Public Health Commons^™

The Yearly Financing Need Of Providing Paid Maternity Leave In The Informal Sector In Indonesia, Adiatma Y. M. Siregar, Pipit Pitriyan, Donny Hardiawan, Paul Zambrano, Mireya Vilar-Compte, Graciela Ma Teruel Belismelis, Meztli Moncada, David Tamayo, Grace Carroll, Rafael Perez-Escamilla, Roger Mathisen

Department of Public Health Scholarship and Creative Works

Background: The economic cost of not breastfeeding in Indonesia is estimated at US$1.5–9.4 billion annually, the highest in South East Asia. Half of the 33.6 million working women of reproductive age (WRA) in Indonesia (15–49 years) are informal employees, meaning they are working as casual workers or they are self-employed (small scale business) and assisted by unpaid/family worker(s). No specific maternity protection entitlements are currently available for WRA working informally in Indonesia. This study aims to estimate the financing need of providing maternity leave cash transfer (MCT) for WRA working in the informal sector in Indonesia. Method: The costing methodology …

Breastfeeding Media Coverage And Beliefs During The Covid-19 Pandemic In Mexico: Implications For Breastfeeding Equity, Mireya Vilar-Compte, P. Gaitán‐Rossi, E. C. Rhodes, V. Cruz‐Villalba, R. Pérez‐Escamilla

Department of Public Health Scholarship and Creative Works

Background: Because breastfeeding offers short- and long- term health benefits to mothers and children, breastfeeding promotion and support is a public health priority. Evidence shows that SARS-CoV-2 is not likely to be transmitted via breastmilk. Moreover, antibodies against SARS-CoV-2 are thought to be contained in breastmilk of mothers with history of COVID-19 infection or vaccination. WHO recommends direct breastfeeding as the preferred infant feeding option during the COVID-19 pandemic, even among women with COVID-19; but conflicting practices have been adopted, which could widen existing inequities in breastfeeding. This study aims to describe how information about breastfeeding was communicated in Mexican …

Maternal Mortality: A Growing Health Inequity In America, Michala Geraty

Senior Honors Theses

The United States (U.S.) is known for its quest for knowledge, innovation, and advancements in all disciplines. However, it has the highest maternal mortality ratio (MMR) among developed nations. The US MMR increased from 12.7 to 17.4 per 100,000 live births between 2007 and 2018. Over 60% of these deaths are preventable, indicating room for improvement. African American or non-Hispanic Black women are disproportionately affected, at over twice the rate of their non-Hispanic White and Hispanic counterparts. The proximal (e.g., individual level) determinants have not been able to fully explain these inequities. Using the socio-ecological model and the social determinants …

Population-Level Prevalence Of Depression And Summary Statistics Of Women With At Least A Year Post-Final Menstruation With And Without Hysterectomy, Happiness Kingi

Capstone Experience: Master of Public Health

Background: Depression is associated with estrogen hormonal changes. There are few comparisons studies on the population-level prevalence of depression in women at least a year post final menstruation with and without hysterectomy.

Objectives: 1) To determine the population-level prevalence of depression in women with at least a year post final menstruation with and without hysterectomy and 2) to calculate the summary statistics of women with at least a year post final menstruation with and without hysterectomy

Methods: A population-based cross-sectional design was used. Respondents were female participants of the U.S. National Health and Nutrition Examination Survey (NHANES) …

Defining The Epidemiology Of Safety Risks In Neonatal Intensive Care Unit Patients Requiring Surgery, Daniel J France, Jason Slagle, Emma Schremp, Sarah Moroz, L Dupree Hatch, Peter Grubb, Timothy J Vogus, Matthew S Shotwell, Amanda Lorinc, Christoph U Lehmann, Jamie Robinson, Marlee Crankshaw, Maria Sullivan, Timothy A Newman, Tamara Wallace, Matthew B Weinger, Martin L Blakely

Faculty, Staff and Student Publications

OBJECTIVE: The aim of the study was to determine the incidence, type, severity, preventability, and contributing factors of nonroutine events (NREs)-events perceived by care providers or skilled observers as a deviations from optimal care based on the clinical situation-in the perioperative (i.e., preoperative, operative, and postoperative) care of surgical neonates in the neonatal intensive care unit and operating room.

METHODS: A prospective observational study of noncardiac surgical neonates, who received preoperative and postoperative neonatal intensive care unit care, was conducted at an urban academic children's hospital between November 1, 2016, and March 31, 2018. One hundred twenty-nine surgical cases in …

Improving Maternal And Child Health In Pakistan: A Programme Evaluation Using A Difference In Difference Analysis, Muhammad Ashar Malik, Lara Riedige Rohm, Pieter Van Baal, Eddy Van Doorslaer Van Doorslaer

Community Health Sciences

Introduction: Pakistan is a country with high maternal and infant mortality. Several large foreign funded projects were targeted at improving maternal, neonatal and child health. The Norway-Pakistan Partnership Initiative (NPPI) was one of these projects. This study aims to evaluate whether NPPI was successful in improving access and use of skilled maternal healthcare.
Methods: We used data from three rounds (2009-2010, 2011-2012 and 2013-2014) of the Pakistan Social and Living Standards Measurement Survey (PSLM). A difference-in-difference regression framework was used to estimate the effectiveness of NPPI and its different programme components with respect to maternal healthcare seeking behaviour of pregnant …

Categorization And Frequency Of Indications For Packed Cell Transfusion In The Preterm Newborn During The Initial Hospital Stay At A Tertiary Care Hospital: A Cross-Sectional Study, Shirin Surani, Heeramani Lohana, Sheraz Ahmed, Rabia Hassan, Sapna Kewalani, Khalil Ahmed

Department of Paediatrics and Child Health

Introduction: Packed cell transfusion is a lifesaving procedure in premature babies as they have more complications as compared to babies who are born at term. Complications related to prematurity increase as gestational age decreases and anemia is one of the complications of prematurity which needs packed cell transfusions. To date, when to transfuse preterm babies and what would be the threshold for hemoglobin and hematocrit is still a point of argument as well as liberal versus restrictive transfusion protocols have been developed but what should be followed still needs more data. In our study, we have observed frequencies of different …

Full Breastfeeding Protection Against Common Enteric Bacteria And Viruses: Results From The Mal-Ed Cohort Study, Benjamin J J. Mccormick, Stephanie A. Richard, Laura E. Murray-Kolb, Gagandeep Kang, Aldo A M. Lima, Estomih Mduma, Margaret N. Kosek, Elizabeth T Rogawski Mcquade, Eric R. Houpt, Zulfiqar Ahmed Bhutta

Woman and Child Health

Background: Breastfeeding is known to reduce risk of enteropathogen infections, but protection from specific enteropathogens is not well characterized.
Objective: To estimate the association between full breastfeeding (days fed breast milk exclusively or with non-nutritive liquids) and enteropathogen detection.
Design: 2,145 newborns were enrolled in eight sites, of whom 1,712 had breastfeeding and key enteropathogen data through 6 months. We focused on eleven enteropathogens: adenovirus 40/41, norovirus, sapovirus, astrovirus, and rotavirus, enterotoxigenic Escherichia coli (ETEC), Campylobacter spp, and typical enteropathogenic E. coli as well as entero-aggregative E. coli, Shigella and Cryptosporidium. Logistic regression was used to estimate the risk of …

Micronutrient Supplements Can Promote Disruptive Protozoan And Fungal Communities In The Developing Infant Gut, Ana Popovic, Celine Bourdon, Pauline W. Wang, David S. Guttman, Sajid Bashir Soofi, Zulfiqar Ahmed Bhutta, Robert H J. Bandsma, John Parkinson, Lisa G. Pell

Centre of Excellence in Women and Child Health

Supplementation with micronutrients, including vitamins, iron and zinc, is a key strategy to alleviate child malnutrition. However, association of gastrointestinal disorders with iron has led to ongoing debate over their administration. To better understand their impact on gut microbiota, we analyse the bacterial, protozoal, fungal and helminth communities of stool samples collected from a subset of 80 children at 12 and 24 months of age, previously enrolled into a large cluster randomized controlled trial of micronutrient supplementation in Pakistan (ClinicalTrials.gov identifier NCT00705445). We show that while bacterial diversity is reduced in supplemented children, vitamins and iron (as well as …

The Contribution Of Racism-Related Stress And Adversity To Disparities In Birth Outcomes: Evidence And Research Recommendations, Sabrina R. Liu, Laura M. Glynn

Psychology Faculty Articles and Research

Currently, racial and ethnic differences in adverse birth outcomes and infant mortality are some of the largest and most persistent health disparities in the United States. This narrative review article synthesizes existing literature to present a conceptual model of how racism-related stress and adversity are critical determinants of such disparities. We describe how historical and ongoing racism has created conditions wherein women of color are disproportionately exposed to chronic, multilayered stress and adversity and how the biological consequences of exposure to these stressors confers risk for adverse birth outcomes. Next, we identify important priorities and considerations for future research, including …

The Efficacy Of A Personalized Mhealth Coaching Program During Pregnancy On Maternal Diet, Supplement Use, And Physical Activity: Protocol For A Parallel-Group Randomized Controlled Trial, Rozina Nuruddin, Khadija Vadsaria, Nuruddin Badruddin Mohammed, Saleem Sayani

Community Health Sciences

Background: Adequate intake of macro- and micronutrients and adoption of an active lifestyle during pregnancy are essential for optimum maternal and fetal health and offspring development. Dietary counseling and advice regarding adequate physical activity are integral components of antenatal care. Personalized coaching through the use of mobile health (mHealth) that supports behavior modification is an innovative approach that needs exploration.
Objective: Our primary aim is to assess the efficacy of an mHealth program in improving diet, supplement use, and physical activity during pregnancy. Secondary objectives include evaluation of the program's effect on maternal and offspring health outcomes and assessment of …

Machine Learning-Based Risk Factor Analysis And Prevalence Prediction Of Intestinal Parasitic Infections, Ahmet Ay

Annual Symposium on Biomathematics and Ecology Education and Research

No abstract provided.

Distance From Healthcare Facilities Is Associated With Increased Morbidity Of Acute Infection In Pediatric Patients In Matiari, Pakistan, Elise Corden, Saman Hasan Siddiqui, Yash Sharma, Sheraz Ahmed, Fayyaz Umrani, Najeeb Rahman, Rafey Ali, Najeeha Talat Iqbal, Syed Asad Ali, Sana Syed

Department of Paediatrics and Child Health

The relationship between environmental factors and child health is not well understood in rural Pakistan. This study characterized the environmental factors related to the morbidity of acute respiratory infections (ARIs), diarrhea, and growth using geographical information systems (GIS) technology. Anthropometric, address and disease prevalence data were collected through the SEEM (Study of Environmental Enteropathy and Malnutrition) study in Matiari, Pakistan. Publicly available map data were used to compile coordinates of healthcare facilities. A Pearson correlation coefficient (r) was used to calculate the correlation between distance from healthcare facilities and participant growth and morbidity. Other continuous variables influencing these …

A Comparison Of Methods Of Discontinuing Nasal Cpap In Premature Infants <30 Weeks Gestation: A Feasibility Study, Brittany Duyka, Claire Beaullieu, Amir M Khan

Faculty, Staff and Student Publications

OBJECTIVE: The objective of this study was to determine whether abrupt discontinuation vs gradual wean of nasal CPAP (NCPAP) in infantstherapy.

STUDY DESIGN: We performed a single-center, randomized control trial of premature infants born(n = 66), comparing discontinuation of NCPAP from 6 cmH

RESULTS: Duration of NCPAP or mechanical ventilation was longer in the slow wean arm compared to the fast wean arm (17 vs 12 days, p = 0.03). There were no differences observed in secondary outcomes.

CONCLUSION: In weaning NCPAP, abrupt discontinuation may be associated with a shorter duration of positive pressure respiratory support compared to a gradual …

Desire To Limiting Child Birth And The Associated Determinants Among Married Females: Sukh Survey-Karachi, Pakistan, Shama Razzaq, Saleem Jessani, Sumera Aziz Ali, Zahid Abbasi, Sarah Saleem

Community Health Sciences

Objective: High rates of population growth negatively influence the social and economic development of a country. This study aimed to determine the women's desire to limiting child birth in future (fertility intention) and its determinants among Pakistani women of reproductive age resident of Karachi.
Methods: A community-based, multistage cross-sectional study was carried out among residents of the squatter settlements in Karachi. The were 4,485 married residents, and currently non-pregnant females of 18 to 49 years old. Framework adapted has been based on "Pullum 1980" to operationalize the outcome of determining the desire to limiting childbearing and the factors related with …

Unintended Pregnancy And The Associated Factors Among Pregnant Females: Sukh Survey-Karachi, Pakistan, Shama Razzaq, Saleem Jessani, Narjis Rizvi, Sarah Saleem

Community Health Sciences

Objective: Unintended pregnancy has become a substantially growing reproductive health concern in South Asian region. The objective of this survey was to assess the magnitude of unintended pregnancy along with its correlates among currently pregnant women residing in Karachi.
Methods: A community based, multistage, cross-sectional study was carried out among 612 currently pregnant women from squatter settlements of Karachi, inquiring for "unintended pregnancy", outcome of interest. Multivariable logistic analysis was done using SPSS v.19 to determine associated factors.
Results: Of 612 pregnant women interviewed, 168(27.4%) reported their pregnancies as unintended. The multivariable regression identified a high likelihood of unintended pregnancy …

Residency Support During A Natural Disaster: Hurricane Ida, Tiffany Chang, Elizabeth W. Kelly, Chi Dola

HCA Healthcare Journal of Medicine

Natural disasters can have extraordinary impacts on a community and its infrastructure. Disasters can weaken systems that provide crucial resources, such as shelter, food security, water and health care. Recently, southeast Louisiana sustained devastating damage from Hurricane Ida on the 16th anniversary of Hurricane Katrina. Our medical workforce faced challenges caring for patients in a facility without potable water and powered by a generator. With the support of corporate entities and our academic institution, however, these barriers were quickly overcome and thus highlights the importance of collective resilience in the face of a natural disaster.

Audiologist Perception On Reporting Hearing Assessment Results To State Early Hearing Detection And Intervention Programs, Winnie Chung, Maria Sanchez-Gomez

Journal of Early Hearing Detection and Intervention

Purpose

To describe an evaluation conducted by 39 state EHDI programs on how acceptable the reporting process and system audiologists had to use when reporting the hearing test results to the EHDI program and the barriers encountered during reporting.

Methods

Each author independently extracted numbers, percentages, and texts from the evaluation reports into an Excel spreadsheet, which then became the dataset. Authors then compared and cross-checked the datasets before coding. Texts conveying similar concepts were coded with the same name and organized into categories. Finally, thematic identification and analysis were performed when a theme(s) or concept(s) that pertained to similar …

The Impact Of The Covid-19 Pandemic On Newborn Hearing Screening Programs In Western States, Nathan A. Blaseg, Hannah M. Williams, Shelby Jepperson, Jessica J. Messersmith

Journal of Early Hearing Detection and Intervention

The primary objective of this study was to determine the impact of the COVID-19 pandemic on newborn hearing screening guideline adherence and the respective rates of screening, diagnosis, and intervention. This was a review of newborn hearing screening data compiled from the Departments of Health of six states for the time periods of March-September 2019 and March-September 2020. Endpoints included the numbers of live births as well as the numbers and timeframes of screening, diagnostic, and intervention events. Two-tailed paired t-tests were performed to determine statistical significance. 181,662 births in six states were assessed. Compared to March-September 2019, March-September 2020 …

Early Gestational Profiling Of Oxidative Stress And Angiogenic Growth Mediators As Predictive, Preventive And Personalised (3p) Medical Approach To Identify Suboptimal Health Pregnant Mothers Likely To Develop Preeclampsia, Enoch O. Anto, David A. Coall, Otchere Addai-Mensah, Yaw Amo Wiafe, William K. B. A. Owiredu, Christian Obirikorang, Max E. Annani-Akollor, Eric Adua, Augustine Tawiah, Emmanuel Acheampong, Evans Adu Asamoah, Xueqing Wang, Stephen Opoku, Derick Kyei Boakye, Haifeng Hou, Youxin Wang, Wei Wang

Research outputs 2014 to 2021

Pregnant women, particularly in developing countries are facing a huge burden of preeclampsia (PE) leading to high morbidity and mortality rates. This is due to delayed diagnosis and unrecognised early targeted preventive measures. Adapting innovative solutions via shifting from delayed to early diagnosis of PE in the context of predictive diagnosis, targeted prevention and personalisation of medical care (PPPM/3 PM) is essential. The subjective assessment of suboptimal health status (SHS) and objective biomarkers of oxidative stress (OS) and angiogenic growth mediators (AGMs) could be used as new PPPM approach for PE; however, these factors have only been studied in isolation …

Evaluation The Effectiveness Of Abridged Imnci (7-Day) Course V Standard (11-Day) Course In Pakistan, Shabina Ariff, Kamran Sadiq, Uswa Jiwani, Khalil Ahmad, Khadija N Humayun, Shakeel Ahmed, Shaikh Qamaruddin Nizami, Iqtidar Khan, Nabeela Ali, Sajid Bashir Soofi, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: The conventional IMCI training for healthcare providers is delivered in 11 days, which can be expensive and disruptive to the normal clinical routines of the providers. An equally effective, shorter training course may address these challenges.
Methods: We conducted a quasi-experimental study in two provinces (Sindh and Punjab) of Pakistan. 104 healthcare providers were conveniently selected to receive either the abridged (7-day) or the standard (11-day) training. Knowledge and clinical skills of the participants were assessed before, immediately on conclusion of, and six months after the training.
Results: The improvement in mean knowledge scores of the 7-day and 11-day …

A Rollout Of A Blood Pressure Remote Patient Monitoring Program To Improve High-Risk Maternal Outcomes At A Pilot Clinic For Systemwide Expansion, Laura Geron

Seton Hall University Dissertations and Theses (ETDs)

An existing virtual care platform provides an innovative means of early recognition, identification, and intervention for women with elevated blood pressures during pregnancy, known as preeclampsia. A pilot program took place at a Northeastern prenatal care clinic where patients were identified as high-risk for preeclampsia, enrolled, educated by their providers, and equipped with Bluetooth-enabled blood pressure cuffs.

Through remote patient monitoring (RPM) technology, blood pressure readings could transmit from a patient’s residence to a portal accessible by their clinic provider at any time. This doctoral-level quality improvement project focuses on the identification of patients at high-risk for preeclampsia, their enrollment …

Opioid Use Disorder (Oud) And Pregnancy In Utah, Saralyn Margetts, Erin Fanning Madden, Lauran Hymas, Katie Zaman, Gabriela Murza, Suzanne Prevedel, Sandra H. Sulzer

All Current Publications

Over the past twenty years, opioid use during pregnancy has become much more common (Haight et al., 2018). Opioids may be prescribed for pain management or the treatment of an opioid use disorder (OUD). For example, methadone or buprenorphine are medications recommended for pregnant women with OUD. Opioid use may also include misusing prescription painkillers or using illicit drugs such as heroin. Regardless of the nature of opioid use, it is important for pregnant women to know how opioid use can impact their pregnancy and what treatment options are available.

Breastfeeding: Tools For Success, Norah Ashby, Casey Coombs, Stacy Bevan, Mateja R. Savoie-Roskos

All Current Publications

Every mother has a unique breastfeeding experience. Breastfeeding is natural, but that does not mean it comes naturally to every mother. The benefits of exclusively breastfeeding for the first six months and supplemental breastfeeding through the second year of life are well documented (Lessen & Kavanagh, 2015). However, there are many barriers that may prevent mothers from breastfeeding, including discomfort or pain, milk supply concerns, or simply not knowing how to breastfeed (Lessen & Kavanagh, 2015; Westerfield et al., 2018). Fortunately, there are a variety of tools that mothers can use to create a successful breastfeeding experience (Dennis et al., …

Adverse Childhood Experiences And Urinary Incontinence In Elementary School Aged Children, Amanda Jill Travis Msn, Fnp-C, Margaret C. Harvey Phd, Aprn, Acnp-Bc, Chfn, Michelle Rickard Dnp, Apnp-C

Doctor of Nursing Practice Projects

Purpose/Background: Adverse Childhood Experiences (ACEs) have an impact on health throughout the lifespan (Filletti et al., 1999; Hughes et al., 2017). These experiences range from physical and mental abuse, substance abuse in the home, parental separation or loss, financial instability, acute illness or injury, witnessing violence in the home or community, and incarceration of family members (Hughes et al., 2017). Understanding and screening for ACEs in children with urinary incontinence can help practitioners identify psychological stress as a potentially modifiable risk factor.

Methods: A 5-month chart review was performed identifying English speaking patients ages 6-11 years presenting to the outpatient …

Intergenerational Perceptions And Practices In Breastfeeding And Child Feeding Among Quilombola Women In Goiás State, Brazil, Priscila Olin Silva, Muriel Bauermann Gubert, Amanda Kellen Pereira Da Silva, Lucélia Luiz Pereira, Leonor Maria Pacheco Santos, Gabriela Buccini

Environmental & Global Health Faculty Research

This exploratory qualitative study aimed to identify sociocultural and intergenerational aspects of perception and practices in child feeding among quilombola women, members of maroon communities in Brazil. A focus group with 12 mothers and another group with four grandmothers of children under five years of age were conducted in a rural quilombola community in the State of Goiás, Brazil. The data were analyzed with thematic content analysis, yielding four central themes and respective subthemes, which were then represented in a socioecological conceptual model with four levels of influence on child feeding as the outcome. Theme 1 dealt with the reasons …

Knowledge, Attitudes, And Beliefs About Safe Sleep Among Preconception Adolescents​, Keita Oumou, Krystal Hunter, Erica Levin, Lori Feldman-Winter

Cooper Rowan Medical Journal

Introduction–To protect against SUID/SIDS, the American Academy of Pediatrics (AAP) released recommendations on creating a safe sleep environment. Studies about teen parents indicate gaps in knowledge regarding infant safe sleep practices, however there are no published studies about adolescents who are preconception. The objective of this stud is to investigate adolescents’ knowledge, attitudes, and beliefs regarding infant safe sleep practices prior to conceiving.

Methods–This was a cross-sectional study of adolescents aged 14-22 years recruited from two outpatient primary care pediatric sites in Southern NJ. Following consent, participants completed a 27-question survey about infant safe sleep practices. For analysis, …

Effectiveness Of Unconditional Cash Transfers Combined With Lipid-Based Nutrient Supplement And/Or Behavior Change Communication To Prevent Stunting Among Children In Pakistan: A Cluster Randomized Controlled Trial, Sajid Bashir Soofi, Shabina Ariff, Gul Nawaz Khan, Atif Habib, Sumra Kureishy, Yasir Ihtesham, Masawar Hussain, Arjumand Rizvi, Muhammad Sajid, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: In Pakistan, the prevalence of stunting among children under-five years has remained above WHO critical thresholds (≥30%) over the last two decades.
Objective: We hypothesized that an unconditional cash transfer (UCT) combined with lipid-based nutrient supplement (LNS) and/or social and behavior change communication (SBCC) will prevent stunting among children 6-23 months of age.
Design: This was a four-arm, community-based cluster randomized controlled trial conducted in the district of Rahim Yar Khan, Pakistan. A total of 1729 children (UCT n = 434); (UCT+SBCC n = 433); (UCT+LNS n = 430) and (UCT+LNS+SBCC n = 432) were enrolled at 6 months …

Draagmoederschap: Surrogacy In The Netherlands, Olivia Murray

Independent Study Project (ISP) Collection

In this paper, I investigated surrogacy in the Netherlands by interviewing four surrogates and one intended parent about their experiences. I found that the participants shared several common experiences and opinions, especially related to why they chose to be surrogates, how surrogates and intended parents negotiate their relationship during and after pregnancy, the tensions of passing on parenthood and merging families, the (non-binding) contracts that surrogates and parents create, Dutch law, and commercial surrogacy. I argue that much of the discourse around surrogacy relitigates many of the arguments made in favor and against sex work, in that it sets surrogacy …

We Won't Go There: Barriers To Accessing Maternal And Newborn Care In District Thatta, Pakistan, Muhammad Asim, Sarah Saleem, Zarak Hussain Ahmed, Imran Naeem Abbasi, Farina Abrejo, Zafar Fatmi, Sameen Siddiqi

Community Health Sciences

Accessibility and utilization of healthcare plays a significant role in preventing complications during pregnancy, labor, and the early postnatal period. However, multiple barriers can prevent women from accessing services. The aim of this study was to explore the multifaceted barriers that inhibit women from seeking maternal and newborn health care in Thatta, Sindh, Pakistan. This study employed an interpretive research design using a purposive sampling approach. Pre-tested, semi-structured interview guides were used for data collection. The data were collected through eight focus group discussions with men and women, and six in-depth interviews with lady health workers and analyzed through thematic …