Drugs, docs, and delays: A qualitative analysis on barriers and facilitators to medical care engagement amongst people living with HIV in St. Petersburg, Russia

: 2.063_NEP Exploring caesarean section decision-making in newcomer and Canadian-born women in Edmonton, Alberta P. Sivananthajothy, Z. Mumtaz; University of Alberta School of Public Health, Edmonton, Alberta, Canada Background: Caesarean section (C-section) deliveries are conducted when there is a failure to progress in labor, or compromised fetal status. However, they place women at higher risk for immediate complications compared to vaginal deliveries. Mumtaz et al. (2014) showed that newcomer women in the prairie provinces experienced significantly higher C-section delivery rates compared to Canadian-born women, even though rates of recommendations by healthcare providers was equal. This on-going study aims to understand this trend, and explore how decisions regardingC-section deliveries aremadewithin the experiences of newcomer and Canadian-born women. Methods: A focused ethnography was conducted at a universityaffiliated hospital in Edmonton, Alberta for an 8-month period in 2015. The study population comprised: 1) newcomer women who immigrated to Canada after 2004 (N1⁄420) and 2) Canadian-born women (N1⁄420). Both groups consisted of women who have a higher risk of undergoing a C-section. Data collection strategies included participant observation of prenatal appointments, labour and delivery along with in-depth interviews with the women. Written informed consent was obtained from all participants and ethics approval was received from the University of Alberta. Findings: Preliminary findings indicate that decisions to have emergency C-sections were solely due to physician recommendations. Women stated the safety of the baby as the main reason for following physician recommendations. Both newcomer and Canadian-born women revealed deep-rooted trust in the recommendations, which was rarely questioned when the health of the baby could be compromised. Conversely, when exploring decision-making of processes, which did not compromise the health of the baby, Canadian-born women were more likely to question the decisions of healthcare providers, and actively provide their opinions compared to newcomer women. Canadian-born women were more likely to recognize their patient rights, especially if they or their family members were part of the medical community. Interpretation: The findings indicate a discrepancy in the role of the Canadian-born and newcomer women as patients, and further research is required to ensure newcomer women play an active, informed role in decision-making processes. Funding: Women and Children’s Health Research Institute, University of Alberta Faculty of Graduate Studies and Research, Soroptimist Foundation of Canada. Abstract #: 2.064_NEP: 2.064_NEP Drugs, docs, and delays: A qualitative analysis on barriers and facilitators to medical care engagement amongst people living with HIV in St. Petersburg, Russia J.A. Smith, Y.A. Amirkhanian, J.A. Kelly; Medical College of Wisconsin, Milwaukee, WI, USA, Center for AIDS Intervention Research, Milwaukee, WI, USA, Interdisciplinary Center for AIDS Research and Training, St. Petersburg, Russia Background: It is well-established that adherence to antiretroviral treatment (ART) and medical care engagement both improve personal health, and reduce infectivity and transmission in People Living with HIV (PLH), potentially leading to widespread reduction in HIV incidence. However, a high proportion of PLH worldwide are out of care. Russia’s situation is even worse with lower medical A n n a l s o f G l o b a l H e a l t h , V O L . 8 2 , N O . 3 , 2 0 1 6 New and Emerging Priorities for Global Health M a yeJ u n e 2 0 1 6 : 5 3 2 – 5 7 4 559 care engagement rates than Sub-Saharan Africa, as well as a growing rate of HIV incidence. Little research has explored why some PLH are actively in care and taking ART regularly as prescribed, while others fall out of care or have never engaged in care. Methods: We sought to identify facilitators and barriers to medical care engagement amongst PLH in Russia from their own individual perspectives through qualitative, in-depth interviews. These interviews were conducted over a period of 4 weeks in June 2015 in St. Petersburg, Russia with 14 PLH who have not been in medical care in the last 6 months or do not take ART regularly as prescribed. Participants were recruited via online forums and social network groups for HIV+ members. Questions asked covered a wide range of topics including opinions of medical care, past and current substance abuse, and social support systems. Audio-recorded interviews were then transcribed and qualitatively analyzed. Findings: Facilitators involved the critical nature of social support systems and positive perception of medical services and relationships with medical providers. Both factors increased the likelihood that PLH engaged in care. Barriers to medical care engagement included issues surrounding substance abuse, perceived social stigma, and poor civilian and prison medical infrastructure and organization, all decreasing the likelihood of care engagement. Interpretation: By encouraging the facilitators and overcoming the barriers at both micro and macro levels, a greater proportion of PLH in Russia may be more likely to engage in care, infection rates could decline, and lifespan could be prolonged. Further research needs to delve deeper into each of these facilitators and barriers and expand on them quantitatively. Funding: Dr. Elaine Kohler Summer Academy of Global Health Research. Abstract #: 2.065_NEP: 2.065_NEP Kumawu polyclinic: A needs assessment of a district facility

Background: Morbidity and mortality from conditions amenable to surgery continue to rise in low-and middle-income countries. Children in Guatemala have difficulty accessing surgical care, although the precise barriers to care are not well-defined. Using a structured anthropologic approach, we sought to explore how parents or adult guardians (hereafter referred to as parents) experience barriers to pediatric surgery in Guatemala, suspecting that financial considerations were among the major obstacles to care.
Methods: We conducted interviews with 29 families of children receiving surgical care at two non-governmental organizations (NGOs) in Guatemala to examine perceptions of barriers to care. Inclusion criteria included being a parent or adult family member/ caregiver of a child undergoing surgical care at an NGO providing free or low-cost care in Guatemala City or Antigua. Subjects were recruited by convenience sampling on the day of initial surgical evaluation. Transcripts were analyzed using a grounded theory approach; study enrollment was closed once thematic saturation was reached.
Findings: Parents identified financial costs, systems limitations, quality of care, and fear/mistrust as the primary barriers to care. It was common for parents to wait several years between when surgery had been recommended and pre-operative surgical evaluation. Transit time to the NGO often took hours. When asked if they would prefer to have a Guatemalan or foreign provider, over half of parents stated they would prefer the latter.
Interpretation: Surgery is an increasing priority in the global health arena. Understanding the barriers to care is critical for policy development to improve access to surgery for children. One unexpected finding of our study was the predominance of fear/mistrust, a theme which emerged more frequently than in previous studies. Despite financial obstacles, most parents cited a fear of the surgery as the single most important barrier to care. This may be due to the negative perceptions of public surgical care in Guatemala. Cooperation and collaboration between sectors, quality improvement, and health promotion may address some of these concerns and reduce barriers to care.  Exploring caesarean section decision-making in newcomer and Canadian-born women in Edmonton, Alberta P. Sivananthajothy, Z. Mumtaz; University of Alberta School of Public Health, Edmonton, Alberta, Canada Background: Caesarean section (C-section) deliveries are conducted when there is a failure to progress in labor, or compromised fetal status. However, they place women at higher risk for immediate complications compared to vaginal deliveries. Mumtaz et al. (2014) showed that newcomer women in the prairie provinces experienced significantly higher C-section delivery rates compared to Canadian-born women, even though rates of recommendations by healthcare providers was equal. This on-going study aims to understand this trend, and explore how decisions regarding C-section deliveries are made within the experiences of newcomer and Canadian-born women.
Methods: A focused ethnography was conducted at a universityaffiliated hospital in Edmonton, Alberta for an 8-month period in 2015. The study population comprised: 1) newcomer women who immigrated to Canada after 2004 (N¼20) and 2) Canadian-born women (N¼20). Both groups consisted of women who have a higher risk of undergoing a C-section. Data collection strategies included participant observation of prenatal appointments, labour and delivery along with in-depth interviews with the women. Written informed consent was obtained from all participants and ethics approval was received from the University of Alberta.
Findings: Preliminary findings indicate that decisions to have emergency C-sections were solely due to physician recommendations. Women stated the safety of the baby as the main reason for following physician recommendations. Both newcomer and Canadian-born women revealed deep-rooted trust in the recommendations, which was rarely questioned when the health of the baby could be compromised.
Conversely, when exploring decision-making of processes, which did not compromise the health of the baby, Canadian-born women were more likely to question the decisions of healthcare providers, and actively provide their opinions compared to newcomer women. Canadian-born women were more likely to recognize their patient rights, especially if they or their family members were part of the medical community. care engagement rates than Sub-Saharan Africa, as well as a growing rate of HIV incidence. Little research has explored why some PLH are actively in care and taking ART regularly as prescribed, while others fall out of care or have never engaged in care.
Methods: We sought to identify facilitators and barriers to medical care engagement amongst PLH in Russia from their own individual perspectives through qualitative, in-depth interviews. These interviews were conducted over a period of 4 weeks in June 2015 in St. Petersburg, Russia with 14 PLH who have not been in medical care in the last 6 months or do not take ART regularly as prescribed. Participants were recruited via online forums and social network groups for HIV+ members. Questions asked covered a wide range of topics including opinions of medical care, past and current substance abuse, and social support systems. Audio-recorded interviews were then transcribed and qualitatively analyzed.
Findings: Facilitators involved the critical nature of social support systems and positive perception of medical services and relationships with medical providers. Both factors increased the likelihood that PLH engaged in care. Barriers to medical care engagement included issues surrounding substance abuse, perceived social stigma, and poor civilian and prison medical infrastructure and organization, all decreasing the likelihood of care engagement.
Interpretation: By encouraging the facilitators and overcoming the barriers at both micro and macro levels, a greater proportion of PLH in Russia may be more likely to engage in care, infection rates could decline, and lifespan could be prolonged. Further research needs to delve deeper into each of these facilitators and barriers and expand on them quantitatively. Background: Many district hospitals and medical centers in Ghana are limited with regard to the number of employed medical staff, hospital resources, and services available. Our team went to Kumawu Polyclinic to learn about the detailed operations of the hospital, resources, and to determine the challenges faced by the facility. A needs assessment was developed that can be used as a model for how to briefly and efficiently evaluate a district facility in Sub Saharan Africa.
Methods: A team consisting of an emergency physician working at a tertiary referral hospital in Ghana and medical students from the United States developed a needs assessment and conducted a visit to Kumawu Polyclinic (Sekyere Afram Plains District, Ashanti Region, Ghana) over three consecutive days in July 2015. The team surveyed the facility, observed rounds with the medical staff, and conducted informal interviews with the polyclinic director and staff.
Findings: Kumawu Polyclinic is a district health facility with 23 inpatient beds, split between three wards. There is only one medical officer (physician) at the hospital, along with one physician's assistant and a physician assistant in training. 25 nurses work at the hospital but only 8 are formally trained. The most common patient presentations are fever in children under five, pregnancy and delivery, and complications of noncommunicable diseases such as stroke and hypertensive crisis. The clinic faces several challenges, one being an unreliable supply of essential consumables from the Ghana Health Service. The polyclinic also has limited capability to run laboratory tests and has to send patients 45 minutes away to a larger facility for any imaging. Electric supply is intermittent and requires the use of a backup generator during periods of electrical failure.
Interpretation: Our team recommended establishing a triage system for patient intake to increase the efficiency of the clinic. In addition, the needs assessment addressed the clinic's limited range of drugs it can prescribe, moving forward on a 25-bed extension, and the challenges of intermittent electricity. This method of assessing the needs of a district facility can be employed at other polyclinics in Ghana and in developing countries in Africa.

Funding: None.
Abstract #: 2.066_NEP Assessing perceptions of genetic risk and breast cancer of women diagnosed and undiagnosed with breast cancer in Ibadan, Nigeria Jasmine Solola, Olufunmi Olopade; The Center for Global Health, University of Chicago Background: The World Health Organization (WHO) projects that cancer will be the leading cause of death worldwide by 2030 if urgent strategies are not implemented arrest the cancer disparity in low-to middle-income countries. 75% of women with breast cancer in developing countries, like Nigeria, are diagnosed in stages 3 or 4. The causes of these disparities, resulting in the lack of early detection, must be examined through the many cultural, economic, and social factors shaping the perceptions held by these communities. Only then, can the appropriate interventions be implemented.
Aims: The primary objectives are to identify the structural, social, and cultural factors that influence perception of risk and understanding of disease in Nigerian women diagnosed with breast cancer and women never diagnosed with breast cancer. The specific aims are to identify the perceptions of risk for developing cancer, to identify where and how information about breast cancer is received, and to identify what social, economical, or demographic factors influence knowledge of breast cancer and the perceptions of risk.
Methods: The survey consisted of 33 questions. The setting was University College Hospital (UCH), a federal tertiary teaching hospital, located in Ibadan, Nigeria. A total of 36 cases e women self-reporting as diagnosed with breast cancer were recruited from the Surgery Out-Patient Oncological and 42 controls e women self-reporting as never diagnosed with breast cancer were recruited from the OB-GYN and Family Planning units.

Results:
The qualitative results of this assessment reveal that although patients have a desire to learn more about breast cancer