Fertility intentions and family size among married men in Khartoum, Sudan.

Numerous factors contribute to high fertility within a specific context some of which are related to women's fertility practices. What has been less frequently examined, however, is how men's preferences and behaviours contribute to high fertility rates. This is imperative in a country such as Sudan which has reported continuously high fertility rates. This study aimed to analyse the socio-cultural factors affecting husbands' preferences and behaviours contributing to high fertility in Sudan. Participants were recruited from the Fertility and Reproductive Health Services Centre in Khartoum and Ahfad Family Health Centre in Omdurman city. Qualitative interviews were used to examine men's fertility preferences and behaviours. The main study findings suggest that husband's fertility preferences and the desire for a large family were prominent, being determined by local socio-cultural factors and religious norms. The data presented offers insight into key factors sustaining high fertility.

Hiv testing and counseling services in Kassala State, Sudan: what are the relevant beliefs of private healthcare providers?

HIV testing and counseling (HTC) services are essential for all HIV prevention and treatment interventions. Evidence is limited on the role of private healthcare providers in providing HTC services. This study assessed the relevant beliefs for intervention to enhance the intention to offer HTC services among private healthcare providers. A cross-sectional study included 387 private healthcare providers who completed a questionnaire about beliefs and intentions regarding offering HTC services. A Confidence Interval Based Estimation of Relevance (CIBER) approach was used to identify the most relevant beliefs. The behavioral belief "Offering HTC services would cause patients to feel worries" and the normative belief "My managers believe that I should offer HTC services to patients" were relevant beliefs for intervention. The control beliefs "If I offer HTC services, I spend more time with the patients" and "Patients are at low risk of HIV, and they would not need HTC services" were significantly associated with intention and important intervention candidates. The belief "If I offer HTC services, I would be concerned about HIV test results confidentiality" was a relevant belief to target with intervention. The beliefs of private service providers differ in their association with relevance to their intention to offer HTC services. More relevant beliefs need to be selected to increase the potential effectiveness of the interventions to promote the private healthcare providers' intentions to offer HTC services.

Psychosocial beliefs related to intention to use HIV testing and counselling services among suspected tuberculosis patients in Kassala state, Sudan.

BACKGROUND: There is limited information about the psychosocial sub-determinants regarding the use of HIV Testing and Counselling (HTC) services among suspected Tuberculosis (TB) patients in Sudan. This study aimed to assess the association between psychosocial beliefs and the intention to use HTC services and to establish the relevance of these beliefs for developing behaviour change interventions among suspected TB patients. METHODS: Suspected TB patients (N = 383) from four separate TB facilities completed a cross-sectional questionnaire which was based on the Reasoned Action Approach theory. Eligibility criteria included attending Tuberculosis Management Units in Kassala State as suspected TB patients and aged 18-64 years. A Confidence Interval Based Estimation of Relevance (CIBER) analysis approach was employed to investigate the association of the beliefs with the intention to use HTC services and to establish their relevance to be targeted in behaviour change interventions. RESULTS: The CIBER results showed the beliefs included in the study accounted for 59 to 70% of the variance in intention to use HTC services. The belief "My friends think I have to use HTC services" was positively associated with the intent to use HTC, and it is highly relevant for intervention development. The belief "I would fear to be stigmatized if I get a HIV positive result" was negatively related to the intention to use HTC services and was considered a highly relevant belief. The belief "If I use HTC services, health care providers will keep my HIV test result confidential" was strongly associated with the intention to use HTC services. However, the relevance of this belief as a target for future interventions development was relatively low. Past experience with HTC services was weakly associated with the intention to use HTC services. CONCLUSION: The intention to use HTC was a function of psychosocial beliefs. The beliefs investigated varied in their relevance for interventions designed to encourage the use of HTC services. Interventions to promote intention to use HIV testing and counselling services should address the most relevant beliefs (sub-determinants). Further study is needed to establish the relevance of sub-determinants of the intention to use HTC services for interventions development.

Social inequalities, sexual tourism and HIV in Cartagena, Colombia: an ethnographic study.

BACKGROUND: Cartagena, Colombia's main port on the Caribbean Coast, reported an HIV incidence of 7.5 per 100,000 inhabitants in 2007 with 90.0% transmission by heterosexual contact and 70 identified as women with a stable partner. Studies across Colombia illustrate that HIV infection relates to social inequalities; most people with HIV live in poverty and have minimal access to health care, education, and secure jobs. The purpose of this article is to analyse the relationship between social inequalities, sexual tourism and HIV infection in Cartagena, Colombia. METHODS: Data come from a five-year participatory ethnography of HIV in Cartagena in the period 2004-2009, in which 96 citizens (30 of whom were living with HIV) participated in different data collection phases. Techniques included participant observation, in-depth interviews and thematic life histories. Out of this material, we selected three life histories of two women and a man living with HIV that are representative of the ways in which participants expressed how social inequalities make it virtually impossible to engage in safe sex practices. RESULTS: At stake is the exchange of condomless sex for goods within the widespread sexual tourism networks that promote an idealisation of dark-skinned men and women as better sexual performers. Our results illustrate the complex interplay of social inequalities based on class, skin colour, gender and sexual orientation. Furthermore, they suggest a synergistic effect between poverty, racialization, and gender inequalities in the historical maintenance of social dynamics for a fruitful growth of a sexual tourism industry that in turn increases vulnerability to HIV infection. CONCLUSIONS: Although the convergence of social inequalities has been thoroughly reported in the literature on social studies of HIV vulnerability; distinctive dynamics are occurring in Cartagena, including a clear link between the contemporary globalised sexual tourism industries and a racialised social structure - both having historical roots in the colonial past-.

Perceptions of Sudanese women of reproductive age toward HIV/AIDS and services for Prevention of Mother-to-Child Transmission of HIV.

BACKGROUND: Access to antenatal HIV testing during pregnancy and the level of uptake of services for Prevention of Mother-to-Child Transmission (PMTCT) in Sudan are very low. This study aimed to obtain insights into the perceptions of Sudanese pregnant women toward HIV/AIDS and the use of PMTCT services. METHODS: Ten focus group discussions (FGDs) with women of reproductive age were conducted at community settings in Khartoum (N = 121). Recruitment eligibility included living near or around a PMTCT site and being in the age range of 18-40 years. Out of 121 women who participated, 72 (61 %) were pregnant. Predefined themes were addressed in the theory-based interview scheme, which was derived from multiple socio-cognitive theories-i.e., the Extended Parallel Process Model, the Reasoned Action Approach and the socio-psychological view on stigma. Emerging themes were incorporated during data analysis. RESULTS: Few women knew about the Mother to child transmission (MTCT) of HIV. No one indicated that MTCT might occur during labor. Most women believed that HIV/AIDS is a serious and fatal condition for them and also for their children. They believed they were susceptible to HIV/AIDS as a result of cesarean section, contaminated items (blood and sharp items) and husband infidelity. The usefulness and advantages of HIV testing were questioned; for some women it was perceived as an additional burden of anxiety and worry. Doctors were the most influential with regard to acceptance of HIV testing. The speed of the testing process and confidentiality were mentioned by some women as key factors affecting willingness to undergo HIV testing at a health facility during pregnancy. CONCLUSION: The study reveals that most of the women felt susceptible to HIV infection with perceived high severity; however, this perception has not translated into positive attitudes toward the importance of HIV testing during pregnancy. Because of anticipated stigma, women are not likely to disclose their HIV status. Further research should focus on gaining a more in-depth understanding of the psycho-social determinants and processes underlying the factors identified above. In addition, the adequate implementation of Provider Initiated Testing and Counseling (PITC) should be critically assessed in future research about PMTCT in Sudan.

Promoting Darfuri women's psychosocial health: developing a war trauma counsellor training programme tailored to the person.

Women are considered special groups who are uniquely vulnerable in the context of war exposures. To effectively target the resources aimed at mitigating mental health consequences and optimising and maximising the use of mental health provisions, culturally relevant war trauma counsellor training is required. The objectives of this study are to promote a new philosophy in the Sudanese mental health care by introducing an integrative approach for targeted prevention and tailored treatments to the Darfuri person in a cost-effective way. Furthermore, the study provides evidence- and theory-based guidelines for developing a war trauma counsellor training programme in Sudan, mainly based on qualitative and quantitative studies among war-affected Darfuri female students. Cultural conceptualisations such as gender roles and religious expectations as well as theories that emphasise resilience and other psychosocial adaptation skills have been operationalised to reflect the totality of the Darfuri women's experiences. Furthermore, the results of four interrelated studies among war-traumatised undergraduate Darfuri women who are internally displaced provide the basis that guides an outline for qualification development, capacity building and skills consolidation among Sudanese mental health care providers. Explicit war-related psychosocial needs assessment tools, specific war-related trauma counsellor training and particular counsellor characteristics, qualities and awareness that pertain to strengthening the efficacy of war trauma Sudanese counsellors are recommended. The aim is to produce expertly trained war trauma counsellors working with war-affected Darfuri women in particular and with regards to their helpfulness in responding to the psychosocial needs of war-exposed Sudanese in general.

Experiences and psychosocial adjustment of Darfuri female students affected by war: an exploratory study.

This paper presents the personal accounts of Darfuri students studying at Ahfad University for Women in Omdurman, Sudan. Their war-related exposure, current ongoing life challenges, emotional distress, and coping strategies were explored using a semistructured interview protocol with a sample of 20 students. Through interpretative phenomenological analysis (IPA), the Darfuri students' stories illustrated that they were exposed to an array of traumatic war events, including personal experiences of parental separation, injury and death of family members, and shortages of essential life-sustaining supplies in internally displaced camps. Also, they were confronted with myriad current life hassles and urban-cultural challenges, including being physically distant from their families, and losing the shelter of parents, the encouragement of extended family members, and their rich and familiar social support networks. Urban-cultural challenges and lack of environmental mastery applied to most Darfuri participants as they relocated to Omdurman city, which included negotiating an unfamiliar transport system, learning the routes and directions to important city landmarks, and insufficient funds for basic hygienic essentials. Emotional distress reactions were coded by forming two distinct lists: directly mentioned by the participant; and observations of emotional manifestation during the interview. Patterns emerged that may be similar to symptoms of mood and anxiety disorders; for example, the DSM-IV criteria for symptoms of generalized anxiety disorder and major depression. Strong religious practices and beliefs (such as praying and reading the Quran), ability to form interpersonal relationships, availability of social support networks, and a positive future outlook seemed to augment their ability to cope with their subsequent emotional distress owing to war-related exposures, current ongoing life hassles and urban-cultural challenges.

Exposures to war-related traumatic events and post-traumatic stress disorder symptoms among displaced Darfuri female university students: an exploratory study.

BACKGROUND: With the deaths of hundreds of thousands and the displacement of up to three million Darfuris, the increasingly complex and on-going war in Darfur has warranted the need to investigate war-related severity and current mental health levels amongst its civilian population. The purpose of this study is to explore the association between war-related exposures and assess post-traumatic stress disorder (PTSD) symptoms amongst a sample of Darfuri female university students at Ahfad University for Women (AUW) in Omdurman city. METHODS: An exploratory cross-sectional study among a representative sample of Darfuri female university students at AUW (N = 123) was conducted in February 2010. Using an adapted version of the Harvard Trauma Questionnaire (HTQ), war-related exposures and post-traumatic stress disorder (PTSD) symptoms were assessed. Means and standard deviations illustrated the experiential severity of war exposure dimensions and PTSD symptom sub-scales, while Pearson correlations tested for the strength of association between dimensions of war exposures and PTSD symptom sub-scales. RESULTS: Approximately 42 % of the Darfuri participants reported being displaced and 54 % have experienced war-related traumatic exposures either as victims or as witnesses (M = 28, SD = 14.24, range 0 - 40 events). Also, there was a strong association between the experiential dimension of war-related trauma exposures and the full symptom of PTSD. Moreover, the refugee-specific self-perception of functioning sub-scale within the PTSD measurement scored a mean of 3.2 (SD = .56), well above the 2.0 cut-off. CONCLUSIONS: This study provides evidence for a relationship between traumatic war-related exposures and symptom rates of PTSD among AUW Darfuri female students. Findings are discussed in terms of AUW counseling service improvement.

Utilization of family planning services by married Sudanese women of reproductive age.

To explore differences in utilization of family planning services and predisposing factors, we surveyed 601 women from urban and rural areas of Khartoum state. About half were using modern family planning techniques; there were no significant differences in utilization rates between urban and rural settings. Contraceptive pills were the most frequently used modern method (47.7%) followed by intrauterine devices (10.2%) and injections (7.5%). Breastfeeding was used by around 33% of both groups. The rhythm method and withdrawal were more often used by urban women (22.2% and 8.6% respectively) than rural women (16.1% and 3.6% respectively). Use of male methods (condom; sterilization) was extremely low. Socioeconomic status, knowledge and education level were the most important determinants of using modern methods.

Utilization of family planning services by married Sudanese women of reproductive age

To explore differences in utilization of family planning services and predisposing factors, we surveyed 601 women from urban and rural areas of Khartoum state. About half were using modern family planning techniques; there were no significant differences in utilization rates between urban and rural settings. Contraceptive pills were the most frequently used modern method [47.7%] followed by intrauterine devices [10.2%] and injections [7.5%]. Breastfeeding was used by around 33% of both groups. The rhythm method and withdrawal were more often used by urban women [22.2% and 8.6% respectively] than rural women [16.1% and 3.6% respectively]. Use of male methods [condom; sterilization] was extremely low. Socioeconomic status, knowledge and education level were the most important determinants of using modern methods

Theory- and evidence-based intervention to improve adherence to antiretroviral therapy among HIV-infected patients in the Netherlands: a pilot study.

The objectives of this study were to describe and pilot-test a theory- and evidence-based intervention to improve adherence of HIV-infected patients with antiretroviral medication. Twenty-six treatment-experienced patients (>6 months on treatment) participated in a within-subject comparison design. Adherence was measured electronically with Medication Event Monitoring System (MEMS) caps for at least 5 months: 2 months before the intervention and 3 months during the intervention. MEMS data were used to measure the outcome of the intervention, but also served as feedback to participants during the intervention. Mean adherence during the month before intervention was compared to mean adherence during the third month of intervention. Data for the process evaluation were gathered through direct observation and semi-structured interviews. Adherence improved significantly during the intervention (Z = -2.1, p < 0.05). Mean adherence (percentage of prescribed doses taken within correct time interval) before the intervention was 81.8% compared to 92.5% during the third month of the intervention. More than 65% of the nonadherent patients (<95% adherence) before the intervention were adherent during the third month of the intervention. Both health care professionals and patients positively evaluated the intervention protocol and the electronic measurement of adherence. The only critique from some patients was the lack of userfriendliness of the MEMS cap and its medication container (size and shape). It can be concluded that the proposed intervention fits in standard care procedures, can be executed by trained HIV nurses, seems to improve adherence to antiretroviral medication, and is positively evaluated by the users. Large-scale and long-term research is warranted.

Values in the care for young persons with Prader-Willi syndrome: creating a meaningful life together.

BACKGROUND: Caregivers sometimes feel frustrated by present emphasis on self-determination in the care for individuals with an intellectual disability. They are confronted with situations in which there is a conflict between providing high quality care and respecting the client's autonomy. Such conflicts are prominent in the care for people with Prader-Willi syndrome (PWS). This condition is characterized by overeating behaviour which frequently leads to serious obesity. The central question in the present study is how persons involved, parents and professional caregivers, deal with the problems of the prevention of obesity in young individuals with PWS in everyday life. METHOD: In-depth qualitative interviews were conducted with 23 parents and 14 professional caregivers of 18 persons with PWS. The interview data were analysed using the constant comparative method as described in grounded theory. RESULTS: On the basis of analysis of the interviews four values emerge that parents and professional caregivers indicate as relevant and directive to their acting towards the child or the client: physical health, well-being, freedom and responsibility, and a liveable life. Furthermore, caregivers mentioned several enabling and limiting conditions that influence these values. And they named several interventions they used to realize the values. CONCLUSION: Of importance is the question how to create life in such a way that it is acceptable and meaningful for everybody involved. By building up a relationship to which acceptance and trust are central, a certain amount of independence and responsibility can be promoted. By creating trust it is possible to deal with rules in a less rigid way and to look where there is room for choices.

The impact of an organ donation registration information program for high school students in the Netherlands.

In 1998, a new organ donor registration system was implemented in the Netherlands to increase the number of potential donors. A high school education program was developed to prepare adolescents to make an informed decision about organ donation. A post-test only randomised controlled trial was conducted in 39 high schools including 2868 students. Students within schools were randomly allocated to either attend the organ donation education program or not. The impact of the program on students' intention to register their organ donation preference (and determinants thereof) were analysed using multivariate multileveling modelling (MlwiN). The results show that students who were exposed to the education program had more favourable registration intentions (B = .40), were more often willing to be donors (OR = 1.45), and had greater knowledge about (B = 3.84) and more positive social outcome expectations (B = .09) and self-efficacy regarding organ donation registration (B=.22). Lastly, they experienced significantly less negative outcome expectations related to organ donation registration (B = -.15). Students' evaluation of the school-based education program was favourable. The present organ donation registration program proved to be effective in changing determinants of organ donation registration, and a large-scale implementation in the Dutch high school curriculum is planned.

Process evaluation of a school-based education program about organ donation and registration, and the intention for continuance.

This paper describes the process evaluation of an organ donation education program for high school students aged 15-18 years of which the effectiveness was established. The program consisted of three components: a video with group discussion, an interactive computer-tailored program and a registration training session. A cross-sectional survey was conducted among 50 teachers who had recently worked with the program. The results show that all teachers reported to have implemented at least two of the three intervention components, while a majority of teachers reported to have implemented all components. Teachers' attitudes toward the program were generally positive. They reported that the opinions of students and colleagues in their own department were most influential in their decision to provide the education program. Furthermore, teachers were very confident about their ability to apply the different parts of the education program. The educational quality of the program was evaluated as moderately positive and almost all teachers had the intention to use the program again in the future. Because of the positive evaluations and intentions for future implementation by teachers, and justified by its previously established effectiveness, the education program should be considered for large-scale dissemination among high schools in The Netherlands.

The impact and evaluation of two school-based interventions on intention to register an organ donation preference.

The present paper describes the impact and evaluation of two intervention components-a video with group discussion and an interactive computer-tailored program-in order to encourage adolescents to register their organ donation preference. Studies were conducted in school during regular school hours. The video with group discussion in class had a positive impact on the intention to register an organ donation preference as well as on the intention to register as a posthumous organ donor. The computer-tailored program had no surplus value when compared to reading an extensive brochure with general information on organ donation. However, participants appreciated the tailored information more than the brochure. It may be that having provided general information before exposure to the tailored program, the tailored intervention will be more effective. This needs to be tested in a further experiment.

Community reactions to the introduction of permethrin-treated bed nets for malaria control during a randomized controlled trial in western Kenya.

Prior to implementation of a randomized controlled trial of insecticide (permethrin)-treated bed nets (ITNs) in western Kenya, ethnographic studies were conducted to understand local perceptions of disease, sleeping patterns, and other factors that might affect use of ITNs. Educational activities took place prior to distribution, but immediately after distribution in Asembo only approximately half of the ITNs were in use. A qualitative study was then conducted to identify the community's perceptions about ITNs and the ITN project. While participants ranked malaria as important and recognized that malaria prevention could be beneficial, they believed ITNs would be only partly effective due to the perception that malaria has multiple causes. Concerns expressed included fear of the insecticide, thought by some to be a toxic family planning aid, the taking of blood during clinical studies, and the mixing up of family ITNs during net re-treatment, which would violate cultural taboos. Attempts were made to allay fears by improved communication on these subjects and modification of the study design.

Perceptions of bed nets and malaria prevention before and after a randomized controlled trial of permethrin-treated bed nets in western Kenya.

A study of mothers' perceptions regarding bed nets and malaria was conducted before and after a randomized controlled trial of insecticide (permethrin)-treated bed nets (ITNs) in western Kenya. Awareness about the trial and the rationale for bed net use increased by the end of the trial. Knowledge that mosquitoes caused malaria also increased; however, a higher proportion of mothers from control, rather than intervention villages, cited this (44.4% versus 27.9%; P < 0.001). Mothers from intervention villages were more knowledgeable about the use and maintenance of bed nets and re-treatment with insecticide. Both groups specified advantages of ITNs. Mothers from intervention villages noted practical advantages such as protection against bedbugs and falling roof debris. Few (< 1%) mothers indicated that ITNs protected children against malaria. Intervention homes used significantly fewer mosquito coils, insect spray, medicines, and burned cow dung less often compared with those in control villages. Mothers were willing to pay approximately 4.5 U.S. dollars for a regular bed net, but only 10.5 U.S. cents (intervention) and 0.036 (control) for re-treating a bed net. This study suggests that, despite two years of experience of use, bed nets and insecticides would not be purchased as a household priority in this impoverished rural community.

Can guardians supervise TB treatment as well as health workers? A study on adherence during the intensive phase.

SETTING: In sub-Saharan Africa, tuberculosis (TB) has increased over the last two decades due to the human immunodeficiency virus pandemic. In Malawi, 20630 new TB patients were notified to the National Tuberculosis Programme in 1996, a fourfold increase since 1986. Due to this increase in cases and lack of resources (both human and monetary) it is becoming more difficult to ensure directly observed treatment (DOT) in the TB wards. METHODS: In Ntcheu district, Malawi, a new TB regimen was introduced from April 1996 in which patients received supervised treatment by either a health worker or a guardian (i.e., family member). Adherence to the different treatment options was measured by form checks, tablet counts, and tests for detecting isoniazid in the urine. Adherence was measured at 2, 4 and 8 weeks after onset of TB treatment. RESULTS: Overall adherence rate was 95-96%. Inpatients showed the highest adherence rates. Patients on guardian-based DOT (GB-DOT) (n = 35) showed 94% adherence, while patients on health centre based DOT (n = 40) showed more non-adherent behaviour: 11% according to monitoring forms, 14% according to tablet counts and 16% according to urine tests. DISCUSSION: The results suggest that decentralised care is a feasible option for anti-tuberculosis treatment and that guardians can supervise TB treatment just as well as health workers during the intensive phase of TB treatment.

Health care seeking behaviour of patients with sexually transmitted diseases: determinants of delay behaviour.

The study aimed to determine the factors associated with a delay in seeking health care for symptoms of sexually transmitted diseases (STDs) among a sample of 1482 patients attending STD clinics. Of the sample 78% were male, 58% sought help from the clinic within the first 6 days of noticing symptoms, 24% waited between 7 and 10 days and 17% waited longer than 10 days before seeking health care. Patients who delayed were those who treated themselves prior to seeking health care, who were female, whose friends waited before seeking treatment, who held misconceptions regarding the cause of STDs, who perceived STDs not to be serious and who valued personal autonomy in sexual behaviours less and had less positive outcome expectations of refusing sex. The data suggest that targeted interventions should be directed specifically at women and the youth. Early health care seeking could be facilitated through improved basic knowledge regarding STDs, control over one's own sexual behaviour and social support for early health care seeking.

The determinants of health care seeking behaviour of adolescents attending STD clinics in South Africa.

The study investigated the determinants of delay behaviour in health care seeking in a sample of 292 adolescent patients (20 years and younger) with STD symptoms. Fifty six percent (56%) of the adolescents sought health care within the first 6 days of noticing symptoms, 23% waited between 7 to 10 days and 21% waited longer than 10 days before seeking health care. Early health care seeking was determined by perceived seriousness of STDs, an absence of self treatment prior to seeking care and positive attitudes regarding personal autonomy in condom use behaviour. Facilitation of early health care seeking remain critical in curbing the threat of AIDS among the South African youth.