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Joshi S, Karki A, Rushton S, Koirala B, Basnet S, Rijal B, Karki J, Pohl G, Baidya M, Chater T, Green D, Lee A. Gender and caste inequalities in primary healthcare usage by under-5 children in rural Nepal: an iterative qualitative study into provider perspectives and the potential role of implicit bias. BMJ Open 2023; 13:e069060. [PMID: 37369413 PMCID: PMC10410982 DOI: 10.1136/bmjopen-2022-069060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVE This study explored provider perspectives on: (1) why inequalities in health service usage persist; and (2) their knowledge and understanding of the role of patient experience and implicit bias (also referred to as unconscious bias). DESIGN A three stage, iterative qualitative study was conducted involving two rounds of in-depth interviews and a training session with healthcare staff. Interview transcripts were analysed using a reflexive thematic approach in relation to the study's aims. SETTING Participants were recruited from rural hill districts (Mugu, Humla, Bajura, Gorkha and Sindhupalchok) of Nepal. PARTICIPANTS Clinical staff from 22 rural health posts. RESULTS Healthcare providers had high levels of understanding of the cultural, educational and socioeconomic factors behind inequalities in healthcare usage in their communities. However, there was less knowledge and understanding of the role of patient experience-and no recognition at all of the concept of implicit bias. CONCLUSION It is highly likely that implicit bias affects provider behaviours in Nepal, just as it does in other countries. However, there is currently not a culture of thinking about the patient experience and how that might impact on future usage of health services. Implicit bias training for health students and workers would help create greater awareness of unintended discriminatory behaviours. This in turn may play a part in improving patient experience and future healthcare usage, particularly among disadvantaged groups.
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Affiliation(s)
| | | | - Simon Rushton
- Department of Politics and International Relations, The University of Sheffield, Sheffield, UK
| | | | | | | | - Jiban Karki
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Tim Chater
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Dan Green
- College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Andrew Lee
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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Khatri RB, Durham J, Karkee R, Assefa Y. High coverage but low quality of maternal and newborn health services in the coverage cascade: who is benefitted and left behind in accessing better quality health services in Nepal? Reprod Health 2022; 19:163. [PMID: 35854265 PMCID: PMC9297647 DOI: 10.1186/s12978-022-01465-z] [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: 10/25/2021] [Accepted: 06/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits are vital to improve the health of mothers and newborns. Despite improved access to these routine maternal and newborn health (MNH) services in Nepal, little is known about the cascade of health service coverage, particularly contact coverage, intervention-specific coverage, and quality-adjusted coverage of MNH services. This study examined the cascade of MNH services coverage, as well as social determinants associated with uptake of quality MNH services in Nepal. METHODS We conducted a secondary analysis of data derived from the Nepal Demographic and Health Survey (NDHS) 2016, taking 1978 women aged 15-49 years who had a live birth in the 2 years preceding the survey. Three outcome variables were (i) four or more (4+) ANC visits, (ii) institutional delivery, and (iii) first PNC visit for mothers and newborns within 48 h of childbirth. We applied a cascade of health services coverage, including contact coverage, intervention-specific and quality-adjusted coverage, using a list of specific intervention components for each outcome variable. Several social determinants of health were included as independent variables to identify determinants of uptake of quality MNH services. We generated a quality score for each outcome variable and dichotomised the scores into two categories of "poor" and "optimal" quality, considering > 0.8 as a cut-off point. Binomial logistic regression was conducted and odds ratios (OR) were reported with 95% confidence intervals (CIs) at the significance level of p < 0.05 (two-tailed). RESULTS Contact coverage was higher than intervention-specific coverage and quality-adjusted coverage across all MNH services. Women with advantaged ethnicities or who had access to bank accounts had higher odds of receiving optimal quality MNH services, while women who speak the Maithili language and who had high birth order (≥ 4) had lower odds of receiving optimal quality ANC services. Women who received better quality ANC services had higher odds of receiving optimal quality institutional delivery. Women received poor quality PNC services if they were from remote provinces, had higher birth order and perceived problems when not having access to female providers. CONCLUSIONS Women experiencing ethnic and social disadvantages, and from remote provinces received poor quality MNH services. The quality-adjusted coverage can be estimated using household survey data, such as demographic and health surveys, especially in countries with limited routine data. Policies and programs should focus on increasing quality of MNH services and targeting disadvantaged populations and those living in remote areas. Ensuring access to female health providers and improving the quality of earlier maternity visits could improve the quality of health care during the pregnancy-delivery-postnatal period.
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Affiliation(s)
- Resham B Khatri
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia. .,Health Social Science and Development Research Institute, Kathmandu, Nepal.
| | - Jo Durham
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Rajendra Karkee
- School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Jin I, Cho HH. Factors influencing the quality of nursing care as perceived by mothers of hospitalized children in South Korea. CHILD HEALTH NURSING RESEARCH 2021; 27:266-275. [PMID: 35004515 PMCID: PMC8650860 DOI: 10.4094/chnr.2021.27.3.266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/20/2021] [Accepted: 06/27/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE This study aimed to identify the factors affecting the quality of nursing care as perceived by mothers of hospitalized children and provide basic data for the development of nursing care quality improvement programs. METHODS The participants consisted of 167 mothers, each of whom had a child hospitalized at a specific children's hospital. Data were collected from June 22 to August 8, 2019. RESULTS The factors that affected how mothers perceived the quality of nursing care were the communication ability of nurses (β=.44, p<.001) and the mother-nurse partnership (β=.33, p=.001). The total explanatory power of these factors was 54.1%. CONCLUSION To improve the quality of pediatric nursing care, it is necessary to improve the communication abilities of nurses and to promote partnership between nurses and the mothers of hospitalized children.
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Affiliation(s)
- Ina Jin
- Head Nurse, Busan Children's Hospital, Busan, Korea
| | - Hun Ha Cho
- Assistant Professor, College of Nursing, Kosin University, Busan, Korea
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Bhura M, Ariff S, Qazi SA, Qazi Z, Ahmed I, Nisar YB, Suhag Z, Soomro AW, Soofi SB. Evaluating implementation of "management of Possible Serious Bacterial Infection (PSBI) when referral is not feasible" in primary health care facilities in Sindh province, Pakistan. PLoS One 2020; 15:e0240688. [PMID: 33052981 PMCID: PMC7556471 DOI: 10.1371/journal.pone.0240688] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022] Open
Abstract
Background The World Health Organization (WHO) launched a guideline in 2015 for managing Possible Serious Bacterial Infection (PSBI) when referral is not feasible in young infants aged 0–59 days. This guideline was implemented across 303 Basic Health Unit (BHU) Plus primary health care (PHC) facilities in peri-urban and rural settings of Sindh, Pakistan. We evaluated the implementation of PSBI guideline, and the quality of care provided to sick young infants at these facilities. Methods Thirty (10%) out of 303 BHU Plus facilities were randomly selected for evaluation. A survey team visited each facility for one day, assessed the health system support, observed the management of sick young infants by health care providers (HCP), validated their management, interviewed HCPs and caretakers of sick infants. HCPs who were unable to see a young infant on the day of survey were evaluated using pre-prepared case scenarios. Results Thirty (100%) BHU Plus facilities had oral amoxicillin, injectable gentamicin, thermometers, baby weighing scales and respiratory timers available; 29 (97%) had disposable syringes and needles; 28 (93%) had integrated management of childhood illness (IMCI)/PSBI chart booklets and job aids and 18 (60%) had a functional ambulance. Each facility had at least one HCP trained in PSBI, and 21 (70%) facilities had been visited by a supervisor in the preceding six months. Of 42 HCPs, 19 (45.3%) were trained within the preceding 12 months. During the survey, 26 sick young infants were identified in 18 facilities. HCPs asked about history of breastfeeding in 23 (89%) infants, history of vomiting in 17 (65%), and history of convulsions in 14 (54%); weighed 25 (97%) infants; measured respiratory rate in all (100%) and temperature in 24 (92%); assessed 20 (77%) for movement and 14 (54%) for chest indrawing. HCPs identified two infants with fast breathing pneumonia and managed them correctly per IMCI/PSBI protocol. HCPs identified six (23%) infants with clinical severe infection (CSI), two of them were referred to a higher-level facility, only one accepted the referral advice. Only one CSI patient was managed correctly per IMCI/PSBI protocol at the outpatient level. HCPs described the PSBI danger signs to eight (31%) caretakers. Caretakers of five infants with CSI and two with pneumonia were not counselled for PSBI danger signs. Five of the six CSI cases categorized by HCPs were validated as CSI on re-examination, whereas one had pneumonia. Similarly, one of the two pneumonia patients categorized by HCPs had CSI and one identified as local bacterial infection was classified as CSI upon re-examination. Conclusion Health system support was adequate but clinical management and counselling by HCPs was sub-optimal particularly with CSI cases who are at higher risk of adverse outcomes. Scaling up PSBI management is potentially feasible in PHC facilities in Pakistan, provided that HCPs are trained well and mentored, receive refresher training to appropriately manage sick young infants, and have adequate supplies and counselling skills.
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Affiliation(s)
- Maria Bhura
- Center of Excellance in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Shabina Ariff
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shamim Ahmad Qazi
- Retired from Department of Maternal, Newborn, Child, and Adolescent Health, WHO, Working as a WHO Consultant, Geneva, Switzerland
| | | | - Imran Ahmed
- Center of Excellance in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Yasir bin Nisar
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Zamir Suhag
- People’s Primary Healthcare Initiative, Sindh, Pakistan
| | | | - Sajid Bashir Soofi
- Center of Excellance in Women & Child Health, Aga Khan University, Karachi, Pakistan
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- * E-mail:
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Carmone AE, Kalaris K, Leydon N, Sirivansanti N, Smith JM, Storey A, Malata A. Developing a Common Understanding of Networks of Care through a Scoping Study. Health Syst Reform 2020; 6:e1810921. [PMID: 33021881 DOI: 10.1080/23288604.2020.1810921] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multi-method scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low- and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.
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Affiliation(s)
- Andy E Carmone
- Clinical Sciences, Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Katherine Kalaris
- Maternal and Neonatal Health, Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Nicholas Leydon
- Global Delivery Programs, Bill & Melinda Gates Foundation , Seattle, Washington, USA
| | - Nicole Sirivansanti
- Maternal, Newborn & Child Health, Bill & Melinda Gates Foundation , Seattle, Washington, USA
| | - Jeffrey M Smith
- Maternal, Newborn & Child Health, Bill & Melinda Gates Foundation , Seattle, Washington, USA
| | - Andrew Storey
- Maternal and Neonatal Health, Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Address Malata
- Office of the Chancellor, Vice Chancellor, Malawi University of Science and Technology , Limbe, Malawi
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