Formal Health Care System Research Articles

Socio-cultural and Economic Determinants of Delayed Reporting of Breast Cancer Among Ghanaian Women: A Qualitative Study

Delayed reporting of breast cancer continues to increase in African countries, including Ghana, which is attributable to socio-cultural and economic factors. However, there is a paucity of data on socio-cultural and economic determinants of delayed reporting of breast cancer in Ghana. This study aimed to explore the socio‐cultural and economic determinants of delayed reporting of breast cancer among Ghanaian women. The study adopted an exploratory descriptive qualitative design with purposive sampling to recruit 17 women with breast cancer from the Tamale Teaching Hospital, Ghana. Data were collected through in-depth interviews. Analysis: Data analysis was done using the thematic analysis approach. Delayed reporting was due to inaccurate information, the influence of social networks, cultural misconceptions, belief in alternative treatment, high cost of treatment, and extreme poverty. A combination of socio‐cultural and economic factors influences the delay in reporting breast cancer in Ghana. Culturally appropriate and adequate health information and education, integration of alternative treatment into the formal healthcare system in Ghana, and financial support from the government are needed to promote early reporting for treatment.

Roots, Leaves, and Flowers: A Narrative Review of Herbs and Botanicals Used for Self-Managed Abortion in Asia and the Pacific.

Abortion has existed throughout history, often outside of formal health care systems. This type of care, now called self-managed abortion, has historically been achieved in part through botanicals and traditional medicines. Their use continues into the modern day, especially in Asia, Hawai'i, and other Pacific Islands, where indigenous medicine traditions practice alongside allopathic medicine. Many of these botanicals, such as papaya leaves, hibiscus flowers, and young kī, and traditional medicines, such as tianhuafen, yuanhua, and Shenghua Decoction, have undergone scientific and clinical investigation of their potential abortifacient and antifertility action. The incidence of self-managed abortion with such abortifacients in countries with severe abortion restrictions are only estimates, leading to the possibility that legal rulings and societal pressures may cause underreporting. The Asian American, Native Hawaiian, and Pacific Islander communities in the United States also suffer from a lack of abortion access in addition to unique health disparities and barriers to reproductive health care. As difficulties in abortion access increases due to the Supreme Court decision in Dobbs v. Jackson Women's Health Organization, some may seek or even prefer self-managed abortion through traditional methods that have been passed down in their communities. Midwives and other health care providers may then be contacted during this process. This narrative review provides an overview of the literature on the use of botanicals, herbs, and traditional medicines used for self-managed abortion, specifically in Asia, Hawai‧i, and other Pacific Islands. Their implications for practice for providers in the United States and further opportunities for research are also presented.

Healthcare-Seeking Behaviors of Homeless Substance Users During the COVID-19 Lockdowns in Gauteng, South Africa: A COREQ-Based Report

Substance use continues to be a social problem globally. Around the world, approximately 275 million people use drugs, including 15% of South Africans, with over 36 million succumbing to drug disorders. In the Gauteng Province, about 55% of autopsies of deceased medicolegal cases (2003–2012) showed the presence of one or more illicit drugs in Pretoria. Most research shows that around one-third of people who have problems with alcohol and drugs are homeless. Evidence suggests that homeless people are often denied access to even the most essential assistance, including healthcare. This study assessed the healthcare-seeking behaviors of homeless substance users during the COVID-19 lockdowns in Gauteng, South Africa. A qualitative approach using an exploratory design assessed referrals based on those suffering from symptoms of COVID-19 during the lockdown period between 2020 and 2022. Data were collected from 25 homeless substance users in the City of Tshwane, Gauteng, through unstructured interviews. Three themes based on the study objectives included the types of healthcare services consulted, the determinants of health-seeking behaviors, and challenges experienced while seeking healthcare. Of the twenty-five participants, aged twenty-one to fifty, thirteen suffered from COVID-19 symptoms. Five used formal healthcare systems and eight used informal healthcare systems. Older participants access healthcare services, while less of the younger population use them. Barriers that are encountered while seeking medical services entail marginalization, stigmatization, and a lack of social support. Despite the formidable barriers posed by homelessness and substance use, homeless individuals demonstrated remarkable resilience in their efforts to access healthcare services during the COVID-19 lockdowns. This study highlights the importance and urgent need for harm reduction strategies and policy development for long-term service provision to this population, as well, as the literature on equity, diversity, and inclusion as a foundation for the rights of marginalized populations and groups. Future research directions should focus on harm reduction among this population group of homeless substance users.

Contextual factors influencing the roles of patent medicine vendors in the provision of injectable contraception services in Nigeria

BackgroundPatent medicine vendors (PMVs) play vital roles in the delivery of family planning services in Nigeria and other developing countries. There is a growing recognition of the need to integrate them into the formal health care system as a strategy to increase the contraceptive prevalence rate and achieve universal health coverage. Though promising, the success of this proposition is largely dependent on a critical analysis of the factors which influence their operations. This study was designed to identify the contextual factors influencing the provision of injectable contraceptive services by PMVs and the broader effects of their activities on the health system to inform similar interventions in Nigeria.MethodsThis was a qualitative study guided by the UK Medical Research Council’s Framework for Complex Interventions. Twenty-seven in-depth interviews were conducted among officials of the association of PMVs, health workers, government regulatory officers and programme implementers who participated in a phased 3-year (2015–2018) intervention designed to enhance the capacity of PMVs to deliver injectable contraceptive services. The data were transcribed and analyzed thematically using NVIVO software.ResultsThe contextual factors which had implications on the roles of PMVs were socio-cultural and religious, the failing Nigerian health system coupled with government regulatory policies. Other factors were interprofessional tensions and rivalry between the PMVs and some categories of health care workers and increasing donors’ interest in exploring the potentials of PMVs for expanded healthcare service provision. According to the respondents, the PMVs bridged the Nigerian health system service delivery gaps serving as the first point of contact for injectable contraceptive services and this increased contraceptive uptake in the study sites. A negative effect of their operation is the tendency to exceed their service provision limits, which has spurred a planned tiered PMV accreditation system.ConclusionsThis study has highlighted the contextual factors which define the roles and scope of practice of PMVs involved in injectable contraceptive service provision. Strategies and interventions aimed at expanding the healthcare delivery roles of PMVs must be encompassing to address the broader contextual factors which underpin their capacities and functions.

Neoliberally framed suffering in professionals and patients in palliative care settings – ’telling cases’ from an ethnographic multi-sited field study in Denmark

ABSTRACT In western countries, palliative care is a part of the formal healthcare system, ruled by neoliberal, organisational ideas. This Danish study illuminates how nurses and patients with non-western immigrant backgrounds (inter)act in relation to encounters in palliative care settings. Two ‘telling’ cases were selected, based on interviews and participating observations from a multi-sited ethnographic field study in Denmark. The results showed different care consequences of the structural framework, referring to, for example, political healthcare logics, strategies, and priorities, and illuminated how neoliberally organised healthcare systems inflicted suffering on patients and frustration amongst professionals. It did not seem that the immigrant background per se induced the challenges. The understandings of care and treatment conflicted as nurses often represented a medical, neoliberal logic of disease, treatment, and care, and patients often represented a non-medical logic of disease, formed by their lives. When palliative care took place in a general setting, (inter)actions were also influenced by a curative agenda of treatment and care. The study added to the evidence of the power of neo-liberal rationality across different forms of care and populations, regardless of ethnicity or location of that care.

Synergy between Skilled and Traditional Birth Attendants on Quality of Maternal and Newborn Care in Nigeria

Maternal and newborn health remains a critical challenge in Nigeria, with high maternal and neonatal mortality rates persisting in many regions. The coexistence of formal healthcare systems with traditional birth practices provides a unique opportunity for synergy between Skilled Birth Attendants (SBAs) and Traditional Birth Attendants (TBAs) to improve the quality of maternal and newborn care. This study explores the potential benefits of collaboration between SBAs and TBAs in Nigeria and investigates the barriers and facilitators to such cooperation. The findings highlight the complementary strengths of SBAs and TBAs. SBAs bring formal medical training, evidence-based practices, and access to medical resources, while TBAs possess cultural knowledge, community trust, and local birthing expertise. Through joint training and capacity building initiatives, TBAs can be equipped with updated medical knowledge, improving their ability to identify high-risk pregnancies and refer cases to skilled healthcare providers effectively. Effective referral systems play a pivotal role in ensuring timely access to emergency obstetric care. Challenges to collaboration include cultural and traditional beliefs, language barriers, limited access to resources, and legal and regulatory obstacles. Addressing these barriers requires a comprehensive approach that promotes cultural sensitivity, mutual respect, and inclusiveness within the healthcare system. The study concludes that harnessing the synergy between SBAs and TBAs can lead to a more integrated and effective maternal and newborn healthcare system in Nigeria. By leveraging the strengths of both groups and creating an enabling environment for collaboration, Nigeria can make significant strides towards reducing maternal and neonatal mortality, improving the quality of care, and achieving better health outcomes for mothers and newborns. Continued research and collaborative efforts are essential to capitalize on this synergy and drive positive change in maternal and newborn healthcare across the country.

Determinants of Rural Women’ Healthcare Behavior in Khyber Pakhtunkhwa, Pakistan

Current study has examined the determinants of healthcare seeking behaviour of rural women in Khyber Pakhtunkhwa province of Pakistan. For this, data were collected from 178 respondents using a questionnaire and key informants interviews i.e. lady health workers (10) and doctors (10). For data analysis, descriptive statistics and thematic analysis were used. It was found that majority of the respondents did not sought immediate healthcare. Various themes have been identified through thematic analysis such as social, cultural and economic factors which influence healthcare seeking behavior of rural women in the study area. Social factors included gender and patriarchy, while restricted mobility, low educational status, and non-preference of women healthcare needs were encompassed by cultural factors. Economic factors comprised of affordability and availability of transportation. Therefore, appropriate and long term planning and execution from the formal health care system of the province in the light of current study findings are suggested.

Rarecare: A policy perspective on the burden of rare diseases on caregivers in Latin America.

In Latin America (LA), 40-50 million people live with rare diseases (RDs) that require constant monitoring, care, and attention. Caregivers help them with their basic life activities and medication administration, which they would otherwise be unable to perform. Family caregivers complement healthcare and social security systems; however, their unpaid work is often underappreciated and under-protected. Recognizing the need to address these unrecognized and undervalued women, the Americas Health Foundation (AHF) convened a panel of LA experts on caregiving for people with RDs to provide recommendations to support the undervalued family caregivers. A panel of LA experts in caregiving for RDs were given questions to address the challenges faced by family caregivers of people with RDs in LA. During a 3-day conference, the panelists' responses were discussed and edited until the panel agreed on recommendations to address the challenges. The identified challenges for caregivers included physical, emotional, and economical areas. Caregivers, primarily women, experienced physical pain, and social isolation, and were forced to pay substantial out-of-pocket expenses in their caregiving roles. Brazil and Colombia are at the forefront of policies to protect caregivers and their experiences in attempting to provide for this group are outlined as case studies for what is possible in LA. Finally, recognizing that caregivers must be included in formulating, executing, and evaluating care policies for people living with RDs and that the caregivers themselves require social assurances, the panel suggested policy objectives aimed at protecting caregivers of people living with RDs. The recommendations ranged from recognizing the role of the family caregiver as an essential supplement to the formal healthcare system to providing financial assistance, training, and workplace protection, among others. Finally, monitoring and evaluating the impact of policies is necessary to ensure that LA is moving forward in caring for family caregivers for people with RDs.

Biomedical doctor as acupuncturist: The business of Chinese medicine in the Philippines

Acupuncture, a specialty of Chinese medicine, has become increasingly popular among urban middle-class health consumers in the Philippines in recent years. Professionalized training courses have started up and bio-medical doctors and nurses are the largest group of trainees enrolled in various programs. They are also the largest group of service providers cum trainers in the formal and private healthcare system. Based on a qualitative study approach, this study conducted face-to-face interviews with a questionnaire among trainees and practitioner cum trainers at the Ateneo de Manila University, the SMIC Institute of Traditional Chinese Medicine, the St. Luke Medical Center- Quezon City, and the St. Luke Medical Center-Global City. This study finds that biomedical doctors and nurses from various ethnic groups have switched to practice acupuncture not only because of their fascination with Chinese medicine but also to respond to the market demand. Their entry is driven by a range of factors including, but not limited to: financial incentives, the limitations of biomedicine and the advantages of acupuncture, family tradition, and the idea of holism that is attached to Chinese medicine. The advantages to becoming an acupuncturist appear to be professional, economic and personal despite the challenges regarding the social and political circumstances. This paper concludes that biomedical professionals are in control of Chinese medicine specialties, which are being professionalized in the Philippines, and are making the industry a private multicultural and urban middle-class phenomenon, thus fulfilling the demand created by the market economy.

Improving nursing education curriculum as a tool for strengthening the nurse-client relationships in maternal and child healthcare: Insights from a human-centered design study in rural Tanzania.

There are growing evidence of poor nurse-client relationships in maternal and child health (MCH). The nursing curriculum forms an important entry point for strengthening such relationships, consequently improving client satisfaction with nurses' competencies, confidence in the formal healthcare system, healthcare-seeking practices, continuity with care, and MCH outcomes. MCH nurses and clients were invited to design an intervention package (prototype) to improve nurse-client relationships using a human-centered design (HCD) approach. A multi-step HCD approach was employed to first examine the contributors of poor nurse-client relationships using nine focus group discussions with nurses and clients and 12 key informant interviews with MCH administrators. Then, three meetings were held with 10 nurses, 10 clients, and 10 administrators to co-develop an intervention package to address the identified contributors. The solutions were validated by collecting qualitative information through six focus groups with nurses and MCH clients who were not involved in the initial HCD stages. Finally, refinement and adaptation meetings were held with 15 nurses, 15 clients, and 10 administrators. The data were managed with NVivo 12 software and analyzed thematically. Nursing curriculum challenges contributing to poor nurse-client relationships in MCH care included inadequate content on nurse-client relationships specifically topics of customer care, communication skills, and patient-centered care; an inadequate practice on communication skills within nursing schools; and the absence of specific trainers on interpersonal relationships. Consequently, improving the nursing curriculum was one of the interventions proposed during the co-design and rated by participants as highly acceptable during validation and refinement meetings. Suggested improvements to the curriculum included increasing hours and credits on communication skills and patient-centered care, including customer care courses in the curriculum and creating a friendly learning environment for clinical practice on strengthening interpersonal relationships. Improving the nursing curriculum was considered by nurses and clients as one of the acceptable interventions to strengthen nurse-client relations in MCH care in rural Tanzania. Nursing education policy and curriculum developers need to ensure the curriculum facilitates the development of much-needed interpersonal skills among nursing graduates for them to have positive therapeutic interactions with their clients.

Perspectives of people with Parkinson's disease and family carers about disease management in community settings: Across-country qualitative study.

To explore perceptions of people with Parkinson's disease and family carers about the use and impact of health and social care services, community and voluntary sector resources for the management of Parkinson's disease. Resources from outside the formal health care system and collaborations between different levels and sectors could address the unmet needs of people with Parkinson's disease and their family carers and improve the management of Parkinson's disease in the community setting. A qualitative exploratory study was carried out in Denmark, Norway, Spain and the United Kingdom and was reported using the COREQ. Individual semi-structured interviews were conducted with people with Parkinson's disease and family carers between May and August 2020. Interviews were digitally recorded, transcribed verbatim and analysed using thematic analysis. A meta-ethnographic approach was used to analyse and synthesise cross-national findings. Forty-seven people with Parkinson's disease and 39 family carers participated in the four countries. Four themes and eight sub-themes emerged: (1) Personalised care for needs throughout the Parkinson's disease journey; (2) Accessibility of different types of support systems (including initiatives to support emotional well-being, physical rehabilitation, information on the healthcare services, voluntary associations and community groups); (3) Multiagency collaborations, a more comprehensive approach; (4) Acknowledgment of people with Parkinson's and family carers own role in Parkinson's disease management. An integrated and person-and-community-centred approach, which includes the participation of the health, social, voluntary and community sectors, is desired by people with Parkinson's disease and their family carers to improve the management of Parkinson's in the community setting. These findings could contribute to the creation of more sustainable care systems at the European level that would better respond to individual and changing needs in people with Parkinson's disease and their family carers, and in other long-term conditions. The Patient and Public Involvement groups contributed to the design of the study, the interview guides and validation of findings. This study will inform the management of Parkinson's disease at the community level and the use of resources not only directly linked to the health system. Taking into account all the actors that provide care and support to people with Parkinson' disease and family carers facilitates the creation of strategies that better respond to individual needs. Nurses and other health and social care professionals in the community and specialist levels of care should collaborate to develop multisectoral strategies that promote personalised and integrated care throughout the Parkinson's journey.

Informal healthcare providers of abortion services among three scheduled tribes of Jharkhand.

There is a dominant role of informal healthcare providers (IHPs) in the current cultural and sociological context of tribal communities. They outnumber formal health-care providers, thus bridging the gap between existing and nonexisting public health facilities despite not having formal training or accreditation. The study examines the role, relevance, and extent of abortion services provided by IHPs- in Jharkhand among three Scheduled Tribe groups. Based on in-depth interviews with 15 IHPs and 42 married women among three Scheduled Tribe groups in three districts of Jharkhand, a qualitative study was conducted. Interview guidelines addressed reasons for preferring IHP services, their scope of practice, dissemination, and quality of services. The majority of women seeking abortions used traditional contraceptives, which often resulted in unwanted pregnancies. The economic, cultural, social, access to services, and confidence factors encouraged women to seek abortion services from IHPs. There were differences in the nature of access to abortion services among tribal groups. The Chero and Korwa tribes continued to rely heavily on simpler life technologies that shaped their beliefs and practices regarding reproduction. The Ho tribe, however, preferred to use the formal health-care system since they were close to a more complex society. IHP plays a significant role in the social structure of Tribes, demonstrating their marginalization in access to formal health-care services. Eventually, they replaced traditional healers with their function as physicians.

History and Politics of Medication Abortion in the United States and the Rise of Telemedicine and Self-Managed Abortion.

This article examines the decades-long campaign to increase access to abortion pills in the United States, including advocates' work to win US Food and Drug Administration approval of mifepristone and misoprostol for abortion, the continuing restrictions on mifepristone, and the multiple strategies advocates have pursued to challenge these restrictions, including lobbying the FDA to remove the restrictions, obtaining a limited research exemption from FDA restrictions, and suing the FDA during the COVID-19 pandemic. The article pays particular attention to the influence of research conducted on the safety and efficacy of medication abortion as well as research on the impact of increased availability of abortion pills through telemedicine during the pandemic. The article also addresses self-managed abortion, wherein people obtain and use mifepristone and/or misoprostol outside the formal health care system, and it documents the growing network of organizations providing logistical, medical, and legal support to people self-managing abortion. The article concludes with reflections on the role abortion pills might play in the post-Roe era amid increasingly divergent abortion access trends across different regions of the United States.

Versatile brokerage: migrant-provider relationships in the third net of the U.S. Healthcare system

ABSTRACT In studies of migrant healthcare, ‘brokerage’ is conceptualised as the process by which community health workers facilitate low-income migrants’ access to the formal healthcare system, acting as both gatekeepers to healthcare and representatives advocating for patients. Building on these conceptualizations, we examine brokerage within what we call the ‘Third Net’ of the U.S. healthcare system, an informal health network comprised of mostly volunteer-run, community-based organisations and clinics that provide medical care to uninsured, undocumented migrants. Our study draws from 52 in-depth interviews with volunteers and a cumulative 23 months of ethnographic fieldwork with two migrant-serving organisations in Houston, Texas, and Phoenix, Arizona. We argue that brokerage roles and relationships within the Third Net are necessarily marked by versatility. This versatile brokerage in the Third Net (1) facilitates ad hoc access to the mainstream health system for uninsured, undocumented migrants; (2) challenges migrants’ racialized disentitlement and discourses of migrant dependency; and (3) de-centers and expands broker roles. Contributing to migrant health and brokerage literature, this research illustrates that brokerage relationships are not always fixed and hierarchical; brokering care is not solely about access to an inequitable health system but can also involve creating new and more equitable configurations of care.

PS-P12-9: PERCEPTIONS AND PERSEPECTIVES OF THE COMMUNITY AND HEALTHCARE PROVIDERS ON HYPERTENSION HEALTHCARE-SEEKING BEHAVIOR AND TREATMENT ADHERENCE IN RURAL NEPAL

Objective: The aim of this study was to identify factors influencing healthcare-seeking behavior and treatment adherence of people living with hypertension in the rural municipalities of Sindhupalchok District, Nepal. In the context of patient-provider relationships and power dynamics, this qualitative study explored and described the perceptions and perspectives of hypertensive patients, formally diagnosed within the past six months, and of their healthcare providers on the encountered challenges, barriers and facilitators in seeking healthcare and adhering to their prescribed treatment regimen for hypertension. Design and method: Semi-structured in-depth interviews were conducted with 20 patients living with hypertension, five healthcare providers and four political leaders in Sindhupalchok District, Nepal. Additionally, two focus group discussions were carried out with ten female community health volunteers who conduct outreach work. Participants were recruited through purposive sampling via snowball and opportunistic sampling techniques from government-run health facilities. The socio-ecological model developed by Mcleroy et al. (1988) was applied. The data collected were transcribed verbatim and translated into English language, and thematically analyzed using NVivo software. Results: Several factors influenced the healthcare-seeking behavior and treatment adherence of hypertensive patients living in the rural municipalities of Sindhupalchok District, Nepal. They consisted of intrapersonal or individual factors (health literacy, knowledge, awareness and perception of disease risk factors, perceived sovereignty and autonomy over ones biological body, symptoms, manifestations and complications), interpersonal factors (family and peer support as well as interactions with the healthcare provider and their perceived authority over the patient), community factors (misconceptions about modern treatments, ayurvedic medicine, community health workers motivations to serve the community), and organizational and governmental factors (misinformation about service provision, accessibility and affordability of healthcare, trust in government authorities). Conclusions: Findings from this study indicate the importance of considering the four major layers and components of the socio-ecological model to understand the healthcare-seeking behavior and treatment adherence of people living with hypertension in the rural communities of Sindhupalchok District, and to design culturally appropriate, low-cost community-based interventions that can improve health service uptake. Taking actions to address the challenges faced by the formal healthcare system in educating patients about health literacy, raising awareness about hypertension risk factors, causes and prevention strategies, building loyalty within the community, conducting routine at-home screening, referrals to primary health facilities and door-to-door distribution of medicines by trusted members of the community are urgently needed to improve acceptance of care and treatment adherence of this chronic non-communicable disease.

Predictors of burden perceived by informal caregivers of patients registered in the home health-care unit.

Studies have reported multiple variables that can affect the level of burden on informal caregivers. The need for informal caregivers is expected to increase in the upcoming years. Informal caregivers are an important extension of the formal health-care system. The aim of this study was to discover the characteristics of informal caregivers of adult patients, to determine the socioeconomic, psychological, and physical consequences facing informal caregivers, and to measure caregivers' burdens and needs. An analytical cross-sectional study that was carried out in Saudi Arabia, in the home health-care unit of King Abdelaziz University Hospital in the city of Jeddah. A. Descriptive statistics consisted of means, standard deviations, frequency tables, cross-tabulation, and charts. Categorical variables were compared using the Chi-square test to determine significant relationships between variables. A. Most of the caregivers reported no burden to minimal burden. The relationship with the care recipient has a negative impact on the burden scale.

Obstetric violence: Apublic health concern.

Obstetric violence is an ongoing public health concern due to it is prevalence rate in maternity care routine and it has been documented widely in maternal care that women experiencing a situation of mistreatment, disrespect, physical abuse, neglected care, verbal abuse, and nonconsented care1 and this alarming situation become prominent in all over the world, Africa, Asia, South America this cases well observed in a sense that pregnant women fail to meet the professional standards2 and loss an autonomy and free decision making regarding their bodies and sexuality this commentary aims to assess the associated factors towards such mistreatments, effects, and recommendation in mitigating the burden of obstetric violence Residency and educational status were reported as among the associated factors of obstetric violence in a sense that rural residency reported fewer cases while more cases were found to be obtained from urban residency and the reason behind is this that many women in rural areas have less awareness regarding the right and autonomy3 and have less been exposed to a system of health care and are not sensitive to the mistreatment and abuse from health care workers and seeing that as normal behavior of health care workers. Age was documented as the associated factor too and findings declare that young aged pregnant women are more prone to face such mistreatment and this is because at that age are more likely to conceive and give birth and data showed that the rate of giving birth at that age group is high than any other age group.4 Type of health care centers, the burden was well recognized in most of the government health care and results showed that most of the women receiving obstetric violence met with experts perpetrate in government health care facilities and is where they fail to meet professional standards1 therefore the attendee to such centers are more likely to face the same situation5 and this is due to the nature of services offered and for sometimes is due to workload of this experts and therefore they fail to offer the professional standard services. Family income has been an ongoing agenda toward the acquiring of health services, it is documented that families with lower income are more prone to get not better services, and this applied in obstetric violence low attention placed on them during care offering among experts and therefore are more prone to face and loss autonomy.4 Stress, depression, and anxiety; happen due to dehumanizing treatment and sometimes physical violence and abuse faced due to that they lose autonomy and free decision-making regarding their bodies and sexuality6 hence leading to anxiety and stress for some time depression may occur. Dehumanizing treatment may lead to general mistrust in health services7 even in experts who offer that services and therefore put psychological distance between pregnant women and care workers this may lead to drives these women away from the formal health care system and give birth outside the system for next time. Infant and child mortality due to physical torturing5 and sometimes death to delivery mothers may happen due to severe and chronic pain The alarming burden of obstetric violence is an urgent call to us all and the following are some of the proposals of what to be done to eradicate these acts of obstetric violence against pregnant women, painting awareness among women regarding their rights8 and autonomy so different seminars must be done in both rural and urban areas, creating public health policies that will directly deal with health care workers who will conduct such violence,9 better interpersonal communication, informed consent, and good medical intervention should be provided to delivering women. Generally, health experts must be encouraged to cultivate a good relationship between themselves and their clients by ensuring trust, confidence, and respect.4 All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication. We would like to extend our sincere gratitude to the faculty of medicine at St. Francis University and TAMSA—SFUCHAS for their guidance and courage. The lead author Majani M. Edward affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. Data was collected from the prior findings.

Uniting behind a common goal: Collaboration between traditional healers and allopathic health care workers to improve rural snakebite care.

Snakebite envenoming is an acute medical emergency which affects hundreds of thousands of people worldwide, primarily in remote rural areas of low-and middle income countries in the Global South. A considerable proportion of snakebite patients turn to traditional healers (THs) for help, driven by a number of push and pull factors. These include socio-cultural factors, geographical proximity, and the absence or inaccessibility of overstretched and often costly allopathic healthcare services. Although traditional healers and allopathic healthcare staff share a common focus -the recovery and well-being of their patients- both systems operate largely in parallel to each other with collaborations being an exception rather than the rule. This is to the detriment of snakebite patients, who frequently find themselves being caught-up in the dualism between the two separate systems. Given the right circumstances, snakebite patients could benefit from elements of care from both modalities. Here, we have reviewed the role of THs in snakebite care and explored how their integration into the formal healthcare system could improve the implementation and outcome of care. The effective recruitment of THs to aid in disease control and treatment efforts in diseases other than snakebite underscores the potential benefits of this strategy. Carefully devised proof of concept studies are needed to test our hypothesis that collaborations between the formal healthcare sector and THs are feasible and improve outcomes in snakebite care.

Middle-aged and older people with urgent, unaware, and unmet mental health care needs: Practitioners’ viewpoints from outside the formal mental health care system

BackgroundMental health challenges are highly significant among older individuals. However, the non-utilization of mental health services increases with age. Although universal health coverage (UHC) was reported to reduce unmet health care needs, it might not be sufficient to reduce unmet mental health care needs from a clinical perspective. Despite the existence of UHC in Japan, this study aimed to explore the factors related to the non-utilization of formal mental health care systems among middle-aged and older people with urgent, unaware, and unmet mental health care needs.MethodsPurposeful sampling was used as the sampling method in this study by combining snowball sampling and a specific criterion. The interviewees were nine practitioners from four sectors outside the mental health care system, including long-term care, the public and private sector, as well as general hospitals in one area of Tokyo, where we had conducted community-based participatory research for five years.The interviews were conducted by an interdisciplinary team, which comprised a psychiatrist, a public health nurse from a non-profit organization, and a Buddhist priest as well as a social researcher to cover the broader unmet health care needs, such as physical, psychosocial, and spiritual needs. The basic characteristics of the interviewees were enquired, followed by whether the interviewees had case of middle-aged or older individuals with urgent, unaware, and unmet mental health care needs. If the answer was yes, we asked the interviewees to describe the details. The interviews pertinent to this study were conducted between October 2021 and November 2021.In this study, we adopted a qualitative descriptive approach. First, we created a summary of each case. Next, we explored the factors related to the non-utilization of formal mental health care systems by conducting a thematic analysis to identify the themes in the data collected.ResultsThe over-arching category involving “the factors related to an individual person” included two categories, as follows: 1) “Individual intrinsic factors,” which comprised two sub-categories, including “difficulty in seeking help” and “delusional disorders,” and 2) “family factors,” which comprised “discord between family members,” “denial of service engagement,” “multiple cases in one family,” and “families’ difficulty in seeking help.”The over-arching category “the factors related to the systems” included four categories, as follows: 1) “Physical health system-related factors,” which comprised “the indifference of physical healthcare providers regarding mental health” and “the discontinuation of physical health conditions,” 2) “mental health system-related factors,” which comprised “irresponsive mental health care systems” and “uncomfortable experiences in previous visits to clinics,” and 3) “social service system-related factors,” which comprised “the lack of time to provide care,” “social service not allowed without diagnosis,” and “no appropriate service in the community,” as well as 4) “ the lack of integration between the systems.”Apart from the aforementioned factors, “the community people-related factor” and “factors related to inter-regional movements” also emerged in this study.ConclusionsThe results of this study suggest a specific intervention target, and they provide further directions for research and policy implementation. The suggested solutions to the issues pertinent to this study are as follows: the recognition of the ways in which older people may inadequately understand their health or be unaware of available services, the building of a therapeutic alliance for “the individual intrinsic factors.” Regarding the “family factors,” the solutions include the provision of particularly intensive care for families with family discords, families with multiple cases, and families who find it difficult to seek help, as well as making intensive efforts for ensuring early involvement after contact with health care services. Regarding the “the factors related to the systems,” the solutions include the implementation of mental health education campaigns aimed at enhancing mental health knowledge among non-mental health professionals, as well as formulating and implementing reforms ensuring that such professionals are increasingly responsible especially with regard to emergency inpatient care. It also include listening without ageism in clinical practice, the expansion of social services regarding human resources and the flexibility of use which increases the breadth of the types of care, as well as facilitating the integration between the associated health care systems. Further suggestions include encouraging community residents to join social security systems as well as the provision of particularly intensive care for people who have just moved in.

Chronic diseases and multi-morbidity in persons experiencing homelessness: a cross-sectional study

Abstract Background Persons experiencing homelessness (PEH) suffer a high burden of chronic diseases, yet face significant barriers in accessing health services. We describe and compare chronic diseases and multi-morbidity in PEH, housing exclusion and secure housing who lacked access to regular health services in the wake of the COVID-19 pandemic in Germany. Methods Study participants were adults who sought care at clinics of the humanitarian organisation “Ärzte der Welt” in Munich, Hamburg and Berlin in 2020. The patients were categorised into three groups according to the European Typology of Homelessness and Housing Exclusion (ETHOS). We described socio-demographic characteristics, self-rated health, chronic diseases, multi-morbidity and SARS-COV-2 infections in each group. Logistic regression analysis was used to identify socio-demographic factors associated with higher odds of chronic diseases and multi-morbidity. Results Of the 695 study participants, 333 experienced homelessness, 292 housing exclusion and 70 had secure housing. 92.3 % had no or limited health insurance and 96.7% were below the poverty line. Males and EU citizens were highly represented among PEH (74.2% and 56.8% respectively). PEH had lower self-rated health (47.8%, p = 0.04), and higher rates of psychiatric illness (20.9%, p = 0.04). In adjusted analyses, being 35-49 and ≥50 years was associated with greater odds of chronic diseases (AOR= 2.33, 95% CI = 1.68-3.24; AOR=3.57, 95% CI = 2.55-5.01, respectively), while being male was associated with lower odds of multi-morbidity (AOR=0.602, 95% CI = 0.38-0.9). Of the 18 symptomatic patients tested for SARS-COV-2 infection, 15 were PEH, of whom one tested positive. Conclusions Housing was not a risk factor for chronic disease and multi-morbidity in this study. However, PEH reported poorer self-rated and psychiatric health. Strategies to improve access to health services for persons experiencing homelessness and housing exclusion are much needed in Germany. Key messages • Research to highlight the health inequity, both in access and outcomes, in persons experiencing all forms of homelessness is much needed. • This study provides data on a population disconnected from the formal healthcare system. Making such data visible is a step towards addressing the structural causes of social exclusion.