Provider perspectives on constraints in providing maternal, neonatal and child health services in the Lao People's democratic republic: a qualitative study

Community engagement and local governance for health equity through trust: lessons from developing the CONNECT Initiative in the Lao People's Democratic Republic

Community engagement and local governance are important components of health interventions aiming to empower local populations. Yet, there is limited evidence on how to effectively engage with communities and codevelop interventions, especially in Southeast Asian contexts. Despite rapid progress, the Lao People's Democratic Republic (Lao PDR) still has high maternal and child mortality, with essential service coverage showing significant disparities across socioeconomic strata. Long-standing challenges in community health were exacerbated by the COVID-19 pandemic and reinforced by poor trust between users and health providers. However, the pandemic also provided an opportunity to develop approaches for enhanced community engagement and local governance capacity to tackle health inequities. The Community Network Engagement for Essential Healthcare and COVID-19 Responses through Trust (CONNECT) Initiative, developed by the Lao PDR government, WHO and partners, has resulted in initial positive outcomes in community health such as increased vaccination uptake, facility births and trust in health providers. This case study describes the iterative, adaptive process by which the CONNECT Initiative was developed, and how the core components, key stakeholders, theory of change and evaluation framework evolved from grounded observations and hypotheses. Lessons learnt include (1) awareness of entry points and existing structures to strengthen local governance for health through mutually beneficial intersectoral collaboration; (2) building relationships and trust with an adaptive, grounds-up approach for sustainability and scalability. As a model which can be adapted to other settings, this case study provides evidence on how to engage with communities, strengthen local governance and codevelop interventions towards greater health equity.

Factors influencing maternal death in Cambodia, Laos, Myanmar, and Vietnam countries: A systematic review

BACKGROUND

A maternal mortality ratio is a sensitive indicator when comparing the overall maternal health between countries and its very high figure indicates the failure of maternal healthcare efforts. Cambodia, Laos, Myanmar, and Vietnam-CLMV countries are the low-income countries of the South-East Asia region where their maternal mortality ratios are disproportionately high. This systematic review aimed to summarize all possible factors influencing maternal mortality in CLMV countries.

METHODS

This systematic review applied "The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist (2020)", Three key phrases: "Maternal Mortality and Health Outcome", "Maternal Healthcare Interventions" and "CLMV Countries" were used for the literature search. 75 full-text papers were systematically selected from three databases (PubMed, Google Scholar and Hinari). Two stages of data analysis were descriptive analysis of the general information of the included papers and qualitative analysis of key findings.

RESULTS

Poor family income, illiteracy, low education levels, living in poor households, and agricultural and unskilled manual job types of mothers contributed to insufficient antenatal care. Maternal factors like non-marital status and sex-associated work were highly associated with induced abortions while being rural women, ethnic minorities, poor maternal knowledge and attitudes, certain social and cultural beliefs and husbands' influences directly contributed to the limitations of maternal healthcare services. Maternal factors that made more contributions to poor maternal healthcare outcomes included lower quintiles of wealth index, maternal smoking and drinking behaviours, early and elderly age at marriage, over 35 years pregnancies, unfavourable birth history, gender-based violence experiences, multigravida and higher parity. Higher unmet needs and lower demands for maternal healthcare services occurred among women living far from healthcare facilities. Regarding the maternal healthcare workforce, the quality and number of healthcare providers, the development of healthcare infrastructures and human resource management policy appeared to be arguable. Concerning maternal healthcare service use, the provisions of mobile and outreach maternal healthcare services were inconvenient and limited.

CONCLUSION

Low utilization rates were due to several supply-side constraints. The results will advance knowledge about maternal healthcare and mortality and provide a valuable summary to policymakers for developing policies and strategies promoting high-quality maternal healthcare.

Barriers and facilitators to the implementation of midwife-led care for childbearing women in low- and middle-income countries: A mixed-methods systematic review

BACKGROUND

Evidence from high-income countries demonstrate improvements in maternal and neonatal health with midwife-led care. Midwife-led care is pivotal to meet the United Nations' Sustainable Development Goals. Despite this, successful implementation of midwife-led care in low- and middle-income countries (LMICs) has been limited. It is therefore necessary to understand the factors that influence the implementation of midwife-led care.

AIM

This systematic review aimed to synthesize the evidence on barriers and facilitators to the implementation of midwife-led care for childbearing women in LMICs from the perspectives of care recipients, providers and wider stakeholders.

METHODS

A mixed-methods systematic review was conducted of primary research studies that expressed the views of those involved in or affected by the implementation of midwife-led care in LMICs. Reporting followed PRISMA guidelines. MEDLINE, EMBASE, PsychINFO, CINAHL, Maternity and Infant Care database (MIDIRS), Global Health and Web of Science databases were systematically searched. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Data was analysed and synthesized using the Supporting the Use of Research Evidence (SURE) framework to identify barriers and enabling factors to implementing midwife-led care.

FINDINGS

A total of 31 studies from 21 LMICs were included. At the care recipient level, women need adequate knowledge and confidence about midwife-led care to utilise services. At the care provider level, strengthening midwifery education and practice by employing experienced educators and supervisors is essential. Findings also suggest that increased collaboration between funders, professional organisations, practitioners, communities, and the government is necessary for successful implementation. However, adequate and sustained funding for midwife-led care programs is often lacking and political instability contributes to poor implementation in LMICs.

CONCLUSION AND IMPLICATIONS FOR PRACTICE AND RESEARCH

There are several enabling factors which increase the success and sustainability of the midwife-led model of care in LMICs. However, current practice guidelines and strategic frameworks need to better reflect the infrastructure and resource limitations of health settings in LMICs.

Equity in antenatal care visits among adolescent mothers: An analysis of 54 country levels trend and projection of coverage from 2000 to 2030

Background

Ensuring utilization of antenatal care (ANC) services by adolescent mothers (ages 10-19) is an enormous challenge in low-and middle-income countries (LMICs). This study provides the first comprehensive analysis of ANC visits among adolescent and adult mothers.

Methods

Using all available Demographic and Health Survey and Multiple Indicator Cluster Surveys between 2000 and 2019 in 54 LMICs, we estimated proportion of ANC visits among women. Bayesian hierarchical regression models were used to estimate trend, projection, and determinants of single and four ANC visits (ANC1 and ANC4) independently. Equity analysis were performed to assess the magnitude of wealth-based and urban-rural inequalities in access to ANC visits.

Results

Compared to women aged 36-49 years, coverage of ANC1 and ANC4 are expected to increase significantly for adolescent mothers and women aged 20-35 years. This increase was observed at the national level, as well as both urban and rural areas in most countries between 2000 and 2030. By 2030, the coverage of ANC1 is predicted to reach 80% or more in all countries except Angola, Central African Republic and Togo, whereas only 16 countries are predicted to reach 80% or more for ANC4. According to wealth quintile, the lowest inequalities with highest coverage of 80% or more ANC4 will be observed in Armenia, Cambodia, Dominican Republic, Ghana, Maldives, Indonesia, and Sao Tome and Principe in 2030. Determinant analysis found increased odds of receiving ANC visits during pregnancy for adolescent mothers with higher educational levels, frequency of listening/watching mass media, and various household socio-economic status factors.

Conclusions

This study calls for advanced, innovative and cost-effective approaches to increase ANC coverage among adolescent mothers, particularly in rural areas and/or in low socioeconomic groups.

Socio-cultural barriers to the delivery and utilisation of child healthcare services in rural Ghana: a qualitative study

BACKGROUND

Over half of global deaths among children under five years of age occur in sub-Saharan Africa. Prompt and consistent access to and utilisation of child healthcare services improves child health outcomes. However, socio-cultural barriers impede the utilisation of child healthcare services among rural dwellers in Ghana. There is a paucity of studies that explore the experiences of nurses and caregivers regarding the socio-cultural barriers to the delivery and utilisation of child healthcare services in rural areas in Ghana such as the Nkwanta South Municipality.

PURPOSE

The purpose of this study was to explore the experiences of nurses and caregivers regarding the socio-cultural barriers that impede the delivery and utilisation of child healthcare services by caregivers for their children in the Nkwanta South Municipality, Ghana.

METHODS

Data were collected through semi-structured interviews conducted with a purposive sample of ten nurses and nine caregivers of children under five years of age who utilised the available child healthcare services in a rural setting. The consent of all participants was sought and given before interviews were conducted. Data analysis entailed coding and the generation of themes the codes.

RESULTS

The exploration of experiences of nurses and caregivers of children under-five years of age revealed that certain socio-cultural beliefs and practices, language barriers and reliance of caregivers on self-medication were the main socio-cultural barriers that impeded the delivery and utilisation of child healthcare services in the Nkwanta South Municipality.

CONCLUSION

Nurses and caregivers experienced several socio-cultural barriers which either delayed care seeking by caregivers for their sick children or interfered with the smooth and prompt delivery of needed child healthcare services by nurses. Some of the barriers negatively affected the interaction between nurses and caregivers with the tendency to affect subsequent child healthcare service utilisation. It is recommended that healthcare managers and nurses should foster close collaboration with caregivers and community leaders to address these socio-cultural barriers and facilitate prompt and consistent utilisation of child healthcare service in rural areas.

Human Resources for Health-Related Challenges to Ensuring Quality Newborn Care in Low- and Middle-Income Countries: A Scoping Review

BACKGROUND

A critical shortage of health workers with needed maternal and newborn competencies remains a major challenge for the provision of quality care for mothers and newborns, particularly in low- and middle-income countries. Supply-side challenges related to human resources for health (HRH) worsen shortages and can negatively affect health worker performance and quality of care. This review scoped country-focused sources to identify and map evidence on HRH-related challenges to quality facility-based newborn care provision by nurses and midwives.

METHODS

Evidence for this review was collected iteratively, beginning with pertinent World Health Organization documents and extending to articles identified via database and manual reference searches and country reports. Evidence from country-focused sources from 2000 onward was extracted using a data extraction tool that was designed iteratively; thematic analysis was used to map the 10 categories of HRH challenges.

FINDINGS

A total of 332 peer-reviewed articles were screened, of which 22 met inclusion criteria. Fourteen additional sources were added from manual reference search and gray literature sources. Evidence has been mapped into 10 categories of HRH-related challenges: (1) lack of health worker data and monitoring; (2) poor health worker preservice education; (3) lack of HW access to evidence-based practice guidelines, continuing education, and continuing professional development; (4) insufficient and inequitable distribution of health workers and heavy workload; (5) poor retention, absenteeism, and rotation of experienced staff; (6) poor work environment, including low salary; (7) limited and poor supervision; (8) low morale, motivation, and attitude, and job dissatisfaction; (9) weaknesses of policy, regulations, management, leadership, governance, and funding; and (10) structural and contextual barriers.

CONCLUSION

The mapping provides needed insight that informed new World Health Organization strategies and supporting efforts to address the challenges identified and strengthen human resources for neonatal care, with the ultimate goal of improving newborn care and outcomes.

Financial protection and equity of access to health services with the free maternal and child health initiative in Lao PDR

Though Lao People’s Democratic Republic (Lao PDR) has made considerable progress in improving maternal and child health (MCH), significant disparities exist nationwide, with the poor and geographically isolated ethnic groups having limited access to services. In its pursuit of universal health coverage, the government introduced a Free MCH initiative in 2011, which has recently been subsumed within the new National Health Insurance (NHI) programme. Although this was a major national health financing reform, there have been few evaluations of the extent to which it improved equitable access to MCH services. We analyse surveys that provide information on demand-side and supply-side factors influencing access and utilization of free MCH services, especially for vulnerable groups. This includes two rounds of household surveys (2010 and 2013) in southern Lao PDR involving, respectively 2766 and 2911 women who delivered within 24 months prior to each survey. These data have been analysed according to the socio-economic status, geographic location and ethnicity of women using the MCH services as well as any associated out-of-pocket expenses and structural quality of these services. Two other surveys analysed here focused on human resources for health and structural quality of health facilities. Together, these data point to persistent large inequities in access and financial protection that need to be addressed. Significant differences were found in the utilization of health services by both economic status and ethnicity. Relatively large costs for institutional births were incurred by the poor and did not decline between 2010 and 2013 whereby there was no significant impact on financial protection. The overall benefit incidence of the universal programme was not pro-poor. The inequity was accentuated by issues related to distribution and nature of human resources, supply-side readiness and thus quality of care provided across different geographical areas.

Health workers' views on audit in maternal and newborn healthcare in LMICs: a qualitative evidence synthesis

OBJECTIVES

To identify and summarise health workers' views on the use of audit as a method to improve the quality of maternal and newborn healthcare in low- and middle-income countries (LMICs).

METHODS

We conducted a qualitative evidence synthesis. PubMed, CINAHL and Global Health databases were searched using keywords, synonyms and MeSH headings for 'audit', 'views' and 'health workers' to find papers that used qualitative methods to explore health workers' views on audit in LMICs. Titles and abstracts were then screened for inclusion. The remaining full-text papers were then screened. The final included papers were quality assessed using the Critical Appraisal Skills Programme tool for qualitative research. Data on audit type and health workers' perceptions were extracted and analysed using thematic synthesis.

RESULTS

Nineteen papers were included in the review, most from sub-Saharan Africa. Health workers generally held favourable views of audit and expressed dedication to the process. Similarly, they described positive experiences conducting audit. The main barriers to implementing audit were the presence of a blame culture, inadequate training and the lack of time and resources to conduct audit. Health workers' motivation and dedication to the audit process helped to overcome such barriers.

CONCLUSIONS

Health workers are dedicated to the process of audit, but must be supported with training, leadership and adequate resources to use it. Decision-makers and technical partners supporting audit should focus on improving audit training and finding ways to conduct audit without requiring too much staff time.

Adapting the 2015 Mother-Baby Friendly Birth Facility Guidelines for Semi-nomadic Pastoralist Communities in Laikipia and Samburu Counties of Kenya

Purpose To adapt the 2015 International Federation of Gynecologists and Obstetricians (FIGO), International Confederation of Midwives (ICM), White Ribbon Alliance (WRA), International Pediatric Association (IPA), and WHO auspiced Guidelines on Mother-Baby Friendly Facilities to a particular sub-population; seminomadic pastoralist communities of Laikipia and Samburu Counties, Kenya. We anticipate an increased utilization of childbirth services by improving their acceptability. Description We drafted a Pastoralist Friendly Birthing Facility Checklist based on the FIGO/ICM/WRA/IPA/WHO guidelines and previous research in this context. We employed mixed methods to finalise the adaptation: a workshop with 27 local stakeholders; interviews with ten health planners and skilled birth attendants (SBAs); and ten focus group discussions (FGDs) with health committee members, community health workers, mothers and traditional birth attendants (TBAs). A facility audit of dispensaries across five group ranches was also undertaken. Assessment The final Checklist was divided into: characteristics of care and the environment; care during labour and birth; post-partum care; and community staff relationships. It was endorsed by the Ministries of Health in the relevant counties, and by women, SBAs and TBAs. No facility currently satisfies all the criteria specified in the Checklist. Conclusion The FIGO/ICM/WRA/IPA/WHO Guidelines were successfully adapted and can be used to ensure health facilities meet the needs of pastoralist women.

Improvement of Quality of Antenatal Care (ANC) Service Provision at the Public Health Facilities in Lao PDR: Perspective and Experiences of Supply and Demand Sides

BACKGROUND

The maternal mortality rate in Lao PDR (Laos) is still the highest in Southeast Asia, at 197 per 100,000 live births. Antenatal care (ANC) could contribute to maternal and child mortality reduction. The quality of ANC service remains inadequate and little information is available on the quality of health education and counseling services of health providers in Laos. This study aims to gain insight into the perceptions of stakeholders on both supply and demand sides of public ANC services in Laos and evidence for recommendations to improve the quality of ANC services.

METHODS

Semi-structured interviews were conducted with 50 participants from different stakeholder groups; on the demand side, couples with a currently pregnant woman and mothers with children under one year of age and a family member; and on the supply side, health providers, managers, policy makers of the Ministry of Health, and development partners. The interviews were voice recorded and transcribed verbatim for analysis by open and thematic coding, using the MAXQDA software program.

RESULTS

All respondents reported that the number of pregnant women who visit ANC services has increased. However, an analysis of the supply side identified issues related to the quality of ANC that need to be improved in the areas of facilities, human resources, privacy and confidentiality, providers' behavior, attitudes, and ineffective communication skills when it comes to providing health education and counseling to pregnant women and their family members. The analysis of the demand side mainly emphasized the issues of providers' behavior, attitude, communication and unequal treatment, and the lack of privacy. Both sides also suggested solutions to the problems, such as training, effective materials, rewarding good role models, and building a feedback system.

CONCLUSION

The number of public ANC services has increased, but both supply and demand sides experienced challenges with the quality of ANC. All respondents proposed possible solutions to improve quality of ANC service in public health facilities in Laos.

Do health care providers give sufficient information and good counseling during ante-natal care in Lao PDR?: an observational study

Background

It is increasingly recognized that improving the quality of maternal health care delivery is of utmost importance in many countries. In Laos, the quality of antenatal care (ANC) service remains inadequate, but it has never been assessed thoroughly. This study aims to determine the ANC quality at the urban and rural public health facilities in Laos and provides suggestions to improve health education and counseling in addition to other routine care in public ANC services.

Methods

This health-facility based, cross-sectional observation study included both health providers (n = 77) and pregnant women (n = 421) from purposively selected health facilities (n = 16). Information on the mothers’ current pregnancies, previous visits and their last children was collected. The time spent for each ANC session as well as ANC services provided were recorded. Descriptive and inferential statistics were applied to analyze the data.

Results

Overall performance of ANC services by health care providers was poor in both urban and rural areas. Insufficient provision of information on danger signs during pregnancy, nutrition, breast feeding and iron supplements was revealed. Generally the communication skills, behavior and attitude of health providers were very poor. Less than a quarter of pregnant women were treated with kindness and respect. Only 4% of the observed ANC session took privacy into consideration. Less than 10% of available information materials were used during each ANC session. None of the health providers in both rural and urban areas performed specific counseling. Overall mean (SD) time-spent for each ANC session was 16.21 (4.28) minutes. A positive correlation was identified between the length of working experience of health providers and their physical performance scores (adjusted R square = 0.017).

Conclusions

The overall performance of ANC services by health care providers was inadequate in both urban and rural areas. Insufficient provision of health education and poor communication skills of health care providers were revealed. Existing IEC materials were scarcely used. Taking action to improve the quality of ANC services by training and providing specific guidelines, creating dedicated rooms, and providing sufficient and effective materials for counseling are all greatly needed in public health facilities in Laos.

Implementation of free maternal and child healthcare policies: assessment of influence of context and institutional capacity of health facilities in South-east Nigeria

BACKGROUND

Studies examining how the capacity of health facilities affect implementation of free healthcare policies in low and middle-income countries are limited.

OBJECTIVE

This study describes how the context and institutional capacity of health facilities influenced implementation of the free maternal and child health programme (FMCHP) in Enugu state, South-east Nigeria.

METHODS

We conducted a qualitative case study at the state level and in two health districts (Isi-Uzo and Enugu Metropolis) in Enugu State. Data were collected through document review and semi-structured, in-depth interviews with policymakers (n = 16), healthcare providers (n = 16) and health facility committee leaders (n = 12) guided by an existing capacity framework and analysed using a thematic framework approach.

RESULTS

The findings reveal that active health facility committees, changes in provider payment process, supportive supervision, drug revolving fund, availability of medical equipment, electronic data transmission and staff sanction system enhanced the capacity of health facilities to offer free healthcare. However, ineffective decentralisation, irregular supervision and weak citizen participation limited this capacity. Uncertain provider payment, evidence of tax payment policy and a co-existing fee-exempt scheme constrained health facilities in following the FMCHP guidelines. Poor recording and reporting skills and lack of support from district officials constrained providers' adherence to claims' submission timeline. Poor funding, weak drug supply system, inadequate infrastructure and lack of participatory decision-making constrained delivery of free healthcare. Insufficient trained workforce, mission-inconsistent postings and transfers, and weak staff disciplinary system limited the human resource capacity.

CONCLUSIONS

Effectiveness of FMCHP at the health facility level depends on the extent of decentralisation, citizen participation, concurrent and conflictive policies, timely payment of providers, organisation of service delivery and human resources practices. Attention to these contextual and institutional factors will enhance responsiveness of health facilities, sustainability of free healthcare policies and progress towards universal health coverage.

Treatment-seeking behaviour for febrile illnesses and its implications for malaria control and elimination in Savannakhet Province, Lao PDR (Laos): a mixed method study

Background

How people respond to febrile illness is critical to malaria prevention, control, and ultimately elimination. This article explores factors affecting treatment-seeking behaviour for febrile illnesses in a remote area of Lao PDR.

Methods

Household heads or their representatives (n = 281) were interviewed using a structured questionnaire. A total of twelve focus group discussions (FGDs) each with eight to ten participants were conducted in four villages. In addition, observations were recorded as field notes (n = 130) and were used to collect information on the local context, including the treatment seeking behaviour and the health services.

Results

Almost three-quarters (201/281) of respondents reported fever in past two months. Most (92%, 185/201) sought treatment of which 80% (149/185) sought treatment at a health centre. Geographic proximity to a health centre (AOR = 6.5; CI = 1.74–24.25; for those < 3.5 km versus those > 3.6 km) and previous experience of attending a health centre (AOR = 4.7; CI = 1.2–19.1) were strong predictors of visiting a health centre for febrile symptoms. During FGDs, respondents described seeking treatment from traditional healers and at health centre for mild to moderate illnesses. Respondents also explained how if symptoms, including fever, were severe or persisted after receiving treatment elsewhere, they sought assistance at health centres. Access to local health centres/hospitals was often constrained by a lack of transportation and an ability to meet the direct and indirect costs of a visit.

Conclusion

In Nong District, a rural area bordering Vietnam, people seek care from health centres offering allopathic medicine and from spiritual healers. Decisions about where and when to attend health care depended on their economic status, mobility (distance to the health centre, road conditions, availability of transport), symptoms severity and illness recognition. Current and future malaria control/elimination programmes could benefit from greater collaboration with the locally accessible sources of treatments, such as health volunteers and traditional healers.

Determinants of continuum of care for maternal, newborn, and child health services in rural Khammouane, Lao PDR

INTRODUCTION

The concept of continuum of care has gained attention as measures to improve maternal, newborn, and child health. However, little is known about the factors associated with the coverage level of continuum of care in Lao PDR. Therefore, this study was conducted 1) to investigate the coverage level of continuum of care and 2) to identify barriers and promoting factors that are associated with mothers' continuation in receiving services in rural Lao PDR.

METHODS

A community-based, cross sectional study was conducted in a rural district in Khammouane Province, Lao PDR, using a structured questionnaire. The outcome to the express continuum of care was assessed by the modified composite coverage index (CCI) that reflects ten maternal and child health services.

RESULTS

In total, 263 mothers were included in the final analyses. Only 6.8% of mothers continued to receive all MNCH services. Five factors were shown to have statistically significant associations with modified CCI score: higher educational attainment (B = 0.070, p<0.001), being a farmer (B = -0.078, p = 0.003), receiving the first antenatal care within the first trimester (B = 0.109, p<0.001), longer distance from district hospital (B = -0.012, p<0.001), and discussion with husband or family members (B = 0.057, p = 0.022).

CONCLUSIONS

In this study, we introduced the modified CCI to better explain the utilization of preventive maternal and child health services along with the continuum of care. By utilizing the modified CCI, we identified five factors as determinants of continuum of care. Furthermore, new and modifiable promoting factors were identified for continuum of care: receiving the first antenatal care within the first trimester and family and male involvement. Such demand side actions should be encouraged to improve the continuity of MNCH service use.

Patients' adherence to artemisinin-based combination therapy and healthcare workers' perception and practice in Savannakhet province, Lao PDR

Background

Artemisinin resistance in Plasmodium falciparum has been spreading across Southeast Asia. Patients’ adherence to artemisinin-based combination therapy (ACT) is critical to avoid expanding this resistance. The objectives of this research were to examine patients’ adherence to ACT for the treatment of uncomplicated malaria and to examine the healthcare workers’ perception of medication adherence and their dispensing practices for malaria patients in Savannakhet province, Lao PDR.

Methods

A prospective observational study of patients and a descriptive study of healthcare workers were conducted in Xepon, Phin, and Nong districts. In the patient study, patients aged 18 years old or older who were prescribed artemether-lumefantrine (AL) at six healthcare facilities between October 2016 and August 2017 were examined. Patient interviews and tablet counts were conducted on the first day of treatment (day 0) and the follow-up day (around day 3). In the healthcare workers study, a self-administered questionnaire survey was conducted.

Results

Of the 54 patients examined, 51 (94.4%) were adherent to the AL regimen. The other three patients stopped medication because they felt better, even though the importance of completing the regimen was explained to all patients when it was prescribed. Among 152 healthcare workers who had ever instructed a malaria patient, 74.3% reported that they occasionally saw a malaria patient who adhered poorly to medication instructions. The healthcare workers perceived the major reasons for poor adherence to be illiteracy and poor understanding of medication instructions by patients. In practice, 27.6% of the healthcare workers did not regularly explain the importance of completing the regimen to patients, and 32.2% did not often or always confirm the patients’ understanding of medication instructions.

Conclusions

Patient adherence to AL was high. The healthcare workers perceived that poor adherence was attributable to the patients, i.e., their poor understanding and illiteracy, which appeared to be related to linguistic differences. However, poor adherence also appeared to be attributable to the healthcare workers, who should tell patients of the importance of completing the AL regimen regardless of their improvement in physical condition and also confirm the patients’ understanding of the instructions.

Electronic supplementary material

The online version of this article (10.1186/s41182-018-0125-6) contains supplementary material, which is available to authorized users.

Barriers and facilitators to institutional delivery in rural areas of Chitwan district, Nepal: a qualitative study

BACKGROUND

Giving birth assisted by skilled care in a health facility plays a vital role in preventing maternal deaths. In Nepal, delivery services are free and a cash incentive is provided to women giving birth at a health facility. Nevertheless, about half of women still deliver at home. This study explores socio-cultural and health service-related barriers to and facilitators of institutional delivery.

METHODS

Six village development committees in hill and plain areas were selected in Chitwan district. We conducted a total of 10 focus group discussions and 12 in-depth-interviews with relevant stakeholder groups, including mothers, husbands, mothers-in-law, traditional birth attendants, female community health volunteers, health service providers and district health managers. Data were analyzed inductively using thematic analysis.

RESULTS

Three main themes played a role in deciding the place of delivery, i.e. socio-cultural norms and values; access to birthing facilities; and perceptions regarding the quality of health services. Factors encouraging an institutional delivery included complications during labour, supportive husbands and mothers-in-law, the availability of an ambulance, having birthing centres nearby, locally sufficient financial incentives and/or material incentives, the 24-h availability of midwives and friendly health service providers. Socio-cultural barriers to institutional deliveries were deeply held beliefs about childbirth being a normal life event, the wish to be cared for by family members, greater freedom of movement at home, a warm environment, the possibility to obtain appropriate "hot" foods, and shyness of young women and their position in the family hierarchy. Accessibility and quality of health services also presented barriers, including lack of road and transportation, insufficient financial incentives, poor infrastructure and equipment at birthing centres and the young age and perceived incompetence of midwives.

CONCLUSION

Despite much progress in recent years, this study revealed some important barriers to the utilization of health services. It suggests that a combination of upgrading birthing centres and strengthening the competencies of health personnel while embracing and addressing deeply rooted family values and traditions can improve existing programmes and further increase institutional delivery rates.

Measuring health literacy in university students in Vientiane, Lao PDR

Health literacy includes the knowledge, motivation and competence of a person to make judgments and decisions on health information in order to promote and maintain their health in relation to health care, disease prevention and health promotion. The role health literacy plays in determining health outcomes makes it an important focus of public health research. In line with a larger Asia wide initiative (HLS-Asia), this study set out to measure health literacy in the Lao People's Democratic Republic (Lao-PDR). A mixed-methods study design was employed. The HLS-Asia questionnaire was conducted as a self-administered survey with first year students at the National University of Lao PDR in Vientiane. The survey was complimented with in-depth, vignette style interviews. Student's scores on the questionnaire showed problematic health literacy levels, with clear patterns to the type of questions students struggled with. However, responses in the interviews suggested a higher level of health literacy. These findings highlight the importance of health systems and social context in health literacy. The results question the appropriateness of the HLS measurement tool, but more broadly suggest that health literacy may be a concept only comparable between populations when social, economic and health systems are measured concurrently.

Recovering disrupted social capital: insights from Lao DPR rural villagers' perceptions of local leadership

Background

Social capital is often believed to be one of the key prerequisites for successful implementation of community-based health programs. In less-developed countries, local leaders are positioned as major players in broad community health strategies and interventions, and their capacities and roles are expected to increase in prominence in future community-health-care promotions. In this study, we examined how local leaders’ capacities could be related to social capital in rural villages in Lao PDR, and thus to villagers’ willingness to participate in community-based health efforts.

Methods

We adopted a qualitative approach, conducting semi-structured interviews for both individuals and focus groups. In 2012, 103 people from six villages in the Khoun and Phoukoud districts participated in the interviews. For the individual interviews, we interviewed 22 mothers who had given birth in the past 5 years. For the focus groups, we interviewed 30 women (six groups), 30 men (six groups), and 21 senior villagers (five groups).

Results

First, we noted large variations in the levels of community social capital across villages: four out of six study villages showed a high level of social capital, while two villages suffered greatly from a low level of social capital. In search of the reasons for the disrupted social capital in the latter two villages, interviews revealed that failed leadership, especially in regard to local resource allocations—lack of transparency and corrupt practices—were commonly cited reasons for disrupted social capital. The data also showed that the villagers’ mistrust of these failed local leaders critically reduced their willingness to participate in community-based health efforts, and especially in those that involved resource mobilization and risk-sharing for healthcare. Finally, we found that good communication skills and participatory decision-making styles were attributes that rural villagers in Lao PDR expected of their local leaders.

Conclusion

This study suggests that failed local leadership is detrimental to community participation, resource mobilization, and building communities’ social capital. To achieve intended health care goals through community-based interventions, there is a need to first support local leadership at all levels through capacity-building and improved communication within communities.

Implementing a culturally appropriate birthing policy: Ethnographic analysis of the experiences of skilled birth attendants in Peru

Policies about skilled birth attendants (SBA) need to account for cultural acceptability of care rendered by SBAs. Few studies have assessed these policies from the perspective of SBAs. I identify challenges and analyze the experiences of SBAs implementing a culturally appropriate birth care policy in Peru. I collected data during 15 months of ethnographic research: conducting semi-structured interviews and informal conversations with 5 SBAs in 2 villages and with health officials. I compared interview results with my observations of consultations and of labor and delivery. Weak institutional support, lack of training, negative perceptions of the policy inhibited implementation, as did detrimental effects on future personal and professional opportunities. SBAs in Peru face many challenges when trying to establish intercultural birth care. My recommendations include provision of focused training, promoting a more diverse workforce, and increasing community engagement.Journal of Public Health Policy advance online publication, 19 May 2016; doi:10.1057/jphp.2016.19.

[Utilization of tacit knowledge by maternal healthcare providers: a systematic mapping of the literature]

INTRODUCTION

The search for efficient answers to strengthen maternal health care has included various sources of evidence for decision making. In this article, we present a systematic mapping of the scientific literature on the use of tacit knowledge in relation to maternal healthcare.

METHODS

A systematic mapping was conducted of scientific articles published in Spanish and English between 1971 and 2014 following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

Of 793 articles, 30 met the inclusion criteria; 60% were from high-income countries and 66.7% were focused on health professionals. We identified a predominance of qualitative methodologies (62%). Four categories regarding the use of tacit knowledge were generated: proposals to improve the organization of the maternal care system (30%) and to improve the care provided to women during the continuum of pregnancy, childbirth and postpartum (26.7%), determination of health workers' perception and skill levels (26.7%) and the interactions between tacit and explicit knowledge in clinical decision making (16.7%).

CONCLUSIONS

This mapping shows that tacit knowledge is an emerging, innovative and versatile research approach used primarily in high-income countries and that includes interesting possibilities for its use as evidence to improve maternal healthcare, particularly in middle- and low-income countries, where it needs to be strengthened.

Provider perspectives on the enabling environment required for skilled birth attendance: a qualitative study in western Nepal

OBJECTIVES

In Nepal, where difficult geography and an under-resourced health system contribute to poor health care access, the government has increased the number of trained skilled birth attendants (SBAs) and posted them in newly constructed birthing centres attached to peripheral health facilities that are available to women 24 h a day. This study describes their views on their enabling environment.

METHODS

Qualitative methods included semi-structured interviews with 22 SBAs within Palpa district, a hill district in the Western Region of Nepal; a focus group discussion with ten SBA trainees, and in-depth interviews with five key informants.

RESULTS

Participants identified the essential components of an enabling environment as: relevant training; ongoing professional support; adequate infrastructure, equipment and drugs; and timely referral pathways. All SBAs who practised alone felt unable to manage obstetric complications because quality management of life-threatening complications requires the attention of more than one SBA.

CONCLUSIONS

Maternal health guidelines should account for the provision of an enabling environment in addition to the deployment of SBAs. In Nepal, referral systems require strengthening, and the policy of posting SBAs alone, in remote clinics, needs to be reconsidered to achieve the goal of reducing maternal deaths through timely management of obstetric complications.