Married women's decision making power on modern contraceptive use in urban and rural southern Ethiopia

<p>Abstract</p> <p>Background</p> <p>Women in developing countries are either under collective decision making with their partners or completely rely on the male partner's decision on issues that affect their reproductive live. Identifying the major barriers of married women's decision making power on contraceptive use has significant relevance for planning contextually appropriate family planning interventions. The objective of this study was to determine current modern contraceptive practices and decision making power among married women in Tercha Town and surrounding rural areas of Dawro zone, Southern Ethiopia.</p> <p>Methods</p> <p>Community based comparative cross-sectional design with both quantitative and Qualitative study has been employed in March and April 2010. The respondents were 699 married women of child bearing age from urban and rural parts of Dawro zone. After conducting census, we took the sample using simple random sampling technique.</p> <p>Results</p> <p>Current modern contraceptive use among married women in the urban was 293 (87.5%) and 243 (72.8%) in rural. Married women who reside in urban area were more likely to decide on the use of modern contraceptive method than rural women. Having better knowledge about modern contraceptive methods, gender equitable attitude, better involvement in decisions related to children, socio-cultural and family relations were statistically significant factors for decision making power of women on the use of modern contraceptive methods in the urban setting. Better knowledge, fear of partner's opposition or negligence, involvement in decisions about child and economic affairs were statistically significant factors for better decision making power of women on the use of modern contraceptive methods in the rural part.</p> <p>Conclusions</p> <p>High level of current modern contraceptive practice with reduced urban-rural difference was found as compared to regional and national figures. Urban women had better power to make decisions on modern contraceptive than rural women. Modern family planning interventions in the area should be promoted by considering empowering of women on modern contraceptive use decision making.</p

Digital Targeted Client Communication for Effective Coverage of Antenatal Care : Assessment, Development, and Evaluation

The effective provision of essential interventions in antenatal care (ANC) is crucial for a positive pregnancy experience. However, the effective coverage of essential interventions in ANC is often low, even in settings where there is high coverage of ANC visits. Untimely use, and low quality, of services are both important factors that contribute to low effective coverage. Digital health interventions are often moderately effective in improving the timeliness of attendance to ANC. The interventions with high effectiveness are often those that are individually tailored, theory based, and co-designed with the end users. Most research reports have focused on evaluating effectiveness, while the design, development, and implementation of such digital health interventions have been a “black box”. This limits the possibility to replicate interventions that proved to be effective, which ultimately results in a waste of research resources. Digital health interventions that aim to change the behavior of end users, such as targeted client communication (TCC), need to be carefully designed to maximize effectiveness and minimize any unintended consequences. This can be achieved through underpinning the design on relevant behavior change theories; careful assessment of the context; co-creating the content, frequency, and mode of the intervention; and iteratively testing and improving the final intervention. To ensure that the finalized intervention results in the intended effects, both effectiveness and any potential unintended consequences should be estimated using robust study designs such as randomized controlled trials. In this thesis, we present the approaches we took to develop an acceptable and safe automated digital TCC intervention and to test its potential unintended consequences in a cluster randomized controlled trial. The effectiveness of the digital TCC intervention is not included in this thesis. This thesis is part of a larger project that combines a national implementation of a digital maternal and child health registry in Palestine (called MCH eRegistry) with several effectiveness trials of digital health interventions. We have used both quantitative and qualitative research methods. We started by identifying the gaps in effective coverage and worked with stakeholders to identify and target contextually relevant essential interventions. A national expert panel identified anemia, hypertensive disorders of pregnancy, diabetes mellitus, fetal growth restriction, and untimeliness of attendance to the routine visits as a priority – in this thesis simply referred to as “the target conditions”. Quantifying the coverage and effective coverage of the essential interventions informed the nature and goal of the digital health intervention – the digital TCC. Understanding the perceptions of women and the healthcare providers was essential towards developing the digital intervention. This was conducted using in-depth interviews guided by a theory. The content of the TCC was developed in an iterative process based on the results of the in-depth interviews, recommended message framing approaches, and feedback from users and other stakeholders. We used concepts and models proven to be helpful in guiding the process of choosing the right words, which are simple to understand, culturally acceptable, and effectively convey the intended messages without increasing worries in pregnancy. We developed algorithms in the digital MCH eRegistry to tailor messages automatically to individual women based on selected variables. Finally, we evaluated any unintended effects of the TCC intervention, such as an increase in pregnancy-related worries (measured by the Cambridge Worry Scale) or reduced satisfaction with ANC services, in a cluster randomized controlled trial. In public primary healthcare clinics in Palestine, we found that 60% of women attended four or more ANC visits and the majority of women started their first visit early. Coverage of at least one screening test of the target conditions was high, but the effective coverage was low. The main contributing factor for the low effective coverage was that the pregnant women did not attend care in a timely manner. We identified three constructs of the Health Belief Model (HBM) that were important in understanding the patterns of ANC attendance. The contents of the intervention, therefore, focused on influencing women’s perceptions of the risks and seriousness (perceived susceptibility and severity) of the target conditions and the benefits of timely ANC attendance. Through the iterative process of co-designing, testing, and refining using tools and methodologies for composing behavior change communication messages, we designed a digital TCC intervention considered acceptable by pregnant women, healthcare providers, and health education experts in Palestine. The TCC, which contained information about the risks of exposure and complications, did not increase pregnancy-related worries among the recipients of the intervention compared to the controls. The women were equally and highly satisfied with the ANC they received in both intervention and control arms. This work contributes to the rapidly growing field of design and implementation of digital health interventions for maternal and child health and beyond. It adds to the limited literature on the scientific development process of TCC, and estimations of potential side-effects using robust study designs. Demonstrating the application of automated digital TCC to women using routine data from the MCH eRegistry, without adding burden to the healthcare providers, can further improve the investment returns of such digital health registries

Intention to use electronic medical record and its predictors among health care providers at referral hospitals, north-West Ethiopia, 2019: using unified theory of acceptance and use technology 2(UTAUT2) model

Background: Electronic Medical Records (EMRs) are systems to store patient information like medical histories, test results, and medications electronically. It helps to give quality service by improving data handling and communication in healthcare setting. EMR implementation in developing countries is increasing exponentially. But, only few of them are successfully implemented. Intention to use EMRs by health care provider is crucial for successful implementation and adoption of EMRs. However, intention of health care providers to use EMR in Ethiopia is unknown. Objective: The aim of this study was to assess health care provider’s intention to use and its predictors towards Electronic Medical Record systems at three referral hospitals in north-west, Ethiopia, 2019. Methods: Institutional based cross-sectional explanatory study design was conducted from March to September among 420 health care providers working at three referral hospitals in north-west Ethiopia. Data were analyzed using structural equation model (SEM). Simple and multiple SEM were used to assess the determinants of health care providers intention to use EMRs. Critical ratio and standardized coefficients were used to measure the association of dependent and independent variables, 95% confidence intervals and P-value were calculated to evaluate statistical significance. Qualitative data was analyzed using thematic analysis. Result: The mean age of the study subjects was 32.4 years ±8.3 SD. More than two-third 293(69.8%) of the participants were male. Among 420 health care providers, only 167 (39.8%) were scored above the mean of intention to use EMRs. Factors positively associated with intention to use EMRs were performance expectancy (β = 0.39, p < 0.001), effort expectancy (β = 0.24,p < 0.001),social influence (β = 0.18,p < 0.001),facilitating condition (β = 0.23,p < 0.001), and computer literacy (β = 0.08,p < 0.001). Performance expectancy was highly associated with intention to use EMRs. Conclusion: Generally, about 40 % of health care providers were scored above the mean of intention to use EMRs. Performance expectancy played a major role in determining health care providers’ intention to use EMRs. The intention of health care providers to use EMRs was attributed by social influence, facilitating condition in the organization, effort expectancy, performance expectancy and computer literacy. Therefore, identifying necessary prerequisites before the actual implementation of EMRs will help to improve the implementation status

Effective coverage of essential antenatal care interventions: A cross-sectional study of public primary healthcare clinics in the West Bank.

BackgroundThe proportion of women attending four or more antenatal care (ANC) visits is widely used for monitoring, but provides limited information on quality of care. Effective coverage metrics, assessing if ANC interventions are completely delivered, can identify critical gaps in healthcare service delivery. We aimed to measure coverage of at least one screening and effective coverage of ANC interventions in the public health system in the West Bank, Palestine, and to explore associations between infrastructure-related and maternal sociodemographic variables and effective coverage.MethodsWe used data from paper-based clinical records of 1369 pregnant women attending ANC in 17 primary healthcare clinics. Infrastructure-related variables were derived from a 2014 national inventory assessment of clinics. Sample size calculations were made to detect effective coverage ranging 40-60% with a 2-3% margin of error, clinics were selected by probability sampling. We calculated inverse probability weighted percentages of: effective coverage of appropriate number and timing of screenings of ANC interventions; and coverage of at least one screening.ResultsCoverage of one screening and effective coverage of ANC interventions were notably different for screening for: hypertension (98% vs. 10%); fetal growth abnormalities (66% vs. 6%); anemia (93% vs. 14%); gestational diabetes (93% vs. 34%), and antenatal ultrasound (74% vs. 24%). Clinics with a laboratory and ultrasound generally performed better in terms of effective coverage, and maternal sociodemographic factors had no associations with effective coverage estimates. Only 13% of the women attended ANC visits according to the recommended national schedule, driving effective coverage down.ConclusionIndicators for ANC monitoring and their definitions can have important consequences for quantifying health system performance and identifying issues with care provision. To achieve more effective coverage in public primary care clinics in the West Bank, efforts should be made to improve care provision according to prescribed guidelines

Effective coverage of essential antenatal care interventions: A cross-sectional study of public primary healthcare clinics in the West Bank

BackgroundThe proportion of women attending four or more antenatal care (ANC) visits is widely used for monitoring, but provides limited information on quality of care. Effective coverage metrics, assessing if ANC interventions are completely delivered, can identify critical gaps in healthcare service delivery. We aimed to measure coverage of at least one screening and effective coverage of ANC interventions in the public health system in the West Bank, Palestine, and to explore associations between infrastructure-related and maternal sociodemographic variables and effective coverage.MethodsWe used data from paper-based clinical records of 1369 pregnant women attending ANC in 17 primary healthcare clinics. Infrastructure-related variables were derived from a 2014 national inventory assessment of clinics. Sample size calculations were made to detect effective coverage ranging 40–60% with a 2–3% margin of error, clinics were selected by probability sampling. We calculated inverse probability weighted percentages of: effective coverage of appropriate number and timing of screenings of ANC interventions; and coverage of at least one screening.ResultsCoverage of one screening and effective coverage of ANC interventions were notably different for screening for: hypertension (98% vs. 10%); fetal growth abnormalities (66% vs. 6%); anemia (93% vs. 14%); gestational diabetes (93% vs. 34%), and antenatal ultrasound (74% vs. 24%). Clinics with a laboratory and ultrasound generally performed better in terms of effective coverage, and maternal sociodemographic factors had no associations with effective coverage estimates. Only 13% of the women attended ANC visits according to the recommended national schedule, driving effective coverage down.ConclusionIndicators for ANC monitoring and their definitions can have important consequences for quantifying health system performance and identifying issues with care provision. To achieve more effective coverage in public primary care clinics in the West Bank, efforts should be made to improve care provision according to prescribed guidelines.</div

Development of a targeted client communication intervention to women using an electronic maternal and child health registry: a qualitative study

Background Targeted client communication (TCC) using text messages can inform, motivate and remind pregnant and postpartum women of timely utilization of care. The mixed results of the effectiveness of TCC interventions points to the importance of theory based interventions that are co-design with users. The aim of this paper is to describe the planning, development, and evaluation of a theory led TCC intervention, tailored to pregnant and postpartum women and automated from the Palestinian electronic maternal and child health registry. Methods We used the Health Belief Model to develop interview guides to explore women’s perceptions of antenatal care (ANC), with a focus on high-risk pregnancy conditions (anemia, hypertensive disorders in pregnancy, gestational diabetes mellitus, and fetal growth restriction), and untimely ANC attendance, issues predefined by a national expert panel as being of high interest. We performed 18 in-depth interviews with women, and eight with healthcare providers in public primary healthcare clinics in the West Bank and Gaza. Grounding on the results of the in-depth interviews, we used concepts from the Model of Actionable Feedback, social nudging and Enhanced Active Choice to compose the TCC content to be sent as text messages. We assessed the acceptability and understandability of the draft text messages through unstructured interviews with local health promotion experts, healthcare providers, and pregnant women. Results We found low awareness of the importance of timely attendance to ANC, and the benefits of ANC for pregnancy outcomes. We identified knowledge gaps and beliefs in the domains of low awareness of susceptibility to, and severity of, anemia, hypertension, and diabetes complications in pregnancy. To increase the utilization of ANC and bridge the identified gaps, we iteratively composed actionable text messages with users, using recommended message framing models. We developed algorithms to trigger tailored text messages with higher intensity for women with a higher risk profile documented in the electronic health registry. Conclusions We developed an optimized TCC intervention underpinned by behavior change theory and concepts, and co-designed with users following an iterative process. The electronic maternal and child health registry can serve as a unique platform for TCC interventions using text messages

The effect of a digital targeted client communication intervention on pregnant women’s worries and satisfaction with antenatal care in Palestine–A cluster randomized controlled trial

Background: The eRegCom cluster randomized controlled trial assesses the effectiveness of targeted client communication (TCC) via short message service (SMS) to pregnant women, from a digital maternal and child health registry (eRegistry) in Palestine, on improving attendance and quality of care. In this paper, we assess whether this TCC intervention could also have unintended consequences on pregnant women’s worries, and their satisfaction with antenatal care (ANC). Methods: We interviewed a sub-sample of Arabic-speaking women attending ANC at public primary healthcare clinics, randomized to either the TCC intervention or no TCC (control) in the eRegCom trial, who were in 38 weeks of gestation and had a phone number registered in the eRegistry. Trained female data collectors interviewed women by phone from 67 intervention and 64 control clusters, after securing informed oral consent. The Arabic interview guide, pilot-tested prior to the data collection, included close-ended questions to capture the woman’s socio-demographic status, agreement questions about their satisfaction with ANC services, and the 13-item Cambridge Worry Scale (CWS). We employed a non-inferiority study design and an intention-to-treat analysis approach. Results: A total of 454 women, 239 from the TCC intervention and 215 from the control arm participated in this sub-study. The mean and standard deviation of the CWS were 1.8 (1.9) for the intervention and 2.0 (1.9) for the control arm. The difference in mean between the intervention and control arms was -0.16 (95% CI: -0.31 to -0.01) after adjusting for clustering, which was below the predefined non-inferiority margin of 0.3. Women in both groups were equally satisfied with the ANC services they received. Conclusion: The TCC intervention via SMS did not increase pregnancy-related worries among recipients. There was no difference in women’s satisfaction with the ANC services between intervention and control arms