Healthcare workers' behaviors and personal determinants associated with providing adequate sexual and reproductive healthcare services in sub-Saharan Africa: a systematic review

Vaccine coverage and timeliness among children of adolescent mothers: A community-based study in the eastern cape, South Africa

BACKGROUND

Children born to adolescent mothers are more vulnerable to infant mortality and morbidity than those born to adult mothers. HIV-exposed children have lower antibody protection against vaccine-preventable diseases at birth compared to unexposed children. In South Africa, 17 % of adolescent girls aged 15-19 years are mothers, yet vaccination coverage and timeliness among their children is underreported.

METHODS

This study estimated age-appropriate vaccination coverage and timeliness among children (n = 1080) of adolescent mothers (n = 1015) in the Eastern Cape, South Africa. Mother-child dyads were recruited through healthcare and community-based sampling strategies. Vaccination data were abstracted from 1013 home-based child health records (2017-2019). Coverage is reported for Diphtheria-Tetanus-Pertussis 3rd dose (DTP3), under-1 vaccination among children over 12 months (n = 613) and measles 2nd dose (MCV2) among children over 24 months (n = 382) using proportions with 95 % confidence intervals (95 %CI). Timeliness is defined as receiving each vaccination within 4 weeks of recommended age. Findings are disaggregated by maternal HIV-status.

RESULTS

Overall, 27.3 % of adolescent mothers were living with HIV. Coverage of DTP3 was 85.6 % (95 %CI: 82.6-88.3 %), under-1 coverage was 53.2 % (95 %CI: 49.1-57.2 %), and MCV2 coverage was 62.3 % (95 %CI: 57.2-67.2 %). Vaccination coverage was lower among children of adolescent mothers living with HIV (AMLHIV) than unexposed children (DTP3 80.3 % vs 88.2 % p-value: 0.01; under-1 46.5 % vs 56.4 % p-value: 0.02; MCV2 55.4 % vs 67.1 % p-value: 0.02). Timeliness of vaccinations declined over time from 98.0 % at birth, 70.7 % at 14 weeks, 71.9 % at 9 months and 37.3 % at 18 months.

CONCLUSION

Vaccination coverage among children of adolescent mothers in the Eastern Cape are below national targets. Children of AMLHIV had lower coverage than HIV-unexposed children. Further research is needed to identify risk factors associated with incomplete and delayed vaccinations among this group, particularly among HIV-exposed children. Enhanced vaccination campaigns may be required for children of adolescent mothers.

Effects of Performance-Based Financing on Availability, Quality, and Use of Family Planning Services in the Democratic Republic of Congo: An Impact Evaluation

Access to high-quality family planning services remains limited in many low- and middle-income countries, resulting in a high burden of unintended pregnancies and adverse health outcomes. We used data from a large randomized controlled trial in the Democratic Republic of Congo to test whether performance-based financing (PBF) can increase the availability, quality, and use of family planning services. Starting at the end of 2016, 30 health zones were randomly assigned to a PBF program, in which health facilities received financing conditional on the quantity and quality of offered services. Twenty-eight health zones were assigned to a control group in which health facilities received unconditional financing of a similar magnitude. Follow-up data collection took place in 2021-2022 and included 346 health facility assessments, 476 direct clinical observations of family planning consultations, and 9,585 household surveys. Findings from multivariable regression models show that the PBF program had strong positive impacts on the availability and quality of family planning services. Specifically, the program increased the likelihood that health facilities offered any family planning services by 20 percentage points and increased the likelihood that health facilities had contraceptive pills, injectables, and implants available by 23, 24, and 20 percentage points, respectively. The program also improved the process quality of family planning consultations by 0.59 standard deviations. Despite these improvements, and in addition to reductions in service fees, the program had a modest impact on contraceptive use, increasing the modern method use among sexually active women of reproductive age by 4 percentage points (equivalent to a 37 percent increase), with no significant impact on adolescent contraceptive use. These results suggest that although PBF can be an effective approach for improving the supply of family planning services, complementary demand-side interventions are likely needed in a setting with very low baseline utilization.

Using the Nominal Group Technique to Inform Approaches for Enhancing Men's Utilization of Sexual and Reproductive Health Services

Sexual and reproductive health (SRH) services' underutilization by men remains a global public health challenge. SRH problems constitute major health challenges in that they form almost one-seventh of the disease burden and contribute to higher and earlier morbidity among men. We, therefore, invited subject matter experts to collaborate in co-creating intervention strategies to enhance men's utilization of SRH services. We employed the nominal group technique (NGT) for data collection. The NGT is a structured method that involves gathering a group of people to discuss a problem for the purpose of achieving a group consensus and planning actions for the selected problem. The participants who were purposively sampled included researchers, scientists, academics, clinicians, and policymakers. The participants suggested the need to improve men's knowledge, provide healthcare resources such as equipment, medical supplies, and SRH-trained male healthcare workers, deal with healthcare workers' negative attitudes through training and capacitation, and destigmatize socially constructed gender norms that deter men from seeking medical help. These important intervention strategies can be implemented to encourage men's use of SRH services. Men's current underutilization of SRH services requires the urgent implementation of evidence-based interventions. Collaborating with SRH experts in identifying appropriate intervention strategies can assist program managers and policymakers in designing SRH services tailored to men's sexual health needs.

Utilisation of Reproductive Health Services among Adolescents in Ghana: Analysis of the 2007 and 2017 Ghana Maternal Health Surveys

Early pubertal development induces early sexual activities among adolescents. In Ghana, despite the high sexual activity among Ghanaian adolescents, sexual and reproductive health (SRH) services are underutilised, primarily due to SRH stigma and a lack of SRH knowledge and information. This study examined the use of SRH services among adolescents aged 15-19 years in Ghana over a ten year period. The study utilised data from the 2007 and 2017 Ghana Maternal Health Surveys (GMHSs). Responses from 2056 and 4909 adolescent females captured in the 2007 and 2017 GMHSs, respectively, were used. The results showed a declining utilisation of SRH services among adolescents from 28.3% in 2007 to 22.5% in 2017. The odds of using family planning among sexually active adolescents increased from 2007 [AOR-0.32, CI-(0.135, 0.77), p < 0.001] to 2017 [AOR-68.62, CI-(36.104, 130.404), p < 0.001]. With increasing age at first sex, adolescents were less likely to use a family planning method in 2007 [AOR-0.94, CI-(0.89,0.99) p < 0.001], but this improved in 2017 [AOR-1.26, CI-(1.220, 1.293), p < 0.001]. Despite this, knowledge of sources for family planning was found to predict its lower utilisation in both 2007 [AOR = 0.15 (95% CI-0.081, 0.283), p < 0.0001] and 2017 [AOR = 0.206 (95% CI-(0.099, 0.426), p < 0.001]. The findings show that even though knowledge of family planning methods predicted low utilisation, knowledge of sources, age at first sex, and educational level positively predicted the utilisation of SRH services from 2007 to 2017. Opportunities for both enhancing the clinical environment and health provider attitudes exist and should be explored for improving SRH outcomes among sexually active adolescents in Ghana.

Unravelling Delay in Care for Sexually Transmitted Infections-Related Symptoms in a Developing Country Setting (Jamaica)

BACKGROUND

Sexually transmitted infections (STIs) and STI treatment remain a challenge in public health. There is little understanding of related factors influencing health seeking behaviour and delay of care among clinic attendees in Jamaica.

AIM

To determine socio-demographic profile of clinic attendees with STI and identify factors associated with delay in seeking care for STI-related symptoms.

METHODS

A cross-sectional study was done. 201 adult patients presenting with STI symptoms from four health centres in Kingston and St Andrew were selected. A 24-item interviewer-assisted questionnaire was used to obtain data on socio-demographic characteristics, patients' symptoms and duration, previous STIs, knowledge of complications and seriousness of STIs, and factors influencing decision to seek medical care.

RESULTS

Almost 75% delayed seeking care for STIs. Recurrent STIs was identified in 41% of patients. 'Could not find time' was the most commonly reported reason for delay in seeking care (36%). Females were 3.4 times more likely to delay seeking care for STI symptoms than males (OR 3.42, 95% CI: 1.73-6.73). Those with primary level education and below were 5 times more likely to delay seeking care for STI symptoms than those with at least secondary level education (OR 5.05, 95% CI: 1.09-23.46). Participants viewed staff as confidential (68%) and 65% thought health-care workers spent adequate time during consultations.

CONCLUSION

Lower education level and the female gender are associated with delay in seeking care for STI-related symptoms. These factors should be considered when developing interventions to reduce delay in care for STI-related symptoms.

Availability of self-care products for sexual and reproductive health provided by community pharmacists in Rwanda: A cross-sectional study

Access to and use of sexual and reproductive health (SRH) services remain a global public health concern, particularly in developing countries. This study aimed to understand the attitudes and perceptions of pharmacists in Rwandan community pharmacies and to assess the availability of sexual and reproductive health products in these pharmacies.In a cross-sectional study conducted in Rwanda from 1 September 2023 to 30 November 2023, registered and licensed pharmacists from 864 community pharmacies were surveyed, employing a quantitative research approach. Systematic sampling was used to collect the data. A chi-square test was conducted for relationships between variables.SRH products for self-care were widely available in Rwandan community pharmacies, ranging from 82.3% to 97.3%, except for ovulation tests (28.4%). Chi-square tests indicated that married pharmacists were more likely to provide educational guidance on SRH products (χ2 =  8.81, P-value = 0.012). Community pharmacists had positive attitudes and self-reported confidence in dispensing and providing education to pharmacy-based SRH users.The Rwandan community pharmacies had extensive availability of SRH products for self-care use. Pharmacists in these pharmacies had positive attitudes and self-reported confidence in dispensing and guiding the community on SRH products. Continuous professional training is recommended to enhance the quality and standards of SRH.

Assessing the effectiveness of a sexual and reproductive health and rights training programme in changing healthcare practitioners' attitudes and practices in low-income countries

INTRODUCTION

In low-income countries the utilisation of sexual and reproductive health and rights (SRHR) services is influenced by healthcare practitioners' knowledge, attitudes and practices. Despite awareness of the potential problems due to ingrained biases and prejudices, few approaches have been effective in changing practitioners' knowledge, attitudes and practices concerning SRHR in low-income countries.

OBJECTIVES

1) To assess whether participating in an SRHR international training programme (ITP) changed healthcare practitioners' SRHR knowledge, SRHR attitudes and SRHR practices and 2) examine associations between trainees' characteristics, their SRHR work environment and transfer of training.

METHODS

A pre- and post-intervention study, involving 107 trainees from ten low-income countries, was conducted between 2017 and 2018. Paired samples t-test and independent samples t-test were used to assess differences between trainees' pre- and post-training scores in self-rated SRHR knowledge, attitudes, knowledge seeking behaviour and practices. Linear regression models were used to examine association between trainees' baseline characteristics and post-training attitudes and practices.

RESULTS

Trainees' self-rated scores for SRHR knowledge, attitudes and practices showed statistically significant improvement. Baseline high SRHR knowledge was positively associated with improvements in attitudes but not practices. High increases in scores on knowledge seeking behaviour were associated with higher practice scores. No statistically significant associations were found between scores that measured changes in SRHR knowledge, attitudes and practices.

CONCLUSION

The findings indicate that the ITP was effective in improving trainees' self-rated scores for SRHR knowledge, attitudes and behaviours (practices). The strongest association was found between improvement in SRHR knowledge seeking behaviour and the improvement in SRHR practices. This suggests that behaviour intention may have a central role in promoting fair open-minded SRHR practices among healthcare practitioners in low-income countries.

Acceptability of a community-embedded intervention for improving adolescent sexual and reproductive health in south-east Nigeria: A qualitative study

INTRODUCTION

Adolescents have limited access to quality sexual and reproductive health (SRH) services that are key to healthy sexual lives in many low and middle-income countries such as Nigeria. Hence, context-specific interventions are required to increase adolescents' access to and utilisation of SRH. This paper provides new knowledge on the acceptability of a community-embedded intervention to improve access to SRH information and services for adolescents in Ebonyi state, southeast Nigeria.

METHODS

A community-embedded intervention was implemented for six months in selected communities. Thereafter the intervention was assessed for its acceptability using a total of 30 in-depth interviews and 18 focus group discussions conducted with policymakers, health service providers, school teachers, community gatekeepers, parents and adolescents who were purposively selected as relevant stakeholders on adolescent SRH. The interview transcripts were coded in NVivo 12 using a coding framework structured according to four key constructs of the theoretical framework for acceptability (TFA): affective attitude, intervention coherence, perceived effectiveness, and self-efficacy. The outputs of the coded transcripts were analysed, and the emergent themes from each of the four constructs of the TFA were identified.

RESULTS

The intervention was acceptable to the stakeholders, from the findings of its positive effects, appropriateness, and positive impact on sexual behaviour. Policymakers were happy to be included in collaborating with multiple stakeholders to co-create multi-faceted interventions relevant to their work (positive affective attitude). The stakeholders understood how the interventions work and perceived them as appropriate at individual and community levels, with adequate and non-complex tools adaptable to different levels of stakeholders (intervention coherence). The intervention promoted mutualistic relations across stakeholders and sectors, including creating multiple platforms to reach the target audience, positive change in sexual behaviour, and cross-learning among policymakers, community gatekeepers, service providers, and adolescents (intervention effectiveness), which empowered them to have the confidence to provide and access SRH information and services (self-efficacy).

CONCLUSIONS

Community-embedded interventions were acceptable as strong mechanisms for improving adolescents' access to SRH in the communities. Policymakers should promote the community-embedded strategy for holistic health promotion of adolescents.

Impact of a capacity-building intervention on views and perceptions of healthcare providers towards the provision of adolescent sexual and reproductive health services in southeast Nigeria: a cross-sectional qualitative study

OBJECTIVES

Negative views of healthcare providers towards adolescent sexual and reproductive health (SRH) services deter adolescents from seeking vital SRH services. This paper assessed the impact of an intervention on the views and perceptions of healthcare providers towards the provision of adolescent SRH services.

DESIGN AND SETTING

A descriptive, cross-sectional, qualitative study was conducted between 14 October and 19 November 2021 in six local government areas (LGAs) in Ebonyi state, southeast Nigeria, after the implementation of an intervention comprising of training and supportive supervision.

PARTICIPANTS AND DATA COLLECTION

Data were collected through: (1) two in-depth interviews (IDIs) with LGA healthcare managers; (2) six IDIs with LGA adolescent health programme managers; (3) two focus group discussions (FGDs) with 15 primary healthcare facility managers; (4) two FGDs with 20 patent medicine vendors and (5) two FGDs with 17 community health volunteers. A total of six FGDs were held with 52 healthcare providers. The interviews were conducted using pretested interview guides. Transcripts were coded in NVivo (V.12) and themes were identified through inductive analysis.

RESULTS

As a result of the intervention, most healthcare providers started recognising the rights of adolescents to obtain contraceptive services and no longer deny them access to contraceptive services. The providers also became friendlier and were no longer harsh in their interactions with adolescents. There were some unique findings relative to whether the providers were formal or informal healthcare providers. It was found that the informal healthcare providers were bolder and more comfortable delivering SRH services to adolescents and reported improved patronage by the adolescents. The formal healthcare providers made their facilities more conducive for adolescents by creating safe spaces and introducing extracurricular activities.

CONCLUSION

These findings highlight the importance of the constant capacity building of both formal and informal healthcare providers, which can address healthcare providers' biases, views and perceptions of delivering SRH services to adolescents.

Perceptions of youth-friendly sexual and reproductive health services in selected Higher and Tertiary Education Institutions of Zambia: A qualitative study on the perspectives of young people and healthcare providers

The recognition of the need for Adolescent and Youth-Friendly Health Services (AYFHS) is growing. It is important to ensure the provision of high-quality sexual and reproductive health (SRH) services that cater to the unique needs of adolescents and young people (AYP). Adolescents and young people spend a significant amount of time in Higher and Tertiary Education Institutions (HTEIs) where adolescent friendly services are needed. However, there is limited evidence on the availability of sexual and reproductive health services for young people in HTEIs in Zambia. Using the Human Rights Based Approach to healthcare availability, accessibility, acceptability, and quality of care (AAAQ) framework, this study explores young people's perceptions of youth-friendly sexual and reproductive health services in selected HTEIs in Zambia. Between March and June 2021, a qualitative case study was conducted in 12 selected HTEIs located in Lusaka, Central, and Copperbelt provinces of Zambia. The study employed In-depth Interviews (IDIs) and Focus Group Discussions (FGDs) with AYPs, as well as Key-informant Interviews (KIIs) with healthcare providers. The healthcare providers at health facility, district and provincial levels were interviewed to provide insights about the services provided in the HTEIs. A total of 112 interviews were conducted. Data analysis was performed using thematic analysis in NVivo version 11. In the study, young people reported the availability of primary health services like malaria, HIV, and pregnancy testing, as well as screening for STIs. However, their awareness of SRH services was limited. Contraception, STI testing and treatment, and HIV and pregnancy screening and testing were the most accessed services. Equipment and commodity shortages were common, hindering care provision. Young people found healthcare services in educational institutions inaccessible, with limited comprehensive care and understanding from providers. Services lacked tailoring for key populations and privacy/confidentiality. Health care providers also reported inadequate youth-friendly spaces, equipment, medication and trained workers which compromised the quality of care. Peer educators and provider training were seen as essential for improving accessibility and acceptability of services. The findings indicate significant barriers to the accessibility, availability, and acceptability of SRH services for AYP in HTEIs in Zambia. There is a pressing need to enhance AYSRH programming by increasing awareness of services and ensuring their availability and accessibility for young people. Sufficient funding for AYFHS can address challenges related to service quality, including inconsistent availability of medical equipment and supplies. Building the capacity of service providers can potentially enhance the uptake of services by AYP. It is crucial to target services to address the specific vulnerabilities of students with disabilities and key populations, aligning with the goal of achieving universal health coverage and leaving no one behind.

Client-centered counseling and facilitation in improving modern contraceptive uptake in urban slum of Karachi Pakistan

BACKGROUND

Population growth in Pakistan necessitates the implementation of comprehensive family planning (FP) initiatives. The adoption of modern contraceptives, especially long-acting reversible contraceptives (LARC), and permanent family planning methods in the country is challenging and has yet to reach an optimal level. These challenges are deeply rooted in the lack of informed decision-making, as well as demographic and maternal obstetric history. Interventions tailored according to women's needs can address the challenges faced by FP programs. This paper presents the findings of the implementation of a client-centered counseling and facilitation approach in an urban slum in Karachi, Pakistan. Such an approach has the potential to inform women and help them make better decisions regarding their health.

METHODS

In Rehri Goth, a slum located in Karachi, client-centered counseling along with facilitation at the facility was implemented to encourage the adoption of any modern contraceptive methods, with a specific emphasis on promoting the use of LARCs and permanent methods (where needed) among married women of reproductive age (MWRA). This approach was integrated into the existing Maternal, Neonatal, and Child Health (MNCH) services established in 2014. During the routine delivery of services, data were collected on various aspects including demographic characteristics, obstetric history, motivation to adopt LARCs, and reasons for refusal.

RESULTS

A total of N = 3079 eligible MWRA received client-centered counseling, and 60.3% accepted modern contraceptive methods after counseling. Furthermore, 32.5% of these MWRA adopted LARCs or permanent methods. Factors explaining reluctance to adopt any method by MWRA despite specialized counselling were: age >25 years (AOR:1.28, 95% CI:1.08-1.51), no formal education (AOR:1.58, 95% CI:1.36-1.89), having no decision making role at household (AOR:1.60, 95% CI:1.36-1.89), the desire of female or male progeny (AOR:1.86, 95% CI:1.59-2.25) and age of youngest alive ≥3 years (AOR:1.50, 95% CI:1.22-1.84). Factors explaining adoption of short-term methods instead of LARCs or permanent method were: being resident in high under-five mortality clusters (AOR:1.56, 95% CI:1.14-2.14), maternal age > 25 years (AOR:1.88, 95% CI: 1.47-2.40), no decision-making role (AOR:11.19, 95% CI:8.74-14.34), no history of abortions (AOR:2.59, 95% CI:1.79-3.75), no female child (AOR:1.85, 95% CI:1.30-2.65) and ≤ 2 children (AOR:1.74, 95% CI:1.08-2.81).

CONCLUSION

Considering the obstacles mothers face when it comes to accessing extended contraception, public health officials can devise effective strategies that empower MWRA to make well-informed and empowered choices regarding their families and reproductive health.

Equipping providers to offer novel MPTs: Developing counseling messages for the Dual Prevention Pill in clinical studies and beyond

Introduction

The pipeline for multi-purpose prevention technologies includes products that simultaneously prevent HIV, pregnancy and/or other sexually transmitted infections. Among these, the Dual Prevention Pill (DPP) is a daily pill co-formulating oral pre-exposure prophylaxis (PrEP), and combined oral contraception (COC). Clinical cross-over acceptability studies for the DPP require training providers to counsel on a combined product. From February 2021-April 2022, a working group of eight HIV and FP experts with clinical and implementation expertise developed counseling recommendations for the DPP based on existing PrEP/COC guidance.

Assessment of policy/guidelines options and implications

The working group conducted a mapping of counseling messages from COC and oral PrEP guidance and provider training materials. Six topics were prioritized: uptake, missed pills, side effects, discontinuation and switching, drug interactions and monitoring. Additional evidence and experts were consulted to answer outstanding questions and counseling recommendations for the DPP were developed. Missed pills was the topic with the most complexity, raising questions about whether women could "double up" on missed pills or skip the last week of the pack to recover protection faster. Uptake required aligning the time to reach protective levels for both DPP components and explaining the need to take DPP pills during week 4 of the pack. The potential intensity of DPP side effects, given the combination of oral PrEP with COC, was an important consideration. Discontinuation and switching looked at managing risk of HIV and unintended pregnancy when stopping or switching from the DPP. Guidance on drug interactions contended with differing contraindications for COC and PrEP. Monitoring required balancing clinical requirements with potential user burden.

Actionable recommendations

The working group developed counseling recommendations for the DPP to be tested in clinical acceptability studies. Uptake: Take one pill every day for the DPP until the pack is empty. Days 1-21 contain COC and oral PrEP. Days 22-28 do not contain COC to allow for monthly bleeding, but do contain oral PrEP and pills should be taken to maintain HIV protection. Take the DPP for 7 consecutive days to reach protective levels against pregnancy and HIV. Missed pills: If you miss 1 pill multiple times in a month or 2+ consecutive pills, take the DPP as soon as you remember. Do not take more than 2 pills in a day. If 2+ consecutive pills are missed, only take the last missed pill and discard the other missed pills. Side effects: You may experience side effects when you start using the DPP, including changes to monthly bleeding. Side effects are typically mild and go away without treatment. Discontinuation/switching: If you decide to discontinue use of the DPP, but want to be protected from HIV and/or unintended pregnancy, in most cases, you can begin using PrEP or another contraceptive method right away. Drug interactions: There are no drug-drug interactions from combining oral PrEP and COC in the DPP. Certain medications are not recommended due to their contraindication with oral PrEP or COC. Monitoring: You will need to get an HIV test prior to initiating or restarting the DPP, and every 3 months during DPP use. Your provider may recommend other screening or testing.

Discussion

Developing recommendations for the DPP as a novel MPT posed unique challenges, with implications for efficacy, cost, and user and provider comprehension and burden. Incorporating counseling recommendations into clinical cross-over acceptability studies allows for real-time feedback from providers and users. Supporting women with information to use the DPP correctly and confidently is critically important for eventual scale and commercialization.

Development and Validation of the Adolescent Sexual and Reproductive Competency Assessment Tool (ASRH-CAT) for Healthcare Providers

OBJECTIVES

This study aimed to validate a competency assessment tool for adolescent sexual and reproductive health (ASRH) services for healthcare providers (HCP) at primary healthcare (PHC) facilities that require a specific set of competency skills to address ASRH problems.

METHODS

The tool development process used the nine steps of scale development and validation. Fifty-four items were yielded through the expert panel discussion. Two hundred and forty respondents were recruited for an online questionnaire using non-probability sampling. The item content validity index (I-CVI) and exploratory factor analysis (EFA) were used for construct validity.

RESULTS

Fourteen items were removed based on the I-CVI (scores < 0.8) and two items were removed in the EFA (factor loadings < 0.4). The reliability analysis, according to the latent factor, yielded a good item-total correlation (ITC) and a good internal consistency value, with Cronbach's alpha values of 0.905-0.949.

CONCLUSIONS

The final ASRH competency assessment tool (ASRH_CAT) contains 40 items and is reliable and suitable for use in studies related to the ASRH competency assessment of HCPs at the PHC level.

Are respectful maternity care (RMC) interventions effective in reducing intrapartum mistreatment against adolescents? A systematic review

Intrapartum mistreatment of women by health professionals is a widespread global public health challenge. It leads to a decreased quality of maternity care and is evinced to precipitate detrimental maternal and neonatal outcomes, especially among adolescents. Relatedly, research indicates that Respectful Maternity Care (RMC) interventions are especially effective in mitigating intrapartum mistreatment and improving birth outcomes. However, evidence on the success of RMC, specifically for adolescents, is insufficient and unaggregated. Accordingly, this review specifically aims to synthesize existing evidence on RMC care provision to adolescent parturients. This review searched for relevant literature from published and gray sources including PubMed, ScienceDirect, Cochrane, CINAHL, PsycINFO, Scopus, as well as Population Council, WHO and White Ribbon Alliance data sources published between January 1990 and December 2021. Based on eligibility, studies were selected and quality appraised after which thematic analysis and narrative synthesis was conducted. Twenty-nine studies were included in the systematic review. Due to paucity and heterogeneity of quantitative studies, the review was limited to a thematic analysis. Adolescent and health provider perspectives alike underscored the burden and outcomes of mistreatment. Need for RMC interventions to improve quality of maternity care was recommended by majority of studies.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42020183440.

Youth migration and access to health services in a trading centre in southern Uganda: A qualitative exploration

Impeded access to health services is a major factor influencing migrant health. In Uganda, previous research has shown lower utilisation of health services for young rural-urban migrants compared to their non-migrant counterparts. However, access to health services does not start at utilisation, but can be hampered by being able to identify a need for care. Using qualitative methods, we aimed to explore young rural-urban migrants' perceptions of health and patterns of engagement with health services. We analysed, using thematic analysis, a purposive sample of 18 in-depth interviews with 10 young people who had recently migrated within Uganda. Our results are presented through a framework conceptualising access at the intersection between abilities of people and characteristics of services. Participants perceived a need for care mostly through serious crises. Their ability to obtain care was hindered by a lack of resources, as well as the relative social isolation brought by migration. Our study highlights other barriers to accessing care such as the role of social norms and HIV-related stigma in health issues prioritisation, and healthcare workers' attitudes. This knowledge can inform approaches to ensure that community-based services are able to support healthcare access and improved health outcomes for this vulnerable group.

Structural violence in South African primary healthcare facilities: insights from discussions with adolescents and young people seeking sexual and reproductive health needs

Introduction. South Africa has an enabling legislative and policy framework that promotes the protection of adolescents and young people’s sexual and reproductive health and rights. Much of the literature in this field has identified discriminatory and hostile attitudes from healthcare workers as a major underlying factor to negative sexual and reproductive health outcomes for this age cohort. Not as well understood is the role of structural violence although this type of violence, through its structures of injustice and inequalities, is closely associated with stigma and discrimination. Data and sources. To contribute to closing this research gap, this paper draws on the findings of a larger qualitative study, specifically focus group discussions with young people aged 15–24 years. Results. The consequences of these attitudes within the structural violence framework are illuminated as are recommendations for enhancing access to sexual and reproductive health and services by adolescents and young people. Discussion and conclusion. Key among the latter is that young people’s sexual and reproductive health needs and wellbeing should be pursued through a multisectoral approach that encompasses stigma reduction interventions involving the young people, families, and communities collaborating with healthcare workers.

Provider–client rapport in pre-exposure prophylaxis delivery: a qualitative analysis of provider and client experiences of an implementation science project in Kenya

Daily oral pre-exposure prophylaxis (PrEP) is being incorporated into services frequented by adolescent girls and young women (AGYW) in sub-Saharan Africa who are at a significant risk of HIV. In non-PrEP studies, positive provider–client rapport has been shown to improve patient decision-making and use of medication in clinical care. We examined AGYW and healthcare provider (HCP) perspectives on the value of and strategies for building positive provider–client rapport. We conducted in-depth interviews from January 2018 to December 2019 with 38 AGYW and 15 HCPs from two family planning clinics in Kisumu, Kenya where PrEP was being delivered to AGYW as part of the Prevention Options for Women Evaluation Research (POWER) study. We used semi-structured interview guides and audio-recorded interviews with participant consent. Verbatim transcripts were analysed using thematic content analysis. HCPs and AGYW emphasised the importance of positive provider–client rapport to meet AGYW support needs in PrEP service delivery. HCPs described how they employed rapport-building strategies that strengthened AGYW PrEP uptake and continuation, including: (1) using friendly and non-judgmental tones; (2) maintaining client confidentiality (to build client trust); (3) adopting a conversational approach (to enable accurate risk assessment); (4) actively listening and tailoring counselling (to promote client knowledge, skills, and self-efficacy); and (5) supporting client agency. Positive provider–client relationships and negative experiences identified in this analysis have the potential to facilitate/deter AGYW from using PrEP while at risk. The strategies to enhance provider–client rapport identified in this study could be integrated into PrEP provider training and delivery practices.

Contraceptive use among female head porters: implications for health policy and programming in Ghana

Objective

Despite the growing literature on the barriers to contraceptives use among women, the perspective of female head porters has not been exhaustively researched. Using Bronfenbrenner's socio-ecological theory, we explore the factors that influence the contraceptive decision-making of migrant female head porters in the Kumasi Metropolis and the implications for health policy and planning.

Methodology

A case study of female head porters in the Kumasi Metropolis was conducted. We employed a qualitative approach in the collection and analysis of the data. A combination of cluster, purposive, and convenience sampling procedures was used to select 48 migrant female head porters to participate in semi-structured in-depth interviews. The data collected were analyzed using the thematic analytical framework.

Results

We found the main barriers to the uptake of contraception among the head porters to include high cost of contraceptives, perceived side effects associated with contraceptive use, and the disapproval of a male sexual partners.

Conclusion

The findings indicate that head porters' contraceptive decision-making is largely influenced by their social and economic circumstances. To address these, we recommend a carefully tailored approach, starting with a free National Health Insurance Scheme (NHIS) enrollment policy for all head porters in the country. There is also the need for the Ghana Health Service, and NGOs in health to work together to create effective awareness among female head porters on the benefits and misconceptions of contraception by incorporating culturally appropriate education that would facilitate the adoption of positive attitudes towards contraception. Additionally, NGOs in health in collaboration with the health facilities should initiate a process that encourages joint reproductive health decision-making among partners which recognises the added value of men's participation. We argue that men's active participation in contraception decision-making could potentially address their scepticism towards uptake.

Knowledge, attitudes, and practices of health providers regarding access to and use of contraceptive methods among adolescents and youth in urban Guinea

Introduction

The objective of this study was to analyze providers' knowledge, attitudes, and practices regarding access to and use of contraception by urban adolescents and youth.

Methods

This is a cross-sectional study of 1,707 health care providers in 173 selected private and public health facilities in the capital city of Conakry and the seven administrative regions of Guinea. Factors associated with health care providers' attitudes and practices were then analyzed using logistic regression.

Results

Among the 1,707 health providers, 71% had a good level of Knowledge about modern contraceptive use among adolescents and youth. In addition, 62% had positive attitudes, and 41% had good prescribing practices toward using modern contraceptive methods by adolescents and youth. Being a midwife (aOR: 1.39, 95%CI: 1.02-1.89), Being aged 25-34 years (aOR: 1.7, 95%CI: 1.2-2.3), 35-44 years (aOR: 2.1, 95%CI: 1.4-3.0), and 45 years, and older (aOR: 2.4, 95%CI: 1.3-4.2), an increase of years in professional experience (aOR:1.05; 95%CI: 1.02-1.08) were factors significantly associated with provider positive attitudes. However, being a medical doctor (aOR: 2.37, 95%CI: 1.04-4.42), an increase of years in professional experience (aOR: 1.07; 95%CI: 1.04-1.10) and a positive attitude (aOR: 3.16. 95%CI: 2.48-4.01) were factors associated with good practice in delivering modern contraceptive methods to adolescents and youth.

Conclusion

Positive attitudes and good practices toward the use of contraceptive services by adolescents and youth were found among providers. However, many health care providers still have unfavorable attitudes and practices toward delivering FP services to urban adolescents and youth. Therefore, future intervention programs should focus on training health care providers in youth- and adolescent-friendly reproductive health services and promoting contraception among adolescents.

Exploring the psychosocial challenges faced by pregnant teenagers in Ditsobotla subdistrict

Background

Pregnant teenagers usually experience psychosocial challenges such as a great amount of stress when they have to deal with an unwanted pregnancy, unpreparedness for parenthood and a lack of income as well as labour and birth complications. These are further complicated by the stigma from their families, friends and community. Unaddressed psychosocial challenges during teenage pregnancy can adversely affect the health outcomes of both mother and the child.

Aim

This study explores and describes the psychosocial challenges faced by pregnant teenagers in the Ditsobotla subdistrict.

Setting

The study was conducted in three health centres in the Ditsobotla subdistrict.

Methods

A qualitative-exploratory-descriptive and contextual research design was used. Non-probability purposive and convenience sampling techniques were used to select the participants. Semistructured individual interviews through WhatsApp video calls were used to collect data, which were analysed using conventional content analysis.

Results

Three themes emerged from the findings of the study, namely psychological challenges, social challenges and suggestions to address psychosocial challenges faced by pregnant teenagers.

Conclusion

The findings established that pregnant teenagers in the Ditsobotla subdistrict are faced with psychosocial challenges which negatively impact their psychological health and social life. Suggestions made in this study have the potential to improve the psychosocial well-being of pregnant teenagers in the Ditsobotla subdistrict if implemented.

Contributions

The findings of this study provide important information that may be used to improve the psychosocial well-being of pregnant teenagers in the Ditsobotla subdistrict.

Health worker perceptions of stigma towards Zambian adolescent girls and young women: a qualitative study

Background

The high prevalence of HIV among adolescent girls and young women aged 15–24 in Eastern and Southern Africa indicates a substantial need for accessible HIV prevention and treatment services in this population. Amidst this need, Zambia has yet to meet global testing and treatment targets among adolescent girls and young women living with HIV. Increasing access to timely, high-quality HIV services in this population requires addressing the intensified anticipated and experienced stigma that adolescent girls and young women often face when seeking HIV care, particularly stigma in the health facility setting. To better understand the multi-level drivers and manifestations of health facility stigma, we explored health workers’ perceptions of clinic- and community-level stigma against adolescent girls and young women seeking sexual and reproductive health, including HIV, services in Lusaka, Zambia.

Methods

We conducted 18 in-depth interviews in August 2020 with clinical and non-clinical health workers across six health facilities in urban and peri-urban Lusaka. Data were coded in Dedoose and thematically analyzed.

Results

Health workers reported observing manifestations of stigma driven by attitudes, awareness, and institutional environment. Clinic-level stigma often mirrored community-level stigma. Health workers clearly described the negative impacts of stigma for adolescent girls and young women and seemed to generally express a desire to avoid stigmatization. Despite this lack of intent to stigmatize, results suggest that community influence perpetuates a lingering presence of stigma, although often unrecognized and unintended, in health workers and clinics.

Conclusions

These findings demonstrate the overlap in health workers’ clinic and community roles and suggest the need for multi-level stigma-reduction approaches that address the influence of community norms on health facility stigma. Stigma-reduction interventions should aim to move beyond fostering basic knowledge about stigma to encouraging critical thinking about internal beliefs and community influence and how these may manifest, often unconsciously, in service delivery to adolescent girls and young women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08636-5.

Stigma in the health clinic and implications for PrEP access and use by adolescent girls and young women: conflicting perspectives in South Africa

BACKGROUND

Globally, an urgent need exists to expand access to HIV prevention among adolescent girls and young women (AGYW), but the need is particularly acute in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) offers an effective HIV prevention method. In many countries, however, accessing PrEP necessitates that AGYW visit their local health clinic, where they may face access challenges. Some countries have implemented youth-friendly services to reduce certain challenges in local health clinics, but barriers to access persist, including clinic stigma. However, evidence of clinic stigma toward AGYW, particularly with respect to PrEP service delivery, is still limited. This mixed methods study explores stigma toward AGYW seeking clinic services, in particular PrEP, from the perspective of both clinic staff (clinical and nonclinical) and AGYW who seek services at clinic sites in Tshwane province, South Africa.

METHODS

Six focus group discussions were conducted with AGYW (43 total participants) and four with clinic staff (42 total participants) and triangulated with survey data with AGYW (n = 449) and clinic staff (n = 130). Thematic analysis was applied to the qualitative data and descriptive statistics were conducted with the survey data.

RESULTS

Four common themes emerged across the qualitative and quantitative data and with both AGYW and clinic staff, although with varying degrees of resonance between these two groups. These themes included (1) clinic manifestations of stigma toward AGYW, (2) concerns about providing PrEP services for AGYW, (3) healthcare providers' identity as mothers, and (4) privacy and breaches of confidentiality. An additional theme identified mainly in the AGYW data pertained to stigma and access to healthcare.

CONCLUSION

Evidence is needed to inform strategies for addressing clinic stigma toward AGYW, with the goal of removing barriers to PrEP services for this group. While awareness has increased and progress has been achieved around the provision of comprehensive, youth-friendly sexual and reproductive health services, these programs need to be adapted for the specific concerns of young people seeking PrEP services. Our findings point to the four key areas noted above where programs seeking to address stigma toward AGYW in clinics can tailor their programming.

Factors influencing contraception choice and use globally: a synthesis of systematic reviews

BACKGROUND

Unintended pregnancy has a huge adverse impact on maternal, child and family health and wealth. There is an unmet need for contraception globally, with an estimated 40% of pregnancies unintended worldwide.

METHODS

We systematically searched PubMed and specialist databases for systematic reviews addressing contraceptive choice, uptake or use, published in English between 2000 and 2019. Two reviewers independently selected and appraised reports and synthesised quantitative and qualitative review findings. We mapped emergent themes to a social determinants of health framework to develop our understanding of the complexities of contraceptive choice and use.

FINDINGS

We found 24 systematic reviews of mostly moderate or high quality. Factors affecting contraception use are remarkably similar among women in very different cultures and settings globally. Use of contraception is influenced by the perceived likelihood and appeal of pregnancy, and relationship status. It is influenced by women's knowledge, beliefs, and perceptions of side effects and health risks. Male partners have a strong influence, as do peers' views and experiences, and families' expectations. Lack of education and poverty is linked with low contraception use, and social and cultural norms influence contraception and expectations of family size and timing. Contraception use also depends upon their availability, the accessibility, confidentiality and costs of health services, and attitudes, behaviour and skills of health practitioners.

INTERPRETATION

Contraception has remarkably far-reaching benefits and is highly cost-effective. However, women worldwide lack sufficient knowledge, capability and opportunity to make reproductive choices, and health care systems often fail to provide access and informed choice.

Perceptions of Sexual Healthcare Provision in Tanzania: a Key Informant Qualitative Study

INTRODUCTION

Sexual health care services must be standard and unbiased, guided by a structured health care system. There is a scarcity of data on how sexual health care is delivered in Tanzania.

METHODS

To address this gap, in July 2019 we interviewed eleven key informants: cultural and public health experts, and political, religious, and community leaders, selected from different organizations in Dar es Salaam, Tanzania. Participants were asked for their opinions about clinical practices of health care professionals when providing care to patients, with an emphasis on sexual health.

RESULTS

Participants' responses were classified into three subcategories: strengths, barriers, and gaps in sexual health care. Availability of services, service delivery to adults, and code of conduct were among the strengths observed in clinical care services. Barriers included the health care provider's attitudes, moral values, and inadequacy in health policies and treatment guidelines. Vulnerable populations including youth were frequently reported to face most challenges when seeking sexual health care services. In terms of gaps, informants emphasized gender equity in sexual health services provision within care settings.

CONCLUSION AND IMPLICATION

Data indicate that lack of training in sexual health and guidelines for dealing with sexual issues are a barrier to comprehensive health care. These findings can inform the main areas for curriculum developers to focus on, when developing an Afro-centric sexual health curriculum suitable for students in health care professional courses. Moreover, these findings can be useful when developing treatment guidelines and policies that are beneficial to the sexual health wellbeing of individuals.

Healthcare workers' perspectives on access to sexual and reproductive health services in the public, private and private not-for-profit sectors: insights from Kenya, Tanzania, Uganda and Zambia

Background

Access to sexual and reproductive health services remains a challenge for many in Kenya, Tanzania, Uganda and Zambia. Health service delivery in the four countries is decentralised and provided by the public, private and private not-for-profit sectors. When accessing sexual and reproductive health services, clients encounter numerous challenges, which might differ per sector. Healthcare workers have first-hand insight into what impediments to access exist at their health facility. The aim of this study was to identify differences and commonalities in barriers to access to sexual and reproductive health services across the public, private and private not-for-profit sectors.

Methods

A cross-sectional survey was conducted among healthcare workers working in health facilities offering sexual and reproductive health services in Kenya (n = 212), Tanzania (n = 371), Uganda (n = 145) and Zambia (n = 243). Data were collected in July 2019. Descriptive statistics were used to describe the data, while binary logistic regression analyses were used to test for significant differences in access barriers and recommendations between sectors.

Results

According to healthcare workers, the most common barrier to accessing sexual and reproductive health services was poor patient knowledge (37.1%). Following, issues with supply of commodities (42.5%) and frequent stockouts (36.0%) were most often raised in the public sector; in the other sectors these were also raised as an issue. Patient costs were a more significant barrier in the private (33.3%) and private not-for-profit sectors (21.1%) compared to the public sector (4.6%), and religious beliefs were a significant barrier in the private not-for-profit sector compared to the public sector (odds ratio = 2.46, 95% confidence interval = 1.69–3.56). In all sectors delays in the delivery of supplies (37.4-63.9%) was given as main stockout cause. Healthcare workers further believed that it was common that clients were reluctant to access sexual and reproductive health services, due to fear of stigmatisation, their lack of knowledge, myths/superstitions, religious beliefs, and fear of side effects. Healthcare workers recommended client education to tackle this.

Conclusions

Demand and supply side barriers were manifold across the public, private and private not-for-profit sectors, with some sector-specific, but mostly cross-cutting barriers. To improve access to sexual and reproductive health services, a multi-pronged approach is needed, targeting client knowledge, the weak supply chain system, high costs in the private and private not-for-profit sectors, and religious beliefs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08249-y.

Low-Level Knowledge and Associated Factor of Sexual and Reproductive Health Rights Among Aksum University Students, Aksum Ethiopia

Background

Reproductive health rights in Africa are unknown. According to international studies, reproductive health rights of young people particularly university students, are violated, and most of these violations go unreported due to a lack of information and awareness of these rights. The aim of this study was to assess the level of knowledge and associated factors on sexual and reproductive health rights in Ethiopia.

Methods

Institution-based cross-sectional study using an interviewer-administered and structured questionnaire was conducted. The study population consisted of students of the selected department between November, 2018 and June, 2019. A simple random sampling method technique was used to select 420 students. Bi-variate and multi-variate logistic regression analysis was performed.

Results

The knowledge level of the respondents was 16.4%. The majority of students 205 (51%) were in the age group < 20 years. Male [AOR: 1.46, 95% CI: 1.09–1.95]; coming from urban areas [AOR: 2.11, 95% CI: (1.02–4.37)]; provision of sexuality education or lecture in departments [AOR: 1.39, 95% CI: 1.02–1.91] and discussion about reproductive health with anyone else [AOR: 2.31, 95% CI: 1.48–3.62] were significant association for the knowledge of sexual and reproductive health rights.

Conclusions

Respondents' knowledge level was found to be very low. Therefore, strengthening students' lectures or education on reproductive health in the curricula of high school, encouraging discussions with parents, and anyone might improve the knowledge toward sexual and reproductive health rights.

Youth-friendly sexual and reproductive health services utilization and its determinants in Ethiopia: A systematic review and meta-analysis

BACKGROUND

In most developing countries, meeting young people's sexual and reproductive health (SRH) needs remains a problem. Despite policy initiatives and strategic measures aimed at increasing youth utilization of sexual and reproductive health services in Ethiopia, its utilization remains very low. Therefore, this study aimed to assess Ethiopia's youth-friendly sexual and reproductive health services' utilisation and determinants.

METHODS

Scopus, Medline, Google Scholar, and CINAHL databases were searched for articles published until March 2021. The pooled prevalence and effect size of youth-friendly sexual and reproductive health service use and associated factors were estimated using a weighted DerSimonian-laird random effect model. The I2 statistics were used to determine the degree of heterogeneity. The funnel plot and Egger's regression test were used to examine publication bias. Subgroup analyses were performed to reduce underlying heterogeneity.

RESULTS

One thousand one hundred and ninety-one articles were generated from various databases, and a final 26 articles were included in the review, including 16246 participants. Ethiopia's pooled prevalence of youth-friendly sexual and reproductive health service utilization was 42.73 % (95% CI: 35.38-50.09). The findings of this study showed that grade level 11-12, grade level 9-10, close to home sexual and reproductive health services, male sex, and discussion of sexual and reproductive health service with family, friends, and groups, ever experience sexual activity were associated with utilization of youth-friendly sexual and reproductive health services. Maternal educational status secondary school and above, age 15-19 years, age 20-24 years, having ever experienced reproductive problems, living with a partner, living alone, knowing about sexual and reproductive health, having a convenient working hour for youth-friendly service, and participation in a school clubs were also associated with the utilization of youth-friendly sexual and reproductive health services.

CONCLUSION

We found several determinant factors for adolescent and youth utilization of sexual and reproductive health services. The review highlights the importance of improving service usage through youth education and promotion and the scaling up and institutionalizing of youth-friendly services through extensive capacity building.

Training, Attitudes, and Practice (TAP) among healthcare professionals in the Nelson Mandela Bay municipality, South Africa: A health promotion and disease prevention perspective

Background

Healthcare professionals (HCPs) play a pivotal role in ensuring access to quality healthcare of patients. However, their role in health promotion (HP) and disease prevention (DP) has not been fully explored. This study aimed at determining how training, attitude, and practice (TAP) of HCPs influence their practice of HP and DP.

Methods

Data on TAP regarding HP and DP were collected from 495 HCPs from twenty-three hospitals in the study area using a standardized questionnaire. Bivariate, univariate, and multivariate analyses were conducted to describe how the TAP of HCPs influence their HP and DP practices. The analysis was further desegregated at the three levels of healthcare (primary, secondary and tertiary levels).

Results

Most of the medical doctors 36.12% (n = 173), registered nurses 28.39% (n = 136), and allied health professionals (AHPs) 11.27% (n = 54) indicated the absence of coordinated HP training for staff in their facilities. Similarly, 32.93% (n = 193) of the HCPs, indicated having participated in HP or DP training. Among those that had participated in HP and DP training, benefits of training were positive behaviour, attributions, and emotional responses. When compared at the different levels of healthcare, enhanced staff satisfaction and continuing professional development for HP were statistically significant only at the tertiary healthcare level. Multivariate analysis showed a likelihood of reduced coordinated HP training for staff among medical doctors (Coef 0.15; 95% CI 0.07–0.32) and AHPs (Coef 0.24; 95% CI 0.10–0.59) compared to nurses. Furthermore, medical doctors (Coeff: 0.66; 95% CI: 0.46–0.94) were less likely to agree that HCPs should model good health behavior to render HP services as compared to nurses.

Conclusion

Training in HP and DP empowers HCPs with the requisite knowledge and attitude necessary for effective practice. Several HCPs at different levels of care had limited knowledge of HP and DP because of inadequate training. We recommend a strategy aimed at addressing the knowledge and attitudinal gaps of HCPs to ensure effective HP and DP services to patients.

Evidence on respectful maternity care for adolescents: a systematic review protocol

BACKGROUND

Intrapartum mistreatment of women is an ubiquitous public health and human rights challenge. The issue reportedly has severe maternal and neonatal outcomes including mortality, and generally leads to a decreased satisfaction with maternity care. Intrapartum mistreatment, despite being ubiquitous, indicates higher incidence amongst adolescent parturients who are simultaneously at a higher risk of maternal morbidity and mortality. Studies have suggested that Respectful Maternity Care interventions reduce intrapartum mistreatment and improve clinical outcomes for women and neonates in general. However, evidence on the effect of RMC on adolescents is unclear. Hence, the specific aim of this study is to synthesise the available evidence relating to the provision of RMC for adolescents during childbirth.

METHODS

The methodology of the proposed systematic review follows the procedural guideline depicted in the preferred reporting items for systematic review protocol. The review will include published studies and gray literature from January 1, 1990, to June 30, 2021. Electronic databases including MEDLINE, PubMed, ScienceDirect, Cochrane, CINAHL, PsycINFO, Scopus, Google Scholar and Web of Science will be searched to retrieve available studies using the appropriate search strings. Studies included in the review will be appraised for quality using tools tailored to each study design. If appropriate, we will conduct random effects meta-analysis of data to summarise the pooled estimates of respectful maternity care prevalence and outcomes. The selection of relevant studies, data extraction and quality assessment of individual studies will be carried out by two independent authors.

RESULTS

Summaries of the findings will be compiled and synthesised in a narrative summary. In addition to the narrative synthesis, where sufficient data are available, a random-effects meta-analysis will be conducted to obtain a pooled estimate value for respectful maternity care prevalence and outcomes.

DISCUSSION

Respectful Maternity Care for adolescents holds great promise for improved maternal and neonatal care. However, there is a gap in knowledge on the interventions that work and the extent of their effectiveness. Findings from this study will be beneficial in improving Adolescents Sexual and Reproductive Health and Rights and reducing maternal mortality, especially for adolescents.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020183440.

Implementation Strategies to Enhance Youth-Friendly Sexual and Reproductive Health Services in Sub-Saharan Africa: A Systematic Review

Introduction: Youth-friendly health service (YFHS) interventions are a promising, cost-effective approaches to delivering sexual and reproductive services that cater to the developmental needs of young people. Despite a growing evidence-base, implementation of such interventions into practice have proven to be challenging in sub-Saharan Africa (SSA). Thus, the purpose of this review is to synthesize existing evidence on YFHS implementation in SSA and understand which implementation strategies were used, in what context, how they were used, and leading to which implementation outcomes.

Methods: A comprehensive literature search in PubMed, Embase, Scopus, and CINAHL, was conducted to identify peer-reviewed research articles published from database inception up until August 2020. Eligible studies were required to include young people (ages 10–24 years) in sub-Saharan Africa. Studies that described implementation strategies, as conceptualized by the Expert Recommendations for Implementing Change (ERIC) project, used to enhance the implementation of YFHS were included. Implementation outcomes were extracted using Proctor and colleagues' 8 taxonomy of implementation outcomes.

Results: We identified 18 unique interventions (reported in 23 articles) from an initial search of 630 articles, including seven from East Africa, seven from South Africa, and four from West Africa. In most studies (n = 15), youth-friendly health services were delivered within the context of a health facility or clinic setting. The most frequently reported categories of implementation strategies were to train and educate stakeholders (n = 16) followed by infrastructure change (n = 10), to engage consumers (n = 9), the use of evaluative and iterative strategies (n = 8), support clinicians (n = 8), and providing interactive assistance (n = 6). The effectiveness of the strategies to enhance YFHS implementation was commonly measured using adoption (n = 15), fidelity (n = 7), acceptability (n = 5), and penetration (n = 5). Few studies reported on sustainability (n = 2), appropriateness (n = 1), implementation cost (n = 1) and feasibility (n = 0).

Conclusion: Results of the review emphasize the need for further research to evaluate and optimize implementation strategies for promoting the scale-up and sustainability of evidence-based, YFHS interventions in resource-constrained settings. This review also highlights the need to design robust studies to better understand which, in what combination, and in what context, can implementation strategies be used to effectively enhance the implementation of YFHS interventions.

A mixed reception: perceptions of pregnant adolescents' experiences with health care workers in Cape Town, South Africa

Background

Maternal mortality among adolescent mothers in South Africa is higher than many middle-income countries. This is largely attributable to conditions that can be prevented or managed by high quality antenatal care. The way in which pregnant adolescents are treated at antenatal clinics influences their timely utilization of antenatal services. This qualitative study reports on the experiences of pregnant adolescents with health care workers when accessing antenatal care.

Methods

Pregnant girls aged 13–19 (n = 19) who attended public health care facilities that provide Basic Antenatal Care (BANC) services in Cape Town, South Africa were recruited. Four face to face in-depth interviews and four mini focus group discussions were undertaken, facilitated by a topic guide. Thematic analyses were used to analyse the data.

Results

Experiences that reinforce antenatal attendance, such as respectful and supportive treatment, were outweighed by negative experiences, such as victimization; discrimination against being pregnant at a young age; experiencing disregard and exclusion; inadequate provision of information about pregnancy, health and childbirth; clinic attendance discouragement; and mental health turmoil.

Conclusions

There is evidence of a discordant relationship between the health care workers and the pregnant adolescents. Adolescents feel mistreated and discriminated against by the health care workers, which in turn discourages their attendance at antenatal clinics. Maternal health care workers need to receive support and regular training on the provision of youth friendly antenatal care and be regularly evaluated, to promote the provision of fair and high quality antenatal services for adolescent girls.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01211-x.

Antenatal care is the routine health care of pregnant women in order to diagnose pregnancy complications and to provide information about lifestyle, pregnancy and delivery. Maternal deaths among teenage mothers in South Africa is high and is largely due to conditions that can be prevented or managed by high quality antenatal care. Timely and routine antenatal care is therefore crucial for pregnant teenagers. The way in which pregnant teenagers are treated by health care workers at antenatal clinics influences their clinic attendance. This study reports on the experiences of pregnant teenagers with health care workers, when accessing antenatal care in Cape Town, South Africa. Nineteen pregnant girls aged 13–19 years were interviewed. Some positive experiences such as respectful and supportive treatment were reported. However, more negative experiences were reported, including victimization; discrimination against being pregnant at a young age; feeling disregarded and excluded; a lack of information about pregnancy, health and childbirth; being discouraged from attending the clinics; and mental health distress. In conclusion, many teenagers felt mistreated and discriminated against by the health care workers, which discouraged their clinic attendance. Maternal health care workers in South Africa need to receive support and regular training to provide youth friendly antenatal care to teenage girls.

Challenges Faced by Female Out-of-School Adolescents in Accessing and Utilizing Sexual and Reproductive Health Service: A Qualitative Exploratory Study in Southwest, Ethiopia

Introduction

Due to the limited access to sexual and reproductive health service, out-of-school-adolescents become at a higher risk for early marriage, early pregnancy early parenthood, and poor health outcomes over their life course. Hence, the aim of this study was to explore the challenges faced by female out-of-school adolescents in accessing sexual and reproductive health service in Bench-Sheko zone.

Methods

A community-based qualitative exploratory study was carried out from November 01/2020 to December 01/2020 among selected out-of-school adolescents residing in rural and urban districts of Bench-Sheko Zone, and healthcare professionals working in the local health centers. FGD participants and healthcare providers were purposely selected for this study. Eight focus group discussions and 8 in-depth interviews were conducted among female out-of-school adolescents, and health care professionals, respectively.

Result

The study revealed that out-of-school adolescents encounter several challenges in accessing sexual reproductive health service which includes socio-cultural barriers, health system barriers, perceived legal barrier, inadequate information regarding sexual reproductive health service, and low parent-adolescent communication.

Conclusion

The finding suggests the need to engage community influencers (religious leaders, community leaders, and elders) in overcoming the socio-cultural barriers. Program planners and policy makers have better make an effort to create adolescent friendly environments in SRH service areas. Furthermore, implementing community-based awareness raising programs, parental involvement in sexual reproductive health programs, and encouraging parent-adolescent communication on sexual reproductive health issues could improve sexual reproductive health service utilization by out-of-school adolescents in the study area.

Health Care Providers as Agents of Change: Integrating PrEP With Other Sexual and Reproductive Health Services for Adolescent Girls and Young Women

Background: Successful integration of pre-exposure prophylaxis (PrEP) with existing reproductive health services will require iterative learning and adaptation. The interaction between the problem-solving required to implement new interventions and health worker motivation has been well-described in the public health literature. This study describes structural and motivational challenges faced by health care providers delivering PrEP to adolescent girls and young women (AGYW) alongside other SRH services, and the strategies used to overcome them. Methods: We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with HCWs from two demonstration projects delivering PrEP to AGYW alongside other SRH services. The Prevention Options for the Women Evaluation Research (POWER) is an open label PrEP study with a focus on learning about PrEP delivery in Kenyan and South African family planning, youth mobile services, and public clinics at six facilities. PrIYA focused on PrEP delivery to AGYW via maternal and child health (MCH) and family planning (FP) clinics in Kenya across 37 facilities. IDIs and FGDs were transcribed verbatim and analyzed using a combination of inductive and deductive methods. Results: We conducted IDIs with 36 participants and 8 FGDs with 50 participants. HCW described a dynamic process of operationalizing PrEP delivery to better respond to patient needs, including modifying patient flow, pill packaging, and counseling. HCWs believed the biggest challenge to sustained integration and scaling of PrEP for AGYW would be lack of health care worker motivation, primarily due to a misalignment of personal and professional values and expectations. HCWs frequently described concerns of PrEP provision being seen as condoning or promoting unprotected sex among young unmarried, sexually active women. Persuasive techniques used to overcome these reservations included emphasizing the social realities of HIV risk, health care worker professional identities, and vocational commitments to keeping young women healthy. Conclusion: Sustained scale-up of PrEP will require HCWs to value and prioritize its incorporation into daily practice. As with the provision of other SRH services, HCWs may have moral reservations about providing PrEP to AGYW. Strategies that strengthen alignment of HCW personal values with professional goals will be important for strengthening motivation to overcome delivery challenges.

Negotiating social norms, the legacy of vertical health initiatives and contradicting health policies: a qualitative study of health professionals' perceptions and attitudes of providing adolescent sexual and reproductive health care in Arusha and Kilimanjaro region, Tanzania

Background

Adolescents in Tanzania are at risk of many health problems attributed to limited access to quality sexual and reproductive health services. Health professionals are a crucial part of service delivery, and their perspective on providing care is important in understanding the barriers that hamper access to sexual and reproductive health services for adolescents. Better understanding these barriers will support the development of more effective interventions. This paper explores these perspectives in view of the health-policy context that surrounds them.

Objective

This study has aimed to explore and understand health professionals’ perceptions and attitudes regarding the provision of adolescent sexual and reproductive health care in a selected national sexual and reproductive health programme in the Arusha region and Kilimanjaro region, Tanzania.

Methods

A qualitative cross-sectional interview design was applied. Sixteen in-depth interviews were conducted with health professionals and community health workers. Data was analysed following inductive thematic analysis.

Results

Four main themes are identified in the data: concern about the stigma directed towards adolescents; over-medicalisation of services; difficulty involving adolescent males; and ambiguous policies and contradictory messages. The findings suggest that health professionals providing care in the current adolescent sexual and reproductive health programme must navigate the legacy of vertical health programmes as well as contradicting views and messages that are influenced by social norms, by uncertainties about current laws and by statements from political leaders.

Conclusions

The findings suggest that future research, policies and health programmes should consider the perspectives of health professionals and their challenges in delivering care for adolescents to help improve the understanding of how to effectively and sensitively implement sexual and reproductive health programmes for adolescents.

Predictors of health care practitioners' normative attitudes and practices towards sexual and reproductive health and rights: a cross-sectional study of participants from low-income countries enrolled in a capacity-building program

Background: Sexual and Reproductive Health and Rights (SRHR) is a concept of human rights applied to sexuality and reproduction. Suboptimal access to SRHR services in many low-income countries results in poor health outcomes. Sustainable development goals (3.7 and 5.6) give a new impetus to the aspiration of universal access to high-quality SRHR services. Indispensable stakeholders in this process are healthcare practitioners who, through their actions or inactions, determine a population’s health choices. Often times, healthcare practitioners’ SRHR decisions are rooted in religious and cultural influences. We seek to understand whether religious and cultural influences differ significantly according to individuals’ characteristics and work environment.

Objective: The purpose of this study was to examine the role of healthcare practitioners’ individual characteristics and their work environment in predicting normative SRHR attitudes and behaviours (practices). We hypothesized that religion and culture could be significant predictors of SRHR attitudes and practices.

Methods: A quantitative cross-sectional study of 115 participants from ten low-income countries attending a capacity-building programme at Lund University Sweden was conducted. Linear regression models were used to assess for the predictive values of different individual characteristics and workplace environment factors for normative SRHR attitudes and SRHR practices.

Results: Self-rated SRHR knowledge was the strongest predictor for both normative SRHR attitudes and normative SRHR practices. However, when adjusted for other individual characteristics, self-rated knowledge lost its significant association with SRHR practices, instead normative SRHR attitudes and active knowledge-seeking behaviour independently predicted normative SRHR practices. Contrary to our hypothesis, importance of religion or culture in an individual’s life was not correlated with the measured SRHR attitudes and practices.

Conclusion: Healthcare practitioners’ cultural and religious beliefs, which are often depicted as barriers for implementing full coverage of SRHR services, seem to be modified by active knowledge-seeking behaviour and accumulated working experience with SRHR over time.

Optimizing Differentiated HIV Treatment Models in Urban Zimbabwe: Assessing Patient Preferences Using a Discrete Choice Experiment

Differentiated service delivery holds great promise for streamlining the delivery of health services for HIV. This study used a discrete choice experiment to assess preferences for differentiated HIV treatment delivery model characteristics among 500 virally suppressed adults on antiretroviral therapy in Harare, Zimbabwe. Treatment model characteristics included location, consultation type, healthcare worker cadre, operation times, visit frequency and duration, and cost. A mixed effects logit model was used for parameter estimates to identify potential preference heterogeneity among participants, and interaction effects were estimated for sex and age as potential sources of divergence in preferences. Results indicated that participants preferred health facility-based services, less frequent visits, individual consultations, shorter waiting times, lower cost and, delivered by respectful and understanding healthcare workers. Some preference heterogeneity was found, particularly for location of service delivery and group vs. individual models; however, this was not fully explained by sex and age characteristics of participants. In urban areas, facility-based models, such as the Fast Track model requiring less frequent clinic visits, are likely to better align with patient preferences than some of the other community-based or group models that have been implemented. As Zimbabwe scales up differentiated treatment models for stable patients, a clear understanding of patient preferences can help in designing services that will ensure optimal utilization and improve the efficiency of service delivery.

Risk factors affecting maternal health outcomes in Rivers State of Nigeria: Towards the PRISMA model

Existing research suggests that Nigeria accounts for about 23% of the world's maternal mortality ratio, with negative impacts on women's wellbeing and the country's socio-economic development. The underlying risk factors can be categorized into political influences, poor access to healthcare, inadequate utilization of health facilities, poor family planning support and complex pregnancy-related illness. Yet, the complex interrelations amongst the factors makes it difficult to ascertain the riskiest ones that affect women's reproduction and child death, with the existing intervening strategies failing to address the problem. This study identifies maternal health risk factors and prioritizes their management in Rivers State of Nigeria, using the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA) model. Taking a quantitative turn, we applied exploratory factor analysis to analyze 174 returned questionnaires from healthcare professionals working in Rivers State and used the results to establish relationships between maternal health risk factors, prioritizing the riskiest factors. The outcomes indicate that the PRISMA model provides an effective framework for identifying and managing maternal mortality risks that can enable healthcare experts and managers to address the avoidable risk factors and mitigate the unavoidable patient-related risk factors in Nigeria. The implications for theory, practice and policy are discussed.

Factors associated with early resumption of sexual intercourse among women during extended postpartum period in Northwest Ethiopia: a cross sectional study

BACKGROUND

Postpartum sexual health and practice need to be integrated in the current maternal healthcare services to address sexual health problems. However, postpartum sexual practice has received little attention, and was not often discussed by healthcare providers during prenatal and postnatal care. Thus, this study was aimed to assess early resumption of sexual intercourse and associated factors among postpartum women in Gondar city, Northwest Ethiopia.

METHODS

A community based cross-sectional study was conducted from January 20 to February 20, 2020. A systematic random sampling technique was used to select 634 postpartum women. A pretested, structured and interviewer-administered questionnaire was used to collect data. Data were entered into Epi Info 7.2.2 and exported to SPSS version 20 for analysis. Bivariable and multivariable logistic regressions analysis were done. Variables with p- value of < 0.05 were considered as statistically significant.

RESULTS

The magnitude of early resumption of sexual intercourse after childbirth was found to be 26.9% (95% CI: 23.2, 30.8). Urban resident (AOR = 6.12, 95% CI: 2.41, 15.66), parity of one (AOR = 2.26, 95% CI: 1.66, 7.78), husband demand (AOR = 2.66, 95% CI: 1.72, 4.11), postnatal care (AOR = 1.45, 95% CI: 1.06, 2.18) and use of family planning (AOR = 2.72, 95% CI: 1.51, 3.43) were factors significantly associated with early resumption of sexual intercourse.

CONCLUSION

The study found that more than one fourth of women had resumed sexual intercourse within six weeks of following childbirth. The finding of this study suggests the need of integrating discussions of postpartum sexual activity into routine prenatal, intrapartum and postnatal care with collaborative effort of policy makers, program planners, health care providers and other stakeholders. Moreover, spousal communication on postpartum sexual activity should be encouraged.

Promoting respectful maternity care for adolescents in Ghana: a quasi-experimental study protocol

BACKGROUND

Intra-partum mistreatment by healthcare providers remains a global public health and human rights challenge. Adolescents, who are typically younger, poorer and less educated have been found to be disproportionately exposed to intra-partum mistreatment. In Ghana, maternal mortality remains a leading cause of death among adolescent females, despite increasing patronage of skilled birth attendance in health facilities. In response to the the World Health Organisation Human Reproduction Programme (WHO-HRP) recommendations to address mistreatment with Respectful Maternity Care (RMC), this study aims to generate evidence on promoting respectful treatment of adolescents using an intervention that trains health providers on the concept of mistreatment, their professional roles in RMC and the rights of adolescents to RMC.

METHODS

This study will employ a pre-test post-test quasi-experimental design. At pre-test and post-test, quantitative surveys will be conducted among adolescents who deliver at health facilities about their labour experience with mistreatment and RMC. A total target of 392 participants will be recruited across intervention and control facilities. Qualitative interviews will also be conducted with selected adolescents and health professionals for an in-depth understanding of the phenomenon. Following the pre-test, a facility-based training module will be implemented at intervention facilities for the facility midwives. The modules will be co-facilitated by the principal investigator and key resource persons from the district health directorate Quality of Care teams. Training will cover the rights of adolescents to quality healthcare, classifications of mistreatment, RMC as a concept and the role of professionals in providing RMC. No intervention will occur in the control facilities. Descriptive statistics, logistic regressions and difference in differences analyses will be computed. Qualitative data will be transcribed and thematically analysed.

DISCUSSION

This study is designed to test the success of an intervention in promoting RMC and reducing intra-partum mistreatment towards adolescents. It is expected that the findings of this study will be beneficial in adding to the body of knowledge in improving maternal healthcare and reducing maternal mortality, especially for adolescents.

TRIAL REGISTRATION

Name of the registry: Pan African Clinical Trials Registry. PACTR202008781392078 .

Perceptions of contraception services among recipients of a combination HIV-prevention interventions for adolescent girls and young women in South Africa: a qualitative study

Background

Adolescent girls and young women (AGYW) in low- and middle- income countries (LMICs) have high rates of unintended pregnancies and are at higher risk for HIV infection compared to older women of reproductive age. Using a socio-ecological model approach, this research investigated perceptions of contraception services among AGYW who had been recipients of a combination HIV-prevention intervention, to better understand factors affecting their access to and use of contraception services.

Method

Qualitative methods used in this study included focus group discussions (FGDs) and in-depth interviews (IDIs) with 185 AGYW aged 15–24 years living in five of the ten intervention districts. All interviews and FGDs were audio-recorded and data were analyzed thematically using Nvivo 12 software with manual identification of themes and labelling of raw data.

Results

The findings reveal that many AGYW, especially those in the younger age group 15–19 years, experience difficulties in accessing contraception services, mainly at the interpersonal and health service levels. Lack of support for the use of contraceptives from parents/caregivers as well as from sexual partners were key barriers at the interpersonal level; while providers’ negative attitude was the main barrier at the health service level. The majority of school-going AGYW felt that bringing contraception services and other sexual and reproductive health (SRH) services on to the school premises would legitimize their use in the eyes of parents and help to overcome barriers related to parental support and acceptance, as well as overcome some of the health service and structural level barriers. However, views among school-going AGYW about school-based provision of contraception services were mixed, clouded with concerns relating to confidentiality.

Conclusion

Interventions to improve parental/caregiver and sexual partner support for the use of contraception services by AGYW, as well as efforts to expand the provision of contraception services on the school premises are urgently needed. Future interventions should incorporate multi-level approaches to address structural and contextual barriers to access and use of contraception services to gain maximum effect.

Determinants of healthcare providers' confidence in their clinical skills to deliver quality obstetric and newborn care in Uganda and Zambia

Background

Poor quality obstetric and newborn care persists in sub-Saharan Africa and weak provider competence is an important contributor. To be competent, providers need to be both knowledgeable and confident in their ability to perform necessary clinical actions. Confidence or self-efficacy has not been extensively studied but may be related to individuals’ knowledge, ability to practice their skills, and other modifiable factors. In this study, we investigated how knowledge and scope of practice are associated with provider confidence in delivering obstetric and newborn health services in Uganda and Zambia.

Methods

This study was a secondary analysis of data from an obstetric and newborn care program implementation evaluation. Provider knowledge, scope of practice (completion of a series of obstetric tasks in the past 3 months) and confidence in delivering obstetric and newborn care were measured post intervention in intervention and comparison districts in Uganda and Zambia. We used multiple linear regression models to investigate the extent to which exposure to a wider range of clinical tasks associated with confidence, adjusting for facility and provider characteristics.

Results

Of the 574 providers included in the study, 69% were female, 24% were nurses, and 6% were doctors. The mean confidence score was 71%. Providers’ mean knowledge score was 56% and they reported performing 57% of basic obstetric tasks in the past 3 months. In the adjusted model, providers who completed more than 69% of the obstetric tasks reported a 13-percentage point (95% CI 0.08, 0.17) higher confidence than providers who performed less than 50% of the tasks. Female providers and nurses were considerably less confident than males and doctors. Provider knowledge was moderately associated with provider confidence.

Conclusions

Our study showed that scope of practice (the range of clinical tasks routinely performed by providers) is an important determinant of confidence. Ensuring that providers are exposed to a variety of services is crucial to support improvement in provider confidence and competence. Policies to improve provider confidence and pre-service training should also address differences by gender and by cadres.

Early Resumption of Sexual Intercourse and Its Associated Factors Among Postpartum Women in Western Ethiopia: A Cross-Sectional Study

Background

Women are often forced to recommence sexual intercourse after childbirth to maintain intimacy and fulfill their partners’ desires. Early resumption of postpartum sexual intercourse leads to sexual health problems and unwanted pregnancy if not complemented with appropriate contraceptive use. However, sexual practice during the early postpartum period has received little attention in clinical and research settings. The aim of this study was therefore to assess the early resumption of sexual intercourse and its associated factors among postpartum women attending public health institutions in Nekemte town, Western Ethiopia.

Methods

An institution-based cross-sectional study was carried out from March to April 2019. A systematic random sampling technique was used to select 528 postpartum women. An interviewer-administered, pretested, and structured questionnaire was used to collect data. Data were coded and entered into Epi Info 7.2.1, and exported to SPSS version 20.0 to run bivariable and multivariable logistic regressions.

Results

One in five postpartum women (20.2%, 95% CI: 17.1–23.6) practiced an early resumption of sexual intercourse, of whom three-fifths (58%) did not use any contraceptives. Women’s secondary education (AOR=0.22, 95% CI: 0.07–0.71), husband’s elementary (AOR=0.23, 95% CI: 0.06–0.87) and secondary education (AOR=0.25, 95% CI: 0.07–0.88), as well as women’s fertility status (parity of one) (AOR=3.52, 95% CI: 1.24–10.01), normal vaginal delivery (AOR=5.44, 95% CI: 1.84–16.12), giving birth to a male child (AOR=1.94, 95% CI: 1.05–3.60), desire for another child (AOR=5.71, 95% CI: 1.89–17.25), and pressure from the husband to initiate intercourse (AOR=9.89, 95% CI: 4.99–19.58) were significantly associated with early resumption of sexual intercourse.

Conclusion

A significant proportion of postpartum women who resume early sexual intercourse do not use any contraceptives. Interventions that focus on strengthening the integration of postpartum sexual health education and service use are warranted.

Barriers to accessing maternal health care amongst pregnant adolescents in South Africa: a qualitative study

Objectives

This study explores the barriers to accessing antenatal care (ANC) services amongst pregnant adolescents within a particular community of South Africa.

Methods

An exploratory qualitative design was applied to examine the views of pregnant adolescents. In-depth interviews were conducted with pregnant adolescents at the Mitchells Plain Midwifery Obstetric Unit, as well as nursing staff working at the facility. Thematic analysis was then used and analysis was framed using the social–ecological model for health-seeking behaviour.

Results

This study found that barriers to adolescents seeking ANC often centered on a discourse of adolescent pregnancy being deviant, irresponsible, and shameful. Pregnant adolescents often absorbed these beliefs and were fearful of other’s reaction within their family, the community, at school, and within the ANC facilities.

Conclusions

Stigma regarding adolescent pregnancy participates in the perpetuation of a culture of non-disclosure and shame, which stands in the way of young pregnant people seeking the care they require. Such beliefs and attitudes need to be challenged at a community and national level.

Electronic supplementary material

The online version of this article (10.1007/s00038-020-01374-7) contains supplementary material, which is available to authorised users.

Strengthening health care worker engagement with early adolescence in low- and middle-income countries: an overdue area for action

The very young adolescent population (ages 10-14) is currently under-served by health care systems, particularly in low- and middle-income countries. Although there is a substantial and growing effort to reach adolescents with the health services and commodities they need, such efforts often overlook the period of early adolescence given this population's lower vulnerability to risk-taking behaviors. However, early adolescence is a period of significant change, with the onset of puberty introducing physiological, emotional, and social changes in girls' and boys' lives. This period also represents a time of intensifying gendered norms, and the transition of youth from childhood focused health care (e.g. deworming programs, nutrition interventions) to additional mid- and older adolescent related care [e.g. human papilloma virus (HPV) vaccine, and contraceptive provision). Strengthening young adolescents' engagement with health care workers around preventative and promotive health behaviors could have profound impacts on their health and wellbeing, which in turn could have cascading effects across the course of their lives. Critically, young adolescents would gain trust in health care systems, and be more likely to return when significant health issues arise later in adolescence or adulthood. Such an effort requires sensitizing health care workers and building their capacity to respond to young adolescents' unique needs, by defining a package of actions that they are mandated to provide, training them, providing them with desk reference tools, and putting in place systems to provide supportive supervision and collaborative learning on the one hand, and encouraging caregivers to connect their pubescent-aged boys and girls with the health care system, on the other hand. This paper presents an argument for increased focus in particular on building attitudes and capacities of health care workers on engaging with early adolescents, applying Principle 3 of the Society of Adolescent Medicine's position paper entitled "Health Care Reform and Adolescents."

Choices and services related to contraception in the Gaza strip, Palestine: perceptions of service users and providers

BACKGROUND

Reliable contraception enables women and men to plan their family sizes and avoid unintended pregnancies, which can cause distress and anxiety, but also increase maternal mortality. This study explored potential barriers to contraceptive use for women in the Gaza Strip, Palestine from user and provider perspectives.

METHODS

A convenient sample was used to recruit women, who were current contraception users, from three healthcare clinics that provide family planning care, two governmental and one non-governmental. A 16-item questionnaire was completed by 204 women, including socio-demographic data, contraceptive use and eight questions exploring user experience. Additionally, 51 women attended focus groups for a deeper insight into their contraceptive use experience and potential barriers. Furthermore, 14 healthcare providers were interviewed about their experience with service provision. Quantitative data are presented as means and frequencies and qualitative data were analysed item by item and are presented in themes jointly with the quantitative data.

RESULTS

Women reported usage of only three main modern methods of contraception with 35.2% using intrauterine devices, 25.8% combined oral contraception and 16.4% condoms, while only 3.1% used the hormonal implant. Expectations from family planning services were low with most women attending the clinic having already decided their contraceptive method with decisions being made by husbands (41.2%) or women jointly with their partner (33.3%), only 13.7% took advice from service providers. Healthcare providers experienced high prevalence of beliefs that modern contraceptives cause infertility and cancer. Main barriers to effective family planning services were misconceptions of potential harm, poor availability and limited choice of contraceptive methods.

CONCLUSION

Women's contraceptive choices in Gaza are limited by prevalent misconceptions and fears as well as recurring shortages, negatively impacting fertility control. Men are a major factor in choosing a contraceptive method, however, they have limited access to information and therefore, potentially more misconceptions. Therefore, male community members need to be included in the delivery of information on contraceptives to increase women's choice. Furthermore, greater access to long-acting reversible contraceptives, such as the hormonal implant, and improved availability might be key factors in improving contraceptive uptake in Gaza and, thus, reducing unintended pregnancies.

'We are the advocates for the babies' - understanding interactions between patients and health care providers during the prevention of mother-to-child transmission of HIV in South Africa: a qualitative study

Background: HIV/AIDS has had a significant impact on maternal and child health in South Africa. It is thus of vital importance to implement interventions to prevent mother-to-child transmission of HIV (PMTCT) as early as possible during pregnancy. Negative interactions between patients and health care providers (HCPs) can be an important barrier to antenatal care, PMTCT use and PMTCT adherence. Research about respectful maternity care has focused more on the patient perspective. We therefore compared the patient and HCP perspectives and reflected on how interactions between HCPs and patients can be improved. Objective: To obtain insights into the attitudes of HCPs in the context of HIV and PMTCT-related care, by studying patient and HCP perceptions of their interactions, in a peri-urban hospital setting in Gauteng province, South Africa. Methods: A qualitative study was conducted in a public tertiary-level hospital. Fourteen semi-structured in-depth interviews were conducted with nurses and doctors in the antenatal clinic and postnatal ward. Thirty-one semi-structured in-depth interviews and two focus group discussions were conducted with HIV positive and negative women on the postnatal ward. Results: HCPs experienced a difficult work environment due to a high workload. This was combined with frustrations when they felt that patients did not take responsibility for their own or their child's health. They were motivated by the need to help the child. Patients experienced judging comments by HCPs especially towards younger, older and foreign women. They expressed fear to ask questions and self-blame, which in some cases delayed health care seeking. No discrimination or isolation of HIV infected patients was reported by patients and HCPs. Conclusion: We hypothesize that more humane working conditions for obstetric HCPs and a caring, personalised approach to patient management can improve patient-provider interactions and access to respectful care. These are critical to preventing mother-to-child transmission of HIV.

In everybody's interest but no one's assigned responsibility: midwives' thoughts and experiences of preventive work for men's sexual and reproductive health and rights within primary care

Background

Sexual and reproductive health and rights (SRHR) have historically been regarded as a woman’s issue. It is likely that these gender norms also hinder health care providers from perceiving boys and men as health care recipients, especially within the area of SRHR. The aim of this study was to explore midwives’ thoughts and experiences regarding preventive work for men’s sexual and reproductive health and rights in the primary care setting.

Methods

An exploratory qualitative study. Five focus group interviews, including 4–5 participants in each group, were conducted with 22 midwives aged 31–64, who worked with reproductive, perinatal and sexual health within primary care. Data were analysed by latent content analysis.

Results

One overall theme emerged, in everybody’s interest, but no one’s assigned responsibility, and three sub-themes: (i) organisational aspects create obstacles, (ii) mixed views on the midwife’s role and responsibility, and (iii) beliefs about men and women: same, but different.

Conclusions

Midwives believed that preventive work for men’s sexual and reproductive health and rights was in everybody’s interest, but no one’s assigned responsibility. To improve men’s access to sexual and reproductive health care, actions are needed from the state, the health care system and health care providers.

Health worker text messaging for blended learning, peer support, and mentoring in pediatric and adolescent HIV/AIDS care: a case study in Zimbabwe

BACKGROUND

In sub-Saharan Africa, shortages of trained healthcare workers and limited resources necessitate innovative and cost-effective approaches for training, supervising, and mentoring. This qualitative case study describes participants' and trainers' perspectives and experiences with a text messaging component of a blended training course in HIV counseling and testing in Zimbabwe, using minimal resources in terms of staff time and equipment requirements. This component included a whole-group discussion forum as well as two-person partner discussions designed to promote reflection and analysis, teamwork, and active learning.

CASE PRESENTATION

The Ministry of Health and Child Care (MoHCC) of Zimbabwe collaborated with the International Training and Education Center for Health (I-TECH) on adaptation of a 5-day in-service training in HIV Testing Services for Children and Adolescents. The new 7-week blended format included in-person sessions, tablet-based self-study, and discussions using the text messaging application, WhatsApp. Between August 2016 and January 2017, 11 cohorts (293 participants in total) were trained with this new curriculum, incorporating text messaging to support peer-to-peer and work-based education. Data collected included training participants' feedback, key informant interviews with the training team, and thematic analysis of WhatsApp messages from full-cohort discussions and a sampling of one-to-one partner discussions. A total of 293 healthcare workers from 233 health facilities across all provinces in Zimbabwe completed the blended learning course. Participants strongly endorsed using WhatsApp groups as part of the training. In the whole-group discussions, the combined cohorts generated over 6300 text messages. Several categories of communication emerged in analysis of group discussions: (1) participants' case experiences and questions; (2) feedback and recommendations for work issues raised; (3) inquiries, comments, and responses about course assignments and specific course content; (4) encouragement; and (5) technical challenges encountered using the blended learning methodology. Case discussions were complex, including patient history, symptoms, medications, and psychosocial issues-child abuse, adherence, and disclosure.

CONCLUSIONS

Using text messaging in a communication platform that is an ongoing part of healthcare workers' daily lives can be an effective adjunct to in-service training, minimizing isolation and providing interactivity, supporting students' ability to fully integrate content into new skill attainment.

Assessing the knowledge and skills on emergency obstetric care among health providers: Implications for health systems strengthening in Nigeria

OBJECTIVE

To assess the existing knowledge and skills relating to Emergency Obstetrics Care (EMOC) among health providers in eight referral maternity hospitals in Nigeria.

STUDY DESIGN

A cross-sectional study of skilled health providers (doctors, nurses and midwives) working in the hospitals during the period.

SETTING

Six general hospitals (4 in the south and 2 in the north), and two teaching hospitals (both in the Northern part) of the country.

POPULATION

All skilled providers offering EMOC services in the hospitals during the study.

METHODS

A pre-tested self-administered questionnaire was used to obtain information relating to socio-demographic characteristics, the respondents' knowledge and skills in offering specific EMOC services (as compared to standard World Health Organization recommendations), and their confidence in transferring the skills to mid-level providers. Data were analyzed with univariate, bivariate, binary and multinomial logistic regression analyses. Main outcome measures: knowledge and skills in EMOC services by hospital and overall.

RESULTS

A total of 341 health providers (148 doctors and 193 nurses/midwives) participated in the study. Averagely, the providers scored less than 46% in a composite EMOC knowledge score, with doctors scoring considerable higher than the nurses/midwives. Similarly, doctors scored higher than nurses/midwives in the self-reporting of confidence in carrying out specific EMOC functions. Health providers that scored higher in knowledge were significantly more likely to report confidence in performing specific EMOC functions as compared to those with lower scores. The self-reporting of confidence in transferring clinical skills was also higher in those with higher EMOC knowledge scores.

CONCLUSION

The knowledge and reported skills on EMOC by health providers in referral facilities in Nigeria was lower than average. We conclude that the in-service training and re-training of health providers should be included in national policy and programs that address maternal mortality prevention in referral facilities in the country.

TRIAL REGISTRATION

Nigeria Clinical Trials Registry 91540209.