Service Delivery Programs Research Articles

Improving Access to Specialist Eye Care for Indigenous Australians via Telehealth: An Observational Cohort Study.

Background: Indigenous people are often neglected in eye health research and service delivery programs, despite having a greater burden of vision loss, most of which is avoidable. The objective of this work was to improve access to specialist eye care for Indigenous Australians living in rural and remote areas, by providing direct access to expert diagnostic services based in metropolitan areas through a tele-ophthalmology system. Methods: Over a four-year study period, 13 remote communities in Queensland and the Northern Territory were identified that had limited or no access to eye screening services. Relationships with health service providers in the communities were established to codesign a sustainable model of service delivery and referral pathways to ensure that patients identified with eye issues received appropriate treatment. Results: Over the course of the study, screening records from 378 patients were uploaded to a web-based telehealth system and diagnosed by ophthalmologists. From these examinations, 64 new cases of diabetic retinopathy (DR) were identified (including 2 cases of proliferative DR and 4 cases of severe nonproliferative DR), and diabetic macular edema was noted in 18 patients. The majority of participants screened had no eye problems, which enables the removal of these patients from the queues of overwhelmed specialist lists, improving service efficiency. The study also demonstrates capacity building of healthcare workers to perform eye screening and improved patient health awareness where the retinal cameras were used as an educational tool. Conclusions: A valuable screening service has been established in the target areas, where access to ophthalmic services has been improved for residents of the study screening locations. Routine eye examination (instead of opportunistic eye examination) is feasible for early detection of some eye diseases for remote and rural patients.

Influence of employee’s intellectual wellness programmes on service delivery in faith-based hospitals in Nairobi metropolitan area

This study sought to investigate the intellectual wellness programmes on service delivery in faith-based hospitals in the Nairobi metropolitan area. In the modern competitive business environment, organisations and their management have realised that their survival and competitiveness lie in the quality of the services and by extension the service providers. The study adopted descriptive survey and correlational research designs. The study targeted the employees in faith-based hospitals in the Nairobi metropolitan area. A stratified random sampling approach was used in selecting the respondents. The study sample size was 297 respondents. Of the 297 questionnaires distributed to the target respondents, 244 of the questionnaires were filled and returned. Thus, there was a response rate of 82 per cent. The study obtained primary data using a questionnaire. Descriptive and inferential statistics were used to analyse data. Descriptive statistics included frequencies, mean, standard deviation and percentage. Correlational analysis was used to determine the relationship between the independent and dependent variables. The study also carried out a regression analysis to determine the level of association of the study variables. Results were presented in tables. The study established that there were employees' intellectual wellness programmes in the faith-based hospitals in the Nairobi metropolitan area. Correlation analysis results showed that a significant moderate positive correlation existed between service delivery and intellectual wellness programmes. The study also determined that intellectual wellness had a significant influence on service delivery in faith-based hospitals in the Nairobi metropolitan area. The study thus concluded that intellectual employee wellness programmes had a significant influence on service delivery in faith-based hospitals in the Nairobi metropolitan area.

A pilot study expanding participatory epidemiology to explore community perceptions of human and livestock diseases among pastoralists in Turkana County, Kenya

Abstract In Kenya, pastoralists grapple with significant health and livelihood challenges due to livestock, zoonotic, and human-specific diseases. These diseases threaten the sustainability of their unique food production system and its considerable economic, nutritional, and ecologic value. Disease control and prevention in arid and semi-arid lands are currently inadequate due to underfunded and ill-adapted health programs coupled with a shortage of personnel. Participatory epidemiology (PE) presents a valuable tool for understanding community perceptions of disease importance and epidemiology, thereby aiding in improving control measures and promoting community involvement in centralized service delivery programs. Yet, the use of PE has focused on livestock and zoonotic diseases, leaving perceptions of human-specific disease and the complex interplay between pastoralists, their livestock, and the rangelands largely unexplored. To address this gap, we utilized PE to achieve three objectives: (1) establish links between human and livestock diseases, (2) determine perceptions of disease priorities, and (3) assess knowledge of disease epidemiology. Our findings indicate that the relationships between human and livestock diseases primarily manifest in two categories: disease symptoms and zoonoses. Disease priorities differed between locations, with no apparent pattern emerging that human or livestock diseases are considered more important. Importance indicators such as prevalence, mortality, morbidity, and spatial/temporal variation were shared across diseases. Diseases perceived as more prevalent and deadly were deemed most consequential, while those seen as less prevalent, less deadly, and exhibiting more spatial/temporal variation were considered important. Our results underscore the added value of including human-specific diseases in PE, which can help improve disease prevention and control initiatives among pastoralists. Human, animal, and environmental health programs and research can leverage and expand upon our approach, combining it with household surveys and other surveillance methods to address health challenges among pastoralists in the drylands of Northern Kenya and beyond.

An Evaluation of the Consequences of Covid-19 On Immunisation Programme Financing and Service Delivery in a Lower Middle Income Country – The Case of Zambia

An Evaluation of the Consequences of Covid-19 On Immunisation Programme Financing and Service Delivery in a Lower Middle Income Country – The Case of Zambia

Synthetic Controls for Implementation Science: Opportunities for HIV Program Evaluation Using Routinely Collected Data.

HIV service delivery programs are some of the largest funded public health programs in the world. Timely, efficient evaluation of these programs can be enhanced with methodologies designed to estimate the effects of policy. We propose using the synthetic control method (SCM) as an implementation science tool to evaluate these HIV programs. SCM, introduced in econometrics, shows increasing utility across fields. Key benefits of this methodology over traditional design-based approaches for evaluation stem from directly approximating pre-intervention trends by weighting of candidate non-intervention units. We demonstrate SCM to evaluate the effectiveness of a public health intervention targeting HIV health facilities with high numbers of recent infections on trends in pre-exposure prophylaxis (PrEP) enrollment. This test case demonstrates SCM's feasibility for effectiveness evaluations of site-level HIV interventions. HIV programs collecting longitudinal, routine service delivery data for many facilities, with only some receiving a time-specified intervention, are well-suited for evaluation using SCM.

Tackling syndemics by integrating infectious and noncommunicable diseases in health systems of low- and middle-income countries: A narrative systematic review.

The co-occurrence of infectious diseases (ID) and non-communicable diseases (NCD) is widespread, presenting health service delivery challenges especially in low-and middle-income countries (LMICs). Integrated health care is a possible solution but may require a paradigm shift to be successfully implemented. This literature review identifies integrated care examples among selected ID and NCD dyads. We searched PubMed, PsycINFO, Cochrane Library, CINAHL, Web of Science, EMBASE, Global Health Database, and selected clinical trials registries. Eligible studies were published between 2010 and December 2022, available in English, and report health service delivery programs or policies for the selected disease dyads in LMICs. We identified 111 studies that met the inclusion criteria, including 56 on tuberculosis and diabetes integration, 46 on health system adaptations to treat COVID-19 and cardiometabolic diseases, and 9 on COVID-19, diabetes, and tuberculosis screening. Prior to the COVID-19 pandemic, most studies on diabetes-tuberculosis integration focused on clinical service delivery screening. By far the most reported health system outcomes across all studies related to health service delivery (n = 72), and 19 addressed health workforce. Outcomes related to health information systems (n = 5), leadership and governance (n = 3), health financing (n = 2), and essential medicines (n = 4)) were sparse. Telemedicine service delivery was the most common adaptation described in studies on COVID-19 and either cardiometabolic diseases or diabetes and tuberculosis. ID-NCD integration is being explored by health systems to deal with increasingly complex health needs, including comorbidities. High excess mortality from COVID-19 associated with NCD-related comorbidity prompted calls for more integrated ID-NCD surveillance and solutions. Evidence of clinical integration of health service delivery and workforce has grown-especially for HIV and NCDs-but other health system building blocks, particularly access to essential medicines, health financing, and leadership and governance, remain in disease silos.

Efficacy of Internet-based Cognitive Behavioral Therapy for Hong Kong University Students: A Randomized Controlled Trial

Purpose: This study examined the efficacy of a 10-week internet-based cognitive behavioral therapy (iCBT) program “REST Online” for Hong Kong university students with mild to moderate levels of psychological distress. Method: A total of 206 Hong Kong university students were randomized into: (1) web-based and (2) app-based iCBT, and (3) waitlist control (WLC) groups. Results: Compared with the WLC group, the participants in the two iCBT groups showed a significant reduction in psychological distress, depression and anxiety symptoms, and negative thoughts and emotions, and significant increase in positive thoughts and emotions, with medium to large effect sizes. The positive effects were sustained at the 3-month follow-up test. No significant intervention effects were found between the two iCBT groups except for anxiety symptoms. Discussion: The findings were discussed in terms of program design and service delivery, and suggestions for delivering digital mental health service in Hong Kong universities were proposed.

Reducing time to differentiated service delivery for newly-diagnosed people living with HIV in Kigali, Rwanda: a pilot, unblinded, randomized controlled trial

BackgroundDifferentiated service delivery (DSD) programs for people living with HIV (PWH) limit eligibility to patients established on antiretroviral therapy (ART), yet uncertainty exists regarding the duration on ART necessary for newly-diagnosed PWH to be considered established. We aimed to determine the feasibility, acceptability, and preliminary impact of entry into DSD at six months after ART initiation for newly-diagnosed PWH.MethodsWe conducted a pilot randomized controlled trial in three health facilities in Rwanda. Participants were randomized to: (1) entry into DSD at six months after ART initiation after one suppressed viral load (DSD-1VL); (2) entry into DSD at six months after ART initiation after two consecutive suppressed viral loads (DSD-2VL); (3) treatment as usual (TAU). We examined feasibility by examining the proportion of participants assigned to intervention arms who entered DSD, assessed acceptability through patient surveys and by examining instances when clinical staff overrode the study assignment, and evaluated preliminary effectiveness by comparing study arms with respect to 12-month viral suppression.ResultsAmong 90 participants, 31 were randomized to DSD-1VL, 31 to DSD-2VL, and 28 to TAU. Among 62 participants randomized to DSD-1VL or DSD-2VL, 37 (60%) entered DSD at 6 months while 21 (34%) did not enter DSD because they were not virally suppressed. Patient-level acceptability was high for both clinical (mean score: 3.8 out of 5) and non-clinical (mean score: 4.1) elements of care and did not differ significantly across study arms. Viral suppression at 12 months was 81%, 81% and 68% in DSD-1VL, DSD-2VL, and TAU, respectively (p = 0.41).ConclusionsThe majority of participants randomized to intervention arms entered DSD and had similar rates of viral suppression compared to TAU. Results suggest that early DSD at six months after ART initiation is feasible for newly-diagnosed PWH, and support current WHO guidelines on DSD.Trial registrationClinicaltrials.gov NCT04567693; first registered on September 28, 2020.

Health situation analysis of cervical cancer in Delhi

The capital city of India, Delhi is endowed with a plethora of multi- and super-specialty hospitals, both private and government, for treating various diseases. Patients from around the globe seek medical care in Delhi. The primary healthcare system is robust, with a network of newly established Mohalla and polyclinics. However, when it comes to a sensitive disease, ‘cervical cancer’, all glorious claims mentioned above seem to be inadequate. Cervical cancer is the 2nd most common cancer among Delhi's females. Delhi was 1st state to launch HPV vaccination as a public health program in 2016 despite resistance from civil societies. A situation analysis from literature reveals that cervical cancer screening services at the primary and secondary levels are on the backburner in Delhi, which is also evident from the poor screening habits of Delhi's females (0.7%) according to NFHS-5. This prompts questions regarding organization of the cervical cancer prevention program (NP-NCD) and the delivery of screening services in Delhi. In this review we have tried to illuminate the contemporary landscape of cervical cancer burden, screening, and treatment, while also identifying opportunities for enhancing cervical cancer management in Delhi. The study finds that implementation research targeted at finding barriers in program organization and service delivery would help strengthen the capacity of Delhi’s health system.

Towards an Integrated Online–Offline Healthcare System: Exploring Chinese Patients’ Preferences for Outpatient Follow-Up Visits Using a Discrete Choice Experiment

Public hospitals in China are working to build an integrated online–offline healthcare system that combines telehealth and traditional healthcare to better serve patients. This study aims to explore Chinese patients’ preferences for online versus offline outpatient follow-up visits after the COVID-19 pandemic and to inform healthcare providers in designing optimal service delivery programmes. A discrete choice experiment was designed to elicit respondents’ stated preferences. A total of 311 valid respondents were recruited. Analysis of the full sample showed that respondents preferred traditional, offline outpatient follow-up visits. Nevertheless, a class of respondents was identified who preferred online outpatient follow-up visits. Our results show that Chinese patients are currently generally cautious about online outpatient follow-up visits since there is proportion of potentially targeted patients who stated a preference for online visits while the overall preference is still offline, in-person follow-up visits. Online outpatient follow-up visits could be attractive alternatives to traditional visits if they could meet potential users’ preferences for shorter waiting time for appointments, lower service cost, and continuity of follow-up visits. This study also suggests that it is necessary and worthwhile for healthcare providers to further explore the optimal integration of telehealth services with traditional healthcare.

Service delivery approaches related to hearing aids in low- and middle-income countries or resource-limited settings: A systematic scoping review.

Hearing loss is an important global public health issue which can be alleviated through treatment with hearing aids. However, most people who would benefit from hearing aids do not receive them, in part due to challenges in accessing hearing aids and related services, which are most salient in low- and middle-income countries (LMIC) and other resource-limited settings. Innovative approaches for hearing aid service delivery can overcome many of the challenges related to access, including that of limited human resources trained to provide ear and hearing care. The purpose of this systematic scoping review is to synthesize evidence on service delivery approaches for hearing aid provision in LMIC and resource-limited settings. We searched 3 databases (PubMed, Scopus, Ovid MEDLINE) for peer-reviewed articles from 2000 to 2022 that focused on service delivery approaches related to hearing aids in LMIC or resource-limited settings. Fifteen peer-reviewed articles were included, which described hospital-based (3 studies), large-scale donation program (1 studies), community-based (7 studies), and remote (telehealth; 4 studies) service delivery approaches. Key findings are that hearing aid services can be successfully delivered in hospital- and community-based settings, and remotely, and that both qualified hearing care providers and trained non-specialists can provide quality hearing aid services. Service delivery approaches focused on community-based and remote care, and task sharing among qualified hearing care providers and trained non-specialists can likely improve access to hearing aids worldwide, thereby reducing the burden of untreated hearing loss.

H - 15 Leveraging Community Health Care Workers in Rural Communities to Address Brain Health Equity.

To address brain health in rural communities, Telehealth ROCKS developed a service delivery program with local partners. Community healthcare workers (CHWs) assess and provide students with referrals to address social determinants of health (SDoH) and mental health needs. Qualitative and quantitative data were collected. This program serves seven school districts and 6876 students in an area historically reliant on a mining/factory economies with high concerns for environmental exposures. Students were from diverse backgrounds with a range of neurological and neurodevelopmental conditions. To close SDOH gaps, CHWs utilized Community CareLink (CCL), an online platform tailored for rural communities that documents, tracks, and identifies SDOH gaps. Since 2022, 85% of families elected to pursue CHW support. To date, 10 CHWs have worked directly with approximately 10% of the school population with 80% of encounters having an attendance component. Thematic analysis shows building trust has been an important encounter theme: "Building that trust within the families is so important. By being able to help them with housing, utility assistance or getting access to Medicaid can be a huge relief..." The pandemic impacted SDOH domains, further exacerbating rural and other systemic disparities that will have long-lasting impact on brain health in rural communities. For neuropsychologists, adopting this program design may help to foster trusted relationships and community partnerships, improve culturally informed referrals, and provide scaffolding/coaching around referrals so that our expertise can aid patients and families where and when it is needed most.

Audit & Analysis of turnover of medical practitioners’ resignation from Mankwneg Academic hospital, Limpopo, South Africa

Background: Shortages and staff turnover have been recognized as one of the big concerns for employer and patient care in the health-care sector worldwide. It has been observed that some of the health professionals particularly medical doctors are resigning from Mankweng academic hospital time to time and which is affecting the service delivery and training program. Purpose of the Research: Main aim of the study to figure out what factors influencing medical practitioner to quit Mankweng hospital. Methods: The study was a retrospective cross sectional descriptive quantitative design to analyse the profile of all Medical doctors, who quitted from Mankweng Academic hospital for 5-year period from January 2018 to December 2022. Categorical variables were described as proportions and frequency tables. Result: Total 74 medical practitioner resigned. Male 37 and female 37 from different departments. Reason of resigning: Lack of prospect advancement 19(25.7%), Relocation to other area 19(25.7%) and Promotion 14(19%), family reason 8(10.8%), work related stress & poor working condition 5.4% each, further study 4% and other 4%. Suggestion for retention: Improve staff 24.3%, employee support 21.6%. Conclusions: Lack of prospect advancement (25.7%), Relocation to other area (25.7%) and Promotion (19%), are responsible for main reasons of resignation among all medical practitioners. Approximately 24% of resigned doctors suggested increasing the staff number. Increased staff would improve the working condition; reduce burnout, fatigue, stress and which would decrease the turnover of medical practitioners. It is paramount important to hire more medical specialist and retain them in order to get accreditation of relevant departments.

Clinical outcomes after extended 12-month antiretroviral therapy prescriptions in a community-based differentiated HIV service delivery programme in South Africa: a retrospective cohort study.

There is an urgent need for more efficient models of differentiated antiretroviral therapy (ART) delivery for people living with HIV (PLHIV), with the World Health Organization calling for evidence to guide whether annual ART prescriptions and consultations (12M scripts) should be recommended in global guidelines. We assessed the association between 12M scripts (allowed temporarily during the COVID-19 pandemic) versus standard 6-month prescriptions and consultations (6M scripts) and clinical outcomes. We performed a retrospective cohort study using routine, de-identified data from 59 public clinics in KwaZulu-Natal, South Africa. We included PLHIV aged ≥18 years with a recent suppressed viral load (VL) who had been referred for community ART delivery with 6M or 12M scripts. We used modified Poisson regression to compare 12-month retention-in-care (≤90 days late for all visits) and viral suppression (<50 copies/ml) between prescription groups. Among 27,148 PLHIV referred for community ART during Jun-Dec 2020, 57.4% received 12M scripts. The median age was 39 years and 69.4% were women. Age, sex, prior community ART use and time on ART were similar across groups. However, more of the 12M script group had dolutegravir-based regimens (60.0% vs. 46.3%). The median (interquartile range) number of clinic visits in the year of follow-up was 1(1-1) in the 12M group and 2(2-3) in the 6M group. Retention was 94.6% (95% confidence interval [CI]: 94.2%-94.9%) among those receiving 12M scripts and 91.8% (95% CI: 91.3%-92.3%) among those with 6M scripts. 17.1% and 16.9% of clients in the 12M and 6M groups were missing follow-up VL data, respectively. Among those with VLs, 92.4% (95% CI: 92.0%-92.9%) in the 12M group and 91.4% (95% CI: 90.8%-92.0%) in the 6M group were suppressed. After adjusting for age, sex, ART regimen, time on ART, prior community ART use and calendar month, retention (adjusted risk ratio [aRR]: 1.03, 95% CI: 1.01-1.05) and suppression (aRR: 1.00, 95% CI: 0.99-1.01) were similar across groups. Among PLHIV referred for community ART with a recent suppressed VL, the use of 12M scripts reduced clinic visits without impacting short-term clinical outcomes. 12M scripts should be considered for differentiated service delivery programmes.

Current Perceptions and Unmet Needs of People with Parkinson Disease and their Families

Purpose: A new diagnosis of Parkinson disease (PD) occurs every nine minutes in the United States. It is a multimodality neurogenic disorder whose prevalence is expected to only increase worldwide in the coming decades. Therefore, a systematic examination of the current perception of PD symptoms and the different unmet needs of people with PD and their families can allow healthcare professionals to design more effective education, awareness, and management programs. The current study examined perceptions of different PD-related symptoms among individuals with PD and care partners (including spouses and family members) living in different communities of the United States (including Oklahoma and surrounding regions).Methods: The study included 39 participants with PD and 11 care partners based in four states (including Arkansas, Kansas, Oklahoma, and Texas).Results: Findings indicated that participants with PD and care partners more frequently reported motor symptoms associated with PD than nonmotor and communication symptoms. In addition, specific to unmet needs, both groups reported the need for specialized services and educational resources related to PD symptoms in their respective communities.Conclusions: Overall, there is a need for more widespread education and access to specialized services specific to PD. Overall, findings from the study will help create more effective service delivery programs for individuals with PD and their families in different communities.

Women empowerment is a tool to improve the quality of life of a community-case study

A reduction in Quality of life (QoL) is evidenced among disempowered populations in Low Middle-Income Countries (LMIC) like Sri Lanka. Women in marginalized populations were culturally identified as potential persons who have care responsibilities to break the vicious cycle of poverty through capacity building. The aim of the study focuses on framework analysis to develop an implementation strategy with women empowerment to enhance the QoL of the community. A study was conducted for 4 years (2018-2022) in the Family Health Center, Kondavil, Northern Province, Sri Lanka, as a qualitative framework analysis using participatory action research methodology. As a result of the study, the empowered women coordinate several health service delivery programs for their community members and financially support their own families. The study can be concluded that women empowerment is an effective tool to improve the QoL of the community.

Availability of medical abortion medicines in eight countries: a descriptive analysis of key findings and opportunities

BackgroundIn recent years a growing number of manufacturers and medical abortion products have entered country markets and health systems, with varying degrees of quality and accessibility. An interplay of factors including pharmaceutical regulations, abortion laws, government policies and service delivery guidelines and provider’s knowledge and practices influence the availability of medical abortion medicines. We assessed the availability of medical abortion in eight countries to increase understanding among policymakers of the need to improve availability and affordability of quality-assured medical abortion products at regional and national levels.MethodsUsing a national assessment protocol and an availability framework, we assessed the availability of medical abortion medicines in Bangladesh, Liberia, Malawi, Nepal, Nigeria, Rwanda, Sierra Leone and South Africa between September 2019 and January 2020.ResultsRegistration of abortion medicines—misoprostol or a combination of mifepristone and misoprostol—was established in all countries assessed, except Rwanda. Mifepristone and misoprostol regimen for medical abortion was identified on the national essential medicines list/standard treatment guidelines for South Africa as well as in specific abortion care service and delivery guidelines for Bangladesh, Nepal, Nigeria, and Rwanda. In Liberia, Malawi, and Sierra Leone—countries with highly restrictive abortion laws and no abortion service delivery guidelines or training curricula—no government-supported training on medical abortion for public sector providers had occurred. Instead, training on medical abortion was either limited in scope to select private sector providers and pharmacists or prohibited. Community awareness activities on medical abortion have been limited in scope across the countries assessed and where abortion is broadly legal, most women do not know that it is an option.ConclusionUnderstanding the factors that influence the availability of medical abortion medicines is important to support policymakers improve availability of these medicines. The landscape assessments documented that medical abortion commodities can be uniquely impacted by the laws, policies, values, and degree of restrictions placed on service delivery programs. Results of the assessments can guide actions to improve access.

Risk factors of HIV and variation in access to clean needles among people who inject drugs in Pakistan

ABSTRACT We identified key risk factors for HIV among people who inject drugs (PWID) in Pakistan and explored access to free clean needles. Multivariable logistic regression was used to investigate associations between HIV prevalence and demographic, behavioral, and socio-economic characteristics of PWID. Data came from the Government of Pakistan’s Integrated Biological and Behavioral Surveillance (IBBS) Round 5 (2016–17; 14 cities). A secondary analysis investigated associations with reported access to clean needles. Unweighted HIV prevalence among 4,062 PWID (99% male) was 21.0%. Longer injecting duration (Odds ratio [OR] 1.06 [95% confidence interval: 1.02–1.10]; per year), higher injecting frequency (OR 1.67 [1.30–2.13]; per unit increase), and injecting heroin (OR 1.90 [1.11–3.25]) were positively associated with HIV prevalence. There was no association between using a used syringe at last injection and HIV. Having>10 years of education had lower odds of HIV than being illiterate (OR 0.58 [0.35–0.95]). Having a regular sexual partner (OR 0.74 [0.57–0.97]) or paying for sex with the opposite sex (OR = 0.62 [0.45–0.85]) had lower odds of HIV than not. Conversely, PWID paying a man/hijra for sex had higher odds of HIV (OR 1.20 [1.00–1.43]). Receipt of clean needles varied by city of residence (0–97% coverage), whilst PWID with knowledge of HIV service delivery programs had higher odds of receiving clean needles (OR 4.58 [3.50–5.99]). Injecting behaviors were associated with HIV prevalence among PWID, though risks related to paying for sex remain complicated. Geographical variation in access to clean needles suggests potential benefits of more widely spread public health services.

Household food insecurity is prevalent in a cohort of postpartum women who registered in the Canada Prenatal Nutrition Program in Toronto.

To assess the prevalence, severity and socio-demographic predictors of household food insecurity among vulnerable women accessing the Canada Prenatal Nutrition Program (CPNP) and to examine associations between household food insecurity and breastfeeding practices to 6 months. Cohort investigation pooling data from two studies which administered the 18-item Household Food Security Survey Module at 6 months postpartum and collected prospective infant feeding data at 2 weeks and 2, 4 and 6 months. Household food insecurity was classified as none, marginal, moderate or severe. Logistic regression analyses were performed to assess predictors of household food insecurity and associations between household food security (any and severity) and continued and exclusive breastfeeding. Three Toronto sites of the CPNP, a federal initiative targeting socially and/or economically vulnerable women. 316 birth mothers registered prenatally in the CPNP from 2017 to 2020. Household food insecurity at 6 months postpartum was highly prevalent (44 %), including 11 % in the severe category. Risk of household food insecurity varied by CPNP site (P < 0·001) and was higher among multiparous participants (OR 2·08; 95 % CI 1·28, 3·39). There was no association between the prevalence or severity of food insecurity and continued or exclusive breastfeeding to 6 months postpartum in the adjusted analyses. Household food insecurity affected nearly half of this cohort of women accessing the CPNP. Further research is needed on household food insecurity across the national CPNP and other similar programmes, with consideration of the implications for programme design, service delivery and policy responses.

'The wife should do as her husband advises': Understanding factors influencing contraceptive use decision making among married Pakistani couples-Qualitative study.

This paper explores the perceptions and attitudes of married couples which prevent them from using modern contraceptive for purpose of family planning, based on semi-structured interviews with 16 married couples from rural Pakistan. This study, with married couples, not using any modern contraceptives, discussed issues of spousal communication and religious norms using qualitative methods. Despite near universal knowledge of modern contraceptives among married Pakistani women, the use continues to be low, with high unmet need. Understanding the couple context about reproductive decision making, pregnancy and family planning intentions is imperative to helping individuals fulfil their reproductive desires. Married couples may have varying intentions and desires about family size; a lack of alignment between partners may lead to unintended pregnancies and affect uptake and use of contraception. This study specifically explored the factors which prevent married couples from using LARCs for family planning, despite their availability, at affordable prices in the study area of rural Islamabad, Pakistan. Findings show differences between concordant and discordant couples regarding desired family size, contraceptive communication and influence of religious beliefs. Understanding the role that male partners play in family planning and use of contraceptives is important in preventing unintended pregnancies and improving service delivery programmes. This study also helped identify the challenges married couples, particularly men have in understanding family planning and contraceptive use. The results also show that while men's participation in family planning decision making is limited, there is also a lack of programs and interventions for Pakistani men. The study findings can support development of appropriate strategies and implementation plans.