Exploring health stakeholders' perceptions on moving towards comprehensive primary health care to address childhood malnutrition in Iran: a qualitative study

<p>Abstract</p> <p>Background</p> <p>Due to the multifaceted aspect of child malnutrition, a comprehensive approach, taking social factors into account, has been frequently recommended in health literature. The Alma-Ata declaration explicitly outlined comprehensive primary health care as an approach that addresses the social, economic and political causes of poor health and nutrition.</p> <p>Iran as a signatory country to the Alma Ata Declaration has established primary health care since 1979 with significant progress on many health indicators during the last three decades. However, the primary health care system is still challenged to reduce inequity in conditions such as child malnutrition which trace back to social factors. This study aimed to explore the perceptions of the Iranian health stakeholders with respect to the Iranian primary health care performance and actions to move towards a comprehensive approach in addressing childhood malnutrition. Health stakeholders are defined as those who affect or can be affected by health system, for example health policy-makers, health providers or health service recipients.</p> <p>Methods</p> <p>Stakeholder analysis approach was undertaken using a qualitative research method. Different levels of stakeholders, including health policy-makers, health providers and community members were interviewed as either individuals or focus groups. Qualitative content analysis was used to interpret and compare/contrast the viewpoints of the study participants.</p> <p>Results</p> <p>The results demonstrated that fundamental differences exist in the perceptions of different health stakeholders in the understanding of comprehensive notion and action. Health policy-makers mainly believed in the need for a secure health management environment and the necessity for a whole of the government approach to enhance collaborative action. Community health workers, on the other hand, indicated that staff motivation, advocacy and involvement are the main challenges need to be addressed. Turning to community stakeholders, greater emphasis has been placed on community capabilities, informal link with other social sectors based on trust and local initiatives.</p> <p>Conclusion</p> <p>This research provided a picture of the differences in the perceptions and values of different stakeholders with respect to primary health care concepts. The study suggests that a top-down approach, which still exists among health policy-makers, is a key obstacle that delays, and possibly worse, undermines the implementation of the comprehensive strategy codified by the Alma-Ata Declaration. A need to revitalise primary health care to use its full potential and to combine top-down and bottom-up approaches by narrowing the gap between perceptions of policy makers and those who provide and receive health-related services is crucial.</p

Using remotely sensed night-time light as a proxy for poverty in Africa

BACKGROUND: Population health is linked closely to poverty. To assess the effectiveness of health interventions it is critical to monitor the spatial and temporal changes in the health indicators of populations and outcomes across varying levels of poverty. Existing measures of poverty based on income, consumption or assets are difficult to compare across geographic settings and are expensive to construct. Remotely sensed data on artificial night time lights (NTL) have been shown to correlate with gross domestic product in developed countries. METHODS: Using national household survey data, principal component analysis was used to compute asset-based poverty indices from aggregated household asset variables at the Administrative 1 level (n = 338) in 37 countries in Africa. Using geographical information systems, mean brightness of and distance to NTL pixels and proportion of area covered by NTL were computed for each Administrative1 polygon. Correlations and agreement of asset-based indices and the three NTL metrics were then examined in both continuous and ordinal forms. RESULTS: At the Administrative 1 level all the NTL metrics distinguished between the most poor and least poor quintiles with greater precision compared to intermediate quintiles. The mean brightness of NTL, however, had the highest correlation coefficient with the asset-based wealth index in continuous (Pearson correlation = 0.64, p &lt; 0.01) and ordinal (Spearman correlation = 0.79, p &lt; 0.01; Kappa = 0.64) forms. CONCLUSION: Metrics of the brightness of NTL data offer a robust and inexpensive alternative to asset-based poverty indices derived from survey data at the Administrative 1 level in Africa. These could be used to explore economic inequity in health outcomes and access to health interventions at sub-national levels where household assets data are not available at the required resolution

Women-focused development intervention reduces delays in accessing emergency obstetric care in urban slums in Bangladesh: a cross-sectional study

<p>Abstract</p> <p>Background</p> <p>Recognizing the burden of maternal mortality in urban slums, in 2007 BRAC (formally known as Bangladesh Rural Advancement Committee) has established a woman-focused development intervention, Manoshi (the Bangla abbreviation of mother, neonate and child), in urban slums of Bangladesh. The intervention emphasizes strengthening the continuum of maternal, newborn and child care through community, delivery centre (DC) and timely referral of the obstetric complications to the emergency obstetric care (EmOC) facilities. This study aimed to assess whether Manoshi DCs reduces delays in accessing EmOC.</p> <p>Methods</p> <p>This cross-sectional study was conducted during October 2008 to January 2009 in the slums of Dhaka city among 450 obstetric complicated cases referred either from DCs of Manoshi or from their home to the EmOC facilities. Trained female interviewers interviewed at their homestead with structured questionnaire. <it>Pearson's </it>chi-square test, <it>t</it>-test and Mann-Whitney test were performed.</p> <p>Results</p> <p>The median time for making the decision to seek care was significantly longer among women who were referred from home than referred from DCs (9.7 hours vs. 5.0 hours, p < 0.001). The median time to reach a facility and to receive treatment was found to be similar in both groups. Time taken to decide to seek care was significantly shorter in the case of life-threatening complications among those who were referred from DC than home (0.9 hours vs.2.3 hours, p = 0.002). Financial assistance from Manoshi significantly reduced the first delay in accessing EmOC services for life-threatening complications referred from DC (p = 0.006). Reasons for first delay include fear of medical intervention, inability to judge maternal condition, traditional beliefs and financial constraints. Role of gender was found to be an important issue in decision making. First delay was significantly higher among elderly women, multiparity, non life-threatening complications and who were not involved in income-generating activities.</p> <p>Conclusions</p> <p>Manoshi program reduces the first delay for life-threatening conditions but not non-life-threatening complications even though providing financial assistance. Programme should give more emphasis on raising awareness through couple/family-based education about maternal complications and dispel fear of clinical care to accelerate seeking EmOC.</p

Descending the sanitation ladder in urban Uganda: evidence from Kampala Slums

BACKGROUND: While the sanitation ladder is useful in analysing progressive improvements in sanitation, studies in Uganda have not indicated the sanitation barriers faced by the urban poor. There are various challenges in shared latrine use, cleaning and maintenance. Results from Kampala city indicate that, failure to clean and maintain sanitation infrastructure can lead to a reversal of the potential benefits that come with various sanitation facilities. METHODS: A cross sectional qualitative study was conducted between March and May 2013. Data were collected through 18 focus group discussions (FGDs) held separately; one with women, men and youth respectively. We also used pictorial methods; in addition, 16 key informant interviews were conducted. Data were analysed using content thematic approach. Relevant quotations per thematic area were identified and have been used in the presentation of the results. RESULTS: Whether a shared sanitation facility was improved or not, it was abandoned once it was not properly used and cleaned. The problem of using shared latrines began with the lack of proper latrine training when people do not know how to squat on the latrine hole. The constrained access and security concerns, obscure paths that were filthy especially at night, lack of light in the latrine cubicle, raised latrines sometimes up to two metres above the ground, coupled with lack of cleaning and emptying the shared facilities only made a bad situation worse. In this way, open defecation gradually substituted use of the available sanitation facilities. This paper argues that, filthy latrines have the same net effect as crude open defection. CONCLUSION: Whereas most sanitation campaigns are geared towards provision of improved sanitation infrastructure, these findings show that mere provision of infrastructure (improved or not) without adequate emphasis on proper use, cleaning and maintenance triggers an involuntary descent off the sanitation ladder. Understanding this reversal movement is critical in sustainable sanitation services and should be a concern for all actors