Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol

Conceptualizing maternal mental health in rural Ghana: a realist qualitative analysis

In low- and middle-income countries, maternal mental health needs remain neglected, and common mental disorders during pregnancy and after birth are routinely associated with hormonal changes. The psycho-social and spiritual components of childbirth are often downplayed. A qualitative study was conducted as part of a wider realist evaluation on health systems responsiveness to examine the interrelationships between pregnant and postnatal women, their families, and their environment, and how these influence women's interactions with healthcare providers in Ghana. Data collection methods combined six qualitative interviews (n = 6) and 18 focus group discussions (n = 121) with pregnant and postnatal women, their relatives, and healthcare providers (midwives, community mental health nurses) at the primary healthcare level. Data analysis was based on the context-mechanism-outcome heuristic of realist evaluation methodology. A programme theory was developed and iteratively refined, drawing on Crowther's ecology of birth theory to unpack how context shapes women's interactions with public and alternative healthcare providers. We found that context interacts dynamically with embodiment, relationality, temporality, spatiality, and mystery of childbirth experiences, which in turn influence women's wellbeing in three primary areas. There is an intricate intersection of pregnancy with mental health impacting women's expectations of temporality, which does not always coincide with the timings provided by formal healthcare services. Societal deficiencies in social support structures for women facing economic challenges become particularly evident during the pregnancy and postnatal period, where women need heightened assistance. Socio-cultural beliefs associated with the mystery of childbirth, the supportive role of private providers and faith healing practices offered women a feeling of protection from uncertainty. Co-production of context-specific interventions, including the integration of maternal and mental health policies, with relevant stakeholders can help formal healthcare providers accommodate women's perspectives on spirituality and mental health, which can subsequently help to make health systems responsive to maternal mental health conditions.

Responsive cancer care in Asia: stigma and pain must be acknowledged and addressed

PURPOSE

This study investigates whether cancer-related stigma and pain among patients with advanced cancer influences their perceptions of receiving responsive care.

METHODS

We surveyed 2138 advanced cancer patients from 11 hospitals in eight Asian countries. Participants rated their most recent healthcare visit and a hypothetical patient's experience described in vignettes concerning dignity, clarity of information, and involvement in decision-making. We used the vignettes to correct for differences in patients' reporting behaviors.

RESULTS

Overall, 39% of patients perceived cancer-related stigma, and 66% reported moderate or severe pain. While most patients rated their own experience of being treated with dignity (89%), receiving clear information (82%), and involvement in decision-making (79%) as "good" or "very good," they generally rated the vignettes less favorably compared to their own care experience. The negative relationship between perceived stigma and severe pain and health system responsiveness was established through the ordered probit models (p < 0.05 for all domains). Correcting for reporting heterogeneity amplified the negative association for all three domains of health system responsiveness for both moderate and severe pain and perceived stigma (p ≤ 0.01 for all domains).

CONCLUSION

The widespread prevalence of cancer-related stigma and pain documented in this study across a diverse sample of patients with advanced cancer is concerning. Moreover, perceived stigma and pain pervade patients' interactions with the healthcare system, diminishing their experience of being treated with dignity, receiving clear information, and participating in decision-making. Our findings underscore the importance of addressing stigma and pain to ensure responsive care for advanced cancer patients in Asia.

Health systems responsiveness towards needs of pregnant women in Vietnam

BACKGROUND

Health systems that are responsive to maternal mental health recognise the importance of integrating mental health services into maternal care. Studies from Vietnam have reported particularly high rates of common perinatal mental health disorders (CPMDs) in both rural and urban areas of the country. Despite the increasing burden of maternal mental health conditions, there is currently no guidance on the screening for CPMDs within maternal care, both antenatal and postnatal. In this paper, we report the findings from a survey that examined health systems responsiveness to the needs of pregnant women at the primary care-level in Vietnam, utilising the WHO's validated responsiveness questionnaire.

METHODS

Cluster sampling was used in two districts, in Bac Giang Province. Data were collected using the WHO responsiveness tool, including questions on the domains of responsiveness relating to pregnant women's last antenatal visit. SPSS (version 24) software was used for data entry and analysis, respectively. Bivariate and multivariable logistic regression were computed to identify the associated factors of health system responsiveness in maternity care at 95% CI.

RESULTS

We found that the overall mean health systems responsiveness score was 2.86 (out of maximum 4), with 30.4% pregnant women rating responsiveness as "poor" for maternal health care (based on the cutoff point of 60 for overall score). The three highest scoring domains were "social support", "trust", and "dignity" and lowest scoring domains were "choice of providers", "prompt attention", and "communication". There is a strong preference for seeking maternal health care at private facilities which meet women's needs of "confidentiality" and "basic amenities". Household income was found to have a significant impact on the six responsiveness domains. Finally, only a small proportion of pregnant women self-reported having CPMDs and accessed mental health facilities.

CONCLUSIONS

These findings highlight the need to improve the responsiveness of the Vietnamese health system to meet pregnant women's expectations, mainly in relation to prompt attention and communication. This study also highlights the importance of specifically targeting efforts towards improving the responsiveness of the public health sector. Integrating maternal and mental health at the primary care-level can be one approach to tackle the mental health treatment gap experienced by pregnant women in Vietnam. This can promote early detection and intervention of CPMDs, but may also contribute towards reducing mental health-related stigma.

Towards an agenda of action and research for making health systems responsive to the needs of people with disabilities

Ensuring health systems responsiveness is crucial for health equity and outcomes of all individuals, particularly disadvantaged groups such as people with disabilities. However, attention to and discussions on health system responsiveness for people with disabilities remains lacking. This viewpoint highlights the pervasive issues within health systems rooted in ableism and proposes an agenda to tackle ableism, aiming to make health systems responsive to the needs of people with disabilities. Their needs are complex and diverse, varying with the disability, its severity, progression, and intersection with other factors. Ableism creates significant obstacles to identifying and addressing their needs and expectations, damages provider-patient interactions, poses multiple challenges in healthcare, and impacts the overall responsiveness of the health system to the populations it is meant to serve. The proposed agenda outlines areas for action and research across six building blocks of health systems as a way forward to enhance the health system's responsiveness to the needs of people with disabilities.

Health systems responsiveness towards the Mentor Mother Program for preventing mother-to-child transmission of HIV in military hospitals

AIM

This study explored health systems responsiveness towards the Mentor Mother Program for PMTCT in the Nigeria Department of Defence hospitals. Factors affecting quality service were also highlighted, which gave helpful insights into the strategies employed by stakeholders to ensure that health systems responsiveness was propagated responsibly.

DESIGN

An exploratory qualitative interview study.

METHODS

Six semistructured interviews were conducted with six key informants (three doctors and three nurses) and one focus group session with six Mentor Mothers. Open coding of data was done to formulate themes and subthemes. Thematic analysis was adopted for analysis.

RESULTS

Four themes emerged-Service Quality, Basic Amenities, Patient-oriented Strategies and Factors affecting service Quality. These showcased the nonmedical components of health systems responsiveness and accentuated how well they were utilized to achieve health systems responsiveness.

Protocol for a realist synthesis of health systems responsiveness in low-income and middle-income countries

INTRODUCTION

Health systems responsiveness is a key objective of any health system, yet it is the least studied of all objectives particularly in low-income and middle-income countries. Research on health systems responsiveness highlights its multiple elements, for example, dignity and confidentiality. Little is known, however, about underlying theories of health systems responsiveness, and the mechanisms through which responsiveness works. This realist synthesis contributes to bridging these two knowledge gaps.

METHODS AND ANALYSIS

In this realist synthesis, we will use a four-step process, comprising: mapping of theoretical bases, formulation of programme theories, theory refinement and testing of programme theories using literature and empirical data from Ghana and Vietnam. We will include theoretical and conceptual pieces, reviews, empirical studies and grey literature, alongside the primary data. We will explore responsiveness as entailing external and internal interactions within health systems. The search strategy will be purposive and iterative, with continuous screening and refinement of theories. Data extraction will be combined with quality appraisal, using appropriate tools. Each fragment of evidence will be appraised as it is being extracted, for its relevance to the emerging programme theories and methodological rigour. The extracted data pertaining to contexts, mechanisms and outcomes will be synthesised to identify patterns and contradictions. Results will be reported using narrative explanations, following established guidance on realist syntheses.

ETHICS AND DISSEMINATION

Ethics approvals for the wider RESPONSE (Improving health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam) study, of which this review is one part, were obtained from the ethics committees of the following institutions: London School of Hygiene and Tropical Medicine (ref: 22981), University of Leeds, School of Medicine (ref: MREC19-051), Ghana Health Service (ref: GHS-ERC 012/03/20) and Hanoi University of Public Health (ref: 020-149/DD-YTCC).We will disseminate results through academic papers, conference presentations and stakeholder workshops in Ghana and Vietnam.

PROSPERO REGISTRATION NUMBER

CRD42020200353. Full record: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020200353.

Perception of the primary health care response capacity by patients with and without mental health problems, and health professionals: qualitative study

BACKGROUND

The objective of this study is to deepen our understanding of perceptions towards Primary Health Care Response Capacity by specifically using patients with and without mental disorders, as well as family doctors and a manager, in order to compare and endorse perspectives. For it, a qualitative study was performed. In-depth interviews were conducted with 28 patients with and without mental health disorders and focus groups were held with 21 professionals and a manager. An inductive thematic content analysis was performed in order to explore, develop and define the emergent categories of analysis.

RESULTS

The fundamental domains for patients are dignity, communication, and rapid service. People with mental health problems also highlight the domain of confidentiality as relevant, while patients who do not have a mental health problem prioritize the domain of autonomy. Patients with mental health disorders report a greater number of negative experiences in relation to the domain of dignity. Patients do not consider their negative experiences to be a structural problem of the system. These findings are also endorsed by health care professionals.

CONCLUSIONS

It is necessary to take these results into account as responsive systems can improve service uptake, ensure adherence to treatment, and ultimately enhance patient welfare.