Trust and the utilization of maternal and child health services in the context of hiv/aids in Palapye, Botswana




Molosiwa, Dintle Senanto

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The current interest in and momentum for improving health outcomes for women and children in sub-Saharan Africa through stronger health systems presents an opportune time for researchers, policy makers and healthcare providers in the region. Access to and utilization of available health services by women and children is one area in which, although research abounds, solutions to ensure access and optimal use of services remain problematic. Methods: Using mixed research methods, women's and children's access to and utilization of maternal and child health services are examined using the notion of trust in healthcare as an overarching paradigm. The study was conducted in Palapye, Botswana. Quantitative data were extracted from a sample of 942 obstetric booklets and related hospital registers for births that occurred at Palapye Primary Hospital in the five-year period between April 1st 2005 and March, 31st 2010. Thirty-six recently delivered women and 11 healthcare providers, including Ministry of Health bureaucrats, were interviewed in-depth to provide qualitative data for the thesis. Results: Findings from the study revealed a mismatch between women's access to and utilization of health services. First, the near universal attendance of ANC (95.8 percent with at least one visit and 85.8 percent with at least four visits) stood in contrast to frequent late first attendance (84.8 percent) and poor confirmed PNC attendance (only 21.3 percent). Second, the near universal enrolment (95 percent) of HIV-positive women into the PMTCT program stood in contrast to poor adherence in the program (53.4 percent defaulted for AZT initiation at 28 weeks, 36.2 percent defaulted on ingestion of AZT at labour/delivery, 73.6 percent of HIV-negative women who should have re-tested at 36 weeks failed to do so, and 6.9 percent of women were definitely lost to follow up before delivery, with another 13.3 percent also possibly lost to follow up). The results further revealed that variations in health service use among women could only be marginally explained by differences in women's socio-demographic characteristics. Trust was found to be a very significant element influencing women's access to and utilization of health services. This influence was best captured using three phases of trust. Naive/blind trust was characterized by an element of untested optimism in the provision and reception of needed care. But because expectations can lead to disappointment, women expressed a sense of disenchantment, mostly characterized by anxiety and frustration with their healthcare, and often leading to delayed use of services and poor adherence. Seeking to address their health needs, women's naive/blind trust and/or disenchantment evolved to re-constructed trust. In this phase women demonstrated low levels of trust in healthcare providers and the health system in general, often characterized by reluctance to use services and excusing healthcare providers' negative behaviours or attitudes. This phase of trust was also characterized by high levels of trust in certain healthcare providers and not others. Conclusion: Women in Palapye have adequate access to maternal and child health services but poor patient-provider relationships, and therefore a breakdown of trust negatively affects their health service use.






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