This study, conducted in five rural districts in Afghanistan, used qualitative methods to explore traditional practices of women, families and communities related to maternal and newborn care, and sociocultural and health system issues that create access barriers. The traditional practices discussed include delayed bathing of mothers and delayed breastfeeding of infants, seclusion of women after childbirth, restricted maternal diet, and use of traditional home remedies and self-medication instead of care in health facilities to treat maternal and newborn conditions. This study also looked at community support structures, transportation and care-seeking behaviour for maternal and newborn problems which create access barriers. Sociocultural barriers to better maternal-newborn health include shame about utilisation of maternal and neonatal services, women's inability to seek care without being accompanied by a male relative, and care-seeking from mullahs for serious health concerns. This study also found a high level of post-partum depression. Targeted and more effective behaviour-change communication programmes are needed. This study presents a set of behaviour-change messages to reduce maternal and newborn mortality associated with births occurring at home in rural communities. This study recommends using religious leaders, trained health workers, family health action groups and radio to disseminate these messages.
BackgroundThrough the Balanced Scorecard program there have been independent, annual and nationwide assessments of the Afghan health system from 2004 to 2013. During this period, Afghanistan remained in a dynamic state of conflict, requiring innovative approaches to health service evaluation in insecure areas. The primary objective of this pilot study was to evaluate the reliability of health facility assessments conducted by a novel, locally-based data collection method compared to a standard survey team.MethodsIn this cross-sectional study, one standard survey team of clinicians and multiple rapidly trained locally-based survey teams of teachers conducted health facility assessments in Badghis province, Afghanistan from March – August, 2010. Outpatient facilities covered under the country’s Basic Package of Health Services were eligible for inclusion. Both approaches attempted to survey as many health facilities as safely possible, up to 25 total facilities per method. Each facility assessed was scored on 23 health services indicators used to evaluate performance in the annual Balanced Scorecard national assessment. For facilities assessed by both survey methods, the indicator scores produced by each method were compared using Spearman’s correlation coefficients and linear regression analysis with generalized estimating equations.ResultsThe standard survey team was able to assess 11 facilities; the locally-based approach was able to assess these 11 facilities, as well as 13 additional facilities in areas of greater insecurity. Among the 11 facilities assessed by both approaches, 19 of 23 indicators were statistically similar by survey method (p < .05). Spearman’s coefficients varied widely from (−0.39) to (0.71). The differences were greatest for items requiring specialized data collector knowledge on reviewing patient records, patient examination and counseling, and health worker reported satisfaction.ConclusionsThis pilot study of a novel method of data collection in health facility assessments showed that an approach using locally-based survey teams provided markedly increased access to areas of insecurity. Though analysis was limited by small sample size, indicator scores used for facility evaluation were relatively comparable overall, but less reliable for items requiring clinical knowledge or when asking health worker opinions, suggesting that alternative approaches may be needed to assess these parameters in insecure environments.
Background: Training courses in integrated management of childhood illness (IMCI) have been conducted for health workers for nearly one and half decades in Afghanistan. The objective of the training courses is to improve quality of care in terms of health workers communication skills and clinical performance when they provide health services for under-5 children in public healthcare facilities. This paper presents our findings on the effects of IMCI training courses on quality of care in public primary healthcare facilities in Afghanistan. Methods: We used a cross-sectional post-intervention design with regression-adjusted difference-in-differences (DiD) analysis, and included 2 groups of health workers (treatment and control). The treatment group were those who have received training in IMCI recently (in the last 12 months), and the control group were those who have never received training in IMCI. The assessment method was direct observation of health workers during patient-provider interaction. We used data, collected over a period of 3 years (2015–2017) from primary healthcare facilities, and investigated training effects on quality of care. The outcome variables were 4 indices of quality care related to history taking, information sharing, counseling/medical advice, and physical examination. Each index was formed as a composite score, composed of several inter-related tasks of quality of care carried out by health workers during patient-provider interaction for under-5 children. Results: Data were collected from 733 primary healthcare facilities with 5818 patients. Quality of care was assessed at the level of patient-provider interaction. Findings from the regression-adjusted DiD multivariate analysis showed significant effects of IMCI training on 2 indices of quality care in 2016, and on 4 indices of quality care in 2017. In 2016 two indices of quality care showed improvement. There was an increase of 8.1% in counseling/medical advice index, and 8.7% in physical examination index. In 2017, there was an increase of 5.7% in history taking index, 8.0% in information sharing index, 10.9% in counseling/medical advice index, and 17.2% in physical examination index. Conclusion: Conducting regular IMCI training courses for health workers can improve quality of care for under-5 children in primary healthcare facilities in Afghanistan. Findings from our study have the potential to influence policy and strategic decisions on IMCI programs in developing countries.
Objectives. To understand Afghan adolescents’ and parents’ attitudes toward interpersonal violence. Methods. We used a 2-stage sampling method in 6 provinces during 2016; we included 916 adolescents aged 12 to 15 years and 454 parents. Results. In the abstract, a minority of adolescents or parents endorsed violence; however, specific situations justified most violence (e.g., husbands beating wives, parents hitting children). Both adolescents (48.0%) and parents (39.0%) thought a wife hitting her husband was least justifiable. Endorsement of violence justification did not appear to vary significantly on the basis of parental education or wealth. More fathers rejected all violence rationale than did mothers, and women were more likely to justify wife beating (75.0% vs 58.6%; P < .01), beating of daughters (78.5% vs 60.6%; P < .01), and teachers hitting students (62.9% vs 51.5%; P < .01). Of all respondents, 25% approved of threatening a child if he or she speaks out against harmful traditional practices. Conclusions. Although it may be socially unacceptable to advocate physical aggression, most Afghans still find numerous conditions that justify it. Without deliberate violence reduction strategies, education alone is unlikely to reduce the high levels of interpersonal violence in Afghanistan.
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