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Parajuli A, Kakchapati S, Arjyal A, Joshi D, Kharel C, Otmani Del Barrio M, Baral SC. Assessing intersectional gender analysis in Nepal's health management information system: a case study on tuberculosis for inclusive health systems. Infect Dis Poverty 2024; 13:31. [PMID: 38659012 PMCID: PMC11044533 DOI: 10.1186/s40249-024-01194-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/06/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a major public health problem in Nepal, high in settings marked by prevalent gender and social inequities. Various social stratifiers intersect, either privileging or oppressing individuals based on their characteristics and contexts, thereby increasing risks, vulnerabilities and marganilisation associated with TB. This study aimed to assess the inclusiveness of gender and other social stratifiers in key health related national policies and the Health Management Information System (HMIS) of National Tuberculosis Programme (NTP) by conducting an intersectional analysis of TB cases recorded via HMIS. METHODS A desk review of key policies and the NTP's HMIS was conducted. Retrospective intersectional analysis utilized two secondary data sources: annual NTP report (2017-2021) and records of 628 TB cases via HMIS 6.5 from two TB centres (2017/18-2018/19). Chi-square test and multi-variate analysis was used to assess the association between social stratifers and types of TB, registration category and treatment outcome. RESULTS Gender, social inclusion and concept of intersectionality are incorporated into various health policies and strategies but lack effective implementation. NTP has initiated the collection of age, sex, ethnicity and location data since 2014/15 through the HMIS. However, only age and sex disaggregated data are routinely reported, leaving recorded social stratifiers of TB patients static without analysis and dissemination. Furthermore, findings from the intersectional analysis using TB secondary data, showed that male more than 25 years exhibited higher odds [adjusted odds ratio (aOR) = 4.95, 95% confidence interval (CI): 1.60-19.06, P = 0.01)] of successful outcome compared to male TB patients less than 25 years. Similarly, sex was significantly associated with types of TB (P < 0.05) whereas both age (P < 0.05) and sex (P < 0.05) were significantly associated with patient registration category (old/new cases). CONCLUSIONS The results highlight inadequacy in the availability of social stratifiers in the routine HMIS. This limitation hampers the NTP's ability to conduct intersectional analyses, crucial for unveiling the roles of other social determinants of TB. Such limitation underscores the need for more disaggregated data in routine NTP to better inform policies and plans contributing to the development of a more responsive and equitable TB programme and effectively addressing disparities.
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Affiliation(s)
- Ayuska Parajuli
- HERD International, Saibu Awas Cr-10 Marga, Bhaisepati, Lalitpur, Nepal
| | | | - Abriti Arjyal
- HERD International, Saibu Awas Cr-10 Marga, Bhaisepati, Lalitpur, Nepal
| | - Deepak Joshi
- HERD International, Saibu Awas Cr-10 Marga, Bhaisepati, Lalitpur, Nepal
| | - Chandani Kharel
- HERD International, Saibu Awas Cr-10 Marga, Bhaisepati, Lalitpur, Nepal
| | - Mariam Otmani Del Barrio
- UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland
| | - Sushil C Baral
- HERD International, Saibu Awas Cr-10 Marga, Bhaisepati, Lalitpur, Nepal.
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Arjyal A, Parajuli A, Kharel C, Del Barrio MO, Baral SC. Understanding gender and its intersection with social stratifiers on prevention and care seeking behavior of lymphatic filariasis in Nepal. Infect Dis Poverty 2023; 12:77. [PMID: 37608332 PMCID: PMC10463999 DOI: 10.1186/s40249-023-01126-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/03/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Lymphatic filariasis (LF) is a debilitating and painful neglected tropical disease and is one of the leading causes of permanent disability. In many countries, the intersection of gender with various social stratifiers has influenced exposure to LF and ultimately impacting the disease burden and its elimination. This study aimed to explore the influence of gender and its intersection with other social stratifiers for the prevention and care seeking behavior of LF in Nepal. METHODS This study employed qualitative research methods: in-depth interviews (IDIs) and focus group discussions (FGDs) for data collection in Bardiya, Nepal. A total of 22 IDIs (11 male, 11 female) and 2 FGDs (1 male and 1 female) were conducted with the community people between January and March 2020. The participants were purposively selected to represent different social stratifiers including age, sex, ethnicity, occupation. The data collected were analyzed using a thematic framework approach with use of intersectional gender analysis matrix. RESULTS The study findings revealed that men spend more time outside their household compared to women while fulfilling their roles and responsibilities, largely determined by societal expectations and gender norms. This resulted in limited access to preventive health services for men, as they often missed annual mass drug administration programme in their community and limited access to preventive methods. Further traditional occupation, specific to particular ethnicity, influenced the vulnerability to LF for certain ethnic groups. The ability to prevent exposure varied among individuals. Although women made decisions regarding the use of protective methods, it was influenced by patriarchal and gender norms. They often felt a responsibility to take care and priorities males and other family members when resources are limited. The intersectionality of gender with other social stratifiers such as marital status, ethnicity, and geographical areas influenced individual's ability to access information related to LF and care seeking. CONCLUSIONS Overall, the findings emphasized how access to resources, division of work, norms and values and decision-making power alone and its interaction with various social stratifiers shaped peoples' vulnerability to disease, ability to prevent exposure and response to illness.
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Affiliation(s)
| | | | - Chandani Kharel
- UNICEF, UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland
| | - Mariam Otmani Del Barrio
- UNICEF, UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland
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Morrison J, Giri R, James P, Arjyal A, Kharel C, Saville N, Baral S, Hillman S, Harris-Fry H. Assessing food-based strategies to address anaemia in pregnancy in rural plains Nepal: a mixed methods study. Br J Nutr 2023; 130:211-220. [PMID: 36205216 PMCID: PMC10277664 DOI: 10.1017/s0007114522003208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/16/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
Anaemia in pregnancy is a persistent health problem in Nepal and could be reduced through nutrition counselling and strengthened iron folic acid supplementation programmes. We analysed 24-hour diet recall data from 846 pregnant women in rural plains Nepal, using linear programming to identify the potential for optimised food-based strategies to increase iron adequacy. We then conducted qualitative research to analyse how anaemia was defined and recognised, how families used food-based strategies to address anaemia, and the acceptability of optimised food-based strategies. We did 16 interviews of recently pregnant mothers, three focus group discussions with fathers, three focus group discussions with mothers-in-law and four interviews with key informants. Dietary analyses showed optimised diets did not achieve 100 % of recommended iron intakes, but iron intakes could be doubled by increasing intakes of green leaves, egg and meat. Families sought to address anaemia through food-based strategies but were often unable to because of the perceived expense of providing an 'energy-giving' diet. Some foods were avoided because of religious or cultural taboos, or because they were low status and could evoke social consequences if eaten. There is a need for counselling to offer affordable ways for families to optimise iron adequacy. The participation of communities in tailoring advice to ensure cultural relevance and alignment with local norms is necessary to enable its effectiveness.
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Affiliation(s)
- Joanna Morrison
- UCL Institute for Global Health, 30 Guilford Street, LondonWC1N 1EH, UK
| | - Romi Giri
- Herd International, Thapathali, Kathmandu, Nepal
| | - Philip James
- London School of Hygiene and Tropical Medicine, Keppel St, LondonWC1E 7HT, UK
| | | | | | - Naomi Saville
- UCL Institute for Global Health, 30 Guilford Street, LondonWC1N 1EH, UK
| | - Sushil Baral
- Herd International, Thapathali, Kathmandu, Nepal
| | - Sara Hillman
- UCL Institute for Women’s Health, 74 Huntley Street, LondonWC1E 6AU, UK
| | - Helen Harris-Fry
- London School of Hygiene and Tropical Medicine, Keppel St, LondonWC1E 7HT, UK
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Saville NM, Kharel C, Morrison J, Harris-Fry H, James P, Copas A, Giri S, Arjyal A, Beard BJ, Haghparast-Bidgoli H, Skordis J, Richter A, Baral S, Hillman S. Comprehensive Anaemia Programme and Personalized Therapies (CAPPT): protocol for a cluster-randomised controlled trial testing the effect women's groups, home counselling and iron supplementation on haemoglobin in pregnancy in southern Nepal. Trials 2022; 23:183. [PMID: 35232469 PMCID: PMC8886560 DOI: 10.1186/s13063-022-06043-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 01/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anaemia in pregnancy remains prevalent in Nepal and causes severe adverse health outcomes. METHODS This non-blinded cluster-randomised controlled trial in the plains of Nepal has two study arms: (1) Control: routine antenatal care (ANC); (2) Home visiting, iron supplementation, Participatory Learning and Action (PLA) groups, plus routine ANC. Participants, including women in 54 non-contiguous clusters (mean 2582; range 1299-4865 population) in Southern Kapilbastu district, are eligible if they consent to menstrual monitoring, are resident, married, aged 13-49 years and able to respond to questions. After 1-2 missed menses and a positive pregnancy test, consenting women < 20 weeks' gestation, who plan to reside locally for most of the pregnancy, enrol into trial follow-up. Interventions comprise two home-counselling visits (at 12-21 and 22-26 weeks' gestation) with iron folic acid (IFA) supplement dosage tailored to women's haemoglobin concentration, plus monthly PLA women's group meetings using a dialogical problem-solving approach to engage pregnant women and their families. Home visits and PLA meetings will be facilitated by auxiliary nurse midwives. The hypothesis is as follows: Haemoglobin of women at 30 ± 2 weeks' gestation is ≥ 0.4 g/dL higher in the intervention arm than in the control. A sample of 842 women (421 per arm, average 15.6 per cluster) will provide 88% power, assuming SD 1.2, ICC 0.09 and CV of cluster size 0.27. Outcomes are captured at 30 ± 2 weeks gestation. Primary outcome is haemoglobin concentration (g/dL). Secondary outcomes are as follows: anaemia prevalence (%), mid-upper arm circumference (cm), mean probability of micronutrient adequacy (MPA) and number of ANC visits at a health facility. Indicators to assess pathways to impact include number of IFA tablets consumed during pregnancy, intake of energy (kcal/day) and dietary iron (mg/day), a score of bioavailability-enhancing behaviours and recall of one nutrition knowledge indicator. Costs and cost-effectiveness of the intervention will be estimated from a provider perspective. Using constrained randomisation, we allocated clusters to study arms, ensuring similarity with respect to cluster size, ethnicity, religion and distance to a health facility. Analysis is by intention-to-treat at the individual level, using mixed-effects regression. DISCUSSION Findings will inform Nepal government policy on approaches to increase adherence to IFA, improve diets and reduce anaemia in pregnancy. TRIAL REGISTRATION ISRCTN 12272130 .
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Affiliation(s)
- Naomi M Saville
- Institute for Global Health, University College London (UCL), London, UK.
| | | | - Joanna Morrison
- Institute for Global Health, University College London (UCL), London, UK
| | - Helen Harris-Fry
- Department of Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Philip James
- Department of Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Andrew Copas
- Institute for Global Health, University College London (UCL), London, UK
| | - Santosh Giri
- HERD International, Thapathali, Kathmandu, Nepal
| | | | | | | | - Jolene Skordis
- Institute for Global Health, University College London (UCL), London, UK
| | - Adam Richter
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Sushil Baral
- HERD International, Thapathali, Kathmandu, Nepal.,Health Research and Social Development Forum (HERD), Kathmandu, Nepal
| | - Sara Hillman
- Institute for Women's Health, University College London (UCL), London, UK
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Morrison J, Giri R, Arjyal A, Kharel C, Harris‐Fry H, James P, Baral S, Saville N, Hillman S. Addressing anaemia in pregnancy in rural plains Nepal: A qualitative, formative study. Matern Child Nutr 2021; 17 Suppl 1:e13170. [PMID: 34241951 PMCID: PMC8269150 DOI: 10.1111/mcn.13170] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 12/01/2022]
Abstract
Maternal anaemia prevalence in low-income countries is unacceptably high. Our research explored the individual-, family- and community-level factors affecting antenatal care uptake, iron folic acid (IFA) intake and consumption of micronutrient-rich diets among pregnant women in the plains of Nepal. We discuss how these findings informed the development of a home visit and community mobilisation intervention to reduce anaemia in pregnancy. We used a qualitative methodology informed by the socio-ecological framework, conducting semi-structured interviews with recently pregnant women and key informants, and focus group discussions with mothers-in-law and fathers. We found that harmful gender norms restricted women's access to nutrient-rich food, restricted their mobility and access to antenatal care. These norms also restricted fathers' role to that of the provider, as opposed to the caregiver. Pregnant women, mothers-in-law and fathers lacked awareness about iron-rich foods and how to manage the side effects of IFA. Fathers lacked trust in government health facilities affecting access to care and trust in the efficacy of IFA. Our research informed interventions by (1) informing the development of intervention tools and training; (2) informing the intervention focus to engaging mothers-in-law and men to enable behaviour change; and (3) demonstrating the need to work in synergy across individual, family and community levels to address power and positionality, gender norms, trust in health services and harmful norms. Participatory groups and home visits will enable the development and implementation of feasible and acceptable strategies to address family and contextual issues generating knowledge and an enabling environment for behaviour change.
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Affiliation(s)
- Joanna Morrison
- UCL Institute for Global HealthUniversity College LondonLondonUK
| | | | | | | | - Helen Harris‐Fry
- Department of Population HealthLondon School of Hygiene & Tropical MedicineLondonUK
| | - Philip James
- Department of Population HealthLondon School of Hygiene & Tropical MedicineLondonUK
| | | | - Naomi Saville
- UCL Institute for Global HealthUniversity College LondonLondonUK
| | - Sara Hillman
- UCL Institute for Women's HealthUniversity College LondonLondonUK
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Rawal LB, Kharel C, Yadav UN, Kanda K, Biswas T, Vandelanotte C, Baral S, Abdullah AS. Community health workers for non-communicable disease prevention and control in Nepal: a qualitative study. BMJ Open 2020; 10:e040350. [PMID: 33318116 PMCID: PMC7737104 DOI: 10.1136/bmjopen-2020-040350] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/21/2020] [Accepted: 11/15/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND/OBJECTIVE The increasing burden of non-communicable diseases (NCDs) in Nepal underscores the importance of strengthening primary healthcare systems to deliver efficient care. In this study, we examined the barriers and facilitators to engaging community health workers (CHWs) for NCDs prevention and control in Nepal. DESIGN We used multiple approaches including (a) review of relevant literature, (b) key personnel and stakeholders' consultation meetings and (c) qualitative data collection using semistructured interviews. A grounded theory approach was used for qualitative data collection and the data were analysed thematically. SETTING Data were collected from health facilities across four districts in Nepal and two stakeholder consultative meetings were conducted at central level. PARTICIPANTS We conducted in-depth interviews with CHWs (Health Assistants, Auxiliary Health Workers, Auxiliary Nurse Midwife) (n=5); key informant interviews with health policymakers/managers (n=3) and focus group discussions (FGDs) with CHWs (four FGDs; total n=27). Participants in two stakeholder consultative meetings included members from the government (n=8), non-government organisations (n=7), private sector (n=3) and universities (n=6). RESULTS The CHWs were engaged in a wide range of public health programmes and they also deliver NCDs specific programmes such as common NCDs screening, provisional diagnosis, primary care, health education and counselling, basic medication and referral and so on. These NCD prevention and control services are concentrated in those districts, where the WHO, Package for prevention and control of NCDs) program is being implemented. Some challenges and barriers were identified, including inadequate NCD training, high workload, poor system-level support, inadequate remuneration, inadequate supply of logistics and drugs. The facilitating factors included government priority, formation of NCD-related policies, community support systems, social prestige and staff motivation. CONCLUSION Engaging CHWs has been considered as key driver to delivering NCDs related services in Nepal. Effective integration of CHWs within the primary care system is essential for CHW's capacity buildings, necessary supervisory arrangements, supply of logistics and medications and setting up effective recording and reporting systems for prevention and control of NCDs in Nepal.
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Affiliation(s)
- Lal B Rawal
- School of Health Medical and Applied Sciences, College of Science and Sustainability, Central Queensland University, Sydney, NSW, Australia
- Physical Activity Research Group, Appleton Institute, Central Queensland University, Adelaide, SA, Australia
- Translational Health Research Institute (THRI) and School of Social Sciences, Western Sydney University, Sydney, NSW, Australia
| | | | - Uday Narayan Yadav
- Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Kie Kanda
- School of Nursing and Midwifery, Western Sydney University, Australia, Sydney, New South Wales, Australia
| | - Tuhin Biswas
- Institute for Social Science Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Corneel Vandelanotte
- Physical Activity Research Group, Appleton Institute, Central Queensland University, Adelaide, SA, Australia
| | | | - Abu S Abdullah
- Global Health Program, Duke Kunshan University, Jiangsu 215347, China, Kunsan, China
- School of Medicine, Boston Medical Center, Boston University, Boston, Massachusetts, USA
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Affiliation(s)
- Rosemary Morgan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | | | - Kui Muraya
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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Morgan R, Dhatt R, Kharel C, Muraya K. Une approche disparate de l’égalité de genre affaiblit les ODD : le temps d’une action transversale. Glob Health Promot 2020. [DOI: 10.1177/1757975920949747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Rosemary Morgan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Kui Muraya
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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Morgan R, Dhatt R, Kharel C, Muraya K. Un enfoque parcial de la igualdad de género debilita a los ODS: es hora de una acción transversal. Glob Health Promot 2020. [DOI: 10.1177/1757975920949745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Rosemary Morgan
- Departamento de Salud Internacional, Escuela Bloomberg de Salud Pública de la Universidad Johns Hopkins, Baltimore, MD, USA
| | | | | | - Kui Muraya
- Programa de Investigación del KEMRI-Wellcome Trust, Nairobi, Kenia
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Hay K, McDougal L, Percival V, Henry S, Klugman J, Wurie H, Raven J, Shabalala F, Fielding-Miller R, Dey A, Dehingia N, Morgan R, Atmavilas Y, Saggurti N, Yore J, Blokhina E, Huque R, Barasa E, Bhan N, Kharel C, Silverman JG, Raj A. Disrupting gender norms in health systems: making the case for change. Lancet 2019; 393:2535-2549. [PMID: 31155270 PMCID: PMC7233290 DOI: 10.1016/s0140-6736(19)30648-8] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 03/06/2019] [Accepted: 03/11/2019] [Indexed: 12/21/2022]
Abstract
Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.
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Affiliation(s)
| | - Lotus McDougal
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Valerie Percival
- Norman Paterson School of International Affairs, Carleton University, Ottawa, ON Canada
| | - Sarah Henry
- Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Jeni Klugman
- Georgetown Institute for Women, Peace and Security, Georgetown University, Washington, DC, USA; Women and Public Policy Program, Harvard Kennedy School, Cambridge, MA, USA
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Rebecca Fielding-Miller
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Arnab Dey
- Sambodhi Research & Communications, Noida, Uttar Pradesh, India
| | | | - Rosemary Morgan
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
| | | | | | - Jennifer Yore
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Elena Blokhina
- Vladman Institute of Pharmacology, Department of Psychiatry, First Pavlov State Medical University of St Petersburg, Saint Petersburg, Russia
| | | | - Edwine Barasa
- Kemri-Wellcome Trust, Kenya Research Programme, Nairobi, Kenya
| | - Nandita Bhan
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Jay G Silverman
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Anita Raj
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA.
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Elsey H, Agyepong I, Huque R, Quayyem Z, Baral S, Ebenso B, Kharel C, Shawon RA, Onwujekwe O, Uzochukwu B, Nonvignon J, Aryeetey GC, Kane S, Ensor T, Mirzoev T. Rethinking health systems in the context of urbanisation: challenges from four rapidly urbanising low-income and middle-income countries. BMJ Glob Health 2019; 4:e001501. [PMID: 31297245 PMCID: PMC6577312 DOI: 10.1136/bmjgh-2019-001501] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/26/2019] [Accepted: 05/18/2019] [Indexed: 11/29/2022] Open
Abstract
The world is now predominantly urban; rapid and uncontrolled urbanisation continues across low-income and middle-income countries (LMICs). Health systems are struggling to respond to the challenges that urbanisation brings. While better-off urbanites can reap the benefits from the 'urban advantage', the poorest, particularly slum dwellers and the homeless, frequently experience worse health outcomes than their rural counterparts. In this position paper, we analyse the challenges urbanisation presents to health systems by drawing on examples from four LMICs: Nigeria, Ghana, Nepal and Bangladesh. Key challenges include: responding to the rising tide of non-communicable diseases and to the wider determinants of health, strengthening urban health governance to enable multisectoral responses, provision of accessible, quality primary healthcare and prevention from a plurality of providers. We consider how these challenges necessitate a rethink of our conceptualisation of health systems. We propose an urban health systems model that focuses on: multisectoral approaches that look beyond the health sector to act on the determinants of health; accountability to, and engagement with, urban residents through participatory decision making; and responses that recognise the plurality of health service providers. Within this model, we explicitly recognise the role of data and evidence to act as glue holding together this complex system and allowing incremental progress in equitable improvement in the health of urban populations.
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Affiliation(s)
- Helen Elsey
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Irene Agyepong
- Research and Development Division, Ghana Health Service, Accra, Greater Accra Region, Ghana
- Public Health Faculty, Ghana College of Physicians and Surgeons, Accra, Ghana
| | | | - Zahidul Quayyem
- Centre of Excellence for Urban Equity and Health, BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | | | - Bassey Ebenso
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | | | - Riffat Ara Shawon
- Public Health Research, Centre for Injury Prevention and Research Bangladesh, Dhaka, Bangladesh
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria Faculty of Medical Sciences, Nsukka, Enugu, Nigeria
| | - Benjamin Uzochukwu
- Health Policy Research Group, College of Medicine, Universiy of Nigeria, Enugu, Nigeria
| | - Justice Nonvignon
- School of Public Health, University of Ghana, Legon, Greater Accra, Ghana
| | | | - Sumit Kane
- Nossal Institute for Global Health Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tim Ensor
- Nuffield Centre for Health, University of Leeds, Leeds, UK
| | - Tolib Mirzoev
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Kharel C, Agrawal S, Rijal A, Bhattarai S. Pyoderma gangrenosum: A clinico- therapeutic profile of patients attending a tertiary care hospital in Nepal. J Coll Med Sci-Nepal 2012. [DOI: 10.3126/jcmsn.v8i1.6823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a primarily sterile inflammatory neutrophilic dermatosis characterized by recurrent cutaneous ulcerations with mucopurulent or hemorrhagic exudate. In many cases, PG is associated with inflammatory bowel disease, rheumatic disorder or neoplasia. The peak of incidence occurs between the ages of 20 to 50 years with women being more often affected than men. To study the clinical and therapeutic profile of patients with pyoderma gangrenosum. All patients diagnosed as pyoderma gangrenosum in the department of dermatology from July 14th 2003- July 12th 2008 were included in the study. Demographic profile, clinical features as well as relevant investigations, treatment and follow-up were noted. A total of 8 patients with pyoderma gangrenosum were diagnosed over a 5 year period. There were 3 males and 5 female patients whose ages ranged from 32 to 80 years. Lower limbs were the commonest site to be involved in 6 patients (75%). Recurrent episodes were noted in 4 patients (50%) and among them 3 patients (75%) had multiple ulcers. Histopathological confirmation of the diagnosis was done in 7 patients (87.5%). Association with ulcerative colitis was seen in 2 patients (25%). All patients were treated with dapsone and systemic steroids which showed resolution of the lesions in all patients. Pyoderma gangrenosum was seen more frequently in females and association with ulcerative colitis was seen in 25% of the patients. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-1, 29-35 DOI: http://dx.doi.org/10.3126/jcmsn.v8i1.6823
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Thapa DP, Jha AK, Kharel C, Shrestha S. Dermatological problems in geriatric patients: a hospital based study. Nepal Med Coll J 2012; 14:193-195. [PMID: 24047013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Geriatric health care has become a major issue worldwide. There are no data regarding geriatric dermatologic diseases are available from Nepal. Patients of 60 years and above were enrolled in the Nepali fiscal year 2067(April 2010-April 2011). The data included age, sex, place, and diagnosis. The aim of the study is to determine the characteristic pattern and frequency of dermatoses in dermatologic patients aged 60 years and above. There were total of 6442 patients who visited out patients department. Out of which frequency of geriatric patients were 330, which constitute about 5.1%. The male to female ratio was 50% each. The most common cutaneous dermatoses was eczema 35.8%, fungal infection 13.6%, viral infection 7%, followed by pruritus 7.3%, scabies and photodermatitis 4.5% each, Inflammatory papulosquamous disorder 3.3%, Bacterial infection and Icthyosis 2.1% each, vesiculobullous 1.8%, tumors and pigmentary disorder 0.6% and Miscellaneous group (keratoderma, callus, urticaria, diabetic ulcer, burgers disease, burning feet syndrome, Rosacea, Drug rash-amoxicillin, senile acne, prurigo nodularis, hansens disease, pellagra, Actinic cheilitis) 15.8%. Few patients had more than one dermatoses which constitute < 1% .Photodermatitis was found to be statistically significant. The most common dermatoses were Eczema in females followed by Photodermatitis and comparatively in males viral and fungal infections were common. This study depicts various characteristic patterns of dermatoses seen in elderly. Eczema and infections was found to be most common diseases seen in elderly. Further epidemiologic studies including treatment, follow-up of elderly patients has to be carried out to know the burden of the disease and decrease morbidity and psychological concern associated with diseases.
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Affiliation(s)
- D P Thapa
- Department of Dermatology, Nepal Medical College and Teaching Hospital, Jorpati, Kathmandu, Nepal.
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Bhattarai S, Rijal A, Pandey SR, Kharel C. A retrospective analysis of Sweet's syndrome in a tertiary care hospital in Nepal: A BPKIHS perspective. J Coll Med Sci-Nepal 2012. [DOI: 10.3126/jcmsn.v7i3.6703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Sweet's syndrome (the eponym for acute febrile neutrophilic dermatosis) is characterized by a constellation of clinical symptoms, physical features, and pathologic findings which include fever, neutrophilia, tender erythematous skin lesions (papules, nodules, and plaques), and a diffuse infiltrate consisting predominantly of mature neutrophils that are typically located in the upper dermis without vasculitis. To study the clinico-pathological features, clinical course and treatment of patients with sweets syndrome. A retrospective observational analysis of 12 diagnosed cases of sweet’s syndrome attending and admitted in the Department of Dermatology from June 2003- April 2009 were considered in this study. The study comprised of 9 females and 3 males (3:1) between the age group of 22-73 years. Typical lesions of sweets syndrome were present in all cases and the duration of illness ranged from 3-8 days. Constitutional symptoms of fever, pain and malaise were present in all and the extremities were the most common site of involvement 12 (100%). Leucocytosis was present in 7 (58.3%), raised ESR in 9 (75%) and raised C reactive protein in 7(58.3%) patients. Characteristic histological features were recorded in specimens of all patients. 9 (75%) patients responded promptly to systemic oral corticosteroids while 3 (25%) were treated with intravenous steroids. Complete Response was seen in 7 (58.3%), partial response in 5 (41.6%) and recurrence in 1(8.3%) patient after therapy. Characteristic skin lesion, histopathological diagnosis and relevant abnormal laboratory parameters can act as a useful diagnostic tool in patients with sweet’s syndrome. DOI: http://dx.doi.org/10.3126/jcmsn.v7i3.6703 Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-3, 17-23
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