BackgroundTreatment seeking delays among people living with HIV have adverse consequences for outcome. Gender differences in treatment outcomes have been observed in sub-Saharan Africa.ObjectiveTo better understand antiretroviral treatment (ART) seeking behaviour in HIV-infected adults in rural Malawi.MethodsQualitative interviews with male and female participants in an ART cohort study at a treatment site in rural northern Malawi triangulated with analysis of baseline clinical and demographic data for 365 individuals attending sequentially for ART screening between January 2008 and September 2009.Results43% of the cohort presented with late stage HIV disease classified as WHO stage 3/4. Respondents reported that women's frequency of testing, health awareness and commitment to children led to earlier ART uptake and that men's commitment to wider social networks of influence, masculine ideals of strength, and success with sexual and marital partners led them to refuse treatment until they were sick. Quantitative analysis of the screening cohort provided supporting evidence for these expressed views. Overall, male gender (adjusted OR 2.3, 95% CI1.3–3.9) and never being married (adjusted OR 4.1, 95% CI1.5–11.5) were risk factors for late presentation, whereas having ≥3 dependent children was associated with earlier presentation (adjusted OR 0.31, 95% CI0.15–0.63),compared to those with no dependent children.ConclusionGender-specific barriers and facilitators operate throughout the whole process of seeking care. Further efforts to enrol men into care earlier should focus on the masculine characteristics that they value, and the risks to these of severe health decline. Our results emphasise the value of exploring as well as identifying behavioural correlates of late presentation.

Background: The proportion of older adults using secure forensic psychiatric services is rising. Research is needed to examine the experience of older service users and evidence how adult services can adapt to meet their needs. Aim: To explore user experiences of being an older adult in secure forensic services and user perceptions of how their age-related needs were being met. Method: Thematic analysis of interviews and observations of weekly routines conducted with fifteen service users aged 50 and over residing in a low and medium secure NHS unit in England. Results: User experiences of ageing and age-related needs are reported using five themes: age related identities; ward environments; participation in activities; management of physical health; and ageing futures. Older adults living with people their own age reported more social integration than those on wards dominated by younger adults. Many participated in the activity program. Most wished to self-manage their physical health needs with the support of primary care staff. Older adults were reluctant to identify as 'old' or 'vulnerable'. Some older adults downplayed their changing care needs. Conclusions: Placement of older people in adult secure services requires awareness of the age balance of the ward. A culture of inclusivity, sensitivity and respect for older persons' agency is key to collaboratively meeting additional care needs and discharge planning. Declaration of Interest : No conflict of interest.

BackgroundMaternity care services provide critical interventions aimed at improving maternal and newborn health. In this study, we examined determinants of antenatal care (ANC) content in Syria, together with changes over time.MethodsWe analysed two national surveys conducted by the Central Bureau of Statistics in Damascus (PAPFAM 2001 and MICS 2006). Findings of this initial analysis led to a qualitative study on adequacy of antenatal care content in two Syrian governorates, Aleppo and Latakia in 2010, which in turn informed further quantitative analysis. The perspectives and practices of doctors, women, midwives and health officials were explored using in-depth interviews. A framework approach was used to analyse the data.ResultsThe quantitative analysis demonstrated that women’s education level, the type of health facility they attended and whether they had experienced health complications were important determinants of adequacy of ANC content received. The qualitative study revealed that additional factors related to supply side and demand side factors (e.g. organization of health services, doctors' selective prescription of ANC tests and women's selective uptake of those tests), influenced the quality of ANC and explained some regional differences between Aleppo and Latakia.ConclusionsThe percentage of women who received adequate ANC content was probably higher in Latakia than in Aleppo because women in Latakia were more educated, and because services were more available, accessible, and acceptable to them.

Background: The number of older people and their proportion of the prison population in high-income countries is increasing substantially. This pattern is mirrored by the age profile in forensic hospital services, and both trends seem counter to the age-crime curve concept. How do we understand this and what are the mental health needs of this growing group? Aim: The aim of this review is to identify existing research robust enough to inform policy and practice in relation to mental health in older offenders and the knowledge gaps that should drive future research. Methods: A keyword-based search strategy of the databases Embase, PsychINFO, Medline, and grey literature 2008-2018. Article selection was limited to empirical research with the potential to inform policy or practice and findings synthesised narratively. Results: Much of the research in this field focuses on prevalence and the increased psychiatric morbidity of the older offender population. Older prisoners and those older

Background Syria has made progress in reducing maternal mortality and morbidity before the conflict in 2011. Despite the improvement in antenatal care (ANC) coverage and patterns of use, analyses of national surveys demonstrated wide regional variations in uptake, timing and number of visits even after controlling for women’s socio-demographic characteristics. This study compares two governorates: Latakia, where uptake of ANC was high and Aleppo, where uptake of ANC was low to highlight the barriers to women’s adequate uptake of ANC that existed in Syria pre-conflict. Methods This qualitative study carried out 30 semi-structured interviews with (18–45-year-old) pregnant women from Aleppo and Latakia (recruited purposively from different types of health facilities in rural and urban areas), and 15 observation sessions at health facilities. Transcripts and fieldnotes were analyzed using the Framework Method with attention to the dimensions of availability, accessibility and acceptability of services. Results Inadequate uptake of ANC in Aleppo included not attending ANC, seeking care with providers who are not trained to provide ANC or discontinuing care. Three themes explained the regional disparities in the uptake of ANC in Aleppo and Latakia: women’s assessment of their health status and reasoning of causes of ill health in pregnancy; women’s evaluation of the risks of seeking ANC; and women’s appraisal of the value of different types of service providers. Poor experiences at public health facilities were reported by women in Aleppo but not by women in Latakia. Evaluations of ANC services were connected with the availability, accessibility (geographical and financial) and acceptability of ANC services, however, women’s views were shaped by the knowledge and prevailing opinions in their families and community. Conclusions Findings are utilized to discuss low-cost interventions addressing the disparities in ANC uptake. Interventions should aim to enable vulnerable women to make informed decisions focusing on regions of low uptake. Women’s groups that foster education and empowerment, which have been effective in other low resource settings, could be of value in Syria. Increased use of mobile phones and social media platforms suggests mobile health technologies (mHealth) may present efficient platforms to deliver these interventions.