Valerie J. Ehlers

Exploring contraceptive use differentials in Sub-Saharan Africa through a workforce lens.

Globally 56% of all married women are using a modern method of contraception up from less than 10% in 1960. In sub-Saharan Africa however only 19% of married women are using a modern method of contraception. Since nearly all family planning services require assistance from a health worker access to health workers is a principal supply-side determinant of family planning service use. This technical brief presents findings from a study that explored if and how health workforce measures differ between eastern and western Africa in an effort to identify factors that may have helped some countries to achieve important gains in contraceptive prevalence while other countries have not. The findings raise questions about whether government commitment and certain policy choices vis-a-vis health workforce distribution and qualifications—even when absolute levels of health worker density are low—could make a difference in the provision of family planning services in resource-constrained countries.Supporting individuals as they disclose their HIV serostatus may lead to a variety of individual and public health benefits. However, many women living with HIV are hesitant to disclose their HIV status due to fear of negative outcomes such as violence, abandonment, relationship dissolution and stigma.

Adherence to antiretroviral treatment by adults in a rural area of Botswana

Background: As antiretroviral therapy (ART) is becoming increasingly available to people in developing countries, ART adherence challenges assume ever greater significance. Often underlying treatment failure is the fact that suboptimal adherence to ART is the strongest predictor of failure to achieve viral suppression below the level of detection. Objectives: The studys main objective was to identify factors affecting ART adherence levels, as well as the impact on immunologic and virologic responses in adult patients in one rural district in Botswana. Methods: A cross-sectional quantitative survey, was used. Structured interviews were conducted with 300 ART patients between November 2011 and February 2012. Data were analysed, then presented in charts, graphs and frequency tables. Results: The prevalence of non-adherence to ART was 14.0%. Motivators of good adherence included disclosure of HIV-positive status to more than one person, frequent adherence counselling, self-efficacy for adherence to ART, positive interactions between patients and healthcare providers; and using adherence partners. Barriers to adherence were forgetfulness, transportation costs to and from the clinic, time away from work and side-effects. There was a strong positive correlation between adherence, CD4 counts and viral load. Adherence was closely tied to immunologic and virologic improvements. Respondents with poor adherence were likely to have unsuppressed viral loads (OR 12.98, 95% CI 4.9–34). Conclusion: Adherence to ART is closely tied to virologic, immunologic, and clinical outcomes. Increases in adherence levels resulted in significant improvements in these outcomes. Near perfect adherence, however, is required to maximise the likelihood of long-term clinical success, which could pose challenges to many ART patients, especially in resource-limited rural settings.

Cardiopulmonary resuscitation knowledge and skills of registered nurses in Botswana

BACKGROUND In Botswana nurses provide most health care in the primary, secondary and tertiary level clinics and hospitals. Trauma and medical emergencies are on the increase, and nurses should have cardiopulmonary resuscitation (CPR) knowledge and skills in order to be able to implement effective interventions in cardiac arrest situations. OBJECTIVE The objective of this descriptive study was to assess registered nurses’ CPR knowledge and skills. METHOD A pre-test, intervention and re-test time-series research design was adopted, and data were collected from 102 nurses from the 2 referral hospitals in Botswana. A multiple-choice questionnaire and checklist were used to collect data. RESULTS All nurses failed the pre-test. Their knowledge and skills improved after training, but deteriorated over the three months until the post-test was conducted. CONCLUSION The significantly low levels of registered nurses’ CPR skills in Botswana should be addressed by instituting country-wide CPR training and regular refresher courses

An audit of diagnosis and treatment of tuberculosis in Ethiopia

Abstract Background Despite the existence of national tuberculosis guidelines (NTG) in Ethiopia, the incidence and prevalence of tuberculosis did not decline markedly. Audits could attempt to determine whether or not healthcare professionals actually implemented these guidelines, as non-implementation could contribute to suboptimal tuberculosis treatment outcomes. Aim To evaluate healthcare providers’ implementation of Ethiopias NTG during the diagnosis and treatment of tuberculosis in order to enhance tuberculosis treatment outcomes. Methods A descriptive, cross-sectional study design was used. Results Healthcare providers implemented the NTG during tuberculosis diagnosis for female (60.9%; n = 67) and male (56.1%; n = 69) patients. The correct numbers of anti-tuberculosis pills, complying with the NTG recommendations, were prescribed for 91.8% (n = 101) of the women and for 90.2% (n = 111) of the men. However, both over- and under-prescriptions of anti-tuberculosis drugs occurred. There was an over-diagnosis of smear-negative pulmonary tuberculosis. Only 2.6% (n = 2) of the 76 smear-negative pulmonary tuberculosis patients had been diagnosed correctly. Conclusion Implementation of the NTG should be enhanced, especially with regard to the diagnosis of smear-negative pulmonary tuberculosis patients and the correct prescription of anti-tuberculosis drugs. This would help to increase the number of correctly-diagnosed and -treated tuberculosis patients, improve tuberculosis treatment outcomes, decrease the spread of tuberculosis and prevent the development of multi-drug-resistant tuberculosis strains.

Health-related quality of life of antiretroviral treatment defaulters in Botswana.

Background Antiretroviral therapy (ART) improves patients’ health-related quality of life (HRQoL). Defaulting from ART has detrimental consequences, including the development of viral resistance, treatment failure and increased risks of disease progression. Little is known about the quality of life of ART defaulters and reasons for discontinuing their ART. Objectives This study sought to measure the HRQoL of ART patients in Botswana who were on ART for up to 5 years but had discontinued treatment for at least 3 months, and to identify factors associated with ART defaulting. Method We conducted a cross-sectional study with 104 eligible respondents in four ART clinics in south eastern Botswana. We assessed respondents’ HRQoL using the World Health Organization Quality of Life Questionnaire for HIV short form. Clinical information was obtained from respondents’ medical records. Data were analysed using SAS version 9.2. Results Reasons for discontinuing ART were inaccessible clinics (22.4%), feeling better (21.4%), running out of pills (11.2%), depression (8.2%), lack of care and/or support (8.2%), failure to understand instructions (7.7%), medications’ side effects (6.1%) and alcohol abuse (3.1%). In multivariate analyses, respondents aged 36–45 years had a 0.03 lower independence HRQoL score compared to those aged 35 and younger (β = -0.03; 95% confidence interval: -1.72, -1.66). Despite defaulting from their ART, respondents’ calculated HRQoL scores were moderate. Conclusion This study highlights the need to enhance ART adherence in order to improve the HRQoL of people living with HIV and/or AIDS.

Women’s utilisation of prevention of mother-to-child transmission of human immunodeficiency virus services in Addis Ababa, Ethiopia

Background Human immunodeficiency virus (HIV) mother-to-child transmission (MTCT) can be prevented when HIV-positive pregnant women use effective prevention of mother-to-child transmission (PMTCT) of HIV services. Approximately 50% of HIV-positive pregnant women used free PMTCT services in Ethiopia. Aim This study attempted to identify factors influencing women’s utilisation of PMTCT services. Addressing such factors could enable more Ethiopian women to use PMTCT services. The study investigated whether women’s utilisation of services was affected by socio-demographic issues, their partners’ known HIV status, disclosure of their HIV-positive status, stigma and discrimination, and satisfaction with services. Setting Prenatal clinics in Addis Ababa, Ethiopia. Methods A quantitative, cross-sectional study design was used and 384 questionnaires were completed by women who used PMTCT services in Addis Ababa. Results No socio-demographic characteristic prevented women’s utilisation of PMTCT services, nor did stigma, discrimination or disclosure of their HIV-positive status. Most respondents’ partners with unknown HIV status did not know that the respondents used PMTCT services. Most women were satisfied with the PMTCT services. Conclusions Prevention of mother-to-child transmission services should remain accessible to all HIV-positive women in Ethiopia. Concurrent HIV partner testing should be encouraged with appropriate counselling. HIV-positive pregnant women should be encouraged to disclose their status to their partners so that they need not use PMTCT services secretly. Patients’ high levels of satisfaction with PMTCT services are a good indicator for rolling out PMTCT initiatives at other facilities. Future research should focus on HIV-positive pregnant women who do not use PMTCT services.

Nursing care at its finest: a personal experience.

As a nurse educator, researcher and supervisor of postgraduate studies, I have taught nursing theories and debated about nursing, nurses’ roles and nursing care. Students’ questions, as to precisely how any specific nursing theory could assist their patients, remained difficult to answer until 2015 when I was admitted to hospital with severe vomiting and diarrhoea and an extremely high infection count. During the critical stages of my illness, I heard nurses talking to me, felt them touching me and encouraging me to ‘hang in there’ as at least Ebola had been excluded by laboratory tests, and a Salmonella infection had been confirmed. This was not much comfort because no person I had encountered with a severe Salmonella infection had survived. Frequent bouts of diarrhoea and vomiting for several days were humiliating and exhausting, but the nurses provided supportive care and hygienic surroundings. They ensured that all my medicines were administered as prescribed, observed my vital signs regularly and were alert to the possibility of septic shock and complications of dehydration. Due to my high infection count, the nurses had to dress up like astronauts before entering my room. Despite this time-consuming procedure, they attended to all aspects of my care while managing to implement infection control measures. After 8 days I was discharged from hospital, only to be readmitted 1 week later for an urgent cholecystectomy. One nurse cared for me and a few other post-operative patients and ensured that our pain levels remained under control. This nurse’s re-assurance, competence and availability facilitated our post-operative recovery. During my recuperation, I realized which nursing theory contextualized my experiences as a patient. It is Virginia Henderson’s view that nurses are helping ‘. . . people, sick or well, in the performance of those activities contributing to health, its recovery (or to a peaceful death), that they would perform unaided if they had the necessary strength, will, or knowledge. It is likewise the function of nurses to help people become independent as rapidly as possible’ (Henderson, 1991 in Halloran & Thorson 1996:79). The nurses who cared for me also displayed all virtues mentioned by the American Nurses Association (ANA 2015) in their code of ethics, namely knowledge, skill, wisdom, patience, compassion, honesty, altruism and courage. The accomplishments of the nurses could partly be attributed to the prevailing culture of care in this particular hospital because ‘. . . a care culture seems to be dependent on how care is interpreted and given meaning by the personnel as well as the organization’ (Rytterstrom et al. 2008:697). Nurses who participated in Enns & Gregory’s (2007:339) Canadian study believed that ‘. . . the extent of support that existed on the acute care units directly affected their ability to provide quality care for their patients and co-workers. . . Support from peers, unit managers and supervisors are the key to fostering teamwork development and enhancement. Nursing is a profession that demands teamwork’. The hospital’s doctors and nurses were instrumental not only in saving my life but also in restoring my health because they managed to ‘. . .integrate and apply knowledge, skills, judgments and personal attributes required to practice safely and ethically in a specific role and setting’ (International Council of Nurses, 2008:8).

Infant feeding practices implemented by HIV-positive mothers in South Africa

Infant feeding is a critical part of the prevention of vertical transmission of HIV process [1], especially in resource poor countries. Thus the infant feeding options selected by HIVpositive mothers influence their babies’ risk of HIV infection. Exclusive breastfeeding for the first six months has a limited risk of vertical transmission of HIV. Although exclusive formula feeding carries no such risk, formula feeding might be inaccessible to some HIV-positive mothers and/or unsafe for some babies. Formula feeding it could increase infant mortality rates due to diarrhoea and malnutrition in resource-limited countries [1, 2]. Mixing breastfeeding with formula feeds increases the babies’ risk of HIV infection. Giving solid foods to babies younger than six months of age could also increase this risk.

An assessment of the outcomes of prevention of mother-to-child transmission of HIV services in Addis Ababa, Ethiopia

Background This article assessed maternal and neonatal outcomes amongst users of prevention of mother-to-child transmission (PMTCT) of HIV services in Addis Ababa, Ethiopia. Objectives The study aimed to assess the health outcomes (antiretroviral prophylaxis versus antiretroviral treatment, CD4 counts, World Health Organization (WHO) stages of illness, other illnesses) of women who had used these services, as well as the HIV status of their babies and the infant feeding method adopted. Methods A quantitative, cross sectional, retrospective cohort design was used. Document reviews were conducted with a sample of 384 mother-infant pairs (out of a population of 796) who had used PMTCT services. Results All respondents were using prophylactic antiretrovirals or antiretroviral therapy, but some were on the wrong treatment based on their CD4 counts. The CD4 counts increased four times more for women on antiretroviral treatment than for those on prophylactic antiretrovirals. The WHO’s stages of HIV illness did not improve but deteriorated in some cases, and 52 other illnesses were recorded. Out of the 384 infants, 6.0% (n = 23) were HIV-positive. Most respondents opted for exclusive breast feeding but some used mixed feeding during the first six months of their infants’ lives, despite having received health education related to infant feeding options. Conclusion The respondents’ improved CD4 counts were inadequate to improve their World Health Organization stages of HIV illness. Some babies received mixed feeding during the first six months of their lives and 6% of the babies were HIV-positive despite their mothers’ utilisation of PMTCT services.

Nurses Perceptions about Reasons for Womenâs Non-utilisation of CervicalCancer Screening Services in Malawi

Malawi offers free cervical cancer screening services in some government health institutions, but most cervical cancer cases are diagnosed during the late inoperable stages. This study attempted to identify, from nurse/midwives’ perspectives, reasons why most Malawian women fail to use cervical cancer screening services. A cross-sectional, exploratory, descriptive design was used and semi-structured interviews were conducted to collect data from the nurses. Purposively selected 14 nurse/midwives were interviewed. Malawian women’s non-utilisation of cervical cancer screening services was reportedly influenced by a shortage of nurse/midwives, inadequate health education, limited resources, unfavourable screening schedules, and geographic distances from these services. These identified factors need to be addressed to enable more women to use the available free cervical cancer screening services in Malawi, so that cervical cancer can get diagnosed during the early stages while effective treatment is available. Unless this happens, most cases of cervical cancer in Malawi will continue to be diagnosed during the terminal inoperable stages of cervical cancer.