Our voices matter : a before-after assessment of the effect of a community-participatory intervention to promote uptake of maternal and child health services in Kwale, Kenya.

Background: Community-participatory approaches are important for effective maternal and child health interventions. A community-participatory intervention (the Dialogue Model) was implemented in Kwale County, Kenya to enhance uptake of select maternal and child health services among women of reproductive age. Methods: Community volunteers were trained to facilitate Dialogue Model sessions in community units associated with intervention health facilities in Matuga, Kwale. Selection of intervention facilities was purposive based on those that had an active community unit in existence. For each facility, uptake of family planning, antenatal care and facility-based delivery as reported in the District Health Information System (DHIS)-2 was compared pre- (October 2012 – September 2013) versus post- (January – December 2016) intervention implementation using a paired sample t-test. Results: Between October 2013 and December 2015, a total of 570 Dialogue Model sessions were held in 12 community units associated with 10 intervention facilities. The median [interquartile range (IQR)] number of sessions per month per facility was 2 (1–3). Overall, these facilities reported 15, 2 and 74% increase in uptake of family planning, antenatal care and facility-based deliveries, respectively. This was statistically significant for family planning pre- (Mean (M) = 1014; Standard deviation (SD) = 381) versus post- (M = 1163; SD = 400); t (18) = − 0.603, P = 0.04) as well as facilitybased deliveries pre- (M = 185; SD = 216) versus post- (M = 323; SD = 384); t (18) = − 0.698, P = 0.03). Conclusions: A structured, community-participatory intervention enhanced uptake of family planning services and facility-based deliveries in a rural Kenyan setting. This approach is useful in addressing demand-side factors by providing communities with a stake in influencing their health outcome

Pattern and determinants of contraceptive usage among women of reproductive age from the Digo community residing in Kwale, Kenya: results from a cross-sectional household survey

Background: Contraceptive usage has been associated with improved maternal and child health (MCH) outcomes. Despite significant resources being allocated to programs, there has been sub-optimal uptake of contraception, especially in the developing world. It is important therefore, to granulate factors that determine uptake and utilization of contraceptive services so as to inform effective programming. Methods: Between March and December 2015, we conducted a cross-sectional survey among women of reproductive age (WRA) from the Digo community residing in Kwale County, Kenya. The study aimed to describe the pattern and determinants of contraceptive usage in this population. Respondents were selected using stratified, systematic sampling and completed a household sexual and reproductive health (SRH) questionnaire. Results: We interviewed 745 respondents from 15 villages in 2 out of 4 sub-counties of Kwale. Their median (interquartile range, IQR) age was 29 (23–37) years. 568 (76%) reported being currently in a marital union. Among these, 308 (54%) were using a contraceptive method. The total unmet need, unmet need for spacing and for limiting was 16%, 8% and 8%, respectively. Determinants of contraceptive usage were education [adjusted Odds Ratio, aOR = 2.1, 95% confidence interval, CI: 1.4–3.4, P = 0.001]; having children [aOR = 5.0, 95% CI: 1.7–15.0, P = 0.004]; having attended antenatal care (ANC) at last delivery [aOR = 4.0, 95% CI: 1.1–14.8, P = 0.04] as well as intention to stop or delay future birth [aOR = 6.7, 95% CI: 3.3–13.8, P \u3c 0.0001]. Conclusions: We found high levels of contraceptive usage among WRA from the Digo community residing in Kwale. To further improve uptake and utilization of contraception in this setting, programs should address demand-side factors including ensuring female educational attainment as well as promotion of ANC and skilled birth attendanc

Religious, socio-cultural norms and gender stereotypes influence uptake and utilization of maternal health services among the Digo community in Kwale, Kenya: a qualitative study

Background: Maternal health outcomes in resource-limited settings are typically influenced by supply-side factors affecting the provision of quality health services. The extent to which demand-side factors contribute to this influence is unclear. We aimed to explore how individual and community-wide factors influenced uptake and utilization of maternal health services among the Digo community residing in Kwale County of coastal Kenya. Methods: Between March and December 2015, we conducted 5 focus group discussions (FGDs) and 15 in-depth interviews (IDIs) with members of the Digo community predominant in Kwale county, Kenya. Respondents were sampled purposively and included female (pregnant and postpartum) as well as male adult community members. A thematic content analytic approach was used. Results: There were a total of 47 FGD respondents, including 15 (32%) females with a median (interquartile, IQR) age of 38 (27-55) years and 6 (3-8) children. Majority (40%) reported attaining secondary-level education. All IDI respondents were female with a median (IQR) age of 27 (24-35) years and 4 (2-5) children. Majority (80%) had attained primary-level education. We found that religious and socio-cultural norms as well as gender stereotypes were important influences on the uptake and utilization of maternal health services, including facility-based delivery and contraception. Key amongst this was the unspoken deference to the counsel of a prominent matriarchal figure in the decision-making process. Conclusions: Among the Digo community of coastal Kenya, a unique social-cultural context comprising of a religious and gendered value belief system influences women\u27s reproductive health and rights. These findings highlight the important role of demand-side factors in influencing maternal health outcomes. In addition to addressing supply-side factors, programs in such settings should aim to address factors that leverage inherent social capital to drive demand for maternal health services ensuring that they are not only effective, but also responsive to the local context

Improving postpartum care delivery and uptake by implementing context-specific interventions in four countries in Africa: a realist evaluation of the Missed Opportunities in Maternal and Infant Health (MOMI) project

Postpartum care (PPC) has remained relatively neglected in many interventions designed to improve maternal and neonatal health in sub-Saharan Africa. The Missed Opportunities in Maternal and Infant Health project developed and implemented a context-specific package of health system strengthening and demand generation in four African countries, aiming to improve access and quality of PPC. A realist evaluation was conducted to enable nuanced understanding of the influence of different contextual factors on both the implementation and impacts of the interventions. Mixed methods were used to collect data and test hypothesised context–mechanism–outcome configurations: 16 case studies (including interviews, observations, monitoring data on key healthcare processes and outcomes), monitoring data for all study health facilities and communities, document analysis and participatory evaluation workshops. After evaluation in individual countries, a cross-country analysis was conducted that led to the development of four middle-range theories. Community health workers (CHWs) were key assets in shifting demand for PPC by ‘bridging’ communities and facilities. Because they were chosen from the community they served, they gained trust from the community and an intrinsic sense of responsibility. Furthermore, if a critical mass of women seek postpartum healthcare as a result of the CHWs bridging function, a ‘buzz’ for change is created, leading eventually to the acceptability and perceived value of attending for PPC that outweighs the costs of attending the health facility. On the supply side, rigid vertical hierarchies and defined roles for health facility workers (HFWs) impede integration of maternal and infant health services. Additionally, HFWs fear being judged negatively which overrides the self-efficacy that could potentially be gained from PPC training. Instead the main driver of HFWs’ motivation to provide comprehensive PPC is dependent on accountability systems for delivering PPC created by other programmes. The realist evaluation offers insights into some of the contextual factors that can be pivotal in enabling the community-level and service-level interventions to be effective

Does the effect of periodic presumptive treatment with oral metronidazole and fluconazole on the incidence of vaginal infections and Lactobacillus colonization depend on baseline vaginal infection status?

Thesis (Master's)--University of Washington, 2013Background: Vaginal infections are common, and associated with adverse health outcomes. Periodic presumptive treatment (PPT) is an effective intervention for preventing these infections. The PPT effect could be improved if it were restricted to women most likely to benefit from it. Methods: We conducted a subgroup analysis of data from a PPT trial in Mombasa, Kenya using Andersen-Gill proportional hazards models with robust variance estimates to assess the effect of the intervention among participants with a baseline vaginal infection versus those without. Results: Of 302 women eligible for analysis, 137 (45%) had one or more vaginal infections at baseline, while 165 (55%) had none. In the subgroup with a baseline vaginal infection, the intervention reduced the risk of incident BV [hazard ratio (HR)=0.55, 95% confidence interval (CI): 0.41-0.76] and increased vaginal colonization with any Lactobacillus species (HR=1.61, 95% CI: 1.01-2.56) as well as H2O2-producing Lactobacillus species (HR=1.85, 95% CI: 1.00-3.45) compared to placebo. In the subgroup without a baseline vaginal infection, the effect of the intervention to reduce incident BV (HR=0.71, 95% CI: 0.47-1.09) and increase vaginal colonization with any Lactobacillus species (HR=1.32, 95% CI: 0.85-2.04) as well as H2O2-producing Lactobacillus species (HR=1.48, 95% CI: 0.73-3.01), was less strong and not statistically significant. Conclusion: In this PPT trial, the effect of the intervention was driven primarily by participants with a baseline vaginal infection. Restricting PPT to women who are most likely to benefit from it may improve the effect of the intervention. "Background" "Methods" "Results" "Conclusion" "Lactobacillus

'Our voices matter' : the role of individuals, families and communities in creating and driving demand for maternal health services

Popularizing Summary This doctoral research was conducted between 2013 - 2015 in Kwale county, Kenya so as to understand the cultural beliefs, traditions and practices of the Digo, the main community living there, and how these could influence whether or not they take up and use interventions aimed at improving the health of women. It was aimed at describing how the community is structured in terms of the place of women in society, who makes decisions around the health of women, the role of religion in determining the health of women and how all these may have changed over time. This was meant to describe the context under which maternal health programs in this setting were being implemented. The main approach to this research involved participating in their day-to-day activities so as to better understand their way of life and how this had changed over time as well as conducting interviews and having group discussions with various community members, community ‘gatekeepers’, local administrators, key opinion leaders, local health providers as well as other local stakeholders. The study also designed and tested an intervention that actively involved the community in making decisions to improve the health and well-being of women. This was implemented through structured community meetings that sought to create awareness of the benefits of using family planning methods and giving birth under the supervision of a skilled health provider. The meetings allowed community members to identify local issues that promoted or discouraged use of these services then create a specific plan of action to encourage more women in the community to use these services. They also tracked the implementation and outcome of these plans of action. To determine whether this intervention had improved the use of family planning methods and increased the number of women giving birth under the supervision of skilled providers, we compared the number of women who had used these services before and after our intervention. We also interviewed individual women in their households regarding their current use of family planning methods as well as their most recent place of giving birth. This assessment showed a significant increase in the use of family planning methods and the number of health facility births. Findings from this study also showed that among the Digo, specific standards related to their predominant Islamic religion as well as widely held beliefs about the place of men versus women in the society, were an important influence on whether women ultimately used family planning methods and/or delivered under the supervision of a skilled health provider. Specifically, we found that a prominent mother-figure in the community played an important role in deciding whether or not women gave birth in a health facility or used family planning methods. The findings from this doctoral research highlight the importance of implementing public health programs by responding to the unique way of life of targeted communities. They illustrate the success that such programs could achieve when they actively involve individuals, families and communities targeted by their interventions. These findings are important for policy makers, public health practitioners and researchers in similar setting to enable them to understand the context within which they are working and to actively involve individuals, families and communities in order to have effective outcomes. Most importantly, the findings underscore the need to be sensitive to the local way of life and address unique factors that either prevent or promote uptake of public health services so as to remain relevant and sustainable over time

Correlates of facility-based delivery among women of reproductive age from the Digo community residing in Kwale, Kenya.

Objective This study sought to describe factors associated with facility-based delivery among women of reproductive age in Kwale County, Kenya. Results Between March and December 2015, 745 women from 15 villages were interviewed through a cross-sectional household survey. Respondents were selected using stratified, systematic sampling and completed a sexual and reproductive health questionnaire. Of 632 (85%) women who had a previous birth, 619 (98%) reported antenatal care attendance. Of these, 491 (79%) subsequently had a facility-based delivery. Factors associated with increased likelihood of facility delivery included respondent’s education (odds ratio, OR = 2.0, 95% confidence interval, CI 1.2–3.2, P = 0.004), ideal antenatal care attendance (OR = 2.3, 95% CI 1.4–3.7, P = 0.001) and pregnancy intention (OR = 1.5, 95% CI 1.0–2.2, P = 0.040). Being in a polygamous relationship (OR = 0.6, 95% CI 0.3–0.9, P = 0.024) and having a husband ≥ 40 years (OR = 0.5, 95% CI 0.3–0.9, P = 0.013) were associated with reduced likelihood of facility delivery. Respondent’s education (aOR = 1.9, 95% CI 1.1–3.3, P = 0.030) as well as ideal ANC attendance (aOR = 2.0, 95% CI 1.0–3.8, P = 0.040) remained significantly associated with facility delivery in multivariate analyses

Research and implementation interactions in a social accountability study: Utilizing guidance for conducting process evaluations of complex interventions

Background: In recent years, researchers and evaluators have made efforts to identify and use appropriate and innovative research designs that account for the complexity in studying social accountability. The relationship between the researchers and those implementing the activities and how this impacts the study have received little attention. In this paper, we reflect on how we managed the relationship between researchers and implementers using the United Kingdom Medical Research Council (MRC) guidance on process evaluation of a complex intervention. Main body: The MRC guidance focuses on three areas of interaction between researchers and stakeholders involved in developing and delivering the intervention: (i) working with program developers and implementers; (ii) communication of emerging findings between researchers/evaluators and implementers; and (iii) overlapping roles of the intervention and research/evaluation. We summarize how the recommendations for each of the three areas were operationalized in the Community and Provider driven Social Accountability Intervention (CaPSAI) Project and provide reflections based on experience. We co-developed various tools, including standard operating procedures, contact lists, and manuals. Activities such as training sessions, regular calls, and meetings were also conducted to enable a good working relationship between the different partners. Conclusions: Studying social accountability requires the collaboration of multiple partners that need to be planned to ensure a good working relationship while safeguarding both the research and intervention implementation. The MRC guidance is a useful tool for making interaction issues explicit and establishing procedures. Planning procedures for dealing with research and implementers’ interactions could be more comprehensive and better adapted to social accountability interventions if both researchers and implementers are involved. There is a need for social accountability research to include clear statements explaining the nature and types of relationships between researchers and implementers involved in the intervention

Impliquer le secteur de la santé dans la prévention et la prise en charge des mutilations génitales féminines: résultats d'une recherche formative en Guinée

Background: Despite efforts to reduce the burden of female genital mutilation (FGM) in Guinea, the practice remains prevalent, and health care providers are increasingly being implicated in its medicalization. This formative study was conducted to understand the factors that facilitate or impede the health sector in providing FGM prevention and care services to inform the development of health sector-based interventions. Methods: Between April and May 2018, a mixed methods formative study was carried out using a rapid assessment methodology in three regions of Guinea—Faranah, Labe and Conakry. A structured questionnaire was completed by one hundred and fifty health care providers of different cadres and 37 semi-structured interviews were conducted with health care providers, women seeking services at public health clinics and key stakeholders, including health systems managers, heads of professional associations and schools of nursing, midwifery, and medicine as well as representatives of the Ministry of Health. Eleven focus group discussions were conducted with female and male community members. Results: This study revealed health systems factors, attitudinal factors held by health care providers, and other factors, that may not only promote FGM medicalization but also impede a comprehensive health sector response. Our findings confirm that there is currently no standardized pre-service training on how to assess, document and manage complications of FGM nor are there interventions to promote the prevention of the practice within the health sector. This research also demonstrates the deeply held beliefs of health care providers and community members that perpetuate this practice, and which need to be addressed as part of a health sector approach to FGM prevention. Conclusion: As integral members of FGM practicing communities, health care providers understand community beliefs and norms, making them potential change agents. The health sector can support them by incorporating FGM content into their clinical training, ensuring accountability to legal and policy standards, and promoting FGM abandonment as part of a multi-sectoral approach. The findings from this formative research have informed the development of a health sector intervention that is being field tested as part of a multi-country implementation research study in Guinea, Kenya, and Somalia.SCOPUS: ar.jinfo:eu-repo/semantics/publishe