Collecting data from migrants in Ghana: lessons learned using respondent-driven sampling

Background: Policymakers and program implementers require high-quality data on migrants and migration in low- and middle-income countries (LMIC); however, a shortage of high-quality data exists in these settings. Sampling migrant populations requires better techniques. Respondent-driven sampling (RDS) may be one such solution. Objective: Using Ghana as a case study, the objectives of this paper are to: 1) assess RDS recruitment productivity, network size, and ties of internal migrants; 2) test for homophily; and 3) detail the successes of and challenges to implementing RDS in Ghana and how these lessons can be applied to migrant populations in other LMIC settings. Methods: This study used RDS to sample 625 rural–urban female migrants working as market porters (kayayei) in Accra, Ghana. Results: This study generated the most comprehensive data set on kayayei to date. Network size increases as participants become more educated and migrate more often to Accra. Ethnic group membership is an important determinant of recruitment, with certain groups preferring to recruit from within. Employing members of the kayayei population to collect data built crucial trust. Conclusions: Whilst RDS is not a one-size-fits-all solution for sampling hard-to-reach migrants in LMIC, it can be a powerful tool to uncover and to recruit hard-to-reach migrant populations. In countries with multiple ethnolinguistic groups, recruiting a migrant population with greater ethnolinguistic overlap may facilitate quicker equilibrium. Contribution: This study expands the evidence base on use of RDS among migrant populations in LMIC and provides lessons learned to assist other researchers implementing RDS in LMIC settings

Health insurance and care-seeking behaviours of female migrants in Accra, Ghana

People working in Ghana’s informal sector have low rates of enrolment in the publicly funded National Health Insurance Scheme. Informal sector workers, including migrant girls and women from northern Ghana working as head porters (kayayei), report challenges obtaining insurance and seeking formal health care. This article analyses how health insurance status affects kayayei migrants’ care-seeking behaviours. This mixed-methods study involved surveying 625 migrants using respondent-driven sampling and conducting in-depth interviews with a sub-sample of 48 migrants. Analyses explore health status and health seeking behaviours for recent illness/injury. Binary logistic regression modelled the effects of selected independent variables on whether or not a recently ill/injured participant (n = 239) sought health care. Although recently ill/injured participants (38.4%) desired health care, less than half (43.5%) sought care. Financial barriers overwhelmingly limit kayayei migrants from seeking health care, preventing them from registering with the National Health Insurance Scheme, renewing their expired health insurance policies, or taking time away from work. Both insured and uninsured migrants did not seek formal health services due to the unpredictable nature of out-of-pocket expenses. Catastrophic and impoverishing medical expenses also drove participants’ migration in search of work to repay loans and hospital bills. Health insurance can help minimize these expenditures, but only 17.4% of currently insured participants (58.2%) reported holding a valid health insurance card in Accra. The others lost their cards or forgot them when migrating. Access to formal health care in Accra remains largely inaccessible to kayayei migrants who suffer from greater illness/injury than the general female population in Accra and who are hindered in their ability to receive insurance exemptions. With internal migration on the rise in many settings, health systems must recognize the varied needs of populations in multi-ethnic and multilingual countries to ensure that internal migrants can access affordable, quality health services across domestic borders

Interventions to provide culturally-appropriate maternity care services: factors affecting implementation

Background The World Health Organization recently made a recommendation supporting ‘culturally-appropriate’ maternity care services to improve maternal and newborn health. This recommendation results, in part, from a systematic review we conducted, which showed that interventions to provide culturally-appropriate maternity care have largely improved women’s use of skilled maternity care. Factors relating to the implementation of these interventions can have implications for their success. This paper examines stakeholders’ perspectives and experiences of these interventions, and facilitators and barriers to implementation; and concludes with how they relate to the effects of the interventions on care-seeking outcomes. Methods We based our analysis on 15 papers included in the systematic review. To extract, collate and organise data on the context and conditions from each paper, we adapted the SURE (Supporting the Use of Research Evidence) framework that lists categories of factors that could influence implementation. We considered information from the background and discussion sections of papers included in the systematic review, as well as cost data and qualitative data when included. Results Women’s and other stakeholders’ perspectives on the interventions were generally positive. Four key themes emerged in our analysis of facilitators and barriers to implementation. Firstly, interventions must consider broader economic, geographical and social factors that affect ethnic minority groups’ access to services, alongside providing culturally-appropriate care. Secondly, community participation is important in understanding problems with existing services and potential solutions from the community perspective, and in the development and implementation of interventions. Thirdly, respectful, person-centred care should be at the core of these interventions. Finally, cohesiveness is essential between the culturally-appropriate service and other health care providers encountered by women and their families along the continuum of care through pregnancy until after birth. Conclusion Several important factors should be considered and addressed when implementing interventions to provide culturally-appropriate care. These factors reflect more general goals on the international agenda of improving access to skilled maternity care; providing high-quality, respectful care; and community participation

Maternal Health Is Women's Health: A Call for Papers for Year 2 of the Maternal Health Task Force–PLOS Collection

The PLOS Medicine editors and the Maternal Health Task Force announce a new call for papers on the theme of “maternal health is women's health.

Experiences of private sector quality care amongst mothers, newborns, and children in low- and middle-income countries: a systematic review

Background: Experience of care is a pillar of quality care; positive experiences are essential during health care encounters and integral to quality health service delivery. Yet, we lack synthesised knowledge of how private sector delivery of quality care affects experiences of care amongst mothers, newborns, and children. To fill this gap, we conducted a systematic review that examined quantitative, qualitative, and mixed-methods studies on the provision of maternal, newborn, and child health (MNCH) care by private providers in low- and middle-income countries (LMICs). This manuscript focuses on experience of care, including respectful care, and satisfaction with care. Methods: Our protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Searches were conducted in eight electronic databases (Cumulative Index to Nursing and Allied Health, EconLit, Excerpta Medica Database, International Bibliography of the Social Sciences, Popline, PubMed, ScienceDirect, and Web of Science) and two websites and supplemented with hand-searches and expert recommendations. For inclusion, studies examining private sector delivery of quality care amongst mothers, newborns, and children in LMICs must have examined maternal, newborn, and/or child morbidity or mortality; quality of care; experience of care; and/or service utilisation. Data were extracted for descriptive statistics and thematic analysis. Results: Of the 139 studies included, 45 studies reported data on experience of care. Most studies reporting experience of care were conducted in India, Bangladesh, and Uganda. Experiences of private care amongst mothers, newborns, and children aligned with four components of quality of care: patient-centeredness, timeliness, effectiveness, and equity. Interpersonal relationships with health care workers were essential to experience of care, in particular staff friendliness, positive attitudes, and time spent with health care providers. Experience of care can be a stronger determining factor in MNCH-related decision-making than the quality of services provided. Conclusion: Positive experiences of care in private facilities can be linked more broadly to privileges of private care that allow for shorter waiting times and more provider time spent with mothers, newborns, and children. Little is known about experiences of private sector care amongst children. Trial registration: This systematic review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42019143383)

Effectiveness of interventions to provide culturally-appropriate maternity care in increasing uptake of skilled maternity care: a systematic review

Addressing cultural factors that affect uptake of skilled maternity care is recognised as an important step in improving maternal and newborn health. This paper describes a systematic review to examine the evidence available on the effects of interventions to provide culturally-appropriate maternity care on the use of skilled maternity care during pregnancy, for birth or in the postpartum period. Items published in English, French and/or Spanish between 1 January 1990 and 31 March 2014 were considered. Fifteen studies describing a range of interventions met the inclusion criteria. Data were extracted on population and intervention characteristics; study design; definitions and data for relevant outcomes; and the contexts and conditions in which interventions occurred. Because most of the included studies focus on antenatal care outcomes, evidence of impact is particularly limited for care seeking for birth and after birth. Evidence in this review is clustered within a small number of countries, and evidence from low- and middle-income countries is notably lacking. Interventions largely had positive effects on uptake of skilled maternity care. Cultural factors are often not the sole factor affecting populations’ use of maternity care services. Broader social, economic, geographical and political factors interacted with cultural factors to affect targeted populations’ access to services in included studies. Programmes and policies should seek to establish an enabling environment and support respectful dialogue with communities to improve use of skilled maternity care. Whilst issues of culture are being recognised by programmes and researchers as being important, interventions that explicitly incorporate issues of culture are rarely evaluated

Maternity care services and culture: a systematic global mapping of interventions

Background A vast body of global research shows that cultural factors affect the use of skilled maternity care services in diverse contexts. While interventions have sought to address this issue, the literature on these efforts has not been synthesised. This paper presents a systematic mapping of interventions that have been implemented to address cultural factors that affect women's use of skilled maternity care. It identifies and develops a map of the literature; describes the range of interventions, types of literature and study designs; and identifies knowledge gaps. Methods and Findings Searches conducted systematically in ten electronic databases and two websites for literature published between 01/01/1990 and 28/02/2013 were combined with expert-recommended references. Potentially eligible literature included journal articles and grey literature published in English, French or Spanish. Items were screened against inclusion and exclusion criteria, yielding 96 items in the final map. Data extracted from the full text documents are presented in tables and a narrative synthesis. The results show that a diverse range of interventions has been implemented in 35 countries to address cultural factors that affect the use of skilled maternity care. Items are classified as follows: (1) service delivery models; (2) service provider interventions; (3) health education interventions; (4) participatory approaches; and (5) mental health interventions. Conclusions The map provides a rich source of information on interventions attempted in diverse settings that might have relevance elsewhere. A range of literature was identified, from narrative descriptions of interventions to studies using randomised controlled trials to evaluate impact. Only 23 items describe studies that aim to measure intervention impact through the use of experimental or observational-analytic designs. Based on the findings, we identify avenues for further research in order to better document and measure the impact of interventions to address cultural factors that affect use of skilled maternity care

Looking beyond Padman: a need to empower girls during menstruation and puberty

Taking India as an example, Ernestina Coast (LSE), Joe Strong (LSE) and Samantha R. Lattof (LSE) explain how weak evidence is prolonging the economic burden, shame, and gendered experience of menstruation in low- and middle-income countries

Puberty and menstruation knowledge among young adolescents in low- and middle-income countries: a scoping review

Objectives This study presents a scoping review of evidence relating to knowledge and experiences of puberty and menstruation among females aged 10–14 years in low- and middle-income countries. Methods Forty-four items from 12 countries were identified from a systematic scoping review and screening of 8083 items. Included studies were quality assessed. Results A majority (40/44) of studies used school-based samples, and fifteen studies reported on interventions. Girls had inadequate knowledge about menstruation; menarche as a trigger for girls learning about menstruation was common. Adolescents struggled with menstrual hygiene. Negative emotions were associated with menarche and menstrual management. A minority of studies dealt explicitly with puberty. Most girls obtained information about menstruation and/or puberty from their mothers, although mothers were not necessarily girls’ preferred source for learning about these topics. Conclusions Young adolescent girls are under-prepared for puberty and menstruation. Predominantly school-based studies mean we know little about young out-of-school adolescents. The evidence base lags behind the rise in interest from practitioners as well as the development (and evaluation) of puberty and/or menstruation intervention

Priorities and challenges accessing health care among female migrants

Women’s ability to access health care requires access to and control of resources as well as the ability to make personal health decisions. Female migrants may experience additional challenges in accessing health care due to marginalization and vulnerability resulting from both their gender and their migrant status. Rural-to-urban migrant women working in the informal sector, such as Ghana’s head porters (kayayei), experience exclusion from the health system, risk of being uninsured, and poor health outcomes. Kayeyei’s survival needs (e.g., food, water) and a need to provide for their families can mean that migrant kayayei avoid health care expenses for illnesses or injuries. To ensure equal access to health care for migrant and non-migrant populations, health insurance is crucial. Yet, improving access to health care and service uptake requires more than health insurance. Incorporating culturally-appropriate care into the provision of health services, or even developing specific migrant-friendly health services, could improve health service uptake and health awareness among migrants. Public health systems should also take account of migrants’ financial situations and priorities in the design and delivery of health service