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Nkurunziza A, Smye VL, Wathen CN, Jackson KT, Cechetto DF, Tryphonopoulos P, Gishoma D. Integrating trauma- and violence-informed care for adolescent mothers in Rwanda: a qualitative study with community health workers. BMC Health Serv Res 2024; 24:868. [PMID: 39080753 PMCID: PMC11289957 DOI: 10.1186/s12913-024-11352-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
INTRODUCTION In Rwanda, maternal community health workers play a critical role to improving maternal, newborn and child health, but little is known about their specific experiences with adolescent mothers, who face unique challenges, including trauma, ongoing violence, stigma, ostracism, mental health issues, barriers within the healthcare system, and lack of access to the social determinants of health. This study explored the experiences of maternal community health workers when caring for adolescent mothers in Rwanda to inform the delivery of trauma- and violence-informed care in community maternal services. METHODS Interpretive Description methodology was used to understand the experiences of 12 community health workers purposively recruited for interviews due to their management roles. To gain additional insights about the context, seven key informants were also interviewed. FINDINGS Maternal community health workers provided personalized support to adolescent mothers through the provision of continuity of care, acting as a liaison, engaging relationally and tailoring home visits. They reported feeling passionate about their work, supporting each other, and receiving support from their leaders as facilitators in caring for adolescent mothers. Challenges in their work included handling disclosures of violence, dealing with adolescent mothers' financial constraints, difficulties accessing these young mothers, and transportation issues. Adolescent mothers' circumstances are generally difficult, leading to self-reports of vicarious trauma among this sample of workers. CONCLUSION Maternal community health workers play a key role in addressing the complex needs of adolescent mothers in Rwanda. However, they face individual and structural challenges highlighting the complexities of their work. To sustain and enhance their roles, it is imperative for government and other stakeholders to invest in resources, mentorship, and support. Additionally, training in equity-oriented approaches, particularly trauma- and violence-informed care, is essential to ensure safe and effective care for adolescent mothers and to mitigate vicarious trauma among maternal community health workers.
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Affiliation(s)
- Aimable Nkurunziza
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, ON, Canada.
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
- School of Nursing, Nipissing University, North Bay, Canada.
| | - Victoria L Smye
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, ON, Canada
| | - C Nadine Wathen
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, ON, Canada
| | - Kimberley T Jackson
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, ON, Canada
| | - David F Cechetto
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Panagiota Tryphonopoulos
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, ON, Canada
| | - Darius Gishoma
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Mental Health Division, Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
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Tiruneh MG, Fenta ET, Endeshaw D, Delie AM, Adal O, Tareke AA, Bogale EK, Anagaw TF. Health extension service utilization in Ethiopia: systematic review and meta-analysis. BMC Health Serv Res 2024; 24:537. [PMID: 38671447 PMCID: PMC11046976 DOI: 10.1186/s12913-024-11038-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 04/24/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Ethiopia strives to achieve Universal Health Coverage (UHC) through Primary Health Care (PHC) by expanding access to services and improving the quality and equitable comprehensive health services at all levels. The Health Extension Program (HEP) is an innovative strategy to deliver primary healthcare services in Ethiopia and is designed to provide basic healthcare to approximately 5000 people through a health post (HP) at the grassroots level. Thus, this review aimed to assess the magnitude of health extension service utilization in Ethiopia. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist guideline was used for this review and meta-analysis. The electronic databases (PubMed, Cochrane Library, and African Journals Online) and search engines (Google Scholar and Grey literature) were searched to retrieve articles by using keywords. The Joanna Briggs Institute (JBI) meta-analysis of statistics assessment and review instrument was used to assess the quality of the studies. Heterogeneity was assessed using the I2 statistic. The meta-analysis with a 95% confidence interval using STATA 17 software was computed to present the pooled utilization of health extension services. Publication bias was assessed by visually inspecting the funnel plot and statistical tests using Egger's and Begg's tests. RESULT 22 studies were included in the systematic review with a total of 28,171 participants, and 8 studies were included in the meta-analysis. The overall pooled magnitude of health extension service utilization was 58.5% (95% CI: 40.53, 76.48%). In the sub-group analysis, the highest pooled proportion of health extension service utilization was 60.42% (28.07, 92.77%) in the mixed study design, and in studies published after 2018, 59.38% (36.42, 82.33%). All studies were found to be within the confidence interval of the pooled proportion of health extension service utilization in leave-out sensitivity analysis. CONCLUSIONS The utilization of health extension services was found to be low compared to the national recommendation. Therefore, policymakers and health planners should come up with a wide variety of health extension service utilization strategies to achieve universal health coverage through the primary health care.
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Affiliation(s)
- Misganaw Guadie Tiruneh
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, P.O. Box: 196, Gondar, Ethiopia.
| | - Eneyew Talie Fenta
- Department of Public Health, College of Medicine and Health Sciences, Injibara University, Injibara, Ethiopia
| | - Destaw Endeshaw
- Department of Adult Health Nursing, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Amare Mebrat Delie
- Department of Public Health, College of Medicine and Health Sciences, Injibara University, Injibara, Ethiopia
| | - Ousman Adal
- Department of Emergency and Critical Care Nursing, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Abiyu Abadi Tareke
- Amref Health Africa in Ethiopia, SLL project COVID-19/EPI technical assistant at West Gondar Zonal Health Department, Gondar, Ethiopia
| | - Eyob Ketema Bogale
- Department of Health Promotion and Behavioral Sciences, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, PO. Box.079, Bahir Dar, Ethiopia
| | - Tadele Fentabel Anagaw
- Department of Health Promotion and Behavioral Sciences, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, PO. Box.079, Bahir Dar, Ethiopia
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Chebrolu P, Chalem A, Ponticiello M, Broderick K, Vaidyanathan A, Lorenc R, Kulkarni V, Onawale A, Mathad JS, Sundararajan R. A community health worker-led program to improve access to gestational diabetes screening in urban slums of Pune, India: Results from a mixed methods study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001622. [PMID: 37889879 PMCID: PMC10610081 DOI: 10.1371/journal.pgph.0001622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 09/14/2023] [Indexed: 10/29/2023]
Abstract
The World Health Organization recommends all pregnant women receive screening for gestational diabetes (GDM) with a fasting oral glucose tolerance test (OGTT). However, very few women receive recommended screening in resource-limited countries like India. We implemented a community health worker (CHW)-delivered program to evaluate if home-based, CHW-delivered OGTT would increase GDM screening in a low-resource setting. We conducted a mixed methods study in two urban slum communities in Pune, India. CHWs were trained to deliver home-based, point-of-care fasting OGTT to women in their third trimester of pregnancy. The primary outcome was uptake of CHW-delivered OGTT. Secondary outcomes included GDM prevalence and linkage to GDM care. Individual interviews were conducted with purposively sampled pregnant women, CHWs, and local clinicians to assess barriers and facilitators of this approach. From October 2021-June 2022, 248 eligible pregnant women were identified. Of these, 223 (90%) accepted CHW-delivered OGTT and 31 (14%) were diagnosed with GDM. Thirty (97%) women diagnosed with GDM subsequently sought GDM care; only 10 (33%) received lifestyle counseling or pharmacologic therapy. Qualitative interviews indicated that CHW-delivered testing was considered highly acceptable as home-based testing saved time and was more convenient than clinic-based testing. Inconsistent clinical management of GDM was attributed to providers' lack of time to deliver counseling, and perceptions that low-income populations are not at risk for GDM. Convenience and trust in a CHW-delivered GDM screening program resulted in high access to gold-standard OGTT screening and identification of a high GDM prevalence among pregnant women in two urban slum communities. Appropriate linkage to care was limited by clinician time constraints and misperceptions of GDM risk. CHW-delivered GDM screening and counseling may improve health education and access to preventive healthcare, offloading busy public clinics in high-need, low-resource settings.
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Affiliation(s)
- Puja Chebrolu
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Andrea Chalem
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Matthew Ponticiello
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Kathryn Broderick
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Arthi Vaidyanathan
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Rachel Lorenc
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | | | | | - Jyoti S. Mathad
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Radhika Sundararajan
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
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Mondal S, Anand A, Awasthi N, Singh B, Pradhan MR. Factors affecting pregnancy registration in India: does the pregnancy intention matter? BMC Pregnancy Childbirth 2023; 23:674. [PMID: 37726663 PMCID: PMC10507949 DOI: 10.1186/s12884-023-06002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 09/14/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Pregnancy registration is one of the most critical components of women's reproductive health because it is the gateway to entering the continuum of care services such as antenatal care, institutional delivery, and postnatal care. There is a lack of studies exploring the relationship between pregnancy intention and pregnancy registration, especially in the Indian context. METHOD This study used the National Family Health Survey-5 (2019-21) data to explore the relationship between birth intention and failure of pregnancy registration. The bivariate and multivariate (binary logistic regression) analysis was carried out. RESULTS Adjusting the effects of socio-demographic and economic characteristics, compared with women with an intended pregnancy, the odds of failure of pregnancy registration were significantly high among women with a mistimed pregnancy (OR = 1.60, 95% CI = 1.47-1.73) and unwanted pregnancy (OR = 1.38, 95% CI = 1.26-1.52). The study found pregnancy intention as a significant predictor of pregnancy registration. CONCLUSIONS Results suggest strengthening the interaction of grassroots-level health workers with women, especially those with possibly lower healthcare autonomy and unintended pregnancy. Higher and earlier pregnancy registration will enhance maternal healthcare utilization and reduce adverse health consequences to mothers and children, thus ensuring better maternal and child health.
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Affiliation(s)
- Sourav Mondal
- International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, Maharashtra, 400088, India
| | - Abhishek Anand
- International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, Maharashtra, 400088, India
| | - Niharika Awasthi
- International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, Maharashtra, 400088, India
| | - Bharti Singh
- International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, Maharashtra, 400088, India
| | - Manas Ranjan Pradhan
- Department of Fertility and Social Demography, International Institute for Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, Maharashtra, 400088, India.
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Mor N, Ananth B, Ambalam V, Edassery A, Meher A, Tiwari P, Sonawane V, Mahajani A, Mathur K, Parekh A, Dharmaraju R. Evolution of community health workers: the fourth stage. Front Public Health 2023; 11:1209673. [PMID: 37333563 PMCID: PMC10270722 DOI: 10.3389/fpubh.2023.1209673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/11/2023] [Indexed: 06/20/2023] Open
Abstract
Introduction Comprehensive primary care is a key component of any good health system. Designers need to incorporate the Starfield requirements of (i) a defined population, (ii) comprehensive range, (iii) continuity of services, and (iv) easy accessibility, as well as address several related issues. They also need to keep in mind that the classical British GP model, because of the severe challenges of physician availability, is all but infeasible for most developing countries. There is, therefore, an urgent need for them to find a new approach which offers comparable, possibly even superior, outcomes. The next evolutionary stage of the traditional Community health worker (CHW) model may well offer them one such approach. Methods We suggest that there are potentially four stages in the evolution of the CHW - the health messenger, the physician extender, the focused provider, and the comprehensive provider. In the latter two stages, the physician becomes much more of an adjunct figure, unlike in the first two, where the physician is at the center. We examine the comprehensive provider stage (stage 4) with the help of programs that have attempted to explore this stage, using Qualitative Comparative Analysis (QCA) developed by Ragin. Starting with the 4 Starfield principles, we first arrive at 17 potential characteristics that could be important. Based on a careful reading of the six programs, we then attempt to determine the characteristics that apply to each program. Using this data, we look across all the programs to ascertain which of these characteristics are important to the success of these six programs. Using a truth table, we then compare the programs which have more than 80% of the characteristics with those that have fewer than 80%, to identify characteristics that distinguish between them. Using these methods, we analyse two global programs and four Indian ones. Results Our analysis suggests that the global Alaskan and Iranian, and the Indian Dvara Health and Swasthya Swaraj programs incorporate more than 80% (> 14) of the 17 characteristics. Of these 17, there are 6 foundational characteristics that are present in all the six stage 4 programs discussed in this study. These include (i) close supervision of the CHW; (ii) care coordination for treatment not directly provided by the CHW; (iii) defined referral pathways to be used to guide referrals; (iv) medication management which closes the loop with patients on all the medicines that they need both immediately and on an ongoing basis (the only characteristic which needs engagement with a licensed physician); (v) proactive care: which ensures adherence to treatment plans; and (vi) cost-effectiveness in the use of scarce physician and financial resources. When comparing between programs, we find that the five essential added elements of a high-performance stage 4 program are (i) the full empanelment of a defined population; (ii) their comprehensive assessment, (iii) risk stratification so that the focus can be on the high-risk individuals, (iv) the use of carefully defined care protocols, and (v) the use of cultural wisdom both to learn from the community and to work with them to persuade them to adhere to treatment regimens.
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Affiliation(s)
- Nachiket Mor
- Banyan Academy of Leadership in Mental Health, Chennai, India
| | | | | | | | | | | | | | | | | | - Amishi Parekh
- Artificial Intelligence and Robotics Technology Park, Bengaluru, India
| | - Raghu Dharmaraju
- Artificial Intelligence and Robotics Technology Park, Bengaluru, India
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Noghanibehambari H, Salari M, Tavassoli N. Maternal human capital and infants' health outcomes: Evidence from minimum dropout age policies in the US. SSM Popul Health 2022; 19:101163. [PMID: 35855970 PMCID: PMC9287432 DOI: 10.1016/j.ssmph.2022.101163] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 11/29/2022] Open
Abstract
The purpose of this cross-sectional study is to examine the causal relationship of maternal education and infants' health outcomes. Using birth certificate data over the years 1970–2004 and exploiting the space-time variation in Minimum Dropout Age laws to solve the endogeneity of education, we find a sizeable effect of mothers' education on their birth outcomes. An additional year of maternal education is associated with a reduction in incidences of low birth weight and preterm birth by 15.2 and 12.7 percent, respectively. The estimates are robust across various specifications and even when allowing mothers’ cohort-of-birth to vary across regions. The results suggest that the candidate mechanisms of impact include improvements in timing, quantity, and quality of prenatal care, lower negative health behavior during pregnancy such as smoking and drinking, and higher spousal education. We provide causal evidence on the effect of mothers' education on birth outcomes. We use Minimum Dropout Age policies as the instrument. Mother education has significant impact on infants' birth outcomes. Candidate mechanisms include improvements in timing, quantity, and quality of prenatal care.
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Affiliation(s)
- Hamid Noghanibehambari
- Center for Demography of Health and Aging, University of Wisconsin-Madison, Madison, WI, 53706, USA
| | - Mahmoud Salari
- Department of Accounting, Finance, and Economics, California State University Dominguez Hills, Carson, CA, 90747, USA
| | - Nahid Tavassoli
- Department of Economics, University of Wisconsin Milwaukee, Milwaukee, WI, 53211, USA
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