Edwin van Teijlingen

Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature

AIM This paper is a report of a systematic review to identify and analyse the main factors affecting the utilization of antenatal care in developing countries. BACKGROUND Antenatal care is a key strategy for reducing maternal mortality, but millions of women in developing countries do not receive it. DATA SOURCES A range of electronic databases was searched for studies conducted in developing countries and published between 1990 and 2006. English-language publications were searched using relevant keywords, and reference lists were hand-searched. REVIEW METHODS A systematic review was carried out and both quantitative and qualitative studies were included. RESULTS Twenty-eight papers were included in the review. Studies most commonly identified the following factors affecting antenatal care uptake: maternal education, husbands education, marital status, availability, cost, household income, womens employment, media exposure and having a history of obstetric complications. Cultural beliefs and ideas about pregnancy also had an influence on antenatal care use. Parity had a statistically significant negative effect on adequate attendance. Whilst women of higher parity tend to use antenatal care less, there is interaction with womens age and religion. Only one study examined the effect of the quality of antenatal services on utilization. None identified an association between the utilization of such services and satisfaction with them. CONCLUSION More qualitative research is required to explore the effect of womens satisfaction, autonomy and gender role in the decision-making process. Adequate utilization of antenatal care cannot be achieved merely by establishing health centres; womens overall (social, political and economic) status needs to be considered.

Family Communication about Genetic Risk: The Little That Is Known

Although family communication is important in clinical genetics only a small number of studies have specifically explored the passing on of genetic knowledge to family members. In addition, many of these present exploratory or tentative findings based upon small sample sizes, or data collected only a short time after testing. Nevertheless, if health professionals are to develop effective strategies to help patients’ deal with communication issues, we need to know more about what actually happens in families. The aim of this commentary is to identify factors which appear to influence whether patients share information about genetic risk with relatives who are unaware of that risk, with whom they share it and how they go about it. The paper draws upon evidence and thinking from the disciplines of psychology (including family therapy), sociology, medicine and genetic counselling. It is presented under the following headings: disease factors, individual factors, family factors and sociocultural factors. It concludes by highlighting a number of key issues which are relevant for health professionals.

Risk, theory, social and medical models: A critical analysis of the concept of risk in maternity care

BACKGROUND there is an on-going debate about perceptions of risk and risk management in maternity care. OBJECTIVES to provide a critical analysis of the risk concept, its development in modern society in general and UK maternity services in particular. Through the associated theory, we explore the origins of the current preoccupation with risk. Using Pickstones historical phases of modern health care, the paper explores the way maternity services changed from a social to a medical model over the twentieth century and suggests that the risk agenda was part of this process. KEY CONCLUSIONS current UK maternity services policy which promotes normality contends that effective risk management screens women suitable for birth in community maternity units (CMUs) or home birth: however, although current policy advocates a return to this more social model, policy implementation is slow in practice. IMPLICATIONS FOR PRACTICE the slow implementation of current maternity policy in is linked to perceptions of risk. We content that intellectual and social capital remains within the medical model.

Women's autonomy in household decision-making: a demographic study in Nepal

BackgroundHow socio-demographic factors influence womens autonomy in decision making on health care including purchasing goods and visiting family and relatives are very poorly studied in Nepal. This study aims to explore the links between womens household position and their autonomy in decision making.MethodsWe used Nepal Demographic Health Survey (NDHS) 2006, which provided data on ever married women aged 15-49 years (n = 8257). The data consists of womens four types of household decision making; own health care, making major household purchases, making purchase for daily household needs and visits to her family or relatives. A number of socio-demographic variables were used in multivariable logistic regression to examine the relationship of these variables to all four types of decision making.ResultsWomens autonomy in decision making is positively associated with their age, employment and number of living children. Women from rural area and Terai region have less autonomy in decision making in all four types of outcome measure. There is a mixed variation in womens autonomy in the development region across all outcome measures. Western women are more likely to make decision in own health care (1.2-1.6), while they are less likely to purchase daily household needs (0.6-0.9). Womens increased education is positively associated with autonomy in own health care decision making (p < 0.01), however their more schooling (SLC and above) shows non-significance with other outcome measures. Interestingly, rich women are less likely to have autonomy to make decision in own healthcare.ConclusionsWomen from rural area and Terai region needs specific empowerment programme to enable them to be more autonomous in the household decision making. Womens autonomy by education, wealth quintile and development region needs a further social science investigation to observe the variations within each stratum. A more comprehensive strategy can enable women to access community resources, to challenge traditional norms and to access economic resources. This will lead the women to be more autonomous in decision making in the due course.

Utilisation of postnatal care among rural women in Nepal

BackgroundPostnatal care is uncommon in Nepal, and where it is available the quality is often poor. Adequate utilisation of postnatal care can help reduce mortality and morbidity among mothers and their babies. Therefore, our study assessed the utilisation of postnatal care at a rural community level.MethodsA descriptive, cross-sectional study was carried out in two neighbouring villages in early 2006. A total of 150 women who had delivered in the previous 24 months were asked to participate in the study using a semi-structured questionnaire.ResultsThe proportion of women who had received postnatal care after delivery was low (34%). Less than one in five women (19%) received care within 48 hours of giving birth. Women in one village had less access to postnatal care than women in the neighbouring one. Lack of awareness was the main barrier to the utilisation of postnatal care.The womans own occupation and ethnicity, the number of pregnancies and children and the husbands socio-economic status, occupation and education were significantly associated with the utilisation of postnatal care.Multivariate analysis showed that wealth as reflected in occupation and having attended antenatal are important factors associated with the uptake of postnatal care. In addition, women experiencing health problems appear strongly motivated to seek postnatal care.ConclusionThe postnatal care has a low uptake and is often regarded as inadequate in Nepal. This is an important message to both service providers and health-policy makers. Therefore, there is an urgent need to assess the actual quality of postnatal care provided. Also there appears to be a need for awareness-raising programmes highlighting the availability of current postnatal care where this is of sufficient quality.

More of the same? Conflicting perspectives of obesity causation and intervention amongst overweight people, health professionals and policy makers

This paper presents the findings of a qualitative study conducted in the United Kingdom of the perceptions of overweight individuals, as well as health professionals and policy makers working in the area of obesity prevention and weight management. In 2006-2007, we conducted interviews with 34 men and women (18-50 years old) who self identified as being overweight; 20 health professionals; and 9 policy makers. We explored their understandings of the causes of obesity/overweight; beliefs about factors that enabled or inhibited weight loss/gain; and opinions regarding effective obesity/overweight interventions. We found a range of views, which corresponded with biomedical and socio-ecological perspectives of health and disease. The lay overweight respondents viewed the problem of obesity arising from their personal shortcomings (i.e. motivational and physical), juxtaposed to blame-absolving accounts often involving specific challenges associated with day-to-day living. All respondents presented personal stories of complex battles of short-term weight loss and longer-term weight gain, usually characterised by a sense of failure. All expressed a strong sense of personal responsibility to overcome their weight problems, and looked to another not-yet-tried, technocratic weight loss programme to address the problem, despite all reporting past failures. Health professionals and policy makers on the other hand viewed obesity as a socio-ecologically determined problem, detailing social and environmental explanations. Health professionals were more inclined towards individual-orientated weight management interventions as effective responses. Policy makers considered environmental and social policy changes as most likely to make a substantial difference to current obesity trends, but considered it unlikely that such policies would be implemented without the political will and popular support. Our data highlight dissonance between policy maker, health professional and public obesity perceptions and points to a challenge for those who believe that wholesale systemic change is required if obesity trends are to be reduced or halted.

Factors Influencing Adherence to Antiretroviral Treatment in Nepal: A Mixed-Methods Study

Background Antiretroviral therapy (ART) is a lifesaver for individual patients treated for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Maintaining optimal adherence to antiretroviral drugs is essential for HIV infection management. This study aimed to understand the factors influencing adherence amongst ART-prescribed patients and care providers in Nepal. Methods A cross-sectional mixed-methods study surveying 330 ART-prescribed patients and 34 in-depth interviews with three different types of stakeholders: patients, care providers, and key people at policy level. Adherence was assessed through survey self-reporting and during the interviews. A multivariate logistic regression model was used to identify factors associated with adherence, supplemented with a thematic analysis of the interview transcripts. Results A total of 282 (85.5%) respondents reported complete adherence, i.e. no missed doses in the four-weeks prior to interview. Major factors influencing adherence were: non-disclosure of HIV status (OR = 17.99, p =  0.014); alcohol use (OR = 12.89, p = <0.001), being female (OR = 6.91, p = 0.001), being illiterate (OR = 4.58, p = 0.015), side-effects (OR = 6.04, p = 0.025), ART started ≤24 months (OR = 3.18, p = 0.009), travel time to hospital >1 hour (OR = 2.84, p = 0.035). Similarly, lack of knowledge and negative perception towards ART medications also significantly affected non-adherence. Transport costs (for repeat prescription), followed by pills running out, not wanting others to notice, side-effects, and being busy were the most common reasons for non-adherence. The interviews also revealed religious or ritual obstacles, stigma and discrimination, ART-associated costs, transport problems, lack of support, and side-effects as contributing to non-adherence. Conclusion Improving adherence requires a supportive environment; accessible treatment; clear instructions about regimens; and regimens tailored to individual patients’ lifestyles. Healthcare workers should address some of the practical and cultural issues around ART medicine whilst policy-makers should develop appropriate social policy to promote adherence among ART-prescribed patients.

The role of mothers-in-law in antenatal care decision-making in Nepal: a qualitative study

BackgroundAntenatal care (ANC) has been recognised as a way to improve health outcomes for pregnant women and their babies. However, only 29% of pregnant women receive the recommended four antenatal visits in Nepal but reasons for such low utilisation are poorly understood. As in many countries of South Asia, mothers-in-law play a crucial role in the decisions around accessing health care facilities and providers. This paper aims to explore the mother-in-laws role in (a) her daughter-in-laws ANC uptake; and (b) the decision-making process about using ANC services in Nepal.MethodsIn-depth interviews were conducted with 30 purposively selected antenatal or postnatal mothers (half users, half non-users of ANC), 10 husbands and 10 mothers-in-law in two different (urban and rural) communities.ResultsOur findings suggest that mothers-in-law sometime have a positive influence, for example when encouraging women to seek ANC, but more often it is negative. Like many rural women of their generation, all mothers-in-law in this study were illiterate and most had not used ANC themselves. The main factors leading mothers-in-law not to support/encourage ANC check ups were expectations regarding pregnant women fulfilling their household duties, perceptions that ANC was not beneficial based largely on their own past experiences, the scarcity of resources under their control and power relations between mothers-in-law and daughters-in-law. Individual knowledge and social class of the mothers-in-law of users and non-users differed significantly, which is likely to have had an effect on their perceptions of the benefits of ANC.ConclusionMothers-in-law have a strong influence on the uptake of ANC in Nepal. Understanding their role is important if we are to design and target effective community-based health promotion interventions. Health promotion and educational interventions to improve the use of ANC should target women, husbands and family members, particularly mothers-in-law where they control access to family resources.

Systematic reviews of and integrated report on the quantitative, qualitative and economic evidence base for the management of obesity in men

BACKGROUND Obesity increases the risk of many serious illnesses such as coronary heart disease, type 2 diabetes and osteoarthritis. More men than women are overweight or obese in the UK but men are less likely to perceive their weight as a problem and less likely to engage with weight-loss services. OBJECTIVE The aim of this study was to systematically review evidence-based management strategies for treating obesity in men and investigate how to engage men in obesity services by integrating the quantitative, qualitative and health economic evidence base. DATA SOURCES Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews of Effects and the NHS Economic Evaluation Database were searched from inception to January 2012, with a limited update search in July 2012. Subject-specific websites, reference lists and professional health-care and commercial organisations were also consulted. REVIEW METHODS Six systematic reviews were conducted to consider the clinical effectiveness, cost-effectiveness and qualitative evidence on interventions for treating obesity in men, and men in contrast to women, and the effectiveness of interventions to engage men in their weight reduction. Randomised controlled trials (RCTs) with follow-up data of at least 1 year, or any study design and length of follow-up for UK studies, were included. Qualitative and mixed-method studies linked to RCTs and non-randomised intervention studies, and UK-based, men-only qualitative studies not linked to interventions were included. One reviewer extracted data from the included studies and a second reviewer checked data for omissions or inaccuracies. Two reviewers carried out quality assessment. We undertook meta-analysis of quantitative data and a realist approach to integrating the qualitative and quantitative evidence synthesis. RESULTS From a total of 12,764 titles reviewed, 33 RCTs with 12 linked reports, 24 non-randomised reports, five economic evaluations with two linked reports, and 22 qualitative studies were included. Men were more likely than women to benefit if physical activity was part of a weight-loss programme. Reducing diets tended to produce more favourable weight loss than physical activity alone (mean weight change after 1 year from a reducing diet compared with an exercise programme -3.2 kg, 95% CI -4.8 kg to -1.6 kg). The type of reducing diet did not affect long-term weight loss. A reducing diet plus physical activity and behaviour change gave the most effective results. Low-fat reducing diets, some with meal replacements, combined with physical activity and behaviour change training gave the most effective long-term weight change in men [-5.2 kg (standard error 0.2 kg) after 4 years]. Such trials may prevent type 2 diabetes in men and improve erectile dysfunction. Although fewer men joined weight-loss programmes, once recruited they were less likely to drop out than women (difference 11%, 95% CI 8% to 14%). The perception of having a health problem (e.g. being defined as obese by a health professional), the impact of weight loss on health problems and desire to improve personal appearance without looking too thin were motivators for weight loss amongst men. The key components differ from those found for women, with men preferring more factual information on how to lose weight and more emphasis on physical activity programmes. Interventions delivered in social settings were preferred to those delivered in health-care settings. Group-based programmes showed benefits by facilitating support for men with similar health problems, and some individual tailoring of advice assisted weight loss in some studies. Generally, men preferred interventions that were individualised, fact-based and flexible, which used business-like language and which included simple to understand information. Preferences for men-only versus mixed-sex weight-loss group programmes were divided. In terms of context, programmes which were cited in a sporting context where participants have a strong sense of affiliation showed low drop out rates and high satisfaction. Although some men preferred weight-loss programmes delivered in an NHS context, the evidence comparing NHS and commercial programmes for men was unclear. The effect of family and friends on participants in weight-loss programmes was inconsistent in the evidence reviewed - benefits were shown in some cases, but the social role of food in maintaining relationships may also act as a barrier to weight loss. Evidence on the economics of managing obesity in men was limited and heterogeneous. LIMITATIONS The main limitations were the limited quantity and quality of the evidence base and narrow outcome reporting, particularly for men from disadvantaged and minority groups. Few of the studies were undertaken in the UK. CONCLUSIONS Weight reduction for men is best achieved and maintained with the combination of a reducing diet, physical activity advice or a physical activity programme, and behaviour change techniques. Tailoring interventions and settings for men may enhance effectiveness, though further research is needed to better understand the influence of context and content. Future studies should include cost-effectiveness analyses in the UK setting. FUNDING This project was funded by the NIHR Health Technology Assessment programme.

What works with men? A systematic review of health promoting interventions targeting men

BackgroundEncouraging men to make more effective use of (preventive) health services is considered one way of improving their health. The aim of this study was to appraise the available evidence of effective interventions aimed at improving mens health.MethodsSystematic review of relevant studies identified through 14 electronic databases and other information resources. Results were pooled within health topic and described qualitatively.ResultsOf 11,749 citations screened, 338 articles were assessed and 27 met our inclusion criteria. Most studies were male sex-specific, i.e. prostate cancer screening and testicular self-examination. Other topics included alcohol, cardiovascular disease, diet and physical activity, skin cancer and smoking cessation. Twenty-three interventions were effective or partially effective and 18 studies satisfied all quality criteria.ConclusionMost of the existing evidence relates to male sex-specific health problems as opposed to general health concerns relevant to both men and women. There is little published evidence on how to improve mens uptake of services. We cannot conclude from this review that targeting men works better than providing services for all people. Large-scale studies are required to help produce evidence that is sufficiently robust to add to the small evidence base that currently exists in this field.