Thesis (M.S.)--Boston University

Thesis (M.S.)--Boston University

Magister Public Health - MPH / Ensuring a good performance of health workers is one of the key components for provision of quality health care services in order to progress toward one of the priorities of MDGs namely improving maternal health care. In 2005, Rwanda adopted the “Performance Based Financing (PBF)” program to remunerate and motivate health professional based on their job performance. This lead to increase in the number of health workers by 62% between 2005 and 2008 and public subsidies for health worker remuneration tripled. Despite promotion of this motivation mechanism to enhance job performance in maternal health care, recent data in Rwanda show that MMR is still high with 383 per 100,000 live births and high rates of postpartum complications. All these problems have been attributed to poor performance of staff. To date, little research has been conducted on the factors that affect job performance among health care providers in low income countries and particularly in Rwanda. The present study assesses factors that influence job performance of health care providers working in postpartum care in two public hospitals of Rwanda. Ninety six nurses and midwives were observed providing early and late postpartum care and interviewed about the presence or absence of the performance factors within their work environment. Data were analyzed to determine if there is an association between observed providers performance and variables of interest. Observation revealed that staff performed poorly in the use of guidelines for the management in the postpartum care. The bivariate analysis showed that (a) receiving feedback about job performance (b) receiving training in postpartum care management, (c) training in the use of the tools for the daily work, (d) being satisfied with the way the work is organized, and (e) finding the organization interested in the staff creativity in general, are factors associated with good performance. In conclusion, the study identified important factors that need to be taken into consideration when planning strategies to improve the quality of care and reducing morbidity and mortality in the postpartum wards of the two hospitals.

Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01

Women with gestational diabetes (GD) are at higher risk of developing type 2 diabetes (DM) after delivery compared to those without GD. Numerous studies in the general population have identified that adoption of healthy lifestyles can prevent DM; however limited research has focused on women with GD. The purpose of this randomized pilot study was to determine the effectiveness of an educational intervention of SUGAR (Start Understanding Gestational Diabetes and Risk of Type 2 Diabetes), on women’s perceived risk of developing DM, knowledge of DM, self-efficacy to adopt healthy lifestyle behaviors and adoption of healthy lifestyle behaviors after childbirth among women with GD. A total of 23 women (mean age of 29.7, SD=3.9), 18 in SUGAR group and 5 in control group (CG) completed self-reported standardized questionnaires (Risk Perception Survey for Developing Diabetes adapted for women with GD; Self-Rated Abilities for Health Practices; Health Promotion Lifestyle Profile II; General Sleep Disturbance Scale; and Demographic Questionnaire) at baseline (third trimester) and post-test (postpartum 6-8 weeks). Intervention was given post the baseline data collection with a booster session at 2-4 weeks postpartum. The women in CG received attention control treatment. Study participants were obese (BMI M=33.1, SD=7.7) and a majority had a family history of DM. Findings showed that self-efficacy was the single significant predictor and accounted for 22% of the variance of healthy lifestyle behaviors. Participants had a clinical significant sleep disturbance during both pregnancy and postpartum. At baseline, poor sleepers reported a lower self-efficacy. The intervention significantly increased DM knowledge for women in the SUGAR group; however, not for perceived risk, self-efficacy nor healthy lifestyle behaviors. There was no difference between groups for postpartum glucose screening rates with only 39% receiving recommended testing. Future research needs to focus on prevention programs and center on self-efficacy, postpartum glucose screening, improve sleep, and adoption of healthy lifestyle behaviors. To ensure a better preventive care for GD women, education provided for both patients and health care provider is needed.

Syfte: Att undersöka mammors behov av kunskapsmässigt, emotionellt och socialt stöd under barnets första år samt identifiera vilka stödgivande aktörer kvinnorna upplever är viktigast. Metod: Deskriptiv tvärsnittstudie. Sjuttio mammor som besökte någon av sex kommunala öppna förskolor i Uppsala läns landsting svarade på en enkät om deras behov av stöd. Resultat: Hälso- och sjukvården var den viktigaste aktören för många av mammorna som sökte informationsstöd. Studien visade att alla mammorna inte fått det kunskapsstöd de önskade. Socialt stöd och emotionellt stöd var viktigt för nästan alla mammor och många efterfrågade emotionellt stöd från hälso- och sjukvården. Mammornas behov var relaterat till deras ålder, och även i viss utsträckning utbildning och sysselsättning. Slutsats: Om BVC-sjuksköterskor och annan vårdpersonal som möter mammor med barn under ett år, ser till helheten i deras situation genom att erbjuda såväl kunskapsstöd som emotionellt stöd kan de bidra till att skapa långsiktigt nöjda och trygga mödrar. / Aim: To explore mother's needs in terms of knowledge, emotional and social support during the baby’s first year and to identify what support giving conductors the women feel important. Method: Descriptive cross-sectional study. Seventy mothers who visited one of six municipal open pre-schools in Uppsala County Council responded to a questionnaire about their support needs. Results: Health care was the main conductor for many of the mothers who sought information support. The study showed that not all mothers have got the knowledge support they wished. Social support and emotional support was important most mothers, and many sought emotional support from health care. Mothers' needs were related to their age, and also to some extent, education and employment. Conclusion: If child health nurses and other health care professionals, who encounter mothers with children under the age of one year, see the whole picture of their situation by offering both knowledge and emotional support, they can help create satisfied and secure mothers in the long term.

Prenatal and postpartum care are important for reducing maternal and infant morbidity. Racial and ethnic disparities are prevalent in maternal peripartum health and infant birth outcomes as well as peripartum care access and utilization. They highlight the need to identify and better understand correlates of poor prenatal and postpartum care compliance. While risk factors for low adherence to peripartum care have been identified, no studies have looked specifically at predictors of prenatal and postpartum care attendance in an at-risk sample of African American pregnant women. Using existing data from an RCT targeting maternal and infant health disparities and comparing a patient navigation/behavioral incentive intervention to treatment as usual, the present study sought to identify predictors of prenatal and postpartum care attendance. Participants were African American women at risk for poor prenatal care compliance, who participated in the RCT and had a documented live birth (n=123). Using hierarchical linear and logistic regression, the study identified predictors of prenatal and postpartum care attendance, respectively. The study found high-risk pregnancy (p < .001) and fewer barriers to care (p = .013) significantly predicted better prenatal care attendance. Less than adequate prenatal care attendance significantly predicted postpartum visit nonattendance (p < .001). In addition, given that study participants were limited to women who provided informed consent to RCT participation, the present study also examined representativeness of the clinical trial sample. Specifically, women who consented to the RCT (consenters; n=149) were compared to those who did not (non-consenters; n=122) on a variety of demographic and psychosocial variables using chi-square for categorical variables and t-tests for continuous variables. Consenters and non-consenters differed only on education level, with consenters more likely to have at least a high school education than non-consenters. The present study provides benchmark data on sample representativeness and predictors of peripartum care in a clinical trial of strategies to improve prenatal care compliance. These findings could have important implications for healthcare system changes and treatment interventions among this population.

Hintergrund: Die Bedeutung der intra- und postpartalen Betreuungserfahrung für die psychische und physische Gesundheit von Mutter und Kind ist weitgehend anerkannt. Aktuelle Daten aus größeren Untersuchungen im deutschen klinischen Kontext liegen nicht vor. Die Evidenzen zur Betreuungszufriedenheit in Abhängigkeit vom Geburtsmodus sind uneinheitlich, der Einfluss einzelner Betreuungsdimensionen auf die Gesamtzufriedenheit ist speziell im Bereich der postpartalen Versorgung wenig untersucht. Ziel: Ermittlung der Dimensionen der intra- und postpartalen Betreuungserfahrungen in deutschen Kliniken, Analyse des Einflusses des Geburtsmodus auf diese Dimensionen sowie Prüfung des Einflusses der Dimensionen auf die Betreuungszufriedenheit insgesamt. Methode: Analyse der Daten aus 235 postalischen Befragungen in 129 geburtshilflichen Abteilungen, durchgeführt vom Picker Institut Deutschland gGmbH zwischen 2002 und 2009. Teilnehmerinnen: 16.315 Wöchnerinnen, die ihr Kind nach der vollendeten 37. Schwangerschaftswoche in einem deutschen Krankenhaus zur Welt gebracht haben. Ergebnisse: Ermittelt wurden 9 Dimensionen, die die intra- und postpartale Betreuung, die postpartale Schmerzlinderung sowie Hotelaspekte der Versorgung im Krankenhaus abbilden. Generell zeigte sich eine hohe Zufriedenheit, jedoch wird die postpartale Betreuung kritischer beurteilt als die intrapartale Betreuung. Es zeigte sich eine unterschiedliche Betreuungszufriedenheit bei Frauen mit geplanter und ungeplanter Sectio, mit einer Tendenz zu höherer Unzufriedenheit bei letzteren. Im Vergleich zu Frauen mit vaginaler Geburt sind Frauen mit geplantem Kaiserschnitt mit der ärztlichen Betreuung zufriedener (OR 0,7, 99% KI 0,6 - 0,9), Frauen mit ungeplantem Kaiserschnitt mit der Hebammenbetreuung unzufriedener (OR 1,5, 99% KI 1,3 - 1,9) und Frauen sowohl mit geplanter als auch ungeplanter Sectio mit der postpartalen Schmerzlinderung unzufriedener (OR 1,8, 99% KI 1,5 - 2,1 bzw. OR 1,8, 99% KI 1,6 - 2,0). Die Dimension Betreuung auf der Wochenbettstation weist den mit Abstand stärksten Einfluss auf die Zufriedenheit mit der klinischen Betreuung insgesamt auf. Darüber hinaus sind es vor allem die Dimensionen mit Fokus auf der Interaktion mit den betreuenden Fachkräften, die maßgeblich die Gesamtzufriedenheit beeinflussen. Der subjektive Gesundheitszustand, die Zuversicht, mit dem Kind zuhause zurecht zu kommen, und die Verweildauer erwiesen sich als weitere wichtige Prädiktoren der Zufriedenheit mit den Betreuungsdimensionen und der Gesamtzufriedenheit. Schlussfolgerung: Die maßgebliche Bedeutung der interpersonellen Betreuungsaspekte sowie die kritischere Beurteilung der postpartalen Betreuung im Vergleich zur intrapartalen bestätigen sich auch für den deutschen klinischen Kontext. Der Geburtsmodus scheint insbesondere für die Zufriedenheit mit der intrapartalen Betreuung sowie der postpartalen Schmerzlinderung eine Rolle zu spielen. Die größere Unzufriedenheit mit der postpartalen Schmerzlinderung bei Kaiserschnittgeburt deutet auf die Notwendigkeit eines effektiveren Schmerzmanagements hin. Vor dem Hintergrund der negativen Auswirkungen starker Schmerzen auf den Aufbau der Mutter-Kind-Beziehung sollte die Entscheidung zum geplanten Kaiserschnitt ebenso wie der Einsatz von Interventionen, die einen ungeplanten Kaiserschnitt begünstigen, sehr sorgfältig abgewogen werden. Den konstituierenden Dimensionen und Einflussfaktoren der postpartalen Betreuungszufriedenheit sollte mehr Aufmerksamkeit gewidmet werden, insbesondere mit Blick auf effektive Betreuungskonzepte und eine systematische Verzahnung mit der ambulanten Betreuung.

Despite PPD’s global extent, scarce research that addresses culturally competent alternative interventions exists. The purposes of this thesis were to 1) analyze the existing literature on non-pharmacological treatment of PPD in the US and across selected cultures; 2) determine the effectiveness of cross-cultural non-pharmaceutical therapy; and 3) examine and suggest ways health care providers can integrate non-pharmacologic interventions into PPD treatment in the US. The systematic electronic search comprised the databases Cumulative Index to Nursing and Allied Health Literature, Medline, PsycINFO and SAGE Research Methods. Searches were limited to English language, peer reviewed, and research articles between 2007 and 2017. A second search was performed through global Healthcare Organizations websites. The World Bank’s country classifications by income level were adopted to present the findings. This review found that passing el calor to the newborn, yoga; and cognitive-behavioral, interpersonal, family, and bright light therapies are successful interventions. Further, seclusion periods were identified as adequate interventions only when women voluntarily adopt the practice and have family support, with less social restrictions. While other non-pharmacological treatments’ effectiveness was not ascertained, this thesis encourages healthcare professionals to integrate cultural traditions congruent with clients’ preferences. Recommended nursing interventions and suggestions for improvement of current practice are also discussed.

Background: Adolescents are more likely to be dissatisfied with perinatal care than adults. Adolescents’ perspectives of their perinatal care experiences have been explored; however, there are few studies exploring adolescent-friendly inpatient care from nurses’ perspectives. Purpose: To explore adolescent-friendly care from the perspective of hospital-based adolescent-friendly perinatal nurses. Research Questions: (1) How and why do perinatal nurses in inpatient settings adapt their practice when caring for adolescents? (2) What are the individual nursing behaviours and organizational characteristics of adolescent-friendly care in inpatient perinatal settings, from the perspective of perinatal nurses? Methods: I report the qualitative component of a mixed methods study. Open-ended interviews were conducted with twenty-seven purposively-sampled expert nurses. Data were analyzed using Interpretive Description. Findings: Nurses described being mother-friendly to adolescents by being nonjudgmental, forming connections, individualizing care, and employing behavioural strategies that facilitate relationship-building. Implications: These findings will inform the development of interventions to facilitate connections between nurses and adolescent mothers.