Health providers' perceptions of adolescent sexual and reproductive health care in Swaziland.

AIM: To explore health providers' perceptions of adolescent sexual and reproductive healthcare services in Swaziland. METHODS: Fifty-six healthcare providers, working in 11 health clinics in Swaziland in 2005, were surveyed using a semi-structured questionnaire. The data were analysed by descriptive statistics and content analysis to identify key themes. FINDINGS: Most participants were women with a mean age of 36 years and a mean number of 6 years in the profession. Services provided included STIs/HIV/AIDS advice, pre- and post-test counselling and testing on HIV, contraceptives and condom use. Half of the nurses/midwives had no continued education and lacked supervision on adolescent sexual and reproductive health care. The majority had unresolved moral doubts, negative attitudes, values and ethical dilemmas towards abortion care between the law, which is against abortion, and the reality of the adolescents' situation. Forty-four wanted to be trained on post-abortion care while eight on how to perform abortions. Twenty-six wanted the government to support adolescent-friendly services and to train heathcare providers in adolescent sexual and reproductive health services. CONCLUSION: The curricula within nursing and midwifery preservice education need to be reviewed to incorporate comprehensive services for adolescents. There is need for provision of comprehensive services for adolescents in Swaziland and appropriate youth-friendly services at all levels. There is need for nurse/midwifery participation, advocacy and leadership in policy development.

Kinetics of carbamazepine and its 10,11-epoxide metabolite in children.

The plasma steady-state concentration of carbamazepine (CBZ) and its metabolite (carbamazepine-10,11-epoxide, CBZ-epoxide) was assessed in 43 children (2-15 yr) on CBZ (Tegretol) treatment. Twenty of the children received combined treatment with other anticonvulsant drugs simultaneously. The plasma concentrations were in the same range as had been found in adult patients on corresponding doses. Only a weak correlation was noted between dose and plasma CBZ concentration in the group of children on single-drug treatment, and there was no correlation in the group of children on combined drug regimen. Plasma levels of CBZ correlated with those of the metabolite. Children on combined treatment had lower CBZ concentration and, expressed as percent of the parent drug, the metabolite concentration was significantly higher than in children treated only with CBZ. In 2 children the plasma half-life of CBZ was estimated and found to be slightly shorter than has previously been reported in adults. In evaluating the plasma level-effect relationship of CBZ, the plasma concentration of the CBZ-epoxide should be measured simultaneously because of its anticonvulsant effect and interindividual variability.

Loading and conventional dose therapy with phenytoin in children: kinetic profile of parent drug and main metabolite in plasma.

Epileptic children were given phenytoin (DPH) in loading (four doses of 4.4 to 6.3 mg/kg/dose given 8-hourly and then 6 mg/kg/day) or conventional (5 to 9 mg/kg/day) doses. Plasma levels of DPH and its main metabolite (p-OH-DPH) were measured by a mass fragmentographic technique. Plasma DPH levels of more than 10 mug/ml were achieved within 16 to 38 hr in the children given loading doses and within 5 days in the conventionally dosed children. No immediate side effects were noted, but within 8 to 10 days 9 of 13 children developed a generalized skin rash. Plasma p-OH-DPH (free or conjugated) paralleled DPH during the accumulation phase but not during DPH elimination. The ratio of metabolite to DPH in plasma showed both an interindividual variation and an inverse relation to the level of DPH. Identical twins in the study had a similar ratio and plasma level-time course profile. It is concluded that the loading dose regiment achieves an appropriate plasma level of DPH rapidly, that saturation kinetics are operative for p-OH-DPH formation, that the ratio of metabolite to DPH in plasma is an individual characteristic in children, and that further studies on the delayed toxicity are needed before the loading dose regimen can be recommended.

Autoinduction of carbamazepine metabolism in children examined by a stable isotope technique.

Autoinduction of carbamazepine (CBZ) metabolism was investigated in 3 children (10 to 13 yr old) using tetradeuterium-labeled CBZ (CBZ-D4). Prior to treatment, CBZ and CBZ-D4 given as a mixture had almost identical kinetics in each patient. During maintenance therapy with CBZ, part of the CBZ was exchanged for CBZ-D4 on 3 occasions. The clearance of CBZ-D4 given on the second day of therapy was 0.036 +/- 0.003 1 . kg-1 . hr-1, whereas it had been 0.028 +/- 0.003 before treatment. After 17 to 32 days of treatment, clearance doubled (0.056 +/- 0.010) but during the next 4 mo there was no further increase, indicating that the autoinduction was complete within 1 mo. As a corollary there was a decrease in steady-state plasma levels.

Utilisation of reproductive health services in rural Vietnam; are there equal opportunities to plan and protect pregnancies?

STUDY OBJECTIVES: To describe the utilisation of reproductive health services (family planning, antenatal care, and delivery services) and the socioeconomic determinants for utilisation of health services. DESIGN: This was a cross sectional survey, using a multistage sampling technique. SETTING: Tien Hai district, Thai Binh Province, Vietnam. Altogether 1132 mothers with children under 5 years of age were interviewed about antenatal, delivery, and family planning services utilisation during a five year period (1987-92). MAIN RESULTS: Seventy per cent of the women used contraceptive methods, with the intrauterine device being the most common. The use of the intrauterine device was positively associated with the number of children alive but not with other sociodemographic factors in the mothers. Thirty per cent of the women had attended an antenatal clinic for check ups during their last pregnancy. It was found that mothers with fewer deliveries, higher education, and who were Buddhist or of no religion had utilised antenatal services more frequently than the others. Seventy five per cent of the mothers in this study had been assisted by health professionals at their last delivery. Those mothers with fewer deliveries, higher education, who were Buddhist or had no religion, and had sufficient to eat were more likely to have their births attended by health professionals. CONCLUSIONS: In spite of a relatively high education level in the population and services which are generally available, there was an under utilisation of antenatal and delivery care and there was no equal opportunity for different groups of mothers to use these services. Family planning services were, however, frequently used and were used to the same extent by different groups of mothers. Except for abortion, alternatives to the intrauterine device method were rarely available. If pregnancies are to be protected in an efficient way in rural Vietnam, reproductive health care must be strengthened and efforts should be made to reach the women who are not using these services at present.

Psycho-social determinants for sexual partner referral in Uganda: quantitative results.

The purpose of this study was to investigate the factors influencing sexual partner referral using the Attitude-Social influence self-Efficacy model as a guiding theoretical framework. The data was collected in an interview survey with 236 women and 190 men attending a sexually transmitted disease clinic in Kampala, Uganda. Intention, attitude, subjective norm, self-efficacy, and past behaviour in relation to partner referral as well as partner type were collected at time 1. At time 2 (1 month later), sexual partner referral was assessed. Intention, self-efficacy, and previous behaviour predicted partner referral for women whereas intention, partner type and previous behaviour predicted partner referral for men. For the women the strongest predictors for intention were self-efficacy followed by attitude and partner type. For the men the strongest predictor was attitude followed by partner type and self-efficacy. Social influence was a better predictor of intention for women than for men. An analysis of underlying cognitive beliefs discriminating those who referred and those who did not refer the sexual partner showed that attitudinal beliefs were the most important for men whereas self-efficacy beliefs were the most important for women. The targeting of the gender-based discriminatory beliefs in intervention may improve compliance with sexual partner referral.

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

In order to understand lay people's 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 akawutka, 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.

PIP: This article aims to understand the perception of lay people in Uganda towards sexually transmitted infections (STIs). Focus group discussions and semi-structured interviews were conducted in the communities and statistical analysis through the Chi-square test was used to treat the data. Results showed that causes and modes of transmission of STIs were known to the people. An STI was perceived as a natural disease from an agent called "akakoko or akawuka," although female infertility, one of the common STI complications, was perceived as a supernatural ailment. People infected with HIV/AIDS were accepted by the society, but a person with another STI was stigmatized, in the sense that, they are infecting themselves when they already knew of AIDS. For STI prevention, avoiding and preventing sexual promiscuity was the most common method, but the people demonstrated a strong negative attitude towards the use of condom. Common among the respondents is the use of traditional healers for treating STIs and self-treatment of the disease.

STD care in Zambia: an evaluation of the guidelines for case management through a syndromic approach.

Clinical diagnosis of STDs is unreliable and therefore constitutes a poor basis for choice of treatment. A syndromic approach has been suggested to increase effectiveness of treatment in resource poor settings. Algorithms for the treatment of STD syndromes were evaluated. A total of 436 patients were followed; cure rates were defined and estimated for genital ulcer disease (GUD), urethral and vaginal discharge. Cure rates for the discharge syndromes were high, 97-98%, for both sexes. The cure rate for GUD was 83% for female and 69% for male patients. A higher prevalence of syphilis in the female study population probably contributed to this. It is likely that a large proportion of the treatment failures were due to decreased susceptibility of Haemophilus ducreyi to trimethoprim-sulpha. The determination of cure rates met with a number of methodological problems. This makes it difficult to evaluate the algorithms as part of routine activities, as suggested earlier by WHO.

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.

Case management and patient reactions: a study of STD care in a province in Zambia.

Sexually transmitted disease (STD) case management was evaluated through observation and interviews at 2 urban and 4 rural health centres and 2 district hospital STD clinics in one urban and 2 rural districts in Central Province, Zambia. The analysis was limited to 59 patients (42 men and 17 women) who paid first visits for their disease and were managed by a clinical officer. The evaluation suffered from the lack of a standard for case management. Results showed that the patients engaged in risky sexual behaviour without being aware of the risks. At the health institutions, few patients were informed about condoms, the risk of HIV, and abstinence from sex during treatment and few were asked to notify their partners. Clinical officers with special STD training performed better than others but sill informed only one-fifth of the patients. Few clinical officers managed patients according to the syndromic approach recommended by the STD control programme.

PIP: Sexually transmitted disease (STD) case management was evaluated through observation and interviews at two urban and four rural health centers and two district hospital STD clinics in one urban and two rural districts in Central Province, Zambia. The analysis was limited to 59 patients (42 men and 17 women) who made first visits for their disease and were managed by a clinical officer. The evaluation suffered from the lack of a standard for case management. Results showed that the patients engaged in risky sexual behavior without being aware of the risks. At the health institutions, few patients were informed about condoms, the risk of HIV, and abstinence from sex during treatment and few were asked to notify their partners. Clinical officers with special STD training performed better than others, but still informed only one-fifth of the patients. Few clinical officers managed patients according to the syndromic approach recommended by the STD control program.

Family planning in Vietnam--women's experiences and dilemma: a community study from the Red River Delta.

In traditional Vietnamese culture the expectations on women were to get at least one son, who could carry on the lineage. In the 1980s, a two-child population policy was introduced and family planning campaigns intensified. The aim of this study was to explore women's experience of family planning in relation to the potentially conflicting demands on their fertility. Data on reproductive histories and contraceptive use were collected in a random sample survey among 206 women of reproductive age in Thai Binh province, northern Vietnam. Qualitative data were obtained in interviews with a selected group of women. Over half of the women used modern contraception, mainly the intrauterine device (IUD). The perceived side-effects of the IUD were higher than those reported by local health workers or from clinical studies of the same IUD. Women's problems in fertility regulation are discussed in the broader context of a society in transition. The importance of male progeny was still strong. Many families with 'only' daughters had a third child, contrary to the two-child policy. It is suggested that conflicting demands on women's fertility are reflected in the high rates of IUD-complaint and psychosomatic side-effects. Improved services and wider contraceptive choice are needed, as well as research on the interaction between population policies, sociocultural change and women's health.

Primary health concept revisited: where do people seek health care in a rural area of Vietnam?

The government of Vietnam is committed to promote and secure equity in access to health care for all citizens. The current rapid changes towards a market economy may challenge the government's wish for maintaining equity, especially for low income and vulnerable groups. The aim of this study was to investigate aspects of access and utilisation of health care of rural people. The study included a random sample of 1075 out of the 11,547 households in the Field Laboratory in Bavi district, northern Vietnam and a structured questionnaire was used. The results indicate that self-treatment is common practice and private providers are an important source of health services not only for those who are better off but also for poor households. The costs for health care are substantial for households, and lower income groups spent a significantly higher proportion of their income on health care than the rich did. The poor are deterred from seeking health care more often than the rich and for financial reason. As regards sources for payments, the poor relied much more on borrowing money to pay for their health care needs, while those who are better off relied mostly on household savings. A burden of high cost for treatment implies high risks for families to fall into a 'medical poverty trap'. Our findings suggest a need for developing risk-sharing schemes (co-payment, pre-payment and insurance), and appropriate allocation of scarce public resources. We suggest that the private health care sector needs both support and regulations to improve the quality and access to health care by the poor.

Traditional healers and the treatment of sexually transmitted illnesses in rural Zambia.

Lately there has been increasing interest regarding the practice of traditional healers and their use of indigenous plants to treat illnesses. Twenty-three local healers (n'ganga) in Chiawa, rural Zambia, were interviewed about knowledge, practices, and their use of indigenous plants in the diagnosis and treatment of sexually transmitted illnesses (STIs) among male clients. They were also asked about their perceptions of modern medicine. The study revealed that all the n'ganga diagnosed and treated three main types of STIs. They named them as: songeya, doroba and bola-bola. They treated the illnesses with Strychnos cocculoides; Musa species; Solanum delegoense; Ximenia caffra; Diplorynchus condylocarpon; and Croton megalobotrys. Ten of the n'ganga perceived modern medicine to be effective against STIs and five of them sometimes referred some of the clients to the local health centre. It is being argued that a scheme to incorporate the n'ganga into STD control activities in which they can be utilised to refer clients to modern medical facilities can be beneficial. Given the necessary health information and support, the n'ganga may effectively execute this scheme.

Persecution and behavior: a report of refugee children from Chile.

A Swedish study of 50 newly resettled refugee children from Chile describes the children's experiences of persecution in their home country and coping patterns in the receiving country. Thirty-six children had experiences directly related to persecution, and seven of these had been victims of physical assault for political reasons. Sleep disturbances and dependency were behaviors significantly associated with experiences of persecution. Resettled refugee families need to be approached by concerned professionals as symptoms of trauma in refugee children are often recognized only in the family sphere.

Expenditure and payment sources for treating acute respiratory infections in rural Vietnam.

This paper highlights important effects of the health sector reform in rural Vietnam, such as the expenditure for treatment, payment sources among patients and provision of private services. Using a cross-sectional design with a structured questionnaire, the occurrence of illnesses and utilization of health care for 4,769 members in randomly selected households were investigated, with a focus on acute respiratory infections (ARI). Three hundred and seventy people were reported to have suffered from an ARI in the four weeks prior to interview. In 96% of the cases some action had been taken, most often self-medication. The average expenditure for the first treatment was high, 25,000 Dong (US$ 1.7), which is appropriately equal to one third of the monthly per capita in the district. The majority of the expenditure was for drug purchasing in the private or public services. Expenditure for treatment of acute respiratory infections was highest in the hospitals, lower in commune health stations and private clinics, and lowest in the case of self-medication. There was no consultation fee at the commune health stations and private clinics. About half of the patients had borrowed money or sold agricultural products to pay for treatment. Only 2% of the patients benefited from health insurance. High burden of ARI, high cost of treatment and poor coverage of health insurance may create severe economic problems in poor families. Our findings indicate a need to develop pre-payment schemes and the appropriate allocation of resources in order to establish an efficient and equitable health care system.

Utilization of reproductive health services in a mountainous area in Vietnam.

This study uses data from two surveys performed in 1991 and 1994 in a mountainous district of northern Vietnam. The aim was to describe the utilization of family planning, antenatal care, delivery and immunization services during a period of rapid structural change in the health services in general and implementation of a primary health care project in the study area. This project was aimed at increasing access to health services and improving the quality of primary health care services. Factors influencing the utilization of reproductive health services were analyzed. The contraceptive prevalence among women aged 15-49 increased significantly from 48% in 1991 to 60% in 1994. The most commonly used contraceptive method was intra-uterine devices. The BCG coverage among children under five years of age increased from 36 to 70%. The proportion of pregnant women receiving three antenatal check-ups, as recommended by the health authorities was low and increased slightly from 15% in 1991 to 20% in 1994. About one third of the pregnant women were delivered in health care institutions during this period. The utilization of family planning, antenatal care and delivery services varied with ethnicity and was positively related to the mother's educational level both in 1991 and 1994. There is a need to strengthen the reproductive health services, especially antenatal care and delivery services, in terms of improving the quality of care and accessibility to women. Efforts should be made to reach women with a low education level as well as those belonging to ethnic minorities.

Child spacing and two child policy in practice in rural Vietnam: cross sectional survey.

OBJECTIVE: To explore the reproductive pattern of women in rural Vietnam in relation to the existing family planning policies and laws. DESIGN: Cross sectional survey with question-naires on reproductive history. SETTING: Tien Hai, a district in Red River Delta area, where the population density is one of the highest in Vietnam. SUBJECTS: 1132 women who had at least one child under 5 years of age in April 1992. MAIN OUTCOME MEASURES: Birth spacing and probability of having a third child. RESULTS: The mean age at first birth was 22.2 years. The average spacing between the first and the second child was 2.6 years. Mothers with a lower educational level, farmers, and women belonging to the Catholic religion had shorter spacing between the first and second child and also a higher probability of having a third child. In addition, women who had no sons or who had lost a previous child were more likely to have a third child. CONCLUSION: Most families do not adhere to the official family planning policy, which was introduced in 1988, stipulating that each couple should have a maximum of two children with 3-5 years' spacing in between. More consideration should be given to family planning needs and perceptions of the population, supporting the woman to be in control of her fertility. This may imply improved contraceptive services and better consideration of sex issues and cultural differences as well as improved social support for elderly people.

PIP: A 1988 decree on population and family planning issued by Viet Nam's Council of Ministers stipulated a maximum of 2 children per couple, with a spacing of 3-5 years. To assess adherence to this policy and changes in reproductive behavior associated with the transition to a market economy, a cross sectional survey was conducted in Tien Hai, a district in Red River Delta with one of the highest population densities in the country. Five communes representing different modes of production were randomly selected. The sample was comprised of 1120 households and 1132 mothers who were interviewed in their homes in 1992. 1662 pregnancies were reported between April 1987 and April 1992, 91% of which resulted in a live birth. The median age at marriage was 20.9 years, while median age at first birth was 22.2 years. The median spacing between first and second children was 2.6 years. The duration of birth spacing was significantly shorter among women whose first child died, Catholics, and younger women; it was significantly longer among women with a secondary or higher education. The sex of the first child exerted no effect on the spacing duration. 46% of the mothers interviewed had at least 3 children. Factors identified through multivariate analysis as predictive of having a third child were the death of a previous child, lack of a son, no formal maternal education, Catholicism, and involvement in farming. The widespread deviations recorded in this survey from official family policy suggest a need for greater consideration of the perceived needs of Vietnamese families. This may result in improved and more diverse contraceptive options, attention to gender issues in Vietnamese households, and social support for the elderly.