The effects of malnutrition on health status and survival of children has been the subject of extensive research for several decades. Malnutrition affects physical growth, cognitive development of children, morbidity and mortality. The current study was an exploratory survey that focused on factors affecting feeding of nursery school children as perceived by their mothers in a rural setting in Usigu Division of Bondo County, Kenya.
The sampling frame was mothers whose children were in Kanyibok, Sanda and Usenge nursery schools. Purposive sampling methods were used to draw a total of 108 respondents. In a logistic regression model, bad management of feeding was the dependent variable while factors perceived to affect management of feeding were the independent variables.
Married mothers were more likely to manage good feeding practices (OR, 0.34, 95% CI, 0.21-0.76; P = 0.022) relative to those who were single or widowed. Additional analyses showed that low education levels (OR, 7.33, 95% CI, 3.37-12.91; P = 0.023), younger mothers (OR, 6.04, 95% CI, 3.22-9.68; P = 0.029) and mothers engaged in business (OR, 4.02, 95% CI, 2.11-7.85; P = 0.027) increased their likelihood of not feeding the pre-school children. Majority of the children who ate the main meals in other houses belonged to young mothers in the age category of 15–29 years. Further analyses demonstrated that if the order of serving food was to the children first, then they had high likelihood of having good feeding relative to when the father was served first (OR, 0.22, 95% CI, 0.14-0.61; P = 0.011).
Based on these findings, there is an urgent need for sensitization of the mothers on the management of feeding of these pre-school children in Bondo County. It is hoped that relevant interventions would then be designed with the view of managing children feeding in such rural settings as in Bondo County in Kenya.
Feeding practices; Children; Mothers; Rural Bondo
Gender-based violence against women, including intimate partner violence (IPV), is a pervasive health and human rights concern. However, relatively little intervention research has been conducted on how to reduce IPV in settings impacted by conflict. The current study reports on the evaluation of the incremental impact of adding “gender dialogue groups” to an economic empowerment group savings program on levels of IPV. This study took place in north and northwestern rural Côte d’Ivoire.
Between 2010 and 2012, we conducted a two-armed, non-blinded randomized-controlled trial (RCT) comparing group savings only (control) to “gender dialogue groups” added to group savings (treatment). The gender dialogue group consisted of eight sessions that targeted women and their male partner. Eligible Ivorian women (18+ years, no prior experience with group savings) were invited to participate. 934 out of 981 (95.2%) partnered women completed baseline and endline data collection. The primary trial outcome measure was an overall measure of past-year physical and/or sexual IPV. Past year physical IPV, sexual IPV, and economic abuse were also separately assessed, as were attitudes towards justification of wife beating and a woman’s ability to refuse sex with her husband.
Intent to treat analyses revealed that compared to groups savings alone, the addition of gender dialogue groups resulted in a slightly lower odds of reporting past year physical and/or sexual IPV (OR: 0.92; 95% CI: 0.58, 1.47; not statistically significant). Reductions in reporting of physical IPV and sexual IPV were also observed (not statistically significant). Women in the treatment group were significantly less likely to report economic abuse than control group counterparts (OR = 0.39; 95% CI: 0.25, 0.60, p < .0001). Acceptance of wife beating was significantly reduced among the treatment group (β = -0.97; 95% CI: -1.67, -0.28, p = 0.006), while attitudes towards refusal of sex did not significantly change Per protocol analysis suggests that compared to control women, treatment women attending more than 75% of intervention sessions with their male partner were less likely to report physical IPV (a OR: 0.45; 95% CI: 0.21, 0.94; p = .04) and report fewer justifications for wife beating (adjusted β = -1.14; 95% CI: -2.01, -0.28, p = 0.01) ; and both low and high adherent women reported significantly decreased economic abuse (a OR: 0.31; 95% CI: 0.18, 0.52, p < 0.0001; a OR: 0.47; 95% CI: 0.27, 0.81, p = 01, respectively). No significant reductions were observed for physical and/or sexual IPV, or sexual IPV alone.
Results from this pilot RCT suggest the importance of addressing household gender inequities alongside economic programming, because this type of combined intervention has potential to reduce levels of IPV. Additional large-scale intervention research is needed to replicate these findings.
Registration Number: NCT01629472.
Gender-based violence; Randomized controlled trial; West Africa; Economic empowerment; Evaluation
In Morocco, the social and legal framework surrounding sexual and reproductive health has transformed greatly in the past decade, especially with the introduction of the new Family Law or Moudawana. Yet, despite raising the minimum age of marriage for girls and stipulating equal rights in the family, child and forced marriage is widespread. The objective of this research study was to explore perspectives of a broad range of professionals on factors that contribute to the occurrence of child and forced marriage in Morocco.
A qualitative approach was used to generate both primary and secondary data for the analysis. Primary data consist of individual semi-structured interviews that were conducted with 22 professionals from various sectors: health, legal, education, NGO’s and government. Sources of secondary data include academic papers, government and NGO reports, various legal documents and media reports. Data were analyzed using thematic qualitative analysis.
Four major themes arose from the data, indicating that the following elements contribute to child and forced marriage: (1) the legal and social divergence in conceptualizing forced and child marriage; (2) the impact of legislation; (3) the role of education; and (4) the economic factor. Emphasis was especially placed on the new Family Code or Moudawana as having the greatest influence on advancement of women's rights in the sphere of marriage. However, participants pointed out that embedded patriarchal attitudes and behaviours limit its effectiveness.
The study provided a comprehensive understanding of the factors that compound the problem of child and forced marriage in Morocco. From the viewpoint of professionals, who are closely involved in tackling the issue, policy measures and the law have the greatest potential to bring child and forced marriage to a halt. However, the implementation of new legal tools is facing barriers and resistance. Additionally, the legal and policy framework should go hand in hand with both education and increased economic opportunities. Education and awareness-raising of all ages is considered essential, seeing that parents and the extended family play a huge role in marrying off girls and young women.
Child and forced marriage; Morocco; Women’s rights; Sexual and reproductive health; Violence
Tribal people in India, as in other parts of the world, reside mostly in forests and/or hilly terrains. Water scarcity and health problems related to it are their prime concern. Watershed management can contribute to resolve their health related problems and can put them on a path of socio-economic development. Integrated management of land, water and biomass resources within a watershed, i.e. in an area or a region which contributes rainfall water to a river or lake, is referred to as watershed management. Watershed management includes soil and water conservation to create water resources, management of drinking water, improving hygiene and sanitation, plantation of trees, improving agriculture, formation of self-help groups and proper utilisation and management of available natural resources. For successful implementation of such a solution, understanding of perceptions of the tribal community members with regard to public health and socioeconomic implications of watershed management is essential.
A qualitative study with six focus group discussions (FGDs), three each separately for men and women, was conducted among tribal community members of the Maharashtra state of India. The data collected from the FGDs were analyzed using manifest and latent content analysis.
“Improvement in health and empowerment of families as a result of watershed management” was identified as the main theme. Participants perceived that their health problems and socio-economic development are directly and/or indirectly dependent upon water availability. They further perceived that watershed management could directly or indirectly result in reduction of their public health related challenges like waterborne diseases, seasonal migration, alcoholism, intimate partner violence, as well as drudgery of women and may enhance overall empowerment of families through agricultural development.
Tribal people perceived that water scarcity is the main reason for their physical, mental and social health problems and a major obstacle for their overall development. The perceptions of tribal participants indicate that infectious diseases, migration, alcoholism, intimate partner violence and drudgery of women are end results of water scarcity and efforts to increase water availability through watershed management may help them to achieve their right to health which is embedded in their right to access to water.
Public health; Watershed management; Perceptions; Tribal; Empowerment
Under the National Rural Health Mission, the current emphasis is on achieving universal institutional births through incentive schemes as part of reforms related to childbirth in India. There has been rapid progress in achieving this goal. To understand the choices made as well as practices and perceptions related to childbirth amongst tribal women in Gujarat and how these have been influenced by modernity in general and modernity brought in through maternal health policies.
A model depicting the transition in childbirth practices amongst tribal women was constructed using the grounded theory approach with; 8 focus groups of women, 5 in depth interviews with traditional birth attendants, women, and service providers and field notes on informal discussions and observations.
A transition in childbirth practices across generations was noted, i.e. a shift from home births attended by Traditional Birth Attendants (TBAs) to hospital births. The women and their families both adapted to and shaped this transition through a constant ’trade-off between desirable and essential’- the desirable being a traditional homebirth in secure surroundings and the essential being the survival of mother and baby by going to hospital. This transition was shaped by complex multiple factors: 1) Overall economic growth and access to modern medical care influencing women’s choices, 2) External context in terms of the international maternal health discourses and national policies, especially incentive schemes for promoting institutional deliveries, 3) Socialisation into medical childbirth practices, through exposure to many years of free outreach services for maternal and child health, 4) Loss of self reliance in the community as a consequence of role redefinition and deskilling of the TBAs and 5) Cultural belief that intervention is necessary during childbirth aiding easy acceptance of medical interventions.
In resource poor settings where choices are limited and mortality is high, hospital births are perceived as increasing the choices for women, saving lives of mothers and babies, though there is a need for region specific strategies. Modern obstetric technology is utilised and given meanings based on socio-cultural conceptualisations of birth, which need to be considered while designing policies for maternal health.
Childbirth practices; Medicalization; India; Grounded theory
Adolescents and parents’ differ in their perceptions regarding engaging in sexual activity and protecting themselves from pregnancy and sexually transmitted infections (STIs). The views of adolescents and parents from two south-eastern communities in Ghana regarding best time for sex and sexual communications were examined.
Focus Group interviews were conducted with parents and adolescents (both In-school and Out-of school) from two communities (Somanya and Adidome) in the Eastern and Volta regions of Ghana with epidemiological differentials in HIV infection.
Findings showed parents and adolescents agree that the best timing for sexual activity amongst adolescents is determined by socioeconomic viability. In practice however, there were tensions between adolescents and parents crystallized by spoilt generation and physiological drive ideologies. Whilst one community relied on a more communal approach in controlling their children; the other relied on a confrontational approach. Sex-talk is examined as a measure to reduce these tensions, and children in both communities were ambivalent over sexual communication between their parents and themselves. Parents from the two communities however differed in their perceptions. Whilst parents in one community attributed reduced teenage pregnancies to sex education, those in the other community indicated a generalized adolescents’ sexual activeness manifested in the perceived widespread delinquency in the community.
Parents in both communities reported significant barriers to parents-adolescents sexual communication. Parents in both communities should be educated to discuss the broader issues on sexuality that affects adolescents and their reproductive health needs.
Adolescents; Parents; Sex; Communication; Ghana
The Japan International Cooperation Agency (JICA) has focused its attention on appraising health development assistance projects and redirecting efforts towards health system strengthening. This study aimed to describe the type of project and targets of interest, and assess the contribution of JICA health-related projects to strengthening health systems worldwide.
We collected a web-based Project Design Matrix (PDM) of 105 JICA projects implemented between January 2005 and December 2009. We developed an analytical matrix based on the World Health Organization (WHO) health system framework to examine the PDM data and thereby assess the projects’ contributions to health system strengthening.
The majority of JICA projects had prioritized workforce development, and improvements in governance and service delivery. Conversely, there was little assistance for finance or medical product development. The vast majority (87.6%) of JICA projects addressed public health issues, for example programs to improve maternal and child health, and the prevention and treatment of infectious diseases such as AIDS, tuberculosis and malaria. Nearly 90% of JICA technical healthcare assistance directly focused on improving governance as the most critical means of accomplishing its goals.
Our study confirmed that JICA projects met the goals of bilateral cooperation by developing workforce capacity and governance. Nevertheless, our findings suggest that JICA assistance could be used to support financial aspects of healthcare systems, which is an area of increasing concern. We also showed that the analytical matrix methodology is an effective means of examining the component of health system strengthening to which the activity and output of a project contributes. This may help policy makers and practitioners focus future projects on priority areas.
Japan International Cooperation Agency (JICA); Health system improvement; Project design matrix
Myths and misconceptions about TB can serve as a barrier to efforts at reducing stigmatisation of people infected and affected by the disease. Understanding such drivers of myths and misconceptions is important for improving information, education and communication (IEC) efforts of national control and preventive interventions. This study therefore assesses the influence of interaction of spatial, socioeconomic and demographic characteristics on myths and misconceptions.
Data was drawn from male (N = 4,546) and female (N = 4,916) files of the 2008 Ghana Demographic and Health Survey. A myth and misconception variable was created from five-related constructs with internal consistency score of r = 0. 8802 for males (inter-item correlation: 0.5951) and for females, r = 0. 0.9312 (inter-item correlation: 0.7303). The Pearson Chi-square was used to test the bivariate relationship between the independent variables and the dependent variable. Logistic regression was subsequently used to explore the factors determining myths and misconceptions of TB transmission.
Majority of Ghanaians (males: 66.75%; females: 66.13%) did not hold myths and misconceptions about TB transmission. Females resident in the Upper East (aOR = 0.31, CI = 0.17-0.55) and Upper West (aOR = 0.41, CI = 0.24-0.69) and males resident in the Northern (aOR = 0.23, CI = 0.13-0.39) and the Greater Accra (aOR = 0.25, CI = 0.16-0.39) regions were independently associated with no misconceptions about TB transmission. Significant differences were also found in education, ethnicity and age.
That spatial and other socioeconomic difference exists in myths and misconceptions suggest the need for spatial, socioeconomic and demographic segmentations in IEC on TB. This holds potentials for reaching out to those who are in critical need of information and education on the transmission processes of TB.
Tuberculosis; Myths; Misconceptions transmission; Spatial; Ghana
The benefits of maternal health care to maternal and neonatal health outcomes have been well documented. Antenatal care attendance, institutional delivery and skilled attendance at delivery all help to improve maternal and neonatal health. However, use of maternal health services is still very low in developing countries with high maternal mortality including Ethiopia. This study examines the association of unintended Pregnancy with the use of maternal health services in Southwestern Ethiopia.
Data for this study come from a survey conducted among 1370 women with a recent birth in a Health and Demographic Surveillance Site (HDSS) in southwestern Ethiopia. An interviewer administered questionnaire was used to gather data on maternal health care, pregnancy intention and other explanatory variables. Data were analyzed using STATA 11, and both bivariate and multivariate analyses were done. Multivariate logistic regression was used to assess the association of pregnancy intention with the use of antenatal and delivery care services. Unadjusted and adjusted odds ratio and their 95% confidence intervals are reported.
More than one third (35%) of women reported that their most recent pregnancy was unintended. With regards to maternal health care, only 42% of women made at least one antenatal care visit during pregnancy, while 17% had four or more visits. Institutional delivery was only 12%. Unintended pregnancy was significantly (OR: 0.75, 95% CI, 0.58-0.97) associated with use of antenatal care services and receiving adequate antenatal care (OR: 0.67, 95% CI, 0.46-0.96), even after adjusting for other socio-demographic factors. However, for delivery care, the association with pregnancy intention was attenuated after adjustment. Other factors associated with antenatal care and delivery care include women’s education, urban residence, wealth and distance from health facility.
Women with unintended pregnancies were less likely to access or receive adequate antenatal care. Interventions are needed to reduce unintended pregnancy such as improving access to family planning information and services. Moreover, improving access to maternal health services and understanding women’s pregnancy intention at the time of first antenatal care visit is important to encourage women with unintended pregnancies to complete antenatal care.
Unintended pregnancy; Antenatal care; Delivery care; Southwestern Ethiopia
Ghana’s National Health Insurance Scheme (NHIS), established into law in 2003 and implemented in 2005 as a ‘pro-poor’ method of health financing, has made great progress in enrolling members of the general population. While many studies have focused on predictors of enrolment this study offers a novel analysis of NHIS members’ perceptions of service provision at the national level.
Using data from the 2008 Ghana Demographic Health Survey we analyzed the perceptions of service provision as indicated by members enrolled in the NHIS at the time of the survey (n = 3468; m = 1422; f = 2046). Ordinal Logistic Regression was applied to examine the relationship between perceptions of service provision and theoretically relevant socioeconomic and demographic variables.
Results demonstrate that wealth, gender and ethnicity all play a role in influencing members’ perceptions of NHIS service provision, distinctive from its influence on enrolment. Notably, although wealth predicted enrolment in other studies, our study found that compared to the poorest men and uneducated women, wealthy men and educated women were less likely to perceive their service provision as better/same (more likely to report it was worse). Wealth was not an important factor for women, suggesting that household gender dynamics supersede household wealth status in influencing perceptions. As well, when compared to Akan women, women from all other ethnic groups were about half as likely to perceive the service provision to be better/same.
Findings of this study suggest there is an important difference between originally enrolling in the NHIS because one believes it is potentially beneficial, and using the NHIS and perceiving it to be of benefit. We conclude that understanding the nature of this relationship is essential for Ghana’s NHIS to ensure its longevity and meet its pro-poor mandate. As national health insurance systems are a relatively new phenomenon in sub-Saharan Africa little is known about their long term viability; understanding user perceptions of service provision is an important piece of that puzzle.
Health care; Ghana; Health insurance; National health insurance scheme; Perceptions; Service
Governance has been cited as a key determinant of economic growth, social advancement and overall development. Achievement of millennium development goals is partly dependant on governance practices. In 2007, Health Systems 20/20 conducted an Internet-based survey on the practice of good governance. The survey posed a set of good practices related to health governance and asked respondents to indicate whether their experience confirmed or disconfirmed those practices. We applied the 17 governance statements in rural health facilities of Zambia. The aim was to establish whether the statements were reliable and valid for assessing governance practices at primary care level.
Both quantitative and qualitative methods were used. We first applied the governance statements developed by the health system 20/20 and then conducted focus group discussion and In-depth interviews to explore some elements of governance including accountability and community participation. The target respondents were the health facility management team and community members. The sample size include 42 health facilities. Data was analyzed using SPSS version 17 and Nvivo version 9.
The 95% one-sided confidence interval for Cronbach’s alpha was between 0.69 and 0.74 for the 16 items.
The mean score for most of the items was above 3. Factor analysis yielded five principle components: Transparency, community participation, Intelligence & vision, Accountability and Regulation & oversight. Most of the items (6) clustered around the transparency latent factor. Chongwe district performed poorly in overall mean governance score and across the five domains of governance. The overall scores in Chongwe ranged between 51 and 94% with the mean of 80%. Kafue and Luangwa districts had similar overall mean governance scores (88%). Community participation was generally low. Generally, it was noted that community members lacked capacity to hold health workers accountable for drugs and medical supplies.
The study successfully validated and applied the new tool for evaluating health system governance at health facility level. The results have shown that it is feasible to measure governance practices at health facility level and that the adapted tool is fairly reliable with the 95% one-sided confidence interval for Cronbach’s alpha laying between 0.69 and 0.74 for the 16 items. Caution should be taken when interpreting overall scores as they tended to mask domain specific variations.
Child sexual abuse (CSA) is a considerable public health problem. Less focus has been paid to the role of community level factors associated with CSA. The aim of this study was to examine the association between neighbourhood-level measures of social disorganization and CSA.
We applied multiple multilevel logistic regression analysis on Demographic and Health Survey data for 6,351 adolescents from six countries in sub-Saharan Africa between 2006 and 2008.
The percentage of adolescents that had experienced CSA ranged from 1.04% to 5.84%. There was a significant variation in the odds of reporting CSA across the communities, suggesting 18% of the variation in CSA could be attributed to community level factors. Respondents currently employed were more likely to have reported CSA than those who were unemployed (odds ratio [OR] = 2.05, 95% confidence interval [CI] 1.48 to 2.83). Respondents from communities with a high family disruption rate were 57% more likely to have reported CSA (OR=1.57, 95% CI 1.14 to 2.16).
We found that exposure to CSA was associated with high community level of family disruption, thus suggesting that neighbourhoods may indeed have significant important effects on exposure to CSA. Further studies are needed to explore pathways that connect the individual and neighbourhood levels, that is, means through which deleterious neighbourhood effects are transmitted to individuals.
Childhood sexual abuse; Sub-Saharan Africa; Socio-demographic factors; Demographic and health survey; Neighborhood; Social disorganization
Some studies show orphanhood to be associated with increased sexual risk-taking while others have not established this relationship, but have found factors other than orphanhood as predictors of sexual risk behaviours and outcomes among adolescents. This study examines community members’ perceptions of how poverty influences adolescent sexual behaviour and outcomes in four districts of Nyanza Province, Kenya.
Eight study sites within the four districts were randomly selected. Focus group discussions were conducted with a purposive sample of adolescents, parents and caregivers. Key informant interviews were undertaken with a purposive sample of community leaders, child welfare and healthcare workers, and adolescents. The two methods elicited information on factors perceived to predispose adolescent orphans and non-orphans to sexual risks. Data were analysed through line-by-line coding, grouped into families and retrieved as themes and sub-themes.
Participants included 147 adolescents and parents/caregivers in 14 focus groups and 13 key informants. Poverty emerged as a key predisposing factor to sexual risk behaviour among orphans and non-orphans. Poverty was associated with lack of food, poor housing, school dropout, and engaging in income generating activities, all of which increase their vulnerability to transactional sex, early marriage, sexual experimentation, and the eventual consequences of increased risk of unintended pregnancies and STI/HIV.
Poverty was perceived to contribute to increasing sexual risks among orphan and non-orphan adolescents through survival strategies adopted to be able to meet their basic needs. Policies for prevention and intervention that target adolescents in a generalized poverty and HIV epidemic should integrate economic empowerment for caregivers and life skills for adolescents to reduce vulnerabilities of orphan and non-orphan adolescents to sexual risk behaviour.
Poverty; Orphan; Non-orphan; Adolescents; Sexual risk behaviour
In South Africa, it is illegal for adolescents under age 16 years to engage in any sexual behaviour whether kissing, petting, or penetrative sex, regardless of consent. This cross-sectional study investigated the extent to which young adolescents engage in various sexual behaviours and the associations between dating status and sexual behaviours.
Grade 8 adolescents (N = 474, ages 12–15 years, mean = 14.14 years) recruited from Cape Town schools completed surveys providing information about their sociodemographic backgrounds, dating experience, sexual behaviour, and substance use.
Lower hierarchy sexual behaviours, such as kissing (71.4% of girls; 88.4% of boys), were more common than oral (3.9% of girls; 13.8% of boys), vaginal (9.3% of girls; 30.0% of boys), or anal (1.4% of girls; 10.5% of boys) sex. Currently dating girls and boys were more likely to engage in sexual behaviours including several risk behaviours in comparison to their currently non-dating counterparts. These risk behaviours included penetrative sex (21.1% of dating vs. 4.5% of non-dating girls; 49.4% of dating vs. 20.2% of non-dating boys), sex with co-occurring substance use (22.2% of dating vs. 0 non-dating girls; 32.1% of dating vs. 40% of non-dating boys), and no contraceptive use (26.1% of sexually experienced girls; 44.4% of sexually experienced boys). Among girls, there were significant associations between ever having penetrative sex and SES (OR = 2.592, p = 0.017) and never dating (OR = 0.330, p = 0.016). Among boys, there were significant associations between ever having penetrative sex and never dating (OR = 0.162, p = 0.008). Although the currently dating group of young adolescents appear to be a precocious group in terms of risk behaviour relative to the currently non-dating group, teenagers in both groups had experience in the full range of sexual behaviours.
Many young adolescents are engaging in a variety of sexual behaviours ranging from kissing and touching to intercourse. Of particular concern are those engaging in risky sexual behaviour. These findings indicate that adolescents need to be prepared for sexual negotiation and decision-making from an early age through comprehensive and accessible education and health services; sections of current legislation may be a barrier to adopting such policies and practices.
Adolescent; Sexual behaviour; Courtship; South Africa; Health policy; Health legislation
Immunization is one of the most effective ways of preventing illness, disability and death from infectious diseases for older people. However, worldwide immunization rates are still low, particularly for the most vulnerable groups within the elderly population. The objective of this study was to estimate the effect of the Oportunidades -an incentive-based poverty alleviation program- on vaccination coverage for poor and rural older people in Mexico.
Cross-sectional study, based on 2007 Oportunidades Evaluation Survey, conducted in low-income households from 741 rural communities (localities with <2,500 inhabitants) of 13 Mexican states. Vaccination coverage was defined according to three individual vaccines: tetanus, influenza and pneumococcal, and for complete vaccination schedule. Propensity score matching and linear probability model were used in order to estimate the Oportunidades effect.
12,146 older people were interviewed, and 7% presented cognitive impairment. Among remaining, 4,628 were matched. Low coverage rates were observed for the vaccines analyzed. For Oportunidades and non-Oportunidades populations were 46% and 41% for influenza, 52% and 45% for pneumococcal disease, and 79% and 71% for tetanus, respectively. Oportunidades effect was significant in increasing the proportion of older people vaccinated: for complete schedule 5.5% (CI95% 2.8-8.3), for influenza 6.9% (CI95% 3.8-9.6), for pneumococcal 7.2% (CI95% 4.3-10.2), and for tetanus 6.6% (CI95% 4.1-9.2).
The results of this study extend the evidence on the effect that conditional transfer programs exert on health indicators. In particular, Oportunidades increased vaccination rates in the population of older people. There is a need to continue raising vaccination rates, however, particularly for the most vulnerable older people.
Older people; Vaccination coverage; Conditional cash transfer; Propensity score matching
Foreign policy holds great potential to improve the health of a global citizenship. Our contemporary political order is, in part, characterized by sovereign states acting either in opposition or cooperation with other sovereign states. This order is also characterized by transnational efforts to address transnational issues such as those featured so prominently in the area of global health, such as the spread of infectious disease, health worker migration and the movement of health-harming products. These two features of the current order understandably create tension for truly global initiatives.
National security has become the dominant ethical frame underlying the health-based foreign policy of many states, despite the transnational nature of many contemporary health challenges. This ethical approach engages global health as a means to achieving national security objectives. Implicit in this ethical frame is the version of humanity that dichotomizes between “us” and “them”. What has been left out of this discourse, for the most part, is the role that foreign policy can play in extending the responsibility of states to protect and promote health of the other, for the sake of the other.
The principal purpose of this paper is to review arguments for a cosmopolitan ethics of health-based foreign policy. I will argue that health-based foreign policy that is motivated by security interests is lacking both morally and practically to further global health goals. In other words, a cosmopolitan ethic is not only intrinsically superior as a moral ideal, but also has potential to contribute to utilitarian ends. This paper draws on the cosmopolitanism literature to build robust support for foreign policies that contribute to sustainable systems of global health governance.
Uncertainty is regarded as a central dimension in the experience of illness and in the processes of alleviating it. Few studies from resource-poor settings have investigated this and how it interacts with other factors. This study aims to shed light on how healthcare-seeking develops in the context of multiple medical alternatives and to understand what bearing uncertainty has on this process.
The study was conducted in six purposively selected rural communities in Lao PDR. In each community, two focus group discussions were held: first with mothers and then with fathers of children younger than five years old. Eleven in-depth interviews with caregivers of severely sick children were conducted. Subsequently, traditional healers, drug vendors, community health workers, nurses and medical doctors were recruited for interviews or group discussions. The data were transcribed and key themes and similarities were identified. Additional readings were conducted to better understand the interactions of factors during which uncertainty was identified as one of several factors mentioned during interviews and focus group discussions.
Care-seekers expressed a strong preference for initially seeking local providers. Subsequently, multiple providers were consulted to increase the chances of recovery. This resulted in patients leaving the health facilities before recovery and in ending the recommended treatment regime prematurely. These healthcare-seeking decisions reflect the social significance of being a responsible caregiver and of showing respect for household norms. In general, healthcare-seeking was shrouded in uncertainty when it came to selecting the right provider, the likelihood of finding the real cause of the illness, spending savings on treatments and ultimately the likelihood of recovery.
Care-seekers’ initial strong preference for local providers irrespective of the providers’ legitimacy indicates the need for a robust primary healthcare system. Care-seekers’ subsequent consultations must be understood in the light of their uncertainty regarding the skills of the available providers. The social connotations of seeking healthcare including the vulnerability of poor households in public health facilities were taken into account to only a limited extent by health workers. Health workers should have greater awareness of the social and cultural aspects of seeking care.
Healthcare-seeking behavior; Uncertainty; Maternal and child mortality; Qualitative interviews; Lao PDR
The failure to reduce preventable maternal deaths represents a violation of women’s right to life, health, non-discrimination and equality. Maternal deaths result from weaknesses in health systems: inadequate financing of services, poor information systems, inefficient logistics management and most important, the lack of investment in the most valuable resource, the human resource of health workers. Inadequate senior leadership, poor communication and low staff morale are cited repeatedly in explaining low quality of healthcare. Vertical programmes undermine other service areas by creating competition for scarce skilled staff, separate reporting systems and duplication of training and tasks.
Confidential enquiries and other quality-improvement activities have identified underlying causes of maternal deaths, but depend on the health system to respond with remedies. Instead of separate vertical programmes for management of HIV, tuberculosis, and reproductive health, integration of care and joint management of pregnancy and HIV would be more effective. Addressing health system failures that lead to each woman’s death would have a wider impact on improving the quality of care provided in the health service as a whole. More could be achieved if existing resources were used more effectively. The challenge for African countries is how to get into practice interventions known from research to be effective in improving quality of care. Advocacy and commitment to saving women’s lives are crucial elements for campaigns to influence governments and policy -makers to act on the findings of these enquiries. Health professional training curricula should be updated to include perspectives on patients’ rights, communication skills, and integrated approaches, while using adult learning methods and problem-solving techniques.
In countries with high rates of Human Immunodeficiency Virus (HIV), indirect causes of maternal deaths from HIV-associated infections now exceed direct causes of hemorrhage, hypertension and sepsis. Advocacy for all pregnant HIV-positive women to be on anti-retroviral therapy must extend to improvements in the quality of service offered, better organised obstetric services and integration of clinical HIV care into maternity services. Improved communication and specialist support to peripheral facilities can be facilitated through advances in technology such as mobile phones.
Maternal mortality; HIV; Health systems; Quality of obstetric care; Southern Africa; Integrated HIV and maternity services
Studies that have looked at the effect of polio eradication efforts in India on routine immunization programs have provided mixed findings. One polio eradication project, funded by US Agency for International Development (USAID) and carried out by the CORE Group Polio Project (CGPP) in the state of Uttar Pradesh of India, has included the strengthening of routine immunization systems as a core part of its polio eradication strategy. This paper explores the performance of routine immunization services in the CGPP intervention areas concurrent with intensive polio eradication activities. The paper also explores determinants of routine immunization performance such as caretaker characteristics and CGPP activities to strengthen routine immunization services.
We conduct secondary data analysis of the latest project household immunization survey in 2011 and compare these findings to reports of past surveys in the CGPP program area and at the Uttar Pradesh state level (as measured by children’s receipt of DPT vaccinations). This is done to judge if there is any evidence that routine immunization services are being disrupted. We also model characteristics of survey respondents and respondents’ exposure to CGPP, communication activities against their children’s receipt of key vaccinations in order to identify determinants of routine immunization coverage.
Routine immunization coverage has increased between the first survey (2005 for state level estimates, 2008 for the CGPP program) and the latest (2011 for both state level and CGPP areas), as measured by children’s receipt of DPT vaccination. This increase occurred concurrent with polio eradication efforts intensive enough to result in interruption of transmission. In addition, a mothers’ exposure to specific communication materials, her religion and education were associated with whether or not her children receive one or more doses of DPT.
A limitation of the analysis is the absence of a controlled comparison. It is possible routine immunization coverage would have increased even more in the absence of polio eradication efforts. At the same time, however, there is no evidence that routine immunization services were disrupted by polio eradication efforts. Targeted health communications are helpful in improving routine immunization performance. Strategies to address other determinants of routine immunization, such as religion and education, are also needed to maximize coverage.
Sexual abuse of boys is a neglected problem in many developing countries including Ethiopia. As a result, its prevalence, contributing factors and circumstance in which sexual abuse occurs are largely unknown. The objective of this study is to determine the prevalence and factors associated with sexual abuse of male high school students in Addis Ababa city administration.
A cross-sectional descriptive study involving 884 randomly selected students of nine high schools in Addis Ababa was conducted in March 2009. A pre-tested questionnaire was used to collect data. Analysis of the data was made using SPSS for windows version 15.
This study indicates the life time prevalence of rape and sexual harassment of boys in Addis Ababa were 4.3%, and 68.2%, respectively. The chance of experiencing sexual coercion was higher among students who live alone (AOR = 2.87; 95% CI; 1.07, 7.66) and among students who live with others (AOR =1.80; 95% CI = 1.04, 3.11) than those living with both parents. Similarly, the odds of experiencing rape in their life time was higher among students who live with others (AOR=2.20; 95% CI; 1.04, 4.68) than those who live with their parents.
Sexual abuse of male students is not uncommon in Addis Ababa. It is higher in those living alone or not living with their parents. Due attention is needed by schools, parents and other concerned bodies. Designing a program to fight against sexual abuse should include young school boys.
Sexual abuse; Rape; Male students
Vaccination is a cost-effective public health measure and is central to the Millennium Development Goal of reducing child mortality. However, childhood vaccination coverage remains sub-optimal in many settings. While communication is a key feature of vaccination programmes, we are not aware of any comprehensive approach to organising the broad range of communication interventions that can be delivered to parents and communities to improve vaccination coverage. Developing a classification system (taxonomy) organised into conceptually similar categories will aid in: understanding the relationships between different types of communication interventions; facilitating conceptual mapping of these interventions; clarifying the key purposes and features of interventions to aid implementation and evaluation; and identifying areas where evidence is strong and where there are gaps. This paper reports on the development of the ‘Communicate to vaccinate’ taxonomy.
The taxonomy was developed in two stages. Stage 1 included: 1) forming an advisory group; 2) searching for descriptions of interventions in trials (CENTRAL database) and general health literature (Medline); 3) developing a sampling strategy; 4) screening the search results; 5) developing a data extraction form; and 6) extracting intervention data. Stage 2 included: 1) grouping the interventions according to purpose; 2) holding deliberative forums in English and French with key vaccination stakeholders to gather feedback; 3) conducting a targeted search of grey literature to supplement the taxonomy; 4) finalising the taxonomy based on the input provided.
The taxonomy includes seven main categories of communication interventions: inform or educate, remind or recall, teach skills, provide support, facilitate decision making, enable communication and enhance community ownership. These categories are broken down into 43 intervention types across three target groups: parents or soon-to-be-parents; communities, community members or volunteers; and health care providers.
Our taxonomy illuminates and organises this field and identifies the range of available communication interventions to increase routine childhood vaccination uptake. We have utilised a variety of data sources, capturing information from rigorous evaluations such as randomised trials as well as experiences and knowledge of practitioners and vaccination stakeholders. The taxonomy reflects current public health practice and can guide the future development of vaccination programmes.
Childhood; Vaccination; Immunisation; Communication; Low- and middle-income country; Intervention; Consumer; Taxonomy; Parents
Millions of African children are having to grow up under harsh and adverse psychosocial conditions but it’s not fully understood how this negative psychosocial environment is affecting their mental health. This paper examines the prevalence and risk factors of depression in childhood and adolescence as seen in a community sample derived from four disadvantaged districts in north-eastern Uganda.
1587 children were assessed using a structured instrument administered by trained psychiatric nurses to collect data on psychiatric disorders (DSM IV criteria), adverse psychosocial factors and socio-demographic factors.
The point prevalence of depressive disorder syndromes (DDS) in this study was 8.6% (95% CI 7.2%–10.1%) with a point prevalence for major depressive episode of 7.6% (95% CI 6.3%–9.0%) and dysthymia of 2.1% (95% CI 1.5%–3.0%). At multiple logistic regression, the factors that were independently significantly associated with DDS were: district (representing ecological factors), nature of living arrangements, domestic violence and psychiatric co-morbidities/psychiatric problems of emotional distress (assessed by the SDQ), suicidality and marginally, anxiety disorder syndromes, eating disorder syndromes, motor disorder syndromes and behavioral and developmental disorder syndromes (the later being protective against depression).
Disadvantaged north-eastern Uganda had a high prevalence of childhood depressive disorders. Ecological factors, markers of the quality of the child-principal caregiver relationship (nature of living arrangements and domestic violence) and the presence of psychiatric co-morbidities/psychiatric problems were the important independent determinants of childhood depression in this study.
The increasingly recognized need for reorganizing the primary health care services in Iraq calls for a comprehensive assessment of the system to better understand its problems and needs for development. As part of such comprehensive assessment and due to the important role of primary health care providers in adopting any change, we ought to explore the range and diversity of viewpoints of primary health care providers towards the Iraqi primary health care system.
This explorative study was carried out in Erbil governorate, Iraq from May to July 2011. Data were collected from primary health care providers using Q-methodology to elicit subjective viewpoints and identify shared patterns among individuals. Forty primary health care providers representing eight primary health care centers sorted 41 statements reflecting different aspects of the Iraqi primary health care system into a distribution on a scale of nine from “disagree most” to “agree most”. By-person factor analysis was used to derive latent viewpoints through centroid factor extraction and varimax rotation of factors.
Analysis of the participants’ Q-sorts resulted in four distinct viewpoints among primary health care providers toward the current primary health care system. One factor emphasized positive aspects of the current primary health care system that is content with the current primary health care system. The other three factors highlighted the negative aspects and they included (i) professionally-centered viewpoint, (ii) comprehensive perception and problem-based solutions and (iii) critical to leadership/governance aspects of the system.
This study revealed diverse viewpoints of primary health care providers toward the current Iraqi primary health care system and recognized the particular issues related to each viewpoint. The findings can contribute to a better understanding of health policy makers and primary health care managers concerning the problems facing the primary health care system that might contribute to change in the management of this system.
Primary health care; Q-methodology; Providers; Assessment