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Tesha GE, Makwaruzi S, Haws R, Mostel J, Lusasi A, Lazaro S, Mwaikambo S, Chacky F, Reaves E, Kitojo C, Serbantez N, Tetteh G, Wolf K, Oseni L. Understanding Antenatal Care Service Quality for Malaria in Pregnancy through Supportive Supervision Data in Tanzania. Am J Trop Med Hyg 2024; 110:56-65. [PMID: 38320309 PMCID: PMC10919228 DOI: 10.4269/ajtmh.23-0399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/01/2023] [Indexed: 02/08/2024] Open
Abstract
Malaria in pregnancy (MiP) is associated with maternal anemia, spontaneous abortion, and infant and maternal death. In Tanzania, MiP service data are collected through routine Malaria Services and Data Quality Improvement (MSDQI) supportive supervision rounds at antenatal care (ANC) facilities. Using structured assessment tools, the U.S. President's Malaria Initiative Impact Malaria Project reviewed two annual rounds of MSDQI data (492 facilities in 2021 and 522 facilities in 2022), including ANC records and client satisfaction interviews. We assessed coverage of key MiP care components, used logistic regression to analyze uptake of the recommended three or more doses of intermittent preventive treatment in pregnancy (IPTp3+), and assessed client satisfaction. Coverage of most MiP care components exceeded 80%; however, only 38% of women received all components. Odds of receiving IPTp3+ were much lower among late ANC initiators than among those who initiated ANC during their first trimester (odds ratio [OR], 0.46; 95% CI, 0.38-0.57). Uptake of IPTp3+ increased almost exponentially by number of ANC visits. Women with seven visits were 30 times more likely than those with three visits to receive IPTp3+ (OR, 30.71; 95% CI, 11.33-83.22). Just 54% of clients had anemia screening and only 46% received IPTp3+. Client satisfaction with services and provider communication was high (98% and 97%, respectively); only 8% of client visits exceeded 3 hours. Increased ANC visits could boost IPTp3+ coverage. Routine MSDQI supportive supervision data are useful to assess quality of care, identify service delivery gaps, and guide policies to improve quality of MiP services.
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Affiliation(s)
- Goodluck Elias Tesha
- U.S. President’s Malaria Initiative Impact Malaria Project, Dar es Salaam, Tanzania
| | - Stella Makwaruzi
- U.S. President’s Malaria Initiative Impact Malaria Project, Dar es Salaam, Tanzania
| | - Rachel Haws
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jadmin Mostel
- U.S. President’s Malaria Initiative Impact Malaria Project, Washington, District of Columbia
| | - Abdallah Lusasi
- Ministry of Health, National Malaria Control Program, Dodoma, Tanzania
| | - Samwel Lazaro
- Ministry of Health, National Malaria Control Program, Dodoma, Tanzania
| | | | - Frank Chacky
- Ministry of Health, National Malaria Control Program, Dodoma, Tanzania
| | - Erik Reaves
- U.S. President’s Malaria Initiative, U.S. Centers for Disease Control and Prevention, Dar es Salaam, Tanzania
| | - Chonge Kitojo
- U.S. President’s Malaria Initiative, United States Agency for International Development, Dar es Salaam, Tanzania
| | - Naomi Serbantez
- U.S. President’s Malaria Initiative, United States Agency for International Development, Dar es Salaam, Tanzania
| | - Gladys Tetteh
- U.S. President’s Malaria Initiative Impact Malaria Project, Washington, District of Columbia
| | - Katherine Wolf
- U.S. President’s Malaria Initiative Impact Malaria Project, Washington, District of Columbia
| | - Lolade Oseni
- U.S. President’s Malaria Initiative Impact Malaria Project, Washington, District of Columbia
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Cardona-Arias JA. Synthesis of Qualitative Evidence on Malaria in Pregnancy, 2005-2022: A Systematic Review. Trop Med Infect Dis 2023; 8:tropicalmed8040235. [PMID: 37104360 PMCID: PMC10145031 DOI: 10.3390/tropicalmed8040235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023] Open
Abstract
Qualitative research on malaria in pregnancy (MiP) is incipient, therefore its contextual, experiential and symbolic associated factors are unknown. This study systematizes the qualitative research on MiP, describes knowledge, perceptions and behaviors about MiP, and compiles individual, socioeconomic, cultural and health system determinants of MiP through a meta-synthesis in 10 databases. A total of 48 studies were included with 2600 pregnant women, 1300 healthcare workers, and 2200 relatives or community members. Extensive knowledge was demonstrated on ITN and case management, but it was lacking on SP-IPTp, risks and consequences of MiP. Attitudes were negative towards ANC and MiP prevention. There were high trustfulness scores and preference for traditional medicine and distrust in the safety of drugs. The main determinants of the Health System were rationing, copayments, delay in payment to clinics, high out-of-pocket expenses, shortage, low workforce and work overload, shortcomings in care quality, low knowledges of healthcare workers on MiP and negative attitude in care. The socioeconomic and cultural determinants were poverty and low educational level of pregnant women, distance to the hospital, patriarchal-sexist gender roles, and predominance of local conceptions on maternal-fetal-neonatal health. The meta-synthesis demonstrates the difficulty to detect MiP determinants and the importance of performed qualitative research before implementing MiP strategies to understand the multidimensionality of the disease.
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Affiliation(s)
- Jaiberth Antonio Cardona-Arias
- Research Group Salud y Comunidad-César Uribe Piedrahita, School of Microbiology, Universidad de Antioquia UdeA, Calle 70 No. 52-21, Medellin 050010, Colombia
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Aberese-Ako M, Doegah P, Acquah E, Magnussen P, Ansah E, Ampofo G, Agyei DD, Klu D, Mottey E, Balen J, Doumbo S, Mbacham W, Gaye O, Gyapong M, Owusu-Agyei S, Tagbor H. Motivators and demotivators to accessing malaria in pregnancy interventions in sub-Saharan Africa: a meta-ethnographic review. Malar J 2022; 21:170. [PMID: 35659232 PMCID: PMC9166609 DOI: 10.1186/s12936-022-04205-7] [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: 02/11/2022] [Accepted: 05/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background Despite the introduction of efficacious interventions for malaria control, sub-Saharan Africa continues to bear the highest burden of malaria and its associated effects on vulnerable populations, such as pregnant women and children. This meta-ethnographic review contributes to literature on malaria in pregnancy interventions in sub-Saharan Africa by offering insights into the multiple factors that motivate or demotivate women from accessing MiP interventions. Methods A meta-ethnographic approach was used for the synthesis. Original qualitative research articles published from 2010 to November 2021 in English in sub-Saharan Africa were searched for. Articles focusing on WHO’s recommended interventions such as intermittent preventive treatment with sulfadoxine-pyrimethamine, long-lasting insecticidal nets and testing and treatment of Malaria in Pregnancy (MiP) were included. Selected articles were uploaded into Nvivo 11 for thematic coding and synthesis. Results Twenty-seven original qualitative research articles were included in the analysis. Main factors motivating uptake of MiP interventions were: (1) well organized ANC, positive attitudes of health workers and availability of MiP services; (2) Women’s knowledge of the effects of malaria in pregnancy, previous experience of accessing responsive ANC; (3) financial resources and encouragement from partners, relatives and friends and (4) favourable weather condition and nearness to a health facility. Factors that demotivated women from using MiP services were: (1) stock-outs, ANC charges and health providers failure to provide women with ample education on the need for MiP care; (2) perception of not being at risk and the culture of self-medication; (3) fear of being bewitched if pregnancy was noticed early, women’s lack of decision-making power and dependence on traditional remedies and (4) warm weather, long distances to health facilities and the style of construction of houses making it difficult to hang LLINs. Conclusions Health system gaps need to be strengthened in order to ensure that MiP interventions become accessible to women. Additionally, health managers need to involve communities in planning, designing and implementing malaria interventions for pregnant women. It is important that the health system engage extensively with communities to facilitate pregnant women and communities understanding of MiP interventions and the need to support pregnant women to access them.
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Affiliation(s)
| | - Phidelia Doegah
- University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Evelyn Acquah
- University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Evelyn Ansah
- University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Gifty Ampofo
- University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | | | - Desmond Klu
- University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Elsie Mottey
- University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Julie Balen
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Safiatou Doumbo
- University of Sciences, Techniques and Technologies of Bamako, Malaria Research and Training Center, Bamako, Mali
| | - Wilfred Mbacham
- The Fobang Institutes for Innovations in Science and Technologies & The Biotechnology Center, The Centre for Health Innovations and Translational Research, University of Yaounde I, Yaounde, Cameroon
| | - Ouma Gaye
- Faculty of Medicine, University Cheikh Anta Diop Dakar, Dakar, Senegal
| | - Margaret Gyapong
- University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Seth Owusu-Agyei
- University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Harry Tagbor
- University of Health and Allied Sciences, Ho, Volta Region, Ghana
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Aberese-Ako M, Magnussen P, Ampofo GD, Gyapong M, Ansah E, Tagbor H. An ethnographic study of how health system, socio-cultural and individual factors influence uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in a Ghanaian context. PLoS One 2021; 16:e0257666. [PMID: 34618812 PMCID: PMC8496863 DOI: 10.1371/journal.pone.0257666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 09/08/2021] [Indexed: 11/29/2022] Open
Abstract
Background Intermittent preventive treatment of malaria among pregnant women with sulfadoxine-pyrimethamine (IPTp-SP), is one of the three recommended interventions for the prevention of malaria in pregnancy (MiP) in sub-Sahara Africa. The World Health Organisation recommended in 2012 that SP be given at each scheduled ANC visit except during the first trimester and can be given a dose every month until the time of delivery, to ensure that a high proportion of women receive at least three doses of SP during pregnancy. Despite implementation of this policy, Ghana did not attain the target of 100% access to IPTp-SP by 2015. Additionally, negative outcomes of malaria infection in pregnancy are still recurring. This ethnographic study explored how health system, individual and socio-cultural factors influence IPTp-SP uptake in two Ghanaian regions. Methods The study design was ethnographic, employing non-participant observation, case studies and in depth interviews in 8 health facilities and 8 communities, from April 2018 to March 2019, in two Ghanaian regions. Recommended ethical procedures were observed. Results Health system factors such as organization of antenatal care (ANC) services and strategies employed by health workers to administer SP contributed to initial uptake. Women’s trust in the health care system contributed to continued uptake. Inadequate information provided to women accessing ANC, stock-outs and fees charged for ANC services reduced access to IPTp-SP. Socio-cultural factor such as encouragement from social networks influenced utilization of ANC services and IPTp-SP uptake. Individual factors such as refusing to take SP, skipping ANC appointments and initiating ANC attendance late affected uptake. Conclusion Health system, socio-cultural and individual factors influence uptake of optimum doses of IPTp-SP. Consequently, interventions that aim at addressing IPTp-SP uptake should focus on regular and sufficient supply of SP to health facilities, effective implementation of free ANC, provision of appropriate and adequate information to women and community outreach programmes to encourage early and regular ANC visits.
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Affiliation(s)
- Matilda Aberese-Ako
- Institute of Health Research, University of Health and Allied Sciences, Ho, Volta Region, Ghana
- * E-mail: ,
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Gifty D. Ampofo
- School of Medicine, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Margaret Gyapong
- Institute of Health Research, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Evelyn Ansah
- Institute of Health Research, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Harry Tagbor
- School of Medicine, University of Health and Allied Sciences, Ho, Volta Region, Ghana
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Aberese-Ako M, Magnussen P, Gyapong M, Ampofo GD, Tagbor H. Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions. Malar J 2020; 19:347. [PMID: 32977827 PMCID: PMC7519547 DOI: 10.1186/s12936-020-03422-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/20/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Malaria in pregnancy (MiP) is an important public health problem across sub-Saharan Africa. The package of measures for its control in Ghana in the last 20 years include regular use of long-lasting insecticide-treated bed nets (LLINs), directly-observed administration (DOT) of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and prompt and effective case management of MiP. Unfortunately, Ghana like other sub-Saharan African countries did not achieve the reset Abuja targets of 100% of pregnant women having access to IPTp and 100% using LLINs by 2015. METHODS This ethnographic study explored how healthcare managers dealt with existing MiP policy implementation challenges and the consequences on IPTp-SP uptake and access to maternal healthcare. The study collected date using non-participant observations, conversations, in-depth interviews and case studies in eight health facilities and 12 communities for 12 months in two Administrative regions in Ghana. RESULTS Healthcare managers addressed frequent stock-outs of malaria programme drugs and supplies from the National Malaria Control Programme and delayed reimbursement from the NHIS, by instituting co-payment, rationing and prescribing drugs for women to buy from private pharmacies. This ensured that facilities had funds to pay creditors, purchase drugs and supplies for health service delivery. However, it affected their ability to enforce DOT and to monitor adherence to treatment. Women who could afford maternal healthcare and MiP services and those who had previously benefitted from such services were happy to access uninterrupted services. Women who could not maternal healthcare services resorted to visiting other sources of health care, delaying ANC and skipping scheduled ANC visits. Consequently, some clients did not receive the recommended 5 + doses of SP, others did not obtain LLINs early and some did not obtain treatment for MiP. Healthcare providers felt frustrated whenever they could not provide comprehensive care to women who could not afford comprehensive maternal and MiP care. CONCLUSION For Ghana to achieve her goal of controlling MiP, the Ministry of Health and other supporting institutions need to ensure prompt reimbursement of funds, regular supply of programme drugs and medical supplies to public, faith-based and private health facilities.
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Affiliation(s)
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Margaret Gyapong
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
| | - Gifty D Ampofo
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
| | - Harry Tagbor
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
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Floyd JR, Ogola J, Fèvre EM, Wardrop N, Tatem AJ, Ruktanonchai NW. Activity-specific mobility of adults in a rural region of western Kenya. PeerJ 2020; 8:e8798. [PMID: 32377444 PMCID: PMC7195828 DOI: 10.7717/peerj.8798] [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: 08/02/2019] [Accepted: 02/25/2020] [Indexed: 11/25/2022] Open
Abstract
Improving rural household access to resources such as markets, schools and healthcare can help alleviate poverty in low-income settings. Current models of geographic accessibility to various resources rarely take individual variation into account due to a lack of appropriate data, yet understanding mobility at an individual level is key to knowing how people access their local resources. Our study used both an activity-specific survey and GPS trackers to evaluate how adults in a rural area of western Kenya accessed local resources. We calculated the travel time and time spent at six different types of resource and compared the GPS and survey data to see how well they matched. We found links between several demographic characteristics and the time spent at different resources, and that the GPS data reflected the survey data well for time spent at some types of resource, but poorly for others. We conclude that demography and activity are important drivers of mobility, and a better understanding of individual variation in mobility could be obtained through the use of GPS trackers on a wider scale.
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Affiliation(s)
- Jessica R Floyd
- WorldPop, Department of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Joseph Ogola
- International Livestock Research Institute, Nairobi, Kenya
| | - Eric M Fèvre
- International Livestock Research Institute, Nairobi, Kenya.,Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Nicola Wardrop
- Department for International Development, Glasgow, United Kingdom
| | - Andrew J Tatem
- WorldPop, Department of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
| | - Nick W Ruktanonchai
- WorldPop, Department of Geography and Environmental Science, University of Southampton, Southampton, United Kingdom
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Aberese-Ako M, Magnussen P, Ampofo GD, Tagbor H. Health system, socio-cultural, economic, environmental and individual factors influencing bed net use in the prevention of malaria in pregnancy in two Ghanaian regions. Malar J 2019; 18:363. [PMID: 31718677 PMCID: PMC6852762 DOI: 10.1186/s12936-019-2994-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/04/2019] [Indexed: 12/04/2022] Open
Abstract
Background Improving maternal health remains a priority to the Ghanaian government. Consequently, it has implemented the World Health Organization recommendation of distributing free long-lasting insecticidal nets (LLINs) to pregnant women—one of the effective strategies to combating malaria in pregnancy. However, the burden of negative outcomes of malaria in pregnancy such as low birth weight and miscarriages is still high. This may be related to the health system, socio-cultural and economic dynamics that influence LLIN use, but their role is not well understood. This ethnographic study sought to understand health system, socio-cultural, economic and environmental dynamics in utilization of LLINs among pregnant women in two Ghanaian regions. Methods An ethnographic study design was used. In-depth interviews and conversations were conducted among health workers, pregnant women and opinion leaders. Observations were conducted in 12 communities and eight health facilities. Ethical clearance was obtained from the University of Health and Allied Sciences’ Research Ethics Committee. Nvivo 11 was used to support data coding. Data were triangulated and analysed using a thematic approach. Results Findings suggest health system, socio-cultural, economic, environmental and individual factors influenced LLIN use. Health facility readiness in stocking LLINs influenced ownership and use. Receiving appropriate information from health providers and encouragement from public officials improved LLIN use. Women with a history of LLIN use prior to becoming pregnant and women who had young children remained consistent users. Experiencing irritating effects of LLINs and preference for traditional methods to wade off mosquitoes, reduced LLIN use. Pregnant women whose household and family members used LLINs were influenced positively to use them. Gender power relations between husbands and wives influenced women’s use of LLINs. The type of housing and weather conditions contributed to inconsistent use. Staying out late for business purposes and to converse, exposed pregnant women to mosquito bites. Conclusion Giving out LLINs at facility level should be accompanied with comprehensive information, which is relevant to the socio-cultural context that women live in. Mass distribution should factor in individual and public information to promote community acceptance and proper use of ITNs. Facilities should be encouraged to constantly maintain LLINs stock in order to ensure that ANC registrants receive LLINs for use.
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Affiliation(s)
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Gifty D Ampofo
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
| | - Harry Tagbor
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
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Health care system changes supporting the development of the nurse practitioner role in Tanzania. J Am Assoc Nurse Pract 2019; 31:488-496. [DOI: 10.1097/jxx.0000000000000168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Geldsetzer P, Mboggo E, Larson E, Lema IA, Magesa L, Machumi L, Ulenga N, Sando D, Mwanyika-Sando M, Spiegelman D, Mungure E, Li N, Siril H, Mujinja P, Naburi H, Chalamilla G, Kilewo C, Ekström AM, Foster D, Fawzi W, Bärnighausen T. Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzania. PLoS Med 2019; 16:e1002768. [PMID: 30925181 PMCID: PMC6440613 DOI: 10.1371/journal.pmed.1002768] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 02/21/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Home delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home. METHODS AND FINDINGS As part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82-1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30-0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified. CONCLUSIONS A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC. TRIAL REGISTRATION ClinicalTrials.gov NCT01932138.
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Affiliation(s)
- Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Eric Mboggo
- Management and Development for Health, Dar es Salaam, Tanzania
- * E-mail:
| | - Elysia Larson
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | - Lucy Magesa
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Lameck Machumi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | - Donna Spiegelman
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Biostatistics, Center for Methods in Implementation and Prevention Science, Yale School of Public Health, Yale University, New Haven, Connecticut, United States of America
| | - Ester Mungure
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Nan Li
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Hellen Siril
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Phares Mujinja
- Department of Behavioural Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Helga Naburi
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Charles Kilewo
- Departments of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Dawn Foster
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut, United States of America
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, Connecticut, United States of America
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa
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Arnaldo P, Cambe MI, Magaço A, Chicumbe S, Rovira-Vallbona E, Rosanas-Urgell A, Enosse SM. Access to and use of preventive intermittent treatment for Malaria during pregnancy: A qualitative study in the Chókwè district, Southern Mozambique. PLoS One 2019; 14:e0203740. [PMID: 30677039 PMCID: PMC6345468 DOI: 10.1371/journal.pone.0203740] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 01/08/2019] [Indexed: 11/18/2022] Open
Abstract
Background Malaria remains a significant health problem in Mozambique, particularly in the case of pregnant women and children less than five years old. Intermittent preventive treatment with sulfadoxine-pyrimethamine (IPT-SP) is recommended for preventing malaria in pregnancy (MiP). Despite the widespread use and cost-effectiveness of IPTp-SP, coverage remains low. In this study, we explored factors limiting access to and use of IPTp-SP in a rural part of Mozambique. Methods and findings We performed a qualitative study using semi-structured interviews to collect data from 46 pregnant women and four health workers in Chókwè, a rural area of southern Mozambique. Data were transcribed, translated where appropriate, manually coded, and the content analyzed according to key themes. The women interviewed were not aware of the risks of MiP or the benefits of its prevention. Delays in accessing antenatal care, irregular attendance of visits, and insufficient time for proper antenatal care counselling by health workers were driving factors for inadequate IPTp delivery. Conclusions Pregnant women face substantial barriers in terms of optimal IPTp-SP uptake. Health system barriers and poor awareness of the risks and consequences of MiP and of the measures available for its prevention were identified as the main factors influencing access to and use of IPTp-SP. Implementation of MiP prevention strategies must be improved through intensive community health education and increased access to other sources of information. Better communication between health workers and ANC clients and better knowledge of national ANC and IPTp policies are important.
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Affiliation(s)
- Paulo Arnaldo
- Plataforma de Parasitologia Molecular, Instituto Nacional de Saúde, Maputo, Mozambique
- Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
- * E-mail:
| | - Maria Isabel Cambe
- Programa de Sistemas de Saúde, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Amílcar Magaço
- Programa de Sistemas de Saúde, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Sérgio Chicumbe
- Programa de Sistemas de Saúde, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Eduard Rovira-Vallbona
- Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Anna Rosanas-Urgell
- Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Sónia M. Enosse
- Plataforma de Parasitologia Molecular, Instituto Nacional de Saúde, Maputo, Mozambique
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11
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Eckhardt M, Carlfjord S, Faresjö T, Crespo-Burgos A, Forsberg BC, Falk M. Universal Health Coverage in Marginalized Populations: A Qualitative Evaluation of a Health Reform Implementation in Rural Ecuador. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2019; 56:46958019880699. [PMID: 31578919 PMCID: PMC6777057 DOI: 10.1177/0046958019880699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 11/17/2022]
Abstract
In 2008, Ecuador underwent a major health reform with the aim of universal coverage. Little is known about the implementation of the reform and its perceived effects in rural parts of the country. The aim of this study was to explore the perceived effects of the 2008 health reform implementation, on rural primary health care services and financial access of the rural poor. A qualitative study using focus group discussions was conducted in a rural region in Ecuador, involving health staff, local health committee members, village leaders, and community health workers. Qualitative content analysis focusing on the manifest content was applied. Three categories emerged from the texts: (1) the prereform situation, which was described as difficult in terms of financial access and quality of care; (2) the reform process, which was perceived as top-down and lacking in communication by the involved actors; lack of interest among the population was reported; (3) the effects of the reform, which were mainly perceived as positive. However, testimonies about understaffing, drug shortages, and access problems for those living furthest away from the health units show that the reform has not fully achieved its intended effects. New problems are a challenging health information system and people without genuine care needs overusing the health services. The results indicate that the Ecuadorean reform has improved rural primary health care services. Still, the reform faces challenges that need continued attention to secure its current achievements and advance the health system further.
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12
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Yasuoka J, Nanishi K, Kikuchi K, Suzuki S, Ly P, Thavrin B, Omatsu T, Mizutani T. Barriers for pregnant women living in rural, agricultural villages to accessing antenatal care in Cambodia: A community-based cross-sectional study combined with a geographic information system. PLoS One 2018; 13:e0194103. [PMID: 29554118 PMCID: PMC5858830 DOI: 10.1371/journal.pone.0194103] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 02/23/2018] [Indexed: 11/18/2022] Open
Abstract
Background Maternal morbidity and mortality is still a major public health issue in low- and middle-income countries such as Cambodia. Improving access to antenatal care (ANC) services for pregnant women has been widely recognized as one of the most effective means of reducing maternal mortality and morbidity. As such, this study examined the barriers for pregnant women living in rural, agricultural villages to accessing ANC based on data collected in the Ratanakiri province, one of the least developed provinces in Cambodia, using a combination of a community-based cross-sectional survey and a geographic information system (GIS). Methods A community-based cross-sectional survey was conducted among 377 mothers with children under the age of two living in 62 villages in the Ratanakiri province, Cambodia, in December 2015. Face-to-face interviews were conducted to ask mothers about their ANC service use, knowledge of ANC, barriers to accessing health facilities, and complications they experienced during the most recent pregnancy. At the same time, GIS data were also collected using a Global Positioning System (GPS) to accurately measure actual travel distance of pregnant women to access health facilities and to examine geographical and environmental barriers in greater detail. Results Only a third of the mothers met the recommendations made by the World Health Organization (WHO) of receiving ANC four times or more (achieved ANC4+), and a quarter of the mothers had never received ANC during their most recent pregnancy. Factors positively associated with achieving ANC4+ were mother’s secondary or higher education (adjusted odds ratio [AOR] = 5.50, 95% confidence interval [CI]: 1.74, 17.37), being aware that receiving ANC is recommended (AOR = 2.74, 95% CI: 1.25, 6.00), and knowledge about the recommended frequency for ANC (AOR = 2.26, 95% CI: 7.22). Actual travel distance was negatively associated with achieving ANC4+. Mothers who had to travel 10.0–14.9 km were 68% less likely (AOR = 0.32, 95% CI: 0.10, 0.99), and those who had to travel 15.0 km or longer were 79% less likely (AOR = 0.21, 95% CI: 0.07, 0.62) to have achieved ANC 4+, both compared to those who travelled 5.0 km or less. While most previous studies have used a straight-line to measure distance traveled, this study much more accurately measured the actual distance traveled by using a GIS. As a result, there was a statistically significant discrepancy between actual travel distance and straight-line distance. Conclusions This study revealed promoting factors and barriers for ANC use among pregnant women living in remote, agricultural villages in Cambodia. Furthermore, this study highlights the importance of measuring travel distances accurately to ensure that targeted interventions for ANC are not misguided by straight-line distances. The methodology used in this study can be applied widely to other developing countries, especially in remote areas with limited road networks where there may be a large discrepancy between actual and straight-line distances.
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Affiliation(s)
- Junko Yasuoka
- Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology, Tokyo, Japan
- * E-mail:
| | - Keiko Nanishi
- Office of International Academic Affairs, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kimiyo Kikuchi
- Graduate Education and Research Training Program in Decision Science for Sustainable Society, Kyushu University, Fukuoka, Japan
| | - Sumihiro Suzuki
- University of North Texas Health Science Center, University of North Texas, Denton, Texas, United States of America
| | - Po Ly
- National Center for Parasitology, Entomology & Malaria Control (CNM), Ministry of Health, Phnom Penh, Cambodia
| | - Boukheng Thavrin
- National Center for Parasitology, Entomology & Malaria Control (CNM), Ministry of Health, Phnom Penh, Cambodia
| | - Tsutomu Omatsu
- Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Tetsuya Mizutani
- Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology, Tokyo, Japan
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13
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Rogerson SJ, Desai M, Mayor A, Sicuri E, Taylor SM, van Eijk AM. Burden, pathology, and costs of malaria in pregnancy: new developments for an old problem. THE LANCET. INFECTIOUS DISEASES 2018; 18:e107-e118. [PMID: 29396010 DOI: 10.1016/s1473-3099(18)30066-5] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 08/07/2017] [Accepted: 10/09/2017] [Indexed: 12/17/2022]
Abstract
Over the past 10 years, knowledge of the burden, economic costs, and consequences of malaria in pregnancy has improved, and the prevalence of malaria caused by Plasmodium falciparum has declined substantially in some geographical areas. In particular, studies outside of Africa have increased the evidence base of Plasmodium vivax in pregnancy. Rapid diagnostic tests have been poor at detecting malaria in pregnant women, while PCR has shown a high prevalence of low density infection, the clinical importance of which is unknown. Erythrocytes infected with P falciparum that express the surface protein VAR2CSA accumulate in the placenta, and VAR2CSA is an important target of protective immunity. Clinical trials for a VAR2CSA vaccine are ongoing, but sequence variation needs to be carefully studied. Health system and household costs still limit access to prevention and treatment services. Within the context of malaria elimination, pregnant women could be used to monitor malaria transmission. This Series paper summarises recent progress and highlights unresolved issues related to the burden of malaria in pregnancy.
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Affiliation(s)
- Stephen J Rogerson
- Department of Medicine at the Doherty Institute, University of Melbourne, Melbourne, Victoria, Australia.
| | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alfredo Mayor
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
| | - Elisa Sicuri
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Health Economics Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College, London, UK
| | - Steve M Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA
| | - Anna M van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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14
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Meehan SA, Rossouw L, Sloot R, Burger R, Beyers N. Access to human immunodeficiency virus testing services in Cape Town, South Africa: a user perspective. Public Health Action 2017; 7:251-257. [PMID: 29584798 DOI: 10.5588/pha.17.0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/21/2017] [Indexed: 11/10/2022] Open
Abstract
Objective: To compare the availability, affordability and acceptability of two non-governmental organisation (NGO) led human immunodeficiency virus (HIV) testing service (HTS) modalities (mobile and stand-alone) with HTS at a public primary health care facility. Methods: Adult participants who self-referred for HIV testing were enrolled as they exited the HTS modalities. Data collection using an electronic questionnaire took place between November 2014 and February 2015. Logistic regression analysis was used to assess differences in the participants' demographic characteristics and the availability, affordability and acceptability of HTS between modalities. Results: There were 130 participants included in the study. Irrespective of modality, most participants walked to the service provider, had a travel time of <30 min and reported no costs. Participants were less likely to report waiting times of ⩾30 min compared to <15 min at the mobile modality compared to the public facility (aOR < 0.001, 95%CI < 0.001-0.03). Conclusion: Irrespective of modality, HIV testing services were available and affordable in our study. Waiting times were significantly higher at the public facility compared to the NGO modalities. As South Africa moves toward achieving the first UNAIDS target, it is essential not only to make HTS available and affordable, but also to ensure that these services are acceptable, especially to those who have never been tested before.
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Affiliation(s)
- S-A Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - L Rossouw
- Department of Economics, Stellenbosch University, Cape Town, South Africa
| | - R Sloot
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - R Burger
- Department of Economics, Stellenbosch University, Cape Town, South Africa
| | - N Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Åhman A, Edvardsson K, Lesio Kidanto H, Ngarina M, Small R, Mogren I. 'Without ultrasound you can't reach the best decision' - Midwives' experiences and views of the role of ultrasound in maternity care in Dar Es Salaam, Tanzania. SEXUAL & REPRODUCTIVE HEALTHCARE 2017; 15:28-34. [PMID: 29389498 DOI: 10.1016/j.srhc.2017.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 11/17/2017] [Accepted: 11/20/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To explore Tanzanian midwives' experiences and views of the role of obstetric ultrasound in relation to clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. METHOD In 2015, five focus group discussions were conducted with midwives (N = 31) at three public referral hospitals in the Dar es Salaam region as part of the CROss Country Ultrasound Study (CROCUS). RESULTS Ultrasound was described as decisive for proper management of pregnancy complications. Midwives noted an increasing interest in ultrasound among pregnant women. However, concerns were expressed about the lack of ultrasound equipment and staff capable of skilful operation. Further, counselling regarding medical management was perceived as difficult due to low levels of education among pregnant women. CONCLUSION Ultrasound has an important role in management of pregnancy complications. However, lack of equipment and shortage of skilled healthcare professionals seem to hamper use of obstetric ultrasound in this particular low-resource setting. Increased availability of obstetric ultrasound seems warranted, but further investments need to be balanced with advanced clinical skills' training as barriers, including power outages and lack of functioning equipment, are likely to continue to limit the provision of pregnancy ultrasound in this setting.
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Affiliation(s)
- Annika Åhman
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Sweden.
| | - Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Sweden; Judith Lumley Centre, La Trobe University, Melbourne, Australia.
| | - Hussein Lesio Kidanto
- Reproductive, Maternal and Child Health, Ministry of Health, Social Welfare, Gender, Children and Elderly Affairs, Dar es Salaam, Tanzania; Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Sweden.
| | - Matilda Ngarina
- Muhimbili National Hospital, Department of Obstetrics and Gynaecology, Dar es Salaam, Tanzania.
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Australia.
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Sweden.
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Hunter BM, Murray SF. Demand-side financing for maternal and newborn health: what do we know about factors that affect implementation of cash transfers and voucher programmes? BMC Pregnancy Childbirth 2017; 17:262. [PMID: 28854877 PMCID: PMC5577737 DOI: 10.1186/s12884-017-1445-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 08/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Demand-side financing (DSF) interventions, including cash transfers and vouchers, have been introduced to promote maternal and newborn health in a range of low- and middle-income countries. These interventions vary in design but have typically been used to increase health service utilisation by offsetting some financial costs for users, or increasing household income and incentivising 'healthy behaviours'. This article documents experiences and implementation factors associated with use of DSF in maternal and newborn health. METHODS A secondary analysis (using an adapted Supporting the Use of Research Evidence framework - SURE) was performed on studies that had previously been identified in a systematic review of evidence on DSF interventions in maternal and newborn health. RESULTS The article draws on findings from 49 quantitative and 49 qualitative studies. The studies give insights on difficulties with exclusion of migrants, young and multiparous women, with demands for informal fees at facilities, and with challenges maintaining quality of care under increasing demand. Schemes experienced difficulties if communities faced long distances to reach participating facilities and poor access to transport, and where there was inadequate health infrastructure and human resources, shortages of medicines and problems with corruption. Studies that documented improved care-seeking indicated the importance of adequate programme scope (in terms of programme eligibility, size and timing of payments and voucher entitlements) to address the issue of concern, concurrent investments in supply-side capacity to sustain and/or improve quality of care, and awareness generation using community-based workers, leaders and women's groups. CONCLUSIONS Evaluations spanning more than 15 years of implementation of DSF programmes reveal a complex picture of experiences that reflect the importance of financial and other social, geographical and health systems factors as barriers to accessing care. Careful design of DSF programmes as part of broader maternal and newborn health initiatives would need to take into account these barriers, the behaviours of staff and the quality of care in health facilities. Research is still needed on the policy context for DSF schemes in order to understand how they become sustainable and where they fit, or do not fit, with plans to achieve equitable universal health coverage.
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Affiliation(s)
- Benjamin M. Hunter
- King’s College London, Department of International Development, The Strand, London, WC2R 2LS UK
| | - Susan F. Murray
- King’s College London, Department of International Development, The Strand, London, WC2R 2LS UK
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17
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Nyathi L, Tugli AK, Tshitangano TG, Mpofu M. Investigating the accessibility factors that influence antenatal care services utilisation in Mangwe district, Zimbabwe. Afr J Prim Health Care Fam Med 2017; 9:e1-e5. [PMID: 28697619 PMCID: PMC5506496 DOI: 10.4102/phcfm.v9i1.1337] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 03/14/2017] [Accepted: 03/23/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Maternal and infant mortality remains a huge public health problem in developing countries. One of the strategies to minimise the risks of both maternal and infant mortality is access to and utilisation of antenatal care (ANC) services. AIM This study aimed to investigate the accessibility factors that influence the use of ANC services in Mangwe district. METHODS A qualitative approach using explorative design was adopted to target women who have babies under 1 year of age. The study was conducted in Mangwe district, Matabeleland South province, Zimbabwe. Data were collected through semi-structured interviews and observations. Data saturation was reached after 15 women who were conveniently sampled were interviewed. Field notes were analysed thematically using Tech's steps. Lincoln and Guba's criteria ensured trustworthiness of the study findings. RESULTS Accessibility factors such as lack of transport, high transport costs and long distances to health care facilities, health care workers' attitudes, type and quality of services as well as delays in receiving care influence women's utilisation of ANC services in Mangwe district, Zimbabwe. CONCLUSION The study concluded that women were still facing problems of unavailability of nearby clinics; therefore, it was recommended that the government should avail resources for women to use. RECOMMENDATIONS Mangwe District Health Department should provide mobile clinics rendering ANC services in distant rural areas.
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Affiliation(s)
- Leoba Nyathi
- Department of Public Health, University of Venda.
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18
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Fowkes FJI, Draper BL, Hellard M, Stoové M. Achieving development goals for HIV, tuberculosis and malaria in sub-Saharan Africa through integrated antenatal care: barriers and challenges. BMC Med 2016; 14:202. [PMID: 27938369 PMCID: PMC5151135 DOI: 10.1186/s12916-016-0753-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/21/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The global health community is currently transitioning from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs). Unfortunately, progress towards maternal, newborn and infant health MDGs has lagged significantly behind other key health goals, demanding a renewed global effort in this key health area. The World Health Organization and other institutions heralded integrated antenatal care (ANC) as the best way to address the inter-related health issues of HIV, tuberculosis (TB) and malaria in the high risk groups of pregnant women and infants; integrated ANC services also offer a mechanism to address slow progress towards improved maternal health. DISCUSSION There is remarkably limited evidence on best practice approaches of program implementation, acceptability and effectiveness for integrated ANC models targeting multiple diseases. Here, we discuss current integrated ANC global guidelines and the limited literature describing integrated ANC implementation and evidence for their role in addressing HIV, malaria and TB during pregnancy in sub-Saharan Africa. We highlight the paucity of data on the effectiveness of integrated ANC models and identify significant structural barriers in the health system (funding, infrastructure, distribution, human resources), the adoption system (limited buy-in from implementers, leadership, governance) and, in the broader context, patient-centred barriers (fear, stigma, personal burdens) and barriers in funding structures. We highlight recommendations for action and discuss avenues for the global health community to develop systems to integrate multiple disease programs into ANC models of care that better address these three priority infectious diseases. With the current transition to the SDGs and concerns regarding the failure to meet maternal health MDGs, the global health community, researchers, implementers and funding bodies must work together to ensure the establishment of quality operational and implementation research to inform integrated ANC models. It is imperative that the global health community engages in a timely discussion about such implementation innovations and instigates appropriate actions to ensure advances in maternal health are sufficient to meet applicable SDGs.
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Affiliation(s)
- Freya J I Fowkes
- Macfarlane Burnet Institute of Medical Research, Melbourne, Australia. .,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia. .,Department of Infectious Diseases, Monash University, Melbourne, Australia. .,Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Australia.
| | - Bridget L Draper
- Macfarlane Burnet Institute of Medical Research, Melbourne, Australia
| | - Margaret Hellard
- Macfarlane Burnet Institute of Medical Research, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark Stoové
- Macfarlane Burnet Institute of Medical Research, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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Rassi C, Graham K, King R, Ssekitooleko J, Mufubenga P, Gudoi SS. Assessing demand-side barriers to uptake of intermittent preventive treatment for malaria in pregnancy: a qualitative study in two regions of Uganda. Malar J 2016; 15:530. [PMID: 27809918 PMCID: PMC5096321 DOI: 10.1186/s12936-016-1589-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 10/28/2016] [Indexed: 11/23/2022] Open
Abstract
Background To prevent malaria infection during pregnancy in endemic areas in Africa, the World Health Organization recommends the administration of intermittent preventive treatment in pregnancy (IPTp) as part of the focused antenatal care package. However, IPTp uptake in most countries remains low despite generally high antenatal care coverage and increased efforts by governments to address known bottlenecks such as drug stock-outs. The study explored factors that continue to impede uptake of IPTp among women who attend antenatal care. This paper focuses on demand-side barriers with regard to accessibility, affordability and acceptability. Methods The research was conducted in 2013/2014 and involved 46 in-depth interviews with four types of respondents: (i) seven district health officials; (ii) 15 health workers; (iii) 19 women who attended antenatal care; (iv) five opinion leaders. Interviews were conducted in Eastern and West Nile regions of Uganda. Data was analysed by thematic analysis. Results District health officials and health workers cited a range of barriers relating to knowledge and attitudes among pregnant women, including lack of awareness of pregnancy-related health risks, a tendency to initiate antenatal care late, reluctance to take medication and concerns about side effects of IPTp. However, women and opinion leaders expressed very positive views of antenatal care and IPTp. They also reported that the burden of travel and cost associated with antenatal care attendance was challenging, but did not keep them from accessing a service they perceived as beneficial. The role of trust in health workers’ expertise was highlighted by all respondents and it was reported that women will typically accept IPTp if encouraged by a health worker. Conclusions Given the positive views of antenatal care and IPTp, high antenatal care coverage and reported low refusal rates for IPTp, supply-side issues are likely to account for the majority of missed opportunities for the provision of IPTp when women attend antenatal care. However, to increase uptake of IPTp on the demand side, health workers should be encouraged to reassure eligible women that IPTp is safe. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1589-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Rassi
- Malaria Consortium, Development House, 56-64 Leonard Street, London, UK.
| | - Kirstie Graham
- Malaria Consortium, Development House, 56-64 Leonard Street, London, UK
| | - Rebecca King
- Nuffield Centre for International Health and Development, Leeds Institute of Health SciencesUniversity of Leeds, Leeds, UK
| | - James Ssekitooleko
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, Kampala, Uganda
| | - Patrobas Mufubenga
- Malaria Consortium Uganda and PAMU Consults (U) Ltd, Plot 577, Block 15, Nsambya Road, Kampala, Uganda
| | - Sam Siduda Gudoi
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, Kampala, Uganda
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Underreporting and Missed Opportunities for Uptake of Intermittent Preventative Treatment of Malaria in Pregnancy (IPTp) in Mali. PLoS One 2016; 11:e0160008. [PMID: 27494250 PMCID: PMC4975448 DOI: 10.1371/journal.pone.0160008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 07/12/2016] [Indexed: 11/21/2022] Open
Abstract
Objectives To identify factors contributing to low uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) in rural Mali. Methods We conducted secondary data analysis on Mali’s 2012–2013 Demographic and Health Survey (DHS) to determine the proportion of women who failed to take IPTp-SP due to ineligibility or non-attendance at antenatal care (ANC). We also identified the proportion who reported taking other or unknown medications to prevent malaria in pregnancy and those who did not know if they took any medication to prevent malaria in pregnancy. We conducted qualitative interviews, focus groups and ANC observations in six rural sites in Mali’s Sikasso and Koulikoro regions to identify reasons for missed opportunities. Results Our secondary data analysis found that reported IPTp-SP coverage estimates are misleading due to their dependence on a variable (“source of IPTp”) that is missing 62% of its data points. Among all women who gave birth in the two years prior to the survey, 56.2% reported taking at least one dose of IPTp-SP. Another 5.2% reported taking chloroquine, 1.9% taking another drug to prevent malaria in pregnancy, 4.4% not knowing what drug they took to prevent malaria, and 1.1% not knowing if they took any drug to prevent malaria. The majority of women who did not receive IPTp-SP were women who also did not attend ANC. Our qualitative data revealed that many health centers neither administer IPTp-SP by directly observed therapy, nor give IPTp-SP at one month intervals through the second and third trimesters, nor provide IPTp-SP free of charge. Women generally reported IPTp-SP as available and tolerable, but frequently could not identify its name or purpose, potentially affecting accuracy of responses in household surveys. Conclusion We estimate IPTp-SP uptake to be significantly higher than stated in Mali’s 2012–13 DHS report. Increasing ANC attendance should be the first priority for increasing IPTp-SP coverage. Reducing cost and access barriers, ensuring that providers follow up-to-date guidelines, and improving patient counseling on IPTp-SP would also facilitate optimal uptake.
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Åhman A, Kidanto HL, Ngarina M, Edvardsson K, Small R, Mogren I. 'Essential but not always available when needed' - an interview study of physicians' experiences and views regarding use of obstetric ultrasound in Tanzania. Glob Health Action 2016; 9:31062. [PMID: 27452066 PMCID: PMC4958909 DOI: 10.3402/gha.v9.31062] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 05/11/2016] [Accepted: 06/02/2016] [Indexed: 12/02/2022] Open
Abstract
Background The value of obstetric ultrasound in high-income countries has been extensively explored but evidence is still lacking regarding the role of obstetric ultrasound in low-income countries. Objective We aimed to explore experiences and views among physicians working in obstetric care in Tanzania, on the role of obstetric ultrasound in relation to clinical management. Design A qualitative study design was applied. Data were collected in 2015, through 16 individual interviews with physicians practicing in obstetric care at hospitals in an urban setting in Tanzania. Data were analyzed using qualitative content analysis. Results Use of obstetric ultrasound in the management of complicated pregnancy was much appreciated by participating physicians, although they expressed considerable concern about the lack of ultrasound equipment and staff able to conduct the examinations. These limitations were recognized as restricting physicians’ ability to manage complications adequately during pregnancy and birth. Better availability of ultrasound was requested to improve obstetric management. Concerns were also raised regarding pregnant women's lack of knowledge and understanding of medical issues which could make counseling in relation to obstetric ultrasound difficult. Although the physicians perceived a positive attitude toward ultrasound among most pregnant women, occasionally they came across women who feared that ultrasound might harm the fetus. Conclusions There seems to be a need to provide more physicians in antenatal care in Tanzania with ultrasound training to enable them to conduct obstetric ultrasound examinations and interpret the results themselves. Physicians also need to acquire adequate counseling skills as counseling can be especially challenging in this setting where many expectant parents have low levels of education. Providers of obstetric care and policy makers in Tanzania will need to take measures to ensure appropriate use of the scarce resources in the Tanzanian health care system and prevent the potential risk of overuse of ultrasound in pregnancy.
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Affiliation(s)
- Annika Åhman
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden;
| | - Hussein Lesio Kidanto
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Matilda Ngarina
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden.,Judith Lumley Centre, La Trobe University, Melbourne, VIC, Australia
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, VIC, Australia
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden
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Callaghan-Koru JA, McMahon SA, Chebet JJ, Kilewo C, Frumence G, Gupta S, Stevenson R, Lipingu C, Baqui AH, Winch PJ. A qualitative exploration of health workers' and clients' perceptions of barriers to completing four antenatal care visits in Morogoro Region, Tanzania. Health Policy Plan 2016; 31:1039-49. [PMID: 27117481 DOI: 10.1093/heapol/czw034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2016] [Indexed: 11/14/2022] Open
Abstract
Antenatal care (ANC) remains an important contact point on the continuum of care for mothers and children in low- and middle-income countries. In Tanzania, the proportion of pregnant women completing at least four ANC visits (ANC-4) dropped from 70% to 43% between 1999 and 2010. To identify potential causes of the decline in the number of ANC visits, we conducted qualitative research at 18 health centres in Morogoro Region, exploring providers' communication about ANC visits and clients' and providers' perceptions of changes in ANC services and barriers to completing four visits. We also observed counselling messages delivered during 203 ANC consultations. Our results indicate that provider communication about ANC visit recommendations is inadequate, and confusion exists among clients about when and how often they should attend. Participants highlighted how the scale up of Prevention of Mother-to-Child Transmission, with routine human immunodeficiency virus testing for women and their male partners, presents additional barriers for some women. Changes to the timing and content of ANC services following the adoption of the Focused ANC model was described by participants as changing women's perceptions and decisions in how they utilize ANC services. In particular, condensed delivery of technical interventions fostered a sense among clients that multiple visits are unnecessary. Other barriers that may contribute to declining ANC-4 include changing norms about family planning and birth spacing, out-of-pocket costs for clients and informal practices adopted by health facilities and providers such as turning women away who attend early in pregnancy or are not accompanied by male partners. Further research is needed to determine the role and extent that these barriers may be contributing to declining ANC-4. Issues of poor communication, supply inadequacies and informal practices, deserve immediate attention from the health system.
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Affiliation(s)
- Jennifer A Callaghan-Koru
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,
| | - Shannon A McMahon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Joy J Chebet
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Charles Kilewo
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gasto Frumence
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Shivam Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Raz Stevenson
- United States Agency for International Development, Dar es Salaam, Tanzania and
| | | | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Klein MC, Harvey SA, Diarra H, Hurley EA, Rao N, Diop S, Doumbia S. "There is no free here, you have to pay": actual and perceived costs as barriers to intermittent preventive treatment of malaria in pregnancy in Mali. Malar J 2016; 15:158. [PMID: 26968167 PMCID: PMC4788908 DOI: 10.1186/s12936-016-1210-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 03/03/2016] [Indexed: 11/11/2022] Open
Abstract
Background “There is no free here,” the words of a Malian husband, illustrate how perceptions of cost can deter uptake of intermittent preventive treatment of malaria in pregnancy (IPTp). The Malian Ministry of Health (MOH) recommends a minimum of three doses of IPTp at monthly intervals. However, despite a national policy that IPTp be provided free of charge, only 35 % of pregnant women receive at least one dose and less than 20 % receive two or more doses. Methods This study explored perceptions and experiences of IPTp cost in Mali and their impact on uptake, using qualitative interviews and focus groups with pregnant women, husbands and mothers-in-law. Study team members also interviewed and observed health workers at four health centres, two in Sikasso Region and two in Koulikoro. Results Despite national-level policies, actual IPTp costs varied widely at study sites—between facilities, and visits. Pregnant women may pay for IPTp, receive it free, or both at different times. Health centres often charge a lump sum for antenatal care (ANC) visits that includes both free and fee-based drugs and services. This makes it difficult for women and families to distinguish between free services and those requiring payment. As a result, some forego free care that, because it is bundled with other fee-based services and medications, appears not to be free. Varying costs also complicate household budgeting for health care, particularly as women often rely on their husbands for money. Finally, while health facilities operating under the cost-recovery model strive to provide free IPTp, their own financial constraints often make this impossible. Conclusions Both actual and perceived costs are currently barriers to IPTp uptake. Given the confusion around cost of services in the two study regions, more detailed national-level studies of both perceived and actual costs could help inform policy and programme decisions promoting IPTp. These studies should evaluate both quantitatively and qualitatively the cost information provided to and understood by pregnant women and their families. Meanwhile, unbundling free and fee-based services, making clear that IPTp is free, and ensuring that it is provided at no cost could help increase uptake. Free community-based distribution might be another route to increased uptake and adherence.
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Affiliation(s)
- Meredith C Klein
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Steven A Harvey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Hawa Diarra
- Techniques and Technologies of Bamako, Faculty of Medicine and Odontostomatology, University of Sciences, Bamako, Mali
| | - Emily A Hurley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Namratha Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Samba Diop
- Techniques and Technologies of Bamako, Faculty of Medicine and Odontostomatology, University of Sciences, Bamako, Mali
| | - Seydou Doumbia
- Techniques and Technologies of Bamako, Faculty of Medicine and Odontostomatology, University of Sciences, Bamako, Mali
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Mahiti GR, Mkoka DA, Kiwara AD, Mbekenga CK, Hurtig AK, Goicolea I. Women's perceptions of antenatal, delivery, and postpartum services in rural Tanzania. Glob Health Action 2015; 8:28567. [PMID: 26498576 PMCID: PMC4617868 DOI: 10.3402/gha.v8.28567] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/17/2015] [Accepted: 09/26/2015] [Indexed: 11/23/2022] Open
Abstract
Background Maternal health care provision remains a major challenge in developing countries. There is agreement that the provision of quality clinical services is essential if high rates of maternal death are to be reduced. However, despite efforts to improve access to these services, a high number of women in Tanzania do not access them. The aim of this study is to explore women's views about the maternal health services (pregnancy, delivery, and postpartum period) that they received at health facilities in order to identify gaps in service provision that may lead to low-quality maternal care and increased risks associated with maternal morbidity and mortality in rural Tanzania. Design We gathered qualitative data from 15 focus group discussions with women attending a health facility after child birth and transcribed it verbatim. Qualitative content analysis was used for analysis. Results ‘Three categories emerged that reflected women's perceptions of maternal health care services: “mothers perceive that maternal health services are beneficial,” “barriers to accessing maternal health services” such as availability and use of traditional birth attendants (TBAs) and the long distances between some villages, and “ambivalence regarding the quality of maternal health services” reflecting that women had both positive and negative perceptions in relation to quality of health care services offered’. Conclusions Mothers perceived that maternal health care services are beneficial during pregnancy and delivery, but their awareness of postpartum complications and the role of medical services during that stage were poor. The study revealed an ambivalence regarding the perceived quality of health care services offered, partly due to shortages of material resources. Barriers to accessing maternal health care services, such as the cost of transport and the use of TBAs, were also shown. These findings call for improvement on the services provided. Improvements should address, accessibility of services, professionals' attitudes and stronger promotion of the importance of postpartum check-ups, both among health care professionals and women.
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Affiliation(s)
- Gladys Reuben Mahiti
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania;
| | - Dickson Ally Mkoka
- School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Angwara Dennis Kiwara
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Anna-Karin Hurtig
- Division of Epidemiology and Global Health, Umea University, Umea, Sweden
| | - Isabel Goicolea
- Division of Epidemiology and Global Health, Umea University, Umea, Sweden
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Paul C, Kramer R, Lesser A, Mutero C, Miranda ML, Dickinson K. Identifying barriers in the malaria control policymaking process in East Africa: insights from stakeholders and a structured literature review. BMC Public Health 2015; 15:862. [PMID: 26341406 PMCID: PMC4560917 DOI: 10.1186/s12889-015-2183-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 08/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The complexity of malaria and public health policy responses presents social, financial, cultural, and institutional barriers to policymaking at multiple stages in the policy process. These barriers reduce the effectiveness of health policy in achieving national goals. METHODS We conducted a structured literature review to characterize malaria policy barriers, and we engaged stakeholders through surveys and workshops in Kenya, Tanzania, and Uganda. We compared common barriers presented in the scientific literature to barriers reported by malaria policy stakeholders. RESULTS The barriers identified in the structured literature review differ from those described in policymaker surveys. The malaria policy literature emphasizes barriers in the implementation stage of policymaking such as those posed by health systems and specific intervention tools. Stakeholder responses placed greater emphasis on the political nature of policymaking, the disconnect between research and policymaking, and the need for better intersectoral collaboration. CONCLUSIONS Identifying barriers to effective malaria control activities provides opportunities to improve health and other outcomes. Such barriers can occur at multiple stages and scales. Employing a stakeholder - designed decision tool framework has the potential to improve existing policies and ultimately the functioning of malaria related institutions. Furthermore, improved coordination between malaria research and policymaking would improve the quality and efficiency of interventions leading to better population health.
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Affiliation(s)
- Christopher Paul
- Nicholas School of the Environment & Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Randall Kramer
- Nicholas School of the Environment & Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Adriane Lesser
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Clifford Mutero
- Centre for Sustainable Malaria Control and School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa, & International Centre of Insect Physiology and Ecology, Nairobi, Kenya.
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August F, Pembe AB, Kayombo E, Mbekenga C, Axemo P, Darj E. Birth preparedness and complication readiness - a qualitative study among community members in rural Tanzania. Glob Health Action 2015; 8:26922. [PMID: 26077145 PMCID: PMC4468055 DOI: 10.3402/gha.v8.26922] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 05/07/2015] [Accepted: 05/21/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Birth preparedness and complication readiness (BP/CR) strategies are aimed at reducing delays in seeking, reaching, and receiving care. Counselling on birth preparedness is provided during antenatal care visits. However, it is not clear why birth preparedness messages do not translate to utilisation of facility delivery. This study explores the perceptions, experiences, and challenges the community faces on BP/CR. DESIGN A qualitative study design using Focused Group Discussions was conducted. Twelve focus group discussions were held with four separate groups: young men and women and older men and women in a rural community in Tanzania. Qualitative content analysis was used to analyse the data. RESULTS The community members expressed a perceived need to prepare for childbirth. They were aware of the importance to attend the antenatal clinics, relied on family support for practical and financial preparations such as saving money for costs related to delivery, moving closer to the nearest hospital, and also to use traditional herbs, in favour of a positive outcome. Community recognised that pregnancy and childbirth complications are preferably treated at hospital. Facility delivery was preferred; however, certain factors including stigma on unmarried women and transportation were identified as hindering birth preparedness and hence utilisation of skilled care. Challenges were related to the consequences of poverty, though the maternal health care should be free, they perceived difficulties due to informal user fees. CONCLUSIONS This study revealed community perceptions that were in favour of using skilled care in BP/CR. However, issues related to inability to prepare in advance hinder the realisation of the intention to use skilled care. It is important to innovate how the community reinforces BP/CR, such as using insurance schemes, using community health funds, and providing information on other birth preparedness messages via community health workers.
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Affiliation(s)
- Furaha August
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden;
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Edmund Kayombo
- Institute of Traditional Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Columba Mbekenga
- Department of Community Health Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Pia Axemo
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Elisabeth Darj
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
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Boncy PJ, Adrien P, Lemoine JF, Existe A, Henry PJ, Raccurt C, Brasseur P, Fenelon N, Dame JB, Okech BA, Kaljee L, Baxa D, Prieur E, El Badry MA, Tagliamonte MS, Mulligan CJ, Carter TE, Beau de Rochars VM, Lutz C, Parke DM, Zervos MJ. Malaria elimination in Haiti by the year 2020: an achievable goal? Malar J 2015; 14:237. [PMID: 26043728 PMCID: PMC4464116 DOI: 10.1186/s12936-015-0753-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 05/27/2015] [Indexed: 12/25/2022] Open
Abstract
Haiti and the Dominican Republic, which share the island of Hispaniola, are the last locations in the Caribbean where malaria still persists. Malaria is an important public health concern in Haiti with 17,094 reported cases in 2014. Further, on January 12, 2010, a record earthquake devastated densely populated areas in Haiti including many healthcare and laboratory facilities. Weakened infrastructure provided fertile reservoirs for uncontrolled transmission of infectious pathogens. This situation results in unique challenges for malaria epidemiology and elimination efforts. To help Haiti achieve its malaria elimination goals by year 2020, the Laboratoire National de Santé Publique and Henry Ford Health System, in close collaboration with the Direction d’Épidémiologie, de Laboratoire et de Recherches and the Programme National de Contrôle de la Malaria, hosted a scientific meeting on “Elimination Strategies for Malaria in Haiti” on January 29-30, 2015 at the National Laboratory in Port-au-Prince, Haiti. The meeting brought together laboratory personnel, researchers, clinicians, academics, public health professionals, and other stakeholders to discuss main stakes and perspectives on malaria elimination. Several themes and recommendations emerged during discussions at this meeting. First, more information and research on malaria transmission in Haiti are needed including information from active surveillance of cases and vectors. Second, many healthcare personnel need additional training and critical resources on how to properly identify malaria cases so as to improve accurate and timely case reporting. Third, it is necessary to continue studies genotyping strains of Plasmodium falciparum in different sites with active transmission to evaluate for drug resistance and impacts on health. Fourth, elimination strategies outlined in this report will continue to incorporate use of primaquine in addition to chloroquine and active surveillance of cases. Elimination of malaria in Haiti will require collaborative multidisciplinary approaches, sound strategic planning, and strong ownership of strategies by the Haiti Ministère de la Santé Publique et de la Population.
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Affiliation(s)
- Paul Jacques Boncy
- Laboratoire National de Santé Publique, Rue Chardonnier #2 and Delmas 33, Port-au-Prince, Haiti.
| | - Paul Adrien
- Direction d'Épidémiologie, de Laboratoire et de Recherches, Port-au-Prince, Haiti.
| | | | - Alexandre Existe
- Laboratoire National de Santé Publique, Rue Chardonnier #2 and Delmas 33, Port-au-Prince, Haiti.
| | - Patricia Jean Henry
- Point focal OHMaSS/Programme National de Contrôle de la Malaria, Port-au-Prince, Haiti.
| | - Christian Raccurt
- Laboratoire National de Santé Publique, Rue Chardonnier #2 and Delmas 33, Port-au-Prince, Haiti.
| | | | - Natael Fenelon
- Direction d'Épidémiologie, de Laboratoire et de Recherches, Port-au-Prince, Haiti.
| | - John B Dame
- University of Florida, Gainesville, FL, 32611, USA.
| | | | - Linda Kaljee
- Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI, 48202, USA. .,Wayne State University, Detroit, MI, 48201, USA.
| | - Dwayne Baxa
- Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI, 48202, USA. .,Oakland University William Beaumont School of Medicine, Rocheste, MI, 48309, USA.
| | - Eric Prieur
- Laboratoire Vac4All, Hôpital Cochin, 75014, Paris, France.
| | | | | | | | | | | | - Chelsea Lutz
- University of Florida, Gainesville, FL, 32611, USA.
| | - Dana M Parke
- Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI, 48202, USA.
| | - Marcus J Zervos
- Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI, 48202, USA. .,Wayne State University, Detroit, MI, 48201, USA.
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Gheibizadeh M, Abedi HA, Mohammadi E, Abedi P. Iranian women and care providers' perceptions of equitable prenatal care: A qualitative study. Nurs Ethics 2015; 23:465-77. [PMID: 25802210 DOI: 10.1177/0969733015573653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Equity as a basic human right builds the foundation of all areas of primary healthcare, especially prenatal care. However, it is unclear how pregnant women and their care providers perceive the equitable prenatal care. OBJECTIVE This study aimed to explore Iranian women's and care providers' perceptions of equitable prenatal care. RESEARCH DESIGN In this study, a qualitative approach was used. Individual in-depth unstructured interviews were conducted with a purposeful sample of pregnant women and their care providers. Data were analyzed using inductive content analysis method. PARTICIPANTS AND RESEARCH CONTEXT A total of 10 pregnant women and 10 prenatal care providers recruited from six urban health centers across Ahvaz, a south western city in Iran, were participated in the study. ETHICAL CONSIDERATIONS The study was approved by the Ethics Committee affiliated to Ahvaz Jundishapur University of Medical Sciences. The ethical principles of voluntary participation, confidentiality, and anonymity were considered. FINDINGS Analysis of participants' interviews resulted in seven themes: guideline-based care, time-saving care, nondiscriminatory care, privacy-respecting care, affordable comprehensive care, effective client-provider relationships, and caregivers' competency. CONCLUSION The findings explain the broader and less discussed dimensions of equitable care that are valuable information for the realization of equity in care. Understanding and focusing on these dimensions will help health policy-makers in designing more equitable healthcare services for pregnant women.
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Affiliation(s)
| | | | | | - Parvin Abedi
- Ahvaz Jundishapur University of Medical Sciences, Iran
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29
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Niang M, Dupéré S, Bédard E. Le non-recours aux soins prénatals au Burkina Faso. SANTE PUBLIQUE 2015. [DOI: 10.3917/spub.153.0405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Meehan SA, Naidoo P, Claassens MM, Lombard C, Beyers N. Characteristics of clients who access mobile compared to clinic HIV counselling and testing services: a matched study from Cape Town, South Africa. BMC Health Serv Res 2014; 14:658. [PMID: 25526815 PMCID: PMC4280046 DOI: 10.1186/s12913-014-0658-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 12/12/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies within sub-Saharan African countries have shown that mobile services increase uptake of HIV counselling and testing (HCT) services when compared to clinics and are able to access different populations, but these have included provider-initiated HCT in clinics. This study aimed to compare the characteristics of clients who self-initiated HCT at either a mobile or a clinic service in terms of demographic and socio-economic variables, also comparing reasons for accessing a particular health service provider. METHODS This study took place in eight areas around Cape Town. A matched design was used with one mobile HCT service matched with one or more clinics (offering routine HCT services) within each of the eight areas. Adult clients who self-referred for an HIV test within a specified time period at either a mobile or clinic service were invited to participate in the study. Data were collected between February and April 2011 using a questionnaire. Summary statistics were calculated for each service type within a matched pair and differences of outcomes from pairs were used to calculate effect sizes and 95% confidence intervals. RESULTS 1063 participants enrolled in the study with 511 from mobile and 552 from clinic HCT services. The proportion of males accessing mobile HCT significantly exceeded that of clinic HCT (p < 0.001). The mean age of participants attending mobile HCT was higher than clinic participants (p = 0.023). No significant difference was found for socio-economic variables between participants, with the exception of access to own piped water (p = 0.029). Participants who accessed mobile HCT were significantly more likely to report that they were just passing, deemed an "opportunistic" visit (p = 0.014). Participants who accessed clinics were significantly more likely to report the service being close to home or work (p = 0.035). CONCLUSIONS An HCT strategy incorporating a mobile HCT service, has a definite role to play in reaching those population groups who do not typically access HCT services at a clinic, especially males and those who take advantage of the opportunity to test. Mobile HCT services can complement clinic services.
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Affiliation(s)
- Sue-Ann Meehan
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Ave, Parow, Cape Town, South Africa.
| | - Pren Naidoo
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Ave, Parow, Cape Town, South Africa.
| | - Mareli M Claassens
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Ave, Parow, Cape Town, South Africa.
| | - Carl Lombard
- Biostatistics Unit, Medical Research Council, Francie van Zijl Ave, Parow, Cape Town, South Africa.
| | - Nulda Beyers
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Ave, Parow, Cape Town, South Africa.
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Graham KJ, Ba-Break MM. Systemic constraints continue to limit coverage of intermittent preventive treatment for malaria in pregnancy in southeast Tanzania. Int Health 2014; 5:126-31. [PMID: 24030112 DOI: 10.1093/inthealth/iht005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Factors limiting coverage of intermittent preventive treatment for malaria in pregnancy (IPTp) in Tanzania were explored from the perspective of health workers, in order to make recommendations to improve service delivery. Recent data estimates coverage of the recommended two doses of IPTp at 26.3%, far short of the national target of 80%. METHODS Semistructured interviews were conducted with 13 health workers and 2 health managers during June 2011 in Ikwiriri, southeast Tanzania. RESULTS Delivery of sulfadoxine-pyrimethamine (SP) was severely constrained by drug shortages and widespread stock-outs, indicative of ongoing difficulties in the wider health system. While SP was well known and attitudes towards IPTp were positive, health workers were often not informed of up-to-date dosing schedules, limiting coverage. Recent literature suggests this could be due to inconsistent and conflicting national guidelines. In addition, it was found that two pills, instead of the recommended three pills, per dose of IPTp were frequently given to pregnant women, a finding previously unreported. CONCLUSION To maximize IPTp coverage, sufficient and consistent supplies of SP to both public and private health facilities are a necessity, combined with effective communication of revised dosing schedules. Further research is warranted to investigate the aberrant administration of two pills per dose, as it may exacerbate drug resistance.
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Affiliation(s)
- Kirstie J Graham
- Ifakara Health Institute, Rufiji Health Demographic Surveillance System, Folk Development College, Ikwiriri, PO Box 40, Tanzania
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Andrew EVW, Pell C, Angwin A, Auwun A, Daniels J, Mueller I, Phuanukoonnon S, Pool R. Factors affecting attendance at and timing of formal antenatal care: results from a qualitative study in Madang, Papua New Guinea. PLoS One 2014; 9:e93025. [PMID: 24842484 PMCID: PMC4026245 DOI: 10.1371/journal.pone.0093025] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 02/28/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Appropriate antenatal care (ANC) is key for the health of mother and child. However, in Papua New Guinea (PNG), only a third of women receive any ANC during pregnancy. Drawing on qualitative research, this paper explores the influences on ANC attendance and timing of first visit in the Madang region of Papua New Guinea. METHODS Data were collected in three sites utilizing several qualitative methods: free-listing and sorting of terms and definitions, focus group discussions, in-depth interviews, observation in health care facilities and case studies of pregnant women. Respondents included pregnant women, their relatives, biomedical and traditional health providers, opinion leaders and community members. RESULTS Although generally reported to be important, respondents' understanding of the procedures involved in ANC was limited. Factors influencing attendance fell into three main categories: accessibility, attitudes to ANC, and interpersonal issues. Although women saw accessibility (distance and cost) as a barrier, those who lived close to health facilities and could easily afford ANC also demonstrated poor attendance. Attitudes were shaped by previous experiences of ANC, such as waiting times, quality of care, and perceptions of preventative care and medical interventions during pregnancy. Interpersonal factors included relationships with healthcare providers, pregnancy disclosure, and family conflict. A desire to avoid repeat clinic visits, ideas about the strength of the fetus and parity were particularly relevant to the timing of first ANC visit. CONCLUSIONS This long-term in-depth study (the first of its kind in Madang, PNG) shows how socio-cultural and economic factors influence ANC attendance. These factors must be addressed to encourage timely ANC visits: interventions could focus on ANC delivery in health facilities, for example, by addressing healthcare staff's attitudes towards pregnant women.
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Affiliation(s)
- Erin V. W. Andrew
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Christopher Pell
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Angeline Angwin
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Alma Auwun
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Job Daniels
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Ivo Mueller
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Infection & Immunity Division, Walter & Eliza Hall Institute, Parkville, Victoria, Australia
| | | | - Robert Pool
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands
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Murray SF, Hunter BM, Bisht R, Ensor T, Bick D. Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review. BMC Pregnancy Childbirth 2014; 14:30. [PMID: 24438560 PMCID: PMC3897964 DOI: 10.1186/1471-2393-14-30] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 01/13/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Demand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system. METHODS The protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis. RESULTS Thirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems. CONCLUSIONS Demand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.
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Affiliation(s)
- Susan F Murray
- King’s International Development Institute, King’s College London, London, UK
| | - Benjamin M Hunter
- King’s International Development Institute, King’s College London, London, UK
| | - Ramila Bisht
- Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
| | - Tim Ensor
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Debra Bick
- Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK
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Mubyazi GM, Byskov J, Magnussen P, Bygbjerg IC, Ijumba JN, Marero M, Mboera LEG, Molteni F, Bloch P. Health facility-based data on women receiving sulphadoxine-pyrimethamine during pregnancy in Tanzania: lessons to learn from a cross-sectional survey in Mkuranga and Mufindi districts and other national survey reports. Reprod Health 2014; 11:6. [PMID: 24433529 PMCID: PMC3897926 DOI: 10.1186/1742-4755-11-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 01/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A study of health facility (HF) data on women receiving sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria during pregnancy (IPTp) was carried out at antenatal care clinics in Mkuranga and Mufindi districts. METHODS A review of health management information system (HMIS) registers, interviews with health-care workers (HWs) and district and national level malaria control program managers corroborated by inter-temporal assessment through observations at HF levels. Statistical data were analyzed in Excel and interpreted in triangulation with qualitative data from interviews and observations. RESULTS Data indicated that IPTp doses administered to women were inadequate and partly inconsistent. HMIS registers lacked space for IPT records, forcing HWs to manipulate their record-keeping. The proportion/number of IPTp recipients in related to the supply of SP for free delivery, to women's attendance behaviours, showed variation by quarter and year of reporting. CONCLUSION It is impossible to achieve rational health service planning when the HMIS is weak. Whilst it is acknowledged that the HMIS is already overloaded, concerted measures are urgently needed to accommodate data on new interventions and other vertical programs if malaria programs are to achieve their goals.
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Affiliation(s)
- Godfrey M Mubyazi
- Department of Health Systems & Policy Research & Centre for Enhancement of Effective Malaria Interventions (CEEMI), National Institute for Medical Research (NIMR) - Headquarters, 2448 Ocean Road, P.O. Box 9653, Dar-Es-Salaam, Tanzania
| | - Jens Byskov
- DBL - Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Pascal Magnussen
- DBL - Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ib C Bygbjerg
- Institute of International Health, Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen, Bleddamsvej 3, DK 2200 Copenhagen N, Denmark
| | - Jasper N Ijumba
- Department of Health Systems & Policy Research & Centre for Enhancement of Effective Malaria Interventions (CEEMI), National Institute for Medical Research (NIMR) - Headquarters, 2448 Ocean Road, P.O. Box 9653, Dar-Es-Salaam, Tanzania
- The Nelson Mandela African Institute of Science and Technology, P.O. Box 447, Arusha, Tanzania
| | - Mufungo Marero
- Ministry of Health and Social Welfare, National Malaria Control Programme (NMCP), Dar Es Salaam, P.O. Box 9083, Dar es Salaam, Tanzania
| | - Leonard EG Mboera
- NIMR, Directorate of Information Technology and Communication, National Institute for Medical Research, Headquarters, P.O. Box 9653, Dar es Salaam, Tanzania
| | - Fabrizio Molteni
- Ministry of Health and Social Welfare, National Malaria Control Programme (NMCP), Dar Es Salaam, P.O. Box 9083, Dar es Salaam, Tanzania
| | - Paul Bloch
- DBL - Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center, Steno Health Promotion Center, Gentofte, Denmark
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Mubyazi GM, Bloch P. Psychosocial, behavioural and health system barriers to delivery and uptake of intermittent preventive treatment of malaria in pregnancy in Tanzania - viewpoints of service providers in Mkuranga and Mufindi districts. BMC Health Serv Res 2014; 14:15. [PMID: 24410770 PMCID: PMC3897909 DOI: 10.1186/1472-6963-14-15] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 12/31/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment of malaria in pregnancy (IPTp) using sulphurdoxine-pyrimethamine (SP) is one of key malaria control strategies in Africa. Yet, IPTp coverage rates across Africa are still low due to several demand and supply constraints. Many countries implement the IPTp-SP strategy at antenatal care (ANC) clinics. This paper reports from a study on the knowledge and experience of health workers (HWs) at ANC clinics regarding psychosocial, behavioural and health system barriers to IPTp-SP delivery and uptake in Tanzania. METHODS Data were collected through questionnaire-based interviews with 78 HWs at 28 ANC clinics supplemented with informal discussions with current and recent ANC users in Mkuranga and Mufindi districts. Qualitative data were analysed using a qualitative content analysis approach. Quantitative data derived from interviews with HWs were analysed using non-parametric statistical analysis. RESULTS The majority of interviewed HWs were aware of the IPTp-SP strategy's existence and of the recommended one month spacing of administration of SP doses. Some HWs were unsure of that it is not recommended to administer IPTp-SP and ferrous/folic acid concurrently. Others were administering three doses of SP per client following instruction from a non-governmental agency while believing that this was in conflict with national guidelines. About half of HWs did not find it appropriate for the government to recommend private ANC providers to provide IPTp-SP free of charge since doing so forces private providers to recover the costs elsewhere. HWs noted that pregnant women often register at clinics late and some do not comply with the regularity of appointments for revisits, hence miss IPTp and other ANC services. HWs also noted some amplified rumours among clients regarding health risks and treatment failures of SP used during pregnancy, and together with clients' disappointment with waiting times and the sharing of cups at ANC clinics for SP, limit the uptake of IPTp-doses. CONCLUSION HWs still question SP's treatment advantages and are confused about policy ambiguity on the recommended number of IPTp-SP doses and other IPTp-SP related guidelines. IPTp-SP uptake is further constrained by pregnant women's perceived health risks of taking SP and of poor service quality.
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Affiliation(s)
- Godfrey M Mubyazi
- National Institute for Medical Research (NIMR), Department of Health Systems and Policy Research, Centre for Enhancement of Effective Malaria Interventions (CEEMI), 2448 Barak Obama Drive (former Luthuli/Ocean Road), P.O Box 9653, Dar es Salaam, Tanzania
| | - Paul Bloch
- Steno Diabetes Center, Steno Health Promotion Center, Gentofte, Denmark
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Vyagusa DB, Mubyazi GM, Masatu M. Involving traditional birth attendants in emergency obstetric care in Tanzania: policy implications of a study of their knowledge and practices in Kigoma Rural District. Int J Equity Health 2013; 12:83. [PMID: 24124663 PMCID: PMC4015773 DOI: 10.1186/1475-9276-12-83] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 10/08/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Access to quality maternal health services mainly depends on existing policies, regulations, skills, knowledge, perceptions, and economic power and motivation of service givers and target users. Critics question policy recommending involvement of traditional birth attendants (TBAs) in emergency obstetric care (EmoC) services in developing countries. OBJECTIVES This paper reports about knowledge and practices of TBAs on EmoC in Kigoma Rural District, Tanzania and discusses policy implications on involving TBAs in maternal health services. METHODS 157 TBAs were identified from several villages in 2005, interviewed and observed on their knowledge and practice in relation to EmoC. Quantitative and qualitative techniques were used for data collection and analysis depending on the nature of the information required. FINDINGS Among all 157 TBAs approached, 57.3% were aged 50+ years while 50% had no formal education. Assisting mothers to deliver without taking their full pregnancy history was confessed by 11% of all respondents. Having been attending pregnant women with complications was experienced by 71.2% of all respondents. Only 58% expressed adequate knowledge on symptoms and signs of pregnancy complications. Lack of knowledge on possible risk of HIV infections while assisting childbirth without taking protective gears was claimed by 5.7% of the respondents. Sharing the same pair of gloves between successful deliveries was reported to be a common practice by 21.1% of the respondents. Use of unsafe delivery materials including local herbs and pieces of cloth for protecting themselves against HIV infections was reported as being commonly practiced among 27.6% of the respondents. Vaginal examination before and during delivery was done by only a few respondents. CONCLUSION TBAs in Tanzania are still consulted by people living in underserved areas. Unfortunately, TBAs' inadequate knowledge on EmOC issues seems to have contributed to the rising concerns about their competence to deliver the recommended maternal services. Thus, the authorities seeming to recognize and promote TBAs should provide support to TBAs in relation to necessary training and giving them essential working facilities, routine supportive supervision and rewarding those seeming to comply with the standard guidelines for delivering EmoC services.
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Affiliation(s)
- Dismas B Vyagusa
- National Institute for Medical Research (NIMR), Headquarters, 2448 Barak Obama/Luthuli Road (former Luthuli/Ocean Road), P,O Box 9653, Dar es Salaam, Tanzania.
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Mubyazi GM, Magnussen P, Byskov J, Bloch P. Feasibility and coverage of implementing intermittent preventive treatment of malaria in pregnant women contacting private or public clinics in Tanzania: experience-based viewpoints of health managers in Mkuranga and Mufindi districts. BMC Health Serv Res 2013; 13:372. [PMID: 24079911 PMCID: PMC3850681 DOI: 10.1186/1472-6963-13-372] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 09/27/2013] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Evidence on healthcare managers' experience on operational feasibility of malaria intermittent preventive treatment for malaria during pregnancy (IPTp) using sulphadoxine-pyrimethamine (SP) in Africa is systematically inadequate. This paper elucidates the perspectives of District Council Health Management Team (CHMT)s regarding the feasibility of IPTp with SP strategy, including its acceptability and ability of district health care systems to cope with the contemporary and potential challenges. METHODS The study was conducted in Mkuranga and Mufindi districts. Data were collected between November 2005 and December 2007, involving focus group discussion (FGD) with Mufindi CHMT and in-depth interviews were conducted with few CHMT members in Mkuranga where it was difficult to summon all members for FGD. RESULTS Participants in both districts acknowledged the IPTp strategy, considering the seriousness of malaria in pregnancy problem; government allocation of funds to support healthcare staff training programmes in focused antenatal care (fANC) issues, procuring essential drugs distributed to districts, staff remuneration, distribution of fANC guidelines, and administrative activities performed by CHMTs. The identified weaknesses include late arrival of funds from central level weakening CHMT's performance in health supervision, organising outreach clinics, distributing essential supplies, and delivery of IPTp services. Participants anticipated the public losing confidence in SP for IPTp after government announced artemither-lumefantrine (ALu) as the new first-line drug for uncomplicated malaria replacing SP. Role of private healthcare staff in IPTp services was acknowledged cautiously because CHMTs rarely supplied private clinics with SP for free delivery in fear that clients would be required to pay for the SP contrary to government policy. In Mufindi, the District Council showed a strong political support by supplementing ANC clinics with bottled water; in Mkuranga such support was not experienced. A combination of health facility understaffing, water scarcity and staff non-adherence to directly observed therapy instructions forced healthcare staff to allow clients to take SP at home. Need for investigating in improving adherence to IPTp administration was emphasised. CONCLUSION High acceptability of the IPTp strategy at district level is meaningless unless necessary support is assured in terms of number, skills and motivation of caregivers and availability of essential supplies.
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Affiliation(s)
- Godfrey M Mubyazi
- Department of Health Systems and Policy Research and Centre for Enhancement of Effective Malaria Interventions (CEEMI), National Institute for Medical Research (NIMR), 2448 Ocean Road, P.O Box 9653, Dar es Salaam, Tanzania
- Amani Medical Research Centre, Muheza, P.O Box 81, Tanga, Tanzania
| | - Pascal Magnussen
- DBL - Centre for Health Research and Development, Institute of Veterinary, Pathobiology, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens Byskov
- DBL - Centre for Health Research and Development, Institute of Veterinary, Pathobiology, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Paul Bloch
- DBL - Centre for Health Research and Development, Institute of Veterinary, Pathobiology, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center, Steno Health Promotion Center, Gentofte, Denmark
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Perception of pregnant women about antenatal care in a cottage hospital in Port Harcourt, Nigeria. J Community Health 2013; 38:360-5. [PMID: 23054423 DOI: 10.1007/s10900-012-9625-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Antenatal care gives opportunity for care of women during pregnancy, prevention and treatment of diseases as well as behavioral change interventions. The perception of users about services influences service utilization. This study was performed to assess user satisfaction with antenatal care services at the centre and to identify constraints at service points. Women attending antenatal care at a cottage hospital In Nigeria were administered questionnaires to evaluate their satisfaction with services and their views about services at various points of care. Data analysis was made using Statistical Package for Social Science version 15.0. Statistical significance was set at P < 0.5. Four hundred correctly completed questionnaires were analysed. The mean age of the respondents was 29 years (SD of 4) and their parity ranged from 0 to 5 (mean 2.5 ± 1.9). The overall satisfaction with care was 94 % and it was highest (95.8 %) with health talks and least with medical consultations (64 %). Attributes valued at service points were educating nature of health talks, prompt attention, and friendly and polite staff. Reasons for dissatisfaction were unfriendly attitudes of staff and delay at service points. Additional care packages women would want were: more staff employed 61 (15.3 %), better organized services 34 (8.5 %) and routine ultrasound scans 25 (6.3 %). Women valued antenatal care and were highly satisfied with services received at the centre. Health education forums should be used to address issues with service delivery. Constraints at service points should be addressed to enhance better service delivery.
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Hill J, Hoyt J, van Eijk AM, D'Mello-Guyett L, Ter Kuile FO, Steketee R, Smith H, Webster J. Factors affecting the delivery, access, and use of interventions to prevent malaria in pregnancy in sub-Saharan Africa: a systematic review and meta-analysis. PLoS Med 2013; 10:e1001488. [PMID: 23935459 PMCID: PMC3720261 DOI: 10.1371/journal.pmed.1001488] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 06/13/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Malaria in pregnancy has important consequences for mother and baby. Coverage with the World Health Organization-recommended prevention strategy for pregnant women in sub-Saharan Africa of intermittent preventive treatment in pregnancy (IPTp) and insecticide-treated nets (ITNs) is low. We conducted a systematic review to explore factors affecting delivery, access, and use of IPTp and ITNs among healthcare providers and women. METHODS AND RESULTS We searched the Malaria in Pregnancy Library and Global Health Database from 1 January 1990 to 23 April 2013, without language restriction. Data extraction was performed by two investigators independently, and data was appraised for quality and content. Data on barriers and facilitators, and the effect of interventions, were explored using content analysis and narrative synthesis. We conducted a meta-analysis of determinants of IPTp and ITN uptake using random effects models, and performed subgroup analysis to evaluate consistency across interventions and study populations, countries, and enrolment sites. We did not perform a meta-ethnography of qualitative data. Ninety-eight articles were included, of which 20 were intervention studies. Key barriers to the provision of IPTp and ITNs were unclear policy and guidance on IPTp; general healthcare system issues, such as stockouts and user fees; health facility issues stemming from poor organisation, leading to poor quality of care; poor healthcare provider performance, including confusion over the timing of each IPTp dose; and women's poor antenatal attendance, affecting IPTp uptake. Key determinants of IPTp coverage were education, knowledge about malaria/IPTp, socio-economic status, parity, and number and timing of antenatal clinic visits. Key determinants of ITN coverage were employment status, education, knowledge about malaria/ITNs, age, and marital status. Predictors showed regional variations. CONCLUSIONS Delivery of ITNs through antenatal clinics presents fewer problems than delivery of IPTp. Many obstacles to IPTp delivery are relatively simple barriers that could be resolved in the short term. Other barriers are more entrenched within the overall healthcare system or socio-economic/cultural contexts, and will require medium- to long-term strategies. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
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Webster J, Kayentao K, Bruce J, Diawara SI, Abathina A, Haiballa AA, Doumbo OK, Hill J. Prevention of malaria in pregnancy with intermittent preventive treatment and insecticide treated nets in Mali: a quantitative health systems effectiveness analysis. PLoS One 2013; 8:e67520. [PMID: 23840729 PMCID: PMC3695962 DOI: 10.1371/journal.pone.0067520] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 05/17/2013] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The objectives of the study were to evaluate the health system effectiveness of ANC for the delivery of a dose of IPTp and an ITN to women attending ANC during eligible gestation, and to identify the predictors of systems effectiveness. METHODS A cross sectional study was undertaken in 10 health facilities including structured non-participant observations of the ANC process for 780 pregnant women followed by exit interviews. The proportion of pregnant women receiving a dose of IPTp-SP and an ITN was assessed. Predictors of each ineffective intermediate process were identified using multivariable logistic regression. RESULTS Overall, 0% and 24.5% of pregnant women of eligible gestation on the first visit to ANC received a dose of IPTp-SP by DOT at the district and community levels respectively. Ineffective intermediate processes were 'given IPTp-SP at the ANC' 63.9% and 74.0% (95% CI 62.0, 83.3), and 'given IPTp-SP by DOT' 0% and 34.3% (95% CI 10.5, 69.8), at district and community levels, respectively. Delivery of ITNs was effective where they were in stock; however stock-outs were a problem. Predictors of receiving IPTp-SP at the district level were 4 to 6 months gestation, not reporting symptoms of malaria at ANC visit and the amount of money spent during the visit. At the community level, the predictors were 4 to 6 months gestation, maternal education below primary level, routine ANC visit (not for an illness), palpation of the abdomen, and expenditure of money in ANC. CONCLUSION In Segou District, the delivery of IPTp-SP was ineffective; whilst ITN delivery was effective if ITNs were in stock. Predictors of receiving IPTp-SP at the district and community levels included gestational age, the amount of expenditure during the ANC visit and no illness.
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Affiliation(s)
- Jayne Webster
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies. PLoS Med 2013; 10:e1001373. [PMID: 23349622 PMCID: PMC3551970 DOI: 10.1371/journal.pmed.1001373] [Citation(s) in RCA: 281] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 12/05/2012] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Almost 50% of women in low- and middle-income countries (LMICs) don't receive adequate antenatal care. Women's views can offer important insights into this problem. Qualitative studies exploring inadequate use of antenatal services have been undertaken in a range of countries, but the findings are not easily transferable. We aimed to inform the development of future antenatal care programmes through a synthesis of findings in all relevant qualitative studies. METHODS AND FINDINGS Using a predetermined search strategy, we identified robust qualitative studies reporting on the views and experiences of women in LMICs who received inadequate antenatal care. We used meta-ethnographic techniques to generate themes and a line-of-argument synthesis. We derived policy-relevant hypotheses from the findings. We included 21 papers representing the views of more than 1,230 women from 15 countries. Three key themes were identified: "pregnancy as socially risky and physiologically healthy", "resource use and survival in conditions of extreme poverty", and "not getting it right the first time". The line-of-argument synthesis describes a dissonance between programme design and cultural contexts that may restrict access and discourage return visits. We hypothesize that centralised, risk-focused antenatal care programmes may be at odds with the resources, beliefs, and experiences of pregnant women who underuse antenatal services. CONCLUSIONS Our findings suggest that there may be a misalignment between current antenatal care provision and the social and cultural context of some women in LMICs. Antenatal care provision that is theoretically and contextually at odds with local contextual beliefs and experiences is likely to be underused, especially when attendance generates increased personal risks of lost family resources or physical danger during travel, when the promised care is not delivered because of resource constraints, and when women experience covert or overt abuse in care settings.
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Affiliation(s)
- Kenneth Finlayson
- Research into Childbirth and Health Unit, School of Health, University of Central Lancashire, Preston, United Kingdom
| | - Soo Downe
- Research into Childbirth and Health Unit, School of Health, University of Central Lancashire, Preston, United Kingdom
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Mubyazi GM, Bloch P, Byskov J, Magnussen P, Bygbjerg IC, Hansen KS. Supply-related drivers of staff motivation for providing intermittent preventive treatment of malaria during pregnancy in Tanzania: evidence from two rural districts. Malar J 2012; 11:48. [PMID: 22340941 PMCID: PMC3298537 DOI: 10.1186/1475-2875-11-48] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 02/18/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since its introduction in the national antenatal care (ANC) system in Tanzania in 2001, little evidence is documented regarding the motivation and performance of health workers (HWs) in the provision of intermittent preventive treatment of malaria during pregnancy (IPTp) services in the national ANC clinics and the implications such motivation and performance might have had on HWs and services' compliance with the recommended IPTp delivery guidelines. This paper describes the supply-related drivers of motivation and performance of HWs in administering IPTp doses among other ANC services delivered in public and private health facilities (HFs) in Tanzania, using a case study of Mkuranga and Mufindi districts. METHODS Interviews were conducted with 78 HWs participating in the delivery of ANC services in private and public HFs and were supplemented by personal communications with the members of the district council health management team. The research instrument used in the data collection process contained a mixture of closed and open-ended questions. Some of the open-ended questions had to be coded in the form that allowed their analysis quantitatively. RESULTS In both districts, respondents acknowledged IPTp as an essential intervention, but expressed dissatisfaction with their working environments constraining their performance, including health facility (HF) unit understaffing; unsystematic and unfriendly supervision by CHMT members; limited opportunities for HW career development; and poor (HF) infrastructure and staff houses. Data also suggest that poor working conditions negatively affect health workers' motivation to perform for ANC (including IPTp) services. Similarities and differences were noted in terms of motivational factors for ANC service delivery between the HWs employed in private HFs and those in public HFs: those in private facilities were more comfortable with staff residential houses, HF buildings, equipment, availability of water, electricity and cups for clients to use while taking doses under direct observed therapy than their public facility counterparts. Employees in public HFs more acknowledged availability of clinical officers, nurses and midwives than their private facility counterparts. More results are presented and discussed. CONCLUSION The study shows conditions related to staffing levels, health infrastructure and essential supplies being among the key determinants or drivers of frontline HWs' motivation to deliver ANC services in both private and public HFs. Efforts of the government to meet the maternal health related Millennium Development Goals and targets for specific interventions need to address challenges related to HWs' motivation to perform their duties at their work-places.
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Affiliation(s)
- Godfrey M Mubyazi
- National Institute for Medical Research (NIMR), Centre for Enhancement of Effective Malaria Interventions (CEEMI), 2338 Ocean Road, P,O Box 9653, Dar-es-Salaam, Tanzania.
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Social and cultural factors affecting uptake of interventions for malaria in pregnancy in Africa: a systematic review of the qualitative research. PLoS One 2011; 6:e22452. [PMID: 21799859 PMCID: PMC3140529 DOI: 10.1371/journal.pone.0022452] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 06/22/2011] [Indexed: 11/23/2022] Open
Abstract
Background Malaria during pregnancy (MiP) results in adverse birth outcomes and poor maternal health. MiP-related morbidity and mortality is most pronounced in sub-Saharan Africa, where recommended MiP interventions include intermittent preventive treatment, insecticide-treated bednets and appropriate case management. Besides their clinical efficacy, the effectiveness of these interventions depends on the attitudes and behaviours of pregnant women and the wider community, which are shaped by social and cultural factors. Although these factors have been studied largely using quantitative methods, qualitative research also offers important insights. This article provides a comprehensive overview of qualitative research on social and cultural factors relevant to uptake of MiP interventions in sub-Saharan Africa. Methods and Findings A systematic search strategy was employed: literature searches were undertaken in several databases (OVID SP, IS Web of Knowledge, MiP Consortium library). MiP-related original research, on social/cultural factors relevant to MiP interventions, in Africa, with findings derived from qualitative methods was included. Non-English language articles were excluded. A meta-ethnographic approach was taken to analysing and synthesizing findings. Thirty-seven studies were identified. Fourteen concentrated on MiP. Others focused on malaria treatment and prevention, antenatal care (ANC), anaemia during pregnancy or reproductive loss. Themes identified included concepts of malaria and risk in pregnancy, attitudes towards interventions, structural factors affecting delivery and uptake, and perceptions of ANC. Conclusions Although malaria risk is associated with pregnancy, women's vulnerability is often considered less disease-specific and MiP interpreted in locally defined categories. Furthermore, local discourses and health workers' ideas and comments influence concerns about MiP interventions. Understandings of ANC, health worker-client interactions, household decision-making, gender relations, cost and distance to health facilities affect pregnant women's access to MiP interventions and lack of healthcare infrastructure limits provision of interventions. Further qualitative research is however required: many studies were principally descriptive and an in-depth comparative approach is recommended.
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Nabbuye-Sekandi J, Makumbi FE, Kasangaki A, Kizza IB, Tugumisirize J, Nshimye E, Mbabali S, Peters DH. Patient satisfaction with services in outpatient clinics at Mulago hospital, Uganda. Int J Qual Health Care 2011; 23:516-23. [PMID: 21775313 DOI: 10.1093/intqhc/mzr040] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To identify factors associated with general satisfaction among clients attending outpatient clinics in a referral hospital in Uganda. DESIGN Cross-sectional exit survey of patients and care-givers in selected outpatient clinics. SETTING Seven outpatients' clinics at Mulago National Referral and Teaching Hospital. MAIN OUTCOME MEASURES Mean score of clients' general satisfaction with health-care services. RESULTS Overall the clients' general satisfaction was suboptimal. Average satisfaction was higher among clients with a primary or secondary education compared with none, those attending HIV treatment and research clinic compared with general outpatient clients, and returning relative to new clients. Conversely, satisfaction was lower among clients incurring costs of at least $1.5 during the visit, and those reporting longer waiting time (>2 h). Client's perceived technical competence of provider, accessibility, convenience and availability of services especially prescribed drugs were the strongest predictor of general satisfaction. CONCLUSIONS This study highlights the important findings about outpatient services at Mulago hospital. The sub-optimal satisfaction scores for outpatient care strongly suggest that more could be done to assure that services provided are more patient centered. Significant factors including category of clinic visited, waiting time, costs incurred, accessibility of services and perceived providers' technical competence at this hospital should be explored by the Makerere University College of Health Sciences and Mulago hospital for potential improvements in quality of the health service delivered.
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Affiliation(s)
- Juliet Nabbuye-Sekandi
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganada.
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The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania. Malar J 2011; 10:140. [PMID: 21599999 PMCID: PMC3126755 DOI: 10.1186/1475-2875-10-140] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 05/21/2011] [Indexed: 11/29/2022] Open
Abstract
Background Intermittent preventive treatment during pregnancy (IPTp) at routine antenatal care (ANC) clinics is an important and efficacious intervention to reduce adverse health outcomes of malaria infections during pregnancy. However, coverage for the recommended two IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage. Methods Data on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Women's timing of ANC visits and health worker's timing of IPTp delivery were analyzed in relation to the different national IPTp schedules and the outcome on IPTp coverage was modelled. Results Among all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. Less than 1% of women started ANC attendance after 32 weeks of gestation. During the second IPTp delivery period health workers delivered IPTp to significantly less women than during the first one (55% vs. 73%) contributing to low second dose coverage. Simplified IPTp guidelines for front-line health workers as recommended by WHO could lead to a 20 percentage point increase in IPTp coverage. Conclusions This study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. To maximize the benefit of the IPTp intervention, revision of existing guidelines is needed. Training on simplified IPTp messages should be consolidated as part of the extended antenatal care training to change health workers' delivery practices and increase IPTp coverage. Pregnant women's knowledge about IPTp and the risks of malaria during pregnancy should be enhanced as well as their ability and power to demand IPTp and other ANC services.
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Le Port A, Cottrell G, Dechavanne C, Briand V, Bouraima A, Guerra J, Choudat I, Massougbodji A, Fayomi B, Migot-Nabias F, Garcia A, Cot M. Prevention of malaria during pregnancy: assessing the effect of the distribution of IPTp through the national policy in Benin. Am J Trop Med Hyg 2011; 84:270-5. [PMID: 21292898 PMCID: PMC3029181 DOI: 10.4269/ajtmh.2011.10-0319] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 09/10/2010] [Indexed: 11/07/2022] Open
Abstract
The efficiency of malaria prevention during pregnancy was compared between three studies in Benin for malaria infection of the placenta (MIP) and low birth weight (LBW). The first was carried out when chloroquine prophylaxis was still recommended, the second was an intermittent preventive treatment in pregnancy (IPTp) clinical trial comparing sulfadoxine pyrimetamine (SP) versus mefloquine, and the third was an observational study after SP-IPTp national implementation. We showed an association between the use of IPTp and the reduction of LBW (10% with national IPTp and 8.7% in IPTp trial versus 15.7% in pre-trial study). The effect on MIP was better in the trial (2.9% versus 11.2% and 16.7% for national IPTp and pre-trial studies, respectively). In spite of a good overall compliance with the national IPTp (with 84% of women taking at least one dose of SP), there are still failures in adherence to the directly observed therapy (DOT) scheme and needs for better training of health staff.
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Affiliation(s)
- Agnès Le Port
- Institut de Recherche pour le Développement (IRD), UMR216, Mère et Enfant Face aux Infections Tropicales, Paris, France.
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Doctor HV. Intergenerational differences in antenatal care and supervised deliveries in Nigeria. Health Place 2010; 17:480-9. [PMID: 21195014 DOI: 10.1016/j.healthplace.2010.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 12/02/2010] [Accepted: 12/03/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess whether age cohort influences the likelihood of receiving antenatal care (ANC) and having a supervised delivery, before and after adjusting for other factors. DESIGN Using data from the 2008 Nigeria Demographic and Health Survey, we grouped women into three distinct cohorts based on their year of birth: the young (1984-1993), the middle (1974-1983) and the older (1959-1973) cohorts. We applied multilevel logistic regression methods to assess the influence of age cohort on receiving ANC and having a supervised delivery among women (n=18,028) whose most recent birth occurred anytime in the five years preceding the survey. RESULTS We identified belonging to the youngest age cohort, rural residence, lack of schooling, higher parity, residence in northern region and poor economic status as determinants of low uptake of ANC and supervised deliveries. CONCLUSION Urgent efforts are needed in Nigeria to ensure that young women in particular receive ANC and have supervised deliveries. An agenda promoting a combination of individuals campaigning for change (particularly in northern Nigeria), communities raising awareness among men and women, and governmental and nongovernmental organizations working together to find practical solutions is an indispensable aim for saving the lives of many women and children who are at risk of dying of maternal and child-related diseases.
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Affiliation(s)
- Henry V Doctor
- Columbia University, Mailman School of Public Health, Department of Population and Family Health, New York, NY 10032, USA.
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Tuba M, Sandoy IF, Bloch P, Byskov J. Fairness and legitimacy of decisions during delivery of malaria services and ITN interventions in Zambia. Malar J 2010; 9:309. [PMID: 21040552 PMCID: PMC2988042 DOI: 10.1186/1475-2875-9-309] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 11/01/2010] [Indexed: 12/04/2022] Open
Abstract
Background Malaria is the leading cause of morbidity and the second leading cause of mortality in Zambia. Perceptions of fairness and legitimacy of decisions relating to treatment of malaria cases within public health facilities and distribution of ITNs were assessed in a district in Zambia. The study was conducted within the framework of REsponse to ACcountable priority setting for Trust in health systems (REACT), a north-south collaborative action research study, which evaluates the Accountability for Reasonableness (AFR) approach to priority setting in Zambia, Tanzania and Kenya. Methods This paper is based on baseline in-depth interviews (IDIs) conducted with 38 decision-makers, who were involved in prioritization of malaria services and ITN distribution at district, facility and community levels in Zambia, one Focus Group Discussion (FGD) with District Health Management Team managers and eight FGDs with outpatients' attendees. Perceptions and attitudes of providers and users and practices of providers were systematized according to the four AFR conditions relevance, publicity, appeals and leadership. Results Conflicting criteria for judging fairness were used by decision-makers and patients. Decision-makers argued that there was fairness in delivery of malaria treatment and distribution of ITNs based on alleged excessive supply of free malaria medicines, subsidized ITNs, and presence of a qualified health-provider in every facility. Patients argued that there was unfairness due to differences in waiting time, distances to health facilities, erratic supply of ITNs, no responsive appeal mechanisms, inadequate access to malaria medicines, ITNs and health providers, and uncaring providers. Decision-makers only perceived government bodies and donors/NGOs to be legitimate stakeholders to involve during delivery. Patients found government bodies, patients, indigenous healers, chiefs and politicians to be legitimate stakeholders during both planning and delivery. Conclusion Poor status of the AFR conditions of relevance, publicity, appeals and leadership corresponds well to the differing perceptions of fairness and unfairness among outpatient attendees and decision-makers. This may have been re-enforced by existing disagreements between the two groups regarding who the legitimate stakeholders to involve during service delivery were. Conflicts identified in this study could be resolved by promoting application of approaches such as AFR during priority setting in the district.
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Affiliation(s)
- Mary Tuba
- Center for International Health, University of Bergen, PO Box 7804, N-5020 Bergen, Norway.
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Kinung'hi SM, Mashauri F, Mwanga JR, Nnko SE, Kaatano GM, Malima R, Kishamawe C, Magesa S, Mboera LEG. Knowledge, attitudes and practices about malaria among communities: comparing epidemic and non-epidemic prone communities of Muleba district, North-western Tanzania. BMC Public Health 2010; 10:395. [PMID: 20602778 PMCID: PMC2910681 DOI: 10.1186/1471-2458-10-395] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 07/05/2010] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Muleba district in North-western Tanzania has experienced malaria epidemics in recent years. Community knowledge, attitudes and practices are important in enhancing disease control interventions. This study investigated determinants of malaria epidemics in the study area in relation to household knowledge, attitudes and practice on malaria. METHODS A community based cross-sectional survey involving 504 study participants was conducted between April and June 2007 using a structured questionnaire focusing on knowledge, attitudes and practices of community members in epidemic and non-epidemic villages about malaria transmission, signs and symptoms, treatment, prevention and control. Multivariate logistic regression analysis was used to assess determinants of malaria epidemics. RESULTS A total of 504 respondents (males = 36.9%) were interviewed. Overall, 453 (90.1%) mentioned malaria as the most important disease in the area. Four hundred and sixty four respondents (92.1%) knew that malaria is transmitted through mosquito bite. A total of 436 (86.7%), 306 (60.8%) and 162 (32.1%) mentioned fever, vomiting and loss of appetite as major symptoms/signs of malaria, respectively. Of those interviewed 328 (65.1%) remembered the recent outbreak of 2006. Of the 504 respondents interviewed, 296 (58.7%) reported that their households owned at least one mosquito net. Three hundred and ninety seven respondents (78.8%) knew insecticides used to impregnate bed nets. About two thirds (63.3%) of the respondents had at least a household member who suffered from malaria during the recent epidemic. During the 2006 outbreak, 278 people (87.2%) sought treatment from health facilities while 27 (8.5%) obtained drugs from drug shops and 10 (3.1%) used local herbs. Logistic regression analysis showed that household location and level of knowledge of cause of malaria were significant predictors of a household being affected by epidemic. CONCLUSIONS Residents of Muleba district have high level of knowledge on malaria. However, this knowledge has not been fully translated into appropriate use of available malaria interventions. Our findings suggest that household location, ineffective usage of insecticide treated nets and knowledge gaps on malaria transmission, signs and symptoms, prevention and control predisposed communities in the district to malaria epidemics. It is important that health education packages are developed to address the identified knowledge gaps.
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Affiliation(s)
- Safari M Kinung'hi
- National Institute for Medical Research, Mwanza Centre, P. O. Box 1462, Mwanza, Tanzania
| | - Fabian Mashauri
- National Institute for Medical Research, Mwanza Centre, P. O. Box 1462, Mwanza, Tanzania
| | - Joseph R Mwanga
- National Institute for Medical Research, Mwanza Centre, P. O. Box 1462, Mwanza, Tanzania
| | - Soori E Nnko
- National Institute for Medical Research, Mwanza Centre, P. O. Box 1462, Mwanza, Tanzania
| | - Godfrey M Kaatano
- National Institute for Medical Research, Mwanza Centre, P. O. Box 1462, Mwanza, Tanzania
| | - Robert Malima
- National Institute for Medical Research, Amani Centre, P. O. Box 81, Muheza, Tanzania
| | - Coleman Kishamawe
- National Institute for Medical Research, Mwanza Centre, P. O. Box 1462, Mwanza, Tanzania
| | - Stephen Magesa
- National Institute for Medical Research, Amani Centre, P. O. Box 81, Muheza, Tanzania
| | - Leonard EG Mboera
- National Institute for Medical Research, Headquarters, P.O. Box 9653, Dar-Es-Salaam, Tanzania
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