- Reproductive Health and AIDS in Sub-Saharan Africa: Problems and Prospects (Population, 4, 1998)
- Discussion:Virus de l'immunodéficience humaine/Archive 01 — Wikipédia
- Discussion:Virus de l'immunodéficience humaine/Archive 01
Relations between AIDS and fertility behaviour seldom feature in studies on sexuality. Not one. Recherches en sciences sociales, for example, mentions the interactions between fertility, reproductive goals and the risk of HIV transmission. In the list of work presented, only one team has considered it, but only as a review of the way AIDS is approached from the medical angle, with a cursory estimate of its place in gynaecological practice Plaza et al, This paucity of the literature on the subject is surprising.
There is no doubt that the problem is much more acutely posed in African societies, where high fertility is the ideal, than in Western societies. By contrast, attempts have been made to project the influence of AIDS on future fertility levels. On the other hand, many indirect effects of the AIDS epidemic on fertility are to be expected because the possible interactions between the disease and the determinants of fertility are many and complex. The epidemic acts first by changing the population age-structure through the disease's differential effects on age patterns of mortality, the most affected groups being adults of reproductive age and children.
But while a reduction in the size of reproductive age groups will produce a decline in the crude birth rate, increased infant mortality may have the opposite effect, decreasing birth spacing by a reduction in the breastfeeding and postpartum abstinence periods Gregson et al, ; it must also be borne in mind that the death of a child creates a replacement need in countries where high fertility is an economic need and social imperative Dozon and Guillaume, The fertility impacts of the anti-AIDS approach are also very mixed.
On the one hand, the main AIDS protection methods currently available - condoms and abstinence - may bring about a fertility decline. Conversely, increasing STD screening and treatment, as part of current anti-AIDS programmes, should produce an increase in fertility by reducing impaired fertility.
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It should not be lost to sight, however, that its very nature as a contraceptive may be a reason for rejecting condom use in communities where fertility is highly valued Delcroix and Guillaume, The birth of a child is a pledge of durability for the affected couple, and for an. HIV-positive individual, increasing his or her fertility is a way of warding off death.
Then there is the problem of breastfeeding: for HIV-positive mothers, breastfeeding is a key factor of mother-to-child AIDS transmission. However, it has not so far been decreed inadvisable in developing countries, whatever the mother's serostatus, because the WHO felt the risks of bottle-feeding outweighed those of mother-to-child HIV transmission. This view could be revised in the future in the light of contrary findings Gray et al. Bottle-feeding, it seems, should be considered with caution and on a case-by-case basis when the mother is HIV-positive UNAIDS, , which could pose problems of birth spacing because breastfeeding plays a contraceptive role which must be taken into account.
Finally, studies in various African countries point to a possible connection between infertility and HIV serostatus. The sperm of symptomatic HIV-infected men display a reduced fertilizing capacity Setel, ; studies of HIV-infected women cohorts show reduced fertility. A Nairobi survey carried out among commercial sex workers demonstrated a connection between HIV serostatus and subfertility Simonsen et al, In 7,mxt, the same connection between subfertility and HIV-infection was found among women surveyed between and Batter et al, In Gabon, again in the s, a survey into the fertility-related responses to retroviral infection seroprevalence revealed a positive correlation between HIV seroprevalence and primary infertility Schrijvers et al.
The initial findings of two longitudinal studies in progress in south-west Uganda confirm these observations: in the Masaka district between , Lucy Carpenter et al. But these factors do not account for all the difference, because most of the women surveyed were asymptomatic and, as mentioned earlier, counselling HIV-positive women against reproduction has little effect. It seems that this subfertility of HIV-positive women can be partly attributed to biological factors, therefore.
However, in the survey by Gray et al, the lower prevalence of pregnancy among HIV-infected women remains significant even when checked by STD, especially syphilis. The more likely assumption, therefore, is of a lower pregnancy rate, or higher risk of negative pregnancy outcomes miscarriage, stillbirth among HIV-positive women. The earliest available data. So, a vast field of research is opening up on the complex interactions between AIDS and fertility, which may equally result in increased or decreased fertility. We could apparently expect to see a fertility decline among affected individuals and groups in African countries, but probably more as a result of the physiological damage done by HIV infection to women's and men's fertility, and more widespread condom use, than conscious choices made by the infected persons themselves Setel, ; Gregson et ai, The proportion of infected individuals who know their serostatus is too low for any modification in their reproductive behaviour if there is one - which remains to be studied to affect total fertility.
This is especially so in that both partners must be involved in the decision, but in Africa infected individuals seldom inform their partners on learning their serostatus. There is a consensus in the literature, however, that this is a fairly unexplored area in which fieldwork data are scarce Gregson et al. Improved knowledge and a better understanding of the interactions between HIV infection and fertility are needed, in particular to work out programs which integrate AIDS prevention, family planning and reproductive health Setel, Whither the levirate?
In many African communities, a dead man's widow or widows are remarried to one of his brothers, or even to a son of one of his mother's co-wives. However, Annie Le Palec in Bamako found that where a man had died of AIDS, doctors tended to warn an elder brother of the deceased so that the widow s should not remarry in the same line and "continue to plunge the family into mourning".
Annie Le Palec and Bernard Taverne pointed up the dangers of this behaviour which puts potentially infectious women, ignorant of their own serostatus, on the sexual and matrimonial market, when the custom of levirate could, with the necessary precautions, be a good way of caring for HIV-positive women and their children by enabling them to remain within the lineage to which their children belong. Target preventive measures.
Reproductive Health and AIDS in Sub-Saharan Africa: Problems and Prospects (Population, 4, 1998)
Public awareness of AIDS seems closely related to access to media and education. Young people - especially the better-educated - are best-informed about the disease. AIDS-awareness is generally lower among women than men, and early marrieds. This is a surprising finding because the idea of an asymptomatic infectious disease - i. In all probability, it is due to the success of information and prevention campaigns waged in these countries, especially as the result correlates positively with access to media.
It must be stressed, however, that knowledge of perinatal transmission, which was quite high in the general population surveys, declined radically in surveys of pregnant women alone. These differences may be attributable to the survey methods used, but may also reflect the difficulty pregnant women have in coping with the idea of this type of AIDS transmission. Very little was known about the risk of mother-to-child transmission through breastfeeding.
Much of this ignorance is due to the lack of any reference to it in prevention campaigns: the strategic choices on breastfeeding and AIDS in Africa are complex ones. Because of the risks of malnutrition related to bottle-feeding, the financial cost of bottle-feeding and the symbolic aspects of breast-feeding, official campaigners have long been reluctant to call for. A detailed description or analysis of all the surveys carried out into AIDS risk perceptions is a study in its own right and far exceeds the scope of this review. I shall simply cite the findings of the WHO KABP surveys that a large section of the public regards the AIDS epidemic as a major health problem approximately two thirds of respondents and as a personal risk over half the respondents.
At the same time, people reported having changed their sexual behaviour as a result: fewer multipartnerships, less use of prostitutes, sexual monogamy, Condom use, on the other hand, was very rarely cited Cleland, That may have skewed the replies, as respondents might find difficulty admitting that they had not changed their behaviour when they had just acknowledged perceiving AIDS as a major personal and public health threat.
It might therefore be better-advised to regard these claims more as a measure of AIDS perception than of real behaviour changes resulting from it. In Mlomp, in rural Senegal, almost one adult in three reported having had at least one casual encounter during the year preceding the survey. Of them, a further third reported using condoms "most of the time". Groups with the highest-risk sexual behaviour widowed or divorced women, migrant seasonal workers also take the fewest precautions, and in particular make least use of condoms in casual sex Lagarde et al, b.
Significantly, the KABP surveys omit any direct reference to the family, the fact that an infected individual can transmit the disease to his spouse and children, proposed strategies for protecting spouses and children from the disease, etc.
AIDS is always approached from the angle of 'high- risk sexual behaviour', i. Risk awareness and As Marcel Calvez aptly points out, im-. The survey of the sexual behaviour of urban married couples in Nigeria clearly illustrates this paradox: in the survey population, Uche Isiugo-Abahine observed a very high rate of extra-marital sexual intercourse at the same time as a high level of awareness about AIDS and its modes of transmission. Respondents cited casual sexual intercourse as a major risk factor in AIDS transmission, but only a third of them thought that fear of AIDS had changed extra-marital sexual behaviour, while most claimed not to be concerned by the epidemic and intended to continue having unprotected casual sex.
The same type of remark recurs in the WHO surveys Ingham, and in other cross-sectional surveys: in Senegal, Emmanuel Lagarde et al. Marcel Calvez suggested that these contradictions could be better understood by considering sexuality as an object of research. We must bear in mind that sexual activity takes place in an emotional setting, and so, even from a prevention angle, cannot be considered in terms of risk-taking alone, because "the deciding factor in sexual intimacy seems to be not health preservation, but the partners' mutual recognition of one another's emotions" Calvez, Few studies on risk and improved prevention take this aspect of sexuality into account.
Nathalie Bajos and Domenica Ludwig's peer review of the literature on risk and risk accommodation classifies them into two broad groups Bajos and Ludwig, One takes an individualistic approach, making individuals' health concerns predominant, based on the premiss that, for an individual "health preservation behaviour is natural and paramount". Accordingly, high-risk behaviour stems from a misperception of the risk. This type of analysis is necessarily over- simplistic on several counts: firstly, its working hypothesis is that behavioural change is a decision taken by the individual independently of emotional, social and especially sexual relations and their setting.
Then, the individual's sexual history is often disregarded, even though it has direct consequences for the uptake of new practices. The second group, by contrast, takes into account the basic sociocul- tural principles which individuals use to define risks. They look at risk definition as the fusion of experience, social and personal identity, and an epidemiologie and preventive rationale. Health is not the paramount concern. Their study shows that only a very small minority of individuals see sexuality in health terms. That calls into question an entire prevention rationale whose driving force was individual health preservation.
This criticism of models for high-risk behaviour analysis based solely on individual risk perception is also found in the article by Jean-Paul Moatti et al. These authors show that the highly rationalist models used often produce only circular results, in which the explanatory factors "are actually only another variant of the dependent variable they purport to explain", and the beliefs advanced as causes of behaviour are very often only efforts to explain away that behaviour ex post.
Finally, these models always start from the false premiss that the social norm is zero risk, or total safety - false because ways of rationalizing the risk-taking exist, especially where the emotions are concerned. Using the "subjective expected utility" economic model, these authors show that maximizing protection against the risk of HIV transmission is far from always being the most rational alternative for the individual.
Prevention could therefore be steered in this direction, with for example, "messages about condom use to maximize the anticipated regret if it is not used with a partner of unknown serostatus" Moatti et al, This entire discussion on risk-taking and the importance of integrating emotional factors in the AIDS risk is particularly interesting in the family context, where affection for the partner, fear of estrangement, and concern for children far outweigh concerns of self-preservation.
So, it must be borne in mind that women in African families must balance the risk of contracting the AIDS virus against that of her husband's rejection if she attempts to negotiate condom use or a halt to family building which may seem to outweigh the risk of bearing an HIV-infected child. Define and improve prevention programmes. AIDS prevention can be considered on two levels in reproductive health terms: prevention of sexual transmission as part of family planning programmes, and prevention of vertical mother-to-child transmission. Interactions with A three-pronged approach must be taken to reduce.
On the face of it, family planning centres are ideal for this type of project. Their particular merit is to reach women - especially uneducated women Rutenberg et al. Although operating in the. A series of questions arise, therefore, demanding urgent answers: how will condom promotion as part of the fight against AIDS impact contraceptive use?
How will resources be allocated between service providers? Can family planning programmes ignore the AIDS epidemic? Adeokun, In an excellent review of the relationship between AIDS and family planning programmes, Saroj Pachauri explains why family planning centres, including those focused on reproductive health, often fail to take account of problems related to sexuality, especially their client groups' sexual health needs. For example, most centres have no services for the diagnosis and treatment of STDs or reproductive tract infections, despite the major impact such infections have on individual fertility, or rather infertility.
The emergence of AIDS has stimulated the interest of public authorities in the treatment of STDs, but STDs and family planning have very often been separate vertical programmes with no interactions, instead of a single programme integrating the different aspects of reproductive health Pachauri, Some attempts have been made to integrate programmes, usually unsuccessfully.
The pressure of economic and demographic priorities brings the risk of a return to vertical programmes. The Indian family planning program offers an instructive example: initially intended to encompass all aspects of reproductive health, it became targeted primarily on reducing population growth, entirely neglecting the needs of adolescents, the unmarried, the infertile, and reproductive tract infections or unwanted pregnancies.
In resource-poor developing countries, is it really feasible in the midst of an AIDS epidemic to develop integrated programs which cater for all aspects of reproductive health, given the cost of combating AIDS and STDs? The implications, especially for resource reallocation, must be considered before such services are put in place.
Opponents of integration argue that the fight against AIDS is expensive and complicated, and that integrating it within family planning programmes could stigmatize them. Its proponents, on the other hand, contend that family planning centres are the most appropriate ways of reaching sexually active persons, and that they have the qualified staff and technologies necessary to promote safe sexual intercourse condoms, spermicides, etc.
Saroj Pachauri has examined the various aspects of such a project. The first step is to integrate the diagnosis and treatment of reproductive tract infections into family planning programmes, because they interact with one another: the presence of a reproductive tract infection may lead to the failure of contraception, either directly because the patient blames the contraception for the infection, or indirectly, because infection is an obstacle to fertility, so individuals are reluctant to voluntarily reduce fertility which they see as in doubt.
Also, family planning services have been operating in some countries for the best part of thirty years, and are among the best-evaluated and highest-profile health programmes: many lessons drawn from the family planning experience can be used in the fight against AIDS. For example, it is known that individuals must be offered a broad range of solutions from which to choose those most suited to them, that communication must be developed with sexual partners, the importance of counselling, support groups, the approachability of health care personnel, the testifying role which satisfied 'clients' can play.
Also because, although results are lacking on the matter, HIV-positive women seem to have a higher incidence of premature births, low-birth-weight children, miscarriages and foetal deaths. Finally, the HIV virus has been found in the breastmilk of HIV-positive mothers Gray et al, , which raises a serious public health problem in countries where breast-feeding is the main and safest source of food for new-borns Pachauri, While the debate on this issue is now well in hand, few field schemes have been tried out.
In Africa, particularly, there is virtually no integration between the two types of programme, whatever the paper aspirations, chiefly because family planning programmes are under-developed. Among the very few noteworthy attempts at integration is that reported by Ricardo Vernon et al. A leading Latin American private family planning agency agreed to integrate a three-pronged anti-AIDS campaign in its programmes: handing out AIDS prevention information, distributing condoms via agency instructors, and putting educational messages across in the media.
This pilot scheme revealed a large demand for information on AIDS, not just from at-risk groups but also among normal family planning centre client groups. It also emerged that family planning centre instructors were able to address these information needs. Finally, one of the most important findings of the study was that integrating AIDS prevention did not impact negatively on family planning, and in particular did not harm the image of condoms, which was seen as a preventive instrument rather than one of 'sexual licence' as might have been feared.
This study concludes on a very optimistic note, therefore, recommending closer integration of anti-AIDS campaigns with health education programmes already in place Vernon et al, While not concerned with an integration scheme, the study by Naomi Rutenberg et al. That would suggest that the information delivered by family planning is also used for other, extra-marital, sexual intercourse. The same study, however, reported that men who used condoms for marital and extra-marital sex also had the most extra-marital intercourse.
Given the earlier finding that the most at-risk groups also tended to be the best informed, it is reasonable to wonder where cause and effect lie: do these men have more extra-marital intercourse because of their knowledge, gleaned from family planning information, that they are protected; or, conversely, do they take more precautions because they knowingly engage in high-risk behaviour, and thus seek out information from any source family planning or elsewhere? The study omitted to ask the men about the source of their information on condoms. The ingoing assumption - but it is only an assumption - is that it comes from family planning services.
Even so, there are obstacles to merging the two types of programme Pachauri, Firstly, they address different target groups: in theory, family planning advice is addressed to all women, which in reality mainly means married women, rarely adolescents or childless women, and, worse still, rarely men. Then, there is the technology issue: the same methods are not effective to prevent reproductive tract infections and pregnancy. Oral contraception, for example, protects effectively against pregnancy, but not infection. This means developing a method which fulfils both functions equally well, but also one which prevents infection but not pregnancy for infected couples who want to have children.
Is that feasible? Finally, most family planning services are used by married women, and while, as we have seen, they may be a primary target, it must also be appreciated that these women often have little ability to assert dominance in the sexual realm. The messages put out must take account of this and develop specific measures for them.
The nature of the sexual encounter gives prostitutes more negotiating power, but other women may not have the leverage to negotiate condom use with a non-compliant partner Pachauri, Finally, we have seen that lone women - unmarried, widowed or divorced - are a group particularly at risk for STD and AIDS transmission Lagarde et al, a. But such women are not, on the face of it, a primary target for family planning services, as presumably not being involved in reproduction.
This particular avenue needs further exploration, to determine how these women's needs might be addressed by family planning centres and anti-AIDS campaigns. To conclude with one problem which, as far as I am aware, has not yet been taken into account in anti-AIDS programmes: postpartum abstinence. As Marianne Hogsborg and Peter Aaby found in Bissau, the protracted period of postpartum sexual abstinence traditionally recommended to avoid "contaminating the mother's milk" is a factor for "sexual licence" among men who comply with the taboo; it creates an entitlement to "compensatory" extra-marital sexual intercourse Hogsborg and Aaby, In their study, these authors suggested condom use during breastfeeding to enable sexual intercourse while "protecting" the mother's milk, but to little avail.
This may be an idea worth taking up, however, as individual antipathy to condom use has receded under the effect of information campaigns. In any event, action on postpartum abstinence may be worthwhile, since the tradition seems to be a major contributor to sexual multiple partnerships. Decrease mother-to- One key way to reduce mother-to-child trans-.
That will be no easy task. In the study in urban Rwanda cited earlier, Susan Allen et al. In their study, 1, women of reproductive age were tested for AIDS and given information about the disease, its modes of transmission, and especially mother-to-child transmission. In the counselling phase, each HIV-positive woman was informed about the risks of pregnancy for herself and her child, and oral contraception was advised.
In spite of this, half the HIV-positive women who used oral contraception at the time of the test had discontinued it one year after the test. Of these, women with fewer than 4 children at the time of the test were significantly more likely to fall pregnant again than the others.
The HIV test results and accompanying instruction, therefore, were not followed, in this study, by decreased fertility among HIV-positive women. On the contrary, it seems that HIV-positive women with fewer than 4 children were in a "rush" to complete their fertility. Moreover, as the authors of the study suggest, for a woman who must live with HIV, becoming pregnant may be a way to continue a normal lifestyle despite the infection, to reduce the risk of losing spouse and family support.
Post-HIV test counselling, therefore, would not seem sufficiently influential to overcome the cultural, psychological, or quite simply practical obstacles cost of contraception facing a woman who plans to reduce her fertility. The article concludes by recommending that linkages be forged between AIDS prevention and family planning services, because HIV-positive women who wish to halt reproduction need special support from the community as a whole.
A culture in which fertility is highly prized and childless women are easily marginalised may justify the risk-taking, especially as the family support networks still found although they are changing in African societies give some women the certainty that their child will be brought up by a relative and so not be orphaned by their death.
Other pathways for decreasing mother-to-child transmission should perhaps be explored: treatments which decrease the risk of transmission, but are affordable to developing country populations, for example. In joint clinical trials conducted in France and the United States, significant reductions in mother-to-child transmission were recorded after zidovudine- AZT was administered to the mother during pregnancy and labour CDC, However, this is a costly treatment, and the trial did not include breastfeeding women. This rules it out for Africa, therefore, not least on cost grounds.
The median distance of 3. Consequently, 11 out of 30 women travel over 4. Some of them are restricted because of lack of transport. Six of them travel on foot or depend on their spouses to reach the health care facility. Nine of them travel by bicycle, two by public transport, 11 by motorcycle and two by car.
The mode of travel is an indicator of the constraints of distance in a territory affected by intense heat which exacerbates the arduousness of the journey taken. Similarly, the kilometres covered seem low when compared with other environments. However, the routes taken are of poor quality, often dirt tracks with frequent potholes, just as on the maintained secondary asphalted roads, moreover, which increase travel time.
It often takes over one hour to travel 4 km. Under-developed public transport systems mean it takes even longer to travel across the city given their low frequency. Average distance between residence and health care km. Median distance between residence and health care km.
Discussion:Virus de l'immunodéficience humaine/Archive 01 — Wikipédia
Car 6. The longest distances travelled by the women on bicycles are not justified by specific factors and do not originate in a particular place of residence. Whatever the method of travel, the facility attended is not chosen according to its closeness to the place of residence. This table of distances demonstrates the effort made to reach the health care centre and the ordeal experienced to escape stigmatization. Indeed, mobility generates fatigue not only through physical effort but also because of climatic conditions which are often difficult. The maximum average annual temperature of the capital was Moreover, these journeys subject women and their infants to the risk of an accident and very high atmospheric pollution in a country where vehicles are, on average, over 15 years old, according to UEMOA, and are not subjected to an anti-pollution test Yelkouni and Kafando, They are state-run facilities, except for the Saint Camille medical centre, a private religious establishment run by Catholic priests.
They mirror the image of facilities in the urban part of the Centre region since merely eight out of 62 belong to the private sector. Against all expectations, six women cite proximity, even though they do not actually attend the closest facility. Among them, four have shared their serology with their husbands. A mere four women in our sample actually attend the PMTCT health care facility closest to their place of residence but they also cite the fear of being stigmatized at each visit.
This sole reason is given by six of the respondents. The fear of coming across an acquaintance who could reveal her serology to the family circle is often mentioned. The confidence, recommendations from health workers, lower cost health care at social cost, food or pharmaceutical aid are the other reasons cited six, five and three women respectively.
Therefore, 20 out of 30 women attend a single medical centre for their care regarding these health issues. The others attend health facilities that are much closer to their home compared with the PMTCT site by travelling an average distance of 1.
Discussion:Virus de l'immunodéficience humaine/Archive 01
Among the respondents, ten women attend several health centres for pathologies with no link to HIV. Women whose spouses are informed travel a greater distance 4. Only age-specific observation shows more pronounced disparities between categories. Thus, on average, women over 35 years of age travel shorter distances 3 km to reach the chosen PMTCT site than women under 30 years of age 4.
Two hypotheses can be put forward: older women are well aware of the availability of care or they seek to limit their travel time because of their workload. The available means of travel cannot justify this difference since cycling is used by half of the group of women surveyed under 30 and over 35 years of age.
In any case, the place of residence, type of courtyard or serology known or unknown to the spouse cannot be used as the main factors to justify choosing a PMTCT care location or to explain the search for anonymity. The age categories show a decrease in the distance differential with the increase in the age of the respondents. However, the gap between the averages of planned and unplanned neighbourhoods is widening.
It can be assumed that health care provision in peripheric areas does not always provide PMTCT care or that care in these sites is judged to be of poorer quality. This is confirmed by the comparaison of the distance from the PMTCT care facility closest to the home: the distance is 1. The search for anonymity therefore does not seem to be more pronounced in a specific part of the city. The quality of the service offered, associated with its distance from the place of residence in a search for anonymity are the only selection criteria regardless of the profile of the women surveyed.
Approached generally through the distance from place of residence to health care site and thus its closeness, it is presented as an indicator of social inequality. It should be defined according to the object analysed Liu and Zhu, The relationship between the distance from place of residence to health care site and the disease can be observed through the context of temporary and organized proximity, defined by Rallet and Torre Developed in an economic approach for the requirements of the analysis of relationships established between enterprises, the concept makes it possible to gain a better understanding of the mechanisms implemented during consultation, in the framework of PMTCT monitoring.
It is the human actions and perceptions that give it a positive or negative dimension and lend it a certain utility.
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It does not translate, therefore, as physical proximity and short distances but as an interplay of relationships and confidence established between parties. It ensures anonymity and has advantages in terms of care. In this context, and by taking up the concepts of either chosen or subjected proximity Torre, , it is possible to qualify the long distances travelled as a chosen rather than an enforced distancing since, despite the close vicinity of specific health care facilities, the women in most cases decide to distance themselves from their homes for their care.
Freeing themselves from the constraints of distance would be for HIV positive mothers the requisite to satisfactorily playing their role as patients. But the frequency and regularity of mobility could also be analysed from a geographic point of view and be compared to the attainment of a productive activity. Organized proximity occurs as the factor triggering the choice of locus of care. It highlights the intensity of relationships established with the facilities, it takes into consideration the organization and not the territory.
This aspect has been observed in the reasons for choosing the locus of care that were given by the women reference, stigmatization, unfamiliarity, free, confidence in the staff, etc. I leave the house at 5. And when she phones me and wants to see me, I go there straightaway I get a lot of support from the lady and even when people have donated things for women, she often keeps some for me.
Harang shows, in her study on the appeal of health care facilities in Ouagadougou, that the primary health care facilities of the type Centre for Care and Social Promotion managed by a nurse operate as community-based care. Only facilities located in a central sector supply a wider catchment area, in conjunction with daily mobility, comparable to that of medical centres, which, by definition, are run by doctors.
The distribution of health care provision can also explain the destination flows. Travelling to private referral health care centres clinics for PMTCT care seems to be towards the city centre. The private health sector is set up to meet profitability criteria, central districts are better equipped, the choice for locating a clinic often favours the high-volume traffic arteries Harang, The choice depends above all on arbitration that the women carry out of their own free will for a service they consider essential.
Indeed, these facilities often have a lack of products shortages in reagents or medicines and the rare cases treated make it difficult for the medical staff to develop their skills. After the first test, the women are generally referred to urban facilities. It was estimated at Territoriality resulting from the mobility of people living with HIV should be sought elsewhere than in the search for therapeutic care according to the spatial distribution of health care provision Nikiema, In northern countries, these choices have also been observed.
However, it is difficult to restrict oneself to this sole finding in the case of pathologies affected by strong social exclusion. The reasons for choosing loci for PMTCT treatment and monitoring thus demonstrate the major influence of non-spatial factors, such as age, social class, level of education, as well as more cultural considerations Luo and Whang, during the health care programme of the patient and the treatment of her disease.
In Ouagadougou, the nearest facilities constitute the principal health care sites. They are chosen by other determiners such as the availability of funds and the mode of travel. New therapeutic territories are emerging. In urban areas, research studies consider that physical distance is not a key issue when considering access to care. However, monitoring HIV positive women in Ouagadougou and the simple study of the context in which they practise their health care show that it has become a decisive criterion in the use of bio-medical provision.
Therefore, the specificity of the disease more than the economic level, social status or the ability to travel constitutes a basic deciding factor and runs counter to the health care expected by focusing on distance. Cognitive factors linked to understanding the disease and the practice of treatment cause patients to make long journeys, which challenge the expected pattern. Consequently, women travel long distances for access to treatment. They explain that this enables them to handle the risks of stigmatization. The distance, in this case geographic, is an adjustment variable in the face of this risk.
Furthermore, the distance from place of residence to health care also arises from the choice of a service that they consider to be of better quality milk, examinations, quality of interaction with the medical staff, free care. Distance, here seen by the political authorities as a form of remoteness, is eliminated. This relationship produces an unexpected use of health care facilities, the true measure of which has not yet been taken by the political authorities. They also emphasize the role played by social factors when using health care and indicate the need for a local approach to health where the elected representatives of territorial authorities, by improving the quality of the built, social or economic environment, constitute favourable leverage to health.
This approach, promoted in northern countries, is as of yet absent from African countries. Aishat U. Al Mujtaba M. Baudet-Michel S. Becquet R. Benoist Y. Berger M. Bonnet E. Bonvalet P. Church K. Coulibaly I. Commeyras C. Desclaux A. Cultural contexts and confrontations", In: Cassidy T. Cultural contexts and confrontations , Bloomsbury, Infant feeding beliefs and practices across cultures , Springer, New York, Develay A.
Diaz Olvera L. Doumbouya ML. Florom-Smith A. Fleuret S. Guigliardo M. Ronzio C. Harang M. Houeto SE. Liu, S. Lompo AB. Lucas-Gabrielli V.