Elisabeth Faxelid

Persistent high fertility in Uganda: young people recount obstacles and enabling factors to use of contraceptives

BackgroundHigh fertility among young people aged 15-24 years is a public health concern in Uganda. Unwanted pregnancy, unsafe induced abortions and associated high morbidity and mortality among young women may be attributed to low contraceptive use. This study aims at exploring reasons for low contraceptive use among young people.MethodsIn 16 focus group discussions, the views of young people about obstacles and enabling factors to contraceptive use in Mityana and Mubende districts, Uganda were explored. The groups were homogeneously composed by married and unmarried men and women, between the ages of 15-24. The data obtained was analyzed using qualitative content analysis.ResultsYoung men and women described multiple obstacles to contraceptive use. The obstacles were categorized as misconceptions and fears related to contraception, gender power relations, socio-cultural expectations and contradictions, short term planning, and health service barriers. Additionally, young people recounted several enabling factors that included female strategies to overcome obstacles, changing perceptions to contraceptive use, and changing attitude towards a small family size.ConclusionsOur findings suggest changing perceptions and behavior shift towards contraceptive use and a small family size although obstacles still exist. Personalized strategies to young women and men are needed to motivate and assist young people plan their future families, adopt and sustain use of contraceptives. Reducing obstacles and reinforcing enabling factors through education, culturally sensitive behavior change strategies have the potential to enhance contraceptives use. Alternative models of contraceptive service delivery to young people are proposed.

Cervical screening participation and risk among Swedish‐born and immigrant women in Sweden

Cervical cancer is one of the most common cancers among women worldwide, although cervical screening has reduced the incidence in many high‐income countries. Low screening uptake among immigrant women may reflect differences in risk of cervical cancer. We investigated the degree of participation in cervical screening among immigrant and Swedish‐born women and their concurrent risk of cervical cancer based on individual information on Pap smears taken both from organized and opportunistic screening. Mean degree of participation in cervical screening was estimated for women between 23 and 60 years from 1993 to 2005, stratified by birth region and age at migration. In Poisson regression models, we estimated relative risks (RRs), incidence rates and incidence rate ratios of cervical cancer for women adhering or not to the cervical screening program. We also assessed effect of adherence to screening on the risk of cervical cancer among immigrant groups compared to Swedish‐born women. The degree of participation was 62% and 49% among Swedish‐born and immigrant women, respectively, with large variations between immigrant groups. Participation was lowest among those immigrating at older ages. Swedish‐born and immigrant women who where nonadherent to the cervical screening program had a fivefold excess risk of cervical cancer compared to adherent women. After adjustment for screening adherence, excess RRs of cervical cancer were statistically significant only for women from Norway and the Baltic States. Participation to screening is lower among immigrant than Swedish‐born women, and adherence to the recommended screening intervals strongly prevents cervical cancer.

Influences on uptake of reproductive health services in Nsangi community of Uganda and their implications for cervical cancer screening

BackgroundCervical cancer is the most common female cancer in Uganda. Over 80% of women diagnosed or referred with cervical cancer in Mulago national referral and teaching hospital have advanced disease. Plans are underway for systematic screening programmes based on visual inspection, as Pap smear screening is not feasible for this low resource country. Effectiveness of population screening programmes requires high uptake and for cervical cancer, minimal loss to follow up. Uganda has poor indicators of reproductive health (RH) services uptake; 10% postnatal care attendance, 23% contraceptive prevalence, and 38% skilled attendance at delivery. For antenatal attendance, attendance to one visit is 90%, but less than 50% for completion of care, i.e. three or more visits.MethodsWe conducted a qualitative study using eight focus group discussions with a total of 82 participants (16 men, 46 women and 20 health workers). We aimed to better understand factors that influence usage of available reproductive health care services and how they would relate to cervical cancer screening, as well as identify feasible interventions to improve cervical cancer screening uptake.ResultsBarriers identified after framework analysis included ignorance about cervical cancer, cultural constructs/beliefs about the illness, economic factors, domestic gender power relations, alternative authoritative sources of reproductive health knowledge, and unfriendly health care services. We discuss how these findings may inform future planned screening programmes in the Ugandan context.ConclusionKnowledge about cervical cancer among Ugandan women is very low. For an effective cervical cancer-screening programme, awareness about cervical cancer needs to be increased. Health planners need to note the power of the various authoritative sources of reproductive health knowledge such as paternal aunts (Sengas) and involve them in the awareness campaign. Cultural and economic issues dictate the perceived reluctance by men to participate in womens reproductive health issues; men in this community are, however, potential willing partners if appropriately informed. Health planners should address the loss of confidence in current health care units, as well as consider use of other cervical cancer screening delivery systems such as mobile clinics/camps.

Efficacy of Patient-Delivered Partner Medication in the Treatment of Sexual Partners in Uganda

Background Patient-based partner referral (PBPR), which is the main method for treating sexual partners of patients with sexually transmitted diseases (STDs), has limited effectiveness. Goal The authors compared the efficacy of PBPR with patient-delivered partner medication (PDPM) among patients attending the Mulago STD clinic in Kampala, Uganda. Study Design A total of 383 patients (187 women, 196 men) with STDs were randomized to the PBPR or PDPM group. The proportion of sexual partners treated in either group was compared using the chi-square statistic by intention to treat for partners whose follow-up status was unknown. Results The two groups had similar background characteristics. Of the 237 partners elicited, 176 (74%) were reported treated in the PDPM group. In the PBPR group, in which 234 partners were elicited, 79 (34%) were referred to the treatment clinic. This difference was statistically significant (risk ratio [RR], 2.44; 95% CI, 1.95–3.07;P < 0.001). Furthermore, PDPM was more effective than PBPR for women and for casual partners for whom PBPR is considered difficult. For women, 86 of 103 partners in the PDPM group were reported treated, compared with 23 of 104 partners in the PBPR group (RR, 4.55; 95% CI, 2.92–7.08;P < 0.001). For casual partners, 18 of 51 (34%) were reported treated in the PDPM group, compared with only three of 45 partners (7%) who were referred in the PBPR group (RR, 1.43; 95% CI, 1.40–2.65;P < 0.01). Conclusion Patient-delivered partner medication is more effective than patient-based partner referral in the treatment of sexual partners.

Lay people's perceptions of sexually transmitted infections in Uganda.

In order to understand lay peoples perceptions of sexually transmitted infections (STIs) focus group discussions and semi-structured interviews were held with community members and patients with STIs in Mbarara and Kampala, Uganda. Symptoms of common STIs and the modes of transmission methods were known. STIs were perceived as naturalistic diseases caused by a tiny insect called akakoko or akawuka, although female infertility, one of the common complications of STIs, was perceived as a supernatural ailment. There was no stigma towards people with AIDS, although stigma towards people with other STIs was high. There were also strong negative attitudes towards the use of condoms. More than 60% of the patients interviewed had received treatment from the informal sector which included self-treatment and traditional healers. To reduce the incidence and complications of STIs, there may be a need to collaborate with the informal sector, to further evaluate the beliefs and practices identified in this study and to target them for health education.

Risk of cervical cancer among immigrants by age at immigration and follow-up time in Sweden, from 1968 to 2004

Because of great variation in the prevalence of human papilloma virus infection and other risk factors of cervical cancer worldwide, migrant studies may help further the understanding of the aetiology and improve prevention of cervical cancer. Our aim was to study the risk of invasive cervical cancer among immigrant women. We followed 758,002 immigrants from different countries who resided in Sweden between 1968 and 2004. Age‐standardised incidence rates (ASRs) of immigrants were compared with that in their countries of origin. Poisson regression models estimated the relative risks of cervical cancer among immigrants, overall and stratified by age at migration and follow‐up time, compared to Swedish‐born women. Overall 1,991 of 19,542 observed cases of cervical cancer occurred among immigrants. Generally they had lower ASRs than in their countries of origin, with the exception of Nordic immigrants. Compared to Swedish‐born women, we observed a higher relative risk of cervical cancer among immigrants overall (RR = 1.13, 95% CI 1.08–1.18), and particularly among women from Denmark (RR = 1.8, 95% CI 1.6–2.1), Norway (RR = 1.7, 95% CI 1.5–1.9) and Central America (RR = 2.5, 95% CI 1.3–4.9), while the relative risks were lower in immigrants from Eastern Africa (RR = 0.2, 95% CI 0.1–0.6), South Central Asia (RR = 0.4, 95% CI 0.2–0.6) and South Western Asia (RR = 0.5, 95% CI 0.4–0.7). Follow‐up time and age at migration were important effect modifiers for cervical cancer risks. We suggest targeted prevention toward high‐risk immigrants, specifically older women, in the first 10 years after arrival into their new homeland.

Individual counseling of patients with sexually transmitted diseases. A way to improve partner notification in a Zambian setting

Background: Sexually transmitted diseases (STD) are a major health problem in Zambia. Partner notification, which is a recommended strategy to decrease STD, must be improved. Goal: To assess whether individual counseling of patients with STD, combined with contact slip(s), had any impact on the proportion of sex partners traced in an urban setting in Zambia. Study Design: A randomized trial comprised of 94 women and 302 men with STD. Results: Women and men in the intervention group informed more partners than did those in the control group. In the intervention group, 1.8 partners per man was treated compared to 1.2 in the control group (P < 0.001). There was no difference between the two groups of women. There was a gradual decline from numbers of partners informed to numbers of partners treated according to the patient to number of contact slips filed. Conclusions: Individual counseling of men with STD improved partner notification.

Health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data

BackgroundUnsafe abortions are a serious public health problem and a major human rights issue. In low-income countries, where restrictive abortion laws are common, safe abortion care is not always available to women in need. Health care providers have an important role in the provision of abortion services. However, the shortage of health care providers in low-income countries is critical and exacerbated by the unwillingness of some health care providers to provide abortion services. The aim of this study was to identify, summarise and synthesise available research addressing health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia.MethodsA systematic literature search of three databases was conducted in November 2014, as well as a manual search of reference lists. The selection criteria included quantitative and qualitative research studies written in English, regardless of the year of publication, exploring health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. The quality of all articles that met the inclusion criteria was assessed. The studies were critically appraised, and thematic analysis was used to synthesise the data.ResultsThirty-six studies, published during 1977 and 2014, including data from 15 different countries, met the inclusion criteria. Nine key themes were identified as influencing the health care providers’ attitudes towards induced abortions: 1) human rights, 2) gender, 3) religion, 4) access, 5) unpreparedness, 6) quality of life, 7) ambivalence 8) quality of care and 9) stigma and victimisation.ConclusionsHealth care providers in sub-Saharan Africa and Southeast Asia have moral-, social- and gender-based reservations about induced abortion. These reservations influence attitudes towards induced abortions and subsequently affect the relationship between the health care provider and the pregnant woman who wishes to have an abortion. A values clarification exercise among abortion care providers is needed.

Psychosocial determinants for sexual partner referral in uganda : qualitative results

In order to understand and elicit the psychosocial factors influencing compliance with sexual partner referral, 10 focus group discussions (FGDs) and 40 individual interviews based on the attitude-social influence-self efficacy (ASE) model were held in Mbarara District of Uganda. The focus groups were derived from both rural and urban areas. Informal interviews were held with 20 men and 20 women presenting with symptoms of a sexually transmitted disease (STD) at the outpatient department of Mbarara Hospital. The emerging outcome of attitudinal beliefs regarding health consequences of partner referral were mainly positive. However, outcome beliefs relating to the relationship with the partners were mainly negative. Social influence for sexual partner referral was from health-care providers, partner(s), friends and relatives. The self-efficacy beliefs were mainly negative especially among women. Barriers hampering sexual partner referral were related to poor quality of health care, gender relations and type of sexual partners. There is a need to target these beliefs and self-efficacy expectations in health education and STD counselling and for more research to evaluate the psychosocial determinants of sexual partner referral quantitatively.

The social contexts of depression during motherhood: A study of explanatory models in Vietnam

BACKGROUND Major depression is increasing world-wide, and is the fourth leading cause of the global disease burden. Depression is rarely diagnosed in primary care settings in Vietnam, and those afflicted usually only seek professional care when the illness has become very severe. Depressive disorders affecting mothers are an important cause of low birth-weight, childhood stunting, under nutrition and adverse mental development, and a study has shown a 33% prevalence of postnatal depression symptoms in Ho Chi Minh City. METHODS The aim of this study was to elicit Illness Explanatory Models (EMs) of depression and postnatal depression from nine mothers and nine health workers. The study was conducted in a semi-rural area in Vietnam, and the EMs were elicited through semi-structured interviews where a case vignette of depression was used as the basis of questioning. RESULTS The EMs elicited were predominantly somatosocial in nature and the mothers assigned a strong personal responsibility for care. Psychiatric treatment and care was seldom recommended. Lack of communication was described as an important factor concealing depression, and together with the lack of care-seeking can be expected to impede effective treatment. LIMITATIONS The results of this study cannot be generalised beyond the group studied, or the context of Ba Vi, though we believe that analytical generalisation to other contexts can be made. CONCLUSION (CLINICAL RELEVANCE): The results of this study highlight the importance of depression and postnatal depression being diagnosed in primary care, and of a cross-sectoral approach for the prevention of depression in Vietnam, which takes into account the social causation of depression in women.