Cross-cultural validation of two scales to assess mental wellbeing in persons affected by leprosy in Province 1 and 7, Nepal.

To assess mental wellbeing among persons affected by leprosy, this study aimed to validate the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) and the Patient Health Questionnaire (PHQ-9, depression tool) in Province 1 and 7, Nepal. Using purposive and convenience sampling, cross-cultural equivalences were assessed through semi-structured interviews with persons affected by leprosy (>18 years). Data were transcribed, translated, analysed and discussed with experts before revising the tools. Psychometric properties of the scales were assessed using an interviewer-administered questionnaire with cases affected by leprosy and controls not affected by leprosy (>18 years). Statistical analysis included internal consistency, construct validity, floor and ceiling effects, and interpretability. The qualitative study included 20 respondents of whom eleven were female. The statements in the original tools were rephrased to questions as participants had difficulties understanding the statements. Six additional changes were made to ensure items were understood well. The quantitative study included 90 cases (46% female) and 50 controls (54% female). The WEMWBS and PHQ-9 had adequate psychometric properties. Cronbach's alphas were 0.85 and 0.76, respectively, indicating good internal consistency, 75% of hypotheses for construct validity were confirmed, no floor and ceiling effects were found, and data to help users interpret results are presented. Our study provides evidence that the adapted versions of the WEMWBS and PHQ-9 have good cultural validity to measure mental wellbeing and depression among persons affected by leprosy in Province 1 and 7, Nepal.

Access to oral health care for undocumented migrants: Perspectives of actors involved in a voluntary dental network in the Netherlands.

OBJECTIVE: Undocumented migrants in Europe face multiple barriers in access to oral health care. This study aimed to explore the accessibility of a voluntary dental network providing dental treatments to undocumented migrants in the Netherlands, from the perspectives of patients, dentists and staff members of nongovernmental organizations involved. METHODS: This qualitative study used semi-structured interviews (n = 21) with undocumented migrants (n = 12), dentists (n = 7) and staff members of nongovernmental organizations (n = 2) during the implementation of a voluntary dental network. Interviews were analysed using a framework analysis method. RESULTS: As a temporary answer to problems in access to oral health for undocumented migrants, the voluntary dental network targeted initial barriers to dental care. Main challenges within the network were conflicting expectations and perceived treatment outcomes by patients, dentist and NGO staff members, limited financial resources, logistic and communication barriers and an increasing administrative burden. Furthermore, feelings of compassion for and trust of the patient affected the ethics of the professional relationship and influenced treatment decisions of dentists. CONCLUSION: Through the implementation of a voluntary dental network, treatments could be provided to undocumented migrants as a temporary solution. However, the voluntary nature of dental care in the network resulted in a fragmented provision of oral health care among undocumented migrants. To reduce inequalities in oral health on the long term, systemic barriers in access to oral health care need to be addressed.

Facilitators and barriers to birth preparedness and complication readiness in rural Rwanda among community health workers and community members: a qualitative study.

BACKGROUND: Birth preparedness and complication readiness (BP/CR) comprise a strategy to make women plan for birth and encourage them to seek professional care in order to reduce poor pregnancy outcome. We aimed to understand the facilitators and barriers to BP/CR among community health workers (CHWs) and community members in rural Rwanda. METHODS: Eight focus group discussions were conducted with 88 participants comprising of CHWs, elderly women aged 45-68 and men aged 18-59, as well as two key informant interviews in Musanze district, Rwanda, between November and December 2015. Qualitative data were digitally recorded, transcribed verbatim and analysed using content analysis. RESULTS: Participants perceived the importance of family assistance, medical insurance and attending antenatal care (ANC) to facilitate BP/CR and enhance professional care at birth. CHWs reinforced BP/CR messages by SMS alerts and during community gatherings. 'Ubudehe (collective action to combat poverty)' was known as a tool to identify the poorest families in need of government aid to pay for medical care. Disrespect and abuse of women during labor by health workers were perceived as important barriers to access professional care, as well as conflicting health policies such as user fees for ANC and family planning services, and imposing fines on women giving birth outside health facilities. CONCLUSION: CHWs, ANC and medical insurance are perceived to be important facilitators of BP/CR. Respectful care is paramount for improved maternal health. There is a need for addressing inconsistent health policies hindering the intention to access professional care.

Birth preparedness and complication readiness among pregnant women admitted in a rural hospital in Rwanda.

BACKGROUND: With an aim to prevent adverse pregnancy outcomes, 'birth preparedness and complication readiness' (BP/CR) promotes timely access to skilled maternal and neonatal services. Objective of this study was to assess implementation of BP/CR among pregnant women admitted with obstetric emergencies in rural Rwanda. METHODS: A cross-sectional study among pregnant women who were referred to Ruhengeri hospital between July and November 2015. The 'Safe Motherhood questionnaire' as developed by Jhpiego's Maternal and Neonatal Health Program was used to collect data. Women were asked to mention key danger signs and respond as to whether they had identified: (A) skilled birth attendant, (B) location to give birth, (C) mode of transport, (D) money to cover health care expenditure. Women who answered 'yes' to three or four items were labeled 'well prepared'. Multivariate logistic regression analysis was conducted to compare the 'well prepared' and 'less prepared'. RESULTS: With regard to complication readiness, out of 350 women, 296 (84.6%), 271 (77.4%) and 288 (82.3%) could mention at least one key danger sign during pregnancy, labor and postpartum respectively, but only 23 (6.6%) could mention three or more key danger signs during all three periods. With regard to birth preparedness, 46 (13.1%) women had identified a skilled birth attendant, 68 (19.4%) birth location, 76 (21.7%) mode of transport, and 306 (87.4%) had saved money for health care costs. Seventy-eight women (22.3%) were 'well prepared', associated factors being first time pregnancy (adjusted Odds Ratio (aOR) = 3.2; 95% CI; 1.2-5.8), knowledge of at least two danger signs (aOR = 2.8; 95% CI; 1.7-3.9) and having been assisted by a community health worker at the antenatal clinic (aOR = 2.2, 95% CI; 1.3-3.7). CONCLUSION: Knowledge of obstetric danger signs was suboptimal and birth preparedness low. We recommend review of practices regarding health promotion in antenatal care, taking care not to exclude multiparous women from messages related to birth preparedness, and do promote use of community health workers to enhance effectiveness of BP/CR.

Impact of Birth Preparedness and Complication Readiness Interventions on Birth with a Skilled Attendant: A Systematic Review.

BACKGROUND: Increased preparedness for birth and complications is an essential part of antenatal care and has the potential to increase birth with a skilled attendant. We conducted a systematic review of studies to assess the effect of birth preparedness and complication readiness interventions on increasing birth with a skilled attendant. METHODS: PubMed, Embase, CINAHL and grey literature were searched for studies from 2000 to 2012 using a broad range of search terms. Studies were included with diverse designs and intervention strategies that contained an element of birth preparedness and complication readiness. Data extracted included population, setting, study design, outcomes, intervention description, type of intervention strategy and funding sources. Quality of the studies was assessed. The studies varied in BP/CR interventions, design, use of control groups, data collection methods, and outcome measures. We therefore deemed meta-analysis was not appropriate and conducted a narrative synthesis of the findings. RESULTS: Thirty-three references encompassing 20 different intervention programmes were included, of which one programmatic element was birth preparedness and complication readiness. Implementation strategies were diverse and included facility-, community-, or home-based services. Thirteen studies resulted in an increase in birth with a skilled attendant or facility birth. The majority of authors reported an increase in knowledge on birth preparedness and complication readiness. CONCLUSIONS: Birth Preparedness and Complication Readiness interventions can increase knowledge of preparations for birth and complications; however this does not always correspond to an increase in the use of a skilled attendant at birth.

Women's perceptions of the quality of emergency obstetric care in a referral hospital in rural Tanzania.

OBJECTIVES: To assess perceptions of the quality of obstetric care of women who delivered in a rural Tanzanian referral hospital. METHODS: A descriptive-exploratory qualitative study, using semistructured in-depth interviews and participatory observation. Nineteen recently delivered women and 3 health workers were interviewed. RESULTS: Although most women held positive views about the care they received in hospital, several participants expressed major concerns about negative attitudes of healthcare workers. Lack of medical communication given by care providers constituted a major complaint. CONCLUSIONS: A more positive attitude by health workers and the provision of adequate medical information may promote a more positive hospital experience of women in need of obstetric care and enhance attendance.

A protocol for a systematic review of birth preparedness and complication readiness programs.

BACKGROUND: One of the effective strategies for reducing the number of maternal deaths is delivery by a skilled birth attendant. Low utilization of skilled birth attendants has been attributed to delay in seeking care, delay in reaching a health facility and delay in receiving adequate care. Health workers could play a role in helping women prepare for birth and anticipate complications, in order to reduce delays. There is little evidence to support these birth preparedness and complication readiness (BP/CR) programs; however, BP/CR programs are frequently implemented. The objective of this review is to assess the effect of BP/CR programs on increasing skilled birth attendance in low-resource settings. METHODS: Due to the complexity of BP/CR programs and the need to understand why certain programs are more effective than others, we will combine both quantitative and qualitative studies in this systematic review. Search terms were selected with the assistance of a health information specialist. Three reviewers will independently select and assess studies for quality. Data will be extracted by one reviewer and checked for accuracy and completeness by a second reviewer. Discussion between the reviewers will resolve disagreements. If disagreements remain, a third party will be consulted. Data analysis will be carried out in accordance with the BP/CR matrix, developed by the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO). Study data will be grouped and analyzed by quality and study design and regrouped according to type of intervention strategy. DISCUSSION: This review will provide: 1) an insight into existing BP/CR programs, 2) recommendations on effective elements of the different approaches, 3) proposals for concrete action plans for health professionals in the field of reproductive health in resource-poor settings and 4) an overview of existing knowledge gaps requiring further research. TRIAL REGISTRATION: PROSPERO registration no.: CRD42012003124.

Barriers to conducting effective obstetric audit in Ifakara: a qualitative assessment in an under-resourced setting in Tanzania.

OBJECTIVE: To explore barriers to and solutions for effective implementation of obstetric audit at Saint Francis Designated District Hospital in Ifakara, Tanzania, where audit results have been disappointing 2 years after its introduction. METHODS: Qualitative study involving participative observation of audit sessions, followed by 23 in-depth interviews with health workers and managers. Knowledge and perceptions of audit were assessed and suggestions for improvement of the audit process explored. RESULTS: During the observational period, audit sessions were held irregularly and only when the head of department of obstetrics and gynaecology was available. Cases with evident substandard care factors were audited. In-depth interviews revealed inadequate knowledge of the purpose of audit, despite the fact that participants regarded obstetric audit as a potentially useful tool. Insufficient staff commitment, managerial support and human and material resources were mentioned as reasons for weak involvement of health workers and poor implementation of recommendations resulting from audit. Suggestions for improvement included enhancing feedback to all staff and managers to attend sessions and assist with the effectuation of audit recommendations. CONCLUSION: Obstetric staff in Ifakara see audit as an important tool for quality improvement. They recognise, however, that in their own situation, insufficient staff commitment and poor managerial support are barriers to successful implementation. They suggested training in concept and principles of audit as well as strengthening feedback of audit outcomes, to achieve structural health care improvements through audit.

Health workers' perceptions of obstetric critical incident audit in Thyolo District, Malawi.

OBJECTIVE: To assess perceptions held by health workers in a Malawian district about obstetric critical incident audit. Insight into factors contributing to participation and endorsement may help to improve the audit process and reduce facility-based maternal and neonatal mortality and morbidity. METHODS: This study involves semi-structured interviews with 25 district health workers, a focus group discussion and observation of audit sessions in health facilities in Thyolo District, Malawi, between August 2009 and January 2010. Data were analysed with maxqda 2010. RESULTS: Findings were categorized into four major areas: (i) general knowledge of audit, (ii) participation in local audit and feedback sessions, (iii) the ability to reproduce the local audit cycle and (iv) effects and outcomes of audit and feedback. All health workers were familiar with the concept of audit and could reproduce the local cycle. Most health workers classified audit as an instructive and helpful tool to improve the quality of their work, provided that it is performed in a manner that enhances motivation and on-the-job learning. CONCLUSIONS: Contradictory to recent reports from other African settings, which showed negative effects of audit on health workers' motivation, staff in this district considered audit and feedback valuable tools to enhance the quality of the care they provide. Audit has become part of the professional routine in the district, and its educational value was considered its most important appeal.