What are the factors affecting primary care choice when the access under health insurance scheme is limited?: a cross-sectional study in Bandung, Indonesia.

BACKGROUND: Ensuring equal access to primary care services is crucial, as the gateway to a higher level of care. Indonesia has been trying to increase financial access to medical care by administering national health insurance known as BPJS-Health (Badan Penyelenggara Jaminan Sosial Kesehatan) since 2014. However, BPJS-Health beneficiaries can only use their benefits at a limited number of registered primary care providers (BPJS-Health partners). This study investigated the geographical coverage of BPJS-Health and BPJS-Health beneficiaries' primary care choices, based on their characteristics and healthcare preferences in the target areas of Bandung, Indonesia. METHODS: The setting of this cross-sectional study was the areas with low physical access to BPJS-Health partners but high physical access to non-BPJS-Health partners. Physical access was determined by spatial network analysis, resulting in a geographical coverage map. A total of 216 adults were recruited and they completed the questionnaire about their primary care choice. All participants had been registered with the BPJS-Health system and living in the study areas. Their participation in non-BPJS-Health was also evaluated. Participants' choice of care was assessed in three different scenarios, when the individual was experiencing mild, chronic, and serious illnesses. RESULTS: BPJS-Health partners' geographical coverage was unequally distributed in Bandung. Being registered with non-BPJS-Health company was negatively associated with the more frequent choice of using BPJS-Health partners' services (AOR = 0.18; 95% CI, 0.06-0.58, P = 0.004) among BPJS-Health beneficiaries. For serious illnesses, having a high income was associated with choosing non-BPJS-Health partners and hospitals (AOR = 4.90; 95% CI, 1.16-20.77, P = 0.031). When dealing with mild and chronic illnesses, participants were concerned about the quality of treatment they would receive as a major factor in choosing a primary care provider. However, receiving better treatment quality was negatively associated with choosing BPJS-Health partners in all cases of illness severities. CONCLUSIONS: Sociodemographic characteristics, healthcare preference factors, and health insurance status were associated with participants' primary care choices in the target areas of Bandung, Indonesia. BPJS-Health partners' coverage map and the preference factors are potentially important for policymakers, especially for the development of future BPJS-Health partnerships.

Mediating role of social capital in the association between socioeconomic status and childcare practices in rural Malawi: a cross-sectional study.

OBJECTIVES: Childcare practices determine the child nutritional outcomes, but resources for good practices are unequally distributed across socioeconomic status (SES). This study first examined the associations between social capital and childcare practices separately across SES groups. It then investigated the mediation effect of social capital between SES and childcare practices. DESIGN: This cross-sectional study used the Short Version of the Adapted Social Capital Assessment Tool to measure structural social capital (group membership, social support and citizenship activities) and cognitive social capital of mothers. Data were analysed using multilevel logistic regressions with random intercepts and mediation modellings. SETTING: Rural Lilongwe, Malawi. PARTICIPANTS: A total of 320 mothers with a child aged between 12 months and 23 months. PRIMARY OUTCOME MEASURES: Childcare practice outcomes included were minimum dietary diversity, handwashing and complete vaccination. RESULTS: Among structural social capital dimensions, social support was found to be positively associated with minimum dietary diversity (adjusted OR (AOR)=1.44, 95% CI 1.22 to 1.71; p<0.001) and handwashing for all mothers (AOR=1.42, 95% CI 1.23 to 1.64; p<0.001). In the subgroup analysis, the higher SES group had higher odds of meeting the minimum dietary diversity (AOR=1.63, 95% CI 1.18 to 2.26; p=0.01) and handwashing with increased social support (AOR=1.53, 95% CI 1.13 to 2.08; p=0.01) than the lower SES. The mediation effect of social support accounted for 27.3% of the total effect between SES and minimum dietary diversity. Cognitive social capital was negatively associated with vaccination for the lower SES group (AOR=0.07, 95% CI 0.01 to 0.68; p=0.03). CONCLUSIONS: To improve feeding and handwashing practices and to reduce health inequalities in rural Malawi, governments and organisations should consider promoting the value of social support and health. Future research is needed to explain the negative association between cognitive social capital and vaccination among the lower SES group.

Effects of mHealth on the psychosocial health of pregnant women and mothers: a systematic review.

OBJECTIVE: To investigate the roles of mobile health, or mHealth, in the psychosocial health of pregnant women and mothers. METHODS: A systematic search was conducted in databases and grey literature including MEDLINE, Web of Science, CINAHL, PsycINFO, PsycARTICLES, Academic Search Complete, SocINDEX, Central Register of Controlled Trials, The Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, Health Technology Assessment, UNICEF and WHO databases. Two searches were conducted to include original research articles published in English until 15 November 2021. Several tools were used to assess the risk of bias: revised Cochrane risk of bias tool for randomised trials, Risk of Bias in Non-randomized Studies of Interventions, National Heart, Lung, and Blood Institute quality assessment tool for cohort and cross-sectional studies, Critical Appraisal Skills Program checklist for qualitative studies and Mixed Methods Appraisal Tool for mixed-methods studies. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation approach. Due to the high heterogeneity and variability of the included studies, data synthesis was conducted narratively. RESULTS: 44 studies were included among 11 999 identified articles. Most studies reported mixed findings on the roles of mHealth interventions in the psychosocial health of pregnant women and mothers; mHealth improved self-management, acceptance of pregnancy/motherhood and social support, while mixed results were observed for anxiety and depressive symptoms, perceived stress, mental well-being, coping and self-efficacy. Furthermore, pregnant women and mothers from vulnerable populations benefited from the use of mHealth to improve their psychosocial health. CONCLUSIONS: The findings suggest that mHealth has the potential to improve self-management, acceptance of pregnancy/motherhood and social support. mHealth can also be a useful tool to reach vulnerable pregnant women and mothers with barriers to health information and facilitate access to healthcare services. However, the high heterogeneity limited the certainty of evidence of these findings. Therefore, future studies should identify the context under which mHealth could be more effective.

Rapidly modifiable factors associated with full vaccination status among children in Niamey, Niger: A cross-sectional, random cluster household survey.

BACKGROUND AND OBJECTIVES: Vaccination status becomes more equitable when interventions are carried out to eliminate poverty or to improve levels in maternal education. Low-income countries need to identify interventions that would have a more immediate and equitable effect. The present study aimed to identify rapidly modifiable factors associated with full vaccination status among children in Niamey, Niger. METHODS: A cross-sectional, random cluster household survey was conducted in Niamey's five health districts. Data on vaccination coverage and socioeconomic household characteristics were collected. Logistic regression analysis was conducted with data on 445 mothers and their children aged 12-23 months. RESULTS: Of 445 children, 38% were fully vaccinated. Mothers who were satisfied with their health worker's attitude and had correct vaccination calendar knowledge (adjusted odds ratio [aOR] 5.32, 95% confidence interval [CI] 2.05-13.82) were more likely to have fully vaccinated children. Mothers who had completed secondary school (aOR 2.04, 95% CI 1.17-3.55) were also associated with having fully vaccinated children. CONCLUSIONS: A higher rate of full vaccination among children could be achieved by relatively short-term modifiable factors. These modifiable factors are mothers' satisfaction with health workers' attitudes and knowledge of the vaccination calendar. Maternal satisfaction with health workers' attitudes could be improved through better interpersonal communication between health workers and mothers. Specifically, mothers should be given specific information on time intervals between appointments. Strengthened communication interventions may be effective in improving both the acceptability of health services and low vaccination coverage.

Unmet Needs and Coping Mechanisms Among Community-Dwelling Senior Citizens in the Philippines: A Qualitative Study.

The Philippine government is facing a burden of improving health and social services for both the growing elderly and young population. The extent of discussion on aging issues and concerns, however, is minimal at best. Therefore, this study aimed to examine the perceptions of unmet needs and to explore the coping mechanisms of senior citizens across local stakeholders in an urban area in the Philippines. In this qualitative study, we collected data using focus group discussions among senior citizens (n = 4) and health providers (n = 4) as well as in-depth interviews among local administrators (n = 7). We analyzed the data through thematic analysis using the social determinants of health as the theoretical framework. We used qualitative research software NVivo10® to track the coding and manage the data. Four major themes related to unmet needs emerged in the analyses: (1) financial security, (2) health care services, (3) age-friendly environment, and (4) family support. Senior citizens responded either positively or negatively to cope with the challenges associated with aging. The government must then revisit existing national policies to address their unmet needs. Actions should be taken to strengthen positive coping and modifying the negative coping mechanisms, with a particular focus on community and family interventions.

Nepalese migrants in Japan: What is holding them back in getting access to healthcare?

INTRODUCTION: Migrants are one of the most deprived and vulnerable groups who receive the least health services in the society. Only a few studies have been conducted on access to healthcare among migrants in Asia, despite hosting 75 million migrants. In Japan, Nepalese migrants constitute the largest South Asian community. Their number increased by three folds from 2011 to 2016. However, little is known about their access to health care in Japan. Based on Andersen's model, we examined the factors associated with access to healthcare among Nepalese migrants in Japan. METHODS: We conducted a cross-sectional study among 642 Nepalese migrants residing in 10 prefectures of Japan. We used multivariable logistic regression model to explore the key predisposing, enabling, and need factors associated with access to healthcare among the migrants. RESULTS: The migrants who had stayed in Japan longer were more likely to perceive better access to a doctor/health worker (AOR = 1.11, 95% CI 1.03-1.19).The migrants were more likely to perceive better access to a doctor/health worker (AOR = 1.79, 95% CI 1.17-2.73) when they did not need Japanese language interpreter during visit to health facilities. They were also less likely not to see a doctor/health worker when needed (AOR = 0.34, 95% CI 0.21-0.56). The migrants were less likely to perceive better access to a doctor/health worker when they had not paid the health insurance premium regularly (AOR = 0.21, 95% CI 0.13-0.33).Their low perception of better access to a doctor/health worker was also associated with self-rated health status as poor or fair (AOR = 0.60, 95% CI 0.41-0.89). CONCLUSION: Nepalese migrants have poor access to health care in Japan. The key factors associated with their access to health care are the length of stay (predisposing factor), Japanese language skill and health insurance (enabling factors) and self-rated health status (need factor).

Education and indoor smoking among parents who smoke: the mediating role of perceived social norms of smoking.

BACKGROUND: Parents with less formal education are more likely to smoke indoors, causing socioeconomic disparity in children's exposure to second-hand smoke. However, little is known about the roles of social factors in the socioeconomic gradients of indoor smoking. We tested the potential mediating role of perceived smoking norms on the associations between education and indoor smoking among parents who smoke. METHODS: In this cross-sectional study, 822 smoking fathers and 823 smoking mothers, who lived with young children and were members of a Japanese online survey panel, participated. Structural equation modelling tested the mediating effects of perceived descriptive and subjective norms on the association between education and indoor smoking. RESULTS: Perceived pro-smoking norms, which were more prevalent among less-educated parents, mediated the association between education and indoor smoking. Household smoking status and worksite smoking ban also mediated this association via perceived norms, but only for fathers. Perceived descriptive norms explained 28.5% of the association for fathers and 37.6% for mothers; the corresponding percentages for perceived subjective norms were 9.8% and 26.6%, respectively. CONCLUSIONS: Perceived smoking norms, household smoking status, and a worksite smoking ban could be vital targets of a strategy aimed at reducing the socioeconomic disparity in parental home smoking behaviours.

Determinants of attending antenatal care at least four times in rural Ghana: analysis of a cross-sectional survey.

BACKGROUND: Improving maternal health is a global challenge. In Ghana, maternal morbidity and mortality rates remain high, particularly in rural areas. Antenatal care (ANC) attendance is known to improve maternal health. However, few studies have updated current knowledge regarding determinants of ANC attendance. OBJECTIVE: This study examined factors associated with ANC attendance in predominantly rural Ghana. METHODS: We conducted a cross-sectional study at three sites (i.e. Navrongo, Kintampo, and Dodowa) in Ghana between August and September 2013. We selected 1500 women who had delivered within the two years preceding the survey (500 from each site) using two-stage random sampling. Data concerning 1497 women's sociodemographic characteristics and antenatal care attendance were collected and analyzed, and factors associated with attending ANC at least four times were identified using logistic regression analysis. RESULTS: Of the 1497 participants, 86% reported attending ANC at least four times, which was positively associated with possession of national health insurance (AOR 1.64, 95% CI: 1.14-2.38) and having a partner with a high educational level (AOR 1.64, 95% CI: 1.02-2.64) and negatively associated with being single (AOR 0.39, 95% CI: 0.22-0.69) and cohabiting (AOR 0.57, 95% CI: 0.34-0.97). In site-specific analyses, factors associated with ANC attendance included marital status in Navrongo; marital status, possession of national health insurance, partners' educational level, and wealth in Kintampo; and preferred pregnancy timing in Dodowa. In the youngest, least educated, and poorest women and women whose partners were uneducated, those with health insurance were more likely to report at least four ANC attendances relative to those who did not have insurance. CONCLUSIONS: Ghanaian women with low socioeconomic status were less likely to report at least four ANC attendances during pregnancy if they did not possess health insurance. The national health insurance scheme should include a higher number of deprived women in predominantly rural communities.

The effectiveness of a nationwide universal coverage campaign of insecticide-treated bed nets on childhood malaria in Malawi.

BACKGROUND: Although the universal coverage campaign of insecticide-treated mosquito bed nets (ITNs) has been associated with improved malaria outcomes, recent reports indicate that the campaign is losing its sparkle in some countries. In Malawi, the universal coverage campaign was implemented in 2012, but its impacts are yet to be ascertained. Thus, this study examined the effects of the campaign on malaria morbidity among children in Malawi. METHODS: This is a repeated cross-sectional study. The study used nationally-representative malaria indicator survey (MIS) data collected in 2012 and 2014. In total, the analysis included 4193 children between the ages of 6 and 59 months (2171 from 2012 MIS and 2022 from 2014 MIS). ITNs coverage and malaria morbidity before (2012 = pre-test/control) and after (2014 = post-test/treated) the universal coverage campaign of ITNs were compared. The treated and control samples were matched on measured relevant covariates using propensity scores. RESULTS: The mean number of ITNs per household improved significantly from 1.1 (SD 1.0) in 2012 to 1.4 (SD 1.1) in 2014 (p < 0.001). Nonetheless, the prevalence of malaria among children increased considerably from 27.7 % (2012) to 32.0 % (2014) (p = 0.002). The risk of malaria was also significantly higher in 2014 compared to 2012 (RR = 1.14; 95 % CI 1.01-1.29). Besides, the use of bed nets was not significantly associated with malaria morbidity in 2014 (RR = 0.92; 95 % CI 0.76-1.12), but it was in 2012 (RR = 0.83; 95 % CI 0.70-1.00). CONCLUSIONS: The universal coverage campaign of ITNs was not associated with a reduced burden of malaria among children in Malawi. This was likely due to increased insecticide resistance, inconsistent use of bed nets and under-utilization of other methods of malaria control. This calls for a multifaceted approach in the fight against malaria instead of simple dependence on ITNs. In particular, local or community level malaria interventions should go hand in hand with the universal coverage campaign.

Motivation and incentive preferences of community health officers in Ghana: an economic behavioral experiment approach.

BACKGROUND: Health worker shortage in rural areas is one of the biggest problems of the health sector in Ghana and many developing countries. This may be due to fewer incentives and support systems available to attract and retain health workers at the rural level. This study explored the willingness of community health officers (CHOs) to accept and hold rural and community job postings in Ghana. METHODS: A discrete choice experiment was used to estimate the motivation and incentive preferences of CHOs in Ghana. All CHOs working in three Health and Demographic Surveillance System sites in Ghana, 200 in total, were interviewed between December 2012 and January 2013. Respondents were asked to choose from choice sets of job preferences. Four mixed logit models were used for the estimation. The first model considered (a) only the main effect. The other models included interaction terms for (b) gender, (c) number of children under 5 in the household, and (d) years worked at the same community. Moreover, a choice probability simulation was performed. RESULTS: Mixed logit analyses of the data project a shorter time frame before study leave as the most important motivation for most CHOs (ß 2.03; 95 % CI 1.69 to 2.36). This is also confirmed by the largest simulated choice probability (29.1 %). The interaction effect of the number of children was significant for education allowance for children (ß 0.58; 95 % CI 0.24 to 0.93), salary increase (ß 0.35; 95 % CI 0.03 to 0.67), and housing provision (ß 0.16; 95 % CI -0.02 to 0.60). Male CHOs had a high affinity for early opportunity to go on study leave (ß 0.78; 95 % CI -0.06 to 1.62). CHOs who had worked at the same place for a long time greatly valued salary increase (ß 0.28; 95 % CI 0.09 to 0.47). CONCLUSIONS: To reduce health worker shortage in rural settings, policymakers could provide "needs-specific" motivational packages. They should include career development opportunities such as shorter period of work before study leave and financial policy in the form of salary increase to recruit and retain them.

Continuum of Care in a Maternal, Newborn and Child Health Program in Ghana: Low Completion Rate and Multiple Obstacle Factors.

BACKGROUND: Slow progress has been made in achieving the Millennium Development Goals 4 and 5 in Ghana. Ensuring continuum of care (at least four antenatal visits; skilled birth attendance; postnatal care within 48 hours, at two weeks, and six weeks) for mother and newborn is crucial in helping Ghana achieve these goals and beyond. This study examined the levels and factors associated with continuum of care (CoC) completion among Ghanaian women aged 15-49. METHODS: A retrospective cross-sectional survey was conducted among women who experienced live births between January 2011 and April 2013 in three regions of Ghana. In a two-stage random sampling method, 1,500 women with infants were selected and interviewed about maternal and newborn service usage in line with CoC. Multiple logistic regression models were used to assess factors associated with CoC completion. RESULTS: Only 8.0% had CoC completion; the greatest gap and contributor to the low CoC was detected between delivery and postnatal care within 48 hours postpartum. About 95% of women had a minimum of four antenatal visits and postnatal care at six weeks postpartum. A total of 75% had skilled assisted delivery and 25% received postnatal care within 48 hours. Factors associated with CoC completion at 95% CI were geographical location (OR = 0.35, CI 0.13-0.39), marital status (OR = 0.45; CI 0.22-0.95), education (OR = 2.71; CI 1.11-6.57), transportation (OR = 1.97; CI 1.07-3.62), and beliefs about childhood illnesses (OR = 0.34; CI0.21-0.61). CONCLUSION: The continuum of care completion rate is low in the study site. Efforts should focus on increasing postnatal care within 48 hours and overcoming the known obstacles to increasing the continuum of care completion rate.

'Only Fathers Smoking' Contributes the Most to Socioeconomic Inequalities: Changes in Socioeconomic Inequalities in Infants' Exposure to Second Hand Smoke over Time in Japan.

BACKGROUND: Exposure to second hand smoke (SHS) is one of the major causes of premature death and disease among children. While socioeconomic inequalities exist for adult smoking, such evidence is limited for SHS exposure in children. Thus, this study examined changes over time in socioeconomic inequalities in infants' SHS exposure in Japan. METHODS: This is a repeated cross-sectional study of 41,833 infants born in 2001 and 32,120 infants born in 2010 in Japan from nationally representative surveys using questionnaires. The prevalence of infants' SHS exposure was determined and related to household income and parental education level. The magnitudes of income and educational inequalities in infants' SHS exposure were estimated in 2001 and 2010 using both absolute and relative inequality indices. RESULTS: The prevalence of SHS exposure in infants declined from 2001 to 2010. The relative index of inequality increased from 0.85 (95% confidence interval [CI], 0.80 to 0.89) to 1.47 (95% CI, 1.37 to 1.56) based on income and from 1.22 (95% CI, 1.17 to 1.26) to 2.09 (95% CI, 2.00 to 2.17) based on education. In contrast, the slope index of inequality decreased from 30.9 (95% CI, 29.3 to 32.6) to 20.1 (95% CI, 18.7 to 21.5) based on income and from 44.6 (95% CI, 43.1 to 46.2) to 28.7 (95% CI, 27.3 to 30.0) based on education. Having only a father who smoked indoors was a major contributor to absolute income inequality in infants' SHS exposure in 2010, which increased in importance from 45.1% in 2001 to 67.0% in 2010. CONCLUSIONS: The socioeconomic inequalities in infants' second hand smoke exposure increased in relative terms but decreased in absolute terms from 2001 to 2010. Further efforts are needed to encourage parents to quit smoking and protect infants from second hand smoke exposure, especially in low socioeconomic households that include non-smoking mothers.

Is baby-friendly breastfeeding support in maternity hospitals associated with breastfeeding satisfaction among Japanese mothers?

While the World Health Organization's Baby-Friendly Hospital Initiative has increased breastfeeding duration and exclusivity, a survey found that only 8.5 % of maternity hospitals in 31 developed countries could be designated baby-friendly. Baby-friendly breastfeeding support is sometimes criticized as mother unfriendly. This study examined whether baby-friendly breastfeeding support was associated with breastfeeding satisfaction, duration, and exclusivity among Japanese mothers. In this cross-sectional study, 601 breastfeeding Japanese mothers completed questionnaires at their infants' 4-month health checkups at two wards in Yokohama, Japan; 363 were included in the analysis. Baby-friendly breastfeeding support was measured based on the WHO's "Ten Steps to Successful Breastfeeding." We measured satisfaction using two subscales of the Japanese version of the Maternal Breastfeeding Evaluation Scale. The association of baby-friendly support with maternal satisfaction was assessed using multiple linear regression, while the prevalence ratios (PRs) for breastfeeding were estimated using Poisson regression. Mothers were stratified by prepartum exclusive breastfeeding intention (yes, n = 256; no, n = 107). Mothers who experienced early skin-to-skin contact with their infants were more likely to report breastfeeding satisfaction than those who did not. Among mothers without exclusive breastfeeding intention, those who were encouraged to feed on demand were more likely to be breastfeeding without formula at 1 month (PR 2.66 [95 % CI 1.32, 5.36]) and to perceive breastfeeding as beneficial for their baby (regression coefficient = 3.14 [95 % CI 0.11, 6.17]) than those who were not so encouraged. Breastfeeding satisfaction was a useful measure of breastfeeding outcome. Early skin-to-skin contact and encouragement to feed on demand in the hospital facilitate breastfeeding satisfaction.

Taking stock of Myanmar's progress toward the health-related Millennium Development Goals: current roadblocks, paths ahead.

Myanmar is a developing country with considerable humanitarian needs, rendering its pursuit of the Millennium Development Goals (MDGs) an especially high priority. Yet progress to date remains under-examined on key fronts. Particularly within the three health-related MDGs (MDGs 4, 5, and 6), the limited data reported point to patchy levels of achievement. This study was undertaken to provide an overview and assessment of Myanmar's progress toward the health-related MDGs, along with possible solutions for accelerating health-related development into 2015 and beyond. The review highlights off-track progress in the spheres of maternal and child health (MDGs 4 and 5). It also shows Myanmar's achievements toward MDG 6 targets--in the areas of HIV/AIDS, malaria, and tuberculosis. Such achievements are especially notable in that Myanmar has been receiving the lowest level of official development assistance among all of the least developed countries in Asia. However, to make similar progress in MDGs 4 and 5, Myanmar needs increased investment and commitment in health. Toward moving forward with the post-2015 development agenda, Myanmar's government also needs to take the lead in calling for attention from the World Health Organization and its global development partners to address the stagnation in health-related development progress within the country. In particular, Myanmar's government should invest greater efforts into health system strengthening to pave the road to universal health coverage.