Master's degree in sexual and reproductive health: enhancing career development opportunities for midwives in Mali.

BACKGROUND: Midwives' contribution to improving outcomes for women and newborns depends on factors such as quality of pre-service training, access to continuing professional development, and the presence of an enabling work environment. The absence of opportunities for career development increases the likelihood that health professionals, including midwives, will consider leaving the profession due to a lack of incentives to sustain and increase motivation to remain in the field. It also limits the opportunities to better contribute to policy, training, and research. This study aimed to assess the influence of a Master in Sexual and Reproductive Health (SRH) at the INFSS on midwives' career progression in Mali. METHODS: This mixed methods study was conducted using an online questionnaire, semi-structured interviews, and a document review. The study participants included graduates from two cohorts (N = 22) as well as employers, managers, and teachers of the graduates (N = 20). Data were analysed according to research questions, comparing, and contrasting answers between different groups of respondents. RESULTS: The study revealed that graduates enrolled in the programme primarily to improve their knowledge and skills in management and public health. The graduates' expected roles are those of programme and health project manager and participation in planning and monitoring activities at national or sub-national level. The managers expected the programme to reflect the needs of the health system and equip midwives with skills in management and planning. The Master enhanced opportunities for graduates to advance their career in fields they are not usually working in such as management, research, and supervision. However, the recognition of the master's degree and of the graduates' profile is not yet fully effective. CONCLUSION: The master's degree in SRH is a capacity building programme. Graduates developed skills and acquired advanced knowledge in research and management, as well as a postgraduate degree. However, the master programme needs to be better aligned with health system needs to increase the recognition of graduates' skills and have a more positive impact on graduates' careers.

Drivers of child marriage in specific settings of Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia - findings from the Yes I Do! baseline study.

BACKGROUND: Child marriage persists in many countries and has severe impacts on health, education, economic and social status of girls. Child marriage has many interlinked causes. This study aimed to explore the drivers of child marriage in specific contexts in Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia. METHODS: The study combined a household survey among youth (15-24 years) with focus group discussions and interviews conducted with youth (15-24 years) and parents. A variety of community stakeholders were interviewed as well. Logistic regression was done to explore associations between individual and family-level characteristics of young women and the occurrence of child marriage. Transcripts were analysed using an inductive approach. Narratives on the main drivers of child marriage across study contexts were written and inspired by the theory of normative spectrum. RESULTS: A lack of education was associated with the occurrence of child marriage in Ethiopia, Kenya and Zambia. In all countries, teenage pregnancy was associated with child marriage. In Ethiopia, Kenya and Mozambique, fathers' education seemed a protective factor for child marriage. Narratives of study participants showed that in Ethiopia, Indonesia and (to a lesser extent) Kenya, child marriage was perceived as an 'appropriate practice' to avoid premarital sex or pregnancy, whether it involved sex with or without consent. In all countries, child marriage was driven by difficult economic circumstances, which were often intertwined with disapproved social circumstances, in particular teenage pregnancy, in case of Kenya, Malawi, Mozambique and Zambia. These circumstances made child marriage an 'acceptable practice'. Some youth, particularly in Indonesia, made their own choices to marry early, making child marriage a 'possible practice'. CONCLUSIONS: Multiple intersecting drivers, which were present in different degrees in each country setting, influenced the occurrence of child marriage. We found that child marriage is a manifestation of social norms, particularly related to girls' sexuality, which are intersecting with other factors at individual, social, material, and institutional level - most prominently poverty or economic constraints. Child marriage was, in some cases, a result of girls' agentic choices. Efforts to prevent child marriage need to take these realities of girls and their families into account.

What makes a woman? Understanding the reasons for and circumstances of female genital mutilation/cutting in Indonesia, Ethiopia and Kenya.

This study presents the reasons for, and circumstances of, female genital mutilation/cutting (FGM/C) in Indonesia, Ethiopia and Kenya. Data were collected in 2016 and 2017 by means of a household survey conducted with young people (15-24 years) and through focus group discussions, in-depth interviews and key informant interviews with youth and community stakeholders. The study findings confirm previously documented reasons for FGM/C, noting that these reasons are interconnected, and are rooted in gender norms. These reasons drive the alterations of bodies to produce a 'cultured' body in the form of the 'pure body' among Sundanese and Sasak peoples in Indonesia, the 'tame' body among the Amhara people in Ethiopia and the 'adult body' among the Maasai people in Kenya. While health workers and parents are important decision-makers in each setting, young Maasai women are, at times, able to exercise their agency to decide whether to undergo FGM/C, owing to their older age at circumcision. Changing legal and social contexts in each setting have brought about changes in the practice of FGM/C such as increased medicalisation of the procedure in Indonesia. The clear links between the different drivers of FGM/C in each setting demonstrate the need for context-specific strategies and interventions to create long-lasting change.

Attitude and intention of migrant populations in the Netherlands regarding female genital mutilation/cutting.

BACKGROUND: Due to migration, the practice female genital mutilation/cutting (FGM/C) has become an issue of concern in high-resource countries such as the Netherlands. It was therefore of utmost importance to explore the attitude and intention of migrant populations in the Netherlands towards FGM/C, which may be leveraged to promote its elimination. Therefore, the aim of the present study was to explore the attitude and intention of migrant populations in the Netherlands regarding FGM/C. METHODS: A qualitative study design was employed using Theory of Planned Behaviour (TPB) as a framework for the analysis. Data were collected using focus-group discussions (FGDs) and individual interviews. The FGDs and individual interviews were audio-recorded and transcribed verbatim. The main topics of the interviews were based on the constructs of TPB (attitude, subjective norms, perceived behavioral control and intention). Thus, concerning the development of categories, we opted for a hybrid form using a deductive as well as an inductive approach. RESULTS: A total of 55 participants, 15 men and 40 women (9 born in the Netherlands) participated in the study. The findings showed that as a result of migration and regardless of country of origin and gender, many participants have changed their attitudes towards the abandonment of FGM/C. None of the participants intended to have FGM/C performed on their daughters. Generally, the social pressure to perform FGM/C seems to be lower in the Netherlands when compared to the country of origin. Most participants felt confident in their ability to resist social pressure. However, some participants feared that they might succumb to social pressure or feared that their daughters would undergo FGM/C without their consent. CONCLUSION: This study aimed to explore the attitude and intention of migration populations in the Netherlands regarding FGM/C. Our findings showed that the study participants had no intention to perform FGM/C on their daughters. As a consequence of acculturation process, interest in the practice of FGM/C could wane following migration. Nonetheless, some pressure to perform FGM/C still exists after migration. Newly arrived migrants and those more vulnerable to social pressure, may benefit from educational interventions that increases knowledge and awareness about various aspects of the practice, with an emphasis on empowering those individuals in facing social pressure.

Female genital mutilation/cutting (FGM/C), also known as female circumcision, is a practice which involves the cutting away of part or the whole of the external female genital organs. The practice has no health benefits, and it harms girls and women in many ways. The migration of girls and women to high-resource countries such as the Netherlands, has led to the development of programs to prevent FGM/C and to care for those affected by FGM/C.The purpose of this study was to explore the attitude and intention of migrant populations in the Netherlands towards FGM/C. The results of this study may be relevant in the development of interventional programs to promote the elimination of FGM/C. Our findings showed that the study participants had no intention to perform FGM/C on their daughters. Many participants may have changed their attitudes towards the abandonment of FGM/C. The social pressure to perform FGM/C seems to be lower in the Netherlands when compared to the country of origin, however, some pressure to perform FGM/C still exist after migration. In this regard, educational programs are necessary, with an emphasis on empowering vulnerable groups such as newly arrived migrants in facing social pressure.

Using a Rapid Knowledge Translation Approach for Better Sexual and Reproductive Health and Rights in Bangladesh, Burundi, Indonesia, and Jordan.

INTRODUCTION: Translation of knowledge into policy and practice is important to prevent sexual reproductive health and rights (SRHR)-related morbidity and mortality and ensure access to rights. Existing approaches to knowledge translation are often relatively rigid and implicitly assume linear processes, leading to time-consuming processes that are not tailored to countries' needs. APPROACH: SRHR knowledge platforms designed and implemented a collaborative rapid improvement model for knowledge translation (CRIM-KT) in Burundi, Bangladesh, Indonesia, and Jordan. The approach consisted of learning sessions and action periods aimed at improving policies and practices addressing the prevention of child marriage and teenage pregnancies. To evaluate the approach, a participatory action learning process took place throughout the implementation (September 2017 and January 2019). An end evaluation was conducted using a desk review of project documentation, in-depth interviews, and a focus group discussion to document the process, outcomes, and lessons learned. ACHIEVEMENTS: In Indonesia, a local government policy was changed that aims to prevent child marriage by avoiding misinterpretation of a local cultural practice. In Jordan, the cabinet endorsed a national action plan to prevent child marriage and changes in practice took place. In Burundi, no tangible changes in policy and practice in SRHR were observed. In Bangladesh, practice changed by strengthening coordination for collaboration and exchange among stakeholders to prevent child marriage. In all countries, the approach considerably strengthened participants' knowledge translation capacities. CONCLUSION: The CRIM-KT led to improvements in policy and practice in a relatively short time frame and different contexts. This can be explained by the systematic, structured, and participatory approach, allowing for contextual adaptation and involvement of stakeholders, as well as the cross-learning on 2 levels (international and country collaboration teams). The principles of the CRIM-KT may be further developed and applied in other fields in global health to strengthen knowledge translation processes.

Being dragged into adulthood? Young people's agency concerning sex, relationships and marriage in Malawi, Mozambique and Zambia.

This study aimed to explore how young people exercise agency in rural Malawi, Mozambique and Zambia in relation to sex, relationships and marriage, to inform local programmes aiming to prevent teenage pregnancy and child marriage. In each country, focus group discussions with young people and parents, in-depth interviews with young people and a variety of other participants, and a household survey with young people (15-24 years) were conducted. We found that (child) marriage was often a response to teenage pregnancy, which was highly prevalent in all study areas. Young people's aspirations to enter adulthood were influenced by their life circumstances. Initiation ceremonies symbolised the transition to adulthood and gave social endorsement to young people to start engaging in (often unprotected) sexual activity. Given the uncertain socio-economic context, resource constraints led families to marry off their daughters; or girls themselves to marry early to relieve the burden on their families, but also to get pregnant as a 'next step' towards adulthood. Transactional sex was common. These intersecting cultural, social and economic contextual factors constrained young women's agency, more as compared to young men. However, young women did manoeuvre within contextual constraints to exercise a degree of agency.

Improving maternal health services through social accountability interventions in Nepal: an analytical review of existing literature.

BACKGROUND: The persistent quality gap in maternal health services in Nepal has resulted in poor maternal health outcomes. Accordingly, the Government of Nepal (GoN) has placed emphasis on responsive and accountable maternal health services and initiated social accountability interventions as a strategical approach simultaneously. This review critically explores the social accountability interventions in maternal health services in Nepal and its outcomes by analyzing existing evidence to contribute to the informed policy formulation process. METHODS: A literature review and desk study undertaken between December 2018 and May 2019. An adapted framework of social accountability by Lodenstein et al. was used for critical analysis of the existing literature between January 2000 and May 2019 from Nepal and other low-and-middle-income countries (LMICs) that have similar operational context to Nepal. The literature was searched and extracted from database such as PubMed and ScienceDirect, and web search engines such as Google Scholar using defined keywords. RESULTS: The study found various social accountability interventions that have been initiated by GoN and external development partners in maternal health services in Nepal. Evidence from Nepal and other LMICs showed that the social accountability interventions improved the quality of maternal health services by improving health system responsiveness, enhancing community ownership, addressing inequalities and enabling the community to influence the policy decision-making process. Strong gender norms, caste-hierarchy system, socio-political and economic context and weak enforceability mechanism in the health system are found to be the major contextual factors influencing community engagement in social accountability interventions in Nepal. CONCLUSIONS: Social accountability interventions have potential to improve the quality of maternal health services in Nepal. The critical factor for successful outcomes in maternal health services is quality implementation of interventions. Similarly, continuous effort is needed from policymakers to strengthen monitoring and regulatory mechanism of the health system and decentralization process, to improve access to the information and to establish proper complaints and feedback system from the community to ensure the effectiveness and sustainability of the interventions. Furthermore, more study needs to be conducted to evaluate the impact of the existing social accountability interventions in improving maternal health services in Nepal.

The influence of quality and respectful care on the uptake of skilled birth attendance in Tanzania.

BACKGROUND: An increase in the uptake of skilled birth attendance is expected to reduce maternal mortality in low- and middle-income countries. In Tanzania, the proportion of deliveries assisted by a skilled birth attendant is only 64% and the maternal mortality ratio is still 398/100.000 live births. This article explores different aspects of quality of care and respectful care in relation to maternal healthcare. It then examines the influence of these aspects of care on the uptake of skilled birth attendance in Tanzania in order to offer recommendations on how to increase the skilled birth attendance rate. METHODS: This narrative review employed the "person-centered care framework for reproductive health equity" as outlined by Sudhinaraset (2017). Academic databases, search engines and websites were consulted, and snowball sampling was used. Full-text English articles from the last 10 years were included. RESULTS: Uptake of skilled birth attendance was influenced by different aspects of technical quality of maternal care as well as person-centred care, and these factors were interrelated. For example, disrespectful care was linked to factors which made the working circumstances of healthcare providers more difficult such as resource shortages, low levels of integrated care, inadequate referral systems, and bad management. These issues disproportionately affected rural facilities. However, disrespectful care could sometimes be attributed to personal attitudes and discrimination on the part of healthcare providers. Dissatisfied patients responded with either quiet acceptance of the circumstances, by delivering at home with a traditional birth attendant, or bypassing to other facilities. Best practices to increase respectful care show that multi-component interventions are needed on birth preparedness, attitude and infrastructure improvement, and birth companionship, with strong management and accountability at all levels. CONCLUSIONS: To further increase the uptake of skilled birth attendance, respectful care needs to be addressed within strategic plans. Multi-component interventions are required, with multi-stakeholder involvement. Participation of traditional birth attendants in counselling and referral can be considered. Future advances in information and communication technology might support improved quality of care.

The prevalence and risk of Female Genital Mutilation/Cutting among migrant women and girls in the Netherlands: An extrapolation method.

OBJECTIVES: The aim of the study was (I) to estimate the prevalence of Female Genital Mutilation/Cutting (FGM/C) and distribution of types of FGM/C among migrant girls and women in the Netherlands, and (II) to estimate the number of migrant girls at risk of being cut in the immediate future. METHODS: National population-based survey data regarding FGM/C prevalence were applied to female migrants in the Netherlands who migrated from 29 countries with available nationally representative data on FGM/C. RESULTS: As of January 1st 2018, there were 95,588 female migrants residing in the Netherlands, originating from 29 countries with available nationally representative data on FGM/C. Our findings suggest that about 41,000 women had undergone FGM/C, of which 37% had Type III (infibulation). In total 4,190 girls are estimated to be at risk of FGM/C in the next 20 years, of whom 394 were first-generation girls. CONCLUSION: These findings show the urgency to develop appropriate strategies and policies to prevent FGM/C, to protect girls and women at risk of the practice, and to provide adequate services and support for those affected by FGM/C in the Netherlands.

Advocating safe abortion: outcomes of a multi-country needs assessment on the potential role of national societies of obstetrics and gynecology.

In 2019 the International Federation of Gynecology and Obstetrics (FIGO) embarked on an initiative that aims to strengthen the capacity of 10 national societies of obstetrics and gynecology (ObGyn) in advocacy for safe abortion. In 2018 needs assessments that entailed a desk study, interviews, and stakeholder workshops were conducted in Benin, Cameroon, Côte d'Ivoire, Kenya, Mali, Mozambique, Panama, Peru, Uganda, and Zambia. The general aim of the needs assessments was to gain a deeper understanding of the contextual situation and identify the needs of ObGyn societies in relation to safe abortion advocacy. This paper provides a cross-country analysis of the outcomes of the needs assessments and reflects on the capabilities, barriers, and opportunities to strengthen this role of ObGyn societies. Common barriers, such as unavailability of services, lack of technical guidance, unawareness and ambiguity about the legal framework, provider attitudes, and abortion stigma, pose challenges for ObGyn societies to work constructively on safe abortion advocacy. However, ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers' advocacy role. Five strategies were developed to strengthen the capacity of ObGyn societies in safe abortion advocacy.

Exploring linkages between research, policy and practice in the Netherlands: perspectives on sexual and reproductive health and rights knowledge flows.

BACKGROUND: The attention to and demand for stronger linkages between research, policy and practice are increasing, especially in fields concerned with sensitive and challenging issues such as sexual and reproductive health and rights (SRHR). The study described in this article was conducted in the Netherlands among actors working in international development, especially the domain of SRHR. It explores the perceived flow of knowledge between research, policy and practice, the perceived impeding factors, and suggested strategies for improvement. METHODS: A narrative literature review was performed and 28 key informants were interviewed between May and August 2015. Most interviewees were either active or passive members of Share-Net Netherlands, an SRHR knowledge platform. All interviews, which lasted 70 minutes on average, were recorded, transcribed verbatim and coded in MAXQDA. RESULTS: Linkages between research, policy and practice are many and diffuse. The demands for and supplies of knowledge within and across the fields vary and do not always match, which is shown by participants' research purposes and approaches. Participants identified various barriers to strengthening knowledge flows, including a lack of familiarity with practices in other fields, power relations and the undervaluation of tacit knowledge. They suggested a more visible and concrete demand for and supply of knowledge, the development of a joint knowledge agenda, more opportunities for the interdisciplinary creation of knowledge, and the development of a system for learning and sharing knowledge. CONCLUSION: This study shows the willingness to undertake, and the perceived advantages of, interdisciplinary dialogues and joint creation of knowledge to advance SRHR research, policies and practices. Whereas barriers to the flow of knowledge may maintain present understandings of knowledge and of whose knowledge is valid, enabling factors, such as interactions between research, policy and practice in knowledge-sharing activities, may challenge such perceptions and create an enabling environment for generating innovative knowledge and increasing knowledge use. Knowledge platforms are recommended to place more emphasis on sharing and documenting tacit knowledge through interdisciplinary dialogues, to address power relations and to set criteria for interdisciplinary funding.

Mental health problems associated with female genital mutilation.

Aims and method To study the mental health status of 66 genitally mutilated immigrant women originating from Africa (i.e. Somalia, Sudan, Eritrea and Sierra Leone). Scores on standardised questionnaires (Harvard Trauma Questionnaire-30, Hopkins Symptom Checklist-25, COPE-Easy, Lowlands Acculturation Scale) and demographic and psychosocial correlates were analysed. Results A third of the respondents reported scores above the cut-off for affective or anxiety disorders; scores indicative for post-traumatic stress disorder were presented by 17.5% of women. Type of circumcision (infibulation), recollection of the event (a vivid memory), coping style (avoidance, in particular substance misuse) and employment status (lack of income) were significantly associated with psychopathology. Clinical implications A considerable minority group, characterised by infibulated women who have a vivid memory of the circumcision and cope with their symptoms in an avoidant way, reports to experience severe consequences of genital circumcision. In terms of public healthcare, interventions should target these groups as a priority.

Factors associated with unintended pregnancy, poor birth outcomes and post-partum contraceptive use among HIV-positive female adolescents in Kenya.

BACKGROUND: Although the experiences of unintended pregnancies and poor birth outcomes among adolescents aged 15-19 years in the general population are well documented, there is limited understanding of the same among those who are living with HIV. This paper examines the factors associated with experiencing unintended pregnancies, poor birth outcomes, and post-partum contraceptive use among HIV-positive female adolescents in Kenya. METHODS: Data are from a cross-sectional study that captured information on pregnancy histories of HIV-positive female adolescents in four regions of Kenya: Coast, Nairobi, Nyanza and Rift Valley provinces. Study participants were identified through HIV and AIDS programs in the four regions. Out of a total of 797 female participants, 394 had ever been pregnant with 24% of them experiencing multiple pregnancies. Analysis entails the estimation of random-effects logit models. RESULTS: Higher order pregnancies were just as likely to be unintended as lower order ones (odds ratios [OR]: 1.2; 95% confidence interval [CI]: 0.8-2.0) while pregnancies occurring within marital unions were significantly less likely to be unintended compared to those occurring outside such unions (OR: 0.1; 95% CI: 0.1-0.2). Higher order pregnancies were significantly more likely to result in poor outcomes compared to lower order ones (OR: 2.5; 95% CI: 1.6-4.0). In addition, pregnancies occurring within marital unions were significantly less likely to result in poor outcomes compared to those occurring outside such unions (OR: 0.3; 95% CI: 0.1-0.9). However, experiencing unintended pregnancy was not significantly associated with adverse birth outcomes (OR: 1.3; 95% CI: 0.5-3.3). There was also no significant difference in the likelihood of post-partum contraceptive use by whether the pregnancy was unintended (OR: 0.9; 95% CI: 0.5-1.5). CONCLUSIONS: The experience of repeat unintended pregnancies among HIV-positive female adolescents in the sample is partly due to inconsistent use of contraception to prevent recurrence while poor birth outcomes among higher order pregnancies are partly due to abortion. This underscores the need for HIV and AIDS programs to provide appropriate sexual and reproductive health information and services to HIV-positive adolescent clients in order to reduce the risk of undesired reproductive health outcomes.

Coping and chronic psychosocial consequences of female genital mutilation in The Netherlands.

OBJECTIVE: The study presented in this article explored psychosocial and relational problems of African immigrant women in The Netherlands who underwent female genital mutilation/cutting (FGM/C), the causes they attribute to these problems--in particular, their opinions about the relationship between these problems and their circumcision--and the way they cope with these health complaints. DESIGN: This mixed-methods study used standardised questionnaires as well as in-depth interviews among a purposive sample of 66 women who had migrated from Somalia, Sudan, Eritrea, Ethiopia or Sierra Leone to The Netherlands. Data were collected by ethnically similar female interviewers; interviews were coded and analysed by two independent researchers. RESULTS: One in six respondents suffered from post-traumatic stress disorder (PTSD), and one-third reported symptoms related to depression or anxiety. The negative feelings caused by FGM/C became more prominent during childbirth or when suffering from physical problems. Migration to the Netherlands led to a shift in how women perceive FGM, making them more aware of the negative consequences of FGM. Many women felt ashamed to be examined by a physician and avoided visiting doctors who did not conceal their astonishment about the FGM. CONCLUSION: FGM/C had a lifelong impact on the majority of the women participating in the study, causing chronic mental and psychosocial problems. Migration made women who underwent FGM/C more aware of their condition. Three types of women could be distinguished according to their coping style: the adaptives, the disempowered and the traumatised. Health care providers should become more aware of their problems and more sensitive in addressing them.

Maternal health care utilization among HIV-positive female adolescents in Kenya.

CONTEXT: Given the health risks of HIV/AIDS and the risks of teenage pregnancy in general, pregnant HIV-positive adolescents in Kenya need maternal health care services that account for their HIV status. However, research on their access to and use of these services is scant. METHODS: To examine maternal health care utilization, pregnancy history data collected in 2009 on 506 pregnancies among 393 HIV-positive female adolescents aged 15-19 enrolled in HIV/AIDS programs in Kenya were analyzed. Multilevel logit models were used to identify the variables associated with use of prenatal care, prevention of mother-to-child transmission (PMTCT) of HIV, skilled attendance at pregnancy outcomes and postnatal/postabortion care. RESULTS: Use of PMTCT services was less common than use of prenatal care services among HIV-positive female adolescents (67% of pregnancies vs. 84%). These adolescents made four or more prenatal care visits in only 45% of pregnancies. In addition, use of skilled care during or after abortion or miscarriage was low (20%). The odds of receiving PMTCT services and skilled assistance were higher in Nairobi than in other regions (odds ratios, 3.8 and 2.7, respectively). HIV-positive adolescents were less likely to use maternal health care services for higher-order pregnancies than for lower-order pregnancies (0.4-0.6). They were, however, more likely to receive prenatal care and PMTCT services when their husband rather than someone else was responsible for the pregnancy (3.7 and 4.9, respectively). CONCLUSION: Pregnant, HIV-positive adolescents need maternal health care services--including PMTCT care--that take into account parity, paternity dynamics and regional variations in use.

Performances of sexuality counselling: a framework for provider-client encounters.

OBJECTIVE: Adequately assessing quality of care poses enormous challenges. While conducting fieldwork, we were struck by the need for a framework that encapsulates provider-client encounters. Little evidence exists concerning the most effective training, and management of health staff engaged in sexuality, reproductive health and HIV related health services. This paper proposes a framework for analysing these encounters. METHODS: This paper is based on five studies. Mixed method studies were carried out in Uganda and Kenya. Two additional studies looked into the effect of HIV on health worker performance in Uganda and Zambia. As a result of the findings, a desk review looked into factors affecting provider-client encounters in order to improve the responsiveness of programs. RESULTS: Positive encounters between provider and client are built on trust and respect, consist of communication, practice and process, and are influenced by space, place and context. Combining these facets allows for a better understanding of their interactions. CONCLUSION: A holistic perspective in which the breadth of dynamics and processes are described should be used when assessing the quality of provider-client encounters. PRACTICE IMPLICATIONS: Within training, management and human resource planning, these dynamics need to be utilized to realize the best possible care.

'We are also dying like any other people, we are also people': perceptions of the impact of HIV/AIDS on health workers in two districts in Zambia.

In countries with a high AIDS prevalence, the health workforce is affected by AIDS in several ways. In Zambia, which has a prevalence rate of 16.5%, a study was carried out in 2004 with the aim to: explore the impact of HIV/AIDS on health workers, describe their coping mechanisms and recommend supportive measures. The qualitative study was complemented by a survey using self-administered questionnaires in four selected health facilities in two rural districts in Zambia, Mpika and Mazabuka. It is one of the few studies to have explored the impact of HIV/AIDS from the perspective of health workers and managers in the region. Thirty-four in-depth interviews and five group discussions were conducted with health workers, managers and volunteers, and 82 self-administered questionnaires were filled out by health workers. In addition, burnout among 42 health workers was measured using the Maslach Burnout Inventory (MBI). The MBI measures three components that contribute to burnout: emotional exhaustion, depersonalization and personal accomplishment. The results show that in both districts, HIV/AIDS has had a negative impact on workload and has considerably changed or added tasks to already overburdened health workers. In Mpika, 76% of respondents (29/38), and in Mazabuka, 79% (34/44) of respondents, expressed fear of infection at the workplace. HIV-positive health workers remained 'in hiding', did not talk about their illness and suffered in silence. Despite the fact that health workers were still relatively motivated, emotional exhaustion occurred among 62% of the respondents (26/42). The interviews revealed that counsellors and nurses were especially at risk for emotional exhaustion. In each of the selected facilities, organizational support for health workers to deal with HIV/AIDS was either haphazardly in place or not in place at all. AIDS complicates the already difficult work environment. In addition to health workers, management also needs support in dealing with AIDS at the workplace.

Health care seeking behaviour and utilisation of traditional healers in Kalabo, Zambia.

OBJECTIVE: To identify traditional healers in the catchment area of Kalabo District Hospital and to investigate determinants which play a role in the choice between different health care options, and to explore possibilities for increasing co-operation between the District Hospital and traditional healers. METHODS: In a cross-sectional comparative and descriptive study, a combination of both quantitative and qualitative methods was used. A total of 12 health workers, 13 traditional healers and 100 community representatives were interviewed, using (semi)-structured questionnaires. A focus group discussion was held with 12 traditional healers. RESULTS: This study shows that all respondents are willing to visit the hospital if they fall ill in future, and 88% of the respondents will visit a traditional healer. More women than men visit traditional healers, but the men who do visit them, do so more frequently. Level of education is not an important determinant. Increasing age leads to more frequent visits to both the hospital and traditional healers. Almost half of the respondents (49%) only have to walk less than 30 min to a traditional healer, but the hospital is the same distance for only 34% of the respondents. Waiting time turned out to be an important factor: in the hospital, 48% of the respondents are not helped within time, and only 28% are not helped in time by the traditional healer. Demon possession, mbaci, kanono and infertility are typical health problems for which people visit a traditional healer. The cost of treatment from a traditional healer is usually one cow, but only if the patient is cured. Satisfaction was measured at 89% after hospital treatment, and 74% after treatment from a traditional healer. If dissatisfied with the traditional healer, 86% would consider attending the hospital.

'Client satisfaction'--guidelines for assessing the quality of leprosy services from the clients' perspective.

In order to ensure that leprosy patients are detected and treated adequately, it is essential that they are satisfied with the services provided. Their satisfaction can be analysed by assessing the quality of the services from a client perspective. This will give crucial information for the identification of strengths and weaknesses of leprosy services, e.g. in areas such as health seeking behaviour and regularity of treatment. It necessitates, however, that special attention is given to clients' opinions and ideas, both of which are rarely included in reviews and evaluations of leprosy programmes. Hence, an initiative was taken to formulate guidelines for the conducting of a study on client satisfaction. These guidelines were pre-tested in two countries, Nepal and Brazil. The development and contents of these guidelines are highlighted and discussed in this paper.