How beneficiaries see complex health interventions: a practice review of the Most Significant Change in ten countries.

BACKGROUND: The Most Significant Change is a story-based evaluation approach used in many international development programs. This practice review summarises practical experience with the approach in complex health interventions in ten countries, with the objective of making it more accessible in evaluation of other complex health interventions. RESULTS: Participatory research practitioners and trainees discussed five themes following brief presentations by each of the seven attendees who led the exercise: (i) sampling and recruitment; (ii) phrasing the questions to elicit stories; (iii) story collection strategies; (iv) quality assurance; and (v) analysis. Notes taken during the meeting provided the framework for this article. Recruitment strategies in small studies included universal engagement and, in larger studies, a purposive, systematic or random sampling. Meeting attendees recommended careful phrasing and piloting of the question(s) as this affects the quality and focus of the stories generated. They stressed the importance of careful training and monitoring of fieldworkers collecting stories to ensure full stories are elicited and recorded. For recording, in most settings they preferred note taking with back-checking or self-writing of stories by story tellers, rather than audio-recording. Analysis can combine participatory selection of a small number of stories, deductive or inductive thematic analysis and discourse analysis. Meeting attendees noted that involvement in collection of the stories and their analysis and discussion had a positive impact for research team members. CONCLUSIONS: Our review confirms the plasticity, feasibility and acceptability of the Most Significant Change technique across different sociopolitical, cultural and environmental contexts of complex interventions. Although the approach can surface unexpected impacts, it is not a 360-degree evaluation. Its strength lies in characterising the changes, where these happen, in the words of the beneficiaries. We hope this distillation of our practice makes the technique more readily available to health sector researchers.

Bridging Western and Indigenous knowledge through intercultural dialogue: lessons from participatory research in Mexico.

Indigenous communities in Latin America and elsewhere have complex bodies of knowledge, but Western health services generally approach them as vulnerable people in need of external solutions. Intercultural dialogue recognises the validity and value of Indigenous standpoints, and participatory research promotes reciprocal respect for stakeholder input in knowledge creation.As part of their decades-long community-based work in Mexico's Guerrero State, researchers at the Centro de Investigación de Enfermedades Tropicales responded to the request from Indigenous communities to help them address poor maternal health. We present the experience from this participatory research in which both parties contributed to finding solutions for a shared concern. The aim was to open an intercultural dialogue by respecting Indigenous skills and customs, recognising the needs of health service stakeholders for scientific evidence.Three steps summarise the opening of intercultural dialogue. Trust building and partnership based on mutual respect and principles of cultural safety. This focused on understanding traditional midwifery and the cultural conflicts in healthcare for Indigenous women. A pilot randomised controlled trial was an opportunity to listen and to adjust the lexicon identifying and testing culturally coherent responses for maternal health led by traditional midwives. Codesign, evaluation and discussion happened during a full cluster randomised trial to identify benefits of supporting traditional midwifery on maternal outcomes. A narrative mid-term evaluation and cognitive mapping of traditional knowledge offered additional evidence to discuss with other stakeholders the benefits of intercultural dialogue. These steps are not mechanistic or invariable. Other contexts might require additional steps. In Guerrero, intercultural dialogue included recovering traditional midwifery and producing high-level epidemiological evidence of the value of traditional midwives, allowing service providers to draw on the strengths of different cultures.

Game-Based Learning Interventions to Foster Cross-Cultural Care Training: A Scoping Review.

Objective: Differences in cultural background between health providers and patients can reduce effective access to health services in multicultural settings. Health sciences educators have recently suggested that game-based learning may be effective for cross-cultural care training. This scoping review maps published knowledge on educational games intended to foster cross-cultural care training and highlights the research gaps for future research. Materials and Methods: A scoping review searched PubMed, Eric, Embase, Lilacs, PsycINFO, and Google Scholar for theoretical and empirical research, using terms relevant to cross-cultural care and game-based learning. A participatory research framework engaged senior medical students and participatory research experts in conducting and evaluating the review. Results: Forty-one documents met the inclusion criteria, all from developed countries. The most common source of publication was nursing and medicine (39%; 16/41) and used the cultural competence approach (44%; 18/41). Around one-half of the publications (51%; 21/41) were theoretical and 39% (16/41) were empirical. Empirical studies most commonly used mixed methods (44%; 7/16), followed by strictly quantitative (31%; 5/16) or qualitative (25%; 4/16) approaches. There were no randomized controlled trials and only one study engaged end-users in the design. Empirical studies most frequently assessed role-play-related games (44%; 7/16) and used game evaluation-related outcomes or learning-related outcomes. None used patient-oriented outcomes. Findings suggest that educational games are an effective and engaging educational intervention for cross-cultural care training. Conclusions: The paucity of studies on educational games and cross-cultural care training precludes a systematic review. Future empirical studies should focus on randomized counterfactual designs and patient-related outcomes. We encourage involving end-users in developing content for educational games.

Women's circles as a culturally safe psychosocial intervention in Guatemalan indigenous communities: a community-led pilot randomised trial.

BACKGROUND: Indigenous Maya women in Guatemala show some of the worst maternal health indicators worldwide. Our objective was to test acceptability, feasibility and impact of a co-designed group psychosocial intervention (Women's Circles) in a population with significant need but no access to mental health services. METHODS: A parallel group pilot randomised study was undertaken in five rural Mam and three periurban K'iche' communities. Participants included 84 women (12 per community, in seven of the communities) randomly allocated to intervention and 71 to control groups; all were pregnant and/or within 2 years postpartum. The intervention consisted of 10 sessions co-designed with and facilitated by 16 circle leaders. Main outcome measures were: maternal psychosocial distress (HSCL-25), wellbeing (MHC-SF), self-efficacy and engagement in early infant stimulation activities. In-depth interviews also assessed acceptability and feasibility. RESULTS: The intervention proved feasible and well accepted by circle leaders and participating women. 1-month post-intervention, wellbeing scores (p-value 0.008) and self-care self-efficacy (0.049) scores were higher among intervention compared to control women. Those women who attended more sessions had higher wellbeing (0.007), self-care and infant-care self-efficacy (0.014 and 0.043, respectively), and early infant stimulation (0.019) scores. CONCLUSIONS: The pilot demonstrated acceptability, feasibility and potential efficacy to justify a future definitive randomised controlled trial. Co-designed women's groups provide a safe space where indigenous women can collectively improve their functioning and wellbeing. TRIAL REGISTRATION: ISRCTN13964819 . Registered 26 June 2018, retrospectively registered.

Quantitative Methodologies Reveal a Diversity of Nutrition, Infection/Illness, and Psychosocial Stressors During Pregnancy and Lactation in Rural Mam-Mayan Mother-Infant Dyads From the Western Highlands of Guatemala.

BACKGROUND: The nature and severity of 3 categories of maternal stressors (nutritional, infectious, and psychosocial) that may impact maternal health and early infant growth are not often considered together. OBJECTIVES: To describe quantitative methodologies; assess construct validity of questionnaires; report variability in sociodemographic, obstetric, nutritional, infectious, and psychosocial characteristics; and compare characteristics between pregnancy and lactation and between study cohorts of Mam-Mayan mother-infant dyads. METHODS: Grounded in participatory action research and a socioecological framework, this observational study enrolled a longitudinal cohort of 155 women, followed during pregnancy (6-9 months), early (0-6 weeks), and later (4-6 months) postpartum, and 2 cross-sectional cohorts (60 early and 56 later postpartum). Household and social factors; obstetric history; nutritional, infectious, and psychosocial stressors; and infant characteristics were explored. RESULTS: Diet diversity (3.4 ± 1.3) and adult food security (38%) were low. Urinary and gastrointestinal infections were rare (<5%), whereas experience of local idioms of distress was frequent (20%-50%). Participants reported low maternal autonomy (81%), high paternal support (70%), small social support networks (2.7 ± 1.3 individuals), and high trust in family (88%) and community-based institutions (61%-65%) but low trust in government services (6%). Domestic violence was commonly reported (22%). Infant stunting was common (36% early postpartum and 43% later postpartum) despite frequent antenatal care visits (7.5 ± 3.8). Participant engagement with the research team did not influence study outcomes based on comparisons between longitudinal and cross-sectional cohorts. CONCLUSIONS: The variability in sociodemographic, nutritional, and psychosocial variables, will allow exploration of factors that promote resilience or increase vulnerability of the mother-infant dyad.

Stunting at birth: recognition of early-life linear growth failure in the western highlands of Guatemala.

OBJECTIVE: Measurements of length at birth, or in the neonatal period, are challenging to obtain and often discounted for lack of validity. Hence, classical 'under-5' stunting rates have been derived from surveys on children from 6 to 59 months of age. Guatemala has a high prevalence of stunting (49.8%), but the age of onset of growth failure is not clearly defined. The objective of the study was to assess length-for-age within the first 1.5 months of life among Guatemalan infants. DESIGN: As part of a cross-sectional observational study, supine length was measured in young infants. Mothers' height was measured. Length-for-age Z-scores (HAZ) were generated and stunting was defined as HAZ <-2 using WHO growth standards. SETTING: Eight rural, indigenous Mam-Mayan villages (n 200, 100% of Mayan indigenous origin) and an urban clinic of Quetzaltenango (n 106, 27% of Mayan indigenous origin), Guatemala. SUBJECTS: Three hundred and six newborns with a median age of 19 d. RESULTS: The median rural HAZ was -1.56 and prevalence of stunting was 38%; the respective urban values were -1.41 and 25%. Linear regression revealed no relationship between infant age and HAZ (r = 0.101, r(2) = 0.010, P = 0.077). Maternal height explained 3% of the variability in HAZ (r = 0.171, r(2) = 0.029, P = 0.003). CONCLUSIONS: Stunting must be carried over from in utero growth retardation in short-stature Guatemalan mothers. As linear growth failure in this setting begins in utero, its prevention must be linked to maternal care strategies during gestation, or even before. A focus on maternal nutrition and health in an intergenerational dimension is needed to reduce its prevalence.

Cultural determinants of optimal breastfeeding practices among indigenous Mam-Mayan women in the Western Highlands of Guatemala.

BACKGROUND: Among indigenous Mam-Mayan women, breastfeeding practices may be intertwined with cultural influences during the early postpartum period. OBJECTIVES: Our study explored whether beliefs regarding transmission of emotions through breast milk, the feeding of agüitas or temascal (traditional sauna) use were associated with achievement of the World Health Organization infant feeding recommendations and if these cultural practices served as moderators of the relationship between optimal breastfeeding practices and infant anthropometry. METHODS: We recruited 190 mother-infant dyads at infant age < 46 days. Data on breastfeeding and cultural practices were collected via questionnaire. Infant length, weight, and head circumference were measured and z scores were calculated. Multiple linear and logistic regression analyses were used to examine determinants of initiation of breastfeeding within 1 hour, breastfeeding frequency, breastfeeding exclusivity, and infant weight-for-age z score (WAZ). RESULTS: Mothers who delivered at the traditional midwife's house (odds ratio [OR] = 2.5) and those who did not believe in the transmission of susto (fright) through breast milk (OR = 2.4) were more likely to initiate breastfeeding within 1 hour postpartum. Higher breastfeeding frequency was observed among mothers who spent more time in the temascal. Initiating early breastfeeding within 1 hour postpartum was the sole infant feeding practice positively associated with exclusive breastfeeding and WAZ. CONCLUSIONS: Our investigation in the Western Highlands of Guatemala has highlighted the link between cultural practices and beliefs during lactation, breastfeeding practices and infant growth. Public health practitioners need to understand how local cultural practices influence early initiation of breastfeeding to promote adequate infant weight.

Maternal health and health-seeking behaviors among indigenous Mam mothers from Quetzaltenango, Guatemala.

OBJECTIVE: To obtain background information about maternal health and health-seeking behaviors among indigenous mothers living in rural Mam-Mayan communities of Quetzaltenango, Guatemala. METHODS: A cross-sectional analysis of 100 pregnant and breastfeeding women in four communities was performed to determine prevalence and determinants of service utilization. RESULTS: Extreme poverty, poor education, and poor access to basic resources were prevalent. Out of 100 women 14-41 years old, 33% did not use the formal health care sector for antenatal care; the majority consulted a traditional birth attendant. Only 13% delivered in a hospital. Lower socioeconomic status, lack of fluency in Spanish, and no ownership of a motorized vehicle were associated with the highest likelihood of poor utilization of services. CONCLUSIONS: A variety of factors affect utilization of maternal health services by indigenous women in rural Quetzaltenango. These include socioeconomic disparities, ethnic and linguistic differences, and poor access to basic resources. The current reproductive needs of women should be addressed to improve their health and increase their chance of having healthy children.

Maternal health and health-seeking behaviors among indigenous Mam mothers from Quetzaltenango, Guatemala / Salud materna y comportamientos relacionados con la búsqueda de asistencia sanitaria en madres indígenas mames del departamento de Quetzaltenango, Guatemala

OBJECTIVE: To obtain background information about maternal health and health-seeking behaviors among indigenous mothers living in rural Mam-Mayan communities of Quetzaltenango, Guatemala. METHODS: A cross-sectional analysis of 100 pregnant and breastfeeding women in four communities was performed to determine prevalence and determinants of service utilization. RESULTS: Extreme poverty, poor education, and poor access to basic resources were prevalent. Out of 100 women 14-41 years old, 33% did not use the formal health care sector for antenatal care; the majority consulted a traditional birth attendant. Only 13% delivered in a hospital. Lower socioeconomic status, lack of fluency in Spanish, and no ownership of a motorized vehicle were associated with the highest likelihood of poor utilization of services. CONCLUSIONS: A variety of factors affect utilization of maternal health services by indigenous women in rural Quetzaltenango. These include socioeconomic disparities, ethnic and linguistic differences, and poor access to basic resources. The current reproductive needs of women should be addressed to improve their health and increase their chance of having healthy children.

OBJETIVO: Obtener información básica acerca de la salud materna y los comportamientos relacionados con la búsqueda de asistencia sanitaria en madres indígenas residentes en comunidades rurales de la etnia maya mam en Quetzaltenango, Guatemala. MÉTODOS: Se llevó a cabo un análisis transversal de 100 mujeres pertenecientes a cuatro comunidades, embarazadas o en período de lactancia, con objeto de determinar la prevalencia y los determinantes de la utilización de servicios. RESULTADOS: La pobreza extrema, la escasa formación y el acceso limitado a los recursos básicos fueron prevalentes. De las 100 mujeres, de 14 a 41 años de edad, 33% no acudieron al sector formal de atención de salud en busca de asistencia prenatal; la mayor parte de ellas consultaron a una partera tradicional. Solo 12% dieron a luz en un hospital. El nivel socioeconómico inferior, la falta de fluidez en español y la carencia de un vehículo motorizado se asociaron con la mayor probabilidad de escasa utilización de los servicios. CONCLUSIONES: Diversos factores afectan a la utilización de los servicios de salud materna por parte de las mujeres indígenas del Quetzaltenango rural. Entre estos factores figuran las desigualdades socioeconómicas, las diferencias lingüísticas y étnicas, y el acceso limitado a los recursos básicos. Es preciso atender a las necesidades reproductivas actuales de las mujeres para mejorar su salud y aumentar sus probabilidades de tener hijos sanos.

Improving average health and persisting health inequities--towards a justice and fairness platform for health policy making in Asia.

BACKGROUND: Following a period of rapid economic and social change across Asia in the 1980s and 1990s, there have been persisting reports of public sector health systems decline and worsening health inequities within countries. Many studies and analyses in the region have indicated that these inequities are socially determined, leading to questions regarding the adequacy of current health policy approaches towards addressing the challenge of persisting health inequities. METHODS: Utilizing published data from Demographic Health Surveys (DHS) and case studies and reviews on health inequity in the Asian region, this article aims to describe the existing patterns of inequity of health access both within and between countries, focusing on immunization, maternal health access, nutritional outcomes and child mortality, with a view to recommending health policy options for addressing these health inequities. We compare the gap in access and outcomes between the highest and the lowest wealth quintiles, as well as cross-reference these findings with case studies and surveys on health inequities in the region. RESULTS: In Asia, while in terms of aggregate health more of the poor are being reached, the reduction in the gap between social groups in some cases is stagnating, particularly for maternal health access and childhood stunting. Inequity gaps for immunization are persisting, and remain very wide in large population countries. For child mortality, more of the poor are surviving, although the rate of mortality decline is more rapid in higher than lower socio-economic groupings. CONCLUSIONS: Both a strategic shift towards public health critique of social and political policy and operational shifts in health management and practice will be required to attain improvements in distributive health in Asia.

Determinants of utilisation of intrapartum obstetric care services in Cambodia, and gaps in coverage.

BACKGROUND: Facility delivery and skilled birth attendance are two of the most effective strategies for decreasing maternal mortality. The objectives of this study were to further define utilisation of these services in Cambodia and to uncover socio-economic or location-specific coverage gaps that may exist. METHODS: We performed a cross-sectional analysis of the 2005 Cambodia Demographic Health Survey (CDHS) to determine prevalence, and determinants, of service utilisation. RESULTS: Out of 6069 women aged 15-49 years, 77% delivered at home, three-fourths without a skilled birth attendant. Poverty, lower education and rural residence were associated with the highest likelihood of poor utilisation of services. Discussion. While there has been an overall increase in facility deliveries and skilled birth attendance since 2000, improvements have been spread unevenly across the population, benefiting mostly urban, wealthier and better educated women. While recent financing initiatives and health system developments appear to have further increased service utilisation since 2005, the extent of their reach to the most vulnerable populations, and their ultimate impact on maternal mortality reduction, remain to be elucidated. CONCLUSION: Further expanding successful initiatives, particularly among vulnerable populations, is essential. Longitudinal evaluation of ongoing strategies and their impact remains critical.

Knowledge, beliefs, and health care practices relating to treatment of HIV in Vellore, India.

In India, little is known about health care-seeking behavior among HIV-infected individuals. Similarly, little is known about how HIV is being treated in the community, in particular by Indian Systems of Medicine (ISM) providers. Therefore, while ART implementation programs continue to expand, it is important to determine whether the knowledge, attitudes, and treatment practices of HIV-infected individuals and their health care providers are aligned with current treatment recommendations. We conducted in-depth qualitative interviews with persons with HIV (n = 9 men and 17 women), family members of persons with HIV (n = 14 men and 3 women), and ISM providers (n = 7). Many of the patients we studied turned at some point to ISM providers because they believed that such practitioners offer a cure for HIV. ISM treatments sometimes had negative impacts including side effects, unchecked progression of an underlying illness, and financial depletion. Indian women tended to be less knowledgeable about HIV and HIV treatments, and had less access to financial and other resources, than men. Finally, most of the ISM providers reported dangerous misconceptions about HIV transmission, diagnosis, and treatment. While the existence of ART in India is potentially of great benefit to those with HIV infection, this study shows that a variety of social, cultural and governmental barriers may interfere with the effective use of these therapies. Partnerships between the allopathic and traditional/complementary health sectors in research, policy, and practice are essential in building comprehensive HIV/AIDS treatment strategies.

Pharmacodynamics and pharmacokinetics of antibacterial drugs in the management of febrile neutropenia.

We review experimental and clinical data on the pharmacokinetics and pharmacodynamics of antibacterial drugs in febrile neutropenic hosts. Since major pharmacokinetic changes have been reported for various classes of antibiotics in these patients, we advocate the need for adequate initial dosing regimens in all cases. Monitoring drug serum concentrations is mandatory for aminoglycosides and glycopeptides, and special attention should be paid to the dosing frequency of the short half-life beta-lactams to optimise the management of febrile neutropenia, especially in patients with severe sepsis.