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1.  The fallacy of coverage: uncovering disparities to improve immunization rates through evidence. Results from the Canadian International Immunization Initiative Phase 2 - Operational Research Grants 
Immunization can and does save lives. However, the presence of vaccines does not easily translate into every child being vaccinated, and this is what the studies in this journal supplement reveal. From South Asia to West Africa,the evidence presented here reveals what we are calling the fallacy of coverage, going beyond uncovering the real vaccination rates to providing evidence on the reasons for the lack of effective coverage.
The evidence for the fallacy of coverage is part of an operational research program entitled the Canadian International Immunization Initiative Phase 2 (CIII2). Through a competitive peer review process, six research grants were awarded to increase access to and enhance immunization services. This journal supplement provides a forum for the presentation of the results of five of the six studies.
The story of the fallacy of coverage is made up of five theme areas of evidence - timeliness of immunization, social and gender inequities, vaccine efficacy, understanding demand side issues to tailor interventions, and national data sets masking actual district level coverage rates - that reveal the discrepancies in immunization coverage rates and the reasons behind these discrepancies. As part of the story, and to turn around the fallacy of coverage, the studies also provide proof of effective and locally relevant solutions.
Policies and funding, while keeping an eye on future diseases, clearly need to maintain and increase support to address existing vaccine-preventable diseases to increase coverage such that by 2015 we can achieve 90% national vaccination coverage and reach the MDG of reducing mortality rates among children under five by two-thirds.The results from the operational research grants of the CIII2 offer some answers on how to reach this goal by demonstrating how locally generated evidence can inform immunization strategies to ensure that children who need to get vaccinated will get vaccinated, and vaccinated on time.
PMCID: PMC3226229  PMID: 19828053
5.  Structure, (governance) and health: authors reply 
This is a reply to the paper entitled Structure, (governance) and health: an unsolicited response by Daniel D Reidpath and Pascale Allotey
PMCID: PMC1790906  PMID: 17257404
6.  Why Muslim women in Northern Ghana do not use skilled maternal healthcare services at health facilities: a qualitative study 
Muslim women are one sub-population in Ghana among whom the rate of skilled maternal health services accessibility and utilisation is very low. However, there are no studies in Ghana that explore the maternity needs and care experiences of Muslim women, and why they do not utilise maternal healthcare services at health facilities. The purpose of this paper is to explore the maternity healthcare needs and care experiences of Muslim women and the barriers to accessing and using maternal health services.
Qualitative research was conducted with 94 Muslim women in three communities in northern Ghana between November 2011 and May 2012. Data were analysed using the Attride-Stirling’s thematic network analysis framework.
Findings suggest that although Muslim women do want to receive skilled care in a health facility, they often experience difficulties with accessing and using such services. These difficulties were often conditioned by a religious obligation to maintain bodily sanctity through modest dressing and the avoidance of unlawful bodily exposure or contact with certain people including male or alien caregivers. Other related access barriers include lack of privacy, healthcare providers’ insensitivity and lack of knowledge about Muslim women’s religious and cultural practices, and health information that lacked the cultural and religious specificity to meet Muslim women’s maternity care needs.
Maternal healthcare services designed to meet the needs of mainstream non-Muslim Ghanaian women might lack the flexibility and responsiveness to meet the unique maternity care needs of Muslim women. Recommendations for change include cultural competence training for healthcare providers and cultural/religious matching to meet Muslim women’s care needs and to enhance their care experience.
PMCID: PMC4417257  PMID: 25928326
Northern Ghana; Maternal health; Maternal healthcare access; Religion; Islam; Muslim women
7.  Neonatal care practice and factors affecting in Southwest Ethiopia: a mixed methods study 
A significant proportion of neonatal mortality can be prevented by the provision of the minimum neonatal care package. However, about 3 million neonates die each year globally because of lack of appropriate care. This situation is the worst in Ethiopia. Thus, the objective of this study was to determine the status of neonatal care and identify factors affecting.
A mixed methods study involving both quantitative and qualitative methods was conducted from September 2012-December 2013 in Southwest Ethiopia. Randomly selected sample of 3463 mothers were interviewed to collect the quantitative data. Twelve in-depth interviews with purposively selected key informants and six focus-group discussions with purposively selected mothers were conducted for the qualitative data. Mixed-effects multilevel linear regression model was used to identify predictors of neonatal care practice by using STATA 13. Audio recording, transcription and thematic content analysis was done for the qualitative data.
The overall status of neonatal care practice was 59.5 % (95 % CI: 57.6 %, 61.3 %). Of the respondents, 53.8 % received tetanus toxoid, 23.8 % planed for birth, 41.9 % received at least one antenatal care and 43.0 % received adequate information during pregnancy. Only, 17.5 % received skilled care at birth and 95.0 % received social support. Of the neonates, 96.5 % received appropriate thermal care, 86.5 % received clean cord care, 64.1 % initiated breast-feeding within one hour, 91.5 % were on exclusive breast-feeding, 56.5 % received appropriate bathing and 8.1 % received vaccination on date of birth. Place of residence, maternal education, husband’s occupation, wealth quintiles, birth order and inter-birth interval were identified as predictors of neonatal care practice.
The status of neonatal care practice was low in the study area. Skilled care at birth and receiving vaccination on date of birth were the worst practices. Factors affecting neonatal care existed both at cluster level and at the individual level and included socio demographic, economic and obstetric factors. Appropriate birth spacing, birth limiting and behaviour change communications on the importance of neonatal care are recommended.
PMCID: PMC4506762  PMID: 26188651
Neonatal care practice; Factors affecting neonatal care; Southwest Ethiopia; Multilevel linear regression; Mixed methods study
8.  Universal health coverage from multiple perspectives: a synthesis of conceptual literature and global debates 
There is an emerging global consensus on the importance of universal health coverage (UHC), but no unanimity on the conceptual definition and scope of UHC, whether UHC is achievable or not, how to move towards it, common indicators for measuring its progress, and its long-term sustainability. This has resulted in various interpretations of the concept, emanating from different disciplinary perspectives. This paper discusses the various dimensions of UHC emerging from these interpretations and argues for the need to pay attention to the complex interactions across the various components of a health system in the pursuit of UHC as a legal human rights issue.
The literature presents UHC as a multi-dimensional concept, operationalized in terms of universal population coverage, universal financial protection, and universal access to quality health care, anchored on the basis of health care as an international legal obligation grounded in international human rights laws. As a legal concept, UHC implies the existence of a legal framework that mandates national governments to provide health care to all residents while compelling the international community to support poor nations in implementing this right. As a humanitarian social concept, UHC aims at achieving universal population coverage by enrolling all residents into health-related social security systems and securing equitable entitlements to the benefits from the health system for all. As a health economics concept, UHC guarantees financial protection by providing a shield against the catastrophic and impoverishing consequences of out-of-pocket expenditure, through the implementation of pooled prepaid financing systems. As a public health concept, UHC has attracted several controversies regarding which services should be covered: comprehensive services vs. minimum basic package, and priority disease-specific interventions vs. primary health care.
As a multi-dimensional concept, grounded in international human rights laws, the move towards UHC in LMICs requires all states to effectively recognize the right to health in their national constitutions. It also requires a human rights-focused integrated approach to health service delivery that recognizes the health system as a complex phenomenon with interlinked functional units whose effective interaction are essential to reach the equilibrium called UHC.
PMCID: PMC4491257  PMID: 26141806
Universal health coverage; Multi-dimensional concept; Rights-based; Population coverage; Financial protection; Access to health services; Health system; Conceptual literature; Global debates
9.  Understanding healthcare practices in superdiverse neighbourhoods and developing the concept of welfare bricolage: Protocol of a cross-national mixed-methods study 
Diversity in Europe has both increased and become more complex posing challenges to both national and local welfare state regimes. Evidence indicates specific barriers for migrant, faith and minority ethnic groups when accessing healthcare. However, previous studies of health in diverse cities in European countries have mainly adopted an ethno-national focus. Taking into account the new complexity of diversity within cities, a deeper and multi-faceted understanding of everyday health practices in superdiverse contexts is needed to support appropriate healthcare provision.
This protocol describes a mixed method study investigating how residents in superdiverse neighbourhoods access healthcare. The study will include participant observation and qualitative interviewing as well as a standardised health survey and will be carried out in eight superdiverse neighbourhoods – with varying deprivations levels and trajectories of change – in four European countries (Germany, Portugal, Sweden and UK). In each neighbourhood, trained polylingual community researchers together with university researchers will map formal and informal provision and infrastructures supportive to health and healthcare. In-depth interviews with residents and healthcare providers in each country will investigate local health-supportive practices. Thematic analysis will be used to identify different types of help-seeking behaviours and support structures across neighbourhoods and countries. Using categories identified from analyses of interview material, a health survey will be set up investigating determinants of access to healthcare. Complex models, such as structural equation modelling, will be applied to analyse commonalities and differences between population groups, neighbourhoods and countries.
This study offers the potential to contribute to a deeper understanding of how residents in superdiverse neighbourhoods deal with health and healthcare in everyday practices. The findings will inform governmental authorities, formal and informal healthcare providers how to further refine health services and how to achieve equitable access in diverse population groups.
PMCID: PMC4501194  PMID: 26117380
Access to healthcare; Health inequality; Superdiversity; Welfare state; Bricolage
10.  Cross-sectional analysis of self-efficacy and social capital in a community-based healthy village project in Santa Cruz, Bolivia 
An assessment of self-efficacy and social capital may have the potential to detect an effect of dynamic, complex and comprehensive collective actions in community-based health promotion. In 2003, a healthy village project was launched in Santa Cruz, Bolivia with technical assistance from the Japan International Cooperation Agency (JICA). The originally developed FORSA (Fortalecimiento de Redes de Salud) model accounted for participatory processes in which people could improve their health and well-being through individual behavioral changes and family/community-driven activities. This study aimed to examine the extent of self-efficacy and social capital obtained via project activities by a cross-sectional analysis.
We randomly selected 340 subjects from the healthy village project site and 113 subjects from a control area. Both groups were interviewed using the same structured questionnaire. Self-efficacy was assessed with a General Self-Efficacy Scale (GSES), while social capital was measured as the frequency of formal group participation in community meetings during the past three months, perceived social solidarity, and general trust.
The study results showed that the participants in the project site had higher self-efficacy and social capital compared to those in the control site. The number of times a subject participated in the health committee activities was positively associated with the self-efficacy scale. Regarding social capital, females and lower-educated people were more likely to have had more frequent participation in formal groups; males and higher-educated participants showed less formal group participation, but more generosity to contribute money for the community. The main perceived benefit of participation in formal group activities varied among individuals.
The findings suggest that people in the healthy village project site have higher self-efficacy, especially those with active participation in the health committee activities. To recruit more participants in future healthy village projects, we should consider the gender and level of education, and match the perceived benefits of participants accordingly.
PMCID: PMC4475302  PMID: 26092283
Health promotion; Self-efficacy; Social capital; Bolivia
11.  Socioeconomic determinants of birth registration in Ghana 
Identity registration is not only a matter of human rights but it also serves as an important instrument for planning about health, education and overall development. This paper examines the chances of a child born in Ghana between 2001 and 2006 obtaining legal status of identity.
Data for this paper were extracted from the 2006 Ghana Multiple Indicator Cluster Survey (MICS). We used discrete choice modelling in estimating the likelihood of child registration in Ghana.
Mother’s education and household wealth are identified to be positively associated with the likelihood of a child being registered. In the context of structural factors, being a resident in the Eastern region of Ghana and rural areas were found to be risk factors for children not being registered. Besides, children who were resident in households where the head is affiliated to Traditional Religion were found to be at significant risk of being unregistered.
Overall, our findings give an impression of birth registration being a privilege for children whose parents are educated, wealthy and resident in urban communities. Policies meant to increase uptake have to be broad-based, targeting the less privileged particularly with practical interventions such as transport vouchers to registration centres. This may help appropriate meaning to international protocols on birth registration as a human right issue to which Ghana affirms.
PMCID: PMC4465725  PMID: 26072313
Birth registration; Right; Privilege; Ghana
12.  Migration-related detention centers: the challenges of an ecological perspective with a focus on justice 
In recent years, border control and migration-related detention have become increasingly widespread practices affecting the lives of undocumented migrants, their families, and communities at large. In spite of the concern within academia, few studies have directly witnessed the life and experiences of people confined to migration-related detention centers. In the medical and psychological fields, a considerable body of research has demonstrated the pathogenic nature of detention in terms of mental health, showing an association between length of detention and severity of distress. Nevertheless, it was limited to the assessment of individuals’ clinical consequences, mainly focusing on asylum seekers. There currently exists a need to adopt an ecological perspective from which to study detained migrants’ experiences as context-dependent, and influenced by power inequalities. This paper addresses this gap.
Drawing upon advances in community psychology, we illustrate an ecological framework for the study of migration-related detention contexts, and their effects on the lives of detained migrants and all people exposed to them. Making use of existing literature, Kelly’s four principles (interdependence, cycling of resources, adaptation, succession) are analyzed at multiple ecological levels (personal, interpersonal, organizational, communal), highlighting implications for future research in this field. A focus on justice, as a key-dimension of analysis, is also discussed. Wellbeing is acknowledged as a multilevel, dynamic, and value-dependent phenomenon.
In presenting this alternative framework, the potential for studying migration-related detention through an ecological lens is highlighted, pointing the way for future fields of study. We argue that ecological multilevel analyses, conceptualized in terms of interdependent systems and with a focus on justice, can enhance the comprehension of the dynamics at play in migration-related detention centers, providing an effective tool to address the multi-level challenges of doing research within them. Furthermore, they can contribute to the development of policies and practices concerned with health, equality, and human rights of all people exposed to migration-related detention. Consistent with these assumptions, empirical studies adopting such a framework are strongly encouraged. These studies should use mixed and multi-method culturally situated designs, based on the development of collaborative and empowering relationships with participants. Ethnographic approaches are recommended.
PMCID: PMC4458055  PMID: 26048135
Migration-related detention; Undocumented migration; Ecological perspective; Justice; Health; Equality; Human rights
13.  Clinics and Churches: lifeworlds and health-seeking practices of older women with noncommunicable disease in rural South Africa 
In this article we describe a phenomenological lifeworld study based on the theory of communicative action of 13 women with noncommunicable disease (NCDs) in a rural area in South Africa. The purpose of the study was to generate key concepts of health care access and the management of NCDs in a rural South African context.
The study employed a qualitative methodology with serial semistructured interviews. We used a content analytical approach to analyse key themes and patterns in participants’ narratives of NCDs and health care access.
The findings are reported by theme and include analyses of narrative sequences related to 1) family environment, 2) experiences of NCDs, 3) understandings of the causes of NCDs, 4) accessibility of formal health care services, 5) experiences of formal health care services, 6) treating NCDs, and 7) experiences of informal health care services. The findings suggest that participation in the routines prescribed by formal health care services and reinforced by families and faith-based communities normalises the experience of NCDs to the extent that narratives of NCDs form the background, rather than the focus of broader illness narratives. Such narratives rather tend to focus on significant life events and relationships. The key features of the narratives include connections between social or autobiographical and biological understandings of NCDs, the appropriation of modern concepts of disease in illness narratives, and reflexive commentary on the modern features of NCDs. In the context of such narrative expertise formal health care services have a high level of acceptability in this rural area.
Lifeworld analysis of health care access based on the theory of communicative action places consensual understandings of NCDs and their treatment as central to the health care experience. Our findings suggest that such analyses can facilitate potential feedback processes between health care users and professionals which generate consensus as well as institutional reform within formal health care services.
PMCID: PMC4445983  PMID: 26017870
Lifeworld; Theory of communicative action; Healthcare; Access to; Healthcare; Remote/Rural; Healthcare; Users’ experiences; Health seeking; Illness and disease; Chronic
14.  Health and human rights: a statistical measurement framework using household survey data in Uganda 
Health is intertwined with human rights as is clearly reflected in the right to life. Promotion of health practices in the context of human rights can be accomplished if there is a better understanding of the level of human rights observance. In this paper, we evaluate and present an appraisal for a possibility of applying household survey to study the determinants of health and human rights and also derive the probability that human rights are observed; an important ingredient into the national planning framework.
Data from the Uganda National Governance Baseline Survey were used. A conceptual framework for predictors of a hybrid dependent variable was developed and both bivariate and multivariate statistical techniques employed. Multivariate post estimation computations were derived after evaluations of the significance of coefficients of health and human rights predictors.
Findings, show that household characteristics of respondents considered in this study were statistically significant (p < 0.05) to provide a reliable assessment of human rights observance. For example, a unit increase of respondents’ schooling levels results in an increase of about 34% level of positively assessing human rights observance. Additionally, the study establishes, through the three models presented, that household assessment of health and human rights observance was 20% which also represents how much of the entire continuum of human rights is demanded.
Findings propose important evidence for monitoring and evaluation of health in the context human rights using household survey data. They provide a benchmark for health and human rights assessments with a focus on international and national development plans to achieve socio-economic transformation and health in society.
PMCID: PMC4429314  PMID: 25935737
Human rights; Health indicators; Statistical models; Household survey
15.  Perceptions on the right to adequate food after a major landslide disaster: a cross-sectional survey of two districts in Uganda 
Despite the instruments on the right to adequate food adopted by the United Nations, there exists limited information on how this right is perceived. Following a major 2010 landslide disaster in the Bududa district of Eastern Uganda and the resettlement of some affected households into the Kiryandongo district in Western Uganda, we surveyed both districts to explore perceptions about the right to adequate food among households with different experiences; disaster-affected and controls.
We deployed qualitative and quantitative techniques to a cross-sectional survey. The index respondent was the head of each randomly selected household from the landslide affected communities and controls from a bordering sub-county. Data was collected by interviews and focus group discussions (FGDs). Structured entries were tested statistically to report associations using Pearson’s Chi-square at the 95% CI. Information from FGDs was transcribed, coded, sequenced and patterned. Findings from both techniques were triangulated to facilitate interpretations.
Analysis included 1,078 interview entries and 12 FGDs. Significant differences between the affected and control households (P < 0.05) were observed with: age; education level; religious affiliation; existence of assets that complement food source; and having received relief food. Analysis between groups showed differences in responses on: whether everyone has a right to adequate food; who was supposed to supply relief food; whether relief food was adequate; and preferred choice on the means to ensure the right to adequate food. FGDs emphasized that access to land was the most important means to food and income. Affected households desired remedial interventions especially alternative land for livelihood. Despite the provision of adequate relief food being a state’s obligation, there was no opportunity to exercise choice and preference. Comprehension and awareness of accountability and transparency issues was also low.
Though a significant proportion of participants affirmed they have a right to adequate food, relief food was largely perceived as insufficient. Given the high regard for land as a preferred remedy, a resettlement policy is of the essence to streamline post-landslide displacement and resettlement. Information materials need to be assembled and disseminated to stimulate awareness and debate on the right to adequate food.
PMCID: PMC4419398  PMID: 25909355
Rights holders’; Perceptions; Right to adequate food; Landslide; Uganda
16.  War trauma and torture experiences reported during public health screening of newly resettled Karen refugees: a qualitative study 
Karen refugees have suffered traumatic experiences that affect their physical and mental health in resettlement. The United States Centers for Disease Control and Prevention recommends assessing traumatic histories and mental health symptoms during initial public health screening. This article reports the traumatic experiences that Karen refugees were able to describe during a short screening and contributes knowledge to existing human rights documentation systems.
Four semi-structured and open-ended items asked about lifetime experiences of war trauma and torture. Interviews were completed with adult, Karen refugees during their initial public health screening. Experiences of war trauma and torture were coded using the extensive Human Rights Information and Documentation (HURIDOCS) Micro-thesauri coding system. Additional codes were created to describe experiences not captured by existing codes.
Over 85% of 179 Karen people interviewed experienced life-threatening war trauma. All participants who reported war trauma or torture stories were able to describe at least one event. New war trauma codes proposed include: widespread community fear, systematic destruction/burning of house or village, exposure to dead bodies, orphaned in the context of war, injury caused by a landmine, fear of Thai police or deportation from Thailand, and harm or killings in the context of war. New torture codes include: forced portering; forced to be a human landmine sweep; forced to be a soldier, including child soldier; forced contact with a dead body; and removal of the eyes.
Karen refugees were able to report traumatic experiences in the context of a brief health screening. The findings confirm existing reports of human rights violations against Karen people and suggest that additional codes be added to the HURIDOCS Micro-thesauri system that is used by torture treatment centers. Understanding the nature of traumatic experiences of this group is important for health providers working with resettled Karen refugees in their countries of resettlement. Health providers may need specialized training to understand the traumatic histories of this new refugee group, learn how to initiate conversations about trauma and its impact on health, and make appropriate mental health referrals in the context of a brief public health screening.
PMCID: PMC4414007  PMID: 25881236
Karen refugees; Burma; Torture; War trauma; HURIDOCS; Qualitative
17.  Perceptions of the effects of armed conflict on maternal and reproductive health services and outcomes in Burundi and Northern Uganda: a qualitative study 
Armed conflict potentially poses serious challenges to access and quality of maternal and reproductive health (MRH) services, resulting in increased maternal morbidity and mortality. The effects of armed conflict may vary from one setting to another, including the mechanisms/channels through which the conflict may lead to poor access to and quality of health services. This study aims to explore the effects of armed conflict on MRH in Burundi and Northern Uganda.
This is a descriptive qualitative study that used in-depth interviews (IDIs) and focus group discussions (FGDs) with women, health providers and staff of NGOs for data collection. Issues discussed include the effects of armed conflict on access and quality of MRH services and outcomes, and the mechanisms through which armed conflict leads to poor access and quality of MRH services. A total of 63 IDIs and 8 FGDs were conducted involving 115 participants.
The main themes that emerged from the study were: armed conflict as a cause of limited access to and poor quality of MRH services; armed conflict as a cause of poor MRH outcomes; and armed conflict as a route to improved access to health care. The main mechanisms through which the conflict led to poor access and quality of MRH services varied across the sites: attacks on health facilities and looting of medical supplies in both sites; targeted killing of health personnel and favouritism in the provision of healthcare in Burundi; and abduction of health providers in Northern Uganda. The perceived effects of the conflict on MRH outcomes included: increased maternal and newborn morbidity and mortality; high prevalence of HIV/AIDS and SGBV; increased levels of prostitution, teenage pregnancy and clandestine abortion; and high fertility levels. Relocation to government recognised IDP camps was perceived to improve access to health services.
The effects of armed conflict on MRH services and outcomes are substantial. The mechanisms through which armed conflict leads to poor access and quality of MRH services vary from one setting to another. All these issues need to be considered in the design and implementation of interventions to improve MRH in these settings.
Electronic supplementary material
The online version of this article (doi:10.1186/s12914-015-0045-z) contains supplementary material, which is available to authorized users.
PMCID: PMC4392810  PMID: 25884930
Armed conflict; Effects; Access to healthcare; Quality of healthcare; Maternal health; Impact; Health system
18.  BMC International Health and Human Rights Reviewer Acknowledgement 2014 
Contributing reviewers
The editors of BMC International health and human rights would like to thank all our reviewers who have contributed to the journal in Volume 14 (2014).
PMCID: PMC4358329
19.  Awareness of human papillomavirus and factors associated with intention to obtain HPV vaccination among Korean youth: quasi experimental study 
This study aimed to determine the awareness among fifth-grade girls and boys of sexually transmitted diseases (STDs), cancer, and human papillomavirus (HPV), and to determine the factors associated with intention to obtain the HPV vaccination.
A quasi experimental design was employed with Korean fifth-grade students as the subjects for this study (n=117). Prior to providing HPV education, the awareness and health beliefs regarding STDs and cancer prevention were assessed according to gender. After 2 hours of HPV education, gender comparisons were made with respect to the awareness and health beliefs, HPV knowledge, and intention to obtain the HPV vaccination, and the factors associated with that intention.
Prior to the 2hours education session, only two boys knew that HPV is a virus. There were significant gender differences with respect to responses to the statements “STD is preventable” (χ2=8.76, p=0.013) and “cancer is preventable” (χ2=6.37, p=0.041), and concerns about the pain associated with vaccine injection (z=−2.44, p=0.015). After HPV education, there were no significant gender differences in HPV knowledge and intention to obtain the HPV vaccination. Awareness that “HPV vaccine can prevent cervical cancer” was significantly related to intention to obtain the HPV vaccine among both boys and girls.
Increased HPV knowledge could positively influence the intention to obtain the HPV vaccination among youth. Thus, HPV education at elementary school would be helpful to make students aware of HPV and the importance of HPV prevention.
Electronic supplementary material
The online version of this article (doi:10.1186/s12914-015-0042-2) contains supplementary material, which is available to authorized users.
PMCID: PMC4339239  PMID: 25889565
HPV; Vaccination; Education; Youth
20.  Lessons learned from the development of a new methodology to assess missed opportunities for vaccination in Latin America and the Caribbean 
The Pan American Health Organization recently developed a practical guide for evaluating missed opportunities for vaccination among children aged <5 years. A missed opportunity occurs when an individual eligible for vaccination has contact with a health facility and does not receive a needed vaccine, despite having no contraindications. In this article, we discuss the strengths and limitations of this new methodology and present lessons learned from recent studies on undervaccination in Latin America. Our findings should be useful to countries embarking on assessing the magnitude and the causes of missed opportunities for vaccination children experience at health facilities.
PMCID: PMC4357152  PMID: 25889653
Missed opportunities for vaccination; National immunization programs; Undervaccination; Immunization surveys
21.  Health inequalities: an analysis of hospitalizations with respect to migrant status, gender and geographical area 
The quality of care includes several aspects which may be influenced by social-economic status.
This study analyzes hospitalizations for several conditions, such as chronic diseases, cancer and appendectomy, in Italians and immigrant people living in Italy with the aim to evaluate possible inequalities in the quality of health care services due to migrant status, gender and geographical macro-areas (Northern, Central, Southern Italy).
The data source of hospital discharges for stroke, myocardial infarction, chronic liver disease, cervical cancer, mastectomy and appendectomy was the Ministry of Health. ICD 9 codes were used for data collection. Crude and standardized hospitalization rates per 100.000 were calculated. Italian resident population and an estimate of immigrants living in Italy were used as denominators while standardization was done with respect to the European population. The data we used covers the 2006–2008 period.
Immigrants showed significantly higher hospitalization rates for stroke, cervical cancer and appendectomy and significantly lower hospitalization rates for chronic liver diseases and mastectomy. Males showed significantly higher hospitalization rates than females for myocardial infarction, chronic liver diseases and appendectomy. Notwithstanding, differences related to migrant status and gender varied according to geographical macro-area. With respect to that, Southern Italy showed significantly higher hospitalization rates for stroke, myocardial infarction and chronic liver diseases and significantly lower hospitalization rates for mastectomy and appendectomy.
The results of this study may reflect inequalities in the quality of health care, in particular in primary and secondary prevention, access to specialized care and inappropriateness, due to migrant status and gender. Also, differences between macro-areas suggest heterogeneities in the integration policies and the promotion of immigrants’ health. Research should be endorsed in this field in order to further describe inequalities and their reasons and in the light of supporting policies development.
Electronic supplementary material
The online version of this article (doi:10.1186/s12914-014-0032-9) contains supplementary material, which is available to authorized users.
PMCID: PMC4336515  PMID: 25881154
Inequalities; Immigrant; Hospitalization; Gender; Citizenship; Italy
22.  ‘Disrespectful men, disrespectable women’: Men’s perceptions on heterosexual relationships and premarital sex in a Sri Lankan Free Trade Zone - a qualitative interview study 
Gender norms have been challenged by unmarried rural women’s migration for employment to urban Sri Lankan Free Trade Zones (FTZ). Men are described as looking for sexual experiences among the women workers, who are then accused of engaging in premarital sex, something seen as taboo in this context. Increased sexual and reproductive health and rights (SRHR) risks for women workers are reported. To improve SRHR it is important to understand the existing gender ideals that shape these behaviours. This qualitative study explores men’s perspectives on gender relations in an urban Sri Lankan FTZ, with a focus on heterosexual relationships and premarital sex. Further, possible implications for SRHR of women workers in FTZs are discussed.
Eighteen qualitative semi-structured interviews were conducted with men living or working in an urban Sri Lankan FTZ and were analysed using thematic analysis.
Two conflicting constructions of masculinity; the ‘disrespectful womaniser’ and the ‘respectful partner’, were discerned. The ‘disrespectful womaniser’ was perceived to be predominant and was considered immoral while the ‘respectful partner’ was considered to be less prevalent, but was seen as morally upright. The migrant women workers’ moral values upon arrival to the FTZ were perceived to deteriorate with time spent in the FTZ. Heterosexual relationships and premarital sex were seen as common, however, ideals of female respectability and secrecy around premarital sex were perceived to jeopardize contraceptive use and thus counteract SRHR.
The ‘disrespectful’ masculinity revealed in the FTZ is reflective of the patriarchal Sri Lankan society that enables men’s entitlement and sexual domination over women. Deterioration of men’s economic power and increase of women’s economic and social independence may also be important aspects contributing to men’s antagonistic attitudes towards women. The promotion of negative attitudes towards women is normalized through masculine peer pressure. This and ambivalence towards women’s premarital sex are undermining the SRHR and well-being of women, but also men, in the FTZ. Awareness and counteraction of destructive gender power relations are essential for the improvement of the SRHR of women and men in the FTZ and the surrounding society.
PMCID: PMC4346104  PMID: 25889367
Masculinity; Free Trade Zones; Migrant women workers; Sexual and Reproductive Health and Rights; Qualitative; Sri Lanka
23.  Steps on a journey to TB control in Solomon Islands: a cross-sectional, mixed methods pre-post evaluation of a local language DVD 
In Solomon Islands many people with Tuberculosis (TB) have challenges in accessing services because of socio-cultural, geographic and health service reasons, resulting in delays in TB treatment and low detection rates. The purpose of this project was to (i) develop a local language audio-visual resource (DVD) about TB (ii) share this resource with people in remote villages and (iii) evaluate the process and outcomes.
The project involved the development and evaluation of a DVD in local Kwaio language. The DVD included five short videos based on the Australian Respiratory Council TB Education Flipchart. The DVD also included short videos of: traditional music/chanting (ai’imae); drama that presented an allegory of TB; and a short documentary on the redevelopment of the local TB Ward.
A mixed-methods approach evaluated changes in TB knowledge and investigated the impact of the DVD.
The DVD was recorded and produced in March–June 2013 and screened in 41 villages and hamlets. The pre-post DVD survey was completed by 64% (255/400) of people who viewed the DVD in the villages. Pre-DVD survey responses showed a moderate to high knowledge about TB signs, symptoms and treatment but 76/255 (30%) stated TB was caused by sorcery and 85/255 (33%) incorrectly stated that TB medication should be stopped when a patient feels better.
The post-DVD survey showed a significant increase in people in coastal villages reporting (i) a 3-week cough would trigger a medical assessment and (ii) TB is mainly spread through the air. Statements that TB is not caused by sorcery increased post-DVD in both coastal and mountain villages, however belief in sorcery in mountain villages remained high at 20/70 (29%).
The local DVD resource was developed within local cultural understandings and oral traditions of Kwaio people. Using modern but accessible DVD technology generated a lot of interest about the disease and the stories.
The project evaluation indicates that current delays in seeking treatment may be more due to socio-cultural and health service factors than awareness of the disease. Therefore the development of TB services, including TB education, which are culturally sensitive, remains important.
PMCID: PMC4320437  PMID: 25644087
Tuberculosis; Solomon Islands; Heath education; Culture; Language
24.  Assessment of a couples HIV counseling and testing program for pregnant women and their partners in antenatal care (ANC) in 7 provinces, Thailand 
Couples HIV testing and counseling (CHTC) at antenatal care (ANC) settings allows pregnant women to learn the HIV status of themselves and their partners. Couples can make decisions together to prevent HIV transmission. In Thailand, men were tested at ANC settings only if their pregnant partners were HIV positive. A CHTC program based in ANC settings was developed and implemented at 16 pilot hospitals in 7 provinces during 2009–2010.
Cross-sectional data were collected using standard data collection forms from all pregnant women and accompanying partners who presented at first ANC visit at 16 hospitals. CHTC data for women and partners were analyzed to determine service uptake and HIV test results among couples. In-depth interviews were conducted among hospital staff of participating hospitals during field supervision visits to assess feasibility and acceptability of CHTC services.
During October 2009-April 2010, 4,524 women initiating ANC were enrolled. Of these, 2,435 (54%) women came for ANC alone; 2,089 (46%) came with partners. Among men presenting with partners, 2,003 (96%) received couples counseling. Of these, 1,723 (86%) men and all pregnant women accepted HIV testing. Among 1,723 couples testing for HIV, 1,604 (93%) returned for test results. Of these, 1,567 (98%) were concordant negative, 6 (0.4%) were concordant positive and 17 (1%) were HIV discordant (7 male+/female- and 10 male-/female+). Nine of ten (90%) executive hospital staff reported high acceptability of CHTC services.
CHTC implemented in ANC settings helps identify more HIV-positive men whose partners were negative than previous practice, with high acceptability among hospital staff.
PMCID: PMC4301829  PMID: 25539670
Couples counseling; Pregnant women; ANC; Thailand
25.  Thriving beyond survival: Understanding utilization of perinatal health services as predictors of birth registration: A cross-sectional study 
There are an estimated 35 million unregistered children in Indonesia. To understand ways to best leverage existing health system-related resources and ensure greater protective measures for these vulnerable children, this study explores the predictive relationship between the utilization of perinatal health services and birth certificate ownership in two Indonesian provinces.
This study employed a cross-sectional design with interviewer-administered household surveys to heads of households in West Nusa Tenggara and East Nusa Tenggara from May to July of 2013. The primary outcome of interest was birth certificate ownership among children under the age of 5 years old. Bivariate and multivariable regression analyses using Generalized Estimating Equations (GEE) considered a set of covariates that represented child and household socio-demographic characteristics along with health services utilization variables during pregnancy and post-pregnancy periods.
389 heads of households were interviewed, yielding data on a sample of 451 children under the age of 5. Fewer than 28% of children in this sample possessed a birth certificate. Nearly 57% (n = 259) of children were delivered in a clinical facility, though only 36% (n = 93) of these were legally registered. Of children born in the home (n = 194), registration dropped to 16% (n = 31). Adjusted analyses accounting for socio-demographic factors suggest that children born in a clinic facility (AOR = 2.33, 95% CI: 1.27, 4.33), hospital (AOR = 2.38, 95% CI: 1.12, 5.09), or in the presence of a skilled birth attendant (AOR = 2.35, 95% CI: 1.31, 4.23) were significantly more likely to be registered. Children whose mothers sought post-natal care were 2.99 times more likely to possess a birth certificate (AOR = 2.99, 95% CI: 1.1, 7.57). Pre-natal care was not associated with birth registration.
These findings suggest that use of perinatal health services increases the likelihood of registering a child’s birth despite a lack of formal integration of vital registration with the health sector. Formally leveraging existing community-based health workers and perinatal services may serve to further increase registration rates in hard to reach areas of Indonesia.
PMCID: PMC4302157  PMID: 25528057
Birth registration; Child protection; Health services utilization; Indonesia; Civil registration and vital statistics (CRVS)

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