Capacity Development for Healthcare Systems in Low- and Middle-Income Countries. Assessing the effectiveness of an advanced international training programme in sexual and reproductive health and rights in Africa and Asia.

Background: The 2030 agenda for sustainable development calls upon all nations to make critical investments in their health systems to deliver universal access to Sexual and Reproductive Health and Rights (SRHR). Capacity development is listed among the strategies for achieving sustainable development goals. Although capacity development has been a major component of international development for decades, its effectiveness has limited evidence. This thesis aims at evaluating the effectiveness of an International Training Programme (ITP) in sexual and reproductive health and rights (SRHR) and to understand the role of different actors and contextual factors in capacity development for health systems in low-and middle-income countries. Religion and culture were hypothesised to be significant determinants for changing healthcare practitioners’ SRHR attitudes and practices. Methods: The study population was healthcare practitioners (HCPs) enrolled in the ITP from 13 countries in Africa and Asia. In study I, in-depth interviews with 28 HCPs were conducted and analysed using qualitative content analysis. Studies II and III were based on quantitative data from a sample of 115 healthcare practitioners and analysis was done using multivariate linear regression. Study IV utilised data from an instrument designed for evaluating the ITP change projects. Data analysis was done using logistic regression and 99 change projects were included in the final analysis.Results: Findings from study I indicate that local context, personal values, and social norms influence healthcare practitioners’ SRHR attitudes and practices. In study II, high level of self-rated SRHR knowledge, normative SRHR attitudes and active knowledge seeking behaviour were significant predictors of normative SRHR practices before the ITP intervention. Study III indicates that the ITP intervention was effective in improving the participants’ SRHR knowledge, attitudes, knowledge seeking behaviour and SRHR practices. Improvement in active knowledge seeking behaviour was a significant predictor of changing SRHR practices. Study IV, indicates that improved team capacity resulted in significant improvement in organisational effectiveness and support from partner organisations increased awareness of and demand for SRHR services. Conclusion: The findings suggest that the ITP approach for improving the capacity of healthcare practitioners (as change agents) was associated with improved organisational effectiveness. Other factors that positively contributed to organizational effectiveness were support from partner organizations and involvement of the media. Support from partner organization was also critical in increasing access to, and demand for, SRHR services. The use of new SRHR approaches seemed to negatively influence the effectiveness of organizations. Additionally, the findings suggest that although healthcare practitioners understand the importance of rights in SRH, they did not conform to the principle that rights apply to all components of SRHR and all persons in all settings. Howver, contrary to the evaluation hypothesis, religion and culture did not have a significant influence on changing SRHR practices. Instead, it was the improvements in participants’ knowledge seeking behavior that significantly predicted positive changes in SRHR practices at the end of the intervention.These findings highlight the potential of training interventions in contributing to the capacity development of healthcare systems in low-and middle-income countries

The Invisible Suffering: Sexual Coercion, Interpersonal Violence, and Mental Health - A Cross-Sectional Study among University Students in South-Western Uganda.

Despite a history of conflicts and widespread human rights violation in sub-Saharan Africa, little is known about the prevalence of interpersonal violence among the population in this region. Evidence from high-income countries suggests that exposure to violence has mental health consequences and violence also has associations with experiences of sexual coercion

The Impact of Socio-Demographic and Religious Factors upon Sexual Behavior among Ugandan University Students

INTRODUCTION: More knowledge is needed about structural factors in society that affect risky sexual behaviors. Educational institutions such as universities provide an opportune arena for interventions among young people. The aim of this study was to investigate the relationship between sociodemographic and religious factors and their impact on sexual behavior among university students in Uganda. METHODS: In 2005, 980 university students (response rate 80%) were assessed by a self-administered questionnaire. Validated instruments were used to assess socio-demographic and religious factors and sexual behavior. Logistic regression analyses were applied. RESULTS: Our findings indicated that 37% of the male and 49% of the female students had not previously had sex. Of those with sexual experience, 46% of the males and 23% of the females had had three or more sexual partners, and 32% of the males and 38% of the females did not consistently use condoms. For those who rated religion as less important in their family, the probability of early sexual activity and having had a high number of lifetime partners increased by a statistically significant amount (OR = 1.7; 95% CI: 1.2-2.4 and OR = 1.6; 95% CI: 1.1-2.3, respectively). However, the role of religion seemed to have no impact on condom use. Being of Protestant faith interacted with gender: among those who had debuted sexually, Protestant female students were more likely to have had three or more lifetime partners; the opposite was true for Protestant male students. CONCLUSION: Religion emerged as an important determinant of sexual behavior among Ugandan university students. Our findings correlate with the increasing number of conservative religious injunctions against premarital sex directed at young people in many countries with a high burden. of HIV/AIDS. Such influence of religion must be taken into account in order to gain a deeper understanding of the forces that shape sexual behavior in Uganda

Determinants of unmet needs for healthcare and sexual health counselling among Ugandan university students with same-sex sexuality experience

Background: Research from sub-Saharan Africa has shown that persons with same-sex sexuality experience are at elevated risk for ill health due to sexual risk taking, stigma, and discrimination. However, studies of healthcare seeking among young people in this region with same-sex sexuality experience are limited. Objective: To identify determinants of unmet healthcare and sexual health counselling needs, respectively, among Ugandan university students with experience of same-sex sexuality. Design: In 2010, 1,954 Ugandan university students completed a questionnaire assessing socio-demographic factors, mental health, alcohol usage, sexual behaviours, and healthcare seeking. The study population consisted of those 570 who reported ever being in love with, sexually attracted to, sexually fantasised about, or sexually engaged with someone of the same sex. Results: Findings showed that 56% and 30% reported unmet healthcare and sexual health counselling needs, respectively. Unmet healthcare needs were associated with poor mental health and exposure to sexual coercion (OR 3.9, 95% confidence intervals [CI]: 2.7–5.7; OR 2.0, 95% CI: 1.3–3.0, respectively). Unmet sexual health counselling needs were significantly associated with poor mental health (OR 3.2, 95% CI: 2.1–4.8), exposure to sexual coercion (OR 2.6, 95% CI: 1.7–3.9), frequent heavy episodic drinking (OR 3.3, 95% CI: 1.9–5.8), and number of sexual partners (OR 1.9, 95% CI: 1.04–3.3). The associations between poor mental health, sexual coercion, and unmet healthcare needs (AOR 4.2, 95% CI: 2.1–8.5; AOR 2.8, 95% CI: 1.3–5.8) and unmet needs for sexual health counselling (AOR 3.3, 95% CI: 1.6–7.1; AOR 2.7, 95% CI: 1.4–5.4) persisted after adjustment for socio-demographic factors, number of sexual partners, and frequent heavy episodic drinking. Conclusions: These findings indicate that exposure to sexual coercion and poor mental health may influence healthcare seeking behaviours of same-sex sexuality experienced students. Targeted interventions that integrate mental health and trauma response are critical to meet the health needs of this population

Assessing the effectiveness of a sexual and reproductive health and rights training programme in changing healthcare practitioners’ attitudes and practices in low-income countries

Introduction In low-income countries the utilisation of sexual and reproductive health and rights (SRHR) services is influenced by healthcare practitioners’ knowledge, attitudes and practices. Despite awareness of the potential problems due to ingrained biases and prejudices, few approaches have been effective in changing practitioners’ knowledge, attitudes and practices concerning SRHR in low-income countries. Objectives 1) To assess whether participating in an SRHR international training programme (ITP) changed healthcare practitioners’ SRHR knowledge, SRHR attitudes and SRHR practices and 2) examine associations between trainees’ characteristics, their SRHR work environment and transfer of training. Methods A pre- and post-intervention study, involving 107 trainees from ten low-income countries, was conducted between 2017 and 2018. Paired samples t-test and independent samples t-test were used to assess differences between trainees’ pre- and post-training scores in self-rated SRHR knowledge, attitudes, knowledge seeking behaviour and practices. Linear regression models were used to examine association between trainees’ baseline characteristics and post-training attitudes and practices. Results Trainees’ self-rated scores for SRHR knowledge, attitudes and practices showed statistically significant improvement. Baseline high SRHR knowledge was positively associated with improvements in attitudes but not practices. High increases in scores on knowledge seeking behaviour were associated with higher practice scores. No statistically significant associations were found between scores that measured changes in SRHR knowledge, attitudes and practices. Conclusion The findings indicate that the ITP was effective in improving trainees’ self-rated scores for SRHR knowledge, attitudes and behaviours (practices). The strongest association was found between improvement in SRHR knowledge seeking behaviour and the improvement in SRHR practices. This suggests that behaviour intention may have a central role in promoting fair open-minded SRHR practices among healthcare practitioners in low-income countries

Analysis of effect modification between sex and role of religion/religious affiliation regarding <i>high number of lifetime sexual partners</i> in a sample of Ugandan university students (n = 980), presented as adjusted OR with 95% CI.

1<p>Adjusted for age.</p

Analysis of effect modification between sex and role of religion/religious affiliation regarding, <i>not always condom use with a new partner</i> in a sample of Ugandan university students (n = 980), presented as adjusted OR with 95% CI.

1<p>Adjusted for age.</p

Association (OR 95% CI) between role of religion and sexual behavior.

<p>Association (OR 95% CI) between role of religion and sexual behavior.</p

Association (OR, 95% CI) between sociodemographic factors, self–rated health, and <i>not always condom use with a new partner</i>.

<p>Association (OR, 95% CI) between sociodemographic factors, self–rated health, and <i>not always condom use with a new partner</i>.</p