'Leaving no one behind': a scoping review on the provision of sexual and reproductive health care to nomadic populations

Forbidden Conversations: A Comprehensive Exploration of Taboos in Sexual and Reproductive Health

This scoping review aims to comprehensively explore the landscape of taboos and their impact on sexual and reproductive health. Titled "Forbidden Conversations," it delves into the intricate web of societal, cultural, and religious norms that have contributed to the elusive and often stigmatized nature of sexual and reproductive health topics. The review navigates through the multifaceted dimensions of these taboos, shedding light on their impact on individuals, communities, and public health while advocating for a paradigm shift toward open, inclusive, and informed dialogue. The analysis within this review spans a decade, capturing the most recent and relevant literature to map the landscape of taboos in sexual and reproductive health. It explores the persistent societal apprehensions and subsequent stigmatization surrounding topics such as menstruation, contraception, fertility, sexual orientation, and gender identity. The review contextualizes the multifaceted challenges presented by these prevailing norms by tracing historically rooted taboos and their evolution across different cultures and contexts. The scoping review identifies the profound implications of these taboos on public health, highlighting how they contribute to disparities in access to healthcare, perpetuate misinformation, and infringe upon the fundamental rights of individuals. It addresses the challenges in sexual education, emphasizing how these taboos impede comprehensive understanding and enforcement of sexual and reproductive health rights among adolescents and young adults. The intersectional approach taken in this review situates these taboos within broader systems of inequality, emphasizing the compounded impact they have on marginalized populations. Through this comprehensive exploration, the review aims to provide actionable insights and identify existing research, policy, and practice gaps. It seeks to lay the foundation for future initiatives that advocate for destigmatization, empowerment, and equity in sexual and reproductive health. Ultimately, "Forbidden Conversations" aims to steer the conversation toward openness and inclusivity while advocating for unbiased, comprehensive sexual and reproductive healthcare with dignity for all individuals.

The sexual and reproductive healthcare challenges when dealing with female migrants and refugees in low and middle-income countries (a qualitative evidence synthesis)

BACKGROUND

Migrants and refugees face unprecedented inequalities in accessing sexual and reproductive health (SRH) in developed and developing countries. Most attention has focused on the rich world perspective, while there are huge numbers of migrants and refugees moving towards less developed countries. This article synthesizes the barriers to proper SRH care from low and middle-income countries perspective.

METHODS

We performed a systematic review of articles containing primary source qualitative and quantitative studies with thick qualitative descriptions. Articles from various databases, including PubMed, Science Direct, HINARI, and Google Scholar, published between 2012 and 2022 were included. Because the context differed, we excluded articles dealing with migrants and refugees from low- and middle-income countries living in high-income countries. To select articles, a preferred reporting item for systematic reviews and meta-analyses (PRISMA) was used. The articles' quality was assessed using the standard QASP checklist. We used a socio-ecological model to investigate barriers at various levels, and thematic analysis was used to identify the strongest themes at each level of the model. This synthesis is registered under PROSPERO number CRD42022341460.

RESULTS

We selected fifteen articles from a total of 985 for the final analysis. The results show that despite the diversity of the participants' homes and countries of origin, their experiences using SRH services were quite similar. Most female migrants and refugees claimed to have encountered discrimination from service providers, and linguistic and cultural obstacles played a significant role in their experiences. In nations lacking universal healthcare coverage, the cost of care was a barrier to the use of SRH services. Other main obstacles to using SRH services were a lack of knowledge about these programs, worries about privacy, inadequate communication, stigma in the community, and gender-related power imbalances.

CONCLUSION

To enhance the use of SRH by female migrants and refugees, it is vital to provide person-centered care and involve husbands, parents, in-laws, and communities in SRH coproduction. Training on cultural competency, compassion, and respect must be provided to healthcare personnel. Increasing financial access for migrant and refugee healthcare is crucial, as is meeting their basic requirements.

Assessment of Place of Delivery and Associated Factors among Pastoralists in Ethiopia: A Systematic Review and Meta-Analysis Evaluation

Background

Pastoralist communities rely on their livestock for at least 50% of their food supply and source of income. Home births raise the risk of maternal morbidity and death, whereas institutional births lessen the likelihood of difficulties during labor. Around 70% of labors in pastoralist regions of Ethiopia were assisted by traditional birth attendants.

Methods

Studies done from January 2004 to January 2023, accessed in PubMed, EMBASE, Medline, and other search engines, were included. PRISMA guidelines and JBI critical appraisal checklist were used to assure the quality of the review. Ten articles were included in this review. Data were extracted with Excel and exported to STATA 16 for analysis. Heterogeneity of literatures was evaluated using I2 statistics and publication bias using the Egger regression asymmetry test and the Duval and Tweedie trim-fill analysis. Statistical significance was declared at p value less than 0.05.

Result

The pooled estimate of institutional delivery among the pastoralist community in Ethiopia is 21.2% (95% CI: 16.2-26.1). Husbands who were involved to decide place of delivery (OR = 3.47; 95% CI: 1.61, 7.50), women with good knowledge of MCH services (OR = 2.283; 95% CI: 1.51, 3.44), women who had a positive attitude towards MCH services (OR = 1.69; 95% CI: 0.79, 3.6), availability of health institutions (OR = 2.6; 95% CI: 0.95, 7.20), and women who had an ANC follow-up (OR = 2.78; 95% CI: 2.07, 3.73) were higher institutional delivery prevalence among pastoralist women. Moreover, institutional delivery among women who were educated above the college level was more than two times (OR = 2.56; 95% CI: 1.985, 3.304) higher than among women who were not educated.

Conclusion

Pastoralist women in Ethiopia were found to be a disadvantaged group for institutional delivery at national level. Husband involvement, educational level, ANC visit, knowledge and attitude for MCH service, and health facility distance were identified to have significant association with institutional delivery.

Applying community health systems lenses to identify determinants of access to surgery among mobile & migrant populations with hydrocele in Zambia: A mixed methods assessment

Hydrocele which is caused by long term lymphatic filariasis infection can be treated through the provision of surgery. Access to surgeries remains low particularly for hard to reach populations. This study applied community health system lenses to identify determinants to the adoption, implementation and integration of hydrocele surgeries among migrants &mobile populations in Luangwa District, Zambia. A concurrent mixed methods design consisting of cross-sectional survey with hydrocele patients (n = 438) and in-depth interviews with different community actors (n = 38) was conducted in October 2021. Data analysis was based on the relational and programmatic lenses of Community Health Systems. Under the Programmatic lens, insufficient resources resulted in most health facilities being incapable of providing the minimum package of care for lymphatic filariasis. The absence of cross border collaborative structures limits the continuity of care for patients moving across the three countries. Other programmatic barriers include language barriers, inappropriate appointment systems, direct and indirect costs. In the relational lens, despite the key role that community leaders play their engagement in service delivery was low. Community actors including patients were rarely included in planning, implementation or evaluation of hydrocele services. Some patients utilized their power within to act as champions for the surgery but local groups such as fishing associations remained underutilized. Community health systems provide a potential avenue through which access amongst mobile and migrant populations can be enhanced through strategies such engagement of patient groups, knowledge sharing across borders and use of community monitoring initiatives.

Determinants of continuum of care for maternal, newborn, and child health services in Ethiopia: Analysis of the modified composite coverage index using a quantile regression approach

Maternal and child mortality remain unacceptably high in the Sustainable Development Goals era. Continuum of care has become a key strategy for improving the health of mothers and newborns. Previous research on the continuum of care in Ethiopia is often limited to maternal health services. Maternal and child health services are inseparably linked, and an integrated approach to care is essential. This study assessed the continuum of maternal, newborn, and child health care and associated factors in Ethiopia. The analysis was based on the 2016 Ethiopian Demographic and Health Survey data. We restricted our analysis to women with their most recent children-alive and living with their mother- aged 12-23 months at the time of the survey (n  =  1891). The modified composite coverage index, constructed from twelve maternal and child health services, was calculated as an indicator of the continuum of care. Bivariable and multivariable quantile regression were used to analyse the relationship between the predictors and specific quantiles of the composite coverage index. The effect of each variable was examined at the 10th, 25th, 50th, 75th, and 95th quantiles. The results showed that the average composite coverage index value was 39%. The overall completion rate of the continuum of care was low (2%). Four % of the women did not receive any of the services along the continuum of care. Postnatal care for newborns had the lowest coverage (12%). This study provides evidence that factors such as the educational status of women, region, residence, socio-economic status, perceived distance to a health facility, pregnancy intention, mode of delivery, parity, and early antenatal care initiation influence the continuum of care differently across levels of the composite coverage index. The findings call for integrated and targeted strategies that aim to improve the continuum of care considering the determinants.

Nomadic pastoralists' experience accessing reproductive and maternal healthcare services in low and middle-income countries: A contextual scoping review

Globally, discriminately vulnerable and marginalized groups, such as nomadic pastoralist populations, have perhaps the least access to reproductive and maternal health services (R/MHCSs). Previous studies report that most nomadic pastoralist mothers use both traditional methods of childbirth (i.e. delivering at home and assistance by traditional birth attendants (TBAs)) and traditional methods of contraception. However, determining factors of R/MHCSs in these nomadic pastoralist communities remain scarcely explored and condensed. This study aims to analyse quantitative, qualitative, and mixed methods studies and summarize pastoralists’ experience accessing R/MHCSs in low- and middle-income countries (LMICs).

We employed a mixed method approach in conducting this scoping review by including studies applying quantitative, qualitative, and mixed methods retrieved from online databases (PubMed, Google Scholar, and JSTOR) as well as reviewing indexes of journals specific to the field by using a set of keywords related to R/MHCSs in LMICs. Thematic content analysis was performed to generate four themes and codes.

We retrieved 2131 articles and retained 25 that met our inclusion criteria. Of these, 6 were quantitative studies, 12 were qualitative studies, and 7 were mixed methods studies. We found that nomadic pastoralists face multi-faceted barriers in access to R/MHCS that can be broadly categorized into four themes: (i) physical (geographic isolation and access), (ii) political (discriminatory/marginalized status, poor transport system, lack of infrastructure, and little political status to improve their lives), (iii) economic (poor quality of service/lack of available resources in rural areas where nomadic pastoralists live, vulnerability, poverty/affordability of R/MHCSs), and (iv) socio-cultural (misconceptions, perception, gender roles in decision-making, low demand for R/MHCSs by nomadic pastoralists, autonomy for females to travel) factors. Therefore, to effectively address the needs of nomadic pastoralist populations, R/MHCSs must be available, accessible, acceptable, and affordable through political, economic, geographic, and socio-culturally sensitive approaches.

Low awareness of, and low access to, modern R/MHCSs and their benefits is a critical barrier to service utilization. Partnership with nomad communities through leveraging existing structures, networks, and decision-making patterns and involvement of nomadic women and girls, community leaders, male partners, and trained traditional birth attendants are key to R/MHCS access.

What is known about this topic?

What the study adds

The role of cultural safety and ethical space within postcolonial healthcare for Maasai in Tanzania

The history of the Maasai tribe in northern Tanzania is characterised by marginalisation, discrimination and political subjugation. Inequities, enacted through power relations, influence healthcare access, practices and outcomes among the Maasai. Cultural safety and ethical space provide lenses into social, political and historical influences on access to care, helping to understand the realities of historically marginalised populations such as the Maasai, and responses to health services. This study aims to examine Maasai experiences of accessing and uptake of health services within a postcolonial discourse in Tanzania. In an ethnographic study examining access and perceptions of healthcare services in Maasai communities, lead authors conducted participant observations and at health facilities to document experiences. Household interviews, a group oral history and interviews with NGOs working with Maasai communities, contributed to the data analysed. Inductive thematic analysis was used to understand healthcare experiences within a framework of cultural safety and ethical space. Despite trust in biomedicine, Maasai people have a strong desire for health services with particular characteristics. Quality of care, including facilities and diagnostics available and used, was important. A sense of fairness was a determinant in respecting services including 'first come first serve' system and transparency when unable to treat a condition. Trust in health services was also influenced by personal interactions with health workers, including provision of health information provided to patients and instances of being mistreated. These findings offer an understanding of ways in which spaces of healthcare can be more approachable and trusted by Maasai. Incorporating cultural safety and ethical spaces to understand healthcare access can help to reduce the power imbalance possibly resulting from a history of marginalisation. This can inform development of culturally appropriate programmes, used to educate healthcare professionals and advocate for improved healthcare services for marginalised groups.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Reach and Utility of COVID-19 Information and Preventive Measures for Nomadic Populations in Massangam, West Region of Cameroon

The separation of nomadic pastoralist settlements from settled communities is a well-known challenge to the health system. Difficulties reaching these groups contribute to inequities in their health and impact the spread or control of several diseases. COVID-19 has led to the suspension of many public health interventions in Cameroon, while preventive measures including behavior change communication have been ongoing since the onset of the pandemic. The reach and utility of these campaigns in semi-nomadic population remain unclear. This exploratory qualitative study was conducted in September to October 2020 using semi-structured interviews and focus group discussions with nomadic camp heads, and their wives to explore their interactions with communication campaigns, awareness, understanding, and acceptance of behavior change messages. The study revealed a general awareness of COVID-19 and its preventive measures and a prevailing belief that they were less at risk because their camps are isolated from the main communities, and the fact that they had never met a COVID-19 case. They perceived that the women were at lower risk because of their limited interaction outside the camps. There was a common concern regarding the transmission of COVID-19 to their cattle. Routes of communication were markets and mosques frequented by men, making access to information limited to or dependent on men. Financial constraints and lack of water were the main barriers affecting the access to and use of COVID-19 prevention measures. There is need for adaptive communication strategies especially tailored to the culture of nomadic pastoralists addressing gender dynamics of this subgroup.

Effects of a four-year health systems intervention on the use of maternal and infant health services: results from a programme evaluation in two districts of rural Chad

Background

Attendance of maternal and infant care services in rural Chad are consistently low. Our study aimed to assess the use of antenatal (ANC) and postnatal care (PNC) services, health facility delivery and infant health services after 4 years of a health systems intervention for improving the infrastructure, supplies, training and sensitization for maternal and infant health in two districts of rural Chad.

Methods

Data from a repeated cross-sectional household survey conducted in Yao and Danamadji in 2015 and in 2018 were analyzed. A stratified two-stage cluster sampling methodology was applied to achieve a representative sample of the rural settled and mobile population groups in the study area. A generalized linear model was applied to determine the health care utilization rates. Multivariate regression models were used to assess the association between the programme intervention and utilization outcomes of selected maternal and infant health services.

Results

Complete datasets were available for 1284 households at baseline. The endline analysis included 1175 households with complete survey data. The use of at least one ANC amongst pregnant women increased in both settled communities (from 80% in 2015 to 90% in 2018) and amongst mobile pastoralist communities (from 48% in 2015 to 56% in 2018). The rate of home delivery among settled communities and mobile pastoralists changed little between baseline and endline and remained high for both population groups. Individuals that were covered by the health systems intervention were however significantly more likely to attend ANC and less likely to give birth at home. PNC services only showed improvements amongst the settled communities (of 30%). Infants’ reported health outcomes and vaccination coverage considerably improved; the latter especially among mobile pastoralist (from 15% in 2015 to 84% in 2018).

Conclusion

A combination of health systems strengthening interventions was associated with an increased use of certain maternal and infant health services. However, to facilitate equitable access to and use of health care services in particular in times of increased vulnerability and by certain population groups in hard-to-reach areas, reinforced health education and culturally adapted communication strategies, including gender-specific messaging will be needed over a sustained period.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12330-2.

Patterns of wasting among pregnant and lactating women in Uganda, 2015-2018: analysis of Nutrition surveillance data

BACKGROUND

Maternal nutrition is closely linked to the survival and development of children during the first 1000 days of life. Maternal wasting, a measure of malnutrition, is measured using the mid-upper arm circumference. However, in 2019, the rate and distribution of wasting among pregnant and lactating women was not known. We described annual trends and distribution of wasting among pregnant and lactating women (PLW), Uganda, 2015-2018, to inform programming on targeted nutritional interventions.

METHODS

We analyzed nutrition surveillance data from the District Health Information System for all PLW from 2015 to 2018. We used the World Health Organization standard thresholds to determine wasting among PLW by year and region, drawing choropleth maps to demonstrate the geographic distribution of wasting among PLW. We used logistic regression to assess wasting trends.

RESULTS

During 2015-2018, 268,636 PLW were wasted (prevalence = 5.5%). Of the 15 regions of Uganda, Karamoja (prevalence = 21%) and Lango (prevalence = 17%) registered the highest prevalence while Toro (prevalence = 2.7%) and Kigezi (prevalence = 2.0%) registered the lowest prevalence. The national annual prevalence of wasting among PLW declined by 31% from 2015 to 2018 (OR = 0.69, p < 0.001). Regions in the north had increasing trends of wasting over the period [Lango (OR = 1.6, p < 0.001) and Acholi (OR = 1.2, p < 0.001)], as did regions in the east [(Bugisu (OR = 3.4, p < 0.001), Bukedi (OR = 1.4, p < 0.001), and Busoga (OR = 1.3, p < 0.001)]. The other 11 regions showed declines.

CONCLUSION

The trend of wasting among PLW nationally declined during the study period. Lango and Acholi regions, both of which were experiencing a nutrition state of emergency during this period, had both high and rising rates of wasting, as did the Karamoja region, which experienced the highest wasting rates. We recommended that the Ministry of Health increases its focus on nutrition monitoring for PLW and conduct an analysis to clearly identify the factors underlying malnutrition specific for PLW in these regions.

Improving provision of family planning among pastoralists in Kenya: Perspectives from health care providers, community and religious leaders

There exist significant inequities in access to family planning (FP) in Kenya, particularly for nomadic and semi-nomadic pastoralists. Health care providers (HCP), are key in delivering FP services. Community leaders and religious leaders are also key influencers in women's decisions to use FP. We found limited research exploring the perspectives of both HCPs and these local leaders in this context. We conducted semi-structured interviews with HCPs (n=4) working in facilities in Wajir and Mandera, and community leaders (n=4) and religious leaders (n=4) from the nomadic and semi-nomadic populations the facilities serve. We conducted deductive and inductive thematic analysis. Three overarching themes emerged: perception of FP as a health priority, explanations for low FP use, and recommendations to improve access. Four overlapping sub-themes explained low FP use: desire for large families, tension in FP decision-making, religion and culture, and fears about FP. Providers were from different socio-demographic backgrounds to the communities they served, who faced structural marginalisation from health and other services. Programmes to improve FP access should be delivered alongside interventions targeting the immediate health concerns of pastoralist communities, incorporating structural changes. HCPs that are aware of religious and cultural reasons for non-use, play a key role in improving access.

Reproductive health decision making among nomadic pastoralists in North Eastern Kenya: a qualitative social network analysis

BACKGROUND

To our knowledge, no studies exist on the influence of nomadic pastoralist women's networks on their reproductive and sexual health (RSH), including uptake of modern family planning (FP).

METHODS

Using name generator questions, we carried out qualitative egocentric social network analysis (SNA) to explore the networks of four women. Networks were analyzed in R, visuals created in Visone and a framework approach used for the qualitative data.

RESULTS

Women named 10-12 individuals. Husbands were key in RSH decisions and never supported modern FP use. Women were unsure who supported their use of modern FP and we found evidence for a norm against it within their networks.

CONCLUSIONS

Egocentric SNA proves valuable to exploring RSH reference groups, particularly where there exists little prior research. Pastoralist women's networks likely change as a result of migration and conflict; however, husbands make RSH decisions and mothers and female neighbors provide key support in broader RSH issues. Interventions to increase awareness of modern FP should engage with women's wider networks.

Using Human-Centered Design to Adapt Supply Chains and Digital Solutions for Community Health Volunteers in Nomadic Communities of Northern Kenya

BACKGROUND

Unreliable and nonexistent supply chain procedures and processes are one of the primary barriers to achieving functional community health units in nomadic communities in the arid/semiarid counties of Kenya.

METHODS

We used a human-centered design (HCD) approach to engage communities and community health volunteers (CHVs) in redesigning a proven data-centric supply chain approach that included a digital solution, called cStock, for this challenging context. We conducted the HCD process in 4 phases: (1) understanding intent, (2) research and insights, (3) ideation and prototyping, and (4) supply chain design and requirements building. Data collection used qualitative methods and involved a range of stakeholders including CHVs, supervisors, and local beneficiaries. CHVs and their supervisors also participated in cStock usability testing. Drawing on insights and personas generated from the research, stakeholders ideated and codesigned supply chain tools.

RESULTS

The research identified critical insights for informing the redesign of cStock for nomadic communities. These insights were categorized into supply chain, information systems, human resources, behaviors, service delivery infrastructure, and connectivity. Four supply chain data solutions were designed, prototyped, tested, and iterated: a stock recording paper-based form, a user-friendly cStock application, a supervisor cStock application, and an unstructured supplementary service data reporting system using feature phones.

CONCLUSIONS

Using the HCD process incorporated the perspective of CHVs and their communities and provided key insights to inform the design of the supply chain and adapt cStock. The process helped make cStock to be inclusive and have the potential to have a meaningful impact on strengthening the supply chain for seminomadic and nomadic communities in northern Kenya. A strong supply chain for these CHVs will increase access to essential and reproductive health commodities and contribute to improving the overall health and well-being of these communities, especially women and children.

Challenges in measuring supplemental immunization activity coverage among measles zero-dose children

•Measles Supplemental Immunization Activities (SIAs) are resource intensive. •SIAs importantly reach some previously unvaccinated (so-called measles zero-dose) children. •We highlight difficulties in measuring how many measles zero-dose children the SIA reaches. •We also suggest some other methods to improve estimation of SIA impact.