Isaac K. Nyamongo

A Qualitative Study of Condom Use among Married Couples in Kampala, Uganda

Twenty-five years into the HIV/AIDS epidemic, condom use among married/stable couples remains low and under-researched in developing countries, even countries with high HIV prevalence. Introducing condoms into a long-standing relationship, in spite of HIV risk, is likely to be awkward. We conducted a qualitative study in Kampala, Uganda, with 39 couples reporting 100% condom use in the previous three months. The women were recruited from among women in a clinical trial who were using condoms and whose partners also agreed to participate. Twenty-two of the women and six of the men reported having taken the initiative to suggest condom use; the remaining couples disagreed who raised the subject first. Women used insistence, refusal to have sex, persuasion, and condoms for family planning or to protect children, which helped to deflect distrust and get their partner to agree. Some men resisted initially but their reactions were often more positive than expected. Men’s reasons for accepting condoms were to please their partner, protect her from HIV, protect their children, protect themselves and, in some cases, continue having other partners. Although condom use is a couple behaviour, an encouraging environment and condom availability are all crucial to increasing condom use by couples in settings like Uganda. Résumé Vingt-cinq ans après le début de l’épidémie de VIH/SIDA, l’utilisation des préservatifs par les couples mariés/stables demeure faible et suscite peu de recherches dans les pays en développement, même avec une forte prévalence du VIH. Introduire les préservatifs dans une relation durable peut être délicat. Nous avons réalisé une étude qualitative à Kampala, Ouganda, auprès de 39 couples ayant notifié une utilisation à 100% de préservatifs les trois mois précédents. Les femmes ont été recrutées parmi les femmes d’un essai clinique qui utilisaient des préservatifs et dont les partenaires avaient accepté de participer. Vingt-deux femmes et six hommes ont indiqué avoir pris l’initiative de proposer un préservatif ; les autres couples ne savaient pas qui avait soulevé la question en premier. Les femmes faisaient preuve d’insistance ou de persuasion, refusaient d’avoir des rapports, invoquaient la planification familiale ou la protection des enfants, ce qui aidait à endormir la méfiance et à obtenir le consentement du partenaire. Certains hommes commençaient par résister, mais leurs réactions étaient souvent plus positives que prévu. Les hommes acceptaient le préservatif pour faire plaisir à leur partenaire, la protéger du VIH, protéger leurs enfants, se protéger et, dans certains cas, continuer d’avoir d’autres partenaires. L’utilisation de préservatifs est un comportement de couple, mais un environnement encourageant et la disponibilité de préservatifs sont des facteurs essentiels pour relever l’utilisation de préservatifs par les couples dans des pays comme l’Ouganda. Resumen Tras 25 años de epidemia del VIH/SIDA, el uso del condón entre las parejas casadas/estables continúa siendo bajo y subinvestigado en los países en desarrollo, incluso en los países con alta prevalencia de VIH. Probablemente resulte difícil asimilar el uso del condón en una antigua relación, pese al riesgo de contraer VIH. Realizamos un estudio cualitativo en Kampala, Uganda, con 39 parejas que informaron utilizar el condón el 100% durante los tres meses anteriores. Las mujeres fueron reclutadas de entre mujeres en un ensayo clínico quienes usaban condones y cuyas parejas también acordaron participar. Veintidós de las mujeres y seis de los hombres informaron haber tomado la iniciativa de sugerir el uso del condón; las otras parejas discreparon en cuanto a quién fue el primero en plantear el tema. Las mujeres utilizaron insistencia, denegación de sexo, persuasión y condones para la planificación familiar o para proteger a los niños, lo cual ayudó a desviar la desconfianza y lograr que su pareja estuviera de acuerdo. Algunos hombres se resistieron inicialmente pero sus reacciones a menudo fueron más positivas que lo esperado. Los motivos de los hombres para aceptar el uso del condón fueron: complacer a su pareja, protegerla del VIH, proteger a sus hijos, protegerse a sí mismos y, en algunos casos, continuar teniendo otras parejas. Aunque el uso del condón es un comportamiento de pareja, un ambiente de apoyo y la disponibilidad del condón son fundamentales para incrementar su uso en lugares como Uganda.

Home case management of malaria: an ethnographic study of lay people's classification of drugs in Suneka division, Kenya.

Summary Lay people in malaria‐affected regions frequently have to choose from many over‐the‐counter malaria management drugs, requiring them to be able to identify these medications and distinguish between them. Lay people make these distinctions at two levels – age of the patient and the whether he or she has fever, pain or malaria. Sometimes decisions are based on incorrect information given by friends and relatives, causing prolonged suffering to the patient, exascerbating chloroquine resistance and leading to resistance to the sulfodoxine/pyrymethamine drugs now recommended as first‐line treatment in Kenya.

A critical assessment of the WHO responsiveness tool: lessons from voluntary HIV testing and counselling services in Kenya.

BackgroundHealth, fair financing and responsiveness to the users needs and expectations are seen as the essential objectives of health systems. Efforts have been made to conceptualise and measure responsiveness as a basis for evaluating the non-health aspects of health systems performance. This study assesses the applicability of the responsiveness tool developed by WHO when applied in the context of voluntary HIV counselling and testing services (VCT) at a district level in Kenya.MethodsA mixed method study was conducted employing a combination of quantitative and qualitative research methods concurrently. The questionnaire proposed by WHO was administered to 328 VCT users and 36 VCT counsellors (health providers). In addition to the questionnaire, qualitative interviews were carried out among a total of 300 participants. Observational field notes were also written.ResultsA majority of the health providers and users indicated that the responsiveness elements were very important, e.g. confidentiality and autonomy were regarded by most users and health providers as very important and were also reported as being highly observed in the VCT room. However, the qualitative findings revealed other important aspects related to confidentiality, autonomy and other responsiveness elements that were not captured by the WHO tool. Striking examples were inappropriate location of the VCT centre, limited information provided, language problems, and concern about the quality of counselling.ConclusionThe results indicate that the WHO developed responsiveness elements are relevant and important in measuring the performance of voluntary HIV counselling and testing. However, the tool needs substantial revision in order to capture other important dimensions or perspectives. The findings also confirm the importance of careful assessment and recognition of locally specific aspects when conducting comparative studies on responsiveness of HIV testing services.

The contribution of social science research to malaria prevention and control

Social science has had an integral role in defining strategies against malaria as affirmed by the growing number of articles in scientific journals and the forging of international partnerships. In spite of this numerous factors impede the integration of social science knowledge and practice into malaria research and programs. First many malaria control personnel physicians and epidemiologists overlook the different complementary disciplines of social science and may only have a superficial knowledge of this type of research. A second factor contributing to the less than optimal contribution of social science research to malaria control is that in many cases those who carry out behavioral research for control programs may have had some training in rapid assessment techniques but limited or no training in social science theory and methodology. The final factor is the expectation that employing a social scientist for a rapid assessment will be sufficient to ensure greater acceptance of whatever intervention is being provided. It is suggested that social scientists need to be more proactive in challenging current orthodoxies and in identifying new intervention methods such as longer periods of ethnographic fieldwork and sharing of experiences working on different diseases of poverty.

The treatment pathways followed by cases of human African trypanosomiasis in western Kenya and eastern Uganda

Abstract Although early diagnosis and treatment are key factors in the effective control of human African trypanosomiasis (HAT), many cases of the disease delay taking appropriate action, leading to untold suffering. As a better understanding of treatment-seeking behaviour should help in identifying the obstacles to early diagnosis and effective treatment, the treatment pathways followed by 203 former HAT cases in western Kenya and eastern Uganda have recently been explored. About 86% of the HAT cases had utilized more than two different healthcare options before being correctly diagnosed for HAT, with about 70% each using more than three different health facilities. Only about 8% of the cases reported that they had been correctly diagnosed the first time they sought treatment. Just over half (51%) of the HAT cases had been symptomatic for >2 months before being correctly diagnosed for HAT, and such time lags in diagnosis contributed to 72% of the cases receiving their first appropriate treatment only in the late stage of the disease. The likelihood of a correct diagnosis increased with the time the case had been symptomatic. These observations indicate an urgent need to build the diagnostic capacity of the primary healthcare facilities in the study area, so that all HAT cases can be identified and treated in the early stage of the disease.

Health Seeking Behaviour of Mothers of Under-Five-Year-Old Children in the Slum Communities of Nairobi, Kenya.

Prompt and appropriate health seeking is critical in the management of childhood illnesses. This paper examines the health seeking behaviour in under-five child morbidity. It explores in detail actions taken by 28 mothers when their children become sick. Sixty-two in-depth interviews with mothers were conducted from four study communities. The mothers were identified from a demographic surveillance system. The interviews were tape-recorded, transcribed and thematically analysed. The study shows that mothers classify childhood illnesses into four main categories: (1) not serious—coughs, colds, diarrhoea; (2) serious but not life-threatening—malaria; (3) sudden and serious—pneumonia; and (4) chronic and therefore not requiring immediate action—malnutrition, tuberculosis, chronic coughs. This classification is reflected in the actions taken and time it takes to act. Shops are used as the first source of healthcare, and when the care moves out of the home, private health facilities are used more compared to public health facilities, while even fewer mothers consult traditional healers. Consequently we conclude that there is a need to train mothers to recognize potentially life-threatening conditions and to seek appropriate treatment promptly. Drug vendors should be involved in intervention programs because they reach many mothers at the critical time of health seeking.

Healthcare priority setting in Kenya: a gap analysis applying the accountability for reasonableness framework

In resource-poor settings, the accountability for reasonableness (A4R) has been identified as an important advance in priority setting that helps to operationalize fair priority setting in specific contexts. The four conditions of A4R are backed by theory, not evidence, that conformance with them improves the priority setting decisions. This paper describes the healthcare priority setting processes in Malindi district, Kenya, prior to the implementation of A4R in 2008 and evaluates the process for its conformance with the conditions for A4R. In-depth interviews and focus group discussions with key players in the Malindi district health system and a review of key policy documents and national guidelines show that the priority setting process in the district relies heavily on guidelines from the national level, making it more of a vertical, top-down orientation. Multilateral and donor agencies, national government, budgetary requirements, traditions and local culture influence the process. The four conditions of A4R are present within the priority setting process, albeit to varying degrees and referred to by different terms. There exists an opportunity for A4R to provide a guiding approach within which its four conditions can be strengthened and assessed to establish whether conformance helps improve on the priority setting process.

Children as caregivers of older relatives living with HIV and AIDS in Nyang'oma division of western Kenya.

There is growing debate about the situations of children who care for a relative with HIV-related illness, especially in developing countries with high HIV prevalence. In particular, there is inadequate information on the long-term consequences of children taking on this caregiving role. The article reanalyses data collected between January and November 2006 in a rural setting in western Kenya where 19 children caring for a total of 15 people living with HIV or AIDS (PLHIV) participated. Data were collected through in-depth interviews, participant observation, focus group discussions and narratives. The findings show that children regularly become involved in caregiving due to lack of a responsible adult to perform the role, which may be as a result of HIV stigma and rejection of the care recipient by extended family members and neighbours or because of cultural barriers. Fulfilling the responsibilities of caregiving had profound repercussions for the childrens lives, including psychological distress, physical burden, dropping out of school, participation in wage labour, and forced early marriage. Financial needs pushed some girls into transactional sexual relations, predisposing them to the risks of unwanted pregnancy or sexually transmitted infections. Since the children providing care for PLHIV are themselves vulnerable, we recommend that they should be targeted with support.

Assessing Intracultural Variability Statistically Using Data on Malaria Perceptions in Gusii, Kenya

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

Ecological niche modelling of Rift Valley fever virus vectors in Baringo, Kenya.

Background Rift Valley fever (RVF) is a vector-borne zoonotic disease that has an impact on human health and animal productivity. Here, we explore the use of vector presence modelling to predict the distribution of RVF vector species under climate change scenario to demonstrate the potential for geographic spread of Rift Valley fever virus (RVFV). Objectives To evaluate the effect of climate change on RVF vector distribution in Baringo County, Kenya, with an aim of developing a risk map for spatial prediction of RVF outbreaks. Methodology The study used data on vector presence and ecological niche modelling (MaxEnt) algorithm to predict the effect of climatic change on habitat suitability and the spatial distribution of RVF vectors in Baringo County. Data on species occurrence were obtained from longitudinal sampling of adult mosquitoes and larvae in the study area. We used present (2000) and future (2050) Bioclim climate databases to model the vector distribution. Results Model results predicted potential suitable areas with high success rates for Culex quinquefasciatus, Culex univitattus, Mansonia africana, and Mansonia uniformis. Under the present climatic conditions, the lowlands were found to be highly suitable for all the species. Future climatic conditions indicate an increase in the spatial distribution of Cx. quinquefasciatus and M. africana. Model performance was statistically significant. Conclusion Soil types, precipitation in the driest quarter, precipitation seasonality, and isothermality showed the highest predictive potential for the four species.