Hiv testing and counseling services in Kassala State, Sudan: what are the relevant beliefs of private healthcare providers?

HIV testing and counseling (HTC) services are essential for all HIV prevention and treatment interventions. Evidence is limited on the role of private healthcare providers in providing HTC services. This study assessed the relevant beliefs for intervention to enhance the intention to offer HTC services among private healthcare providers. A cross-sectional study included 387 private healthcare providers who completed a questionnaire about beliefs and intentions regarding offering HTC services. A Confidence Interval Based Estimation of Relevance (CIBER) approach was used to identify the most relevant beliefs. The behavioral belief "Offering HTC services would cause patients to feel worries" and the normative belief "My managers believe that I should offer HTC services to patients" were relevant beliefs for intervention. The control beliefs "If I offer HTC services, I spend more time with the patients" and "Patients are at low risk of HIV, and they would not need HTC services" were significantly associated with intention and important intervention candidates. The belief "If I offer HTC services, I would be concerned about HIV test results confidentiality" was a relevant belief to target with intervention. The beliefs of private service providers differ in their association with relevance to their intention to offer HTC services. More relevant beliefs need to be selected to increase the potential effectiveness of the interventions to promote the private healthcare providers' intentions to offer HTC services.

Fertility intentions and family size among married men in Khartoum, Sudan.

Numerous factors contribute to high fertility within a specific context some of which are related to women's fertility practices. What has been less frequently examined, however, is how men's preferences and behaviours contribute to high fertility rates. This is imperative in a country such as Sudan which has reported continuously high fertility rates. This study aimed to analyse the socio-cultural factors affecting husbands' preferences and behaviours contributing to high fertility in Sudan. Participants were recruited from the Fertility and Reproductive Health Services Centre in Khartoum and Ahfad Family Health Centre in Omdurman city. Qualitative interviews were used to examine men's fertility preferences and behaviours. The main study findings suggest that husband's fertility preferences and the desire for a large family were prominent, being determined by local socio-cultural factors and religious norms. The data presented offers insight into key factors sustaining high fertility.

Psychosocial beliefs related to intention to use HIV testing and counselling services among suspected tuberculosis patients in Kassala state, Sudan.

BACKGROUND: There is limited information about the psychosocial sub-determinants regarding the use of HIV Testing and Counselling (HTC) services among suspected Tuberculosis (TB) patients in Sudan. This study aimed to assess the association between psychosocial beliefs and the intention to use HTC services and to establish the relevance of these beliefs for developing behaviour change interventions among suspected TB patients. METHODS: Suspected TB patients (N = 383) from four separate TB facilities completed a cross-sectional questionnaire which was based on the Reasoned Action Approach theory. Eligibility criteria included attending Tuberculosis Management Units in Kassala State as suspected TB patients and aged 18-64 years. A Confidence Interval Based Estimation of Relevance (CIBER) analysis approach was employed to investigate the association of the beliefs with the intention to use HTC services and to establish their relevance to be targeted in behaviour change interventions. RESULTS: The CIBER results showed the beliefs included in the study accounted for 59 to 70% of the variance in intention to use HTC services. The belief "My friends think I have to use HTC services" was positively associated with the intent to use HTC, and it is highly relevant for intervention development. The belief "I would fear to be stigmatized if I get a HIV positive result" was negatively related to the intention to use HTC services and was considered a highly relevant belief. The belief "If I use HTC services, health care providers will keep my HIV test result confidential" was strongly associated with the intention to use HTC services. However, the relevance of this belief as a target for future interventions development was relatively low. Past experience with HTC services was weakly associated with the intention to use HTC services. CONCLUSION: The intention to use HTC was a function of psychosocial beliefs. The beliefs investigated varied in their relevance for interventions designed to encourage the use of HTC services. Interventions to promote intention to use HIV testing and counselling services should address the most relevant beliefs (sub-determinants). Further study is needed to establish the relevance of sub-determinants of the intention to use HTC services for interventions development.

Social inequalities, sexual tourism and HIV in Cartagena, Colombia: an ethnographic study.

BACKGROUND: Cartagena, Colombia's main port on the Caribbean Coast, reported an HIV incidence of 7.5 per 100,000 inhabitants in 2007 with 90.0% transmission by heterosexual contact and 70 identified as women with a stable partner. Studies across Colombia illustrate that HIV infection relates to social inequalities; most people with HIV live in poverty and have minimal access to health care, education, and secure jobs. The purpose of this article is to analyse the relationship between social inequalities, sexual tourism and HIV infection in Cartagena, Colombia. METHODS: Data come from a five-year participatory ethnography of HIV in Cartagena in the period 2004-2009, in which 96 citizens (30 of whom were living with HIV) participated in different data collection phases. Techniques included participant observation, in-depth interviews and thematic life histories. Out of this material, we selected three life histories of two women and a man living with HIV that are representative of the ways in which participants expressed how social inequalities make it virtually impossible to engage in safe sex practices. RESULTS: At stake is the exchange of condomless sex for goods within the widespread sexual tourism networks that promote an idealisation of dark-skinned men and women as better sexual performers. Our results illustrate the complex interplay of social inequalities based on class, skin colour, gender and sexual orientation. Furthermore, they suggest a synergistic effect between poverty, racialization, and gender inequalities in the historical maintenance of social dynamics for a fruitful growth of a sexual tourism industry that in turn increases vulnerability to HIV infection. CONCLUSIONS: Although the convergence of social inequalities has been thoroughly reported in the literature on social studies of HIV vulnerability; distinctive dynamics are occurring in Cartagena, including a clear link between the contemporary globalised sexual tourism industries and a racialised social structure - both having historical roots in the colonial past-.

Perceptions of Sudanese women of reproductive age toward HIV/AIDS and services for Prevention of Mother-to-Child Transmission of HIV.

BACKGROUND: Access to antenatal HIV testing during pregnancy and the level of uptake of services for Prevention of Mother-to-Child Transmission (PMTCT) in Sudan are very low. This study aimed to obtain insights into the perceptions of Sudanese pregnant women toward HIV/AIDS and the use of PMTCT services. METHODS: Ten focus group discussions (FGDs) with women of reproductive age were conducted at community settings in Khartoum (N = 121). Recruitment eligibility included living near or around a PMTCT site and being in the age range of 18-40 years. Out of 121 women who participated, 72 (61 %) were pregnant. Predefined themes were addressed in the theory-based interview scheme, which was derived from multiple socio-cognitive theories-i.e., the Extended Parallel Process Model, the Reasoned Action Approach and the socio-psychological view on stigma. Emerging themes were incorporated during data analysis. RESULTS: Few women knew about the Mother to child transmission (MTCT) of HIV. No one indicated that MTCT might occur during labor. Most women believed that HIV/AIDS is a serious and fatal condition for them and also for their children. They believed they were susceptible to HIV/AIDS as a result of cesarean section, contaminated items (blood and sharp items) and husband infidelity. The usefulness and advantages of HIV testing were questioned; for some women it was perceived as an additional burden of anxiety and worry. Doctors were the most influential with regard to acceptance of HIV testing. The speed of the testing process and confidentiality were mentioned by some women as key factors affecting willingness to undergo HIV testing at a health facility during pregnancy. CONCLUSION: The study reveals that most of the women felt susceptible to HIV infection with perceived high severity; however, this perception has not translated into positive attitudes toward the importance of HIV testing during pregnancy. Because of anticipated stigma, women are not likely to disclose their HIV status. Further research should focus on gaining a more in-depth understanding of the psycho-social determinants and processes underlying the factors identified above. In addition, the adequate implementation of Provider Initiated Testing and Counseling (PITC) should be critically assessed in future research about PMTCT in Sudan.

Experiences and psychosocial adjustment of Darfuri female students affected by war: an exploratory study.

This paper presents the personal accounts of Darfuri students studying at Ahfad University for Women in Omdurman, Sudan. Their war-related exposure, current ongoing life challenges, emotional distress, and coping strategies were explored using a semistructured interview protocol with a sample of 20 students. Through interpretative phenomenological analysis (IPA), the Darfuri students' stories illustrated that they were exposed to an array of traumatic war events, including personal experiences of parental separation, injury and death of family members, and shortages of essential life-sustaining supplies in internally displaced camps. Also, they were confronted with myriad current life hassles and urban-cultural challenges, including being physically distant from their families, and losing the shelter of parents, the encouragement of extended family members, and their rich and familiar social support networks. Urban-cultural challenges and lack of environmental mastery applied to most Darfuri participants as they relocated to Omdurman city, which included negotiating an unfamiliar transport system, learning the routes and directions to important city landmarks, and insufficient funds for basic hygienic essentials. Emotional distress reactions were coded by forming two distinct lists: directly mentioned by the participant; and observations of emotional manifestation during the interview. Patterns emerged that may be similar to symptoms of mood and anxiety disorders; for example, the DSM-IV criteria for symptoms of generalized anxiety disorder and major depression. Strong religious practices and beliefs (such as praying and reading the Quran), ability to form interpersonal relationships, availability of social support networks, and a positive future outlook seemed to augment their ability to cope with their subsequent emotional distress owing to war-related exposures, current ongoing life hassles and urban-cultural challenges.

Exposures to war-related traumatic events and post-traumatic stress disorder symptoms among displaced Darfuri female university students: an exploratory study.

BACKGROUND: With the deaths of hundreds of thousands and the displacement of up to three million Darfuris, the increasingly complex and on-going war in Darfur has warranted the need to investigate war-related severity and current mental health levels amongst its civilian population. The purpose of this study is to explore the association between war-related exposures and assess post-traumatic stress disorder (PTSD) symptoms amongst a sample of Darfuri female university students at Ahfad University for Women (AUW) in Omdurman city. METHODS: An exploratory cross-sectional study among a representative sample of Darfuri female university students at AUW (N = 123) was conducted in February 2010. Using an adapted version of the Harvard Trauma Questionnaire (HTQ), war-related exposures and post-traumatic stress disorder (PTSD) symptoms were assessed. Means and standard deviations illustrated the experiential severity of war exposure dimensions and PTSD symptom sub-scales, while Pearson correlations tested for the strength of association between dimensions of war exposures and PTSD symptom sub-scales. RESULTS: Approximately 42 % of the Darfuri participants reported being displaced and 54 % have experienced war-related traumatic exposures either as victims or as witnesses (M = 28, SD = 14.24, range 0 - 40 events). Also, there was a strong association between the experiential dimension of war-related trauma exposures and the full symptom of PTSD. Moreover, the refugee-specific self-perception of functioning sub-scale within the PTSD measurement scored a mean of 3.2 (SD = .56), well above the 2.0 cut-off. CONCLUSIONS: This study provides evidence for a relationship between traumatic war-related exposures and symptom rates of PTSD among AUW Darfuri female students. Findings are discussed in terms of AUW counseling service improvement.

The significance of neighbours: views and experiences of people with intellectual disability on neighbouring.

BACKGROUND: People with intellectual disability (ID) who live in regular neighbourhoods have experiences with their neighbours, which are important to understand when studying social integration. METHOD: This study describes and analyses the opinions on, and experiences with, neighbour relationships of 39 people with ID living in neighbourhood housing facilities. RESULTS: We found that, while the views of people with ID on 'good neighbouring' were consistent with 'neighbouring' described in sociological literature, their experiences may be influenced by an organisational context, the tendency to formalise relationships and apprehension towards meeting unfamiliar people. CONCLUSION: Understanding influential factors to neighbouring for people with ID may shed light on the processes involved in social integration of people with ID at a neighbourhood level. This paper contributes to understanding the opinions of people with ID on satisfactory neighbourhood relationships, and explores opportunities to improve them.

Utilization of family planning services by married Sudanese women of reproductive age.

To explore differences in utilization of family planning services and predisposing factors, we surveyed 601 women from urban and rural areas of Khartoum state. About half were using modern family planning techniques; there were no significant differences in utilization rates between urban and rural settings. Contraceptive pills were the most frequently used modern method (47.7%) followed by intrauterine devices (10.2%) and injections (7.5%). Breastfeeding was used by around 33% of both groups. The rhythm method and withdrawal were more often used by urban women (22.2% and 8.6% respectively) than rural women (16.1% and 3.6% respectively). Use of male methods (condom; sterilization) was extremely low. Socioeconomic status, knowledge and education level were the most important determinants of using modern methods.

The impact of an organ donation registration information program for high school students in the Netherlands.

In 1998, a new organ donor registration system was implemented in the Netherlands to increase the number of potential donors. A high school education program was developed to prepare adolescents to make an informed decision about organ donation. A post-test only randomised controlled trial was conducted in 39 high schools including 2868 students. Students within schools were randomly allocated to either attend the organ donation education program or not. The impact of the program on students' intention to register their organ donation preference (and determinants thereof) were analysed using multivariate multileveling modelling (MlwiN). The results show that students who were exposed to the education program had more favourable registration intentions (B = .40), were more often willing to be donors (OR = 1.45), and had greater knowledge about (B = 3.84) and more positive social outcome expectations (B = .09) and self-efficacy regarding organ donation registration (B=.22). Lastly, they experienced significantly less negative outcome expectations related to organ donation registration (B = -.15). Students' evaluation of the school-based education program was favourable. The present organ donation registration program proved to be effective in changing determinants of organ donation registration, and a large-scale implementation in the Dutch high school curriculum is planned.

Theory- and evidence-based intervention to improve adherence to antiretroviral therapy among HIV-infected patients in the Netherlands: a pilot study.

The objectives of this study were to describe and pilot-test a theory- and evidence-based intervention to improve adherence of HIV-infected patients with antiretroviral medication. Twenty-six treatment-experienced patients (>6 months on treatment) participated in a within-subject comparison design. Adherence was measured electronically with Medication Event Monitoring System (MEMS) caps for at least 5 months: 2 months before the intervention and 3 months during the intervention. MEMS data were used to measure the outcome of the intervention, but also served as feedback to participants during the intervention. Mean adherence during the month before intervention was compared to mean adherence during the third month of intervention. Data for the process evaluation were gathered through direct observation and semi-structured interviews. Adherence improved significantly during the intervention (Z = -2.1, p < 0.05). Mean adherence (percentage of prescribed doses taken within correct time interval) before the intervention was 81.8% compared to 92.5% during the third month of the intervention. More than 65% of the nonadherent patients (<95% adherence) before the intervention were adherent during the third month of the intervention. Both health care professionals and patients positively evaluated the intervention protocol and the electronic measurement of adherence. The only critique from some patients was the lack of userfriendliness of the MEMS cap and its medication container (size and shape). It can be concluded that the proposed intervention fits in standard care procedures, can be executed by trained HIV nurses, seems to improve adherence to antiretroviral medication, and is positively evaluated by the users. Large-scale and long-term research is warranted.

Exclusion of deep venous thrombosis with D-dimer testing--comparison of 13 D-dimer methods in 99 outpatients suspected of deep venous thrombosis using venography as reference standard.

In a direct assay comparison we evaluated the diagnostic performance of 10 novel D-Dimer assays for the exclusion of deep venous thrombosis (DVT). In addition, 3 conventional ELISA D-Dimer assays were included as reference tests. The study was performed in 99 consecutive outpatients referred to the emergency department for clinical suspicion of DVT. Venography was used as reference standard and demonstrated the presence of DVT in 50 patients (6 patients with isolated distal DVT and 44 patients with proximal DVT). The qualitative D-Dimer assays Minutex and SimpliRED and the quantitative BC DD showed overall sensitivities (for proximal and distal DVT) of only 80-83% with specificities that ranged from 87 to 94%. Overall sensitivity was 94% for the qualitative INSTANT I.A. and 98% for the quantitative Turbiquant at a cut-off level equal to the detection limit. Using different cut-off levels a sensitivity of 100% for proximal DVT and for proximal as well as distal DVT could be obtained for NycoCard, IL DD, Liatest, Tinaquant and VIDAS D-Dimer assays with specificities that ranged from 31% (NycoCard) to 71% (VIDAS) for proximal DVT and from 12% (NycoCard) to 47% (IL DD) for overall DVT. At a cut-off level equal to the upper limit of the reference range only Tinaquant and VIDAS showed a sensitivity of 100% for proximal as well as for distal DVT with a specificity of 39% and 41% respectively. The results of this study suggest that the VIDAS and Tinaquant D-Dimer assays have the highest sensitivity for the exclusion of DVT in outpatients. In outpatients that have a low or moderate pretest probability for DVT, these tests may be used in management studies where anticoagulation is withheld on the basis of D-Dimer testing alone.

Community reactions to the introduction of permethrin-treated bed nets for malaria control during a randomized controlled trial in western Kenya.

Prior to implementation of a randomized controlled trial of insecticide (permethrin)-treated bed nets (ITNs) in western Kenya, ethnographic studies were conducted to understand local perceptions of disease, sleeping patterns, and other factors that might affect use of ITNs. Educational activities took place prior to distribution, but immediately after distribution in Asembo only approximately half of the ITNs were in use. A qualitative study was then conducted to identify the community's perceptions about ITNs and the ITN project. While participants ranked malaria as important and recognized that malaria prevention could be beneficial, they believed ITNs would be only partly effective due to the perception that malaria has multiple causes. Concerns expressed included fear of the insecticide, thought by some to be a toxic family planning aid, the taking of blood during clinical studies, and the mixing up of family ITNs during net re-treatment, which would violate cultural taboos. Attempts were made to allay fears by improved communication on these subjects and modification of the study design.

Perceptions of bed nets and malaria prevention before and after a randomized controlled trial of permethrin-treated bed nets in western Kenya.

A study of mothers' perceptions regarding bed nets and malaria was conducted before and after a randomized controlled trial of insecticide (permethrin)-treated bed nets (ITNs) in western Kenya. Awareness about the trial and the rationale for bed net use increased by the end of the trial. Knowledge that mosquitoes caused malaria also increased; however, a higher proportion of mothers from control, rather than intervention villages, cited this (44.4% versus 27.9%; P < 0.001). Mothers from intervention villages were more knowledgeable about the use and maintenance of bed nets and re-treatment with insecticide. Both groups specified advantages of ITNs. Mothers from intervention villages noted practical advantages such as protection against bedbugs and falling roof debris. Few (< 1%) mothers indicated that ITNs protected children against malaria. Intervention homes used significantly fewer mosquito coils, insect spray, medicines, and burned cow dung less often compared with those in control villages. Mothers were willing to pay approximately 4.5 U.S. dollars for a regular bed net, but only 10.5 U.S. cents (intervention) and 0.036 (control) for re-treating a bed net. This study suggests that, despite two years of experience of use, bed nets and insecticides would not be purchased as a household priority in this impoverished rural community.

Can guardians supervise TB treatment as well as health workers? A study on adherence during the intensive phase.

SETTING: In sub-Saharan Africa, tuberculosis (TB) has increased over the last two decades due to the human immunodeficiency virus pandemic. In Malawi, 20630 new TB patients were notified to the National Tuberculosis Programme in 1996, a fourfold increase since 1986. Due to this increase in cases and lack of resources (both human and monetary) it is becoming more difficult to ensure directly observed treatment (DOT) in the TB wards. METHODS: In Ntcheu district, Malawi, a new TB regimen was introduced from April 1996 in which patients received supervised treatment by either a health worker or a guardian (i.e., family member). Adherence to the different treatment options was measured by form checks, tablet counts, and tests for detecting isoniazid in the urine. Adherence was measured at 2, 4 and 8 weeks after onset of TB treatment. RESULTS: Overall adherence rate was 95-96%. Inpatients showed the highest adherence rates. Patients on guardian-based DOT (GB-DOT) (n = 35) showed 94% adherence, while patients on health centre based DOT (n = 40) showed more non-adherent behaviour: 11% according to monitoring forms, 14% according to tablet counts and 16% according to urine tests. DISCUSSION: The results suggest that decentralised care is a feasible option for anti-tuberculosis treatment and that guardians can supervise TB treatment just as well as health workers during the intensive phase of TB treatment.

Cancer patients' personality characteristics, physician-patient communication and adoption of the Moerman diet.

Breast cancer patients and patients with Hodgkin's disease (N = 663) were contacted initially by medical specialists at 15 medical centers across The Netherlands and subsequently 498 of them were interviewed in their homes in order to examine interactions between their personality characteristics, their assessment of the adequacy of information feedback from their physicians about their illness, its treatment and prognosis, and their adoption of an unproven diet remedy. The data indicate that patients who believed they had received insufficient and unclear information were more likely to be adopters of the Moerman diet than patients who believed the information was adequate. Personality moderator analyses indicated further that the relationship between information adequacy and diet adoption held specifically for those patients with high trait anxiety, low self-esteem, angry-aggressive coping styles or impulsive attitudes. The discussion focused on rational and irrational elements in physician-patient communications, the strategies available to physicians to improve their communication skills, the desirability of constructing and distributing educational and informational materials for use by patients, and the need for physicians to offer their patients an opportunity for contact with companions in distress.

Survival and psychosocial adjustment to stoma surgery and nonstoma bowel resection: a 4-year follow-up.

A prospective 4-year follow-up study was conducted to compare the psychosocial adjustment process and survival rate of 59 stoma patients with 64 bowel-resected nonstoma patients. Adjustment was assessed at 4 months. 1 year, and 4 years after surgery by the Psychosocial Adjustment to Illness Scale, a self-report questionnaire (PAIS-SR). Analyses of covariance demonstrated that both subgroups experienced the same level of psychosocial problems 4 years after surgery. Interestingly, patients with poor early adjustment scores (4 months after surgery) were at significantly higher risk of dropping out because of death and terminal status during the follow-up period (1 and 4 years postoperatively). The presence of a stoma did not influence the risk rate for dropping out. These results demonstrate the need for prolonged psychosocial guidance of outpatients who have been surgically treated for colorectal cancer or inflammatory bowel disease.

The patient from receiver of information to informed decision-maker.

In this article the change of paradigm currently taking place within the field of patient education is indicated. In this change of paradigm the patient is increasingly being seen as responsible for his own health and as someone who makes independent choices in this respect. This has consequences for the role the patient is given in decisions on individuals care. The consequences of current developments within the Dutch society and in medical techniques as these relate to the need for patient education are enlightened. Some of the main topics for patient education are mentioned and the effects of patient education as established through meta-analyses are summarised. A planning model for a systematic development of patient education interventions is recommended. Relevant topics for research on patient education in the Netherlands are indicated.

Case study: development and evaluation of a model of patient education in surgical wards.

In this contribution we offer a description of a research project in which an attempt is undertaken to improve patient education by nurses at surgical wards in hospitals. In a pilot study it was found that the current practice of patient education is inconsistent and often does not meet patients' demands. Based on this pilot, measures are developed to (a) standardise the information supplied to patients and (b) promote patients' opportunities to collect information by themselves, in order to meet individual demands. The effectiveness of the measures is evaluated by collecting data on physical recovery and emotional well-being among patients undergoing cholecystectomy or herniorraphy.

Inadequacies of surgical patient education.

Education of surgical patients by hospital staff members is often hampered by temporal, spatial and personnel barriers. It is desirable that regular staff members themselves provide patients with information. To improve surgical patient education by staff members, an examination was performed in two hospitals of events related to surgical patients' treatment, care and education during the course of their admission in hospital. The method consisted of interviews with patients and health care providers and observations of critical events. Patients were found to experience emotional problems, such as fear of surgery and anesthesia and lack of information about medical details, the roles of various health care providers and about discharge from the hospital. These problems appeared to be caused by organizational barriers and by inadequacies of the method of information provision. The results of the examination provide a sound basis to develop, in collaboration with hospital staff members, programs to improve surgical patient education.