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.

Sexuality and health: a study of Tanzanian men's experiences of living with HIV/AIDS

The aim of this study was to explore Tanzanian men's experiences regarding their health and sex life after they had been diagnosed with HIV. In-depth interviews were performed with a purposive sample of ten men living in an urban area in Tanzania and who had been HIV positive for more than one year. A phenomenological-hermeneutic approach was used for analyzing the transcribed interviews. Three themes emerged from the texts; "awareness of HIV infection", "perceived and ideal health", and "sex life a source of happiness and caring". Living with HIV meant profound adjustments to daily life activities for the participants. HIV forced them to learn new ways of having sexual intercourse and new ways of acting as a man. The meaning of being a "real man" had changed from being a man with great sexual prowess to being a "caring man" within one relationship. (Afr Reprod Health 2008; 12[1]:35-46)

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.

Public health services use in a mountainous area, Vietnam: implications for health for policy.

AIMS: The aim of this study is to describe the use of public health services in different social and ethnic groups and to explore the implementation of user fee exemption in a mountainous area in Vietnam. METHODS: A cross-sectional household survey with a structured questionnaire and a four-week diary were used to collect information on illnesses, health seeking behaviour and socioeconomic factors. Three communes in a mountainous district in Northern Vietnam were selected and a random sample of 1,452 individuals in 300 households was drawn. RESULTS: Self-medication was most common (57%) while 30% used public health services when suffering from a health problem. Persons living far from health services attended public health services less frequently than the others (adjusted OR = 0.28; 95% CI 0.15-0.51). This was especially the case for ethnic minorities who were less likely to use public health services than the others were (adjusted OR = 0.47; 95% CI 0.25-0.87). Persons with mild conditions tended to use public health services less than those with more severe conditions (OR = 0.19; 95% CI 0.10-0.37). Health services use was similar among women and men, but the total expenditure per visit was higher for men. Almost no patients supposed to get free attendance had been exempted from user fees. CONCLUSIONS: It was found that there was a geographical inequity in use of public health services while there was relatively equal use of these services between social, gender, and ethnic groups. Long distance in combination with failure of the fee exemption may increase inequity in use of health services in remote and isolated areas. These observations contribute to the basis for implementation of the Vietnamese health policy, emphasizing efficiency and equity.

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.

Efficacy of patient-delivered partner medication in the treatment of sexual partners in Uganda.

BACKGROUND: Patient-based partner referral (PBPR), which is the main method for treating sexual partners of patients with sexually transmitted diseases (STDs), has limited effectiveness. GOAL: The authors compared the efficacy of PBPR with patient-delivered partner medication (PDPM) among patients attending the Mulago STD clinic in Kampala, Uganda. STUDY DESIGN: A total of 383 patients (187 women, 196 men) with STDs were randomized to the PBPR or PDPM group. The proportion of sexual partners treated in either group was compared using the chi-square statistic by intention to treat for partners whose follow-up status was unknown. RESULTS: The two groups had similar background characteristics. Of the 237 partners elicited, 176 (74%) were reported treated in the PDPM group. In the PBPR group, in which 234 partners were elicited, 79 (34%) were referred to the treatment clinic. This difference was statistically significant (risk ratio [RR], 2.44; 95% CI, 1.95-3.07; P < 0.001). Furthermore, PDPM was more effective than PBPR for women and for casual partners for whom PBPR is considered difficult. For women, 86 of 103 partners in the PDPM group were reported treated, compared with 23 of 104 partners in the PBPR group (RR, 4.55; 95% CI, 2.92-7.08; P < 0.001). For casual partners, 18 of 51 (34%) were reported treated in the PDPM group, compared with only three of 45 partners (7%) who were referred in the PBPR group (RR, 1.43; 95% CI, 1.40-2.65; P < 0.01). CONCLUSION: Patient-delivered partner medication is more effective than patient-based partner referral in the treatment of sexual partners.

Sexual behaviour and sexually transmitted diseases among young men in Zambia.

Sexually transmitted diseases (STDs) are an increasing public health problem in Zambia. About 200 000 cases of STDs are treated annually in the formal health sector. Young people are the most affected by STDs. High-risk sexual behaviour has been identified as the major risk factor for STDs among young people. We conducted interviews and focus group discussions with a purposely selected sample of 126 young men aged between 16 and 26 in Chiawa, rural Zambia. The aim of the interviews and focus group discussions was to explore views about sexual practices and attitudes towards STD. Fifty-eight (59%) young men reported having had pre-marital or extra-marital sexual partners during the past year. The maximum number was five partners for six individuals. Forty-two (43%) had pre-marital or extra-marital sexual partners at the time of the interviews. Focus group discussions revealed that perceptions of manhood encouraged multiple sexual relationships. Twenty-two (23%) reported having suffered from an STD in the past. Seventy-nine (81%) said they were likely to inform their sexual partners if they had an STD. Although condoms were believed to give protection against STDs by the majority (94%), only 6% said they always used condoms. The data suggest that condoms were perceived to affect male potency. These results show that STDs, multiple sexual relationships and unprotected sex are common among the young men of Chiawa. Perceptions that emphasize manhood are widespread and these may negatively affect efforts for positive behavioural change. Health messages that target the young men should take into account the local perceptions and values that seem to sustain risky sexual behaviour.

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.

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.

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.

Predictors of condom use among patients with sexually transmitted diseases in Uganda.

BACKGROUND AND OBJECTIVE: Patients with sexually transmitted diseases (STDs) are at an increased risk of HIV infection and they must be targeted for increased condom use. GOAL: To identify predictors of condom use among patients with STDs. STUDY DESIGN: In a cross-sectional survey, an interview-administered questionnaire was administered to 138 patients at the STD clinic, Mulago, and the outpatients department, Mbarara Hospital, in Uganda. Data were collected on socio-demographic situations, STD symptoms, type of sexual partners, and use of condoms. Multivariate logistic regression models were used to identify independent predictors of condom use. RESULTS: Of the 138 patients, 87 (66%) knew how to use condoms, 81 (59%) ever used a condom, 34 (25%) used a condom at least once in the previous 3 months, 20 (15%) used a condom during the last sexual intercourse, and 80 (58%) accepted a free supply of condoms. Reasons for not using condoms among the 57 who had never were: having a regular partner or spouse (28, 49%), partner does not approve (17, 30%), reduced sexual pleasure (5, 9%), and no answer (7, 12%). The independent predictors of condom use were: being a man, not having a regular partner, having had sex with a casual partner, being able to read English, having at least secondary education, and using electricity for lighting. CONCLUSION: Providing health promotion messages in local languages may improve condom use in this population. There is a need for complementary HIV prevention strategies for women and for regular sexual partnerships.

PIP: A cross-sectional survey was undertaken among 138 sexually transmitted disease (STD) patients in Mbarara Hospital, Uganda, to understand the predictors of condom use among patients with STDs with a view of suggesting measures for increased condom use. Data were collected on sociodemographic situations, STD symptoms, type of sexual partners, and use of condoms. Multivariate logistic regression models were used to identify independent predictors of condom use. Results showed that of the 138 patients (58 men, 80 women), 87 (42 men, 45 women) knew how to use a condom; 81 had ever used a condom, 34 had used a condom at least once in the previous 3 months, 20 had used one during the last intercourse, and 80 had accepted a free supply of condoms. Reasons among the 57 patients for not using condoms were: having a regular partner or spouse (28.49%); partner does not approve (30%); reduced sexual pleasure (9%); and no answer (12%). The results also showed that the predictors of condom use were: being a man; not having a regular partner; having had sex with a casual partner; able to read English; having a secondary education; and using electricity for lighting. Therefore, the results suggested that providing health promotion in local languages would improve condom use in the area. Furthermore, a complementary HIV prevention strategy is needed for women and regular sexual partners.

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.

Are there social inequities in child morbidity and mortality in rural Vietnam.

This study was conducted to investigate the relationship between various socio-economic factors, and child morbidity and mortality during a period of rapid social change in Vietnam. One-thousand-one-hundred-and-thirty-two rural mothers with children under 5 years of age were interviewed regarding their reproductive history, survival of their children, and morbidity of their children under 5 years of age. Causes of child death were established by a verbal autopsy technique. Fifty-seven per cent of the children were reported to have suffered from some illness during the preceding 2 weeks. Acute respiratory infection (ARI) (46 per cent of all children) was most common. Two-thirds of the sick children had been treated with antibiotics. Eighty-one children under 5 years of age had died during the 10-year period 1982-1992. Two-thirds of these deaths occurred in infancy, most of them were related to prematurity, asphyxia or tetanus. ARI was more common in poor families while neither education nor occupation were associated with ARI occurrence. No significant relationship between education or occupation of the mother and mortality was found. The low under-5 mortality (U5MR) in spite of the high morbidity may be related to good child health care both by families and by the health care system.

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.

Maternal factors influencing the occurrence of low birthweight in northern Vietnam.

The relationship between the birthweight of newborn infants and their mothers' health characteristics as well as socio-economic status were studied in 1474 consecutive deliveries from eight areas in the delta region of north Vietnam. The results showed that the proportion of low birthweight (LBW) infants varied from 7.9% to 12.5%. Body mass index (BMI) of the mothers, good nutrition during pregnancy and maternity leave before delivery were negatively associated with the occurrence of LBW. The association between chronic energy deficiency (low BMI) and LBW was seen only among the farming women. Measures should be taken to reduce the workload and to supply sufficient food for pregnant women, and special priority should be given to rural areas.

PIP: This study examines the prevalence of low-birth-weight (LBW) deliveries among a sample of women from 17 communes in five provinces in the Red River delta region of north Vietnam during 1992-93. The final sample included 1474 consecutive deliveries from five rural and three urban areas. Trained medical staff measured the weight and height of newborns and mothers after delivery. Body mass index (BMI) was used to determine maternal energy deficiency. Gestational age was determined by measuring the time interval between the last menstrual period and delivery. Maternal diet was categorized as very poor (rice and vegetables only), poor (rice and some supplementary food), or sufficient (rice and enough supplementary food). Findings indicate that LBW deliveries amounted to 7.9% in rural Ha Tay (health center deliveries), 10.5% in rural Nam Ha (health center deliveries), and 8.5% in rural Thai Binh (home deliveries). The number of LBW deliveries was very low in urban Hanoi and in the Nam Dinh factory hospital. LBW infants did not vary by gender. LBW deliveries were more prevalent for first-born children (12% among girls and 7% among boys). Farming mothers were twice as likely to have a LBW delivery. LBW deliveries were less common among mothers who had made over four prenatal visits. An increase in the likelihood of delivering a LBW infant was associated with insufficient food intake, heavy physical work during pregnancy, and chronic energy deficiency. LBW was independently associated with BMI, food availability during pregnancy, maternity leave before delivery, and parity. Farming mothers with a BMI under 18.5 had three times the risk of having a LBW delivery than normal mothers. 94% of farming mothers and only 40% of nonfarming mothers had insufficient food intake. LBW deliveries were more common in the summer and autumn. 8% showed some disease during pregnancy, such as toxemia, infectious diseases, or other diseases. LBW risk doubled with any of these conditions.

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.

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.