Generating demand and community support for sexual and reproductive health services for young people: A review of the Literature and Programs.

BACKGROUND: This review investigates the effectiveness of interventions aimed at generating demand for and use of sexual and reproductive health (SRH) services by young people; and interventions aimed at generating wider community support for their use. METHODS: Reports and publications were found in the peer-reviewed and grey literature through academic search engines; web searches; the bibliographies of known conference proceedings and papers; and consultation with experts. The studies were reviewed against a set of inclusion criteria and those that met these were explored in more depth. RESULTS: The evidence-base for interventions aimed at both generating demand and community support for SRH services for young people was found under-developed and many available studies do not provide strong evidence. However, the potential of several methods to increase youth uptake has been demonstrated, this includes the linking of school education programs with youth friendly services, life skills approaches and social marketing and franchising. There is also evidence that the involvement of key community gatekeepers such as parents and religious leaders is vital to generating wider community support. In general a combined multi-component approach seems most promising with several success stories to build on. CONCLUSIONS: Many areas for further research have been highlighted and there is a great need for more rigorous evaluation of programmes in this area. In particular, further evaluation of individual components within a multi-component approach is needed to elucidate the most effective interventions.

Institutional delivery in rural India: the relative importance of accessibility and economic status.

BACKGROUND: Skilled attendance at delivery is an important indicator in monitoring progress towards Millennium Development Goal 5 to reduce the maternal mortality ratio by three quarters between 1990 and 2015. In addition to professional attention, it is important that mothers deliver their babies in an appropriate setting, where life saving equipment and hygienic conditions can also help reduce the risk of complications that may cause death or illness to mother and child. Over the past decade interest has grown in examining influences on care-seeking behavior and this study investigates the determinants of place of delivery in rural India, with a particular focus on assessing the relative importance of community access and economic status. METHODS: A descriptive analysis of trends in place of delivery using data from two national representative sample surveys in 1992 and 1998 is followed by a two-level (child/mother and community) random-effects logistical regression model using the second survey to investigate the determinants. RESULTS: In this investigation of institutional care seeking for child birth in rural India, economic status emerges as a more crucial determinant than access. Economic status is also the strongest influence on the choice between a private-for-profit or public facility amongst institutional births. CONCLUSION: Greater availability of obstetric services will not alone solve the problem of low institutional delivery rates. This is particularly true for the use of private-for-profit institutions, in which the distance to services does not have a significant adjusted effect. In the light of these findings a focus on increasing demand for existing services seems the most rational action. In particular, financial constraints need to be addressed, and results support current trials of demand side financing in India.

Neonatal care in rural Karnataka: healthy and harmful practices, the potential for change.

BACKGROUND: Every year four million babies die in the first month of life and a quarter of these take place in India. A package of essential newborn care practices exists, which has a proven impact on reducing mortality, and can be implemented in low resource settings. However, childbirth and the neonatal period are culturally important times, during which there is strong adherence to traditional practices. Successful implementation of the package therefore requires in-depth knowledge of the local context and tailored behaviour change communication. METHODS: This study was carried out in rural Karnataka, India. It uses quantitative data from a prospective survey following mothers through their experience of pregnancy and the postnatal period; and qualitative data from in depth interviews and focus group discussions conducted with mothers, grandmothers and birth attendants. It explores local newborn care practices and beliefs, analyses their harmful or beneficial characteristics and elucidates areas of potential resistance to behaviour change and implementation of the essential newborn care package. RESULTS: Findings show that many potentially harmful newborn care practices are being carried out in the study area, such as unhygienic cord cutting, delayed breastfeeding and early bathing. Some are more amenable to change than others, depending on the strength of the underlying beliefs, and acceptability of alternative care. However, movement away from traditional practices is already taking place, particularly amongst the more educated and better off, and there is a clear opportunity to broaden, direct and accelerate this process. CONCLUSION: Community education should be a focus of the National Rural Health Mission (NRHM) and Integrated Management of Neonatal and Childhood Illness (IMNCI) program being implemented in Karnataka. The added capacity of the new Accredited Social Health Activists (ASHAs) could enable more women to be reached. With careful tailoring of behaviour change messages to the local context, government outreach workers can become effective brokers of positive change and significant improvements in home newborn care and neonatal mortality are possible.