Project description:In high-income countries, group antenatal care (ANC) offers an alternative to individual care and is associated with improved attendance, client satisfaction, and health outcomes for pregnant women and newborns. In low- and middle-income country (LMIC) settings, this model could be adapted to address low antenatal care uptake and improve quality. However, evidence on key attributes of a group care model for low-resource settings remains scant. We conducted a systematic review of the published literature on models of group antenatal care in LMICs to identify attributes that may increase the relevance, acceptability and effectiveness of group ANC in such settings. We systematically searched five databases and conducted hand and reference searches. We also conducted key informant interviews with researchers and program implementers who have introduced group antenatal care models in LMICs. Using a pre-defined evidence summary template, we extracted evidence on key attributes-like session content and frequency, and group composition and organization-of group care models introduced across LMIC settings. Our systematic literature review identified nine unique descriptions of group antenatal care models. We supplemented this information with evidence from 10 key informant interviews. We synthesized evidence from these 19 data sources to identify attributes of group care models for pregnant women that appeared consistently across all of them. We considered these components that are fundamental to the delivery of group antenatal care. We also identified attributes that need to be tailored to the context in which they are implemented to meet local standards for comprehensive ANC, for example, the number of sessions and the session content. We compiled these attributes to codify a composite "generic" model of group antenatal care for adaptation and implementation in LMIC settings. With this combination of standard and flexible components, group antenatal care, a service delivery alternative that has been successfully introduced and implemented in high-income country settings, can be adapted for improving provision and experiences of care for pregnant women in LMIC. Any conclusions about the benefits of this model for women, babies, and health systems in LMICs, however, must be based on robust evaluations of group antenatal care programs in those settings.

Project description:BackgroundThere is growing recognition of the importance of menstruation in achieving health, education, and gender equality for all. New policies in high income countries (HICs) have responded to anecdotal evidence that many struggle to meet their menstrual health needs. Qualitative research has explored lived experiences of menstruating in HICs and can contribute to designing intervention approaches. To inform the growing policy attention to support people who menstruate, here we review and synthesise the existing research.Methods and findingsPrimary, qualitative studies capturing experiences of menstruation in HICs were eligible for inclusion. Systematic database and hand searching identified 11485 records. Following screening and quality appraisal using the EPPI-Centre checklist, 104 studies (120 publications) detailing the menstrual experiences of over 3800 individuals across sixteen countries were included. We used the integrated model of menstrual experiences developed from studies in low- and middle-income countries (LMICs) as a starting framework and deductively and inductively identified antecedents contributing to menstrual experiences; menstrual experiences themselves and impacts of menstrual experiences. Included studies described consistent themes and relationships that fit well with the LMIC integrated model, with modifications to themes and model pathways identified through our analysis. The socio-cultural context heavily shaped menstrual experiences, manifesting in strict behavioural expectations to conceal menstruation and limiting the provision of menstrual materials. Resource limitations contributed to negative experiences, where dissatisfaction with menstrual practices and management environments were expressed along with feelings of disgust if participants felt they failed to manage their menstruation in a discrete, hygienic way. Physical menstrual factors such as pain were commonly associated with negative experiences, with mixed experiences of healthcare reported. Across studies participants described negative impacts of their menstrual experience including increased mental burden and detrimental impacts on participation and personal relationships. Positive experiences were more rarely reported, although relationships between cis-women were sometimes strengthened by shared experiences of menstrual bleeding. Included studies reflected a broad range of disciplines and epistemologies. Many aimed to understand the constructed meanings of menstruation, but few were explicitly designed to inform policy or practice. Few studies focused on socioeconomically disadvantaged groups relevant to new policy efforts.ConclusionsWe developed an integrated model of menstrual experience in HICs which can be used to inform research, policy and practice decisions by emphasising the pathways through which positive and negative menstrual experiences manifest.Review protocol registrationThe review protocol registration is PROSPERO: CRD42019157618.

Project description:BackgroundCOVID-19 has impacted the capacity of healthcare systems worldwide, particularly in low- and middle-income countries (LMICs), which are already under strain due to population growth and insufficient resources. Since the COVID-19 pandemic's emergence, there has been an urgent need for a rapid and adequate reaction to the pandemic's disruption of healthcare systems. To this end, telemedicine has been shown in prior research to be a feasible approach. The overarching objective of this scoping review was to determine the extent and acceptance of telemedicine in healthcare in low- and middle-income countries (LMICs) during the COVID-19 pandemic.MethodsThis scoping review followed PRISMA guidelines and Arksey and O'Malley's five-stage framework to identify available evidence. We systematically searched four academic databases for peer-reviewed literature published between January 2020 and April 2021: Medline, PubMed, Web of Science, and Scopus, as well as Google Scholar as a source for grey literature.ResultsThe search identified 54 articles with 45,843 participants, including 6,966 healthcare professionals and 36,877 healthcare users. We identified a range of reasons for introducing telemedicine in LMICs during COVID-19, most notably to maintain non-emergency healthcare, enhance access to healthcare providers, and reduce the risk of infection among health users and providers. Overall, healthcare providers and users have shown a high level of acceptance for telemedicine services. During the COVID-19 pandemic, telemedicine provided access to healthcare in the majority of included articles. Nonetheless, some challenges to accepting telemedicine as a method of healthcare delivery have been reported, including technological, regulatory, and economical challenges.ConclusionTelemedicine was found to improve access to high-quality healthcare and decrease infection risk in LMICs during COVID-19. In general, infrastructure and regulatory barriers found to be the most significant barriers to wider telemedicine use, and should be considered when implementing telemedicine more broadly. There appears to be a need to prioritize patient data safety, as many healthcare practitioners utilized commercial apps and services as telemedicine systems. Additionally, it appears as though there is a need to increase capacity, skill, and transparency, as well as to educate patients about telemedicine.

Project description:High-quality obstetric delivery in a health facility reduces maternal and perinatal morbidity and mortality. This systematic review synthesizes qualitative evidence related to the facilitators and barriers to delivering at health facilities in low- and middle-income countries. We aim to provide a useful framework for better understanding how various factors influence the decision-making process and the ultimate location of delivery at a facility or elsewhere. We conducted a qualitative evidence synthesis using a thematic analysis. Searches were conducted in PubMed, CINAHL and gray literature databases. Study quality was evaluated using the CASP checklist. The confidence in the findings was assessed using the CERQual method. Thirty-four studies from 17 countries were included. Findings were organized under four broad themes: (1) perceptions of pregnancy and childbirth; (2) influence of sociocultural context and care experiences; (3) resource availability and access; (4) perceptions of quality of care. Key barriers to facility-based delivery include traditional and familial influences, distance to the facility, cost of delivery, and low perceived quality of care and fear of discrimination during facility-based delivery. The emphasis placed on increasing facility-based deliveries by public health entities has led women and their families to believe that childbirth has become medicalized and dehumanized. When faced with the prospect of facility birth, women in low- and middle-income countries may fear various undesirable procedures, and may prefer to deliver at home with a traditional birth attendant. Given the abundant reports of disrespectful and abusive obstetric care highlighted by this synthesis, future research should focus on achieving respectful, non-abusive, and high-quality obstetric care for all women. Funding for this project was provided by The United States Agency for International Development (USAID) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization.

Project description:BackgroundThe COVID-19 pandemic has disrupted immunization services critical to the prevention of vaccine-preventable diseases in many low- and middle- income countries around the world. These services will need to be modified in order to minimize COVID-19 transmission and ensure the safety of health workers and the community. Additional budget will be required to implement these modifications that ensure safe delivery.MethodsUsing a simple modeling analysis, we estimated the additional resource requirements associated with modifications to supplementary immunization activities (campaigns) and routine immunization services via fixed sites and outreach in 2020 US dollars. We considered the following four categories of costs: (1) personal protective equipment (PPE) & infection prevention and control (IPC) measures for immunization sessions; (2) physical distancing and screening during immunization sessions; (3) delivery strategy changes, such as changes in session sizes and frequency; and (4) other operational cost increases, including additional social mobilization, training, and hazard pay to compensate health workers.ResultsWe found that implementing a range of measures to protect health workers and communities from COVID-19 transmission could result in a per-facility start-up cost of $466-799 for routine fixed-site delivery and $12-220 for routine outreach delivery, and $12-108 per immunization campaign site. A recurrent monthly cost of $137-1,024 for fixed-site delivery and $152-848 for outreach delivery per facility could be incurred, and a $0.32-0.85 increase in the cost per dose during campaigns.ConclusionsBy illustrating potential cost implications of providing immunization services through a range of strategies in a safe manner, these estimates can provide a benchmark for program managers and policy makers on the additional budget required. These findings can help country practitioners and global development partners planning the continuation of immunization services in the context of COVID-19.

Project description:BackgroundVaccine acceptance and hesitancy among the general population and health care workers play an important role in successfully controlling the Coronavirus Disease (COVID)-19 pandemic. While there is evidence for vaccine hesitancy across the globe, wide variation in factors influencing vaccine acceptance has been reported, mainly from High-Income Countries (HIC). However, the evidence from Low- and Middle-Income Countries (LMICs) remains unclear. The objective of this review was to describe the determinants of vaccine acceptance and strategies to address those in an LMIC context.MethodsThe World Health Organization's (WHO) Measuring Behavioral and Social Drivers of Vaccination (BeSD) Increasing Vaccination Model was employed to identify factors that influenced vaccine acceptance. All evidence related to supply-side and demand-side determinants and social and health system processes were examined. A comprehensive search for published literature was conducted in three databases and grey literature in relevant websites of government, multinational agencies, and COVID-19 resource aggregators, followed by a narrative synthesis.ResultsOverall, the results showed that the vaccine acceptance rates differed across LMICs, with a wide variety of reasons cited for vaccine hesitancy. Vaccine acceptance was reportedly greater among males, those with higher education, elevated socio-economic status, the unmarried, those employed as health care workers. Evidence suggested that exposure to misinformation about COVID-19 vaccines and public concerns over the safety of vaccines may contribute to lower acceptance rates. Strategies to increase vaccine acceptance rates included direct engagement with communities through influencers, including community leaders and health experts; clear and transparent communication about COVID-19 vaccines, financial and non-financial incentives; and strong endorsement from health care workers. Trust in government was identified as a significant enabler of vaccine acceptance.ConclusionsThere is a need for measures to address public acceptability, trust and concern over the safety and benefit of approved vaccines. Local context is essential to consider while developing programs to promote vaccine uptake. The governments worldwide also need to strategize to develop plans to address the anxiety and vaccine related concerns of community regarding vaccine hesitancy. There is a need for further research to evaluate strategies to address vaccine hesitancy in LMIC.

Project description:CONTEXT The COVID-19 pandemic caused unprecedented global disruption and continues to wreak havoc. Dire predictions were made about the risks to smallholder farmers in lower- and middle- income, but hard data have been lacking. We present the results from 9201 interviews with smallholder farmers from seven countries. OBJECTIVE The objectives are to describe: i) how farmers perceive the key effects of the COVID-19 pandemic and containment measures on livelihoods and food security; ii) the effects on agricultural activities; iii) the coping strategies households deployed. METHODS Household surveys were conducted as part of ongoing monitoring programs during the latter half of 2020. Sites in seven countries were covered: Burundi; Kenya; Rwanda; Tanzania; Uganda; and then Vietnam and Zambia. Findings are representative of smallholder farmers across multiple districts per country. RESULTS AND CONCLUSIONS Our results show that the effects of the COVID-19 containment measures were widespread and often perceived to be severe. Food purchase, off farm income, sale of farm produce, and access to crop inputs were all affected. In locations under more stringent restrictions during the time of the survey, up to 80% of households had to reduce food consumption or variety. Almost all households with off-farm incomes reported reductions, by half on average. A half to three-quarters of households (depending on the location) with income from farm sales reported losses compared to the pre-pandemic situation. In locations with more relaxed containment measures in place during the time of the survey, less frequent and less severe economic and food security outcomes were perceived by the respondent, with around 20% of households reporting negative outcomes. Mobility restrictions, reduced market access, crashes in sale price for agricultural goods, and soaring prices for food purchase were key factors. Sale prices generally dropped for all agricultural products in any given location, and affected not only high value perishable products, but also staple crops such as maize and cassava. Depending on the location, between 30% and 90% of the households applied coping strategies in response to the pandemic during 2020. There was an almost complete absence of official aid amongst households interviewed. SIGNIFICANCE Our results raise the thorny issue of how best to balance containment of COVID-19 against the wellbeing of the vulnerable rural population in lower- and middle-income countries. There is a risk that the buffering capacity of rural people will become exhausted. Possible policy measures to limit negative outcomes include i) tiered mobility restrictions with travel allowed for economic reasons; ii) short-term price guarantee schemes to stabilise the food system; iii) direct aid; iv) the timely re-installation of distribution channels for agricultural inputs. Graphical abstract Unlabelled Image

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Evidence synthesis communities in low-income and middle-income countries and the COVID-19 response.

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