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Cantet N, Ibañez M, Muñoz-Mora JC, Quintero LM. Key Determinants of COVID-19 Vaccination Take-Up in Remote Rural Areas: Evidence From Colombia. Int J Public Health 2024; 69:1606689. [PMID: 38939517 PMCID: PMC11208315 DOI: 10.3389/ijph.2024.1606689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 04/19/2024] [Indexed: 06/29/2024] Open
Abstract
Objetives The adoption of vaccines was a crucial factor in overcoming the COVID-19 pandemic. However, vaccination rates between rural and urban areas varied greatly. In this paper, our objective is to understand the individual and institutional factors associated with the uptake of vaccines in remote rural areas in Colombia. Methods We interviewed a random sample of 800 households (1,592 individuals) in remote rural areas of Antioquia (Colombia) during February 2022 when vaccinations were available. Then, we use a linear probability model to explain the uptake of the COVID-19 vaccine. Results The results indicate that the probability of having at least the first dose of the COVID-19 vaccine is positively associated with access to information, trust in police and army, and the perceived risk of contracting COVID-19. Trust in the church is negatively related to vaccination. Conclusion Institutions can play a critical role in the management of pandemics. Timely information on the risks associated with the disease and perceived riskiness are key factors that mobilize the population to take the COVID-19 vaccine.
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Affiliation(s)
- Natalia Cantet
- Darla Moore School of Business, University of South Carolina, Columbia, SC, United States
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2
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Rodríguez Caicedo N, León-Giraldo S, González-Uribe C, Bernal O. Access to health services during the Colombian armed conflict: a challenge for the population with disabilities in the department of Meta. BMC Health Serv Res 2023; 23:628. [PMID: 37312099 PMCID: PMC10265762 DOI: 10.1186/s12913-023-09472-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 04/28/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND The Colombian armed conflict has left millions of victims and has restricted access to different services provided by the government, especially for people with disabilities. This article studies the barriers faced by the victim population with disabilities when they want to access the health system in the department of Meta, Colombia, and offers a perspective from the experiences of people with disabilities who have been victims of the armed conflict in the country. METHODS To carry out this qualitative study, focus groups were conducted to capture the experiences and feelings of this population in the context of violence and high conflict. RESULTS The results show the barriers encountered by the victim population with disabilities, their families, and their caregivers when they want to access medical or health services. CONCLUSIONS Many problems affect the population with disabilities and the victim population in Colombia today. The Colombian government has not been able to establish adequate policies to eliminate or even reduce access to services such as health, education, housing, and social protection.
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Affiliation(s)
| | - Sebastián León-Giraldo
- Alberto Lleras Camargo School of Government, Universidad de los Andes, Bogotá, 11711 Colombia
| | | | - Oscar Bernal
- Alberto Lleras Camargo School of Government, Universidad de los Andes, Bogotá, 11711 Colombia
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3
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Reynolds CW, Duarte A, Fricke A, Gómez Restrepo C, Patiño A, Arbelaez C, Moretti K, Aguiar LG. Supporting healthcare workers caring for ex-combatants: incentives among Colombian providers with FARC ex-combatants. Glob Public Health 2022; 17:3005-3021. [PMID: 35132944 DOI: 10.1080/17441692.2022.2037150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
With the Peace Agreement between Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised healthcare to 13,000 'reincorporating' FARC ex-combatants. Shortages of healthcare workers in reincorporation camps means this promise is in danger of going unfulfilled. More information is needed to determine incentives, disincentives, and recruitment of healthcare providers to address this shortage. Semi-structured interviews were conducted with healthcare providers across FARC reincorporation camps, and a multidisciplinary team conducted analysis in NVivo12 using a team-based coding method. Twenty-four healthcare professionals from 15 camps participated, of which 75% were female. Incentives to work with FARC included improved clinical skills, professional advancement, increased comfort with FARC, and contributing to the peace process. Disincentives included poor living conditions, lack of support, biases, familial commitments, and sacrificing career opportunities. Three-fourths of the sample recommended working with FARC, and 92% reported a shortage of healthcare workers. Recruitment strategies included improved resources and specialised career development for healthcare workers, facilitating interactions between FARC and healthcare professionals outside clinical scenarios, and integrating medicine for vulnerable populations into health education. This study shows the impact that working with FARC ex-combatants can have on healthcare providers and tangible suggestions for increasing provider participation to address the healthcare worker shortage.
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Affiliation(s)
| | - Andrés Duarte
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| | | | - Carlos Gómez Restrepo
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Andres Patiño
- Emory University School of Medicine, Atlanta, GA, USA
| | - Christian Arbelaez
- Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | | | - Leonar G Aguiar
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
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Krishnan S, Zaman S, Ferdaus M, Kabir MH, Khatun H, Rahman SMS, Marzouk M, Durrance-Bagale A, Howard N. How can humanitarian services provision during mass displacement better support health systems? An exploratory qualitative study of humanitarian service provider perspectives in Cox's Bazar, Bangladesh. J Migr Health 2022; 6:100132. [PMID: 36158594 PMCID: PMC9489749 DOI: 10.1016/j.jmh.2022.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/30/2022] [Accepted: 09/12/2022] [Indexed: 12/30/2022] Open
Abstract
Health services provision in mass displacement settings is a humanitarian imperative and essential to promoting international and regional security. Internationally displaced populations experience a range of issues pre-, peri-, post-displacement and residing in host countries that affect their health and well-being. This study examined links between humanitarian and government health services provision for forcibly displaced Myanmar nationals (FDMN) in Cox's Bazar to consider how improved knowledge sharing and collaboration might better support health systems during mass displacement. We conducted a qualitative descriptive study, interviewing 25 humanitarian service providers in-person in Bangladesh in early 2021 and analysing data thematically. We found that government restricted what essential services humanitarian health actors could provide and FDMN had to undergo stringent screening and referral to receive tertiary healthcare. Concurrently, the government health system was challenged by accessibility, affordability and availability of medicines, equipment, and trained staff. Humanitarian health service providers augmented government responses by working with community groups, recruiting and training Rohingya volunteers, and involving religious leaders. Findings suggest that easing barriers to a fuller range of health services, allowing access to digital devices, and hiring FDMN to support their communities would improve health system responsiveness to the legitimate needs of FDMN displaced around Cox's Bazar. It is imperative to amplify and listen to the voices of FDMN and collaborate in addressing structural and social barriers constraining their access to effective health services, both to increase trust in and responsiveness of the health system.
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Affiliation(s)
- Sneha Krishnan
- Jindal School of Environment and Sustainability, Jindal Global University, Haryana and Environment, Technology and Community Health Consultancy Services, Mumbai, Maharashtra, India
| | - Samia Zaman
- BRAC University, UB04–66 Bir Uttam AK Khandakar Road, Dhaka 1212, Bangladesh
| | - Muhammad Ferdaus
- BRAC University, UB04–66 Bir Uttam AK Khandakar Road, Dhaka 1212, Bangladesh
| | - Md Humayun Kabir
- University of Dhaka, Department of Geography & Environment, Nilkhet Road, Dhaka 1000, Bangladesh
| | - Hafiza Khatun
- University of Dhaka, Department of Geography & Environment, Nilkhet Road, Dhaka 1000, Bangladesh
| | - SM Safiqur Rahman
- BRAC University, UB04–66 Bir Uttam AK Khandakar Road, Dhaka 1212, Bangladesh
| | - Manar Marzouk
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore 117549, Singapore
| | - Anna Durrance-Bagale
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore 117549, Singapore,London School of Hygiene & Tropical Medicine, Department of Global Health & Development, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom,Corresponding author at: London School of Hygiene & Tropical Medicine, Department of Global Health & Development, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom.
| | - Natasha Howard
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore 117549, Singapore,London School of Hygiene & Tropical Medicine, Department of Global Health & Development, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
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Bwirire D, Crutzen R, Ntabe Namegabe E, Letschert R, de Vries N. Health inequalities in post-conflict settings: A systematic review. PLoS One 2022; 17:e0265038. [PMID: 35286351 PMCID: PMC8920275 DOI: 10.1371/journal.pone.0265038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 02/23/2022] [Indexed: 11/18/2022] Open
Abstract
Conflict can be a primary driver of health inequalities, but its impact on the distribution of social determinants of health is not very well documented. Also, there is limited evidence on the most suitable approaches aiming at addressing health inequalities in post-conflict settings. Thus, we undertook a systematic review of the literature concerning the current knowledge and knowledge gaps about structural determinants of health inequalities and assessed the effects of approaches aimed at addressing health inequalities in post-conflict settings. We performed a systematic search in bibliographic databases such as Web of Science, PubMed, and PsycINFO for relevant publications, as well as institutional websites that are relevant to this topic. The search was initiated in March 2018 and ultimately updated in December 2020. No time or geographical restrictions were applied. The quality of each study included in this review was independently assessed using criteria developed by CASP to assess all study types. Sixty-two articles were deemed eligible for analysis. The key findings were captured by the most vulnerable population groups, including the civilian population, women, children, internally displaced persons (IDPs), and people with symptoms of mental illness. A considerable range of approaches has been used to address health inequalities in post-conflict settings. These approaches include those used to address structural determinants of health inequalities which are accountable for the association between poverty, education, and health inequalities, the association between human rights and health inequalities, and the association between health inequalities and healthcare utilization patterns. However, these approaches may not be the most applicable in this environment. Given the multifactorial characteristics of health inequalities, it is important to work with the beneficiaries in developing a multi-sector approach and a strategy targeting long-term impacts by decision-makers at various levels. When addressing health inequalities in post-conflict settings, it may be best to combine approaches at different stages of the recovery process.
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Affiliation(s)
- Dieudonne Bwirire
- Faculty of Health, Medicine and Life Science, Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Rik Crutzen
- Faculty of Health, Medicine and Life Science, Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Edmond Ntabe Namegabe
- Faculté de Santé et Développement Communautaires, Université Libre des Pays des Grands Lacs (ULPGL), Goma, Democratic Republic of the Congo
| | | | - Nanne de Vries
- Faculty of Health, Medicine and Life Science, Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
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González-Uribe C, Olmos-Pinzón A, León-Giraldo S, Bernal O, Moreno-Serra R. Health perceptions among victims in post-accord Colombia: Focus groups in a province affected by the armed conflict. PLoS One 2022; 17:e0264684. [PMID: 35235591 PMCID: PMC8890648 DOI: 10.1371/journal.pone.0264684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/15/2022] [Indexed: 11/19/2022] Open
Abstract
The peace agreement with the Colombian guerrilla group Fuerzas Armadas Revolucionarias de Colombia-Ejército del Pueblo represented an opportunity for peacebuilding and victims' reparation, rather than the end of the internal armed conflict. In this context, this study aimed to uncover the consequences of conflict on victims' health and on health service provision, and their perceived health status during the post-accord stage in the Meta region, located in the country's eastern plains. Historically, this region has been one of the territories most affected by the presence of conflict-related groups and armed confrontations. Through focus groups, this research explored the health perceptions and experiences of victims of armed conflict. Ten focus groups were conducted with men and women, victims of the armed-conflict, in four municipalities with different degrees of armed conflict intensity. The focus group transcripts were coded using NVivo. The results show that the way women have experienced conflict and the effects of conflict on mental health in general for men, women, and children were recurrent themes in the dialogue of victims. Likewise, it highlights the need to understand the barriers that the current health model imposes on the right to health itself. From the victim's perspective, they experience stigmatization, discrimination, and revictimization when accessing health services. These barriers co-occur along with structural limitations of the health system that affect the general population.
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Affiliation(s)
| | - Antonio Olmos-Pinzón
- Alberto Lleras Camargo School of Government, Universidad de los Andes, Bogotá, Colombia
| | - Sebastián León-Giraldo
- Alberto Lleras Camargo School of Government, Universidad de los Andes, Bogotá, Colombia
- Interdisciplinary Centre of Development Studies, Universidad de los Andes, Bogotá, Colombia
| | - Oscar Bernal
- Alberto Lleras Camargo School of Government, Universidad de los Andes, Bogotá, Colombia
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Freed B, Hillman S, Shantikumar S, Bick D, Dale J, Gauly J. The impact of disasters on contraception in OECD member countries: a scoping review. EUR J CONTRACEP REPR 2021; 26:429-438. [PMID: 34126834 DOI: 10.1080/13625187.2021.1934440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Review evidence is lacking about how contraception is affected by severe social disruption, such as that caused by the COVID-19 pandemic. The purpose of this scoping review was to explore the impact of natural and man-made disasters on contraception in OECD member countries. METHODS Manual searches and systematic searches in six electronic databases were conducted with no language restrictions. All articles were screened by at least two researchers. The data were analysed thematically. RESULTS 108 articles were included. Most focussed on the Zika virus outbreak (n = 50) and the COVID-19 pandemic (n = 28). Four key themes were identified: importance of contraception during disasters, impact of disasters on contraceptive behaviour, barriers to contraception during disasters and ways of improving use of contraception during disasters. Despite efforts to increase access to contraception including by transforming ways of delivery, barriers to use meant that unmet need persisted. CONCLUSIONS To prevent adverse health outcomes and reduce health costs as a result of failure to have access to contraception during disasters, there is a need to intensify efforts to remove barriers to use. This should include increasing access and information on methods of contraception and their side effects (e.g., menstrual suppression) and making contraception freely available.
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Affiliation(s)
- Benjamin Freed
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sarah Hillman
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Debra Bick
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Julia Gauly
- Warwick Medical School, University of Warwick, Coventry, UK
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8
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The HIV epidemic in Colombia: spatial and temporal trends analysis. BMC Public Health 2021; 21:178. [PMID: 33478434 PMCID: PMC7818909 DOI: 10.1186/s12889-021-10196-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 01/07/2021] [Indexed: 02/08/2023] Open
Abstract
Background Colombia has the fourth highest incidence rate of HIV/AIDS among all Latin American countries and it has been increasing since the 1980s. However, the number of studies that addresses this trend is limited. Here, we employed spatial and temporal trend analyses to study the behaviour of the epidemic in the Colombian territory. Methods Our sample included 72,994 cases of HIV/AIDS and 21,898 AIDS-related deaths reported to the National Ministry of Health between 2008 and 2016. We employed the joinpoint regression model to analyse the annual HIV/AIDS incidence and AIDS mortality rates. In the spatial analysis, we used univariate autocorrelation techniques and the Kernel density estimator. Results While the HIV/AIDS incidence had an increasing trend in Colombia, the AIDS mortality rate was stable. HIV/AIDS incidence and AIDS mortality showed a downward trend in the 0–14 age group. An upward trend was observed for HIV/AIDS incidence in people older than 15 years and with the highest trend in the 65 years and above group. AIDS mortality showed an increasing trend among people aged 65 years or older. The comparison between the sexes showed an upward trend of HIV/AIDS incidence in all age groups and AIDS-mortality rates in 65 years and above in men, while in women, the incidence was upward among those aged 45 years and above, and concerning the AIDS-mortality rate in the 45–64 group. The high–high clusters of HIV/AIDS incidence and AIDS mortality were located in the Andean and Caribbean regions. Conclusion Our study found an upward trend in HIV/AIDS incidence and a stable trend in the AIDS mortality rate in Colombia. The downward trend in HIV/AIDS incidence and AIDS mortality rate in the 0–14 age group reflects the downwards mother-to-child HIV transmission. The upward trend in HIV/AIDS incidence in older women and AIDS mortality in younger women rates, compared with men, may be due to late diagnosis and treatment. The Caribbean and the ‘coffee belt’ regions were the most impacted by the HIV epidemic, most likely due to sexual tourism. Our results provide crucial information that may help Colombian health authorities fight HIV transmission. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10196-y.
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Franco J, Vizcaya D. Availability of secondary healthcare data for conducting pharmacoepidemiology studies in Colombia: A systematic review. Pharmacol Res Perspect 2020; 8:e00661. [PMID: 32965783 PMCID: PMC7510335 DOI: 10.1002/prp2.661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 12/12/2022] Open
Abstract
Real-world evidence (RWE) is emerging as a fundamental component of the post-marketing evaluation of medicinal products. Even though the focus on RWE studies has increased in Colombia, the availability of secondary data sources to perform this type of research is not well documented. Thus, we aimed at identifying and characterizing secondary data sources available in Colombia. We performed a systematic literature review on PubMed, EMBASE, and VHL using a combination of controlled vocabulary and keywords for the concepts of electronic health records, epidemiologic studies and Colombia. A total of 323 publications were included. These comprised 123 identified secondary data sources including pharmacy dispensing databases, government datasets, disease registries, insurance databases, and electronic heath records, among others. These data sources were mostly used for cross-sectional studies focused on disease epidemiology in a specific population. Almost all databases (95%) contained demographic information, followed by pharmacological treatment (44%) and diagnostic tests (39%). Even though the database owner was identifiable in 94%, access information was only available in 44% of the articles. Only a pharmacy-dispensing database, local cancer registries, and government databases included a description regarding the quality of the information available. The diversity of databases identified shows that Colombia has a high potential to continue enhancing its RWE strategy. Greater efforts are required to improve data quality and accessibility. The linkage between databases will expand data pooling and integration to boost the translational potential of RWE.
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González-Fernández D, Sahajpal R, Chagüendo JE, Ortiz Martínez RA, Herrera JA, Scott ME, Koski KG. Associations of History of Displacement, Food Insecurity, and Stress With Maternal-Fetal Health in a Conflict Zone: A Case Study. Front Public Health 2020; 8:319. [PMID: 32903835 PMCID: PMC7438926 DOI: 10.3389/fpubh.2020.00319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/11/2020] [Indexed: 12/12/2022] Open
Abstract
Background: In populations with a history of conflict, early identification of pregnant women who are at risk of adverse pregnancy outcomes is challenging, especially if sonography is not available. We evaluated the performance of symphysis-fundal height (SFH) for identification of high-risk pregnancies and investigated if food security and diet quality, clinical biomarkers, and stress were associated with SFH and two known indicators of maternal-fetal well-being, sonography-estimated fetal weight and amniotic fluid index (AFI). Methods: For this cross-sectional study, 61 women with high-risk pregnancies were recruited after referral to the obstetrics and gynecology unit at San José Hospital in Popayán, Colombia. Multiple stepwise linear and ordered logistic regressions were used to identify associations of SFH, sonography-estimated fetal weight and AFI classification with history of displacement, food insecurity, post-traumatic stress symptoms as well as biopsychosocial risk evaluated through the Colombian risk scale. Results: History of displacement was associated with lower SFH Z-scores, but higher hemoglobin, taking iron supplements and a higher diastolic blood pressure were associated with higher SFH Z-scores. SFH was also associated with AFI but not with sonography-estimated fetal weight. Stress indicators were associated with a higher AFI. In contrast family support, an element of the Colombian biopsychosocial risk assessment, was associated with a higher sonography-estimated fetal weight, whereas more hours of sleep/day were associated with lower sonography-estimated fetal weight. Conclusion: SFH was not only associated with biological factors known to affect maternal/fetal health but also with history of displacement, thus validating its use in conflict areas for pregnancy assessment. Associations of biopsychosocial stressors with maternal-fetal outcomes highlight the need for a systematic assessment of stress in pregnant women from conflict zones.
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Affiliation(s)
- Doris González-Fernández
- School of Human Nutrition, McGill University (Macdonald Campus), Sainte-Anne-de-Bellevue, QC, Canada
| | - Revathi Sahajpal
- School of Human Nutrition, McGill University (Macdonald Campus), Sainte-Anne-de-Bellevue, QC, Canada
| | - José E Chagüendo
- Obstetrics and Gynecology Unit, San José Hospital, University of Cauca, Popayán, Colombia
| | | | - Julián A Herrera
- Department of Family Medicine, School of Medicine, University of Valle, Cali, Colombia
| | - Marilyn E Scott
- Institute of Parasitology, McGill University (Macdonald Campus), Sainte-Anne-de-Bellevue, QC, Canada
| | - Kristine G Koski
- School of Human Nutrition, McGill University (Macdonald Campus), Sainte-Anne-de-Bellevue, QC, Canada
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Akseer N, Wright J, Tasic H, Everett K, Scudder E, Amsalu R, Boerma T, Bendavid E, Kamali M, Barros AJD, da Silva ICM, Bhutta ZA. Women, children and adolescents in conflict countries: an assessment of inequalities in intervention coverage and survival. BMJ Glob Health 2020; 5:e002214. [PMID: 32133179 PMCID: PMC7042600 DOI: 10.1136/bmjgh-2019-002214] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/18/2019] [Indexed: 01/22/2023] Open
Abstract
Introduction Conflict adversely impacts health and health systems, yet its effect on health inequalities, particularly for women and children, has not been systematically studied. We examined wealth, education and urban/rural residence inequalities for child mortality and essential reproductive, maternal, newborn and child health interventions between conflict and non-conflict low-income and middle-income countries (LMICs). Methods We carried out a time-series multicountry ecological study using data for 137 LMICs between 1990 and 2017, as defined by the 2019 World Bank classification. The data set covers approximately 3.8 million surveyed mothers (15-49 years) and 1.1 million children under 5 years including newborns (<1 month), young children (1-59 months) and school-aged children and adolescents (5-14 years). Outcomes include annual maternal and child mortality rates and coverage (%) of family planning services, 1+antenatal care visit, skilled attendant at birth (SBA), exclusive breast feeding (0-5 months), early initiation of breast feeding (within 1 hour), neonatal protection against tetanus, newborn postnatal care within 2 days, 3 doses of diphtheria, pertussis and tetanus vaccine, measles vaccination, and careseeking for pneumonia and diarrhoea. Results Conflict countries had consistently higher maternal and child mortality rates than non-conflict countries since 1990 and these gaps persist despite rates continually declining for both groups. Access to essential reproductive and maternal health services for poorer, less educated and rural-based families was several folds worse in conflict versus non-conflict countries. Conclusions Inequalities in coverage of reproductive/maternal health and child vaccine interventions are significantly worse in conflict-affected countries. Efforts to protect maternal and child health interventions in conflict settings should target the most disadvantaged families including the poorest, least educated and those living in rural areas.
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Affiliation(s)
- Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Wright
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hana Tasic
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karl Everett
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elaine Scudder
- Save the Children USA, Washington, District of Columbia, USA
| | - Ribka Amsalu
- Save the Children USA, Washington, District of Columbia, USA
| | - Ties Boerma
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Eran Bendavid
- Centers for Health Policy, Primary Care and Outcomes Research, Stanford University, Stanford, California, USA
| | - Mahdis Kamali
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aluisio J D Barros
- International Centre for Equity in Health, Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | - Zulfiqar Ahmed Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
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Scott J, Onyango MA, Burkhardt G, Mullen C, Rouhani S, Haider S, Albutt K, Greiner A, VanRooyen M, Bartels S. A qualitative analysis of decision-making among women with sexual violence-related pregnancies in conflict-affected eastern Democratic Republic of the Congo. BMC Pregnancy Childbirth 2018; 18:322. [PMID: 30089448 PMCID: PMC6083512 DOI: 10.1186/s12884-018-1942-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 07/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sexual violence is prevalent in conflict-affected settings and may result in sexual violence-related pregnancies (SVRPs). There are limited data on how women with SVRPs make decisions about pregnancy continuation or termination, especially in contexts with limited or restricted access to comprehensive reproductive health services. METHODS A qualitative study was conducted in Bukavu, Democratic Republic of the Congo (DRC) as part of a larger mixed methods study in 2012. Utilizing respondent-driven sampling (RDS), adult women who self-reported sexual violence and a resultant SVRP were enrolled into two study subgroups: 1) women currently raising a child from an SVRP (parenting group) and 2) women who terminated an SVRP (termination group). Trained female research assistants conducted semi-structured interviews with a subset of women in a private setting and responses were manually recorded. Interview notes were translated and uploaded to a qualitative software program, coded, and thematic content analysis was conducted. RESULTS A total of 55 women were interviewed: 38 in the parenting group and 17 in the termination group. There were a myriad of expressed attitudes, beliefs, and emotional responses toward SVRPs and the termination of SVRPs with three predominant influences on decision-making, including: 1) the biologic, ethnic, and social identities of the fetus and/or future child; 2) social reactions, including fear of social stigmatization and/or rejection; and 3) the power of religious beliefs and moral considerations on women's autonomy in the decision-making process. CONCLUSION Findings from women who continued and women who terminated SVRPs reveal the complexities of decision-making related to SVRPs, including the emotional reasoning and responses, and the social, moral, and religious dimensions of the decision-making processes. It is important to consider these multi-faceted influences on decision-making for women with SVRPs in conflict-affected settings in order to improve provision of health services and to offer useful insights for subsequent programmatic and policy decisions.
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Affiliation(s)
- Jennifer Scott
- Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Kirstein 3rd Floor, Boston, MA 02215 USA
- Division of Women’s Health, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
- Harvard Humanitarian Initiative, 14 Story Street, Cambridge, MA 02138 USA
| | - Monica A. Onyango
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Gillian Burkhardt
- Harvard Humanitarian Initiative, 14 Story Street, Cambridge, MA 02138 USA
- Department of Obstetrics and Gynecology, Boston University School of Medicine, 85 East Concord Street, Boston, MA 02115 USA
- Department of Obstetrics and Gynecology, University of New Mexico, MSC 10 5582, Albuquerque, NM 87131 USA
| | - Colleen Mullen
- Department of Psychiatry, Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118 USA
| | - Shada Rouhani
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
- Harvard Humanitarian Initiative, 14 Story Street, Cambridge, MA 02138 USA
- Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Sadia Haider
- Department of Obstetrics & Gynecology, University of Chicago, 5837 S. Maryland Avenue, Chicago, IL 60615 USA
| | - Katherine Albutt
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
- Harvard Humanitarian Initiative, 14 Story Street, Cambridge, MA 02138 USA
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | - Ashley Greiner
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
- Harvard Humanitarian Initiative, 14 Story Street, Cambridge, MA 02138 USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215 USA
| | - Michael VanRooyen
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
- Harvard Humanitarian Initiative, 14 Story Street, Cambridge, MA 02138 USA
- Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
- Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
| | - Susan Bartels
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
- Harvard Humanitarian Initiative, 14 Story Street, Cambridge, MA 02138 USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215 USA
- Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
- Department of Emergency Medicine, Queen’s University, 76 Stuart Street, Kingston, ON K7L 2V7 Canada
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