RESUMEN
BACKGROUND: Poor quality obstetric and newborn care persists in sub-Saharan Africa and weak provider competence is an important contributor. To be competent, providers need to be both knowledgeable and confident in their ability to perform necessary clinical actions. Confidence or self-efficacy has not been extensively studied but may be related to individuals' knowledge, ability to practice their skills, and other modifiable factors. In this study, we investigated how knowledge and scope of practice are associated with provider confidence in delivering obstetric and newborn health services in Uganda and Zambia. METHODS: This study was a secondary analysis of data from an obstetric and newborn care program implementation evaluation. Provider knowledge, scope of practice (completion of a series of obstetric tasks in the past 3 months) and confidence in delivering obstetric and newborn care were measured post intervention in intervention and comparison districts in Uganda and Zambia. We used multiple linear regression models to investigate the extent to which exposure to a wider range of clinical tasks associated with confidence, adjusting for facility and provider characteristics. RESULTS: Of the 574 providers included in the study, 69% were female, 24% were nurses, and 6% were doctors. The mean confidence score was 71%. Providers' mean knowledge score was 56% and they reported performing 57% of basic obstetric tasks in the past 3 months. In the adjusted model, providers who completed more than 69% of the obstetric tasks reported a 13-percentage point (95% CI 0.08, 0.17) higher confidence than providers who performed less than 50% of the tasks. Female providers and nurses were considerably less confident than males and doctors. Provider knowledge was moderately associated with provider confidence. CONCLUSIONS: Our study showed that scope of practice (the range of clinical tasks routinely performed by providers) is an important determinant of confidence. Ensuring that providers are exposed to a variety of services is crucial to support improvement in provider confidence and competence. Policies to improve provider confidence and pre-service training should also address differences by gender and by cadres.
Asunto(s)
Competencia Clínica/normas , Personal de Salud/psicología , Cuidado del Lactante/normas , Obstetricia/normas , Adulto , Femenino , Humanos , Recién Nacido , Modelos Lineales , Masculino , Persona de Mediana Edad , Análisis Multivariante , Embarazo , Evaluación de Programas y Proyectos de Salud , Calidad de la Atención de Salud , Autoeficacia , Uganda , ZambiaRESUMEN
BACKGROUND: Sub-Saharan Africa, including Zambia, has experienced an increase in overweight and obesity due to rapid lifestyle changes associated with recent economic growth. We explored the prevalence and correlates of overweight and obesity in rural Zambia. We also investigated the role of self-perception of body weight in weight control given the local socio-cultural context. METHODS: In this cross-sectional study, we recruited 690 residents of the Mumbwa district aged 25-64 years through a multistage, clustered, household random sampling. We administered a questionnaire and collected anthropometric and bio-behavioral data from May to July 2016. Factors associated with body mass index (BMI) ≥25 kg/m2 and underestimation of body weight were assessed using multiple logistic regression. RESULTS: Of the weighted sample of 689 participants (335 men and 354 women), 185 (26.8%) had BMI ≥25 kg/m2. In multivariate analyses, female gender, age 45-64 years, tertiary education, higher fruit and vegetable intake, high blood pressure, abnormal blood lipid profile, and Hemoglobin A1c ≥5.7% were significantly associated with BMI ≥25 kg/m2. Among participants with BMI ≥25 kg/m2, 14.2% and 58.2% perceived themselves as being underweight and normal weight, respectively. Age 45-64 years was the only factor significantly associated with body weight underestimation. Preference for obesity was reported by 17.5% and 3.6% of respondents with BMI <25 kg/m2 and BMI≥25 kg/m2, respectively; "looks attractive" and "fear of being perceived as HIV-positive" were the main reasons. CONCLUSION: In rural Zambia, overweight and obesity are prevalent and significantly associated with alterations in blood pressure, blood lipid profile, and glucose metabolism. However, most subjects with BMI ≥25 kg/m2 underestimated their body weight; some preferred obesity, in part due to cultural factors and HIV-related stigma. A health promotion program that addresses such perceptions and body weight underestimation should be urgently introduced in Zambia.
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Enfermedades Cardiovasculares/etiología , Obesidad/complicaciones , Adulto , Actitud Frente a la Salud , Presión Sanguínea , Índice de Masa Corporal , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/fisiopatología , Estudios Transversales , Femenino , Hemoglobina Glucada/análisis , Humanos , Lípidos/sangre , Masculino , Persona de Mediana Edad , Obesidad/sangre , Obesidad/fisiopatología , Factores de Riesgo , Población Rural , Zambia/epidemiologíaRESUMEN
Objectives The objective of this study was to examine experiences with, and barriers to, accessing postnatal care services, in the context of a maternal health initiative. Methods As part of a larger evaluation of an initiative to promote facility deliveries in 8 rural districts in Uganda and Zambia, 48 focus groups were held with recently-delivered women with previous home and facility deliveries (6 per district). Data on postnatal care experiences were translated, coded and analyzed using thematic content analysis techniques. Results were categorized into: positive postnatal care experiences, barriers to postnatal care utilization, and negative postnatal care experiences. Results Women who accessed care largely reported positive experiences, with Zambian women generally reporting more positive interactions than Ugandan women. The main reasons given for low postnatal care utilization were low awareness about the need, fear of mistreatment by clinic staff, cost and distance. In half of the focus groups, women described personal experience or knowledge of denial or threatened denial of postnatal care due to the birth location. Although outright denial of care was not common, women frequently described various types of actual or presumed discrimination because of having a home birth. Conclusions for Practice While many women reported positive experiences with postnatal care utilization, cases of delay or denial of postnatal care exist. As programs incentivize facility deliveries, the lack of focus on postnatal support may place home-delivered newborns in "double jeopardy" due to poor quality intra-partum care and reduced access to postnatal care.
Asunto(s)
Parto Obstétrico/psicología , Parto Normal/psicología , Atención Posnatal/psicología , Atención Posnatal/estadística & datos numéricos , Conducta de Elección , Parto Obstétrico/estadística & datos numéricos , Femenino , Grupos Focales , Humanos , Parto Normal/estadística & datos numéricos , Embarazo , Investigación Cualitativa , Calidad de la Atención de Salud , Población Rural/estadística & datos numéricos , Uganda , ZambiaRESUMEN
Global health initiatives (GHIs) are implemented across a variety of geographies and cultures. Those targeting maternal health often prioritise increasing facility delivery rates. Pressure on local implementers to meet GHI goals may lead to unintended programme features that could negatively impact women. This study investigates penalties for home births imposed by traditional leaders on women during the implementation of Saving Mothers, Giving Life (SMGL) in Zambia. Forty focus group discussions (FGDs) were conducted across four rural districts to assess community experiences of SMGL at the conclusion of its first year. Participants included women who recently delivered at home (3 FGDs/district), women who recently delivered in a health facility (3 FGDs/district), community health workers (2 FGDs/district) and local leaders (2 FGDs/district). Findings indicate that community leaders in some districts-independently of formal programme directive-used fines to penalise women who delivered at home rather than in a facility. Participants in nearly all focus groups reported hearing about the imposition of penalties following programme implementation. Some women reported experiencing penalties firsthand, including cash and livestock fines, or fees for child health cards that are typically free. Many women who delivered at home reported their intention to deliver in a facility in the future to avoid penalties. While communities largely supported the use of penalties to promote facility delivery, the penalties effectively introduced a new tax on poor rural women and may have deterred their utilization of postnatal and child health care services. The imposition of penalties is thus a punitive adaptation that can impose new financial burdens on vulnerable women and contribute to widening health, economic and gender inequities in communities. Health initiatives that aim to increase demand for health services should monitor local efforts to achieve programme targets in order to better understand their impact on communities and on overall programme goals.
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Salud Global , Mal Uso de los Servicios de Salud , Parto Domiciliario/economía , Servicios de Salud Materna/estadística & datos numéricos , Motivación , Adulto , Agentes Comunitarios de Salud , Parto Obstétrico , Femenino , Grupos Focales , Instituciones de Salud/estadística & datos numéricos , Humanos , Masculino , Servicios de Salud Materna/economía , Persona de Mediana Edad , Embarazo , Investigación Cualitativa , Población Rural , ZambiaRESUMEN
Saving Mothers, Giving Life is a multidonor program designed to reduce maternal mortality in Uganda and Zambia. We used a quasi-random research design to evaluate its effects on provider obstetric knowledge, clinical confidence, and job satisfaction, and on patients' receipt of services, perceived quality, and satisfaction. Study participants were 1,267 health workers and 2,488 female patients. Providers' knowledge was significantly higher in Ugandan and Zambian intervention districts than in comparison districts, and in Uganda there were similar positive differences for providers' clinical confidence and job satisfaction. Patients in Ugandan intervention facilities were more likely to give high ratings for equipment availability, providers' knowledge and communication skills, and care quality, among other factors, than patients in comparison facilities. There were fewer differences between Zambian intervention and comparison facilities. Country differences likely reflect differing intensity of program implementation and the more favorable geography of intervention districts in Uganda than in Zambia. National investments in the health system and provider training and the identification of intervention components most associated with improved performance will be required for scaling up and sustaining the program.
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Servicios de Salud Materna/organización & administración , Salud Materna/tendencias , Mortalidad Materna/tendencias , Satisfacción del Paciente/estadística & datos numéricos , Calidad de la Atención de Salud , Adulto , Factores de Edad , Países en Desarrollo , Femenino , Humanos , Modelos Logísticos , Salud Materna/economía , Análisis Multivariante , Embarazo , Medición de Riesgo , Factores Socioeconómicos , Encuestas y Cuestionarios , Uganda , Adulto Joven , ZambiaRESUMEN
Transportation is an important barrier to accessing obstetric care for many pregnant and postpartum women in low-resource settings, particularly in rural areas. However, little is known about how pregnant women travel to health facilities in these settings. We conducted 1633 exit surveys with women who had a recent facility delivery and 48 focus group discussions with women who had either a home or a facility birth in the past year in eight districts in Uganda and Zambia. Quantitative data were analysed using univariate statistics, and qualitative data were analysed using thematic content analysis techniques. On average, women spent 62-68 min travelling to a clinic for delivery. Very different patterns in modes of transport were observed in the two countries: 91% of Ugandan women employed motorized forms of transportation, while only 57% of women in Zambia did. Motorcycle taxis were the most commonly used in Uganda, while cars, trucks and taxis were the most commonly used mode of transportation in Zambia. Lower-income women were less likely to use motorized modes of transportation: in Zambia, women in the poorest quintile took 94 min to travel to a health facility, compared with 34 for the wealthiest quintile; this difference between quintiles was â¼50 min in Uganda. Focus group discussions confirmed that transport is a major challenge due to a number of factors we categorized as the 'three A's:' affordability, accessibility and adequacy of transport options. Women reported that all of these factors had influenced their decision not to deliver in a health facility. The two countries had markedly different patterns of transportation for obstetric care, and modes of transport and travel times varied dramatically by wealth quintile, which policymakers need to take into account when designing obstetric transport interventions.
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Servicios de Salud Materna , Transportes/métodos , Viaje , Adolescente , Adulto , Estudios Transversales , Femenino , Humanos , Embarazo , Factores de Tiempo , Adulto Joven , ZambiaRESUMEN
OBJECTIVE: The objective of this study was to assess the conditions under which Zambian women with a history of cervical cancer screening by visual inspection with acetic acid might switch to human papillomavirus-based testing in the future. MATERIALS AND METHODS: We conducted a choice-based conjoint survey in a sample of women recently screened by visual inspection in Lusaka, Zambia. The screening attribute considered in hypothetical-choice scenarios included screening modality, sex and age of the examiner, whether screening results would be presented visually, distance from home to the clinic, and wait time for results. RESULTS: Of 238 women in the sample, 208 (87.4%) provided responses sufficiently reliable for analysis. Laboratory testing on a urine sample was the preferred screening modality, followed by visual screening, laboratory testing on a self-collected vaginal specimen, and laboratory testing on a nurse-collected cervical specimen. Market simulation suggested that only 39.7% (95% CI = 33.8-45.6) of the respondents would prefer urine testing offered by a female nurse in her 30s over visual inspection of the cervix conducted by a male nurse in his 20s if extra wait time were as short as 1 hour and the option of viewing how their cervix looks like were not available. CONCLUSIONS: Our study suggests that, for some women, the level of preference for human papillomavirus-based screening strategies may depend highly on the process and conditions of service delivery.
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Detección Precoz del Cáncer/métodos , Técnicas de Diagnóstico Molecular/métodos , Papillomaviridae/aislamiento & purificación , Aceptación de la Atención de Salud , Neoplasias del Cuello Uterino/diagnóstico , Adolescente , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , ZambiaRESUMEN
This three-phase study characterized, validated, and applied community capacity domains in a health communication project evaluation in Zambia. Phase I explored community capacity domains from community members' perspectives (16 focus groups, 14 in-depth interviews, 4 sites. These were validated in Phase II with 720 randomly selected adults. The validated domains were incorporated into a program evaluation survey (2,462 adult women, 2,354 adult men; October 2009). The results indicated that the intervention had direct effects on community capacity; enhanced capacity was then associated with having taken community action for health. Finally, community capacity mediated by community action and controlling for confounders, had a significant effect on women's contraceptive use, children's bed net use, and HIV testing. The results indicate that building community capacity served as a means to an end-improved health behaviors and reported collective action for health-and an end-in-itself, both of which are essential to overall wellbeing.