Armenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the ...rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health.
This was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services.
The mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government's reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers' concern.
The study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.
The COVID-19 pandemic has presented significant global healthcare challenges, particularly impacting the continuity of essential health services in low- and middle-income countries. This study ...investigates the impact of the COVID-19 pandemic on the utilization and provision of essential health services in Armenia.
We employed a conventional qualitative study design, conducting semi-structured in-depth interviews (n = 17) within public and private primary healthcare (PHC) facilities in Armenia in 2021. Our study participants encompassed physicians providing specialty services in PHC facilities (e.g. endocrinologists, gynecologists/obstetricians, and pediatricians), regular visitors to PHC facilities (e.g. adults with chronic diseases, parents of children), and policymakers. Thematic analysis was conducted, yielding five emergent categories: mobilization and organization of PHC services during COVID-19; PHC visits during COVID-19; worsening of chronic conditions due to the decline in PHC visits; problems with routine childhood vaccinations; and patient-provider communication challenges.
The number of in-person visits to PHC facilities declined due to adaptations in service delivery, imposed lockdown measures, and the public's fear of visiting healthcare facilities. Maternal and child health services continued with no major disruptions. PHC providers deliberately limited the number of maternal and child visits to essential antenatal care, newborn screenings, and routine childhood immunizations. Still, children experienced some delays in vaccination administration. The pandemic resulted in a notable reduction in follow-up visits and monitoring of patients with chronic conditions, thereby exacerbating their chronic conditions. Phone calls were the primary method of patient-provider communication during the pandemic.
The COVID-19 pandemic has had a profound impact on the delivery and utilization of essential healthcare services at PHC facilities, especially for those with chronic conditions who needed continuous care. Unified national-level guidance and technical capacity are needed to direct the provision of essential services at the PHC level, promote effective health communication, and implement digital platforms for the uninterrupted provision of essential care during public health emergencies.
The worldwide uptake of COVID-19 vaccines was suboptimal throughout the pandemic; vaccine hesitancy played a principle role in low vaccine acceptance both globally and in Armenia. In order to ...understand the factors behind the slow vaccine uptake in Armenia, we aimed to explore the prevailing perceptions and experiences of healthcare providers and the general public related to COVID-19 vaccines. The study applied a convergent parallel mixed-methods study design (QUAL-quant) through in-depth interviews (IDI) and a telephone survey. We completed 34 IDIs with different physician and beneficiary groups and a telephone survey with 355 primary healthcare (PHC) providers. The IDIs found that physicians held variable views on the need for COVID-19 vaccination which, combined with mixed messaging in the media landscape, fueled the public's vaccine hesitancy. The survey results were mostly consistent with the qualitative findings as 54% of physicians hypothesized that COVID-19 vaccines were rushed without appropriate testing and 42% were concerned about the safety of those vaccines. Strategies to improve vaccination rates must target the main drivers of hesitancy, such as physicians' poor knowledge of specific vaccines and spiraling misconceptions about them. Meanwhile, timely educational campaigns with targeted messaging for the general public should address misinformation, promote vaccine acceptance, and empower their capacity to make decisions about their health.
WHO's directly observed therapy (DOT) strategy for tuberculosis (TB) treatment depends upon a well-organized healthcare system. This study sought to evaluate the effectiveness of self-administered ...drug intake supported by a family member versus in-clinic DOT.
This open-label, nationally-representative stratified cluster randomized controlled non-inferiority trial with two parallel equal arms involved drug-susceptible pulmonary TB patients in the continuation treatment phase. We randomly assigned outpatient-TB-centres (52 clusters) to intervention and control arms. The intervention included an educational/counseling session to enhance treatment adherence; weekly visits to outpatient-TB-centres to receive medication, and daily SMS medication reminders and phone calls to track adherence and record side effects. Controls followed clinical DOT at Outpatient-TB-centres. Both groups participated in baseline and 4-5 months follow-up surveys. The trial's non-inferiority comparisons include: treatment success as the clinical (primary) outcome and medication adherence (self-reported), knowledge, depressive symptoms, stigma, quality of life, and social support as non-clinical (secondary) outcomes.
Per-protocol analysis showed that the intervention (n = 187) and control (n = 198) arms achieved successful treatment outcome of 92.0 and 92.9%, respectively, indicating that the treatment success in the intervention group was non-inferior to DOT. Knowledge, depression, stigma, quality of life, and social support also showed non-inferiority, demonstrating substantial improvement over time for knowledge (change in the intervention = 1.05: 95%CL (0.49, 1.60); change in the control = 1.09: 95%CL (0.56, 1.64)), depression score (change in the intervention = - 3.56: 95%CL (- 4.99, - 2.13); change in the control = - 1.88: 95% CL (- 3.26, - 0.49)) and quality of life (change in the intervention = 5.01: 95%CL (- 0.64, 10.66); change in the control = 7.29: 95%CL (1.77, 12.81)). The intervention resulted in improved treatment adherence.
This socially empowering alternative strategy might be a preferable alternative to DOT available to patients in Armenia and in other countries. Further research evaluating cost effectiveness of the intervention and generalizability of the results is warranted.
Clinicaltrials.gov: NCT02082340, March 10, 2014.
ObjectivesGiven high prevalence of smoking and secondhand smoke exposure in Armenia and Georgia and quicker implementation of tobacco legislation in Georgia versus Armenia, we examined correlates of ...having no/partial versus complete smoke-free home (SFH) restrictions across countries, particularly smoking characteristics, risk perceptions, social influences and public smoking restrictions.DesignCross-sectional survey study design.Setting28 communities in Armenia and Georgia surveyed in 2018.Participants1456 adults ages 18–64 in Armenia (n=705) and Georgia (n=751).MeasurementsWe used binary logistic regression to examine aforementioned correlates of no/partial versus complete SFH among non-smokers and smokers in Armenia and Georgia, respectively.ResultsParticipants were an average age of 43.35, 60.5% women and 27.3% smokers. In Armenia, among non-smokers, having no/partial SFHs correlated with being men (OR=2.63, p=0.001) and having more friend smokers (OR=1.23, p=0.002); among smokers, having no/partial SFHs correlated with being unmarried (OR=10.00, p=0.001), lower quitting importance (OR=0.82, p=0.010) and less favourable smoking attitudes among friends/family/public (OR=0.48, p=0.034). In Georgia, among non-smokers, having no/partial SFHs correlated with older age (OR=1.04, p=0.002), being men (OR=5.56, p<0.001), lower SHS risk perception (OR=0.43, p<0.001), more friend smokers (OR=1.49, p=0.002) and fewer workplace (indoor) restrictions (OR=0.51, p=0.026); among smokers, having no/partial SFHs correlated with being men (OR=50.00, p<0.001), without children (OR=5.88, p<0.001), daily smoking (OR=4.30, p=0.050), lower quitting confidence (OR=0.81, p=0.004), more friend smokers (OR=1.62, p=0.038) and fewer community restrictions (OR=0.68, p=0.026).ConclusionsPrivate settings continue to lack smoking restrictions in Armenia and Georgia. Findings highlight the importance of social influences and comprehensive tobacco legislation, particularly smoke-free policies, in changing household smoking restrictions and behaviours.Trial registration numberNCT03447912.
This paper focuses on the particular challenges in cancer prevention and control (CPC) in low- and middle-income countries (LMICs). In particular, this paper extrapolates challenges and opportunities ...in Armenia, which has the 2nd highest rate of cancer-related deaths in the world, the 11th highest smoking prevalence among men globally, and an evolving health system infrastructure for non-communicable disease (NCD) prevention and control, including CPC. Despite significant progress in enhancing research capacity in Armenia over the past decade, additional efforts are needed, particularly in CPC-related research. Key opportunities are to advance tobacco control and utilization of mHealth. Public health training programs remain insufficient in the area of CPC, and in-country research expertise regarding CPC and related areas (e.g., tobacco control, mHealth, policy) is limited, particularly given the need to address the diverse and complex determinants of onset, prevention, and management of cancer. Moreover, critical gaps in research dissemination and knowledge translation from evidence to policy and practice continue to exist. Thus, public health infrastructure must be enhanced, in-country CPC leaders across various relevant disciplines must be further developed and supported, and medical and public health training must more fully integrate CPC and research dissemination and translation to inform policy and practice.
Background: Despite well-established advantages of smoking cessation in the prevention and treatment of myocardial infarction (MI) many patients continue smoking after a diagnosis of MI. Recent ...evidence suggests that higher self-efficacy (SE), or confidence in one's ability to abstain from smoking, is positively associated with successful smoking cessation attempts. This study aimed to investigate the association between SE and smoking cessation outcome at 6 to 12 months after MI in Armenia. Methods: Cross-sectional survey was conducted among smoker adult MI patients who were hospitalized at the largest cardiac hospital in Armenia (Nork-Marash Medical Center). Data collection was done at 6 to 12 months after MI through medical chart review and interviewer administered telephone survey. SE at the time of MI was measured through widely used and validated Self-Efficacy Questionnaire (SEQ-12). SEQ-12 consists of two six-item subscales which measure confidence in aptitude to abstain from smoking when facing internal stimuli (e.g. feeling nervous) and external stimuli (e.g. being with a smoker). Logistic regression analysis was performed to reveal the association between SE and quitting outcome. Results: About half (54.37%) of 103 surveyed participants quitted smoking after MI. The mean SE score was 33.55 (SD: 16.49) (out of possible 60) which was significantly higher among quitters compared to non-quitters (45.55 vs. 19.26, p< 0.001). Likewise, the difference between was significant in terms of both internal and external subscale scores. Adjusted logistic regression elucidated that each unit increase in SE score was associated with 1.3 times higher odds of quitting (95% CI: 1.17-1.44; p< 0.001). Conclusions: The results illustrated that SE is an independent predictor of smoking cessation after MI suggesting that increase in patients' confidence in ability to abstain from smoking will contribute to successful cessation outcomes. This emphasized the importance of behavioral interventions in encouraging and assisting smoking cessation attempts among MI patients.
Although smoking rates have declined in most of the countries in the world, there are population groups within these countries whose smoking rates remain significantly higher than the general ...population. These "forgotten groups" who have not been receiving the needed attention in tobacco control policies and tobacco cessation efforts include people with serious mental illness, substance use disorders, tuberculosis, people living with human immunodeficiency virus (HIV), lesbian-gay-bisexual-transgender-queer people, and pregnant women. A number of steps are needed at the national level in countries where these disparities exist, including modifications to national smoking cessation treatment guidelines that address the special needs of these populations, as well as targeted smoking cessation research, since these populations are often not included in clinical trials. Because of the higher smoking prevalence in these populations, as well as their lower smoking cessation treatment success rates than the general population, more resources are needed if we are to reduce health disparities in these vulnerable populations. Additionally, we believe that more effort should be focused on integrating smoking cessation treatment in the specialized care settings frequented by these subpopulations.
Background: Healthcare providers play a central role in promoting smoking cessation. Patients getting advice from physicians are 1.6 times more likely to quit, and trained physicians are twice as ...likely to offer assistance to patients. This study aimed to design, implement, and evaluate the first smoking cessation training for primary healthcare physicians (PHP) in Armenia. Methods: We recruited 58 PHPs for a two-day training (intervention group) and 51 PHPs in the control group from the two biggest cities. We utilized a quasi-experimental design to evaluate the training effectiveness using a self-administered questionnaire at baseline and 4-months follow-up. Practice score was calculated by awarding 1 point when the recommended practice was reported as being “Always” performed in physicians'' everyday work. We performed paired analysis to compare baseline and follow-up data using paired t-test and Wilcoxon test. Results: Overall, 105 PHPs (57-intervention, 48-control) participated in both baseline and follow-up surveys. The self-reported mean practice score significantly increased in the intervention group (10.34 vs. 14.96; p< 0.001) but not in the control group (10.03 vs. 10.25; p=0.739). The improvements from baseline to follow-up in the intervention group were observed regarding most of the selected evidence-based recommendations. However, the most vivid improvements were observed pertaining to practices in assisting patients to quit. At follow-up, more intervention group PHPs were always proposing their help to patients in quitting (45.61% vs. 85.96%, p< 0.001) and prescribing pharmacological aids such as Nicotine replacement therapy (5.36% vs. 24.56%, p< 0.001), Cytisine (1.75% vs. 24.56%, p< 0.001) and Varenicline (3.51% vs. 8.77%, p< 0.001). Conclusions: Training of healthcare providers can greatly improve compliance with the evidence-based smoking cessation recommendations. Similar tobacco dependence treatment trainings should be applied for all primary healthcare physicians in Armenia as well as adapted and implemented for other healthcare professional groups.
Background: Teachable moments (TM) have been advocated for endorsing health behavior change in a variety of settings. While primary healthcare settings have been the most potential venue for ...providing smoking cessation, physicians miss many TM to discuss smoking with their patients at every medical visit. The study aimed to reveal what influences primary healthcare physicians' (PHPs) decision to utilize TMs to facilitate smoking cessation counselling with patients. Methods: The study team implemented a qualitative research through focus group discussions with PHPs using a semi-structured guide. Purposive sampling was used to recruit participants (n=23) from two Armenian cities (the capital city Yerevan and the second largest city Gyumri). We transcribed the collected data and analyzed by the directed content analysis technique. Results: The study results illustrated several misconceptions that hamper PHPs to utilize TM for providing smoking cessation counselling to their patients. Majority of PHPs reported that they preferred discussing smoking only with those patients who expressed explicit concern about smoking, as they were afraid of harming physician-patient relationship. PHPs' believed that asking patients about their smoking status could be intrusive and lead to conflict situations. Some of PHPs were considering smoking as a culturally sensitive issue and preferred checking smoking status of men rather than women. Physicians also tend to miss the opportunity to discuss smoking with special patient subgroups (elderly patients, patients with other co-morbidities) because of the misbelief that smoking "already harmed" them and their health problems take precedence over smoking cessation counseling. Conclusions: Physicians missed opportunities to employ TMs for smoking cessation counseling with patients. Physicians appear to prioritize smoking cessation counseling based on patients' socio-demographic characteristic (age, gender), as well as diagnosis at the time of the visit. Specific interventions should be implemented to instruct physicians' to capitalize on TM and discuss smoking cessation during routine consultations with all patients.
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