Reproductive health for refugees by refugees in Guinea IV: Peer education and HIV knowledge, attitudes, and reported practices

BACKGROUND: Both conflict and HIV affect sub-Saharan Africa, and supportive approaches for HIV prevention among refugees are crucial. Peer education has been associated with improved HIV outcomes, though relatively little research has been published on refugee settings. The primary objective of this study was to assess whether exposure to refugee peer education was associated with improved HIV knowledge, attitudes, or practice outcomes among refugees in Guinea. Secondary objectives were to assess whether gender, age, or formal education were more strongly associated than peer education with improved HIV outcomes. METHODS: Data was collected by cross-sectional survey from 889 reproductive-age men and women in 23 camps in the Forest Region of Guinea. Selected exposures (i.e. peer education, gender, formal education, age) were analysed for associations with HIV outcomes using logistic regression odds ratios (OR). RESULTS: Most participants (88%) had heard of HIV, particularly those exposed to peer or formal education. Most correctly identified ways to protect themselves, while maintaining misconceptions about HIV transmission. Women and those exposed to either peer or formal education had significantly fewer misconceptions. Half of participants considered themselves at risk of HIV, women with 52% higher odds than men (adjusted OR 1.52, 95%CI 1.01-2.29). Participants exposed to peer education had more than twice the odds of reporting having made HIV-avoidant behavioural changes than unexposed participants (72% versus 58%; adjusted OR 2.49, 95%CI 1.52-4.08). While women had 57% lower odds than men of reporting HIV-avoidant behavioural changes (OR 0.43, 95%CI 0.31-0.60), women exposed to peer education had greater odds than exposed men of reporting HIV-avoidant changes (OR 2.70 versus OR 1.95). Staying faithful (66%) was the most frequent behavioural change reported. CONCLUSIONS: Peer education was most strongly associated with reported HIV-avoidant behaviour change. Gender was most associated with HIV knowledge and risk perception. Refugee women had fewer misconceptions than men had, but were more likely to report HIV risk and less likely to report making behavioural changes. Peer education appears promising for HIV interventions in chronic-emergency settings, if gender disparities and related barriers to condom usage are also addressed

Reproductive health services for refugees by refugees in Guinea I: family planning.

BACKGROUND: Comprehensive studies of family planning (FP) in refugee camps are relatively uncommon. This paper examines gender and age differences in family planning knowledge, attitudes, and practices among Sierra Leonean and Liberian refugees living in Guinea. METHODS: In 1999, a cross-sectional survey was conducted of 889 reproductive-age men and women refugees from 48 camps served by the refugee-organised Reproductive Health Group (RHG). Sampling was multi-stage with data collected for socio-demographics, family planning, sexual health, and antenatal care. Statistics were calculated for selected indicators. RESULTS: Women knew more about FP, although men's education reduced this difference. RHG facilitators were the primary source of reproductive health information for all respondents. However, more men then women obtained information from non-health sources, such as friends and media. Approval of FP was high, significantly higher in women than in men (90% vs. 70%). However, more than 40% reported not having discussed FP with their partner. Perceived service quality was an important determinant in choosing where to get contraceptives. Contraceptive use in the camps served by RHG was much higher than typical for either refugees' country of origin or the host country (17% vs. 3.9 and 4.1% respectively), but the risk of unwanted pregnancy remained considerable (69%). CONCLUSION: This refugee self-help model appeared largely effective and could be considered for reproductive health needs in similar settings. Having any formal education appeared a major determinant of FP knowledge for men, while this was less noticeable for women. Thus, FP communication strategies for refugees should consider gender-specific messages and channels

HIV knowledge, risk perception and avoidant behaviour change among Sierra Leonean refugees in Guinea.

A common assumption underpinning health communications design in humanitarian settings is that increasing knowledge and risk perception will lead to appropriate behaviour change. This study compares associations of HIV knowledge and perceived risk with reported HIV-avoidant behaviour changes and sexual health choices from a community survey of 698 sexually experienced male and female Sierra Leonean refugees in Guinea. HIV knowledge was not significantly associated with reported HIV-avoidant changes (OR 1.25; adjusted for gender; 95%CI 0.76-2.04), while perceived HIV risk was negatively associated (OR 0.38, adjusted for age at sexual debut; 95%CI 0.22-0.66). Trying to conceive was the main reason reported for not using condoms or other contraception (28%; 138/498), followed by current pregnancy/lactation (19%; 93/498). Results suggest contextual factors (e.g. desire for children) can be as important as knowledge and risk-perception, and HIV prevention initiatives in stable and chronic humanitarian settings should account for these

Reproductive health for refugees by refugees in Guinea III: maternal health

BACKGROUND: Maternal mortality can be particularly high in conflict and chronic emergency settings, partly due to inaccessible maternal care. This paper examines associations of refugee-led health education, formal education, age, and parity on maternal knowledge, attitudes, and practices among reproductive-age women in refugee camps in Guinea. METHODS: Data comes from a 1999 cross-sectional survey of 444 female refugees in 23 camps. Associations of reported maternal health outcomes with exposure to health education (exposed versus unexposed), formal education (none versus some), age (adolescent versus adult), or parity (nulliparous, parous, grand multiparous), were analysed using logistic regression. RESULTS: No significant differences were found in maternal knowledge or attitudes. Virtually all respondents said pregnant women should attend antenatal care and knew the importance of tetanus vaccination. Most recognised abdominal pain (75%) and headaches (24%) as maternal danger signs and recommended facility attendance for danger signs. Most had last delivered at a facility (67%), mainly for safety reasons (99%). Higher odds of facility delivery were found for those exposed to RHG health education (adjusted odds ratio 2.03, 95%CI 1.23-3.01), formally educated (adjusted OR 1.93, 95%CI 1.05-3.92), or grand multipara (adjusted OR 2.13, 95%CI 1.21-3.75). Main reasons for delivering at home were distance to a facility (94%) and privacy (55%). CONCLUSIONS: Refugee-led maternal health education appeared to increase facility delivery for these refugee women. Improved knowledge of danger signs and the importance of skilled birth attendance, while vital, may be less important in chronic emergency settings than improving facility access where quality of care is acceptable

Reproductive health for refugees by refugees in Guinea III: maternal health

Abstract Background Maternal mortality can be particularly high in conflict and chronic emergency settings, partly due to inaccessible maternal care. This paper examines associations of refugee-led health education, formal education, age, and parity on maternal knowledge, attitudes, and practices among reproductive-age women in refugee camps in Guinea. Methods Data comes from a 1999 cross-sectional survey of 444 female refugees in 23 camps. Associations of reported maternal health outcomes with exposure to health education (exposed versus unexposed), formal education (none versus some), age (adolescent versus adult), or parity (nulliparous, parous, grand multiparous), were analysed using logistic regression. Results No significant differences were found in maternal knowledge or attitudes. Virtually all respondents said pregnant women should attend antenatal care and knew the importance of tetanus vaccination. Most recognised abdominal pain (75%) and headaches (24%) as maternal danger signs and recommended facility attendance for danger signs. Most had last delivered at a facility (67%), mainly for safety reasons (99%). Higher odds of facility delivery were found for those exposed to RHG health education (adjusted odds ratio 2.03, 95%CI 1.23-3.01), formally educated (adjusted OR 1.93, 95%CI 1.05-3.92), or grand multipara (adjusted OR 2.13, 95%CI 1.21-3.75). Main reasons for delivering at home were distance to a facility (94%) and privacy (55%). Conclusions Refugee-led maternal health education appeared to increase facility delivery for these refugee women. Improved knowledge of danger signs and the importance of skilled birth attendance, while vital, may be less important in chronic emergency settings than improving facility access where quality of care is acceptable.</p

Reproductive health for refugees by refugees in Guinea II: sexually transmitted infections.

BACKGROUND: Providing reproductive and sexual health services is an important and challenging aspect of caring for displaced populations, and preventive and curative sexual health services may play a role in reducing HIV transmission in complex emergencies. From 1995, the non-governmental "Reproductive Health Group" (RHG) worked amongst refugees displaced by conflicts in Sierra Leone and Liberia (1989-2004). RHG recruited refugee nurses and midwives to provide reproductive and sexual health services for refugees in the Forest Region of Guinea, and trained refugee women as lay health workers. A cross-sectional survey was conducted in 1999 to assess sexual health needs, knowledge and practices among refugees, and the potential impact of RHG's work. METHODS: Trained interviewers administered a questionnaire on self-reported STI symptoms, and sexual health knowledge, attitudes and practices to 445 men and 444 women selected through multistage stratified cluster sampling. Chi-squared tests were used where appropriate. Multivariable logistic regression with robust standard errors (to adjust for the cluster sampling design) was used to assess if factors such as source of information about sexually transmitted infections (STIs) was associated with better knowledge. RESULTS: 30% of women and 24% of men reported at least one episode of genital discharge and/or genital ulceration within the past 12 months. Only 25% correctly named all key symptoms of STIs in both sexes. Inappropriate beliefs (e.g. that swallowing tablets before sex, avoiding public toilets, and/or washing their genitals after sex protected against STIs) were prevalent. Respondents citing RHG facilitators as their information source were more likely to respond correctly about STIs; RHG facilitators were more frequently cited than non-healthcare information sources in men who correctly named the key STI symptoms (odds ratio (OR) = 5.2, 95% confidence interval (CI) 1.9-13.9), and in men and women who correctly identified effective STI protection methods (OR = 2.9, 95% CI 1.5-5.8 and OR = 4.6, 95% CI 1.6-13.2 respectively). CONCLUSION: Our study revealed a high prevalence of STI symptoms, and gaps in sexual health knowledge in this displaced population. Learning about STIs from RHG health facilitators was associated with better knowledge. RHG's model could be considered in other complex emergency settings