PrEP reminds me that I am the one to take responsibility of my life: a qualitative study exploring experiences of and attitudes towards pre-exposure prophylaxis use by women in Eswatini.

BACKGROUND: Pre-exposure-prophylaxis (PrEP) has been heralded for its potential to put women in control of preventing HIV infection, but uptake and continuation rates have been disappointing in high-incidence settings in sub-Saharan Africa. We explored structural and social factors that influenced PrEP use among young women and pregnant or breastfeeding women in rural Eswatini. METHODS: We conducted two in-depth interviews with ten women on PrEP, and one-time in-depth interviews with fourteen women who declined or discontinued PrEP. Interviews covered decision-making processes around PrEP initiation and experiences with pill-taking. In-depth interviews were conducted with nine health workers, covering experiences in delivering PrEP services, and two focus group discussions were held with men to elicit their perceptions of PrEP. Interviews and discussions were audio-recorded, translated, transcribed and analysed thematically, using an inductive approach. RESULTS: PrEP initiation and use were experienced by many women as empowering them to take control of their health and well-being, and stay HIV free, facilitating them to realise their aspirations relating to motherhood and educational attainment. However, the social norms that defined relationship dynamics with partners or family members either undermined or promoted this empowerment potential. In particular, young women were rarely supported by family members to take PrEP unless it was perceived to be for protecting an unborn child. Stigmatisation of pill-taking through its associations with HIV and the burden of daily pill-taking also contributed to PrEP discontinuation. CONCLUSIONS: Unlike many prevention tools, PrEP enabled women to achieve a sense of control over their lives. Nevertheless, women's agency to continue and adhere to PrEP was influenced by social and structural factors including gender norms, family expectations of young women, relationship dynamics and stigma related to HIV. Future interventions should address these barriers to promote PrEP use among sexually-active women.

A life in waiting: Refugees' mental health and narratives of social suffering after European Union border closures in March 2016.

RATIONALE: In 2015, an estimated 856,723 refugees, predominantly from Syria, Afghanistan, and Iraq arrived in Greece as an entry point into the European Union. The border of the Former Yugoslav Republic of Macedonia closed in March 2016, blocking a popular route for refugees through Europe, and left around 60,000 people stranded in Greece. OBJECTIVE: A mixed-method study was conducted among refugees in the regions of Attica, Epirus, and Samos between November 2016 and February 2017. The epidemiological survey showed that depending on study sites between 73% and 100% of the refugees suffered from anxiety disorder. The explanatory qualitative study aimed to understand refugees' mental health and narratives of social suffering in regards to experienced violence, the effect of current border closures, and the lack of an onward journey. METHOD: The explanatory qualitative study included 47 in-depth interviews and five focus group discussions with refugees purposely recruited through the concomitant epidemiological survey, representing both genders and a range of nationalities and ages. Data were thematically analysed to identify emergent patterns and categories using NVivo 11. RESULTS: The refugees overwhelmingly reported experiencing uncertainty and lack of control over their current life and future, which caused psychosocial distress and suffering. The passivity of life in refugee camps aggravated feelings of meaninglessness and powerlessness. The disruption of key social networks and absence of interactions with the surrounding Greek society led to feelings of isolation and being unwelcome. CONCLUSIONS: Refugees in Greece experience psychosocial distress and social suffering as a consequence of their uncertain and disrupted lives and the loss of social networks. Faster and transparent asylum procedures, the development of meaningful and empowering activities, and fostered social interactions with the surrounding society would contribute to alleviating their psychosocial suffering.

"Children get sick all the time": A qualitative study of socio-cultural and health system factors contributing to recurrent child illnesses in rural Burkina Faso.

BACKGROUND: In Burkina Faso, the government has implemented various health sector reforms in order to overcome financial and geographical barriers to citizens' access to primary healthcare throughout the country. Despite these efforts, morbidity and mortality rates among children remain high and the utilization of public healthcare services low. This study explores the relationship between mothers' intentions to use public health services in cases of child sickness, their social strategies and cultural practices to act on these intentions and the actual services provided at the primary health care facilities. Focusing on mothers as the primary caregivers, we follow their pathways from the onset of symptoms through their various attempts of providing treatment for their sick children. The overall objective is to discuss the interconnectedness of various factors, inside and outside of the primary health care services that contribute to the continuing high child morbidity and mortality rates. METHODS: The study is based on ethnographic fieldwork, including in-depth interviews and follow-up interviews with 27 mothers, informal observations of daily-life activities and structured observations of clinical encounters. Data analysis took the form of thematic analysis. RESULTS AND DISCUSSION: Focusing on the mothers' social strategies and cultural practices, three forms of responses/actions have been identified: home-treatment, consultation with a traditional specialist, and consultation at the primary health care services. Due to their accumulated vulnerabilities, mothers shift pragmatically from one treatment to another. However, the sporadic nature of their treatment-seeking hinders them in obtaining long-term solutions and the result is recurrent child illnesses and relapses over long periods of time. The routinization of the clinical encounter at rural dispensaries furthermore fails to address these complexities of children's illnesses. CONCLUSIONS: The analysis of case studies, interviews and observations shows how mothers in a rural area struggle and often fail to receive care at public healthcare facilities. Health service delivery could be organized in a manner that responds better to the needs of these mothers in terms of both access and retention.