National COVID-19 preparedness and response plans: a global review from the perspective of services for maternal, newborn, child and adolescent health and older people.

INTRODUCTION: Infectious disease outbreaks have historically led to widespread disruptions in routine essential health services. Disruptions due to COVID-19 responses led to excess deaths, including among women and children. This review builds on earlier reviews of essential health services in national COVID-19 response and preparedness plans, focusing specifically on maternal, newborn, child, adolescent and ageing health (MNCAAH) in the context of renewed global emphasis on monitoring, recovering and strengthening these services. METHODS: Using Google searches, we identified publicly available COVID-19 response and preparedness plans authored by a national government body or Public Health Institute from any country, territory and/or area, published between January 2020 and December 2022. We assessed whether each plan considered maintenance of MNCAAH services with related activities, costing or monitoring plans, and whether these considerations were integrated into the national incident management system for COVID-19. RESULTS: We identified plans from 110 countries, representing 56% of our sample, in 10 languages. Most plans came from low-income and middle-income countries. Three quarters of dated documents were published between February and April 2020. 22% of plans referenced the impact of COVID-19 on MNCAAH, but only 13% included a planned activity for monitoring or mitigating this impact and less than 5% included relevant indicators, costing or integration of services in the incident management system. CONCLUSION: We propose that unless content specifically related to the services and needs of these populations is integrated, these services will suffer in a future disruptive event. The COVID-19 response demonstrated the need for an interdisciplinary response to address the unforeseen impacts that arose, yet plans continue to have a narrow focus and a generic approach which may be limiting.

Primary healthcare system and provider responses to the Taliban takeover in Afghanistan.

INTRODUCTION: Existing health system challenges in Afghanistan were amplified by the Taliban's August 2021 government takeover during which the country faced an evolving security situation, border closures, banking interruptions, donor funding disruptions and international staff evacuations. We investigated factors that influenced health sector and health service delivery following the takeover. METHODS: We purposively sampled individuals knowledgeable about Afghanistan's health sector and health professionals working in underserved areas of the country. We identified codes and themes of the data using framework analysis. RESULTS: Factors identified as supporting continued health service delivery following August 2021 include external funding and operational flexibilities, ongoing care provision by local implementers and providers, health worker motivation, flexible contracting out arrangements and improved security. Factors identified as contributing to disruptions include damaged infrastructure, limited supplies, ineffective government implementation efforts and changes in government leadership and policies resulting in new coordination and capacity challenges. There were mixed views on the role pay-for-performance schemes played. Participants also shared concerns about the new working environment. These included loss of qualified health professionals and the associated impact on quality of care, continued dependency on external funding, women's inability to finish their studies or take on any leadership positions, various impacts of the Mahram policy, mental stress, the future of care provision for female patients and widespread economic hardship which impacts nearly every aspect of Afghan life. CONCLUSION: Afghanistan's health sector presents a compelling case of adaptability in the face of crisis. Despite the anticipated and reported total collapse due to the country's power shift, various factors enabled health services to continue in some settings while others acted as barriers. The potential role of these factors should be considered in the context of future service delivery in Afghanistan and other settings at risk of political and societal disruption.

Analysis of the impact of COVID-19 pandemic and response on routine childhood vaccination coverage and equity in Northern Nigeria: a mixed methods study.

BACKGROUND: Based on 2021 data, Nigeria had the second largest number of zero-dose children globally estimated at over 2.25 million, concentrated in the northern part of the country due to factors some of which are sociocultural. This study analysed the impact of the COVID-19 pandemic and response on childhood vaccination in Northern Nigeria. METHODS: Using a mixed methods sequential study design in the most populous northern states of Kaduna and Kano, quantitative routine immunisation data for the period 2018-2021 and qualitative data collected through 16 focus group discussions and 40 key informant interviews were used. An adaptation of the socioecological model was used as a conceptual framework. Mean vaccination coverages and test of statistical difference in childhood vaccination data were computed. Qualitative data were coded and analysed thematically. RESULTS: Mean Penta 1 coverage declined in Kaduna from 69.88% (SD=21.02) in 2018 to 59.54% (SD=19.14%) by 2021, contrasting with Kano where mean Penta 1 coverage increased from 51.87% (SD=12.61) to 56.32% (SD=17.62%) over the same period. Outreaches and vaccination in urban areas declined for Kaduna state by 10% over the pandemic period in contrast to Kano state where it showed a marginal increase. The two states combined had an estimated 25% of the country's zero-dose burden in 2021. Lockdowns, lack of transport and no outreaches which varied across the states were some of the factors mentioned by participants to have negatively impacted childhood vaccination. Special vaccination outreaches were among the recommendations for ensuring continued vaccination through a future pandemic. CONCLUSION: While further interrogating the accuracy of denominator estimates for the urban population, incorporating findings into pandemic preparedness and response will ensure uninterrupted childhood vaccination during emergencies. Addressing the identified issues will be critical to achieving and sustaining universal childhood vaccination in Nigeria.

The political economy of financing traditional vaccines and vitamin A supplements in six African countries.

Vaccines and vitamin A supplementation (VAS) are financed by donors in several countries, indicating that challenges remain with achieving sustainable government financing of these critical health commodities. This qualitative study aimed to explore political economy variables of actors' interests, roles, power and commitment to ensure government financing of vaccines and VAS. A total of 77 interviews were conducted in Burundi, Comoros, Ethiopia, Madagascar, Malawi and Zimbabwe. Governments and development partners had similar interests. Donor commitment to vaccines and VAS was sometimes dependent on the priorities and political situation of the donor country. Governments' commitment to financing vaccines was demonstrated through policy measures, such as enactment of immunization laws. Explicit government financial commitment to VAS was absent in all six countries. Some development partners were able to influence governments directly via allocation of health funding while others influenced indirectly through coordination, consolidation and networks. Government power was exercised through multiple systemic and individual processes, including hierarchy, bureaucracy in governance and budgetary process, proactiveness of Ministry of Health officials in engaging with Ministry of Finance, and control over resources. Enablers that were likely to increase government commitment to financing vaccines and VAS included emerging reforms, attention to the voice of citizens and improvements in the domestic economy that in turn increased government revenues. Barriers identified were political instability, health sector inefficiencies, overly complicated bureaucracy, frequent changes of health sector leadership and non-health competing needs. Country governments were aware of their role in financing vaccines, but only a few had made tangible efforts to increase government financing. Discussions on government financing of VAS were absent. Development partners continue to influence government health commodity financing decisions. The political economy environment and contextual factors work together to facilitate or impede domestic financing.

Mapping of Pro-Equity Interventions Proposed by Immunisation Programs in Gavi Health Systems Strengthening Grants.

Reaching zero-dose (ZD) children, operationally defined as children who have not received a first dose of the diphtheria, tetanus, and pertussis (DTP1) vaccine, is crucial to increase equitable immunisation coverage and access to primary health care. However, little is known about the approaches already taken by countries to improve immunisation equity. We reviewed all Health System Strengthening (HSS) proposals submitted by Gavi-supported countries from 2014 to 2021 inclusively and extracted information on interventions favouring equity. Pro-equity interventions were mapped to an analytical framework representing Gavi 5.0 programmatic guidance on reaching ZD children and missed communities. Data from keyword searches and manual screening were extracted into an Excel database. Open format responses were analysed using inductive and deductive thematic coding. Data analysis was conducted using Excel and R. Of the 56 proposals included, 51 (91%) included at least one pro-equity intervention. The most common interventions were conducting outreach sessions, tailoring the location of service delivery, and partnerships. Many proposals had "bundles" of interventions, most often involving outreach, microplanning and community-level education activities. Nearly half prioritised remote-rural areas and only 30% addressed gender-related barriers to immunisation. The findings can help identify specific interventions on which to focus future evidence syntheses, case studies and implementation research and inform discussions on what may or may not need to change to better reach ZD children and missed communities moving forward.

Advancing Immunization Coverage and Equity: A Structured Synthesis of Pro-Equity Strategies in 61 Gavi-Supported Countries.

BACKGROUND: Global immunization inequities persist, reflected in the 25 million underimmunized and 18 million zero-dose children in 2021. To identify country approaches to reach underimmunized and zero-dose children, we undertook a structured synthesis of pro-equity strategies across 61 countries receiving programmatic support from Gavi, the Vaccine Alliance. METHODS: We extracted data from 174 Country Joint Appraisals and Multi-Stakeholder Dialogue reports (2016-2020). We identified strategies via a targeted keyword search, informed by a determinants of immunization coverage framework. Strategies were synthesized into themes consolidated from UNICEF's Journey to Health and Immunization (JTHI) and the Global Routine Immunization Strategies and Practices (GRISP) frameworks. RESULTS: We found 607 unique strategies across 61 countries and 24 themes. Strategies to improve care at the point of service (44%); to improve knowledge, awareness and beliefs (25%); and to address preparation, cost and effort barriers (13%) were common. Fewer strategies targeted experience of care (8%), intent, (7%) and after-service (3%). We also identified strategies addressing gender-related barriers to immunization and targeting specific types of communities. CONCLUSIONS: We summarize the range of pro-equity immunization strategies employed in Gavi-supported countries and interpret them thematically. Findings are incorporated into a searchable database which can be used to inform equity-driven immunization programs, policies and decision-making which target underimmunized and zero-dose communities.

Closing the know-do gap for child health: UNICEF's experiences from embedding implementation research in child health and nutrition programming.

UNICEF operates in 190 countries and territories, where it advocates for the protection of children's rights and helps meet children's basic needs to reach their full potential. Embedded implementation research (IR) is an approach to health systems strengthening in which (a) generation and use of research is led by decision-makers and implementers; (b) local context, priorities, and system complexity are taken into account; and (c) research is an integrated and systematic part of decision-making and implementation. By addressing research questions of direct relevance to programs, embedded IR increases the likelihood of evidence-informed policies and programs, with the ultimate goal of improving child health and nutrition.This paper presents UNICEF's embedded IR approach, describes its application to challenges and lessons learned, and considers implications for future work.From 2015, UNICEF has collaborated with global development partners (e.g. WHO, USAID), governments and research institutions to conduct embedded IR studies in over 25 high burden countries. These studies focused on a variety of programs, including immunization, prevention of mother-to-child transmission of HIV, birth registration, nutrition, and newborn and child health services in emergency settings. The studies also used a variety of methods, including quantitative, qualitative and mixed-methods.UNICEF has found that this systematically embedding research in programs to identify implementation barriers can address concerns of implementers in country programs and support action to improve implementation. In addition, it can be used to test innovations, in particular applicability of approaches for introduction and scaling of programs across different contexts (e.g., geographic, political, physical environment, social, economic, etc.). UNICEF aims to generate evidence as to what implementation strategies will lead to more effective programs and better outcomes for children, accounting for local context and complexity, and as prioritized by local service providers. The adaptation of implementation research theory and practice within a large, multi-sectoral program has shown positive results in UNICEF-supported programs for children and taking them to scale.

Cross-cutting lessons from the Decision-Maker Led Implementation Research initiative.

BACKGROUND: Almost 20 million children under one year of age did not receive basic vaccines in 2019, and most of these children lived in low- and middle-income countries. Implementation research has been recognized as an emerging area that is critical to strengthen the implementation of interventions proven to be effective. As a component of strengthening implementation, WHO has called for greater embedding of research within decision-making processes. One strategy to facilitate the embedding of research is to engage decision-makers as Principal Investigators of the research. Since 2015, the Alliance for Health Policy and Systems Research within the WHO and the United Nations Children's Fund have supported decision-maker led research by partnering with Gavi, the Vaccine Alliance, in an initiative called "Decision-Maker Led Implementation Research". This synthesis paper describes the cross-cutting lessons from the initiative to further understand and develop future use of the decision-maker led strategy. METHODS: This study used qualitative methods of data collection, including a document review and in-depth interviews with decision-makers and researchers engaged in the initiative. Document extraction and thematic content analysis were applied. The individual project was the unit of analysis and the results were summarized across projects. RESULTS: Research teams from 11 of the 14 projects participated in this study, for an overall response rate of 78.6%. Most projects were carried out in countries in Africa and conducted at the sub-state or sub-district level. Seven enablers and five barriers to the process of conducting the studies or bringing about changes were identified. Key enablers were the relevance, acceptability, and integration of the research, while key barriers included unclear results, limited planning and support, and the limited role of a single study in informing changes to strengthen implementation. CONCLUSIONS: Decision-maker led research is a promising strategy to facilitate the embedding of research into decision-making processes and contribute to greater use of research to strengthen implementation of proven-effective interventions, such as immunization. We identified several lessons for consideration in the future design and use of the decision-maker led strategy.

An embedded implementation research initiative to tackle service delivery bottlenecks in the expanded programme on immunisation in Pakistan: Overview and reflections.

BACKGROUND: Embedded implementation research (IR) can play a critical role in health systems strengthening by tackling systems and implementation bottlenecks of a program. To achieve this aim, with the financial support of GAVI, the Vaccine Alliance, in 2016, the Government of Pakistan, UNICEF and the Alliance for Health Policy and Systems Research (AHPSR) launched an Embedded IR for Immunisation Initiative (the Initiative) to explore health systems and implementation bottlenecks, and potential strategies to tackle such bottlenecks in the Expanded Programme on Immunisation (EPI) in Pakistan. In total, 10 research teams were involved in the Initiative, which was the first of its kind in the country. In this paper, we provided a brief overview of the Initiative's approach as well as the key learnings including challenges and successes of the research teams which could inform future embedded IR Initiatives. METHODS: Data were collected from members of the IR teams through an online survey. In addition, in-depth interviews were conducted via phone and in-person from IR team members to explore further the challenges they faced while conducting IR in Pakistan and recommendations for future IR initiatives. The qualitative information obtained from these sources was collated and categorized into themes reflecting some of the challenges, successes, and lessons learned, as well as teams' recommendations for future initiatives. RESULTS: The embedded IR Initiative in Pakistan followed several steps starting with a desk review to compile information on key implementation challenges of EPI and ended with a dissemination workshop where all the research teams shared their IR results with policymakers and implementers. Key factors that facilitated the successful and timely completion of the studies included appreciation by and leadership of implementers in generation and use of local knowledge, identification of research priorities jointly by EPI managers and researchers and provision of continuous and high-quality support from in-country research partners. Participants in the Initiative indicated that challenges included a lack of clarity on the role and responsibilities of each partner involved and need for further support to facilitate use and dissemination of research findings. CONCLUSIONS: The Initiative established that an immunisation programme in a lower middle-income country can use small and time-bound embedded IR, based on partnerships between programme managers and local researchers, to generate information and evidence that can inform decision-making. Future embedded IR initiatives should strive to ensure effective coordination and active participation of all key stakeholders, a clear research utilisation plan from the outset, and efforts to strengthen research teams' capacity to foster utilisation of research findings.

Pro-equity immunization and health systems strengthening strategies in select Gavi-supported countries.

BACKGROUND: Achieving universal immunization coverage and reaching every child with life-saving vaccines will require the implementation of pro-equity immunization strategies, especially in poorer countries. Gavi-supported countries continue to implement and report strategies that aim to address implementation challenges and improve equity. This paper summarizes the first mapping of these strategies from country reports. METHODS: Thirteen Gavi-supported countries were purposively selected with emphasis on Gavi's priority countries. Following a scoping of different documents submitted to Gavi by countries, 47 Gavi Joint Appraisals (JAs) for the period 2016-2019 from the 13 selected countries were included in the mapping. We used a consolidated framework synthesized from 16 different equity and health systems frameworks, which incorporated UNICEF's coverage and equity assessment approach - an adaptation of the Tanahashi model. Using search terms, the mapping was conducted using a combination of manual search and the MAXQDA qualitative analysis tool. Pro-equity strategies meeting the inclusion criteria were identified and compiled in an Excel database, and then populated on a tableau visualization dashboard. RESULTS: In total, 258 pro-equity strategies were implemented by the 13 sampled Gavi-supported countries between 2016 and 2019. The framework determinants of social norms, utilization, and management and coordination accounted for more than three-quarters of all pro-equity strategies implemented in these countries. The median number of strategies reported per country was 17. Afghanistan, Nigeria, and Uganda reported the highest number of strategies that we considered as pro-equity. CONCLUSION: Findings from this mapping can be useful in addressing equity gaps, reaching partially immunized, and 'zero-dose' vaccinated children, and valuable resource for countries planning to implement pro-equity strategies, especially as immunization stakeholders reimagine immunization delivery in light of COVID-19, and as Gavi finalizes its fifth organizational strategy. Future efforts should seek to identify pro-equity strategies being implemented across additional countries, and to assess the extent to which these strategies have improved immunization coverage and equity.

The Effect of Ebola Virus Disease on Maternal and Child Health Services and Child Mortality in Sierra Leone, 2014-2015: Implications for COVID-19.

During Sierra Leone's 2014-2015 Ebola virus disease (EVD) epidemic, early reports warned of health system collapse and potential effects on other-cause mortality. These same warnings are reverberating during the COVID-19 pandemic. Consideration of the impacts of EVD on maternal and child health services from facility data can be instructive during COVID-19. We surveyed all peripheral healthcare units (PHUs) in Sierra Leone in October 2014 and March 2015 to assess closures, staffing, amenities, medicines, supplies, and service utilization during May 2014-January 2015 and October 2013-January 2014. We report PHU characteristics and service utilization changes for equivalent 4-month periods during the epidemic and the prior year. We present utilization changes by district and service type, and model excess child mortality. PHU closures (-8%) and staff attrition (-3%) were limited, but many facilities lacked amenities, medicines, and supplies. Utilization of preventive and scheduled services fell more than individualized, clinical care interventions, aside from malaria treatment which declined significantly. Ebola virus disease intensity in districts was weakly associated with utilization, aside from two districts that were severely affected. Modeling suggests utilization declines resulted in 6,782 excess under-five deaths (an increase of 21%) between 2014 and 2015. Ebola virus disease negatively affected service provision, but utilization declined relatively more, particularly for preventive and scheduled interventions. Although these findings are specific to Sierra Leone's EVD epidemic, they illustrate the magnitude of possible effects in other settings due to COVID-19-induced service disruptions, where collateral impacts on child mortality from other preventable causes may far outweigh COVID-19 mortality.

What we know and don't know about the immunization program of Ethiopia: a scoping review of the literature.

BACKGROUND: There has been significant recent prioritization and investment in the immunization program in Ethiopia. However, coverage rates have stagnated and remained low for many years, suggesting the presence of systemic barriers to implementation. Hence, there is a need to consolidate the existing knowledge, in order to address them and consequently improve program effectiveness. METHODS: A thorough literature review and Delphi method were used. In this review, we searched Pubmed/Medline, WHO library, Science direct, Cochrane library, Google scholar and Google using different combinations of search strategies. Studies that applied any study design, data collection and analysis methods related to immunization program were included. In the Delphi method, a panel of 28 national and international experts were participated to identify current evidence gaps and set research priorities under the immunization program. RESULTS: In this review, a total of 55 studies and national documents were included. The review showed that the vaccination coverage ranged from 20.6% in Afar to 91.7% in Amhara region with large inequities related to socio-economic, health service access and knowledge about vaccination across different settings. Only one study reported evidence on timeliness of immunization as 60%. The review revealed that 80% of health facilities provide immunization service nationally while service availability was only 2% in private health facilities. This review indicated that poor vaccine storage, vaccine shortage, service interruptions, poor defaulter tracing, low community engagement and poor documentation were the main barriers for the Expanded Program on Immunization with variations across different regions. Through expert panel of discussion using Delphi method, 10 priority research areas were identified across different domains of the immunization program at national level. CONCLUSION: We found out that there is substantial knowledge on vaccination coverage, however, there is little evidence on timeliness of vaccination. The existing barriers that affect full immunization coverage also varied from context to context which indicates there is a need to design and implement evidence based locally tailored interventions. This review also indicated evidence gaps with more focus on health system related implementation barriers at lower level and identified further research priorities in the immunization program of Ethiopia.

Carrying out embedded implementation research in humanitarian settings: A qualitative study in Cox's Bazar, Bangladesh.

BACKGROUND: Embedded implementation research (IR) promotes evidence-informed policy and practices by involving decision-makers and program implementers in research activities that focus on understanding and solving existing implementation challenges. Although embedded IR has been conducted in multiple settings by different organizations, there are limited experiences of embedded IR in humanitarian settings. This study highlights some of the key challenges of conducting embedded IR in a humanitarian setting based on our experience with the Rohingya refugee population in Cox's Bazar, Bangladesh. METHODS AND FINDINGS: We collected qualitative data in between January and July 2019. First, we visited Rohingya refugee camps and interviewed representatives from different humanitarian organizations. Second, we conducted interviews with researchers from BRAC University who were engaged with data collection and analysis in a broader embedded IR study on maternal, newborn, child, and adolescent health (MNCAH) program implementation challenges. Data were analyzed using a thematic analysis approach. Two researchers developed and agreed on codes and relevant themes based on the objectives of this study. The findings of this study highlight several challenges encountered while conducting embedded IR in the Rohingya emergency setting in Cox's Bazar, which may have implications for other humanitarian settings. The overall context of the camps was complex, with more than 100 organizations devoted to providing health services for approximately 1 million refugees. Despite the presence of the Bangladesh government, United Nations agencies and other international organizations played key roles in making programmatic and policy decisions for the Rohingya. Because health service delivery modalities and policies and related implementation challenges for MNCAH programs for the refugees changed rapidly, the embedded IR approach used was flexible and able to adapt to changes identified, with research questions and methods modified accordingly. Access to the camps, reaching Rohingya respondents, overcoming language barriers in order to get quality information, and the limited availability of local research collaborators were additional challenges. Working with researchers or research institutes that are familiar with the context and have experience in conducting implementation and health systems research can help with collection of quality data, identifying key stakeholders and bringing them on board to ensure the execution of the project, and ensuring utilization of the research findings. Study limitations include possible constraints in generalizing our conclusions to other humanitarian settings. Implementation research conducted in additional humanitarian settings can contribute to the evidence on this topic. CONCLUSIONS: Findings indicate that embedded IR can be done effectively in humanitarian settings if the challenges are anticipated, and appropriate strategies and in-country partners put in place to address or mitigate them, before commencing the funding or starting of the project. Understanding the context and analyzing the role of relevant stakeholders prior to conducting the research, considering a simple descriptive method appropriate to answering real-time IR questions, and working with local researchers or research institutes with specific skill sets and prior experience conducting research in humanization contexts may reduce costs and time spent, and ensure collection of quality data relevant for policy and practice.

Correction: Effective maternal, newborn and child health programming among Rohingya refugees in Cox's Bazar, Bangladesh: Implementation challenges and potential solutions.

[This corrects the article DOI: 10.1371/journal.pone.0230732.].

Effective maternal, newborn and child health programming among Rohingya refugees in Cox's Bazar, Bangladesh: Implementation challenges and potential solutions.

BACKGROUND: The health status of Rohingya refugees or Forcibly Displaced Myanmar Nationals (FDMNs), especially women and children, is a significant challenge for humanitarian workers in Bangladesh. Though the Government of Bangladesh, in partnership with other organizations, is offering health care services to FDMNs, a comprehensive understanding of the program implementation is required for continuation in the future. This study explores the challenges and potential solutions for effective implementation of maternal, newborn, and child health (MNCH) programs for FDMNs residing in camps of Cox's Bazar, Bangladesh. METHODS: We conducted a qualitative study conducted in Cox's Bazar district, Bangladesh, which involved 34 interviews (15 key informant interviews and 19 in-depth interviews) with relevant persons working in organizations responsible for MNCH services to FDMNs. We relied on both inductive and deductive coding and applied the Consolidated Framework for Implementation Research (CFIR) as a guide to our thematic analysis and presentation of qualitative data. RESULTS: Our study identified some key challenges hindering the effective implementation of MNCH service delivery for the FDMNs. High turnover and poor retention of staff, overlapping of service, weak referral mechanism, complex health information system, and lack of security of the front line health providers were some of the key challenges identified. Motivating the health workers, task shifting, capacity building on emergency obstetric care, training CHW & TBA on danger signs, and ensuring the security of the workers are the potential solutions suggested by the respondents. Selecting a few indicators and the introduction of E-tracker can harmonize the health information system. CONCLUSION: Providing healthcare in an emergency setting has several associated challenges. Considering the CFIR as the base for identifying different challenges and their potential solutions at a different level of the program can prove to be an excellent asset for the program implementers in designing their plans. Two additional domains, context, and security should be included in the CFIR framework for any humanitarian settings.

The influence of gender on immunisation: using an ecological framework to examine intersecting inequities and pathways to change.

There is still a substantial knowledge gap on how gender mediates child health in general, and child immunisation outcomes in particular. Similarly, implementation of interventions to mitigate gender inequities that hinder children from being vaccinated requires additional perspectives and research. We adopt an intersectional approach to gender and delve into the social ecology of implementation, to show how gender inequities and their connection with immunisation are grounded in the interplay between individual, household, community and system factors. We show how an ecological model can be used as an overarching framework to support more precise identification of the mechanisms causing gender inequity and their structural complexity, to identify suitable change agents and interventions that target the underlying causes of marginalisation, and to ensure outcomes are relevant within specific population groups.

Maternal health care-seeking behaviour of married adolescent girls: A prospective qualitative study in Banke District, Nepal.

BACKGROUND: Nepal has one of the highest rates of maternal mortality in the South Asia region, partly due to the underutilization of maternal health services and the high number of adolescent pregnancies. This study explores married Nepali adolescent girls' healthcare-seeking behaviour throughout their pregnancies, during their delivery and postpartum. METHODS: We conducted a prospective qualitative study in Banke district, Nepal. In-depth interviews were conducted with 27 married adolescent girls before and after delivery. In addition, a focus group discussion was conducted with community health works and key-informant interviews were conducted with family members of adolescent girls, representatives from the government and health care providers. We applied the Social-Ecological Model (SEM) as a framework to guide thematic content analysis and presentation of our qualitative data. RESULTS: Several factors in the SEM influenced maternal health care-seeking behaviour of adolescents. At the individual level, girls' perceptions, their lack of knowledge about maternal and reproductive health, certain traditional practices, their sole dependency on their husbands and mothers-in-laws and their low decision-making autonomy towards their own health care negatively influenced their utilization of skilled maternal health services. Mothers-in-law and other family members played a critical role in either encouraging or discouraging the use of skilled maternal health services. At the health systems level, lack of adolescent-friendly maternal health services, difficulties in accessing quality maternal health services, and the fixed operating hours of public health facilities restricted their ability to obtain services. The existence of the Safe Motherhood Programme, knowledge sharing platforms such as "women's groups" and the active role of Female Community Health Volunteers (FCHVs) positively influenced utilization of skilled maternal health services among these girls. CONCLUSION: Influences on married adolescent girls' use of skilled maternal health services in Banke District, Nepal were multi-factoral. Ensuring easy access and availability of adolescent-friendly maternal health services are important to encourage adolescent girls to use skilled maternal health services. Moreover, interventions are needed to improve adolescent girls' knowledge of maternal health, keep them in school, involve family members (mainly mothers-in-law) in health interventions, as well as overcome negative traditional beliefs within the community that discourage care-seeking for skilled maternal health services.