Improved postpartum care after a participatory facilitation intervention in Dar es Salaam, Tanzania: a mixed method evaluation

Background: In order to improve the health and survival of mothers/newborns, the quality and attendance rates of postpartum care (PPC) must be increased, particularly in low-resource settings. Objective: To describe outcomes of a collegial facilitation intervention to improve PPC in government-owned health institutions in a low-resource suburb in Dar es Salaam, Tanzania. Methods: A before-and-after evaluation of an intervention and comparison group was conducted using mixed methods (focus group discussions, questionnaires, observations, interviews, and field-notes) at health institutions. Maternal and child health aiders, enrolled nurse midwives, registered nurse midwives, and medical and clinical officers participated. A collegial facilitation intervention was conducted and healthcare providers were organized in teams to improve PPC at their workplaces. Facilitators defined areas of improvement with colleagues and met regularly with a supervisor for support. Results: The number of mothers visiting the institution for PPC increased in the intervention group. Some care actions were noted in more than 80% of the observations and mothers reported high satisfaction with care. In the comparison group, PPC continued to be next to non-existent. The healthcare providers’ knowledge increased in both groups but was higher in the intervention group. The t-test showed a significant difference in knowledge between the intervention and comparison groups and between before and after the intervention in both groups. The difference of differences for knowledge was 1.3. The providers perceived the intervention outcomes to include growing professional confidence/knowledge, improved PPC quality, and mothers’ positive response. The quality grading was based on the national guidelines and involved nine experts and showed that none of the providers reached the level of good quality of care. Conclusions: The participatory facilitation intervention contributed to improved quality of PPC, healthcare providers’ knowledge and professional confidence, awareness of PPC among mothers, and increased PPC attendance

The Nicaraguan Health and Demographic Surveillance Site, HDSS-Leon: a platform for public health research.

AIM: To describe the Health and Demographic Surveillance System (HDSS) in León, Nicaragua and to present results from the 2002-2003 baseline. DESIGN AND METHODS: A 22% sample of the total population in León, both urban and rural, was selected in 1993. This sample was updated in 2002 and will be followed up on a biannual basis with regard to births, deaths, in-migration, and out-migration. A group of 18 female fieldworkers perform 10 household interviews per day, 20 days per month. They use a map that is produced by a Geographical Information System. It shows all the households, and is the main means of the interviewers finding the households. An extensive data quality control system is used. RESULTS: In total, 54,647 persons lived in the area of the surveillance system, and they resided in 10,994 households. The mean age was 26 years; the sex ratio was 0.93. The infant and neonatal mortality rates were 25.4 and 20.5 per 1,000 live births, respectively. In total, 2,034 people out-migrated from the study area and 3,377 in-migrated. Of the households, 53% were classified as non-poor, 41% as poor, and 6% as extremely poor. Six per cent of the population did not have a toilet or a latrine, and only 16% in the rural area had indoor running water. The surveillance system revealed that 10% were illiterate. CONCLUSIONS: The HDSS in León has shown that it can serve as a platform for further intervention studies as well as for research training

Geographical accessibility and spatial coverage modeling of the primary health care network in the Western Province of Rwanda.

BACKGROUND: Primary health care is essential in improving and maintaining the health of populations. It has the potential to accelerate achievement of the Millennium Development Goals and fulfill the "Health for All" doctrine of the Alma-Ata Declaration. Understanding the performance of the health system from a geographic perspective is important for improved health planning and evidence-based policy development. The aims of this study were to measure geographical accessibility, model spatial coverage of the existing primary health facility network, estimate the number of primary health facilities working under capacity and the population underserved in the Western Province of Rwanda. METHODS: This study uses health facility, population and ancillary data for the Western Province of Rwanda. Three different travel scenarios utilized by the population to attend the nearest primary health facility were defined with a maximum travelling time of 60 minutes: Scenario 1--walking; Scenario 2--walking and cycling; and Scenario 3--walking and public transportation. Considering these scenarios, a raster surface of travel time between primary health facilities and population was developed. To model spatial coverage and estimate the number of primary health facilities working under capacity, the catchment area of each facility was calculated by taking into account population coverage capacity, the population distribution, the terrain topography and the travelling modes through the different land categories. RESULTS: Scenario 2 (walking and cycling) has the highest degree of geographical accessibility followed by Scenario 3 (walking and public transportation). The lowest level of accessibility can be observed in Scenario 1 (walking). The total population covered differs depending on the type of travel scenario. The existing primary health facility network covers only 26.6% of the population in Scenario 1. In Scenario 2, the use of a bicycle greatly increases the population being served to 58% of inhabitants. When considering Scenario 3, the total population served is 34.3%. CONCLUSIONS: Significant spatial variations in geographical accessibility and spatial coverage were observed across the three travel scenarios. The analysis demonstrates that regardless of which travel scenario is used, the majority of the population in the Western Province does not have access to the existing primary health facility network. Our findings also demonstrate the usefulness of GIS methods to leverage multiple datasets from different sources in a spatial framework to provide support to evidence-based planning and resource allocation decision-making in developing countries

Breaking the cycles of poverty: Strategies, achievements, and lessons learned in Los Cuatro Santos, Nicaragua, 1990-2014.

BACKGROUND: In a post-war frontier area in north-western Nicaragua that was severely hit by Hurricane Mitch in 1998, local stakeholders embarked on and facilitated multi-dimensional development initiatives to break the cycles of poverty. OBJECTIVE: The aim of this paper is to describe the process of priority-setting, and the strategies, guiding principles, activities, achievements, and lessons learned in these local development efforts from 1990 to 2014 in the Cuatro Santos area, Nicaragua. METHODS: Data were derived from project records and a Health and Demographic Surveillance System that was initiated in 2004. The area had 25,893 inhabitants living in 5,966 households in 2014. RESULTS: A participatory process with local stakeholders and community representatives resulted in a long-term strategic plan. Guiding principles were local ownership, political reconciliation, consensus decision-making, social and gender equity, an environmental and public health perspective, and sustainability. Local data were used in workshops with communities to re-prioritise and formulate new goals. The interventions included water and sanitation, house construction, microcredits, environmental protection, school breakfasts, technical training, university scholarships, home gardening, breastfeeding promotion, and maternity waiting homes. During the last decade, the proportion of individuals living in poverty was reduced from 79 to 47%. Primary school enrolment increased from 70 to 98% after the start of the school breakfast program. Under-five mortality was around 50 per 1,000 live births in 1990 and again peaked after Hurricane Mitch and was approaching 20 per 1,000 in 2014. Several of the interventions have been scaled up as national programs. CONCLUSIONS: The lessons learned from the Cuatro Santos initiative underline the importance of a bottom-up approach and local ownership of the development process, the value of local data for monitoring and evaluation, and the need for multi-dimensional local interventions to break the cycles of poverty and gain better health and welfare

Assessing the Multiple Dimensions of Poverty. Data Mining Approaches to the 2004-14 Health and Demographic Surveillance System in Cuatro Santos, Nicaragua.

We identified clusters of multiple dimensions of poverty according to the capability approach theory by applying data mining approaches to the Cuatro Santos Health and Demographic Surveillance database, Nicaragua. Four municipalities in northern Nicaragua constitute the Cuatro Santos area, with 25,893 inhabitants in 5,966 households (2014). A local process analyzing poverty-related problems, prioritizing suggested actions, was initiated in 1997 and generated a community action plan 2002-2015. Interventions were school breakfasts, environmental protection, water and sanitation, preventive healthcare, home gardening, microcredit, technical training, university education stipends, and use of the Internet. In 2004, a survey of basic health and demographic information was performed in the whole population, followed by surveillance updates in 2007, 2009, and 2014 linking households and individuals. Information included the house material (floor, walls) and services (water, sanitation, electricity) as well as demographic data (birth, deaths, migration). Data on participation in interventions, food security, household assets, and women's self-rated health were collected in 2014. A K-means algorithm was used to cluster the household data (56 variables) in six clusters. The poverty ranking of household clusters using the unsatisfied basic needs index variables changed when including variables describing basic capabilities. The households in the fairly rich cluster with assets such as motorbikes and computers were described as modern. Those in the fairly poor cluster, having different degrees of food insecurity, were labeled vulnerable. Poor and poorest clusters of households were traditional, e.g., in using horses for transport. Results displayed a society transforming from traditional to modern, where the forerunners were not the richest but educated, had more working members in household, had fewer children, and were food secure. Those lagging were the poor, traditional, and food insecure. The approach may be useful for an improved understanding of poverty and to direct local policy and interventions

Baseline data from a planned RCT on attitudes to female genital cutting after migration: when are interventions justified?

OBJECTIVES: To present the primary outcomes from a baseline study on attitudes towards female genital cutting (FGC) after migration. DESIGN: Baseline data from a planned cluster randomised, controlled trial. Face-to-face interviews were used to collect questionnaire data in 2015. Based on our hypothesis that established Somalis could be used as facilitators of change among those newly arrived, data were stratified into years of residency in Sweden. SETTING: Sweden. PARTICIPANTS: 372 Somali men and women, 206 newly arrived (0-4 years), 166 established (>4 years). PRIMARY OUTCOME MEASURES: Whether FGC is acceptable, preferred for daughter and should continue, specified on anatomical extent. RESULTS: The support for anatomical change of girls and women's genitals ranged from 0% to 2% among established and from 4% to 8% among newly arrived. Among those supporting no anatomical change, 75%-83% among established and 53%-67% among newly arrived opposed all forms of FGC, with the remaining supporting pricking of the skin with no removal of tissue. Among newly arrived, 37% stated that pricking was acceptable, 39% said they wanted their daughter to be pricked and 26% reported they wanted pricking to continue being practised. Those who had lived in Sweden ≤ 2 years had highest odds of supporting FGC; thereafter, the opposition towards FGC increased over time after migration. CONCLUSION: A majority of Somali immigrants, including those newly arrived, opposed all forms of FGC with increased opposition over time after migration. The majority of proponents of FGC supported pricking. We argue that it would have been unethical to proceed with the intervention as it, with this baseline, would have been difficult to detect a change in attitudes given that a majority opposed all forms of FGC together with the evidence that a strong attitude change is already happening. Therefore, we decided not to implement the planned intervention. TRIAL REGISTRATION NUMBER: Trial registration number NCT02335697;Pre-results

Causes of death among undocumented migrants in Sweden, 1997–2010

Background: Undocumented migrants are one of the most vulnerable groups in Swedish society, where they generally suffer from poor health and limited health care access. Due to their irregular status, such migrants are an under-researched group and are not included in the country's Cause of Death Register (CDR). Objective: To determine the causes of death among undocumented migrants in Sweden and to ascertain whether there are patterns in causes of death that differ between residents and undocumented migrants. Design: This is a cross-sectional study of death certificates issued from 1997 to 2010 but never included in the CDR from which we established our study sample of undocumented migrants. As age adjustments could not be performed due to lack of data, comparisons between residents and undocumented migrants were made at specific age intervals, based on the study sample's mean age at death±a half standard deviation. Results: Out of 7,925 individuals surveyed, 860 were classified as likely to have been undocumented migrants. External causes (49.8%) were the most frequent cause of death, followed by circulatory system diseases, and then neoplasms. Undocumented migrants had a statistically significant increased risk of dying from external causes (odds ratio [OR] 3.57, 95% confidence interval [CI]: 2.83–4.52) and circulatory system diseases (OR 2.20, 95% CI: 1.73–2.82) compared to residents, and a lower risk of dying from neoplasms (OR 0.07, 95% CI: 0.04–0.14). Conclusions: We believe our study is the first to determine national figures on causes of death of undocumented migrants. We found inequity in health as substantial differences in causes of death between undocumented migrants and residents were seen. Legal ambiguities regarding health care provision must be addressed if equity in health is to be achieved in a country otherwise known for its universal health coverage

Improving quality and use of routine health information system data in low- and middle-income countries: A scoping review.

BACKGROUND: A routine health information system is one of the essential components of a health system. Interventions to improve routine health information system data quality and use for decision-making in low- and middle-income countries differ in design, methods, and scope. There have been limited efforts to synthesise the knowledge across the currently available intervention studies. Thus, this scoping review synthesised published results from interventions that aimed at improving data quality and use in routine health information systems in low- and middle-income countries. METHOD: We included articles on intervention studies that aimed to improve data quality and use within routine health information systems in low- and middle-income countries, published in English from January 2008 to February 2020. We searched the literature in the databases Medline/PubMed, Web of Science, Embase, and Global Health. After a meticulous screening, we identified 20 articles on data quality and 16 on data use. We prepared and presented the results as a narrative. RESULTS: Most of the studies were from Sub-Saharan Africa and designed as case studies. Interventions enhancing the quality of data targeted health facilities and staff within districts, and district health managers for improved data use. Combinations of technology enhancement along with capacity building activities, and data quality assessment and feedback system were found useful in improving data quality. Interventions facilitating data availability combined with technology enhancement increased the use of data for planning. CONCLUSION: The studies in this scoping review showed that a combination of interventions, addressing both behavioural and technical factors, improved data quality and use. Interventions addressing organisational factors were non-existent, but these factors were reported to pose challenges to the implementation and performance of reported interventions

Food insecurity and self-rated health in rural Nicaraguan women of reproductive age: a cross-sectional study.

BACKGROUND: Access to food is a basic necessity, and food insecurity may impair the individual's well-being and health. Self-rated health measurements have frequently been used to assess population health. Little is known, however, as to whether food security is associated with self-rated health in low- and middle-income settings. This study aims at analyzing the association between food security and self-rated health among non-pregnant women of reproductive age in a rural Nicaraguan setting. METHODS: Data was taken from the 2014 update of a health and demographic surveillance system in the municipalities of Los Cuatro Santos in northwestern Nicaragua. Fieldworkers interviewed women about their self-rated health using a 5-point Likert scale. Food insecurity was assessed by the household food insecurity access (HFIAS) scale. A multilevel Poisson random-intercept model was used to calculate the prevalence ratio. RESULTS: The survey included 5866 women. In total, 89% were food insecure, and 48% had poor self-rated health. Food insecurity was associated with poor self-rated health, and remained so after adjustment for potential confounders and accounting for community dependency. CONCLUSION: In this Nicaraguan resource-limited setting, there was an association between food insecurity and poor self-rated health. Food insecurity is a facet of poverty and measures an important missing capability directly related to health

Afghan migrants face more suboptimal care than natives: a maternal near-miss audit study at university hospitals in Tehran, Iran.

BACKGROUND: Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM. METHODS: An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined. RESULTS: Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient- (31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM. CONCLUSIONS: Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes