Empowering women as enablers in public health: A quantitative-qualitative systematic review of the gender-transformative approach.

Women are expected to take on multiple roles as caregivers and health care providers, but they are still often perceived as victims or beneficiaries rather than enablers. We aimed to explore women's empowerment and gender equality in public health systems and identify proactive enablers that can be incorporated into projects. A systematic review of peer-reviewed literature as well as text analysis were conducted to examine changes in perceptions of women's roles in public health projects. The authors conducted a quantitative analysis of the collected article titles, which revealed a shift in research from identifying risk factors to exploring women's autonomy in health promotion. However, our qualitative review of the articles showed that previous gender-related projects used a gender-sensitive approach that perpetuated the view of women as victims or beneficiaries rather than enablers. The concept of proactive enablers in all aspects of project planning and implementation ensures that women's roles are fully recognized and valued.

Building alternative payment models in health care.

Introduction: Global interest is growing in new value-based models of financing, delivering, and paying for health care services that could produce higher-quality and lower cost outcomes for patients and for society. However, research indicates evidence gaps in knowledge related to alternative payment models (APMs) in early experimentation phases or those contracted between private insurers and their health care provider-partners. The aim of this research was to understand and update the literature related to learning how industry experts design and implement APMs, including specific elements of their models and their choice of stakeholders to be involved in the design and contractual details. Methods: A literature review was conducted to guide the research focus and to select themes. The sample was selected using snowball sampling to identify subject matter experts (SMEs). Researchers conducted 16 semi-structured interviews with SMEs in the US, the Netherlands, and Germany in September and October 2021. Interviews were transcribed and using Braun and Clarke's six-phase approach to thematic analysis, researchers independently read, reviewed, and coded participants' responses related to APM design and implementation and subsequently reviewed each other's codes and themes for consistency. Results: Participants represented diverse perspectives of the payer, provider, consulting, and government areas of the health care sector. We found design considerations had five overarching themes: (1) population and scope of care and services, (2) benchmarking, metrics, data, and technology; (3) finance, APM type, risk adjustment, incentives, and influencing provider behavior, (4) provider partnerships and the role of physicians, and (5) leadership and regulatory issues. Discussion: This study confirmed several of the core components of APM model designs and implementations found in the literature and brought insights on additional aspects not previously emphasized, particularly the role of physicians (especially in leadership) and practice transformation/care processes necessary for providers to thrive under APM models. Importantly, researchers found significant concerns relevant for policymakers about regulations relating to health data sharing, rigid price-setting, and inter-organizational data communication that greatly inhibit the ability to experiment with APMs and those models' abilities to succeed long-term.

Lessons Learned During Large-Scale Implementation Project Focused on Workplace Lactation Practices and Policies.

PURPOSE: This practice-based research funded by the Centers for Disease Control and Prevention (CDC) focuses on the translation of evidence-based practices and policies into real-world applications. To the best of our knowledge, this is the largest study to research the implementation process for lactation accommodations and policies for work sites. DESIGN OR APPROACH: Pre-/post-test evaluation of work-site lactation accommodations, and 6-month follow-up with business that worked on the project. SETTING/PARTICIPANTS: 34 businesses across New Hampshire. METHOD: The team developed work-site selection criteria to award mini-grants; developed trainings and a toolkit; and worked with 34 businesses over a 3-year period. Pre-/post-implementation data were collected using the CDC work-site scorecard. A 6-month follow-up phone interview was conducted with each site. RESULTS: We assessed the CDC scorecard and evaluated the challenges of implementing lactation spaces by industry. In our 6-month follow-up, we found that spaces were still being utilized and we identified specific research to inform practical evidence-based applications and lessons learned when implementing a work-site lactation space. CONCLUSION: We successfully provided financial/technical support to develop or improve 45 lactation spaces, with policies and practices to support mothers and families for 34 businesses. We identified key takeaway lessons that can be used to guide the development of lactation spaces and policies in work sites. Sites self-report that these work-site changes were sustainable at 6-month follow-up.

Adolescent Mothers' Experiences With Community Health Assistants in Rural Zambia.

Adolescent health demands specific attention because adolescents have the lowest levels of health-care coverage of any age-group globally. The main objective as addressed in this article was to explore the lived experience of adolescent mothers and the services provided to them by community health assistants (CHAs) in rural Zambia. Because the number of adolescent mothers in rural Zambia is so high, it is even more critical to describe the lived experiences of health care among these young women with particular emphasis on primary health care as delivered by CHAs in rural Zambia. We used a mixed-methods design to address our research questions. Data were collected from nine focus groups, which were conducted with young mothers from four provinces and 10 districts (n = 60). To support our effort to better understand the delivery of maternal and child health care in rural Zambia, key informant interviews were conducted with adolescent mothers (n = 12). We also conducted surveys (n = 44) and one-on-one interviews (n = 22) with CHAs. To the best of our knowledge, this is the largest study focused on the intersection of adolescents, maternal child health, and CHA delivery of care in Zambia. The results of our study suggest opportunities for change to operational practices within the rural health-care setting and the need to develop structured and age-appropriate services that focus on adolescents. This work addresses the gap in research for adolescents in health care in rural Zambia and brings attention to the unique health-care needs of adolescent mothers within the rural health-care setting.

Identifying Barriers and Supports to Breastfeeding in the Workplace Experienced by Mothers in the New Hampshire Special Supplemental Nutrition Program for Women, Infants, and Children Utilizing the Total Worker Health Framework.

Variations in the barriers and contributors to breastfeeding across industries have not been well characterized for vulnerable populations such as mothers participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Our study used the Total Worker Health Framework to characterize workplace factors acting as barriers and/or contributors to breastfeeding among women participating in the New Hampshire WIC. Surveys were collected from WIC mothers (n = 682), which asked about employment, industry, and workplace accommodation and supports related to breastfeeding in the workplace. We found workplace policy factors supporting breastfeeding (i.e., having paid maternity leave, other maternity leave, and a breastfeeding policy) varied by industry. Women in specific service-oriented industries (i.e., accommodation and retail) reported the lowest rates of breastfeeding initiation and workplace supports for breastfeeding and pumping. Further, how a woman hoped to feed and having a private pumping space at work were significantly associated with industry, breastfeeding initiation, and breastfeeding duration. A substantial portion of women reported being not sure about their workplace environment, policies, and culture related to breastfeeding. Additional studies with larger sample sizes of women participating in WIC are needed to further characterize the barriers to breastfeeding associated with specific industries.

Overburden, Stigma, and Perceived Agency: Teachers as HIV Prevention Educators in Urban Zambia.

Sub-Saharan Africa is home to more than 70% of the global HIV-positive population. In Zambia, as well as in other parts of Africa, deaths from AIDS and associated infections have created a generation of households headed by children, a situation that negatively affects the chances for economic and health improvements in the region. In contemplating possible public health interventions around HIV prevention, we found that a growing body of research advocates for school-based HIV programs as an effective strategy to stop the spread of the disease. This work is critical because it explores schoolteachers' perspectives on their potential roles as HIV prevention educators. Semi-structured interviews (n = 12) were conducted among schoolteachers in the Lusaka province of Zambia to collect qualitative data. Analysis of qualitative data revealed three broad and interconnected themes related to the roles and concerns of the participating teachers: 1) the role of overburden; 2) fear of stigma; and 3) perceived lack of agency. These themes are further discussed in the context of the results that focused on the teachers and the adoption of HIV education. Little is known about teachers' perceptions of themselves as HIV educators. Our study suggests that understanding teachers' perceptions and the contextual factors is crucial to the adoption of school-based HIV programs.

Engaging field-based professionals in a qualitative assessment of barriers and positive contributors to breastfeeding using the social ecological model.

Despite broad recognition of benefits associated with breastfeeding, rates in the United States continue to be below targets established by Healthy People 2020, especially for economically disadvantaged women. This study engaged field-based professionals through a focus group process to collect perceptions on factors that determine a woman's decision to breastfeed. Field-based professionals participated in one of six focus groups. Following the social ecological model (SEM), focus group questions addressed barriers and contributors to breastfeeding at the individual, interpersonal, community, organizational, and public policy levels. Thematic content analysis was used in identifying, analyzing, and reporting on themes within the focus group data. Commonly reported themes were identified that negatively influence a mother's decision to breastfeed such as modesty/general discomfort to breastfeed in front of others, negative breastfeeding perceptions of family members, friends, boyfriends and co-workers, breastfeeding not being viewed as the societal "norm", and the availability of free formula samples. Despite identified barriers, commonly reported themes that positively influence a mother's decision to breastfeed included general knowledge on the benefits, positive breastfeeding perceptions of family members, friends, boyfriends, and co-workers, the availability of "mom and baby" groups, and Baby Friendly hospital practices. The findings provide field-based perspectives that identify opportunities to support breastfeeding through the lens of the SEM. Opportunities to better support breastfeeding include educating mothers and their social support systems on the specific benefits of breastfeeding, challenging existing breastfeeding norms, and working with hospitals on establishing policy to not provide free formula samples.

Exploring the role and capacity of school teachers in Zambia to support orphans and vulnerable children: considerations for educational resource allocation in Lusaka, Zambia.

This study investigated teachers' perceptions of their role as HIV/AIDS educators and also their role in providing care for orphans and vulnerable children (OVC) across the different school systems in Lusaka, Zambia. Researchers used a combined quantitative and qualitative narrative approach. Original cross-sectional data were collected through face-to-face survey and in-depth interviews with school teachers in the Lusaka. A sample of 720 teachers from 123 schools completed surveys in 2008, with a 91% response rate for teachers, and 100% for schools sampled. Teachers for all school types reported that schools and teachers are the appropriate community resource for HIV-prevention education for youth and support for OVC. This study suggests that schools could serve as a source and alternative mechanism of support for vulnerable children.