Prevalence and predictors of giving birth in health facilities in Bugesera District, Rwanda.

BACKGROUND: The proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75% reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249-584 maternal deaths per 100,000 live births. The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services among women living in rural villages in Bugesera District, Eastern Province, Rwanda. METHODS: Using census data and probability proportional to size cluster sampling methodology, 30 villages were selected for community-based, cross-sectional surveys of women aged 18-50 who had given birth in the previous three years. Complete obstetric histories and detailed demographic data were elicited from respondents using iPad technology. Geospatial coordinates were used to calculate the path distances between each village and its designated health center and district hospital. Bivariate and multivariate logistic regressions were used to identify factors associated with delivery in health facilities. RESULTS: Analysis of 3106 lifetime deliveries from 859 respondents shows a sharp increase in the percentage of health facility deliveries in recent years. Delivering a penultimate baby at a health facility (OR = 4.681 [3.204 - 6.839]), possessing health insurance (OR = 3.812 [1.795 - 8.097]), managing household finances (OR = 1.897 [1.046 - 3.439]), attending more antenatal care visits (OR = 1.567 [1.163 - 2.112]), delivering more recently (OR = 1.438 [1.120 - 1.847] annually), and living closer to a health center (OR = 0.909 [0.846 - 0.976] per km) were independently associated with facility delivery. CONCLUSIONS: The strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health center. Recent structural interventions in Rwanda, including the rapid scale-up of community-financed health insurance, likely contributed to the dramatic improvement in the health facility delivery rate observed in our study.

The life of leaders: an intensive health program for clergy.

Clergy suffer from chronic disease rates that are higher than those of non-clergy. Health interventions for clergy are needed, and some exist, although none to date have been described in the literature. Life of Leaders is a clergy health intervention designed with particular attention to the lifestyle and beliefs of United Methodist clergy, directed by Methodist LeBonheur Healthcare Center of Excellence in Faith and Health. It consists of a two-day retreat of a comprehensive executive physical and leadership development process. Its guiding principles include a focus on personal assets, multi-disciplinary, integrated care, and an emphasis on the contexts of ministry for the poor and community leadership. Consistent with calls to intervene on clergy health across multiple ecological levels, Life of Leaders intervenes at the individual and interpersonal levels, with potential for congregational and religious denominational change. Persons wishing to improve the health of clergy may wish to implement Life of Leaders or borrow from its guiding principles.

Spousal concordance in health behavior change.

OBJECTIVE: This study examines the degree to which a married individual's health habits and use of preventive medical care are influenced by his or her spouse's behaviors. STUDY DESIGN: Using longitudinal data on individuals and their spouses, we examine changes over time in the health habits of each person as a function of changes in his or her spouse's health habits. Specifically, we analyze changes in smoking, drinking, exercising, cholesterol screening, and obtaining a flu shot. DATA SOURCE: This study uses data from the Health and Retirement Study (HRS), a nationally representative sample of individuals born between 1931 and 1941 and their spouses. Beginning in 1992, 12,652 persons (age-eligible individuals as well as their spouses) from 7,702 households were surveyed about many aspects of their life, including health behaviors, use of preventive services, and disease diagnosis. SAMPLE: The analytic sample includes 6,072 individuals who are married at the time of the initial HRS survey and who remain married and in the sample at the time of the 1996 and 2000 waves. PRINCIPAL FINDINGS: We consistently find that when one spouse improves his or her behavior, the other spouse is likely to do so as well. This is found across all the behaviors analyzed, and persists despite controlling for many other factors. CONCLUSIONS: Simultaneous changes occur in a number of health behaviors. This conclusion has prescriptive implications for developing interventions, treatments, and policies to improve health habits and for evaluating the impact of such measures.

Participatory Methods for Climate Change and Mental Health Research: Photovoice in Nepal

Background: The relationship between mental health and climate change are poorly understood. Participatory methods represent ethical, feasible, and culturally-appropriate approaches to engage community members for mental health promotion in the context of climate change. Aim: Photovoice, a community-based participatory research methodology uses images as a tool to deconstruct problems by posing meaningful questions in a community to find actionable solutions. This community-enhancing technique was used to elicit experiences of climate change among women in rural Nepal and the association of climate change with mental health. Subjects and methods: Mixed-methods, including in-depth interviews and self-report questionnaires, were used to evaluate the experience of 10 women participating in photovoice. Quantitative tools included Nepali versions of Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) and a resilience scale. Results: In qualitative interviews after photovoice, women reported climate change adaptation and behavior change strategies including environmental knowledge-sharing, group mobilization, and increased hygiene practices. Women also reported beneficial effects for mental health. The mean BDI score prior to photovoice was 23.20 (SD=9.00) and two weeks after completion of photovoice, the mean BDI score was 7.40 (SD=7.93), paired t-test = 8.02, p<.001, n=10. Conclusion: Photovoice, as a participatory method, has potential to inform resources, adaptive strategies and potential interventions to for climate change and mental health.

Are State legislatures responding to public opinion when allocating funds for tobacco control programs?

This study explored the factors associated with state-level allocations to tobacco-control programs. The primary research question was whether public sentiment regarding tobacco control was a significant factor in the states' 2001 budget decisions. In addition to public opinion, several additional political and economic measures were considered. Significant associations were found between our outcome, state-level tobacco-control funding per capita, and key variables of interest including public opinion, amount of tobacco settlement received, the party affiliation of the governor, the state's smoking rate, excise tax revenue received, and whether the state was a major producer of tobacco. The findings from this study supported our hypothesis that states with citizens who favor more restrictive indoor air policies allocate more to tobacco control. Effective public education to change public opinion and the cultural norms surrounding smoking may affect political decisions and, in turn, increase funding for crucial public health programs.

Teaching yoga to seniors: essential considerations to enhance safety and reduce risk in a uniquely vulnerable age group.

BACKGROUND: Seniors age 65 and older represent the fastest-growing sector of the population and, like many Americans, are increasingly drawn to yoga. This presents both an extraordinary opportunity and a serious challenge for yoga instructors who must be both a resource and guardians of safety for this uniquely vulnerable group. A typical class of seniors is likely to represent the most diverse mix of abilities of any age group. While some may be exceedingly healthy, most fit the profile of the average older adult in America, 80% of whom have at least one chronic health condition and 50% of whom have at least two. OBJECTIVES: This article discusses the Therapeutic Yoga for Seniors program, offered since 2007 at Duke Integrative Medicine to fill a critical need to help yoga instructors work safely and effectively with the increasing number of older adults coming to yoga classes, and explores three areas that pose the greatest risk of compromise to older adult students: sedentary lifestyle, cardiovascular disease, and osteoporosis. To provide a skillful framework for teaching yoga to seniors, we have developed specific Principles of Practice that integrate the knowledge gained from Western medicine with yogic teachings.