Understanding individual, family and community perspectives on delaying early birth among adolescent girls: findings from a formative evaluation in rural Bangladesh.

BACKGROUND: Pregnancy among adolescent girls in Bangladesh is high, with 66% of women under the age of 18 reporting a first birth; this issue is particularly acute in the northern region of Bangladesh, an area that is especially impoverished and where girls are at heightened risk. Using formative research, CARE USA examined the underlying social, individual and structural factors influencing married girls' early first birth and participation in alternative opportunities (such as education or economic pursuits) in Bangladesh. METHODS: In July of 2017, researchers conducted in-depth interviews of community members in two sub-districts of northern Bangladesh (Kurigram Sadar and Rajarhat). Participants (n = 127) included adolescent girls (both married and unmarredi), husbands of adolescent girls, influential adults in the girls' lives, community leaders, and health providers. All interviews were transcribed, coded and organized using Dedoose software. RESULTS: Participants recognize the health benefits of delaying first birth, but stigma around infertility and contraceptive use, pressure from mothers-in-law and health provider bias interfere with a girl's ability to delay childbearing. Girls' social isolation, lack of mobility or autonomy, and inability to envision alternatives to early motherhood compound the issue; provider bias may also prevent access to methods. While participants agree that pursuit of education and economic opportunities are important, better futures for girls do not necessarily supersede their marital obligations of childrearing and domestic chores. CONCLUSIONS: Findings indicate the need for a multi-level approach to delaying early birth and stimulating girls' participation in economic and educational pursuits. Interventions must mitigate barriers to reproductive health care; train adolescent girls on viable economic activities; and provide educational opportunities for girls. Effective programs should also address contextual issues by including immediate members of the girls' families, particularly the husband and mother-in-law.

Prevalence of Coronavirus Disease 2019 Infection and Outcomes Among Symptomatic Healthcare Workers in Seattle, Washington.

BACKGROUND: Healthcare workers (HCWs) who serve on the front lines of the coronavirus disease 2019 (COVID-19) pandemic have been at increased risk for infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in some settings. Healthcare-acquired infection has been reported in similar epidemics, but there are limited data on the prevalence of COVID-19 among HCWs and their associated clinical outcomes in the United States. METHODS: We established 2 high-throughput employee testing centers in Seattle, Washington, with drive-through and walk-through options for symptomatic employees in the University of Washington Medicine system and its affiliated organizations. Using data from these testing centers, we report the prevalence of SARS-CoV-2 infection among symptomatic employees and describe the clinical characteristics and outcomes among employees with COVID-19. RESULTS: Between 12 March 2020 and 23 April 2020, 3477 symptomatic employees were tested for COVID-19 at 2 employee testing centers; 185 (5.3%) employees tested positive for COVID-19. The prevalence of SARS-CoV-2 was similar when comparing frontline HCWs (5.2%) with nonfrontline staff (5.5%). Among 174 positive employees reached for follow-up at least 14 days after diagnosis, 6 reported COVID-related hospitalization; all recovered. CONCLUSIONS: During the study period, we observed that the prevalence of positive SARS-CoV-2 tests among symptomatic HCWs was comparable to that of symptomatic nonfrontline staff. Reliable and rapid access to testing for employees is essential to preserve the health, safety, and availability of the healthcare workforce during this pandemic and to facilitate the rapid return of SARS-CoV-2-negative employees to work.

"It is a thing that depends on God": barriers to delaying first birth and pursuing alternative futures among newly married adolescent girls in Niger.

BACKGROUND: Pregnancy among adolescent girls in Niger contributes to 34% of all deaths among females ages 15-19, but there is a dearth of research as to the specific contextual causes. In Zinder region, an area that is especially impoverished and where girls are at heightened risk, there is very little information on the main obstacles to improving adolescents' health and well-being. This qualitative study examines the underlying social, individual and structural factors influencing married girls' early first birth and participation in alternative opportunities (such as education or economic pursuits) in Niger. METHODOLOGY: In July of 2017, researchers conducted in-depth interviews with a non-probability sample of community members in three communes of Zinder Region, Niger. Participants (n = 107) included adolescent girls, husbands of adolescent girls, influential adults, community leaders, health providers, and positive deviants. All interviews were transcribed, coded and analyzed using Dedoose software. RESULTS: Participants recognize the health benefits of delaying first birth, but stigma around infertility and contraceptive use, desire for children, and belief that childbirth is "God's will" interfere with a girl's ability to delay. Girls' social isolation, lack of mobility or autonomy, and inability to envision alternatives to early motherhood compound the issue. Participants favor adolescents' pursuit of increased economic opportunities or education, but would not support delaying birth to do so. CONCLUSIONS: Findings indicate the need for a holistic approach to delaying early birth and stimulating girls' participation in economic and educational pursuits. Potential interventions include mitigating barriers to reproductive health care; training adolescent girls on viable economic activities; and providing educational opportunities for girls. Effective programs should also include or target immediate members of the girls' families (husbands, parents, in-laws), influential local leaders and members of the community at large.

'We pledge to improve the health of our entire community': Improving health worker motivation and performance in Bihar, India through teamwork, recognition, and non-financial incentives.

BACKGROUND: Motivation is critical to health worker performance and work quality. In Bihar, India, frontline health workers provide essential health services for the state's poorest citizens. Yet, there is a shortfall of motivated and skilled providers and a lack of coordination between two cadres of frontline health workers and their supervisors. CARE India developed an approach aimed at improving health workers' performance by shifting work culture and strengthening teamwork and motivation. The intervention-"Team-Based Goals and Incentives"-supported health workers to work as teams towards collective goals and rewarded success with public recognition and non-financial incentives. METHODS: Thirty months after initiating the intervention, 885 health workers and 98 supervisors completed an interviewer-administered questionnaire in 38 intervention and 38 control health sub-centers in one district. The questionnaire included measures of social cohesion, teamwork attitudes, self-efficacy, job satisfaction, teamwork behaviors, equitable service delivery, taking initiative, and supervisory support. We conducted bivariate analyses to examine the impact of the intervention on these psychosocial and behavioral outcomes. RESULTS: Results show statistically significant differences across several measures between intervention and control frontline health workers, including improved teamwork (mean = 8.8 vs. 7.3), empowerment (8.5 vs. 7.4), job satisfaction (7.1 vs. 5.99) and equitable service delivery (6.7 vs. 4.99). While fewer significant differences were found for supervisors, they reported improved teamwork (8.4 vs. 5.3), and frontline health workers reported improved fulfillment of supervisory duties by their supervisors (8.9 vs. 7.6). Both frontline health workers and supervisors found public recognition and enhanced teamwork more motivating than the non-financial incentives. CONCLUSIONS: The Team-Based Goals and Incentives model reinforces intrinsic motivation and supports improvements in the teamwork, motivation, and performance of health workers. It offers an approach to practitioners and governments for improving the work environment in a resource-constrained setting and where there are multiple cadres of health workers.