Hannah Tappis

Availability and quality of emergency obstetric and neonatal care services in Afghanistan

To assess the availability and utilization of emergency obstetric and neonatal care (EmONC) facilities in Afghanistan, as defined by UN indicators.

Job satisfaction and retention of health-care providers in Afghanistan and Malawi

BackgroundThis study describes job satisfaction and intention to stay on the job among primary health-care providers in countries with distinctly different human resources crises, Afghanistan and Malawi.MethodsUsing a cross-sectional design, we enrolled 87 health-care providers in 32 primary health-care facilities in Afghanistan and 360 providers in 10 regional hospitals in Malawi. The study questionnaire was used to assess job satisfaction, intention to stay on the job and five features of the workplace environment: resources, performance recognition, financial compensation, training opportunities and safety. Descriptive analyses, exploratory factor analyses for scale development, bivariate correlation analyses and bivariate and multiple linear regression analyses were conducted.ResultsThe multivariate model for Afghanistan, with demographic, background and work environment variables, explained 23.9% of variance in job satisfaction (F(9,73) = 5.08; P < 0.01). However, none of the work environment variables were significantly related to job satisfaction. The multivariate model for intention to stay for Afghanistan explained 23.6% of variance (F(8,74) = 4.10; P < 0.01). Those with high scores for recognition were more likely to have higher intention to stay (β = 0.328, P < 0.05). However, being paid an appropriate salary was negatively related to intent to stay (β = -0.326, P < 0.01). For Malawi, the overall model explained only 9.8% of variance in job satisfaction (F(8,332) = 4.19; P < 0.01) and 9.1% of variance in intention to stay (F(10,330) = 3.57; P < 0.01).ConclusionsThe construction of concepts of health-care worker satisfaction and intention to stay on the job are highly dependent on the local context. Although health-care workers in both Afghanistan and Malawi reported satisfaction with their jobs, the predictors of satisfaction, and the extent to which those predictors explained variations in job satisfaction and intention to stay on the job, differed substantially. These findings demonstrate the need for more detailed comparative human resources for health-care research, particularly regarding the relative importance of different determinants of job satisfaction and intention to stay in different contexts and the effectiveness of interventions designed to improve health-care worker performance and retention.

Quality of caesarean delivery services and documentation in first-line referral facilities in Afghanistan: a chart review

BackgroundIncreasing appropriate use and documentation of caesarean section (CS) has the potential to decrease maternal and perinatal mortality in settings with low CS rates. We analyzed data collected as part of a comprehensive needs assessment of emergency obstetric and newborn care (EmONC) facilities in Afghanistan to gain a greater understanding of the clinical indications, timeliness, and outcomes of CS deliveries.MethodsRecords were reviewed at 78 government health facilities expected to function as EmONC providers that were located in secure areas of the country. Information was collected on the three most recent CS deliveries in the preceding 12 months at facilities with at least one CS delivery in the preceding three months. After excluding 16 facilities with no recent CS deliveries, the sample includes 173 CS deliveries at 62 facilities.ResultsNo CS deliveries were performed in the previous three months at 21% of facilities surveyed; all of these were lower-level facilities. Most CS deliveries (88%) were classified as emergencies, and only 12% were referrals from another facility. General anesthesia was used in 62% of cases, and spinal or epidural anesthesia in 34%. Only 28% of cases were managed with a partograph. Surgery began less than one hour after the decision for a CS delivery in just 30% of emergency cases. Among the 173 cases, 27 maternal deaths, 28 stillbirths, and 3 early neonatal deaths were documented. In cases of maternal and fetal death, the most common indications for CS delivery were placenta praevia or abruption and malpresentation. In 62% of maternal deaths, the fetus was stillborn or died shortly after birth. In 48% of stillbirths, the fetus had a normal heart rate at the last check. Information on partograph use was missing in 38% of cases, information on parity missing in 23% of cases and indications for cesareans missing in 9%.ConclusionsTimely referral within and to EmONC facilities would decrease the proportion of CS deliveries that develop to emergency status. While the substantial mortality associated with CS in Afghanistan may be partly due to women coming late for obstetric care, efforts to increase the availability and utilization of CS must also focus on improving the quality of care to reduce mortality. Key goals should be encouraging use of partographs and improving decision-making and documentation around CS deliveries.

Effectiveness of Interventions, Programs and Strategies for Gender-based Violence Prevention in Refugee Populations: An Integrative Review.

Background: Gender based violence (GBV) remains one of the most serious threats to the health and safety of women and girls worldwide. The problem is even more pronounced in refugee populations where women and girls are at increased risk of violence. In 2015, UNHCR reported the highest number of forcibly displaced people in recorded history. Despite growing need, there have been few rigorous evaluations of interventions aimed at primary GBV prevention and no systematic reviews of GBV prevention efforts specifically focused on refugee populations; reviews to date have primarily examined prevention of conflict related sexual violence, with very limited focus on other forms of GBV such as intimate partner violence Methods: This study reviewed the scientific literature addressing strategies for primary prevention of GBV and their effectiveness among refugee populations over the past ten years (2006 to 2015). Narrative content analysis methods were used to extract findings related to prevention activities/programs recommended by the global humanitarian community, such as sociocultural norms change, rebuilding family and community support structures, improving accountability systems, designing effective services and facilities, working with formal and traditional legal systems, monitoring and documenting GBV, and/or engaging men and boys in GBV prevention and response. Results: Study findings indicate that a range of GBV prevention activities recommended by the global humanitarian community are currently being applied in a variety of settings. However, there remains a limited body of evidence on the effectiveness of GBV prevention programs, interventions, and strategies, especially among refugee populations. Conclusion: Commonly agreed upon standards or guidelines for evaluation of GBV prevention programming, and publication of evaluations conducted using these guidelines, could assist humanitarian stakeholders to build and disseminate an evidence base of effective GBV prevention interventions, programs and strategies. Evaluation of GBV prevention efforts, especially among refugee populations, must be given higher priority to justify continuation or revision of recommended GBV activities/programs being implemented in diverse humanitarian settings.

Assessing the capacity for newborn resuscitation and factors associated with providers’ knowledge and skills: a cross-sectional study in Afghanistan

BackgroundResuscitation with bag and mask is a high-impact intervention that can reduce neonatal deaths in resource-poor countries. This study assessed the capacity to perform newborn resuscitation at facilities offering comprehensive emergency obstetric and newborn care (EmONC) in Afghanistan, as well as individual and facility characteristics associated with providers’ knowledge and clinical skills.MethodsAssessors interviewed 82 doctors and 142 midwives at 78 facilities on their knowledge of newborn resuscitation and observed them perform the procedure on an anatomical model. Supplies, equipment, and infrastructure were assessed at each facility. Descriptive statistics and simple and multivariate regression analyses were performed using STATA 11.2 and SAS 9.1.3.ResultsOver 90% of facilities had essential equipment for newborn resuscitation, including a mucus extractor, bag, and mask. More than 80% of providers had been trained on newborn resuscitation, but midwives were more likely than doctors to receive such training as part of pre-service education (59% and 35%, respectively, p < 0.001). No significant differences were found between doctors and midwives on knowledge, clinical skills, or confidence in performing newborn resuscitation. Doctors and midwives scored 71% and 66%, respectively, on knowledge questions and 66% and 71% on the skills assessment; 75% of doctors and 83% of midwives felt very confident in their ability to perform newborn resuscitation. Training was associated with greater knowledge (p < 0.001) and clinical skills (p < 0.05) in a multivariable model that adjusted for facility type, provider type, and years of experience offering EmONC services.ConclusionsLack of equipment and training do not pose major barriers to newborn resuscitation in Afghanistan, but providers’ knowledge and skills need strengthening in some areas. Midwives proved to be as capable as doctors of performing newborn resuscitation, which validates the major investment made in midwifery education. Competency-based pre-service and in-service training, complemented by supportive supervision, is an effective way to build providers’ capacity to perform newborn resuscitation. This kind of training could also help skilled birth attendants based in the community, at private clinics, or at primary care facilities save the lives of newborns.

Domestic Violence Among Iraqi Refugees in Syria

A domestic violence questionnaire was administered to 701 adult females in a sample of 813 Iraqi households in Syria; unmarried women and women whose husbands were away were excluded, yielding a final sample of 486. Lifetime physical, verbal, or emotional abuse was reported by 30%, and approximately 20% experienced abuse within the past year. Non-Damascus residence, children <18 years in the household, no financial challenges upon arrival, and borrowing money in Syria were associated with increased risk of domestic violence within the past year. Support services are inadequate and should be expanded; and longer-term prevention measures also should be implemented.

Prevention and management of severe pre-eclampsia/eclampsia in Afghanistan

BackgroundAn evidence-based strategy exists to reduce maternal morbidity and mortality associated with severe pre-eclampsia/eclampsia (PE/E), but it may be difficult to implement in low-resource settings. This study examines whether facilities that provide emergency obstetric and newborn care (EmONC) in Afghanistan have the capacity to manage severe PE/E cases.MethodsA further analysis was conducted of the 2009–10 Afghanistan EmONC Needs Assessment. Assessors observed equipment and supplies available, and services provided at 78 of the 127 facilities offering comprehensive EmONC services and interviewed 224 providers. The providers also completed a written case scenario on severe PE/E. Descriptive statistics were used to summarize facility and provider characteristics. Student t-test, one-way ANOVA, and chi-square tests were performed to determine whether there were significant differences between facility types, doctors and midwives, and trained and untrained providers.ResultsThe median number of severe PE/E cases in the past year was just 5 (range 0–42) at comprehensive health centers (CHCs) and district hospitals, compared with 44 (range 0–130) at provincial hospitals and 108 (range 32–540) at regional and specialized hospitals (p < 0.001). Most facilities had the drugs and supplies needed to treat severe PE/E, including the preferred anticonvulsant, magnesium sulfate (MgSO4). One-third of the smallest facilities and half of larger facilities reported administering a second-line drug, diazepam, in some cases. In the case scenario, 96% of doctors and 89% of midwives recognized that MgSO4 should be used to manage severe PE/E, but 42% of doctors and 58% of midwives also thought diazepam had a role to play. Providers who were trained on the use of MgSO4 scored significantly higher than untrained providers on six of 20 items in the case scenario. Providers at larger facilities significantly outscored those at smaller facilities on five items. There was a significant difference between doctors and midwives on only one item: continued use of anti-hypertensives after convulsions are controlled.ConclusionsDrugs and supplies needed to treat severe PE/E are widely available at EmONC facilities in Afghanistan, but providers lack knowledge in some areas, especially concerning the use of MgSO4 and diazepam. Providers who have specialized training or work at larger facilities are better at managing cases of severe PE/E. The findings suggest a need to clarify service delivery guidelines, offer refresher training, and reinforce best practices with supervision and reinforcement.

United Nations High Commissioner for Refugees Feeding Program Performance in Kenya and Tanzania: A Retrospective Analysis of Routine Health Information System Data

Background The United Nations High Commissioner for Refugees (UNHCR) Health Information System is a primary source of routine nutrition program data and provides a comprehensive assessment of UNHCR selective feeding programs in more than 90 refugee camps in 18 countries worldwide. Objective To evaluate the coverage and effectiveness of UNHCR supplementary and therapeutic feeding programs for malnourished children under 5 years of age in Kenya and Tanzania refugee camps. Methods Analysis of Kenya and Tanzania refugee camp population, growth monitoring, and nutrition program data from the UNHCR Health Information System. Results UNHCR-supported implementing partners in Kenya and Tanzania admitted nearly 45,000 malnourished refugee children in selective feeding programs between January 2006 and May 2009. Average recovery rates of 77.1% and 84.6% in the therapeutic and supplementary programs, respectively, mortality rates of less than 1%, and average readmission below 5% suggest that feeding programs had a beneficial effect on enrolled children. Conclusions Increasing admission and enrollment in supplementary feeding programs was successful in preventing cases of severe malnutrition in some camps. Further attention to these camps would be likely to yield sizeable benefits in terms of absolute reductions in malnutrition prevalence and mortality rates.

Performance of UNHCR nutrition programs in post-emergency refugee camps

BackgroundThe United Nations High Commissioner for Refugees (UNHCR) launched a health information system (HIS) in 2005 to enhance quality and consistency of routine health information available in post-emergency refugee camps. This paper reviews nutrition indicators and examines their application for monitoring and evaluating the performance of UNHCR nutrition programs in more than 90 refugee camps in 18 countries.MethodsThe HIS is a primary source of feeding program data which is collected using standardized case definitions and reporting formats across refugee camps in multiple settings. Data was aggregated across time periods and within and across countries for analysis. Basic descriptive statistics were then compared to UNHCR program performance standards.ResultsCamp populations covered by the HIS ranged from 192,000 to 219,000 between 2007 and mid-2009; 87% of under five children covered by the HIS were in Africa and 13% in Asia. Average moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) rates reported in 74 of 81 camps for the 2007-2009 time periods were 7.0% and 1.6%, respectively. The supplementary feeding program (SFP) admission rate was 151/1000/yr with 93% of SFP admissions occurring in Africa. SFP performance consistently exceeded all UNHCR standards with the exception of length of enrollment. Average length of SFP enrollment was 12 weeks in Africa and 22 weeks in Asia as compared to the UNHCR standard of < 8 weeks. The therapeutic feeding program (TFP) admission was 22/1000/yr with 95% of TFP admissions in Africa. TFP performance met UNHCR standards with the exception of daily weight gain.ConclusionsInclusion of children identified as moderately and severely wasted in the HIS would allow UNHCR to better track and respond to changes in nutrition status. Improved growth monitoring coverage or active malnutrition surveillance would increase UNHCRs ability to identify and treat cases of acute malnutrition. Expansion of nutrition reporting to address the transition to community-based therapeutic care is essential for adequate performance monitoring in the future. In terms of program priorities, a focus on camps and countries with large refugee populations and high feeding program enrollment rates would have the greatest impact in terms of absolute reductions in the incidence and prevalence of malnutrition.

Utilization of outpatient services in refugee settlement health facilities: a comparison by age, gender, and refugee versus host national status

BackgroundComparisons between refugees receiving health care in settlement-based facilities and persons living in host communities have found that refugees have better health outcomes. However, data that compares utilization of health services between refugees and the host population, and across refugee settlements, countries and regions is limited. The paper will address this information gap. The analysis in this paper uses data from the United Nations High Commissioner of Refugees (UNHCR) Health Information System (HIS).MethodsData about settlement populations and the use of outpatient health services were exported from the UNHCR health information system database. Tableau Desktop was used to explore the data. STATA was used for data cleaning and statistical analysis. Differences in various indicators of the use of health services by region, gender, age groups, and status (host national vs. refugee population) were analyzed for statistical significance using generalized estimating equation models that adjusted for correlated data within refugee settlements over time.ResultsEighty-one refugee settlements were included in this study and an average population of 1.53 million refugees was receiving outpatient health services between 2008 and 2009. The crude utilization rate among refugees is 2.2 visits per person per year across all settlements. The refugee utilization rate in Asia (3.5) was higher than in Africa on average (1.8). Among refugees, females have a statistically significant higher utilization rate than males (2.4 visits per person per year vs. 2.1). The proportion of new outpatient attributable to refugees is higher than that attributable to host nationals. In the Asian settlements, only 2% outpatient visits, on average, were attributable to host community members. By contrast, in Africa, the proportion of new outpatient (OPD) visits by host nationals was 21% on average; in many Ugandan settlements, the proportion of outpatient visits attributable to host community members was higher than that for refugees. There was no statistically significant difference between the size of the male and female populations across refugee settlements. Across all settlements reporting to the UNHCR database, the percent of the refugee population that was less than five years of age is 16% on average.ConclusionsThe availability of a centralized database of health information across UNHCR-supported refugee settlements is a rich resource. The SPHERE standard for emergencies of 1-4 visits per person per year appears to be relevant for Asia in the post-emergency phase, but not for Africa. In Africa, a post-emergency standard of 1-2 visits per person per year should be considered. Although it is often assumed that the size of the female population in refugee settlements is higher than males, we found no statistically significant difference between the size of the male and female populations in refugee settlements overall. Another assumption---that the under-fives make up 20% of the settlement population during the emergency phase---does not appear to hold for the post-emergency phase; under-fives made up about 16% of refugee settlement populations.