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Background In parallel with the change of malaria policy from control to elimination and declines in the malaria burden in Greater Mekong Sub-region, the motivation and social role of malaria volunteers has declined. To address this public health problem, in Myanmar, the role and responsibilities of malaria volunteers have been transformed into integrated community malaria volunteers (ICMV), that includes the integration of activities for five additional diseases (dengue, lymphatic filariasis, tuberculosis, HIV/AIDS and leprosy) into their current activities. However, this transformation was not evidence-based and did not consider inputs of different stakeholders. Therefore, qualitative stakeholder consultations were performed to optimize future malaria volunteer models in Myanmar. Methods Semi-structured interviews were conducted with key health stakeholders from the Myanmar Ministry of Health and Sports (MoHS) and malaria implementing partners to obtain their perspectives on community-delivered malaria models. A qualitative descriptive approach was used to explore the experiences of the stakeholders in policymaking and programme implementation. Interview topic guides were used during the interviews and inductive thematic data analysis was performed. Results While ICMVs successfully provided malaria services in the community, the stakeholders considered the ICMV model as not optimal and suggested that many aspects needed to be improved including better training, supervision, support, and basic health staff’s recognition for ICMVs. Stakeholders believe that the upgraded ICMV model could contribute significantly to achieving malaria elimination and universal health care in Myanmar. Discussion and conclusion In the context of high community demand for non-malaria treatment services from volunteers, the integrated volunteer service package must be developed carefully in order to make it effective in malaria elimination programme and to contribute in Myanmar’s pathway to universal health coverage (UHC), but without harming the community. An evidenced-based, community-delivered and preferred model, that is also accepted by the MoHS, is yet to be developed to effectively contribute to achieving malaria elimination and UHC goals in Myanmar by 2030.

Background Malaria volunteers have contributed significantly to malaria control achieving a reduction of annual parasite incidence to pre-elimination levels in several townships across Myanmar. However, the volunteers’ role is changing as Myanmar transitions from a malaria control to elimination programme and towards the goal of universal health coverage. The aim of the study is to explore the perspectives of community leaders, members and malaria volunteers in South-East Myanmar on community-delivered models to inform an optimal design that targets malaria elimination in the context of primary health care in Myanmar. Methods Qualitative methods including focus group discussions (FGDs) with community members and current or ex-malaria volunteers, and participatory workshops with community leaders were conducted. All data collection tools were pilot tested with similar participants. The FGDs were stratified into male and female participants in consideration of diverse gender roles among the ethnic groups of Myanmar. Data saturation was the key cut-off point to cease recruitment of participants. Inductive thematic analysis was used. Results Community members were willing to be tested for malaria because they were concerned about the consequences of malaria although they were aware that malaria prevalence is low in their villages. Malaria volunteers were the main service providers for malaria and other infectious diseases in the community. Apart from malaria, the community identified common health problems such as the flu (fever, sneezing and coughing), diarrhoea, skin infections and tuberculosis as priority diseases in this order. Incorporating preventive, and whenever possible curative, services for those diseases into the current malaria volunteer model was recommended. Discussion and conclusion There was a gap between the communities’ expectations of health services and the health services currently being delivered by volunteers in the community that highlights the need for reassessment and reform of the volunteer model in the changing context. An evidence-based, community preferred, pragmatic community-delivered integrated model should be constructed based on the context of malaria elimination and progressing towards universal health coverage in Myanmar.

(1) Background: Women using unreliable traditional contraception need to be included in the proportion of women having an &lsquo, unmet need for modern contraception&rsquo, instead of the current classification which presumes they have a &lsquo, met need&rsquo, (2) Methods: Mix methods research design comprising initial quantitative analyses utilizing data from the nationally representative 2014 Cambodian Demographic and Health Survey (CDHS) for 4823 Cambodian, sexually active females aged 15&ndash, 29 years. Then a qualitative phase explored knowledge about the menstrual cycle and misconceptions about modern contraception with 30 females aged 15&ndash, 29 years in urban Cambodia using semi-structured interviews, transcribed verbatim with quality checks. Purposive and snowball sampling strategies were used until data saturation was reached. Inductive thematic data analysis was conducted, (3) Results: Unmet need for modern contraception increased to 25.4% when traditional contraception users were included. The qualitative themes show women have a lack of information about the menstrual cycle and misconceptions about modern contraception which contributed to increased use of traditional contraception, (4) Conclusion: Major drivers of increased unmet need for modern contraception include lack of literacy, misconceptions and low autonomy to choose modern contraception. Cambodia needs to endorse a policy shift to implement targeted, countrywide sexual and reproductive health literacy and family planning services.

There is an increase in risky sexual behavior (RSB) in Cambodian female youth aged 10 to 24 years, which can contribute to detrimental sexual and reproductive health due to the increased risk of acquiring sexually transmitted infections, unintended pregnancies, or abortions. Bronfenbrenner’s social ecological model was used to identify factors at personal, microenvironment, and macroenvironment levels potentially associated with RSB. A systematic literature review employing PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted to search 8 databases for articles published between 1994 and 2019. A risk of bias tool was applied for methodological quality of the 4 included studies. RSB is associated with multiple factors including sexual debut at young age, alcohol and substance abuse, multiple partners, living away from parents or orphan status, peer delinquency, non-use of condoms by partners, transactional sex, low education and socioeconomic status, and no access to sexual and reproductive health services. Multipronged preventive strategies operating at different levels are recommended in terms of including sex education and increasing reproductive health literacy programs at the schools and community programs for safe sex, condom use and sexual negotiation skills, and access to modern contraceptive methods.

Unintended pregnancy and an unmet need for modern contraception remain high among adolescent girls and women in Cambodia. Qualitative descriptive research was conducted to explore the barriers to contraceptive use among young women in urban Cambodia.Semi-structured interviews were conducted among 30 adolescent girls and women aged 16-27 years, using purposive and snowball sampling strategies until data saturation was achieved. The audio-recorded interviews were transcribed verbatim and quality-checked. Inductive thematic data analysis was conducted. The results are presented using Bronfenbrenner's theoretical social ecological model.The emerging major and minor themes indicate misconceptions about hormonal contraception as well as women's preference for using oral contraceptive pills for family planning after an unintended pregnancy. Women had low autonomy in choosing a contraceptive method, as their partners or husbands tended to prefer the withdrawal method. Young women faced cultural and supply chain barriers in accessing short- and long-acting reversible modern contraceptive methods at health centres.Cambodian women aged 16-27 years are a vulnerable group who have low autonomy and sexual and reproductive health literacy and also face gender inequality.

Background Unmet need is the gap between women’s need and their practice of using contraception. Unmet need for contraception in female adolescents and women in Cambodia is a public health concern which may lead to unintended pregnancies or abortions that can contribute to maternal morbidity and mortality. Methods Bronfenbrenner’s Social Ecological Model was used as a theoretical framework to analyze data from the 2014 Cambodian Demographic and Health Survey to ascertain demographic and social factors potentially associated with unmet need for contraception. Bivariate and weighted multiple logistic regression analyses with adjusted odds ratios (AOR) were conducted for 4,823 Cambodian, sexually active females aged 15–29 years. Results The percentage of unmet need for contraception was 11.7%. At the individual level of the Social Ecological Model, there was an increased likelihood of unmet need in adolescent girls 15–19 years and women 20–24 years. Unmet need was decreased in currently employed women. At the microenvironment level, there was an increased likelihood of unmet need with the husband’s desire for more children and when the decision for a woman’s access to healthcare was made by someone else in the household. At the macroenvironment level, unmet need was decreased in women who could access a health facility near their residence to obtain medical care. There were no urban rural differences found in the Cambodian sample population. Conclusion Unmet need for contraception in Cambodian females adolescents and women is associated with younger age, unemployment and low personal autonomy for accessing healthcare but not with education or wealth status. There is a need to implement culturally appropriate reproductive and sexual health literacy programs to increase access to modern contraception and to raise women’s autonomy.

Background: Female adolescents undergo drastic changes in their bodies during puberty. Therefore, they need to be informed about these pending changes at an early age so they can build a foundation for healthy reproductive behaviour. This study explored young female adolescents’ understanding of pubertal body changes and knowledge of their reproductive system. Method: Female students in grades seven, eight and nine were recruited from eight junior high schools in Kupang, Indonesia. Body mapping was conducted together with a semi-structured interview. Data was analyzed using inductive thematic analysis. Result: The median age of participants was 13 years and more than 85% had experienced menstruation. During interviews participants listed their pubertal body changes and then located the female reproductive system on body maps. Two main themes emerged in regards to participants’ perceived pubertal body changes and understanding of reproductive system. Participants aware the changes in their five body areas and could name one or two organs in the female reproductive system but they were unable to locate them on the body maps. The body mapping exercise revealed that participants have limited knowledge of the anatomy and physiology of the female reproductive system. Conclusion: Young female adolescents demonstrated sound knowledge of pubertal body changes. However, they lacked an accurate understanding of the anatomy and physiology of the female reproductive system. The study identified a gap in young female adolescents' knowledge about the anatomy and physiology of the female reproductive system. This study provides evidence on the value of using the body mapping exercise in conjunction with semi-structured interviews in research with young female adolescents on a sensitive topic.

Introduction An effective continuum of care for pregnancy and childbirth connects women and girls with essential reproductive and maternity care services. This study aimed to estimate the continuum of care utilisation rate of women who lived in remote and isolated regions of Pakistan and explored factors that influence women's utilisation of reproductive and maternity care services. Methods A mixed-methods study was conducted in five rural villages of Sindh, Pakistan. A cross-sectional survey with 669 women who gave birth between July 2010 and September 2014 investigated women's maternity-care service utilisation during pregnancy, childbirth, and in the postpartum period. In-depth interviews with 15 women explored their maternity-care experiences with health providers. Results Only 6.4% of 669 women participants reported to have completed the continuum of care for their last pregnancy. Skilled birth attendants, including health professionals, were used by 56.1% for antenatal care, 40.8% for both antenatal and childbirth, 22.3% for antenatal, childbirth and postnatal, and only 6.4% reported using all pregnancy-related and postpartum services. Limited knowledge about affordable health services, poor health literacy, and access to health services was associated with women's fragmented utilisation of maternity care. A lack of respectful maternity-care was also identified as a major barrier to women's utilisation of primary health care facilities, especially for childbirth. Conclusion The existing primary health structure in Pakistan provides a good foundation to deliver continuity of care services; however, health services utilisation for reproductive and maternity care remains suboptimal in women who live in geographically remote regions of Pakistan.

ObjectiveValidity refers to the extent to which evidence and theory support the adequacy and appropriateness of inferences based on score interpretations. The health sector is lacking a theoretically-driven framework for the development, testing and use of health assessments. This study used the Standards for Educational and Psychological Testing framework of five sources of validity evidence to assess the types of evidence reported for health literacy assessments, and to identify studies that referred to a theoretical validity testing framework.MethodsA systematic descriptive literature review investigated methods and results in health literacy assessment development, application and validity testing studies. Electronic searches were conducted in EBSCOhost, Embase, Open Access Theses and Dissertations and ProQuest Dissertations. Data were coded to the Standards’ five sources of validity evidence, and for reference to a validity testing framework.ResultsCoding on 46 studies resulted in 195 instances of validity evidence across the five sources. Only nine studies directly or indirectly referenced a validity testing framework. Evidence based on relations to other variables is most frequently reported.ConclusionsThe health and health equity of individuals and populations are increasingly dependent on decisions based on data collected through health assessments. An evidence-based theoretical framework provides structure and coherence to existing evidence and stipulates where further evidence is required to evaluate the extent to which data are valid for an intended purpose. This review demonstrates the use of the Standards’ theoretical validity testing framework to evaluate sources of evidence reported for health literacy assessments. Findings indicate that theoretical validity testing frameworks are rarely used to collate and evaluate evidence in validation practice for health literacy assessments. Use of the Standards’ theoretical validity testing framework would improve evaluation of the evidence for inferences derived from health assessment data on which public health and health equity decisions are based.

Across the Asian region, models of health administration vary from centralized management arrangements to more open decentralized systems. Utilizing a historical perspective, this review compares and contrasts health systems transition in seven countries (the Democratic People’s Republic of Korea, Myanmar, Timor Leste, Bhutan, Mongolia, Cambodia and the Philippines) against the background of macro-political and economic reform, and then considers the implications of these findings for approaches to health policy analysis. Four management areas are presented to demonstrate variation in health system design over the last 40 years: centralization and decentralization, human resource management, health financing and constituency emergence. Historical records illustrate that these functions have evolved through political reform eras of centralist, early reform, established reform and pluralist models of administration, with the main driver of system change being periodic historical shifts in the design of the macro-political and socio-economic order. The cross referencing of management variables with these stages of transition illustrates the degree to which health policy parameters are reset by periodic historical shifts in the political and social order. The findings in these case studies call for a more nuanced classificatory system for health systems and policy analysis that unites a technical perspective with a wider social and political field of vision, and, in doing so, builds a more comprehensive picture of the way in which health systems function in the real world.

Objective to explore the postpartum experiences of Cambodian born migrant women who gave birth for the first time in Victoria, Australia between 2000 and 2010. Design an ethnographic study with 35 women using semi-structured and unstructured interviews and participant observation; this paper draws on interviews with 20 women who fit the criteria of first time mothers who gave birth in an Australian public hospital. Setting the City of Greater Dandenong, Victoria Australia. Participants twenty Cambodian born migrant women aged 23–30 years who gave birth for the first time in a public hospital in Victoria, Australia. Findings after one or two home visits by midwives in the first 10 day postpartum women did not see a health professional until 4–6 weeks postpartum when they presented to the MCH centre. Women were home alone, experienced loneliness and anxiety and struggled with breast feeding and infant care while they attempted to follow traditional Khmer postpartum practices. Implications for practice results of this study indicate that Cambodian migrant women who are first time mothers in a new country with no female kin support in the postpartum period experience significant emotional stress, loneliness and social isolation and are at risk of developing postnatal depression. These women would benefit from the introduction of a midwife-led model of care, from antenatal through to postpartum, where midwives provide high-intensity home visits, supported by interpreters, and when required refer women to professionals and community services such as Healthy Mothers Healthy Babies (Victoria Department of Health, 2011) for up to 6 weeks postpartum.

Existing research suggests that children are largely affected by the health and eating behaviours practiced and normalised in their family and home environment. Few studies have considered specifically how migrant parents choose food for their children. This paper examines the food decisionmaking process of Cambodian mothers for their children in Melbourne. Nine Cambodian mothers were individually interviewed in this study. They were asked to discuss their experiences and perceptions of their food decision-making process. Data analysis showed six major themes: Home-food decisions, factors influencing home-food decisions, fast-food and school tuckshop-food decisions, factors influencing fast-food and school tuckshop-food decisions, and settlement experience and acculturation. Overall, the findings suggest that the challenges and aspirations of mothers in relation to providing food for their children were not about meeting demands and negotiating with children on food decisions, instead it was having enough financial capital and time to put healthy food on the table. This paper contributes to the limited literature on the food decision-making process of migrant mothers for their children in the context of socio-economic and settlement challenges.

Background: Women are more vulnerable than men in the same natural disaster setting. Preexisting gender inequality, socio-cultural community dynamics and poverty puts women at significant risk of mortality. Pregnant women are particularly vulnerable because of their limited or no access to prenatal and obstetric care during any disaster or humanitarian emergency setting. Methods: In-depth interviews were conducted with 15 women who gave birth during the 2011 floods in Sindh Province, Pakistan. Thematic analysis explored women’s experiences of pregnancy and giving birth in natural disaster settings, the challenges they faced at this time and strategies they employed to cope with them. Results: Women were not afforded any control over decisions about their health and safety during the floods. Decisions about the family’s relocation prior to and during the floods were made by male kin and women made no contribution to that decision making process. There were no skilled birth attendants, ambulances, birthing or breastfeeding stations and postnatal care for women in the relief camps. Women sought the assistance of the traditional birth attendants when they gave birth in unhygienic conditions in the camps. Conclusion: The absence of skilled birth attendants and a clean physical space for childbirth put women and their newborn infants at risk of mortality. A clean physical space or birthing station with essential obstetric supplies managed by skilled birth attendants or community health workers can significantly reduce the risks of maternal morbidity and mortality in crisis situations.

Reproductive health research and policies in Cambodia focus on safe motherhood programs particularly for married women, ignoring comprehensive fertility regulation programs for unmarried migrant women of reproductive age. Maternal mortality risks arising due to unsafe abortion methods practiced by unmarried Cambodian women, across the Thai-Cambodia border, can be considered as a public health emergency. Since Thailand has restrictive abortion laws, Cambodian migrant women who have irregular migration status in Thailand experimented with unsafe abortion methods that allowed them to terminate their pregnancies surreptitiously. Unmarried migrant women choose abortion as a preferred birth control method seeking repeat “unsafe” abortions instead of preventing conception. Drawing on the data collected through surveys, in-depth interviews, and document analysis in Chup Commune (pseudonym), Phnom Penh, and Bangkok, the authors describe the public health dimensions of maternal mortality risks faced by unmarried Cambodian migrant women due to various unsafe abortion methods employed as birth control methods.

Collaborative research undertaken in the state of Queensland, Australia, resulted in major changes in cervical cancer screening and treatment for Indigenous women. Guided by an Indigenous statewide reference group and with an Indigenous researcher playing a lead role, qualitative data were collected using interviews, focus groups, larger community meetings; and case studies were conducted with health workers and community members from diverse rural, remote and urban communities, to explore the different cultural and structural factors affecting understanding and awareness of cervical cancer and Indigenous women's use of and access to health services for screening, diagnosis and treatment. These data were supplemented by an analysis of clinical data and health service checklists. We discuss the methodology and summarize the key social and structural factors that discourage women from presenting for screening or returning for follow-up. These include women's misunderstanding of cervical cancer screening, fear of cancer, and distrust of health services, poor recall and follow-up systems, and the economic and social burden to women to presenting for treatment. We describe how the research process and subsequent activities provided Indigenous women with a vehicle for their own advocacy, resulting in important policy and program changes.

Background Excess gestational weight gain (GWG) can affect the immediate and long term health outcomes of mother and infant. Understanding health providers’ views, attitudes and practices around GWG is crucial to assist in the development of practical, time efficient and cost effective ways of supporting health providers to promote healthy GWGs. This study aimed to explore midwives’ views, attitudes and approaches to the assessment, management and promotion of healthy GWG and to investigate their views on optimal interventions. Methods Midwives working in antenatal care were recruited from one rural and one urban Australian maternity hospital employing purposive sampling strategies to assess a range of practice areas. Face-to-face interviews were conducted with 15 experienced midwives using an interview guide and all interviews were digitally recorded, transcribed verbatim and analysed thematically. Results Midwives interviewed exhibited a range of views, attitudes and practices related to GWG. Three dominant themes emerged. Overall GWG was given low priority for midwives working in the antenatal care service in both hospitals. In addition, the midwives were deeply concerned for the physical and psychological health of pregnant women and worried about perceived negative impacts of discussion about weight and related interventions with women. Finally, the midwives saw themselves as central in providing lifestyle behaviour education to pregnant women and identified opportunities for support to promote healthy GWG. Conclusions The findings indicate that planning and implementation of healthy GWG interventions are likely to be challenging because the factors impacting on midwives’ engagement in the GWG arena are varied and complex. This study provides insights for guideline and intervention development for the promotion of healthy GWG.

Objective to identify first time pregnant women's infant feeding intentions for the first 2 years of life. Design a qualitative phenomenological approach was used, with semi-structured interviews as the primary method of data collection. Setting two of Eastern Health's antenatal clinics in the outer east region of Melbourne, Australia. Participants seven first time pregnant women from an Eastern Health antenatal clinic. Main outcome measure women's infant feeding intention for the first 2 years of life. Main findings all the participants intend to breast feed their infant for around 6 months. Women rely heavily on information about infant feeding options from friends, books and the internet, as the information provided by health professionals was found to be inadequate, acquired late in the pregnancy and difficult to access. Key conclusions the information women receive from midwives at antenatal appointments and parenting classes about infant feeding options is inadequate, as women are not satisfied with the timing, amount and usefulness of the information they receive. Implications for practice in order to see an increase in the rate of breast feeding it is imperative to create supportive environments for women to breast feed, and for midwives and health professionals to provide information and continued support for women in both the pre- and postnatal period.

The trafficking of women and children for work in the globalized sex industry is a global social problem. Quality data is needed to provide a basis for legislation, policy, and programs, but first, numerous research design, ethical, and methodological problems must be addressed. Research design issues in studying women trafficked for sex work (WTSW) include how to (a) develop coalitions to fund and support research, (b) maintain a critical stance on prostitution, and therefore WTSW (c) use multiple paradigms and methods to accurately reflect WTSW's reality, (d) present the purpose of the study, and (e) protect respondents' identities. Ethical issues include (a) complications with informed consent procedures, (b) problematic access to WTSW (c) loss of WTSW to follow-up, (d) inability to intervene in illegal acts or human rights violations, and (e) the need to maintain trustworthiness as researchers. Methodological issues include (a) constructing representative samples, (b) managing media interest, and (c) handling incriminating materials about law enforcement and immigration.

Objective:To identify social, structural and personal factors among Indigenous women in Queensland associated with the detection of breast cancer, and the treatment and post-treatment care and support of cancer. Methods:Qualitative research including interviews, case studies and focus group discussions were conducted, among Aboriginal women and service providers in urban, rural and remote areas of Queensland over nine months in 1998/99. Results:A range of factors were identified as influencing women's willingness to perform BSE, receive screening mammograms, and receive and complete treatment compared to the non-Indigenous population. Personal history of health services, provision of information about mammography, the cost of treatment and care, and availability of personal support, all influenced women's willingness to access services and maintain treatment. Indigenous women in Queensland experience various barriers to effective and appropriate detection, treatment and care of breast cancer. Conclusion: Barriers to diagnosis, treatment and care can be addressed by increasing women's awareness of breast cancer and the benefits of preventative health behaviour, and improving the quality and appropriateness of health care and counselling services for Indigenous women and their families. Implications:Indigenous women's knowledge and practice relating to the early diagnosis and prevention of breast cancer may improve through outreach work with women, to encourage their confidence in preventative health. Women's commitment to preventive health will also be enhanced by improved quality and access to health care, and improved relationships between practitioners and patients.