A Social Ecological Approach to Exploring Barriers to Accessing Sexual and Reproductive Health Services among Couples Living with HIV in Southern Malawi
Abstract:With wide access to antiretroviral therapy, people living with HIV are living longer. The reduction in the mother-to-child transmission of HIV has encouraged some people living with HIV to have children and remarry. However, some continue to have limited access to sexual and reproductive health services. The study explores barriers encountered by couples living with HIV in accessing sexual and reproductive health services using the social ecological model. Data were collected using in-depth interviews with twe… Show more
“…A socioecological model 16 extended to include additional psychosocial dimensions ( figure 1 ) has previously been used to explore factors relating to uptake and retention on ART in PLHIV. 17 In our analysis, we draw from this framework to disentangle the specific issues relating to pregnancy and medication-taking when living without symptoms of HIV-related illnesses.…”
ObjectiveTo explore what influences on engagement with Option B+ in four sub-Saharan African settings.MethodsIn-depth interviews were conducted in 2015, with 22 HIV-positive women who had been pregnant since Option B+ was available, and 15 healthcare workers (HCWs) involved in HIV service delivery. Participants were purposely selected from four health and demographic surveillance sites in Malawi, Tanzania and Uganda. A thematic content analysis was conducted to investigate what influenced engagement with Option B+.ResultsFeeling ‘ready’ was key to pregnant women accepting antiretroviral treatment (ART) on the same day as diagnosis at antenatal clinic; this was influenced by previous knowledge of HIV-positive status, interactions with HCWs and relationship with their partners. The desire to protect their unborn infant was the main issue that motivated women to initiate treatment, temporarily over-riding barriers to starting ART. Many HCWs recognised that pressurising women into starting ART may lead them to stop treatment following delivery. However, their own responsibility to protect the infant sometimes drove HCWs to use strong persuasive techniques to initiate pregnant women onto ART as early as possible, occasionally causing women to disengage.ConclusionsProtecting the baby superseded feelings of unpreparedness for lifelong ART and may explain poor retention observed in Option B+ programmes. Women may benefit from more time to accept their status, and counselling on the long-term value of ART beyond the pregnancy and breastfeeding period. Strategies to promote readiness for same-day initiation of lifelong treatment are urgently needed, and may provide important lessons for universal test-and-treat implementation.
“…A socioecological model 16 extended to include additional psychosocial dimensions ( figure 1 ) has previously been used to explore factors relating to uptake and retention on ART in PLHIV. 17 In our analysis, we draw from this framework to disentangle the specific issues relating to pregnancy and medication-taking when living without symptoms of HIV-related illnesses.…”
ObjectiveTo explore what influences on engagement with Option B+ in four sub-Saharan African settings.MethodsIn-depth interviews were conducted in 2015, with 22 HIV-positive women who had been pregnant since Option B+ was available, and 15 healthcare workers (HCWs) involved in HIV service delivery. Participants were purposely selected from four health and demographic surveillance sites in Malawi, Tanzania and Uganda. A thematic content analysis was conducted to investigate what influenced engagement with Option B+.ResultsFeeling ‘ready’ was key to pregnant women accepting antiretroviral treatment (ART) on the same day as diagnosis at antenatal clinic; this was influenced by previous knowledge of HIV-positive status, interactions with HCWs and relationship with their partners. The desire to protect their unborn infant was the main issue that motivated women to initiate treatment, temporarily over-riding barriers to starting ART. Many HCWs recognised that pressurising women into starting ART may lead them to stop treatment following delivery. However, their own responsibility to protect the infant sometimes drove HCWs to use strong persuasive techniques to initiate pregnant women onto ART as early as possible, occasionally causing women to disengage.ConclusionsProtecting the baby superseded feelings of unpreparedness for lifelong ART and may explain poor retention observed in Option B+ programmes. Women may benefit from more time to accept their status, and counselling on the long-term value of ART beyond the pregnancy and breastfeeding period. Strategies to promote readiness for same-day initiation of lifelong treatment are urgently needed, and may provide important lessons for universal test-and-treat implementation.
“…The social ecological model recognizes that whereas individuals are responsible for instituting and maintaining lifestyle changes necessary to reduce risk and improve health, individual behaviour is influenced by factors at different levels within their social environment [ 8 , 14 ] as illustrated in Figure 2 . Thus, using the social ecological model as our analytical lens, the main aim of this study was to explore HIV-infected pregnant women’s interactions with their social environment in the utilization of PMTCT services in western Kenya.…”
Objective
Throughout most of sub-Saharan Africa (SSA), prevention of mother-to-child transmission (PMTCT) services are readily available. However, PMTCT programs in SSA have had suboptimal performance compared to other regions of the world. The main objective of this study is to explore the socio-ecological and individual factors influencing the utilization of PMTCT services among HIV-positive pregnant women in western Kenya using a social ecological model as our analytical lens.
Methods
Data were collected using in-depth interviews with 33 HIV-infected women attending government health facilities in rural western Kenya. Women with HIV-infected infants aged between 6 weeks to 6 months with a definitive diagnosis of HIV in the infant, as well as those with an HIV-negative test result in the infant were interviewed between November 2012 and June 2013. Coding and analysis of the transcripts followed grounded theory tenets. Coding reports were discussed in a series of meetings held among the authors. We then employed constant comparative analysis to discover dominant individual, family, society and structural determinants of PMTCT use.
Results
Barriers to women’s utilization of PMTCT services fell within the broad constructs of the socio-ecological model of individual, family, society and structural determinants. Several themes cut across the different steps of PMTCT cascade and relate to different constructs of the socio-ecological model. These themes include: self-motivation, confidence and resilience, family support, absence or reduced stigma, right provider attitude and quality of health services provided. We also found out that these factors ensured enhanced maternal health and HIV negative children.
Conclusion
The findings of this study suggest that a woman’s social environment is an important determinant of MTCT. PMTCT Interventions must comprehensively address multiple factors across the different ecological levels. More research is however required for the development of multi-component interventions that combine strategies at different ecological levels.
“…This model was also used for examining barriers within the different layers of the individual, family and society, including interactions with the service providers (see Fig. 1) [28, 29]. Fig.…”
Background
Blindness and visual impairment from diabetic retinopathy (DR) are avoidable through early detection and timely treatment. The Western Province of Sri Lanka has the highest prevalence of diabetes mellitus (DM) (18.6%) in the country. A situational analysis identified a significant gap in DR screening services (DRSS) uptake in this region. Barriers that hinder people with DM (PwDM) from attending DRSS are poorly understood. The purpose of this study is to understand the factors which influence the uptake of DRSS and follow-up to inform health promotion strategies and improve the uptake of these services.
Methods
Eleven focus group discussions (FGDs) were conducted with PwDM who presented to medical, general eye and vitreoretinal services in three public sector institutions (two tertiary and one secondary level) in the Western Province between October 2016 and March 2017. We enrolled six groups (four Sinhala speaking, two Tamil) of women and five groups (three Sinhala and two Tamil) of men representing ethnicity and gender. We performed a thematic analysis and described the main themes and subthemes using the socio-ecological model as a framework.
Results
We identified lack of knowledge of both the condition and the need for screening as key barriers to access DRSS. Socio-cultural factors in the family environment, economic reasons and institutional factors were also important barriers. Additional reasons include long waiting time at eye clinics and poor referrals exacerbated by the lack of a systematic DRSS. In addition, attitudes to DRSS such as fear of discomfort from the procedure and the need for accompaniment following mydriasis were also deterrents to follow-up screening.
Conclusion
This study has shown that there are inter-related user, family, and institutional factors which affect the uptake of DRSS. Understanding how DR is conceptualised by PwDM in this region is essential to refine strategies to improve access to DRSS. Strategies to improve knowledge need to be more culturally acceptable and relevant to PwDM and their families, with increased availability of DRSS at convenient locations may increase timely uptake of screening.
Electronic supplementary material
The online version of this article (10.1186/s41182-019-0160-y) contains supplementary material, which is available to authorized users.
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