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Abstract Background Japan is one of the countries experiencing a “super-aged society.” The government has looked to Southeast Asia for recruiting workers to fill the demand for long-term care (LTC) workers. However, migrant LTC workers have faced many job-related stressors. This study aimed to examine the factors associated with job satisfaction and subjective well-being among Filipino, Indonesian, and Vietnamese LTC workers in Japan and explore the specific factors behind what makes them satisfied in their jobs. Methods A convergent mixed methods study was conducted. The workers were recruited through snowball and convenience sampling and completed a self-administered questionnaire for the quantitative part. The association of the work environment with the workers’ job satisfaction and subjective well-being were analyzed using multiple linear regression analysis. An interpretive phenomenological approach was used to conduct in-depth interviews of the workers, which were analyzed using a deductive and inductive approach for the qualitative part. Quantitative and qualitative results were integrated and interpreted to expand on the findings with new insights. Results In the final analysis, 122 workers were included (20 Filipino, 43 Indonesian, and 59 Vietnamese). In the quantitative part, having the necessary tools/equipment (Unstandardized Coefficient [B] = 16.1, 95% Confidence Interval [CI] = 6.8, 25.3) and support from work (B = 18.1, 95% CI = 8.6, 27.6) were associated with a higher level of job satisfaction. Having experienced harassment on the job was associated with a lower level of job satisfaction (B = -18.2, p = 0.007, 95% CI = -28.5, -7.8). There is no strong evidence for the association with subjective well-being. In the qualitative part, prominent themes emerged related to cultural sensitivity and an inadequate knowledge of caring for older adults living with dementia. The integrated findings suggested inadequate and unequal Japanese language training across the facilities. Moreover, the importance of human relations in the workplace emerged, with some workers desiring a deeper connection with their Japanese coworkers. Conclusions A supportive and culturally sensitive work environment may bring about more motivated employees and increase employee retention from migrant LTC workers. Government and facilities should consider policies supporting a culturally sensitive work environment and more equitable Japanese language training across all facilities.

Background HIV testing and starting antiretroviral therapy (ART) are pivotal in treating people living with HIV (PLHIV) but sustaining PLHIV on treatment remains challenging. We assessed retention and attrition in community client-led antiretroviral distribution groups (CCLADs) in Uganda and identified positive deviant practices that foster long-term retention.Methods Using explanatory mixed methods, we collected longitudinal medical data from 65 health facilities across 12 districts in East Central Uganda. Quantitative phase, from 18 April 2021 to 30 May 2021, employed survival analysis and Cox regression to assess retention and identify attrition risk factors. Qualitative inquiry focused on four districts with high attrition from 11 August 2021 to 20 September 2021, where we identified nine health facilities exhibiting high retention in CCLADs. We purposively selected 50 clients for in-depth interviews (n=22) or focus group discussions (n=28). Using thematic analysis, we identified positive deviant practices. We integrated quantitative and qualitative findings into joint displays.Results Involving 3055 PLHIV, the study showed retention rates of 97.5% at 6 months, declining to 89.7% at 96 months. Attrition risk factors were lower levels of care (health centre three (adjusted HR (aHR) 2.80, 95% CI 2.00 to 3.65) and health centre four (aHR 3.61, 95% CI 2.35 to 5.54)); being unemployed (aHR 2.21, 95% CI 1.00 to 4.84); enrolment year into CCLAD (aHR 23.93, 95% CI 4.66 to 123.05) and virological failure (aHR 3.41, 95% CI 2.51 to 4.63). Of 22 clients interviewed, 8 were positive deviants. Positive deviants were characterised by prolonged retention in CCLADs, improved clinical outcomes and practised uncommon behaviours that enabled them to find better solutions than their peers. Positive deviant practices included fostering family-like settings, offering financial or self-development advice, and promoting healthy lifestyles.Conclusions Findings underscore the importance of addressing factors contributing to attrition and leveraging positive deviant practices to optimise retention and long-term engagement in HIV care.

Abstract Background Parental vaccine hesitancy could lead to outbreaks of vaccine-preventable diseases. Although parental vaccine hesitancy exists in the Vietnamese community, no research has directly investigated this social phenomenon in Vietnam. Among the validated measures, the 15-item Parent Attitudes About Childhood Vaccines survey tool (PACV) was reliable for predicting vaccine-hesitant parents. However, the PACV was not available in Vietnamese. This study aimed to develop a Vietnamese version of the PACV and examine factors associated with parental vaccine hesitancy in Hue city, Vietnam. Methods This study was a cross-sectional study. The English PACV was translated into Vietnamese with content and face validation. Self-administered questionnaires were distributed to 400 parents at ten commune health centres in Hue city, Vietnam. The parents were asked to answer the questionnaire again after two weeks for the test–retest reliability. The Vietnamese PACV reliability was assessed using Cronbach’s alpha and McDonald’s omega, and the intra-class correlation (ICC) coefficients were used for the test–retest reliability. The construct validity was tested by the hypothesis that parental vaccine hesitancy would be related to the intention of getting the children vaccinated. Exploratory factor analysis was also undertaken to determine the construct validity. Bivariate and multivariable logistic regression were used to identify the factors associated with parental vaccine hesitancy. Results The Vietnamese PACV final version (PACV-Viet) contained 14 items. Three hundred and fifteen parents returned completed questionnaires, giving a response rate of 78.8%. The Cronbach’s alpha and McDonald’s omega were 0.72 and 0.70, respectively. Out of 315 parents, 84 responses were returned for test–retest reliability. All ICCs were good to excellent, ranging from 0.81 to 0.99. The PACV-Viet was confirmed to have construct validity. Using the PACV-Viet, 8.9% of the parents were found hesitant to childhood vaccination. Being unemployed and having seen the news about adverse events following immunisation were associated with parental vaccine hesitancy, with AOR = 3.2 (95% CI 1.3–8.0) and AOR = 4.5 (95% CI 1.2–16.7), respectively. Conclusions The PACV-Viet is a valid and reliable tool. Community outreach is necessary to alleviate parents’ concerns about childhood vaccination.

Abstract Background Ensuring equal access to primary care services is crucial, as the gateway to a higher level of care. Indonesia has been trying to increase financial access to medical care by administering national health insurance known as BPJS-Health (Badan Penyelenggara Jaminan Sosial Kesehatan) since 2014. However, BPJS-Health beneficiaries can only use their benefits at a limited number of registered primary care providers (BPJS-Health partners). This study investigated the geographical coverage of BPJS-Health and BPJS-Health beneficiaries’ primary care choices, based on their characteristics and healthcare preferences in the target areas of Bandung, Indonesia. Methods The setting of this cross-sectional study was the areas with low physical access to BPJS-Health partners but high physical access to non-BPJS-Health partners. Physical access was determined by spatial network analysis, resulting in a geographical coverage map. A total of 216 adults were recruited and they completed the questionnaire about their primary care choice. All participants had been registered with the BPJS-Health system and living in the study areas. Their participation in non-BPJS-Health was also evaluated. Participants’ choice of care was assessed in three different scenarios, when the individual was experiencing mild, chronic, and serious illnesses. Results BPJS-Health partners’ geographical coverage was unequally distributed in Bandung. Being registered with non-BPJS-Health company was negatively associated with the more frequent choice of using BPJS-Health partners’ services (AOR = 0.18; 95% CI, 0.06-0.58, P = 0.004) among BPJS-Health beneficiaries. For serious illnesses, having a high income was associated with choosing non-BPJS-Health partners and hospitals (AOR = 4.90; 95% CI, 1.16-20.77, P = 0.031). When dealing with mild and chronic illnesses, participants were concerned about the quality of treatment they would receive as a major factor in choosing a primary care provider. However, receiving better treatment quality was negatively associated with choosing BPJS-Health partners in all cases of illness severities. Conclusions Sociodemographic characteristics, healthcare preference factors, and health insurance status were associated with participants’ primary care choices in the target areas of Bandung, Indonesia. BPJS-Health partners’ coverage map and the preference factors are potentially important for policymakers, especially for the development of future BPJS-Health partnerships.

Abstract Background In the last decade, nursing education has begun to reform to competency-based education worldwide, including in low-and middle-income countries. Case-Based Learning (CBL), an approach to delivering competency-based education, contributes to acquiring critical thinking competency, problem-solving, higher knowledge, professional value and attitude. However, it needs to be taught in a culturally appropriate manner. In Cambodia, CBL was initiated in a classroom and clinical practicum by faculty and preceptors who graduated from the upgrading course. This study examined the factors associated with the competency level of nursing students, explored the practice and perceptions of teaching–learning activities among students, faculty members and preceptors and assessed the coherence of qualitative and quantitative findings. Methods This was a convergent, mixed methods study. Data were collected from eight educational institutions for quantitative and qualitative studies and seven hospitals for qualitative studies. From June to September 2019, a cross-sectional survey of nursing students in the third year of the three-year programme (n = 719), eight focus group discussions (FGDs; n = 55) with 6–8 members and 15 FGDs with faculty (n = 38) and clinical preceptors (n = 37) with 4–7 members were conducted to elicit the teaching–learning experience and perceptions. Multiple linear regression was performed to investigate the factors associated with student competency. Moreover, the study conducted thematic content analysis on the qualitative data. The integrated analysis was presented as side-by-side joint displays. Results First, the quantitative and qualitative findings confirmed each other ’s CBL learning experiences. Students had higher levels of nursing competencies if they had CBL experiences, both in the classroom and clinical practicum, both in a group manner. Next, the quantitative and qualitative findings complemented students’ academic satisfaction with the teaching by faculty members and preceptors. Finally, the quantitative and qualitative findings were expanded to explain students’ academic satisfaction with the programme. Conclusions The finding of CBL experiences in a group and students’ satisfaction with faculty members’ and preceptors’ teaching improved nursing students’ competency development. Meanwhile, students’ satisfaction with the design and delivery of the educational programme provides implications for policy level to narrow the theory and practice gaps in low- and middle-income countries.

Summary: Background: In Lao Peoples Democratic Republic, midwives are the main providers of primary reproductive, maternal, newborn, child and adolescent (RMNCAH) services. We analyzed to what extent practice regulations allow midwives to provide nationally defined essential RMNCAH services. Methods: Stakeholder consultations and document reviews were conducted to identify the essential RMNCAH interventions and care tasks midwives are expected to provide without physicians. These were defined in: 1) the Essential Health Service Package (EHSP) and 2) 18 national standards and guidelines. We then mapped whether midwifery regulations, which provide the legal framework for clinical service provision, supported delivery of these standards to identify regulatory gaps. Data were used to update regulations. Findings: Midwives were expected to provide 39 RMNCAH interventions without physicians, representing 1100 care tasks. Midwifery practice regulations allowed eight of 39 interventions (20.5%) and 705 of 1100 care tasks (64.1%) at baseline. Of the 31 interventions not allowed for provision by midwives, 83.9% (26) required prescribing and giving medicines, 51.6% (16) ordering and conducting diagnostics, 38.7% (12) making a clinical diagnosis, and 22.6% (7) use of non-pharmacological interventions. The Ministry of Health convened a multi-stakeholder group to revise the midwifery practice regulations, which increased the legally supported interventions and care tasks to 37 (94.9%) and 1081 (98.3%), respectively. Interpretation: This novel methodology enabled systematic identification and quantification of regulatory gaps in midwifery practice and data-driven revisions. Consequently, regulatory support for delivery of primary RMNCAH interventions vastly improved. The approach can be applied to other clinical cadres, service areas and countries. Funding: Korea Foundation for International Health Care (KOFIH) supported research operation.

Abstract Introduction International travel to Japan increased steadily until the coronavirus disease 2019 (COVID-19) outbreak. Although international travel was curtailed worldwide due to the pandemic, the number of overseas visitors to Japan should increase again after the restrictions are lifted. We assessed the effect of a five-minute digital game on the knowledge of health information and the level of satisfaction with educational health resources of overseas visitors to Japan. Methods We conducted a randomized controlled trial among 1062 previous and potential visitors to Japan utilizing an internet portal. We recruited previous and potential visitors to Japan from the internet portal sites of the UK, the US and Australia. We randomly allocated participants to two groups: an intervention group that played an animated game and a control group that viewed an online animation. All participants answered a self-administered questionnaire online from March 16 to 19, 2021. We assessed visitors’ levels of health knowledge and satisfaction using the CSQ-8. We analyzed the data with a t test and the difference in differences test. Our RCT followed the SPIRIT guidelines. Results Of the 1062 previous and potential visitors recruited via the three countries’ internet portals (354 from each country), some had visited Japan previously (174 in the intervention group, 220 in the control group), while some were potential visitors to Japan (357 in the intervention group, 311 in the control group). Some had gathered health and safety information about Japan prior to this study (180 in the intervention group, 211 in the control group). Both groups improved their health information levels after the intervention. The level of satisfaction with health information in Japan was significantly increased in the intervention group (average difference of 4.5 points) compared to that in the control group (average difference of 3.9 points) (p

Abstract Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disease which impacts patients’ lives. Many studies in high-income countries have focused on their health-related quality of life (HRQoL). However, evidence of awareness of SLE and HRQoL in low- and middle-income countries is lacking. Therefore, this study aimed to identify the determinants of HRQoL of SLE patients in Vietnam, a lower-middle income country. Methods This cross-sectional study was conducted at the National Hospital of Dermatology and Venereology in 2019. A pre-tested structured questionnaire was used to collect data. It consisted of Short Form-36 to assess HRQoL which comprised physical and mental component summaries, Multidimensional Scale of Perceived Social Support, Satisfaction with Life Scale, and Mental Adjustment to SLE. Multiple linear regression was used to identify the determinants of HRQoL. Results One hundred thirty four patients with SLE participated in this study. The majority of the patients were women (n = 126, 94.0%). The mean age of all participants was 37.9 years old (standard deviation [SD] 12.5). Of 134 participants, 104 (77.6%) were married. Older patients were more likely to have a lower score of mental component summary (B=-0.45, 95% CI -0.73, -0.17). Patients with more children were more likely to have a lower score of physical component summary (B=-5.14, 95% CI -9.27, -1.00). Patients who felt more helplessness or hopelessness were more likely to have lower scores of physical and mental component summaries (B=-1.85, 95% CI -2.80, -0.90; B=-1.69, 95% CI -2.57, -0.81). Also, patients who felt more anxious were more likely to have a lower score of mental component summary (B=-1.04, 95% CI -1.77, -0.32). Patients who were more satisfied with their lives were more likely to have higher scores of physical and mental component summaries (B = 1.07, 95% CI 0.50, 1.64; B = 1.08, 95% CI 0.55, 1.61). Conclusion Factors associated with lower HRQoL in Vietnam were feelings of helplessness or hopelessness, and burdens of parenting roles. However, social support can contribute to a higher HRQoL, such as information support, self-support groups, and daycare services provided at the community level.

Abstract Background Person-centered maternity care is a component of quality care, which includes effective communication, respect, and dignity. Supportive care has a positive effect on mothers’ perinatal experience. In contrast, negative childbirth experiences can cause psychological problems. However, the impact of person-centered maternity care experience on mothers’ mental health after delivery remains unknown. Therefore, in this study, we examined the association between person-centered maternity care experience at healthcare facilities and maternal mental health after delivery among Nepali women. Methods We conducted a cross-sectional study in urban and rural areas in Dhading District, Nepal. Participants were women who gave birth at public healthcare facilities, and their baby’s age was between 1 and 12 months. After purposively selecting the target areas, we recruited the women from July to August 2019 and interviewed them using questionnaires. We conducted multiple regression analyses to analyze the association between delivery care experience and depressive symptoms and the association between delivery care experience and mental well-being. Results In total, 595 women were included in the data analysis. The experience of better person-centered maternity care was associated with lower depressive symptom scores in urban (unstandardized coefficient [B]= − 0.09, p

Abstract Introduction Respectful maternity care is an approach that involves respecting women’s belief, choices, emotions, and dignity during the childbirth process. As the workload among maternity care workforce affects intrapartum quality care, respectful maternity care might have also been affected, particularly during the pandemic. Thus, this study was conducted to examine the association between workload among healthcare providers and their practice of respectful maternity care, before and during the early phase of pandemic. Methods A cross-sectional study was conducted in South Western Nepal. A total of 267 healthcare providers from 78 birthing centers were included. Data collection was done through telephone interviews. The exposure variable was workload among the healthcare providers, and the outcome variable was respectful maternity care practice before and during the COVID-19 pandemic. Multilevel mixed-effect linear regression was used to examine the association. Results The median client-provider ratio before and during the pandemic was 21.7 and 13.0, respectively. The mean score of respectful maternity care practice was 44.5 (SD 3.8) before the pandemic, which was decreased to 43.6 (SD 4.5) during the pandemic. Client-provider ratio was negatively associated with respectful maternity care practice for both times; before (Coef. -5.16; 95% CI -8.41 to -1.91) and during (Coef. -7.47; 95% CI -12.72 to -2.23) the pandemic. Conclusions While a higher client-provider was associated with a lower respectful maternity care practice score both before and during the COVID-19 pandemic, the coefficient was larger during the pandemic. Therefore, workload among the healthcare providers should be considered before the implementation of respectful maternity care, and more attention should be given during the pandemic.

Abstract Background School-based interventions have been implemented in resource-limited settings to promote healthy dietary habits, but their sustainability remains a challenge. This study identified positive deviants (PDs) and negative deviants (NDs) from the control and treatment groups in a nutrition-sensitive agricultural intervention in Nepal to identify factors associated with healthy dietary practices. Methods This is an explanatory mixed methods study. Quantitative data come from the endline survey of a cluster randomized controlled trial of a school and home garden intervention in Nepal. Data were analyzed from 332 and 317 schoolchildren (grades 4 and 5) in the control and treatment group, respectively. From the control group, PDs were identified as schoolchildren with a minimum dietary diversity score (DDS) ≥ 4 and coming from low wealth index households. From the treatment group, NDs were identified as schoolchildren with a DDS

Abstract Background Worldwide, more than 150 million children

Abstract Background Lack of financial preparedness for pregnancy can lead to adverse outcomes during childbirth. Behavioral science interventions have been shown to influence savings behavior. Financial savings interventions can be adapted for the purpose of encouraging individuals to save towards maternal healthcare costs. This article describes a protocol to assess the effectiveness of an intervention formulated with a behavioral science approach for encouraging use of maternal health services through increased financial savings for birth preparedness and maternal healthcare costs among pregnant women or their partners in Uganda. Methods A randomized controlled trial will be conducted to assess the effectiveness of the intervention among pregnant women or their partners in Uganda’s central region, including the capital of Kampala. Seven hundred pregnant women (12–35 gestational weeks) or their partners will be recruited. All participants will receive access to a committed mobile money health savings account provided by a local organization that also offers savings targets and reminders for antenatal care appointments and health tips as part of a “Mamas Program” offered to expectant mothers. The time period in the intervention is from the day of enrollment until two weeks after the delivery date. The control group will receive the standard Mama Program offering. The intervention group will receive the standard Mama Program offering plus behavioral designs encouraging savings behavior through short-message service (SMS) text messages. The primary outcome is usage of maternal health services measured by level of birth preparedness and delivery at a health facility. Secondary outcomes include male involvement in maternal healthcare, measured by financial support, as well as total savings for healthcare, assessed using the validated amount of savings accrued in participants’ clinicPesa accounts from the day of enrollment plus any withdrawals for healthcare expenditures during the intervention period. Discussion The study will contribute to a better understanding of the effectiveness of behavioral designs encouraging financial savings during pregnancy into committed mobile money health savings accounts. The study could contribute to demonstrating the effectiveness of savings on birth preparedness, usage of maternal health services, and male involvement in maternal healthcare. Trial registration UMIN-CTR Clinical Trial, UMIN000046472. Registered on 19 January 2022. https://center6.umin.ac.jp/cgi-open-bin/icdr_e/ctr_view.cgi?recptno=R000053008

Objectives For adolescents and young adults, most health literacy research has been conducted in Western countries, but few studies have been conducted in the Eastern Mediterranean region (EMR). This review aimed to explore the existing health literacy research in the EMR in addition to the levels of health literacy and its associated factors among adolescents and young adults.Methods The search, conducted using the PubMed/MEDLINE, EBSCOhost/CINAHL plus, Web of Science and J-STAGE databases, was initially performed on 16 June 2022 and later updated on 1 October 2022. Studies that targeted 10–25 years old persons, conducted in any of the EMR countries and that used the health literacy concept and/or described its levels or predictors were included in the review. Content analysis was used for data extraction and analysis. Data related to the study methods, participants, outcome variables and health literacy were extracted.Results The review included 82 studies, most of which were conducted in Iran and Turkey and adopted a cross-sectional design. Half of the studies showed that more than half of adolescents and young adults had low or moderate health literacy. Nine studies applied university-based or school-based health education interventions to improve health literacy, which was also predicted by demographic and socioeconomic factors and internet usage. Little attention was paid to assessing the health literacy of vulnerable people, such as refugees and those with a disability and exposed to violence. Finally, various health literacy topics were investigated, including nutrition, non-communicable diseases, media and depression.Conclusion Health literacy levels were low-to-moderate in adolescents and young adults in the EMR. To promote health literacy, it is recommended to use school-based health education and attempt to reach adolescents and young adults through social media platforms. More attention should be paid to refugees, people with disabilities and those exposed to violence.

Objectives There has been comparatively little research on the association between social capital and depressive symptoms in low- and middle-income countries. To address this deficit this study examined the association among middle-aged adults in rural Vietnam.Design A cross-sectional study.Setting Data came from the baseline survey of the Khánh Hòa Cardiovascular Study, which is an ongoing prospective cohort study aiming to elucidate the determinants of cardiovascular diseases.Participants A total of 3000 people aged 40–60 years old residing in rural communes in Khánh Hòa province, Vietnam.Exposure of interest Cognitive social capital (ie, low, middle and high) and structural social capital (in terms of social participation; yes or no) were assessed via a questionnaire.Primary outcome measure Depressive symptoms were assessed with the 11-item Center for Epidemiologic Studies Depression Scale.Results A robust Poisson regression model revealed that adults in the highest versus lowest cognitive social capital tertile had a 61% lower prevalence of depressive symptoms (prevalence ratio (PR)=0.39, 95% CI=0.31 to 0.49). Individuals with higher structural social capital were also significantly less likely to experience depressive symptoms (PR=0.74, 95% CI=0.61 to 0.90).Conclusion In a cohort of 3000 middle-aged rural residents in Vietnam, both cognitive and structural social capital assessed at the individual level were inversely associated with the prevalence of depressive symptoms.

Abstract Background Multi-month dispensing (MMD) is the mainstay mechanism for clinically stable people living with HIV in Cambodia to refill antiretroviral therapy (ART) every 3-6 months. However, less frequent ART dispensing through the community-based ART delivery (CAD) model could further reduce the clients’ and health facilities’ burden. While community-based services have been recognized as an integral component of HIV response in Cambodia, their role and effectiveness in ART delivery have yet to be systematically assessed. This study aims to evaluate the CAD model’s effectiveness on the continuum of care and treatment outcomes for stable people living with HIV in Cambodia. Methods We will conduct this quasi-experimental study in 20 ART clinics across the capital city and nine provinces between May 2021 and April 2023. Study sites were purposively selected based on the availability of implementing partners, the number of people living with HIV each clinic serves, and the accessibility of the clinics. In the intervention arm, approximately 2000 stable people living with HIV will receive ART and services from the CAD model. Another 2000 stable people living with HIV in the control arm will receive MMD—a standard care model for stable people living with HIV. The primary outcomes will be retention in care, viral load suppression, and adherence to ART. The secondary endpoints will include health providers’ work burden, the model’s cost-effectiveness, quality of life, mental health, social support, stigma, and discrimination. We will compare the outcome indicators within each arm at baseline, midline, and endline using descriptive and inferential statistics. We will evaluate the differences between the intervention and control arms using the difference-in-differences method. We will perform economic evaluations to determine if the intervention is cost-effective. Discussion This study will build the evidence base for future implementation and scale-up of CAD model in Cambodia and other similar settings. Furthermore, it will strengthen engagements with community stakeholders and further improve community mobilization, a vital pillar of the Cambodian HIV response. Trial registration ClinicalTrials.gov, NCT04766710 . Registered 23 February 2021, Version 1.

Objective To examine the moderating role of health literacy in the association between direct exposure to violence and weight status among Palestinian adolescents.Design A household cross-sectional study conducted in 2017.Setting A Palestinian district of the West Bank.Participants Palestinian adolescents aged 11–16 years.Results After excluding underweight adolescents from the 1200 who were initially recruited, the data of 1173 adolescents were analysed. A high proportion (62%) of adolescents were directly exposed to violence. The prevalence of obesity and overweight was 6.5% and 17.1%, respectively. The odds of obesity and overweight were 2.8 and 1.8 times higher among adolescents who were not exposed to domestic and school violence when they had low health literacy in the communication subscale. The odds of obesity were 62% and 57% lower among adolescents with high functional health literacy when exposed to domestic and school violence and to any form of violence, respectively. Among adolescents who were not exposed to any form of violence, those who had high health literacy in the communication subscale were 72% less likely to be obese compared with those who had low health literacy.Conclusions Health literacy moderated the association between direct exposure to violence and weight status. When health literacy levels were higher, lower obesity rates were observed among adolescents who were directly exposed to any form of violence or exposed either to political violence only or domestic and school violence only. The results warrant further investigation of the role of health literacy in adolescent health. It is recommended that policy-makers integrate the health literacy concept into both education and health systems.

BACKGROUND: The number of cesarean deliveries has increased sharply worldwide over the last 3 decades. The World Health Organization recommends using the Robson classification as the best tool for monitoring and auditing cesarean delivery rates and to safely reduce the rate of avoidable cesarean deliveries. OBJECTIVE: This study aimed to identify the association between the Robson classification groups and cesarean delivery in 2008 and 2018 at the Urguu Maternity Hospital, Ulaanbaatar, Mongolia, and to examine the changes in this association over 10 years. STUDY DESIGN: This cross-sectional study was conducted using 21,225 participants’ electronic birth records (9544 in 2008 and 11,681 in 2018) from the Urguu Maternity Hospital. Birth records were categorized into 10 groups using the Robson classification report table. Multiple logistic regressions were conducted to examine the association between the Robson classification group and the cesarean delivery rate for 2008 and 2018. The same regression analysis was subsequently conducted using a pooled data set to capture the changes in the association among the Robson classification group, a birth-year dummy, and the cesarean delivery rate. RESULTS: The odds of having a cesarean delivery when classified in group 1 in 2018 (adjusted odds ratio, 3.02; 95% confidence interval, 1.85–4.94; P

Abstract Background Before the COVID-19 pandemic occurred in January 2020, the number of overseas visitors to Japan had increased threefold over the last decade. To minimize the risk of health problems, visitors should be able to access information on the health care systems of the places they visit. Most short-term overseas visitors are young adults. Although they are not very likely to get sick from noncommunicable diseases, they are at high risk for injury and often experience stomach ailments, fever, or nausea when travelling. The objective of this study is to evaluate culturally and linguistically appropriate health information on preventive health behaviours and the health care system in Japan. We will examine the level of satisfaction of overseas visitors to Japan with health care-related educational materials using a five-minute digital game named Sa-Chan Japan. Methods Our study is a randomized controlled trial (RCT). We will assess both satisfaction and motivation before, during, and after the interventions and examine the changes over time. The intervention group will comprise overseas visitors who will view and answer questions in an animation named Sa-Chan Japan. The control group will comprise overseas visitors who will watch an English digital animation named Mari Info Japan. We will recruit 1002 participants through the Macromill Internet portal. We will contact overseas visitors who have either visited or wish to visit Japan from the United Kingdom, United States, and Australia. The participants will fill out a self-administered questionnaire online in the first quarter of 2021. We will determine the participants’ levels of satisfaction with the CSQ-8 (8-item Client Satisfaction Questionnaire). We will analyse the median score of the overseas visitors with both the Wilcoxon rank-sum and the Wilcoxon signed-rank tests. Our protocol of randomized controlled trials follows the SPIRIT guidelines. Discussion Our research will utilize unique digital education strategies in a game that promotes health and safety among overseas visitors to Japan. We believe the results of this study will be useful in overcoming the current challenges regarding pretravel health requirements for overseas visitors worldwide. Trial registration Version 1 of this trial was registered in the UMIN-CTR (University Hospital Medical Information Network Center Clinical Trials Registry), and the trial registration data are available on UMIN000042483 , November 17, 2020.

Abstract Background Although the prevalence of bronchial asthma has been increasing worldwide since the 1970′s, the prevalence among 5-year-old children was significantly lower in 2016 than in 2001 in rural Bangladesh. We aimed to determine whether the Haemophilus influenzae type b (Hib) combination vaccination (without booster) started in 2009 contributed to this decrease. Methods A case–control study was conducted among 1658 randomly selected 5-year-old children from Matlab, Bangladesh. Data on wheezing were collected using the International Study of Asthma and Allergies in Childhood questionnaire. The vaccination data were collected from the records of the Matlab Health and Demographic Surveillance System, while data on pneumonia were obtained from the clinical records of Matlab Hospital. Adjusted odds ratios (aORs) were calculated for the risk for wheezing. The reduction rate was calculated to determine the impact of the vaccination on pneumonia history between the present study and our previous study conducted in 2001 by using the following formula: (percentage of pneumonia cases in 2001 − percentage of pneumonia cases in 2016)/(percentage of pneumonia cases in 2001) times 100 (%). Results Hib combination vaccination was a protecting factor against wheezing (aOR: 0.50; p = 0.010), while pneumonia at 1, 2, 3–4 years of age were risk factors for wheezing (aOR: 2.86, 3.19, 2.86; p = 0.046, 0.030, 0.030, respectively). The history of pneumonia was significantly lower in the 2016 study participants than those in 2001 both in the overall cohort and the wheezing group (paired t-test: p = 0.012, p

Objectives Childcare practices determine the child nutritional outcomes, but resources for good practices are unequally distributed across socioeconomic status (SES). This study first examined the associations between social capital and childcare practices separately across SES groups. It then investigated the mediation effect of social capital between SES and childcare practices.Design This cross-sectional study used the Short Version of the Adapted Social Capital Assessment Tool to measure structural social capital (group membership, social support and citizenship activities) and cognitive social capital of mothers. Data were analysed using multilevel logistic regressions with random intercepts and mediation modellings.Setting Rural Lilongwe, Malawi.Participants A total of 320 mothers with a child aged between 12 months and 23 months.Primary outcome measures Childcare practice outcomes included were minimum dietary diversity, handwashing and complete vaccination.Results Among structural social capital dimensions, social support was found to be positively associated with minimum dietary diversity (adjusted OR (AOR)=1.44, 95% CI 1.22 to 1.71; p

Abstract Background International migration is a stressful process for which non-Western nations are a growing destination. However, little attention has been paid to the psychological well-being of international residents or their local integration in such settings. Prosocial behavior, like volunteering in one’s local community, has been demonstrated to improve mental health in native populations. Volunteerism may be a mental health promotion strategy applicable to non-native migrants as well. In order to assess such a hypothesis, this study investigated the mental well-being of international migrants living in Tokyo, Japan, who did or did not participate in formal volunteering. Methods This convergent mixed-methods study assessed mental well-being with the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) and qualitative follow-up interviews. Migrants who contributed their time to structured volunteering roles (formal volunteers, n = 150) were recruited from local non-profit organizations. Migrants who did not formally volunteer (n = 150) were recruited from social media sites. In parallel, a nested participant sample from both groups (n = 20) were interviewed about their satisfaction with life in Tokyo. Results After adjusting for sociodemographic characteristics, volunteering was not associated with higher mental well-being score (p = 0.215), but instead, not feeling isolated (p = 0.008), feeling connected to Japan (p = 0.001) and employment satisfaction (p

Abstract Background The current study investigated the prevalence of depressed mood, suicide ideation, suicide plan, and suicide attempt and their associations with health risk behaviors among high school adolescents in the Commonwealth of the Northern Mariana Islands (CNMI). Methods This is a cross-sectional study analyzing self-reported data from the 2017 CNMI Youth Risk Behavior Survey (n = 1943). Modified Poisson regression models were used to identify the associations between 17 health risk behavior variables, including violence-related behaviors, substance use behaviors, sexual behaviors, and early risk-taking behaviors, and four variables related to depressed mood and suicidal behaviors. Results 40.7% adolescents reported being depressed, 25.0% reported suicide ideation, 22.8% reported formulating a suicide plan, and 13.6% attempted suicide. Female adolescents were more likely to report depressed mood and all included suicidal behaviors (p

Abstract Background Dual-method use is known as the most reliable protection against unintended pregnancies and sexually transmitted infections, including HIV. However, it is not commonly used in sub-Sharan Africa, especially among women using highly effective contraceptives. This article describes a protocol to evaluate the effect of an intervention formulated under the positive deviance approach for promoting dual-method use in Uganda. Methods A total of 150 women will be interviewed using a structured questionnaire to find those practicing dual-method use. In-depth interviews will then be conducted with all women using the dual method and 10 women using only highly effective contraceptives to identify their unique practice. Then, a cluster randomized controlled trial will be conducted to examine the effect of an intervention formulated under the positive deviance approach on dual-method uptake and adherence. Twenty health facilities will be randomized to an intervention or control arm and 480 women will be enrolled in each group. The participants will be followed up for 8 months. Discussion This trial focuses on women who already adapted dual-method use and identifies their unique solutions to promote dual-method use. This trial could tackle barriers for dual-method use, which expert outsiders may fail to recognize, by analyzing and promulgating their unique behaviors. This study could provide evidence that the positive deviance approach can address unintended pregnancies and sexually transmitted infections as well as other health problems which usual approaches have failed to address. Trial registration UMIN-CTR Clinical Trial, UMIN000037065 . Registered on 14 June 2019.

Female entertainment workers (FEWs) are at higher risk of gender-based violence (GBV) than the general population. The prolonged stress and fear caused by GBV increase the likelihood of depression, a major mental health problem among FEWs. However, their mental health issue has received limited attention and remains poorly researched in the context of GBV. We examined the association between GBV and depressive symptoms among FEWs in Cambodia. We conducted this cross-sectional study in 2017. We used a two-stage cluster random sampling method to select FEWs from the municipality and six provinces for face-to-face interviews. We used the Centre for Epidemiologic Studies Depression Scale (CES-D) to measure depressive symptoms. We conducted a multivariable logistic regression analysis to identify factors associated with depressive symptoms. We included a total of 645 FEWs in data analyses. The proportions of FEWs experiencing emotional, physical, and sexual violence were 36.1%, 11.6%, and 17.2%, respectively. Of the total participants, 65.9% had high levels of depressive symptoms. The adjusted odds of having high levels of depressive symptoms were higher among FEWs who engaged in transactional sex (AOR 1.79, 95% CI 1.09-2.94), experienced emotional abuse (AOR 3.15, 95% CI 1.90-5.23), and experienced two (AOR 7.89, 95% CI 3.28-18.99) and three overlapping types of GBV (AOR 12.12, 95% CI 2.47-59.25) than those who did not. FEWs in this study experienced high levels and overlapping types of GBV associated with high levels of depressive symptoms. Policy interventions and services should be designed to prevent GBV and support the victims of GBV to mitigate depressive symptoms among FEWs in Cambodia.

The spreading of the coronavirus disease (COVID-19) is growing out of control in Indonesia since the first two confirmed cases were announced in March 2020. Physical distancing measures are key to slowing down COVID-19 transmission. This study investigated factors associated with physical distancing compliance among young adults in the Jakarta Metropolitan Area, Indonesia. A convergent photovoice mixed methods design was used. Quantitatively, using data from 330 young adults in Jakarta Metropolitan Area, Indonesia, physical distancing compliance scores and its associated factors were analyzed with hierarchical linear regression. Responses from 18 young adults in online focus group discussions and 29 young adults in photovoice were analyzed with thematic analysis. Then, the findings were integrated using joint displays. The mean compliance score of young adults was 23.2 out of 27.0. The physical distancing compliance score was higher among those who worked or studied from home (β = 0.14, p

The poor assessment of child malnutrition impacts both national-level trends and prioritisation of regions and vulnerable groups based on malnutrition burden. Namibia has reported a high prevalence of malnutrition among children younger than 5 years of age. The present study's aim was to identify the optimal methods for estimating child stunting and wasting prevalence in Namibia using two datasets with suspected poor data quality: Namibia Demographic and Health Surveys (NDHS) (1992–2013) and Namibia Household Income and Expenditure Survey (NHIES), 2015/16. This comparative secondary data analysis used two prevalence estimation methods: WHO flags and PROBIT. WHO flags is the standard analysis method for most national household surveys, while the PROBIT method is recommended for poor quality anthropometry. In NHIES (n 4960), the prevalence of stunting (n 4780) was 30·3 and 20·9 % for the WHO flags and PROBIT estimates, respectively, and the national wasting prevalence (n 4637) was 11·2 and 4·2 %, respectively. The trends in nutritional status from NDHS and NHIES showed improvement across WHO flags and PROBIT until 2013; however, from 2013 to 2016, PROBIT showed smaller increases in stunting and wasting prevalence (2·5 and 0·6 percentage points) than WHO flags (6·6 and 5·0 percentage points). PROBIT identified the Khoisan ethnic group and Northern geographical regions with the highest stunting and wasting prevalence, while WHO flags identified similar prevalence across most groups and regions. The present study supports the recommendation to use PROBIT when poor data quality is suspected for constructing trends, and for targeting regions and vulnerable groups.

Government policy to address the COVID-19 pandemic has been complex with profound impacts on vulnerable minorities like international migrants. In Japan migrants are an important and growing community but their consideration in health policy is rare. We conducted a rapid realist review about ‘what works’ for the equitable inclusion of migrants during the pandemic as a case study for other public health emergencies. Due to the time-sensitive needs of policy-makers in the ongoing COVID-19 emergency, our evidence search was purposive, yet exploratory and iterative in nature. We assessed academic and gray literature sources, published in either English or Japanese, that examined the policy response to COVID-19 in Japan and its impact on migrants. A panel of external stakeholders was also consulted during the review process. This evidence synthesis suggests that, rather than illness alone, restrictions on movement and socioeconomic background lead to the considerable impact of policy on the well-being of migrants. Many policy responses, while conceptually inclusive and flexible, were often structurally inequitable for migrants. Poor outcomes included confusion about changing virus-related regulations and need for technical assistance to access support. Social support from volunteers and non-profit organizations were consistently left to connect migrants with unmet needs to available services. Using the diverse international community of Japan as an example, we show that, during public health emergencies, social support from civil society remains crucial for bridging structural inequities. For equitable inclusion of migrants, evidence-informed policy will be key for governments to better protect migrants’ right to health and well-being in future emergencies.

Objectives This mixed methods study was conducted to explore the barriers and facilitators for health-seeking behaviours in a malaria endemic district in Lao PDR.Design A convergent mixed methods design.Setting Two malaria endemic villages in Thapangthong district, Savannakhet Province, Lao PDR.Participants Villagers and healthcare workers in the two villages in Thapangthong district.Methods In the quantitative part, a pretested questionnaire was used to identify the health-seeking behaviours of the villagers. In the qualitative part, focus group discussions were employed to explore health-seeking behaviours of the villagers and in-depth interviews were used to explore the perceptions of the healthcare workers. Descriptive statistics were computed and multiple logistic regressions were used to identify the factors associated with perceived severity and perceived susceptibility. Thematic analysis was used to analyse the qualitative data. Quantitative and qualitative results were integrated in joint displays.Results In the quantitative part, data were collected from 313 villagers from both villages. For malaria, 96.0% and 98.2% of villagers from villages A and B, respectively, would first seek treatment at public health facilities. Villagers who have not experienced malaria before were more likely to perceive that the consequences of malaria were serious compared with those who have experienced malaria before (adjusted OR=1.69, 95% CI: 1.03 to 2.75). However, qualitative data showed that villagers faced problems such as lack of medicines and medical equipment. Healthcare workers also mentioned the lack of manpower and equipment in the in-depth interviews. Nevertheless, villagers still preferred to seek treatment at the health center as the National Health Insurance was introduced.Conclusions Public health facility usage was high but barriers existed. Effective policy and enabling environment such as the introduction of the National Health Insurance could help accelerate the progress towards the malaria elimination goal. Moreover, the benefits could go beyond the context of malaria.

Objectives This study aimed to identify the multilevel factors that influence contraceptive use and childbearing decisions in Nepal and examine relationships among these factors.Design The study drew on qualitative data collected through in-depth interviews (IDIs) and key informant interviews (KIIs) and triangulated results.Setting An urban municipality and a rural municipality in Bara district, Nepal.Participants We recruited a total of 60 participants (e.g., 20 married adolescent girls aged 15–19, 20 husbands, 20 mothers-in-law) for IDIs and 10 (e.g., four healthcare providers, three health coordinators, three female community health volunteers) for KIIs.Results Married adolescent girls faced a range of barriers that are inter-related across different levels. Patriarchal norms and power imbalances between spouses limited their decision-making power regarding contraception. Social pressures to give birth soon after marriage drove the fear of infertility, abandonment and the stigmatisation of childless married couples, which leads to lack of women’s autonomy in making decisions about family planning. Mothers-in-law and religion exerted considerable influence over couples’ decisions regarding contraception. Limited access to information about the benefits and methods of family planning contributed to fear of the side effects of contraceptives and low awareness about the risks involved in adolescent pregnancy.Conclusions The convergent results from triangulation confirm that the decision to postpone childbearing is not merely the personal choice of an individual or a couple, highlighting the importance of targeting families and communities. The study underscores the need to challenge restrictive sociocultural norms so that adolescent girls become empowered to exercise greater control over contraceptive use.

Objective To examine the effects of a positive deviance intervention on dual-method contraceptive use among married or in-union women.Design Open-label cluster randomised controlled trial.Setting 20 health facilities in Mbarara District, Uganda.Participants 960 married or in-union women aged 18–49 years using a non-barrier modern contraceptive method.Interventions A combination of clinic-based and telephone-based counselling and a 1-day participatory workshop, which were developed based on a preliminary qualitative study of women practising dual-method contraception.Primary outcome measure Dual-method contraceptive use at the last sexual intercourse and its consistent use in the 2 months prior to each follow-up. These outcomes were measured based on participants’ self-reports, and the effect of intervention was assessed using a mixed-effects logistic regression model.Results More women in the intervention group used dual-method contraception at the last sexual intercourse at 2 months (adjusted OR (AOR)=4.12; 95% CI 2.02 to 8.39) and 8 months (AOR=2.16; 95% CI 1.06 to 4.41) than in the control group. At 4 and 6 months, however, the proportion of dual-method contraceptive users was not significantly different between the two groups. Its consistent use was more prevalent in the intervention group than in the control group at 2 months (AOR=14.53; 95% CI 3.63 to 58.13), and this intervention effect lasted throughout the follow-up period.Conclusions The positive deviance intervention increased dual-method contraceptive use among women, and could be effective at reducing the dual risk of unintended pregnancies and HIV infections. This study demonstrated that the intervention targeting only women can change behaviours of couples to practise dual-method contraception. Because women using non-barrier modern contraceptives may be more reachable than men, interventions targeting such women should be recommended.Trial registration number UMIN000037065.

Abstract Introduction Epidemiological research on the prevalence of asthma and helminthic infections in various countries has led to the hypothesis that helminthic infections protect against asthma by suppressing the host's immune response. This study was conducted to elucidate whether decreased Ascaris infection following a national deworming program was associated with increased recurrent wheezing among rural Bangladeshi children and to test their anti‐inflammatory immunity. Methods This nested case‐control study was conducted from December 2015 to October 2016 in the rural service area of the International Centre for Diarrhoeal Disease Research, Bangladesh. Of the 1800 5–year old children randomly selected for the study, informed consent was obtained from the guardians of 1658 children. Data were collected using a semistructured questionnaire adopted from the International Study of Asthma and Allergies in Childhood and blood samples for the analysis of regulatory T (Treg) cell immune responses and the balance between Th1 and Th2 immunity in Ascaris infections. Results A total of 145 children were found to have wheezing, yielding a prevalence rate of 8.7%, which was significantly lower than the rate found in 2001 (16.2%, P

Abstract Background Skilled birth delivery has increased up to nearly 74% in Ghana, but its quality has been questioned over the years. As understanding women’s satisfaction could be important to improving service quality, this study aimed to determine what factors were associated with women’s overall satisfaction with delivery services quantitatively and qualitatively in rural Ghanaian health facilities. Results This cross-sectional, mixed methods study used an explanatory sequential design across three Ghana Health Service research areas in 2013. Participants were women who had delivered in the preceding 2 years. Two-stage random sampling was used to recruit women for the quantitative survey. Relationships between women’s socio-demographic characteristics and their overall satisfaction with health facility delivery services were examined using univariate and multiple logistic regression analyses. For qualitative analyses, women who completed the quantitative survey were purposively selected to participate in focus group discussions. Data from the focus group discussions were analyzed based on predefined and emerging themes. Overall, 1130 women were included in the quantitative analyses and 136 women participated in 15 focus group discussions. Women’s mean age was 29 years. Nearly all women (94%) were satisfied with the overall services received during delivery. Women with middle level/junior high school education [adjusted odds ratio (AOR) = 0.50, 95% confidence interval (CI) = (0.26–0.98)] were less likely to be satisfied with overall delivery services compared to women with no education. Qualitatively, women were not satisfied with the unconventional demands, negative attitude, and unavailability of healthcare workers, as well as the long wait time. Conclusions Although most women were satisfied with the overall service they received during delivery, they were not satisfied with specific aspects of the health services; therefore, higher quality service delivery is necessary to improve women’s satisfaction. Additional sensitivity training and a reduction in work hours may also improve the experience of clients.

Abstract Background The School Health and Nutrition (SHN) program is a cost-effective intervention for resource-poor countries. SHN program aims to provide timely support and preventive measures to improve the health of school children, which can be associated with their cognitive development, learning, and academic performance. Stakeholders at different tiers can play significant roles in the program implementation and its success. Their perceptions are equally important to provide information on the factors influencing the implementation process and help to identify the gaps in the process. However, the evidence is scarce on the school health and nutrition policy and program implementation in developing countries. No study has yet explored stakeholders’ perceptions on the SHN program implementation process in low-income countries, including Nepal. Therefore, we conducted a qualitative study to explore (1) the SHN program implementation, (2) its impact, and (3) challenges in Nepal. Methods We conducted a qualitative study through 32 in-depth interviews of the key informants who were actively involved in SHN program implementation in Nepal. The key informants were identified through personal network and snowballing procedure. We adopted a thematic approach for the data analysis. Results We categorized interview data into three broad themes: (1) SHN program implementation, (2) its impact, and (3) challenges during implementation. Almost all the key informants appreciated the program for its positive impact on students, schools, and communities. The positive impacts included improved students’ health and school environment and enhanced community awareness. However, the key impediments in implementing the program included a lack of coordination between stakeholders, lack of resources, limited training opportunities, and doubts regarding the sustainability of the program. Conclusions This study provided a deeper understanding of the linkage between the SHN program implementation, impact, and challenges in Nepal. Despite the challenges, all the stakeholders acknowledged that the SHN program had positive impacts on students, schools, and communities. Our findings highlighted that stakeholders from all tiers should coordinate, collaborate, and continue their efforts to effectively implement and expand the program nationwide. Awareness campaigns and advocacy for the program are indispensable to pull more resources from relevant stakeholders.

Abstract Background Primaquine is effective against the latent liver stage of Plasmodium vivax. Eliminating the latent liver stage of P. vivax is one of the necessary conditions to achieve the goal of malaria elimination in Lao People’s Democratic Republic (PDR) by 2030. However, people with glucose-6-phosphate dehydrogenase (G6PD) deficiency are at risk of haemolysis when ingesting primaquine. The aim of this study was to detect the prevalence of the G6PD Viangchan variant, which is said to be common in Lao PDR and which can result in severe haemolysis in patients exposed to primaquine. Methods Blood samples were collected from villagers in three malaria endemic provinces: Champasak and Savannakhet in the south, and Phongsaly in the north. Each blood sample was semi-quantitatively assayed for G6PD enzyme activity using the G6PD Assay Kit-WST Lyophilized (DOJINDO Laboratories, Japan). Blood samples that were found to be G6PD deficient were sequenced to detect G6PD Viangchan mutation. Results In total, 2043 blood samples were collected from Phongsaly (n = 426, 20.9%), Savannakhet (n = 924, 45.2%), and Champasak (n = 693, 33.9%) provinces in Lao PDR from 2016 to 2017. Of these, 964 (47.2%) were taken from male villagers and 1079 (52.8%) were taken from female villagers. G6PD Viangchan mutation was not detected in Phongsaly province in this study. In Savannakhet province, 48 of the 924 samples (45 males, 3 females) had the G6PD Viangchan mutation (n = 48, 5.2%). In Champasak province, 42 of the 693 samples (18 males, 24 females) had the G6PD Viangchan mutation (n = 42, 6.1%). Conclusions G6PD Viangchan variant, which can cause severe haemolysis in the carrier when exposed to primaquine, was detected among 6.1% of the villagers in Champasak and 5.2% in Savannakhet but not in Phongsaly in this study. G6PD Viangchan variant might be common in the south of Laos but not so in the north. In the north, other G6PD deficiency variants might be more prevalent. However, in order not to overlook anyone and ensure a safe primaquine therapy for people living in malaria endemic areas in Lao PDR, G6PD testing is necessary.

Vaccination is a proven equitable intervention if people take advantage of the opportunity to get vaccinated. Niger is a low-income country in West Africa, with a 76% measles 1 vaccination coverage rate in 2016. This study was conducted to identify individual- and neighborhood-level factors that could improve measles 1 vaccination coverage in Niamey, the capital. In October 2016, 460 mothers with children aged 12–23 months were surveyed. The outcome was to determine whether the mother’s child had been vaccinated against measles 1 or not. For individual-level variables of measles 1 vaccination status, the following were included: mother’s age group, mother tongue, maternal education level, husband’s job, where the mother gave birth (at home or at a health center) and whether the mother discussed vaccination with friends. Neighborhood-level factors were access time to the health center, household access to electricity, and a grand-mean-centered wealth score. Multilevel logistic regression analysis was performed. At the individual-level, primary and secondary-educated mothers were more likely to vaccinate their children against measles 1 (aOR 1.97, 95% CI 1.11–3.51). At the neighborhood-level, no factors were identified. Therefore, a strengthened focus on equity-based, individual factors is recommended, including individual motivation, prompts and ability to access vaccination services.

Objectives This study aimed to investigate the continuum of care (CoC) completion rate in maternal, neonatal and child health and its associated factors among mothers in two ecological regions in Nepal.Design This was a community-based, cross-sectional study, for which data were collected through face-to-face interviews using a structured questionnaire. Multiple logistic regression analyses were conducted to determine the associated factors.Setting This was carried out in two rural districts of Nepal, in different regions: one in the hills (Dhading) and another in the flatlands called Terai (Nawalparasi). The data were collected between July and December 2016.Participants Mothers who gave birth within a year before this study were included as participants. In total, there were 1803 participants.An outcome measure The outcome of this study was measured by the CoC completion rate when a mother completes four antenatal check-ups, deliver at a health facility and receives postnatal care within 24 hours of delivery.Results The CoC completion rates were 41% in Dhading and 28% in Nawalparasi. In Dhading, shorter travel time to a health facility and higher wealth quintiles were associated with a better CoC completion rate. In Nawalparasi, the CoC completion rate was affected by parity and decision-making for pregnancy care.Conclusions The CoC completion rate was low in both districts in Nepal. However, factors associated with the CoC completion rate varied by district. Differences in these factors might be reflected by geographical and socioeconomic conditions and the characteristics of household decision making in these districts.

BackgroundIn low- and middle-income countries (LMICs), the continuum of care (CoC) for maternal, newborn, and child health (MNCH) is not always complete. This study aimed to evaluate the effectiveness of an integrated package of CoC interventions on the CoC completion, morbidity, and mortality outcomes of woman-child pairs in Ghana.Methods and findingsThis cluster-randomized controlled trial (ISRCTN: 90618993) was conducted at 3 Health and Demographic Surveillance System (HDSS) sites in Ghana. The primary outcome was CoC completion by a woman-child pair, defined as receiving antenatal care (ANC) 4 times or more, delivery assistance from a skilled birth attendant (SBA), and postnatal care (PNC) 3 times or more. Other outcomes were the morbidity and mortality of women and children. Women received a package of interventions and routine services at health facilities (October 2014 to December 2015). The package comprised providing a CoC card for women, CoC orientation for health workers, and offering women with 24-hour stay at a health facility or a home visit within 48 hours after delivery. In the control arm, women received routine services only. Eligibility criteria were as follows: women who gave birth or had a stillbirth from September 1, 2012 to September 30, 2014 (before the trial period), from October 1, 2014 to December 31, 2015 (during the trial period), or from January 1, 2016 to December 31, 2016 (after the trial period). Health service and morbidity outcomes were assessed before and during the trial periods through face-to-face interviews. Mortality was assessed using demographic surveillance data for the 3 periods above. Mixed-effects logistic regression models were used to evaluate the effectiveness as difference in differences (DiD). For health service and morbidity outcomes, 2,970 woman-child pairs were assessed: 1,480 from the baseline survey and 1,490 from the follow-up survey. Additionally, 33,819 cases were assessed for perinatal mortality, 33,322 for neonatal mortality, and 39,205 for maternal mortality. The intervention arm had higher proportions of completed CoC (410/870 [47.1%]) than the control arm (246/620 [39.7%]; adjusted odds ratio [AOR] for DiD = 1.77; 95% confidence interval [CI]: 1.08 to 2.92; p = 0.024). Maternal complications that required hospitalization during pregnancy were lower in the intervention (95/870 [10.9%]) than in the control arm (83/620 [13.4%]) (AOR for DiD = 0.49; 95% CI: 0.29 to 0.83; p = 0.008). Maternal mortality was 8/6,163 live births (intervention arm) and 4/4,068 live births during the trial period (AOR for DiD = 1.60; 95% CI: 0.40 to 6.34; p = 0.507) and 1/4,626 (intervention arm) and 9/3,937 (control arm) after the trial period (AOR for DiD = 0.11; 95% CI: 0.11 to 1.00; p = 0.050). Perinatal and neonatal mortality was not significantly reduced. As this study was conducted in a real-world setting, possible limitations included differences in the type and scale of health facilities and the size of subdistricts, contamination for intervention effectiveness due to the geographic proximity of the arms, and insufficient number of cases for the mortality assessment.ConclusionsThis study found that an integrated package of CoC interventions increased CoC completion and decreased maternal complications requiring hospitalization during pregnancy and maternal mortality after the trial period. It did not find evidence of reduced perinatal and neonatal mortality.Trial registrationThe study protocol was registered in the International Standard Randomised Controlled Trial Number Registry (90618993).

Objective To measure the length of stay at a health facility after childbirth, identify factors associated with the length of stay and measure the gap between the timings of the last check-up and discharge.Design A cross-sectional study.Setting Five public health facilities in Dhading, Nepal.Participants 351 randomly selected mothers who gave birth at selected health facilities within 1 year of data collection between 10 and 31 August 2018.Outcome measure Length of stay (hours) at a health facility after childbirth. Adequate length was defined as 24 hours or longer based on the WHO guidelines.Results Among 350 mothers (99.7%) out of 351 recruited, 61.7% were discharged within 24 hours after childbirth. Factors associated with shorter length of stay were as follows: travel time less than 30 min to a health facility (incidence rate ratio (IRR)=0.69, 95% CI 0.61 to 0.78); delivery attended by auxiliary staff (IRR=0.86, 95% CI 0.75 to 0.98); and delivery in a primary healthcare centre (IRR=0.67, 95% CI 0.58 to 0.79). Factors associated with longer length of stay were as follows: aged 22 years or above at the first pregnancy (IRR=1.25, 95% CI 1.13 to 1.40); having maternal complications (IRR=2.41, 95% CI 2.16 to 2.70); accompanied by her own family (IRR=1.17, 95% CI 1.03 to 1.34), accompanied by her husband (IRR=1.16, 95% CI 1.04 to 1.29); and delivered at a facility with a physical space where mother and newborn could stay overnight (IRR=1.20, 95% CI 1.07 to 1.34). Among mothers without complications, 32% received the last check-up 3 hours or less before discharge.Conclusions Multiple factors, such as mothers’ conditions, health facility characteristics and external support, were associated with the length of stay after childbirth. However, even if mothers stayed long, they might have not necessarily received timely and proper assessment before discharge.

Objectives This study aimed to investigate whether child marriage had causal effects on unmet needs for modern contraception, and unintended pregnancy, by estimating the marginal (population-averaged) treatment effect of child marriage.Design This study used secondary data from the Nepal Demographic and Health Survey 2016. Applying one-to-one nearest-neighbour matching with replacement within a calliper range of ±0.01, 15–49 years old women married before the age of 18 were matched with similar women who were married at 18 or above to reduce selection bias.Setting Nationally representative population survey data.Participants The sample consisted of 7833 women aged 15–49 years who were married for more than 5 years.Outcome measures Unmet needs for modern contraception and unintended pregnancy.Results The matching method achieved adequate overlap in the propensity score distributions and balance in measured covariates between treatment and control groups with the same propensity score. Propensity score matching analysis showed that the risk of unmet needs for modern contraception, and unintended pregnancy among women married as children were a 14.3 percentage point (95 % CI 10.3 to 18.2) and a 10.1 percentage point (95 % CI 3.7 to 16.4) higher, respectively, than among women married as adults. Sensitivity analysis indicated that the estimated effects were robust to unmeasured covariates.Conclusions Child marriage appears to increase the risk of unmet needs for modern contraception and unintended pregnancy. These findings call for social development and public health programmes that promote delayed entry into marriage and childbearing to improve reproductive health and rights.

[This corrects the article DOI: 10.1371/journal.pone.0245873.].

IntroductionInternational migration is increasing rapidly around the world mostly to obtain a job. International migrant workers usually leave their children back in their country of origin, and among family members, adolescents may experience greater psychological distress from parental separation. However, limited evidence is available on the relationship between parental international migration and psychological well-being of left-behind adolescents. Nepal has a relatively higher and increasing number of international migrants, and this study was conducted to examine the association between parental international migration and the psychological well-being of left-behind adolescents in Nepal.MethodsA school-based cross-sectional study was conducted among 626 adolescents in two districts of Western Nepal, where international migration is common. Adolescents were recruited through random sampling. Pre-tested "Strengths and Difficulties Questionnaire" was used to measure their psychological well-being and simple and multiple linear regression were used to examine the association between parental international migration and the psychological well-being of left-behind adolescents.ResultsAdolescents with none of the parents living abroad were more likely to have higher total difficulties score compared to those with one of the parents living abroad (B: 1.02; 95% CI: 0.18, 1.86; p = 0.017). Adolescents with the following factors were more likely to have higher total difficulties score in comparison to their counterparts: adolescents in their late adolescence period, female adolescents, adolescents from ethnicities other than Brahmin and adolescents studying in private schools.ConclusionIn rural districts of Nepal, where international migration is common, adolescents living with the parents were more likely to have poorer psychological well-being compared to those with one of the parents living abroad. Adolescents' adaptation mechanism for the absence of parents for international migration might be explored in the future studies.

BackgroundBreast cancer burden is increasing in low-income countries (LICs). Increasing incidence and delayed presentation of breast cancer are mainly responsible for this burden. Many women do not participate in breast cancer screening despite its effectiveness. Moreover, studies are limited on the barriers associated with low utilization of breast cancer screening in LICs. This study identified breast cancer screening behavior and factors associated with breast cancer screening intention among women in Kathmandu Valley, Nepal.MethodsA cross-sectional study was conducted among 500 women living in five municipalities of Kathmandu Valley, Nepal. Data were collected from July to September 2018, using a structured questionnaire. Interviews were conducted among women selected through proportionate random household sampling. This study was conceptualized using the theory of planned behavior, fatalism, perceived susceptibility, and perceived severity. The outcome variables included: the intention to have mammography (MMG) biennially, the intention to have clinical breast examination (CBE) annually, and the intention to perform breast self-examination (BSE) monthly. Analysis was conducted separately for each outcome variable using partial proportional odds model.ResultsOut of 500 women, 3.4% had undergone MMG biennially, 7.2% CBE annually, and 14.4% BSE monthly. Women with a positive attitude, high subjective norms, and high perceived behavioral control were more likely to have the intention to undergo all three screening methods. Similarly, women were more likely to have intention to undergo CBE and MMG when they perceived themselves susceptible to breast cancer. Conversely, women were less likely to have intention to undergo CBE when they had high fatalistic beliefs towards breast cancer.ConclusionWomen in this study had poor screening behavior. The practice of breast self-examination was comparatively higher than clinical breast examination and mammography. Multidimensional culturally sensitive interventions are needed to enhance screening intentions. Efforts should be directed to improve attitude, family support, and fatalistic belief towards cancer. Furthermore, the proper availability of screening methods should be ensured while encouraging women to screen before the appearance of symptoms.

BackgroundAdolescents are vulnerable to various sexual and reproductive health (SRH) problems such as unintended pregnancy, HIV or other sexually transmitted infections (STIs), and unsafe abortion. Adolescent-friendly health services offer SRH services such as SRH counseling, contraceptive services, STI and HIV services, and abortion-related services, which may help prevent these risks. Parent-adolescent communication about SRH prevents adolescents from adopting unhealthy SRH practices. However, its association with the utilization of SRH services is less known. Therefore, this study examined the association between parent-adolescent communication on SRH issues and the utilization of adolescent-friendly health services in Nepal.MethodsThis was a school-based, cross-sectional study conducted in Kailali district, Nepal, among students aged 15-19 years in Grade 11 and 12 from seven schools. We used multivariable logistic regression analysis to examine the association between parent-adolescent communication and service utilization.ResultsWe analyzed the data from 594 students. Students with a higher score of parent-adolescent communication on SRH were significantly more likely to use adolescent-friendly health services (adjusted odds ratio, AOR: 1.70, 95% Confidence Interval, CI: 1.29-2.23, pConclusionStudents with a higher score on parent-adolescent communication on SRH were more likely to use adolescent-friendly health services. Thus, parental involvement in SRH communication could contribute to the use of adolescent-friendly health services and ultimately prevent negative SRH outcomes among students in late adolescence.

IntroductionFrailty is a state of being vulnerable to adverse health outcomes such as falls, delirium, and disability in older people. Identifying frailty is important in a low-income setting to prevent it from progressing, reducing healthcare costs, increasing the chances of reversibility, and implementing effective interventions. The factors affecting frailty in older people living in old age homes could differ from those living in the community. This study was conducted to identify the factors associated with frailty in older people residing in old age homes and communities in Kathmandu Valley, Nepal.MethodsThis is a cross-sectional study conducted from April to June 2019 in three districts of Kathmandu Valley, Nepal. Data were collected from 193 older people residing in old age homes and 501 residing in communities aged 60 and above using convenience sampling. Frailty was measured using the Groningen Frailty Indicator. Data were collected via face-to-face interviews. Multiple linear regression analyses were used to examine the association between independent variables and frailty.ResultsFrailty was more prevalent among older people in old age homes (71.5%) compared to those in the community (56.3%). Older people who were satisfied with their living environment had lower frailty scores in both old age homes (β = -0.20, pConclusionThe living environment and lifestyle are key modifiable risk factors of frailty, both in old age homes and the community. The findings suggest a need for lifestyle modification and reforms in building standards, especially in old age homes, to promote age-friendly communities.

Background and objectivesVaccination status becomes more equitable when interventions are carried out to eliminate poverty or to improve levels in maternal education. Low-income countries need to identify interventions that would have a more immediate and equitable effect. The present study aimed to identify rapidly modifiable factors associated with full vaccination status among children in Niamey, Niger.MethodsA cross-sectional, random cluster household survey was conducted in Niamey's five health districts. Data on vaccination coverage and socioeconomic household characteristics were collected. Logistic regression analysis was conducted with data on 445 mothers and their children aged 12-23 months.ResultsOf 445 children, 38% were fully vaccinated. Mothers who were satisfied with their health worker's attitude and had correct vaccination calendar knowledge (adjusted odds ratio [aOR] 5.32, 95% confidence interval [CI] 2.05-13.82) were more likely to have fully vaccinated children. Mothers who had completed secondary school (aOR 2.04, 95% CI 1.17-3.55) were also associated with having fully vaccinated children.ConclusionsA higher rate of full vaccination among children could be achieved by relatively short-term modifiable factors. These modifiable factors are mothers' satisfaction with health workers' attitudes and knowledge of the vaccination calendar. Maternal satisfaction with health workers' attitudes could be improved through better interpersonal communication between health workers and mothers. Specifically, mothers should be given specific information on time intervals between appointments. Strengthened communication interventions may be effective in improving both the acceptability of health services and low vaccination coverage.