Utilization Of Health Facilities Research Articles

The effect of text-messaging on the utilisation of health facilities among pregnant women during delivery in Cross River State, Nigeria

Objective: Uptake of skilled care during delivery is associated with positive maternal and neonatal health outcomes. Studies reveal Nigeria accounts for a significant percentage of global maternal deaths, which have been associated with poor skilled attendants at delivery. Text messaging has proven to be effective in promoting health facilities’ utilisation in Nigeria. Therefore, this research assessed the influence of text messaging intervention on the utilisation of health facilities during delivery in Cross River State Methods: Quasi-experimental research design was employed. A sample size of thirty per LGA in two LGAs was used. Participants were purposively selected and grouped into text messaging and Control Groups ). The experimental group received text briefs three times per week for four weeks, while the control group received regular ANC sessions. A structured and validated questionnaire with Cronbach’s alpha coefficients ranging from 0.76 to 0.81 was used for data collection. Data were analyzed using descriptive and inferential statistics at a 5% level of significance. Results: At baseline, the proportion of women who utilised HFs during delivery was 13.3% (experimental group) and 33.3% (control group). Furthermore, at the 8th-week follow-up, there was a significant difference (p < 0.05) in T-M (76.7%), compared with CG (33.3%) with an increase of 63.4% for the T-M compared to CG (3.3%, p > 0.05). Conclusion: T-M intervention improved the utilisation of HFs during delivery among PW. The study recommends that health workers should incorporate mobile T-M intervention strategy which has proven to be a useful tool during ANC.

Utilization of maternal health facilities and rural women’s well-being: towards the attainment of sustainable development goals

BackgroundThe sustenance of any household is tied to the well-being of the mother's health before, during, and after pregnancy. Maternal health care has continued a downward slope, increasing maternal mortality in rural communities in Nigeria. Presently, few empirical findings connect maternal healthcare facilities' use to mothers' well-being in Nigeria. Using maternal health facilities and the well-being of rural women is crucial in achieving the United Nations’ Sustainable Development Goals 1, 2, and 3 (No poverty, zero hunger, good health, and well-being).ObjectiveThe objective of the study was to examine the level of maternal healthcare utilization and its effect on mothers’ well-being status among mothers in rural Nigeria.MethodsIn this study, secondary data extracted from the Nigeria’s 2018 National Demographic Health Survey was used. Data was analyzed with Multiple correspondence analysis, Fuzzy set analysis, and Extended ordered logit model.ResultsWomen in rural Nigeria were moderate users of maternal health care services and had moderate well-being indices (0.54 ± 0.2, 0.424 ± 0.2, respectively). Mothers' moderate well-being status was increased by using maternal health care facilities, having a larger household, and having mothers who worked exclusively in agriculture.ConclusionWe concluded that mothers in rural Nigeria use maternal healthcare facilities moderately, and their well-being level was improved using maternal healthcare facilities. Therefore, Nigeria’s Ministry of Health should raise awareness about the vitality of mothers using health care services before, during, and after pregnancy. In order to promote greater female participation in full-scale agricultural production, it is imperative for the Nigerian government to allocate substantial resources in the form of subsidies and incentives. The Nigerian government should source these resources from various channels, including expanded development cooperation. Additionally, policymakers should focus on designing developmental programmes specifically tailored for rural households and the health sector.

Learnings From the Implementation of an Electronic Human Resource Management System for the Health Workforce in Uttar Pradesh, India.

The state of Uttar Pradesh (UP), India, has one of the largest single public health systems globally, serving about 235 million people through more than 30,000 public health facilities with approximately 160,000 health personnel. Yet, the UP health system has a shortfall of public health facilities to meet the population's needs, a shortage of clinical and nonclinical health personnel, inequitable distribution of existing health personnel, and low utilization of public health facilities. A robust and effective electronic human resource management system (eHRMS) that provides real-time information about the lifecycle of all health professionals in UP may aid in improving the health workforce, resulting in better health services and improved health outcomes. The Government of UP rolled out Manav Sampada, a comprehensive eHRMS that complied with global norms and requirements. We describe the implementation of Manav Sampada at scale and elaborate on key learnings and adoption strategies. Manav Sampada was based on key principles of integration and data-sharing with other digital systems, included functional components, a minimum dataset, used a lifecycle-based approach, and a workflow-based system, all of which acted to improve human resource data quality. The eHRMS emerged as a valuable tool for key stakeholders in reviewing worker performance, identifying skill-building needs, and allocating resources for training, leading to improved availability and equity in the distribution of a few critical cadres. The eHRMS in UP is well positioned to become an integral part of the Ayushman Bharat Digital Mission, the backbone of India's integrated digital health infrastructure. Linking eHRMS to a planned beneficiary-centric unitized health service delivery system (capturing information at the individual level rather than the aggregate level) will enable the measurement of service delivery and quality, leading to improved workforce management.

Care seeking behavior of the victims of unintentional injuries: A community-based study in a community development block of Purba Bardhaman District, West Bengal.

Care-seeking after injury episodes is generally associated with major uncertainties concerning its incidence, care, and cure/disappearance, and the price of care. Though the utilization pattern of the population is shaped by social, economic, cultural and political factors, it varies widely for the rich and the poor. With this background, a community-based epidemiological study was conducted to determine the care-seeking behavior of victims of unintentional injuries. A cross-sectional study was conducted from May 2023-September 2023 in the Bhatar block of Purba Bardhaman district, West Bengal. Cluster random sampling was applied to select a required sample of 555 individuals from 24 villages. Study tools used were predesigned and pretested schedules developed by the researchers with the help of guidelines for conducting community surveys on injuries provided by the World Health Organization (WHO). The study had approval from the Institutional Ethics Committee. Descriptive statistics were performed using SPSS V16. Out of 49 injury episodes, 51.0% had received first aid. Out of 39 injury episodes seeking medical attention, a traditional practitioner, healer or bone setter was the type of first medical contact in the case of the majority of injury episodes (38.5%), followed by a hospital (35.9%). Low utilization of government healthcare facilities is a cause for concern. Reliance on unqualified informal healthcare providers is also a cause for concern. Our findings will help design community interventions to increase the provision of appropriate first aid in unintentional injuries.

IJCM_15A: Health-seeking behaviour among Fishermen community mothers of under-five children on childcare– A cross-sectional study

Background: Globally in 2020 an estimated 5 million children under5 years died mostly from preventable and treatable causes. India ranks second worldwide in under5 mortality (WHO2020). Health of the children is strongly dependent on parental healthcare behaviour Fishermen-community possesses unique characteristics of a folk-society, Major portion of the life of fishermen is spent at sea, mothers assume a vital place with regard to the upbringing of the children. Objective: To study the health-seeking behaviour among Fishermen- community mothers of under-five children during acute illness and factors associated with it Methodology: A cross sectional study was conducted among 100 Mothers of Under five children in a Fishermen community, Kovalam, Chengalpattu district of Tamil Nadu over a period of 3months (October 2023–November 2023). Data collection was done using interviewer administered semi-structured questionnaire, statistical analysis was done using SPSS v21.0 Results: In total, 100 mothers with mean age of 27± 3.3 years participated in the study, all of them reported of some health morbidity. The proportion of health seeking behaviour in terms of appropriate and prompt care among the study population was 42%. The reason for delayed health care seeking among the participants were due to over-the-counter drugs(33%), self-medication(17%) and home remedies(8%). Among them 84% sought health care from private health facility. Appropriate and prompt care has found to be significantly associated with the age of the child less than 2 years (OR-3.485,95%CI-1.449-8.382), educational status of the mother (above high-school) (OR-3,95%CI-1.328-6.977), extended family type (OR- 2.679,95%CI-1.151-6.233) and perception about severity of illness during an episode of acute illness. Conclusion: Appropriate Health-seeking behaviour and seeking prompt care among parents of children was inadequate. Utilization of public health facility was less. Hence, steps can be taken to sensitize the mothers about the services available in the public health care facility.

Determinants of public institutional births in India: An analysis using the National Family Health Survey (NFHS-5) factsheet data.

Institutional births ensure deliveries happen under the supervision of skilled healthcare personnel in an enabling environment. For countries like India, with high neonatal and maternal mortalities, achieving 100% coverage of institutional births is a top policy priority. In this respect, public health institutions have a key role, given that they remain the preferred choice by most of the population, owing to the existing barriers to healthcare access. While research in this domain has focused on private health institutions, there are limited studies, especially in the Indian context, that look at the enablers of institutional births in public health facilities. In this study, we look to identify the significant predictors of institutional birth in public health facilities in India. We rely on the National Family Health Survey (NFHS-5) factsheet data for analysis. Our dependent variable (DV) in this study is the % of institutional births in public health facilities. We first use Welch's t-test to determine if there is any significant difference between urban and rural areas in terms of the DV. We then use multiple linear regression and partial F-test to identify the best-fit model that predicts the variation in the DV. We generate two models in this study and use Akaike's Information Criterion (AIC) and adjusted R2 values to identify the best-fit model. We find no significant difference between urban and rural areas (P = 0.02, α =0.05) regarding the mean % of institutional births in public health facilities. The best-fit model is an interaction model with a moderate effect size (Adjusted2 = 0.35) and an AIC of 179.93, lower than the competitive model (AIC = 183.56). We find household health insurance (β = -0.29) and homebirth conducted under the supervision of skilled healthcare personnel (β = -0.56) to be significant predictors of institutional births in public facilities in India. Additionally, we observe low body mass index (BMI) and obesity to have a synergistic impact on the DV. Our findings show that the interaction between low BMI and obesity has a strong negative influence (β = -0.61) on institutional births in public health facilities in India. Providing households with health insurance coverage may not improve the utilisation of public health facilities for deliveries in India, where other barriers to public healthcare access exist. Therefore, it is important to look at interventions that minimise the existing barriers to access. While the ultimate objective from a policy perspective should be achieving 100% coverage of institutional births in the long run, a short-term strategy makes sense in the Indian context, especially to manage the complications arising during births outside an institutional setting.

Loneliness impact on healthcare utilization in primary care: A retrospective study

BackgroundAn increased number of patients seek help for loneliness in primary care. ObjectiveTo analyze whether loneliness was associated with a higher utilization of healthcare facilities. MethodsObservational, retrospective study based on the review of routinely coded data in the digital medical record system in a random sample of patients aged 65 or older, stratified by population size of their residence area. A minimum sample size was estimated at 892 medical records. Loneliness was defined as the negative feeling that arises when there is a mismatch between the quantity and quality of a person's social relationships and those, they desire. Thirty-three primary care nurses (30 females and 3 males) were reviewing the data. ResultsA total of 932 medical records of patients were reviewed (72% belonged to female patients). Of these, 657 individuals were living alone (71.9%). DeJong Scale average scores was 8.9 points (SD 3.1, 95CI 8.6–9.1). The average annual attendance to primary care ranged from 12.2 visits per year in the case of family practice, 10.7 nurse, 0.7 social workers. The average number of home visits was 3.2, and the urgent consultations attended at health centers were 1.5 per year. Higher feelings of loneliness were associated with extreme values in the frequency of healthcare resource usage. Compared to their peers of the same age, the additional healthcare resource consumption amounted to €802.18 per patient per year. ConclusionLoneliness is linked to higher healthcare resource usage in primary care, with individuals experiencing poorer physical and mental health utilizing these resources up to twice as much as their peers of the same age.

IJCM_204A: A qualitative research to identify the barriers and facilitating factors in the utilization of healthcare services by a Particularly Vulnerable Tribal Group (PVTG) in Udupi District

Background: Udupi district hosts two major Particularly Vulnerable Tribal Groups (PVTG) namely Malaikudiya and Koraga. Koraga tribes are declining in number and deprived of availability of healthcare services and accessibility to healthcare facilities. There are a lot of barriers such as lack of awareness and social stigma amalgamate the existing conditions of Koraga tribes in Udupi district. Research studies pertaining to this problem has been seldom done. Objective: We aim to explore the barriers and facilitating factors in accessing healthcare services by a Particularly Vulnerable Tribal Group (PVTG) in Udupi district. Methodology: We conducted qualitative research through 8 in-depth interviews with AMOs from PHC and CHC, ITDP staff and NGO workers, and 3 focus group discussions with community health nurses, ASHA workers, and Koraga community leaders from Udupi district. We explored the major facilitators and barriers that influence the utilization of health care services by the PVTG. Results: On the beneficiaries’ point of view, lack of awareness, distance to health facilities, poor public transportation, perceived negative behavior of hospital staff, lack of infrastructure, unwelcoming neighbourhood approaches, and economic instability were the main barriers to utilizing healthcare facilities. On the stakeholders (providers) point of view, availability of healthcare facilities, government policies and schemes and NGO activities are the facilitating factors. Conclusion: Our study highlights the barriers to utilizing health facilities; these are not always driven by factors linked to the PVTG members’ socio- economic status but also depend significantly on the quality of the health services and other contextual factors. Although the government has made efforts to improve the rural healthcare system through national-level programs, our qualitative study shows that there are a number of barriers which lessens the effectiveness of the programs to enhance the utilization of healthcare facilities by the PVTG in the study area.

Chronic diseases and determinants of community health services utilization among adult residents in southern China: a community-based cross-sectional study

BackgroundThe burden of chronic diseases has become a major public health concern, and high-efficiency use of community health services is essential in combating chronic diseases. This study described the status of chronic diseases in southern China and explored the determinants of health service utilization among adult residents.MethodsData were obtained from one part of community survey data from four counties in Ganzhou City, southern China. A multistage, stratified random sampling method was used to conduct a cross-sectional survey between 2018 and 2020. Overall, 7430 valid questionnaires were collected. A lasso-linear regression analysis was performed to explore the determinants of community health service utilization.ResultsAccording to the study, most participants (44.6%) reported having relatively good health, while 42.1% reported having moderate health. Chronic diseases were reported by 66.9% of the respondents. The three most prevalent self-reported chronic diseases were hypertension (22.6%), hyperlipidemia (5.9%), and diabetes (5.9%). Among residents with chronic diseases, 72.1% had one chronic disease, while the rest had multiple. Only 13.9% of residents frequently utilized community health services, while 18.9% never used them. Additionally, among residents who reported having chronic diseases, 14.1% had never attended community health services. Four categories of factors were the key determinants of community health service utilization: (1) personal characteristics, age, and sex; (2) health-related factors, such as family history, self-reported health conditions, and the number of chronic diseases; (3) community health service characteristics, such as satisfaction with and accessibility to community health services; and (4) knowledge of chronic diseases. Specifically, women tend to utilize healthcare services more frequently than men. Additionally, residents who are advanced in age, have a family history of chronic diseases, suffer from multiple chronic conditions, rate their self-reported health condition as poor, have a better knowledge about chronic diseases, have better accessibility to community health services, and have higher the satisfaction with community health services, tend to utilize them more frequently.ConclusionsGiven the limited healthcare resources, the government should promote the effective utilization of community health facilities as a critical community-based strategy to combat the growing threat of chronic diseases in southern China. The priority measures involve enhancing residents’ access to and satisfaction with community health services and raising awareness of chronic illnesses among older individuals with poor health status.

Comparison of Janani Suraksha Yojana (JSY) and augmented Arogya Laxmi scheme (ALS) in improving maternal and child health outcomes in urban settlements of Hyderabad, South India

BackgroundIndia accounts for the largest number of global neonatal deaths with around 20 per 1000 live births. To improve the utilization of government services for institutional deliveries, Augmented Arogya Laxmi Scheme (ALS) was launched in Telangana state of southern India. This study assessed the effectiveness of the Janani Suraksha Yojana (JSY), which combines cash assistance with delivery and post-delivery care, in comparison to ALS in improving the outcomes related to antenatal, natal, and postnatal care in urban settlements of Hyderabad, Telangana, southern India.MethodsThis was a two-year cross-sectional study conducted in 14 urban settlements of Hyderabad city from September 2017- August 2019. All mothers delivered during the 18 months preceding the survey were enrolled after a written informed consent. Field investigators collected data on variables related to socio-demographic characteristics, awareness, and utilization of JSY and ALS programs. Variables related to antenatal history, antenatal care, complications during birth, delivery outcomes, newborn care, and postnatal care till 28 days were assessed. We used multivariable logistic regression model to examine the association between the different maternal, child, and socio-demographic characteristics of the two study groups.ResultsA total of 926 mothers were beneficiaries of Janani Suraksha Yojana (JSY) program while 933 mothers were beneficiaries of augmented Arogya Laxmi Scheme (ALS). Mothers in ALS group (AOR 1.71; 95% CI 1.21–2.43) were at increased odds of having more than eight antenatal care (ANC) visits compared to the mothers availing JSY. Mothers in ALS group were at decreased odds of having complications like severe pain in the abdomen (AOR 0.43; 95% CI 0.22–0.86), swelling of legs or feet (AOR 0.59; 95% CI 0.44–0.80) compared to mothers in JSY group. Children of mothers in the ALS group had increased odds of receiving breastfeeding within 30 minutes of birth (AOR 1.46; 95% CI 1.13–1.88) compared to children of mothers in JSY group.ConclusionsThe newly launched augmented ALS led to the increased utilization of the government health facilities and improved the maternal and child health outcomes.

Utilisation of public healthcare services by an indigenous group: a mixed-method study among Santals of West Bengal, India.

A barrier to meeting the goal of universal health coverage in India is the inequality in utilisation of health services between indigenous and non-indigenous people. This study aimed to explore the determinants of utilisation, or non-utilisation, of public healthcare services among the Santals, an indigenous community living in West Bengal, India. The study holistically explored the utilisation of public healthcare facilities using a framework that conceptualised service coverage to be dependent on a set of determinants - viz. the nature and severity of the ailment, availability, accessibility (geographical and financial), and acceptability of the healthcare options and decision-making around these further depends on background characteristics of the individual or their family/household. This cross-sectional study adopts ethnographic approach for detailed insight into the issue and interviewed 422 adult members of Santals living in both rural (Bankura) and urban (Howrah) areas of West Bengal for demographic, socio-economic characteristics and healthcare utilisation behaviour using pre-tested data collection schedule. The findings revealed that utilisation of the public healthcare facilities was low, especially in urban areas. Residence in urban areas, being female, having higher education, engaging in salaried occupation and having availability of private allopathic and homoeopathic doctors in the locality had higher odds of not utilising public healthcare services. Issues like misbehaviour from the health personnel, unavailability of medicine, poor quality of care, and high patient load were reported as the major reasons for non-utilisation of public health services. The finding highlights the importance of improving the availability and quality of care of healthcare services for marginalised populations because these communities live in geographically isolated places and have low affordability of private healthcare. The health programme needs to address these issues to improve the utilisation and reduce the inequality in healthcare utilisation, which would be beneficial for all segments of Indian population.

Impact of Referral Guideline Enforcement on Orthopedic and Trauma Admissions at Kenyatta National Teaching and Referral Hospital, Kenya: A Pre-Post Test Design

Background: The suboptimal utilization of tertiary health facilities and inadequate management of referral systems in low- and middle-income countries pose challenges to health system administration, characterized by frequent self-referrals and bypassing of lower-tier health facilities. On July 1, 2021, Kenyatta National Hospital (KNH) implemented referral guidelines, mandating that all admitted patients be referred from lower-tier health facilities, aligning with the KNH legal statute of 1987. This study aimed to evaluate the impact of enforcing referral guidelines on the spatial distribution of orthopedic and trauma admissions at KNH.
 Methodology: A pre-posttest study design was employed, reviewing a total of 459 and 446 charts in 2021 before and after the enforcement of referral guidelines. Measures of central tendencies and Chi-squared tests were applied, and density plots were generated using Geographic Information System (QGIS 2.18.19) to illustrate the spatial distribution of admissions.
 Results: of KNH admissions, 85.3% and 79.3% originated from Nairobi County and its environs. Admissions were geographically diverse, with a notable concentration from Nairobi County and its environs. Enforcement of referral guidelines led to a significant decrease in admissions from Nairobi County, dropping from 64.3% to 56.9% (p=0.019). Declines were particularly observed in Kamukunji, Embakasi, and Ruaraka sub-counties, serving as the catchment population for Mama Lucy Kibaki Referral Hospital. Conversely, admissions from Kibra and most of Kajiado County were notable. There was a concurrent increase in admissions from other parts of the country (p = 0.003).
 Conclusion: Over four-fifths of KNH admissions are from Nairobi County and its environs. The enforcement of referral guidelines resulted in decreased local admissions and an uptick in admissions from other regions in the country.

Patterns of facility and patient related factors to the orthopedic and trauma admissions at the Kenyatta National Hospital: A qualitative assessment.

Inappropriate utilization of higher-level health facilities and ineffective management of the referral processes in resource-limited settings is increasingly becoming a concern in health care management in developing countries. This is characterized by self-referrals and frequent bypassing of nearest health facilities coupled with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. This situation compromises the ability and capacity of Kenyatta National Hospital (KNH) to function as a tertiary referral health facility as envisioned by Kenya Health Sector Referral Implementation Guidelines of 2014, Kenya 201 constitution and KNH legal statue of 1987. The study objective was to assess the patterns of facility and patient related factors to the orthopaedic and trauma admissions at the KNH. This was a descriptive qualitative study design. The study was conducted amongst the orthopaedic and trauma admission caseload for 2021. Data collection was done through a) data abstraction from 905 patients charts admitted during February to December 2021 and b) 10 (ten) semi-structured interviews with 10 major health facilities that refer to KNH to understand the reasons for referral to KNH. Quantitative data was analysed using Statistical Package for Social Science version 21.0 to calculate the frequency distribution. Qualitative data from the data abstraction and transcripts from the KIIs were analysed using NVivo version 12. The major facility and patient related factors to the orthopaedic and trauma admissions at KNH were inadequate human resource capacity and availability (42.7%), financial constraints (23.3%), inadequate Orthopaedic equipment's and implants availability (20.0%) and inadequate health facility infrastructure (6.3%) while the major patient related factor was patient's preference (23.4%). In conclusion, to decongest KNH requires that the lower-level health facilities need to be better equipped and resourced to handle essential orthopaedic and trauma care.

The effects of cool roofs on health, environmental, and economic outcomes in rural Africa: study protocol for a community-based cluster randomized controlled trial

BackgroundHigh ambient air temperatures in Africa pose significant health and behavioral challenges in populations with limited access to cooling adaptations. The built environment can exacerbate heat exposure, making passive home cooling adaptations a potential method for protecting occupants against indoor heat exposure.MethodsWe are conducting a 2-year community-based stratified cluster randomized controlled trial (cRCT) implementing sunlight-reflecting roof coatings, known as “cool roofs,” as a climate change adaptation intervention for passive indoor home cooling. Our primary research objective is to investigate the effects of cool roofs on health, indoor climate, economic, and behavioral outcomes in rural Burkina Faso. This cRCT is nested in the Nouna Health and Demographic Surveillance System (HDSS), a population-based dynamic cohort study of all people living in a geographically contiguous area covering 59 villages, 14305 households and 28610 individuals. We recruited 1200 participants, one woman and one man, each in 600 households in 25 villages in the Nouna HDSS. We stratified our sample by (i) village and (ii) two prevalent roof types in this area of Burkina Faso: mud brick and tin. We randomized the same number of people (12) and homes (6) in each stratum 1:1 to receiving vs. not receiving the cool roof. We are collecting outcome data on one primary endpoint - heart rate, (a measure of heat stress) and 22 secondary outcomes encompassing indoor climate parameters, blood pressure, body temperature, heat-related outcomes, blood glucose, sleep, cognition, mental health, health facility utilization, economic and productivity outcomes, mosquito count, life satisfaction, gender-based violence, and food consumption. We followed all participants for 2 years, conducting monthly home visits to collect objective and subjective outcomes. Approximately 12% of participants (n = 152) used smartwatches to continuously measure endpoints including heart rate, sleep and activity.DiscussionOur study demonstrates the potential of large-scale cRCTs to evaluate novel climate change adaptation interventions and provide evidence supporting investments in heat resilience in sub-Saharan Africa. By conducting this research, we will contribute to better policies and interventions to help climate-vulnerable populations ward off the detrimental effects of extreme indoor heat on health.Trial registrationGerman Clinical Trials Register (DRKS) DRKS00023207. Registered on April 19, 2021.

Predictors of Medical Care Delay or Avoidance Among Chinese Adults During the COVID-19 Pandemic.

Medical care delay or avoidance increases morbidity and mortality risk and is costly for the national healthcare system. The objective of this study was to identify factors associated with medical care delay or avoidance among Chinese adults during the COVID-19 pandemic. A cross-sectional analysis was conducted using data from the 2020 China Family Panel Study (CFPS). The CFPS was conducted from July to December 2020 during the COVID-19 pandemic. The final sample included 4369 adults. A logistic regression model was employed to identify the factors associated with medical care delay or avoidance. The empirical results indicate that regardless of rural-urban residence, older adults and adults with chronic conditions were less likely to delay or avoid medical care during the pandemic. However, individuals who had completed more than three years of college showed a higher likelihood of delaying or avoiding medical care. In urban areas, larger family sizes, greater general trust in physicians, and higher provider structural quality were associated with a decreased probability of delaying or avoiding medical care during the pandemic. In contrast, employed adults were more likely to delay or avoid medical care. In rural areas, current smokers were more likely to delay or avoid medical care during the pandemic. This study has identified several factors affecting medical care delay or avoidance, some of which are amenable to policy changes. Policymakers can help improve the utilization of health facilities and patient health outcomes by implementing a series of reforms.

DETERMINANTS OF SELF-REFERRAL FROM PRIMARY TO SECONDARY LEVEL HEALTH FACILITIES AMONG OUTPATIENTS IN TANZANIA

Introduction 
 In Tanzania, self-referrals have been one of the sources of underutilization of primary-level health facilities resulting in the overutilization and overburdening of secondary-level health facilities. A significant number of patients receiving services at the outpatient departments in the secondary-level health facilities could have been served at the primary health facilities. Understanding of determinants of self-referral is critical to informing important interventions to improve the referral processes and rational utilization of health facilities at the two levels. 
 Methods
 A cross-sectional study was conducted among 230 outpatients at Katavi Regional Referral Hospital in Tanzania. A convenient sampling method was used to enroll study participants. An interviewer-administered questionnaire was used to collect data. STATA version 15 was used to analyze data descriptively while the chi-square test was performed to establish the association between dependent and independent variables at a p-value of less than 0.05.
 Results
 The magnitude of self-referral was 66.5%. The perceived determinants of self-referral were quality of care offered (90.8 %), availability of medicine (89.4%), proximity of health facility (88.8%), and patient-perceived severity of the disease (86.7%). The availability of medicine (p= 0.015), quality of care offered (p=0.00), location of the facility (p=0.044), place of residence (p=0.04), and patient-perceived severity of disease (p=0.017) were statistically significantly associated with the self-referral practices.
 Conclusion
 The magnitude of self-referral practice was high. Availability of essential medicines, quality of care offered by the hospital, hospital proximity, patient-perceived severity of the disease, and availability of barriers to accessing healthcare in lower-level facilities were factors significantly associated with the self-referral practice. It is recommended that continuous investment should be made in lower-level facilities to ensure patients receive the care they need at every point of care.

Factors Associated with Increased Cases of Brucelosis among Patients at Kampala International University Teaching Hospital, Bushenyi District, Uganda

Background: The government has employed numerous strategies ranging from animal vaccination, quarantines, free tests and diagnosis.
 The purpose of this study was to determine factors associated with increased cases of brucellosis at Kampala International University Teaching Hospital.
 Methodology: We conducted a quantitative cross-sectional study which employed simple random sampling to select 36 patients aged 18 years and above attending at Kampala International University Teaching Hospital who consented to take part.
 Results: The majority of the respondents (n=14, 38.9%) belonged to the age group of 26-30years, followed by the respondents belonged to the age group of 31 years and above 12 (n=12, 33.3%) while the interrogated persons belonged to the age group of 18-25 years were weak (n= 10; 27.8%). Majority of the respondents (n= 15; 41.7%) revealed that they were Christian-catholic. Moreover, most of these respondents (n= 19; 52.8%) revealed that they studied only secondary education meanwhile only (n=10, 27.8%) were primary leavers. These respondents belonged in the majority to Banyankole/Bakiga tribe (n= 19; 52.8%) and were married (n= 28; 77.8%). The results of this study showed that 36.1% (n= 13) of respondents lived with the incomes included between 100,000 and 150,000 Uganda shillings. They were in majority 14 (n= 14; 38.9%) at 1 – 2 kilometers to the nearest health facility meanwhile 27.8% (n= 10) of respondents were at 5 and above kilometers. Approximately 58.4% (n= 21) of respondents were agreed that there is presence of diagnostic facilities of brucellosis and 63.9 % (n= 23) of these respondents adhered to treatment of brucellosis.
 Conclusion: This study showed that age, level of education, tribe, household income, property ownership, cost of treatment, distance from the health facility and poor service utilization influence increase in brucellosis cases among patients at Kampala International University Teaching Hospital. Brucellosis places significant burdens on human healthcare systems and limits the economic potential of individuals, communities, and nations where such development is especially important to diminish the prevalence of poverty.

Barriers to access health facilities: a self-reported cross-sectional study of women in India

Background: Accessing healthcare facilities by the women is one of the biggest challenges in the low- and middle-income countries. The present study aimed to understand the barriers to access health facilities for women in India and examine the various determinants that interplay healthcare accessing behaviour among women in India. Methods: The study utilised the Indian National Family Health Survey 4 data from all the 29 member states and seven union territories and performed cross-tabulations with chi-square tests and multivariate logistic regression. Results: The disparity in access to health facilities for Indian women still exists for minorities and lower-income groups. Women aged 40+, living in urban areas, belonging to rich families, and women who hold bank accounts have shown better access to healthcare facilities. Women’s education was an important factor for accessing healthcare facilities. Conclusions: This significant difference in the rate of healthcare utilization among women suggests that it may contribute to more prevalent and severe health decrements among the disadvantaged group. It is also worth mentioning that the cultural and educational differences in health measures may further explain women's low utilization of healthcare facilities. Women's experiences regarding access to healthcare facilities raise essential questions about policymakers’ priorities that increasingly allow women and their families to bear the brunt of poverty and poor health.

Holistic health care and maternal death in a hospital in south Nigeria: A case report

Ac­cording to the World Health Organization (WHO), the maternal mortality ratio (MMR) of Nigeria is 814 (per 100,000 live births. The Sustainable Development Goal aims to achieve a maternal mortality ratio of less than 70 maternal deaths per 100,000 live births by 2030. This may be feasible only if the perception, values, religious beliefs and practices of the pregnant women observed as factors implicated in the poor utilization of health facilities in Nigeria as in other developing countries are properly addressed. While effort is being made to provide standard well-equipped Health facilities, integration of holistic care into reproductive health programs by taking a detailed spirituality history of the pregnant women early enough in the antenatal clinic to elicit and effectively address these monsters, need also be explored. We present a 27yrs old primigravida who duly attended antenatal care in the zonal hospital Bori, was booked for an elective caesarian section at 38 weeks of gestation for cephalo-pelvic disproportion (CPD),but she went to a church where during prayers and deliverance it was prophesied that she would deliver like the ‘Hebrew women’. She remained in labor at a mission home for 3 days. She had an intrauterine fetal death and subsequently died on arrival at the hospital.

Prevalence and factors associated with utilization of emergency obstetric newborn care services among women of reproductive age in Nakuru county Kenya

Background: Emergency obstetric and newborn care (EmONC) mediates maternal survival. To prevent deaths, mothers require access to quality care and utilization of health facilities where professionals can promptly diagnose and manage emergencies related to pregnancy and childbirth. The study focused on socio-demographic, social cultural and social economic factors. Methods: The study was a randomized control trial and utilized a mixed method. Pregnant mother 26 to 32 weeks gestation and aged 15-49 years totaling to 382 respondents were enrolled in the study. Allocation to each study group was done on a 1:1 ratio; hence each group had 191 participants. The study was conducted from January to July 2020. Results: The intervention group had 95.93% (n=165) utilization of EmONC services in comparison to the control arm 75.29% (n=128). There was no discrepancy in both groups from base line to final survey OR=1.209, CI=0.742 to 1.969 and p=0.446. The level of education significantly influenced utilization at χ2=40.402 and a p<0.001. Secondary education influences utilization of EmONC services at AOR=8.791, 95% CI=3.631 to 21.285 and p<0.001. Respondents with tertiary education were 2.5 times likely to utilize EmONC services. Parity was significant at χ2=43.724, p<0.001. There was no significant difference between socioeconomic factors, sociocultural factors and utilization of EmONC services at baseline level. Conclusions: There was an increase in utilization of EmONC services. The education level and parity of the woman determined the utilization of EmONC services.