Elin C. Larsson

Mistrust in marriage-Reasons why men do not accept couple HIV testing during antenatal care- a qualitative study in eastern Uganda

BackgroundA policy for couple HIV counseling and testing was introduced in 2006 in Uganda, urging pregnant women and their spouses to be HIV tested together during antenatal care (ANC). The policy aims to identify HIV-infected pregnant women to prevent mother-to-child transmission of HIV through prophylactic antiretroviral treatment, to provide counseling, and to link HIV-infected persons to care. However, the uptake of couple testing remains low. This study explores mens views on, and experiences of couple HIV testing during ANC.MethodsThe study was conducted at two time points, in 2008 and 2009, in the rural Iganga and Mayuge districts of eastern Uganda. We carried out nine focus group discussions, about 10 participants in each, and in-depth interviews with 13 men, all of whom were fathers. Data were collected in the local language, Lusoga, audio-recorded and thereafter translated and transcribed into English and analyzed using content analysis.ResultsMen were fully aware of the availability of couple HIV testing, but cited several barriers to their use of these services. The men perceived their marriages as unstable and distrustful, making the idea of couple testing unappealing because of the conflicts it could give rise to. Further, they did not understand why they should be tested if they did not have symptoms. Finally, the perceived stigmatizing nature of HIV care and rude attitudes among health workers at the health facilities led them to view the health facilities providing ANC as unwelcoming. The men in our study had several suggestions for how to improve the current policy: peer sensitization of men, make health facilities less stigmatizing and more male-friendly, train health workers to meet mens needs, and hold discussions between health workers and community members.ConclusionsIn summary, pursuing couple HIV testing as a main avenue for making men more willing to test and support PMTCT for their wives, does not seem to work in its current form in this region. HIV services must be better adapted to local gender systems taking into account that incentives, health-seeking behavior and health system barriers differ between men and women.

Quality of antenatal care in rural southern Tanzania: a reality check

BackgroundCounselling on the danger signs of unpredictable obstetric complications and the appropriate management of such complications are crucial in reducing maternal mortality. The objectives of this study were to identify gaps in the provision of ANC services and knowledge of danger signs as well as the quality of care women receive in case of complications.FindingsThe study took place in the Rufiji District of Tanzania in 2008 and was conducted in seven health facilities. The study used (1) observations from 63 antenatal care (ANC) sessions evaluated with an ANC checklist, (2) self-assessments of 11 Health workers, (3) interviews with 28 pregnant women and (4) follow-up of 12 women hospitalized for pregnancy-related conditions.Blood pressure measurements and abdominal examinations were common during ANC visits while urine testing for albumin or sugar or haemoglobin levels was rare which was often explained as due to a lack of supplies. The reasons for measuring blood pressure or abdominal examinations were usually not explained to the women. Only 15/28 (54%) women were able to mention at least one obstetric danger sign requiring medical attention. The outcomes of ten complicated cases were five stillbirths and three maternal complications. There was a considerable delay in first contact with a health professional or the start of timely interventions including checking vital signs, using a partograph, and detailed record keeping.ConclusionLinking danger signs to clinical and laboratory examination results during ANC with the appropriate follow up and avoiding delays in emergency obstetric care are crucial to the delivery of coordinated, effective care interventions.

Missed Opportunities: barriers to HIV testing during pregnancy from a population based cohort study in rural Uganda.

The aim was to assess population-level HIV-testing uptake among pregnant women, key for access to prevention-of mother to child transmission (PMTCT) services, and to identify risk factors for not being HIV tested, The study was conducted May 2008–May 2010 in the Iganga/Mayuge Health and Demographic Surveillance Site (HDSS), Eastern Uganda, during regular surveillance of 68,000 individuals. All women identified to be pregnant May–July 2008 (n = 881) were interviewed about pregnancy-related issues and linked to the HDSS database for socio-demographic data. Women were followed-up via antenatal care (ANC) register reviews at the health facilities to collect data related to ANC services received, including HIV testing. Adjusted relative risk (aRR), and 95% confidence intervals (CI) for not being HIV tested were calculated using multivariable binomial regression among the 544 women who remained after record review. Despite high ANC attendance (96%), the coverage of HIV testing was 64%. Only 6% of pregnant women who sought ANC at a facility without HIV testing services were referred for testing and only 20% received counseling regarding HIV. At ANC facilities with HIV testing services, 85% were tested. Only 4% of the women tested had been couple tested for HIV. Living more than three kilometers away from a health facility with HIV testing services was associated with not being tested both among the poorest (aRR,CI; 1.44,1.02–2.04) and the least poor women (aRR,CI;1.72,1.12–2.63). The lack of onsite HIV testing services and distant ANC facilities lead to missed opportunities for PMTCT, especially for the poorest women. Referral systems for HIV testing need to be improved and testing should be expanded to lower level health facilities. This is in order to ensure that the policy of HIV testing during pregnancy is implemented more effectively and that testing is accessible for all.

Antenatal Care Services in Rural Uganda: Missed Opportunities for Good-Quality Care

Experience from countries that have achieved low maternal mortality suggests that access to good-quality maternity services is critical to improve maternal health. In this article we appraise the quality of antenatal care (ANC) services in a rural district of Uganda. We used a mixed methods approach, relying on a combination of semistructured interviews with both clients and providers, structured observations of provider–patient interactions, and infrastructure assessment of selected health facilities. We found several bottlenecks in health service delivery, including ineffective organization of educational sessions; selective omission of certain services; lack of explanation of important clinical and laboratory procedures; failure to link the performed procedures with preventive information; and occasional lack of respect for clients. The policy implications of these findings are discussed in relation to the need to (a) ensure an adequate supply of medical equipment and drugs, (b) enhance health workers’ compliance with ANC guidelines, and (c) combine medical procedures with educational messages.

Health information, an area for competition in Swedish pharmacies

Objective To investigate the views and expectations of a selected group of customers regarding health information in Swedish pharmacies. Methods A repeated cross sectional, questionnaire study carried out in 2004 and 2005. Customers buying calcium products answered questions on osteoporosis and general questions on health promotion and information. Results Respondents had a positive attitude towards receiving health information from the pharmacies and towards the pharmacies’ future role in health promotion. However, only 30% of the respondents expected to get information on general health issues from the pharmacy. In spite of this, 76% (2004) and 72% (2005) of the respondents believed that the pharmacies could influence people’s willingness to improve their health. Conclusion There is a gap between the respondents’ positive attitudes towards the Swedish pharmacies and their low expectations as regards the pharmacies’ ability to provide health information. In the light of the upcoming change to the state monopoly on medicine sales, this gap could be an important area for competition between the actors in the new situation for medicine sales in Sweden.

Low uptake of HIV testing during antenatal care: a population-based study from eastern Uganda.

This article discusses a population-based study from rural eastern Uganda that examines the uptake and determinants for HIV testing among pregnant women in Iganga/Mayuge Demographic Surveillance Site (DSS) where field assistants regularly collect data from households on vital events and other variables in a population of 67200 inhabitants. It finds that intensified counseling at health facilities and referral follow-up are needed as well as HIV testing services at ANC facilities to increase the coverage of HIV testing among pregnant women.

Time to act-comprehensive abortion care in east Africa

Time to act-comprehensive abortion care in east Africa. Access to the published version may require subscription.

Treatment patterns of childhood diarrhoea in rural Uganda: a cross-sectional survey.

BackgroundDiarrhoea is the second leading cause of death in children under five accounting for 1.8 million deaths yearly. Despite global efforts to reduce diarrhoea mortality through promotion of proper case management, there is still room for ample improvement. In order to seek options for such improvements this study explored the knowledge and practices of diarrhoea case management among health care providers at health centres and drug shops in Uganda.MethodsRecords were reviewed for case management and structured interviews concerning knowledge and practices were conducted with the staff at all health centres and at all identified drug shops in the rural district of Namutumba, Uganda.ResultsThere was a significant gap between knowledge and documented practices among staff. Antibiotics, antimalarials and antipyretics were prescribed or recommended as frequently as Oral Rehydration Solution (ORS). In almost a third of the health facilities, ORS was out of stock. 81% of staff in health centres and 87% of staff in drug shops stated that they prescribed antibiotics for common diarrhoea. Zinc was not prescribed or recommended in any case.ConclusionsThe findings indicate that many children presenting with diarrhoea are inadequately treated. As a result they may not get the rehydration they need and are at risk of potential side effects from unjustified usage of antibiotics. Practices must be improved at health centres and drug shops in order to reduce childhood mortality due to diarrhoeal diseases.

Healthcare-seeking behaviour in relation to sexual and reproductive health among Thai-born women in Sweden: a qualitative study

Abstract Thailand is one of the most common countries of origin among immigrants in Sweden and Thai immigrants comprise the immigrant group most frequently diagnosed with HIV. Little is known about their healthcare-seeking behaviour and views on HIV prevention. This study explored Thai women’s healthcare-seeking behaviour in relation to sexual and reproductive health and their views on HIV prevention. Nineteen in-depth interviews were conducted with Thai-born women in the Stockholm area. Three themes were identified: (1) poor access to healthcare in Sweden, preferring to seek care in Thailand; (2) partners playing a key role in women’s access to healthcare; (3) no perceived risk of HIV, but a positive attitude towards prevention. Despite expressing sexual and reproductive healthcare needs, most women had not sought this type of care, except for the cervical cancer screening programme to which they had been invited. Identified barriers for poor access to healthcare were lack of knowledge about the healthcare system and language difficulties. To achieve ‘healthcare on equal terms’, programmes and interventions must meet Thai women’s healthcare needs and consider what factors influence their care-seeking behaviour. Integrating HIV prevention and contraceptive counselling into the cervical screening programme might be one way to improve access.

Prevention of mother-to-child transmission of HIV in rural Uganda: Modelling effectiveness and impact of scaling-up PMTCT services

Background The reported coverage of any antiretroviral (ARV) prophylaxis for prevention of mother-to-child transmission (PMTCT) has increased in sub-Saharan Africa in recent years, but was still only 60% in 2010. However, the coverage estimate is subject to overestimations since it only considers enrolment and not completion of the PMTCT programme. The PMTCT programme is complex as it builds on a cascade of sequential interventions that should take place to reduce mother-to-child transmission (MTCT) of HIV: starting with antenatal care (ANC), HIV testing, and ARVs for the woman and the baby. Objective The objective was to estimate the number of children infected with HIV in a district population, using empirical data on uptake of PMTCT components combined with data on MTCT rates. Design This study is based on a population-based cohort of pregnant women recruited in the Iganga-Mayuge Health and Demographic Surveillance Site in rural Uganda 2008-2010. We later modelled different scenarios assuming increased uptake of specific PMTCT components to estimate the impact on MTCT for each scenario. Results In this setting, HIV infections in children could be reduced by 28% by increasing HIV testing capacity at health facilities to ensure 100% testing among women seeking ANC. Providing ART to all women who received ARV prophylaxis would give an 18% MTCT reduction. Conclusions Our results highlight the urgency in scaling-up universal access to HIV testing at all ANC facilities, and the potential gains of early enrolment of all pregnant women on antiretroviral treatment for PMTCT. Further, to determine the effectiveness of PMTCT programmes in different settings, it is crucial to analyse at what stages of the PMTCT cascade that dropouts occur to target interventions accordingly.Background The reported coverage of any antiretroviral (ARV) prophylaxis for prevention of mother-to-child transmission (PMTCT) has increased in sub-Saharan Africa in recent years, but was still only 60% in 2010. However, the coverage estimate is subject to overestimations since it only considers enrolment and not completion of the PMTCT programme. The PMTCT programme is complex as it builds on a cascade of sequential interventions that should take place to reduce mother-to-child transmission (MTCT) of HIV: starting with antenatal care (ANC), HIV testing, and ARVs for the woman and the baby. Objective The objective was to estimate the number of children infected with HIV in a district population, using empirical data on uptake of PMTCT components combined with data on MTCT rates. Design This study is based on a population-based cohort of pregnant women recruited in the Iganga-Mayuge Health and Demographic Surveillance Site in rural Uganda 2008–2010. We later modelled different scenarios assuming increased uptake of specific PMTCT components to estimate the impact on MTCT for each scenario. Results In this setting, HIV infections in children could be reduced by 28% by increasing HIV testing capacity at health facilities to ensure 100% testing among women seeking ANC. Providing ART to all women who received ARV prophylaxis would give an 18% MTCT reduction. Conclusions Our results highlight the urgency in scaling-up universal access to HIV testing at all ANC facilities, and the potential gains of early enrolment of all pregnant women on antiretroviral treatment for PMTCT. Further, to determine the effectiveness of PMTCT programmes in different settings, it is crucial to analyse at what stages of the PMTCT cascade that dropouts occur to target interventions accordingly.