Health service utilization, perspectives, and health-seeking behavior for maternal and child health services in the Amazon of Peru, a mixed-methods study

'You have a lot of mirrors': structural and socioecological factors impacting adolescent pregnancy and reproductive health in the Amazon basin, Peru, a qualitative study

Loreto, in the Peruvian Amazon, has one of the highest adolescent pregnancy rates in the country. However, underlying causes of adolescent pregnancy are not fully understood as data are limited in Indigenous and remote Amazonian communities. This study investigated adolescent reproductive health within Loreto using an ecological systems framework. Forty-one semi-structured interviews were conducted in June 2022: community leaders (n = 12) and adolescent participants between 15 and 17 years of age (pregnant girls, n = 11; never pregnant girls, n = 9; and boys, n = 9). We also conducted focus group discussions with community health workers and educators in October 2022 (three focus groups, n = 15). Adolescent reproductive health is complex with multi-layered factors that put girls at higher risk of pregnancy. We found a paradoxical relationship between expected social and gender norms and individual desires. This research provides a contextual understanding of the lived experience of adolescents and young people in the Amazon region of Peru. Our findings suggest the need for greater exploration of the contradictory ideas surrounding adolescent pregnancy and female sexuality.

Pathways to strengthen the climate resilience of health systems in the Peruvian Amazon by working with Indigenous leaders, communities and health officers

BACKGROUND

Indigenous knowledge and responses were implemented during the COVID-19 pandemic to protect health, showcasing how Indigenous communities participation in health systems could be a pathway to increase resilience to emergent hazards like climate change. This study aimed to inform efforts to enhance climate change resilience in a health context by: (1) examining if and how adaptation to climate change is taking place within health systems in the Peruvian Amazon, (2) understanding how Indigenous communities and leaders' responses to climatic hazards are being articulated within the official health system and (3) to provide recommendations to increase the climate change resilience of Amazon health systems.

METHODS

This study was conducted among two Peruvian Amazon healthcare networks in Junin and Loreto regions. A mixed methodology design was performed using a cross-sectional survey (13 healthcare facilities), semistructured interviews (27 official health system participants and 17 Indigenous participants) and two in-person workshops to validate and select key priorities (32 participants). We used a climate-resilient health system framework linked to the WHO health systems building blocks.

RESULTS

Indigenous and official health systems in the Peruvian Amazon are adapting to climate change. Indigenous responses included the use of Indigenous knowledge on weather variability, vegetal medicine to manage health risks and networks to share food and resources. Official health responses included strategies for climate change and response platforms that acted mainly after the occurrence of climate hazards. Key pathways to articulate Indigenous and official health systems encompass incorporating Indigenous representations in climate and health governance, training the health work force, improving service delivery and access, strengthening the evidence to support Indigenous responses and increasing the budget for climate emergency responses.

CONCLUSIONS

Key resilience pathways call for a broader paradigm shift in health systems that recognises Indigenous resilience as valuable for health adaptation, moves towards a more participatory health system and broadens the vision of health as a dimension inherently tied to the environment.

Perceived barriers and factors influencing uptake of breast cancer screening among women: a population-based cross-sectional study

Breast cancer (BC) screening plays a major role in the prevention of BC through early detection and timely treatment. This study aims to determine the level of uptake of BC screening and associated factors. A community-based analytical cross-sectional study was conducted in Dodoma City, Tanzania from July to December 2020. The study included women aged 8 years and above without a known history of breast cancer. Multivariable logistic regression was used to determine the socio-demographic factors associated with BC screening. P value < 0.05 was considered significant. A total of 354 study participants were included in the present study. The mean age of participants was 31.0 ± 11.8 years. The majority of study participants (67.5%, n = 239) were aware of BC screening. However, only (35.3%, n = 125) reported to have ever practised BC screening. Breast self-examination was the most (16.4%, n = 58) frequently used method for BC screening among study participants. Lack of knowledge of all methods of BC screening was the barrier that was perceived by the vast majority (60.2%, n = 213) of the study participants. Having low family income was the only predictor of failure to practice BC screening. In this study, most of the women were aware of BC, however, few of them had undergone breast cancer (BC) screening at the time of the interview. The study also found that the main barrier to BC screening was the lack of knowledge about BC among the study participants. Immediate measures are necessary to increase women's awareness of BC. Such as community sensitization on the importance of screening, can help improve the uptake of BC screening and the early detection of BC.

Utilisation of public healthcare services by an indigenous group: a mixed-method study among Santals of West Bengal, India

A barrier to meeting the goal of universal health coverage in India is the inequality in utilisation of health services between indigenous and non-indigenous people. This study aimed to explore the determinants of utilisation, or non-utilisation, of public healthcare services among the Santals, an indigenous community living in West Bengal, India. The study holistically explored the utilisation of public healthcare facilities using a framework that conceptualised service coverage to be dependent on a set of determinants - viz. the nature and severity of the ailment, availability, accessibility (geographical and financial), and acceptability of the healthcare options and decision-making around these further depends on background characteristics of the individual or their family/household. This cross-sectional study adopts ethnographic approach for detailed insight into the issue and interviewed 422 adult members of Santals living in both rural (Bankura) and urban (Howrah) areas of West Bengal for demographic, socio-economic characteristics and healthcare utilisation behaviour using pre-tested data collection schedule. The findings revealed that utilisation of the public healthcare facilities was low, especially in urban areas. Residence in urban areas, being female, having higher education, engaging in salaried occupation and having availability of private allopathic and homoeopathic doctors in the locality had higher odds of not utilising public healthcare services. Issues like misbehaviour from the health personnel, unavailability of medicine, poor quality of care, and high patient load were reported as the major reasons for non-utilisation of public health services. The finding highlights the importance of improving the availability and quality of care of healthcare services for marginalised populations because these communities live in geographically isolated places and have low affordability of private healthcare. The health programme needs to address these issues to improve the utilisation and reduce the inequality in healthcare utilisation, which would be beneficial for all segments of Indian population.

The downstream effects of COVID-19 on adolescent girls in the Peruvian Amazon: qualitative findings on how the pandemic affected education and reproductive health

Due to COVID-19, schools were closed to mitigate disease spread. Past studies have shown that disruptions in education have unintended consequences for adolescents, including increasing their risk of school dropout, exploitation, gender-based violence, pregnancy and early unions. In Peru, the government closed schools from March 2020 to March 2022, declaring a national emergency that affected an estimated 8 million children. These closures may have unintended consequences, including increased adolescent pregnancy, particularly in Peru's rural, largely indigenous regions. Loreto, located in the Peruvian Amazon, has one of the highest adolescent pregnancy rates in the country and poor maternal and child health outcomes. The underlying causes may not be fully understood as data are limited, especially as we transition out of the pandemic. This qualitative study investigated the downstream effects of COVID-19 on adolescent education and reproductive health in Loreto's districts of Nauta and Parinari. In-depth interviews (n=41) were conducted with adolescents and community leaders. These were held in June 2022, 3 months after the reinstitution of in-person classes throughout Peru. Focus group discussions (FGDs) were also completed with community health workers and educators from the same study area in October 2022 to supplement our findings (3 FGDs, n=15). We observed that the economic, educational and health effects of the COVID-19 pandemic contributed to reduced contraceptive use, and increased school abandonment, early unions and adolescent pregnancy. The interplay between adolescent pregnancy and both early unions and school abandonment was bidirectional, with each acting as both a cause and consequence of the other.

The Creation of a Field Manual for Community Health Workers to Teach Child Health and Development During Home Visits: A Case Study of Participatory Content Creation

Community health workers (CHWs) play a crucial role in improving child health and development in underserved populations. However, CHWs often face challenges in accessing appropriate guidance and materials for their home visits, hindering their ability to deliver accurate and relevant information to families. Extensive searches for existing resources were conducted to search for established field manual guidebooks for CHWs, however, no suitable material was found, highlighting the need for this case study. The exercise aimed to develop a comprehensive field manual guidebook and animated videos to support CHWs in the Amazon of Peru during their home visits. A multidisciplinary team of specialists was assembled to develop the material. The material development process employed a design thinking methodology, incorporating participatory content creation workshops with CHWs and experts in health topics relevant to the Amazon. This approach ensured cultural relevance and sensitivity in conveying information. The team created a list of 38 essential health and early childhood development messages for Amazonian communities. Infographics were designed for each topic, accompanied by easy-to-understand language and images to assist CHWs in conveying information effectively. To provide additional support, seven animated videos were created based on health behavior theory, covering topics such as anemia, healthy diet, diarrhea, breastfeeding, clean water, child-caregiver bond, and early childhood stimulation. The videos were designed for CHWs to share with caregivers during home visits, enhancing information transmission. The resulting guidebook, infographics, and animated videos were presented to CHWs in Loreto, Peru for feedback. Updated versions were printed and distributed to CHWs in seven communities in Loreto.

[Comparative Analysis of Influencing Factors of Health Service Utilization Among Urban and Rural Residents in Tibet]

Objective

To examine the differences and commonalities of factors influencing the utilization of health services among urban and rural residents in Tibet and to identify vulnerable populations in the utilization of health services, thereby providing references for the formulation of local health policies and the allocation of health resources.

Methods

Using the Tibetan area data from the Sixth National Health Service Survey, we conducted statistical analysis of the health service utilization status of 8 297 residents of agro-pastoral areas and 2 179 residents of urban areas with χ 2 test and logistic regression model.

Results

The two-week outpatient visit rates of residents in agro-pastoral areas and that of the urban residents were 65.3% and 57.1%, respectively, and the one-year hospitalization rates were 8.3% and 8.9%, respectively. The influencing factors of two-week outpatient visits for rural and pastoral residents included urban and rural health insurance coverage, Three Guarantees in One coverage, distance to medical facilities, chronic disease status, physical examination, family doctor contract status, employment status, and health status self-assessment. The influencing factors of two-week outpatient visit for urban residents included chronic disease status, urban and rural medical insurance coverage, health status self-assessment, health records, and physical examination. The factors influencing hospitalization for agro-pastoral residents were sex, age, marital status, urban and rural medical insurance coverage, Three Guarantees in One coverage, critical illness insurance, health self-assessment, mobility, health records, physical examination, and chronic disease status. The factors influencing the hospitalization of urban residents were sex, marital status, health status self-assessment, health records, urban employee medical insurance coverage, and chronic disease status. The factors influencing the hospitalization of urban residents were sex, marital status, health status self-assessment, health records, urban employee medical insurance coverage, and chronic disease status.

Conclusion

The urban and rural residents in Tibet have relatively poor health and their awareness of seeking early medical help after they fall ill is relatively weak. The health institutions concerned should dedicate more attention to the vulnerable populations who have difficulty accessing health services, focus on the commonly shared influencing factors of health service utilization among urban and rural residents, take into account the differences, rationally allocate health resources, and improve the effective utilization rate of health services among residents in Tibet.

Perceptions, health seeking behavior and utilization of maternal and newborn health services among an indigenous tribal community in Northeast India-a community-based mixed methods study

Background

Evidence suggests that healthcare utilization among tribal communities in isolated regions can be influenced by social determinants of health, particularly cultural and geographical factors. The true mortality and morbidity due to these factors in remote tribal communities are often underestimated due to facility-dependent reporting systems often difficult to access. We studied the utilization of health services for maternal and newborn care and explored how cultural beliefs, perceptions, and practices influence the health-seeking behavior (HSB) of an indigenous tribal community in Northeast India.

Methods

Within a concurrent triangulation design, the combined results from 7 focus group discussions and 19 in-depth interviews, and the 109 interviews of mothers from a community-based survey were interpreted in a complementary manner. The qualitative data were analyzed using a conceptual framework adapted from the socio-ecological and three-delays model, using a priori thematic coding. Multivariable logistic regression was carried out to identify factors associated with home delivery.

Results

Only 3.7% of the interviewed mothers received the four recommended antenatal check-ups in health centers, and 40.1% delivered at home. Mothers residing in the villages without a health center or one that was not operational were more likely to deliver at home. HSB was influenced significantly by available finances, the mother's education, low self-esteem, and a strong belief in traditional medicine favored by its availability and religious affiliation. The community sought health services in facilities only in emergency situations, determined primarily by the tribe's poor perception of the quality of health services provided in the irregularly open centers, locally available traditional medicine practitioners, and challenges in geographical access. National schemes intended to incentivize access to facilities failed to impact this community due to flawed program implementation that did not consider this region's cultural, social, and geographical differences.

Conclusion

The health-seeking behavior of the tribe is a complex, interrelated, and interdependent process framed in a medical pluralistic context. The utilization of health centers and HSBs of indigenous communities may improve when policymakers adopt a "bottom-up approach," addressing structural barriers, tailoring programs to be culturally appropriate, and guaranteeing that the perceived needs of indigenous communities are met before national objectives.

Experiences of patients with chronic diseases during the COVID-19 pandemic in the North West province, South Africa

BACKGROUND

Patients with chronic diseases (PWCDs) were severely affected by the coronavirus disease 2019 (COVID-19) pandemic, as they were prevented from making the necessary visits to health facilities for medical review and to collect their medication. The emergence of the health crisis and inadequate access to quality care affected chronic care management. The perspectives of PWCDs are not known, and therefore the research on which this paper is based sought to investigate the lived experiences of these patients during the COVID-19 pandemic.

METHODS

A qualitative phenomenological design was used to obtain the lived experiences of PWCDs identified for participation in the study by means of purposive sampling. Patients' experiences were obtained during individual structured interviews, and a checklist was used to gather patient characteristics from their files.

RESULTS

Three themes emerged from the study findings, namely poor healthcare services, the socio-economic impact of the COVID-19 pandemic, and the psychological impact of the COVID-19 pandemic. The COVID-19 pandemic had devastating effects on PWCDs, in that they experienced barriers to accessing quality chronic care services and suffered psychological and financial difficulties that affected their health, life, needs and expectations.

CONCLUSION

Policymakers should consider PWCDs when responding to a public health concern in the future.Contribution: The study findings may have an impact on future policies regulating the management of chronic diseases during epidemics, in order to improve patient health outcomes and satisfaction with healthcare services and the chronic care model based on the experiences of PWCDs.

Uptake of antepartum care services in a matrilineal-matrilocal society: a study of Garo indigenous women in Bangladesh

BACKGROUND

The indigenous Garo is a close-knit matrilineal-matrilocal community. This community's expectant mothers receive less antepartum biomedical care, making them prone to maternal mortality. This study developed a conceptual framework to explore how the external environment, personal predispositions, enabling components and perceived antepartum care needs influence and generate a gap in antepartum biomedical care uptake.

METHODS

The author used qualitative data from the study area. The data were collected through conducting 24 semi-structured interviews with purposively selected Garo women. After transcribing the data, the author generated the themes, grouped them into two broader domains, and analyzed them using the grounded theory approach.

RESULTS

The emergent themes suggest adding the external environment (i.e., healthcare facilities' availability and services and culturally relevant healthcare services) to Anderson's behavioral model to understand indigenous women's antepartum care uptake disparity. Antepartum care uptake disparities arise when Andersen's behavioral model's other three drivers-personal predisposition, enabling components, and needs components-interact with the external environment. The interplay between enabling resources and the external environment is the conduit by which their predispositions and perceived needs are shaped and, thus, generate a disparity in antepartum care uptake. The data demonstrate that enabling resources include gendered power dynamics in families, home composition and income, men's spousal role, community practices of maternal health, and mother groups' and husbands' knowledge. Birth order, past treatment, late pregnancy, and healthcare knowledge are predispositions. According to data, social support, home-based care, mental health well-being, cultural norms and rituals, doctors' friendliness, affordable care, and transportation costs are perceived needs.

CONCLUSIONS

Garo family members (mothers/in-laws and male husbands) should be included in health intervention initiatives to address the problem with effective health education, highlighting the advantages of biomedical antepartum care. Health policymakers should ensure the availability of nearby and culturally appropriate pregnancy care services.

The Influence of COVID-19 Pandemic on the Health Seeking Behaviors of Adults Living With Chronic Conditions: A View Through the Health Belief Model

The COVID-19 pandemic resulted in disruption in every facet of life including health service delivery. This has threatened the attainment of global targets to improve health and wellbeing of all persons. In particular, for persons living with chronic diseases, who require consistent monitoring by health professionals and medication to enhance their health, understanding how the pandemic has disruption their access to health care delivery is critical for interventions aimed at improving health service delivery for all as well as preparedness for future pandemic. This study applied the constructs of the Health Belief Model, to explore the influences of the COVID-19 pandemic on the health seeking behaviors of persons living with chronic diseases. The design was exploratory descriptive. Semi-structured interviews were conducted to collect data among persons living with chronic diseases in the Cape Coast Metropolis of Ghana. Thematic analysis, both inductive and deductive, was conducted to unearth the findings. Awareness of increased susceptibility and risk of a more severe episode if they contracted COVID-19 as a result of the existing chronic diseases was identified. Lack of access to health professionals during the peak of the pandemic as well as the fear of contracting the virus while accessing their regular chronic disease clinic was the main barriers identified. Information in the media served as cues to action for adopting preventive health strategies. Behavior modifications; dietary and lifestyle, self-medication and adoption of COVID-19 related precautions were practiced. Susceptibility to contracting COVID-19 contributed to missed adherence to treatment appointment. The health belief model was a useful framework in exploring the health seeking behavior of the adults living with chronic conditions during the COVID-19 in this study setting. Intensifying targeted education for persons living with chronic diseases will contribute to the adoption of positive health seeking behaviors during future pandemic.

The impact of the COVID-19 pandemic on healthcare access and utilisation in South Sudan: a cross-sectional mixed methods study

BACKGROUND

Indirect effects of the COVID-19 pandemic on communities in fragile and conflict-affected settings may be severe due to reduced access and use of healthcare, as happened during the 2015 Ebola Virus Disease outbreak. Achieving a balance between short-term emergency response and addressing long-term health needs is particularly challenging in fragile and conflict-affected settings such as South Sudan, given the already significant barriers to accessing healthcare for the population. This study sought to characterise the effect of COVID-19 on healthcare access and South Sudan's healthcare response. This can inform efforts to mitigate the potential impacts of COVID-19 or other epidemiological threats, and contribute to understanding how these may be balanced for greater health system resilience in fragile contexts.

METHODS

We conducted a mixed methods study in three of South Sudan's states, combining data from a cross-sectional quantitative household survey with qualitative interviews and Focus Group Discussions.

RESULTS

Even though some fears related to COVID-19 were reported, we found these did not greatly dissuade people from seeking care and do not yield significant consequences for health system programming in South Sudan. The pillars of the response focused on risk communication and community engagement were effective in reaching communities through different channels. Respondents and participants reported behaviour changes that were in line with public health advice. We also found that the implementation of COVID-19 response activities sometimes created frictions between the national government and international health actors, and that COVID-19 caused a greater reliance on, and increased responsibility for, international donors for health planning.

CONCLUSIONS

Given the fact that global priorities on COVID-19 are greatly shifting, power dynamics between international health agencies and the national government may be useful to consider in further COVID-19 planning, particularly for the vaccine roll-out. South Sudan must now navigate a period of transition where COVID-19 vaccine roll-out continues and other domestic health burdens are re-prioritised.

Challenges of design, implementation, acceptability, and potential for, biomedical technologies in the Peruvian Amazon

BACKGROUND

Biomedical technologies have the potential to be advantageous in remote communities. However, information about barriers faced by users of technology in general and in remote Indigenous communities is scarce. The purpose of this study was to characterize the leading challenges faced by researchers who have used biomedical technologies in the Peruvian Amazon.

METHODS

This exploratory, qualitative study with a phenomenological approach depicts the lived experience of participants who were researchers with experience working with biomedical technologies in the Peruvian Amazon in the past five years. Analysis was based on three core themes: design, implementation, and acceptability. Sub-themes included environment, community, and culture. Of the 24 potential participants identified and contacted, 14 agreed to participate, and 13 met inclusion criteria and completed semi-structured interviews. Results were sent to each participant with the opportunity to provide feedback and partake in a 30-minute validation meeting. Five participants consented to a follow-up meeting to validate the results and provide further understanding.

RESULTS

Participants recognized significant challenges, including technologies designed out-of-context, difficulty transporting the technologies through the Amazon, the impact of the physical environment (e.g., humidity, flooding), and limited existing infrastructure, such as electricity and appropriately trained health personnel. Participants also identified cultural factors, including the need to address past experiences with technology and health interventions, understand and appropriately communicate community benefits, and understand the effect of demographics (e.g., age, education) on the acceptance and uptake of technology. Complementary challenges, such as corruption in authority and waste disposal, and recommendations for technological and health interventions such as co-design were also identified.

CONCLUSIONS

This study proposes that technological and health interventions without efforts to respect local cultures and health priorities, or understand and anticipate contextual challenges, will not meet its goal of improving access to healthcare in remote Amazon communities. Furthermore, the implications of corruption on health services, and improper waste disposal on the environment may lead to more detrimental health inequities.

Perception of Health Care Workers (HCWs) towards early antenatal booking in Fiji: A qualitative study

BACKGROUND

Early booking or registration into Antenatal Care (ANC) can be defined as initiation of ANC before 12 weeks of gestation and is important for the best health outcome of the mother and the baby. Delayed initiation of ANC has been linked to increased rate of maternal and fetal mortality. There is international consensus that ANC should begin within first trimester yet pregnant women delay initiation of ANC. Health Care Workers (HCWs) understanding of reasons for this can improve patient provider relationship.

OBJECTIVES

This study aims to explore the perception of the HCWs in Fiji towards early antenatal booking.

METHODS

A qualitative study was employed using four Focus-Group Discussions (FGDs)with the HCWs who provide health care service for pregnant women in Ba Mission Hospital (BMH) in 2020. Each group comprised of medical officers, mid-wives and registered nurse who were chosen purposively. A semi-structured open ended questionnaire was used to guide the discussion. Data was transcribed and analyzed manually using thematic content analysis using the following process: familiarization, coding, identifying themes, reviewing and refining, integration and interpretation.

RESULTS

There was a total of 18 HCWs for the FGDs. The mean age of the participants was 37.4±11.8years. The three themes identified were: knowledge of HCWs on early booking, their perceived barriers and perceived enabling factors to early antenatal booking. The FGDs identified that the HCWs had adequate knowledge on early initiation of ANC and that there were a range of barriers to early initiation of ANC. The HCWs also suggested factors that could enable women to book early.

CONCLUSION

Based on the study it can be concluded that the HCWs have a positive perception of early antenatal booking, however, there are various factors that contribute to delayed antenatal booking. The barriers to early ANC are both an opportunity and a challenge to strengthen and review the maternal services offered. The enabling factors should be reinforced from an individual level to the health system and the general context. The implications of the barriers and enabling factors identified in this study is to implement evidence-based policies to improve early antenatal booking in Ba, Fiji.

Factors associated with diphtheria vaccination completion among children under five years old in Peru 2010-2019: A cross-sectional population-based study

The World Health Organization (WHO) recommends a minimum of 90% coverage of diphtheria three-dose complete vaccination scheme (DPT) as part of routine immunization programs in children. However, diphtheria coverage in Peru has not reached the minimum recommended during the last decades. Our study aimed to determine the complete three-dose DPT coverage and factors associated with compliance towards complete vaccination in Peru between 2010-2019. We conducted a secondary cross-sectional study using the "Encuesta Demográfica y de Salud Familiar (ENDES)"- Demographic and Family Health Survey, which is a survey that targets mothers between 15 and 49 years of age. DPT vaccination coverage was 72.4% and several factors were associated with the DPT scheme completion. Women in the age groups 18 to 24 (ORa = 2.31, 95%CI: 2.11-2.52), 25 to 34 (ORa = 3.37, 95% CI: 3.08-3.69), and 35 to 49 (ORa = 4.74, 95% CI: 4.29-5.22) were more likely to complete their children's DPT vaccination scheme compared to those between 15 to 17 years of age. Both Spanish (ORa = 1.39, 95% CI: 1.31-1.48) and Quechua (ORa = 1.34, 95% CI: 1.25-1.43) as first spoken language were associated with DPT completion compared to native language speaking mothers. Women who worked (ORa = 1.72, 95% CI: 1.57-1.88), studied (ORa = 1.47, 95% CI: 1.33-1.62), or were housewives (ORa = 1.41, 95% CI: 1.29-1.54) during the previous week were more likely to complete their children's DPT scheme compared to participants that did not work during the previous week. Women with the financial capability to access health care were less likely to complete the DPT scheme (ORa = 0.95, 95% CI: 0.92-0.97). Considering the accessibility to health care centers, women who knew the nearest location (ORa = 1.07, 95% CI: 1.03-1.11), had geographic accessibility (ORa = 1.09, 95% CI: 1.06-1.13) or a current transport (ORa = 1.06, 95% CI: 1.02-1.09) were more likely to complete their children 's DPT scheme. Our results highlight low diphtheria vaccine coverage levels in Peru, with values lower than what is recommended by the WHO. Results may serve as a baseline for future studies to improve vaccination programs, reduce barriers and increase DPT coverage in Peru.

Prevalence and determinants of home delivery among reproductive age women, Margibi County, Liberia

Background

The use of institutional delivery services is essential for improving maternal and child health. However, studies in Liberia reveal over 20% of women still deliver at home. We assessed the prevalence and associated factors of home delivery among women of reproductive age in Margibi County, Liberia.

Methods

We conducted a cross-sectional study among 438 women of reproductive age in Margibi County. Data were obtained using a semi-structured questionnaire. A simple random sampling approach was used to select the participants for the study. We performed binary logistic regression to identify factors influencing home delivery. Findings were summarized into tables displaying the frequencies, percentages, crude, and adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Prevalence of home delivery in the County was 90.6% (95% CI = 87.5 – 93.0). Women who were ≥ 31 years (aOR = 6.74, 95%CI = 2.86—15.90), women who had two or more children (aOR = 9.68, 95%CI = 4.07—22.99) and those who had rapid onset of labor (aOR = 6.35, 95%CI = 1.59 – 25.27) were associated with increased odds of home delivery. Good attitude of health workers (aOR = 0.01, 95%CI = 0.001 – 0.08) and the availability of transport to the nearest health facility (aOR = 0.01, 95%CI = 0.003 – 0.03) were factors associated with a decreased odds of home delivery among the study participants.

Conclusion

The high prevalence of home delivery in the county is a call for urgent interventions by the government of Liberia and various non-governmental organizations. The government may need to supply the county with ambulances and ensure in-service training of health workers on good attitudes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04975-7.

Geographic and socioeconomic inequalities in cesarean birth rates in Peru: A comparison between 2009 and 2018

BACKGROUND

There is a global concern about the high rates of cesarean birth (CB). This study aimed to investigate the geographic and socioeconomic inequalities in CB rates in the Peruvian population.

METHODS

We conducted a population-based study using the Peruvian Demographic and Family Health Surveys (ENDES, the Spanish acronym for Encuesta Demográfica y de Salud Familiar) between 2009 and 2018. ENDES reported data from births registered in the five years preceding survey execution. For the years 2009 (n = 10 289) and 2018 (n = 23 077), we calculated the weighted rates of CB among variables such as natural geographic domain (Coast, Andean, or Amazon), area of residence (rural or urban), wealth index quintile (quintile 1 is poorest, and quintile 5 is richest), and educational level. To assess inequalities, we calculated the concentration index (CIs), the slope index of inequality (SII), and the relative index of inequality (RII).

RESULTS

The CB rates by year were 21.4% (95% confidence interval [CI]: 20.0-22.9) in 2009 and 34.5% (95% CI: 33.4-35.5) in 2018. Women living in urban and coastal regions and with a higher education level had the highest CB rates. All the CIs were positive, reflecting a prowealthy inequality in CB rates, and both SII and RII were positive, indicating a gap between the use of cesarean in women in the higher wealth quintile compared with those in the lower quintile.

CONCLUSIONS

Cesarean birth rates have increased by 60% during the last decade in Peru. The richest wealth quintiles had the highest CB rates during the study years, which were well above global recommendations.

An mHealth tool for community health workers to improve caregiver knowledge of child health in the Amazon: An effectiveness-implementation hybrid evaluation

When community health workers (CHWs) are effective, they can teach healthy child rearing practices in their communities and improve child health and development outcomes. An effective mHealth tool can improve the capacity of CHWs to transmit knowledge to caregivers. This article evaluates the implementation of an mHealth tool in a CHW program in the Amazon of Peru. The intervention was designed, implemented, and evaluated with the guidance of multiple implementation science tools. A Hybrid Type 3 evaluation design was used to test the effectiveness of the implementation strategies and appropriateness of the intervention. The implementation outcomes: acceptability, adoption, dosage, and fidelity were analyzed with mixed methods approach to determine if the intervention was successfully installed in the CHW program. The service outcome, knowledge scores, was analyzed with an independent samples t-test and one way ANOVA to determine the effect of the program. The implementation strategies resulted in high degrees of acceptability, adoption, and fidelity of the mHealth tool. The surveillance component of the mHealth tools was not adequately adopted. The group of caregivers that received home visits with the mHealth tool (N = 48) had significantly higher knowledge scores (+1.26 standard deviations) than those in the control group (N = 138) (t(184) = -4.39, p<0.001). The COVID-19 pandemic significantly decreased the dosage of the intervention received by the participants. The CHEST App intervention is a promising tool to improve the capacity of CHWs during their home visits. Trial registered with ISRCTN on 11/29/2018 at https://doi.org/10.1186/ISRCTN43591826.

Exploring women's decisions of where to give birth in the Peruvian Amazon; why do women continue to give birth at home? A qualitative study

Background

Despite improvements in maternal mortality globally, hundreds of women continue to die daily. The World Health Organisation therefore advises all women in low-and-middle income countries to give birth in healthcare facilities. Barriers to seeking intrapartum care have been described in Thaddeus and Maine’s Three Delays Model, however these decisions are complex and often unique to different settings. Loreto, a rural province in Peru has one of the highest homebirth rates in the country at 31.8%. The aim of this study was to explore facilitators and barriers to facility births and explore women’s experiences of intrapartum care in Amazonian Peru.

Methods

Through purposive sampling, postnatal women were recruited for semi-structured interviews (n = 25). Interviews were transcribed verbatim and thematically analysed. A combination of deductive and inductive coding was used. Analytical triangulation was undertaken, and data saturation was used to determine when no further interviews were necessary.

Results

Five themes were generated from the data: 1) Financial barriers; 2) Accessing care; 3) Fear of healthcare facilities; 4) Importance of seeking care and 5) Comfort and traditions of home. Generally, participants realised the importance of seeking skilled care however barriers persisted, across all areas of the Three Delays Model. Barriers identified included fear of healthcare facilities and interventions, direct and indirect costs, continuation of daily activities, distance and availability of transport. Women who delivered in healthcare facilities had mixed experiences, many reporting good attention, however a selection experienced poor treatment including abusive behaviour.

Conclusion

Despite free care, women continue to face barriers seeking obstetric care in Amazonian Peru, including fear of hospitals, cost and availability of transport. However, women accessing care do not always receive positive care experiences highlighting implications for changes in accessibility and provision of care. Minimising these barriers is critical to improve maternal and neonatal outcomes in rural Peru.

Dietary intake, intestinal infection, and safe drinking water among children with anemia in Peru: a cross-sectional analysis

BACKGROUND

Anemia is a major public health concern that is present in 41.7% of children under 5 worldwide. The prevalence of anemia in Peru was 43.6% in 2017, a decrease by only 6.8% in 8 years. Despite great efforts made by the government to reduce anemia by distributing free multi-micronutrient supplements and promote the consumption of iron rich foods, progress has been slow. The current study sought to better understand why the prevalence remains high by analyzing the dietary intake, incidence of intestinal infectious disease, and access to safe drinking water by children with anemia in Peru.

METHODS

A cross-sectional analysis was conducted using data from two national surveys that were combined by child ID. Descriptive statistics was analyzed to understand the experience of children with anemia in comparison to child without anemia. Logistic multivariate regression analyses were conducted to test the associations between anemia and dietary intake, intestinal infection, and access to safe drinking water.

RESULTS

The sample included 586 children between 6 and 35 months. The prevalence of anemia in this population was 53%. The portion of children that consumed sufficient iron to meet the recommendation for their age was 62%. Of the children with anemia, 52% consumed sufficient iron to meet their recommendation, vs. 72% of children without anemia (p < 0.001). The children with anemia were more likely to have an intestinal infection during the previous year (35% vs. 26%, p = 0.057) and less likely to have access to safe drinking water (77% vs. 86%, p = 0.002) than those without anemia. The logistic analysis revealed that having an intestinal infection increased the odds of having anemia (OR = 1.64, CI 95% [1.041-2.584]), and having access to safe drinking waters decreased the odds of having anemia (OR = 0.578, [0.334-0.998]).

CONCLUSIONS

More than half of the children with anemia in Peru already consume sufficient iron to meet their daily requirement. However, they continue to have anemia, likely due to intestinal infection, such as diarrhea and parasites, from a lack of access to safe drinking water and hygienic practices.

Factors associated with home births in Peru 2015-2017: A cross-sectional population-based study

Background

Higher rates of maternal complications and deaths have been described in home births. However, few local studies have evaluated factors associated with home births in Peru. The study aims to determine the prevalence and factors associated with home birth in the Peruvian population.

Methods

A population-based analytical cross-sectional study was conducted using pooled data from the 2015–2017 Peruvian Demographic and Health Surveys. A logistic regression model was performed to calculate crude and adjusted odds ratios (aOR) for the association between sociodemographic and mother-related factors and home births.

Results

Seven out of every 100 births were home births. Living in a rural area (aOR = 3.10; 95% CI: 2.52–3.81), having a primary or secondary educational level, belonging to a medium or low wealth tertile, being from the rest of the Coast, Andean or Amazon regions, the second or greater number of birth order and considering the distance to the health center as problematic (aOR: 1.32; 95% CI: 1.17–1.48) were found to be associated with a higher probability of home births. Contrarily, being in the age groups of 25–34 and 35–39 years old, having a multiple pregnancy and giving birth to a medium (aOR: 0.88; 95% CI: 0.78–1.00) or large-sized newborn (aOR = 0.81; 95% CI: 0.72–0.93) were associated with a lower probability of presenting home births.

Conclusions

Sociodemographic factors are associated with home births in Peru. Further study of these factors is required to develop strategies specific to the needs of the population of childbearing age.

Individual Capital Structure and Health Behaviors among Chinese Middle-Aged and Older Adults: A Cross-Sectional Analysis Using Bourdieu's Theory of Capitals

This study draws on Bourdieu’s theory of capitals to analyze the relative importance of economic, cultural, and social capital on health behaviors in Chinese middle-aged and older adults. Based on data from the China Family Panel Studies of 2016 (N = 15,147), we first harnessed a binary logistic regression model to discuss the associations between the three capitals and four types of health behaviors (i.e., physical exercise, smoking, binge drinking and stay-up). Using the sheaf coefficients technique, we then compared the relative effects of three of the capitals on health behaviors. The results suggest that cultural capital is the most influential one, which would significantly increase physical exercise and stay-up behaviors, and reduce smoking and binge drinking behaviors. Economic capital is also an important predictor, that may reduce smoking behavior but increase binge drinking and stay-up behaviors. Social capital has shown the least importance, although it would still be saliently associated with physical exercise, smoking and stay-up behaviors. In addition, some significant group disparities are also identified. This article is one of the first to explain health behavior inequalities through a Bourdieusian capital-based approach in Chinese contexts.

Socioeconomic inequalities in women's access to health care: has Ecuadorian health reform been successful?

BACKGROUND

Over the last 12 years, Ecuador has implemented comprehensive health sector reform to ensure equitable access to health care services according to need. While there have been important achievements in terms of health care coverage, the effects of these reforms on socioeconomic inequalities in health care have not been analysed. The present study assesses whether the health care reforms implemented in the decade between 2007 and 2017 have contributed to reducing the socioeconomic inequalities in women's health care access.

METHODS

The present study was based on two waves (2006 and 2014) of the Living Standards Measurement Survey conducted in Ecuador. Data from women of reproductive age (15 to 49 years) were analysed to evaluate health care coverage across three indicators: skilled birth attendance, cervical cancer screening, and the use of modern contraceptives. Absolute risk differences were calculated between the heath care indicators and the socioeconomic variables using binomial regression analysis for each time period. The Slope Index of Inequality (SII) was also calculated for each socioeconomic variable and period. A multiplicative interaction term between the socioeconomic variables and period was included to assess the changes in socioeconomic inequalities in health care over time.

RESULTS

Access to health care increased in the three studied outcomes during the health sector reform. Significant reductions in inequality in skilled birth attendance were observed in all socioeconomic variables except in the occupational class. Cervical cancer screening inequalities increased according to education and occupation, but decreased by wealth. Only a poorer education was observed for modern contraceptive use.

CONCLUSIONS

While most socioeconomic inequalities in skilled birth attendance decreased during the reform period, this was not the case for inequalities in cervical cancer screening or the use of modern contraceptives. Further studies are needed to address the social determinants of these health inequalities.

The Use of Implementation Science Tools to Design, Implement, and Monitor a Community-Based mHealth Intervention for Child Health in the Amazon

It is essential to analyze the local context and implementation components to effectively deliver evidence-based solutions to public health problems. Tools provided by the field of implementation science can guide practitioners through a comprehensive implementation process, making innovations more adaptable, efficient, and sustainable. It is equally important to report on the design and implementation process so others can analyze, replicate, and improve on the progress made from an intervention. The current study reports on the design and implementation of an mHealth intervention to improve child health in the Amazon of Peru. The study aims to provide insight into how an implementation science tool can be used to improve implementation and reporting of an evidence-based intervention in a global health setting.

Methods: Implementation of a community-based mHealth intervention is analyzed and reported through the lens of the Active Implementation Frameworks (AIF). The AIF is used to analyze the design, implementation, adaptation, and monitoring of the intervention. The implementation process is categorized in the four stages of implementation. The results of the analysis and subsequent implementation activities are reported.

Results: The exploration stage was used to learn about the local context in the Amazonian communities and identify an evidence-based solution to address poor child health. Several potential solutions were combined to create an innovative mHealth tool. During the installation stage, the stakeholders worked together to improve the intervention and plan for implementation through human-centered design. The providers in the field were trained and data was gathered to monitor implementation. During initial implementation stage, electronic tablets were distributed to community health agents and continuous quality improvement activities allowed for rapid improvements to be implemented. The intervention moved on to full implementation stage as acceptance and fidelity approached 100%.

Conclusion: The AIF highlighted several potential barriers to implementation that may have been overlooked without the guidance of a science-based implementation tool. Reporting on the implementation process shows how implementation science tools can be used to foresee and address potential threats to successful implementation. The results of this study provide insight into the components of implementation in Amazonian communities, as well as the process of using implementation science tools in any global health setting.