Provider perceptions of lack of supportive care during childbirth: A mixed methods study in Kenya.

Supportive care is a key component of person-centered maternity care (PCMC), and includes aspects such as timely and attentive care, pain control, and the health facility environment. Yet, few researchers have explored the degree of supportive care delivered or providers' perceptions on supportive care practices during childbirth. The researchers' aim is to evaluate the extent of supportive care provided to women during childbirth and to identify the drivers behind the lack of supportive care from the perspective of maternity providers in a rural county in Western Kenya. Data are from a mixed-methods study in Migori County in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical). Providers were asked structured questions on various aspects of supportive care followed by open ended questions on why certain practices were performed or not. We conducted descriptive analysis of the quantitative data and thematic analysis of the qualitative data. We analyzed data and found inconsistent and suboptimal practices with regards to supportive care. Some providers reported long patient wait times in their facilities as well as the inability to provide the best care due to staff shortages in their facilities. Others also reported low interest and inquiry about women's experience of pain during childbirth, which was driven by perceptions of pain during childbirth as normal, facility culture and norms, and lack of pain medicine. For the facility environment, providers reported relatively clean facilities. They, however, noted inconsistent water and electricity as well as inadequate safety. We conclude that many drivers of the lack of supportive care are caused by structural health systems issues, therefore a health system strengthening approach can be useful for improving the supportive care dimension of PCMC, and thus quality of care overall.

Providers' perceptions of communication and women's autonomy during childbirth: a mixed methods study in Kenya.

BACKGROUND: Effective communication and respect for women's autonomy are critical components of person-centered care. Yet, there is limited evidence in low-resource settings on providers' perceptions of the importance and extent of communication and women's autonomy during childbirth. Similarly, few studies have assessed the potential barriers to effective communication and maintenance of women's autonomy during childbirth. We sought to bridge these gaps. METHODS: Data are from a mixed-methods study in Migori County in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical). Providers were asked structured questions on various aspects of communication and autonomy followed by open ended questions on why certain practices were performed or not. We conducted descriptive analysis of the quantitative data and thematic analysis of the qualitative data. RESULTS: Despite acknowledging the importance of various aspects of communication and women's autonomy, providers reported incidences of poor communication and lack of respect for women's autonomy: 57% of respondents reported that providers never introduce themselves to women and 38% reported that women are never able to be in the birthing position of their choice. Also, 33% of providers reported that they did not always explain why they are doing exams or procedures and 73% reported that women were not always asked for permission before exams or procedures. The reasons for lack of communication and autonomy fall under three themes with several sub-themes: (1) work environment-perceived lack of time, language barriers, stress and burnout, and facility culture; (2) provider knowledge, intentions, and assumptions-inadequate provider knowledge and skill, forgetfulness and unconscious behaviors, self-protection and comfort, and assumptions about women's knowledge and expectations; and (3) women's ability to demand or command effective communication and respect for their autonomy-women's lack of participation, women's empowerment and provider bias. CONCLUSIONS: Most providers recognize the importance of various aspects of communication and women's autonomy, but they fail to provide it for various reasons. To improve communication and autonomy, we need to address the different factors that negatively affect providers' interactions with women.

Quality of antenatal care and associated factors in a rural county in Kenya: an assessment of service provision and experience dimensions.

BACKGROUND: This study aimed to assess the quality of antenatal care (ANC) women received in Migori county, Kenya-including both service provision and experience dimensions-and to examine factors associated with each dimension. METHODS: We used survey data collected in 2016 in Migori county from 1031 women aged 15-49 who attended ANC at least once in their most recent pregnancy. ANC quality service provision was measured by nine questions on receipt of recommended ANC services, and experience of care by 18 questions on information, communication, dignity, and facility environment. We summed the responses to the individual items to generate ANC service provision and experience of care scores. We used both linear and logistic regression to examine predictors. RESULTS: The average service provision score was 10.9 (SD = 2.4) out of a total of 16. Most women received some recommended services once, but not at the frequency recommended by the Kenyan Ministry of Health. About 90% had their blood pressure measured, and 78% had a urine test, but only 58 and 14% reported blood pressure monitoring and urine test, respectively, at every visit. Only 16% received an ultrasound at any time during ANC. The average experience score is 27.3 (SD = 8.2) out of a total score of 42, with key gaps demonstrated in communication. About half of women were not educated on pregnancy complications. Also, about one-third did not often understand the purposes of tests and medicines received and did not feel able to ask questions to the health care provider. In multivariate analysis, women who were literate, employed, and who received all their ANC in a health center had higher experiences scores than women who were illiterate (coefficient = 1.52, CI:0.26,2.79), unemployed (coefficient = 2.73, CI:1.46,4.00), and received some ANC from a hospital (coefficient = 1.99, CI: 0.84, 3.14) respectively. The wealthiest women had two times higher odds of receiving an ultrasound than the poorest women (OR = 2.00, CI:1.20,3.33). CONCLUSION: Quality of ANC is suboptimal in both service provision and experience domains, with disparities by demographic and socioeconomic factors and facility type. More efforts are needed to improve quality of ANC and to eliminate the disparities.

Expanded roles of community health workers to sustain malaria services in the Asia-Pacific: A landscaping survey.

Malaria Community Health Workers (CHWs) in the Greater Mekong Subregion (GMS) are an important component of malaria elimination efforts. As malaria declines with intensified efforts to eliminate by 2030, expanding their roles beyond malaria could help to sustain funding and provision of malaria services at the community level. Evidence of how programmes have implemented and managed CHWs performing both malaria and non-malaria roles across the Asia-Pacific region can provide insight into the viability of this strategy. A short survey was distributed to national malaria programmes and implementing organizations in the Asia-Pacific region in 2021-2022. The survey identified CHW programmes in the region, and collected information on malaria and non-malarial services provided by CHWs, characteristics of each identified programme, and the impact of COVID-19 on these programmes. 35 survey responses identified 28 programmes in 14 countries. The most frequently reported services provided by malaria CHWs were health promotion and education for malaria (13/14 countries) and other diseases (11/14); and COVID-19 related activities (10/14). Most programmes were financed wholly through donor funding (18/28 programmes), or donor plus government funding (6/28). Of 21 programmes which performed programme evaluation, only 2 evaluated their impacts on diseases beyond malaria. Declining donor funding, and COVID-19 related travel and activity restrictions were identified as implementation challenges. CHWs across the Asia Pacific provide a range of health services with malaria and are resilient under changing public health landscapes such as the COVID-19 pandemic. Further investigation into the impact of additional roles on malaria CHW performance and targeted health outcomes is needed to verify the benefits and feasibility of role expansion. As the GMS approaches elimination, and funding declines, verifying the cost effectiveness of malaria CHW programmes will be vital to persuade donors and countries to invest in malaria CHWs to sustain malaria services, and strengthen community-based health care.

Factors Influencing Parent and Guardian Decisions on Vaccinating Their Children Against SARS-CoV-2: A Qualitative Study.

This qualitative analysis sought to explore factors that influenced parent/guardian intentions to vaccinate their children against SARS-CoV-2 in San Francisco, California, USA in order to inform San Francisco Department of Public Health's (SFDPH) youth vaccine rollout program. 30-minute, semi-structured telephone interviews were conducted with parents and guardians in either Spanish or English. Respondents shared their perspectives on vaccinating their children against SARS-CoV-2. Interviews were conducted over the telephone and recorded on Zoom. Participants (n = 40) were parents/guardians responding on behalf of their adolescent children (age 13+) and parents/guardians identified from the SFDPH COVID-19 testing database who tested for SARS-CoV-2 within the last 2 weeks. Interviews were conducted, audio recorded, transcribed, translated into English as appropriate, and rapidly analyzed in REDCap according to matrix analysis methodology to develop parent study themes. Perspectives on child vaccination were then explored through thematic analysis. Three themes were identified from the thematic analysis: (1) parental desires for children to return to school safely, (2) unclear messaging and information on COVID-19 prevention and vaccination, and (3) consideration of child's desires or opinions on receiving the vaccine. This study highlights specific factors influencing parent/guardian decisions on whether to vaccinate their children against SARS-CoV-2. The analysis also illustrates a potential role for children to play in influencing household vaccine decision-making.

Policies and program implementation experience to improve maternal nutrition in Ethiopia.

BACKGROUND: Maternal undernutrition persists as a serious problem in Ethiopia. Although there are maternal nutrition interventions that are efficacious and effective in improving maternal, neonatal, and child health (MNCH) outcomes, implementation has been limited. OBJECTIVE: This study explored needs, perceptions, priorities,facilitatingfactors and barriers to implementation of relevant policies and programs to find opportunities to improve maternal nutrition in Ethiopia METHODS: Background information was compiled and synthesized for a situation analysis. This informed focus group discussions and in-depth interviews with mothers, community leaders, health workers, and district health officials in four woredas (districts) in Tigray and Southern Nations, Nationalities and Peoples Region. RESULTS: Findings focused on three priority issues: maternal anemia, intrauterine growth retardation (IUGR), and maternal thinness and stunting. Community-level investigations found that women's low status, food insecurity and poverty, and workload were key factors perceived to contribute to women's undernutrition. Awareness of and demand for services to improve women's nutrition were low, except for high demand for supplementary food. On the supply side, barriers included low prioritization of maternal nutrition in health and nutrition service delivery and weak technical capacity to deliver context-sensitive maternal nutrition interventions at all levels. CONCLUSIONS: Community-based health and nutrition services were promising platforms for expanding access to interventions such as micronutrient supplements and social and behavior change communication. Investments are needed to support these community-based programs, including training, supplies, supervision and monitoring. To address IUGR at scale, increased access to cash or food transfers could be explored.

Outdoor Activities Associated with Lower Odds of SARS-CoV-2 Acquisition: A Case-Control Study.

Access to recreational physical activities, particularly in outdoor spaces, has been a crucial outlet for physical and mental health during the COVID-19 pandemic. There is a need to understand how conducting these activities modulates the risk of SARS-CoV-2 infection. In this case-control study of unvaccinated individuals conducted in San Francisco, California, the odds of testing positive to SARS-CoV-2 were lower for those who conducted physical activity in outdoor locations (adjusted odds ratio [aOR]: 0.16, 95% confidence interval [CI]: 0.05, 0.40) in the two weeks prior to testing than for those who conducted no activity or indoor physical activity only. Individuals who visited outdoor parks, beaches, or playgrounds also had lower odds of testing positive to SARS-CoV-2 (aOR: 0.28, 95% CI: 0.11, 0.68) as compared with those who did not visit outdoor parks, beaches, or playgrounds. These findings, albeit in an unvaccinated population, offer observational data to support pre-existing ecological studies that suggest that activity in outdoor spaces lowers COVID-19 risk.

Providers' perceptions of disrespect and abuse during childbirth: a mixed-methods study in Kenya.

Disrespect and abuse during childbirth are violations of women's human rights and an indicator of poor-quality care. Disrespect and abuse during childbirth are widespread, yet data on providers' perspectives on the topic are limited. We examined providers' perspectives on the frequency and drivers of disrespect and abuse during facility-based childbirth in a rural county in Kenya. We used data from a mixed-methods study in a rural county in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical) in 2016. Providers were asked structured questions on disrespect and abuse, followed by open-ended questions on why certain behaviours were exhibited (or not). Most providers reported that women were often treated with dignity and respect. However, 53% of providers reported ever observing other providers verbally abuse women and 45% reported doing so themselves. Observation of physical abuse was reported by 37% of providers while 35% reported doing so themselves. Drivers of disrespect and abuse included perceptions of women being difficult, stress and burnout, facility culture and lack of accountability, poor facility infrastructure and lack of medicines and supplies, and provider attitudes. Provider bias, training and women's empowerment influenced how different women were treated. We conclude that disrespect and abuse are driven by difficult situations in a health system coupled with a facilitating sociocultural environment. Providers resorted to disrespect and abuse as a means of gaining compliance when they were stressed and feeling helpless. Interventions to address disrespect and abuse need to tackle the multiplicity of contributing factors. These should include empowering providers to deal with difficult situations, develop positive coping mechanisms for stress and address their biases. We also need to change the culture in facilities and strengthen the health systems to address the system-level stressors.

A Rapid Review of Available Evidence to Inform Indicators for Routine Monitoring and Evaluation of Respectful Maternity Care.

BACKGROUND: Some opportunities to routinely capture and improve respectful maternity care (RMC) during facility-based childbirth include quality improvement (QI) initiatives, community-based monitoring efforts through community score cards (CSC), and performance-based financing (PBF) initiatives. But there is limited guidance on which types of RMC indicators are best suited for inclusion in these initiatives. We sought to provide practical evidence-based recommendations on indicators that may be used for routine measurement of RMC in programs. METHODS: We used a rapid review approach, which included (1) reviewing existing documents and publications to extract RMC indicators and identify which have or can be used in facility-based QI, CSCs, and PBF schemes; (2) surveying RMC and maternal health experts to rank indicators, and (3) analyzing survey data to select the most recommended indicators. RESULTS: We identified 49 indicators spanning several domains of RMC and mistreatment including dignified/nondignified care, verbal and physical abuse, privacy/confidentiality, autonomy/loss of autonomy, supportive care/lack thereof, communication, stigma, discrimination, trust, facility environment/culture, responsiveness, and nonevidence-based care. Based on the analysis of the survey data, we recommend 33 indicators (between 2 and 6 indicators for each RMC domain) that may be suited for incorporation in both facility-based QI and CSC-related monitoring efforts. CONCLUSION: Integrating RMC indicators into QI and CSC initiatives, as well as in other maternal and neonatal health programs, could help improve RMC at the facility and community level. More research is needed into whether RMC can be integrated into PBF initiatives. Integration of RMC indicators into programs to improve quality of care and other health system outcomes will facilitate routine monitoring and accountability around experience of care. Measurement and improvement of women's experiences will increase maternal health service utilization and improve quality of care as a means of reducing maternal and neonatal morbidity and mortality.

Using mHealth to improve health care delivery in India: A qualitative examination of the perspectives of community health workers and beneficiaries.

BACKGROUND: mHealth technologies are proliferating globally to address quality and timeliness of health care delivery by Community Health Workers (CHWs). This study aimed to examine CHW and beneficiaries' perceptions of a new mHealth intervention (Common Application Software [CAS] for CHWs in India. The objectives of the study were to seek perspectives of CHWs and beneficiaries on the uptake of CAS, changes in CHW-beneficiary interactions since the introduction of CAS and potential barriers faced by CHWs in use of CAS. Further, important contextual factors related to CHW-beneficiary interface and dynamics that may have a bearing on CAS have been described. METHODS: A qualitative study was conducted in two states of India (Bihar and Madhya Pradesh) from March-April 2018 with CHWs (n = 32) and beneficiaries (n = 55). All interviews were conducted and recorded in Hindi, transcribed and translated into English, and coded and thematically analysed using Dedoose. FINDINGS: The mHealth intervention was acceptable to the CHWs who felt that CAS improved their status in the communities where they worked. Beneficiaries' views were a mix of positive and negative perceptions. The divergent views between CHWs and beneficiaries surrounding the use and impact of CAS highlight an underlying mistrust, socio-cultural barriers in engagement, and technological barriers in implementation. All these contextual factors can influence the perception and uptake of CAS. CONCLUSIONS: mHealth interventions targeting CHWs and beneficiaries have the potential to improve performance of CHWs, reduce barriers to information and potentially change the behaviors of beneficiaries. While technology is an enabler for CHWs to improve their service delivery, it does not necessarily help overcome social and cultural barriers that impede CHW-beneficiary interactions to bring about improvements in knowledge and health behaviors. Future interventions for CHWs including mHealth interventions should examine contextual factors along with the acceptability, accessibility, and usability by beneficiaries and community members.

Mobile-Based Nutrition and Child Health Monitoring to Inform Program Development: An Experience From Liberia.

BACKGROUND: Implementing complex nutrition and other public health projects and tracking nutrition interventions, such as women's diet and supplementation and infant and young child feeding practices, requires reliable routine data to identify potential program gaps and to monitor trends in behaviors in real time. However, current monitoring and evaluation practices generally do not create an environment for this real-time tracking. This article describes the development and application of a mobile-based nutrition and health monitoring system, which collected monitoring data on project activities, women's nutrition, and infant and young child feeding practices in real time. PROGRAM DESCRIPTION: The Liberia Agricultural Upgrading Nutrition and Child Health (LAUNCH) project implemented a nutrition and health monitoring system between April 2012 and June 2014. The LAUNCH project analyzed project monitoring and outcome data from the system and shared selected behavioral and programmatic indicators with program managers through a short report, which later evolved into a visual data dashboard, during program-update meetings. The project designed protocols to ensure representativeness of program participants. FINDINGS: LAUNCH made programmatic adjustments in response to findings from the monitoring system; these changes were then reflected in subsequent quarterly trends, indicating that the availability of timely data allowed for the project to react quickly to issues and adapt the program appropriately. Such issues included lack of participation in community groups and insufficient numbers of food distribution points. Likewise, the system captured trends in key outcome indicators such as breastfeeding and complementary feeding practices, linking them to project activities and external factors including seasonal changes and national health campaigns. CONCLUSION: Digital data collection platforms can play a vital role in improving routine programmatic functions. Fixed gathering locations such as food distribution points represent an opportunity to easily access program participants and enable managers to identify strengths and weaknesses in project implementation. For programs that track individuals over time, a mobile tool combined with a strong database can greatly improve efficiency and data visibility and reduce resource leakages.