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BackgroundIn South Asia, roughly half of women attend at least four antenatal care visits with skilled health personnel, the minimum number recommended by the World Health Organization for optimal birth outcomes. A much greater proportion of women attend at least one antenatal care visit, suggesting that a key challenge is ensuring that women initiate antenatal care early in pregnancy and continue to attend after their first visit. One critical barrier to antenatal care attendance may be that women do not have sufficient power in their relationships, households, or communities to attend antenatal care when they want to. The main goals of this paper were to 1) understand the potential effects of intervening on direct measures of women's empowerment-including household decision making, freedom of movement, and control over assets-on antenatal care attendance in a rural population of women in Bangladesh, and 2) examine whether differential associations exist across strata of socioeconomic status.MethodsWe analyzed data on 1609 mothers with children under 24 months old in rural Bangladesh and employed targeted maximum likelihood estimation with ensemble machine learning to estimate population average treatment effects.ResultsGreater women's empowerment was associated with an increased number of antenatal care visits. Specifically, among women who attended at least one antenatal care visit, having high empowerment was associated with a greater probability of ≥ 4 antenatal care visits, both in comparison to low empowerment (15.2 pp, 95% CI: 6.0, 24.4) and medium empowerment (9.1 pp, 95% CI: 2.5, 15.7). The subscales of women's empowerment driving the associations were women's decision-making power and control over assets. We found that greater women's empowerment is associated with more antenatal care visits regardless of socioeconomic status.ConclusionsEmpowerment-based interventions, particularly those targeting women's involvement in household decisions and/or facilitating greater control over assets, may be a valuable strategy for increasing antenatal care attendance.Trial registrationClinicalTrials.gov Identifier: NCT04111016, Date First Registered: 01/10/2019.

BackgroundReliable and valid measurement of early child development are necessary for the design of effective interventions, programs, and policies to improve early child outcomes. One widely used measure in low- and middle-income countries (LMICs) is the Bayley Scales of Infant and Toddler Development III (Bayley-III). Alternatively, the Bangladeshi-adapted Ages and Stages Questionnaire Inventory (ASQ:I) can be administered more quickly, inexpensively, and with less training than the Bayley-III. We aimed to assess the concurrent validity of the Bangladeshi-adapted ASQ:I with the Bayley-III in children 4-27 months old in rural Bangladesh.MethodsThe sample was a sub-sample (n = 244) of endline participants from an evaluation of an early child development intervention (July-August 2018). We assessed concurrent validity between internally age-standardized domain-specific and total scores using Pearson correlations both overall and stratified by age and intervention status. We also assessed correlations between scores and variables theoretically related to child development including maternal education and stimulation in the home.ResultsThe overall correlation between ASQ:I and Bayley-III total scores was moderate (r = 0.42 95% CI: 0.30-0.53), with no systematic differences by intervention status. Overall, concurrent validity was highest for the gross motor domain (r = 0.51, 0.40-0.60), and lowest for the fine motor domain (r = 0.20, 0.04-0.33). Total ASQ:I and Bayley-III scores were positively correlated with child stimulation and maternal education.ConclusionThe Bangladeshi-adapted ASQ:I is a low-cost tool that can be feasibly administered in rural Bangladesh, is moderately correlated with the Bayley-III, and can be used to measure child development when human, time, or financial resources are constrained.

Introduction Maternal mortality is one of the main causes of death for women of childbearing age in Mali, and improving this outcome is slow, even in regions with relatively good geographic access to care. Disparities in maternal health services utilization can constitute a major obstacle in the reduction of maternal mortality in Mali and indicates a lack of equity in the Malian health system. Literature on maternal health inequity has explored structural and individual factors influencing outcomes but has not examined inequities in health facility distribution within districts with moderate geographic access. The purpose of this article is to examine disparities in education and geographic distance and how they affect utilization of maternal care within the Sélingué health district, a district with moderate geographic access to care, near Bamako, Mali. Methods We conducted a cross sectional survey with cluster sampling in the Sélingué health district. Maternal health services characteristics and indicators were described. Association between dependent and independent variables was verified using Kendall's tau-b correlation, Chi square, logistic regression with odds ratio and 95% confidence interval. Gini index and concentration curve were used to measure inequity. Results Most respondents were 20 to 24 years old. Over 31% of our sample had some education, 65% completed at least four ANC visits, and 60.8% delivered at a health facility. Despite this evidence of healthcare access in Sélingué, disparities within the health district contribute to inadequate utilization among approximately 40% of the women in our sample. The concentration index demonstrated the impact of inequity in geographic access, comparing women residing near and far from the referral care facility. Conclusion Maternal health services underutilization, within a district with moderate geographic access, indicates that deliberate attention should be paid to addressing geographic access even in such a district., Author(s): Moctar Tounkara [sup.1] , Oumar Sangho [sup.1] [sup.2] , Madeleine Beebe [sup.3] , Lillian Joyce Whiting-Collins [sup.3] , Rebecca R. Goins [sup.3] , Hannah C. Marker [sup.3] , Peter [...]

Anthropogenic climate change is increasing the frequency and severity of extreme heat events, leading to increased morbidity and mortality. Many of the populations at greatest risk from the health threats of extreme heat are also more likely to receive health insurance coverage from the Medicaid program. While Medicaid has not historically covered air conditioners, an increasing number of states are offering coverage. Of the Medicaid programs administered by the 50 states and Washington DC, 13 currently offer an air conditioner coverage benefit and 2 have applied to offer coverage to the federal government. Most of these states have obtained various types of waivers under the Social Security Act to cover air conditioners. Section 1115 waivers tend to offer more flexible and holistic coverage. The states offering coverage vary in the types of air conditioners covered, the approximate frequency with which air conditioners have been furnished, and the billing codes utilized. The lack of a specific billing code or procedure modifier code for air conditioners is a barrier to tracking the effectiveness, reach, and implementation of air conditioner coverage policies within and across states. [ABSTRACT FROM AUTHOR]

Background Meningitis causes significant mortality in regions with high comorbid HIV and TB. Improved outcomes are hindered by limited understanding of factors that delay adequate care. Methods In-depth interviews of patients admitted to the University Teaching Hospital with suspected meningitis, their caregivers, doctors and nurses were conducted. Patient/caregiver interviews explored meningitis understanding, treatment prior to admission and experiences since admission. Provider interviews addressed current and prior experiences with meningitis patients and hospital barriers to care. A conceptual framework based on the Three Delays Model identified factors that delayed care. Results Twenty-six patient/caregiver, eight doctor and eight nurse interviews occurred. Four delays were identified: in-home care; transportation to a health facility; clinic/first-level hospital care; and third-level hospital. Overcrowding and costly diagnostic testing delayed outpatient care; 23% of patients began with treatment inside the home due to prior negative experiences with biomedical care. Admission occurred after multiple clinic visits, where subsequent delays occurred during testing and treatment. Conclusions Delays in care from home to hospital impair quality meningitis care in Zambia. Interventions to improve outcomes must address patient, community and health systems factors. Patient/caregiver education regarding signs of meningitis and indications for care-seeking are warranted to reduce treatment delays. [ABSTRACT FROM AUTHOR]

Puerperal sepsis is an important cause of maternal morbidity and mortality in developing countries. Awareness of local terminology for its signs and symptoms may improve communication about this illness, what actions to take when symptoms appear, timely care seeking, and clinical outcomes. This formative research aimed to improve recognition and management of postpartum sepsis in Pakistan by eliciting local terms used for postpartum illnesses and symptoms. We conducted 32 in-depth interviews with recently delivered women, their relatives, traditional birth attendants, and health care providers to explore postpartum experiences. Terms for symptoms and illness are used interchangeably (i.e. bukhar, the Urdu word for fever), many variations exist for the same term, and gradations of severity for each term as not associated with different types of illnesses. The lack of a designated term for postpartum sepsis in Urdu delays care-seeking and proper diagnosis, particularly at the community level. Ideally, a common lexicon for symptoms and postpartum sepsis would be developed but this may not be feasible or appropriate given the nature of the Urdu language and local understandings of postpartum illness. These insights can inform how we approach educational campaigns, the development of clinical algorithms that focus on symptoms, and counselling protocols. [ABSTRACT FROM AUTHOR]

There is increasing evidence that green space in communities reduces the risk of aggression and violence, and increases wellbeing. Positive associations between green space and resilience have been found among children, older adults and university students in the United States, China and Bulgaria. Little is known about these associations among predominately Black communities with structural disadvantage. This study explored the potential community resilience in predominately Black neighborhoods with elevated violent crime and different amounts of green space. This embedded mixed-methods study started with quantitative analysis of women who self-identified as "Black and/or African American." We found inequality in environments, including the amount of green space, traffic density, vacant property, and violent crime. This led to 10 indepth interviews representing communities with elevated crime and different amounts of green space. Emergent coding of the first 3 interviews, a subset of the 98 in the quantitative analysis, led to a priori coding of barriers and facilitators to potential green space supported community resilience applied to the final 7 interview data. Barriers were a combination of the physical and social environment, including traffic patterns, vacant property, and crime. Facilitators included subjective qualities of green space. Green spaces drew people in through community building and promoting feelings of calmness. The transformation of vacant lots into green spaces by community members affords space for people to come together and build community. Green spaces, a modifiable factor, may serve to increase community resilience and decrease the risk of violence. [ABSTRACT FROM AUTHOR]

While increasing numbers of North Korean refugees (NKRs) are migrating to South Korea, different understandings of physical pain between NKR patients and the South Korean healthcare providers may create miscommunication and less satisfaction with their care management. To identify strategies to improve care, this study elicits and presents an ethnomedical model of chronic pain among NKR women. Twenty semi-structured individual interviews were conducted with NKR women with chronic pain living in South Korea. Inductive and deductive thematic analysis was performed on three types of data: interview transcripts, field notes created after each interview, and memos written during the analysis. Participants reported that pain started after a certain period of resettlement and expressed frustration when there was no definite diagnosis for pain. They identified physical factors (e.g. excessive labor, exposure to violence, and poor diet) as the primary causes, while psychological factors (e.g. loneliness, rumination, and financial burden of sending remittances to North Korea) were viewed as collateral or contributing causes. Several participants indicated emotional discomfort when they were referred to psychiatrists for unceasing pain. Physical treatment (injections, medications, or acupuncture) and providers' sincere attitudes were expectations of care considered capable of addressing both physical and emotional distress. Findings highlight the need to understand NKR women's ethnomedical model of chronic pain, which is distinct from illness model of healthcare providers. These preliminary findings could be used to improve care strategies based on NKRs' care needs. [ABSTRACT FROM AUTHOR]

We examine how the changes in migration patterns and humanitarian assistance policies in response to the 2015–2016 migration crisis in Greece affected unaccompanied migrant children's access to shelters in Greece. Forty-four migrant youth aged 18–21 who arrived in Greece as unaccompanied children were recruited for in-depth interviews regarding their experiences in Greece. Life history calendars were constructed to establish the sequence of events and changes in living situations. We found that after EU-Turkey Statement was signed in March of 2016, unaccompanied minors' experience of the humanitarian border changed according to the route by which they entered Greece. The policy changes that were implemented in March 2016 created new disparities in access to child protection settings based on minors' route of entry into Greece. [ABSTRACT FROM AUTHOR]

Objective: Artisanal and small-scale mining (ASM) is a widespread livelihood in low- and middle-income countries; however, many in ASM communities face high levels of poverty and malnutrition. The food environments in ASM communities have non-agricultural rural characteristics that differ from those in urban and agricultural rural areas examined in much existing food environment literature.Design: We examine these complex external and personal food environments in ASM communities via a study using qualitative and quantitative methods. Market surveys and a cross-sectional household survey, plus qualitative mining site non-participant observations and in-depth structured interviews, were conducted in three waves.Setting: Eighteen study sites in ASM communities in northern Guinea.Participants: Surveys covered mothers in mining households with young children (n 613); in-depth interviews engaged caregivers of young children (n 45), food vendors (n 40) and young single miners (n 15); observations focused on mothers of young children (n 25).Results: The external food environment in these ASM communities combines widespread availability of commercially processed and staple-heavy foods with lower availability and higher prices for more nutritious, non-staple foods. Within the personal food environment, miners are constrained in their food choices by considerable variability in daily cash income and limited time for acquisition and preparation.Conclusions: We demonstrate that ASM communities have characteristics of both urban and rural populations and argue for greater nuance and appreciation of complexity in food environment research and resultant policy and programming. [ABSTRACT FROM AUTHOR]

Acculturation and racial discrimination have been independently associated with physical function limitations in immigrant and United States (U.S.)-born populations. This study examined the relationships among acculturation, racial discrimination, and physical function limitations in N = 165 African immigrant older adults using multiple linear regression. The mean age was 62 years (SD = 8 years), and 61% were female. Older adults who resided in the United States for 10 years or more had more physical function limitations compared with those who resided here for less than 10 years (b = −2.62, 95% confidence interval [CI] = [–5.01, –0.23]). Compared to lower discrimination, those with high discrimination had more physical function limitations (b = −2.51, 95% CI = [–4.91, –0.17]), but this was no longer significant after controlling for length of residence and acculturation strategy. Residing in the United States for more than 10 years is associated with poorer physical function. Longitudinal studies with large, diverse samples of African immigrants are needed to confirm these associations. [ABSTRACT FROM AUTHOR]