HIV-1 infected women and prenatal care utilization: barriers and facilitators

Quality of antenatal care and its sociodemographic determinants: results of the 2015 Pelotas birth cohort, Brazil

Background

Inadequate antenatal care (ANC) has been associated with adverse pregnancy outcomes. ANC quality is considered a key component of the right to health and a route to equity and dignity for women and their children. Although ANC coverage is relatively high in Brazil, there are revealed some health disparities when coverage is examined by socio-demographic determinants. In this study we evaluated ANC quality and its socio-demographic determinants using data from the 2015 Pelotas birth cohort, Rio Grande do Sul, Brazil.

Methods

This study is part of the 2015 Pelotas population-based birth cohort (n = 3923 pregnant women) conducted in southern Brazil. ANC quality was assessed through 19 content and service utilization indicators recommended by the Brazilian Ministry of Health. Descriptive analyses and associations of each of the ANC indicators and independent variables were performed using the chi-square and linear trend test. ANC indicators were analyzed individually and aggregated as a score. Associations between ANC score quality and socio-demographic variables were assessed with ordinal regressions. Mediation analysis with G-computation was performed to estimate direct and indirect effect of mother’s level of education on ANC quality mediated by the number of consultations and timing of ANC initiation. Base and post confounders were included.

Results

The results showed that except for breast examination, height measurement, tetanus toxoid vaccination and ANC starting at the first trimester, all ANC indicators showed more than 80% coverage during ANC visits.

In the adjusted analysis, inadequate quality ANC was associated with lower maternal education level, not having a partner, being multiparous, being attended by a private provider and by the same professional in all consultations. In the mediation analyses, 6.8% of the association between ANC quality and mother’s education was mediated by the trimester in which ANC started, while 12.8% was mediated by the number of ANC visits.

Conclusions

ANC quality is associated with pregnant women’s socio-demographic characteristics. Significant efforts are needed to improve the quality of facility-based maternity care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07053-4.

Propensity score matching evaluation of psychological stress and hair cortisol among people living with HIV in China

To compare the psychological stress level and hair cortisol level of people living with HIV (PLWH) with those without HIV in China, a total of 220 participants were initially enrolled in the study, including 200 PLWH and 20 people living without HIV. Psychological stress level, including quality of life, anxiety, perceived stress and psychological resilience, was self-reported in both groups with related scales. The cortisol in hair was extracted and assessed by LC-APCI-MS/MS method. Propensity score matching analysis was performed to balance the baseline covariates of the two groups, whereas the difference in psychological stress level and hair cortisol level between the two groups was compared. Furthermore, the associations between psychological stress level and cortisol level were examined. Two comparison groups were matched by 1:3 propensity score matching, which yielding 20 people living without HIV and 60 PLWH. Ultimately, in regarding to the psychological stress, the levels of the anxiety (34 vs. 26, p < 0.001), perceived stress (38.5 vs. 33, p = 0.001) and psychological resilience (31 vs. 26, p = 0.004) were higher among PLWH than those living without HIV, but the people without HIV showed higher quality of life (109 vs.116, p < 0. 001). The hair cortisol level (34.66 vs. 21.61, p = 0.002) in PLWH was higher than those living without HIV. However, there were no significant associations between psychological stress level and cortisol level (p > 0.05). The PLWH showed higher level of psychological stress and cortisol than those without HIV. No relationship was seen between psychological stress level and cortisol level in PLWH.

Postpartum HIV care continuum outcomes in the southeastern USA

OBJECTIVE

The aim of this study was to evaluate postpartum HIV care outcomes.

DESIGN

A prospective clinical cohort of women with HIV and a live birth at the University of North Carolina, 1996-2014.

METHODS

We estimated two stages of the HIV care continuum in the first 24 months postpartum: care retention (at least two visits per year, ≥90 days apart) and viral suppression (HIV RNA < 400 copies/ml). Multivariable models were fit using logistic regression.

RESULTS

Among 1416 women, 141 experienced a live birth at a median age of 28 years, with 74% virally suppressed at delivery. Among all women, 48% were retained in care and 25% maintained viral suppression for the first 24 months postpartum. Among women with available HIV RNA measures, 42% were suppressed at 24 months. HIV care retention estimates were stable across calendar years, but viral suppression rates at 24 months postpartum, among women with available HIV RNA measures, increased from 33 to 67% from 1996-2001 to 2009-2014 (P = 0.04). Being at least 30 years old was positively, and receiving less than 12 weeks of antenatal antiretroviral therapy was negatively, associated with HIV care retention at 24 months postpartum [adjusted odds ratio (AOR): 2.41, 95% confidence interval (95% CI): 1.09-5.29 and AOR: 0.27, 95% CI: 0.08-0.86]. Older maternal age and viral suppression at delivery were both positively associated with virologic suppression at 24 months postpartum (AOR: 2.52, CI: 1.02-6.22, and AOR: 6.42 CI: 1.29-31.97, respectively).

CONCLUSION

HIV care continuum outcomes decrease substantially postpartum, with younger women and those with less antenatal HIV care less likely to successfully remain engaged in HIV care following childbirth.

A tale of two pregnancies: A Critical Interpretive Synthesis of women's perceptions about delayed initiation of antenatal care

BACKGROUND

Delayed access to antenatal care in high income countries is associated with poor maternal, fetal and neonatal outcomes. The aim was to synthesise the diverse body of evidence around women's views of early antenatal care and barriers to attendance in such countries. Critical Interpretive Synthesis integrates the process of systematic review with the qualitative methods of meta-ethnography and grounded theory, with a focus on theory generation to inform policy, practice and future research.

METHODS

Database searches were conducted, supplemented with reference and citation tracking and website searching between February 2014 and April 2016. Qualitative data analysis methods were used to extract and summarise the key themes from each study. A taxonomy of constructs was created, with the synthesis developed to thread these together. Fifty-four papers were synthesised, including qualitative, quantitative, mixed method and systematic review, published between 1987 and 2016.

FINDINGS

Seventeen constructs around the core concept of 'acceptance of personal and public pregnancies' were produced. Acceptance of the 'personal' pregnancy considers the contribution of mindset in the recognition and acceptance of pregnancy, influenced by knowledge of pregnancy symptoms, pregnancy planning and desire. Acceptance of the 'public' pregnancy considers women's assessment of the social consequences of pregnancy, and the relevance and priority of antenatal care.

CONCLUSION

Critical Interpretive Synthesis offers a systematic yet creative approach to the synthesis of diverse evidence. The findings offer new perspectives on women's perceptions of early pregnancy and attendance for care, which may be used to facilitate timely antenatal provision for all pregnant women.

Perceptions of barriers, facilitators and motivators related to use of prenatal care: A qualitative descriptive study of inner-city women in Winnipeg, Canada

OBJECTIVE

The objective of this qualitative descriptive study was to explore the perceptions of women living in inner-city Winnipeg, Canada, about barriers, facilitators, and motivators related to their use of prenatal care.

METHODS

Individual, semi-structured interviews were conducted in person with 26 pregnant or postpartum women living in inner-city neighborhoods with high rates of inadequate prenatal care. Interviews averaged 67 min in length. Recruitment of participants continued until data saturation was achieved. Inductive content analysis was used to identify themes and subthemes under four broad topics of interest (barriers, facilitators, motivators, and suggestions). Sword's socio-ecological model of health services use provided the theoretical framework for the research. This model conceptualizes service use as a product of two interacting systems: the personal and situational attributes of potential users and the characteristics of health services.

RESULTS

Half of the women in our sample were single and half self-identified as Aboriginal. Participants discussed several personal and system-related barriers affecting use of prenatal care, such as problems with transportation and child care, lack of prenatal care providers, and inaccessible services. Facilitating factors included transportation assistance, convenient location of services, positive care provider qualities, and tangible rewards. Women were motivated to attend prenatal care to gain knowledge and skills and to have a healthy baby.

CONCLUSION

Consistent with the theoretical framework, women's utilization of prenatal care was a product of two interacting systems, with several barriers related to personal and situational factors affecting women's lives, while other barriers were related to problems with service delivery and the broader healthcare system. Overcoming barriers to prenatal care and capitalizing on factors that motivate women to seek prenatal care despite difficult living circumstances may help improve use of prenatal care by inner-city women.

Stigma, HIV and health: a qualitative synthesis

Background

HIV-related stigma continues to negatively impact the health and well-being of people living with HIV, with deleterious effects on their care, treatment and quality of life. A growing body of qualitative research has documented the relationship between HIV-related stigma and health. This review aims to synthesize qualitative evidence that explored the intersections of stigma and health for people with HIV.

Methods

A thematic summary was conducted that was guided by the qualitative metasummary technique developed by Sandelowski and Barraso. Literature searches yielded 8,622 references of which 55 qualitative studies were identified that illustrated HIV-related stigma in the context of health.

Results

The metasummary classified qualitative findings into three overarching categories: conceptualizing stigma which identified key dimensions of HIV-related stigma; experiencing stigma which highlighted experiences of stigma in the health context, and managing stigma which described ways in which stigma is avoided or addressed. To better illustrate these connections, the qualitative literature was summarized into the following themes: stigma within health care settings, the role of stigma in caring for one’s health, and strategies to address HIV-related stigma in the health context. A number of health care practices were identified – some rooted in institutional practices, others shaped by personal perceptions held by practitioners – that could be stigmatizing or discriminatory towards people with HIV. There existed interconnections between enacted stigma and felt stigma that influenced health care utilization, treatment adherence, and overall health and well-being of people with HIV. Intersectional stigma also emerged as instrumental in the stigma experiences of people living with HIV. A number of strategies to address stigma were identified including social support, education, self-efficacy, resilience activities, and advocacy.

Conclusion

This review of the qualitative evidence indicates that HIV-related stigma within health contexts is a broad social phenomenon that manifests within multiple social spheres, including health care environments. Findings from this review indicate that future stigma research should consider the social structures and societal practices – within and outside of health care environments – that perpetuate and reinforce stigma and discrimination towards people with HIV.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2197-0) contains supplementary material, which is available to authorized users.

Adequacy of prenatal care among women living with human immunodeficiency virus: a population-based study

Background

Prenatal care reduces perinatal morbidity. However, there are no population-based studies examining the adequacy of prenatal care among women living with HIV. Accordingly, we compared the prevalence of adequate prenatal care among women living with and without HIV infection in Ontario, Canada.

Methods

Using administrative data in a universal single-payer setting, we determined the proportions of women initiating care in the first trimester and receiving adequate prenatal care according to the Revised-Graduated Prenatal Care Utilization Index . We also determined the proportion of women with HIV receiving adequate prenatal care by immigration status. We used generalized estimating equations with a logit link function to derive adjusted odds ratios (aORs) and 95 % confidence intervals (CI) for all analyses.

Results

Between April 1, 2002 and March 31, 2011, a total of 1,132,135 pregnancies were available for analysis, of which 634 (0.06 %) were among women living with HIV. Following multivariable adjustment, women living with HIV were less likely to receive adequate prenatal care (36.1 % versus 43.3 %; aOR 0.74, 95 % CI 0.62 to 0.88) or initiate prenatal care in the first trimester (50.8 % versus 70.0 %; aOR 0.51, 95 % CI 0.43 to 0.60) than women without HIV. Among women with HIV, recent (i.e. ≤ 5 years) immigrants from Africa and the Caribbean were less likely to receive adequate prenatal care (25.5 % versus 38.5 %; adjusted odds ratio 0.51; 95 % CI, 0.32 to 0.81) than Canadian-born women.

Conclusion

Despite universal health care, disparities exist in the receipt of adequate prenatal care between women living with and without HIV. Interventions are required to ensure that women with HIV receive timely and adequate prenatal care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1842-y) contains supplementary material, which is available to authorized users.

Providers caring for adolescents with perinatally-acquired HIV: Current practices and barriers to communication about sexual and reproductive health

The population of adolescents and young adults (AYA) with perinatally-acquired HIV (PHIV) present challenges to HIV healthcare providers (HHCPs). Originally not expected to survive childhood, they are now living well into young adulthood. Little is known about the type of sexual and reproductive (SRH) information/services offered to AYA with PHIV by HHCPs. HHCPs (n=67) were recruited using snowball sampling, and completed an online survey. Providers' most frequently endorsed SRH topics discussed with both male and female patients included condom use (77.3%), STD prevention (73.1%), and screening (62.1%). Providers' reports indicated that females received significantly more education about SRH topics overall. The most frequently noted barriers to SRH communication included more pressing health concerns (53.0%), parent/guardian not receptive (43.9%), and lack of time during appointment (43.9%). Provider-reported SRH conversations with HHCPs were highly focused on horizontal transmission and pregnancy prevention. Salient social aspects of SRH promotion for AYAs with PHIV (e.g., managing disclosure and romantic relationships) were less commonly discussed, though such conversations may serve to reduce secondary transmission and enhance the overall well-being of AYA with PHIV. Findings indicated that further work must be done to identify strategies to address unmet SRH needs of the aging population of AYA with PHIV.

Quality, not just quantity: lessons learned from HIV testing in Salvador, Brazil

Studies have demonstrated that an early HIV diagnosis is a critical first step towards continued engagement in care. We examined HIV testing experiences in Salvador, Brazil, to understand how a focus on quality services can inform service provision more generally in the post-2015 global health agenda. Seventeen semi-structured interviews were conducted with HIV-positive pregnant women in Salvador, a large urban centre of north-east Brazil. Interviews were transcribed, translated and coded for analysis. Deductive codes confirmed factors identified in the literature review. Inductive codes highlighted new factors emerging from the initial coding. 'Quality' was defined according to global and national guidelines as HIV testing with informed and voluntary consent, counselling and confidentiality (3Cs). No pregnant woman experienced all elements of the 3Cs. Three women did not experience any informed and voluntary consent, counselling or confidentiality. Few women provided consent overall and none received pre-test counselling. Post-test counselling and confidentiality of services were more consistently provided. This study suggests that testing in Salvador - the third-largest city in the country - is not of the quality called for by global and national guidelines, despite the fact that HIV testing is being routinely provided for HIV-positive pregnant women in Brazil. Going forward, additional clarity around the 3Cs is necessary to improve how the quality, not just the quantity, of HIV services is measured.

Social context of rural Women with HIV/AIDS

The South has more AIDS cases than any other region of the US, with most new diagnoses among African American women (56%). In a previous study, a peer counseling intervention for rural women with HIV/AIDS was developed and tested. The purpose of this analysis was to describe, from the peer counselors' perspective, the predominant concerns of the women, contextualized by living in isolated, impoverished circumstances in the rural Deep South. Following home visits, peer counselors recorded a description of the encounter. A multidisciplinary qualitative research group extracted, coded, and thematized the chief concerns and context of the women's lives. Findings provide a vivid portrait of HIV-infected women experiencing deeply troubling psychological and physiological symptoms of HIV/AIDS against the contextual ground of poverty and isolation. Themes include: (1) struggle/effort; (2) stigma/hiding; (3) loss/depression; and (4) independence/ dependence. These women lived in extremely difficult life circumstances that reflected not only a devastating chronic illness, but a life of poverty and abuse. Appropriate care for HIV-infected women living in the rural Deep South will need to address the whole context of their lives.

Human immunodeficiency virus prevalence in an unbooked obstetric population in the Niger Delta

Despite recent advances in the prevention of transmission of human immunodeficiency virus (HIV) infection from mother to child during pregnancy, infants continue to be born and infected with HIV, particularly in Africa. This study was undertaken to determine the seroprevalence of HIV infection among unbooked pregnant women in the Niger Delta of Nigeria. One hundred and eighteen consecutively recruited unbooked subjects presenting to the isolation ward at the University of Port Harcourt Teaching Hospital were screened for HIV. Among the 118 subjects studied, 30 (25.4%) were positive for HIV. HIV-1 was the predominant viral strain. Gestational age of subjects at presentation was 28–40 weeks and mean age was 35.04 ± 8.06 years. The majority of subjects were primigravidas 66 (55.9%), while 52 (44.1%) were multigravidas. The prevalence of HIV was significantly higher among unbooked pregnant women with less formal education: 14 (11.9%) compared with 9 (7.6%), 5 (4.2%), and 2 (1.7%) for those with primary, secondary, and tertiary education, respectively (P = 0.01). Among the occupational groups, the prevalence of HIV was significantly higher among traders 14 (11.9%) than in career women 5 (4.2%, P = 0.04). Multigravid women were more susceptible to HIV infection 17 (14.4%) than primigravid women. Perinatal mortality and emergency cesarean section was high among unbooked pregnant women. The prevalence of HIV observed amongst unbooked antenatal subjects in this study is significantly higher than those of booked patients in previous studies. These findings are very pertinent to health care delivery, because this pool of unbooked patients may not be benefiting from the Prevention of Maternal to Child Transmission program, thus increasing the pediatric HIV burden in our environment.

'Weighing up and balancing out': a meta-synthesis of barriers to antenatal care for marginalised women in high-income countries

BACKGROUND

In high-resource settings around 20% of maternal deaths are attributed to women who fail to receive adequate antenatal care. Epidemiological evidence suggests many of these women belong to marginalised groups often living in areas of relative deprivation. Reasons for inadequate antenatal attendance have yet to be fully evaluated.

OBJECTIVES

To identify the factors affecting access to antenatal care for marginalised pregnant women living in developed countries.

SEARCH STRATEGY

We included qualitative studies from developed countries published in English language journals (1980-2007).

SELECTION CRITERIA

Qualitative studies exploring the views of marginalised women living in developed countries who either failed to attend for any antenatal care or did so late or irregularly.

DATA COLLECTION AND ANALYSIS

Eight studies fulfilled the selection criteria and were synthesised in accord with the techniques derived from meta-ethnography.

MAIN RESULTS

Initial access is influenced by late pregnancy recognition and subsequent denial or acceptance. Continuing access appears to depend on a strategy of weighing up and balancing out of the perceived gains and losses. Personal resources in terms of time, money and social support are considered alongside service provision issues including the perceived quality of care, the trustworthiness and cultural sensitivity of staff and feelings of mutual respect.

CONCLUSIONS

A nonthreatening, nonjudgemental antenatal service run by culturally sensitive staff may increase access to antenatal care for marginalised women. Multiagency initiatives aimed at raising awareness of, and providing access to, antenatal care may also increase uptake.

Acesso universal? Obstáculos ao acesso, continuidade do uso e gênero em um serviço especializado em HIV/AIDS em Salvador, Bahia, Brasil

Desde 1996, o Brasil mantém políticas internacionalmente conhecidas como de acesso universal ao tratamento especializado em HIV/AIDS. Observa-se, que o impacto da iniciativa tem sido desigual entre diferentes populações e regiões brasileiras. Desde uma perspectiva de gênero, o estudo buscou avaliar o acesso a um serviço especializado em HIV/AIDS localizado em Salvador, Bahia, identificando fatores facilitadores e obstaculizadores ao acesso e continuidade do uso vivenciados por mulheres vivendo com HIV/AIDS. Foram realizadas observação participante e entrevistas semi e não estruturadas com 13 usuárias. Resultados indicaram que a organização das rotinas do serviço e as relações travadas entre usuários e entre eles e trabalhadores em saúde condicionavam-se por valores, concepções e práticas associados a gênero, classe e aparência. O acesso e continuidade do uso no Serviço de Atenção à AIDS de Salvador eram condicionados à disponibilidade de bens sociais e simbólicos; o serviço apresentava capacidade limitada de adequação às especificidades dos usuários. Os achados apontam para limitações da operacionalização das políticas de acesso universal; e reforçam a necessidade de estudos que considerem a noção de vulnerabilidade e regionalização da epidemia no Brasil.

The relationship between housing status and HIV risk among active drug users: a qualitative analysis

This paper examines the relationship between housing status and HIV risk using longitudinal, qualitative data collected in 2004-2005, from a purposeful sample of 65 active drug users in a variety of housed and homeless situations in Hartford, Connecticut. These data were supplemented with observations and in-depth interviews regarding drug use behavior collected in 2001-2005 to evaluate a peer-led HIV prevention intervention. Data reveal differences in social context within and among different housing statuses that affect HIV risk or protective behaviors including the ability to carry drug paraphernalia and HIV prevention materials, the amount of drugs in the immediate environment, access to subsidized and supportive housing, and relationships with those with whom drug users live. Policy implications of the findings, limitations to the data, and future research are discussed.

Initiation of and barriers to prenatal care use among low-income women in San Antonio, Texas

Healthy People 2010 goals set a target of 90% of mothers starting prenatal care in the first trimester of pregnancy. While there are questions about the value of prenatal care (PNC), there is much observational evidence of the benefits of PNC including reduction in maternal, fetal, perinatal, and infant deaths. The objective of this study was to understand barriers to PNC as well as factors that impact early initiation of care among low-income women in San Antonio, Texas. A survey study was conducted among low-income women seeking care at selected public health clinics in San Antonio. Interviews were conducted with 444 women. Study results show that women with social barriers, those who were less educated, who were living alone (i.e. without an adult partner or spouse), or who had not planned their pregnancies were more likely to initiate PNC late in their pregnancies. It was also observed that women who enrolled in the WIC program were more likely to initiate PNC early in their pregnancies. Women who initiated PNC late in pregnancy had the highest odds of reporting service-related barriers to receiving care. However, financial and personal barriers created no significant obstacles to women initiating PNC. The majority of women in this study reported that they were aware of the importance of PNC, knew where to go for care during pregnancy, and were able to pay for care through financial assistance, yet some did not initiate early prenatal care. This clearly establishes that the decision making process regarding PNC is complex. It is important that programs consider the complexity of the decision-making process and the priorities women set during pregnancy in planning interventions, particularly those that target low-income women. This could increase the likelihood that these women will seek PNC early in their pregnancies.

Shifting moral values to enhance access to health care: harm reduction as a context for ethical nursing practice

BACKGROUND

People who are street involved including those experiencing homelessness and substance use are at increased risk of morbidity and mortality. Such inequities are exacerbated when those facing the greatest inequities in health have the least access to health care. These concerns have rarely been addressed in bioethics and there has been a lack of explicit attention to the dominant societal and organizational values that structure such injustices. The purpose of this paper is to describe the underlying value tensions that impact ethical nursing practice and affect equity in access to health care for those who are street involved.

METHODS

In this paper, findings from a larger qualitative ethnographic study of ethical practice in nursing in the context of homelessness and substance use are reported. The original research was undertaken in two 'inner city' health care centres and one emergency department (ED) to gain a better understanding of ethical nursing practice within health care interactions. Data were collected over a period of 10 months through face-to-face interviews and participant observation.

RESULTS

In order to facilitate access to health care for those who are street-involved nurses had to navigate a series of value tensions. These value tensions included shifting from an ideology of fixing to reducing harm; stigma to moral worth; and personal responsibility to enhancing decision-making capacity. A context of harm reduction provided a basis for the development of relationships and shifted the moral orientation to reducing harm as a primary moral principle in which the worth of individuals and the development of their capacity for decision-making was fostered.

CONCLUSIONS

Implementation of a harm reduction philosophy in acute care settings has the potential to enhance access to health care for people who are street involved. However, explicit attention to defining the harms and values associated with harm reduction is needed. While nurses adopted values consistent with harm reduction and recognized constraints on personal responsibility, there was little attention to action on the social determinants of health such as housing. The individual and collective role of professional nurses in addressing the harms associated with drug use and homelessness requires additional examination.

HIV/AIDS related discrimination in health care service: a cross-sectional study in Gejiu City, Yunnan Province

OBJECTIVES

To investigate discrimination against people living with HIV (PLWH) and its impacts.

METHODS

Forty people who were either HIV positive (7/40) or had high risk behavior (33/40) were interviewed. Focus group discussion was held in the interview with people who were suspected to be infected with HIV, and in-depth interview was conducted in the survey of HIV positive persons whose privacy was strictly protected to ensure the confidentiality of the collected information.

RESULTS

It was identified that six forms of discrimination against people living with HIV occurred in health care service in Gejiu, including speaking to patients in an insulting manner, refusing to provide health care service, delaying treatment, treating differently, uncovering patients' privacy, and over-protecting themselves against patients. Discrimination against people living with HIV greatly affected their health conditions.

CONCLUSIONS

Discrimination against people living with HIV in health service has negative impact on their physical and mental health.

Harm reduction through a social justice lens

BACKGROUND

People who are street involved such as those experiencing homelessness and drug use face multiple inequities in health and access to health care. Morbidity and mortality are significantly increased among those who are street involved. Incorporation of a harm reduction philosophy in health care has the potential to shift the moral context of health care delivery and enhance access to health care services. However, harm reduction with a primary focus on reducing the harms of drug use fails focus on the harms associated with the context of drug use such as homelessness, violence and poverty.

METHODS

Ethical analysis of the underlying values of harm reduction and examination of different conceptions of justice are discussed as a basis for action that addresses a broad range of harms associated with drug use.

RESULTS

Theories of distributive justice that focus primarily on the distribution of material goods are limited as theoretical frameworks for addressing the root causes of harm associated with drug use. Social justice, reconceptualised and interpreted through a critical lens as described by Iris Marion Young, is presented as a promising alternative ethical framework.

CONCLUSIONS

A critical reinterpretation of social justice leads to insights that can illuminate structural inequities that contribute to the harms associated with the context of drug use. Such an approach provides promise as means of informing policy that aims to reduce a broad range of harms associated with drug use such as homelessness and poverty.

System and patient barriers to appropriate HIV care for disadvantaged populations: the HIV medical care provider perspective

Little is known about the perception of system and patient barriers to adequate HIV care by an essential resource in the provision of HIV care, HIV medical care providers. To evaluate such perceptions, between November 2000 and June 2001 a survey was mailed to 526 HIV medical care providers who cared for HIV-infected individuals in Atlanta, Baltimore, Los Angeles, and Miami. Logistic regression analysis of survey results revealed significant differences in perceptions of system barriers between Black and Hispanic providers versus White providers and non-medical doctor providers versus medical doctor providers. Female providers differed significantly from male providers in assessing the importance of certain system and patient barriers. The authors observed that there are seeming disparities in perceptions of system and patient barriers to HIV medical care by providers of different race/ethnic groups, genders, and professions. More research needs to be conducted to determine if these disparities reflect differences in the provision of adequate HIV care for disadvantaged individuals.

Substance abuse in HIV-positive women

Early in the U.S. HIV/AIDS pandemic, the role of substance abuse in the spread of AIDS was clearly established. However, the relationship of HIV and substance abuse is more complex than simply noting that injection drug use is a mode of transmission for the virus. HIV infection and substance abuse disorders interact in a complex fashion, with each acting as a potential catalyst or obstacle in the treatment of the other. In this article, we report the results of a qualitative metasynthesis of studies containing information on substance abuse among HIV-positive women, using 74 published and unpublished reports. The data on 1,548 women, who were primarily mothers from minority groups, allowed us to construct a trajectory that describes the events of their lives with regard to substance abuse and its intersection with HIV infection.

"The rock always comes first": drug users' accounts about using formal health care

Illicit drug use remains a significant public health threat. The issues surrounding drug use are recognized by public health professionals as important for several reasons. The incidence and prevalence of drug use persists in spite of the extensive societal, interpersonal, and individual consequences. In addition, the chronic health issues and health care costs associated with drug use continue to spiral. A wide variety of quantitative studies have examined the extent of health care problems, access, cost, and health care satisfaction among illicit drug users. While these studies offer important information through survey formats, fewer studies focus on subjective constructions of health care management from the users' perspective. This article examines the elements of the decision-making process involved in accessing formal health care among chronic and injecting street drug users. Twenty-eight in-depth interviews provide the data for this analysis, which is part of a large quantitative study of 1,479 injecting and chronic drug users and nondrug users in Miami, Florida. By exploring the elements of health care access through the eyes of the drug users, researchers and treatment professionals may gain insights into new ways to improve health care access for this at-risk population.

Motherhood in the context of maternal HIV infection

Metasummary and metasynthesis techniques were used to integrate findings pertaining to motherhood in 56 reports of qualitative studies conducted with HIV-positive women. Motherhood in the context of maternal HIV infection entailed work directed toward the illness itself and the social consequences of having HIV infection in the service of two primary goals: the protection of children from HIV infection and HIV-related stigma and the preservation of a positive maternal identity. Motherhood both intensified and mitigated the negative physical and social effects of HIV infection. HIV-positive mothers engaged in a distinctive kind of maternal practice-virtual motherhood-to resist forces that disrupted their relationships with and ability to care for their children, as well as their identities as mothers.

Classifying the findings in qualitative studies

A key task in conducting research integration studies is determining what features to account for in the research reports eligible for inclusion. In the course of a methodological project, the authors found a remarkable uniformity in the way findings were produced and presented, no matter what the stated or implied frame of reference or method. They describe a typology of findings, which they developed to bypass the discrepancy between method claims and the actual use of methods, and efforts to ascertain its utility and reliability. The authors propose that the findings in journal reports of qualitative studies in the health domain can be classified on a continuum of data transformation as no finding, topical survey, thematic survey, conceptual/thematic description, or interpretive explanation.

Toward a metasynthesis of qualitative findings on motherhood in HIV-positive women

A qualitative metasynthesis of qualitative findings ought to be more than a mere summary of those findings. Yet the processes by which the interpretive innovation expected of qualitative metasynthesis projects can be achieved remain opaque. Several analytic devices for the metasynthesis of findings were clarified in the course of an ongoing methodological project involving 45 reports of qualitative studies of HIV-positive women. These devices include the creation of a taxonomy of findings, the explicit use of sustained comparisons, the translation of in vivo concepts, and the use of imported concepts. Any qualitative metasynthesis of findings constitutes an interpretation at least three times removed from the lives represented in them. Clarifying the analytic devices used to create such metasyntheses is essential to demonstrating that despite being far away from participants' lives, these interpretations remain close to them.

Perceptions about prenatal care: views of urban vulnerable groups

BACKGROUND

In the United States, infant mortality rates remain more than twice as high for African Americans as compared to other racial groups. Lack of adherence to prenatal care schedules in vulnerable, hard to reach, urban, poor women is associated with high infant mortality, particularly for women who abuse substances, are homeless, or live in communities having high poverty and high infant mortality. This issue is of concern to the women, their partners, and members of their communities. Because they are not part of the system, these womens' views are often not included in other studies.

METHODS

This qualitative study used focus groups with four distinct categories of people, to collect observations about prenatal care from various perspectives. The 169 subjects included homeless women; women with current or history of substance abuse; significant others of homeless women; and residents of a community with high infant mortality and poverty indices, and low incidence of adequate prenatal care. A process of coding and recoding using Ethnograph and counting ensured reliability and validity of the process of theme identification.

RESULTS

Barriers and motivators to prenatal care were identified in focus groups. Pervasive issues identified were drug lifestyle, negative attitudes of health care providers and staff, and non-inclusion of male partners in the prenatal experience.

CONCLUSIONS

Designing prenatal care relevant to vulnerable women in urban communities takes creativity, thoughtfulness, and sensitivity. System changes recommended include increased attention to substance abuse treatment/prenatal care interaction, focus on provider/staff attitudes, and commitment to inclusion of male partners.