[Reproductive health among migrant women in Geneva: what are the challenges for Community-based participatory research]

Community-based participatory research (CBPR) focuses on inequalities in health by involving community members and researchers in all parts of the research process. The project COMIRES (COmmunity Migrant RESearch), based in the Department of Obstetrics and Gynecology at the University Hospitals of Geneva, engages academic researchers and migrant communities in Geneva in a co-learning process to understand barriers to reproductive health services and evaluate the role of the community. The article illustrates the methodological approach, but also advantages and challenges of CBPR.

Training and deployment of lay refugee/internally displaced persons to provide basic health services in camps: a systematic review

BACKGROUND

Training of lay refugees/internally displaced persons (IDPs) and deploying them to provide basic health services to other women, children, and families in camps is perceived to be associated with public health benefits. However, there is limited evidence to support this hypothesis.

OBJECTIVES

To assess the effects of interventions to train and deploy lay refugees and/or IDPs for the provision of basic health service to other women, children, and families in camps.

METHODS

PubMed, Science and Social Science Citation Indices, PsycINFO, EMBASE, POPLINE, CINAHL, and reference lists of relevant articles were searched (from inception to June 30, 2014) with the aim of identifying studies that reported the effects of interventions that trained and deployed lay refugees and/or IDPs for the provision of basic health service to other women, children, and families in camps. Two investigators independently reviewed all titles and abstracts to identify potentially relevant articles. Discrepancies were resolved by repeated review, discussion, and consensus. Study quality assessment was undertaken using standard protocols.

RESULTS

Ten studies (five cross-sectional, four pre-post, and one post-test only) conducted in Africa (Guinea and Tanzania), Central America (Belize), and Asia (Myanmar) were included. The studies demonstrated some positive impact on population health associated with training and deployment of trained lay refugees/IDPs as health workers in camps. Reported effects included increased service coverage, increased knowledge about disease symptoms and prevention, increased adoption of improved treatment seeking and protective behaviors, increased uptake of services, and improved access to reproductive health information. One study, which assessed the effect of peer refugee health education on sexual and reproductive health, did not demonstrate a marked reduction in unintended pregnancies among refugee/IDP women.

CONCLUSION

Although available evidence suggests a positive impact of training and deployment of lay refugees/IDPs as health workers in camps, existing body of evidence is weak, and calls for a re-examination of current practices. Interventions that promote training and deployment of lay refugees/IDPs as health workers in camps should include strong evaluation components in order to facilitate assessment of effects on population health.

Tackling the sexual and reproductive health and rights of adolescents living with HIV/AIDS: a priority need in Nigeria

Very little is known about the sexual and reproductive health (SRH) needs of adolescents living with HIV (ALHIV) in general and the needs of those in Nigeria specifically. A review was conducted to identify the SRH of ALHIV, assess if these are different from the SRH of adolescents who are free from HIV infection, and from those of adults living with HIV. Few research have been conducted on how ALHIV deal with sexual and reproductive health challenges faced in their everyday lives - as adolescents and as persons living with HIV living in sub-Saharan Africa - to help make any meaningful inferences on these differing needs. The review suggests that the SRH needs and practices of ALHIV may differ from that of other adolescents and that of adults living with HIV. ALHIV would require support to cope with sex and sexual needs, through full integration of individualized SRH services into the HIV services received. Service providers need to appreciate the individualistic nature of health problems of ALHIV and address their health care from this holistic perspective. A 'one-size-fits-all' approach for designing SRH programmes for ALHIV would not be appropriate. We conclude that research evidence should inform the design and implementation of ALHIV friendly SRH programmes services in both urban and rural settings in Nigeria.

Evaluation of a reproductive health program to support married adolescent girls in rural Ethiopia

Few reproductive health programs are targeted to married adolescent girls. This study measures changes associated with a program for married adolescent girls and a parallel husbands' program, in rural Ethiopia. The married girls' program provided information on communication, self-esteem, reproductive health and gender through girls' groups. The husbands' program focused on non-violence, support to families, and reproductive health. Population-based surveys were undertaken among married girls, at midterm and end line. Outcomes of interest were husbands' assistance with domestic work, accompaniment to the clinic, family planning use, voluntary counseling and testing (VCT), and domestic violence. Overall, 1,010 married girls were interviewed. Participation in the girls' groups was associated with improvements in help with domestic work, accompaniment to the clinic, family planning and VCT. Further improvements were recorded when both partners participated. For example, participating girls were nearly 8 times more likely to receive VCT (OR 7.7) than nonparticipants, and more than 18 times more likely if both partners participated (OR 18.3). While these results are promising, there were indications of selectivity bias that could have contributed to the positive results. Programs engaging both wives and husbands can result in incremental improvements to the health and well-being of girls married early.

Midwives caring for asylum-seeking women: research findings

Over the past decade, the numbers of women seeking asylum in the United Kingdom (UK) and requiring midwifery care have increased significantly (Office for National Statistics (ONS) 2012). This article describes findings from a small study that explored the experiences of midwives caring for asylum seeking women. Time and communication emerged as significant factors impacting on quality of care and these are the focus of this article. Caring for these women was emotionally challenging and at times frustrating due to poor access to information and support. In conclusion, whilst considerable knowledge and skills were required to care for this vulnerable group, these appeared to be learned almost solely 'on the job': Implications for service delivery and education are explored and recommendations made to improve experiences for women and midwives.

HIV, unwanted pregnancy and abortion--where is the human rights approach?

The HIV/AIDS field is addressing how legal and policy restrictions affect access to health promotion and care, e.g., in relation to criminalization of HIV transmission, drug use and sex work. Work to address the reproductive rights of women living with HIV, particularly regarding unwanted pregnancy and abortion, has nevertheless lagged behind, despite its potential to contribute to broader advocacy for access to comprehensive reproductive health information and services for all women. It is in that context that this paper examines abortion in relation to the rights of women and girls living with HIV. The paper first presents findings from recent research on HIV-positive women's reasons for seeking abortions and experiences with abortion-related care. This is followed by a discussion of abortion in relation to human rights and how this has been both addressed and neglected in policy and guidance related to the reproductive health of women living with HIV. The concluding remarks offer recommendations for expanding efforts to provide comprehensive, human rights-based sexual and reproductive health care to women living with HIV by including abortion-related information and services.

Improving health services for adolescents living with HIV in sub-Saharan Africa: a multi-country assessment

In sub-Saharan Africa (SSA), the aging of HIV-positive pediatric cohorts and growing numbers of adolescents on treatment, coupled with high HIV incidence in this age group, means the number of adolescents living with HIV (ALHIV) will continue to grow. The clinical, psychological, social, and reproductive health needs of ALHIV remain poorly understood and efforts to mobilize and advocate for their treatment, care, and support have been inadequate. A multi-country assessment of the needs of ALHIV in SSA found that comprehensive, adolescent-friendly services that champion peer support and collaboration between health care organizations can foster successful transitions into adulthood for ALHIV.

Healthcare reform: implications for knowledge translation in primary care

BACKGROUND

The primary care sector represents the linchpin of many health systems. However, the translation of evidence-based practices into patient care can be difficult, particularly during healthcare reform. This can have significant implications for patients, their communities, and the public purse. This is aptly demonstrated in the area of sexual health. The aim of this paper is to determine what works to facilitate evidence-based sexual healthcare within the primary care sector.

METHODS

431 clinicians (214 general practitioners and 217 practice nurses) in New South Wales, Australia, were surveyed about their awareness, their use, the perceived impact, and the factors that hindered the use of six resources to promote sexual healthcare. Descriptive statistics were calculated from the responses to the closed survey items, while responses to open-ended item were thematically analyzed.

RESULTS

All six resources were reported to improve the delivery of evidence-based sexual healthcare. Two resources - both double-sided A4-placards - had the greatest reach and use. Barriers that hindered resource-use included limited time, limited perceived need, and limited access to, or familiarity with the resources. Furthermore, the reorganization of the primary care sector and the removal of particular medical benefits scheme items may have hampered clinician capacity to translate evidence-based practices into patient care.

CONCLUSIONS

Findings reveal: (1) the translation of evidence-based practices into patient care is viable despite reform; (2) the potential value of a multi-modal approach; (3) the dissemination of relatively inexpensive resources might influence clinical practices; and (4) reforms to governance and/or funding arrangements may widen the void between evidence-based practices and patient care.

Investing in the health of future populations through a youth-focused programme

OBJECTIVE

This paper describes different approaches and results of the holistic integrated model of Rahnuma Family Planning Association of Pakistan (R-FPAP). The model seeks to provide sexual and reproductive health (SRH) services to adolescents and young people based on their rights as opposed to simply on their needs.

METHODS

Combined methodical efforts were performed by the organization for the provision of SRH services to adolescents and young people including youth-friendly services at clinics, outreach interventions, youth empowerment, and advocating for youth sexual and reproductive health rights (SRHR). Service delivery statistics available in the organization from 2007-2011 were utilized for estimating the results of these efforts.

RESULTS

An increase of 157.5% in the total number of SRH services received by adolescent and young clients aged 10-24 years was observed during a span of five years. About 310.8% more human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) and reproductive tract infection (RTI)/sexually transmitted infection (STI)-related services were received by the clients of the same age group. The integration of different methodical efforts helped in reaching one of every 100 adolescents and young people in Pakistan aged 10-24 years during 2011, which was an increase from four of every 1,000 adolescents and young people of the same age bracket served in year 2007.

CONCLUSION

The unmet need of the SRH rights of adolescents and youth, especially underserved young clients, can be addressed comprehensively through rights-based integrated approaches by providing clinical services, involving them through outreach initiatives, advocating for their SRHR, and facilitating them by establishing conducive environments for the promulgation of supportive laws and policies.

A long-term evaluation of a required reproductive health training rotation with opt-out provisions for family medicine residents

BACKGROUND

Family physicians are critical to reproductive health care provision. Previous studies have evaluated the immediate impact of training family physicians in abortion and reproductive health care but have not conducted long-term follow-up of those trained.

METHODS

In a cross-sectional survey performed in 2009, all 2003--2008 graduates from four family medicine residency programs with a required abortion training rotation with opt-out provisions were asked to participate in a confidential online follow-up survey that was linked to rotation evaluations. The follow-up surveys addressed current reproductive health practice, desire to integrate services in ideal practice, perceived barriers, and desired support for provision of services.

RESULTS

Of 183 eligible graduates, 173 had contact information, and 116 completed the survey. The majority of respondents had provided a range of reproductive health services since residency. Of full training participants, many had performed IUD insertion (72%), endometrial biopsies (55%), miscarriage management (52%), and abortion (27%), compared to 39%, 22%, 17%, and 0% of opt-out training participants, respectively. Of those residents intending future abortion provision, 40% went on to do so. In multivariate analysis among full participants, procedural volume was positively correlated with future abortion provision after controlling for intention to provide abortions, gender, and residency program (adjusted OR=1.42 [95% CI=1.03--1.94]). While most respondents considered comprehensive reproductive health services including miscarriage management and abortion as important to include in their ideal practice, many faced barriers to providing all the services they desired.

CONCLUSIONS

Family medicine residency graduates fully participating in abortion training reported increased provision of most reproductive health services compared to opt-out graduates. Many intending to provide abortions reported a variety of barriers to provision. Training programs that provide assistance for overcoming obstacles to practice initiation may improve comprehensive reproductive health provision among graduates.

Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies

Trichomonas vaginalis (TV) is the most common curable sexually transmitted infection worldwide. Annually, 7.4 million new infections are estimated in the United States, which is greater than combined new cases of Chlamydia, gonorrhea, and syphilis. Serious adverse reproductive health outcomes including pregnancy complications, pelvic inflammatory disease, and an increased risk of HIV acquisition have been linked to TV infection. There are several sensitive and specific diagnostic tests available, including a newly approved nucleic acid amplification test (NAAT) that utilizes the same instrumentation platform and clinical sample as Chlamydia and gonorrhea tests. In this article, we review TV pathogenicity, adverse reproductive health outcomes, detection, and treatment followed by clinical scenarios for which TV diagnosis may prove useful in obstetrics and gynecology practice.

A review of reproductive health research, guidelines and related gaps for women living with HIV

The study of pregnancy and motherhood in women living with HIV (WLWH) has concentrated on the health of the unborn baby and the prevention of mother-to-child transmission, whereas consideration of the broader aspects of women's reproductive health has been largely overlooked. The rights of WLWH with respect to their reproductive health should be exactly the same as non-HIV-positive women, however, inequalities exist due to discrimination and also because the treatment guidelines used in the care of women are often based on insufficient evidence. The purpose of this article is to review the available literature on reproductive health issues for WLWH and to identify gaps requiring further investigation. Our review indicates that further research is warranted into a number of aspects of reproductive health among WLWH. Currently, access to the relevant reproductive health resources and services, such as advice on contraception and fertility services, for WLWH is far from optimal in many developed countries and most developing countries. More data are needed on the most appropriate family planning options with the consideration of drug interactions between contraceptives and antiretroviral therapy and the risk of HIV transmission. Also, more research is needed to improve understanding of the maternal health challenges facing WLWH. Similarly, our understanding of the impact of HIV on the physical and emotional health of pregnant women and new mothers is far from complete. Answering these questions and countering these inequalities will help to ensure the reproductive health and child-bearing intentions of WLWH become an integral part of HIV medicine.

Check the box that best describes you: reflexively managing theory and praxis in LGBTQ health communication research

The intersections between identity and health communication are complex and dynamic, yet few studies employ a critical-empirical research strategy to understand how these factors affect patient experiences. And although other disciplines have examined lesbian, gay, bisexual, transgendered, and queer (LGBTQ)-specific issues surrounding identity and health care, there is a gap in communication studies literature on the topic. The present study examines how LGBTQ patients experience the language and structure of medical intake forms by analyzing both existing forms and patient survey responses. Relying on a queer theory framework, we illustrate how intake forms can foreclose on LGBTQ identity with heteronormative assumptions about sexuality, gender, and relationships. We also offer recommendations for creating queer-friendly intake forms and avoiding heteronormativity in health communication research. Overall, we argue that researchers must use reflexive methodology in considering how identity categories can both limit and assist LGBTQ patients.

Barriers and enablers to becoming abortion providers: the reproductive health program

BACKGROUND AND OBJECTIVES

Despite abortion being one of the most common procedures undergone by women of reproductive age in the United States, the number of abortion providers has been declining for the last 20 years. We sought to assess the long-term impact of the Reproductive Health Program (RHP), a national elective abortion training program for primary care abortion providers that operated from 1999-2005.

METHODS

We conducted a mixed-methods cross-sectional study of 220 former RHP trainees. Participants were interviewed over the phone and asked a series of questions about their training at RHP, their current practice, abortion provision since RHP, and enablers and barriers to abortion provision.

RESULTS

More than half of respondents (58.8%) have provided any abortions since RHP; more have provided medical abortions (56.5%) than surgical abortions (47.1%). Of respondents who have provided abortions, most have performed more than 50 surgical (87.5%) or medical (77.1%) abortions since RHP and had provided an abortion in the last 3 months (67.5%, 70.8%). More than 90% of abortion providers reported having liability insurance that covers abortion, colleague support, ease of obtaining medications and/or equipment, reimbursement, and administrative and/or staff support at the site where they provide abortions. Relative to providers, the greatest barriers reported by non-providers were lack of skills, concerns about liability, and difficulty obtaining supplies.

CONCLUSIONS

Our findings suggest that the RHP model of elective training can yield a substantial percentage of abortion providers. We also describe enablers and barriers to provision once trainees are in practice, highlighting the importance of continued support after training is completed.

Key informant perspectives on policy- and service-level challenges and opportunities for delivering integrated sexual and reproductive health and HIV care in South Africa

BACKGROUND

Integration of sexual and reproductive health (SRH) and HIV services is a policy priority, both globally and in South Africa. Recent studies examining SRH/HIV integration in South Africa have focused primarily on the SRH needs of HIV patients, and less on the policy and service-delivery environment in which these programs operate. To fill this gap we undertook a qualitative study to elicit the views of key informants on policy-and service-level challenges and opportunities for improving integrated SRH and HIV care in South Africa. This study comprised formative research for the development of an integrated service delivery model in KwaZulu-Natal (KZN) Province.

METHODS

Semi-structured in-depth interviews were conducted with 21 expert key informants from the South African Department of Health, and local and international NGOs and universities. Thematic codes were generated from a subset of the transcripts, and these were modified, refined and organized during coding and analysis.

RESULTS

While there was consensus among key informants on the need for more integrated systems of SRH and HIV care in South Africa, a range of inter-related systems factors at policy and service-delivery levels were identified as challenges to delivering integrated care. At the policy level these included vertical programming, lack of policy guidance on integrated care, under-funding of SRH, program territorialism, and weak referral systems; at the service level, factors included high client load, staff shortages and insufficient training and skills in SRH, resistance to change, and inadequate monitoring systems related to integration. Informants had varying views on the best way to achieve integration: while some favored a one-stop shop approach, others preferred retaining sub-specialisms while strengthening referral systems. The introduction of task-shifting policies and decentralization of HIV treatment to primary care provide opportunities for integrating services.

CONCLUSION

Now that HIV treatment programs have been scaled up, actions are needed at both policy and service-delivery levels to develop an integrated approach to the provision of SRH and HIV services in South Africa. Concurrent national policies to deliver HIV treatment within a primary care context can be used to promote more integrated approaches.

Building a national model for knowledge exchange in Malawi: findings from a health information needs assessment

Getting the right information into the right hands at the right time is a challenge for many health systems in developing countries. Health workers need access to reliable and up-to-date health information in order to support their clients. This health information needs assessment, conducted in the capital city and 3 districts of Malawi from July 2009 to September 2009, aimed to determine access to, and need for, health information in HIV/AIDS and family planning/reproductive health at all levels of the health system. Using qualitative research methods, the study showed the need to (a) build the capacity of government technical working groups to collect and store information and to promote information exchange at all levels of the health system; (b) improve information synthesis and packaging, particularly for users at peripheral levels; (c) strengthen the district level to serve as an information hub for district- and community-level providers; and (d) explore mobile technologies to increase provider access to knowledge and information.

Qualitative study of health information needs, flow, and use in Senegal

Many health professionals and policymakers in Africa lack access to the information needed to make evidence-based decisions for effective health care. This study collected qualitative data from 75 key informants and members of two focus groups in Senegal on various aspects of health information needs, particularly in family planning and reproductive health, including information sources, strategies, and systems to transfer and share information; and barriers to accessing, sharing, and using health information. Respondents reported needing information on ways to motivate men's involvement in reproductive health and to address rumors and religious barriers to family planning. Results identified mobile phones as one scalable platform to improve health knowledge. Nevertheless, a nearly universal and persistent need for paper-based information exists, and many health personnel prefer interpersonal communication as a method for information sharing, knowledge synthesis, and learning. Hierarchy and social organization play a crucial role in the flow of communication and in knowledge exchange. The study also identified the importance of political support for a comprehensive knowledge management strategy for the health sector, including the need for strategies to empower and better support the knowledge role of health coordinators and supervisors.