Toward communities as systems: a sequential mixed methods study to understand factors enabling implementation of a skilled birth attendance intervention in Nampula Province, Mozambique.

BACKGROUND: Skilled birth attendance, institutional deliveries, and provision of quality, respectful care are key practices to improve maternal and neonatal health outcomes. In Mozambique, the government has prioritized improved service delivery and demand for these practices, alongside "humanization of the birth process." An intervention implemented in Nampula province beginning in 2009 saw marked improvement in institutional delivery rates. This study uses a sequential explanatory mixed methods case study design to explore the contextual factors that may have contributed to the observed increase in institutional deliveries. METHODS: A descriptive time series analysis was conducted using clinic register data from 2009 to 2014 to assess institutional delivery coverage rates in two primary health care facilities, in two districts of Nampula province. Site selection was based on facilities exhibiting an initial increase in institutional deliveries from 2009 to 2011, similarity of health system attributes, and accessibility for study participation. Using a modified Delphi technique, two expert panels-each composed of ten stakeholders familiar with maternal health implementation at facility, district, provincial, and national levels-were convened to formulate the "story" of the implementation and to identify contextual factors to use in developing semi-structured interview guides. Thirty-four key informant interviews with facility MCH nurses, facility managers, traditional birth attendants, community leaders, and beneficiaries were then conducted and analyzed using the Consolidated Framework for Implementation Research through inductive and deductive coding. RESULTS: The two sites' skilled birth attendance coverage of estimated live births reached 80 and 100%, respectively. Eight contextual and human factors were found as dominant themes. Though both sites achieved increases, implementation context differed significantly with compelling examples of both respectful and disrespectful care. In one site, facility and community actors worked together as complementary systems to sustain improved care and institutional deliveries. In the other, community actors sustained implementation and institutional deliveries largely in absence of health system counterparts. CONCLUSION: Findings support global health recommendations for combined health system and community interventions for improved MNH outcomes including delivery of respectful care, and further suggest the capacity of communities to act as systems both in partnership to and independent of the formal health system.

Optimistic perception of HIV/AIDS, unprotected sex and implications for prevention among men who have sex with men, São Paulo, Brazil.

BACKGROUND: This study examines the association between optimistic perceptions about AIDS and unprotected sex among men who have sex with men (MSM) in the city of São Paulo, Brazil. METHODS: A cross-sectional study was carried out among MSM in leisure areas of São Paulo in 2003. We interviewed 161 participants aged 18-30 years. RESULTS: Thirty-nine per cent (95% confidence interval 32-47%) reported unprotected anal sex with steady or casual partners in the previous 6 months. The optimistic perception score created for this study was associated with unprotected sex (P = 0.01) and higher education (P = 0.02). The quartile with the most optimistic perception was 1.8 times more likely to engage in unprotected anal sex compared with the quartile with the least optimistic perception. CONCLUSION: This study suggests that the current situation regarding AIDS, which is seemingly favourable, may create optimistic perceptions leading to unprotected sexual practices. Prevention programmes, particularly for MSM, need to take this into account.