Todd P. Lewis

Background: Across the globe, rates of depression and anxiety have risen substantially since the COVID pandemic. Consequently, poor mental health is now a top health policy priority in many countries and more people than ever are seeking treatment. While the segment of people with poor mental health is large and growing, there is a dearth of data about their demographics and health needs and their use of and experience in the health system. Health systems require this information to effectively organize and provide services. Methods and findings: We investigated population prevalence of fair or poor mental health and compared health system experience and quality of care among adults with poor versus good mental health in 18 high-, middle-, and low-income countries using data from the People’s Voice Survey ( n = 32,419). Data were collected in 2022 and 2023 through a combination of nationally representative telephone, online, and in-person surveys. Prevalence of self-reported poor mental health ranged from 4.7% in Nigeria to 39.6% in China and was unrelated to national income per capita. More women than men reported poor mental health in most countries. Across all countries, people with poor mental health had worse self-rated overall health and more chronic illness. Between 0.9% (Lao PDR) and 52.4% (UK) of those with poor mental health had received mental healthcare in the past year. People with poor mental health reported lower patient activation, worse care quality, and lower confidence in the health system. A study limitation is that results are based on self-reported mental health rather than clinical diagnoses. Conclusions: People with poor mental health have markedly different health profiles and health system experience. These findings should prompt health systems to re-assess their services to better serve this growing patient group. Comparison of user experience and quality over time and across countries with similar health systems may assist in benchmarking performance.

Todd Lewis and co-authors discuss development and use of the People’s Voice Survey for health system assessment.

Fever and malaria are highly prevalent among children under five across sub-Saharan Africa, but utilization and quality of care for febrile illness remain insufficient. Many studies examine socioeconomic and demographic determinants of care seeking; however, few assess how women’s empowerment influences care seeking and quality. We examine associations of women’s empowerment with: a) care utilization for children with fever and malaria and b) the quality of that care in 16 sub-Saharan African countries. This cross-sectional study used data from Demographic and Health Surveys conducted between 2010 and 2018. We constructed indices for economic, educational, sociocultural, and health-related empowerment and calculated the proportion of children with fever and malaria who sought care and received a range of recommended clinical actions. We used multivariable Poisson hurdle models to assess associations between empowerment, utilization, and number of components of quality care, controlling for socioeconomic and demographic factors. Our sample consisted of 25 871 febrile children, 4731 of whom had malaria diagnosed by rapid diagnostic test. Empowerment among mothers of children with fever was 0.50 (interquartile range, 0.38-0.63). In both the fever and malaria groups, over 30% of children were not taken for care. Among care seekers, febrile children received on average 0.47 (SD = 0.37) of components of quality care, and children with malaria received 0.38 (SD = 0.34). Multidimensional women’s empowerment was significantly associated with care seeking and quality among febrile children, and with quality among children with malaria. Associations persisted after adjustment for socioeconomic and demographic characteristics. Results demonstrate substantial gaps in women’s empowerment and poor utilization and quality of care for fever and malaria among children. Increased women’s empowerment is associated with seeking care and, separately, obtaining high-quality care. To improve health outcomes, consideration of how empowering women can promote care seeking and extract quality from the health system is warranted.

Preterm birth is a leading cause of morbidity and mortality in children under five and often requires a newborn to have an extended stay in a neonatal intensive care unit (NICU). Maternal engagement, such as visiting the NICU to provide kangaroo mother care (KMC), can improve outcomes for preterm infants but requires significant investment of time and resources. This study sought to understand barriers and facilitators to provision of KMC in the NICU. We conducted semi-structured in-depth interviews with mothers of preterm infants (N = 20) at a large academic medical center in Massachusetts. A series of open-ended interview questions were designed to elicit all aspects of mothers’ experiences and to understand how these experiences influence provision of KMC. All interviews were recorded and transcribed verbatim. We conducted an inductive thematic analysis to identify themes in the data with a focus on the barriers and facilitators of KMC provision in the NICU. Findings show that engaging in KMC is heavily influenced by the mental, emotional, and physical effects of preterm birth on the birth mother, such as stress around preterm birth and difficulty recovering from birth. These challenges are compounded by structural barriers such as costly accommodations, unreliable transportation, lack of child care, and inadequate maternity leave policies that limit the frequency and duration of KMC and parental ability to provide care. A complex array of mental, emotional, physical, and structural factors determine a mother’s ability to visit the NICU and provide kangaroo mother care. Providing social supports, such as improved maternity leave policies and reliable hospital access through child care, accommodation, and transportation services, may address the structural barriers that inhibit KMC, reduce burdensome costs, and improve the health of mothers and their preterm infants.

Summary: Objectives: Recent studies have identified large and systematic deficits in clinical care in low‐income countries that are likely to limit health gains. This has focused attention on effectiveness of pre‐service education. One approach to assessing this is observation of clinical performance among recent graduates providing care. However, no studies have assessed performance in a standard manner across countries. We analysed clinical performance among recently graduated providers in nine low‐ or middle‐income countries.Methods: Service Provision Assessments from Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda were used. We constructed a Good Medical Practice Index that assesses completion of essential clinical actions using direct observations of care (range 0–1), calculated index scores by country and clinical cadre, and assessed the role of facility and clinical characteristics using regression analysis.Results: Our sample consisted of 2223 clinicians with at least one observation of care. The Good Medical Practice score for the sample was 0.50 (SD = 0.20). Nurses and midwives had the highest score at 0.57 (SD = 0.20), followed by associate clinicians at 0.43 (SD = 0.18), and physicians at 0.42 (SD = 0.16). The average national performance varied from 0.63 (SD = 0.18) in Uganda to 0.39 (SD = 0.17) in Nepal, persisting after adjustment for facility and clinician characteristics.Conclusions: These results show substantial gaps in clinical performance among recently graduated clinicians, raising concerns about models of clinical education. Competency‐based education should be considered to improve quality of care in LMICs. Observations of care offer important insight into the quality of clinical education.