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Nida S, Tyas ASA, Putri NE, Larasanti A, Widoyopi AA, Sumayyah R, Listiana S, Espressivo A. A systematic review of the types, workload, and supervision mechanism of community health workers: lessons learned for Indonesia. BMC PRIMARY CARE 2024; 25:82. [PMID: 38468218 PMCID: PMC10926673 DOI: 10.1186/s12875-024-02319-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Community health workers (CHWs) have demonstrated capability to improve various health indicators, however, many programmes require support in meeting their objectives due to subpar performance and a high rate of CHW attrition. This systematic review investigated the types of CHWs, their workloads, and supervision practices that contribute to their performance in different countries. METHODS The search was carried out in November 2022 in Medline, Embase, and Neliti for studies published in Indonesian or English between 1986 and 2022 that reported public health services delivered by CHWs who live and serve the community where they live but are not considered health professionals. The findings were synthesised using a thematic analysis to assess key factors influencing the performance of CHWs. RESULTS Sixty eligible articles were included in this review. CHWs were responsible for more than two diseases (n = 35) and up to fifteen, with more than eighteen activities. Their roles covered the human life cycle, from preparation for pregnancy, care for newborns, health for children, adolescents, and productive age to elderly individuals. They were also involved in improving environmental health, community empowerment, and other social issues hindering access to health services. They carried out promotive, preventive, and curative interventions. The CHW-population ratio varied from eight to tens of thousands of people. Some CHWs did not have a clear supervision system. Challenges that were often faced by CHWs included inappropriate incentives, inadequate facilities, insufficient mentoring, and supervision, many roles, and a broad catchment area. Many studies revealed that CHWs felt overburdened and stressed. They needed help to balance their significant work and domestic tasks. CONCLUSIONS Effective planning that considered the scope of work of CHWs in proportion to their responsibilities and the provision of necessary facilities were crucial factors in improving the performance of CHWs. Supportive supervision and peer-supervision methods are promising, however, any CHW supervision required a detailed protocol. This systematic review emphasised the opportunity for CHW management system improvement in Indonesia.
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Affiliation(s)
- Sofwatun Nida
- Research and Policy Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia.
| | - Agatha Swasti Ayuning Tyas
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Nidya Eka Putri
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Ayudina Larasanti
- Research and Policy Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Aldhea Ayu Widoyopi
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Rima Sumayyah
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Saetia Listiana
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Aufia Espressivo
- Research and Policy Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
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Riyanti, Salim LA, Heriteluna M, Legawati. Development of pregnancy class with husband's assistance on the outcome of teenage pregnancy. J Public Health Res 2023; 12:22799036231197195. [PMID: 37746517 PMCID: PMC10515537 DOI: 10.1177/22799036231197195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 07/30/2023] [Indexed: 09/26/2023] Open
Abstract
Background Teenage pregnancy is an international phenomenon without a definite solution to date. Globally, an estimated 16 million girls aged 15-19 give birth each year. Husbands need to play their assistance role in order to thwart the negative impact of the outcome of teenage pregnancy. Research objective To identify the effect of the development of Pregnancy Classes with the Husband's Assistance on the Outcome of Teenage Pregnancy in the Dayak community, Central Kalimantan. Research methods This was a quasi-experimental study with the posttest-only non-equivalent control group design involving the husband's assistance in pregnancy classes. The respondents were 60 individuals where 30 of them were given the pregnancy class assistance intervention while the other 30 were not given any intervention (control group). Results and discussion Pregnancy class with Assistance by the husband increases positive pregnancy outcomes 2.4 times compared to without the husband's assistance. Family support increases positive pregnancy outcomes 2.5 times compared to pregnant women without support from the family. Pregnant women that are highly motivated regarding antenatal care are likely to have positive pregnancy outcomes 5.4 times greater than pregnant women with low motivation. Based on the analysis, then the variables that have no effect are the history of antenatal care, frequency of antenatal care, and support from health workers. Conclusions Pregnancy class with husband's assistance affects positive outcomes of teenage pregnancy. Other factors with meaningful influence on pregnancy outcomes include family support and motivation to seek teenage antenatal care. Furthermore, other factors that have no influence include the teenager's age, history of antenatal care, frequency of antenatal care, and support from health workers. An intervention is needed that involves the husband/partner in the form of active assistance.
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Affiliation(s)
- Riyanti
- Faculty of Public Health, UNAIR, Surabaya, Jawa Timur, Indonesia
| | - Lutfi Agus Salim
- Department of Epidemiology, Population Biostatistics and Health Promotion, Faculty of Public Health, UNAIR, Surabaya, Jawa Timur, Indonesia
| | - Marselinus Heriteluna
- Diploma IV Program of Nursing, Politeknik Kesehatan Kemenkes Palangka Raya, Palangka Raya, Kalimantan Tengah, Indonesia
| | - Legawati
- Diploma III Program of Midwifery, Politeknik Kesehatan Kemenkes Palangka Raya, Palangka Raya, Center of Kalimantan, Indonesia
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Monteiro DLM, Miranda FRD, Bruno ZV, Cavalcante MB, Lacerda IMS, Ramos JAS, Rodrigues NCP. Repeated adolescent pregnancy in Brazil from 2015 to 2019. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20221513. [PMID: 37222326 DOI: 10.1590/1806-9282.20221513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/02/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVE The aim of this study was to assess the rate of repeated pregnancy in adolescence and its association with early marriage and education level. METHODS This is a cross-sectional study conducted by searching the Live Births Data System. The study included all adolescents in the age group 10-19 years with live births from 2015 to 2019 (n=2,405,248), divided into three groups: G1: primiparas; G2: with 1 previous pregnancy; and G3: with two or more previous pregnancies. RESULTS Total repeated pregnancies remained stable, along the years. In the age group 10-14 years, the decrease in the period was from 5.0 to 4.7%, whereas in the age group 15-19 years, it was from 27.8 to 27.3%. Being married or in a stable union increases by 96% the chance of repeated pregnancy in the age group 10-14 years (p<0.001; OR=1.96; 95% confidence interval [CI] 1.85-2.09). In the age group 15-19 years, the chance of repeated pregnancy among the married or in stable union increased 40% (p<0.001; OR=1.40; 95%CI 1.39-1.41)). Girls aged 10-14 years with an education level of<8 years had a 64% higher chance of repeated pregnancy (p<0.001; OR=1.64; 95%CI 1.53-1.75), and among those aged 15-19 years, there was a 137% higher chance of repeated pregnancy (p<0.001; OR=2.37; 95%CI 2.35-2.38). CONCLUSION Repeated pregnancy in adolescence in Brazil remains very high over the years. There is an association between low education level and early marriage with repeated pregnancies in adolescence.
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Affiliation(s)
- Denise Leite Maia Monteiro
- Universidade do Estado do Rio de Janeiro - Rio de Janeiro (RJ), Brazil
- Centro Universitário Serra dos Órgãos - Teresópolis (RJ), Brazil
| | - Fátima Regina Dias Miranda
- Universidade do Estado do Rio de Janeiro - Rio de Janeiro (RJ), Brazil
- Universidade do Grande Rio - Rio de Janeiro (RJ), Brazil
| | | | | | | | | | - Nádia Cristina Pinheiro Rodrigues
- Universidade do Estado do Rio de Janeiro - Rio de Janeiro (RJ), Brazil
- Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brazil
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Ndambo MK, Munyaneza F, Aron M, Makungwa H, Nhlema B, Connolly E. The role of community health workers in influencing social connectedness using the household model: a qualitative case study from Malawi. Glob Health Action 2022; 15:2090123. [PMID: 35960168 PMCID: PMC9377265 DOI: 10.1080/16549716.2022.2090123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Community health workers (CHWs) play a vital role in facilitating social connectedness, building trust, decrease stigma, and link communities to essential healthcare and social support services. More studies are needed to understand the factors facilitating these interactions among CHWs, clients, and community members. OBJECTIVE This study examined the CHW role and relationships between CHWs, communities, and health facilities that promote trust, positive relationships, and social connectedness. METHODS In 2016, the CHW program in Neno District, Malawi, was transitioned to a household-level assignment of CHWs to provide screening, linkage to care, and psychosocial and chronic disease support from a disease-based program. We employed an exploratory qualitative study with thematic analysis linked to Fredrickson's broaden-and-build theory of positive emotions through focus group discussions (FGDs) and in-depth interviews (IDIs) to understand the impact of the household assignment. We purposively sampled community stakeholders, CHWs, health service providers, and clients (total N = 180) from October 2018 through March 2020. All interviews were audiotaped, transcribed verbatim, translated, coded, and analyzed. RESULTS Participants reported decreased stigma and discrimination with increased trust and confidence in CHWs with household-level assignment. Positive relationships between CHWs in their households, community members, and health facility staff fostered health knowledge, individual agency, and personal resources for the community members to access health services. Community members' personal resources of increased health knowledge, trust, gratitude, and social support improved social connectedness and subjective wellbeing. Areas to improve positive relationships include CHWs maintaining confidentiality and caring for pregnant women. CONCLUSION Our study findings demonstrate that by building solid relationships as a community chosen, well informed, and household-level workforce, CHWs can develop positive relationships with communities and the health-care facility staff through building knowledge, trust, gratitude, and hope. Further work is needed in maintaining CHW confidentiality and new ways to approach culturally sensitive health areas.
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Affiliation(s)
| | - Fabien Munyaneza
- Community Health Department, Partners In Health/Abwenzi Pa Za Umoyo, Neno, Malawi
| | - Moses Aron
- Community Health Department, Partners In Health/Abwenzi Pa Za Umoyo, Neno, Malawi
| | - Henry Makungwa
- Community Health Department, Partners In Health/Abwenzi Pa Za Umoyo, Neno, Malawi
| | - Basimenye Nhlema
- Community Health Department, Partners In Health/Abwenzi Pa Za Umoyo, Neno, Malawi
| | - Emilia Connolly
- Community Health Department, Partners In Health/Abwenzi Pa Za Umoyo, Neno, Malawi
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Abstract
Pregnancy outcomes impact subsequent contraceptive behaviour. The purpose of this study was to assess the relationship between previous pregnancy outcomes and subsequent contraceptive behaviours among unmarried young women intending to delay childbearing. Using data from the 2014 Ghana Demographic and Health Survey, among 1118 sexually experienced, fecund and non-pregnant unmarried women aged 15-24 years, the study assessed how childbirth and abortion are related to sexual abstinence and use of modern contraception. While about 70% of unmarried young women were nulligravid, approximately 11% had had an abortion and 18.2% were postpartum. The majority of respondents were sexually abstinent while 21% and 27% were using and not using contraception, respectively. Postpartum women were more likely than nulligravid and post-abortion women to use contraceptives. Post-abortion women were least likely to be sexually abstinent. Number of years since the respondent's sexual debut was positively associated with the likelihood of using modern contraception, particularly among postpartum women, and negatively associated with sexual abstinence among those who had aborted. The findings show that prior pregnancy outcomes have significant implications for secondary abstinence and contraceptive use among unmarried young women in Ghana. Post-abortion women are more likely than postpartum women to be sexually active but less likely to use contraceptives. Efforts must be strengthened towards increasing access to modern contraceptives for young women who present for abortion in Ghana.
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Ahinkorah BO, Hagan JE, Seidu AA, Budu E, Hormenu T, Mintah JK, Sambah F, Schack T. Access to Adolescent Pregnancy Prevention Information and Services in Ghana: A Community-Based Case-Control Study. Front Public Health 2019; 7:382. [PMID: 31921747 PMCID: PMC6927296 DOI: 10.3389/fpubh.2019.00382] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/28/2019] [Indexed: 12/02/2022] Open
Abstract
Background: Pregnancy among girls 10-19 years remains a challenge that requires critical resolution all over the world. Despite this worrying sexual phenomenon, research pertaining to prevention information and related services in Sub-Saharan nations like Ghana is sparse. This study sought to determine the influence of access to pregnancy prevention information and services on adolescent pregnancy in the Komenda-Edina-Eguafo-Abrem Municipality in the Central Region of Ghana. Methods and Results: Adopting a matched case-control research design with a 1:1 mapping, female adolescents aged between 15 and 19 years in the KEEA Municipality were selected using a facility based sampling technique. Results from both bivariate and multivariate analyses revealed that non-pregnant adolescents were about two times more likely to have access to pregnancy prevention information from health workers compared to pregnant adolescents [OR = 0.57, 95% CI = (0.33-0.96), p = 0.036]. Likewise, pregnant adolescents were five times more likely to have access to pregnancy prevention information from media compared to non-pregnant adolescents [OR = 5.44, 95% CI = (2.64-11.23), p = 0.000]. Additionally, non-pregnant adolescents were two times more likely to receive information on pregnancy prevention from school compared to pregnant adolescents [OR = 0.48, 95% CI = (0.28-0.81), p = 0.006]. Conclusion: Sexuality and reproductive health (SRH) programme organizers should target specific intervention programmes that focus on training health workers and/or other analogous staff to enhance their awareness, attitudes, and skills to more effectively meet with the specific needs of adolescents. Specific health workers training and redesign of health facilities to foster more adolescent user friendly working environment (e.g., extension in operational times, reduction in fees of SRH services, transforming physical design to promote privacy or confidentiality) ought to be encouraged. Different media outreach programmes should also combine other community level events [e.g., informative methods through schools (e.g., focus group discussions, participatory learning), assisting connections to health services, community information network (e.g., use of sirens)] to provide well-tailored advocacy that would help modify SRH and sociocultural norms that hinder positive sexual behaviors among young people.
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Affiliation(s)
- Bright Opoku Ahinkorah
- Faculty of Health, The Australian Centre for Public and Population Health Research (ACPPHR), University of Technology Sydney, Sydney, NSW, Australia
| | - John Elvis Hagan
- Department of Health, Physical Education and Recreation, University of Cape Coast, Cape Coast, Ghana
- Neurocognition and Action-Biomechanics-Research Group, Faculty of Psychology and Sport Sciences, Bielefeld University, Bielefeld, Germany
| | - Abdul-Aziz Seidu
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | - Eugene Budu
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | - Thomas Hormenu
- Department of Health, Physical Education and Recreation, University of Cape Coast, Cape Coast, Ghana
| | - Joseph Kwame Mintah
- Department of Health, Physical Education and Recreation, University of Cape Coast, Cape Coast, Ghana
| | - Francis Sambah
- Department of Health, Physical Education and Recreation, University of Cape Coast, Cape Coast, Ghana
| | - Thomas Schack
- Neurocognition and Action-Biomechanics-Research Group, Faculty of Psychology and Sport Sciences, Bielefeld University, Bielefeld, Germany
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Scott K, Beckham SW, Gross M, Pariyo G, Rao KD, Cometto G, Perry HB. What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. HUMAN RESOURCES FOR HEALTH 2018; 16:39. [PMID: 30115074 PMCID: PMC6097220 DOI: 10.1186/s12960-018-0304-x] [Citation(s) in RCA: 310] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 07/30/2018] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems. METHODS We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards. FINDINGS We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance. CONCLUSION Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.
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Affiliation(s)
- Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
| | - S. W. Beckham
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, 21205 United States of America
| | - Margaret Gross
- Welch Medical Library, Johns Hopkins Medical Institutions, 1900 E Monument Street, Baltimore, 21205 United States of America
| | - George Pariyo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
| | - Giorgio Cometto
- Health Workforce Department, World Health Organization, Avenue Appia 20, 1202 Geneva, Switzerland
| | - Henry B. Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
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Govender D, Naidoo S, Taylor M. Scoping review of risk factors of and interventions for adolescent repeat pregnancies: A public health perspective. Afr J Prim Health Care Fam Med 2018; 10:e1-e10. [PMID: 29943611 PMCID: PMC6018382 DOI: 10.4102/phcfm.v10i1.1685] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 05/03/2018] [Accepted: 05/19/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Adolescent repeat pregnancy is of importance in public health because the birth of a second child to an adolescent mother compounds the adverse medical, educational, socioeconomic and parenting outcomes. Repeat pregnancy in adolescence is not only an international phenomenon but also a local concern as it also occurs in South Africa. The prevalence of adolescent repeat pregnancy in Durban, KwaZulu-Natal, was reported as 17.6% in 2013. AIM This review aimed to gather relevant information from national and international sources to inform practice and to provide an understanding of what is known about the risk factors of and the interventions for adolescent repeat pregnancy. METHODS A scoping review was undertaken using the Arksey and O'Malley framework. An electronic search was conducted using PubMed, Medline, Science Direct, Ebscohost, Sage and Wiley Online and Google Scholar. RESULTS The search identified 3032 citations. After a review of the full text articles, 26 articles met the inclusion criteria. Risk factors pertaining to adolescent repeat pregnancy are categorised according to individual factors, partner relationship factors, family factors, peer factors, and social and community factors. Interventions to reduce adolescent repeat pregnancy have been largely influenced by the ecological framework. Across studies, adolescent mothers who received medical, psychosocial, educational, and family planning support experienced lower rates of repeat pregnancy. CONCLUSION A single 'one-size-fits-all' intervention for adolescent repeat pregnancy prevention is unlikely as different strategies were employed by the intervention programmes in this scoping review.
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Affiliation(s)
- Desiree Govender
- KwaZulu-Natal Department of Health, South Africa, Discipline of Public Health, University of KwaZulu-Natal.
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de Souza MDL, Lynn FA, Johnston L, Tavares ECT, Brüggemann OM, Botelho LJ. Fertility rates and perinatal outcomes of adolescent pregnancies: a retrospective population-based study. Rev Lat Am Enfermagem 2017; 25:e2876. [PMID: 28403340 PMCID: PMC5396488 DOI: 10.1590/1518-8345.1820.2876] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 01/31/2017] [Indexed: 11/21/2022] Open
Abstract
Objective analyze trends in fertility rates and associations with perinatal outcomes for adolescents in Santa Catarina, Brazil. Methods a population-based study covering 2006 to 2013 was carried out to evaluate associations between perinatal outcomes and age groups, using odds ratios, and Chi-squared tests. Results differences in the fertility rate among female adolescents across regions and time period were observed, ranging from 40.9 to 72.0 per 1,000 in mothers aged 15-19 years. Adolescents had fewer prenatal care appointments than mothers ≥20 years, and a higher proportion had no partner. Mothers aged 15-19 years were more likely to experience preterm birth (OR:1.1; CI:1.08-1.13; p<0.001), have an infant with low birthweight (OR:1.1; CI:1.10-1.15; p<0.001) and low Apgar score at 5 minutes (OR:1.4; CI:1.34-1.45; p<0.001) than mothers ≥20 years, with the odds for adverse outcomes greater for those aged 10-14 years. Conclusion this study provides evidence of fertility rates among adolescents remaining higher in regions of social and economic deprivation. Adolescent mothers and their infants more likely to experience adverse perinatal outcomes. Nurses, public health practitioners, health and social care professionals and educators need to work collaboratively to better target strategies for adolescents at greater risk; to help reduce fertility rates and improve outcomes.
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Affiliation(s)
| | - Fiona Ann Lynn
- PhD, Professor, School of Nursing & Midwifery, Queen's University,
Belfast, Northern Ireland, United Kingdom
| | - Linda Johnston
- PhD, Professor, Lawrence S. Bloomberg Faculty of Nursing, University of
Toronto, Toronto, CA, Canada
| | | | | | - Lúcio José Botelho
- Doctoral student, Universidade Federal de Santa Catarina, Florianópolis,
SC, Brazil. Associate Professor, Universidade Federal de Santa Catarina, Florianópolis,
SC, Brazil
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