, Dhana A, Becerra-Posada F, Mlotshwa L, Becerril-Montekio V, Mannava P, Luchters S, Pham MD, Portela AG, Rees H. Mapping of research on maternal health interventions in low- and middle-income countries: a review of 2292 publications between 2000 and 2012. Global Health 2016; 12:52. [PMID: 27600397 PMCID: PMC5011860 DOI: 10.1186/s12992-016-0189-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 08/15/2016] [Indexed: 11/29/2022] Open
Abstract
Background Progress in achieving maternal health goals and the rates of reductions in deaths from individual conditions have varied over time and across countries. Assessing whether research priorities in maternal health align with the main causes of mortality, and those factors responsible for inequitable health outcomes, such as health system performance, may help direct future research. The study thus investigated whether the research done in low- and middle-income countries (LMICs) matched the principal causes of maternal deaths in these settings. Methods Systematic mapping was done of maternal health interventional research in LMICs from 2000 to 2012. Articles were included on health systems strengthening, health promotion; and on five tracer conditions (haemorrhage, hypertension, malaria, HIV and other sexually transmitted infections (STIs)). Following review of 35,078 titles and abstracts in duplicate, data were extracted from 2292 full-text publications. Results Over time, the number of publications rose several-fold, especially in 2004–2007, and the range of methods used broadened considerably. More than half the studies were done in sub-Saharan Africa (55.4 %), mostly addressing HIV and malaria. This region had low numbers of publications per hypertension and haemorrhage deaths, though South Asia had even fewer. The proportion of studies set in East Asia Pacific dropped steadily over the period, and in Latin America from 2008 to 2012. By 2008–2012, 39.1 % of articles included health systems components and 30.2 % health promotion. Only 5.4 % of studies assessed maternal STI interventions, diminishing with time. More than a third of haemorrhage research included health systems or health promotion components, double that of HIV research. Conclusion Several mismatches were noted between research publications, and the burden and causes of maternal deaths. This is especially true for South Asia; haemorrhage and hypertension in sub-Saharan Africa; and for STIs worldwide. The large rise in research outputs and range of methods employed indicates a major expansion in the number of researchers and their skills. This bodes well for maternal health if variations in research priorities across settings and topics are corrected. Electronic supplementary material The online version of this article (doi:10.1186/s12992-016-0189-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. .,Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | - Duane Blaauw
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Mari Dumbaugh
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Society, Gender and Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Loveday Penn-Kekana
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Siphiwe Thwala
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Leon Bijlmakers
- Radboud University Medical Center, Radboud Institute for Health Sciences (RIHS), Nijmegen, The Netherlands
| | - Emily Vargas
- Innovation in Public Health Department, National Institute of Health, Bogotá D.C, Colombia.,National Institute of Public Health (Instituto Nacional de Salud Pública)/Centre for Health Systems Research, Cuernavaca, Mexico
| | - Elinor Kern
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Josephine Kavanagh
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Ashar Dhana
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | | | - Langelihle Mlotshwa
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology and Public Health, Society, Gender and Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Victor Becerril-Montekio
- National Institute of Public Health (Instituto Nacional de Salud Pública)/Centre for Health Systems Research, Cuernavaca, Mexico
| | - Priya Mannava
- Centre for International Health, Burnet Institute, Melbourne, VIC, Australia
| | - Stanley Luchters
- Centre for International Health, Burnet Institute, Melbourne, VIC, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Minh Duc Pham
- Centre for International Health, Burnet Institute, Melbourne, VIC, Australia
| | - Anayda Gerarda Portela
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,London School of Hygiene and Tropical Medicine, London, UK
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Chersich M, Becerril-Montekio V, Becerra-Posada F, Dumbaugh M, Kavanagh J, Blaauw D, Thwala S, Kern E, Penn-Kekana L, Vargas E, Mlotshwa L, Dhana A, Mannava P, Portela A, Tristan M, Rees H, Bijlmakers L. Perspectives on the methods of a large systematic mapping of maternal health interventions. Global Health 2016; 12:51. [PMID: 27562360 PMCID: PMC5000454 DOI: 10.1186/s12992-016-0191-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 08/17/2016] [Indexed: 11/17/2022] Open
Abstract
Background Mapping studies describe a broad body of literature, and differ from classical systematic reviews, which assess more narrowly-defined questions and evaluate the quality of the studies included in the review. While the steps involved in mapping studies have been described previously, a detailed qualitative account of the methodology could inform the design of future mapping studies. Objectives Describe the perspectives of a large research team on the methods used and collaborative experiences in a study that mapped the literature published on maternal health interventions in low- and middle-income countries (2292 full text articles included, after screening 35,048 titles and abstracts in duplicate). Methods Fifteen members of the mapping team, drawn from eight countries, provided their experiences and perspectives of the study in response to a list of questions and probes. The responses were collated and analysed thematically following a grounded theory approach. Results The objectives of the mapping evolved over time, posing difficulties in ensuring a uniform understanding of the purpose of the mapping among the team members. Ambiguity of some study variables and modifications in data extraction codes were the main threats to the quality of data extraction. The desire for obtaining detailed information on a few topics needed to be weighed against the benefits of collecting more superficial data on a wider range of topics. Team members acquired skills in systematic review methodology and software, and a broad knowledge of maternal health literature. Participation in analysis and dissemination was lower than during the screening of articles for eligibility and data coding. Though all respondents believed the workload involved was high, study outputs were viewed as novel and important contributions to evidence. Overall, most believed there was a favourable balance between the amount of work done and the project’s outputs. Conclusions A large mapping of literature is feasible with a committed team aiming to build their research capacity, and with a limited, simplified set of data extraction codes. In the team’s view, the balance between the time spent on the review, and the outputs and skills acquired was favourable. Assessments of the value of a mapping need, however, to take into account the limitations inherent in such exercises, especially the exclusion of grey literature and of assessments of the quality of the studies identified. Electronic supplementary material The online version of this article (doi:10.1186/s12992-016-0191-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. .,Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | - Victor Becerril-Montekio
- Centre for Health Systems Research, National Institute of Public Health (Instituto Nacional de Salud Pública), Cuernavaca, Mexico
| | | | - Mari Dumbaugh
- Department of Epidemiology and Public Health, Society, Gender and Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Josephine Kavanagh
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Duane Blaauw
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Siphiwe Thwala
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Elinor Kern
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Loveday Penn-Kekana
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Emily Vargas
- Centre for Health Systems Research, National Institute of Public Health (Instituto Nacional de Salud Pública), Cuernavaca, Mexico.,Innovation in Public Health Department, National Institute of Health, Bogotá D.C, Colombia
| | - Langelihle Mlotshwa
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology and Public Health, Society, Gender and Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Ashar Dhana
- Centre for Health Policy and MRC Health Policy Research Group, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Priya Mannava
- Centre for International Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Helen Rees
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Leon Bijlmakers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Chersich MF, Blaauw D, Dumbaugh M, Penn-Kekana L, Dhana A, Thwala S, Bijlmakers L, Vargas E, Kern E, Becerra-Posada F, Kavanagh J, Mannava P, Mlotshwa L, Becerril-Montekio V, Footman K, Rees H. Local and foreign authorship of maternal health interventional research in low- and middle-income countries: systematic mapping of publications 2000-2012. Global Health 2016; 12:35. [PMID: 27338707 PMCID: PMC4917998 DOI: 10.1186/s12992-016-0172-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 06/09/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Researchers in low- and middle-income countries (LMICs) are under-represented in scientific literature. Mapping of authorship of articles can provide an assessment of data ownership and research capacity in LMICs over time and identify variations between different settings. METHODS Systematic mapping of maternal health interventional research in LMICs from 2000 to 2012, comparing country of study and of affiliation of first authors. Studies on health systems or promotion; community-based activities; and haemorrhage, hypertension, HIV/STIs and malaria were included. Following review of 35,078 titles and abstracts, 2292 full-text publications were included. Data ownership was measured by the proportion of articles with an LMIC lead author (author affiliated with an LMIC institution). RESULTS The total number of papers led by an LMIC author rose from 45.0/year in 2000-2003 to 98.0/year in 2004-2007, but increased only slightly thereafter to 113.1/year in 2008-2012. In the same periods, the proportion of papers led by a local author was 58.4 %, 60.8 % and 60.1 %, respectively. Data ownership varies markedly between countries. A quarter of countries led more than 75 % of their research; while in 10 countries, under 25 % of publications had a local first author. Researchers at LMIC institutions led 56.6 % (1297) of all papers, but only 26.8 % of systematic reviews (65/243), 29.9 % of modelling studies (44/147), and 33.2 % of articles in journals with an Impact Factor ≥5 (61/184). Sub-Saharan Africa authors led 54.2 % (538/993) of studies in the region, while 73.4 % did in Latin America and the Caribbean (223/304). Authors affiliated with United States (561) and United Kingdom (207) institutions together account for a third of publications. Around two thirds of USAID and European Union funded studies had high-income country leads, twice as many as that of Wellcome Trust and Rockefeller Foundation. CONCLUSIONS There are marked gaps in data ownership and these have not diminished over time. Increased locally-led publications, however, does suggest a growing capacity in LMIC institutions to analyse and articulate research findings. Differences in author attribution between funders might signal important variations in funders' expectations of authorship and discrepancies in how funders understand collaboration. More stringent authorship oversight and reconsideration of authorship guidelines could facilitate growth in LMIC leadership. Left unaddressed, deficiencies in research ownership will continue to hinder alignment between the research undertaken and knowledge needs of LMICs.
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Affiliation(s)
- Matthew F Chersich
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.
- Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Ghent University, Ghent, Belgium.
| | - Duane Blaauw
- Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mari Dumbaugh
- Independent Consultant, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Society, Gender and Health Unit, Basel, Switzerland
| | - Loveday Penn-Kekana
- Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ashar Dhana
- Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Siphiwe Thwala
- Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Leon Bijlmakers
- Radboud University Medical Center, Radboud Institute for Health Sciences (RIHS), Nijmegen, The Netherlands
| | - Emily Vargas
- Innovation in Public Health Department, National Institute of Health, Bogotá D.C., Colombia
- Centre for Health Systems Research/National Institute of Public Health (Instituto Nacional de Salud Pública), Cuernavaca, México
| | - Elinor Kern
- Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Josephine Kavanagh
- Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Priya Mannava
- Centre for International Health, Burnet Institute, Melbourne, VIC, Australia
| | - Langelihle Mlotshwa
- Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Society, Gender and Health Unit, Basel, Switzerland
| | - Victor Becerril-Montekio
- Centre for Health Systems Research/National Institute of Public Health (Instituto Nacional de Salud Pública), Cuernavaca, México
| | - Katharine Footman
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
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Pereira SK, Kumar P, Dutt V, Haldar K, Penn-Kekana L, Santos A, Powell-Jackson T. Protocol for the evaluation of a social franchising model to improve maternal health in Uttar Pradesh, India. Implement Sci 2015; 10:77. [PMID: 26008202 PMCID: PMC4448271 DOI: 10.1186/s13012-015-0269-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 05/16/2015] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Social franchising is the fastest growing market-based approach to organising and improving the quality of care in the private sector of low- and middle-income countries, but there is limited evidence on its impact and cost-effectiveness. The "Sky" social franchise model was introduced in the Indian state of Uttar Pradesh in late 2013. METHODS/DESIGN Difference-in-difference methods will be used to estimate the impact of the social franchise programme on the quality and coverage of health services along the continuum of care for reproductive, maternal and newborn health. Comparison clusters will be selected to be as similar as possible to intervention clusters using nearest neighbour matching methods. Two rounds of data will be collected from a household survey of 3600 women with a birth in the last 2 years and a survey of 450 health providers in the same localities. To capture the full range of effects, 59 study outcomes have been specified and then grouped into conceptually similar domains. Methods to account for multiple inferences will be used based on the pre-specified grouping of outcomes. A process evaluation will seek to understand the scale of the social franchise network, the extent to which various components of the programme are implemented and how impacts are achieved. An economic evaluation will measure the costs of setting up, maintaining and running the social franchise as well as the cost-effectiveness and financial sustainability of the programme. DISCUSSION There is a dearth of evidence demonstrating whether market-based approaches such as social franchising can improve care in the private sector. This evaluation will provide rigorous evidence on whether an innovative model of social franchising can contribute to better population health in a low-income setting.
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Affiliation(s)
- Shreya K Pereira
- Department of Global Health and Development, London School Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Paresh Kumar
- Sambodhi Research and Communications Limited, C-126, Sector-2, Noida, Uttar Pradesh, India.
| | - Varun Dutt
- Sambodhi Research and Communications Limited, C-126, Sector-2, Noida, Uttar Pradesh, India.
| | - Kaveri Haldar
- Sambodhi Research and Communications Limited, C-126, Sector-2, Noida, Uttar Pradesh, India.
| | - Loveday Penn-Kekana
- Department of Infectious Disease Epidemiology, London School Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Andreia Santos
- Department of Global Health and Development, London School Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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Armstrong SJ, Rispel LC, Penn-Kekana L. The activities of hospital nursing unit managers and quality of patient care in South African hospitals: a paradox? Glob Health Action 2015; 8:26243. [PMID: 25971397 PMCID: PMC4430688 DOI: 10.3402/gha.v8.26243] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 12/23/2014] [Accepted: 01/13/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Improving the quality of health care is central to the proposed health care reforms in South Africa. Nursing unit managers play a key role in coordinating patient care activities and in ensuring quality care in hospitals. OBJECTIVE This paper examines whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals. METHODS During 2011, a cross-sectional, descriptive study was conducted in nine randomly selected hospitals (six public, three private) in two South African provinces. In each hospital, one of each of the medical, surgical, paediatric, and maternity units was selected (n=36). Following informed consent, each unit manager was observed for a period of 2 hours on the survey day and the activities recorded on a minute-by-minute basis. The activities were entered into Microsoft Excel, coded into categories, and analysed according to the time spent on activities in each category. The observation data were complemented by semi-structured interviews with the unit managers who were asked to recall their activities on the day preceding the interview. The interviews were analysed using thematic content analysis. RESULTS The study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management, and 11.8% on miscellaneous activities. There were also numerous interruptions and distractions. The semi-structured interviews revealed concordance between unit managers' recall of the time spent on patient care, but a marked inflation of their perceived time spent on hospital administration. CONCLUSION The creation of an enabling practice environment, supportive executive management, and continuing professional development are needed to enable nursing managers to lead the provision of consistent and high-quality patient care.
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Affiliation(s)
- Susan J Armstrong
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Nursing Education, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
| | - Laetitia C Rispel
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Loveday Penn-Kekana
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Footman K, Benova L, Goodman C, Macleod D, Lynch CA, Penn-Kekana L, Campbell OMR. Using multi-country household surveys to understand who provides reproductive and maternal health services in low- and middle-income countries: a critical appraisal of the Demographic and Health Surveys. Trop Med Int Health 2015; 20:589-606. [PMID: 25641212 PMCID: PMC4409817 DOI: 10.1111/tmi.12471] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The Demographic and Health Surveys (DHS) are a vital data resource for cross-country comparative analyses. This study is part of a set of analyses assessing the types of providers being used for reproductive and maternal health care across 57 countries. Here, we examine some of the challenges encountered using DHS data for this purpose, present the provider classification we used, and provide recommendations to enable more detailed and accurate cross-country comparisons of healthcare provision. METHODS We used the most recent DHS surveys between 2000 and 2012; 57 countries had data on family planning and delivery care providers and 47 countries had data on antenatal care. Every possible response option across the 57 countries was listed and categorised. We then developed a classification to group provider response options according to two key dimensions: clinical nature and profit motive. RESULTS We classified the different types of maternal and reproductive healthcare providers, and the individuals providing care. Documented challenges encountered during this process were limitations inherent in household survey data based on respondents' self-report; conflation of response options in the questionnaire or at the data processing stage; category errors of the place vs. professional for delivery; inability to determine whether care received at home is from the public or private sector; a large number of negligible response options; inconsistencies in coding and analysis of data sets; and the use of inconsistent headings. CONCLUSIONS To improve clarity, we recommend addressing issues such as conflation of response options, data on public vs. private provider, inconsistent coding and obtaining metadata. More systematic and standardised collection of data would aid international comparisons of progress towards improved financial protection, and allow us to better characterise the incentives and commercial nature of different providers.
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Affiliation(s)
- K Footman
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - L Benova
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - C Goodman
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - D Macleod
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - C A Lynch
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - L Penn-Kekana
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - O M R Campbell
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
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Eyles J, Harris B, Fried J, Govender V, Penn-Kekana L. Suspicious Minds: Apportioning and Avoiding Blame for Distrustful Relationships and Deferring Medical Treatment in South Africa. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/sm.2015.53017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ditlopo P, Blaauw D, Penn-Kekana L, Rispel LC. Contestations and complexities of nurses' participation in policy-making in South Africa. Glob Health Action 2014; 7:25327. [PMID: 25537938 PMCID: PMC4275627 DOI: 10.3402/gha.v7.25327] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 10/01/2014] [Accepted: 10/08/2014] [Indexed: 11/30/2022] Open
Abstract
Background There has been increased emphasis globally on nurses’ involvement in health policy and systems development. However, there has been limited scholarly attention on nurses’ participation in policy-making in South Africa. Objective This paper analyses the dynamics, strengths, and weaknesses of nurses’ participation in four national health workforce policies: the 2008 Nursing Strategy, revision of the Scope of Practice for nurses, the new Framework for Nursing Qualifications, and the Occupation-Specific Dispensation (OSD) remuneration policy. Design Using a policy analysis framework, we conducted in-depth interviews with 28 key informants and 73 frontline nurses in four South African provinces. Thematic content analysis was done using the Atlas.ti software. Results The study found that nurses’ participation in policy-making is both contested and complex. The contestation relates to the extent and nature of nurses’ participation in nursing policies. There was a disjuncture between nursing leadership and frontline nurses in their levels of awareness of the four policies. The latter group was generally unaware of these policies with the exception of the OSD remuneration policy as it affected them directly. There was also limited consensus on which nursing group legitimately represented nursing issues in the policy arena. Shifting power relationships influenced who participated, how the participation happened, and the degree to which nurses’ views and inputs were considered and incorporated. Conclusions The South African health system presents major opportunities for nurses to influence and direct policies that affect them. This will require a combination of proactive leadership, health policy capacity and skills development among nurses, and strong support from the national nursing association.
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Affiliation(s)
- Prudence Ditlopo
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
| | - Duane Blaauw
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Loveday Penn-Kekana
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Laetitia C Rispel
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Footman K, Chersich M, Blaauw D, Campbell OMR, Dhana A, Kavanagh J, Dumbaugh M, Thwala S, Bijlmakers L, Vargas E, Kern E, Becerra F, Penn-Kekana L. A systematic mapping of funders of maternal health intervention research 2000-2012. Global Health 2014; 10:72. [PMID: 25367638 PMCID: PMC4243307 DOI: 10.1186/s12992-014-0072-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 09/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The priorities of research funding bodies govern the research agenda, which has important implications for the provision of evidence to inform policy. This study examines the research funding landscape for maternal health interventions in low- and middle-income countries (LMICs). METHODS This review draws on a database of 2340 academic papers collected through a large-scale systematic mapping of research on maternal health interventions in LMICs published from 2000-2012. The names of funders acknowledged on each paper were extracted and categorised into groups. It was noted whether support took a specific form, such as staff fellowships or drugs. Variations between funder types across regions and topics of research were assessed. RESULTS Funding sources were only reported in 1572 (67%) of articles reviewed. A high number of different funders (685) were acknowledged, but only a few dominated funding of published research. Bilateral funders, national research agencies and private foundations were most prominent, while private companies were most commonly acknowledged for support 'in kind'. The intervention topics and geographic regions of research funded by the various funder types had much in common, with HIV being the most common topic and sub-Saharan Africa being the most common region for all types of funder. Publication outputs rose substantially for several funder types over the period, with the largest increase among bilateral funders. CONCLUSIONS A considerable number of organisations provide funding for maternal health research, but a handful account for most funding acknowledgements. Broadly speaking, these organisations address similar topics and regions. This suggests little coordination between funding agencies, risking duplication and neglect of some areas of maternal health research, and limiting the ability of organisations to develop the specialised skills required for systematically addressing a research topic. Greater transparency in reporting of funding is required, as the role of funders in the research process is often unclear.
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Affiliation(s)
- Katharine Footman
- />Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Matthew Chersich
- />Centre for Health Policy, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, 2000 South Africa
- />International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Ghent University, De Pintelaan 185 UZP114, 9000 Gent, Belgium
- />Wits Reproductive Health and HIV research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, 2000 South Africa
| | - Duane Blaauw
- />Centre for Health Policy, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, 2000 South Africa
| | - Oona MR Campbell
- />Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Ashar Dhana
- />Centre for Health Policy, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, 2000 South Africa
| | - Josephine Kavanagh
- />Department of Childhood, Families and Health, Institute of Education, 20 Bedford Way, London, WC1H 0AL UK
| | - Mari Dumbaugh
- />Independent Consultant, World Health Organization, Geneva, Switzerland
| | - Siphiwe Thwala
- />Centre for Health Policy, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, 2000 South Africa
| | - Leon Bijlmakers
- />Radboud University Medical Center, Department of Epidemiology, Biostatistics and Health Technology Assessment (HEV), Nijmegen, The Netherlands
| | - Emily Vargas
- />Centre for Health Systems Research, National Institute of Public Health, Colonia Santa María Ahuacatitlán, Cerrada Los Pinos y Caminera, C.P. 62100 Cuernavaca, México
| | - Elinor Kern
- />Centre for Health Policy, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, 2000 South Africa
| | - Francisco Becerra
- />Pan American Health Organization, 525 Twenty-third Street, N.W., Washington, D.C. 20037 USA
| | - Loveday Penn-Kekana
- />Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
- />Centre for Health Policy, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, 2000 South Africa
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Silal SP, Penn-Kekana L, Bärnighausen T, Schneider H. Local level inequalities in the use of hospital-based maternal delivery in rural South Africa. Global Health 2014; 10:60. [PMID: 25927416 PMCID: PMC4110704 DOI: 10.1186/s12992-014-0060-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 07/02/2014] [Indexed: 11/11/2022] Open
Abstract
Background There is global concern with geographical and socio-economic inequalities in access to and use of maternal delivery services. Little is known, however, on how local-level socio-economic inequalities are related to the uptake of needed maternal health care. We conducted a study of relative socio-economic inequalities in use of hospital-based maternal delivery services within two rural sub-districts of South Africa. Methods We used both population-based surveillance and facility-based clinical record data to examine differences in the relative distribution of socio-economic status (SES), using a household assets index to measure wealth, among those needing maternal delivery services and those using them in the Bushbuckridge sub-district, Mpumalanga, and Hlabisa sub-district, Kwa-Zulu Natal. We compared the SES distributions in households with a birth in the previous year with the household SES distributions of representative samples of women who had delivered in hospitals in these two sub-districts. Results In both sub-districts, women in the lowest SES quintile were significantly under-represented in the hospital user population, relative to need for delivery services (8% in user population vs 21% in population in need; p < 0.001 in each sub-district). Exit interviews provided additional evidence on potential barriers to access, in particular the affordability constraints associated with hospital delivery. Conclusions The findings highlight the need for alternative strategies to make maternal delivery services accessible to the poorest women within overall poor communities and, in doing so, decrease socioeconomic inequalities in utilisation of maternal delivery services.
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Affiliation(s)
- Sheetal Prakash Silal
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa.
| | - Loveday Penn-Kekana
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard School of Public Health, Boston, USA. .,Wellcome Trust Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa.
| | - Helen Schneider
- School of Public Health, University of the Western Cape, Cape Town, South Africa.
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Motta S, Penn-Kekana L, Bewley S. Domestic violence in a UK abortion clinic: anonymous cross-sectional prevalence survey. J Fam Plann Reprod Health Care 2014; 41:128-33. [DOI: 10.1136/jfprhc-2013-100843] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Harris B, Eyles J, Penn-Kekana L, Thomas L, Goudge J. Adverse or acceptable: negotiating access to a post-apartheid health care contract. Global Health 2014; 10:35. [PMID: 24885882 PMCID: PMC4036079 DOI: 10.1186/1744-8603-10-35] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 02/06/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As in many fragile and post-conflict countries, South Africa's social contract has formally changed from authoritarianism to democracy, yet access to services, including health care, remains inequitable and contested. We examine access barriers to quality health services and draw on social contract theory to explore ways in which a post-apartheid health care contract is narrated, practiced and negotiated by patients and providers. We consider implications for conceptualizing and promoting more inclusive, equitable health services in a post-conflict setting. METHODS Using in-depth interviews with 45 patients and 67 providers, and field observations from twelve health facilities in one rural and two urban sub-districts, we explore access narratives of those seeking and delivering - negotiating - maternal health, tuberculosis and antiretroviral services in South Africa. RESULTS Although South Africa's right to access to health care is constitutionally guaranteed, in practice, a post-apartheid health care contract is not automatically or unconditionally inclusive. Access barriers, including poverty, an under-resourced, hierarchical health system, the nature of illness and treatment, and negative attitudes and actions, create conditions for insecure or adverse incorporation into this contract, or even exclusion (sometimes temporary) from health care services. Such barriers are exacerbated by differences in the expectations that patients and providers have of each other and the contract, leading to differing, potentially conflicting, identities of inclusion and exclusion: defaulting versus suffering patients, uncaring versus overstretched providers. Conversely, caring, respectful communication, individual acts of kindness, and institutional flexibility and leadership may mitigate key access barriers and limit threats to the contract, fostering more positive forms of inclusion and facilitating easier access to health care. CONCLUSIONS Building health in fragile and post-conflict societies requires the negotiation of a new social contract. Surfacing and engaging with differences in patient and provider expectations of this contract may contribute to more acceptable, accessible health care services. Additionally, the health system is well positioned to highlight and connect the political economy, institutions and social relationships that create and sustain identities of exclusion and inclusion - (re)politicise suffering - and co-ordinate and lead intersectoral action for overcoming affordability and availability barriers to inclusive and equitable health care services.
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Affiliation(s)
- Bronwyn Harris
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Health Policy Research Group, Medical Research Council of South Africa, Johannesburg, Gauteng, South Africa
| | - John Eyles
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Health Policy Research Group, Medical Research Council of South Africa, Johannesburg, Gauteng, South Africa
- School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Loveday Penn-Kekana
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Health Policy Research Group, Medical Research Council of South Africa, Johannesburg, Gauteng, South Africa
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Liz Thomas
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Health Policy Research Group, Medical Research Council of South Africa, Johannesburg, Gauteng, South Africa
| | - Jane Goudge
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Health Policy Research Group, Medical Research Council of South Africa, Johannesburg, Gauteng, South Africa
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Balabanova D, Mills A, Conteh L, Akkazieva B, Banteyerga H, Dash U, Gilson L, Harmer A, Ibraimova A, Islam Z, Kidanu A, Koehlmoos TP, Limwattananon S, Muraleedharan VR, Murzalieva G, Palafox B, Panichkriangkrai W, Patcharanarumol W, Penn-Kekana L, Powell-Jackson T, Tangcharoensathien V, McKee M. Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening. Lancet 2013; 381:2118-33. [PMID: 23574803 DOI: 10.1016/s0140-6736(12)62000-5] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.
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Affiliation(s)
- Dina Balabanova
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
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Jewkes R, Morrell R, Sikweyiya Y, Dunkle K, Penn-Kekana L. Men, prostitution and the provider role: understanding the intersections of economic exchange, sex, crime and violence in South Africa. PLoS One 2012; 7:e40821. [PMID: 22911711 PMCID: PMC3401205 DOI: 10.1371/journal.pone.0040821] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 06/13/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND South African policy makers are reviewing legislation of prostitution, concerned that criminalisation hampers HIV prevention. They seek to understand the relationship between transactional sex, prostitution, and the nature of the involved men. METHODS 1645 randomly-selected adult South African men participated in a household study, disclosing whether they had sex with a woman in prostitution or had had a provider relationship (or sex), participation in crime and violence and completing psychological measures. These became outcomes in multivariable regression models, where the former were exposure variables. RESULTS 51% of men had had a provider relationship and expected sex in return, 3% had had sex with a woman in prostitution, 15% men had done both of these and 31% neither. Provider role men, and those who had just had sex with a woman in prostitution, were socially conservative and quite violent. Yet the men who had done both (75% of those having sex with a woman in prostitution) were significantly more misogynist, highly scoring on dimensions of psychopathy, more sexually and physically violent to women, and extensively engaged in crime. They had often bullied at school, suggesting that this instrumental, self-seeking masculinity was manifest in childhood. The men who had not engaged in sex for economic exchange expressed a much less violent, more law abiding and gender equitable masculinity; challenging assumptions about the inevitability of intersections of age, poverty, crime and misogyny. CONCLUSIONS Provider role relationships (or sex) are normative for low income men, but not having sex with a woman in prostitution. Men who do the latter operate extensively outside the law and their violence poses a substantial threat to women. Those drafting legislation and policy on the sex industry in South Africa need to distinguish between these two groups to avoid criminalising the normal, and consider measures to protect women.
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Affiliation(s)
- Rachel Jewkes
- Gender and Health Research Unit, Medical Research Council, Pretoria, South Africa.
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Silal SP, Penn-Kekana L, Harris B, Birch S, McIntyre D. Exploring inequalities in access to and use of maternal health services in South Africa. BMC Health Serv Res 2012; 12:120. [PMID: 22613037 PMCID: PMC3467180 DOI: 10.1186/1472-6963-12-120] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 05/21/2012] [Indexed: 11/10/2022] Open
Abstract
Background South Africa’s maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country’s Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, “patient-oriented” barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. Methods A mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers. Results Access to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care. Conclusions To move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these “patient-oriented” barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers.
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Affiliation(s)
- Sheetal P Silal
- Department of Statistical Sciences, University of Cape Town, Rondebosch, South Africa.
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Jewkes R, Morrell R, Sikweyiya Y, Dunkle K, Penn-Kekana L. Transactional relationships and sex with a woman in prostitution: prevalence and patterns in a representative sample of South African men. BMC Public Health 2012; 12:325. [PMID: 22551102 PMCID: PMC3433345 DOI: 10.1186/1471-2458-12-325] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 05/02/2012] [Indexed: 11/12/2022] Open
Abstract
Background Sex motivated by economic exchange is a public health concern as a driver of the Sub-Saharan African HIV epidemic. We describe patterns of engagement in transactional sexual relationships and sex with women in prostitution of South African men, and suggest interpretations that advance our understanding of the phenomenon. Methods Cross-sectional study with a randomly-selected sample of 1645 sexually active men aged 18–49 years who completed interviews in a household study and were asked whether they had had sex with a woman in prostitution, or had had a relationship or sex they took to be motivated by the expectation of material gain (transactional sex). Results 18% of men had ever had sex with a woman in prostitution, 66% at least one type of transactional sexual relationship, only 30% of men had done neither. Most men had had a transactional relationship/sex with a main partner (58% of all men), 42% with a concurrent partner (or makhwapheni) and 44% with a once off partner, and there was almost no difference in reports of what was provided to women of different partner types. The majority of men distinguished the two types of sexual relationships and even among men who had once-off transactional sex and gave cash (n = 314), few (34%) reported that they had had sex with a ‘prostitute’. Transactional sex was more common among men aged 25–34 years, less educated men and low income earners rather than those with none or higher income. Having had sex with a woman in prostitution varied little between social and demographic categories, but was less common among the unwaged or very low earners. Conclusions The notion of ‘transactional sex’ developed through research with women does not translate easily to men. Many perceive expectations that they fulfil a provider role, with quid pro quo entitlement to sex. Men distinguished these circumstances of sex from having sex with a woman in prostitution. Whilst there may be similarities, when viewed relationally, these are quite distinct practices. Conflating them is sociologically inappropriate. Efforts to work with men to reduce transactional sex should focus on addressing sexual entitlement and promoting gender inequity.
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Affiliation(s)
- Rachel Jewkes
- Gender & Health Research Unit, Medical Research Council, Pretoria and School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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