Coverage of private sector community midwife services in rural Punjab, Pakistan: development and demand.

BACKGROUND: In 2007, the Government of Pakistan introduced a new cadre of community midwives (CMWs) to address low skilled birth attendance rates in rural areas; this workforce is located in the private-sector. There are concerns about the effectiveness of the programme for increasing skilled birth attendance as previous experience from private-sector programmes has been sub-optimal. Indonesia first promoted private sector midwifery care, but the initiative failed to provide universal coverage and reduce maternal mortality rates. METHODS: A clustered, stratified survey was conducted in the districts of Jhelum and Layyah, Punjab. A total of 1,457 women who gave birth in the 2 years prior to the survey were interviewed. χ(2) analyses were performed to assess variation in coverage of maternal health services between the two districts. Logistic regression models were developed to explore whether differentials in coverage between the two districts could be explained by differential levels of development and demand for skilled birth attendance. Mean cost of childbirth care by type of provider was also calculated. RESULTS: Overall, 7.9% of women surveyed reported a CMW-attended birth. Women in Jhelum were six times more likely to report a CMW-attended birth than women in Layyah. The mean cost of a CMW-attended birth compared favourably with a dai-attended birth. The CMWs were, however, having difficulty garnering community trust. The majority of women, when asked why they had not sought care from their neighbourhood CMW, cited a lack of trust in CMWs' competency and that they wanted a different provider. CONCLUSIONS: The CMWs have yet to emerge as a significant maternity care provider in rural Punjab. Levels of overall community development determined uptake and hence coverage of CMW care. The CMWs were able to insert themselves into the maternal health marketplace in Jhelum because of an existing demand. A lower demand in Layyah meant there was less 'space' for the CMWs to enter the market. To ensure universal coverage, there is a need to revisit the strategy of introducing a new midwifery workforce in the private sector in contexts of low demand and marketing the benefits of skilled birth attendance.

The relationship between spirituality, psychosocial adjustment to illness, and health-related quality of life in patients with advanced chronic kidney disease.

CONTEXT: Spirituality may promote psychosocial adjustment to illness, and this may be a mechanism by which patients with greater existential well-being (EWB) experience better health-related quality of life (HRQL) in the context of life-limiting illness. OBJECTIVES: This study explored the relationship between psychosocial adjustment to illness, EWB, and HRQL in patients with advanced chronic kidney disease and sought to determine whether adjustment to illness mediates the relationship between EWB and HRQL. METHODS: This was a cohort study of 253 prevalent Stage 4 or 5 chronic kidney disease and dialysis patients. Participants completed the Spiritual Well-Being Scale, the Psychological Adjustment to Illness Scale (PAIS)-Self-Report, and the Kidney Dialysis Quality of Life Short Form. RESULTS: Psychosocial adjustment to illness was highly correlated with HRQL, accounting for 29% and 27% of the variance in physical and mental HRQL scores, respectively. Although PAIS domains were associated with EWB, EWB remained a significant predictor of HRQL after all PAIS domains were considered. Adjustment in the domains of psychological distress and extended family relationships did appear to mediate some of the relationship between EWB and HRQL. CONCLUSION: Adjustment in the domains of psychological distress and extended family relationships appears to mediate some of the beneficial effect of EWB on HRQL. Spirituality, however, provides unique variance in patients' HRQL, independent of their psychosocial adjustment. This study testifies to the importance of targeting both psychosocial adjustment to illness and spirituality as ways to preserve or enhance HRQL of predialysis and dialysis patients.

Tuberculosis in the era of infection with the human immunodeficiency virus: assessment and comparison of community knowledge of both infections in rural Uganda.

BACKGROUND: In Uganda, despite a significant public health burden of tuberculosis (TB) in the context of high human immunodeficiency virus (HIV) prevalence, little is known about community knowledge of TB. The purpose of this study was to assess and compare knowledge about TB and HIV in the general population of western Uganda and to examine common knowledge gaps and misconceptions. METHODS: We implemented a multi-stage survey design to randomly survey 360 participants from one district in western Uganda. Weighted summary knowledge scores for TB and HIV were calculated and multiple linear regression (with knowledge score as the dependant variable) was used to determine significant predictors. Six focus group discussions were conducted to supplement survey findings. RESULTS: Mean (SD) HIV knowledge score was 58 (12) and TB knowledge score was 33 (15), both scores out of 100. The TB knowledge score was statistically significantly (p < 0.001) lower. Multivariate regression models included age, sex, marital status, education, residence, and having a friend with HIV/TB as independent variables. TB knowledge was predicted by rural residence (coefficient = -6.27, 95% CI: -11.7 to -0.8), and age ≥45 years (coefficient = 7.45, 95% CI: 0.3-14.6). HIV knowledge was only predicted by higher education (coefficient = 0.94, 95%CI: 0.3-1.6). Focus group participants mentioned various beliefs in the aetiology of TB including sharing cups, alcohol consumption, smoking, air pollution, and HIV. Some respondents believed that TB was not curable. CONCLUSION: TB knowledge is low and many misconceptions about TB exist: these should be targeted through health education programs. Both TB and HIV-infection knowledge gaps could be better addressed through an integrated health education program on both infections, whereby TB program managers include HIV information and vice versa.

Are community midwives addressing the inequities in access to skilled birth attendance in Punjab, Pakistan? Gender, class and social exclusion.

BACKGROUND: Pakistan is one of the six countries estimated to contribute to over half of all maternal deaths worldwide. To address its high maternal mortality rate, in particular the inequities in access to maternal health care services, the government of Pakistan created a new cadre of community-based midwives (CMW). A key expectation is that the CMWs will improve access to skilled antenatal and intra-partum care for the poor and disadvantaged women. A critical gap in our knowledge is whether this cadre of workers, operating in the private health care context, will meet the expectation to provide care to the poorest and most marginalized women. There is an inherent paradox between the notions of fee-for-service and increasing access to health care for the poorest who, by definition, are unable to pay. METHODS/DESIGN: Data will be collected in three interlinked modules. Module 1 will consist of a population-based survey in the catchment areas of the CMW's in districts Jhelum and Layyah in Punjab. Proportions of socially excluded women who are served by CMWs and their satisfaction levels with their maternity care provider will be assessed. Module 2 will explore, using an institutional ethnographic approach, the challenges (organizational, social, financial) that CMWs face in providing care to the poor and socially marginalized women. Module 3 will identify the social, financial, geographical and other barriers to uncover the hidden forces and power relations that shape the choices and opportunities of poor and marginalized women in accessing CMW services. An extensive knowledge dissemination plan will facilitate uptake of research findings to inform positive developments in maternal health policy, service design and care delivery in Pakistan. DISCUSSION: The findings of this study will enhance understanding of the power dynamics of gender and class that may underlie poor women's marginalization from health care systems, including community midwifery care. One key outcome will be an increased sensitization of the special needs of socially excluded women, an otherwise invisible group. Another expectation is that the poor, socially excluded women will be targeted for provision of maternity care. The research will support the achievement of the 5th Millennium Development Goal in Pakistan.

Existential and supportive care needs among patients with chronic kidney disease.

CONTEXT: Living with chronic kidney disease (CKD) is associated with spiritual distress and frequently precipitates a search for meaning and hope; yet, very little is known about these patients' spiritual needs. OBJECTIVES: To describe the nature, prevalence, and predictors of spiritual and supportive care needs in CKD. METHODS: Prospective cohort study of 253 CKD patients who completed a seven-item spiritual and seven-item supportive care needs assessment. RESULTS: Patients reported a mean (standard deviation [SD]) number of 2.9 (2.6) spiritual needs, with 69.1% of patients reporting at least one spiritual need. The mean (SD) number of supportive care needs was 3.5 (2.1), with 91.4% of patients reporting at least one of these needs. Thirty-two percent of the patients had high spiritual needs (defined as reporting ≥5 of the seven needs). Similarly, 37% of the patients reported high supportive care needs. Neither spiritual nor supportive care needs were associated with age, gender, race, marital status, dialysis modality, time on dialysis, or comorbidity. CONCLUSION: These patients had substantial spiritual and supportive care needs. There were no clear predictors of high spiritual or supportive care needs, highlighting the importance of evaluating all CKD patients for unmet needs. Health professionals will need to better understand and attend to CKD patients' spiritual needs to optimize quality care.

Existential and religious dimensions of spirituality and their relationship with health-related quality of life in chronic kidney disease.

BACKGROUND AND OBJECTIVES: Spiritual aspects of health-related quality of life (HRQoL) in patients with chronic kidney disease (CKD) have not been fully assessed. This study described the religious and existential dimensions of spirituality of patients with CKD, provided evidence to support construct validity of the ESRD Spiritual Beliefs Scale, and examined the relationship between constructs of spirituality and HRQoL. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a prospective, cohort study of 253 predominantly white (81.5%) prevalent patients with stage 4 or 5 CKD or receiving long-term dialysis. Participants completed the Kidney Dialysis Quality of Life Short Form, the ESRD Spiritual Beliefs Scale, the Spiritual Perspective Scale, and the Spiritual Well-Being Scale. RESULTS: Three subscales of ESRD Spiritual Beliefs Scale were highly correlated with other measures of religiosity and weakly correlated with existential well-being. Mean of three subscales of ESRD Spiritual Beliefs Scale and overall Spiritual Perspective Scale scores were 8.8 to 9.9 and 3.3, respectively. Mean ± SD existential and religious scores of the Spiritual Well-Being Scale were 42.9 ± 8.8 and 38.8 ± 11.4, respectively. Negligible correlations existed between religious scores and HRQoL. Conversely, existential well-being was moderately associated with several domains of HRQoL. CONCLUSIONS: Our study supports construct validity of the ESRD Spiritual Beliefs Scale as a measure of religiosity. It did not seem to capture the existential dimension of spirituality. The existential domain of spirituality was more clinically relevant to patients in this study and had a greater impact on HRQoL compared with measures of religiosity.

Use of traditional herbal medicine by AIDS patients in Kabarole District, western Uganda.

The objective of this cross-sectional study was to assess the use of traditional herbal medicine by AIDS patients in Kabarole District, western Uganda. Using systematic sampling, 137 AIDS patients were selected from outpatient departments of 3 hospitals and interviewed via questionnaire. The questions related to such areas as type and frequency of herbal medicine intake, concomitant herb-pharmaceutical drug use (including herb-antiretroviral drug cotherapy), and the perceived effectiveness of herbal medicine. Overall, 63.5% of AIDS patients had used herbal medicine after HIV diagnosis. Same-day herbal medicine and pharmaceutical drugs use was reported by 32.8% of AIDS patients. Patterns of traditional herbal medicine use were quite similar between those on antiretroviral therapy and those who received supportive therapy only. The primary conclusion is that AIDS outpatients commonly use herbal medicine for the treatment of HIV/AIDS. Pharmacological interactions between antiretroviral drugs and traditional herbal medicines need to be further examined.