No abstract

Background: Recently, a growing body of literature has established that disrespect and abuse during delivery is prevalent around the world. This complex issue has not been well studied through the lens of behavioral science, which could shed light on the psychological dimensions of health worker behavior and how their micro-level context may be triggering abuse. Our research focuses on the behavioral drivers of disrespect and abuse in Zambia to develop solutions with health workers and women that improve the experience of care during delivery. Methods: A qualitative study based on the behavioral design methodology was conducted in Chipata District, Eastern Province. Study participants included postpartum women, providers (staff who attend deliveries), supervisors and mentors, health volunteers, and birth companions. Observations were conducted of client-provider interactions on labor wards at two urban health centers and a district hospital. In-depth interviews were audio recorded and English interpretation from these recordings was transcribed verbatim. Data was analyzed using thematic analysis and findings were synthesized following the behavioral design methodology. Results: Five key behavioral barriers were identified: 1) providers do not consider the decision to provide respectful care because they believe they are doing what they are expected to do, 2) providers do not consider the decision to provide respectful care explicitly since abuse and violence are normalized and therefore the default, 3) providers may decide that the costs of providing respectful care outweigh the gains, 4) providers believe they do not need to provide respectful care, and 5) providers may change their mind about the quality of care they will provide when they believe that disrespectful care will assist their clinical objectives. We identified features of providers' contextthe environment in which they live and work, and their past experienceswhich contribute to each barrier, including supervisory systems, visual cues, social constructs, clinical processes, and other features. Conclusions: Client experience of disrespectful care during labor and delivery in Chipata, Zambia is prevalent. Providers experience several behavioral barriers to providing respectful maternity care. Each of these barriers is triggered by one or more addressable features in a provider's environment. By applying the behavioral design methodology to the challenge of respectful maternity care, we have identified specific and concrete contextual cues that targeted solutions could address in order to facilitate respectful maternity care.

Purpose The purpose of this study was to identify factors influencing participant engagement in a community-based diabetes self-management program (DSMP), with a focus on the needs of underserved groups (eg, racial/ethnic minorities, low income). Methods Focus groups were conducted with participants (n = 22) from the YMCA of Greater Richmond’s Diabetes Control Program, who were recruited using a purposeful sampling frame to capture a range of experiences. In-depth interviews were conducted with lay health coaches (n = 3). The RADaR qualitative analysis technique was used to identify themes related to factors across the continuum of engagement. Results Fear affected program enrollment and retention in complex ways. Peers and coaches were important for social support and accountability. The length of the program (12 weeks), accessible information, practical skill building, and emphasis on making small, feasible improvements in pursuit of larger goals were identified as critical for engagement and improving diabetes self-management. Health and outside obligations were the major barriers to program attendance. Conclusions Participant and coach perspectives provide important insight into existing strengths of community-based DSMPs that can be expanded on to promote engagement as well as potential opportunities for improvement. Actionable recommendations for increasing engagement of underserved groups in community-based DSMPs are provided.

Background Respectful maternity care (RMC) has been elevated in the global discourse, however, instances of disrespect and abuse remain prevalent. While several studies have highlighted promising approaches to promote RMC, this body of literature is still limited and few approaches have been scaled outside the initial study sites. Building on formative research conducted through a behavioral science lens, we sought to develop and test evidence-based, low-cost solutions to promote RMC which would be well-positioned for scale-up. Our study highlights the effectiveness of the solution package on provider provision of respectful care and client satisfaction, as well as intermediary outcomes and behavioral mechanisms. Methods A quasi-experimental evaluation, informed by the behavioral design approach, was completed to test the effectiveness of a 5-component solution package in Chipata, Zambia. Quantitative surveys were collected from health facility providers and postpartum clients at baseline and endline in intervention and comparison facilities. Additional qualitative interviews were conducted with health facility providers and postpartum clients at endline. We also conducted interviews with health facility in-charges and observed labor and delivery practices at intervention facilities over the course of implementation. Results Evidence suggested that at endline, clients at implementation facilities were less likely to experience disrespect and abuse compared to clients at comparison facilities (ß = − 0.15 p = 0.01). Clients at intervention facilities were more likely to request pain management compared to clients at comparison facilities (ß = 0.33, p = 0.003). The solutions were simple for providers to implement and were easily integrated into existing services by providers during labor and delivery. Providers at intervention facilities also described the pain management toolkit as helpful in expanding the types of pain management techniques used during labor. Conclusions The results of this small-scale study act as a proof of concept, demonstrating that the behavioral design approach can lead to solutions that show potential for impact. In other settings where providers face similar barriers to providing RMC, an adaptation of this solution package might lead to similarly positive results. Given the global scale of disrespectful care, these low-cost solutions hold promise for improving the quality of care women receive during labor and delivery.

Purpose The purpose of this study was to describe how a community-academic partnership developed and implemented a shared goal of evaluating the impact of a large community-based diabetes self-management program on diabetes care and mental health outcomes. Methods Data came from the YMCA of Greater Richmond Diabetes Control Program (DCP), a 12-week, group-format self-management program led by lay health coaches. Adults with type 2 diabetes (N = 312) completed baseline assessments of sociodemographic characteristics, diabetes history, and mental health. Four outcomes were assessed pre- and post-DCP on 141 participants who completed the program: hemoglobin A1C (A1C), weight, depressive symptoms (Patient Health Questionnaire-8), and glucose monitoring. The team worked with a Community Advisory Board throughout the research process. Results The DCP had wide geographic reach, including lower-income neighborhoods. The average age of the participants was 53.9 years, 71.4% were female, and 69% were African American. During the DCP, A1C declined from 8.4% to 7.6% (P < .001), but weight was unchanged (229.2 vs 227.9, P < .282). During the DCP, the proportion of participants with clinically significant depressive symptoms declined from 32.4% to 15.5% (P < .001), and frequency of glucose monitoring significantly increased. Conclusions The YMCA of Greater Richmond DCP has wide reach into underserved populations throughout the metropolitan area. This program is effective at improving diabetes self-management and mental health. Findings have implications for supporting academic-community partnerships to address diabetes disparities.