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Newberry Le Vay J, Fraser A, Byass P, Tollman S, Kahn K, D'Ambruoso L, Davies JI. Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa: a mixed-methods analysis of verbal autopsy data. BMJ Open 2021; 11:e048592. [PMID: 34172550 PMCID: PMC8237742 DOI: 10.1136/bmjopen-2020-048592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Cardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data. DESIGN A mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts. SETTING This study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa. PARTICIPANTS Deaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data. RESULTS Between 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391). CONCLUSIONS The temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.
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Affiliation(s)
| | - Andrew Fraser
- Education Centre, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Peter Byass
- Department of Epidemiology & Global Health, Umea Universitet, Umeå, Sweden
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Stephen Tollman
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Lucia D'Ambruoso
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- WHO Collaborating Centre for Verbal Autopsy, Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
| | - Justine I Davies
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
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Girma M, Robles C, Asrat M, Hagos H, G/Slassie M, Hagos A. Community Perception Regarding Maternity Service Provision in Public Health Institutions in 2018 and 2019: A Qualitative Study. Int J Womens Health 2020; 12:773-783. [PMID: 33116927 PMCID: PMC7547801 DOI: 10.2147/ijwh.s250044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 09/02/2020] [Indexed: 11/28/2022] Open
Abstract
Background In the perspective of health care, community perception is defined as a combination of experiences, expectations and perceived needs. The community and client’s perception of health services seem to have been largely ignored by health-care providers in developing countries. There is a knowledge gap about communities’ perception and perspective of maternal health. If the community’s perception is known, the quality of maternity care may be improved, maternal morbidity and mortality could be decreased, and the overall health of the mother can be improved. The aim of this study was to explore community’s perception of maternity service provision in public health institutions. Methods A qualitative study with the underpinning philosophy of phenomenology was conducted in five subcities of Mekelle city, Ethiopia. Focus group discussions (FGDs) and in-depth interviews (IDSs) with participants who are residing in Mekelle city and who experienced maternity service as a client or as attendants were conducted to collect the necessary information. Using a semi-structured tool that has been translated into the local language, collected data were analyzed thematically using computer-assisted qualitative data analysis software ATLAS version 7. Qualitative data were transcribed through replaying the tape recorded interview from IDIs and FGDs. The text was carefully read and similar ideas were organized together. The participant's inductive meanings were extracted verbatim and described in narratives. The researcher and research assistants independently transcribed participant's comments verbatim to confirm the reliability of the findings. Results Participants reported that maternal health services in public health institutions were negative. Participants described experiencing poor staff attitude, lack of prescribed drugs in the institutional pharmacies, long waiting time, family proximity by professionals, poor attention to women during labor, lack of privacy and mistreatment made them develop a negative perception towards public health institutions. Despite these complaints, participants acknowledged public health facilities for affordable, accessible, qualified personnel and usually stocked with quality medications and equipment. Conclusion This study revealed that the community has a negative perception of the maternal health services in the public health institutions. The main reasons for their negative perception were poor staff attitude, unavailability of prescribed drugs in the institutional pharmacies, long waiting time, family proximity by professionals, poor attention to women during labor, lack of privacy and mistreatment.
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Affiliation(s)
- Meklit Girma
- College of Health Sciences, Mekelle University, Mekelle City, Ethiopia
| | - Carmen Robles
- College of Health Sciences, Mekelle University, Mekelle City, Ethiopia
| | - Mekdes Asrat
- College of Health Sciences, Mekelle University, Mekelle City, Ethiopia
| | - Hadgay Hagos
- College of Health Sciences, Mekelle University, Mekelle City, Ethiopia
| | - Measho G/Slassie
- College of Health Sciences, Mekelle University, Mekelle City, Ethiopia
| | - Assefa Hagos
- College of Health Sciences, Mekelle University, Mekelle City, Ethiopia
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Wong KKL, von Mollendorf C, Martinson N, Norris S, Tempia S, Walaza S, Variava E, McMorrow ML, Madhi S, Cohen C, Cohen AL. Healthcare utilization for common infectious disease syndromes in Soweto and Klerksdorp, South Africa. Pan Afr Med J 2018; 30:271. [PMID: 30637056 PMCID: PMC6317391 DOI: 10.11604/pamj.2018.30.271.14477] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/27/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction Understanding healthcare utilization helps characterize access to healthcare, identify barriers and improve surveillance data interpretation. We describe healthcare-seeking behaviors for common infectious syndromes and identify reasons for seeking care. Methods We conducted a cross-sectional survey among residents in Soweto and Klerksdorp, South Africa. Households were interviewed about demographic characteristics; recent self-reported episodes of pneumonia, influenza-like illness (ILI), chronic febrile respiratory illness and meningitis in individuals of all ages; recent diarrhea in children aged < 5 years; and consultation with healthcare facilities and providers. Results From July-October 2012, we interviewed 1,442 households in Klerksdorp and 973 households in Soweto. Public clinics were consulted most frequently for pneumonia, ILI and diarrhea in a child <5 years old at both sites; public hospitals were most frequently consulted for chronic respiratory and meningitis syndromes. Of all illness episodes reported, there were 110 (35%) in Klerksdorp and 127 (32%) in Soweto for which the person did not seek care with a licensed medical provider. Pharmacies were often consulted by individuals with pneumonia (Klerksdorp: 17, 16%; Soweto: 38, 22%) or ILI (Klerksdorp: 35, 24%; 44, 28%). Patients who did not seek care with a licensed provider reported insufficient time (Klerksdorp: 7%; Soweto, 20%) and lack of medications at the facility (Klerksdorp: 4%; Soweto: 8%) as barriers. Conclusion Public government healthcare facilities are commonly consulted for infectious syndromes and pharmacies are frequently consulted particularly for respiratory diseases. Improving medication availability at healthcare facilities and streamlining healthcare delivery may improve access of licensed providers for serious illnesses.
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Affiliation(s)
- Karen Kai-Lun Wong
- Centers for Disease Control and Prevention, Atlanta, Georgia USA.,United States Public Health Service
| | - Claire von Mollendorf
- National Institute for Communicable Diseases, Johannesburg, South Africa.,University of Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- MRC Developmental Pathways for Health Research Unit, University of Witwatersrand, Johannesburg, South Africa.,Johns Hopkins University, Baltimore, Maryland USA
| | - Shane Norris
- University of Witwatersrand, Johannesburg, South Africa
| | - Stefano Tempia
- Centers for Disease Control and Prevention, Atlanta, Georgia USA.,National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Sibongile Walaza
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Ebrahim Variava
- University of Witwatersrand, Johannesburg, South Africa.,Klerksdorp-Tshepong Hospital Complex, Klerksdorp, South Africa
| | - Meredith Lynn McMorrow
- Centers for Disease Control and Prevention, Atlanta, Georgia USA.,United States Public Health Service
| | - Shabir Madhi
- National Institute for Communicable Diseases, Johannesburg, South Africa.,University of Witwatersrand, Johannesburg, South Africa
| | - Cheryl Cohen
- National Institute for Communicable Diseases, Johannesburg, South Africa.,University of Witwatersrand, Johannesburg, South Africa
| | - Adam Lauren Cohen
- Centers for Disease Control and Prevention, Atlanta, Georgia USA.,United States Public Health Service
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Matsea T, Ryke E, Weyers M. Assessing mental health services in a rural setting: Service providers’ perspective. INTERNATIONAL JOURNAL OF MENTAL HEALTH 2017. [DOI: 10.1080/00207411.2017.1377805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Thabisa Matsea
- Social Work, School for Psycho-social Behavioural Sciences: Social Work Division, North-West University, Potchefstroom, South Africa
| | - Elma Ryke
- Social Work, School for Psycho-social Behavioural Sciences: Social Work Division, North-West University, Potchefstroom, South Africa
| | - Mike Weyers
- Social Work, School for Psycho-social Behavioural Sciences: Social Work Division, North-West University, Potchefstroom, South Africa
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Abstract
Compared to their urban counterparts, rural and remote inhabitants experience lower life expectancy and poorer health status. Nowhere is the worldwide shortage of health professionals more pronounced than in rural areas of developing countries. Sub-Saharan Africa (SSA) includes a disproportionately large number of developing countries; therefore, this article explores SSA in depth as an example. Using the conceptual framework of access to primary health care, sustainable rural health service models, rural health workforce supply, and policy implications, this article presents a review of the academic and gray literature as the basis for recommendations designed to achieve greater health equity. An alternative international standard for health professional education is recommended. Decision makers should draw upon the expertise of communities to identify community-specific health priorities and should build capacity to enable the recruitment and training of local students from underserviced areas to deliver quality health care in rural community settings.
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Affiliation(s)
- Roger Strasser
- Northern Ontario School of Medicine, Sudbury and Thunder Bay, Ontario, Canada;
| | - Sophia M Kam
- School of Rural and Northern Health, Laurentian University, Sudbury, ON P3E 2C6 Canada
| | - Sophie M Regalado
- Northern Ontario School of Medicine, Sudbury and Thunder Bay, Ontario, Canada;
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Ogaji DS, Giles S, Daker-White G, Bower P. Systematic review of patients' views on the quality of primary health care in sub-Saharan Africa. SAGE Open Med 2015; 3:2050312115608338. [PMID: 27170843 PMCID: PMC4855308 DOI: 10.1177/2050312115608338] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 08/31/2015] [Indexed: 11/17/2022] Open
Abstract
This is the first systematic review of patient views on the quality of primary health care services in sub-Saharan Africa using studies identified from MEDLINE, CINAHL Plus, EMBASE and PsycINFO. In total, 20 studies (3 qualitative, 3 mixed method and 14 quantitative) were included. Meta-analysis was done using quantitative findings from facility- and community-based studies of patient evaluation of primary health care. There was low use of validated measures, and the most common scales assessed were humanness (70%) and access (70%). While 66% (standard deviation = 21%) of respondents gave favourable feedback, there were discrepancies between surveys in community and facility contexts. Findings suggest that patient views could vary with subject recruitment site. We recommend improvement in the methods used to examine patient views on quality of primary health care.
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Affiliation(s)
- Daprim S Ogaji
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Department of Preventive and Social Medicine, University of Port Harcourt, Port Harcourt, Nigeria
| | - Sally Giles
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Gavin Daker-White
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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Friend-du Preez N, Cameron N, Griffiths P. "So they believe that if the baby is sick you must give drugs…" The importance of medicines in health-seeking behaviour for childhood illnesses in urban South Africa. Soc Sci Med 2013; 92:43-52. [PMID: 23849278 DOI: 10.1016/j.socscimed.2013.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 05/10/2013] [Accepted: 05/13/2013] [Indexed: 11/25/2022]
Abstract
A mixed method approach was used to investigate the treatment of childhood illnesses in Johannesburg and Soweto. In 2004, in-depth interviews were held with caregivers (n = 5), providers of traditional (n = 6) and Western (n = 6) health care, as well as 5 focus groups with black caregivers of children under 6 years. An utilisation-based survey was conducted with 206 black caregivers of children under 6 years of age at 1 public clinic in Soweto (n = 50), 2 private clinics (n = 50) in Johannesburg, 2 public hospitals (n = 53) from Johannesburg and Soweto and 2 traditional healers (n = 53) from Johannesburg and Orange Farm, an informal settlement on the outskirts of Johannesburg. Caregivers reported how they would respond to 4 common child health problems. Home treatments would be a common first resort particularly for diarrhoea (79%, mostly salt and sugar solution) and constipation (53%). In the case of constipation, the spuit [enema] was cited as a particularly effective home treatment method, particularly amongst TMP patients. Approximately 50% of caregivers would access a health care provider as a first resort for coughs. OTC medicines are commonly used for fever (63%), less-so for coughs (37%). Overall, higher SES respondents would be more likely to use over-the-counter (OTC) medicines and less likely than other groups to use home treatments. Shortages of medicines at clinics and caregiver beliefs about the efficacy of medicines affect health-care seeking behaviour. Medicines are not always used as intended or according to instructions and some products such as household detergents may be used medicinally. As well as the need for improving facility-readiness for delivering IMCI (Integrated Management of Childhood Illnesses), the patient-provider relationship is instrumental in improving the treatment of childhood illnesses.
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Affiliation(s)
- Natalie Friend-du Preez
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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8
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Linda NSB, Mtshali NG, Engelbrecht C. Lived experiences of a community regarding its involvement in a university community-based education programme. Curationis 2013; 36:E1-13. [PMID: 23718158 DOI: 10.4102/curationis.v36i1.78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 01/15/2013] [Accepted: 01/28/2013] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Community involvement is one of the crucial principles in the implementation of successful community-based education programmes. However, a gap continues to exist between the rhetoric of this principle and the reality of involving or engaging communities in the education of health professionals. OBJECTIVES This study investigated the experiences of a community regarding its involvement in a community-based education programme offered by a university nursing school in Durban, South Africa. METHODS An interpretive existentialist-phenomenological design was employed for its richness in extracting human experiences. Individual interviews were held with school teachers and coordinators from non-government organisations, whilst focus groups were used for school children and community health workers. Although focus group discussions are not well suited for phenomenological studies, they can promote active participation and reduce possible intimidation by providing support through group interaction. Analysis of data was guided by Schweitzer's model for analysing phenomenological data. RESULTS Themes that emerged from the data include: (1) Community experience of unmet expectations; (2) Benefits to the community from its involvement in the University Nursing School community-based education programme; (3) Existing partnership between the community and the university; (4) Sharing in the case-based learning activities; (5) Awareness of available services, human rights and self-reliance. CONCLUSION The researched community indeed benefited in its participation in the University Nursing School (UNS) CBE programme. However, there is a need to improve the communication between partners to make the partnership more sustainable through close relationships and interaction. There is also a need for further research on related aspects of the community's involvement.
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Nteta TP, Mokgatle-Nthabu M, Oguntibeju OO. Utilization of the primary health care services in the Tshwane Region of Gauteng Province, South Africa. PLoS One 2010; 5:e13909. [PMID: 21085475 PMCID: PMC2976689 DOI: 10.1371/journal.pone.0013909] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 10/13/2010] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In South Africa, the provision of primary health care is a basic service designed to be cost effective and bring healthcare as close as possible to the population, particularly to those people of low economic status. It is a service which is provided free of charge by the South African government and as part of the millennium health goals, it is intended that the service should be accessible to the populace and be effectively utilized. OBJECTIVE This study was designed to investigate the accessibility and utilization of the primary health care services in three community health care centres in the Tshwane of the Gauteng Province, South Africa. METHODOLOGY Data were obtained from participants attending three Community Health Care Centres in the Tshwane Region using self-administered structured questionnaires. A document review of the Community Health Care Centres records was conducted to investigate the utilization trends of the services provided and descriptive statistics were used to analyze the data obtained. RESULTS The results showed that the Community Health Care Centres in the Tshwane Region are accessible to most participants who lived within 5 km of such centres and who traveled 30 minutes or less to the clinic. Using a taxi or walking were found to be the most common means of transport used to gain access to such a clinic. The findings showed that generally, participants were satisfied with the services provided. CONCLUSION Participants of this study have access to the community health care centres in the Tshwane Region and there seems to be effective utilization by patients attending them.
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Affiliation(s)
- Thembi P. Nteta
- School of Public Health, MEDUNSA, University of Limpopo, Pretoria, South Africa
| | | | - Oluwafemi O. Oguntibeju
- Department of Biomedical Sciences, Faculty of Health and Wellness Sciences, Cape Peninsula University of Technology, Bellville, South Africa
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Peltzer K. Patient experiences and health system responsiveness in South Africa. BMC Health Serv Res 2009; 9:117. [PMID: 19602290 PMCID: PMC2716320 DOI: 10.1186/1472-6963-9-117] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 07/14/2009] [Indexed: 11/10/2022] Open
Abstract
Background Patients' views are being given more and more importance in policy-making. Understanding populations' perceptions of quality of care is critical to developing measures to increase the utilization of primary health care services. Using the data from the South African World Health Survey (WHS), the current study aims to evaluate the degree of health care service responsiveness (both out-patient and in-patient) and comparing experiences of individuals who used public and private services in South Africa. Methods A population-based survey of 2352 participants (1116 men and 1236 women) was conducted in South Africa in 2003, the WHS – as part of a World Health Organization (WHO) project focused on health system performance assessment in member countries. Results Health care utilization was among those who attended in-patient care 72.2% attended a public and 24.3% a private facility, and of those who attended out-patient care 58.7% attended a public and 35.7% a private facility. Major components identified for out-patient care responsiveness in this survey were highly correlated with health care access, communication and autonomy, secondarily to dignity, confidentiality and quality of basic amenities, and thirdly to health problem solution. The degree of responsiveness with publicly provided care was in this study significantly lower than in private health care. Overall patient non-responsiveness for the public out-patient service was 16.8% and 3.2% for private care. Discrimination was also one of the principal reasons for non-responsiveness in all aspects of provided health care. Conclusion Health care access, communication, autonomy, and discriminatory experiences were identified as priority areas for actions to improve responsiveness of health care services in South Africa.
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Affiliation(s)
- Karl Peltzer
- Health Promotion Research Unit, Social Aspect of HIV/AIDS and Health, Human Sciences Research Council, Pretoria, South Africa.
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Varga C, Brookes H. Preventing Mother-to-Child HIV Transmission Among South African Adolescents. JOURNAL OF ADOLESCENT RESEARCH 2008. [DOI: 10.1177/0743558407310771] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although prevention of mother-to-child HIV transmission (PMTCT) programs are predicated on maternal behavior change, little is known about sociocultural factors affecting maternal—child care practices in this arena. The authors used narrative methods (key informant workshops, questionnaires, focus groups, and case study analysis) to explore how sociocultural context shapes adolescent mothers' ability to adhere to programmatic recommendations in rural and urban South Africa. The study aims were to understand the extent to which mothers' decisions are borne out in PMTCT-related practices and to identify contextual elements that affect the link between individual resolutions and action. The results revealed rural adolescents as less likely than urbanites to successfully implement most PMTCT-related practices. HIV stigma, family decision making, and cultural norms surrounding infant feeding hampered mothers' efforts to implement practices that would decrease the risk for infant infection. Barriers to behavior change were analyzed along four domains: history, culture, gender, and power. Methodological aspects and programmatic implications are discussed.
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