Padam Simkhada

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.

COPD and chronic bronchitis risk of indoor air pollution from solid fuel: a systematic review and meta-analysis

Background Over half the world is exposed daily to the smoke from combustion of solid fuels. Chronic obstructive pulmonary disease (COPD) is one of the main contributors to the global burden of disease and can be caused by biomass smoke exposure. However, studies of biomass exposure and COPD show a wide range of effect sizes. The aim of this systematic review was to quantify the impact of biomass smoke on the development of COPD and define reasons for differences in the reported effect sizes. Methods A systematic review was conducted of studies with sufficient statistical power to calculate the health risk of COPD from the use of solid fuel, which followed standardised criteria for the diagnosis of COPD and which dealt with confounding factors. The results were pooled by fuel type and country to produce summary estimates using a random effects model. Publication bias was also estimated. Results There were positive associations between the use of solid fuels and COPD (OR=2.80, 95% CI 1.85 to 4.0) and chronic bronchitis (OR=2.32, 95% CI 1.92 to 2.80). Pooled estimates for different types of fuel show that exposure to wood smoke while performing domestic work presents a greater risk of development of COPD and chronic bronchitis than other fuels. Conclusion Despite heterogeneity across the selected studies, exposure to solid fuel smoke is consistently associated with COPD and chronic bronchitis. Efforts should be made to reduce exposure to solid fuel by using either cleaner fuel or relatively cleaner technology while performing domestic work.

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.

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.

Reduced lung function due to biomass smoke exposure in young adults in rural Nepal.

This study aimed to assess the effects of biomass smoke exposure on lung function in a Nepalese population, addressing some of the methodological issues seen in previous studies. We carried out a cross-sectional study of adults in a population exposed to biomass smoke and a non-exposed population in Nepal. Questionnaire and lung function data were acquired along with direct measures of indoor and outdoor air quality. Ventilatory function (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and forced expiratory flow at 25–75% of FVC) was significantly reduced in the population using biomass across all age groups compared to the non-biomass-using population, even in the youngest (16–25 yrs) age group (mean FEV1 (95% CI) 2.65 (2.57–2.73) versus 2.83 (2.74–2.91) L; p=0.004). Airflow obstruction was twice as common among biomass users compared with liquefied petroleum gas users (8.1% versus 3.6%; p<0.001), with similar patterns for males (7.4% versus 3.3%; p=0.022) and females (10.8% versus 3.8%; p<0.001), based on the lower limit of normal. Smoking was a major risk factor for airflow obstruction, but biomass exposure added to the risk. Exposure to biomass smoke is associated with deficits in lung function, an effect that can be detected as early as the late teenage years. Biomass smoke and cigarette smoke have additive adverse effects on airflow obstruction in this setting.

Sex Trafficking in Nepal: Context and Process.

The aim of this study was to provide a clearer understanding of the process and context of sex trafficking from Nepal using data from trafficked women themselves. It develops a conceptual framework of the trafficking process and uses this to identify detailed strategies for reducing the risk of trafficking. Quantitative data were analyzed from case records of 202 sex-trafficked women at rehabilitation centers in Nepal. In-depth interviews with 42 sex trafficked women, mostly residing at rehabilitation centers in Kathmandu, provide contextual information on the process and circumstances of sex trafficking. The results of this study provide a clearer understanding of the stages of movement through the sex trafficking process; in particular that sex trafficking does not always begin at the village level, it may also occur after voluntary migration or after trafficking to urban areas for other purposes (i.e., labor exploitation). Interventions therefore need to target each stage of movement through sex trafficking. Respondents were most commonly sex trafficked by familiar persons, including relatives; and force and abduction are less common. Women exited from sex trafficking through rescue, escape or release. One of the outcomes of sex trafficking is a return to sex work upon return to Nepal.

Factors influencing adherence to antiretroviral treatment in Asian developing countries: a systematic review

Objective  To systematically review the literature of factors affecting adherence to Antiretroviral treatment (ART) in Asian developing countries.

Infection control knowledge, attitude, and practice among Nepalese health care workers

This study was designed to assess the knowledge, attitudes, and infection control practices among Nepalese health care workers (HCWs). The study comprised a questionnaire survey of 324 staff from acute care hospitals in Kathmandu, Nepal. A total of 158 doctors and 166 nurses participated, 27% of whom had received infection control training. Only 16%, 14%, and 0.3% of the respondents achieved maximum scores for knowledge, attitude, and practice items, respectively. Staff had good knowledge and positive attitude toward most aspects of infection control, although only half had heard of methicillin-resistant Staphylococcus aureus. Logistic regression revealed that profession, age, and having studied abroad significantly predicted markers of infection control knowledge, attitudes, and practice. This is the first survey of infection control practice among Nepalese HCWs and provides useful baseline data by professional group. There is ample opportunity for improvement in current practice, which should be recognized by hospital managers and Nepalese health authorities.

Health problems of Nepalese migrants working in three Gulf countries

BackgroundNepal is one of the largest suppliers of labour to countries where there is a demand for cheap and low skilled workers. In the recent years the Gulf countries have collectively become the main destinations for international migration. This paper aims to explore the health problems and accidents experienced by a sample of Nepalese migrant in three Gulf countries.MethodsA cross-sectional survey was conducted among 408 Nepalese migrants who had at least one period of work experience of at least six months in any of three Gulf countries: Qatar, Saudi Arabia and United Arab Emirates (UAE). Face to face questionnaire interviews were conducted applying a convenience technique to select the study participants.ResultsNepalese migrants in these Gulf countries were generally young men between 26-35 years of age. Unskilled construction jobs including labourer, scaffolder, plumber and carpenter were the most common jobs. Health problems were widespread and one quarter of study participants reported experiencing injuries or accidents at work within the last 12 months. The rates of health problems and accidents reported were very similar in the three countries. Only one third of the respondents were provided with insurance for health services by their employer. Lack of leave for illness, cost and fear of losing their job were the barriers to accessing health care services. The study found that construction and agricultural workers were more likely to experience accidents at their workplace and health problems than other workers.ConclusionThe findings suggest important messages for the migration policy makers in Nepal. There is a lack of adequate information for the migrants making them aware of their health risks and rights in relation to health services in the destination countries and we suggest that the government of Nepal should be responsible for providing this information. Employers should provide orientation on possible health risks and appropriate training for preventive measures and all necessary access to health care services to all their workers.