Maria Emmelin

Women's health in a rural setting in societal transition in Ethiopia.

There are reports indicating a worsening of womens health in transitional rural societies in sub-Saharan Africa in relation to autonomy, workload, illiteracy, nutrition and disease prevalence. Although these problems are rampant, proper documentation is lacking. The objective of this study was to reflect the health situation of women in rural Ethiopia. Furthermore, the study attempts to address the socio-demographic and cultural factors that have potential influence on the health of women in the context of a low-income setting. A combination of qualitative and quantitative research methods was utilised. In-depth interviews and a cross-sectional survey of randomly selected women were the main methods employed. The Butajira Rural Health Program demographic surveillance database provided the sampling frame. Heavy workload, lack of access to health services, poverty, traditional practices, poor social status and decision-making power, and lack of access to education were among the highly prevalent socio-cultural factors that potentially affect the health of women in Butajira. Though the majority of the women use traditional healers younger women show more tendency to use health services. No improvement of womens status was perceived by the younger generation compared to the older generation. Female genital mutilation is universal with a strong motivation to its maintenance. Nail polish has replaced the rite of nail-extraction before marriage in the younger generation. As the factors influencing the health of women are multiple and complex a holistic approach should be adopted with emphasis on improving access to health care and education, enhancing social status, and mechanisms to alleviate poverty.

Intimate partner violence and depression among women in rural Ethiopia: a cross-sectional study

BackgroundStudies from high-income countries have shown intimate partner violence to be associated with depression among women. The present paper examines whether this finding can be confirmed in a very different cultural setting in rural Ethiopia.MethodA community-based cross-sectional study was undertaken in Ethiopia among 1994 currently married women. Using the Composite International Diagnostic Interview (CIDI), cases of depressive episode were identified according to the ICD-10 diagnosis. Using a standardized questionnaire, women who experienced violence by an intimate partner were identified. A multivariate analysis was conducted between the explanatory variables and depressive status of the women, after adjusting for possible confounders.ResultsThe 12-month prevalence of depressive episode among the women was 4.8% (95% CI, 3.9% and 5.8%), while the lifetime prevalence of any form of intimate partner violence was 72.0% (95% CI, 70.0% and 73.9%). Physical violence (OR = 2.56, 95% CI, 1.61, 4.06), childhood sexual abuse (OR = 2.00, 95% CI, 1.13, 3.56), mild emotional violence (OR = 3.19, 95% CI, 1.98, 5.14), severe emotional violence (OR = 3.90, 95% CI, 2.20, 6.93) and high spousal control of women (OR = 3.30, 95% CI, 1.58, 6.90) by their partners were independently associated with depressive episode, even after adjusting for socioeconomic factors.ConclusionThe high prevalence of intimate partner violence, a factor often obscured within general life event categories, requires attention to consider it as an independent factor for depression, and thus to find new possibilities of prevention and treatment in terms of public health strategies, interventions and service provision.

Monitoring of HIV-1 infection prevalence and trends in the general population using pregnant women as a sentinel population: 9 years experience from the Kagera region of Tanzania.

Summary: In the Kagera region of Tanzania, a population‐based study was initiated in 1987 followed by the establishment of antenatal‐clinic‐based sentinel surveillance system in the town of Bukoba in 1990. Repeat studies in both populations in Bukoba in 1993 and 1996 made it possible to study the dynamics of HIV infection prevalence and incidence in the area. This study aims at comparing the findings from this sentinel surveillance system with those of cross‐sectional studies in the general population to assess its validity in estimating HIV prevalence and their trends in the general population. A multistage cluster sampling technique was used in the population‐based studies whereas the antenatal‐clinic‐based population was obtained by consecutively recruiting antenatal care attenders coming for the first time during a given pregnancy. Antibodies against HIV infection were tested using two independent enzyme‐linked immunosorbent assay (ELISA) antibody detection tests. Unlinked anonymous testing strategy was adopted for the sentinel population. Age‐adjusted prevalence among antenatal care attenders decreased from 22.4% (95% confidence interval [CI], 20.6‐25.2) in 1990 to 16.1% (95% CI, 15.9‐18.8) in 1993 and further to 13.7% (95% CI, 11.8‐14.3) in 1996. These results closely resemble those of the general population of adult women in the clinics catchment area (the town of Bukoba) where the ageadjusted prevalence of 29.1% (95% CI, 24.4‐34.6) in 1987 showed a decrease in the studies in 1993 18.7% (95% CI, 15.1‐23.0) and in 1996 14.9% (95% CI, 12.0‐17.1). The study indicates that general population trend estimates can be generated using sentinel surveillance data based on pregnant women visiting an antenatal clinic for the first time during a given pregnancy. The benefits of using this group outweigh its limitations that are brought about by possible selection bias. Continued surveillance of the epidemic based on antenatal care patients as a sentinel population is therefore recommended.

The implications of policy changes on the uptake of a PMTCT programme in rural Malawi: first three years of experience

Objective: To study how the demand for antenatal care (ANC), HIV testing and hospital delivery was influenced by policy changes among pregnant women in rural Malawi. Design: Retrospective analysis of monthly reports. Setting: Malamulo SDA hospital in Thyolo district, Makwasa, Malawi. Methods: Three hospital-based registers were analysed from 2005 to 2007. These were general ANC, delivery and Prevention of Mother to Child Transmission (PMTCT) registers. Observations were documented regarding the introduction of specific policies and when changes were effected. Descriptive analytical methods were used. Results: The ANC programme reached 4,528 pregnant mothers during the study period. HIV testing among the ANC attendees increased from 52.6 to 98.8% after the introduction of routine (opt-out) HIV testing and 15.6% of them tested positive. After the introduction of free maternity services, ANC attendance increased by 42% and the ratio of hospital deliveries to ANC attendees increased from 0.50:1 to 0.66:1. Of the HIV-tested ANC attendees, 52.6% who tested positive delivered in the hospital and got nevirapine at the time of delivery. Conclusions: Increasing maternity service availability and uptake can increase the coverage of PMTCT programmes. Barriers such as economic constraints that prevent women in poor communities from accessing services can be removed by making maternity services free. However, it is likely, particularly in resource-poor settings, that significant increases in PMTCT coverage among those at risk can only be achieved by substantially increasing uptake of general ANC and delivery services.

The pathway of obstructed labour as perceived by communities in south-western Uganda: a grounded theory study

Background : Obstructed labour is still a major cause of maternal and perinatal morbidity and mortality in Uganda, where many women give birth at home alone or assisted by non-skilled birth attendants. Little is known of how the community view obstructed labour, and what actions they take in cases where this complication occurs. Objective : The objective of the study was to explore community members’ understanding of and actions taken in cases of obstructed labour in south-western Uganda. Design : Grounded theory (GT) was used to analyse data from 20 focus group discussions (FGDs), 10 with women and 10 with men, which were conducted in eight rural and two urban communities. Results : A conceptual model based on the community members’ understanding of obstructed labour and actions taken in response is presented as a pathway initiated by womens desire to ‘protecting own integrity’ (core category). The pathway consisted of six other categories closely linked to the core category, namely: (1) ‘taking control of own birth process’; (2) ‘reaching the limit – failing to give birth’ (individual level); (3) ‘exhausting traditional options’; 4 ‘partner taking charge’; (5) ‘facing challenging referral conditions’ (community level); and finally (6) ‘enduring a non-responsive healthcare system’ (healthcare system level). Conclusions : There is a need to understand and acknowledge womens reluctance to involve others during childbirth. However, the healthcare system should provide acceptable care and a functional referral system closer to the community, thus supporting the communitys ability to seek timely care as a response to obstructed labour. Easy access to mobile phones may improve referral systems. Upgrading of infrastructure in the region requires a multi-sectoral approach. Testing of the conceptual model through a quantitative questionnaire is recommended.

How many lives is equity worth? A proposal for equity adjusted years of life saved.

STUDY OBJECTIVE: To present a formula for equity adjusted years of life saved (EYLS). DESIGN: A mailed questionnaire. The survey participants were given a scenario describing a trade off between a health maximization programme and a programme that is less efficient, but eliminates social inequalities. SETTING: Swedish politicians responsible for health care in the county councils. PARTICIPANTS: A sample of 449 Swedish politicians responsible for health care in the county councils. MAIN RESULTS: The principle of health maximization was rejected. Under certain conditions, the Swedish politicians are prepared to sacrifice 15 of 100 preventable deaths to achieve equity. Based on the results a formula for EYLS is presented. CONCLUSIONS: An equity adjusted formula for years of life saved has been proposed, but must be developed and revised according to each countrys specific conditions and value premises. In the future, such formulas could serve the purpose of incorporating explicit considerations of equity into cost effectiveness analyses.

Social capital and sexual behavior among Ugandan university students.

Background: Uganda has reduced its prevalence of HIV/AIDS from 18 to 6.5% within a decade. An important factor behind this might have been the response from faith-based voluntary organizations, which developed social capital for achieving this. Three behaviors have been targeted: Abstinence, Being faithful, and Condom use (the ABC strategy). The aim of this study was to explore the association between social capital and the ABC behaviors, especially with reference to religious factors. Methods: In 2005, 980 Ugandan university students responded to a self-administered questionnaire (response rate 80%). It assessed sociodemographic factors, social capital, importance of religion, sexual debut, number of lifetime sexual partners, and condom use. Logistic regression analysis was applied as the main analytical tool. Results: Thirty-seven percent of the male and 49% of the female students had not had sexual intercourse. Of those with sexual experience, 46% of the males and 23% of the females had had three or more lifetime sexual partners, and 32% of those males and 38% of the females stated they did not always use condoms with a new partner. Low trust in others was associated with a higher risk for not always using condoms with a new partner among male students (OR 1.7, 95% CI 1.1–2.8), and with a lower risk for sexual debut among female students (OR 0.5, 95% CI 0.3–0.9). Non-dominant bridging trust among male students was associated with a higher risk for having had many sexual partners (OR1.8, 95% CI 1.2–2.9). However, low trust in others was associated with a greater likelihood of sexual debut in men, while the opposite was true in women, and a similar pattern was also seen regarding a high number of lifetime sexual partners in individuals who were raised in families where religion played a major role. Conclusions: In general, social capital was associated with less risky sexual behavior in our sample. However, gender and role of religion modified the effect so that we can not assume that risky sexual behavior is automatically reduced by increasing social capital in a highly religious society. The findings indicate the importance of understanding the interplay between social capital, religious influence, and gender issues in HIV/AIDS preventive strategies in Uganda.

An epidemiological approach towards measuring the trade-off between equity and efficiency in health policy

The concept of social welfare functions has been discussed in health economic literature, as it provides a way of examining the extent to which society is prepared to accept a trade-off between efficiency and equity. In this paper requirements for meaningful empirical estimates of the willingness to accept lower per capita health status in order to achieve greater equity are examined. Results from a pilot study aimed at testing the proposed measurement procedure are reported. They show that at least two thirds of the politicians who participated are prepared to accept a lower growth in per capita health in exchange for increased equity. Accordingly, we found a weak empirical support for the common health economic assumption that only total health benefit should guide the use of resources.

Home deliveries: implications for adherence to nevirapine in a PMTCT programme in rural Malawi.

Abstract Although nevirapine (NVP) is provided by prevention of mother-to-child-transmission (PMTCT) of HIV programmes to be taken at onset of labor independent of place of delivery, few studies have assessed adherence to NVP outside the hospital setting. This study aimed to follow women in a PMTCT programme up to delivery and to assess the adherence to the prophylaxis in rural Malawi. A total of 75 HIV-positive women were registered in the PMTCT at Malamulo SDA hospital between January and June 2005. Forty women (53%) delivered in the hospital and 35 (47%) did not. Of the 35 women who delivered at home, it was possible to trace 27 (77.2%). All women who delivered in the hospital took their NVP tablets and all their babies had NVP syrup except one baby who died soon after delivery. Of the 27 traced women who had not delivered in the hospital, 16 (59.3%) had access to NVP and had taken their tablets during labor. However, none of their babies was taken back to the health facility for NVP syrup. Traditional birth attendants might be crucial in efforts aiming to increase adherence to NVP among women and their babies.

HIV-1 infection prevalence and incidence trends in areas of contrasting levels of infection in the Kagera region, Tanzania, 1987-2000.

This study aimed at assessing the extent to which decline in HIV infection prevalence reflects decline in incidence in 3 areas with contrasting initial exposure to the HIV epidemic in the Kagera region of Tanzania. A population sample was recruited for the baseline study in 1987 through a multistage cluster sampling technique to determine HIV prevalence. Seronegative individuals identified in the baseline and subsequent studies were followed up for 3 years to yield trends in incidence that were compared for the 3 areas. The overall age-adjusted HIV-1 prevalence in the high-prevalence area of Bukoba urban declined significantly from 24.2% in 1987 to 18.2% in 1993 and later to 13.3% in 1996 (P = 0.0001). In the medium-prevalence area of Muleba, overall age-adjusted prevalence declined significantly from 10.0% in 1987 to 6.8% in 1996 and later to 4.3% in 1999 (P = 0.0003), whereas in the low-prevalence area of Karagwe the prevalence declined from 4.5% in 1987 to 2.6% in 1999 (P = 0.01). In all 3 areas, the most significant decline was consistently observed among women in the age group 15-24 years. No age group exhibited a significant upward prevalence trend. The HIV-1 incidence for Bukoba urban declined from 47.5 to 9.1 per 1000 person-years of observation in 1989 and 1996, respectively, whereas in Muleba it decreased from 8.2 to 3.9 in 1989 and 2000, respectively. Sex-specific estimates indicated a significant decline among women in the high-prevalence area of Bukoba urban from 51.5 to 9.2 per 1000 person-years at risk (P = 0.001). It is concluded that the HIV-1 epidemic in Kagera is on the decrease as reflected by the decline in HIV-1 incidence and prevalence trends particularly among the 15-24 year olds. The decline in the 3 areas of differing magnitude implies that the HIV/AIDS epidemic may be arrested early without necessarily peaking to saturation levels.