Qualitative evaluation of a package of implementation strategies codesigned to support the introduction of multiple micronutrient supplementation (MMS) for pregnant women in Bamako, Mali.

Mali national policy recommends that women take iron and folic acid supplements (IFA) from the time of the first antenatal care (ANC) visit, throughout pregnancy and during the first 3 months after delivery. In 2020, the World Health Organization (WHO) updated their ANC guidelines to recommend the United Nations International Multiple Micronutrient Antenatal Preparation (UNIMMAP) formulation of multiple micronutrient supplements (MMS) in the context of rigorous research, including implementation research. In Bamako, Mali, a codesign process was used to tailor antenatal care MMS packaging and counselling materials aimed at optimizing delivery and uptake of and adherence to MMS. This paper presents the codesign process along with the results of a post-intervention qualitative assessment to evaluate the behaviour change intervention. At the conclusion of the intervention, we conducted semistructured qualitative interviews with 24 women who had received the intervention and six pharmacy managers from the six health centres participating in the study. We conducted two focus groups with midwives who had delivered the intervention and two group discussions with family members of women who had received the intervention. Respondent perspectives reveal an easy experience transitioning from previously used IFA. Women and providers concur that the intervention counselling materials and visual aids were instrumental in influencing the perceived benefit and uptake of MMS. Family members play an influential role in pregnant women's decision-making regarding MMS uptake. MMS and the associated implementation strategies developed through the codesign process were found to be a highly acceptable intervention.

Gender-Based Violence Narratives in Internet-Based Conversations in Nigeria: Social Listening Study.

BACKGROUND: Overcoming gender inequities is a global priority recognized as essential for improved health and human development. Gender-based violence (GBV) is an extreme manifestation of gender inequities enacted in real-world and internet-based environments. In Nigeria, GBV has come to the forefront of attention since 2020, when a state of emergency was declared due to increased reporting of sexual violence. Understanding GBV-related social narratives is important to design public health interventions. OBJECTIVE: We explore how gender-related internet-based conversations in Nigeria specifically related to sexual consent (actively agreeing to sexual behavior), lack of consent, and slut-shaming (stigmatization in the form of insults based on actual or perceived sexuality and behaviors) manifest themselves and whether they changed between 2017 and 2022. Additionally, we explore what role events or social movements have in shaping gender-related narratives in Nigeria. METHODS: Social listening was carried out on 12,031 social media posts (Twitter, Facebook, forums, and blogs) and almost 2 million public searches (Google and Yahoo search engines) between April 2017 and May 2022. The data were analyzed using natural language processing to determine the most salient conversation thematic clusters, qualitatively analyze time trends in discourse, and compare data against selected key events. RESULTS: Between 2017 and 2022, internet-based conversation about sexual consent increased 72,633%, from an average 3 to 2182 posts per month, while slut-shaming conversation (perpetrating or condemning) shrunk by 9%, from an average 3560 to 3253 posts per month. Thematic analysis shows conversation revolves around the objectification of women, poor comprehension of elements of sexual consent, and advocacy for public education about sexual consent. Additionally, posters created space for sexual empowerment and expressions of sex positivity, pushing back against others who weaponize posts in support of slut-shaming narrative. Time trend analysis shows a greater sense of empowerment in advocating for education around the legal age of consent for sexual activity, calling out double standards, and rejecting slut-shaming. However, analysis of emotions in social media posts shows anger was most prominent in sexual consent (n=1213, 73%) and slut-shaming (n=226, 64%) posts. Organic social movements and key events (#ArewaMeToo and #ChurchToo, the #SexforGrades scandal, and the #BBNaija television program) played a notable role in sparking discourse related to sexual consent and slut-shaming. CONCLUSIONS: Social media narratives are significantly impacted by popular culture events, mass media programs, social movements, and micro influencers speaking out against GBV. Hashtags, media clips, and other content can be leveraged effectively to spread awareness and spark conversation around evolving gender norms. Public health practitioners and other stakeholders including policymakers, researchers, and social advocates should be prepared to capitalize on social media events and discourse to help shape the conversation in support of a normative environment that rejects GBV in all its forms.

Measuring barriers to fistula care: investigating composite measures for targeted fistula programming in Nigeria and Uganda.

BACKGROUND: Accessing surgical repair poses challenges to women living with female genital fistula who experience intersectional vulnerabilities including poverty, gender, stigma and geography. Barriers to fistula care have been described qualitatively in several low- and middle-income countries, but limited effort has been made to quantify these factors. This study aimed to develop and validate composite measures to assess barriers to accessing fistula repair in Nigeria and Uganda. METHODS: This quantitative study built on qualitative findings to content validate composite measures and investigates post-repair client surveys conducted at tertiary hospitals in Northern and Southern Nigeria and Central Uganda asking women about the degree to which a range of barriers affected their access. An iterative scale development approach included exploratory and confirmatory factor analyses of two samples (n = 315 and n = 142, respectively) using STATA 13 software. Reliability, goodness-of-fit, and convergent and predictive validity were assessed. RESULTS: A preliminary 43-item list demonstrated face and content validity, triangulated with qualitative data collected prior to and concurrently with survey data. The iterative item reduction approach resulted in the validation of a set of composite measures, including two indices and three sub-scales. These include a Financial/Transport Inaccessibility Index (6 items) and a multidimensional Barriers to Fistula Care Index of 17 items comprised of three latent sub-scales: Limited awareness (4 items), Social abandonment (6 items), and Internalized stigma (7 items). Factor analyses resulted in favorable psychometric properties and good reliability across measures (ordinal thetas: 0.70-0.91). Higher levels of barriers to fistula care are associated with a woman living with fistula for longer periods of time, with age and geographic settings as potential confounders. CONCLUSIONS: This set of composite measures that quantitatively captures barriers to fistula care can be used separately or together in research and programming in low- and middle-income countries.

Knowledge of pharmacy workers on antihypertensive and anticonvulsant drugs for managing pre-eclampsia and eclampsia in Bangladesh.

BACKGROUND: Pharmacy workers in Bangladesh play an important role in managing pregnancy complications by dispensing, counselling and selling drugs to pregnant women and their families. This study examined pharmacy workers' drug knowledge and practice for pre-eclampsia and eclampsia (PE/E) management, including antihypertensives and anticonvulsants, and determine factors associated with their knowledge. METHODS: A cross-sectional survey with 382 pharmacy workers in public facilities (government) and private pharmacies and drug stores assessed their knowledge of antihypertensive and anticonvulsant drugs. 'Pharmacy workers' include personnel who work at pharmacies, pharmacists, family welfare visitors (FWVs), sub-assistant community medical officers (SACMOs), drug storekeepers. Exploratory and multivariate logistic models were used to describe association between knowledge of medicines used in pregnancy and demographic characteristics of pharmacy workers. RESULTS: Overall, 53% pharmacy workers interviewed were drug store owners in private pharmacies while 27% FWVs/SACMOs, who are government service providers also work as drug prescribers and/or dispensers in public facility pharmacies. Majority of pharmacy workers had poor knowledge compared to correct knowledge on both antihypertensive (77.8% vs 22.3%; p < 0.001) and anticonvulsant drugs (MgSO4) (82.2% vs 17.8%; p < 0.001). Multivariate analysis showed SACMOs and FWVs were greater than 4 times more likely to have correct knowledge on anti-hypertensives (AOR = 4.2, 95% CI:1.3-12.3, P < 0.01) and anticonvulsant drugs (AOR = 4.9, 95% CI:1.3-18.1, P < 0.01) compared to pharmacists. Pharmacy workers who had received training were more likely to have correct knowledge on antihypertensive and anticonvulsant drugs than those who had no training. CONCLUSIONS: Pharmacy workers' knowledge and understanding of antihypertensive and anticonvulsant drugs, particularly for prevention and management of PE/E is limited in Bangladesh. Most pharmacies surveyed are private and staffed with unskilled workers with no formal training on drugs. Expansion of maternal and newborn health programs should consider providing additional skills training to pharmacy workers, as well as regulating these medicines at informal pharmacies to mitigate any harmful practices or adverse outcomes of unauthorized and incorrectly prescribed and used drugs. It is important that correct messaging and medicines are available as drug stores are often the first point of contact for most of the women and their families.

Removing barriers to fistula care: Applying appreciative inquiry to improve access to screening and treatment in Nigeria and Uganda.

A research-to-action collaboration sought to understand and respond to barriers to female genital fistula treatment in Nigeria and Uganda. This was guided by appreciative inquiry, a participatory approach for transformative programing with four phases: (1) inquire, (2) imagine, (3) innovate, and (4) implement. Through this process, partners designed and refined a treatment barrier reduction intervention using multiple communication channels to disseminate a consistent fistula screening algorithm and provide transportation vouchers to those screening positive. Partnership between an implementation organization, a research institution, and local community partners enabled data-driven design and patient-centered implementation to address specific barriers experienced by women.

Exploring survivor perceptions of pre-eclampsia and eclampsia in Nigeria through the health belief model.

BACKGROUND: In Nigeria, hypertensive disorders have become the leading cause of facility-based maternal mortality. Many factors influence pregnant women's health-seeking behaviors and perceptions around the importance of antenatal care. This qualitative study describes the care-seeking pathways of Nigerian women who suffer from pre-eclampsia and eclampsia. It identifies the influences - barriers and enablers - that affect their decision making, and proposes solutions articulated by women themselves to overcome the obstacles they face. Informing this study is the health belief model, a cognitive value-expectancy theory that provides a framework for exploring perceptions and understanding women's narratives around pre-eclampsia and eclampsia-related care seeking. METHODS: This study adopted a qualitative design that enables fully capturing the narratives of women who experienced pre-eclampsia and eclampsia during their pregnancy. In-depth interviews were conducted with 42 women aged 17-48 years over five months in 2015 from Bauchi, Cross River, Ebonyi, Katsina, Kogi, Ondo and Sokoto states to ensure representation from each geo-political zone in Nigeria. These qualitative data were analyzed through coding and memo-writing, using NVivo 11 software. RESULTS: We found that many of the beliefs, attitudes, knowledge and behaviors of women are consistent across the country, with some variation between the north and south. In Nigeria, women's perceived susceptibility and threat of health complications during pregnancy and childbirth, including pre-eclampsia and eclampsia, influence care-seeking behaviors. Moderating influences include acquisition of knowledge of causes and signs of pre-eclampsia, the quality of patient-provider antenatal care interactions, and supportive discussions and care seeking-enabling decisions with families and communities. These cues to action mitigate perceived mobility, financial, mistrust, and contextual barriers to seeking timely care and promote the benefits of maternal and newborn survival and greater confidence in and access to the health system. CONCLUSIONS: The health belief model reveals intersectional effects of childbearing norms, socio-cultural beliefs and trust in the health system and elucidates opportunities to intervene and improve access to quality and respectful care throughout a woman's pregnancy and childbirth. Across Nigerian settings, it is critical to enhance context-adapted community awareness programs and interventions to promote birth preparedness and social support.

Setting the global research agenda for community health systems: literature and consultative review.

BACKGROUND: Globally, there is renewed interest in and momentum for strengthening community health systems, as also emphasized by the recent Astana Declaration. Recent reviews have identified factors critical to successful community health worker (CHW) programs but pointed to significant evidence gaps. This review aims to propose a global research agenda to strengthen CHW programs. METHODS AND RESULTS: We conducted a search for extant systematic reviews on any intermediate factors affecting the effectiveness of CHW programs in February 2018. A total of 30 articles published after year 2000 were included. Data on research gaps were abstracted and summarized under headings based on predominant themes identified in the literature. Following this data gathering phase, two technical advisory groups comprised of experts in the field of community health-including policymakers, implementors, researchers, advocates and donors-were convened to discuss, validate, and prioritize the research gaps identified. Research gap areas that were identified in the literature and validated through expert consultation include selection and training of CHWs, community embeddedness, institutionalization of CHW programs (referrals, supervision, and supply chain), CHW needs including incentives and remuneration, governance and sustainability of CHW programs, performance and quality of care, and cost-effectiveness of CHW programs. Priority research questions included queries on effective policy, financing, governance, supervision and monitoring systems for CHWs and community health systems, implementation questions around the role of digital technologies, CHW preferences, and drivers of CHW motivation and retention over time. CONCLUSIONS: As international interest and investment in CHW programs and community health systems continue to grow, it becomes critical not only to analyze the evidence that exists, but also to clearly define research questions and collect additional evidence to ensure that CHW programs are effective, efficient, equity promoting, and evidence based. Generally, the literature places a strong emphasis on the need for higher quality, more robust research.

A conceptual framework for measuring community health workforce performance within primary health care systems.

BACKGROUND: With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries. METHODS: A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input. RESULTS: Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited. CONCLUSIONS: Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.

Measuring mistreatment of women throughout the birthing process: implications for quality of care assessments.

Measuring mistreatment and quality of care during childbirth is important in promoting respectful maternity care. We describe these dimensions throughout the birthing process from admission, delivery and immediate postpartum care. We observed 677 client-provider interactions and conducted 13 facility assessments in Kenya. We used descriptive statistics and logistic regression model to illustrate how mistreatment and clinical process of care vary through the birthing process. During admission, the prevalence of verbal abuse was 18%, lack of informed consent 59%, and lack of privacy 67%. Women with higher parity were more likely to be verbally abused [AOR: 1.69; (95% CI 1.03,2.77)]. During delivery, low levels of verbal and physical abuse were observed, but lack of privacy and unhygienic practices were prevalent during delivery and postpartum (>65%). Women were less likely to be verbally abused [AOR: 0.88 (95% CI 0.78, 0.99)] or experience unhygienic practices, [AOR: 0.87 (95% CI 0.78, 0.97)] in better-equipped facilities. During admission, providers were observed creating rapport (52%), taking medical history (82%), conducting physical assessments (5%). Women's likelihood to receive a physical assessment increased with higher infrastructural scores during admission [AOR: 2.52; (95% CI 2.03, 3.21)] and immediately postpartum [AOR 2.18; (95% CI 1.24, 3.82)]. Night-time deliveries were associated with lower likelihood of physical assessment and rapport creation [AOR; 0.58; (95% CI 0.41,0.86)]. The variability of mistreatment and clinical quality of maternity along the birthing process suggests health system drivers that influence provider behaviour and health facility environment should be considered for quality improvement and reduction of mistreatment.

"Poverty is the big thing": exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda.

BACKGROUND: Women living with obstetric fistula often live in poverty and in remote areas far from hospitals offering surgical repair. These women and their families face a range of costs while accessing fistula repair, some of which include: management of their condition, lost productivity and time, and transport to facilities. This study explores, through women's, communities', and providers' perspectives, the financial, transport, and opportunity cost barriers and enabling factors for seeking repair services. METHODS: A qualitative approach was applied in Kano and Ebonyi in Nigeria and Hoima and Masaka in Uganda. Between June and December 2015, the study team conducted in-depth interviews (IDIs) with women affected by fistula (n = 52) - including those awaiting repair, living with fistula, and after repair, and their spouses and other family members (n = 17), along with health service providers involved in fistula repair and counseling (n = 38). Focus group discussions (FGDs) with male and female community stakeholders (n = 8) and post-repair clients (n = 6) were also conducted. RESULTS: Women's experiences indicate the obstetric fistula results in a combined set of costs associated with delivery, repair, transportation, lost income, and companion expenses that are often limiting. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly among all fistula care centers or camps due to funding shortages. In Uganda, experienced transport costs indicate that women spend Ugandan Shilling (UGX) 10,000 to 90,000 (US$3.00-US$25.00) for two people for a single trip to a camp (client and her caregiver), while Nigerian women (Kano) spent Naira 250 to 2000 (US$0.80-US$6.41) for transportation. Factors that influence women's and families' ability to cover costs of fistula care access include education and vocational skills, community savings mechanisms, available resources in repair centers, client counseling, and subsidized care and transportation. CONCLUSIONS: The concentration of women in poverty and the perceived and actual out of pocket costs associated with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Findings recommend innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers.

Exploring Meaning and Types of Trust in Maternity Care in Peri-Urban Kenya: A Qualitative Cross-Perspective Analysis.

Trust offers a distinctive lens on facility responsiveness during labor and birth. Though acknowledged in prior literature, limited work exists linking conceptual and empirical spheres. This study explores trust in the maternity setting in Kenya through a theoretically driven qualitative approach. Focus groups ( n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews ( n = 33) with WRB, frontline providers, and management, were conducted in and around a peri-urban public hospital. Combined coding and memo-writing showed that trust in maternity care is nested within understandings of institutional and societal trust. Content areas of trust include confidence, communication, integrity, mutual respect, competence, fairness, confidentiality, and systems trust. Trust is relevant, multidimensional, and dynamic. Examining trust provides a basis for developing quantitative measures and reveals structural underpinnings, repercussions for trust in other health areas, and health systems inequities, which have implications for maternal health policy, programming, and service utilization.

Sowing the seeds of transformative practice to actualize women's rights to respectful maternity care: reflections from Kenya using the consolidated framework for implementation research.

BACKGROUND: Despite years of growing concern about poor provider attitudes and women experiencing mistreatment during facility based childbirth, there are limited interventions that specifically focus on addressing these issues. The Heshima project is an evidence-based participatory implementation research study conducted in 13 facilities in Kenya. It engaged a range of community, facility, and policy stakeholders to address the causes of mistreatment during childbirth and promote respectful maternity care. METHODS: We used the consolidated framework for implementation research (CFIR) as an analytical lens to describe a complex, multifaceted set of interventions through a reflexive and iterative process for triangulating qualitative data. Data from a broad range of project documents, reports, and interviews were collected at different time points during the implementation of Heshima. Assessment of in-depth interview data used NVivo (Version 10) and Atlas.ti software to inductively derive codes for themes at baseline, supplemental, and endline. Our purpose was to generate categories of themes for analysis found across the intervention design and implementation stages. RESULTS: The implementation process, intervention characteristics, individual champions, and inner and outer settings influenced both Heshima's successes and challenges at policy, facility, and community levels. Implementation success stemmed from readiness for change at multiple levels, constant communication between stakeholders, and perceived importance to communities. The relative advantage and adequacy of implementation of the Respectful Maternity Care (RMC) resource package was meaningful within Kenyan politics and health policy, given the timing and national promise to improve the quality of maternity care. CONCLUSION: We found the CFIR lens a promising and flexible one for understanding the complex interventions. Despite the relatively nascent stage of RMC implementation research, we feel this study is an important start to understanding a range of interventions that can begin to address issues of mistreatment in maternity care; replication of these activities is needed globally to better understand if the Heshima implementation process can be successful in different countries and regions.

Exploring provider perspectives on respectful maternity care in Kenya: "Work with what you have".

BACKGROUND: Promoting respect and dignity is a key component of providing quality care during facility-based childbirth and is becoming a critical indicator of maternal health care. Providing quality care requires essential skills and attitudes from healthcare providers, as their role is central to optimizing interventions in maternity settings. METHODS: In 13 facilities in Kenya we conducted a mixed methods, pre-post study design to assess health providers' perspectives of a multi-component intervention (the Heshima project), which aimed to mitigate aspects of disrespect and abuse during facility-based childbirth. Providers working in maternity units at study facilities were interviewed using a two-part quantitative questionnaire: an interviewer-guided section on knowledge and practice, and a self-administered section focusing on intrinsic value systems and perceptions. Eleven distinct composite scores were created on client rights and care, provider emotional wellbeing, and work environments. Bivariate analyses compared pre- and post-scores. Qualitative in-depth interviews focused on underlying factors that affected provider attitudes and behaviors including the complexities of service delivery, and perceptions of the Heshima interventions. RESULTS: Composite scales were developed on provider knowledge of client rights (Chronbach α = 0.70), client-centered care (α = 0.80), and HIV care (α = 0.81); providers' emotional health (α = 0.76) and working relationships (α = 0.88); and provider perceptions of management (α = 0.93), job fairness (α = 0.68), supervision (α = 0.84), promotion (α = 0.83), health systems (α = 0.85), and work environment (α = 0.85). Comparison of baseline and endline individual item scores and composite scores showed that provider knowledge of client rights and practice of a rights-based approach, treatment of clients living with HIV, and client-centered care during labor, delivery, and postnatal periods improved (p < 0.001). Changes in emotional health, perceptions of management, job fairness, supervision, and promotion seen in composite scores did not directly align with changes in item-specific responses. Qualitative data reveal health system challenges limit the translation of providers' positive attitudes and behaviors into implementation of a rights-based approach to maternity care. CONCLUSION: Behavior change interventions, central to promoting respectful care, are feasible to implement, as seen in the Heshima experience, but require sustained interaction with health systems where providers practice. Provider emotional health has the potential to drive (mis)treatment and affect women's care.

Interpersonal communication as an agent of normative influence: a mixed method study among the urban poor in India.

BACKGROUND: Although social norms are thought to play an important role in couples' reproductive decisions, only limited theoretical or empirical guidance exists on how the underlying process works. Using the theory of normative social behavior (TNSB), through a mixed-method design, we investigated the role played by injunctive norms and interpersonal discussion in the relationship between descriptive norms and use of modern contraceptive methods among the urban poor in India. METHODS: Data from a household survey (N = 11,811) were used to test the underlying theoretical propositions, and focus group interviews among men and women were then conducted to obtain more in-depth knowledge about decision-making processes related to modern contraceptive use. RESULTS: Spousal influence and interpersonal communication emerged as key factors in decision-making, waning in the later years of marriage, and they also moderated the influence of descriptive norms on behaviors. Norms around contraceptive use, which varied by parity, are rapidly changing with the country's urbanization and increased access to health information. CONCLUSION: Open interpersonal discussion, community norms, and perspectives are integral in enabling women and couples to use modern family planning to meet their current fertility desires and warrant sensitivity in the design of family planning policy and programs.

Measuring social norms related to child marriage among married women and men in Niger.

BACKGROUND: Child marriage remains prevalent in the Sahel region. Pervasive norms regarding child marriage, and sexual behavior persist. We explored norms from multiple perspectives to strengthen interventions aimed at delaying age at marriage. METHODS: This study analyzed a cross-sectional household survey conducted in Niger in 2022 with women aged 15-49 (n = 2,726) and a subset of their male household members aged 15-59 (n = 1,136). Separate logistic regression models assessed factors associated with three descriptive (e.g., perception of what others do) and injunctive (e.g., perception of a group's approval or disapproval) normative outcomes related to practices that support marriage as soon as a girl reaches puberty and beliefs related to premarital sex. RESULTS: Our study found a greater proportion of men described early marriage as protective from the fear of socially induced ruined marital prospects for women (70% vs. 64%), while women expressed its protection from being harassed (62% compared to 42%). The injunctive norm outcome that "my neighbors think that one should marry off one's daughter as soon as she reaches puberty" was significantly associated with the belief that child marriage was protective for females among women (OR = 4.49; 95% CI 3.13. 5.50) and men (OR = 8.21; 95% CI 5.88, 11.45). CONCLUSIONS: Programs addressing child marriage should consider both male and female perspectives to address differences and foster an environment where communities and families shift norms to delay early marriage.

Provider imposed restrictions to clients' access to family planning in urban Uttar Pradesh, India: a mixed methods study.

BACKGROUND: Medical barriers refer to unnecessary policies or procedures imposed by health care providers that are not necessarily medically advised; these restrictions impede clients' access to family planning (FP). This mixed methods study investigates provider imposed barriers to provision of FP using recent quantitative and qualitative data from urban Uttar Pradesh, India. METHODS: Baseline quantitative data were collected in six cities in Uttar Pradesh, India from service delivery points (SDP), using facility audits, exit interviews, and provider surveys; for this study, the focus is on the provider surveys. More than 250 providers were surveyed in each city. Providers were asked about the FP methods they provide, and if they restrict clients' access to each method based on age, parity, partner consent, or marital status. For the qualitative research, we conducted one-on-one interviews with 21 service providers in four of the six cities in Uttar Pradesh. Each interview lasted approximately 45 minutes. RESULTS: The quantitative findings show that providers restrict clients' access to spacing and long-acting and permanent methods of FP based on age, parity, partner consent and marital status. Qualitative findings reinforce that providers, at times, make judgments about their clients' education, FP needs and ability to understand FP options thereby imposing unnecessary barriers to FP methods. CONCLUSIONS: Provider restrictions on FP methods are common in these urban Uttar Pradesh sites. This means that women who are young, unmarried, have few or no children, do not have the support of their partner, or are less educated may not be able to access or use FP or their preferred method. These findings highlight the need for in-service training for staff, with a focus on reviewing current guidelines and eligibility criteria for provision of methods.

Lessons From a Behavior Change Intervention to Improve Provider-Parent Partnerships and Care for Hospitalized Newborns and Young Children in Kenya.

Enhancing respectful, responsive, integrative, and nurturing care for hospitalized newborns and young children (aged 0-24 months) is globally recognized but under-researched in low- and middle-income countries. Responsive, family-centered interventions target providers and parents and emphasize partnership in caring roles. From February 2020 to August 2021, we engaged in a participatory co-creation process with parents, providers, and newborn and child health stakeholders in Kenya to develop a comprehensive provider behavior change intervention and implemented it across 5 hospitals in Nairobi and Bungoma counties in Kenya. The multifaceted intervention included a 7-module orientation, feedback meetings, job aids, and psychosocial support-leveraging in-person and remote modalities-for providers working in newborn and pediatric units. We used a mixed-methods evaluation drawing on a pre-post provider survey, pre-post qualitative interviews with providers and parents, and a follow-up parental survey. There were significant post-intervention improvements in provider knowledge on safeguarding sleep, positioning and handling, and protecting skin. However, there were also significant reductions in providers' knowledge in identifying a child's pain, parental stress, and environmental stress. Among parents who received coaching from providers, there were higher levels of interpersonal communication between parent and provider, parental empowerment, and improved ability to provide integrated, responsive care to their child. Despite the challenges of implementing a provider-focused intervention to improve care for hospitalized newborns and young children during the global COVID-19 pandemic, we have demonstrated that it is feasible to implement a hybrid virtual and in-person process to influence several outcomes, including provider knowledge and practice, improved provider partnerships with parents, and parents' capacity to engage in the care of their newborn or young child.

Applying a Power and Gender Lens to Understanding Health Care Provider Experience and Behavior: A Multicountry Qualitative Study.

A limited but growing body of literature shows that health care providers (HCPs) in reproductive, maternal, and newborn health face challenges that affect how they provide services. Our study investigates provider perspectives and behaviors using 4 interrelated power domains-beliefs and perceptions; practices and participation; access to assets; and structures-to explore how these constructs are differentially experienced based on one's gender, position, and function within the health system. We conducted a framework-based secondary analysis of qualitative in-depth interview data gathered with different cadres of HCPs across Kenya, Malawi, Madagascar, and Togo (n=123). We find across countries that power dynamics manifest in and are affected by all 4 domains, with some variation by HCP cadre and gender. At the service interface, HCPs' power derives from the nature and quality of their relationships with clients and the community. Providers' power within working relationships stems from unequal decision-making autonomy among HCP cadres. Limited and sometimes gendered access to remuneration, development opportunities, material resources, supervision quality, and emotional support affect HCPs' power to care for clients effectively. Power manifests variably among community and facility-based providers because of differences in prevailing hierarchical norms in routine and acute settings, community linkages, and type of collaboration required in their work. Our findings suggest that applying power-and secondarily, gender lenses-can elucidate consistencies in how providers perceive, internalize, and react to a range of relational and environmental stressors. The findings also have implications on how to improve the design of social behavior change interventions aimed at better supporting HCPs.

"You can't even ask a question about your child": Examining experiences of parents or caregivers during hospitalization of their sick young children in Kenya: A qualitative study.

Background: Globally, about 5.2 million children under the age of five died in 2019, and more than half of those deaths occurred in Sub-Saharan Africa. In almost every death of a sick child, there is a parent/caregiver seeking health services for their child. This study sought to understand the experiences of care for parents/caregivers (caregivers) as they navigate the hospital system with the aim of identifying opportunities to improve service delivery and child health outcomes. Methods: Qualitative data were collected from five hospitals in Kenya: three in Nairobi County and two in Bungoma County. Twenty-five in-depth interviews with caregivers (couples and single women) of young children 0-24 months old, 17 focus group discussions with women and men, and 64 institutional ethnographic observations were completed. Data were analyzed by initial annotation of transcripts and field materials, followed by open coding and thematic analysis using Nvivo 12 software. Summary themes were used to compare experiences between female and male caregivers, their child's age group, and study sites. Results: Caregivers faced complex processes of care while seeking health services for their sick young children. Three overarching themes emerged with some variability across female and male caregiver perspectives: (1) Navigating structural issues: long wait times, confusing payment mechanisms, overcrowding, unhygienic conditions, and strict visitation policies; (2) Interactions with providers: positive experiences, including providers showing empathy and concern, and negative experiences of harsh language, neglect, lack of privacy, discounting caregiver perspectives, and not involving men; Limited communication between caregivers and providers on child's diagnosis, treatment, and progress and lack of communication specifically between male caregivers and providers; and (3) Limited emotional support for both caregivers during difficult diagnosis or bereavement. Conclusions: To improve experiences, interventions, programs, and policies need to focus on good provider-caregiver partnerships; enhancing opportunities for male engagement, such as supportive visiting hours; effective communication between caregivers and providers; access to adequate emotional support; and an enabling hospital environment.