Promoting wellbeing and empowerment via Youth First: Exploring psychosocial outcomes of a school-based resilience intervention in Bihar, India

Youth worldwide are struggling with increased mental health concerns. As youth in low- and middle-income countries make up more than 20% of the world's population, finding ways to improve their psychosocial wellbeing is crucial. CorStone's Youth First program is a school-based psychosocial resilience program that seeks to improve the mental, physical, social, and educational wellbeing of early adolescents. The program is delivered via trained government schoolteachers who facilitate students' learning and development in small groups using a discussion and activity-based curriculum. In August 2021, a study among 322 adolescents was conducted to investigate and compare program participants' and non- participants' understanding and use of inter- and intra-personal psychosocial skills. Focus group discussions were held with students in eight intervention schools and four comparable schools not receiving the intervention (control). Through the focus group discussions, students provided their opinions, thoughts, and ideas about vignettes describing challenges that youth in their communities frequently face, including early marriage and financial pressures. Analysis integrated qualitative and quantitative approaches, consisting of an iterative thematic analysis process followed by quantizing data and conducting t-tests. Youth who had received Youth First had greater awareness of problems, perspective-taking, problem-solving strategies, helping approaches, awareness of their own strengths, and visions for the future, when compared with the control group. Findings provide insights into potential outcomes for measurement in future evaluations of mental health promotion and prevention programs among youth in low- and middle-income countries.

Impact of a protein-based assay that predicts prostate cancer aggressiveness on urologists' recommendations for active treatment or active surveillance: a randomized clinical utility trial

Background

Of the more than 1.1 million men diagnosed worldwide annually with prostate cancer, the majority have indolent tumors. Distinguishing between aggressive and indolent cancer is an important clinical challenge. The current approaches for assessing tumor aggressiveness are recognized as insufficient. A validated protein-based assay has been shown to predict tumor aggressiveness from prostate biopsy. The main objective of this study was to measure the clinical utility of this new assay in the management of early-stage prostate cancer.

Methods

One hundred twenty nine board-certified urologists were asked to participate in a randomized, two-arm experiment. We collected data over 2 rounds using simulated clinical cases administered via an online platform. The cases were all newly diagnosed Gleason 3 + 3 or 3 + 4 prostate camcer patients. Urologists in the intervention arm received a 15-min webinar on this protein-based assay and given assay test results for their simulated patients in round 2. Each case had a preferred recommendation of either active surveillance or active treatment. The measured outcome was rate of preferred recommendation, defined as urologists who recommended the proper treatment course. Analyses were done using difference-in-difference estimations.

Results

Using multinomial logistical regression, urologists who were given the assay results were significantly more likely to choose the preferred recommendation (active surveillance or active treatment) compared to controls (p = 0.004). These urologists were also significantly more likely to involve their patients in the treatment decision compared to controls (p = 0.001).

Conclusions

By providing additional information to inform the physician’s treatment plan, a protein-based assay shows demonstrable clinical utility confirmed through a rigorous randomized controlled study design and regression analyses to test for effects.

Indications for Cesarean Delivery in Mexico: Evaluation of Appropriate Use and Justification

BACKGROUND

Cesarean delivery is one of the most widely used surgical interventions in Latin America and in many cases it is performed with no clear medical indication. Our objective was to analyze the relationship between reported indications for a cesarean and support for that indication in the clinical record in four Mexican hospitals, during the 2006-2007 period.

METHODS

The data are from 604 (37.1%) women from a total of 1,625 who were admitted to the hospital in labor, and who gave birth through cesarean. Multivariate logistical regression analysis was used to explore the association between indications for clinically justified or unjustified surgery and other clinical and sociodemographic variables.

RESULTS

Supporting clinical information for indications of cesarean delivery were found in only 45 percent of the cases considered. The adjusted statistical analysis showed that the variables associated with an unjustified indication for cesarean were: not having had a prior birth (OR 1.84 [95% CI 1.16-2.89]), having a maximum cervical dilation of 4 centimeters or less at time of cesarean (OR 2.44 [95% CI 1.53-3.87]), and having received care in a private hospital (OR 6.11 [95% CI 1.90-19.57]).

DISCUSSION

The indications for cesarean related to labor dynamics were those least supported. Not having had a prior birth poses the greatest risk of having a poorly supported indication for a cesarean delivery. It would be prudent to institute audits, and greater requirements for and surveillance of documentation for cesarean delivery indications.

A psychosocial resilience curriculum provides the "missing piece" to boost adolescent physical health: A randomized controlled trial of Girls First in India

RATIONALE AND OBJECTIVES

Despite a recent proliferation of interventions to improve health, education, and livelihoods for girls in low and middle income countries, psychosocial wellbeing has been neglected. This oversight is particularly problematic as attending to psychosocial development may be important not only for psychosocial but also physical wellbeing. This study examines the physical health effects of Girls First, a combined psychosocial (Girls First Resilience Curriculum [RC]) and adolescent physical health (Girls First Health Curriculum [HC]) intervention (RC + HC) versus its individual components (i.e., RC, HC) and a control group. We expected Girls First to improve physical health versus HC and controls.

METHODS

Over 3000 girls in 76 government middle schools in rural Bihar, India participated. Interventions were delivered through in-school peer-support groups, facilitated by pairs of local women. Girls were assessed before and after program participation on two primary outcomes (health knowledge and gender equality attitudes) and nine secondary outcomes (clean water behaviors, hand washing, menstrual hygiene, health communication, ability to get to a doctor when needed, substance use, nutrition, safety, vitality and functioning). Analyses included Difference-in-Difference Ordinary Least-Squares Regressions and F-tests for equality among conditions.

RESULTS

Girls First significantly improved both primary and eight secondary outcomes (all except nutrition) versus controls. Additionally, Girls First demonstrated significantly greater effects, improving both primary and six secondary outcomes (clean water behaviors, hand washing, health communication, ability to get to a doctor, nutrition, safety) versus HC.

CONCLUSIONS

This study is among the first to assess the impact of a combined psychosocial and adolescent health program on physical health. We found that combining these curricula amplified effects achieved by either curriculum alone. These findings suggest that psychosocial wellbeing should receive much broader attention, not only from those interested in improving psychosocial outcomes but also from those interested in improving physical health outcomes.

Fostering emotional, social, physical and educational wellbeing in rural India: the methods of a multi-arm randomized controlled trial of Girls First

Background

There are 600 million girls in low and middle income countries (LMICs), many of whom are at great risk for poor health and education. There is thus great need for programs that can effectively improve wellbeing for these girls. Although many interventions have been developed to address these issues, most focus on health and education without integrating attention to social and emotional factors. This omission is unfortunate, as nascent evidence indicates that these factors are closely related to health and education.

This paper describes the methods of a 4-arm randomized controlled trial among 3,560 adolescent girls in rural Bihar, India that tested whether adding an intervention targeting social-emotional issues (based on a “resilience framework”) to an adolescent health intervention would improve emotional, social, physical, and educational wellbeing to a greater extent than its components and a control group. Study arms were: (1) Girls First, a combination of the Girls First Resilience Curriculum (RC) and the Girls First Health Curriculum (HC); (2) Girls First Resilience Curriculum (RC) alone; (3) Girls First Health Curriculum (HC) alone; and (4) a school-as-usual control group (SC).

Methods

Seventy-six schools were randomized (19 per condition) and 74 local women with a tenth grade education were trained and monitored to facilitate the program. Quantitative data were collected from 3,560 girls over 4 assessment points with very low rates of participant attrition. Qualitative assessments were conducted with a subset of 99 girls and 27 facilitators.

Results and conclusions

In this article, we discuss guiding principles that facilitated trial implementation, including integrating diverse local and non-local sources of knowledge, focusing on flexibility of planning and implementation, prioritizing systematic measurement selection, and striking a balance between scientific rigor and real-world feasibility.

Trial registration

Clinicaltrials.gov NCT02429661. Registered 24 April 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-1008-3) contains supplementary material, which is available to authorized users.

Patient and provider perspectives on quality and health system effectiveness in a transition economy: evidence from Ukraine

Facing a severe population health crisis due to noncommunicable diseases, Ukraine and other former Soviet republics and Eastern European countries have a pressing need for more effective health systems. Policies to enhance health system effectiveness should consider the perspectives of different stakeholder groups, including providers as well as patients. In addition, policies that directly target the quality of clinical care should be based on objective performance measures. In 2009 and 2010 we conducted a coordinated series of household and facility-level surveys to capture the perspectives of Ukrainian household members, outpatient clinic patients, and physicians regarding the country's health system overall, as well as the quality, access, and affordability of health care. We objectively measured the quality of care for heart failure and chronic obstructive pulmonary disease using CPV(®) vignettes. There was broad agreement among household respondents (79%) and physicians (95%) that Ukraine's health system should be reformed. CPV(®) results indicate that the quality of care for common noncommunicable diseases is poor in all regions of the country and in hospitals as well as polyclinics. However, perspectives about the quality of care differ, with household respondents seeing quality as a serious concern, clinic patients having more positive perceptions, and physicians not viewing quality as a reform priority. All stakeholder groups viewed affordability as a problem. These findings have several implications for policies to enhance health system effectiveness. The shared desire for health system reform among all stakeholder groups provides a basis for action in Ukraine. Improving quality, strengthening primary care, and enhancing affordability should be major goals of new health policies. Policies to improve quality directly, such as pay-for-performance, would be mutually reinforcing with purchasing reforms such as transparent payment mechanisms. Such policies would align the incentives of physicians with the desires of the population they serve.

Non-physician providers of obstetric care in Mexico: Perspectives of physicians, obstetric nurses and professional midwives

BACKGROUND

In Mexico 87% of births are attended by physicians. However, the decline in the national maternal mortality rate has been slower than expected. The Mexican Ministry of Health's 2009 strategy to reduce maternal mortality gives a role to two non-physician models that meet criteria for skilled attendants: obstetric nurses and professional midwives. This study compares and contrasts these two provider types with the medical model, analyzing perspectives on their respective training, scope of practice, and also their perception and/or experiences with integration into the public system as skilled birth attendants.

METHODOLOGY

This paper synthesizes qualitative research that was obtained as a component of the quantitative and qualitative study that evaluated three models of obstetric care: professional midwives (PM), obstetric nurses (ON) and general physicians (GP). A total of 27 individual interviews using a semi-structured guide were carried out with PMs, ONs, GPs and specialists. Interviews were transcribed following the principles of grounded theory, codes and categories were created as they emerged from the data. We analyzed data in ATLAS.ti.

RESULTS

All provider types interviewed expressed confidence in their professional training and acknowledge that both professional midwives and obstetric nurses have the necessary skills and knowledge to care for women during normal pregnancy and childbirth. The three types of providers recognize limits to their practice, namely in the area of managing complications.We found differences in how each type of practitioner perceived the concept and process of birth and their role in this process. The barriers to incorporation as a model to attend birth faced by PMs and ONs are at the individual, hospital and system level. GPs question their ability and training to handle deliveries, in particular those that become complicated, and the professional midwifery model particularly as it relates to a clinical setting, is also questioned.

CONCLUSIONS

Hospitals in the Mexican public health sector have a heavy obstetric workload; physicians carry the additional burden of non-obstetric cases. The incorporation of a non- physician model at the primary health center level to attend low-risk, normal deliveries would contribute to the reduction of non-necessary referrals. There is also a role for these providers at the hospital level.

Skilled birth attendants in Mexico: how does care during normal birth by general physicians, obstetric nurses, and professional midwives compare with World Health Organization evidence-based practice guidelines?

INTRODUCTION

We evaluated the quality of basic obstetric care provided by Mexican general physicians, obstetric nurses, and professional midwives compared with World Health Organization (WHO) guidelines for evidence-based practices and national guidelines.

METHODS

Vaginal births were observed in 5 hospitals in 5 states from June 2006 until July 2007. We created 5 indices based on WHO guidelines and national standards for care during normal birth. These indices included 1) favorable practices at admission, 2) favorable practices during labor, birth, and immediately postpartum, 3) harmful or excessively used practices, 4) newborn practices, and 5) obstetric outcomes. We assessed each provider type's performance as high or low compared with the WHO standard and performed bivariate and multivariate logistic regression analyses to assess the association between indices, patient characteristics, and provider type, adjusting for standard errors for intragroup correlation.

RESULTS

We observed 876 independently managed vaginal births. Adjusted regression analyses compared with the general physicians standard revealed significant results for favorable care by obstetric nurses on admission (odds ratio [OR] 6.25; 95% confidence interval [CI], 2.08-18.84); for care by professional midwives (OR 21.08; 95% CI, 4.24-104.94) and obstetric nurses (OR 7.88; 95% CI, 2.76-22.52) during labor, birth, and postpartum; and for newborn practices by obstetric nurses (OR 4.14; 95% CI, 1.08-15.90). Professional midwives were least likely to perform harmful/excessively used practices during labor, birth, and the postpartum period (OR 0.06; 95% CI, 0.00-0.35).

DISCUSSION

Professional midwives and obstetric nurses perform equally or better than general physicians when assessed by use or misuse of evidence-based practices. Professional midwives are an underutilized resource in Mexico. If integrated into the mainstream Mexican health system, they may improve the quality of obstetric care.

Educating skilled birth attendants in Mexico: do the curricula meet international confederation of midwives standards?

Although the majority of births in Mexico are attended by skilled birth attendants, maternal mortality remains moderately high, raising questions about the quality of training and delivery care. We conducted an exhaustive review of the curricula of three representative schools for the education and clinical preparation of three types of birth attendant - obstetric nurses, professional midwives and general physicians - National Autonomous University of Mexico (UNAM) School of Obstetric Nursing; CASA Professional Midwifery School; and UNAM School of Medicine, Iztacala Campus. All curricular materials were measured against the 214 indicators of knowledge and ability in the International Confederation of Midwives (ICM) skilled attendant training guidelines. The CASA curriculum covered 83% of the competencies, 93% of basic knowledge and 86% of basic abilities, compared with 54%, 59% and 64% for UNAM Obstetric Nursing School and 43%, 60% and 36% for UNAM School of Medicine, respectively. Neither the Obstetric Nursing School nor the School of Medicine documented the quantity or types of clinical experience required for graduation. General physicians attend the most births in Mexico, yet based on our analysis, professional midwives had the most complete education and training as measured against the ICM competencies. We recommend that professional midwives and obstetric nurses should be formally integrated into the public health system to attend deliveries.