“If I am alive, I am happy”: Defining quality of care from the perspectives of key maternal and newborn health stakeholders in Papua New Guinea
1Maternal, Child and Adolescent Health Program, International Development, Burnet Institute, Melbourne, Australia
2School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
3Healthy Mothers, Healthy Babies Program, Burnet Institute, Kokopo, PNG
4St Mary’s Hospital Vunapope, East New Britain Province, PNG
5Nonga General Hospital, Rabaul, Papua New Guinea
6Papua New Guinea Institute for Medical Research, Goroka, Papua New Guinea
7Kirby Institute, University of New South Wales, Kensington, Australia
8Royal Hobart Hospital, Hobart, Australia
9University of Melbourne, Melbourne, Australia
*Corresponding author: Email: lachlan.faktor@student.burnet.edu.auABSTRACT
Background
Quality maternal and newborn healthcare is essential to improve experiences and health outcomes for mothers and babies. In many low to middle income countries, such as Papua New Guinea, there are initiatives to increase antenatal care attendance and facility births. To develop and implement initiatives that are appropriate, relevant, and contextualised to a community, it is important to understand how quality of care is perceived and defined by different maternal and newborn healthcare stakeholders. The aim of this study was to understand how women, their partners, healthcare professionals, healthcare managers, and provincial health administrators in East New Britain, Papua New Guinea define quality of pregnancy, childbirth, and immediate postnatal care.
Methods
An exploratory qualitative study underpinned by a partnership-defined quality approach was undertaken. In total, 42 participants from five different healthcare facilities in East New Britain, Papua New Guinea, were interviewed. These included women, partners, healthcare professionals, healthcare managers, and provincial health administrators. Interviews were analysed using reflexive thematic analysis, assisted by NVivo computer software.
Results
Four themes were identified aligning with the journey a woman takes throughout the health system. These included (I) Ensuring Access: Arriving at the health centre, (II) Experiencing Positive Care: What the staff do, (III) Having the Bare Minimum: Resources available to the service, and (IV) Meeting Expectations: Outcomes of care.
Conclusion
Stakeholder groups had significant overlap in how quality of care was defined, however women and partners focussed more on elements relating to experience of care, while clinical stakeholders focussed on elements relating to provision of care. Participants believe that the current standard of care does not align with how they define quality of care.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
Funding was provided by the Burnet Institute through philanthropic support from numerous private and business donors in Australia and PNG. Major funding was provided by June Canavan Foundation Australia Gras Foundation, Australia Bank South Pacific PNG Community Grant Steamships PNG Community Grant Alistair Lucas Prize for Medical Research National Health and Medical Research Council (NHMRC) of Australia (Fellowships to CSE and JGB, Postgraduate Research Scholarship to AW) Naylor Steward Ancillary Fund, and the Chrysalis Foundation. MJLS received a Basser Research Entry Scholarship from the Royal Australasian College of Physicians Foundation (2018 and 2020). Burnet Institute is supported by an Operational Infrastructure Grant from the State Government of Victoria, Australia, and the NHMRC Independent Research Institutes Infrastructure Support Scheme. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
INTRODUCTION
Papua New Guinea (PNG) is the largest of the small island nations of the Pacific region, with a population estimated at over ten million1. Multiple barriers to accessing maternal and newborn health care exist including a predominantly rural population (86.8%)2, difficult geography including mountainous terrain, as well as numerous hard-to-access islands. Chronic health workforce shortages3, limited infrastructure and consumables, high rates of adolescent pregnancy and premature birth are additional challenges to achieving high quality care4–6. While estimates of the Maternal Mortality Ratio in PNG vary (from 215 to 930 per 100,000 live births), the broadly accepted figure is around 500 maternal deaths per 100,000 live births, one of the highest in the Pacific region7. The Neonatal Mortality Ratio (20 per 1,000 live births) and stillbirth rate (20-30 per 1,000 live births) are similarly high8. These outcomes are in part due to low rates of access to care throughout the pregnancy and birth journey. Across PNG, only 48% of pregnant women attended one or more antenatal care visits and 36% gave birth in a facility in 20209.
There is increasing recognition that high quality care leads to optimum health outcomes10, 11. The World Health Organization’s definition of quality care is care which is effective, safe, people-centred, timely equitable, integrated and efficient12, and is one of several accepted definitions13, 14, along with specific definitions focussed on quality of maternal and newborn care15–17. However, these definitions do not necessarily capture how key stakeholders, the providers, and receivers of care, see, define, or experience quality of care. Understanding quality of care from different perspectives can inform interventions, engage users as active participants in service delivery, and encourage community collaboration in co-designing and implementing quality improvement interventions and initiatives18. Key maternal and newborn health stakeholders include clients of the services, their partners and families, healthcare professionals (including midwives, nurses, obstetricians, and paediatricians), traditional birth attendants, community members, health managers, and health administrators. In PNG, the maternity workforce also includes community health workers and health extension officers; specially trained health workers who assist with patient care, daily administration, and coordination of community health services19.
Previous research across low and middle income countries (LMICs) has found that definitions of quality of care from both women and providers of maternal and newborn health care include aspects such as timeliness of care, autonomy, adequate human and physical resources, respectful care, and privacy, and there can be similarity between stakeholder groups20–23. While there can be similarities in quality of care priortities between stakeholder groups, women tend to have a greater focus on the care experience, such as positive relationships with caregivers and patient-centred care, while providers of care tend to emphasise structural elements relating to the provision of care, such as availability of resources24, 25. Evidence from the Asia Pacific region defining perspectives of quality maternal and newborn health care is limited, with much of the literature in LMICs coming from Sub-Saharan Africa. To our knowledge, there are no such publishd reports from PNG. The aim of this study was to inform this knowledge gap and describe how women, their partners, healthcare professionals, healthcare managers, and provincial health administrators in East New Britain, PNG define quality of pregnancy, childbirth, and immediate postnatal care.
METHODS
Ethics Statement
This study received ethical approval in PNG from the PNG Institute of Medical Research Institutional Review Board (1903) and the National Department of Health Medical Research Advisory Committee (19.16), and in Australia from the Alfred Hospital Human Research Ethics Committee (267/19). All participants involved in the study provided written and verbal informed consent.
Study Design and Setting
This study used an exploratory, qualitative methodology, and a phenomenological approach which aimed to understand the lived experiences and perspectives of maternal and newborn health care stakeholders in East New Britain. This study was co-designed by the Burnet Institute and the East New Britain Provincial Health Authority, using a partnership-defined quality approach to integrate community involvement and mobilisation26. This facilitated the project being driven by local preferences and needs. Qualitative methods allowed researchers to capture the complexity of different stakeholder definitions of quality maternal and newborn care, and explore the experience associated with that care27. Findings are reported according to the consolidated criteria for reporting qualitative research (COREQ) checklist (supplementary materials) 28. This study took place in the rural island province of East New Britain, which has a population of around 400,0009. In addition to English and Tok Pisin, multiple local languages are spoken by the three main cultural groups – the Baining, Pomio and Tolai people. Whilst there is access via roads to larger towns and villages, many rural and coastal communities are only accessible via walking track and/or boat9. As in wider PNG, East New Britain suffers from a chronic health workforce shortage, with 15 healthcare workers per 10,00009, around a third of the WHO recommended 44.5 per 10,00029. East New Britain has one tertiary health service (Nonga General Hospital), three rural hospitals, 32 health centres, and 109 community health posts. The Provincial Health Authority are ultimately responsible for these centres, however Catholic and other faith-based services manage approximately 50 per cent of health facilities. The National Department of Health expects that all facilities can provide basic emergency obstetric care30, however this is often not practicable for chronically short-staffed, resource-strained health facilities, especially in remote, hard-to-reach areas. Five health facilities were involved in this study including government-run facilities and Catholic health services, which ranged significantly in size, funding, staffing, and services offered (Table 1).
Participants
Participants were all community members of East New Britain, PNG, and aged over 18. Women, partners, and healthcare professionals were recruited face-to-face from postnatal wards of participating health centres through convenience sampling. Healthcare managers and provincial health administrators (henceforth referred to as ‘administrators’) were recruited purposefully, to ensure views were captured from all levels of the provincial health system. All participants who were invited to take part were provided with written and verbal information and explanations about the study in Tok Pisin, Kuanua (common languages in East New Britain) and/or English. Participants were informed of the voluntary nature of the study with the ability to withdraw at any stage, and no participants declined the invitation to participate. Women and partners interviewed were not known previously to researchers, but some healthcare professionals, managers, and administrators were known to researchers from previous projects. Participants understood the researchers to be a part of the research team and local community, aiming to improve maternal healthcare in East New Britain.
Data Collection
The research team comprised four PNG national researchers; three female researchers (P.M., R.S., and P.H.), and one male researcher (D.K.). All four were experienced maternal and child health researchers, with qualifications in nursing, medicine, public health, had extensive training in qualitative interview techniques, and detailed knowledge of the East New Britain healthcare system, through both personal and professional experience. All members of the research team spoke English and Tok Pisin, whilst two of the researchers (P.M. and D.K.) also spoke Kuanua. Interview guides (available in the supplementary materials) were piloted by the research team in various health facilities in East New Britain to ensure appropriateness of questions asked, and responses elicited. Interviews covered demographic details, experiences delivering or receiving maternal and newborn health care, perceptions of quality of care, men’s involvement in care, and views around how care experiences could be improved.
Data were collected through semi-structured, in-depth interviews conducted from 1st September 2019 to 31st Dec 2020. Interviews lasted 30-60 minutes and were conducted in quiet, private locations in healthcare facilities by gender concordant facilitators as recommended by the study advisory team. During interviews, two researchers (one conducting the interview, and one taking field notes) were present in the room with participants. Interviews were audio-recorded, and field notes were cross checked with participants at the conclusion of the interview. There was no further follow up with participants. Interviews were conducted in Tok Pisin, Kuanua, or English (depending on participant preference), recorded, transcribed verbatim in the originally spoken language, then translated to English for analysis.
A two-day workshop on quality maternal and newborn health care where a separate group of 35 community members, healthcare professionals, and healthcare managers attended was held post data collection. This provided an opportunity to member-check and validate the data and preliminary findings. Whist data saturation was reached prior to the completion of data collection, the research team continued with the remaining scheduled interviews to ensure different stakeholders across all selected catchment areas were able to take part. This was especially important to understand varying quality maternal and newborn care definitions from different stakeholders, as was the aim of this project.
Data Analysis
Braun and Clarke’s six-phase approach to thematic analysis was applied to analyse the data31. The use of thematic analysis allowed for interpretation of patterns of meaning in the data32. The computer software NVivo (Version 20, QST International Pty Ltd) was used to manage the data. Interview transcripts were translated to English, and the authors familiarised themselves with the data. A combination of an inductive and deductive approach to create initial codes was taken, with deductive codes identified through reviewing relevant literature. Codes were then synthesised into themes and sub-themes by three authors, which formed the coding tree, with associated supporting quotations documented, aided by Microsoft Word to organise the data. The authors then met to refine and agree on themes and sub-themes which emerged from the data. Preliminary results were presented to PNG national researchers to facilitate and ensure correct interpretation of findings, and suggest thematic and coding changes, which were integrated into the results. This was an opportunity for findings to be validated, and greater context to be provided.
Exemplar quotes were chosen from coded data for inclusion in the results throughout the analysis process. Some quotes have been edited to facilitate readability. In the results, quotes are indicated in “italics”. Where context and additional information has been provided, this is indicated with [square brackets]. Where non-relevant sections of text have been omitted, this is indicated with […].
RESULTS
In total 42 stakeholders participated in the study, comprised of 13 women, seven partners, nine healthcare professionals, nine healthcare managers, and four provincial health administrators (Tables 2 and 3).
Four themes and 15 sub-themes were identified from the thematic analysis (Table 4). Theme results are presented in the order a client journeys through the maternity system; first accessing care and arriving at the healthcare centre, followed by the experience of care impacted by the resources available at the centre, and finally, the outcome of care.
Theme I: Ensuring Access – Arriving at the Health Centre
Women, partners, and healthcare professionals discussed the importance of affordability of care, stating that financial barriers can prevent women from accessing care, medications, and resources. Women appreciated low fees, with one woman saying “The fees are low for antenatal and delivery. It’s just five kina [kina is the PNG currency, roughly equivalent to $2.10 AUD] for clinic card and all other treatments are free”. However, women and partners described hidden fees in transport, drugs, and food. A woman from Vunapope said “I will go to City Pharmacy and I will spend […] more money again.” Women may decide to not access care for financial reasons, as described by a healthcare professional: “Sometimes they [women] won’t have transport or money [so] they will just give birth in the village.” Participants discussed how many births occur outside facilities, and that a substantial proportion of patients do not access antenatal care. Staff described difficulty in delivering quality care to these patients, as test results, due dates, and clinical history were unknown. Provision of antenatal care and facility-based births were specifically highlighted by a healthcare professional as an essential part of quality of care: “One of the things is that we need to emphasise on mothers to attend antenatal clinics and give birth in health facility.” A healthcare professional discussed that antenatal care improves outcomes; “So if we give them that first care at their clinics at their pregnancy for those 9 months, we get a good outcome in the labour ward.”
A positive and welcoming environment was an important aspect of quality of care. Being greeted kindly, and oriented to the hospital and ward were considered key components of quality of care by women, partners, professionals, managers, and administrators. A partner described the experience of being left outside of the health centre with his labouring wife, unable to gain access as the door was locked and unmonitored: “[The staff] must be ready, they must come with the trolley and push the mother straight in. In here there was nothing when we arrived […]. Every staff was busy doing their own things. So when my wife came she was standing outside calling in to the ward from outside.” – Partner. A healthcare manager discussed quality of care beginning with how staff members approach a patient when they enter the health centre. “Quality care means, not only with [having the] drugs, it’s with our approach.” The environment and interactions that women were initially exposed to, access to antenatal care and the affordability of care set the tone for the rest of the healthcare interaction.
Theme II: Experiencing Positive Care – What the Staff Do
All participant groups discussed the importance of respectful care, including care which is holistic, and patient centred. A healthcare manager summarised “I’m looking at her holistically so meaning I have to look at her physiological state; her physical, her spiritual, emotional [state].” Staff who had an open and kind approach, who spoke compassionately, and avoided negative language exemplified quality care according to participants. Some women described instances where they feared or experienced verbal and physical abuse (such as scolding or slapping) from healthcare workers. A healthcare manager described quality of care including a safe environment and trustworthy care; “They [patients] feel free to access [care] and they are happy and satisfied with the kind of care that they receive without any complaints, dissatisfaction, doubt or fear about of the staff and the facility.” Additionally, participants discussed the importance of being provided with information, and autonomy to make treatment decisions. A healthcare professional emphasised the importance of autonomy; “So guide them, and the choice is in their hand don’t force them…it’s their choice.” A healthcare manager from the same facility agreed, stating “We have to respect her rights.” This included supporting women to choose their birthing position and seeking consent for procedures such as tubal ligation. The importance of clear communication was described, women wanted to be provided with information about procedures, as well as test and examination results. A health administrator stated that “Quality maternal care mainly is a well-informed mother.” A woman stated “The doctors and nurses […] must explain properly to the mothers who are coming to the hospital, […] they [must] explain according to their level of their understanding.” Women appreciated when healthcare professionals provided encouragement and support with kind language, especially in the absence of a companion, demonstrated by this woman “[We want staff who] will stay close and talk; ‘you are like this and the baby is coming close now’ or things like that, we want this kind of advice.” Quality of care meant a relationship between the patient and professional which put communication at the centre.
Timely care was a necessary component of quality of care. There were many situations described where women waited for extended periods of time before being seen and treated. Timely care was identified as an important domain of quality of care, as demonstrated by a partner who said: “When the mother gives birth to the baby the mother and baby must be served quickly.”
All groups discussed the importance of companionship for quality of care. Partners had mixed views, but most expressed a desire to be physically present during birth, so they could support their wife and in turn understand more about the birth process. A partner stated, “It’s good to be there during the time of delivery so that we can see and feel the pain that the mothers are going through so that we will take good care of them.” However, partners, and companions more broadly, were sometimes barred from labour wards for several reasons including the lack of privacy for other labouring women. Some partners preferred not to be involved in birth due to cultural traditions. The benefits of companions in improving quality of care were noted by participants. For example, a healthcare manager stated, “Since I do almost all the deliveries myself, I usually tell the husbands in assisting in things like making the beds for their wives.” This was supported by a woman concurring “If I go to the hospital with my guardian, […] let my mother come in with me to the delivery room to stay […] my mother can help me in some things.” For many receivers and providers of care, companionship was a valued component of quality of care.
Best clinical practice was seen as a part of quality of care. Women noted details about the sort of care they expected for their newborn, including thorough newborn checks and regular bathing, whilst healthcare professionals and managers tended to discuss technical aspects, such as HIV and syphilis screening, complication management pathways, and preventing infection. A healthcare manager stated “I see that quality is given [when the] baby is comfortable, the baby is happy, there is no infection. Sometimes, […] the baby will develop a sepsis infection if we don’t give quality care.”
Theme IV: Meeting Expectations – Outcomes of Care
Many participants, particularly women and partners, discussed the outcome of care as the most important part of quality of care, as outlined by a healthcare professional stating “In my opinion, I say that quality is the outcome.” Survival and a safe birth were discussed by women, healthcare professionals, and healthcare managers. Emerging from the birth experience alive and well, with a healthy baby was the ultimate marker of quality for some participants, including this woman who stated “They deliver my baby and gave me, I am happy and I am here. If I am alive, I am happy.” Additionally, a birth free from life-threatening complications was hailed as quality care by women, demonstrated by a woman who said; “I want the nurse to […] help me until I deliver safe, delivered normal”, as well as a healthcare professional; “The mother went into labour with-without any complications or without any problems; that’s quality maternal care.” Women, healthcare managers, and administrators emphasised patient satisfaction as important. A healthcare manager stated “Quality is not in numbers…I’m looking at it as how this woman expresses as her feelings and satisfaction of the care that is been given and well…so that’s quality maternal health.” Administrators discussed staff also being satisfied with the care they provide as an important marker of quality of care, with one stating “Would you [staff] think you have provided good work today? You go and sit down at the end of every afternoon and measure yourself, have you done quality, or you just go and roughly do the job just because you name was on for that day.” From these perspectives, quality care was achieved when both providers and receivers of healthcare were satisfied with the birth experience.
Overall, the groups defined quality of care similarly, with all stakeholder groups discussing a welcoming environment, adequate staffing, respectful care, and best practice. A visualisation of the components of quality care as defined by each stakeholder group can be found in the supplementary materials (Fig 1).
DISCUSSION
This study aimed to define how different maternal and newborn care stakeholders in East New Britain, PNG, define quality of care. We found a significant overlap in the way that stakeholder groups defined quality of care. A welcoming environment, having enough staff, best practice, and respectful care were domains of quality of care included by all stakeholder groups in their definitions. Companionship, patient satisfaction with care, basic utilities such as water and electricity, and survival and safety were other key components of quality care. Studies conducted in Tanzania, India, and Uganda also found that definitions between stakeholder groups had significant overlap20–23. One key difference in our study was that clinical and administrative provider groups focussed more on elements relating to provision of care and structural components of the healthcare system, while receivers of care (women and partners) focussed more on the care experience. Such differences between providers and receivers of care were seen in two studies conducted in Malawi24, 25.
All stakeholders, but especially providers of care, identified that inadequate staffing created barriers to quality of care. These findings are consistent with other qualitative studies in Malawi, Uganda, and Tanzania21, 22, 33. In our study, healthcare professionals discussed instances where they were physically unable to provide timely care, with women left waiting for substantial time periods. Staff found it harder to provide respectful care when physically and emotionally strained, as they were managing many patients with long hours and minimal breaks. Hygiene was also compromised, as there were insufficient cleaning staff to clean bathrooms and wards to create a hygienic and safe environment, which left healthcare professionals to fill this role, further increasing their workload. Previous research has outlined how inadequate staffing has negative implications for both healthcare professionals, and women, as staff experience increased workloads and perform tasks outside of scope, which can overburden health workers and result in loss of job satisfaction33–35.
Allowing and encouraging companionship was a strong sub-theme highlighted by many participants, especially women and partners, and has also been found as an important aspect in defining quality of care in several qualitative studies across Nigeria, Malawi, Tanzania, and Afghanistan20, 36–38, as well as PNG. Though barriers such as maintaining women’s privacy on the ward, and cultural taboo were present, our study found companions were not only emotional and physical supports for women in labour but could assist with workforce shortage issues in completing tasks like delivering food, changing sheets and assist with after birth hygiene and cleaning. Additionally, most male partners wanted to be involved in the birth process to better understand birth and what women go through, and to support their partners. A mixed methods study on companionship during labour in PNG echoes these findings, as well as noting companions could help with communication barriers, and even found healthcare professionals felt companionship helped labour progress39.
Strengths and Limitations
To our knowledge, this project is the first to explore how a wide range of stakeholders define quality maternal and newborn care in PNG, and the Asia Pacific region more broadly. The exploratory, qualitative methodology helped to understand what is sought by stakeholders in maternal and newborn healthcare. Qualitative research allows groups who have not had the opportunity to participate in research previously, and traditionally been excluded from research, to have their voices amplified27. Many participants expressed they were grateful for the opportunity to participate in the research:
“Just one thing to add; it’s good you people came in to help with what we have discussed. For us mothers we cannot speak up for ourselves, it’s difficult, we just listen and obey what they instruct us” – Woman, Vunapope.
Another strength was the leadership of PNG national researchers from study inception through to completion, ensuring the project was relevant to the needs of, and informed by, the local community. To capture a diverse section of the community, this study was conducted with participants from five healthcare facilities, which varied in size and resources, and were based in urban, rural, and remote settings. Facilities included both government and faith-based facilities, and participants came from five diverse stakeholder groups. Findings from this study are therefore likely to be relevant to other LMIC settings where similar challenges to achieving quality care exist, especially throughout the wider Asia Pacific region.
A limitation of this study is that only women using a health service for labour and birth participated. Currently 37% of women giving birth in East New Britain, and 64% in PNG more widely, do not access a health facility for birth9. There are likely to be differences in how those who access facility care and those who do not define quality of care. Additionally, while medical professionals are an important stakeholder group, they were not included as participants in this study.
Implications
This study found there is a gap in how stakeholders in East New Britain, PNG define quality maternal and newborn healthcare, and the care that is provided and received. Poor quality care has real world implications in how women seek maternal and newborn healthcare. In PNG, where the proportion of women birthing in a facility is already low, at 36% of all births9, it is important women have positive experiences to ensure they return and encourage friends and family to utilise facilities for birth. Previous negative experiences and perceived poor quality of care at facilities impacts future utilisation of services and care seeking behaviours40,41.
Many changes required to improve maternal quality of care in PNG are not feasible in a short timeframe due to financial, workforce, and systemic constraints. In the short term, some recommendations that may be more feasibly implemented include provision of food and water by health facilities for mothers and encouraging companionship during labour and birth. This study’s results showed companionship is an important part of quality of care definitions for key stakeholder groups and has previously been shown to be a low cost, effective quality improvement intervention in PNG39. Companionship is also supported as an important part of quality of care by healthcare professionals and women in Nigeria, Uganda, and Malwai24, 36, 42, 43.
Longer term considerations could include an increase in the health workforce, (currently only around a quarter of the health workforce required to meet the needs of the population are available)5, undisrupted access to utilities such as water and electricity, and infrastructure projects to design and build labour wards which ensure privacy and space for companions
CONCLUSION
Ensuring quality maternal and newborn healthcare is a complex challenge, especially in a low resource setting. To guide quality improvement initiatives that are maximally effective, culturally safe, and likely to be implemented, it is important to understand how stakeholders administering and receiving care define quality of care. This project has demonstrated key maternal and newborn healthcare stakeholders from East New Britain, PNG define quality of care as that which is respectful, welcoming, with facilities that are well-staffed, where best practice is employed, companions are welcomed, there is access to basic resources, and providers and receivers of care are all satisfied with the healthcare interaction. There is an opportunity to use these findings to inform the development of community informed and evidence-based quality improvement interventions in East New Britain, PNG, and across other areas of PNG and the Pacific where similar changes to quality of care are experienced.
Data Availability
The datasets generated and/or analysed during the current study are not publicly available due to potential confidentiality concerns. Additional information can be made available from the Scientific Integrity Officer at Burnet Institute, (admin@burnet.edu.au), on reasonable request. These restrictions are per the Papua New Guinea, Institute of Medical Research, Institutional Review Board.
ACKNOWLEDGEMENTS
The Gutpela Sevis Study team includes (in alphabetical order) Delly Babona, James Beeson, Arthur Elijah, Priscah Hezeri, Stenard Hiasihri, Caroline SE Homer, Dukduk Kabiu, Angela Kelly-Hanku, Elissa Kennedy, Alison Morgan, Christopher Morgan, Pele Melepia, Michelle Scoullar, Naomi Spotswood, Rose Suruka, Lisa M Vallely, Joshua P Vogel, Pinip Wapi, Alyce N Wilson.
We would like to acknowledge the community of East New Britain, PNG for generously taking part in the study. We recognise and gratefully acknowledge the dedication and contribution by the HMHB study team in Kokopo and Melbourne, in addition to colleagues at PNG Institute for Medical Research. Our special thanks to the National Department of Health, the East New Britain Provincial Administration, the Provincial Health Authority, Catholic Health Services, and participating health facilities (Nonga General Hospital, St Mary’s Vunapope, Kerevat Rural Hospital, Napapar Health Centre, Malasait Community Health Post) for enthusiastically facilitating our research team to work with them.