Perspectives of community and facility stakeholders on community health workers in rural Malawi

BACKGROUND

Community health workers (CHWs) bridge the primary health care (PHC) system and communities by providing care in the household. In Malawi, few studies have examined the perspective of users of household-level CHW services, in remote areas, to understand CHW's role in community-based PHC.

AIM

To explore perspectives of community and facility stakeholders on the enablers and challenges of the CHW role in community-based PHC in Neno District.

SETTING

The study was conducted in the Neno District health facilities, namely, Ligowe, Dambe, Chifunga, and Zalewa.

METHODS

We conducted eight focus group discussions (FGDs) with purposively sampled community members and conveniently sampled facility stakeholders. Data were transcribed and analysed thematically through an adapted COM-B model of behaviour change.

RESULTS

Three main themes of perceived behaviour change within the CHW role were identified: (1) capacity - the CHW programme aids health education and promotion within the community; (2) opportunity - the CHW programme facilitates community-based PHC and linkage to the facility; and (3) motivation - the CHW programme enablers and challenges in providing community-based PHC.

CONCLUSION

Community health workers enrich community-based PHC delivery through health education, timely access to care, and linking communities to the facility. Optimising workload and programme support is critical for the help of CHWs. Further studies are required to address programme and cultural challenges to enhance positive health-seeking behaviours.Contribution: This study provides contextual knowledge for further research on bringing together spiritual and formal health practices and considering the cultural background when planning for health interventions in remote areas.

Confronting misconceptions of public housing communities: A qualitative report of community-informed narratives by community members and partners

Objectives were (a) to understand a community-informed narrative, as told by community members (CMs) and community partners (CPs), about the strengths, experiences, and perspectives of public housing communities; and (b) to analyze similarities and differences between CMs' and CPs' experiences and perspectives. Qualitative interviews were conducted with 22 CMs of public housing (ages 26-58, 100% female caregivers, 96% Black, 4% multiethnic) and 43 CPs (ages 28-78, 67.4% female, 81.4% Black and African American). Four themes were derived from the CM and CP interviews: (1) counters to public narratives, (2) disinvestment begets disinvestment, (3) community conditions should be better, and (4) community cohesion and connection. Findings from this study present community-centered narratives and experiences that were counter to stereotyped public narratives and could influence public perceptions and behavior to inform policy changes related to improving living conditions and supporting CMs in public and low-income housing communities.

Exploring the perspectives of community members on use of Nyaope in Tshwane, South Africa

BACKGROUND

 Substance use is a major public health issue in South Africa. Cocktails, containing two or more low-quality substances, have been reported. Nyaope is one of the most popular and is widely available. It has a significant impact on users and communities. The aim of this study was to explore community members' perceptions of the potential contributors to Nyaope use and dependency.

METHODS

 This was an exploratory descriptive qualitative study that conducted three focus group interviews with 29 community members. A maximum variation sample was used. Data were analysed using the framework method, assisted by Atlas-ti.

RESULTS

 Seven main themes were identified, namely unfavourable home environments, distrust between community members and the local police, easy access to Nyaope at school, inadequate social services, lack of religious or spiritual drive, unfavourable community environments and the effects of Nyaope on users.

CONCLUSION

 The factors identified, were used to construct an emerging model of how Nyaope use is driven in Tshwane. It is clear that a multisectoral response is required involving health and social services, basic education, policing and community leadership. Further research will explore the views of family members and users and quantify the importance of the factors identified.Contribution: This study showed that rather than a simple linear chain of events, Nyaope use is enabled by a complex system of interconnected elements. According to the respondents, variables in the community at large, the school, the home and the specific user all have a role in Nyaope usage and dependency.

Community-guided measurement-based care for autistic youth and adults receiving psychotherapy: A conceptual overview and pilot implementation study of MBC-AUT

LAY ABSTRACT

Autistic youth and adults are more likely to experience psychiatric symptoms (e.g. depression, anxiety) and to use psychiatric services than non-autistic people, yet research on evidence-based approaches to enhance psychiatric care for autistic people is limited. Measurement-based care is an evidence-based approach to psychotherapy that improves outcomes for clients, clinicians, and organizations by routinely administering and evaluating measures to clients. Despite this, research on measurement-based care systems for autistic clients is sparse. To address this gap, we developed an autism-adapted measurement-based care (MBC-AUT) system for and with autistic people and pilot tested the system in an outpatient psychiatry clinic to investigate the preliminary feasibility, acceptability, benefits, and barriers to this system for clients and clinicians. Findings suggested that the MBC-AUT system was a feasible and acceptable system for the first 18 autistic youth, their caregivers, and autistic adults to use the system. In semi-structured interviews, clients and clinicians discussed the benefits of the MBC-AUT system to various therapeutic processes, as well as several important barriers to the use of the system. We offer potential solutions to address these barriers and to reduce client and clinician burden, and propose future directions for this line of research to increase access to more autistic people. As autistic clients continue to seek psychological services amid social landscapes of increasing complexity (e.g. COVID-19 pandemic), efforts to enhance the delivery of psychotherapy for this population are critical.

A Qualitative Evaluation of COVID-19 Preventative Response Activities in South Kivu, Democratic Republic of the Congo

OBJECTIVE

In this evaluation of COVID-19 preventative response programs in South Kivu, Democratic Republic of the Congo (DRC), we aimed to explore community understandings of COVID-19, assess operational successes and challenges of COVID response activities, and identify barriers to practicing COVID-19 preventative behaviors.

METHODS

Thirty-one semi-structured interviews were conducted from April to September 2021 in South Kivu, DRC, with community members (n = 16) and programmatic stakeholders (n = 15) (healthcare providers, government officials, and developmental and NGO staff engaged in COVID-19 response).

FINDINGS

Most community members were aware of COVID-19 and its global burden, but few were aware of local transmission in their area. Some community members attributed COVID-19 to actions of malevolent neighbors, miasma ("bad air"), or spirits. Awareness of COVID-19 preventative measures was widespread, largely because of radio and TV health promotion programs. Community members and programmatic stakeholders both said community-level non-compliance to COVID-19 preventative measures was high despite high awareness of preventative methods. Community members expressed concern that face masks distributed as part of preventative programs contained the COVID-19 virus. Programmatic stakeholders emphasized the need for broader health system strengthening with improved coordination, provision of resources to health facilities at the provincial level, and prioritization of research. Lessons learned from addressing Ebola were leveraged for COVID-19 health promotion, rapid training of healthcare personnel, and surveillance.

CONCLUSIONS

Community-informed approaches are needed for effective COVID-19 preventative response programs in South Kivu, DRC. Our study identified successes and challenges in COVID-19 response activities. Future research should assess the effectiveness of integrating preventive programs with COVID-19 vaccination efforts.

Randomized Controlled Trial of the Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) Cholera Rapid Response Program to Reduce Diarrheal Diseases in Bangladesh

(a) Objective: To build an evidence base on effective water, sanitation, and hygiene interventions to reduce diarrheal diseases in cholera hotspots, we developed the CHoBI7 Cholera Rapid Response Program. (b) Methods: Once a cholera patient (confirmed by bacterial culture) is identified at a health facility, a health promoter delivers a targeted WASH intervention to the cholera hotspot (households within 20 m of a cholera patient) through both in-person visits during the first week and bi-weekly WASH mobile messages for the 3-month program period. A randomized controlled trial of the CHoBI7 Cholera Rapid Response Program was conducted with 284 participants in 15 cholera hotspots around cholera patients in urban Dhaka, Bangladesh. This program was compared to the standard message in Bangladesh on the use of oral rehydration solution for dehydration. Five-hour structured observation of handwashing with soap and diarrhea surveillance was conducted monthly. (c) Findings: Handwashing with soap at food- and stool-related events was significantly higher in the CHoBI7 Cholera Rapid Response Program arm compared to the standard message arm at all timepoints (overall 54% in the CHoBI7 arm vs. 23% in the standard arm, p < 0.05). Furthermore, there was a significant reduction in diarrheal prevalence for all participants (adults and children) (Prevalence Ratio (PR) 0.35, 95% CI: 0.14-0.85) and for children under 5 years of age (PR: 0.27, 95% CI: 0.085-0.87) during the 3-month program. (d) Conclusions: These findings demonstrate that the CHoBI7 Cholera Rapid Response Program is effective in lowering diarrhea prevalence and increasing handwashing with soap for a population at high risk of cholera.

"We Were Afraid": Mental Health Effects of the COVID-19 Pandemic in Two South African Districts

The impacts of pandemics are recognized to go beyond infection, physical suffering, and socio-economic disruptions. Other consequences include psychological responses. Using a mental wellbeing lens, we analyzed COVID-19-related stressors in healthcare workers (HCWs) and community members who provided and regularly accessed health services in South Africa, respectively. From February to September 2021, during the second COVID-19 wave we conducted a qualitative study in one urban and one rural district. In-depth interviews and focus group discussions were used to collect data among 43 HCWs and 51 community members purposely and conveniently selected. Most participants experienced mental health challenges regarding multiple aspects of the COVID-19 pandemic and its resulting lockdown, with a few reporting positive adjustments to change. COVID-19 impacts on mental health were consistent among both HCWs and community members in urban and rural alike. Participants' COVID-19-induced psychological responses included anxiety and fear of the unknown, perceived risk of infection, fear of hospitalization, and fear of dying. Physical effects of the pandemic on participants included COVID-19 infection and associated symptoms, possibilities of severe illness and discomfort of using personal protective equipment. These distresses were exacerbated by social repercussions related to concerns for family wellbeing and infection stigma. Lockdown regulations also intensified anxieties about financial insecurities and social isolation. At times when common coping mechanisms such as family support were inaccessible, cultural consequences related to lack of spiritual gatherings and limited funeral rites posed additional stress on participants. In preparation for future public health emergencies, recognition needs to be given to mental health support and treatment.

The association between HIV stigma and HIV incidence in the context of universal testing and treatment: analysis of data from the HPTN 071 (PopART) trial in Zambia and South Africa

INTRODUCTION

To investigate the association between individual and community-level measures of HIV stigma and HIV incidence within the 21 communities participating in the HPTN (071) PopART trial in Zambia and South Africa.

METHODS

Secondary analysis of data from a population-based cohort followed-up over 36 months between 2013 and 2018. The outcome was rate of incident HIV infection among individuals who were HIV negative at cohort entry. Individual-level exposures, measured in a random sample of all participants, were: (1) perception of stigma in the community, (2) perception of stigma in health settings and (3) fear and judgement towards people living with HIV. Individual-level analyses were conducted with adjusted, individual-level Poisson regression. Community-level HIV stigma exposures drew on data reported by people living with HIV, health workers and community members. We used linear regression to explore the association between HIV stigma and community-level HIV incidence.

RESULTS

Among 8172 individuals who were HIV negative and answered individual-level stigma questions at enrolment to the cohort, there was no evidence of a statistically significant association between any domain of HIV stigma and risk of incident HIV infection. Among the full cohort of 26,110 individuals among whom HIV incidence was measured, there was no evidence that community-level HIV incidence was associated with any domain of HIV stigma.

CONCLUSIONS

HIV stigma is often cited as a barrier to the effectiveness of HIV prevention programming. However, in the setting for the HPTN 071 "PopART trial," measured stigma alone was not associated with the risk of HIV infection.

Perspectives of community members on homeless people with mental illness in Nsawam, Ghana

BACKGROUND

Homelessness among people with mental illness has grown to become a common phenomenon in many developed and developing countries. Just like in any other country, the living conditions of homeless people with mental illness in Ghana are unwholesome. Despite the increased population of these vulnerable individuals on the streets, not much is known about the perspectives of the general public towards this phenomenon in Ghana.

AIM

This research was conducted to explore the perspectives of community members on homeless people with mental illness. The main study objectives were (a) to find out the impacts of the presence of persons with mental illness on the streets and (b) to ascertain the reasons accounting for homelessness among persons with mental illness.

METHOD

Utilizing a qualitative research design, twenty community members were sampled from selected suburbs in Nsawam and interviewed with the use of a semi-structured interview guide. The audio data gathered from the interviews were transcribed verbatim and analysed thematically.

RESULTS

Majority of the participants asserted that homeless people with mental illness had no access to good food, shelter, and health care. They further stated that some homeless people with mental illness perpetrated physical and sexual violence against the residents. Moreover, the participants believed that persons with mental illness remained on the streets due to neglect by their family members, and limited access to psychiatric services.

CONCLUSION

This paper concludes by recommending to government to make mental health services accessible and affordable to homeless persons with mental illness nationwide.

Cross-sectional survey of knowledge and attitudes of healthcare workers and community members toward the Ebola virus disease and antimicrobial resistance pathogens outbreaks in Nigeria

Introduction

the 2014 Ebola virus disease (EVD) outbreak in Nigeria has further raised the awareness of health-care workers (HCWs) and community members (MCs) on the threat posed by infectious diseases and the need for improvement on infection control practices. However, awareness of dangers of increasing incidences of antimicrobial resistance (AMR) in hospitals and communities remained low.

Methods

a cross-sectional survey of awareness of 195 HCWs and 265 MCs toward EVD and AMR was conducted through a structured questionnaire.

Results

majority of HCWs (95.4%) and MCs (82.8%) still have knowledge of EVD´s danger and give reasons like its unique way of killing and unavailability of drugs for their awareness. Only 17.2% of MCs are aware of AMR as a problem, and only 3.4% of MCs and 10.3% of HCWs agreed that AMR is more dangerous than EVD. On the contrary, 76.4% of doctors, 95.1% nurses, 67.9% laboratory scientists, 66.7% pharmacists, 77.4% students and 100% of civil servants, drivers and religious leaders believed that EVD is more horrific and spread faster. They both attributed the rapid awareness of EVD in Nigeria, despite being new at the time of the outbreak, to the seriousness with which stakeholders and the media fought EVD, the gesture AMR is yet to receive. Though both HCWs and MCs agreed that prevention, not treatment is the best option to tackle Ebola like-diseases, but surprisingly, about 37% and 65% of HCWs and MCs respectively, still believe that traditional medicines can be used to treat Ebola related illnesses.

Conclusion

AMR awareness remains low among MCs and some HCWs when compared with EVD. It is recommended that efforts put in place during EVD outbreak by all stakeholders and the media need to be doubled to increase the knowledge of both HCWs and MCs toward AMR.

HIV Stigma and Viral Suppression Among People Living With HIV in the Context of Universal Test and Treat: Analysis of Data From the HPTN 071 (PopART) Trial in Zambia and South Africa

BACKGROUND

The impact of HIV stigma on viral suppression among people living with HIV (PLHIV) is not well characterized.

SETTING

Twenty-one communities in Zambia and South Africa, nested within the HPTN 071 (PopART) trial.

METHODS

We analyzed data on viral suppression (<400 copies HIV RNA/mL) among 5662 laboratory-confirmed PLHIV aged 18-44 years who were randomly sampled within the PopART trial population cohort 24 months after enrolment (PC24). We collected data on experiences and internalization of stigma from those PLHIV who self-reported their HIV status (n = 3963/5662) and data on perceptions of stigma from a 20% random sample of all PLHIV (n = 1154/5662). We also measured stigma at the community-level among PLHIV, community members, and health workers. We analyzed the association between individual- and community-level measures of HIV stigma and viral suppression among PLHIV, adjusting for confounding.

RESULTS

Of all 5662 PLHIV, 69.1% were virally suppressed at PC24. Viral suppression was highest among those 3963 cohort participants who self-reported living with HIV and were on ART (88.3%), and lower among those not on treatment (37.5%). Self-identifying PLHIV who reported internalized stigma were less likely to be virally suppressed (75.0%) than those who did not (80.7%; adjusted risk ratio, 0.94 95% CI: 0.89 to 0.98). Experiences, perceptions, and community-level measures of stigma were not associated with viral suppression.

CONCLUSION

Internalized stigma among PLHIV was associated with a lower level of viral suppression; other dimensions of stigma were not. Stigma reduction approaches that address internalized stigma should be an integral component of efforts to control the HIV epidemic.

Two Sides of the Same Coin: The Relationship Between Modern Racism and Rape Blaming Attitudes among Swedish Students and Community Members

The objective of this study is to investigate the relationship between modern racism and rape victim and perpetrator blame, and rape perception. Participants from both a community population (n = 211) and a student population (n = 200) read a rape vignette and provided their judgements of blame towards a victim and perpetrator, their perception of the event as rape, and later answered the modern racism scale. Results showed a significant positive relationship between modern racism and rape victim blame (r = .35, R²× 100 = 12.1%), while modern racism had a significant negative relationship with perpetrator blame (r = −.27, R²× 100 = 7.5%) and rape perception (r = −.29, R²× 100 = 8.7%). Implications for the criminal justice system as well as suggestions for future research were discussed.

In Our Backyard: Perceptions About Fracking, Science, and Health by Community Members

Unconventional oil and gas (UOG) extraction (fracking) has increased in the United States, as well as interest in the associated risks and benefits. This study’s purpose was to qualitatively examine residents’ perceptions about UOG development in their community. Fifteen interviewees involving residents of Garfield County, Colorado, a drilling-dense region, were transcribed and analyzed. The study found six themes: (1) health concerns, both human and animal, (2) power struggles between government and industry/between industry and residents, and (3) perception and some acceptance of increased risk. Less common themes were (4) reliance on science to accurately determine risk, (5) frustration with potential threat and loss of power, and (6) traffic and safety concerns. Community perceptions of UOG development are complex, and understanding the position of community members can support the need for additional public health research and impact assessments regarding community exposures from UOG drilling operation exposures.

Caregivers and community perceptions of blood transfusion for children with severe anaemia in Uganda

OBJECTIVE

To describe local perceptions of blood transfusion for children with severe anaemia in Uganda.

BACKGROUND

Blood transfusion is a common emergency treatment for children with severe anaemia and saves millions of lives of African children. However, the perceptions of transfusion recipients have not been well studied. A better understanding of the perceived risk may improve transfusion care.

METHODS

A qualitative study based on 16 in-depth interviews of caregivers of transfused children, and six focus group discussions with community members was conducted in three regions of Uganda between October and November 2017.

RESULTS

Caregivers of children and community members held blood transfusion in high regard and valued it as life-saving. However, there were widespread perceived transfusion risks, including: Human immunodeficiency virus (HIV) transmission, too rapid blood infusion and blood incompatibility. Other concerns were: fatality, changes in behaviour, donor blood being 'too strong' and use of animal blood. In contrast, recent transfusion, older age, knowledge of HIV screening of blood for transfusion, faith in God and having a critically ill child were associated with less fear about transfusion. Respondents also emphasised challenges to transfusion services access including distance to hospitals, scarcity of blood and health workers' attitudes.

CONCLUSION

Perceptions of the community and caregivers of transfused children in Uganda about blood transfusion were complex: transfusion is considered life-saving but there were strong perceived transfusion risks of HIV transmission and blood incompatibility. Addressing community perceptions and facilitating access to blood transfusion represent important strategies to improve paediatric transfusion care.

Strengthening of Surveillance during Monkeypox Outbreak, Republic of the Congo, 2017

Reports of 10 suspected cases of monkeypox in Likouala Department, Republic of the Congo, triggered an investigation and response in March 2017 that included community education and surveillance strengthening. Increasing numbers of outbreaks suggest that monkeypox virus is becoming a more prevalent human pathogen. Diverse approaches are necessary for disease control and prevention.

Worth the Risk? Muddled Relationships in Community-Based Participatory Research

Community-based participatory research (CBPR) is a collaborative research approach that has two purposes: (a) to generate knowledge about and (b) to take action to improve the lives of people facing health, social, economic, political, and environmental inequities. The foundation of all CBPR projects is its partnership--its cooperative relationship between community members, service providers, program planners, policy makers, and academics. It is with people--and through relationships--that partnerships are built and sustained. Although relationships between academics and community members are critical to creating knowledge and change, they are overlooked in the literature. We often hear about CBPR "gone wrong," when tensions and conflicts arise because relationship boundaries become blurred. Our purpose is to expose the muddled relationships that can be created between academics and community members in CBPR projects. Drawing upon our experiences presented in a series of vignettes, we consider the nature of these relationships. We explore whether we conduct, in CBPR, good research at the expense of muddling relationships. Despite the potential for muddled relationships, we believe that CBPR is the best approach for research aimed at achieving a more equitable and just society.

Inducible clindamycin resistance and nasal carriage rates of Staphylococcus aureus among healthcare workers and community members

BACKGROUND

Nasal carriage of Staphylococcus aureus is becoming an increasing problem among healthcare workers and community individuals.

OBJECTIVES

To determine the prevalence of methicillin-resistant S. aureus (MRSA) nasal colonization and inducible clindamycin resistance (ICR) of S. aureus among healthcare workers at Soba University Hospital and community members in Khartoum State, Sudan.

METHODS

Five hundred nasal swabs samples were collected during March 2009 to April 2010. Isolates were identified using conventional laboratory assays and MRSA determined by the disk diffusion method. The D-test was performed for detection of ICR isolates with Clinical Laboratory Standard Institute guidelines.

RESULTS

Of the 114 S. aureus isolated, 20.2% represented MRSA. The occurrence of MRSA was significantly higher among healthcare worker than community individuals [32.7% (18/55) vs. 6.9% (5/59)] (p=0.001). Overall the 114 S. aureus isolates tested for ICR by D-test, 29 (25.4%) yielded inducible resistance. Significantly higher (p=0.026) ICR was detected among MRSA (43.5%) than methicillin-susceptible S. aureus (MSSA) (20.9%).

CONCLUSION

MRSA nasal carriage among healthcare workers needs infection control practice in hospitals to prevent transmission of MRSA. The occurrence of ICR in S. aureus is of a great concern, D- test should be carried out routinely in our hospitals to avoid therapeutic failure.

Assessment of HIV-related stigma in a US faith-based HIV education and testing intervention

INTRODUCTION

The African American church is a highly influential institution with the potential to greatly increase the reach of HIV prevention interventions and address HIV-related stigma in US African American communities. However, there are few studies on HIV-related stigma and African American church populations. This study explored HIV-related stigma among church and community members participating in an HIV education and testing intervention pilot study in African American churches, named Taking It to the Pews.

METHODS

Four African American churches located in Kansas City, MO and KS, were randomized to either intervention or comparison groups. Churches assigned to the intervention group received religiously tailored HIV education, testing and compassion messages/activities (e.g. sermons, brochures/church bulletins, testimonials) via the Taking It to the Pews HIV Tool Kit. Comparison churches received non-religiously tailored HIV information. HIV-related stigma was assessed with 543 church members and with community members served through church outreach services (e.g. food/clothing pantries, social services) in the four churches. Participants completed surveys at baseline, 6 months and 12 months to assess their HIV-related stigma beliefs, exposure to intervention components and satisfaction with the study.

RESULTS

At baseline, HIV-related stigma beliefs were similar across experimental groups and were quite low. Mean HIV-related stigma scores were not significantly different between experimental groups at 6 months (p=0.92) or at 12 months (p=0.70). However, mean HIV-related stigma scores within both groups showed decreasing trends at six months, which approached significance. Analysis of previously studied HIV-related stigma factors (e.g. age, gender, income, HIV knowledge, religiosity) did not yield changes in the null findings. Intervention group participants were highly exposed to several intervention components (sermons, HIV resource tables, posters, brochures/church bulletins). Overall, participants were highly satisfied with the intervention pilot study.

CONCLUSIONS

African American churches may be well positioned to increase the reach of HIV prevention interventions to church and community members and could serve an important role in addressing HIV-related stigma in their church communities. Future research is needed on measuring HIV-related stigma beliefs and on testing intensive, scalable, religiously tailored HIV interventions to impact HIV-related stigma in African American churches.

The pathway of obstructed labour as perceived by communities in south-western Uganda: a grounded theory study

BACKGROUND

Obstructed labour is still a major cause of maternal and perinatal morbidity and mortality in Uganda, where many women give birth at home alone or assisted by non-skilled birth attendants. Little is known of how the community view obstructed labour, and what actions they take in cases where this complication occurs.

OBJECTIVE

The objective of the study was to explore community members' understanding of and actions taken in cases of obstructed labour in south-western Uganda.

DESIGN

Grounded theory (GT) was used to analyse data from 20 focus group discussions (FGDs), 10 with women and 10 with men, which were conducted in eight rural and two urban communities.

RESULTS

A conceptual model based on the community members' understanding of obstructed labour and actions taken in response is presented as a pathway initiated by women's desire to 'protecting own integrity' (core category). The pathway consisted of six other categories closely linked to the core category, namely: (1) 'taking control of own birth process'; (2) 'reaching the limit--failing to give birth' (individual level); (3) 'exhausting traditional options'; (4) 'partner taking charge'; (5) 'facing challenging referral conditions' (community level); and finally (6) 'enduring a non-responsive healthcare system' (healthcare system level).

CONCLUSIONS

There is a need to understand and acknowledge women's reluctance to involve others during childbirth. However, the healthcare system should provide acceptable care and a functional referral system closer to the community, thus supporting the community's ability to seek timely care as a response to obstructed labour. Easy access to mobile phones may improve referral systems. Upgrading of infrastructure in the region requires a multi-sectoral approach. Testing of the conceptual model through a quantitative questionnaire is recommended.