Battles on women's bodies: war, rape and traumatisation in eastern Democratic Republic of Congo.

Rape has been used as a weapon in the conflict in eastern Democratic Republic of Congo (DRC) in unprecedented ways. Research into the phenomenon of war-rape is limited, particularly in this context. The aim of this study was to explore perceptions of local leaders in eastern DRC concerning rape and raped women in the war context. Local leaders were chosen for their ability to both reflect and influence their constituencies. Interviews were conducted with 10 local leaders and transcripts subjected to qualitative content analysis. The study suggests that mass raping and the methods of perpetration created a chaos effectively destroying communities and the entire society and that humanitarian aid was often inappropriate. Furthermore, an exclusive focus on raped women missed the extent of traumatisation entire communities suffered. More significantly, the lack of political will, corruption, greed and inappropriate aid creates a tangled web serving to intensify the war. This complexity has implications for humanitarian interventions including public health.

Obstetric care at the intersection of science and culture: Swedish doctors' perspectives on obstetric care of women who have undergone female genital cutting.

Providing healthcare for women having undergone female genital cutting can present challenges. The women might require special obstetric care, including an anterior episiotomy (defibulation) for infibulated women. This paper explores how Swedish doctors caring for these women describe, explain and reason about their care and relevant policies in a Swedish context. A qualitative study was carried out with 13 chief/senior obstetricians and seven senior house officers. There was little consensus among the interviewed doctors on what constitutes good obstetric care for women with FGC or how care should be provided. Major problems include: inconsistent policy and praxis; uncoordinated care trajectories; diffuse professional role responsibilities; difficulties in monitoring labour and fetal status; and inhibited communication. The data highlight the need for increased awareness and reflective praxis both on the part of individual practitioners, and on an organisational level, which takes account of the special needs of different users.

Dilemmas and paradoxes in providing and changing antenatal care: a study of nurses and midwives in rural Zimbabwe.

This paper describes the experiences of caregivers in a rural district in Zimbabwe, in caring for pregnant women within a context of changing antenatal care routines. Data were generated using individual interviews with 18 nurses and midwives. The caregivers experienced their working situation as stressful and frustrating due to high staff turnover, inconsistent policies, parallel programmes and limited resources, including time. They also faced difficulties when implementing some of the proposed changes. Furthermore, the caregivers had to deal with the pressure and resistance from the pregnant women, whose reasoning and rationale for using care appeared different from those of the health professionals. In light of the above, we stress the necessity for reflecting on and including the experiences and perspectives of caregivers and the users of care, as well as their contexts and realities, when implementing change.

Quality of maternity care for adolescent mothers in Mbabane, Swaziland.

Early pregnancy and unplanned childbirth may have far-reaching physical, psychological and social consequences for the adolescent girl and her offspring and are therefore public health issues of concern. A number of evidence-based maternity practices might, if properly applied, prevent unnecessary health-related problems in mothers and newborns, postnatally. In order to identify the areas of maternity practice that require improvement in Swaziland, the overall aim of this study was to generate systematic data on the maternity care and social support provided by health professionals (for adolescent mothers and their children) on admission, in the labour ward, and during and after delivery. The study was carried out during a 3-month period from April to June 1998. All pregnant adolescents with an uneventful term pregnancy, admitted to the Mbabane Government Hospital maternity ward in the morning of the study days, were informed about the purpose of the study and asked if they would like to participate. A total of 33 pregnant adolescents agreed and in-depth interviews were conducted with those participants. Observations and checklists were used to assess the maternity care given to the study participants. Results revealed that on admission to the labour ward, verbal communication and interaction between the midwife and the adolescent were minimal, and none of the adolescents was encouraged to bring a social support person to remain with them during labour. During the progress of labour, nearly 50% of the adolescent mothers developed complications and approximately 27% had a lower-segment Caesarean section. Special attention should therefore be paid to adolescent sexual and reproductive health service needs. These should include contraceptive counselling in order to prevent pregnancy at a young age and also to improve their sexual and reproductive health statuses.

Gendered construction of sexual risks: implications for safer sex among young people in Kenya and Sweden.

This study compared perceptions of sexual risk and sexual practices among youth in Kenya and Sweden. Self-generated questions on the body, perceptions of sexual risk and sexual practices were collected in Kenya while focus group discussions and individual interviews on these same issues were used in Sweden. The most striking differences between the two countries were in the level of knowledge on matters of sexuality and the ability to talk with ease on these matters. The refusal in Kenya to provide adolescents with information and services has left the 'safe period' as their only protective option and pregnancy as the overriding concern. Communication at the partner level and lack of condom use are problematic in both countries and even where access to information and preventive services exist, these may not be used optimally. In both countries, boys had more sexual freedom, while girls were controlled through labelling and rumours, and girls were assigned responsibility for safer sex. We conclude that sexual education should be based more broadly on an understanding of the social norms defining sexual behaviour. It is at the level of sexual relations that the tensions between culturally-defined sexual and gender norms and public health assumptions should be addressed, a level at which health policy and education are silent in both countries.

Health-seeking behaviour of patients with sexually transmitted diseases in Zambia.

The aim of this paper is to describe health-seeking behaviour, time with symptoms and sexual activity during symptom period among patients attending the public health sector in urban and rural Zambia for treatment of an STD. The study was conducted at two urban health centres and at one rural mission hospital during four months in 1994 and 1995. Four hundred and seventy nine patients seeking health care for STD symptoms were interviewed. The patients had experienced STD symptoms for one to two weeks before they came to the clinic. During this period two thirds in the urban and one third in the rural setting had had sex. Sixty per cent of the patients in the urban and 50% in the rural setting had taken some kind of medicine before they came to the clinic. More people had used modern compared to traditional medicine, especially in the urban area. Market places, other clinics and doctors, friends, and relatives were common treatment sources. Ten per cent had received medicine from a traditional healer. Thus, a majority of the patients had received medication from other sources before they came to the clinic. Sex during periods with STD symptoms was common. This has serious implications for STD as well as HIV transmission.

PIP: A number of factors influence which treatment sources people seek when symptoms of morbidity occur and a person alone, or with the advice of others, decides that the condition warrants additional attention. Some such factors are related to social structures such as kinship, social networks, gender, and economic status, while others are related to belief systems which define how people conceptualize the etiology of disease. Service quality, the introduction of user fees, and the cost of treatment can also affect health-seeking behavior (HSB). One highly important factor affecting HSB for sexually transmitted diseases (STD) is social stigma. For example, in Zambia, where STDs are a major public health problem, it is considered highly shameful to have an STD, especially for women. This paper describes the HSB, time with symptoms, and sexual activity during symptom period among patients attending 2 urban public health centers and 1 rural mission hospital in Zambia during 4 months in 1994 and 1995 to receive treatment for their STDs. 479 patients seeking health care for STD symptoms were interviewed. The patients had experienced STD symptoms for 1-2 weeks before coming to the clinic. During that period, two-thirds in the urban and one-third in the rural areas had had sexual intercourse. 60% of the patients in the urban and 50% in the rural settings had taken some kind of medicine before coming to the clinic. However, more people had used modern rather than traditional medicine, especially in the urban area. Marketplaces, other clinics, physicians, friends, and relatives were common treatment sources, although 10% had received medicine from a traditional healer.

Quality of STD care in Zambia. Impact of training in STD management.

STUDY OBJECTIVE: To assess quality of care of sexually transmitted diseases (STDs) and evaluate interactive training methods aimed at improving providers' performance. DESIGN AND SETTING: This comparative study, with a baseline, intervention, and evaluation phases was conducted at two urban health centers in Zambia. The personnel at one health center were trained in STD management using interactive training methods. The other health center acted as a control. SUBJECTS AND METHODS: Two-hundred patients with STD were interviewed and their interaction with health care providers observed before and after the training. Another 200 interviews and observations were conducted at the control health center. RESULTS: The proportion of patients being examined, given health education and informed about partner notification increased significantly after the intervention. The proportion of patients who had complaints about the health care did not decrease. Long waiting time and lack of time to discuss the disease were the main complaints. CONCLUSION: The training solved some, but not all, problems of poor case management. This indicates the need for a more process-oriented approach for improving quality of care.

Quality of STD care in an urban Zambian setting: the providers' perspective.

The aim of this paper is to analyse obstacles to optimal STD care in an urban setting in Zambia. Eight-two health professionals answered a questionnaire with closed and open-ended questions. More than 50% were not satisfied with their working conditions, due to heavy workload, lack of equipment/drugs, poor salary, and lack of continuing education. Negative opinions about STD patients were common. Treatment and preventive activities were considered important but most respondents found patient compliance poor--especially for partner notification. To improve the quality of STD care, training in STD management should be combined with improved working conditions.

PIP: Improvement of the quality of care is a major goal of the Government of Zambia's health reform program. A questionnaire administered to 82 health professionals from two health centers in Lusaka, Zambia, sought to identify obstacles to high-quality sexually transmitted disease (STD) care. Both health centers had an antenatal and general outpatient department, a maternity ward, and a laboratory. Respondents, who were primarily enrolled nurses (n = 41) and midwives (n = 22), had a median of 11 years of working experience. The questionnaire had both closed and open-ended items. Negative opinions about STD clients (e.g., they risk other people's lives, they are difficult patients, they are bad people) were common. The most frequently cited components of high-quality STD care were diagnosis, treatment, prevention, and interpersonal relationships. Shortages of equipment and drugs, lack of patient compliance with clinic instructions (especially regarding partner notification), inadequate staff training, and lack of time for patient care were the major obstacles identified. Of the 78 health workers who answered this question, 34 were satisfied with their current working conditions, 25 were partly satisfied, and 19 were dissatisfied. Reasons for dissatisfaction included the heavy workload, lack of equipment and drugs in the clinic, poor staff salaries, lack of transport and housing allowances, absence of continuing education, no team work, and professional isolation. To improve the quality of STD care at the health center, respondents suggested a separate room for STD patients to ensure privacy, specialized training for staff in STD management, regular clinical meetings where staff can raise suggestions, staff seminars, and purchase of equipment and drugs with money from the user fees.

Do young women in tropical regions constitute a recognized social category?

In most tropical regions there is little organized health care for young women, yet their household roles within contexts of worsening socio-economic situations create special health problems. In the area of sexual and reproductive health, the onset of reproductive roles does not entitle the young women to either maternal and child health services or family planning services unless they are married and have children under 5 years. Societal values and norms at macro and micro levels have prevented young women from benefiting from reproductive technology, although they are, at the same time, increasingly expected to spend a great deal of their youth in school and outside marriage. Young women thus live in paradoxical situations as indicated by the increasing levels of early teenage pregnancy, induced abortion and related complications, school drop-out and infection with sexually transmitted diseases including HIV/AIDS. Young women clearly constitute an unrecognized social category, and research focusing on them would be particularly rewarding because of the potential it offers for addressing the gender imbalances and their dynamics in health.

Staff and patient attitudes to tuberculosis and compliance with treatment: an exploratory study in a district in Vietnam.

SETTING: The study, a collaboration between the National Tuberculosis Institute, Hanoi, Vietnam and the Karolinska Institutet, Stockholm, Sweden, was carried out in a district of Quang Ninh Province in North Vietnam. OBJECTIVES: To describe tuberculosis (TB) services, attitudes of staff, and attitudes of patients considered as defaulters to TB treatment. DESIGN: Two focus group discussions were carried out with staff at the district hospital. Ten defaulter patients were interviewed in their homes. RESULTS AND CONCLUSIONS: This exploratory study has revealed some important aspects of staff and patients' attitudes to TB and its treatment. Tuberculosis is considered a 'dirty' disease, which mainly affects poor people. There is a tendency to avoid telling others about it. Obvious symptoms are explained as 'being overworked'. A patient with TB feels 'less respected' by others. The social stigmatization leads to delays in seeking medical care, often only after self-medication: anti-tuberculosis drugs can be bought without prescription in various pharmacies. The patient's economic situation is also an important determinant of compliance and non-compliance. These factors need to be taken into consideration in TB control in Vietnam.

Behaviour, knowledge and reactions concerning sexually transmitted diseases: implications for partner notification in Lusaka.

Available data show that STDs and their consequences are a major health problem in Zambia. This study focuses on factors which could have implications for partner notification, as a tool for prevention. Fifty women and fifty men with STD were interviewed at two outpatient clinics in Lusaka, where partner notification is not functioning optimally. A majority of the sexual partners during the last three months were known by the patients who also stated a willingness to bring more partners than they were asked to do. Women had symptoms for a longer period than men before they came for treatment. They were less aware of symptoms connected with STD and a majority of them did not know that they were receiving treatment for STD. The communication between the health care provider and the patients about disease, treatment and partner notification needs to be improved especially for women.

PIP: Sexually/transmitted diseases (STD) and their consequences are a major health problem in Zambia. Partner notification is a strategy to find, counsel, and treat the sex partners of STD patients in the attempt to control the spread of STDs. The authors describe existing health care for STD patients in two urban health centers in Lusaka where partner notification is not functioning optimally with focus upon issues with implications for partner notification such as the number of sex partners identifiable and patients knowledge of and reactions to having an STD. 50 men of mean age 28.9 years and 50 women of mean age 23.7 years with STDs were interviewed at the clinics. 52% were married and 32% were unmarried. The men and women had had symptoms for medians of 5 and 14 days, respectively. STD patients are usually asked to bring their sex partners to the clinic for evaluation and treatment. This study found, however, that some patients were not asked to bring their partners. A majority of the sexual partners during the last three months were known by the patients who were also willing to bring more partners than they were asked to by health personnel. Partners of STD patients in Zambia could therefore be found and treated more extensively than is now the case. The research also found women to be less aware of symptoms connected with STDs and a majority did not know that they were receiving treatment for STD. It is concluded that communication between the health care provider and patients about disease, treatment, and partner notification needs to be improved, especially for women.

Is there a distinct African sexuality? A critical response to Caldwell.

The author challenges the hypothesis developed by Caldwell and others that sexuality in Africa is inherently permissive, and that prevailing attitudes and behavior are primary reasons for the relative failure of family planning programs to reduce fertility, and thereby will be major factors hindering efforts to control the spread of HIV infections and AIDS. The article is in three parts. "The first is a summary of the thesis as presented by Caldwell et al., including their location of African sexuality and their conceptualisation of change. The second offers a critical response, focusing mainly on the problems of research into sexual behaviour and the christianisation process, with special reference to the case of the Kikuyu people, among whom, recent studies suggest, even where sexual activity may have appeared largely free of moral restraint, there was indeed a moral order.... Part three offers a new way forward." (SUMMARY IN FRE)