Social determinants of mixed feeding behavior among HIV-infected mothers in Jos, Nigeria

Mixed feeding confers excess risk of mother-to-child transmission (MTCT) of Human Immunodeficiency Virus (HIV) compared with exclusive breastfeeding (EBF) and exclusive formula feeding (EFF). We undertook a quantitative and qualitative cross-sectional survey to identify the social determinants of mixed feeding among a subset of HIV-infected women enrolled in a MTCT prevention program in Jos, Nigeria. Of the 91 participants, 68(75%) exclusively formula fed, 7(8%) exclusively breastfed, and 16(18%) practiced mixed feeding. Of the mixed feeding women, 7 primarily formula fed and 9 primarily breastfed. Women who primarily formula fed described family pressure as the reason for mixed feeding, whereas women who primarily breastfed indicated insufficient breast milk. In a multivariate analysis, lack of partner support of the feeding decision predicted mixed feeding behavior (OR: 4.2; 95% CI: 1.2-14.9; p=0.03). Disclosure of HIV status was significantly correlated (p\u3c0.001) with partner support. HIV prevention interventions aimed at reducing mixed feeding should encourage supportive partner relationships that facilitate disclosure of HIV status. Attention should also be made to the differing pressures faced by women attempting to exclusively breastfeed and exclusively formula feed

Building a Global Evidence Base to Guide Policy and Implementation for Group Antenatal Care in Low‐ and Middle‐Income Countries: Key Principles and Research Framework Recommendations from the Global Group Antenatal Care Collaborative

Evidence from high‐income countries suggests that group antenatal care, an alternative service delivery model, may be an effective strategy for improving both the provision and experience of care. Until recently, published research about group antenatal care did not represent findings from low‐ and middle‐income countries, which have health priorities, system challenges, and opportunities that are different than those in high‐income countries. Because high‐quality evidence is limited, the World Health Organization recommends group antenatal care be implemented only in the context of rigorous research. In 2016 the Global Group Antenatal Care Collaborative was formed as a platform for group antenatal care researchers working in low‐ and middle‐income countries to share experiences and shape future research to accelerate development of a robust global evidence base reflecting implementation and outcomes specific to low‐ and middle‐income countries. This article presents a brief history of the Collaborative’s work to date, proposes a common definition and key principles for group antenatal care, and recommends an evaluation and reporting framework for group antenatal care research.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163383/2/jmwh13143.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163383/1/jmwh13143_am.pd

Impact of the roll out of comprehensive emergency obstetric care on institutional birth rate in rural Nepal

© 2017 The Author(s). Background: Increasing institutional births rates and improving access to comprehensive emergency obstetric care are central strategies for reducing maternal and neonatal deaths globally. While some studies show women consider service availability when determining where to deliver, the dynamics of how and why institutional birth rates change as comprehensive emergency obstetric care availability increases are unclear. Methods: In this pre-post intervention study, we surveyed two exhaustive samples of postpartum women before and after comprehensive emergency obstetric care implementation at a hospital in rural Nepal. We developed a logistic regression model of institutional birth factors through manual backward selection of all significant covariates within and across periods. Qualitatively, we analyzed birth stories through immersion crystallization. Results: Institutional birth rates increased after comprehensive emergency obstetric care implementation (from 30 to 77%, OR 7.7) at both hospital (OR 2.5) and low-level facilities (OR 4.6, p < 0.01 for all). The logistic regression indicated that comprehensive emergency obstetric care availability (OR 5.6), belief that the hospital is the safest birth location (OR 44.8), safety prioritization in decision-making (OR 7.7), and higher income (OR 1.1) predict institutional birth (p ≤ 0.01 for all). Qualitative analysis revealed comprehensive emergency obstetric care awareness, increased social expectation for institutional birth, and birth planning as important factors. Conclusion: Comprehensive emergency obstetric care expansion appears to have generated significant demand for institutional births through increased safety perceptions and birth planning. Increasing comprehensive emergency obstetric care availability increases birth safety, but it may also be a mechanism for increasing the institutional birth rate in areas of under-utilization

Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

Background Access to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women’s groups suggests that group care models may both improve access to care and the quality of care delivered through women’s empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes. Methods The study was conducted at Bayalata Hospital in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allows for iterative improvement in design, making changes to improve the quality of the intervention. Assessments of implementation process and model fidelity were undertaken using a mobile checklist completed by nurse supervisors, and observation forms completed by program leadership. We evaluated data quarterly using descriptive statistics to identify trends. Qualitative interviews and team communications were analyzed through immersion crystallization to identify major themes that evolved during the implementation process. Results A total of 141 group antenatal sessions were run during the study period. This paper reports on implementation results, whereas we analyze and present patient-level effectiveness outcomes in a complementary paper in this journal. There was high process fidelity to the model, with 85.7% (95% CI 77.1–91.5%) of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. The annual per capita cost for group antenatal care was 0.50 USD. Qualitative analysis revealed the compromise of stable gestation-matched composition of the group members in order to make the intervention feasible. Major adaptations were made in training, documentation, feedback and logistics. Conclusion Group antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system. Trial registration ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered

Understanding perceptions of global healthcare experiences on provider values and practices in the USA: a qualitative study among global health physicians and program directors

International audienceObjectives The study aimed to qualitatively examine the perspectives of US-based physicians and academic global health programme leaders on how global health work shapes their viewpoints, values and healthcare practices back in the USA.DesignA prospective, qualitative exploratory study that employed online questionnaires and open-ended, semi-structured interviews with two participant groups: (1) global health physicians and (2) global health programme leaders affiliated with USA-based academic medical centres. Open coding procedures and thematic content analysis were used to analyse data and derive themes for discussion.Participants 159 global health physicians and global health programme leaders at 25 academic medical institutions were invited via email to take a survey and participate in a follow-up interview. Twelve participants completed online questionnaires (7.5% response rate) and eight participants (four survey participants and four additionally recruited participants) participated in in-depth, in-person or phone semi-structured interviews.Results Five themes emerged that highlight how global health physicians and academic global health programme leaders perceive global health work abroad in shaping USA-based medical practices: (1) a sense of improved patient rapport, particularly with low-income, refugee and immigrant patients, and improved and more engaged patient care; (2) reduced spending on healthcare services; (3) greater awareness of the social determinants of health; (4) deeper understanding of the USA’s healthcare system compared with systems in other countries; and (5) a reinforcement of values that initially motivated physicians to pursue work in global health.Conclusions A majority of participating global health physicians and programme leaders believed that international engagements improved patient care back in the USA. Participant responses relating to the five themes were contextualised by highlighting factors that simultaneously impinge on their ability to provide improved patient care, such as the social determinants of health, and the challenges of changing USA healthcare policy.This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial

Understanding perceptions of global healthcare experiences on provider values and practices in the USA: a qualitative study among global health physicians and program directors.

ObjectivesThe study aimed to qualitatively examine the perspectives of US-based physicians and academic global health programme leaders on how global health work shapes their viewpoints, values and healthcare practices back in the USA.DesignA prospective, qualitative exploratory study that employed online questionnaires and open-ended, semi-structured interviews with two participant groups: (1) global health physicians and (2) global health programme leaders affiliated with USA-based academic medical centres. Open coding procedures and thematic content analysis were used to analyse data and derive themes for discussion.Participants159 global health physicians and global health programme leaders at 25 academic medical institutions were invited via email to take a survey and participate in a follow-up interview. Twelve participants completed online questionnaires (7.5% response rate) and eight participants (four survey participants and four additionally recruited participants) participated in in-depth, in-person or phone semi-structured interviews.ResultsFive themes emerged that highlight how global health physicians and academic global health programme leaders perceive global health work abroad in shaping USA-based medical practices: (1) a sense of improved patient rapport, particularly with low-income, refugee and immigrant patients, and improved and more engaged patient care; (2) reduced spending on healthcare services; (3) greater awareness of the social determinants of health; (4) deeper understanding of the USA's healthcare system compared with systems in other countries; and (5) a reinforcement of values that initially motivated physicians to pursue work in global health.ConclusionsA majority of participating global health physicians and programme leaders believed that international engagements improved patient care back in the USA. Participant responses relating to the five themes were contextualised by highlighting factors that simultaneously impinge on their ability to provide improved patient care, such as the social determinants of health, and the challenges of changing USA healthcare policy

Practical issues in the measurement of child survival in health systems trials: experience developing a digital community-based mortality surveillance programme in rural Nepal

Child mortality measurement is essential to the impact evaluation of maternal and child healthcare systems interventions. In the absence of vital statistics systems, however, assessment methodologies for locally relevant interventions are severely challenged. Methods for assessing the under-5 mortality rate for cross-country comparisons, often used in determining progress towards development targets, pose challenges to implementers and researchers trying to assess the population impact of targeted interventions at more local levels. Here, we discuss the programmatic approach we have taken to mortality measurement in the context of delivering healthcare via a public–private partnership in rural Nepal. Both government officials and the delivery organisation, Possible, felt it was important to understand child mortality at a fine-grain spatial and temporal level. We discuss both the short-term and the long-term approach. In the short term, the team chose to use the under-2 mortality rate as a metric for mortality measurement for the following reasons: (1) as overall childhood mortality declines, like it has in rural Nepal, deaths concentrate among children under the age of 2; (2) 2-year cohorts are shorter and thus may show an impact more readily in the short term of intervention trials; and (3) 2-year cohorts are smaller, making prospective census cohorts more feasible in small populations. In the long term, Possible developed a digital continuous surveillance system to capture deaths as they occur, at which point under-5 mortality assessment would be desirable, largely owing to its role as a global standard

Additional file 1: of Determinants of institutional birth among women in rural Nepal: a mixed-methods cross-sectional study

Institutional Birth Survey_Pre-Surgical Expansion_Eng,Nep (PDF 257 kb

An integrated community health worker intervention in rural Nepal: a type 2 hybrid effectiveness-implementation study protocol

Background: Evidence-based medicines, technologies, and protocols exist to prevent many of the annual 300,000 maternal, 2.7 million neonatal, and 9 million child deaths, but they are not being effectively implemented and utilized in rural areas. Nepal, one of South Asia’s poorest countries with over 80% of its population living in rural areas, exemplifies this challenge. Community health workers are an important cadre in low-income countries where human resources for health and health care infrastructure are limited. As local women, they are uniquely positioned to understand and successfully navigate barriers to health care access. Recent case studies of large community health worker programs have highlighted the importance of training, both initial and ongoing, and accountability through structured management, salaries, and ongoing monitoring and evaluation. A gap in the evidence regarding whether such community health worker systems can change health outcomes, as well as be sustainably adopted at scale, remains. In this study, we plan to evaluate a community health worker system delivering an evidence-based integrated reproductive, maternal, newborn, and child health intervention as it is scaled up in rural Nepal. Methods: We will conduct a type 2 hybrid effectiveness-implementation study to test both the effect of an integrated reproductive, maternal, newborn, and child health intervention and the implementation process via a professional community health worker system. The intervention integrates five evidence-based approaches: (1) home-based antenatal care and post-natal care counseling and care coordination; (2) continuous surveillance of all reproductive age women, pregnancies, and children under age 2 years via a mobile application; (3) Community-Based Integrated Management of Newborn and Childhood Illness; (4) group antenatal and postnatal care; and 5) the Balanced Counseling Strategy to post-partum contraception. We will evaluate effectiveness using a pre-post quasi-experimental design with stepped implementation and implementation using the RE-AIM framework. Discussion This is the first hybrid effectiveness-implementation study of an integrated reproductive, maternal, newborn, and child health intervention in rural Nepal that we are aware of. As Nepal takes steps towards achieving the Sustainable Development Goals, the data from this three-year study will be useful in the detailed planning of a professionalized community health worker cadre delivering evidence-based reproductive, maternal, newborn, and child health interventions to the country’s rural population. Trial registration ClinicalTrials.gov Identifier: NCT03371186, registered 04 December 2017, retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13012-018-0741-x) contains supplementary material, which is available to authorized users