Background: Armed conflict, food insecurity, epidemic cholera, economic decline and deterioration of essential public services present overwhelming challenges to population health and well-being in Yemen. Although the majority of the population is in need of humanitarian assistance and civil servants in many areas have not received salaries since 2016, many healthcare providers continue to work, and families continue to need and seek care.Methods: This case study examines how reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH+N) services have been delivered since 2015, and identifies factors influencing implementation of these services in three governorates of Yemen. Content analysis methods were used to analyze publicly available documents and datasets published since 2000 as well as 94 semi-structured individual and group interviews conducted with government officials, humanitarian agency staff and facility-based healthcare providers and six focus group discussions conducted with community health midwives and volunteers in September-October 2018.Results: Humanitarian response efforts focus on maintaining basic services at functioning facilities, and deploying mobile clinics, outreach teams and community health volunteer networks to address urgent needs where access is possible. Attention to specific aspects of RMNCAH+N varies slightly by location, with differences driven by priorities of government authorities, levels of violence, humanitarian access and availability of qualified human resources. Health services for women and children are generally considered to be a priority; however, cholera control and treatment of acute malnutrition are given precedence over other services along the continuum of care. Although health workers display notable resilience working in difficult conditions, challenges resulting from insecurity, limited functionality of health facilities, and challenges in importation and distribution of supplies limit the availability and quality of services.
The war in Yemen, described as the world's ‘worst humanitarian crisis,’ has seen numerous attacks against health care. While global attention to attacks on health workers has increased significantly over the past decade, gaps in research on the lived experiences of frontline staff persist. This study draws on perspectives of frontline health workers in Yemen to understand the impact of the ongoing conflict on their personal and professional lives. Forty-three facility-based health worker interviews, and 6 focus group discussions with community-based health workers and midwives were conducted in Sana'a, Aden and Taiz governorates at the peak of the Yemen conflict. Data were analysed using content analysis methods. Findings highlight the extent and range of violence confronting health workers in Yemen as well as the coping strategies they use to attenuate the impact of acute and chronic stressors resulting from conflict. We find that the complex security situation – characterized by multiple parties to the conflict, politicization of humanitarian aid and constraints in humanitarian access – was coupled with everyday stressors that prevented health workers from carrying out their work. Participants reported sporadic attacks by armed civilians, tensions with patients, and harassment at checkpoints. Working conditions were dire, and participants reported chronic suspension of salaries as well as serious shortages of essential supplies and medicines. Themes specific to coping centered around fatalism and religious motivation, resourcefulness and innovation, and sense of duty and patriotism. Our findings demonstrate that health workers experience substantial stress and face various pressures while delivering lifesaving services in Yemen. While they exhibit considerable resilience and coping, they have needs that remain largely unaddressed. Accordingly, the humanitarian community should direct more attention to responding to the mental health and psychosocial needs of health workers, while actively working to ameliorate the conditions in which they work.
ObjectiveTo explore the behavioural drivers of fear of litigation among healthcare providers influencing caesarean section (CS) rates.DesignScoping review.Data sourcesWe searched MEDLINE, Scopus and WHO Global Index (1 January 2001 to 9 March 2022).Data extraction and synthesisData were extracted using a form specifically designed for this review and we conducted content analysis using textual coding for relevant themes. We used the WHO principles for the adoption of a behavioural science perspective in public health developed by the WHO Technical Advisory Group for Behavioural Sciences and Insights to organise and analyse the findings. We used a narrative approach to summarise the findings.ResultsWe screened 2968 citations and 56 were included. Reviewed articles did not use a standard measure of influence of fear of litigation on provider’s behaviour. None of the studies used a clear theoretical framework to discuss the behavioural drivers of fear of litigation. We identified 12 drivers under the three domains of the WHO principles: (1) cognitive drivers: availability bias, ambiguity aversion, relative risk bias, commission bias and loss aversion bias; (2) social and cultural drivers: patient pressure, social norms and blame culture and (3) environmental drivers: legal, insurance, medical and professional, and media. Cognitive biases were the most discussed drivers of fear of litigation, followed by legal environment and patient pressure.ConclusionsDespite the lack of consensus on a definition or measurement, we found that fear of litigation as a driver for rising CS rates results from a complex interaction between cognitive, social and environmental drivers. Many of our findings were transferable across geographical and practice settings. Behavioural interventions that consider these drivers are crucial to address the fear of litigation as part of strategies to reduce CS.
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