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C-Channel Issue 16

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C-Channel header  January 2010

Dear Colleagues,

C-Channel is the monthly e-newsletter from C-Change that features current research from the peer-reviewed literature on social and behavior change communication (SBCC) across HIV prevention, family planning/reproductive health, and malaria. Issue 16 highlights HIV prevention. Four articles explore sexual risk behavior in the context of HIV and STIs, one article looks at antiretroviral knowledge and attitudes towards HIV, and another article looks at church leaders’ attitudes and HIV prevention messages. Three articles explore women’s reproductive health issues in the context of HIV. A final two articles are on malaria in pregnancy. Research for these articles was conducted in Gambia, Kenya, Madagascar, South Africa, Tanzania, Uganda, and Brazil.

In December 2009, C-Change conducted a 2-week training workshop in Nigeria for 24 NGO-based health professionals working in HIV prevention, using the new C-Change learning package Understanding Social and Behavior Change Communication. This training is part of a larger focus by C-Change to build effective and sustainable SBCC capacity of local institutions and their professionals to carry out evidence-based interventions to improve the health and well-being of people in the developing world. Similar trainings--in western Kenya for partners implementing malaria prevention programs in Kenya, and Nairobi for USAID partners carrying out malaria prevention programming in Southern, West and East Africa--were conducted in Fall 2009, with training in Southern Africa scheduled for January 2010. See the C-Change website for additional information about the SBCC learning package.

Thank you,
The Knowledge Management Team at C-Change
 


To view archived issues, visit www.c-changeprogram.org/c-channel


HIV AND SEXUAL RISK BEHAVIORS

1. Impact of five years of peer-mediated interventions on sexual behavior and sexually transmitted infections among female sex workers in Mombasa, Kenya
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2. Risky sexual practices among youth attending a sexually transmitted infection clinic in Dar es Salaam, Tanzania
FREE full text

3. Is sexual risk taking behaviour changing in rural south-west Uganda? Behaviour trends in a rural population cohort 1993-2006
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4. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil
FREE full text

HIV PREVENTION

5. Public knowledge and attitudes toward HIV/AIDS and antiretroviral therapy in Kabarole district, western Uganda

6. Ambivalence, silence and gender differences in church leaders' HIV-prevention messages to young people in KwaZulu-Natal, South Africa

REPRODUCTIVE HEALTH AND HIV

7. Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa

8. Barriers to the use of modern contraceptives and implications for woman-controlled prevention of sexually transmitted infections in Madagascar

9. Acceptance of HIV testing among women attending antenatal care in south-western Uganda: Risk factors and reasons for test refusal

MALARIA IN PREGNANCY

10. Effect of a community-based delivery of intermittent preventive treatment of malaria in pregnancy on treatment seeking for malaria at health units in Uganda

11. Rural Gambian women's reliance on health workers to deliver sulphadoxine – pyrimethamine as recommended intermittent preventive treatment for malaria in pregnancy
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OTHER RESOURCES

C-Change has provided technical assistance to MTV Networks International to produce a television drama titled “Shuga” that entertains and engages young people with awareness about and prevention information on HIV and AIDS. See additional information and highlights from the drama on the C-Change website.
 


HIV AND SEXUAL RISK BEHAVIORS

1. Impact of five years of peer-mediated interventions on sexual behavior and sexually transmitted infections among female sex workers in Mombasa, Kenya

Authors: Luchters S 1,2; Chersich MF 1,2; Rinyiru A 1; Barasa MS 3; King'ola N 1; Mandaliya K 4; Bosire W 1; Wambugu S 3; Mwarogo P 3; Temmerman M 2
Institutions: 1 International Centre for Reproductive Health, Mombasa, Kenya; 2 International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Ghent University, Belgium; 3 Family Health International, Nairobi, Kenya; 4 Coast Provincial General Hospital, Mombasa, Kenya
Source: BMC Public Health 29 Apr 2008; 8:143.

ABSTRACT

BACKGROUND: Since 2000, peer-mediated interventions among female sex workers (FSW) in Mombasa Kenya have promoted behavioural change through improving knowledge, attitudes and awareness of HIV serostatus, and aimed to prevent HIV and other sexually transmitted infection (STI) by facilitating early STI treatment. Impact of these interventions was evaluated among those who attended peer education and at the FSW population level.

METHODS: A pre-intervention survey in 2000, recruited 503 FSW using snowball sampling. Thereafter, peer educators provided STI/HIV education, condoms, and facilitated HIV testing, treatment and care services. In 2005, data were collected using identical survey methods, allowing comparison with historical controls, and between FSW who had or had not received peer interventions.

RESULTS: Over five years, sex work became predominately a full-time activity, with increased mean sexual partners (2.8 versus 4.9/week; P < 0.001). Consistent condom use with clients increased from 28.8% (145/503) to 70.4% (356/506; P < 0.001) as well as the likelihood of refusing clients who were unwilling to use condoms (OR = 4.9, 95%CI = 3.7-6.6). In 2005, FSW who received peer interventions (28.7%, 145/506), had more consistent condom use with clients compared with unexposed FSW (86.2% versus 64.0%; AOR = 3.6, 95%CI = 2.1-6.1). These differences were larger among FSW with greater peer-intervention exposure. HIV prevalence was 25% (17/69) in FSW attending ≥ 4 peer-education sessions, compared with 34% (25/73) in those attending 1-3 sessions (P = 0.21). Overall HIV prevalence was 30.6 (151/493) in 2000 and 33.3% (166/498) in 2005 (P = 0.36).

CONCLUSION: Peer-mediated interventions were associated with an increase in protected sex. Though peer-mediated interventions remain important, higher coverage is needed and more efficacious interventions to reduce overall vulnerability and risk.

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2. Risky sexual practices among youth attending a sexually transmitted infection clinic in Dar es Salaam, Tanzania

Authors: Urassa W 1; Moshiro C 2; Chalamilla G 3; Mhalu F 1; Sandstrom E 4
Institutions: 1 Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Tanzania; 2 Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Tanzania; 3 Ilala Municipal Council, Dar es Salaam, Tanzania; 4 Karolinska Institute Stockholm, Sweden
Source: BMC Infectious Diseases 19 Nov 2008; 8:159.

ABSTRACT

BACKGROUND: Youth have been reported to be at a higher risk of acquiring STIs with significant adverse health and social consequences. Knowledge on the prevailing risky practices is an essential tool to guide preventive strategies.

METHODS: Youth aged between 18 and 25 years attending an STI clinic were recruited. Social, sexual and demographic characteristics were elicited using a structured standard questionnaire. Blood samples were tested for syphilis and HIV infections. Urethral, high vaginal and cervical swabs were screened for common STI agents.

RESULTS: A total of 304 youth were studied with mean age of 21.5 and 20.3 years for males and females respectively. 63.5% of youth were seeking STI care. The mean age of coitache was 16.4 and 16.2 years for males and females respectively. The first sexual partner was significantly older in females compared to male youth (23.0 vs 16.8 years) (p < 0.01). 93.2% of male youth reported more than one sexual lifetime partner compared to 63.0% of the females. Only 50% of males compared to 43% of females had ever used a condom and fewer than 8.3% of female youth used other contraceptive methods. 27.1% of pregnancies were unplanned and 60% of abortions were induced. 42.0% of female youth had received gifts/money for sexual favours. The HIV prevalence was 15.3% and 7.5% for females and males respectively. The prevalence of other STIs was relatively low. Among male youth, use of alcohol or illicit drugs was associated with increased risk of HIV infection. However, the age of sexual initiation, number of sexual partners or the age of the first sexual partner were not associated with increased risk of being HIV infected.

CONCLUSION: Most female youth seen at the STI clinic had their first sexual intercourse with older males. Youth were engaging in high risk unprotected sexual practices which were predisposing them to STIs and unplanned pregnancies. There is a great need to establish more youth-friendly reproductive health clinics, encourage consistent and correct use of condoms, delay in sexual debut and avoid older sexual partners in females.

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3. Is sexual risk taking behaviour changing in rural south-west Uganda? Behaviour trends in a rural population cohort 1993-2006

Authors: Biraro S 1; Shafer LA 1; Kleinschmidt I 2; Wolff B 1; Karabalinde A 1; Nalwoga A 1; Musinguzi J 3; Kirungi W 3; Opio A 3; Whitworth J 4; Grosskurth H 1
Institutions: 1 Medical Research Council (MRC)/Uganda Virus Research Institute (UVRI) Uganda Research Unit on AIDS, Entebbe, Uganda; 2 London School of Hygiene and Tropical Medicine, London, UK; 3 Ministry of Health, Government of Uganda; 4 Wellcome Trust
Source: Sexually Transmitted Infections Apr 2009; 85 Suppl 1: i3-11. [PubMed Central]

ABSTRACT

OBJECTIVE: To describe sexual behaviour trends in a rural Ugandan cohort in the context of an evolving HIV epidemic, 1993-2006.

METHODS: Sexual behaviour data were collected annually from a population cohort in which HIV serological surveys were also conducted. Behaviour trends were determined using survival analysis and logistic regression. Trends are reported based on the years in which the respective indicators were collected.

RESULTS: Between 1993 and 2006, median age at first sex increased from 16.7 years to 18.2 years among 17-20-year-old girls and from 18.5 years to 19.9 years among boys. Both sexes reported a dip in age at sexual debut between 1998 and 2001. One or more casual partners in the past 12 months among men rose from 11.6% in 1997 to 12.7% in 2004 and then declined to 10.2% in 2006. Among women it increased from 1.4% in 1997 to 3.7% in 2004 and then reduced to 1.4% in 2006. The rise in casual partners between 1997 and 2004 was driven mainly by older age groups. Trends in condom use with casual partners varied by age, increasing among those aged 35+ years, declining in the middle age groups and presenting a dip and then a rise in the youngest aged group (13-19 years).

CONCLUSION: Among youth, risky behaviour declined but increased in the late 1990s/early 2000s. Among those aged 35+ years, condom use rose but casual partners also rose. Several indicators portrayed a temporary increase in risk taking behaviour from 1998 to 2002.

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4. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil

Authors: Tun W 1; de Mello M 2; Pinho A 3; Chinaglia M 4; Diaz J 4
Institutions: 1 Population Council, Washington DC; 2 ICICT, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil; 3 Graduate Program in Epidemiology, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil; 4 Reprolatina, Campinas, São Paulo, Brazil
Source: Sexually Transmitted Infections Nov 2008; 84(6): 455-7.

ABSTRACT

OBJECTIVES: To compare population-based prevalence estimates of sexual risk behaviours and HIV seroprevalence of male sex workers who have sex with men (MSM) and those not engaged in sex work in Campinas, Brazil.

METHODS: MSM (n = 658) were recruited for a cross-sectional study through respondent-driven sampling. Audio-assisted computer self-interview was used to collect information on sexual behaviours and HIV testing (optional) was performed. Population-based prevalence estimates with 95% CI of characteristics and behaviours of MSM sex workers and non-sex workers are reported.

RESULTS: One-quarter reported ever receiving payment for sex and 14.8% (95% CI 11.1 to 19.0) had been paid in the previous 2 months; most exclusively with men. MSM sex workers were significantly more likely than non-sex workers to report being transgendered (40.5% vs 8.1%), to practise unprotected receptive (22.4% vs 4.6%) and insertive (20.5% vs 5.0%) anal intercourse with > or =2 male partners and to have unprotected vaginal sex with women (22.7% vs 5.6%). MSM sex workers experienced significantly greater rates of psychological abuse (80.9% vs 58.4%) and physical abuse (48.2% vs 15.2%).

CONCLUSIONS: MSM sex workers have higher sexual risk behaviours as well as social vulnerabilities than the general population of MSM. HIV/sexually transmitted infection prevention efforts should be targeted to this riskier subgroup. Programmes should be transgender sensitive, should recognise that MSM sex workers have sex with men and women and address other factors that influence risk, such as homophobic abuse.

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HIV PREVENTION

5. Public knowledge and attitudes toward HIV/AIDS and antiretroviral therapy in Kabarole district, western Uganda

Authors: Kipp WE; Alibhai A; Saunders D; Konde-Lule J; Ruhunda A
Institutions: a Department of Public Health Sciences, School of Public Health, University of Alberta, Edmonton, Alberta, Canada; b School of Public Health, Makerere University, Kampala, Uganda; c Kabarole Research & Resource Centre, Fort Portal, Uganda
Source: AIDS Care Jan 2009; 21(1): 118-24. [PubMed]

ABSTRACT

A study on knowledge about HIV/AIDS and antiretroviral therapy (ART) was conducted in the general population of a rural district in western Uganda. Three hundred seventy-two participants were selected by random cluster sampling and interviewed with an interview-administered questionnaire. Data were analyzed quantitatively with descriptive, univariate and linear multivariate statistical analysis with the knowledge score about ART as the dependent variable. The results indicate that the mean knowledge was 7.7 in a scale from 0 to 13. Predictor for better ART knowledge was a higher educational status of the participants. Older participants over 50 years were less ART knowledgeable. Only 19% of the participants have been tested for HIV. The conclusions are that the ART knowledge in this population is remarkably high which is reaffirming and important for achieving a high adherence to ART. Of concern is the low proportion of persons tested for HIV in this general population.

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6. Ambivalence, silence and gender differences in church leaders' HIV-prevention messages to young people in KwaZulu-Natal, South Africa

Authors: Eriksson E a; Lindmark G a; Axemo P a; Haddad B b; Ahlberg BM a
Institutions: a International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Sweden; b School of Religion and Theology, University of KwaZulu-Natal, Pietermaritzburg, South Africa
Source: Culture, Health & Sexuality Jan 2010; 12(1): 103-114. [Epub ahead of print; PubMed]

ABSTRACT

A series of semi-structured interviews on HIV prevention were conducted with South African clergy with pastoral and liturgical responsibilities from the Roman Catholic Church, the Lutheran Church and the Assemblies of God. The interviews were tape-recorded, transcribed verbatim and analysed by interpretive descriptive analysis. Three themes indicative of church leaders' approach to HIV prevention among youth emerged: dilemmas in breaking the silence on HIV and AIDS; ambivalent HIV-prevention messages from church leaders to young people; and gender differences in HIV-prevention messages. While church leaders had taken steps to overcome the stigma, the dilemmas of balancing theological understanding with resistance from their congregations presented a complex scenario. Ambivalence to HIV prevention concerned whose responsibility it was to educate young people about HIV; talking about sexuality in public; pre-marital abstinence and condom use; and resistance from congregation members towards HIV prevention. Finally, findings indicated a discrepancy between church leaders' belief in gender equality and the HIV-prevention messages they verbalised, which appears to burden girls.

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REPRODUCTIVE HEALTH AND HIV

7. Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa

Authors Desgrées-du-Loû A a; Orne-Gliemann J b
Institutions: a Demographer, Institut de Recherche pour le Développement, Centre Population Développement (CEPED), Paris, France; b Public Health Researcher, Institut de Santé Publique Epidémiologie Développement, Université Victor Segalen Bordeaux 2, Bordeaux, France
Source: Reproductive Health Matters Nov 2008; 16(32): 151-61.

ABSTRACT

In Africa, a large proportion of HIV infections occur within stable relationships, either because of prior infection of one of the partners or because of infidelity. In five African countries at least two-thirds of couples with at least one HIV-positive partner were HIV serodiscordant; in half of them, the woman was the HIV-positive partner. Hence, there is an urgent need to define strategies to prevent HIV transmission within couple relationships. HIV counselling and testing have largely been organised on an individual and sex-specific basis, for pregnant women in programmes for prevention of mother-to-child transmission of HIV and in STI consultations and recently male circumcision for men. A couple-centred approach to HIV counselling and testing would facilitate communication about HIV status and adoption of preventive behaviours within couples. This paper reviews what is known about HIV serodiscordance in heterosexual couples in sub-Saharan Africa and what has been published about couple-centred initiatives for HIV counselling and testing since the early 1990s. Despite positive outcomes, couple-oriented programmes have not been implemented on a large scale. In order to stimulate and strengthen HIV prevention efforts, increased attention is required to promote prevention and testing and counselling for couples in stable relationships.

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8. Barriers to the use of modern contraceptives and implications for woman-controlled prevention of sexually transmitted infections in Madagascar

Authors: Randrianasolo B 1; Swezey T 2; Van Damme K 3; Khan MR 2; Ravelomanana N 1; Lovaniaina Rabenja N 1; Raharinivo M 1; Bell AJ 4; Jamieson D 4; Behets F 2
Institutions: 1 University of North Carolina, Madagascar (UNC-Mad), Antananarivo, Madagascar; 2 Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, NC; 3 Department of Medicine, University of North Carolina, Chapel Hill, NC; 4 Centers for Disease Control and Prevention, Atlanta, GA,
Source: Journal of Biosocial Science Nov 2008; 40(6): 879-93. [PubMed]

ABSTRACT

Globally, unplanned pregnancies and sexually transmitted infections (STIs) persist as significant threats to women's reproductive health. Barriers to the use of modern contraceptives by women might inhibit uptake of novel woman-controlled methods for preventing STIs/HIV. Use of modern contraceptives and perceptions and attitudes towards contraceptive use were investigated among women in Antananarivo, Madagascar, using qualitative research. The hypothetical acceptability of the diaphragm--a woman-controlled barrier contraceptive device that also holds promise of protecting against STIs/HIV--was assessed. Women consecutively seeking care for vaginal discharge at a public health clinic were recruited for participation in a semi-structured interview (SSI) or focus group discussion (FGD). Audiotaped SSIs and FGDs were transcribed, translated and coded for predetermined and emerging themes. Of 46 participating women, 70% reported occasional use of male condoms, mostly for preventing pregnancy during their fertile days. Although women could name effective contraceptive methods, only 14% reported using hormonal contraception. Three barriers to use of modern contraceptives emerged: gaps in knowledge about the range of available contraceptive methods; misinformation and negative perceptions about some methods; and concern about social opposition to contraceptive use, mainly from male partners. These results demonstrate the need for programmes in both family planning and STI prevention to improve women's knowledge of modern contraceptives and methods to prevent STI and to dispel misinformation and negative perceptions of methods. In addition, involvement of men will probably be a critical component of increased uptake of woman-controlled pregnancy and STI/HIV prevention methods and improved health.

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9. Acceptance of HIV testing among women attending antenatal care in south-western Uganda: Risk factors and reasons for test refusal

Authors: Dahl V a; Mellhammar L a; Bajunirwe F b; Björkman P a
Institutions: a Department of Clinical Sciences, Malm University Hospital, Sweden; b Department Of Community Health, Mbarara University of Science and Technology, Uganda
Source: AIDS Care 6 Jul 2008; 20(6): 746-752. [PubMed]

ABSTRACT

A problem commonly encountered in programs for prevention of mother-to-child-transmission (PMTCT) of HIV in sub-Saharan Africa is low rates of HIV test acceptance among pregnant women. In this study, we examined risk factors and reasons for HIV test refusal among 432 women attending three antenatal care clinics offering PMTCT in urban and semi-urban parts of the Mbarara district, Uganda. Structured interviews were performed following pre-test counselling. Three-hundred-eighty women were included in the study, 323 (85%) of whom accepted HIV testing. In multivariate analysis, testing site (Site A: OR = 1.0; Site B: OR = 3.08; 95%CI: 1.12-8.46; Site C: OR = 5.93; 95%CI: 2.94-11.98), age between 30 and 34 years (<20 years: OR = 1.0; 20-24 years: OR = 1.81; 95%CI: 0.58-5.67; 25-29 years: OR = 2.15; 95%CI: 0.66-6.97; 30-34 years: OR = 3.88; 95%CI: 1.21-13.41), mistrust in reliability of the HIV test (OR = 20.60; 95%CI: 3.24-131.0) and not having been tested for HIV previously (OR = 2.15; 95%CI: 1.02-4.54) were associated with test refusal. Testing sites operating for longer durations had higher rates of acceptance. The most common reasons claimed for test refusal were: lack of access to antiretroviral therapy (ART) for HIV-infected women (88%; n=57), a need to discuss with partner before decision (82%; n=57) and fear of partner's reaction (54%; n=57). Comparison with previous periods showed that the acceptance rate increased with the duration of the program. Our study identified risk factors for HIV test refusal among pregnant women in Uganda and common reasons for not accepting testing. These findings may suggest modifications and improvements in the performance of HIV testing in this and similar populations.

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MALARIA IN PREGNANCY

10. Effect of a community-based delivery of intermittent preventive treatment of malaria in pregnancy on treatment seeking for malaria at health units in Uganda

Authors: Mbonye AK a; Schultz Hansen K b; Bygbjerg IC c; Magnussen P d
Institutions: a Department of Community Health, Ministry of Health, Kampala, Uganda; b Department of Health Services Research, Institute of Public Health, University of Aarhus, Aarhus, Denmark; c Institute of Immunology, Microbiology and International Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark; d DBL Centre for Health Research and Development, Institute of Pathobiology, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
Source: Public Health May 2008; 122(5): 516-25. [PubMed]

ABSTRACT

BACKGROUND: The impact of intermittent preventive treatment (IPTp) on malaria in pregnancy is well known. However, in countries where this policy is implemented, poor access and low compliance have been widely reported. Novel approaches are needed to deliver this intervention.

OBJECTIVE: To assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilizers can administer IPTp with sulphadoxine-pyrimethamine (SP) to pregnant women, reach those at greatest risk of malaria, and increase access and compliance with IPTp.

STUDY DESIGN: An intervention study compared the delivery of IPTp in the community with routine delivery of IPTp at health units. The primary outcome measures were the proportion of adolescents and primigravidae accessed, and the proportion of women who received two doses of SP. The study also assessed the effect of the intervention on access to malaria treatment, antenatal care, other services and related costs.

RESULTS: More women (67.5%) received two doses of SP through the community approach compared with health units (39.9%; P<0.0001). Women who accessed IPTp in the community were at an earlier stage of pregnancy (21.0 weeks of gestation) than women who accessed IPTp at health units (23.1 weeks of gestation; P<0.0001). However, health units were visited by a higher proportion of primigravidae (23.6% vs 20.0%; P<0.04) and adolescents (28.4% vs 25.0%; P<0.03). Generally, women who accessed IPTp at health units made more visits for malaria treatment (2.6 (1.0-4.7) vs 1.8 (1.4-2.2); P<0.03). At recruitment, more women who accessed IPTp at health units sought malaria treatment compared with those who accessed IPTp in the community (56.9% vs 49.2%). However, at delivery, a high proportion of women who accessed IPTp in the community had sought malaria treatment (70.3%), suggesting the possibility that the novel approach had a positive impact on care seeking for malaria. Similarly, utilization of antenatal care, insecticide-treated nets and delivery care by women in the community was high. The total costs per woman receiving two doses of SP for IPTp were 4093 Uganda shillings (US$ 2.3) for women who accessed IPTp at health units, and 4491 Uganda shillings (US$ 2.6) for women who accessed IPTp in the community.

CONCLUSION: The community approach was effective for the delivery of IPTp, although women still accessed and benefited from malaria treatment and other services at health units. However, the costs for accessing malaria treatment and other services are high and could be a limiting factor in mitigating the burden of malaria in Uganda.

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11. Rural Gambian women's reliance on health workers to deliver sulphadoxine – pyrimethamine as recommended intermittent preventive treatment for malaria in pregnancy

Authors: Brabin L; Stokes E; Dumbaya I; Owens S
Institutions: 1 Academic Unit of Obstetrics & Gynaecology, University of Manchester, Manchester, UK; 2 Medical Research Council, Keneba Field Station, Keneba, the Gambia
Source: Malaria Journal 12 Feb 2009; 8:25. [PubMed Central]

ABSTRACT

BACKGROUND: The use of most anti-malarial medications is restricted during pregnancy, but two doses of sulphadoxine-pyrimethamine are recommended after the first trimester as intermittent preventive treatment in pregnancy (IPTp). In The Gambia, only 32% of women receive two doses and very little research has been conducted on women's awareness of drug safety during pregnancy. The objective of this paper was to assess whether rural Gambian women were aware of the importance of the timing of the two-dose IPT dose schedule and its relevance to drug safety.

METHODS: This was a qualitative study in which 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants were conducted. A generic qualitative approach was used to generate a theory as to why women might not participate in IPTp as recommended.

RESULTS: Although most women used calendar months to count their stage of pregnancy, these months did not correlate with their concept of foetal development. Foetal growth was described following Islamic tradition as water, clot, piece of meat and human being, although there was little consensus about the order or timing in which these stages occurred. Common signs and conditions of malaria were known. Women were anxious about miscarriage and recognized that some medicines should not be taken in the first trimester, but were urged by men and traditional birth attendants to attend for antenatal care in the first trimester to "start treatment." General knowledge about the purpose of pregnancy medications and when they should be taken was poor among both men and women. One important result was that women relied entirely on health workers to provide safe drugs, at the correct time.

CONCLUSION: Women did not have relevant information to judge the safety and appropriate timing of pregnancy drugs, which made them over-reliant on health workers. They should be encouraged to date their own pregnancies in culturally relevant terms and to anticipate when and which medications they should receive.

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