| 1. |
- Daca, Chanvo Salvador Lucas, 1976-
(författare)
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Making the connections : understanding inequalities in reproductive and child health in Mozambique
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: In Mozambique, despite significant socio-economic and health system challenges, there has been progress in reproductive and child health in recent years. However, there is still a lack of comprehensive studies that thoroughly unravel the socio-economic determinants of health and health inequalities in the country.The overall aim of this thesis was to understand the socio-economic and geographic inequalities in reproductive and child health with the intention of informing and optimizing the implementation of targeted health programmes in Mozambique.Methods: This thesis is based on three sub-studies that used data obtained from population-based health surveys. In sub-study I, prevalence ratios (PRs) with 95% confidence intervals (95% CI) were calculated by log binomial regression to assess the relationship of socio-economic, demographic, and geographic characteristics with three outcomes of interest: insecticide-treated bed nets (ITNs), child immunization coverage and modern contraceptive use. Sub-study II used the concentration index (Cindex) and decomposition analysis to assess the socio-economic and regional contributions to the wealth inequality in health preventive care. Sub-study III estimated absolute risk differences and the slope index of inequality (SII) as the measures of association between the socio-economic variables and the outcomes (ITN use, fever treatment and Fansidar prophylaxis) for the 2015 and 2018 surveys, as well as for the differences between the two time points.Results: The proportion of mothers with at least one child aged under five years that did not use an ITN was 51.01%, while 46.25% of women had children aged one to four years who were not fully immunized and 74.28% of women did not use modern contraceptives. Non-educated mothers and residents of the southern region were more likely to report not using an ITN (PR = 1.36; 95% CI: 1.17–1.59), while those in the lowest wealth quintile had a higher chance of having children who were not fully immunized (PR = 1.34; 95% CI: 1.04–1.71). Similarly, non-educated mothers (PR = 1.17; 95% CI: 1.10–1.25), non-working women (PR = 1.09; 95% CI: 1.04–1.16) and those in the poorest wealth quintile (PR = 1.13; 95% CI: 1.04–1.24) were more likely to not use modern contraception (sub-study I). Sub-study II found a Cindex of -0.081 for non-ITN, -0.189 for a lack of vaccination coverage and -0.284 for non-contraceptive use, showing a worse health outcome among the poorest population. The study revealed that 88.41% of the wealth gap for ITNs was explained by socio-economic factors, with education and wealth playing the largest roles. With regard to the lack of full vaccination, socio-economic factors (47.74%), particularly the wealth quintile (35.79%), emerged as the predominant contributor to the inequality. Similarly, socio-economic factors (39.39%) were also the main explanatory factors for the lack of contraceptive use, but to a lesser degree than for the other two outcomes (sub-study II). Access to health preventive activities increased in all of the three studied outcomes between 2015 and 2018. Significant reductions in ITN inequality were observed for all socio-economic variables, but no decrease of inequalities in fever treatment and Fansidar prophylaxis was found over time (sub-study III).Conclusion: This thesis revealed that bed net use and immunization coverage among children, and modern contraceptive use among women, were notably low. There was inequality, concentrated among the poor, in reproductive and child preventive measures. The greater part of this inequality could be attributed to low wealth and education, as well as to residence in rural areas. Reductions in socio-economic inequalities between 2015 and 2018 were observed for ITN use but not for fever treatment or malaria prophylaxis. Based on these findings, achieving universal health coverage in Mozambique will require an equitable resource distribution among rural regions, increased community education on health preventative measures and health service expansion to socio-economically disadvantaged households.
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| 2. |
- Kambugyiro, Doris Kwesiga, 1981-
(författare)
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Exploring the Under Reporting of Pregnancy and Adverse Pregnancy Outcomes in Population and Health Surveys : A Multi-Country Qualitative Study
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Globally in 2021, an estimated 2.3 million newborn deaths and 1.9 million stillbirths occurred, with highest mortality in sub-Saharan Africa and southern Asia. True mortality is likely higher due to under reporting of pregnancies and Adverse Pregnancy Outcomes (APOs). Accurate data are critical for monitoring and preventing these events but many countries rely on Demographic and Health Surveys (DHS), despite measurement challenges. Few studies have explored reasons for under reporting pregnancy and APOs in low income countries, within surveys and surveillance settings.Objective: To explore enablers and barriers to reporting pregnancy and APOs during population and health surveys in multi-country contexts, informing measurement improvements.Methods: The study was conducted in Uganda, Guinea-Bissau, Ghana, Ethiopia and Bangladesh between 2018 and 2021. Focus group discussions (Study I and II), narratives (Study III) and cognitive interviews (Study IV) were undertaken. Thematic analysis was done for the first three studies and qualitative description for Study IV.Results: Methodological challenges included question framing, where double barrelled questions resulted in wrong answers. There were incorrect definitions for miscarriages and stillbirths. Enablers were mostly around interviewers’ skills like building rapport, probing and empathy. Community barriers comprised socio-cultural factors that encouraged silence, including fear of witchcraft. Stigma towards APOs was common, with some foetal deaths viewed as not human, thus less reported. Informal reporting of APOs within social networks sometimes resulted in social support. Individually, APOs left women and men with negative psychosocial effects like depression, thus their reluctance to report. Nevertheless, some respondents said interviews left them feeling better, especially if the interviewer comforted them. Respondents accepted interviews hoping to receive health education about pregnancy loss.Conclusions: Many adverse pregnancy outcomes are avoidable, but they must be accurately measured before designing appropriate interventions. Surveys like the DHS are globally trusted but this study demonstrates that they have weaknesses and sometimes inaccurate data. Improving measurement requires precise questions, strengthened interviewer training, embedded counseling and health education. Supportive policies encouraging reporting are critical, alongside sensitizing citizens on its importance. Otherwise, APOs shall remain invisible and a continued burden to the mental health of those who experience them.
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| 3. |
- Niemeyer Hultstrand, Jenny, 1990-
(författare)
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Before Being Born : Studies on Preconception Health and Unplanned Pregnancies in Low- and High-Income Settings
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Nearly half of all pregnancies globally are unplanned. They represent a failure to meet individuals’ reproductive health needs and are associated with adverse maternal and child outcomes. Preconception and contraception care can help improving outcomes of pregnancies that are desired, and preventing those that are undesired. The aim of this thesis was to investigate factors that affect individuals and their children before they are born: parental preconception health and pregnancy planning. These phenomena were studied in Sweden and in Eswatini. Furthermore, a counseling tool to improve preconception care called the Reproductive Life Plan (RLP) was evaluated in Eswatini.In Sweden, baseline data from a cohort on pregnant women (n=3,389) of different origin were used. Many Nordic-born women drank alcohol (80% n=2,400) and smoked (20% n=607) preconception. Women born outside Europe were less likely to have these habits but more likely to have an unplanned pregnancy compared with Nordic-born women (AOR 1.37; 95% CI 1.01, 1.88).In Eswatini, data from client records were used (n=1,436). Seven out of ten pregnancies were unplanned (789/1,124). Adolescents had more than two-fold increased odds of unplanned pregnancy compared with women aged 20 or older (AOR 2.39; 95% CI 1.53, 3.75). Women with unplanned pregnancies were less likely to attend antenatal care (AOR 0.68; 95% CI 0.49, 0.95). We collected qualitative data on unplanned pregnancy using focus groups discussions (n=3) with health workers called mentor mothers (n=29). Unplanned pregnancies were thoroughly perceived as negative events with major social and health implications. Driven by poor socioeconomic conditions, young women often engaged in sexual relationships characterized by violence and gender inequality, resulting in unplanned pregnancies. These pregnancies often resulted in neglected children growing up to become vulnerable adolescents at risk of becoming pregnant unintendedly, thus generating a perpetuating cycle of unplanned childbearing.The RLP was used by the mentor mothers in client counseling (n=29). Focus groups discussions (n=7) and a questionnaire were used to collect data. The mentor mothers were key persons in implementing the RLP. Using this tool, they observed progress in pregnancy planning among their clients and thought it improved quality of contraceptive care. The clients' ability to form and achieve their reproductive goals was hindered by contextual factors such as intimate partner violence and limited reproductive health and rights.
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| 4. |
- Al-Adhami, Maissa, 1972-
(författare)
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Health of refugee migrants in the early post-migration phase in Sweden : The role of health resources and health promotion
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In the early post-migration phase, the health and well-being of newly settled refugee migrants is negatively affected by structural factors such as restrictive immigration policies, hostile political discourse and limited housing and work opportunities. There is a need for a better understanding of how individual health resources and health promotion can mitigate the impact of these ongoing stressors. The thesis aimed to explore, assess, and further the understanding of the role of health promotion and individual health resources for health and well-being of newly settled refugee migrants in Sweden.In Study I, six focus group discussions were conducted with 32 newly settled refugees, exploring their perceptions of a Swedish Civic Orientation (CO) course with added health communication. The results showed that the course inspired them to focus on their health, promoted independence and empowerment, and gave new social contacts. However, the course is needed earlier in the post-migration phase and should be adjusted to better fit refugee migrants’ varying pre-existing knowledge. Study II was a cross-sectional study, exploring how individual resources of newly settled refugee migrants (n=787) were associated with self-rated health and psychological well-being. Logistical regression analysis showed that limited health literacy, lack of emotional support, and low self-efficacy were consistently associated with poor health outcomes. In Study III, interviews with 10 civic communicators were performed to explore their perceptions of an in-depth training course on mental health in relation to observed psychological needs among newly settled refugee migrants. The overall result was that the attainment of new knowledge and new tools enabled them to lead reflective conversations about mental health with participants. Mental health needs were perceived to be related to pre- and post-migration experiences. Barriers included stigma and lack of arenas to address mental health needs of refugee migrants.In Study IV, the effectiveness of a regular and an extended CO course was compared in a quasi-experimental study design among newly settled refugee migrants (n=173 and 143 respectively). Linear mixed models and Chi-square analyses showed that the extended course led to a small, but significant increase in health literacy. No significant differences were observed regarding other outcomes (emotional and practical support, general self-rated health, or psychological well-being).The thesis illustrates the potential of early health promotion initiatives focusing on individual health resources to enhance health. However, overarching structural barriers related to living conditions, work opportunities and inclusion must also be addressed.
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| 5. |
- Brunell, Olivia
(författare)
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Improving neonatal health care in Nepal
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Every year, millions of newborns die globally due to poor quality of care around the time of birth. The overall aim of this thesis was to inform and test design of quality improvement (QI) interventions in Nepal. Contextual factors of importance for implementation of evidence-based newborn care practices were investigated, and the effect of a package of QI interventions on provision and experience of care was evaluated. In Paper I, we used focus group discussions and key informant interviews with delivery care staff to identify barriers and enablers for delayed umbilical cord clamping (DCC). Results indicate that delivery care staff needed knowledge of the benefits of DCC to gain motivation for change. Training, supervision and evaluation were requested to be able to change old routines, and they wanted authorized guidelines to bring uniformity in clinical practice. In Paper II, individual interviews with staff working with newborn infants were used to explore factors affecting parent-infant closeness in hospitals. Informants thought that offering a comfortable environment, privacy and counselling would enhance parent-infant closeness, but hospital resources were insufficient to achieve this. They described routines in the hospitals, and traditions and cultural beliefs in the society, which separated parents and newborns. In Paper III, a stepped-wedge randomized control design was applied to evaluate the effect of a QI package including training, facilitation and feedback, on patient satisfaction. The likelihood of women being overall satisfied with care during childbirth increased (aOR 1.66 [CI: 1.59-1.73, ICC: 0.275]) but the overall proportion of satisfaction was low, increasing from 58% to 62%. In Paper IV, clinical observations of early essential newborn care (EENC) practices were done before and after the introduction of the QI package. Overall, the rate of initiation of breastfeeding within one hour increased from 5% to 12%, and DCC increased from 22% to 33%. In conclusion, when designing interventions to improve quality of care, in Nepal or similar settings, it is important to use authorized guidelines and include education, training, supervision and evaluation. Hospital resources, routines and cultural beliefs need to be considered. The results indicate that a multi-pronged QI package can improve quality of newborn care in Nepal.
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| 6. |
- Chaulagain, Dipak Raj, 1980-
(författare)
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Improving quality of neonatal care practices in Nepal
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Despite the availability of cost-effective interventions, resource-poor countries are facing a high burden of preventable neonatal deaths, mainly due to low coverage and poor quality of care. The aim of this thesis was to evaluate the effect of a scaled-up neonatal resuscitation quality improvement (QI) package on newborn care practices in Nepal. The studies were conducted in 12 second-level public hospitals in Nepal where the QI package was scaled up. The QI package was based on the Plan-Do-Study and Act (PDSA) approach with three major implementation strategies; facilitation, training, and audit and feedback. At baseline, readiness and availability of perinatal care services were evaluated using a cross-sectional design (Paper I). A pre-post study design was used to assess the effect of the QI package on the competency of health workers on neonatal resuscitation (Paper II). Prospective observational studies were conducted in four out of the 12 hospitals to assess the effect of QI package on neonatal resuscitation and early essential newborn care (EENC) practices (Paper III and IV). At baseline, only five out of the 12 hospitals had all basic newborn care services under assessment and only 60% of the health workers had received training on neonatal resuscitation. After introducing the QI package, we observed an improvement in the knowledge and skills of health workers on neonatal resuscitation, which was maintained over time in all participating hospitals. In clinical practice, the proportion of clearing the airway increased among non-crying infants. We observed improved performance of health workers on the most crucial neonatal resuscitation action; initiation of bag and mask ventilation (BMV). The cumulative median time to first ventilation during the implementation period was 39 seconds less compared to the baseline. Overall, the rate of initiation of breastfeeding increased from 5% to 13%, and delayed cord clamping increased from 25% to 31%. The likelihood for a newborn to receive at least three of the four observed EENC practices increased threefold during the intervention period. The QI package showed a positive impact in improving quality of newborn care and can be scaled up in other hospitals in Nepal and similar settings.
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| 7. |
- Holloway, Bronwen, 1982-
(författare)
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Acute febrile illness, antibiotic use, and the role of diagnostics to target treatment in India
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aim: This thesis examined the causes of acute febrile illness (AFI), the current use of antibiotics and diagnostics, and evaluated the diagnostic accuracy of C-Reactive Protein (CRP) to differentiate bacterial from non-bacterial causes of AFI in children and adult outpatients at R.D. Gardi Medical College hospital, in Ujjain, India. Methods: A prospective cross-sectional study of children and adult outpatients with fever ≥37.5°C, or history of fever in the past 48 hours, and no signs of severe illness. Patient history, physical examination, culture, rapid diagnostic tests, and follow-up after one week was performed for all patients. Whole blood and urine were collected from all patients, and symptom based nasopharyngeal throat swabs, stool, and skin/ear/joint/aspirate specimens. Fever was classified as bacterial or non-bacterial based on microbiology and laboratory results together with an expert panel review. Data on antibiotic use before, during, and after enrolment was described by Anatomical Therapeutic Chemical classification and AWaRe categories. Serum CRP levels were measured and the performance characteristics for CRP to differentiate between bacterial and non-bacterial AFI were calculated. The area under the receiver operating curve (AUC), sensitivity, specificity, positive and negative predictive values, and likelihood ratios were estimated using 10, 20, 40, 60 and 80 mg/L thresholds. A rapid ethnographic qualitative study on the utilization of diagnostics was conducted using unstructured observations, structured observations and 43 semi-structured interviews. Interview data were analyzed using inductive thematic analysis. Results: Of 1000 outpatients, 24.4% were categorized as bacterial; 71.8% non-bacterial; and 3.8% an undetermined cause of fever. Throughout the course of AFI, 41.0% of patients received one or more antibiotics. The leading contributors to total antibiotic volume were macrolides. ‘Watch’ antibiotics accounted for 72.3%, 52.7%, and 32.6% of encounters before, during and after the outpatient visit. The overall median CRP was low but higher in the group classified as bacterial compared to non-bacterial (3.6 mg/L vs. 2.7 mg/L, p<0.0001, respectively). The AUC was low at 0.60 (95% CI 0.56 - 0.65). Caregivers trusted and understood the importance of diagnostics, but their acceptance wavered depending on the severity of illness and preference to treat their child directly with medicines. Caregivers struggled to get tests done and return for follow-up due to costs, delays in testing, further complicated by travel time, distance and competing priorities. Conclusion: This thesis highlights the challenges in determining the cause of AFI. Over,under, and inappropriate use of antibiotics throughout the course of AFI are of major concern.The organization of diagnostic services, together with direct and indirect costs, hinder caregiversfrom utilizing diagnostics. CRP is too weak as a single indicator of bacterial infection to safelysupport physicians in making treatment decisions for febrile outpatients in India.
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| 8. |
- KC, Ashish, 1982-
(författare)
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Neonatal Resuscitation : Understanding challenges and identifying a strategy for implementation in Nepal
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Despite the unprecedented improvement in child health in last 15 years, burden of stillbirth and neonatal death remain the key challenge in Nepal and the reduction of these deaths will be crucial for reaching the health targets for Sustainable development goal by 2030.The aim of this thesis was to explore the risk factors for stillbirth and neonatal death and change in perinatal outcomes after the introduction of the Helping Babies Breathe Quality Improvement Cycle (HBB QIC) in Nepal.This was a prospective cohort study with a nested case-control design completed in a tertiary hospital in Nepal. Information were collected from the women who had experienced perinatal death and live birth among referent population; a video recording was done in the neonatal resuscitation corner to collect information on the health workers’ performance in neonatal resuscitation. Lack of antenatal care had the highest association with antepartum stillbirth (aOR 4.2, 95% CI 3.2–5.4), births that had inadequate fetal heart rate monitoring were associated with intrapartum stillbirth (aOR 1.9, CI 95% 1.5–2.4), and babies who were born premature and small-for-gestational-age had the highest risk for neonatal death in the hospital (aOR 16.2, 95% CI 12.3–21.3). Before the introduction of the HBB QIC, health workers displayed poor adherence to the neonatal resuscitation protocol. After the introduction of HBB QIC, the health workers demonstrated improvement in their neonatal resuscitation skills and these were retained until six months after training. Daily bag-and-mask skill checks (RR 5.1 95% CI 1.9–13.5), preparation for birth (RR 2.4, 95% CI 1.0–5.6), self-evaluation checklists (RR 3.8, 95% CI 1.4–9.7) and weekly review and reflection meetings (RR 2.6, 95% 1.0–7.4) helped the health workers to retain their neonatal resuscitation skills. The health workers demonstrated improvement in ventilation of babies within one minute of birth and there was a reduction in intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and first-day neonatal mortality (aOR 0.51, 95% CI 0.31–0.83). The study provides information on challenges in reducing stillbirth and neonatal death in low income settings and provides a strategy to improve health workers adherence to neonatal resuscitation to reduce the mortality. The HBB QIC can be implemented in similar clinical settings to improve quality of care and survival in Nepal, but for primary care settings, the QIC need to be evaluated further.
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| 9. |
- Målqvist, Mats, 1971-
(författare)
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Who can save the unseen? : Studies on neonatal mortality in Quang Ninh province, Vietnam
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Globally, neonatal mortality has remained basically unchanged for the last three to four decades and every year almost four million newborns die before reaching one month of age. This persistent mortality is related to an invisibility of the newborn child in policies and statistics and a neglect of health care decision-makers, planners and practitioners to deliver a perinatal continuum of care. In recent years attention has however been brought to the unchanged neonatal mortality in an effort to improve survival. The present thesis seeks to increase understanding of obstacles for better neonatal survival. The studies performed are undertaken as sub-studies to the NeoKIP project in Quang Ninh province in northern Vietnam, a randomized controlled trial of knowledge implementation for improved neonatal survival (Neonatal Health – Knowledge Into Practice, ISRCTN 44599712). In the first paper we investigated and discussed the scope of invisibility of neonatal mortality through measuring the accuracy of official statistics on neonatal deaths. The second paper reports an inquiry of determinants of neonatal mortality by use of a population-based case-referent design. Paper III and IV analyse delivery care utilization and care seeking patterns prior to and at delivery using narratives and GIS technique. There was a substantial under-reporting of neonatal mortality in the official statistics, with study results showing a four times higher neonatal mortality rate in Quang Ninh province than reported to the Ministry of Health. This neonatal mortality rate of 16/1000 live births (as compared to 4.2/1000 in official reports) was unevenly distributed in the province, showing large geographical discrepancies. In the rural and remote areas of Vietnam education level is lower and the concentrations of ethnic minorities and poor households are higher. Ethnic minority belonging was associated with a more than doubled risk of neonatal death compared to the hegemonic group of Kinh (OR 2.08 CI 95 % 1.39 – 3.10). This increased risk was independent of household economic status or maternal education level. Neonatal mortality was also associated with home deliveries, non-attendance to antenatal care and distance to the health care facilities. However, ethnic minority mothers still had an increased risk of experiencing a neonatal death even if they attended antenatal care, delivered at or lived close to a health facility. The invisibility of the neonatal period in health information systems hides the true width of the neonatal mortality challenge. By not acknowledging the problem, the marginalization of already disadvantaged groups continues, leaving ethnic minority babies with an elevated risk of dying during the first month in life. This example of ethnic inequity highlights the importance to target those most in need. The studies of the present thesis should therefore be looked upon as a contribution to the struggle to illuminate the global burden of neonatal mortality.
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| 10. |
- Sjömar, Johanna, 1975-
(författare)
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Kangaroo Mother Care in Bangladesh : Experiences of Caregivers and Healthcare Providers
- 2024
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Kangaroo Mother Care (KMC) is an evidence-based intervention, recommended by the World Health Organization, with the potential to prevent neonatal deaths and morbidity among low-birthweight and preterm babies. In Bangladesh, where the number of neonatal deaths is high, KMC is identified as a priority intervention to be scaled up in the country. Our aim was to explore the experiences of caregivers and healthcare providers (HCPs) of KMC in Bangladesh. We conducted semi-structured interviews in two hospitals in Dhaka, where KCM service was provided. In Study I, we interviewed fifteen caregivers. The results showed conducive conditions for caregivers to perform KMC at the hospital and at home, but support is needed from both healthcare providers and their families. Caregivers felt empowered and motivated when they observed improvements in the child's well-being. However, there are challenges to KMC implementation due to the struggle to keep the baby skin-to-skin, pain after caesarean section, delayed initiation of KMC, and routines that promote an initial separation between the mother and baby. In Study II, we interviewed eleven HCPs. The results showed that HCPs experienced KMC as a continuous process that requires both support and counselling, adapted to caregivers’ needs. Commitment, supervision, and training are necessary. However, there are structural conditions that challenge KMC implementation, including clinical routines that promote the initial separation of the mother and baby, staff shortages, and incomplete follow-up. In conclusion, the findings from this exploratory research can inform the design of interventions for scaling up KMC in Bangladesh. Caregivers' and HCPs' experiences show that continuous support, counselling, and family involvement are essential in the care, and that providing KMC empowers caregivers. Their experiences also indicate that KMC is sub-optimally implemented due to structural conditions and routines that need to be addressed to scale up KMC in the country by avoiding the initial separation of mother and baby, meeting the mothers' needs for care and support, and strengthening the follow-up. Our results also suggest a need to update clinical practices in line with the new WHO recommendations.
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