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Manuscript: Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities
2023-11-27T20:43:00+00:00
2023-11-27T20:43:00+00:00
https://pachodo.org/latest-news-articles/pachodo-english-articles/43355-manuscript-health-facility-and-workforce-factors-influencing-utilization-of-reproductive-health-services-in-selected-south-sudan-public-health-facilities
Dr. Emmanuel Timothy Thwol
LamArop@pachodo.org
<p><img src="https://pachodo.org/images/Health_facility_and_workforce_factors_influencing_utilization_of_reproductive_health_services_in_selected_South_Sudan_public_health_facilities0.jpg" alt="Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities" title="Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities" /></p>
<p><img src="https://pachodo.org/images/Health_facility_and_workforce_factors_influencing_utilization_of_reproductive_health_services_in_selected_South_Sudan_public_health_facilities1.jpg" alt="Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities 2" title="Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities 2" /></p>
<p><em>(Images: Supplied)</em></p>
<p> </p>
<p><em><strong>By DR. Emmanuel Timothy Thwol Onak (PhD)</strong></em></p>
<h3> </h3>
<h3>Abstract</h3>
<p>Background: Despite Africa's representation of only one-tenth of the global population and 20% of worldwide births, nearly half of all maternal deaths occur in this region. Reproductive health issues account for up to 18% of the global disease burden and 32% of the total burden for women of reproductive age (WHO Africa, 2020). Access to crucial reproductive health (RH) interventions, particularly family planning, remains restricted, characterized by low contraceptive use (13%) and a high total fertility rate (5.5 children per woman) in Sub-Saharan Africa (WHO, 2021).</p>
<p>Method: This study employed a mixed-method research design, which integrated both quantitative and qualitative research approaches to provide a comprehensive understanding of the topic, The mixed-method design enabled the research to capture the richness and depth of the phenomenon under investigation while also allowing for quantitative analysis to identify patterns, trends, and relationships within the data.</p>
<p>Results: The research findings illustrate key aspects of reproductive health service utilization among women in South Sudan. A significant percentage of women were aware of the nearest RH clinic; however, around 42.3% lacked awareness. Accessibility to RH services was notably limited, with over 45.8% of women living beyond a 2 km radius from the nearest RH clinic. The mean distance from households to the nearest RH centre was 2.2 km, indicating substantial distance barriers. The study revealed statistically significant relationships between health facility characteristics (such as RHS accessibility, hospital classification, revenue resources, NGO affiliation, and provision of modern contraceptives) and the use of reproductive health services. Additionally, interviews with key informants highlighted the importance of healthcare providers' higher education levels in enhancing specialized skills, critical thinking, and the delivery of comprehensive and individualized RH care, ultimately influencing RHS utilization positively. Conversely, findings indicated that overworked health workers receiving low wages negatively impacted the uptake and utilization of RHS in South Sudan's public health facilities, suggesting the pivotal role of fair compensation and manageable workloads in enhancing service utilization.</p>
<p>Conclusions: The study yielded significant insights into the factors influencing RHS uptake in South Sudan's public health facilities. It highlighted the impact of health facility characteristics, including awareness of services, proximity to facilities, and available contraceptives, on RHS utilization. Similarly, the health workforce's influence, encompassing staffing levels, qualifications, workload management, and fair compensation, emerged as crucial determinants affecting service utilization. To enhance RHS utilization, targeted measures such as community outreach to raise awareness, expanding health facilities in remote areas, and offering a diverse range of contraceptives were suggested. Limitations, including sampling biases and regional focus, need consideration, while future research should explore broader geographical areas, longitudinal trends, specific interventions' impacts, and technology's role in improving RHS access for remote populations. Qualitative studies involving stakeholders could offer deeper insights into barriers and facilitators to RHS utilization, guiding more effective policy interventions.</p>
<h3>Introduction</h3>
<p>The healthcare system comprises a network of production units aimed at enhancing the population's health status. Primary healthcare and its associated facilities serve as the gateway to advanced care levels (Murray & Frenk, 1999). Evaluating health system performance commonly involves analyzing care delivery components, which sheds light on the efficacy and efficiency of service provision (Olafsdottir et al., 2011). Measurement of health system functioning encompasses cost-effective analysis, technical efficiency, and allocative efficiency.</p>
<p>The World Health Organization (WHO) predicts a projected deficit of 12.9 million skilled healthcare workers by 2035, primarily concentrated in Africa and Southeast Asia due to low remuneration and insufficient incentives, potentially leading to a departure of 40% of health professionals within the next decade (Global Health Workforce Alliance and World Health Organization, 2013). This trend, exacerbated by internal and international health worker migrations, worsens regional disparities in healthcare staffing. The evolution of medical technology and the demand for advanced care underscore the need for a more proficient healthcare workforce. WHO emphasizes the pivotal role of health workers as the backbone of healthcare systems, responsible for care delivery, program management, and crisis response (Dieleman & Harnmeijer, 2006).</p>
<p>The utilization of health services significantly influences health outcomes, particularly in resource-limited rural regions, such as rural sub-Saharan Africa, where access to health services profoundly impacts health utilization patterns (Tanser et al., 2006). Enhancing health service accessibility is vital for improving quality of life, reducing health disparities, and better serving target populations, necessitating a comprehensive understanding and assessment of healthcare access and its spatial variations for effective resource allocation and program planning.</p>
<p>Despite Africa's representation of only one-tenth of the global population and 20% of worldwide births, nearly half of all maternal deaths occur in this region. Reproductive health issues account for up to 18% of the global disease burden and 32% of the total burden for women of reproductive age (WHO Africa, 2020). Access to crucial reproductive health (RH) interventions, particularly family planning, remains restricted, characterized by low contraceptive use (13%) and a high total fertility rate (5.5 children per woman) in Sub-Saharan Africa (WHO, 2021).</p>
<p>In the context of South Sudan, limitations in capacity and a challenging governance environment significantly impede the implementation of basic health services and governmental policies. Reports suggest persistent inadequacies in building government capacity (Larson et al., 2013). Moreover, economic and social challenges, encompassing health budget cuts, inflation, and food insecurity, further compound these difficulties (Integrity, 2018; IPC, 2018). The economic crisis has adversely affected programs, including reproductive health services, funded by external donors (Integrity, 2018). Consequently, the utilization and adoption of RH services in South Sudan are intricately linked to these multifaceted challenges, heightening the critical nature of this issue.</p>
<p>While global health outcomes have exhibited improvement over the past two decades, South Sudan has also experienced substantial progress, notably a reduction in maternal mortality, neonatal mortality, infant mortality, and under-five stunting (World Bank, 2018). Access to Reproductive Health Services (RHS), such as antenatal care and contraception, has shown significant improvement in Sub-Saharan Africa (United Nations, 2015). Nonetheless, access to healthcare, particularly RH services, remains a significant hurdle in South Sudan, largely due to ongoing conflicts and an unstable peace process (Pendle, 2014). The East African region, including nations like Uganda, Tanzania, and Kenya, continues to grapple with high maternal mortality rates compared to developed countries, emphasizing the urgent need for enhanced RH services (UNICEF, 2016). Low usage of modern contraceptives and unmet family planning needs affect a considerable proportion of married women in this region (United Nations, 2015).</p>
<p>South Sudan faces multifaceted challenges in its healthcare system, notably concerning reproductive health services. These challenges are compounded by capacity limitations, a challenging governance environment, ongoing conflicts, and external economic pressures, which have adversely affected the implementation and accessibility of basic health services, including reproductive health interventions. As a consequence, the uptake and utilization of RHS within the country are intricately tied to these complex healthcare, economic, and sociopolitical dynamics. The purpose of this study is to examine and assess the influence of health facility characteristics and the health workforce on the uptake and utilization of Reproductive Health Services (RHS) within selected public health facilities in South Sudan. Specifically, the research aims to scrutinize how varying health facility attributes and workforce dynamics impact the access, adoption, and utilization of essential reproductive health interventions among the population.</p>
<p>Understanding the nuanced relationship between health facility characteristics, the health workforce, and the utilization of RHS is imperative to address the persisting barriers and challenges faced by South Sudan's healthcare system. This study seeks to fill the existing research gap by offering an in-depth exploration of these determinants and their impact on reproductive health service accessibility and utilization. By identifying key influencers affecting the uptake of RHS, the study aims to provide evidence-based recommendations for policy formulation, resource allocation, and program planning to enhance reproductive health outcomes in South Sudan.</p>
<h3>Methods</h3>
<p>This study employed a mixed-method research design, which integrates both quantitative and qualitative research approaches to provide a comprehensive understanding of the topic, The mixed-method design enabled the research to capture the richness and depth of the phenomenon under investigation while also allowing for quantitative analysis to identify patterns, trends, and relationships within the data.</p>
<p>The quantitative data was collected from women of reproductive age visiting selected public health facilities during the study period. A structured questionnaire with only closed-ended questions was developed as the primary research instrument, focusing on the influence of health facility characteristics on the uptake and utilization of RHS. The qualitative data, on the other hand, was collected from the key informants who are knowledgeable about RHS. An interview guide with open-ended questions was used to establish the influence of the health workforce on the uptake and utilization of RHS.</p>
<p>The study's theoretical foundation primarily relies on two established theories: the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These theories have been extensively employed in previous research to elucidate and forecast the utilization and adoption of reproductive health services.</p>
<p>The Health Belief Model (HBM) emphasizes individual subjective beliefs that shape decision-making processes. It incorporates elements such as perceived susceptibility, severity, benefits, barriers, and cues to action. In prior studies, these constructs were instrumental in constructing a predictive model for risky sexual practices among college students, effectively elucidating variations in risk behaviours and sexual partnerships. On the other hand, the Theory of Reasoned Action (TRA) provides a framework for examining attitudes toward behaviours, aiming to predict and comprehend individual actions. This theory operates under the assumption that individuals act rationally, considering available information and potential outcomes before making decisions. Key components of TRA include behaviour, intention, and personal attitude. In this context, intention stands as the primary influencer of behaviour, with stronger intentions indicating a higher probability of engaging in a specific behaviour.</p>
<p>The utilization of these theories within the context of this study aims to assess how health facility characteristics and the health workforce influence the uptake and utilization of Reproductive Health Services (RHS) in selected South Sudan public health facilities. By applying the principles of HBM and TRA, the study endeavours to elucidate the mechanisms and influences behind the utilization patterns of reproductive health services within the specified healthcare settings.</p>
<p><strong>Study sites</strong></p>
<p>The research was conducted within public health facilities situated in two specific states of South Sudan: Western Equatoria and Central Equatoria. In South Sudan, the majority of the population resides in rural areas, constituting roughly 83% of the total populace. Rural areas are characterized by a sparse population density of approximately 15 individuals per square kilometre. Challenges in healthcare service delivery arise from this low density, along with the presence of mobile pastoral communities and restricted access due to prolonged conflicts.</p>
<p>The data collection process encompassed all four tiers of the South Sudan health system, incorporating the Boma Health Teams at the community level, Primary Healthcare Units (PHCU), Primary Healthcare Centers (PHCC), and hospitals. These healthcare facilities are strategically distributed across the administrative subdivisions of the country, catering to both rural and urban regions (Ministry of Health, 2012; WHO South Sudan, 2020).</p>
<p><strong>Sampling, recruitment of study participants and data collection</strong></p>
<p>Sampling, recruitment of study participants, and data collection procedures were conducted within public health facilities situated in Western Equatoria and Central Equatoria. A multi-stage cluster random sampling method was employed for quantitative data collection, involving two distinct stages: the selection of health facilities and the subsequent identification of participants.</p>
<p>Initially, health facilities were selected within each state by creating a comprehensive list of public health facilities. From this list, specific facilities were chosen using a systematic random sampling method. A minimum of three public health facilities were randomly selected in each state. Subsequently, the selection of participants utilized a probability proportionate to size approach. Population lists, such as the 2018 census detailing women aged 15 to 49 in the selected states, were employed. The sampling interval was calculated by dividing the total population of the program area by the number of women in the specified age group visiting health facilities. A systematic random start number was used to identify the first client, followed by subsequent selections based on the sampling interval until the required number of participants was reached.</p>
<p>For key informants knowledgeable about Reproductive Health Services (RHS), a snowball sampling method was utilized. Prior notification of interviews was sent to key informants via letter, followed by confirmation through telephone communication. Appointments were scheduled for interviews and Focus Group Discussions (FGDs).</p>
<p>The responsibility for field data collection and management was assumed by the researcher. Prior to data collection, comprehensive training sessions were conducted for five research assistants (RAs). RAs were trained on the study's objectives, methodologies, and the administration of data collection tools. Training encompassed tool review, practical exercises, ethical considerations, data confidentiality protocols, and logistical aspects.</p>
<p>Written consent was obtained from participants before the interviews, ensuring the confidentiality of their information. Interviews commenced with an introduction by the interviewer, outlining their identity, organizational affiliation, and the study's objectives. Face-to-face interviews were conducted using the designated data collection tools.</p>
<p><strong>Data analysis</strong></p>
<p>The data derived from the questionnaires underwent a comprehensive data analysis process. Initially, all data were entered into a computer file using Microsoft Excel Spreadsheet. Subsequently, the data were exported to IBM Statistical Package for the Social Sciences (SPSS) version 23, where all sub-files were amalgamated into one master file for further analysis. The initial phase of data analysis was data preparation, which involved transforming raw data into a comprehensible and meaningful format. This process included data validation, editing, and coding.</p>
<p>Various statistical techniques were then employed to identify significant correlations between variables and assess the impact of one variable on another. Descriptive statistics, such as mean, median, mode, percentage, frequency, and range, were utilized to gain an overview of the data. Descriptive statistics are particularly valuable when the scope of the research is confined to the sample and does not necessitate generalization to a larger population. For example, when comparing the percentage of youth utilizing RHS in different states, descriptive statistics provide sufficient insights. Subsequently, cross-tabulations were utilized to delve deeper into the dataset. Cross-tabulations are a means to elucidate the relationship between two variables and are commonly employed to compare outcomes across demographic groups. They allow for the examination of results based on factors like age and the utilization of RHS.</p>
<p>To assess hypotheses, the researcher calculated measures of statistical significance, which ascertain whether findings are statistically meaningful or merely the result of chance. Statistical significance was indicated by the p-value statistic. Typically, a p-value of less than 0.05 is considered statistically significant, signifying a less than 5% probability that the results occurred by chance. Furthermore, the researcher applied various inferential analyses, including correlation, regression, and analysis of variance where relevant. Linear regression was employed, for instance, to predict the value of one variable based on another. This approach allowed the exploration of whether the utilization of RHS could be predicted based on factors like climate change or socio-cultural characteristics.</p>
<p>The researcher conducted preliminary content analysis of the qualitative data to identify any common patterns and trends arising from the narratives regarding: a) the influence of health facility characteristics on the uptake and utilization of RHS; and b) the influence of the health workforce on the uptake and utilization of RHS. This involved drawing connections between themes and discussing their implications.</p>
<p><strong>Ethical considerations</strong></p>
<p>Ethical considerations were paramount throughout the course of this study. Prior to the commencement of data collection, the researcher diligently sought ethical approval from the Division of Research, Monitoring and Evaluation within the Directorate of Planning and Coordination at the Ministry of Health, as well as the Research Ethics Committee (REC) of the Republic of South Sudan. Additional approvals were obtained from the Institutional Ethical Review Committee (IERC) of Mount Kenya University. In accordance with ethical standards, formal permissions were also secured from the respective sectoral and departmental heads, including the Ministry of Health and Local Governments within the Republic of South Sudan, to access public health facilities and other relevant offices.</p>
<p>The participants who willingly consented to take part in the study were assured of strict anonymity and confidentiality. These measures were implemented to safeguard their identities and instil confidence in the research process, thereby promoting the provision of accurate information. Furthermore, participants were granted the unequivocal right to exercise their free will, allowing them to decide whether they wished to participate in the research. The option of withdrawal from the study was extended to participants at any point, without the requirement to provide a reason. This opportunity was explicitly communicated to participants before the commencement of interviews and was also documented in writing.</p>
<p>In adhering to high ethical standards and principles for research, the study conformed to data collection, security, and protection requirements. Special consideration was also given to adaptations necessary to comply with COVID-19 control regulations. The risk level to both the research team and the communities was identified, and all personnel and participants were provided with essential protective equipment to mitigate risks effectively.</p>
<h3>Results</h3>
<h4>Influence of Health Facility Characteristics on Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities</h4>
<h5>Quantitative Analysis</h5>
<p><strong>Awareness of the Nearest Reproductive Health Clinic</strong></p>
<p>The respondents asked whether they were aware of the nearest RH clinic in the region. Figure 1 shows that most of the women (57.8%) were aware of the nearest RH clinic with 42.3% of women reporting a lack of awareness of the nearest RH clinic.</p>
<p><img src="https://lh7-us.googleusercontent.com/6MGfxIxor3kR3vTtyl5FoSN5XY6Yeeuo1ZoPJV1FdixihiMz_tUugHOlvu-do2wk8oOdeC-28zYtd7Y3GP--i704vXDuH_AhWMdGuKaVHnH5erCipZ1iEC_APWc0RHLBuZTWUbwHQO5OmSzC3XxA" alt="" width="627" height="366" /></p>
<p><strong>Figure 1:</strong> Awareness of the nearest RH clinic</p>
<p><strong>Source:</strong> Research Data (2023)</p>
<p><em>Distance to the Nearest RH Clinic</em></p>
<p>Most of the women (33.3%, 133) reported that public health facilities offering RHS were within 3 km from their households with 22.8% of women reporting that there were public health facilities offering RHS within 0.5 km (Figure 2). Women who lived within 2 km radius distance from the nearest RH service clinic and from their home less than 30 minutes walking distance were classified as having high geographical accessibility and low otherwise. Thus, over 45.8% of the women reported living outside 2 km radius distance from the nearest RH service clinic. The overall, mean distance to the nearest RHS centre from your household was 2.2 km.</p>
<p><img src="https://lh7-us.googleusercontent.com/blSm_bJK5MCmtnK2IYjytM-yUkVtn83kATF6rsdCB-TEstF9ssIVffNGRNfSS2kFA-fILb5ghpGpevax0nvFJopBltxXks_2s6IS2uIsgNYhl0vttw72QXlR6BXa9Q5_BTDOzPtTOn9ZmVPNRRI6" alt="" width="630" height="384" /></p>
<p><strong>Figure 2:</strong> Mean total PH facilities offering RHS within 0.5 to 5 km (range)</p>
<p><strong>Source:</strong> Research Data (2023)</p>
<p><em>Health Facility Characteristics Associated with RH Services Utilization</em></p>
<p>Based on the provided research findings in Table 1, the relationship between health facility characteristics (RHS accessibility, hospital classification, revenue resources and NGO affiliation, and provision of modern contraceptives) and use of reproductive health services shows some statistically significant results. </p>
<p>Relationship between the provision of intrauterine devices and uptake/utilization of reproductive health services: the p-value of 0.000 indicates a highly significant relationship between the provision of intrauterine devices and the uptake/utilization of reproductive health services. The odds ratio of 10.473 suggests that the provision of intrauterine devices is associated with a 10.473 times higher likelihood of uptake and utilization of reproductive health services compared to not providing intrauterine devices.</p>
<p>Relationship between provision of oral contraceptives and uptake/utilization of reproductive health service: the p-value of 0.000 indicates a highly significant relationship between the provision of oral contraceptives and the uptake/utilization of reproductive health services. The odds ratio of 33.060 suggests that the provision of oral contraceptives is associated with a 33.060 times higher likelihood of uptake and utilization of reproductive health services compared to not providing oral contraceptives. However, the wide range of the confidence interval (7.444 to 146.827) suggests some uncertainty in estimating the true odds ratio, but it still supports the notion that the odds of experiencing the outcome are significantly higher in the exposed group.</p>
<p>Table 1: Health facility characteristics associated with RH services utilization among women of reproductive age</p>
<table border="1">
<tbody>
<tr>
<td>
<p><strong>Variables</strong></p>
</td>
<td>
<p><strong>User of RH services</strong></p>
<p>n (%)</p>
<p>n = 290</p>
</td>
<td>
<p><strong>Non-user of RH services</strong></p>
<p>n (%)</p>
<p>n = 110</p>
</td>
<td>
<p><strong>OR</strong></p>
<p><strong>(95% CI)</strong></p>
</td>
<td>
<p><strong>P Value</strong></p>
</td>
</tr>
<tr>
<td>
<p><strong>Hospital classification</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Hospital (State, Teaching, and County)</p>
</td>
<td>
<p>101(34.8)</p>
</td>
<td>
<p>40 (36.4)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Primary Health Care Unit/Centre</p>
</td>
<td>
<p>189 (65.2)</p>
</td>
<td>
<p>70 (63.6)</p>
</td>
<td>
<p>1.178 (0.476-2.916)</p>
</td>
<td>
<p>0.723</p>
</td>
</tr>
<tr>
<td>
<p><strong>RHS accessibility</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Living within 2 km radius</p>
</td>
<td>
<p>160 (55.2)</p>
</td>
<td>
<p>57 (51.8)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Living outside 2 km radius</p>
</td>
<td>
<p>130 (44.8)</p>
</td>
<td>
<p>53 (48.2)</p>
</td>
<td>
<p>0.916 (0.429-1.956)</p>
</td>
<td>
<p>0.820</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Additional revenue resources & NGO affiliation </strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes</p>
</td>
<td>
<p>99 (34.1)</p>
</td>
<td>
<p>39 (35.5)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No</p>
</td>
<td>
<p>191 (65.9)</p>
</td>
<td>
<p>71 (64.5)</p>
</td>
<td>
<p>0.681 (0.271-1.709)</p>
</td>
<td>
<p>0.413</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Provision of intrauterine devices</strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes</p>
</td>
<td>
<p>105 (36.2)</p>
</td>
<td>
<p>71 (64.5)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No </p>
</td>
<td>
<p>185 (63.8)</p>
</td>
<td>
<p>39 (35.5)</p>
</td>
<td>
<p>10.473 (3.992-27.472)</p>
</td>
<td>
<p>0.000**</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Provision of oral contraceptives</strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes </p>
</td>
<td>
<p>203 (70.0)</p>
</td>
<td>
<p>108 (98.2)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No</p>
</td>
<td>
<p>87 (30.0)</p>
</td>
<td>
<p>2 (1.8)</p>
</td>
<td>
<p>33.060 (7.444 -146.827)</p>
</td>
<td>
<p>0.000**</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Provision of condoms (male & female)</strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes</p>
</td>
<td>
<p>206 (71.0)</p>
</td>
<td>
<p>89 (80.9)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No</p>
</td>
<td>
<p>84 (29.0)</p>
</td>
<td>
<p>21 (19.1)</p>
</td>
<td>
<p>0.993 (.466-2.116)</p>
</td>
<td>
<p>0.986</p>
</td>
</tr>
<tr>
<td>
<p><strong>Provision of injectables</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes</p>
</td>
<td>
<p>125 (43.1)</p>
</td>
<td>
<p>65 (59.1)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No</p>
</td>
<td>
<p>165 (56.9)</p>
</td>
<td>
<p>45 (40.9)</p>
</td>
<td>
<p>0.213 (0.074-0.613)</p>
</td>
<td>
<p>0.004**</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Provision of emergency contraceptive pills</strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes</p>
</td>
<td>
<p>258 (89.0)</p>
</td>
<td>
<p>78 (70.9)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No</p>
</td>
<td>
<p>32 (11.0)</p>
</td>
<td>
<p>32 (29.1)</p>
</td>
<td>
<p>0.453 (0.187-1.101)</p>
</td>
<td>
<p>0.080</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Provision of spermicidal agents</strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes </p>
</td>
<td>
<p>58 (20.0)</p>
</td>
<td>
<p>40 (36.4)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No </p>
</td>
<td>
<p>232 (80.0)</p>
</td>
<td>
<p>70 (63.6)</p>
</td>
<td>
<p>3.171 (1.496-6.720)</p>
</td>
<td>
<p>0.003**</p>
</td>
</tr>
</tbody>
</table>
<p><strong>Source:</strong> Research Data (2023)</p>
<p><em>**. Correlation is significant at the 0.01 level</em></p>
<p><em>*. Correlation is significant at the 0.05 level</em></p>
<p>Relationship between provision of injectables and uptake/utilization of reproductive health service: the p-value of 0.004 suggests a statistically significant relationship between the provision of injectables and the uptake/utilization of reproductive health services, though with a slightly lower level of significance compared to the previous two relationships. The odds ratio of 0.213 indicates that the provision of injectables is associated with a 0.213 times lower likelihood of uptake and utilization of reproductive health services compared to not providing injectables.</p>
<p>Relationship between the provision of spermicidal agents and uptake/utilization of reproductive health services: the p-value of 0.003 suggests a statistically significant relationship between the provision of spermicidal agents and the uptake/utilization of reproductive health services. The odds ratio of 3.171 indicates that the provision of spermicidal agents is associated with a 3.171 times higher likelihood of uptake and utilization of reproductive health services compared to not providing spermicidal agents.</p>
<p><strong>Influence of Health Workforce on Uptake and Utilization of RHS In Selected South Sudan’s Public Health Facilities</strong></p>
<p>This section presented a qualitative analysis of workforce variables (level of education, cadre or academic qualification, workload, and salary) that are likely to influence the uptake and utilization of RHS in the selected public health services.</p>
<p>Table 2: Socio-demographic characteristics of the health workers in selected public health facilities</p>
<table border="1">
<tbody>
<tr>
<td>
<p><strong>Variable </strong></p>
</td>
<td>
<p><strong>Category</strong></p>
</td>
<td>
<p><strong>Frequency</strong></p>
</td>
</tr>
<tr>
<td rowspan="2">
<p>State </p>
</td>
<td>
<p>Central Equatoria</p>
</td>
<td>
<p>14</p>
</td>
</tr>
<tr>
<td>
<p>Western Equatoria</p>
</td>
<td>
<p>10</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Cadre</p>
</td>
<td>
<p>Clinicians (Medical doctor/Public health officer)</p>
</td>
<td>
<p>5</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Nurses</p>
</td>
<td>
<p>6</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Midwives</p>
</td>
<td>
<p>4</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Clinical Officers</p>
</td>
<td>
<p>4</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Boma Health Workers (BHW)</p>
</td>
<td>
<p>5</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="2">
<p>Age (in Years)</p>
</td>
<td>
<p>18 – 34</p>
</td>
<td>
<p>8</p>
</td>
</tr>
<tr>
<td>
<p>35 – 49</p>
</td>
<td>
<p>11</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>50 – 60</p>
</td>
<td>
<p>6</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Educational level</p>
</td>
<td>
<p>Only traditional/non-formal school</p>
</td>
<td>
<p>3</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Completed secondary</p>
</td>
<td>
<p>2</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Technical College</p>
</td>
<td>
<p>12</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>University</p>
</td>
<td>
<p>7</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="2">
<p>Place of residence</p>
</td>
<td>
<p>Urban</p>
</td>
<td>
<p>10</p>
</td>
</tr>
<tr>
<td>
<p>Rural</p>
</td>
<td>
<p>14</p>
</td>
</tr>
</tbody>
</table>
<p><strong>Source:</strong> Research Data (2023)</p>
<p>The health workforce refers to the professionals and staff involved in delivering healthcare services within public health facilities. This includes doctors, nurses, midwives, community health workers, and other healthcare providers who play a direct role in delivering reproductive health services to the population. The number of health workers that were selected and participated in the study was 24 health workers (see Table 2).</p>
<p><strong>Adequate and Qualified Personnel Providing RH Services in Public Health Facilities</strong></p>
<p>The research hypothesis in this study is that the presence of adequate and qualified personnel providing reproductive health services in South Sudan public health facilities significantly influences the uptake and utilization of these services. Several subthemes were established through conducting interviews with the key informants.</p>
<p><em>Adequate Staffing</em></p>
<p>The analysis reveals that the presence of an adequate number of healthcare providers in the public health facilities is crucial for meeting the demand for reproductive health services. Sufficient staffing levels ensure that individuals have timely access to services and reduce waiting times, leading to improved utilization. However, it was established that RH services in selected South Sudan's public health facilities is hindered by having few qualified staff and staff needing refresher training to improve reproductive health service delivery.</p>
<p>The analysis revealed that having a limited number of qualified staff, including doctors, nurses, and midwives, impacted the delivery of RH services. The lack of specialized skills and expertise result in suboptimal service provision and limited capacity to address the diverse needs of individuals seeking RHS in the selected public health facilities. In addition, with the shortage of qualified staff, it was evident that delays and bottlenecks in service delivery were a recurrent theme, leading to longer waiting times and decreased utilization of RHS. For instance, one of the key informants that was interviewed stated that:</p>
<p><em>“The limited availability of qualified personnel can hinder the ability to meet the demand for RHS, thereby affecting uptake and utilization.” (Nurse L.O., 2023)</em></p>
<p>It was also established that due to inadequate staffing levels, the quality of RH services provided was compromised. For instance, participants reported that the lack of qualified staff contributed to cases of errors during pregnancy tests, and reduced adherence to RHS guidelines such as building the capacity at all levels of MOH and partners in order to deliver quality comprehensive reproductive health services, which was found to negatively impact individuals' trust in and utilization of RH services.</p>
<p>Though it was established that personnel working in the selected health facilities had relevant academic qualifications, most of them needed refresher training. Participants argued that when it comes to RH service delivery, the field is continuously evolving, with new research, guidelines, and best practices emerging. Thus, it was important for staff including nurses and midwives, to undergo regular refresher training, since most of the staff knowledge and skills on RHS was considered outdated, it hindered their ability to provide up-to-date and evidence-based RH strategy such as the provision of modern contraceptives. From the interaction with key informants, it was evident that some of the personnel providing RH services in public health facilities had limited confidence and competence. One of the participants stated that: </p>
<p><em>“Nurses and midwives who have not received refresher training lack confidence and competence in certain areas of RH service provision. This results in hesitation, suboptimal decision-making, and a decreased ability to address complex or specialized cases, leading to reduced uptake and utilization of RHS.” (Doctor P.O., 2023)</em></p>
<p>Refresher training ensures that all personnel are aligned with standardized protocols and practices in RH service delivery. Lack of refresher training can result in variations in care provided by different staff members, potentially leading to inconsistencies in service quality and patient experiences. Thus, the research findings suggest that the influence of adequate staffing on the uptake and utilization of RHS in South Sudan's public health facilities is constrained by having few qualified staff and staff needing refresher training. These factors can impact the quality, availability, and consistency of reproductive health services, ultimately affecting individuals' utilization of these services. </p>
<p>For example, the analysis established that there was increased access to skilled birth attendants through the training and recruitment of midwives and training on life-saving skills including an authorization of mid-level cadres namely, nurses, clinical officers, and midwives to function as Clinical Associates (CAs) to provide essential obstetric care and selected life-saving obstetric and neonatal care (task shifting/sharing).</p>
<p>The analysis revealed that having qualified personnel, such as doctors, nurses, midwives, and skilled birth attendants, is essential. These professionals possess the necessary knowledge, skills, and training to provide comprehensive RHS, including family planning, HIV counselling and testing, prevention and management of STIs, and maternal and newborn care. In addition, healthcare providers with appropriate training and skills in RH can effectively address the specific needs and concerns of women seeking RHS. The participants mentioned that training programs and continuing education opportunities will enable health providers to stay updated on best practices and evidence-based approaches, ensuring the delivery of high-quality RH care.</p>
<p><em>Health Workforce Education Level</em></p>
<p>The analysis revealed that healthcare providers with higher education levels, such as advanced degrees in medicine, nursing, or midwifery, bring advanced knowledge and specialized skills to RHS provision. Advanced education equips them with a deeper understanding of RH concepts, research, and evidence-based practices, enabling them to deliver high-quality care. The experts that were interviewed posit that health professionals with higher education levels possess critical thinking abilities and analytical skills, enabling them to make informed decisions and provide comprehensive and individualized RH care. Individualized RH care was further found to contribute to improved utilization of RHS, as women visiting public health facilities felt confident in the expertise of the healthcare provider.</p>
<p>The study also found that having higher education levels empowered healthcare providers to take on leadership roles and engage in advocacy efforts to promote RHS. For instance, doctors and nurses who are well-trained were found to contribute to policy development, program implementation, and community education, which can positively impact the uptake and utilization of RHS. </p>
<p>At the community level, trained mid-level cadres namely, nurses, clinical officers, and midwives. encouraged and supported community and home-based initiatives on life-saving skills. Emphasis was based on building the capacity of other community health workers/groups on health promotion (including referral for deliveries to the Primary health care centres (BHW, 2023).</p>
<p>It was also important to note that, the key informants believed that continuous professional development, including training, workshops, and conferences, helps healthcare providers stay abreast of advancements in RH. </p>
<p><em>“By continuously updating their knowledge and skills, healthcare providers can provide up-to-date and evidence-based RH care, which can enhance the uptake and utilization of reproductive health services. In addition, professional development opportunities that are mainly offered by NGOs, allowed the healthcare providers to refine their skills and learn best practices for health service delivery including RHS (CO, 2023).”</em></p>
<p>The study proposes that by improving the health workforce education level and promoting continuous professional development, the influence of adequate staffing on the uptake and utilization of RHS in South Sudan's public health facilities can be strengthened. Investing in higher education levels and providing opportunities for continuous learning can enhance healthcare providers' knowledge, skills, confidence, and leadership abilities. Consequently, this can improve the quality of RHS, increase patient trust, and positively influence individuals' utilization of these services.</p>
<p><strong>Workload and Salary</strong></p>
<p>The research findings in this study evidenced the fact that the influence of workload and salary issues on the uptake and utilization of RHS in selected South Sudan public health facilities is negatively affected by health workers being overworked and receiving low wages.</p>
<p><em>Workload Issues</em></p>
<p>The analysis revealed that the health workers including nurses, clinical officers, and midwives are overburdened with excessive workload, and have limited time to spend with clients seeking RHS. For instance, one of the clinical officers who was interviewed complained that:</p>
<p><em>“Due to workload issues Clinical Associates (CAs) end up doing rushed consultations and reduced opportunities for thorough assessments and discussions about family planning, antenatal care, HIV testing and counselling or other RHS. As a result, most women visiting public health facilities felt that their concerns are not adequately addressed, leading to decreased utilization of RHS.” (KI-CO, 2023)</em></p>
<p>The study also established that overworked health workers struggle to provide individualized care due to time constraints. They had difficulty tailoring services to meet the specific needs and preferences of each woman visiting the clinic. This results in a standardized approach to care, which may not fully address the unique circumstances and concerns of women, potentially leading to decreased utilization of RHS. Therefore, MOH and other stakeholders should focus on expanding comprehensive RH coverage by developing a priority-oriented focus on RH service delivery and ensuring the best use of resources as well as addressing the unique circumstances and concerns of women of reproductive age.</p>
<p>The analysis also revealed that overworked health workers faced challenges in managing the demand for RHS, leading to longer waiting times for appointments and checkups. Women seeking timely care became discouraged or sought alternative options, especially in modern contraception, resulting in decreased utilization of RHS in public health facilities. It was also established that most of the health workers (doctors, nurses, clinical officers, and midwives) experienced excessive workloads that contributed to delays in service delivery, which were further perceived as inconvenient by the women who were seeking RHS. The perception of prolonged waiting times and service delays discouraged women from utilizing RHS across South Sudan.</p>
<p>Fatigue and burnout also emerged as common themes from the thematic analysis. It was evident from the analysis that most of the health workers felt that they were being overworked which led to fatigue and burnout. One of the doctors who was interviewed pointed that:</p>
<p>“As the only qualified hospital doctor in the health facility, I am extremely overworked, and this is likely to lead to reduced concentration, compromised decision-making, and increased likelihood of errors. This can also lead to suboptimal service delivery and reduced satisfaction among women who are seeking RHS in this health facility.” (KI-MD, 2023)</p>
<p>In addition to fatigue and burnout, it was established that overworking health workers will eventually lead to emotional exhaustion, which can further affect their ability to empathize and communicate effectively with clients who are seeking to use RHS in public health facilities. Indeed, emotional exhaustion can hinder the formation of trust and rapport with women of reproductive age seeking RH services.</p>
<p>The research findings suggest that the influence of workload issues on the uptake and utilization of RHS in South Sudan's public health facilities is negatively affected by health workers being overworked. By examining the challenges related to workload issues, the findings of this study can inform strategies to address these issues. For instance, increasing access to skilled health workers through training and recruitment of midwives and training on RH skills including an authorization of mid-level cadres namely, nurses, clinical officers, and midwives to function as CAs to provide essential RH services. Ultimately, addressing workload issues can enhance the uptake and utilization of RHS in South Sudan through workforce planning, task-shifting, sharing, and workload redistribution.</p>
<p><em>Salary Issues</em></p>
<p>The analysis established that the influence of salary issues on the uptake and utilization of RHS in selected South Sudan public health facilities is negatively affected by health workers being paid low wages and feeling that they are unfairly compensated for the amount of work done. For instance, the key informant stated that: </p>
<p><em>“Most of the health workers complained that they are receiving low wages that may lead to experiencing a lack of motivation and job satisfaction. The perception of being undervalued and under-compensated can negatively impact their dedication to providing high-quality RHS, further resulting in decreased motivation to go above and beyond, potentially affecting the utilization of RHS (MW, 2023).”</em></p>
<p>The analysis also revealed that being paid a low salary contributed to overall job dissatisfaction among the health workers in public health facilities, creating feelings of frustration, leading to reduced job engagement, as well as decreased enthusiasm for delivering RHS. </p>
<p><em>“Low wages contributed to higher turnover rates among health workers in the public health facilities. Most of the health professionals are likely to seek better opportunities elsewhere or opt for alternative employment. The frequent turnover among trained and skilled health workers is likely to disrupt the continuity of care and decrease clients' trust and confidence in the RHS provided in the public health facilities.” (PHO, 2023)</em></p>
<p>The study established that some of the health workers who were working in the selected RH clinics believed that they were being paid low salaries, and a result created the perception that RHS are undervalued within the healthcare system. This perception can impact the community's trust and confidence in the quality of care provided, resulting in decreased utilization of reproductive health services. In addition, one of the participants stipulated that:</p>
<p><em>“Health workers who feel undervalued may be less inclined to invest their time and effort in enhancing their skills and knowledge, leading to stagnation in service delivery including RH services.” (MW, 2023)</em></p>
<p>According to the participants addressing salary issues and ensuring fair compensation for health workers can lead to increased motivation, job satisfaction, and retention rates. Adequate wages can also contribute to improved quality of care and increased trust from women who are seeking RHS in public health facilities. The findings of this study can guide policymakers and stakeholders in implementing interventions to improve the financial compensation of health workers, particularly those working in RH clinics, and address the salary disparities, thereby positively impacting the uptake and utilization of RHS in South Sudan public health facilities.</p>
<h3>Discussion</h3>
<h4>Influence of Health Facility Characteristics on Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities</h4>
<p>The study found that 57.8% of the women were aware of the nearest RH clinic in the region, while 42.3% reported a lack of awareness. This indicates that there is a significant proportion of women who may not have knowledge about the availability of reproductive health services in their vicinity. Previous studies (Binu et al., 2018; and Helamo et al., 2017). also show a significant proportion of women lacking knowledge, for instance, lack of access to information about what RH services are available and where to seek service. They also found that young women who lacked knowledge of the type of RHS were not more likely to utilize the service than their counterparts. Lack of awareness can be a barrier to seeking and utilizing these services, as women may not know where to go or what services are offered. Increasing awareness through community outreach, education campaigns, and improved information dissemination can help address this issue.</p>
<p>The study examined the distance between women's households and the nearest RHS center. The findings showed that most women (33.3%) reported that public health facilities offering RHS were within 3 km from their households, while 22.8% reported that the facilities were within 0.5 km. However, over 45.8% of the women reported living outside the 2 km radius distance from the nearest RHS clinic. Study by Kane, Kok, et al. (2016) conducted in South Sudan also indicates that many women and girls live too far away to access emergency care or live on the other side of frontlines of conflict, making it too hazardous to travel to the facilities. In most cases RHS is not available in conflict-affected areas except in rare instances. This suggests that a significant number of women may face challenges accessing RHS due to long distances. Long travel distances can deter women from seeking care, particularly in rural areas with limited transportation options. To improve accessibility, efforts should be made to establish more health facilities or outreach services in underserved areas, particularly those far from existing clinics.</p>
<p>The study further investigated the relationship between the provision of specific RHS and the uptake of these services. The findings revealed that the provision of IUDs showed a highly significant relationship with the uptake and utilization of RHS. The odds ratio of 10.473 suggests that the provision of IUDs is associated with a 10.473 times higher likelihood of uptake and utilization of RHS compared to not providing IUDs. Studies across Africa show that IUD’s share of modern method mix is pitifully small, at less than 5%, in 63 countries and only5–9% in a further 32 countries as noted in a previous study (Cleland, Benova, and Daniele, 2017). This current finding highlights the importance of making IUDs available as a contraceptive option to promote RHS utilization.</p>
<p>The provision of oral contraceptives also demonstrated a highly significant relationship with the uptake and utilization of RHS. The odds ratio of 33.060 suggests that the provision of oral contraceptives is associated with a 33.060 times higher likelihood of uptake and utilization of RHS compared to not providing oral contraceptives. Previous studies (Cottingham, Germain, and Hunt, 2012: and World Health Organization, 2012) support this finding by stipulating that unmet need for contraception remains high in many settings, and is highest among the most vulnerable in society including those living in rural areas. This finding underscores the importance of ensuring access to oral contraceptives as an essential component of RHS. In addition, the provision of spermicidal agents also demonstrated a statistically significant relationship with the uptake and utilization of reproductive health services. These findings suggest that offering a range of contraceptive options, including spermicidal agents, can contribute to increased RHS utilization.</p>
<p>A previous study conducted by Kane et al. (2016) in South Sudan, established that the provision of family planning, including injectables, is largely unavailable in the majority of the States, largely due to the overall gaps in health infrastructure and services, and in part because the major healthcare provider does not provide contraception. The current study evidenced that the provision of injectables showed a statistically significant relationship with the uptake and utilization of reproductive health services. However, the odds ratio of 0.213 suggests that the provision of injectables is associated with a 0.213 times lower likelihood of uptake and utilization of RHS compared to not providing injectables. This finding suggests that factors such as availability, awareness, and preferences regarding contraceptive methods may influence the utilization of injectables.</p>
<p>These findings emphasize the importance of the availability and provision of a diverse range of RHS to meet the varied needs and preferences of women. It highlights the significance of including contraceptives like IUDs, oral contraceptives, injectables, and spermicidal agents as part of the service package in public health facilities. By expanding the range of available services and ensuring their accessibility, the uptake and utilization of RHS can be improved, leading to better RH outcomes for women in South Sudan.</p>
<h4>Influence of Health Workforce on Uptake and Utilization of RHS In Selected South Sudan’s Public Health Facilities</h4>
<p>The analysis revealed that the presence of an adequate number of healthcare providers in public health facilities is crucial for meeting the demand for reproductive health services and improving utilization. Sufficient staffing levels ensure timely access to services and reduce waiting times. However, the study found that the RH services in selected South Sudan's public health facilities were hindered by having few qualified staff and a need for refresher training. Previous studies support these findings by showing evidence of a direct and positive link between the number of health workers and population health outcomes (WHO, 2010). This limitation in the workforce resulted in suboptimal service provision and a limited capacity to address the diverse needs of women seeking RHS.</p>
<p>The analysis highlighted the importance of healthcare providers' qualifications and education levels in the delivery of reproductive health services. The study found that healthcare providers with higher education levels, such as advanced degrees in medicine, nursing, or midwifery, bring advanced knowledge and specialized skills to the provision of reproductive health services. Previous studies (Kane, Kok, et al., 2016) conducted in South Sudan support this finding, they established that pregnant women have extremely limited access to skilled health providers in public health facilities. These providers are better equipped to meet the diverse needs of individuals seeking RHS and are empowered to take on leadership roles and engage in advocacy efforts to promote reproductive health.</p>
<p>The analysis revealed that healthcare providers, including nurses, clinical officers, and midwives, were overburdened with excessive workloads. This excessive workload resulted in limited time to spend with clients seeking RHS, which compromised the quality of care provided. Previous studies (Kane, Kok, et al., 2016: and Belaid et al., 2020) found that insecurity in some part of Central Equatoria and Western Equatoria State have led to a lack of staff and thus hindering women from accessing healthcare, including making antenatal visits. In addition, overworked health workers faced challenges in managing the demand for RHS, leading to longer waiting times for appointments and checkups. These findings suggest that workload issues negatively impact the uptake and utilization of RHS in South Sudan's public health facilities.</p>
<p>The analysis found that health workers in selected public health facilities perceived low salaries and felt unfairly compensated for the amount of work they performed. The low salary levels contributed to overall job dissatisfaction among the health workforce, leading to reduced job engagement and decreased enthusiasm in delivering reproductive health services. Previous studies (WHO, 2010a) further revealed that the ability of a country to meet its health goals depends largely on motivation and financial compensation of the people responsible for organizing and delivering healthcare services. Thus, the perception of low salaries created the notion that reproductive health services are undervalued within the healthcare system. This finding suggests that salary issues negatively affect the uptake and utilization of RHS.</p>
<p>In conclusion, the findings highlight several workforce-related factors that influence the uptake and utilization of reproductive health services in South Sudan's public health facilities. These factors include having an adequate number of qualified staff, staff with higher education levels, manageable workloads, and fair compensation for healthcare providers. Addressing these workforce challenges is crucial to improving the delivery of reproductive health services and ensuring better access and utilization of these services by women of reproductive age in South Sudan. Policy measures should focus on recruiting and retaining qualified staff, providing opportunities for professional development and training, improving working conditions, and offering fair compensation to healthcare providers in order to strengthen the reproductive health workforce and enhance service delivery.</p>
<h3>Conclusions</h3>
<p>The study revealed significant insights into the factors influencing the uptake and utilization of RHS in South Sudan's public health facilities. The examination of health facility characteristics on RHS uptake indicated that awareness of available services, proximity to health facilities, and the provision of specific contraceptives significantly impacted utilization. Additionally, the influence of the health workforce on RHS utilization highlighted the importance of staffing levels, healthcare providers' qualifications, workload management, and fair compensation in facilitating or hindering service utilization.</p>
<p>The findings underscore the critical need for targeted interventions for RHS utilization in South Sudan. Increasing awareness through community outreach, educating women about available services, and enhancing information dissemination are crucial steps to address the lack of awareness among women regarding nearby RH clinics. Moreover, efforts to establish more health facilities or outreach services in remote areas could mitigate the challenges faced due to long travel distances, ensuring better accessibility to RHS. The study emphasizes the significance of including a diverse range of contraceptives such as IUDs, oral contraceptives, injectables, and spermicidal agents as part of the service package in public health facilities. This approach caters to varying preferences and needs, potentially enhancing RHS utilization. Furthermore, the study highlights the necessity of maintaining an adequate number of qualified healthcare providers, managing their workloads, and providing fair compensation to enhance service delivery and improve access to RHS.</p>
<p>The study faced certain limitations, including potential biases in participant selection due to the sampling method employed. The reliance on self-reported data might have introduced response biases, impacting the accuracy of the findings. Additionally, the study's scope focused on selected regions of South Sudan, limiting the generalizability of the results to the entire country. Furthermore, contextual factors such as ongoing conflicts or geopolitical situations might have influenced the availability and accessibility of reproductive health services.</p>
<p>Future research endeavours should aim to conduct comprehensive studies encompassing a broader geographical area within South Sudan, considering diverse socio-economic and cultural contexts. Longitudinal studies tracking changes in reproductive health service utilization over time could provide valuable insights into trends and variations. Exploring the impact of specific interventions, such as awareness campaigns or infrastructure improvements, on RHS utilization could guide targeted policy interventions. Furthermore, in-depth qualitative studies involving healthcare providers and community members could offer nuanced perspectives on barriers and facilitators to RHS utilization. Additionally, examining the role of technology, telemedicine, or mobile health interventions in improving access to reproductive health services among remote populations warrants exploration.</p>
<h5><strong>Acknowledgements:</strong></h5>
<p>This study was made possible through the support of my supervisors Dr. Alfred Owino Odongo and Dr. John Kariuki, and my colleagues within the Ministry of Health, particularly my fellow Public Health Officers and Surveillance Officers. Their support is acknowledged.</p>
<h6>Funding Acknowledgements:</h6>
<p>The author(s) received no financial support for the research, authorship, and/or publication of this article.</p>
<h6>Competing Interests:</h6>
<p>Author(s) declares there were no competing interests.</p>
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<p> </p>
<p> </p>
<p><img src="https://pachodo.org/images/Health_facility_and_workforce_factors_influencing_utilization_of_reproductive_health_services_in_selected_South_Sudan_public_health_facilities0.jpg" alt="Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities" title="Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities" /></p>
<p><img src="https://pachodo.org/images/Health_facility_and_workforce_factors_influencing_utilization_of_reproductive_health_services_in_selected_South_Sudan_public_health_facilities1.jpg" alt="Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities 2" title="Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities 2" /></p>
<p><em>(Images: Supplied)</em></p>
<p> </p>
<p><em><strong>By DR. Emmanuel Timothy Thwol Onak (PhD)</strong></em></p>
<h3> </h3>
<h3>Abstract</h3>
<p>Background: Despite Africa's representation of only one-tenth of the global population and 20% of worldwide births, nearly half of all maternal deaths occur in this region. Reproductive health issues account for up to 18% of the global disease burden and 32% of the total burden for women of reproductive age (WHO Africa, 2020). Access to crucial reproductive health (RH) interventions, particularly family planning, remains restricted, characterized by low contraceptive use (13%) and a high total fertility rate (5.5 children per woman) in Sub-Saharan Africa (WHO, 2021).</p>
<p>Method: This study employed a mixed-method research design, which integrated both quantitative and qualitative research approaches to provide a comprehensive understanding of the topic, The mixed-method design enabled the research to capture the richness and depth of the phenomenon under investigation while also allowing for quantitative analysis to identify patterns, trends, and relationships within the data.</p>
<p>Results: The research findings illustrate key aspects of reproductive health service utilization among women in South Sudan. A significant percentage of women were aware of the nearest RH clinic; however, around 42.3% lacked awareness. Accessibility to RH services was notably limited, with over 45.8% of women living beyond a 2 km radius from the nearest RH clinic. The mean distance from households to the nearest RH centre was 2.2 km, indicating substantial distance barriers. The study revealed statistically significant relationships between health facility characteristics (such as RHS accessibility, hospital classification, revenue resources, NGO affiliation, and provision of modern contraceptives) and the use of reproductive health services. Additionally, interviews with key informants highlighted the importance of healthcare providers' higher education levels in enhancing specialized skills, critical thinking, and the delivery of comprehensive and individualized RH care, ultimately influencing RHS utilization positively. Conversely, findings indicated that overworked health workers receiving low wages negatively impacted the uptake and utilization of RHS in South Sudan's public health facilities, suggesting the pivotal role of fair compensation and manageable workloads in enhancing service utilization.</p>
<p>Conclusions: The study yielded significant insights into the factors influencing RHS uptake in South Sudan's public health facilities. It highlighted the impact of health facility characteristics, including awareness of services, proximity to facilities, and available contraceptives, on RHS utilization. Similarly, the health workforce's influence, encompassing staffing levels, qualifications, workload management, and fair compensation, emerged as crucial determinants affecting service utilization. To enhance RHS utilization, targeted measures such as community outreach to raise awareness, expanding health facilities in remote areas, and offering a diverse range of contraceptives were suggested. Limitations, including sampling biases and regional focus, need consideration, while future research should explore broader geographical areas, longitudinal trends, specific interventions' impacts, and technology's role in improving RHS access for remote populations. Qualitative studies involving stakeholders could offer deeper insights into barriers and facilitators to RHS utilization, guiding more effective policy interventions.</p>
<h3>Introduction</h3>
<p>The healthcare system comprises a network of production units aimed at enhancing the population's health status. Primary healthcare and its associated facilities serve as the gateway to advanced care levels (Murray & Frenk, 1999). Evaluating health system performance commonly involves analyzing care delivery components, which sheds light on the efficacy and efficiency of service provision (Olafsdottir et al., 2011). Measurement of health system functioning encompasses cost-effective analysis, technical efficiency, and allocative efficiency.</p>
<p>The World Health Organization (WHO) predicts a projected deficit of 12.9 million skilled healthcare workers by 2035, primarily concentrated in Africa and Southeast Asia due to low remuneration and insufficient incentives, potentially leading to a departure of 40% of health professionals within the next decade (Global Health Workforce Alliance and World Health Organization, 2013). This trend, exacerbated by internal and international health worker migrations, worsens regional disparities in healthcare staffing. The evolution of medical technology and the demand for advanced care underscore the need for a more proficient healthcare workforce. WHO emphasizes the pivotal role of health workers as the backbone of healthcare systems, responsible for care delivery, program management, and crisis response (Dieleman & Harnmeijer, 2006).</p>
<p>The utilization of health services significantly influences health outcomes, particularly in resource-limited rural regions, such as rural sub-Saharan Africa, where access to health services profoundly impacts health utilization patterns (Tanser et al., 2006). Enhancing health service accessibility is vital for improving quality of life, reducing health disparities, and better serving target populations, necessitating a comprehensive understanding and assessment of healthcare access and its spatial variations for effective resource allocation and program planning.</p>
<p>Despite Africa's representation of only one-tenth of the global population and 20% of worldwide births, nearly half of all maternal deaths occur in this region. Reproductive health issues account for up to 18% of the global disease burden and 32% of the total burden for women of reproductive age (WHO Africa, 2020). Access to crucial reproductive health (RH) interventions, particularly family planning, remains restricted, characterized by low contraceptive use (13%) and a high total fertility rate (5.5 children per woman) in Sub-Saharan Africa (WHO, 2021).</p>
<p>In the context of South Sudan, limitations in capacity and a challenging governance environment significantly impede the implementation of basic health services and governmental policies. Reports suggest persistent inadequacies in building government capacity (Larson et al., 2013). Moreover, economic and social challenges, encompassing health budget cuts, inflation, and food insecurity, further compound these difficulties (Integrity, 2018; IPC, 2018). The economic crisis has adversely affected programs, including reproductive health services, funded by external donors (Integrity, 2018). Consequently, the utilization and adoption of RH services in South Sudan are intricately linked to these multifaceted challenges, heightening the critical nature of this issue.</p>
<p>While global health outcomes have exhibited improvement over the past two decades, South Sudan has also experienced substantial progress, notably a reduction in maternal mortality, neonatal mortality, infant mortality, and under-five stunting (World Bank, 2018). Access to Reproductive Health Services (RHS), such as antenatal care and contraception, has shown significant improvement in Sub-Saharan Africa (United Nations, 2015). Nonetheless, access to healthcare, particularly RH services, remains a significant hurdle in South Sudan, largely due to ongoing conflicts and an unstable peace process (Pendle, 2014). The East African region, including nations like Uganda, Tanzania, and Kenya, continues to grapple with high maternal mortality rates compared to developed countries, emphasizing the urgent need for enhanced RH services (UNICEF, 2016). Low usage of modern contraceptives and unmet family planning needs affect a considerable proportion of married women in this region (United Nations, 2015).</p>
<p>South Sudan faces multifaceted challenges in its healthcare system, notably concerning reproductive health services. These challenges are compounded by capacity limitations, a challenging governance environment, ongoing conflicts, and external economic pressures, which have adversely affected the implementation and accessibility of basic health services, including reproductive health interventions. As a consequence, the uptake and utilization of RHS within the country are intricately tied to these complex healthcare, economic, and sociopolitical dynamics. The purpose of this study is to examine and assess the influence of health facility characteristics and the health workforce on the uptake and utilization of Reproductive Health Services (RHS) within selected public health facilities in South Sudan. Specifically, the research aims to scrutinize how varying health facility attributes and workforce dynamics impact the access, adoption, and utilization of essential reproductive health interventions among the population.</p>
<p>Understanding the nuanced relationship between health facility characteristics, the health workforce, and the utilization of RHS is imperative to address the persisting barriers and challenges faced by South Sudan's healthcare system. This study seeks to fill the existing research gap by offering an in-depth exploration of these determinants and their impact on reproductive health service accessibility and utilization. By identifying key influencers affecting the uptake of RHS, the study aims to provide evidence-based recommendations for policy formulation, resource allocation, and program planning to enhance reproductive health outcomes in South Sudan.</p>
<h3>Methods</h3>
<p>This study employed a mixed-method research design, which integrates both quantitative and qualitative research approaches to provide a comprehensive understanding of the topic, The mixed-method design enabled the research to capture the richness and depth of the phenomenon under investigation while also allowing for quantitative analysis to identify patterns, trends, and relationships within the data.</p>
<p>The quantitative data was collected from women of reproductive age visiting selected public health facilities during the study period. A structured questionnaire with only closed-ended questions was developed as the primary research instrument, focusing on the influence of health facility characteristics on the uptake and utilization of RHS. The qualitative data, on the other hand, was collected from the key informants who are knowledgeable about RHS. An interview guide with open-ended questions was used to establish the influence of the health workforce on the uptake and utilization of RHS.</p>
<p>The study's theoretical foundation primarily relies on two established theories: the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These theories have been extensively employed in previous research to elucidate and forecast the utilization and adoption of reproductive health services.</p>
<p>The Health Belief Model (HBM) emphasizes individual subjective beliefs that shape decision-making processes. It incorporates elements such as perceived susceptibility, severity, benefits, barriers, and cues to action. In prior studies, these constructs were instrumental in constructing a predictive model for risky sexual practices among college students, effectively elucidating variations in risk behaviours and sexual partnerships. On the other hand, the Theory of Reasoned Action (TRA) provides a framework for examining attitudes toward behaviours, aiming to predict and comprehend individual actions. This theory operates under the assumption that individuals act rationally, considering available information and potential outcomes before making decisions. Key components of TRA include behaviour, intention, and personal attitude. In this context, intention stands as the primary influencer of behaviour, with stronger intentions indicating a higher probability of engaging in a specific behaviour.</p>
<p>The utilization of these theories within the context of this study aims to assess how health facility characteristics and the health workforce influence the uptake and utilization of Reproductive Health Services (RHS) in selected South Sudan public health facilities. By applying the principles of HBM and TRA, the study endeavours to elucidate the mechanisms and influences behind the utilization patterns of reproductive health services within the specified healthcare settings.</p>
<p><strong>Study sites</strong></p>
<p>The research was conducted within public health facilities situated in two specific states of South Sudan: Western Equatoria and Central Equatoria. In South Sudan, the majority of the population resides in rural areas, constituting roughly 83% of the total populace. Rural areas are characterized by a sparse population density of approximately 15 individuals per square kilometre. Challenges in healthcare service delivery arise from this low density, along with the presence of mobile pastoral communities and restricted access due to prolonged conflicts.</p>
<p>The data collection process encompassed all four tiers of the South Sudan health system, incorporating the Boma Health Teams at the community level, Primary Healthcare Units (PHCU), Primary Healthcare Centers (PHCC), and hospitals. These healthcare facilities are strategically distributed across the administrative subdivisions of the country, catering to both rural and urban regions (Ministry of Health, 2012; WHO South Sudan, 2020).</p>
<p><strong>Sampling, recruitment of study participants and data collection</strong></p>
<p>Sampling, recruitment of study participants, and data collection procedures were conducted within public health facilities situated in Western Equatoria and Central Equatoria. A multi-stage cluster random sampling method was employed for quantitative data collection, involving two distinct stages: the selection of health facilities and the subsequent identification of participants.</p>
<p>Initially, health facilities were selected within each state by creating a comprehensive list of public health facilities. From this list, specific facilities were chosen using a systematic random sampling method. A minimum of three public health facilities were randomly selected in each state. Subsequently, the selection of participants utilized a probability proportionate to size approach. Population lists, such as the 2018 census detailing women aged 15 to 49 in the selected states, were employed. The sampling interval was calculated by dividing the total population of the program area by the number of women in the specified age group visiting health facilities. A systematic random start number was used to identify the first client, followed by subsequent selections based on the sampling interval until the required number of participants was reached.</p>
<p>For key informants knowledgeable about Reproductive Health Services (RHS), a snowball sampling method was utilized. Prior notification of interviews was sent to key informants via letter, followed by confirmation through telephone communication. Appointments were scheduled for interviews and Focus Group Discussions (FGDs).</p>
<p>The responsibility for field data collection and management was assumed by the researcher. Prior to data collection, comprehensive training sessions were conducted for five research assistants (RAs). RAs were trained on the study's objectives, methodologies, and the administration of data collection tools. Training encompassed tool review, practical exercises, ethical considerations, data confidentiality protocols, and logistical aspects.</p>
<p>Written consent was obtained from participants before the interviews, ensuring the confidentiality of their information. Interviews commenced with an introduction by the interviewer, outlining their identity, organizational affiliation, and the study's objectives. Face-to-face interviews were conducted using the designated data collection tools.</p>
<p><strong>Data analysis</strong></p>
<p>The data derived from the questionnaires underwent a comprehensive data analysis process. Initially, all data were entered into a computer file using Microsoft Excel Spreadsheet. Subsequently, the data were exported to IBM Statistical Package for the Social Sciences (SPSS) version 23, where all sub-files were amalgamated into one master file for further analysis. The initial phase of data analysis was data preparation, which involved transforming raw data into a comprehensible and meaningful format. This process included data validation, editing, and coding.</p>
<p>Various statistical techniques were then employed to identify significant correlations between variables and assess the impact of one variable on another. Descriptive statistics, such as mean, median, mode, percentage, frequency, and range, were utilized to gain an overview of the data. Descriptive statistics are particularly valuable when the scope of the research is confined to the sample and does not necessitate generalization to a larger population. For example, when comparing the percentage of youth utilizing RHS in different states, descriptive statistics provide sufficient insights. Subsequently, cross-tabulations were utilized to delve deeper into the dataset. Cross-tabulations are a means to elucidate the relationship between two variables and are commonly employed to compare outcomes across demographic groups. They allow for the examination of results based on factors like age and the utilization of RHS.</p>
<p>To assess hypotheses, the researcher calculated measures of statistical significance, which ascertain whether findings are statistically meaningful or merely the result of chance. Statistical significance was indicated by the p-value statistic. Typically, a p-value of less than 0.05 is considered statistically significant, signifying a less than 5% probability that the results occurred by chance. Furthermore, the researcher applied various inferential analyses, including correlation, regression, and analysis of variance where relevant. Linear regression was employed, for instance, to predict the value of one variable based on another. This approach allowed the exploration of whether the utilization of RHS could be predicted based on factors like climate change or socio-cultural characteristics.</p>
<p>The researcher conducted preliminary content analysis of the qualitative data to identify any common patterns and trends arising from the narratives regarding: a) the influence of health facility characteristics on the uptake and utilization of RHS; and b) the influence of the health workforce on the uptake and utilization of RHS. This involved drawing connections between themes and discussing their implications.</p>
<p><strong>Ethical considerations</strong></p>
<p>Ethical considerations were paramount throughout the course of this study. Prior to the commencement of data collection, the researcher diligently sought ethical approval from the Division of Research, Monitoring and Evaluation within the Directorate of Planning and Coordination at the Ministry of Health, as well as the Research Ethics Committee (REC) of the Republic of South Sudan. Additional approvals were obtained from the Institutional Ethical Review Committee (IERC) of Mount Kenya University. In accordance with ethical standards, formal permissions were also secured from the respective sectoral and departmental heads, including the Ministry of Health and Local Governments within the Republic of South Sudan, to access public health facilities and other relevant offices.</p>
<p>The participants who willingly consented to take part in the study were assured of strict anonymity and confidentiality. These measures were implemented to safeguard their identities and instil confidence in the research process, thereby promoting the provision of accurate information. Furthermore, participants were granted the unequivocal right to exercise their free will, allowing them to decide whether they wished to participate in the research. The option of withdrawal from the study was extended to participants at any point, without the requirement to provide a reason. This opportunity was explicitly communicated to participants before the commencement of interviews and was also documented in writing.</p>
<p>In adhering to high ethical standards and principles for research, the study conformed to data collection, security, and protection requirements. Special consideration was also given to adaptations necessary to comply with COVID-19 control regulations. The risk level to both the research team and the communities was identified, and all personnel and participants were provided with essential protective equipment to mitigate risks effectively.</p>
<h3>Results</h3>
<h4>Influence of Health Facility Characteristics on Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities</h4>
<h5>Quantitative Analysis</h5>
<p><strong>Awareness of the Nearest Reproductive Health Clinic</strong></p>
<p>The respondents asked whether they were aware of the nearest RH clinic in the region. Figure 1 shows that most of the women (57.8%) were aware of the nearest RH clinic with 42.3% of women reporting a lack of awareness of the nearest RH clinic.</p>
<p><img src="https://lh7-us.googleusercontent.com/6MGfxIxor3kR3vTtyl5FoSN5XY6Yeeuo1ZoPJV1FdixihiMz_tUugHOlvu-do2wk8oOdeC-28zYtd7Y3GP--i704vXDuH_AhWMdGuKaVHnH5erCipZ1iEC_APWc0RHLBuZTWUbwHQO5OmSzC3XxA" alt="" width="627" height="366" /></p>
<p><strong>Figure 1:</strong> Awareness of the nearest RH clinic</p>
<p><strong>Source:</strong> Research Data (2023)</p>
<p><em>Distance to the Nearest RH Clinic</em></p>
<p>Most of the women (33.3%, 133) reported that public health facilities offering RHS were within 3 km from their households with 22.8% of women reporting that there were public health facilities offering RHS within 0.5 km (Figure 2). Women who lived within 2 km radius distance from the nearest RH service clinic and from their home less than 30 minutes walking distance were classified as having high geographical accessibility and low otherwise. Thus, over 45.8% of the women reported living outside 2 km radius distance from the nearest RH service clinic. The overall, mean distance to the nearest RHS centre from your household was 2.2 km.</p>
<p><img src="https://lh7-us.googleusercontent.com/blSm_bJK5MCmtnK2IYjytM-yUkVtn83kATF6rsdCB-TEstF9ssIVffNGRNfSS2kFA-fILb5ghpGpevax0nvFJopBltxXks_2s6IS2uIsgNYhl0vttw72QXlR6BXa9Q5_BTDOzPtTOn9ZmVPNRRI6" alt="" width="630" height="384" /></p>
<p><strong>Figure 2:</strong> Mean total PH facilities offering RHS within 0.5 to 5 km (range)</p>
<p><strong>Source:</strong> Research Data (2023)</p>
<p><em>Health Facility Characteristics Associated with RH Services Utilization</em></p>
<p>Based on the provided research findings in Table 1, the relationship between health facility characteristics (RHS accessibility, hospital classification, revenue resources and NGO affiliation, and provision of modern contraceptives) and use of reproductive health services shows some statistically significant results. </p>
<p>Relationship between the provision of intrauterine devices and uptake/utilization of reproductive health services: the p-value of 0.000 indicates a highly significant relationship between the provision of intrauterine devices and the uptake/utilization of reproductive health services. The odds ratio of 10.473 suggests that the provision of intrauterine devices is associated with a 10.473 times higher likelihood of uptake and utilization of reproductive health services compared to not providing intrauterine devices.</p>
<p>Relationship between provision of oral contraceptives and uptake/utilization of reproductive health service: the p-value of 0.000 indicates a highly significant relationship between the provision of oral contraceptives and the uptake/utilization of reproductive health services. The odds ratio of 33.060 suggests that the provision of oral contraceptives is associated with a 33.060 times higher likelihood of uptake and utilization of reproductive health services compared to not providing oral contraceptives. However, the wide range of the confidence interval (7.444 to 146.827) suggests some uncertainty in estimating the true odds ratio, but it still supports the notion that the odds of experiencing the outcome are significantly higher in the exposed group.</p>
<p>Table 1: Health facility characteristics associated with RH services utilization among women of reproductive age</p>
<table border="1">
<tbody>
<tr>
<td>
<p><strong>Variables</strong></p>
</td>
<td>
<p><strong>User of RH services</strong></p>
<p>n (%)</p>
<p>n = 290</p>
</td>
<td>
<p><strong>Non-user of RH services</strong></p>
<p>n (%)</p>
<p>n = 110</p>
</td>
<td>
<p><strong>OR</strong></p>
<p><strong>(95% CI)</strong></p>
</td>
<td>
<p><strong>P Value</strong></p>
</td>
</tr>
<tr>
<td>
<p><strong>Hospital classification</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Hospital (State, Teaching, and County)</p>
</td>
<td>
<p>101(34.8)</p>
</td>
<td>
<p>40 (36.4)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Primary Health Care Unit/Centre</p>
</td>
<td>
<p>189 (65.2)</p>
</td>
<td>
<p>70 (63.6)</p>
</td>
<td>
<p>1.178 (0.476-2.916)</p>
</td>
<td>
<p>0.723</p>
</td>
</tr>
<tr>
<td>
<p><strong>RHS accessibility</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Living within 2 km radius</p>
</td>
<td>
<p>160 (55.2)</p>
</td>
<td>
<p>57 (51.8)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Living outside 2 km radius</p>
</td>
<td>
<p>130 (44.8)</p>
</td>
<td>
<p>53 (48.2)</p>
</td>
<td>
<p>0.916 (0.429-1.956)</p>
</td>
<td>
<p>0.820</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Additional revenue resources & NGO affiliation </strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes</p>
</td>
<td>
<p>99 (34.1)</p>
</td>
<td>
<p>39 (35.5)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No</p>
</td>
<td>
<p>191 (65.9)</p>
</td>
<td>
<p>71 (64.5)</p>
</td>
<td>
<p>0.681 (0.271-1.709)</p>
</td>
<td>
<p>0.413</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Provision of intrauterine devices</strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes</p>
</td>
<td>
<p>105 (36.2)</p>
</td>
<td>
<p>71 (64.5)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No </p>
</td>
<td>
<p>185 (63.8)</p>
</td>
<td>
<p>39 (35.5)</p>
</td>
<td>
<p>10.473 (3.992-27.472)</p>
</td>
<td>
<p>0.000**</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Provision of oral contraceptives</strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes </p>
</td>
<td>
<p>203 (70.0)</p>
</td>
<td>
<p>108 (98.2)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No</p>
</td>
<td>
<p>87 (30.0)</p>
</td>
<td>
<p>2 (1.8)</p>
</td>
<td>
<p>33.060 (7.444 -146.827)</p>
</td>
<td>
<p>0.000**</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Provision of condoms (male & female)</strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes</p>
</td>
<td>
<p>206 (71.0)</p>
</td>
<td>
<p>89 (80.9)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No</p>
</td>
<td>
<p>84 (29.0)</p>
</td>
<td>
<p>21 (19.1)</p>
</td>
<td>
<p>0.993 (.466-2.116)</p>
</td>
<td>
<p>0.986</p>
</td>
</tr>
<tr>
<td>
<p><strong>Provision of injectables</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes</p>
</td>
<td>
<p>125 (43.1)</p>
</td>
<td>
<p>65 (59.1)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No</p>
</td>
<td>
<p>165 (56.9)</p>
</td>
<td>
<p>45 (40.9)</p>
</td>
<td>
<p>0.213 (0.074-0.613)</p>
</td>
<td>
<p>0.004**</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Provision of emergency contraceptive pills</strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes</p>
</td>
<td>
<p>258 (89.0)</p>
</td>
<td>
<p>78 (70.9)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No</p>
</td>
<td>
<p>32 (11.0)</p>
</td>
<td>
<p>32 (29.1)</p>
</td>
<td>
<p>0.453 (0.187-1.101)</p>
</td>
<td>
<p>0.080</p>
</td>
</tr>
<tr>
<td colspan="3">
<p><strong>Provision of spermicidal agents</strong></p>
</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Yes </p>
</td>
<td>
<p>58 (20.0)</p>
</td>
<td>
<p>40 (36.4)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>No </p>
</td>
<td>
<p>232 (80.0)</p>
</td>
<td>
<p>70 (63.6)</p>
</td>
<td>
<p>3.171 (1.496-6.720)</p>
</td>
<td>
<p>0.003**</p>
</td>
</tr>
</tbody>
</table>
<p><strong>Source:</strong> Research Data (2023)</p>
<p><em>**. Correlation is significant at the 0.01 level</em></p>
<p><em>*. Correlation is significant at the 0.05 level</em></p>
<p>Relationship between provision of injectables and uptake/utilization of reproductive health service: the p-value of 0.004 suggests a statistically significant relationship between the provision of injectables and the uptake/utilization of reproductive health services, though with a slightly lower level of significance compared to the previous two relationships. The odds ratio of 0.213 indicates that the provision of injectables is associated with a 0.213 times lower likelihood of uptake and utilization of reproductive health services compared to not providing injectables.</p>
<p>Relationship between the provision of spermicidal agents and uptake/utilization of reproductive health services: the p-value of 0.003 suggests a statistically significant relationship between the provision of spermicidal agents and the uptake/utilization of reproductive health services. The odds ratio of 3.171 indicates that the provision of spermicidal agents is associated with a 3.171 times higher likelihood of uptake and utilization of reproductive health services compared to not providing spermicidal agents.</p>
<p><strong>Influence of Health Workforce on Uptake and Utilization of RHS In Selected South Sudan’s Public Health Facilities</strong></p>
<p>This section presented a qualitative analysis of workforce variables (level of education, cadre or academic qualification, workload, and salary) that are likely to influence the uptake and utilization of RHS in the selected public health services.</p>
<p>Table 2: Socio-demographic characteristics of the health workers in selected public health facilities</p>
<table border="1">
<tbody>
<tr>
<td>
<p><strong>Variable </strong></p>
</td>
<td>
<p><strong>Category</strong></p>
</td>
<td>
<p><strong>Frequency</strong></p>
</td>
</tr>
<tr>
<td rowspan="2">
<p>State </p>
</td>
<td>
<p>Central Equatoria</p>
</td>
<td>
<p>14</p>
</td>
</tr>
<tr>
<td>
<p>Western Equatoria</p>
</td>
<td>
<p>10</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Cadre</p>
</td>
<td>
<p>Clinicians (Medical doctor/Public health officer)</p>
</td>
<td>
<p>5</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Nurses</p>
</td>
<td>
<p>6</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Midwives</p>
</td>
<td>
<p>4</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Clinical Officers</p>
</td>
<td>
<p>4</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Boma Health Workers (BHW)</p>
</td>
<td>
<p>5</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="2">
<p>Age (in Years)</p>
</td>
<td>
<p>18 – 34</p>
</td>
<td>
<p>8</p>
</td>
</tr>
<tr>
<td>
<p>35 – 49</p>
</td>
<td>
<p>11</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>50 – 60</p>
</td>
<td>
<p>6</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Educational level</p>
</td>
<td>
<p>Only traditional/non-formal school</p>
</td>
<td>
<p>3</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Completed secondary</p>
</td>
<td>
<p>2</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>Technical College</p>
</td>
<td>
<p>12</p>
</td>
</tr>
<tr>
<td> </td>
<td>
<p>University</p>
</td>
<td>
<p>7</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="2">
<p>Place of residence</p>
</td>
<td>
<p>Urban</p>
</td>
<td>
<p>10</p>
</td>
</tr>
<tr>
<td>
<p>Rural</p>
</td>
<td>
<p>14</p>
</td>
</tr>
</tbody>
</table>
<p><strong>Source:</strong> Research Data (2023)</p>
<p>The health workforce refers to the professionals and staff involved in delivering healthcare services within public health facilities. This includes doctors, nurses, midwives, community health workers, and other healthcare providers who play a direct role in delivering reproductive health services to the population. The number of health workers that were selected and participated in the study was 24 health workers (see Table 2).</p>
<p><strong>Adequate and Qualified Personnel Providing RH Services in Public Health Facilities</strong></p>
<p>The research hypothesis in this study is that the presence of adequate and qualified personnel providing reproductive health services in South Sudan public health facilities significantly influences the uptake and utilization of these services. Several subthemes were established through conducting interviews with the key informants.</p>
<p><em>Adequate Staffing</em></p>
<p>The analysis reveals that the presence of an adequate number of healthcare providers in the public health facilities is crucial for meeting the demand for reproductive health services. Sufficient staffing levels ensure that individuals have timely access to services and reduce waiting times, leading to improved utilization. However, it was established that RH services in selected South Sudan's public health facilities is hindered by having few qualified staff and staff needing refresher training to improve reproductive health service delivery.</p>
<p>The analysis revealed that having a limited number of qualified staff, including doctors, nurses, and midwives, impacted the delivery of RH services. The lack of specialized skills and expertise result in suboptimal service provision and limited capacity to address the diverse needs of individuals seeking RHS in the selected public health facilities. In addition, with the shortage of qualified staff, it was evident that delays and bottlenecks in service delivery were a recurrent theme, leading to longer waiting times and decreased utilization of RHS. For instance, one of the key informants that was interviewed stated that:</p>
<p><em>“The limited availability of qualified personnel can hinder the ability to meet the demand for RHS, thereby affecting uptake and utilization.” (Nurse L.O., 2023)</em></p>
<p>It was also established that due to inadequate staffing levels, the quality of RH services provided was compromised. For instance, participants reported that the lack of qualified staff contributed to cases of errors during pregnancy tests, and reduced adherence to RHS guidelines such as building the capacity at all levels of MOH and partners in order to deliver quality comprehensive reproductive health services, which was found to negatively impact individuals' trust in and utilization of RH services.</p>
<p>Though it was established that personnel working in the selected health facilities had relevant academic qualifications, most of them needed refresher training. Participants argued that when it comes to RH service delivery, the field is continuously evolving, with new research, guidelines, and best practices emerging. Thus, it was important for staff including nurses and midwives, to undergo regular refresher training, since most of the staff knowledge and skills on RHS was considered outdated, it hindered their ability to provide up-to-date and evidence-based RH strategy such as the provision of modern contraceptives. From the interaction with key informants, it was evident that some of the personnel providing RH services in public health facilities had limited confidence and competence. One of the participants stated that: </p>
<p><em>“Nurses and midwives who have not received refresher training lack confidence and competence in certain areas of RH service provision. This results in hesitation, suboptimal decision-making, and a decreased ability to address complex or specialized cases, leading to reduced uptake and utilization of RHS.” (Doctor P.O., 2023)</em></p>
<p>Refresher training ensures that all personnel are aligned with standardized protocols and practices in RH service delivery. Lack of refresher training can result in variations in care provided by different staff members, potentially leading to inconsistencies in service quality and patient experiences. Thus, the research findings suggest that the influence of adequate staffing on the uptake and utilization of RHS in South Sudan's public health facilities is constrained by having few qualified staff and staff needing refresher training. These factors can impact the quality, availability, and consistency of reproductive health services, ultimately affecting individuals' utilization of these services. </p>
<p>For example, the analysis established that there was increased access to skilled birth attendants through the training and recruitment of midwives and training on life-saving skills including an authorization of mid-level cadres namely, nurses, clinical officers, and midwives to function as Clinical Associates (CAs) to provide essential obstetric care and selected life-saving obstetric and neonatal care (task shifting/sharing).</p>
<p>The analysis revealed that having qualified personnel, such as doctors, nurses, midwives, and skilled birth attendants, is essential. These professionals possess the necessary knowledge, skills, and training to provide comprehensive RHS, including family planning, HIV counselling and testing, prevention and management of STIs, and maternal and newborn care. In addition, healthcare providers with appropriate training and skills in RH can effectively address the specific needs and concerns of women seeking RHS. The participants mentioned that training programs and continuing education opportunities will enable health providers to stay updated on best practices and evidence-based approaches, ensuring the delivery of high-quality RH care.</p>
<p><em>Health Workforce Education Level</em></p>
<p>The analysis revealed that healthcare providers with higher education levels, such as advanced degrees in medicine, nursing, or midwifery, bring advanced knowledge and specialized skills to RHS provision. Advanced education equips them with a deeper understanding of RH concepts, research, and evidence-based practices, enabling them to deliver high-quality care. The experts that were interviewed posit that health professionals with higher education levels possess critical thinking abilities and analytical skills, enabling them to make informed decisions and provide comprehensive and individualized RH care. Individualized RH care was further found to contribute to improved utilization of RHS, as women visiting public health facilities felt confident in the expertise of the healthcare provider.</p>
<p>The study also found that having higher education levels empowered healthcare providers to take on leadership roles and engage in advocacy efforts to promote RHS. For instance, doctors and nurses who are well-trained were found to contribute to policy development, program implementation, and community education, which can positively impact the uptake and utilization of RHS. </p>
<p>At the community level, trained mid-level cadres namely, nurses, clinical officers, and midwives. encouraged and supported community and home-based initiatives on life-saving skills. Emphasis was based on building the capacity of other community health workers/groups on health promotion (including referral for deliveries to the Primary health care centres (BHW, 2023).</p>
<p>It was also important to note that, the key informants believed that continuous professional development, including training, workshops, and conferences, helps healthcare providers stay abreast of advancements in RH. </p>
<p><em>“By continuously updating their knowledge and skills, healthcare providers can provide up-to-date and evidence-based RH care, which can enhance the uptake and utilization of reproductive health services. In addition, professional development opportunities that are mainly offered by NGOs, allowed the healthcare providers to refine their skills and learn best practices for health service delivery including RHS (CO, 2023).”</em></p>
<p>The study proposes that by improving the health workforce education level and promoting continuous professional development, the influence of adequate staffing on the uptake and utilization of RHS in South Sudan's public health facilities can be strengthened. Investing in higher education levels and providing opportunities for continuous learning can enhance healthcare providers' knowledge, skills, confidence, and leadership abilities. Consequently, this can improve the quality of RHS, increase patient trust, and positively influence individuals' utilization of these services.</p>
<p><strong>Workload and Salary</strong></p>
<p>The research findings in this study evidenced the fact that the influence of workload and salary issues on the uptake and utilization of RHS in selected South Sudan public health facilities is negatively affected by health workers being overworked and receiving low wages.</p>
<p><em>Workload Issues</em></p>
<p>The analysis revealed that the health workers including nurses, clinical officers, and midwives are overburdened with excessive workload, and have limited time to spend with clients seeking RHS. For instance, one of the clinical officers who was interviewed complained that:</p>
<p><em>“Due to workload issues Clinical Associates (CAs) end up doing rushed consultations and reduced opportunities for thorough assessments and discussions about family planning, antenatal care, HIV testing and counselling or other RHS. As a result, most women visiting public health facilities felt that their concerns are not adequately addressed, leading to decreased utilization of RHS.” (KI-CO, 2023)</em></p>
<p>The study also established that overworked health workers struggle to provide individualized care due to time constraints. They had difficulty tailoring services to meet the specific needs and preferences of each woman visiting the clinic. This results in a standardized approach to care, which may not fully address the unique circumstances and concerns of women, potentially leading to decreased utilization of RHS. Therefore, MOH and other stakeholders should focus on expanding comprehensive RH coverage by developing a priority-oriented focus on RH service delivery and ensuring the best use of resources as well as addressing the unique circumstances and concerns of women of reproductive age.</p>
<p>The analysis also revealed that overworked health workers faced challenges in managing the demand for RHS, leading to longer waiting times for appointments and checkups. Women seeking timely care became discouraged or sought alternative options, especially in modern contraception, resulting in decreased utilization of RHS in public health facilities. It was also established that most of the health workers (doctors, nurses, clinical officers, and midwives) experienced excessive workloads that contributed to delays in service delivery, which were further perceived as inconvenient by the women who were seeking RHS. The perception of prolonged waiting times and service delays discouraged women from utilizing RHS across South Sudan.</p>
<p>Fatigue and burnout also emerged as common themes from the thematic analysis. It was evident from the analysis that most of the health workers felt that they were being overworked which led to fatigue and burnout. One of the doctors who was interviewed pointed that:</p>
<p>“As the only qualified hospital doctor in the health facility, I am extremely overworked, and this is likely to lead to reduced concentration, compromised decision-making, and increased likelihood of errors. This can also lead to suboptimal service delivery and reduced satisfaction among women who are seeking RHS in this health facility.” (KI-MD, 2023)</p>
<p>In addition to fatigue and burnout, it was established that overworking health workers will eventually lead to emotional exhaustion, which can further affect their ability to empathize and communicate effectively with clients who are seeking to use RHS in public health facilities. Indeed, emotional exhaustion can hinder the formation of trust and rapport with women of reproductive age seeking RH services.</p>
<p>The research findings suggest that the influence of workload issues on the uptake and utilization of RHS in South Sudan's public health facilities is negatively affected by health workers being overworked. By examining the challenges related to workload issues, the findings of this study can inform strategies to address these issues. For instance, increasing access to skilled health workers through training and recruitment of midwives and training on RH skills including an authorization of mid-level cadres namely, nurses, clinical officers, and midwives to function as CAs to provide essential RH services. Ultimately, addressing workload issues can enhance the uptake and utilization of RHS in South Sudan through workforce planning, task-shifting, sharing, and workload redistribution.</p>
<p><em>Salary Issues</em></p>
<p>The analysis established that the influence of salary issues on the uptake and utilization of RHS in selected South Sudan public health facilities is negatively affected by health workers being paid low wages and feeling that they are unfairly compensated for the amount of work done. For instance, the key informant stated that: </p>
<p><em>“Most of the health workers complained that they are receiving low wages that may lead to experiencing a lack of motivation and job satisfaction. The perception of being undervalued and under-compensated can negatively impact their dedication to providing high-quality RHS, further resulting in decreased motivation to go above and beyond, potentially affecting the utilization of RHS (MW, 2023).”</em></p>
<p>The analysis also revealed that being paid a low salary contributed to overall job dissatisfaction among the health workers in public health facilities, creating feelings of frustration, leading to reduced job engagement, as well as decreased enthusiasm for delivering RHS. </p>
<p><em>“Low wages contributed to higher turnover rates among health workers in the public health facilities. Most of the health professionals are likely to seek better opportunities elsewhere or opt for alternative employment. The frequent turnover among trained and skilled health workers is likely to disrupt the continuity of care and decrease clients' trust and confidence in the RHS provided in the public health facilities.” (PHO, 2023)</em></p>
<p>The study established that some of the health workers who were working in the selected RH clinics believed that they were being paid low salaries, and a result created the perception that RHS are undervalued within the healthcare system. This perception can impact the community's trust and confidence in the quality of care provided, resulting in decreased utilization of reproductive health services. In addition, one of the participants stipulated that:</p>
<p><em>“Health workers who feel undervalued may be less inclined to invest their time and effort in enhancing their skills and knowledge, leading to stagnation in service delivery including RH services.” (MW, 2023)</em></p>
<p>According to the participants addressing salary issues and ensuring fair compensation for health workers can lead to increased motivation, job satisfaction, and retention rates. Adequate wages can also contribute to improved quality of care and increased trust from women who are seeking RHS in public health facilities. The findings of this study can guide policymakers and stakeholders in implementing interventions to improve the financial compensation of health workers, particularly those working in RH clinics, and address the salary disparities, thereby positively impacting the uptake and utilization of RHS in South Sudan public health facilities.</p>
<h3>Discussion</h3>
<h4>Influence of Health Facility Characteristics on Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities</h4>
<p>The study found that 57.8% of the women were aware of the nearest RH clinic in the region, while 42.3% reported a lack of awareness. This indicates that there is a significant proportion of women who may not have knowledge about the availability of reproductive health services in their vicinity. Previous studies (Binu et al., 2018; and Helamo et al., 2017). also show a significant proportion of women lacking knowledge, for instance, lack of access to information about what RH services are available and where to seek service. They also found that young women who lacked knowledge of the type of RHS were not more likely to utilize the service than their counterparts. Lack of awareness can be a barrier to seeking and utilizing these services, as women may not know where to go or what services are offered. Increasing awareness through community outreach, education campaigns, and improved information dissemination can help address this issue.</p>
<p>The study examined the distance between women's households and the nearest RHS center. The findings showed that most women (33.3%) reported that public health facilities offering RHS were within 3 km from their households, while 22.8% reported that the facilities were within 0.5 km. However, over 45.8% of the women reported living outside the 2 km radius distance from the nearest RHS clinic. Study by Kane, Kok, et al. (2016) conducted in South Sudan also indicates that many women and girls live too far away to access emergency care or live on the other side of frontlines of conflict, making it too hazardous to travel to the facilities. In most cases RHS is not available in conflict-affected areas except in rare instances. This suggests that a significant number of women may face challenges accessing RHS due to long distances. Long travel distances can deter women from seeking care, particularly in rural areas with limited transportation options. To improve accessibility, efforts should be made to establish more health facilities or outreach services in underserved areas, particularly those far from existing clinics.</p>
<p>The study further investigated the relationship between the provision of specific RHS and the uptake of these services. The findings revealed that the provision of IUDs showed a highly significant relationship with the uptake and utilization of RHS. The odds ratio of 10.473 suggests that the provision of IUDs is associated with a 10.473 times higher likelihood of uptake and utilization of RHS compared to not providing IUDs. Studies across Africa show that IUD’s share of modern method mix is pitifully small, at less than 5%, in 63 countries and only5–9% in a further 32 countries as noted in a previous study (Cleland, Benova, and Daniele, 2017). This current finding highlights the importance of making IUDs available as a contraceptive option to promote RHS utilization.</p>
<p>The provision of oral contraceptives also demonstrated a highly significant relationship with the uptake and utilization of RHS. The odds ratio of 33.060 suggests that the provision of oral contraceptives is associated with a 33.060 times higher likelihood of uptake and utilization of RHS compared to not providing oral contraceptives. Previous studies (Cottingham, Germain, and Hunt, 2012: and World Health Organization, 2012) support this finding by stipulating that unmet need for contraception remains high in many settings, and is highest among the most vulnerable in society including those living in rural areas. This finding underscores the importance of ensuring access to oral contraceptives as an essential component of RHS. In addition, the provision of spermicidal agents also demonstrated a statistically significant relationship with the uptake and utilization of reproductive health services. These findings suggest that offering a range of contraceptive options, including spermicidal agents, can contribute to increased RHS utilization.</p>
<p>A previous study conducted by Kane et al. (2016) in South Sudan, established that the provision of family planning, including injectables, is largely unavailable in the majority of the States, largely due to the overall gaps in health infrastructure and services, and in part because the major healthcare provider does not provide contraception. The current study evidenced that the provision of injectables showed a statistically significant relationship with the uptake and utilization of reproductive health services. However, the odds ratio of 0.213 suggests that the provision of injectables is associated with a 0.213 times lower likelihood of uptake and utilization of RHS compared to not providing injectables. This finding suggests that factors such as availability, awareness, and preferences regarding contraceptive methods may influence the utilization of injectables.</p>
<p>These findings emphasize the importance of the availability and provision of a diverse range of RHS to meet the varied needs and preferences of women. It highlights the significance of including contraceptives like IUDs, oral contraceptives, injectables, and spermicidal agents as part of the service package in public health facilities. By expanding the range of available services and ensuring their accessibility, the uptake and utilization of RHS can be improved, leading to better RH outcomes for women in South Sudan.</p>
<h4>Influence of Health Workforce on Uptake and Utilization of RHS In Selected South Sudan’s Public Health Facilities</h4>
<p>The analysis revealed that the presence of an adequate number of healthcare providers in public health facilities is crucial for meeting the demand for reproductive health services and improving utilization. Sufficient staffing levels ensure timely access to services and reduce waiting times. However, the study found that the RH services in selected South Sudan's public health facilities were hindered by having few qualified staff and a need for refresher training. Previous studies support these findings by showing evidence of a direct and positive link between the number of health workers and population health outcomes (WHO, 2010). This limitation in the workforce resulted in suboptimal service provision and a limited capacity to address the diverse needs of women seeking RHS.</p>
<p>The analysis highlighted the importance of healthcare providers' qualifications and education levels in the delivery of reproductive health services. The study found that healthcare providers with higher education levels, such as advanced degrees in medicine, nursing, or midwifery, bring advanced knowledge and specialized skills to the provision of reproductive health services. Previous studies (Kane, Kok, et al., 2016) conducted in South Sudan support this finding, they established that pregnant women have extremely limited access to skilled health providers in public health facilities. These providers are better equipped to meet the diverse needs of individuals seeking RHS and are empowered to take on leadership roles and engage in advocacy efforts to promote reproductive health.</p>
<p>The analysis revealed that healthcare providers, including nurses, clinical officers, and midwives, were overburdened with excessive workloads. This excessive workload resulted in limited time to spend with clients seeking RHS, which compromised the quality of care provided. Previous studies (Kane, Kok, et al., 2016: and Belaid et al., 2020) found that insecurity in some part of Central Equatoria and Western Equatoria State have led to a lack of staff and thus hindering women from accessing healthcare, including making antenatal visits. In addition, overworked health workers faced challenges in managing the demand for RHS, leading to longer waiting times for appointments and checkups. These findings suggest that workload issues negatively impact the uptake and utilization of RHS in South Sudan's public health facilities.</p>
<p>The analysis found that health workers in selected public health facilities perceived low salaries and felt unfairly compensated for the amount of work they performed. The low salary levels contributed to overall job dissatisfaction among the health workforce, leading to reduced job engagement and decreased enthusiasm in delivering reproductive health services. Previous studies (WHO, 2010a) further revealed that the ability of a country to meet its health goals depends largely on motivation and financial compensation of the people responsible for organizing and delivering healthcare services. Thus, the perception of low salaries created the notion that reproductive health services are undervalued within the healthcare system. This finding suggests that salary issues negatively affect the uptake and utilization of RHS.</p>
<p>In conclusion, the findings highlight several workforce-related factors that influence the uptake and utilization of reproductive health services in South Sudan's public health facilities. These factors include having an adequate number of qualified staff, staff with higher education levels, manageable workloads, and fair compensation for healthcare providers. Addressing these workforce challenges is crucial to improving the delivery of reproductive health services and ensuring better access and utilization of these services by women of reproductive age in South Sudan. Policy measures should focus on recruiting and retaining qualified staff, providing opportunities for professional development and training, improving working conditions, and offering fair compensation to healthcare providers in order to strengthen the reproductive health workforce and enhance service delivery.</p>
<h3>Conclusions</h3>
<p>The study revealed significant insights into the factors influencing the uptake and utilization of RHS in South Sudan's public health facilities. The examination of health facility characteristics on RHS uptake indicated that awareness of available services, proximity to health facilities, and the provision of specific contraceptives significantly impacted utilization. Additionally, the influence of the health workforce on RHS utilization highlighted the importance of staffing levels, healthcare providers' qualifications, workload management, and fair compensation in facilitating or hindering service utilization.</p>
<p>The findings underscore the critical need for targeted interventions for RHS utilization in South Sudan. Increasing awareness through community outreach, educating women about available services, and enhancing information dissemination are crucial steps to address the lack of awareness among women regarding nearby RH clinics. Moreover, efforts to establish more health facilities or outreach services in remote areas could mitigate the challenges faced due to long travel distances, ensuring better accessibility to RHS. The study emphasizes the significance of including a diverse range of contraceptives such as IUDs, oral contraceptives, injectables, and spermicidal agents as part of the service package in public health facilities. This approach caters to varying preferences and needs, potentially enhancing RHS utilization. Furthermore, the study highlights the necessity of maintaining an adequate number of qualified healthcare providers, managing their workloads, and providing fair compensation to enhance service delivery and improve access to RHS.</p>
<p>The study faced certain limitations, including potential biases in participant selection due to the sampling method employed. The reliance on self-reported data might have introduced response biases, impacting the accuracy of the findings. Additionally, the study's scope focused on selected regions of South Sudan, limiting the generalizability of the results to the entire country. Furthermore, contextual factors such as ongoing conflicts or geopolitical situations might have influenced the availability and accessibility of reproductive health services.</p>
<p>Future research endeavours should aim to conduct comprehensive studies encompassing a broader geographical area within South Sudan, considering diverse socio-economic and cultural contexts. Longitudinal studies tracking changes in reproductive health service utilization over time could provide valuable insights into trends and variations. Exploring the impact of specific interventions, such as awareness campaigns or infrastructure improvements, on RHS utilization could guide targeted policy interventions. Furthermore, in-depth qualitative studies involving healthcare providers and community members could offer nuanced perspectives on barriers and facilitators to RHS utilization. Additionally, examining the role of technology, telemedicine, or mobile health interventions in improving access to reproductive health services among remote populations warrants exploration.</p>
<h5><strong>Acknowledgements:</strong></h5>
<p>This study was made possible through the support of my supervisors Dr. Alfred Owino Odongo and Dr. John Kariuki, and my colleagues within the Ministry of Health, particularly my fellow Public Health Officers and Surveillance Officers. Their support is acknowledged.</p>
<h6>Funding Acknowledgements:</h6>
<p>The author(s) received no financial support for the research, authorship, and/or publication of this article.</p>
<h6>Competing Interests:</h6>
<p>Author(s) declares there were no competing interests.</p>
<h6>References</h6>
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<p> </p>
<p> </p>
Manuscript: Sociocultural factors influencing utilization of reproductive health services in selected South Sudan public health facilities
2023-10-27T18:28:00+01:00
2023-10-27T18:28:00+01:00
https://pachodo.org/latest-news-articles/pachodo-english-articles/42919-sociocultural-factors-influencing-utilization-of-reproductive-health-services-in-selected-south-sudan-public-health-facilities
Dr. Emmanuel Timothy Thwol
LamArop@pachodo.org
<p><img src="https://pachodo.org/images/Dr_Emmanuel_Timothy_THWOL.png" alt="DR. EMMANUEL TIMOTHY THWOL" title="DR. EMMANUEL TIMOTHY THWOL" /></p>
<p><em><strong>By DR. Emmanuel Timothy Thwol Onak (PhD)</strong></em></p>
<p> </p>
<p><strong>Abstract</strong></p>
<p><strong>Background:</strong> Africa constitutes roughly 10% of the global population and witnesses around 20% of worldwide childbirths. Alarmingly, nearly half of all maternal deaths during pregnancy and childbirth occur in this region. The World Health Organization (WHO) estimates that inadequate reproductive health contributes to approximately 18% of the overall global disease burden, with women of reproductive age bearing 32% of this burden. In light of these concerns, this study investigates the sociocultural elements influencing the adoption and use of Reproductive Health Services (RHS) in specific public health facilities in South Sudan while also assessing the extent to which these services are being embraced and utilized.</p>
<p><strong>Method:</strong> The research utilized a mixed-methods strategy, comprising a longitudinal ecological study and an analytical cross-sectional investigation, which took place in specifically chosen states - Western Equatoria and Central Equatoria. The study focused on women aged 15 to 49 who were seeking healthcare services during the study timeframe. Data collection methods encompassed structured questionnaires and data abstraction instruments. The quantitative data analysis encompassed descriptive statistics and inferential analyses.</p>
<p><strong>Results: </strong></p>
<p>The study's findings reveal that a significant portion of respondents (72.5%) had utilized reproductive health services in selected public health facilities, with family planning and prevention/management of STIs being the most commonly used services, each accounting for 25.1% of the sampled population. Maternal and newborn care and HIV counseling/testing were also frequently accessed, at 18.1% and 15.3%, respectively. Over the years, there was a consistent increase in the uptake of reproductive health services, although specific declines were observed during the third quarter of each year from 2015 to 2020 for family planning, HIV counselling/testing, and maternal/newborn care. The study noted that a significant relationship existed between the age of the respondents and service utilization, with 53.5% of respondents aged 30 and older. Additionally, there was a statistically significant link between the respondent's place of residence and service utilization, with individuals in urban areas being twice as likely to utilize services compared to those in rural areas. The study also found a significant relationship between the educational level of the respondents and the uptake of reproductive health services.</p>
<p><strong>Conclusions: </strong></p>
<p>While the study reveals a positive trend in the overall uptake of RHS, specific declines in family planning, HIV counselling/testing, and maternal/newborn care during certain quarters require attention. Notably, age, place of residence, and educational levels significantly influence service utilization, with older individuals, urban residents, and those with higher educational attainment more likely to access reproductive health services. To address these disparities and improve reproductive health outcomes, policy and healthcare interventions should be tailored to the unique sociocultural contexts and demographic characteristics of South Sudan. Greater emphasis on education and awareness campaigns, particularly in rural areas, is recommended to promote comprehensive RHS utilization and reduce maternal mortality rates. Additionally, sustained efforts to enhance the quality and accessibility of these services, especially in the specified areas of decline, are crucial to advancing reproductive health in the region.</p>
<p><strong>Introduction</strong></p>
<p>Reproductive Health (RH) is a fundamental component of overall well-being, encompassing physical, mental, and social aspects that go beyond the mere absence of disease or infirmity, as defined by the World Health Organization (WHO, 2021). RH extends to all matters related to the reproductive system, its functions, and processes. The United Nations Population Fund (UNPF, 2019) further emphasizes that RH includes the ability to reproduce, regulate fertility, engage in safe and fulfilling sexual relationships, and achieve successful outcomes in reproduction, such as infant and child survival, growth, and healthy development. It also entails safe pregnancy and childbirth, risk-free fertility regulation, and the assurance of safe sexual experiences.</p>
<p>The WHO RH Strategy, established in 2004 and guided by international human rights principles, outlines the core elements of Sexual and Reproductive Health (SRH), aiming to enhance the well-being of communities (WHO Africa, 2020). These core aspects encompass improving antenatal, perinatal, postpartum, and newborn care; providing high-quality family planning services, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer, and other gynaecological morbidities; and promoting sexual health. Additionally, the strategy underscores the critical importance of preventing and responding to violence against women to improve reproductive health outcomes.</p>
<p>Despite some progress within the European Region, challenges persist. While the contraceptive prevalence rate has increased from 55.6% in 2000 to 61.2% in 2015, there remains a significant lack of information and awareness concerning critical RH issues such as sexuality, family planning, pregnancy, childbirth, sexually transmitted infections, infertility, cervical cancer prevention, and menopause (WHO Europe, 2021). The region faces complications in pregnancy and childbirth, unsafe abortions, reproductive tract infections, and sexual violence, which contribute to avoidable cancer-related deaths among women. Notably, there are disparities in RH within and between countries. A study in 13 European Union countries in 2012 highlighted the higher proportion of women with unmet family planning needs among people living with HIV (PLHIV) compared to the general population (UNPF, 2012). New HIV infections in the European Region increased by 75% since 2005, and the region reported nearly 137,000 new HIV diagnoses in 2019 (WHO Europe, 2020).</p>
<p>Contraception and abortion are significant concerns in Asia. In 2017, approximately 132 million women of reproductive age in Asia had an unmet need for modern contraception, leading to an estimated 53.8 million unintended pregnancies, two-thirds of which ended in abortion (Center for Reproductive Rights, 2021). The majority of these abortions occurred in South and Central Asia, including India, and Eastern Asia, including China. Although the proportion of unsafe abortions is uncertain, it is estimated that 4.6 million women in Asia (excluding Eastern Asia) experience complications from unsafe abortions annually (Guttmacher Institute, 2017). Adolescent childbearing rates have decreased in most Asian and Pacific countries, but they remain high in South and South-West Asia, particularly in Bangladesh (35%), Nepal (21%), and India. South Asia also grapples with a high prevalence of child marriage, with 45% of women aged 20-24 reporting marriage before the age of 18 and 17% before the age of 15 (Center for Reproductive Rights, 2021). Maternal mortality related to pregnancy and childbirth affected approximately 85,000 women in the region in 2015, with 92% of these maternal deaths occurring in just 12 countries (UNICEF, 2021).</p>
<p>In Africa, women face a higher risk of death from communicable diseases, maternal and perinatal conditions, and nutritional deficiencies. About 30% of women worldwide, including 468 million aged 15-49, experience anaemia, with the majority living in Africa (48-57%) due to iron deficiency. Gender inequity, poverty, weak economic capacity, and sexual and gender-based violence, including Female Genital Mutilation (FGM), present significant obstacles to improving women's health in the African Region (United Nations, 2015). Despite Africa accounting for one-tenth of the world's population and 20% of global births, nearly half of maternal deaths occur in this region. Poor reproductive health accounts for up to 18% of the global burden of disease and 32% of the total burden for women of reproductive age (WHO Africa, 2020). Access to essential RH interventions, particularly family planning, remains limited, with low contraceptive use (13%) and a high total fertility rate (5.5 children per woman) in Sub-Saharan Africa (WHO, 2021).</p>
<p>However, just as health outcomes have improved globally in the past two decades, South Sudan has also seen substantial progress, such as a decline in maternal mortality, neonatal mortality, infant mortality, and under-five stunting (World Bank, 2018). Access to Reproductive Health Services (RHS), including antenatal care and contraception, has significantly increased in Sub-Saharan Africa (United Nations, 2015). Nevertheless, access to healthcare, especially RH services, remains a significant challenge in South Sudan due to persistent conflicts and a fragile peace process (Pendle, 2014). In the East African region, including countries like Uganda, Tanzania, and Kenya, maternal mortality remains high compared to developed nations, highlighting the need for improved RH services (UNICEF, 2016). The use of modern contraceptives is low, and unmet family planning needs affect a significant proportion of married women (United Nations, 2015).</p>
<p>In the context of South Sudan, capacity constraints and a challenging governance environment affect the implementation of basic health services and government policies. Reports suggest a lack of progress in building government capacity (Larson et al., 2013), and economic and social challenges, including budget cuts for health, inflation, and food insecurity, exacerbate the situation (Integrity, 2018; IPC, 2018). The economic crisis affects programs funded by donors, including RH services (Integrity, 2018). Consequently, the utilization and uptake of RH services in South Sudan are subject to these complexities, making this an issue of critical importance.</p>
<p>This study's rationale is rooted in the urgent necessity to comprehend and enhance the utilization of Reproductive Health Services (RHS) in South Sudan, a region characterized by persistent conflict, fragile governance, and substantial economic challenges. South Sudan has grappled with prolonged instability, violence, and a feeble healthcare infrastructure, resulting in limited access to essential healthcare services, particularly reproductive health. Consequently, investigating the determinants of RH service uptake in this complex environment is not only justifiable but also profoundly pertinent. The relevance of this study extends to multiple dimensions. Firstly, it is essential to devise effective strategies to improve reproductive health outcomes in conflict-affected regions like South Sudan, where ongoing instability has triggered economic crises and healthcare infrastructure limitations, making it imperative to ensure access to vital RH services, thereby reducing maternal and infant mortality, bolstering family planning, and addressing the consequences of unmet reproductive health needs. Secondly, the study's global relevance is underscored by the fact that South Sudan's challenges are not unique; many conflict-affected regions worldwide face analogous difficulties in delivering healthcare services, including reproductive health. Therefore, the study's findings offer valuable insights for other nations and organizations working in such settings, providing guidance on strategies to surmount challenges and enhance RH service utilization. </p>
<p>The primary question guiding this study is: "What are the determinants of Reproductive Health (RH) services uptake and utilization in South Sudan, and how do sociocultural factors impact these processes?" To address this overarching question, the study has two specific objectives: 1) to assess the level of uptake and utilization of RH services in selected South Sudan public health facilities, and 2) to examine the sociocultural factors influencing the uptake and utilization of RH services in these facilities. These objectives guide the study's focus on understanding the factors influencing the utilization of RH services in a conflict-affected and resource-constrained setting.</p>
<p><strong>Methods</strong></p>
<p>The study employed a mixed-methods approach to gather and analyze data. It consisted of two main parts: a longitudinal ecological study using retrospective data from South Sudan's Ministry of Health covering the period from 2015 to 2020 and an analytical cross-sectional study conducted at public health facilities involving women of reproductive age.</p>
<p>In the analytical cross-sectional study, quantitative data was collected from women of reproductive age visiting selected public health facilities during the study period. A structured questionnaire with only closed-ended questions was developed as the primary research instrument, focusing on specific study objectives. This questionnaire aimed to assess the level of reproductive health service utilization and socio-cultural factors. Additionally, a data abstraction tool, a standard instrument, was employed to systematically collect data from the Health Management Information System database and health facilities. This tool was used to extract utilization data from the period between 2015 and 2020.</p>
<p>The study drew its theoretical framework primarily from two established theories: the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These theories have been widely used in previous studies to explain and predict the utilization and uptake of reproductive health services. The Health Belief Model (HBM) focuses on unique and subjective beliefs that influence an individual's decision-making process. It includes perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action. These constructs were used to develop a predictive model for risky sexual practices in college students and were found to significantly explain variations in risk behaviours and sexual partnerships. The Theory of Reasoned Action (TRA) provides a framework for studying attitudes toward behaviours and aims to predict and understand an individual's behaviour. It assumes that individuals are rational and base their actions on a thoughtful consideration of available information and potential consequences. The TRA comprises key constructs, including behaviour, intention, and personal attitude. The intention is considered the primary determinant of behaviour, with stronger intention indicating a higher likelihood of performing a particular behaviour.</p>
<p>This methodological approach allowed for a comprehensive examination of reproductive health service utilization and the underlying factors, drawing on well-established theoretical frameworks.</p>
<p><em>Study sites</em></p>
<p>The study was conducted at public health facilities in two specific states of South Sudan, namely, Western Equatoria and Central Equatoria. South Sudan's population predominantly resides in rural areas, accounting for approximately 83% of the total population. The rural landscape is characterized by low population density at 15 individuals per square kilometre, which, combined with the presence of mobile pastoral communities and restricted access due to prolonged conflicts, presents substantial challenges to healthcare service provision. Data collection was carried out at all four levels of the South Sudan health system, encompassing the Boma Health Teams representing the community level, Primary Healthcare Units (PHCU), Primary Healthcare Centers (PHCC), and hospitals. These healthcare facilities are strategically aligned with the country's administrative subdivisions, serving both rural and urban regions (Ministry of Health, 2012; WHO South Sudan, 2020).</p>
<p><em>Sampling, recruitment of study participants and data collection</em></p>
<p>The primary respondents for this study were situated in public health facilities located in Western Equatoria and Central Equatoria. The quantitative sampling approach employed a multi-stage cluster random sampling method, involving two distinct stages: the selection of health facilities and the subsequent selection of participants.</p>
<p>In the first stage of sampling, the selection of health facilities commenced within each of the chosen states. A comprehensive list of existing public health facilities was compiled, and from this list, a systematic random sampling method was employed to designate a specific facility as a sample for the study. A minimum of three public health facilities were randomly chosen in each state.</p>
<p>The second stage of sampling centred on the selection of participants; a process facilitated by probability proportionate to size. Utilizing available population lists, such as the 2018 census, which included women of reproductive age falling within the bracket of 15 to 49 years, from the pre-selected states of Western Equatoria and Central Equatoria. The sampling interval was computed by dividing the total population of the program area by the number of women of reproductive age who visited health facilities. A systematic random start number was used to identify the first client. Subsequent clients were determined by incrementing the random number by the sampling interval, and this process continued until the required number of clients was attained.</p>
<p>The researcher assumed the responsibility for both the collection and management of field data. Preceding the commencement of data collection, the researcher recruited and conducted comprehensive training for five research assistants (RAs). The RAs were thoroughly acquainted with the study's objectives and methodological approach, and they received training in the administration of data collection tools, which encompassed a detailed review of the tools and practical exercises. Ethical considerations, data confidentiality protocols, and field logistics were also integral parts of the training. Prior to the commencement of the interview, written consent was obtained from the participants, and the participants were assured of the confidentiality of their information. The interviews were initiated with a concise introduction, elucidating the interviewer's identity, the organization they represented, and the study's objectives. The data collection tools were administered through face-to-face interviews.</p>
<p>Additionally, the data needed for completing the data abstraction form encompassed information related to the intervention under investigation, evaluation setting, study population, outcomes, results, and study quality. The form comprised three key sections: Part I, which pertained to Classification Information and was initially filled out by the chapter development team and subsequently reviewed and edited by the abstractors; Part II, which covered Descriptive Information concerning the intervention, evaluation study characteristics, measurement of outcomes, and results; and Part III, which delved into Study Quality, evaluating the execution of the study.</p>
<p><em>Data analysis</em></p>
<p>The data derived from the questionnaires and the data abstraction form underwent a comprehensive data analysis process. Initially, all data were entered into a computer file using Microsoft Excel Spreadsheet. Subsequently, the data were exported to IBM Statistical Package for the Social Sciences (SPSS) version 23, where all sub-files were amalgamated into one master file for further analysis. The initial phase of data analysis was data preparation, which involved transforming raw data into a comprehensible and meaningful format. This process included data validation, editing, and coding.</p>
<p>Various statistical techniques were then employed to identify significant correlations between variables and assess the impact of one variable on another. Descriptive statistics, such as mean, median, mode, percentage, frequency, and range, were utilized to gain an overview of the data. Descriptive statistics are particularly valuable when the scope of the research is confined to the sample and does not necessitate generalization to a larger population. For example, when comparing the percentage of youth utilizing RHS in different states, descriptive statistics provide sufficient insights. Subsequently, cross-tabulations were utilized to delve deeper into the dataset. Cross-tabulations are a means to elucidate the relationship between two variables and are commonly employed to compare outcomes across demographic groups. They allow for the examination of results based on factors like age and the utilization of RHS.</p>
<p>To assess hypotheses, the researcher calculated measures of statistical significance, which ascertain whether findings are statistically meaningful or merely the result of chance. Statistical significance was indicated by the p-value statistic. Typically, a p-value of less than 0.05 is considered statistically significant, signifying a less than 5% probability that the results occurred by chance. Furthermore, the researcher applied various inferential analyses, including correlation, regression, and analysis of variance where relevant. Linear regression was employed, for instance, to predict the value of one variable based on another. This approach allowed the exploration of whether the utilization of RHS could be predicted based on factors like climate change or socio-cultural characteristics. Additionally, one-way analysis of variance (ANOVA) was used to determine if statistically significant differences existed between the means of two or more independent groups.</p>
<p><em>Ethical considerations</em></p>
<p>Ethical considerations were paramount throughout the course of this study. Prior to the commencement of data collection, the researcher diligently sought ethical approval from the Division of Research, Monitoring and Evaluation within the Directorate of Planning and Coordination at the Ministry of Health, as well as the Research Ethics Committee (REC) of the Republic of South Sudan. Additional approvals were obtained from the Institutional Ethical Review Committee (IERC) of Mount Kenya University. In accordance with ethical standards, formal permissions were also secured from the respective sectoral and departmental heads, including the Ministry of Health and Local Governments within the Republic of South Sudan, to access public health facilities and other relevant offices.</p>
<p>The participants who willingly consented to take part in the study were assured of strict anonymity and confidentiality. These measures were implemented to safeguard their identities and instil confidence in the research process, thereby promoting the provision of accurate information. Furthermore, participants were granted the unequivocal right to exercise their free will, allowing them to decide whether they wished to participate in the research. The option of withdrawal from the study was extended to participants at any point, without the requirement to provide a reason. This opportunity was explicitly communicated to participants before the commencement of interviews and was also documented in writing.</p>
<p>In adhering to high ethical standards and principles for research, the study conformed to data collection, security, and protection requirements. Special consideration was also given to adaptations necessary to comply with COVID-19 control regulations. The risk level to both the research team and the communities was identified, and all personnel and participants were provided with essential protective equipment to mitigate risks effectively.</p>
<p><strong>Results</strong></p>
<p><em><strong>Socio-Demographic Characteristics</strong></em></p>
<p>Table 1 provides a comprehensive overview of the demographic characteristics of the study's respondents. The data reveals that a significant portion of the participants (53.5%) were aged 30 years and older, while the remaining 46.5% were younger, with the age range spanning from 17 to 49 years. The mean age was calculated at 29.8 years, with a standard deviation of 7.80. Regarding marital status, the majority of respondents indicated that they were married (67.0%), followed by those who reported being single (20.5%). A smaller percentage of respondents identified as divorcees (6.3%), and another 6.3% stated they were widowed.</p>
<p>Table 1: Socio-demographic characteristics of women of reproductive health visiting selected public health facilities in South Sudan</p>
<div style="overflow-x: auto;">
<table border="1">
<tbody>
<tr>
<td>
<p><strong>Variable </strong></p>
</td>
<td>
<p><strong>Category</strong></p>
</td>
<td>
<p><strong>Frequency</strong></p>
</td>
<td>
<p><strong>Percentage (%)</strong></p>
</td>
</tr>
<tr>
<td rowspan="2">
<p>State </p>
</td>
<td>
<p>Central Equatoria</p>
</td>
<td>
<p>232</p>
</td>
<td>
<p>58.0</p>
</td>
</tr>
<tr>
<td>
<p>Western Equatoria</p>
</td>
<td>
<p>168</p>
</td>
<td>
<p>42.0</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="2">
<p>Age</p>
</td>
<td>
<p>Younger than 30 years</p>
</td>
<td>
<p>186</p>
</td>
<td>
<p>46.5</p>
</td>
</tr>
<tr>
<td>
<p>30 years and older</p>
</td>
<td>
<p>214</p>
</td>
<td>
<p>53.5</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="4">
<p>Marital status </p>
</td>
<td>
<p>Single </p>
</td>
<td>
<p>82</p>
</td>
<td>
<p>20.5</p>
</td>
</tr>
<tr>
<td>
<p>Married </p>
</td>
<td>
<p>268</p>
</td>
<td>
<p>67.0</p>
</td>
</tr>
<tr>
<td>
<p>Divorced </p>
</td>
<td>
<p>25</p>
</td>
<td>
<p>6.3</p>
</td>
</tr>
<tr>
<td>
<p>Widowed </p>
</td>
<td>
<p>25</p>
</td>
<td>
<p>6.3</p>
</td>
</tr>
<tr>
<td rowspan="2">
<p>Place of residence</p>
</td>
<td>
<p>Urban</p>
</td>
<td>
<p>74</p>
</td>
<td>
<p>18.5</p>
</td>
</tr>
<tr>
<td>
<p>Rural</p>
</td>
<td>
<p>326</p>
</td>
<td>
<p>81.5</p>
</td>
</tr>
<tr>
<td rowspan="5">
<p>Employment status</p>
</td>
<td>
<p>In school or training</p>
</td>
<td>
<p>48</p>
</td>
<td>
<p>12.0</p>
</td>
</tr>
<tr>
<td>
<p>Paid/wage/paid in kind employed</p>
</td>
<td>
<p>19</p>
</td>
<td>
<p>4.8</p>
</td>
</tr>
<tr>
<td>
<p>Self-employed</p>
</td>
<td>
<p>121</p>
</td>
<td>
<p>30.3</p>
</td>
</tr>
<tr>
<td>
<p>Unemployed</p>
</td>
<td>
<p>173</p>
</td>
<td>
<p>43.3</p>
</td>
</tr>
<tr>
<td>
<p>Unemployed but not seeking work for other reasons</p>
</td>
<td>
<p>39</p>
</td>
<td>
<p>9.8</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="2">
<p>Household wealth status </p>
</td>
<td>
<p>Poor (<500,000 SSP)</p>
</td>
<td>
<p>365</p>
</td>
<td>
<p>91.3</p>
</td>
</tr>
<tr>
<td>
<p>Middle (500,000 SSP -1,000,000 SSP)</p>
</td>
<td>
<p>35</p>
</td>
<td>
<p>8.8</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="2">
<p>Religion </p>
</td>
<td>
<p>Christian</p>
</td>
<td>
<p>348</p>
</td>
<td>
<p>87.0</p>
</td>
</tr>
<tr>
<td>
<p>Traditional</p>
</td>
<td>
<p>52</p>
</td>
<td>
<p>13.0</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="4">
<p>Education status</p>
</td>
<td>
<p>No school</p>
</td>
<td>
<p>147</p>
</td>
<td>
<p>36.8</p>
</td>
</tr>
<tr>
<td>
<p>Only traditional/non-formal school</p>
</td>
<td>
<p>53</p>
</td>
<td>
<p>13.3</p>
</td>
</tr>
<tr>
<td>
<p>Dropped-out of school</p>
</td>
<td>
<p>27</p>
</td>
<td>
<p>6.8</p>
</td>
</tr>
<tr>
<td>
<p>Completed secondary</p>
</td>
<td>
<p>173</p>
</td>
<td>
<p>43.3</p>
</td>
</tr>
</tbody>
</table>
</div>
<p><em><strong>Source:</strong></em> Research Data (2023)</p>
<p>Geographically, over 80% of the participants resided in rural areas, while the remaining 18.5% lived in urban regions. The employment status of the respondents varied, with the highest proportion reporting being unemployed (30.3%), closely followed by those who identified as self-employed (30.3%). In terms of household wealth status, the analysis categorized a substantial majority of respondents (91.3%) as belonging to the "poor" category, as their household income fell below 500,000 South Sudanese Pounds (SSP).</p>
<p>Religiously, 87% of the respondents identified as Christians, while a smaller percentage (13.0%) stated they followed traditional belief systems. When examining the education level of the participants, it was found that 43.3% had completed their education up to the secondary school level, followed by 36.8% who had not attended any formal schooling. This rich demographic information lays the foundation for a more in-depth understanding of the study's participants (refer to Table 1).</p>
<p><em><strong>Level of Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities</strong></em></p>
<p>Reproductive health services received in the past 12 months</p>
<p>Inquiries were made to determine whether women of reproductive age, during their visits to the clinics, had utilized the Reproductive Health Services (RHS) offered within the selected public health facilities over the preceding 12 months. Figure 1 presents the findings, indicating that a substantial majority of the respondents (72.5%, 290 individuals) had indeed taken advantage of the available RHS during this period. In contrast, a noteworthy segment of the participants (27.5%, 110 individuals) reported that they had not utilized RHS within the past 12 months. This information sheds light on the utilization of RHS among the study's respondents.</p>
<p><img src="https://lh7-us.googleusercontent.com/PmD1dGGHYhwYWpbRCy0-4Fs82aQia7Leas9RyTCVQVddRuvvIanvQdxV2DaT1ymSsqjDnPeVyh98LY7mBg-CWaUnWHC7SRGlBVLhpK_YMaxTpQl9Afee2zOBI7DWHc_ff0OUdkUt52qeVZBTpwVPNA" alt="" width="627" height="313" /></p>
<p><em><strong>Figure 1:</strong></em> Users and non-users of RH services in the past 12 months</p>
<p><em><strong>Source:</strong></em> Research Data (2023)</p>
<p>The study's respondents, women of reproductive age visiting the designated public health facility, were surveyed to ascertain the types of services they had received at the facility over the previous 12 months. Figure 2 illustrates the outcomes, highlighting that family planning services (25.1%) and prevention and management of Sexually Transmitted Infections (STIs) (25.1%) were the most frequently utilized Reproductive Health (RH) services among the surveyed women visiting these facilities. Additionally, maternal and newborn care services, as well as HIV counselling and testing, emerged as other commonly accessed services, accounting for 18.1% (290 respondents) and 15.3% (244 respondents) of the sampled population, respectively. These findings underscore the prevalence of specific RH services among the women utilizing these health facilities.</p>
<p><img src="https://lh7-us.googleusercontent.com/EQ6EZtp7OD_9yNeiLbZFYzOiSmubfpOJ03A7E4i1YBCn6H4gY6UxMkICUEgGrQd1SUzSLw27RnmQCtnptNNUuEl8AFsYbc2ewJbKYiTvwp2SneEY3H4Bpv23p0N4s0ljtixVONm3wzEQiNX1r05Gaw" alt="" width="654" height="454" /></p>
<p><em><strong>Figure 2:</strong></em> List of services received in the selected public health facilities</p>
<p><em><strong>Source:</strong></em> Research Data (2023)</p>
<p>Temporal patterns in reproductive health service clinic utilization in public health facilities from 2015 to 2020</p>
<p>The study investigated attendance trends at reproductive health services (RHS) clinics in public health facilities between 2015 and 2020, specifically focusing on services such as family planning, HIV counselling and testing, and maternal and newborn care. The data from women of reproductive age attending the RHS clinics during the first and third quarters of each year were analyzed and plotted, revealing notable patterns.</p>
<p>Figure 3 demonstrates seasonal variations in clinic attendance for family planning, HIV counselling and testing, and maternal and newborn care services, with recurring peaks and troughs each year. The trend curve for all three services indicates a consistent increase in utilization from the first to the third quarters spanning from 2015 to 2020. Notably, the third quarter consistently shows a decline in attendance, highlighting these seasonal fluctuations in service utilization.</p>
<p> </p>
<p><img src="https://lh7-us.googleusercontent.com/-rF_JFNNo5Tk-N7l0F5MKSPWvBCiA7lNiygGlteoz89W_lx8toW9kX9vWwEC8kAHW2-uJI9PugLcxosD3haJfVJMRTJp5M5WNvwclTblqR9ilgkfqq7l5UaRYx5lWwGY62FsSSI0U26Y0TaeZpJzxg" alt="" width="626" height="458" /></p>
<p><em><strong>Figure 3:</strong></em> Scatter and trend plots of RHS visits in selected public health facilities</p>
<p><em><strong>Source:</strong> </em>Research Data (2023)</p>
<p>These findings underscore the dynamic nature of attendance at RHS clinics over the study period, characterized by seasonal fluctuations, while also highlighting the overall increasing trend in the utilization of family planning, HIV counselling and testing, and maternal and newborn care services from 2015 to 2020.</p>
<p>Socio-Cultural Factors Associated with RH Services Utilization</p>
<p>Bivariable and multivariable logistic regression analyses were conducted to assess the relationship between various factors and the uptake/utilization of reproductive health services. The results indicated significant associations. Firstly, there was a statistically significant relationship between the age of the respondent and reproductive health service utilization (p-value = 0.049). The odds ratio of 0.571 suggested a negative association, signifying that with each unit increase in the respondent's age, the odds of utilizing reproductive health services decreased by a factor of 0.571. The 95% confidence interval ranged from 0.327 to 0.997, including the value 1, indicating some variability in the data but still supporting the tendency for lower utilization with increasing age.</p>
<p>Secondly, a significant relationship was found between the place of residence (urban or rural) and reproductive health service utilization (p-value = 0.046). The odds ratio of 2.000 indicated that individuals in urban areas had twice the odds of utilizing reproductive health services compared to their rural counterparts. The 95% confidence interval ranged from 1.012 to 3.950, not including the value 1, which reinforced the significance of this association.</p>
<p>Lastly, there was a highly significant relationship between education status and reproductive health service utilization (p-value = 0.000). The odds ratio of 0.223 highlighted those individuals with higher education levels had 0.223 times lower odds of utilizing reproductive health services than those with lower education levels. The 95% confidence interval ranged from 0.223 to 0.406, excluding the value 1, further emphasizing the significance of this educational factor in relation to reproductive health service utilization.</p>
<p>Table 2: Socio-cultural factors associated with RH services utilization among women of reproductive age in South Sudan</p>
<div style="overflow-x: auto;">
<table border="1">
<tbody>
<tr>
<td>
<p><strong>Variables</strong></p>
</td>
<td>
<p><strong>User of RH services</strong></p>
<p><strong>n (%)</strong></p>
<p><strong>n = 290</strong></p>
</td>
<td>
<p><strong>Non-user of RH services</strong></p>
<p><strong>n (%)</strong></p>
<p><strong>n = 110</strong></p>
</td>
<td>
<p><strong>OR</strong></p>
<p><strong>(95% CI)</strong></p>
</td>
<td>
<p><strong>P Value</strong></p>
</td>
</tr>
<tr>
<td>
<p><strong>State </strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Central Equatoria</p>
</td>
<td>
<p>173 (59.7)</p>
</td>
<td>
<p>59 (53.6)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Western Equatoria</p>
</td>
<td>
<p>117 (40.3)</p>
</td>
<td>
<p>51 (46.4)</p>
</td>
<td>
<p>1.197 (0.725-1.976)</p>
</td>
<td>
<p>0.482</p>
</td>
</tr>
<tr>
<td>
<p><strong>Age </strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Younger than 30 years</p>
</td>
<td>
<p>132 (45.5)</p>
</td>
<td>
<p>54 (49.1)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>30 years and older</p>
</td>
<td>
<p>158 (54.5)</p>
</td>
<td>
<p>56 (50.9)</p>
</td>
<td>
<p>0.571 (0.327-0.997)</p>
</td>
<td>
<p>0.049*</p>
</td>
</tr>
<tr>
<td>
<p><strong>Marital status</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Married</p>
</td>
<td>
<p>186 (75.3)</p>
</td>
<td>
<p>82 (79.6)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Single</p>
</td>
<td>
<p>61 (24.7)</p>
</td>
<td>
<p>21(20.4)</p>
</td>
<td>
<p>0.858 (0.437-1.685)</p>
</td>
<td>
<p>0.657</p>
</td>
</tr>
<tr>
<td>
<p><strong>Place of residence</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Urban</p>
</td>
<td>
<p>60 (20.7)</p>
</td>
<td>
<p>14 (12.7)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Rural</p>
</td>
<td>
<p>230 (79.3)</p>
</td>
<td>
<p>96 (87.3)</p>
</td>
<td>
<p>2.000 (1.012-3.950)</p>
</td>
<td>
<p>0.046*</p>
</td>
</tr>
<tr>
<td>
<p><strong>Employment status </strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Not employed</p>
</td>
<td>
<p>176 (60.7)</p>
</td>
<td>
<p>84 (76.4)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Employed</p>
</td>
<td>
<p>114 (30,3)</p>
</td>
<td>
<p>26 (23.6)</p>
</td>
<td>
<p>0.631 (0.360-1.104)</p>
</td>
<td>
<p>0.107</p>
</td>
</tr>
<tr>
<td>
<p><strong>Religion </strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Christian</p>
</td>
<td>
<p>245 (84.5)</p>
</td>
<td>
<p>103 (93.6)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Traditional</p>
</td>
<td>
<p>45 (15.5)</p>
</td>
<td>
<p>7 (6.4)</p>
</td>
<td>
<p>0.617 (0.242-1.572)</p>
</td>
<td>
<p>0.311</p>
</td>
</tr>
<tr>
<td>
<p><strong>Education status</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>No school/non-formal/dropped-out</p>
</td>
<td>
<p>138 (47.6)</p>
</td>
<td>
<p>89 (80.9)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Completed secondary</p>
</td>
<td>
<p>152 (52.4)</p>
</td>
<td>
<p>21(19.1)</p>
</td>
<td>
<p>0.223 (0.122-0.406)</p>
</td>
<td>
<p>0.000**</p>
</td>
</tr>
</tbody>
</table>
</div>
<p><em><strong>Source:</strong></em> Research Data (2023)</p>
<p>**. Correlation is significant at the 0.01 level</p>
<p>*. Correlation is significant at the 0.05 level</p>
<p>In summary, the research findings regarding socio-cultural factors influencing the uptake and utilization of reproductive health services indicate the following: older age is associated with a decreased likelihood of utilizing reproductive health services; individuals residing in urban areas have higher odds of utilizing reproductive health services compared to those in rural areas; and higher education levels are associated with lower odds of utilizing reproductive health services. These findings suggest that addressing socio-cultural factors such as age, place of residence, and education status is crucial in promoting and improving the uptake and utilization of reproductive health services in the context of South Sudan.</p>
<p><strong>Discussion</strong></p>
<p>The research findings related to the uptake and utilization of Reproductive Health Services (RHS) in selected South Sudan public health facilities were analyzed within the conceptual frameworks of the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These models provide essential insights into the factors influencing individuals' decisions regarding RHS utilization.</p>
<p>In this study, the HBM was employed to investigate the determinants of RHS utilization. The HBM encompasses key constructs, such as perceived susceptibility and severity, perceived benefits, perceived barriers, and cues to action, to understand how people perceive and make decisions about their health behaviours. Findings from the study indicate that perceived susceptibility and severity of RH issues are crucial in motivating individuals to engage in RH behaviours. Perceived susceptibility varies among individuals, underscoring the importance of threat perception. The perceived severity is influenced by factors including emotional responses and cognitive assessments of health problems, encompassing medical complications and broader consequences on individuals' lives. Additionally, the study highlights those perceived benefits significantly influence individuals to take action in preventing RH threats. When individuals believe that RHS are effective in addressing their health concerns, they are more likely to utilize these services. Moreover, the study underscores the role of "cues to action" as triggers for health behaviour, including physical symptoms, mass media communications, interpersonal interactions, advice from others, health education campaigns, and reminders from healthcare providers. These cues play a substantial role in motivating individuals to access RHS.</p>
<p>In parallel, the TRA provides insights into the role of attitudes, subjective norms, and intentions in predicting health-related behaviours. The study findings demonstrated that attitudes toward RHS significantly correlated with beliefs and outcome evaluations related to these services. The stronger an individual's intention to use RHS, the more likely they are to engage in the behaviour. Attitudes and subjective norms were identified as significant determinants of the intention to utilize RHS. These results highlight the importance of shaping positive attitudes toward RHS and considering the influence of social norms and peer opinions when designing interventions to promote RHS utilization.</p>
<p><em>Level of Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities</em></p>
<p>The findings of the study indicate that a significant proportion of the respondents (72.5%) had utilized reproductive health services in the selected public health facilities, while 27.5% reported not having utilized any services in the past 12 months. Studies conducted in the region reveal that approximately 17% of all women in Sub-Saharan Africa and 23% of married or in-union women have an unmet need for RH services (United Nations, 2019). However, despite the significant utilization of RH services, the current study found that the majority of women (86.3%) reported not receiving all the RHS they were seeking in the selected public health facilities. This highlights a gap in the availability of comprehensive reproductive health services, indicating a need for improvement in the facilities' service delivery.</p>
<p>Among the RHS, family planning and prevention and management of sexually transmitted infections (STIs) were the most utilized, each accounting for 25.1% of the sampled population. Maternal and newborn care and HIV counselling and testing were also commonly used services, representing 18.1% and 15.3% of the respondents, respectively. However, studies conducted across Africa show that the majority of women of reproductive age would like to stop or delay childbearing but only 28% of women are using modern methods of family planning (WHO Africa, 2020). In addition, this study revealed that prior to their latest visit, a significant portion of the respondents (77.3%) were not aware that public health facilities provided free access to RHS. This lack of awareness may have hindered women's utilization of these services, emphasizing the importance of enhancing public awareness campaigns to ensure women are informed about the availability and accessibility of RHS.</p>
<p>From the longitudinal ecological study, it was observed seasonal variations in the number of visits for family planning, HIV counselling and testing, and maternal and newborn care services from 2015 to 2020. The trend analysis indicated a consistent increase in the uptake of RH services throughout the years. A previous study conducted in South Sudan found that the return of peace in South Sudan presented opportunities unlike before, including utilization and uptake of RHS among women of reproductive health (Kane, et al., 2016). However, this current study showed that there were specific declines in family planning, HIV counselling and testing, and maternal and newborn care attendance during the third quarter of each year from 2015 to 2020. This finding suggests a potential need for targeted interventions to address barriers or factors affecting attendance during the third quarter period.</p>
<p>The findings of this research objective shed light on the utilization and availability of RHS among women of reproductive age in South Sudan's public health facilities. The findings highlight the need for improved service provision to ensure comprehensive RHS are accessible to all women. Increasing awareness among the target population about free access to RHS can also contribute to improved utilization. Thus, addressing the seasonal differences in attendance, particularly for family planning services, HIV counselling and testing, and maternal and newborn care may require targeted strategies to ensure consistent access throughout the year.</p>
<p><em>Socio-Cultural Factors Associated with RH Services Utilization</em></p>
<p>The study revealed that the majority of the respondents (53.5%) were 30 years and older, while the remaining 46.5% were younger than 30 years. The statistical analysis showed a significant relationship between the age of the respondents and the uptake and utilization of RHS. The p-value of 0.049 suggests that age is a contributing factor in determining the utilization of these services. A study conducted in Kenya by Kinaro et al. (2019) found that early marriage, being young, male-only decisions on sexuality matters and fear of family contribute to unprotected sex while myths and misconceptions on contraceptives affected the utilization of RHS. Another study conducted in Kenya by Godia et al. (2014) found that most youths are not aware of existing RHS. They found that young people’s perception and knowledge of younger girls (12–14 years) is limited with a majority reporting that they don’t know much about RHS. This current finding implies that older women are less likely to utilize RHS compared to younger women. Possible reasons for this could include cultural norms, lack of awareness, or different reproductive health needs at different stages of life.</p>
<p>The study found that over 80% of the respondents resided in rural areas, while the remaining 18.5% lived in urban regions. The analysis demonstrated a statistically significant relationship between the place of residence and the uptake and utilization of RHS. The p-value of 0.046 indicates that the place of residence plays a role in determining the utilization of these services. A previous study conducted by Sumankuuro et al. (2018) shared similar findings, they found that women from rural (or poverty-stricken) areas are vulnerable because of their status and lack of access to RH services. Their risk behaviors as well as their access to RH services are influenced significantly by the type of place that they reside. The current study established that individuals residing in urban areas have twice the odds of utilizing RHS compared to those in rural areas. This could be attributed to better access to healthcare facilities, increased availability of services, and potentially higher levels of education and awareness in urban settings.</p>
<p>The study showed that the educational level of the respondents is significantly related to the uptake and utilization of RHS. The p-value of 0.000 indicates a highly significant relationship between education status and service utilization. This finding contradicted other studies (Aragie and Abate, 2021; Abebe and Awoke, 2014), which stipulated that those families with higher educational status are more likely to be familiar with RHS-related issues. However, this study indicates that individuals with higher education levels have 0.223 times lower odds of utilizing RHS compared to those with lower education levels. This finding may seem counterintuitive, as higher education is often associated with better access to information and resources. However, it's important to consider other factors such as socioeconomic status, cultural beliefs, and personal preferences that may influence the relationship between education and service utilization.</p>
<p>Overall, the findings suggest that age, place of residence, and education status are significant socio-cultural factors influencing the uptake and utilization of RHS among women in South Sudan. These findings highlight the need for targeted interventions and strategies to address barriers and promote RHS among older women, rural populations, and individuals with lower levels of education. Improving access to healthcare facilities, increasing awareness about available services, and addressing cultural norms and beliefs are crucial steps toward enhancing reproductive healthcare utilization and ultimately improving the well-being of women in South Sudan.</p>
<p><strong>Conclusions</strong></p>
<p>The study revealed that perceived susceptibility and severity of RH issues significantly motivate individuals to engage in RH behaviours. The perceived benefits of utilizing RHS play a pivotal role in encouraging individuals to take action to prevent RH threats. Additionally, the study emphasized the importance of "cues to action" as mechanisms to trigger health behaviour, including physical symptoms, mass media communications, interpersonal interactions, advice from others, health education campaigns, and reminders from healthcare providers. These cues significantly motivated individuals to access reproductive health services.</p>
<p>The findings also demonstrated that age, place of residence, and education status are crucial socio-cultural factors influencing the uptake and utilization of RHS. Older women were less likely to utilize these services compared to younger women, which may be attributed to cultural norms, varying RH needs at different life stages, or a lack of awareness. Urban residents were found to have higher odds of utilizing RHS, potentially due to better access to healthcare facilities, increased service availability, and higher levels of education and awareness. Surprisingly, individuals with higher education levels exhibited lower odds of utilizing RHS, emphasizing the complex interplay of socioeconomic status, cultural beliefs, and personal preferences in the relationship between education and service utilization.</p>
<p>The study's findings hold significant implications for policy, practice, and future research in the field of RHS. First and foremost, enhancing public awareness campaigns is crucial to ensure women are well-informed about the availability and accessibility of RHS. These campaigns should be tailored to address the diverse needs and perceptions of both urban and rural populations. Second, improving service delivery is imperative to bridge the existing gap in comprehensive RHS availability. This entails expanding the range of services offered by public health facilities, extending beyond family planning and STI management to encompass maternal and newborn care and HIV counselling and testing. Lastly, the study underscores the importance of implementing targeted interventions to overcome barriers faced by specific demographic groups, including older women, rural residents, and individuals with lower educational attainment. These interventions should take into account the influence of cultural norms, socioeconomic factors, and individual preferences to effectively promote the utilization of RHS services.</p>
<p>The study presents several limitations that warrant consideration. First, it is essential to acknowledge that the research centred on two specific states within South Sudan, potentially limiting the generalizability of the findings to the broader national context. Furthermore, the cross-sectional design employed in this study offers a snapshot of the observed relationships, but it does not permit the establishment of causal relationships. Lastly, the data collection relied on self-reporting, which may introduce biases related to recall and social desirability. </p>
<p>Future research should aim to expand the geographical scope to include a more representative sample of South Sudan. Longitudinal studies can provide more robust insights into trends and causal relationships regarding RHS utilization. Furthermore, exploring the influence of other socio-cultural factors, such as socioeconomic status, cultural beliefs, and access to healthcare facilities, will provide a more comprehensive understanding of the determinants of RHS utilization in South Sudan. Additionally, comparative studies between different theoretical frameworks, such as the HBM and TRA, can offer insights into which model best explains RH behaviours in this context. These avenues of research can contribute to a more holistic approach to addressing RH challenges in South Sudan and similar settings.</p>
<p><strong>Acknowledgements:</strong></p>
<p>This study was made possible through the support of my supervisors Dr. Alfred Owino Odongo and Dr. John Kariuki, and my colleagues within the Ministry of Health, particularly my fellow Public Health Officers and Surveillance Officers. Their support is acknowledged.</p>
<p><strong>Funding Acknowledgements:</strong></p>
<p>The author(s) received no financial support for the research, authorship, and/or publication of this article.</p>
<p><strong>Competing Interests:</strong></p>
<p>Author(s) declares there were no competing interests.</p>
<p><strong>References</strong></p>
<ol>
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<li aria-level="1">Aragie, T. G., & Abate, B. B. (2021). Utilization of Reproductive Health Services and Associated Factors among Secondary School Students in Woldia Town, Northeast Ethiopia. J Environ Public Health, 2021, 2917874. <a href="https://doi.org/10.1155/2021/2917874"></a><a href="https://doi.org/10.1155/2021/2917874">https://doi.org/10.1155/2021/2917874</a></li>
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<li aria-level="1">IPC. (2018). Integrated food security phase classification, The Republic of South Sudan: Key findings.</li>
<li aria-level="1">Kane, S., Kok, M., Rial, M., Matere, A., Dieleman, M., & Broerse, J. E. (2016). Social norms and family planning decisions in South Sudan. BMC Public Health, 16(1), 1–12. <a href="https://doi.org/10.1186/s12889-016-3839-6"></a><a href="https://doi.org/10.1186/s12889-016-3839-6">https://doi.org/10.1186/s12889-016-3839-6</a></li>
<li aria-level="1">Kinaro, J. W., Wangalwa, G., Karanja, S., Adika, B., Lengewa, C., & Masitsa, P. (2019). Socio-Cultural Barriers Influencing Utilization of Sexual and Reproductive Health (SRH) Information and Services among Adolescents and Youth 10 - 24 Years in Pastoral Communities in Kenya. Advances in Sexual Medicine, 9, 1–16. <a href="https://doi.org/10.4236/asm.2019.91001"></a><a href="https://doi.org/10.4236/asm.2019.91001">https://doi.org/10.4236/asm.2019.91001</a></li>
<li aria-level="1">Larson, G., Ajak, P., & Pritchett, L. (2013). South Sudan’s Capability Trap: Building a State with Disruptive Innovation; 2013.</li>
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<li aria-level="1">UNICEF. (2016). The State of the World’s Children 2016: a fair chance for every child. <a href="https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-020-09155-w.pdf"></a><a href="https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-020-09155-w.pdf">https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-020-09155-w.pdf</a></li>
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<li aria-level="1">UNPF. (2019). Sexual and Reproductive Health and Rights: An Essential Element of Universal Health Coverage. <a href="https://www.unfpa.org/sites/default/files/pub-pdf/SRHR_an_essential_element_of_UHC_SupplementAndUniversalAccess_27-online.pdf"></a><a href="https://www.unfpa.org/sites/default/files/pub-pdf/SRHR_an_essential_element_of_UHC_SupplementAndUniversalAccess_27-online.pdf">https://www.unfpa.org/sites/default/files/pub-pdf/SRHR_an_essential_element_of_UHC_SupplementAndUniversalAccess_27-online.pdf</a></li>
<li aria-level="1">United Nations. (2015). Trends in contraceptive use worldwide 2015.</li>
<li aria-level="1">United Nations. (2019). Estimates and Projections of Family Planning Indicators.</li>
<li aria-level="1">WHO. (2021). Reproductive health. <a href="https://www.who.int/westernpacific/health-topics/reproductive-health"></a><a href="https://www.who.int/westernpacific/health-topics/reproductive-health">https://www.who.int/westernpacific/health-topics/reproductive-health</a></li>
<li aria-level="1">WHO Africa. (2020). Sexual and Reproductive Health Fact Sheet.</li>
<li aria-level="1">WHO Africa. (2021). Sexual and Reproductive Health. <a href="https://www.afro.who.int/health-topics/sexual-and-reproductive-health"></a><a href="https://www.afro.who.int/health-topics/sexual-and-reproductive-health">https://www.afro.who.int/health-topics/sexual-and-reproductive-health</a></li>
<li aria-level="1">WHO Europe. (2020). HIV/AIDS surveillance in Europe.</li>
<li aria-level="1">WHO Europe. (2021). Sexual and Reproductive Health. <a href="https://www.euro.who.int/en/health-topics/Life-stages/sexual-and-reproductive-health/sexual-and-reproductive-health"></a><a href="https://www.euro.who.int/en/health-topics/Life-stages/sexual-and-reproductive-health/sexual-and-reproductive-health">https://www.euro.who.int/en/health-topics/Life-stages/sexual-and-reproductive-health/sexual-and-reproductive-health</a></li>
<li aria-level="1">World Bank. (2018). World Development Indicators. <a href="http://databank.worldbank.org/data/source/healthnutrition-and-population-statistics"></a><a href="http://databank.worldbank.org/data/source/healthnutrition-and-population-statistics">http://databank.worldbank.org/data/source/healthnutrition-and-population-statistics</a></li>
</ol>
<p><img src="https://pachodo.org/images/Dr_Emmanuel_Timothy_THWOL.png" alt="DR. EMMANUEL TIMOTHY THWOL" title="DR. EMMANUEL TIMOTHY THWOL" /></p>
<p><em><strong>By DR. Emmanuel Timothy Thwol Onak (PhD)</strong></em></p>
<p> </p>
<p><strong>Abstract</strong></p>
<p><strong>Background:</strong> Africa constitutes roughly 10% of the global population and witnesses around 20% of worldwide childbirths. Alarmingly, nearly half of all maternal deaths during pregnancy and childbirth occur in this region. The World Health Organization (WHO) estimates that inadequate reproductive health contributes to approximately 18% of the overall global disease burden, with women of reproductive age bearing 32% of this burden. In light of these concerns, this study investigates the sociocultural elements influencing the adoption and use of Reproductive Health Services (RHS) in specific public health facilities in South Sudan while also assessing the extent to which these services are being embraced and utilized.</p>
<p><strong>Method:</strong> The research utilized a mixed-methods strategy, comprising a longitudinal ecological study and an analytical cross-sectional investigation, which took place in specifically chosen states - Western Equatoria and Central Equatoria. The study focused on women aged 15 to 49 who were seeking healthcare services during the study timeframe. Data collection methods encompassed structured questionnaires and data abstraction instruments. The quantitative data analysis encompassed descriptive statistics and inferential analyses.</p>
<p><strong>Results: </strong></p>
<p>The study's findings reveal that a significant portion of respondents (72.5%) had utilized reproductive health services in selected public health facilities, with family planning and prevention/management of STIs being the most commonly used services, each accounting for 25.1% of the sampled population. Maternal and newborn care and HIV counseling/testing were also frequently accessed, at 18.1% and 15.3%, respectively. Over the years, there was a consistent increase in the uptake of reproductive health services, although specific declines were observed during the third quarter of each year from 2015 to 2020 for family planning, HIV counselling/testing, and maternal/newborn care. The study noted that a significant relationship existed between the age of the respondents and service utilization, with 53.5% of respondents aged 30 and older. Additionally, there was a statistically significant link between the respondent's place of residence and service utilization, with individuals in urban areas being twice as likely to utilize services compared to those in rural areas. The study also found a significant relationship between the educational level of the respondents and the uptake of reproductive health services.</p>
<p><strong>Conclusions: </strong></p>
<p>While the study reveals a positive trend in the overall uptake of RHS, specific declines in family planning, HIV counselling/testing, and maternal/newborn care during certain quarters require attention. Notably, age, place of residence, and educational levels significantly influence service utilization, with older individuals, urban residents, and those with higher educational attainment more likely to access reproductive health services. To address these disparities and improve reproductive health outcomes, policy and healthcare interventions should be tailored to the unique sociocultural contexts and demographic characteristics of South Sudan. Greater emphasis on education and awareness campaigns, particularly in rural areas, is recommended to promote comprehensive RHS utilization and reduce maternal mortality rates. Additionally, sustained efforts to enhance the quality and accessibility of these services, especially in the specified areas of decline, are crucial to advancing reproductive health in the region.</p>
<p><strong>Introduction</strong></p>
<p>Reproductive Health (RH) is a fundamental component of overall well-being, encompassing physical, mental, and social aspects that go beyond the mere absence of disease or infirmity, as defined by the World Health Organization (WHO, 2021). RH extends to all matters related to the reproductive system, its functions, and processes. The United Nations Population Fund (UNPF, 2019) further emphasizes that RH includes the ability to reproduce, regulate fertility, engage in safe and fulfilling sexual relationships, and achieve successful outcomes in reproduction, such as infant and child survival, growth, and healthy development. It also entails safe pregnancy and childbirth, risk-free fertility regulation, and the assurance of safe sexual experiences.</p>
<p>The WHO RH Strategy, established in 2004 and guided by international human rights principles, outlines the core elements of Sexual and Reproductive Health (SRH), aiming to enhance the well-being of communities (WHO Africa, 2020). These core aspects encompass improving antenatal, perinatal, postpartum, and newborn care; providing high-quality family planning services, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer, and other gynaecological morbidities; and promoting sexual health. Additionally, the strategy underscores the critical importance of preventing and responding to violence against women to improve reproductive health outcomes.</p>
<p>Despite some progress within the European Region, challenges persist. While the contraceptive prevalence rate has increased from 55.6% in 2000 to 61.2% in 2015, there remains a significant lack of information and awareness concerning critical RH issues such as sexuality, family planning, pregnancy, childbirth, sexually transmitted infections, infertility, cervical cancer prevention, and menopause (WHO Europe, 2021). The region faces complications in pregnancy and childbirth, unsafe abortions, reproductive tract infections, and sexual violence, which contribute to avoidable cancer-related deaths among women. Notably, there are disparities in RH within and between countries. A study in 13 European Union countries in 2012 highlighted the higher proportion of women with unmet family planning needs among people living with HIV (PLHIV) compared to the general population (UNPF, 2012). New HIV infections in the European Region increased by 75% since 2005, and the region reported nearly 137,000 new HIV diagnoses in 2019 (WHO Europe, 2020).</p>
<p>Contraception and abortion are significant concerns in Asia. In 2017, approximately 132 million women of reproductive age in Asia had an unmet need for modern contraception, leading to an estimated 53.8 million unintended pregnancies, two-thirds of which ended in abortion (Center for Reproductive Rights, 2021). The majority of these abortions occurred in South and Central Asia, including India, and Eastern Asia, including China. Although the proportion of unsafe abortions is uncertain, it is estimated that 4.6 million women in Asia (excluding Eastern Asia) experience complications from unsafe abortions annually (Guttmacher Institute, 2017). Adolescent childbearing rates have decreased in most Asian and Pacific countries, but they remain high in South and South-West Asia, particularly in Bangladesh (35%), Nepal (21%), and India. South Asia also grapples with a high prevalence of child marriage, with 45% of women aged 20-24 reporting marriage before the age of 18 and 17% before the age of 15 (Center for Reproductive Rights, 2021). Maternal mortality related to pregnancy and childbirth affected approximately 85,000 women in the region in 2015, with 92% of these maternal deaths occurring in just 12 countries (UNICEF, 2021).</p>
<p>In Africa, women face a higher risk of death from communicable diseases, maternal and perinatal conditions, and nutritional deficiencies. About 30% of women worldwide, including 468 million aged 15-49, experience anaemia, with the majority living in Africa (48-57%) due to iron deficiency. Gender inequity, poverty, weak economic capacity, and sexual and gender-based violence, including Female Genital Mutilation (FGM), present significant obstacles to improving women's health in the African Region (United Nations, 2015). Despite Africa accounting for one-tenth of the world's population and 20% of global births, nearly half of maternal deaths occur in this region. Poor reproductive health accounts for up to 18% of the global burden of disease and 32% of the total burden for women of reproductive age (WHO Africa, 2020). Access to essential RH interventions, particularly family planning, remains limited, with low contraceptive use (13%) and a high total fertility rate (5.5 children per woman) in Sub-Saharan Africa (WHO, 2021).</p>
<p>However, just as health outcomes have improved globally in the past two decades, South Sudan has also seen substantial progress, such as a decline in maternal mortality, neonatal mortality, infant mortality, and under-five stunting (World Bank, 2018). Access to Reproductive Health Services (RHS), including antenatal care and contraception, has significantly increased in Sub-Saharan Africa (United Nations, 2015). Nevertheless, access to healthcare, especially RH services, remains a significant challenge in South Sudan due to persistent conflicts and a fragile peace process (Pendle, 2014). In the East African region, including countries like Uganda, Tanzania, and Kenya, maternal mortality remains high compared to developed nations, highlighting the need for improved RH services (UNICEF, 2016). The use of modern contraceptives is low, and unmet family planning needs affect a significant proportion of married women (United Nations, 2015).</p>
<p>In the context of South Sudan, capacity constraints and a challenging governance environment affect the implementation of basic health services and government policies. Reports suggest a lack of progress in building government capacity (Larson et al., 2013), and economic and social challenges, including budget cuts for health, inflation, and food insecurity, exacerbate the situation (Integrity, 2018; IPC, 2018). The economic crisis affects programs funded by donors, including RH services (Integrity, 2018). Consequently, the utilization and uptake of RH services in South Sudan are subject to these complexities, making this an issue of critical importance.</p>
<p>This study's rationale is rooted in the urgent necessity to comprehend and enhance the utilization of Reproductive Health Services (RHS) in South Sudan, a region characterized by persistent conflict, fragile governance, and substantial economic challenges. South Sudan has grappled with prolonged instability, violence, and a feeble healthcare infrastructure, resulting in limited access to essential healthcare services, particularly reproductive health. Consequently, investigating the determinants of RH service uptake in this complex environment is not only justifiable but also profoundly pertinent. The relevance of this study extends to multiple dimensions. Firstly, it is essential to devise effective strategies to improve reproductive health outcomes in conflict-affected regions like South Sudan, where ongoing instability has triggered economic crises and healthcare infrastructure limitations, making it imperative to ensure access to vital RH services, thereby reducing maternal and infant mortality, bolstering family planning, and addressing the consequences of unmet reproductive health needs. Secondly, the study's global relevance is underscored by the fact that South Sudan's challenges are not unique; many conflict-affected regions worldwide face analogous difficulties in delivering healthcare services, including reproductive health. Therefore, the study's findings offer valuable insights for other nations and organizations working in such settings, providing guidance on strategies to surmount challenges and enhance RH service utilization. </p>
<p>The primary question guiding this study is: "What are the determinants of Reproductive Health (RH) services uptake and utilization in South Sudan, and how do sociocultural factors impact these processes?" To address this overarching question, the study has two specific objectives: 1) to assess the level of uptake and utilization of RH services in selected South Sudan public health facilities, and 2) to examine the sociocultural factors influencing the uptake and utilization of RH services in these facilities. These objectives guide the study's focus on understanding the factors influencing the utilization of RH services in a conflict-affected and resource-constrained setting.</p>
<p><strong>Methods</strong></p>
<p>The study employed a mixed-methods approach to gather and analyze data. It consisted of two main parts: a longitudinal ecological study using retrospective data from South Sudan's Ministry of Health covering the period from 2015 to 2020 and an analytical cross-sectional study conducted at public health facilities involving women of reproductive age.</p>
<p>In the analytical cross-sectional study, quantitative data was collected from women of reproductive age visiting selected public health facilities during the study period. A structured questionnaire with only closed-ended questions was developed as the primary research instrument, focusing on specific study objectives. This questionnaire aimed to assess the level of reproductive health service utilization and socio-cultural factors. Additionally, a data abstraction tool, a standard instrument, was employed to systematically collect data from the Health Management Information System database and health facilities. This tool was used to extract utilization data from the period between 2015 and 2020.</p>
<p>The study drew its theoretical framework primarily from two established theories: the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These theories have been widely used in previous studies to explain and predict the utilization and uptake of reproductive health services. The Health Belief Model (HBM) focuses on unique and subjective beliefs that influence an individual's decision-making process. It includes perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action. These constructs were used to develop a predictive model for risky sexual practices in college students and were found to significantly explain variations in risk behaviours and sexual partnerships. The Theory of Reasoned Action (TRA) provides a framework for studying attitudes toward behaviours and aims to predict and understand an individual's behaviour. It assumes that individuals are rational and base their actions on a thoughtful consideration of available information and potential consequences. The TRA comprises key constructs, including behaviour, intention, and personal attitude. The intention is considered the primary determinant of behaviour, with stronger intention indicating a higher likelihood of performing a particular behaviour.</p>
<p>This methodological approach allowed for a comprehensive examination of reproductive health service utilization and the underlying factors, drawing on well-established theoretical frameworks.</p>
<p><em>Study sites</em></p>
<p>The study was conducted at public health facilities in two specific states of South Sudan, namely, Western Equatoria and Central Equatoria. South Sudan's population predominantly resides in rural areas, accounting for approximately 83% of the total population. The rural landscape is characterized by low population density at 15 individuals per square kilometre, which, combined with the presence of mobile pastoral communities and restricted access due to prolonged conflicts, presents substantial challenges to healthcare service provision. Data collection was carried out at all four levels of the South Sudan health system, encompassing the Boma Health Teams representing the community level, Primary Healthcare Units (PHCU), Primary Healthcare Centers (PHCC), and hospitals. These healthcare facilities are strategically aligned with the country's administrative subdivisions, serving both rural and urban regions (Ministry of Health, 2012; WHO South Sudan, 2020).</p>
<p><em>Sampling, recruitment of study participants and data collection</em></p>
<p>The primary respondents for this study were situated in public health facilities located in Western Equatoria and Central Equatoria. The quantitative sampling approach employed a multi-stage cluster random sampling method, involving two distinct stages: the selection of health facilities and the subsequent selection of participants.</p>
<p>In the first stage of sampling, the selection of health facilities commenced within each of the chosen states. A comprehensive list of existing public health facilities was compiled, and from this list, a systematic random sampling method was employed to designate a specific facility as a sample for the study. A minimum of three public health facilities were randomly chosen in each state.</p>
<p>The second stage of sampling centred on the selection of participants; a process facilitated by probability proportionate to size. Utilizing available population lists, such as the 2018 census, which included women of reproductive age falling within the bracket of 15 to 49 years, from the pre-selected states of Western Equatoria and Central Equatoria. The sampling interval was computed by dividing the total population of the program area by the number of women of reproductive age who visited health facilities. A systematic random start number was used to identify the first client. Subsequent clients were determined by incrementing the random number by the sampling interval, and this process continued until the required number of clients was attained.</p>
<p>The researcher assumed the responsibility for both the collection and management of field data. Preceding the commencement of data collection, the researcher recruited and conducted comprehensive training for five research assistants (RAs). The RAs were thoroughly acquainted with the study's objectives and methodological approach, and they received training in the administration of data collection tools, which encompassed a detailed review of the tools and practical exercises. Ethical considerations, data confidentiality protocols, and field logistics were also integral parts of the training. Prior to the commencement of the interview, written consent was obtained from the participants, and the participants were assured of the confidentiality of their information. The interviews were initiated with a concise introduction, elucidating the interviewer's identity, the organization they represented, and the study's objectives. The data collection tools were administered through face-to-face interviews.</p>
<p>Additionally, the data needed for completing the data abstraction form encompassed information related to the intervention under investigation, evaluation setting, study population, outcomes, results, and study quality. The form comprised three key sections: Part I, which pertained to Classification Information and was initially filled out by the chapter development team and subsequently reviewed and edited by the abstractors; Part II, which covered Descriptive Information concerning the intervention, evaluation study characteristics, measurement of outcomes, and results; and Part III, which delved into Study Quality, evaluating the execution of the study.</p>
<p><em>Data analysis</em></p>
<p>The data derived from the questionnaires and the data abstraction form underwent a comprehensive data analysis process. Initially, all data were entered into a computer file using Microsoft Excel Spreadsheet. Subsequently, the data were exported to IBM Statistical Package for the Social Sciences (SPSS) version 23, where all sub-files were amalgamated into one master file for further analysis. The initial phase of data analysis was data preparation, which involved transforming raw data into a comprehensible and meaningful format. This process included data validation, editing, and coding.</p>
<p>Various statistical techniques were then employed to identify significant correlations between variables and assess the impact of one variable on another. Descriptive statistics, such as mean, median, mode, percentage, frequency, and range, were utilized to gain an overview of the data. Descriptive statistics are particularly valuable when the scope of the research is confined to the sample and does not necessitate generalization to a larger population. For example, when comparing the percentage of youth utilizing RHS in different states, descriptive statistics provide sufficient insights. Subsequently, cross-tabulations were utilized to delve deeper into the dataset. Cross-tabulations are a means to elucidate the relationship between two variables and are commonly employed to compare outcomes across demographic groups. They allow for the examination of results based on factors like age and the utilization of RHS.</p>
<p>To assess hypotheses, the researcher calculated measures of statistical significance, which ascertain whether findings are statistically meaningful or merely the result of chance. Statistical significance was indicated by the p-value statistic. Typically, a p-value of less than 0.05 is considered statistically significant, signifying a less than 5% probability that the results occurred by chance. Furthermore, the researcher applied various inferential analyses, including correlation, regression, and analysis of variance where relevant. Linear regression was employed, for instance, to predict the value of one variable based on another. This approach allowed the exploration of whether the utilization of RHS could be predicted based on factors like climate change or socio-cultural characteristics. Additionally, one-way analysis of variance (ANOVA) was used to determine if statistically significant differences existed between the means of two or more independent groups.</p>
<p><em>Ethical considerations</em></p>
<p>Ethical considerations were paramount throughout the course of this study. Prior to the commencement of data collection, the researcher diligently sought ethical approval from the Division of Research, Monitoring and Evaluation within the Directorate of Planning and Coordination at the Ministry of Health, as well as the Research Ethics Committee (REC) of the Republic of South Sudan. Additional approvals were obtained from the Institutional Ethical Review Committee (IERC) of Mount Kenya University. In accordance with ethical standards, formal permissions were also secured from the respective sectoral and departmental heads, including the Ministry of Health and Local Governments within the Republic of South Sudan, to access public health facilities and other relevant offices.</p>
<p>The participants who willingly consented to take part in the study were assured of strict anonymity and confidentiality. These measures were implemented to safeguard their identities and instil confidence in the research process, thereby promoting the provision of accurate information. Furthermore, participants were granted the unequivocal right to exercise their free will, allowing them to decide whether they wished to participate in the research. The option of withdrawal from the study was extended to participants at any point, without the requirement to provide a reason. This opportunity was explicitly communicated to participants before the commencement of interviews and was also documented in writing.</p>
<p>In adhering to high ethical standards and principles for research, the study conformed to data collection, security, and protection requirements. Special consideration was also given to adaptations necessary to comply with COVID-19 control regulations. The risk level to both the research team and the communities was identified, and all personnel and participants were provided with essential protective equipment to mitigate risks effectively.</p>
<p><strong>Results</strong></p>
<p><em><strong>Socio-Demographic Characteristics</strong></em></p>
<p>Table 1 provides a comprehensive overview of the demographic characteristics of the study's respondents. The data reveals that a significant portion of the participants (53.5%) were aged 30 years and older, while the remaining 46.5% were younger, with the age range spanning from 17 to 49 years. The mean age was calculated at 29.8 years, with a standard deviation of 7.80. Regarding marital status, the majority of respondents indicated that they were married (67.0%), followed by those who reported being single (20.5%). A smaller percentage of respondents identified as divorcees (6.3%), and another 6.3% stated they were widowed.</p>
<p>Table 1: Socio-demographic characteristics of women of reproductive health visiting selected public health facilities in South Sudan</p>
<div style="overflow-x: auto;">
<table border="1">
<tbody>
<tr>
<td>
<p><strong>Variable </strong></p>
</td>
<td>
<p><strong>Category</strong></p>
</td>
<td>
<p><strong>Frequency</strong></p>
</td>
<td>
<p><strong>Percentage (%)</strong></p>
</td>
</tr>
<tr>
<td rowspan="2">
<p>State </p>
</td>
<td>
<p>Central Equatoria</p>
</td>
<td>
<p>232</p>
</td>
<td>
<p>58.0</p>
</td>
</tr>
<tr>
<td>
<p>Western Equatoria</p>
</td>
<td>
<p>168</p>
</td>
<td>
<p>42.0</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="2">
<p>Age</p>
</td>
<td>
<p>Younger than 30 years</p>
</td>
<td>
<p>186</p>
</td>
<td>
<p>46.5</p>
</td>
</tr>
<tr>
<td>
<p>30 years and older</p>
</td>
<td>
<p>214</p>
</td>
<td>
<p>53.5</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="4">
<p>Marital status </p>
</td>
<td>
<p>Single </p>
</td>
<td>
<p>82</p>
</td>
<td>
<p>20.5</p>
</td>
</tr>
<tr>
<td>
<p>Married </p>
</td>
<td>
<p>268</p>
</td>
<td>
<p>67.0</p>
</td>
</tr>
<tr>
<td>
<p>Divorced </p>
</td>
<td>
<p>25</p>
</td>
<td>
<p>6.3</p>
</td>
</tr>
<tr>
<td>
<p>Widowed </p>
</td>
<td>
<p>25</p>
</td>
<td>
<p>6.3</p>
</td>
</tr>
<tr>
<td rowspan="2">
<p>Place of residence</p>
</td>
<td>
<p>Urban</p>
</td>
<td>
<p>74</p>
</td>
<td>
<p>18.5</p>
</td>
</tr>
<tr>
<td>
<p>Rural</p>
</td>
<td>
<p>326</p>
</td>
<td>
<p>81.5</p>
</td>
</tr>
<tr>
<td rowspan="5">
<p>Employment status</p>
</td>
<td>
<p>In school or training</p>
</td>
<td>
<p>48</p>
</td>
<td>
<p>12.0</p>
</td>
</tr>
<tr>
<td>
<p>Paid/wage/paid in kind employed</p>
</td>
<td>
<p>19</p>
</td>
<td>
<p>4.8</p>
</td>
</tr>
<tr>
<td>
<p>Self-employed</p>
</td>
<td>
<p>121</p>
</td>
<td>
<p>30.3</p>
</td>
</tr>
<tr>
<td>
<p>Unemployed</p>
</td>
<td>
<p>173</p>
</td>
<td>
<p>43.3</p>
</td>
</tr>
<tr>
<td>
<p>Unemployed but not seeking work for other reasons</p>
</td>
<td>
<p>39</p>
</td>
<td>
<p>9.8</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="2">
<p>Household wealth status </p>
</td>
<td>
<p>Poor (<500,000 SSP)</p>
</td>
<td>
<p>365</p>
</td>
<td>
<p>91.3</p>
</td>
</tr>
<tr>
<td>
<p>Middle (500,000 SSP -1,000,000 SSP)</p>
</td>
<td>
<p>35</p>
</td>
<td>
<p>8.8</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="2">
<p>Religion </p>
</td>
<td>
<p>Christian</p>
</td>
<td>
<p>348</p>
</td>
<td>
<p>87.0</p>
</td>
</tr>
<tr>
<td>
<p>Traditional</p>
</td>
<td>
<p>52</p>
</td>
<td>
<p>13.0</p>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td rowspan="4">
<p>Education status</p>
</td>
<td>
<p>No school</p>
</td>
<td>
<p>147</p>
</td>
<td>
<p>36.8</p>
</td>
</tr>
<tr>
<td>
<p>Only traditional/non-formal school</p>
</td>
<td>
<p>53</p>
</td>
<td>
<p>13.3</p>
</td>
</tr>
<tr>
<td>
<p>Dropped-out of school</p>
</td>
<td>
<p>27</p>
</td>
<td>
<p>6.8</p>
</td>
</tr>
<tr>
<td>
<p>Completed secondary</p>
</td>
<td>
<p>173</p>
</td>
<td>
<p>43.3</p>
</td>
</tr>
</tbody>
</table>
</div>
<p><em><strong>Source:</strong></em> Research Data (2023)</p>
<p>Geographically, over 80% of the participants resided in rural areas, while the remaining 18.5% lived in urban regions. The employment status of the respondents varied, with the highest proportion reporting being unemployed (30.3%), closely followed by those who identified as self-employed (30.3%). In terms of household wealth status, the analysis categorized a substantial majority of respondents (91.3%) as belonging to the "poor" category, as their household income fell below 500,000 South Sudanese Pounds (SSP).</p>
<p>Religiously, 87% of the respondents identified as Christians, while a smaller percentage (13.0%) stated they followed traditional belief systems. When examining the education level of the participants, it was found that 43.3% had completed their education up to the secondary school level, followed by 36.8% who had not attended any formal schooling. This rich demographic information lays the foundation for a more in-depth understanding of the study's participants (refer to Table 1).</p>
<p><em><strong>Level of Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities</strong></em></p>
<p>Reproductive health services received in the past 12 months</p>
<p>Inquiries were made to determine whether women of reproductive age, during their visits to the clinics, had utilized the Reproductive Health Services (RHS) offered within the selected public health facilities over the preceding 12 months. Figure 1 presents the findings, indicating that a substantial majority of the respondents (72.5%, 290 individuals) had indeed taken advantage of the available RHS during this period. In contrast, a noteworthy segment of the participants (27.5%, 110 individuals) reported that they had not utilized RHS within the past 12 months. This information sheds light on the utilization of RHS among the study's respondents.</p>
<p><img src="https://lh7-us.googleusercontent.com/PmD1dGGHYhwYWpbRCy0-4Fs82aQia7Leas9RyTCVQVddRuvvIanvQdxV2DaT1ymSsqjDnPeVyh98LY7mBg-CWaUnWHC7SRGlBVLhpK_YMaxTpQl9Afee2zOBI7DWHc_ff0OUdkUt52qeVZBTpwVPNA" alt="" width="627" height="313" /></p>
<p><em><strong>Figure 1:</strong></em> Users and non-users of RH services in the past 12 months</p>
<p><em><strong>Source:</strong></em> Research Data (2023)</p>
<p>The study's respondents, women of reproductive age visiting the designated public health facility, were surveyed to ascertain the types of services they had received at the facility over the previous 12 months. Figure 2 illustrates the outcomes, highlighting that family planning services (25.1%) and prevention and management of Sexually Transmitted Infections (STIs) (25.1%) were the most frequently utilized Reproductive Health (RH) services among the surveyed women visiting these facilities. Additionally, maternal and newborn care services, as well as HIV counselling and testing, emerged as other commonly accessed services, accounting for 18.1% (290 respondents) and 15.3% (244 respondents) of the sampled population, respectively. These findings underscore the prevalence of specific RH services among the women utilizing these health facilities.</p>
<p><img src="https://lh7-us.googleusercontent.com/EQ6EZtp7OD_9yNeiLbZFYzOiSmubfpOJ03A7E4i1YBCn6H4gY6UxMkICUEgGrQd1SUzSLw27RnmQCtnptNNUuEl8AFsYbc2ewJbKYiTvwp2SneEY3H4Bpv23p0N4s0ljtixVONm3wzEQiNX1r05Gaw" alt="" width="654" height="454" /></p>
<p><em><strong>Figure 2:</strong></em> List of services received in the selected public health facilities</p>
<p><em><strong>Source:</strong></em> Research Data (2023)</p>
<p>Temporal patterns in reproductive health service clinic utilization in public health facilities from 2015 to 2020</p>
<p>The study investigated attendance trends at reproductive health services (RHS) clinics in public health facilities between 2015 and 2020, specifically focusing on services such as family planning, HIV counselling and testing, and maternal and newborn care. The data from women of reproductive age attending the RHS clinics during the first and third quarters of each year were analyzed and plotted, revealing notable patterns.</p>
<p>Figure 3 demonstrates seasonal variations in clinic attendance for family planning, HIV counselling and testing, and maternal and newborn care services, with recurring peaks and troughs each year. The trend curve for all three services indicates a consistent increase in utilization from the first to the third quarters spanning from 2015 to 2020. Notably, the third quarter consistently shows a decline in attendance, highlighting these seasonal fluctuations in service utilization.</p>
<p> </p>
<p><img src="https://lh7-us.googleusercontent.com/-rF_JFNNo5Tk-N7l0F5MKSPWvBCiA7lNiygGlteoz89W_lx8toW9kX9vWwEC8kAHW2-uJI9PugLcxosD3haJfVJMRTJp5M5WNvwclTblqR9ilgkfqq7l5UaRYx5lWwGY62FsSSI0U26Y0TaeZpJzxg" alt="" width="626" height="458" /></p>
<p><em><strong>Figure 3:</strong></em> Scatter and trend plots of RHS visits in selected public health facilities</p>
<p><em><strong>Source:</strong> </em>Research Data (2023)</p>
<p>These findings underscore the dynamic nature of attendance at RHS clinics over the study period, characterized by seasonal fluctuations, while also highlighting the overall increasing trend in the utilization of family planning, HIV counselling and testing, and maternal and newborn care services from 2015 to 2020.</p>
<p>Socio-Cultural Factors Associated with RH Services Utilization</p>
<p>Bivariable and multivariable logistic regression analyses were conducted to assess the relationship between various factors and the uptake/utilization of reproductive health services. The results indicated significant associations. Firstly, there was a statistically significant relationship between the age of the respondent and reproductive health service utilization (p-value = 0.049). The odds ratio of 0.571 suggested a negative association, signifying that with each unit increase in the respondent's age, the odds of utilizing reproductive health services decreased by a factor of 0.571. The 95% confidence interval ranged from 0.327 to 0.997, including the value 1, indicating some variability in the data but still supporting the tendency for lower utilization with increasing age.</p>
<p>Secondly, a significant relationship was found between the place of residence (urban or rural) and reproductive health service utilization (p-value = 0.046). The odds ratio of 2.000 indicated that individuals in urban areas had twice the odds of utilizing reproductive health services compared to their rural counterparts. The 95% confidence interval ranged from 1.012 to 3.950, not including the value 1, which reinforced the significance of this association.</p>
<p>Lastly, there was a highly significant relationship between education status and reproductive health service utilization (p-value = 0.000). The odds ratio of 0.223 highlighted those individuals with higher education levels had 0.223 times lower odds of utilizing reproductive health services than those with lower education levels. The 95% confidence interval ranged from 0.223 to 0.406, excluding the value 1, further emphasizing the significance of this educational factor in relation to reproductive health service utilization.</p>
<p>Table 2: Socio-cultural factors associated with RH services utilization among women of reproductive age in South Sudan</p>
<div style="overflow-x: auto;">
<table border="1">
<tbody>
<tr>
<td>
<p><strong>Variables</strong></p>
</td>
<td>
<p><strong>User of RH services</strong></p>
<p><strong>n (%)</strong></p>
<p><strong>n = 290</strong></p>
</td>
<td>
<p><strong>Non-user of RH services</strong></p>
<p><strong>n (%)</strong></p>
<p><strong>n = 110</strong></p>
</td>
<td>
<p><strong>OR</strong></p>
<p><strong>(95% CI)</strong></p>
</td>
<td>
<p><strong>P Value</strong></p>
</td>
</tr>
<tr>
<td>
<p><strong>State </strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Central Equatoria</p>
</td>
<td>
<p>173 (59.7)</p>
</td>
<td>
<p>59 (53.6)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Western Equatoria</p>
</td>
<td>
<p>117 (40.3)</p>
</td>
<td>
<p>51 (46.4)</p>
</td>
<td>
<p>1.197 (0.725-1.976)</p>
</td>
<td>
<p>0.482</p>
</td>
</tr>
<tr>
<td>
<p><strong>Age </strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Younger than 30 years</p>
</td>
<td>
<p>132 (45.5)</p>
</td>
<td>
<p>54 (49.1)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>30 years and older</p>
</td>
<td>
<p>158 (54.5)</p>
</td>
<td>
<p>56 (50.9)</p>
</td>
<td>
<p>0.571 (0.327-0.997)</p>
</td>
<td>
<p>0.049*</p>
</td>
</tr>
<tr>
<td>
<p><strong>Marital status</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Married</p>
</td>
<td>
<p>186 (75.3)</p>
</td>
<td>
<p>82 (79.6)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Single</p>
</td>
<td>
<p>61 (24.7)</p>
</td>
<td>
<p>21(20.4)</p>
</td>
<td>
<p>0.858 (0.437-1.685)</p>
</td>
<td>
<p>0.657</p>
</td>
</tr>
<tr>
<td>
<p><strong>Place of residence</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Urban</p>
</td>
<td>
<p>60 (20.7)</p>
</td>
<td>
<p>14 (12.7)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Rural</p>
</td>
<td>
<p>230 (79.3)</p>
</td>
<td>
<p>96 (87.3)</p>
</td>
<td>
<p>2.000 (1.012-3.950)</p>
</td>
<td>
<p>0.046*</p>
</td>
</tr>
<tr>
<td>
<p><strong>Employment status </strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Not employed</p>
</td>
<td>
<p>176 (60.7)</p>
</td>
<td>
<p>84 (76.4)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Employed</p>
</td>
<td>
<p>114 (30,3)</p>
</td>
<td>
<p>26 (23.6)</p>
</td>
<td>
<p>0.631 (0.360-1.104)</p>
</td>
<td>
<p>0.107</p>
</td>
</tr>
<tr>
<td>
<p><strong>Religion </strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>Christian</p>
</td>
<td>
<p>245 (84.5)</p>
</td>
<td>
<p>103 (93.6)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Traditional</p>
</td>
<td>
<p>45 (15.5)</p>
</td>
<td>
<p>7 (6.4)</p>
</td>
<td>
<p>0.617 (0.242-1.572)</p>
</td>
<td>
<p>0.311</p>
</td>
</tr>
<tr>
<td>
<p><strong>Education status</strong></p>
</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>
<p>No school/non-formal/dropped-out</p>
</td>
<td>
<p>138 (47.6)</p>
</td>
<td>
<p>89 (80.9)</p>
</td>
<td>
<p>1</p>
</td>
<td> </td>
</tr>
<tr>
<td>
<p>Completed secondary</p>
</td>
<td>
<p>152 (52.4)</p>
</td>
<td>
<p>21(19.1)</p>
</td>
<td>
<p>0.223 (0.122-0.406)</p>
</td>
<td>
<p>0.000**</p>
</td>
</tr>
</tbody>
</table>
</div>
<p><em><strong>Source:</strong></em> Research Data (2023)</p>
<p>**. Correlation is significant at the 0.01 level</p>
<p>*. Correlation is significant at the 0.05 level</p>
<p>In summary, the research findings regarding socio-cultural factors influencing the uptake and utilization of reproductive health services indicate the following: older age is associated with a decreased likelihood of utilizing reproductive health services; individuals residing in urban areas have higher odds of utilizing reproductive health services compared to those in rural areas; and higher education levels are associated with lower odds of utilizing reproductive health services. These findings suggest that addressing socio-cultural factors such as age, place of residence, and education status is crucial in promoting and improving the uptake and utilization of reproductive health services in the context of South Sudan.</p>
<p><strong>Discussion</strong></p>
<p>The research findings related to the uptake and utilization of Reproductive Health Services (RHS) in selected South Sudan public health facilities were analyzed within the conceptual frameworks of the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These models provide essential insights into the factors influencing individuals' decisions regarding RHS utilization.</p>
<p>In this study, the HBM was employed to investigate the determinants of RHS utilization. The HBM encompasses key constructs, such as perceived susceptibility and severity, perceived benefits, perceived barriers, and cues to action, to understand how people perceive and make decisions about their health behaviours. Findings from the study indicate that perceived susceptibility and severity of RH issues are crucial in motivating individuals to engage in RH behaviours. Perceived susceptibility varies among individuals, underscoring the importance of threat perception. The perceived severity is influenced by factors including emotional responses and cognitive assessments of health problems, encompassing medical complications and broader consequences on individuals' lives. Additionally, the study highlights those perceived benefits significantly influence individuals to take action in preventing RH threats. When individuals believe that RHS are effective in addressing their health concerns, they are more likely to utilize these services. Moreover, the study underscores the role of "cues to action" as triggers for health behaviour, including physical symptoms, mass media communications, interpersonal interactions, advice from others, health education campaigns, and reminders from healthcare providers. These cues play a substantial role in motivating individuals to access RHS.</p>
<p>In parallel, the TRA provides insights into the role of attitudes, subjective norms, and intentions in predicting health-related behaviours. The study findings demonstrated that attitudes toward RHS significantly correlated with beliefs and outcome evaluations related to these services. The stronger an individual's intention to use RHS, the more likely they are to engage in the behaviour. Attitudes and subjective norms were identified as significant determinants of the intention to utilize RHS. These results highlight the importance of shaping positive attitudes toward RHS and considering the influence of social norms and peer opinions when designing interventions to promote RHS utilization.</p>
<p><em>Level of Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities</em></p>
<p>The findings of the study indicate that a significant proportion of the respondents (72.5%) had utilized reproductive health services in the selected public health facilities, while 27.5% reported not having utilized any services in the past 12 months. Studies conducted in the region reveal that approximately 17% of all women in Sub-Saharan Africa and 23% of married or in-union women have an unmet need for RH services (United Nations, 2019). However, despite the significant utilization of RH services, the current study found that the majority of women (86.3%) reported not receiving all the RHS they were seeking in the selected public health facilities. This highlights a gap in the availability of comprehensive reproductive health services, indicating a need for improvement in the facilities' service delivery.</p>
<p>Among the RHS, family planning and prevention and management of sexually transmitted infections (STIs) were the most utilized, each accounting for 25.1% of the sampled population. Maternal and newborn care and HIV counselling and testing were also commonly used services, representing 18.1% and 15.3% of the respondents, respectively. However, studies conducted across Africa show that the majority of women of reproductive age would like to stop or delay childbearing but only 28% of women are using modern methods of family planning (WHO Africa, 2020). In addition, this study revealed that prior to their latest visit, a significant portion of the respondents (77.3%) were not aware that public health facilities provided free access to RHS. This lack of awareness may have hindered women's utilization of these services, emphasizing the importance of enhancing public awareness campaigns to ensure women are informed about the availability and accessibility of RHS.</p>
<p>From the longitudinal ecological study, it was observed seasonal variations in the number of visits for family planning, HIV counselling and testing, and maternal and newborn care services from 2015 to 2020. The trend analysis indicated a consistent increase in the uptake of RH services throughout the years. A previous study conducted in South Sudan found that the return of peace in South Sudan presented opportunities unlike before, including utilization and uptake of RHS among women of reproductive health (Kane, et al., 2016). However, this current study showed that there were specific declines in family planning, HIV counselling and testing, and maternal and newborn care attendance during the third quarter of each year from 2015 to 2020. This finding suggests a potential need for targeted interventions to address barriers or factors affecting attendance during the third quarter period.</p>
<p>The findings of this research objective shed light on the utilization and availability of RHS among women of reproductive age in South Sudan's public health facilities. The findings highlight the need for improved service provision to ensure comprehensive RHS are accessible to all women. Increasing awareness among the target population about free access to RHS can also contribute to improved utilization. Thus, addressing the seasonal differences in attendance, particularly for family planning services, HIV counselling and testing, and maternal and newborn care may require targeted strategies to ensure consistent access throughout the year.</p>
<p><em>Socio-Cultural Factors Associated with RH Services Utilization</em></p>
<p>The study revealed that the majority of the respondents (53.5%) were 30 years and older, while the remaining 46.5% were younger than 30 years. The statistical analysis showed a significant relationship between the age of the respondents and the uptake and utilization of RHS. The p-value of 0.049 suggests that age is a contributing factor in determining the utilization of these services. A study conducted in Kenya by Kinaro et al. (2019) found that early marriage, being young, male-only decisions on sexuality matters and fear of family contribute to unprotected sex while myths and misconceptions on contraceptives affected the utilization of RHS. Another study conducted in Kenya by Godia et al. (2014) found that most youths are not aware of existing RHS. They found that young people’s perception and knowledge of younger girls (12–14 years) is limited with a majority reporting that they don’t know much about RHS. This current finding implies that older women are less likely to utilize RHS compared to younger women. Possible reasons for this could include cultural norms, lack of awareness, or different reproductive health needs at different stages of life.</p>
<p>The study found that over 80% of the respondents resided in rural areas, while the remaining 18.5% lived in urban regions. The analysis demonstrated a statistically significant relationship between the place of residence and the uptake and utilization of RHS. The p-value of 0.046 indicates that the place of residence plays a role in determining the utilization of these services. A previous study conducted by Sumankuuro et al. (2018) shared similar findings, they found that women from rural (or poverty-stricken) areas are vulnerable because of their status and lack of access to RH services. Their risk behaviors as well as their access to RH services are influenced significantly by the type of place that they reside. The current study established that individuals residing in urban areas have twice the odds of utilizing RHS compared to those in rural areas. This could be attributed to better access to healthcare facilities, increased availability of services, and potentially higher levels of education and awareness in urban settings.</p>
<p>The study showed that the educational level of the respondents is significantly related to the uptake and utilization of RHS. The p-value of 0.000 indicates a highly significant relationship between education status and service utilization. This finding contradicted other studies (Aragie and Abate, 2021; Abebe and Awoke, 2014), which stipulated that those families with higher educational status are more likely to be familiar with RHS-related issues. However, this study indicates that individuals with higher education levels have 0.223 times lower odds of utilizing RHS compared to those with lower education levels. This finding may seem counterintuitive, as higher education is often associated with better access to information and resources. However, it's important to consider other factors such as socioeconomic status, cultural beliefs, and personal preferences that may influence the relationship between education and service utilization.</p>
<p>Overall, the findings suggest that age, place of residence, and education status are significant socio-cultural factors influencing the uptake and utilization of RHS among women in South Sudan. These findings highlight the need for targeted interventions and strategies to address barriers and promote RHS among older women, rural populations, and individuals with lower levels of education. Improving access to healthcare facilities, increasing awareness about available services, and addressing cultural norms and beliefs are crucial steps toward enhancing reproductive healthcare utilization and ultimately improving the well-being of women in South Sudan.</p>
<p><strong>Conclusions</strong></p>
<p>The study revealed that perceived susceptibility and severity of RH issues significantly motivate individuals to engage in RH behaviours. The perceived benefits of utilizing RHS play a pivotal role in encouraging individuals to take action to prevent RH threats. Additionally, the study emphasized the importance of "cues to action" as mechanisms to trigger health behaviour, including physical symptoms, mass media communications, interpersonal interactions, advice from others, health education campaigns, and reminders from healthcare providers. These cues significantly motivated individuals to access reproductive health services.</p>
<p>The findings also demonstrated that age, place of residence, and education status are crucial socio-cultural factors influencing the uptake and utilization of RHS. Older women were less likely to utilize these services compared to younger women, which may be attributed to cultural norms, varying RH needs at different life stages, or a lack of awareness. Urban residents were found to have higher odds of utilizing RHS, potentially due to better access to healthcare facilities, increased service availability, and higher levels of education and awareness. Surprisingly, individuals with higher education levels exhibited lower odds of utilizing RHS, emphasizing the complex interplay of socioeconomic status, cultural beliefs, and personal preferences in the relationship between education and service utilization.</p>
<p>The study's findings hold significant implications for policy, practice, and future research in the field of RHS. First and foremost, enhancing public awareness campaigns is crucial to ensure women are well-informed about the availability and accessibility of RHS. These campaigns should be tailored to address the diverse needs and perceptions of both urban and rural populations. Second, improving service delivery is imperative to bridge the existing gap in comprehensive RHS availability. This entails expanding the range of services offered by public health facilities, extending beyond family planning and STI management to encompass maternal and newborn care and HIV counselling and testing. Lastly, the study underscores the importance of implementing targeted interventions to overcome barriers faced by specific demographic groups, including older women, rural residents, and individuals with lower educational attainment. These interventions should take into account the influence of cultural norms, socioeconomic factors, and individual preferences to effectively promote the utilization of RHS services.</p>
<p>The study presents several limitations that warrant consideration. First, it is essential to acknowledge that the research centred on two specific states within South Sudan, potentially limiting the generalizability of the findings to the broader national context. Furthermore, the cross-sectional design employed in this study offers a snapshot of the observed relationships, but it does not permit the establishment of causal relationships. Lastly, the data collection relied on self-reporting, which may introduce biases related to recall and social desirability. </p>
<p>Future research should aim to expand the geographical scope to include a more representative sample of South Sudan. Longitudinal studies can provide more robust insights into trends and causal relationships regarding RHS utilization. Furthermore, exploring the influence of other socio-cultural factors, such as socioeconomic status, cultural beliefs, and access to healthcare facilities, will provide a more comprehensive understanding of the determinants of RHS utilization in South Sudan. Additionally, comparative studies between different theoretical frameworks, such as the HBM and TRA, can offer insights into which model best explains RH behaviours in this context. These avenues of research can contribute to a more holistic approach to addressing RH challenges in South Sudan and similar settings.</p>
<p><strong>Acknowledgements:</strong></p>
<p>This study was made possible through the support of my supervisors Dr. Alfred Owino Odongo and Dr. John Kariuki, and my colleagues within the Ministry of Health, particularly my fellow Public Health Officers and Surveillance Officers. Their support is acknowledged.</p>
<p><strong>Funding Acknowledgements:</strong></p>
<p>The author(s) received no financial support for the research, authorship, and/or publication of this article.</p>
<p><strong>Competing Interests:</strong></p>
<p>Author(s) declares there were no competing interests.</p>
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<li aria-level="1">Aragie, T. G., & Abate, B. B. (2021). Utilization of Reproductive Health Services and Associated Factors among Secondary School Students in Woldia Town, Northeast Ethiopia. J Environ Public Health, 2021, 2917874. <a href="https://doi.org/10.1155/2021/2917874"></a><a href="https://doi.org/10.1155/2021/2917874">https://doi.org/10.1155/2021/2917874</a></li>
<li aria-level="1">Guttmacher Institute. (2017). Fact Sheet: Abortion in Asia. <a href="https://www.guttmacher.org/sites/default/files/factsheet/ib_aww-asia_0.pdf"></a><a href="https://www.guttmacher.org/sites/default/files/factsheet/ib_aww-asia_0.pdf">https://www.guttmacher.org/sites/default/files/factsheet/ib_aww-asia_0.pdf</a></li>
<li aria-level="1">Integrity. (2018). Evaluation of the South Sudan Health Pooled Fund.</li>
<li aria-level="1">IPC. (2018). Integrated food security phase classification, The Republic of South Sudan: Key findings.</li>
<li aria-level="1">Kane, S., Kok, M., Rial, M., Matere, A., Dieleman, M., & Broerse, J. E. (2016). Social norms and family planning decisions in South Sudan. BMC Public Health, 16(1), 1–12. <a href="https://doi.org/10.1186/s12889-016-3839-6"></a><a href="https://doi.org/10.1186/s12889-016-3839-6">https://doi.org/10.1186/s12889-016-3839-6</a></li>
<li aria-level="1">Kinaro, J. W., Wangalwa, G., Karanja, S., Adika, B., Lengewa, C., & Masitsa, P. (2019). Socio-Cultural Barriers Influencing Utilization of Sexual and Reproductive Health (SRH) Information and Services among Adolescents and Youth 10 - 24 Years in Pastoral Communities in Kenya. Advances in Sexual Medicine, 9, 1–16. <a href="https://doi.org/10.4236/asm.2019.91001"></a><a href="https://doi.org/10.4236/asm.2019.91001">https://doi.org/10.4236/asm.2019.91001</a></li>
<li aria-level="1">Larson, G., Ajak, P., & Pritchett, L. (2013). South Sudan’s Capability Trap: Building a State with Disruptive Innovation; 2013.</li>
<li aria-level="1">Ministry of Health. (2012). Health Sector Development Plan 2012-2016.</li>
<li aria-level="1">Sumankuuro, J., Crockett, J., & Wang, S. (2018). Sociocultural barriers to maternity services delivery: a qualitative meta-synthesis of the literature. Public Health, 157, 77–85.</li>
<li aria-level="1">UNICEF. (2016). The State of the World’s Children 2016: a fair chance for every child. <a href="https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-020-09155-w.pdf"></a><a href="https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-020-09155-w.pdf">https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-020-09155-w.pdf</a></li>
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<li aria-level="1">UNPF. (2019). Sexual and Reproductive Health and Rights: An Essential Element of Universal Health Coverage. <a href="https://www.unfpa.org/sites/default/files/pub-pdf/SRHR_an_essential_element_of_UHC_SupplementAndUniversalAccess_27-online.pdf"></a><a href="https://www.unfpa.org/sites/default/files/pub-pdf/SRHR_an_essential_element_of_UHC_SupplementAndUniversalAccess_27-online.pdf">https://www.unfpa.org/sites/default/files/pub-pdf/SRHR_an_essential_element_of_UHC_SupplementAndUniversalAccess_27-online.pdf</a></li>
<li aria-level="1">United Nations. (2015). Trends in contraceptive use worldwide 2015.</li>
<li aria-level="1">United Nations. (2019). Estimates and Projections of Family Planning Indicators.</li>
<li aria-level="1">WHO. (2021). Reproductive health. <a href="https://www.who.int/westernpacific/health-topics/reproductive-health"></a><a href="https://www.who.int/westernpacific/health-topics/reproductive-health">https://www.who.int/westernpacific/health-topics/reproductive-health</a></li>
<li aria-level="1">WHO Africa. (2020). Sexual and Reproductive Health Fact Sheet.</li>
<li aria-level="1">WHO Africa. (2021). Sexual and Reproductive Health. <a href="https://www.afro.who.int/health-topics/sexual-and-reproductive-health"></a><a href="https://www.afro.who.int/health-topics/sexual-and-reproductive-health">https://www.afro.who.int/health-topics/sexual-and-reproductive-health</a></li>
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</ol>
IBA condemns Hamas attacks on Israel which represent a clear violation of human rights and humanitarian law and urges for a just solution to be achieved between Israel and Palestine
2023-10-11T04:11:15+01:00
2023-10-11T04:11:15+01:00
https://pachodo.org/latest-news-articles/pachodo-english-articles/42744-iba-condemns-hamas-attacks-on-israel-which-represent-a-clear-violation-of-human-rights-and-humanitarian-law-and-urges-for-a-just-solution-to-be-achieved-between-israel-and-palestine
IBA
LamArop@pachodo.org
<p><img src="https://pachodo.org/images/IBA-logo.png" alt="IBA Logo" title="IBA Logo" /></p>
<p> </p>
<p><strong>IBA reminds Israel of need to adhere to international standards in its response</strong></p>
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<p><strong>Statement by the President of the International Bar Association Almudena Arpón de Mendívil Aldama:</strong><br /><br />The <strong><a href="https://ibanet.us6.list-manage.com/track/click?u=f882d6a06de3911defe4390de&id=1a02ad17ad&e=727eea15dc" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://ibanet.us6.list-manage.com/track/click?u%3Df882d6a06de3911defe4390de%26id%3D1a02ad17ad%26e%3D727eea15dc&source=gmail&ust=1697112352147000&usg=AOvVaw13uCmCg_hjuX2WUhjom29m">International Bar Association</a></strong> (IBA) strongly condemns the heinous attacks on Israel by the militant group Hamas. These indiscriminate and targeted atrocities against Israeli citizens contravene an unequivocal, non-derogable prohibition under international law. The murder of civilians, the assaults, and the trespass into private homes to kill and maim are all internationally recognised crimes of profound gravity; the abductions and taking of hostages, including women, children and the elderly, are crimes in violation of human rights and humanitarian law.</p>
<p>Israel has an inherent right to self-defence from these unlawful attacks. However, in doing so, it, too, must ensure that civilian populations are shielded from harm and that military actions are conducted with a clear commitment to the international legal principles of distinction and proportionality.</p>
<p>The IBA, representing the global voice of the legal profession, urges all international institutions and governments to use their best diplomatic efforts to secure the release of the hostages, to prevent the escalation of violence in the region and to return to the peace tables so that a just solution is achieved between Israel and Palestine<em>.</em><em><br /></em></p>
<p><strong>ENDS</strong></p>
</div>
</div>
<p> </p>
<p><img src="https://pachodo.org/images/IBA-logo.png" alt="IBA Logo" title="IBA Logo" /></p>
<p> </p>
<p><strong>IBA reminds Israel of need to adhere to international standards in its response</strong></p>
<div>
<div>
<p><strong>Statement by the President of the International Bar Association Almudena Arpón de Mendívil Aldama:</strong><br /><br />The <strong><a href="https://ibanet.us6.list-manage.com/track/click?u=f882d6a06de3911defe4390de&id=1a02ad17ad&e=727eea15dc" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://ibanet.us6.list-manage.com/track/click?u%3Df882d6a06de3911defe4390de%26id%3D1a02ad17ad%26e%3D727eea15dc&source=gmail&ust=1697112352147000&usg=AOvVaw13uCmCg_hjuX2WUhjom29m">International Bar Association</a></strong> (IBA) strongly condemns the heinous attacks on Israel by the militant group Hamas. These indiscriminate and targeted atrocities against Israeli citizens contravene an unequivocal, non-derogable prohibition under international law. The murder of civilians, the assaults, and the trespass into private homes to kill and maim are all internationally recognised crimes of profound gravity; the abductions and taking of hostages, including women, children and the elderly, are crimes in violation of human rights and humanitarian law.</p>
<p>Israel has an inherent right to self-defence from these unlawful attacks. However, in doing so, it, too, must ensure that civilian populations are shielded from harm and that military actions are conducted with a clear commitment to the international legal principles of distinction and proportionality.</p>
<p>The IBA, representing the global voice of the legal profession, urges all international institutions and governments to use their best diplomatic efforts to secure the release of the hostages, to prevent the escalation of violence in the region and to return to the peace tables so that a just solution is achieved between Israel and Palestine<em>.</em><em><br /></em></p>
<p><strong>ENDS</strong></p>
</div>
</div>
<p> </p>
Manuscript: Changes in weather season and utilization of RHS in selected South Sudan public health facilities
2023-10-11T04:00:27+01:00
2023-10-11T04:00:27+01:00
https://pachodo.org/latest-news-articles/pachodo-english-articles/42745-manuscript-paper-changes-in-weather-season-and-utilization-of-rhs-in-selected-south-sudan-public-health-facilities
Dr. Emmanuel Timothy Thwol
LamArop@pachodo.org
<p> </p>
<figure data-wf-figure="1"><img src="https://pachodo.org/images/south-Sudan-Floods_AP_Photo.jpeg" alt="Thatched huts surrounded by floodwaters are seen from the air in Old Fangak county, Jonglei state, South Sudan Friday, Nov. 27, 2020 (Associated Press / Alamy Stock Photo)" title="Thatched huts surrounded by floodwaters are seen from the air in Old Fangak county, Jonglei state, South Sudan Friday, Nov. 27, 2020 (Associated Press / Alamy Stock Photo)" /><figcaption><em>Thatched huts surrounded by floodwaters are seen from the air in Old Fangak county, Jonglei state, South Sudan Friday, Nov. 27, 2020 (Associated Press / Alamy Stock Photo)</em></figcaption></figure>
<p> </p>
<p><strong>By: Dr. Emmanuel Timothy Thwol Onak1</strong></p>
<p> </p>
<p><span style="text-decoration: underline;"><em>Abstract</em></span></p>
<p>Background: Overall unmet needs for contraceptives among women are high; across the East Africa region including South Sudan, it ranges from 38.6 to 66.9%. Exploring the relationship between changes in weather season and utilization of RHS in selected South Sudan’s public health facilities, is key to developing and implementing locally appropriate public health responses.</p>
<p>Method: A qualitative study was conducted at South Sudan’s public health facilities in two (2) purposively selected States i.e., Western Equatoria and Central Equatoria. An interview guide was used to conduct in-depth interviews with the key informants who are knowledgeable about RHS. A data abstraction tool was also used to systematically collect data focused in obtaining the weather seasons and utilization data between the period of the years 2015 and 2020. </p>
<p>Results: The research study investigates the relationship between changes in weather seasons and the utilization of RHS among women of reproductive age in Central Equatoria and Western Equatoria States, South Sudan, from 2015 to 2020, focusing on dry (Quarter 1) and rainy (Quarter 3) seasons. The findings reveal a consistent decline in RHS utilization during the rainy season, particularly during flooding events. Over 35% of women experienced extreme weather events, leading to constrained access to RHS clinics, primarily due to flooding. Extreme cold weather during the rainy season and floods disrupts transportation routes, hindering women from seeking RHS. The qualitative analysis underscores the need for strategies such as outreach programs, mobile clinics, improved infrastructure, early warning systems, and climate resilience in health facilities to address these weather-related barriers and enhance reproductive health outcomes for women in the region.</p>
<p>Conclusions: The study's findings underscore the significant impact of weather seasonality, particularly flooding, on the utilization of RHS in South Sudan, specifically in Central Equatoria and Western Equatoria. The study reveals that weather events such as heavy rainfall and flooding coincide with a consistent decline in the uptake of RHS, emphasizing the need for climate-informed RHS planning and delivery. Extreme weather events were reported to constrain access to RHS services for a substantial proportion of women, highlighting the importance of preparedness and resilience-building strategies. These findings align with existing research indicating climate change's adverse effects on maternal health and access to RHS. Overall, this research highlights the urgency of addressing climate-related barriers to ensure consistent and equitable access to RHS for women in South Sudan, especially in the face of increasing weather variability and extreme events.</p>
<p><span style="text-decoration: underline;"><em>Background</em></span></p>
<p>The study investigates the critical nexus between weather seasonality and the utilization of reproductive health services (RHS) in South Sudan, with a focus on addressing a multifaceted challenge impacting women's health and well-being in the African Region. As highlighted by WHO Africa (2021), women in this region face higher mortality rates due to communicable diseases, maternal and perinatal conditions, and nutritional deficiencies, underscoring the pressing need for comprehensive reproductive health services. Additionally, the disproportionate vulnerability of women and children to climate-related disasters, exemplified by mortality rates following extreme weather events, emphasizes the link between climate change and women's health (United Nations, 2015). These health disparities underscore the urgent need for improved access to RHS in the African Region.</p>
<p>Extensive research highlights the disproportionate impact of climate change-related weather seasonality on women's broader health, social, and economic well-being (Sorensen et al., 2018; Zeid et al., 2015). Women and children are reported to be up to 14 times more likely than men to die in the aftermath of disasters, including extreme weather events like hurricanes, wildfires, and flooding. While comparative mortality rates may vary across contexts, the literature consistently underscores the heightened vulnerability of women during climate-related disasters. These disasters disrupt health systems and hinder access to critical reproductive health services and supplies (Benjamin, 2016).</p>
<p>Climate change has been linked to negative maternal health outcomes, an increased prevalence of gender-based violence (GBV), and restricted access to RHS, which in turn negatively affect family planning, abortion, and STI outcomes (Women Deliver, 2021). Inadequate disaster-risk management (DRM) exacerbates these challenges, as climate-related disasters can lead to physical damage to health facilities and infrastructure, supply chain disruptions, and the loss of medical records. Consequently, the immediate and direct impact is reduced access to high-quality RH services such as post-exposure prophylaxis for HIV, HIV treatment, emergency contraception, and safe abortion services (Onyango & Heidari, 2017).</p>
<p>Beyond the immediate aftermath of climate events, there are enduring consequences for RH services. Disruptions in health services can compromise access to contraceptives, maternal and child care, HIV and STI testing and treatment, counselling, psychosocial support, abortion services, and post-abortion care for crisis-affected communities (Benjamin, 2016). Untreated STIs can lead to long-term health implications for women, including infertility, tubal or ectopic pregnancy, cervical cancer, and perinatal or congenital infections in infants born to affected mothers (Behrman & Weitzman, 2016). Reduced access to contraception can result in higher rates of unintended pregnancy, pregnancy complications, and maternal mortality (Behrman & Weitzman, 2016).</p>
<p>During natural or man-made crises, governance, support systems, and services often break down, significantly impacting girls' and women's sexual and reproductive health and rights (SRHR). Weaknesses in health systems during crises increase vulnerability to climate change, leading to gaps in access, availability, acceptability, and quality of RH information and services (Castro, 2020). The added fear, stigma, and harmful social norms in post-disaster settings exacerbate the utilization of RHS outcomes.</p>
<p>The African Region, particularly sub-Saharan Africa, experiences rapid population growth and high climatic vulnerability. Many communities depend on small-scale, rain-fed agriculture and livestock systems, which are susceptible to climate variations (Brown, 2015). Poor rainy seasons, characterized by late or sporadic rains, impact food availability and economic resources. These changes influence sexual behaviour, fertility goals, miscarriage rates, stillbirths, and overall maternal and child health (Grace, 2017). Additionally, direct impacts of climate and the natural environment, such as droughts, floods, heatwaves, and extreme weather events, can further affect RH outcomes and access to health services (Grace et al., 2015).</p>
<p>South Sudan, like other countries in the region, faces the destructive consequences of severe droughts, floods, and climate-driven challenges (UNFPA, 2021). These disasters often limit access to health services, including sexual and reproductive health, leaving women to give birth without adequate medical support. The lack of clean water and menstrual products further impairs women's and girls' dignity and access to essential menstrual hygiene management (UNHCR Africa, 2022). South Sudan experienced its worst flooding on record in 2021, highlighting the increasing frequency and severity of such events, which are likely to impact RHS utilization in public health facilities.</p>
<p>Although South Sudan has made progress in reducing maternal mortality rates, challenges persist, particularly in climate-affected areas. Ongoing violence, a decrease in the health budget, and high inflation rates have strained the population (Integrity, 2018). The Integrated Food Security Phase Classification reported that 48% of South Sudan's population faced acute food insecurity in January 2018 (IPC, 2018). The underfunding of humanitarian response plans, including RHS, exacerbates the crisis. This economic turmoil places additional pressure on donor-funded programs, including RHS.</p>
<p>While service delivery in South Sudan's health sector has been documented, there is a significant knowledge gap concerning the utilization of RHS in the public health sector, including health workforce and service delivery. Moreover, the linkages between climate change and the uptake of RHS have received limited attention, potentially due to inadequate governmental prioritization and the sensitive nature of the climate change-RHS relationship. This study aims to address this critical gap through a qualitative, exploratory investigation of the determinants of RHS uptake and utilization in public health facilities in South Sudan. The specific objective is to determine whether there is a relationship between changes in weather season and the utilization of RHS in selected public health facilities in South</p>
<p><span style="text-decoration: underline;"><em>Methods</em></span></p>
<p>The study utilized a mixed-methods approach to collect and analyse data. The first part was a longitudinal ecological study in which quarterly returns of weather seasonality/season and service utilization indicators were obtained from South Sudan National Bureau of Statistics, and the Ministry of Agriculture and Food Security, as well as the Health Management Information System database and health facilities. The scoping review and data collection were retrospective data derived from South Sudan’s respective Government Ministries from 2015 to 2020. The second part was an analytical cross-sectional study that was undertaken at the public health facilities and involved the health professionals.</p>
<p>An interview guide was used to conduct in-depth interviews with the key informants who are knowledgeable about RHS. The KIIs involved interviewing people who had particularly informed perspectives on an aspect of the RHS or who had a deep understanding of the health system at the state and county levels. The interview guide consisted of open-ended questions focusing on the specific objective of the study. This data abstraction tool is a standard instrument used to systematically collect data from scientific reports in the development of the Guide to Community Preventive Services (the Guide). The data abstraction tool was focused on obtaining the weather seasons and utilization data between the proposed period of the year 2015 and 2020. The tool was designed to collect important information that helped generate useful data for analysis in that period as pertains to weather season and utilization of RHS.</p>
<p>The study borrowed mainly from two main theories i.e., the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These two theories have been adopted in studies to explain and predict utilization and uptake of RH service and proved to be useful in many empirical studies. Specifically, for developing a new behaviour or changing an existing behaviour of an individual, the HBM suggests the following unique and subjective beliefs of the person would be involved in the decision-making process: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action (Green et al., 2020). The four constructs of the HBM, perceived barriers, benefits, susceptibility and severity, were used to develop a predictive model for risky sexual practices in college students. Their results revealed that these constructs significantly explained 18% of variance in total number of risk behaviors, and 22% of variance in multiple sexual partnerships, but failed to predict condom usage in college women (Green et al., 2020). The HBM was shown to be a potentially useful theoretical framework for determining the uptake and utilization of RH services.</p>
<p>On the other hand, the TRA provides a framework to study attitudes toward behaviours with the ultimate goal being to predict and understand an individual’s behaviour. Rooted in value expectancy theories, the TRA assumes that humans are rational and make decisions for their actions by contemplating all the information available to them and the possible implications of the action (Glanz et al., 2015). Based on these assumptions, the TRA attempts to explain how intention converts into behaviour and what specific beliefs, attitudes, and subjective norms influence this transition. The TRA is composed of the following main constructs: behaviour, intention, and personal attitude. Behaviour is defined as being comprised of four elements: the action, the target at which the action is directed, the context in which it occurs, and the time at which it is performed. In addition, intention is the primary determinant of behaviour. It is believed that the stronger an individual’s intention toward a particular behaviour, the more successful he/she is expected to perform the behaviour.</p>
<p><span style="text-decoration: underline;"><em>Study sites</em></span></p>
<p>The study was conducted at South Sudan’s public health facilities in two (2) purposively selected States i.e., Western Equatoria and Central Equatoria. Approximately 83% of the population live in rural areas. The low population density (15/square kilometre) coupled with mobile pastoral communities and limited access due to the protracted crises poses a huge challenge to health service delivery. In these two selected States, data gathering was conducted in the four levels of the South Sudan health system, namely, the Boma Health Teams (community), Primary Healthcare Units (PHCU), Primary Healthcare Centres (PHCC) and the hospitals. These facilities are to a large extent aligned to the administrative subdivisions of the Country in both rural and urban areas (Ministry of Health, 2012; and WHO South Sudan, 2020). </p>
<p>Sampling, recruitment of study participants and data collection</p>
<p>The qualitative part of this study included purposively selected 25 key informants (health workers). The selection of health workers providing RHS was made according to health cadres and geographical locations (state and administrative areas) of health facilities across the selected states. Data was also abstracted between the years 2015 to 2020 for the longitudinal ecological arm of this study. Retrospective data from the Health Ministry of Health and from the health facilities was obtained within the specified period to assess the utilization of the RH services between two weather seasons (wet and dry seasons). </p>
<p>The interview guide consisted of open-ended questions focusing on the specific objectives of the study. It was a face-to-face conversation with the key informants that was recorded as part of note-taking. With the consent of the interviewee, the researcher recorded the conversation using a digital voice recorder. The researcher also observed the body language, expressions and other reactions to the questions during the interview. The data required to fill in the data abstraction form provided information on the intervention under study, evaluation setting and study population, outcomes, results, and study quality. The three sections of the form will consist of Part I. Classification Information, which was filled out by the chapter development team and reviewed and edited by the abstractors; Part II. Descriptive Information about the intervention, evaluation study characteristics, measurement of outcomes, and results; and Part III. Study Quality about the execution of the study.</p>
<p><span style="text-decoration: underline;"><em>Data analysis</em></span></p>
<p>In the proposed study, quantitative and qualitative approaches was used to analyse data emanating from different data collection tools. Data, once collected, was stored carefully to prevent damage or violations of subject privacy. The researcher ensured that unauthorized access to the files is not possible. Data files were stored in a computer that can only be accessed by the researcher and statistician and placed into files with password protection. Qualitative data and quantitative data were triangulated during post data analysis </p>
<p>Data emanating from the questionnaires was entered into a computer file for analysis using Microsoft Excel Spreadsheet. Here the researcher used descriptive statistics such as mean, median, mode, percentage, frequency and range. Descriptive statistics are most helpful when the research is limited to the sample and does not need to be generalized to a larger population. The researcher conducted preliminary content analysis of the qualitative data to identify any common patterns and trends arising from the narratives regarding relationship between climate change and utilization of RHS. The narratives were written on the main themes and illustrated by state-specific data whenever possible. Sequel Data Analytics was also used to translate data for analysing and interpreting.</p>
<p><span style="text-decoration: underline;"><em>Ethical considerations</em></span></p>
<p>Researcher sought ethical approval from the Division of Research, Monitoring and Evaluation (Directorate of Planning and Coordination) in the Ministry of Health, and Research Ethics Committee (REC), Republic of South Sudan. Approval was also sought form Mount Kenya University Institutional Ethical Review Committee (IERC). The permission to access public health facilities and other offices was sought from the respective sectoral and departmental heads including the Ministry of Health and Local Governments in the Republic of South Sudan.</p>
<p>Participants who consent to participate in the research were accorded anonymity and confidentiality to protect them as well as boost confidence in order to obtain accurate information. They were also accorded exercise of free will in deciding whether to participate in the research activity. In addition, the participants reserved unconditional or absolute ‘right’ of withdrawal at any time and without giving any reason. This was expressly communicated before conducting the interviews and reduced in writing. All responses were recorded verbatim and reported objectively. The study was voluntary and the participants were able to withdraw from any point in the study if they so wish. </p>
<p>The study strictly adhered to good practice ethics and principles for research and align with data collection and security/protection requirements. The researcher also took into consideration adaptations required to meet COVID-19 control regulations. They identified the level of risk for the team and communities and equipped both personnel and participants with the necessary protective equipment.</p>
<p><span style="text-decoration: underline;"><em>Results</em></span></p>
<p>Quantitative Analysis for Changes in Weather Season and Utilization of RHS</p>
<p>To explore the relationship between weather seasonality and utilization of RHS, the researcher analyzed the data from 2015 to 2020, focusing on Quarter 1 (dry season: January to April) and Quarter 3 (rainy season: August to November). These quarters were chosen as they represent a comparison between different weather conditions and are crucial for establishing a relationship between weather seasonality and utilization of RHS. Additionally, the selected RH services data (including family planning, HIV counselling & testing, and maternal & newborn care) of women of reproductive age attending RHS clinic was plotted against time period (Quarter 1 and Quarter 3).</p>
<h4>Weather Patterns in Central Equatoria and Western Equatoria</h4>
<p>Located at an elevation of 613.3 meters (2012.14 feet) above sea level, Central Equatoria has a Tropical wet and dry or savanna climate. The findings shows that the State’s yearly temperature is 29.52ºC (85.14ºF) and it is 0.02% higher than South Sudan’s averages. Central Equatoria typically receives about 130.25 millimeters (5.13 inches) of precipitation and has 197.45 rainy days (54.1% of the time) annually (see Figure 1).</p>
<p><img src="https://lh6.googleusercontent.com/mBiE7Rvh0FFrg5CUnzuim8C8uKf7ByI2Otgp8_zrEEMKi86lj4FjOo6nmTbMwOw4gCWHMq3M8nOE0i1s8CMDjU5-up_MDRTh7MIlwk8rltwDh_uXNA8yMFKlNnVlcFeaUUrD1He2ytmcJ2XFOhFt" alt="" width="617" height="416" /></p>
<p><em>Figure 1: Sunshine pattern in Central Equatoria and Western Equatoria</em></p>
<p><em>Source: Research Data (2023)</em></p>
<p>Located at an elevation of 636.91 meters (2089.6 feet) above sea level, Western Equatoria has a Tropical wet and dry or savanna climate. The findings establish that the State’s yearly temperature is 27.25ºC (81.05ºF) and it is -2.25% lower than South Sudan’s averages. Western Equatoria typically receives about 203.23 millimeters (8.0 inches) of precipitation and has 223.82 rainy days (61.32% of the time) annually (see Figure 2).</p>
<p><br /><br /></p>
<p><img src="https://lh3.googleusercontent.com/3OfzLP4WmjLDJEXwYsqLlLDWDj2I133nIZrtgnX3GZm4sZMo7C2ZRRU4db2povK9Hw_WfD8YxxFYrEyRd-zcheJc8WtzbLz6J7RxIxi8xsfsuCmU2oDvk0MaDBBizwK1WdoQnOT96pGr8ei2dOT5" alt="" width="619" height="456" /></p>
<p><em>Figure 2: Rain pattern in Central Equatoria and Western Equatoria</em></p>
<p><em>Source: Research Data (2023)</em></p>
<h4>Trend and Seasonal Components (2015 to 2020) of RHS Visits </h4>
<p>Figures 3, 4 and 5 show that there were seasonal variations in the number of family planning visits, HIV counselling & testing visits; and maternal and newborn care visits since there were a number of peaks and troughs each year. The trend curve shows that there was a steady increase in the RHS all through from the first and third quarters of 2015 up to the first and third quarters of 2020. However, there are some seasonal differences in the selected RHS attendance in terms of first and third quarters all from 2015 to 2020, there is a consistent decline in attendance during the third quarters.</p>
<p><br /><br /></p>
<p><img src="https://lh4.googleusercontent.com/9dGXNia6CsSHHday3diPa_7ISav6A-uAMHxBHLpKBmRve1q3CBmSQIML6lrOza6ZdsyS6SUFmgpR44qm-tD5U1o05jans-YN0HE9wYxmui-9exOE4cYkgHvro5fyUjy4PI29Y62d32BuG_qJaErK" alt="" width="619" height="442" /></p>
<p><em>Figure 3: Scatter and trend plots of family planning visits in selected public health facilities</em></p>
<p><em>Source: Research Data (2023)</em></p>
<p><br /><br /><br /></p>
<p><img src="https://lh6.googleusercontent.com/32v5jYLIqSZ9u9TdsfSHcD6kLvDLKgNkShDs2rwAdaSlOnE0FptA92TWWQafvITH61GROkCuOLQC-q0R6ULe2LQ7-tWDRbfMA_uKr9_1IybAfEqHMP_dYNVxFtOmd9XMEVooRI1szVDJRj9MZ3va" alt="" width="608" height="459" /></p>
<p><em>Figure 4: Scatter and trend plots of HIV counselling and testing visits in selected public health facilities</em></p>
<p><em>Source: Research Data (2023)</em></p>
<p><br /><br /><br /></p>
<p><img src="https://lh6.googleusercontent.com/OVPEMi1WZZgFRn1hj_YuBueXkYGPqCjc3kQDmFQ4foqV5GCqgR3bMFZPdQHiiXRTJFLq44tGi9XBfGQ70Nd_tApKTqoM6yB0Y9-uEC08Q0hmmXhJTtS-XNrapRy_2ofyfT0F2lM0sniztqaCX0Lk" alt="" width="611" height="497" /></p>
<p><em>Figure 5: Scatter and trend plots of maternal and newborn care visits in selected public health facilities</em></p>
<p><em>Source: Research Data (2023)</em></p>
<p> </p>
<p>The selected RH services data of respondents attending the RHS clinic was plotted against the time period of 2015 to 2020 focusing on Quarter 1 and Quarter 3 (see Figures 3, 4 and 5). These two quarters represent a comparison between the dry (January to April) and rainy (August to November) seasons in Central Equatoria and Western Equatoria essential for establishing a relationship between weather season and utilization of RHS (see Figures 1 and 2).</p>
<p>The findings show that there are some seasonal differences of uptake and utilization of RHS in the first and third quarters all through 2015 to 2022 with a consistent decline in uptake of RHS during the third quarters. This coincides with the rainiest season of August and September (see figure 4.9 and 4.10) where there are high chances of experiencing flooding. The findings imply that there are long-lasting impacts on the uptake and utilization of RHS after a climate event such as flooding takes place. It was further established that disruptions in people’s household and public health facilities was likely to compromise uptake and utilization of RHS across the selected public health facilities.</p>
<p>Qualitative Analysis for Changes in Weather Season and Utilization of RHS</p>
<p>The thematic analysis highlights the significant influence of extreme weather events on the utilization and uptake of reproductive health services in Western Equatoria and Central Equatoria States in South Sudan.</p>
<p>The theme identified is the impact of extreme weather events, including drought and flooding, on the utilization and uptake of RHS. The weather conditions in Western Equatoria and Central Equatoria States, characterized by very cold temperatures during the rainy season and hot temperatures during the dry seasons, pose challenges for women seeking RHS. The extreme cold weather during the rainy season hinders women's willingness to go out and visit reproductive health clinics, potentially leading to reduced utilization. Similarly, floods resulting from heavy rains can disrupt transportation routes, making it difficult for women to access public health facilities and avail of RHS.</p>
<p>“The extreme cold weather during the rainy season acts as a deterrent for women seeking reproductive health services. It creates discomfort and poses health risks, making it less likely for women to venture out to access public health facilities. Addressing this challenge requires strategies such as improving the availability and accessibility of services closer to communities, including outreach programs and mobile clinics, to mitigate the impact of extreme cold weather on service utilization.” (FGD-Media, 2023)</p>
<p>Another theme revolves around limited access to RHS due to extreme weather conditions. The cold weather during the rainy season may discourage women from venturing outside their homes, especially for non-emergency services like reproductive health. Additionally, floods can render roads impassable, making it challenging for women to travel to public health facilities. These access barriers limit the utilization of RHS and negatively impact the overall reproductive health outcomes for women of reproductive age.</p>
<p>“Floods resulting from heavy rains further exacerbate the barriers to RHS. The disruption of transportation routes and infrastructure makes it challenging for women to access public health facilities, particularly during emergencies or when seeking routine reproductive health services. To address this issue, it is crucial to strengthen the resilience of health systems by improving transportation infrastructure, implementing early warning systems, and establishing contingency plans to ensure continuous service provision during extreme weather events.” (KI-Nurse, 2023)</p>
<p>Solutions to overcome these weather-related barriers should involve a multi-sectoral approach. Collaborating with meteorological departments and disaster management authorities can facilitate the integration of weather forecasts and early warning systems into the planning and delivery of reproductive health services. Engaging local communities through awareness campaigns and community-based approaches can also help in building resilience and preparedness, enabling women to make informed decisions and seek reproductive health services even during challenging weather conditions.</p>
<p>It is important to prioritize climate resilience in the design and management of reproductive health programs and services. This includes assessing the vulnerability of health facilities to extreme weather events, incorporating climate change adaptation strategies into facility infrastructure planning, and strengthening the capacity of health workers to respond effectively to climate-related challenges. By addressing the climate-related barriers and ensuring that reproductive health services are resilient to extreme weather events, South Sudan can enhance the utilization and uptake of reproductive health services, ultimately improving the reproductive health outcomes for women of reproductive age in Western Equatoria and Central Equatoria States.</p>
<p><em><span style="text-decoration: underline;">Discussion</span></em></p>
<p>The study's findings, which examined the relationship between changes in weather seasons and the utilization of RHS in South Sudan, were analyzed through the lens of the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These two theoretical frameworks provided valuable insights into the mechanisms and factors influencing individuals' decisions regarding RHS utilization. For instance, the HBM highlights the importance of an individual's perception of their susceptibility to a health condition and the severity of its consequences. In the case of South Sudan, where extreme weather events like flooding are prevalent, individuals may perceive themselves as susceptible to reproductive health risks due to the disruption of health services caused by flooding. The severity of these consequences may encompass complications related to pregnancy, STIs, and maternal and child health issues. These perceptions could motivate individuals to seek reproductive health services as a preventive measure. </p>
<p>In addition, the TRA posits that attitudes toward a behaviour influence an individual's intention to engage in that behaviour. Attitudes can be shaped by the perceived benefits and risks associated with the behaviour. In the case of RHS utilization, attitudes may be influenced by the perceived benefits of accessing these services for reproductive health, such as family planning and STI prevention. However, during adverse weather conditions, individuals' attitudes toward RHS utilization may become less favourable due to perceived barriers and challenges associated with accessing services.</p>
<p>The findings of the study indicate that a significant proportion of the respondents (72.5%) had utilized reproductive health services in the selected public health facilities, while 27.5% reported not having utilized any services in the past 12 months. Studies conducted in the region reveal that approximately 17% of all women in Sub-Saharan Africa and 23% of married or in-union women have an unmet need for RH services (United Nations, 2019). However, despite the significant utilization of RH services, the current study found that the majority of women (86.3%) reported not receiving all the RHS they were seeking in the selected public health facilities. This highlights a gap in the availability of comprehensive reproductive health services, indicating a need for improvement in the facilities' service delivery.</p>
<p>Among the RHS, family planning and prevention and management of sexually transmitted infections (STIs) were the most utilized, each accounting for 25.1% of the sampled population. Maternal and newborn care and HIV counselling and testing were also commonly used services, representing 18.1% and 15.3% of the respondents, respectively. However, studies conducted across Africa show that the majority of women of reproductive age would like to stop or delay childbearing but only 28% of women are using modern methods of family planning (WHO Africa, 2020). In addition, this study revealed that prior to their latest visit, a significant portion of the respondents (77.3%) were not aware that public health facilities provided free access to RHS. This lack of awareness may have hindered women's utilization of these services, emphasizing the importance of enhancing public awareness campaigns to ensure women are informed about the availability and accessibility of RHS.</p>
<p>From the longitudinal ecological study, it was observed seasonal variations in the number of visits for family planning, HIV counselling and testing, and maternal and newborn care services from 2015 to 2020. The trend analysis indicated a consistent increase in the uptake of RH services throughout the years. A previous study conducted in South Sudan found that the return of peace in South Sudan presented opportunities unlike before, including utilization and uptake of RHS among women of reproductive health (Kane, et al., 2016). However, this current study showed that there were specific declines in family planning, HIV counselling and testing, and maternal and newborn care attendance during the third quarter of each year from 2015 to 2020. This finding suggests a potential need for targeted interventions to address barriers or factors affecting attendance during the third quarter period.</p>
<p>The findings of this research objective shed light on the utilization and availability of RHS among women of reproductive age in South Sudan's public health facilities. The findings highlight the need for improved service provision to ensure comprehensive RHS are accessible to all women. Increasing awareness among the target population about free access to RHS can also contribute to improved utilization. Thus, addressing the seasonal differences in attendance, particularly for family planning services, HIV counselling and testing, and maternal and newborn care may require targeted strategies to ensure consistent access throughout the year.</p>
<p><span style="text-decoration: underline;"><em>Limitations</em></span></p>
<p>There are certain limitations associated with this study. Although the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA) offer valuable insights into individual behaviour, it's important to acknowledge that they are somewhat simplified models. Real-world decision-making is often shaped by intricate interactions among numerous factors, encompassing social, cultural, and economic determinants. While the HBM and TRA provide theoretical frameworks to grasp behaviour, they may not encompass the entirety of variations in reproductive health service (RHS) utilization. Factors beyond the scope of these theories might exert considerable influence on RHS utilization patterns</p>
<p>This study drew upon existing data sources, including government records and health facility databases. However, it's essential to acknowledge that the accuracy and completeness of these data sources may vary, potentially introducing measurement errors or biases during the analysis. Moreover, the study utilized retrospective data spanning from 2015 to 2020, which may be susceptible to recall bias as participants may have limitations in accurately remembering events or experiences over an extended period. Furthermore, the selection of health professionals for interviews followed a purposive approach, which could potentially introduce selection bias. This means that the health workers chosen for interviews may not be fully representative of all health professionals, and this could limit the generalizability of the qualitative findings. </p>
<p>While the study has identified associations between weather seasonality and RHS utilization, it's important to note that it may not definitively establish causality. There could be other unmeasured factors that influence the observed patterns. Additionally, the study primarily relies on quantitative data sourced from government records and health facilities. To gain a more comprehensive understanding of the factors influencing RHS utilization, it could be beneficial to incorporate additional qualitative data sources, such as conducting direct interviews with service users. This would provide richer insights into the subject matter.</p>
<p>To mitigate the limitations of this study effectively, several strategies can be envisaged. In future research, it would be beneficial to delve into and embrace more holistic theoretical frameworks that accommodate the intricate nature of behaviour, encompassing factors such as social, cultural, and economic determinants. The integration of multiple theories or models might offer a more nuanced and comprehensive understanding of RHS utilization. Moreover, to establish a stronger causal link between weather seasonality and RHS utilization, forthcoming studies could adopt more robust research designs, such as experimental or quasi-experimental approaches. Additionally, exploring mediating and moderating factors could aid in clarifying the causal pathways involved in this relationship, enhancing the depth of analysis and insight.</p>
<p><span style="text-decoration: underline;"><em>Conclusions</em></span></p>
<p>The HBM underscores the significance of an individual's perception of susceptibility to health conditions and the severity of potential consequences. In South Sudan, where extreme weather events like flooding are prevalent, individuals may perceive themselves as vulnerable to reproductive health risks due to disruptions in health services caused by flooding. Furthermore, the TRA highlights that attitude towards behavior play a pivotal role in shaping an individual's intention to engage in that behavior. Attitudes can be molded by the perceived benefits and risks associated with RHS utilization. </p>
<p>The longitudinal ecological study uncovered seasonal variations in the utilization of family planning, HIV counseling and testing, and maternal and newborn care services from 2015 to 2020. While there was a general increase in RHS uptake over the years, the study noted specific declines during the third quarter of each year. This finding suggests the need for targeted interventions to address barriers or factors affecting RHS attendance during the third quarter period. In addressing the limitations of this study, future research should consider more comprehensive theoretical frameworks that account for the multifaceted nature of behavior and incorporate a broader range of factors. Robust research designs, including experimental or quasi-experimental approaches, could strengthen causal inferences, and investigating mediating and moderating factors may provide deeper insights into the observed relationships.</p>
<p>In summary, this study underscores the importance of understanding the impact of weather seasonality on RHS utilization and highlights the need for improved service provision, increased awareness, and targeted interventions to ensure consistent access to reproductive health services throughout the year in South Sudan.</p>
<p><em><strong>Acknowledgements:</strong></em></p>
<p>This study was made possible through the support of my supervisors Dr. Alfred Owino Odongo and Dr. John Kariuki, and my colleagues within the Ministry of Health, particularly my fellow Public Health Officers and Surveillance Officers. Their support is acknowledged.</p>
<p><em><strong>Funding Acknowledgements:</strong></em></p>
<p>The author(s) received no financial support for the research, authorship, and/or publication of this article.</p>
<p><em><strong>Competing Interests:</strong></em></p>
<p>Author(s) declares there were no competing interests</p>
<p><em><strong>References</strong></em></p>
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<p> </p>
<figure data-wf-figure="1"><img src="https://pachodo.org/images/south-Sudan-Floods_AP_Photo.jpeg" alt="Thatched huts surrounded by floodwaters are seen from the air in Old Fangak county, Jonglei state, South Sudan Friday, Nov. 27, 2020 (Associated Press / Alamy Stock Photo)" title="Thatched huts surrounded by floodwaters are seen from the air in Old Fangak county, Jonglei state, South Sudan Friday, Nov. 27, 2020 (Associated Press / Alamy Stock Photo)" /><figcaption><em>Thatched huts surrounded by floodwaters are seen from the air in Old Fangak county, Jonglei state, South Sudan Friday, Nov. 27, 2020 (Associated Press / Alamy Stock Photo)</em></figcaption></figure>
<p> </p>
<p><strong>By: Dr. Emmanuel Timothy Thwol Onak1</strong></p>
<p> </p>
<p><span style="text-decoration: underline;"><em>Abstract</em></span></p>
<p>Background: Overall unmet needs for contraceptives among women are high; across the East Africa region including South Sudan, it ranges from 38.6 to 66.9%. Exploring the relationship between changes in weather season and utilization of RHS in selected South Sudan’s public health facilities, is key to developing and implementing locally appropriate public health responses.</p>
<p>Method: A qualitative study was conducted at South Sudan’s public health facilities in two (2) purposively selected States i.e., Western Equatoria and Central Equatoria. An interview guide was used to conduct in-depth interviews with the key informants who are knowledgeable about RHS. A data abstraction tool was also used to systematically collect data focused in obtaining the weather seasons and utilization data between the period of the years 2015 and 2020. </p>
<p>Results: The research study investigates the relationship between changes in weather seasons and the utilization of RHS among women of reproductive age in Central Equatoria and Western Equatoria States, South Sudan, from 2015 to 2020, focusing on dry (Quarter 1) and rainy (Quarter 3) seasons. The findings reveal a consistent decline in RHS utilization during the rainy season, particularly during flooding events. Over 35% of women experienced extreme weather events, leading to constrained access to RHS clinics, primarily due to flooding. Extreme cold weather during the rainy season and floods disrupts transportation routes, hindering women from seeking RHS. The qualitative analysis underscores the need for strategies such as outreach programs, mobile clinics, improved infrastructure, early warning systems, and climate resilience in health facilities to address these weather-related barriers and enhance reproductive health outcomes for women in the region.</p>
<p>Conclusions: The study's findings underscore the significant impact of weather seasonality, particularly flooding, on the utilization of RHS in South Sudan, specifically in Central Equatoria and Western Equatoria. The study reveals that weather events such as heavy rainfall and flooding coincide with a consistent decline in the uptake of RHS, emphasizing the need for climate-informed RHS planning and delivery. Extreme weather events were reported to constrain access to RHS services for a substantial proportion of women, highlighting the importance of preparedness and resilience-building strategies. These findings align with existing research indicating climate change's adverse effects on maternal health and access to RHS. Overall, this research highlights the urgency of addressing climate-related barriers to ensure consistent and equitable access to RHS for women in South Sudan, especially in the face of increasing weather variability and extreme events.</p>
<p><span style="text-decoration: underline;"><em>Background</em></span></p>
<p>The study investigates the critical nexus between weather seasonality and the utilization of reproductive health services (RHS) in South Sudan, with a focus on addressing a multifaceted challenge impacting women's health and well-being in the African Region. As highlighted by WHO Africa (2021), women in this region face higher mortality rates due to communicable diseases, maternal and perinatal conditions, and nutritional deficiencies, underscoring the pressing need for comprehensive reproductive health services. Additionally, the disproportionate vulnerability of women and children to climate-related disasters, exemplified by mortality rates following extreme weather events, emphasizes the link between climate change and women's health (United Nations, 2015). These health disparities underscore the urgent need for improved access to RHS in the African Region.</p>
<p>Extensive research highlights the disproportionate impact of climate change-related weather seasonality on women's broader health, social, and economic well-being (Sorensen et al., 2018; Zeid et al., 2015). Women and children are reported to be up to 14 times more likely than men to die in the aftermath of disasters, including extreme weather events like hurricanes, wildfires, and flooding. While comparative mortality rates may vary across contexts, the literature consistently underscores the heightened vulnerability of women during climate-related disasters. These disasters disrupt health systems and hinder access to critical reproductive health services and supplies (Benjamin, 2016).</p>
<p>Climate change has been linked to negative maternal health outcomes, an increased prevalence of gender-based violence (GBV), and restricted access to RHS, which in turn negatively affect family planning, abortion, and STI outcomes (Women Deliver, 2021). Inadequate disaster-risk management (DRM) exacerbates these challenges, as climate-related disasters can lead to physical damage to health facilities and infrastructure, supply chain disruptions, and the loss of medical records. Consequently, the immediate and direct impact is reduced access to high-quality RH services such as post-exposure prophylaxis for HIV, HIV treatment, emergency contraception, and safe abortion services (Onyango & Heidari, 2017).</p>
<p>Beyond the immediate aftermath of climate events, there are enduring consequences for RH services. Disruptions in health services can compromise access to contraceptives, maternal and child care, HIV and STI testing and treatment, counselling, psychosocial support, abortion services, and post-abortion care for crisis-affected communities (Benjamin, 2016). Untreated STIs can lead to long-term health implications for women, including infertility, tubal or ectopic pregnancy, cervical cancer, and perinatal or congenital infections in infants born to affected mothers (Behrman & Weitzman, 2016). Reduced access to contraception can result in higher rates of unintended pregnancy, pregnancy complications, and maternal mortality (Behrman & Weitzman, 2016).</p>
<p>During natural or man-made crises, governance, support systems, and services often break down, significantly impacting girls' and women's sexual and reproductive health and rights (SRHR). Weaknesses in health systems during crises increase vulnerability to climate change, leading to gaps in access, availability, acceptability, and quality of RH information and services (Castro, 2020). The added fear, stigma, and harmful social norms in post-disaster settings exacerbate the utilization of RHS outcomes.</p>
<p>The African Region, particularly sub-Saharan Africa, experiences rapid population growth and high climatic vulnerability. Many communities depend on small-scale, rain-fed agriculture and livestock systems, which are susceptible to climate variations (Brown, 2015). Poor rainy seasons, characterized by late or sporadic rains, impact food availability and economic resources. These changes influence sexual behaviour, fertility goals, miscarriage rates, stillbirths, and overall maternal and child health (Grace, 2017). Additionally, direct impacts of climate and the natural environment, such as droughts, floods, heatwaves, and extreme weather events, can further affect RH outcomes and access to health services (Grace et al., 2015).</p>
<p>South Sudan, like other countries in the region, faces the destructive consequences of severe droughts, floods, and climate-driven challenges (UNFPA, 2021). These disasters often limit access to health services, including sexual and reproductive health, leaving women to give birth without adequate medical support. The lack of clean water and menstrual products further impairs women's and girls' dignity and access to essential menstrual hygiene management (UNHCR Africa, 2022). South Sudan experienced its worst flooding on record in 2021, highlighting the increasing frequency and severity of such events, which are likely to impact RHS utilization in public health facilities.</p>
<p>Although South Sudan has made progress in reducing maternal mortality rates, challenges persist, particularly in climate-affected areas. Ongoing violence, a decrease in the health budget, and high inflation rates have strained the population (Integrity, 2018). The Integrated Food Security Phase Classification reported that 48% of South Sudan's population faced acute food insecurity in January 2018 (IPC, 2018). The underfunding of humanitarian response plans, including RHS, exacerbates the crisis. This economic turmoil places additional pressure on donor-funded programs, including RHS.</p>
<p>While service delivery in South Sudan's health sector has been documented, there is a significant knowledge gap concerning the utilization of RHS in the public health sector, including health workforce and service delivery. Moreover, the linkages between climate change and the uptake of RHS have received limited attention, potentially due to inadequate governmental prioritization and the sensitive nature of the climate change-RHS relationship. This study aims to address this critical gap through a qualitative, exploratory investigation of the determinants of RHS uptake and utilization in public health facilities in South Sudan. The specific objective is to determine whether there is a relationship between changes in weather season and the utilization of RHS in selected public health facilities in South</p>
<p><span style="text-decoration: underline;"><em>Methods</em></span></p>
<p>The study utilized a mixed-methods approach to collect and analyse data. The first part was a longitudinal ecological study in which quarterly returns of weather seasonality/season and service utilization indicators were obtained from South Sudan National Bureau of Statistics, and the Ministry of Agriculture and Food Security, as well as the Health Management Information System database and health facilities. The scoping review and data collection were retrospective data derived from South Sudan’s respective Government Ministries from 2015 to 2020. The second part was an analytical cross-sectional study that was undertaken at the public health facilities and involved the health professionals.</p>
<p>An interview guide was used to conduct in-depth interviews with the key informants who are knowledgeable about RHS. The KIIs involved interviewing people who had particularly informed perspectives on an aspect of the RHS or who had a deep understanding of the health system at the state and county levels. The interview guide consisted of open-ended questions focusing on the specific objective of the study. This data abstraction tool is a standard instrument used to systematically collect data from scientific reports in the development of the Guide to Community Preventive Services (the Guide). The data abstraction tool was focused on obtaining the weather seasons and utilization data between the proposed period of the year 2015 and 2020. The tool was designed to collect important information that helped generate useful data for analysis in that period as pertains to weather season and utilization of RHS.</p>
<p>The study borrowed mainly from two main theories i.e., the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These two theories have been adopted in studies to explain and predict utilization and uptake of RH service and proved to be useful in many empirical studies. Specifically, for developing a new behaviour or changing an existing behaviour of an individual, the HBM suggests the following unique and subjective beliefs of the person would be involved in the decision-making process: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action (Green et al., 2020). The four constructs of the HBM, perceived barriers, benefits, susceptibility and severity, were used to develop a predictive model for risky sexual practices in college students. Their results revealed that these constructs significantly explained 18% of variance in total number of risk behaviors, and 22% of variance in multiple sexual partnerships, but failed to predict condom usage in college women (Green et al., 2020). The HBM was shown to be a potentially useful theoretical framework for determining the uptake and utilization of RH services.</p>
<p>On the other hand, the TRA provides a framework to study attitudes toward behaviours with the ultimate goal being to predict and understand an individual’s behaviour. Rooted in value expectancy theories, the TRA assumes that humans are rational and make decisions for their actions by contemplating all the information available to them and the possible implications of the action (Glanz et al., 2015). Based on these assumptions, the TRA attempts to explain how intention converts into behaviour and what specific beliefs, attitudes, and subjective norms influence this transition. The TRA is composed of the following main constructs: behaviour, intention, and personal attitude. Behaviour is defined as being comprised of four elements: the action, the target at which the action is directed, the context in which it occurs, and the time at which it is performed. In addition, intention is the primary determinant of behaviour. It is believed that the stronger an individual’s intention toward a particular behaviour, the more successful he/she is expected to perform the behaviour.</p>
<p><span style="text-decoration: underline;"><em>Study sites</em></span></p>
<p>The study was conducted at South Sudan’s public health facilities in two (2) purposively selected States i.e., Western Equatoria and Central Equatoria. Approximately 83% of the population live in rural areas. The low population density (15/square kilometre) coupled with mobile pastoral communities and limited access due to the protracted crises poses a huge challenge to health service delivery. In these two selected States, data gathering was conducted in the four levels of the South Sudan health system, namely, the Boma Health Teams (community), Primary Healthcare Units (PHCU), Primary Healthcare Centres (PHCC) and the hospitals. These facilities are to a large extent aligned to the administrative subdivisions of the Country in both rural and urban areas (Ministry of Health, 2012; and WHO South Sudan, 2020). </p>
<p>Sampling, recruitment of study participants and data collection</p>
<p>The qualitative part of this study included purposively selected 25 key informants (health workers). The selection of health workers providing RHS was made according to health cadres and geographical locations (state and administrative areas) of health facilities across the selected states. Data was also abstracted between the years 2015 to 2020 for the longitudinal ecological arm of this study. Retrospective data from the Health Ministry of Health and from the health facilities was obtained within the specified period to assess the utilization of the RH services between two weather seasons (wet and dry seasons). </p>
<p>The interview guide consisted of open-ended questions focusing on the specific objectives of the study. It was a face-to-face conversation with the key informants that was recorded as part of note-taking. With the consent of the interviewee, the researcher recorded the conversation using a digital voice recorder. The researcher also observed the body language, expressions and other reactions to the questions during the interview. The data required to fill in the data abstraction form provided information on the intervention under study, evaluation setting and study population, outcomes, results, and study quality. The three sections of the form will consist of Part I. Classification Information, which was filled out by the chapter development team and reviewed and edited by the abstractors; Part II. Descriptive Information about the intervention, evaluation study characteristics, measurement of outcomes, and results; and Part III. Study Quality about the execution of the study.</p>
<p><span style="text-decoration: underline;"><em>Data analysis</em></span></p>
<p>In the proposed study, quantitative and qualitative approaches was used to analyse data emanating from different data collection tools. Data, once collected, was stored carefully to prevent damage or violations of subject privacy. The researcher ensured that unauthorized access to the files is not possible. Data files were stored in a computer that can only be accessed by the researcher and statistician and placed into files with password protection. Qualitative data and quantitative data were triangulated during post data analysis </p>
<p>Data emanating from the questionnaires was entered into a computer file for analysis using Microsoft Excel Spreadsheet. Here the researcher used descriptive statistics such as mean, median, mode, percentage, frequency and range. Descriptive statistics are most helpful when the research is limited to the sample and does not need to be generalized to a larger population. The researcher conducted preliminary content analysis of the qualitative data to identify any common patterns and trends arising from the narratives regarding relationship between climate change and utilization of RHS. The narratives were written on the main themes and illustrated by state-specific data whenever possible. Sequel Data Analytics was also used to translate data for analysing and interpreting.</p>
<p><span style="text-decoration: underline;"><em>Ethical considerations</em></span></p>
<p>Researcher sought ethical approval from the Division of Research, Monitoring and Evaluation (Directorate of Planning and Coordination) in the Ministry of Health, and Research Ethics Committee (REC), Republic of South Sudan. Approval was also sought form Mount Kenya University Institutional Ethical Review Committee (IERC). The permission to access public health facilities and other offices was sought from the respective sectoral and departmental heads including the Ministry of Health and Local Governments in the Republic of South Sudan.</p>
<p>Participants who consent to participate in the research were accorded anonymity and confidentiality to protect them as well as boost confidence in order to obtain accurate information. They were also accorded exercise of free will in deciding whether to participate in the research activity. In addition, the participants reserved unconditional or absolute ‘right’ of withdrawal at any time and without giving any reason. This was expressly communicated before conducting the interviews and reduced in writing. All responses were recorded verbatim and reported objectively. The study was voluntary and the participants were able to withdraw from any point in the study if they so wish. </p>
<p>The study strictly adhered to good practice ethics and principles for research and align with data collection and security/protection requirements. The researcher also took into consideration adaptations required to meet COVID-19 control regulations. They identified the level of risk for the team and communities and equipped both personnel and participants with the necessary protective equipment.</p>
<p><span style="text-decoration: underline;"><em>Results</em></span></p>
<p>Quantitative Analysis for Changes in Weather Season and Utilization of RHS</p>
<p>To explore the relationship between weather seasonality and utilization of RHS, the researcher analyzed the data from 2015 to 2020, focusing on Quarter 1 (dry season: January to April) and Quarter 3 (rainy season: August to November). These quarters were chosen as they represent a comparison between different weather conditions and are crucial for establishing a relationship between weather seasonality and utilization of RHS. Additionally, the selected RH services data (including family planning, HIV counselling & testing, and maternal & newborn care) of women of reproductive age attending RHS clinic was plotted against time period (Quarter 1 and Quarter 3).</p>
<h4>Weather Patterns in Central Equatoria and Western Equatoria</h4>
<p>Located at an elevation of 613.3 meters (2012.14 feet) above sea level, Central Equatoria has a Tropical wet and dry or savanna climate. The findings shows that the State’s yearly temperature is 29.52ºC (85.14ºF) and it is 0.02% higher than South Sudan’s averages. Central Equatoria typically receives about 130.25 millimeters (5.13 inches) of precipitation and has 197.45 rainy days (54.1% of the time) annually (see Figure 1).</p>
<p><img src="https://lh6.googleusercontent.com/mBiE7Rvh0FFrg5CUnzuim8C8uKf7ByI2Otgp8_zrEEMKi86lj4FjOo6nmTbMwOw4gCWHMq3M8nOE0i1s8CMDjU5-up_MDRTh7MIlwk8rltwDh_uXNA8yMFKlNnVlcFeaUUrD1He2ytmcJ2XFOhFt" alt="" width="617" height="416" /></p>
<p><em>Figure 1: Sunshine pattern in Central Equatoria and Western Equatoria</em></p>
<p><em>Source: Research Data (2023)</em></p>
<p>Located at an elevation of 636.91 meters (2089.6 feet) above sea level, Western Equatoria has a Tropical wet and dry or savanna climate. The findings establish that the State’s yearly temperature is 27.25ºC (81.05ºF) and it is -2.25% lower than South Sudan’s averages. Western Equatoria typically receives about 203.23 millimeters (8.0 inches) of precipitation and has 223.82 rainy days (61.32% of the time) annually (see Figure 2).</p>
<p><br /><br /></p>
<p><img src="https://lh3.googleusercontent.com/3OfzLP4WmjLDJEXwYsqLlLDWDj2I133nIZrtgnX3GZm4sZMo7C2ZRRU4db2povK9Hw_WfD8YxxFYrEyRd-zcheJc8WtzbLz6J7RxIxi8xsfsuCmU2oDvk0MaDBBizwK1WdoQnOT96pGr8ei2dOT5" alt="" width="619" height="456" /></p>
<p><em>Figure 2: Rain pattern in Central Equatoria and Western Equatoria</em></p>
<p><em>Source: Research Data (2023)</em></p>
<h4>Trend and Seasonal Components (2015 to 2020) of RHS Visits </h4>
<p>Figures 3, 4 and 5 show that there were seasonal variations in the number of family planning visits, HIV counselling & testing visits; and maternal and newborn care visits since there were a number of peaks and troughs each year. The trend curve shows that there was a steady increase in the RHS all through from the first and third quarters of 2015 up to the first and third quarters of 2020. However, there are some seasonal differences in the selected RHS attendance in terms of first and third quarters all from 2015 to 2020, there is a consistent decline in attendance during the third quarters.</p>
<p><br /><br /></p>
<p><img src="https://lh4.googleusercontent.com/9dGXNia6CsSHHday3diPa_7ISav6A-uAMHxBHLpKBmRve1q3CBmSQIML6lrOza6ZdsyS6SUFmgpR44qm-tD5U1o05jans-YN0HE9wYxmui-9exOE4cYkgHvro5fyUjy4PI29Y62d32BuG_qJaErK" alt="" width="619" height="442" /></p>
<p><em>Figure 3: Scatter and trend plots of family planning visits in selected public health facilities</em></p>
<p><em>Source: Research Data (2023)</em></p>
<p><br /><br /><br /></p>
<p><img src="https://lh6.googleusercontent.com/32v5jYLIqSZ9u9TdsfSHcD6kLvDLKgNkShDs2rwAdaSlOnE0FptA92TWWQafvITH61GROkCuOLQC-q0R6ULe2LQ7-tWDRbfMA_uKr9_1IybAfEqHMP_dYNVxFtOmd9XMEVooRI1szVDJRj9MZ3va" alt="" width="608" height="459" /></p>
<p><em>Figure 4: Scatter and trend plots of HIV counselling and testing visits in selected public health facilities</em></p>
<p><em>Source: Research Data (2023)</em></p>
<p><br /><br /><br /></p>
<p><img src="https://lh6.googleusercontent.com/OVPEMi1WZZgFRn1hj_YuBueXkYGPqCjc3kQDmFQ4foqV5GCqgR3bMFZPdQHiiXRTJFLq44tGi9XBfGQ70Nd_tApKTqoM6yB0Y9-uEC08Q0hmmXhJTtS-XNrapRy_2ofyfT0F2lM0sniztqaCX0Lk" alt="" width="611" height="497" /></p>
<p><em>Figure 5: Scatter and trend plots of maternal and newborn care visits in selected public health facilities</em></p>
<p><em>Source: Research Data (2023)</em></p>
<p> </p>
<p>The selected RH services data of respondents attending the RHS clinic was plotted against the time period of 2015 to 2020 focusing on Quarter 1 and Quarter 3 (see Figures 3, 4 and 5). These two quarters represent a comparison between the dry (January to April) and rainy (August to November) seasons in Central Equatoria and Western Equatoria essential for establishing a relationship between weather season and utilization of RHS (see Figures 1 and 2).</p>
<p>The findings show that there are some seasonal differences of uptake and utilization of RHS in the first and third quarters all through 2015 to 2022 with a consistent decline in uptake of RHS during the third quarters. This coincides with the rainiest season of August and September (see figure 4.9 and 4.10) where there are high chances of experiencing flooding. The findings imply that there are long-lasting impacts on the uptake and utilization of RHS after a climate event such as flooding takes place. It was further established that disruptions in people’s household and public health facilities was likely to compromise uptake and utilization of RHS across the selected public health facilities.</p>
<p>Qualitative Analysis for Changes in Weather Season and Utilization of RHS</p>
<p>The thematic analysis highlights the significant influence of extreme weather events on the utilization and uptake of reproductive health services in Western Equatoria and Central Equatoria States in South Sudan.</p>
<p>The theme identified is the impact of extreme weather events, including drought and flooding, on the utilization and uptake of RHS. The weather conditions in Western Equatoria and Central Equatoria States, characterized by very cold temperatures during the rainy season and hot temperatures during the dry seasons, pose challenges for women seeking RHS. The extreme cold weather during the rainy season hinders women's willingness to go out and visit reproductive health clinics, potentially leading to reduced utilization. Similarly, floods resulting from heavy rains can disrupt transportation routes, making it difficult for women to access public health facilities and avail of RHS.</p>
<p>“The extreme cold weather during the rainy season acts as a deterrent for women seeking reproductive health services. It creates discomfort and poses health risks, making it less likely for women to venture out to access public health facilities. Addressing this challenge requires strategies such as improving the availability and accessibility of services closer to communities, including outreach programs and mobile clinics, to mitigate the impact of extreme cold weather on service utilization.” (FGD-Media, 2023)</p>
<p>Another theme revolves around limited access to RHS due to extreme weather conditions. The cold weather during the rainy season may discourage women from venturing outside their homes, especially for non-emergency services like reproductive health. Additionally, floods can render roads impassable, making it challenging for women to travel to public health facilities. These access barriers limit the utilization of RHS and negatively impact the overall reproductive health outcomes for women of reproductive age.</p>
<p>“Floods resulting from heavy rains further exacerbate the barriers to RHS. The disruption of transportation routes and infrastructure makes it challenging for women to access public health facilities, particularly during emergencies or when seeking routine reproductive health services. To address this issue, it is crucial to strengthen the resilience of health systems by improving transportation infrastructure, implementing early warning systems, and establishing contingency plans to ensure continuous service provision during extreme weather events.” (KI-Nurse, 2023)</p>
<p>Solutions to overcome these weather-related barriers should involve a multi-sectoral approach. Collaborating with meteorological departments and disaster management authorities can facilitate the integration of weather forecasts and early warning systems into the planning and delivery of reproductive health services. Engaging local communities through awareness campaigns and community-based approaches can also help in building resilience and preparedness, enabling women to make informed decisions and seek reproductive health services even during challenging weather conditions.</p>
<p>It is important to prioritize climate resilience in the design and management of reproductive health programs and services. This includes assessing the vulnerability of health facilities to extreme weather events, incorporating climate change adaptation strategies into facility infrastructure planning, and strengthening the capacity of health workers to respond effectively to climate-related challenges. By addressing the climate-related barriers and ensuring that reproductive health services are resilient to extreme weather events, South Sudan can enhance the utilization and uptake of reproductive health services, ultimately improving the reproductive health outcomes for women of reproductive age in Western Equatoria and Central Equatoria States.</p>
<p><em><span style="text-decoration: underline;">Discussion</span></em></p>
<p>The study's findings, which examined the relationship between changes in weather seasons and the utilization of RHS in South Sudan, were analyzed through the lens of the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These two theoretical frameworks provided valuable insights into the mechanisms and factors influencing individuals' decisions regarding RHS utilization. For instance, the HBM highlights the importance of an individual's perception of their susceptibility to a health condition and the severity of its consequences. In the case of South Sudan, where extreme weather events like flooding are prevalent, individuals may perceive themselves as susceptible to reproductive health risks due to the disruption of health services caused by flooding. The severity of these consequences may encompass complications related to pregnancy, STIs, and maternal and child health issues. These perceptions could motivate individuals to seek reproductive health services as a preventive measure. </p>
<p>In addition, the TRA posits that attitudes toward a behaviour influence an individual's intention to engage in that behaviour. Attitudes can be shaped by the perceived benefits and risks associated with the behaviour. In the case of RHS utilization, attitudes may be influenced by the perceived benefits of accessing these services for reproductive health, such as family planning and STI prevention. However, during adverse weather conditions, individuals' attitudes toward RHS utilization may become less favourable due to perceived barriers and challenges associated with accessing services.</p>
<p>The findings of the study indicate that a significant proportion of the respondents (72.5%) had utilized reproductive health services in the selected public health facilities, while 27.5% reported not having utilized any services in the past 12 months. Studies conducted in the region reveal that approximately 17% of all women in Sub-Saharan Africa and 23% of married or in-union women have an unmet need for RH services (United Nations, 2019). However, despite the significant utilization of RH services, the current study found that the majority of women (86.3%) reported not receiving all the RHS they were seeking in the selected public health facilities. This highlights a gap in the availability of comprehensive reproductive health services, indicating a need for improvement in the facilities' service delivery.</p>
<p>Among the RHS, family planning and prevention and management of sexually transmitted infections (STIs) were the most utilized, each accounting for 25.1% of the sampled population. Maternal and newborn care and HIV counselling and testing were also commonly used services, representing 18.1% and 15.3% of the respondents, respectively. However, studies conducted across Africa show that the majority of women of reproductive age would like to stop or delay childbearing but only 28% of women are using modern methods of family planning (WHO Africa, 2020). In addition, this study revealed that prior to their latest visit, a significant portion of the respondents (77.3%) were not aware that public health facilities provided free access to RHS. This lack of awareness may have hindered women's utilization of these services, emphasizing the importance of enhancing public awareness campaigns to ensure women are informed about the availability and accessibility of RHS.</p>
<p>From the longitudinal ecological study, it was observed seasonal variations in the number of visits for family planning, HIV counselling and testing, and maternal and newborn care services from 2015 to 2020. The trend analysis indicated a consistent increase in the uptake of RH services throughout the years. A previous study conducted in South Sudan found that the return of peace in South Sudan presented opportunities unlike before, including utilization and uptake of RHS among women of reproductive health (Kane, et al., 2016). However, this current study showed that there were specific declines in family planning, HIV counselling and testing, and maternal and newborn care attendance during the third quarter of each year from 2015 to 2020. This finding suggests a potential need for targeted interventions to address barriers or factors affecting attendance during the third quarter period.</p>
<p>The findings of this research objective shed light on the utilization and availability of RHS among women of reproductive age in South Sudan's public health facilities. The findings highlight the need for improved service provision to ensure comprehensive RHS are accessible to all women. Increasing awareness among the target population about free access to RHS can also contribute to improved utilization. Thus, addressing the seasonal differences in attendance, particularly for family planning services, HIV counselling and testing, and maternal and newborn care may require targeted strategies to ensure consistent access throughout the year.</p>
<p><span style="text-decoration: underline;"><em>Limitations</em></span></p>
<p>There are certain limitations associated with this study. Although the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA) offer valuable insights into individual behaviour, it's important to acknowledge that they are somewhat simplified models. Real-world decision-making is often shaped by intricate interactions among numerous factors, encompassing social, cultural, and economic determinants. While the HBM and TRA provide theoretical frameworks to grasp behaviour, they may not encompass the entirety of variations in reproductive health service (RHS) utilization. Factors beyond the scope of these theories might exert considerable influence on RHS utilization patterns</p>
<p>This study drew upon existing data sources, including government records and health facility databases. However, it's essential to acknowledge that the accuracy and completeness of these data sources may vary, potentially introducing measurement errors or biases during the analysis. Moreover, the study utilized retrospective data spanning from 2015 to 2020, which may be susceptible to recall bias as participants may have limitations in accurately remembering events or experiences over an extended period. Furthermore, the selection of health professionals for interviews followed a purposive approach, which could potentially introduce selection bias. This means that the health workers chosen for interviews may not be fully representative of all health professionals, and this could limit the generalizability of the qualitative findings. </p>
<p>While the study has identified associations between weather seasonality and RHS utilization, it's important to note that it may not definitively establish causality. There could be other unmeasured factors that influence the observed patterns. Additionally, the study primarily relies on quantitative data sourced from government records and health facilities. To gain a more comprehensive understanding of the factors influencing RHS utilization, it could be beneficial to incorporate additional qualitative data sources, such as conducting direct interviews with service users. This would provide richer insights into the subject matter.</p>
<p>To mitigate the limitations of this study effectively, several strategies can be envisaged. In future research, it would be beneficial to delve into and embrace more holistic theoretical frameworks that accommodate the intricate nature of behaviour, encompassing factors such as social, cultural, and economic determinants. The integration of multiple theories or models might offer a more nuanced and comprehensive understanding of RHS utilization. Moreover, to establish a stronger causal link between weather seasonality and RHS utilization, forthcoming studies could adopt more robust research designs, such as experimental or quasi-experimental approaches. Additionally, exploring mediating and moderating factors could aid in clarifying the causal pathways involved in this relationship, enhancing the depth of analysis and insight.</p>
<p><span style="text-decoration: underline;"><em>Conclusions</em></span></p>
<p>The HBM underscores the significance of an individual's perception of susceptibility to health conditions and the severity of potential consequences. In South Sudan, where extreme weather events like flooding are prevalent, individuals may perceive themselves as vulnerable to reproductive health risks due to disruptions in health services caused by flooding. Furthermore, the TRA highlights that attitude towards behavior play a pivotal role in shaping an individual's intention to engage in that behavior. Attitudes can be molded by the perceived benefits and risks associated with RHS utilization. </p>
<p>The longitudinal ecological study uncovered seasonal variations in the utilization of family planning, HIV counseling and testing, and maternal and newborn care services from 2015 to 2020. While there was a general increase in RHS uptake over the years, the study noted specific declines during the third quarter of each year. This finding suggests the need for targeted interventions to address barriers or factors affecting RHS attendance during the third quarter period. In addressing the limitations of this study, future research should consider more comprehensive theoretical frameworks that account for the multifaceted nature of behavior and incorporate a broader range of factors. Robust research designs, including experimental or quasi-experimental approaches, could strengthen causal inferences, and investigating mediating and moderating factors may provide deeper insights into the observed relationships.</p>
<p>In summary, this study underscores the importance of understanding the impact of weather seasonality on RHS utilization and highlights the need for improved service provision, increased awareness, and targeted interventions to ensure consistent access to reproductive health services throughout the year in South Sudan.</p>
<p><em><strong>Acknowledgements:</strong></em></p>
<p>This study was made possible through the support of my supervisors Dr. Alfred Owino Odongo and Dr. John Kariuki, and my colleagues within the Ministry of Health, particularly my fellow Public Health Officers and Surveillance Officers. Their support is acknowledged.</p>
<p><em><strong>Funding Acknowledgements:</strong></em></p>
<p>The author(s) received no financial support for the research, authorship, and/or publication of this article.</p>
<p><em><strong>Competing Interests:</strong></em></p>
<p>Author(s) declares there were no competing interests</p>
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Abstract On Determinants Of Uptake And Utilization Of Reproductive Health Services Among Women Of Reproductive Age In South Sudan’s Public Health Facilities
2023-10-06T04:09:55+01:00
2023-10-06T04:09:55+01:00
https://pachodo.org/latest-news-articles/pachodo-english-articles/42694-abstract-on-determinants-of-uptake-and-utilization-of-reproductive-health-services-among-women-of-reproductive-age-in-south-sudan%E2%80%99s-public-health-facilities
Dr. Emmanuel Timothy Thwol
LamArop@pachodo.org
<p><img src="https://pachodo.org/images/Dr_Emmanuel_Timothy_THWOL.png" alt="DR. EMMANUEL TIMOTHY THWOL" title="DR. EMMANUEL TIMOTHY THWOL" /></p>
<p><em><strong>By DR. EMMANUEL TIMOTHY THWOL (PhD)</strong></em></p>
<p><em>© OCTOBER 2023</em></p>
<p>Despite comprising only about one-tenth of the global population in Africa, the region accounts for a disproportionate 20 per cent of worldwide births and nearly half of all maternal deaths during pregnancy and childbirth. Poor reproductive health is a significant contributor to the global disease burden, particularly affecting women of reproductive age. This dire situation is partly attributed to limited access to essential reproductive health interventions. For example, contraceptive use among married women in Sub-Saharan Africa is notably low at 13 per cent, leading to a high total fertility rate of 5.5 children per woman and an elevated adult lifetime risk of maternal death, with Africa having the highest risk at 1 in 26, while developed countries have the lowest risk at 1 in 7,300.</p>
<p>The study's objective was to investigate the factors influencing the uptake and utilization of reproductive health services among women of reproductive age in South Sudan's public health facilities.</p>
<p>The study employed a mixed-methods approach, including a longitudinal ecological study and an analytical cross-sectional study, conducted in selected States - Western Equatoria and Central Equatoria. The target population included women aged 15 to 49 visiting health facilities during the study period and key informants involved in reproductive health services and policy implementation. Data collection methods included structured questionnaires, in-depth interviews, focus group discussions, and data abstraction tools. Quantitative data analysis involved descriptive statistics and inferential analyses, while qualitative data underwent content and thematic analysis to identify common patterns and trends.</p>
<p>The study's findings in South Sudan's public health facilities indicate that a significant portion of respondents (72.5%) utilized reproductive health services, with family planning and STI prevention being the most used (25.1% each), followed by maternal and newborn care (18.1%) and HIV counselling and testing (15.3%). While overall uptake of reproductive health services increased over the years, there were declines during the third quarter from 2015 to 2020, coinciding with the rainy season.</p>
<p>Extreme weather events, like flooding and drought, hindered access to services for over 35% of women surveyed. Socio-cultural factors played a role, with age, place of residence, and educational level influencing utilization. Furthermore, awareness of nearby clinics, distance from clinics, and the availability of specific contraceptives were related to service utilization. Adequate and qualified healthcare staff, education levels, manageable workloads, and fair compensation were identified as crucial factors in improving reproductive health service delivery and access in South Sudan's public health facilities.</p>
<p>To enhance the uptake and utilization of RHS among women of reproductive age in South Sudan's public health facilities, several recommendations should be implemented. These include improving the availability of RHS by ensuring a consistent supply of essential resources and adequate staffing, raising awareness about free RHS through targeted campaigns, addressing seasonal variations and climate-related challenges, mitigating socio-cultural barriers, enhancing health facility characteristics to improve geographical accessibility, strengthening the health workforce through training and capacity-building, and providing competitive compensation packages and a supportive work environment for healthcare providers.</p>
<p>These measures collectively aim to improve reproductive health outcomes and access to services for women in South Sudan. Top of Form Further research can delve deeper into specific interventions and their effectiveness in overcoming these determinants to enhance RHS utilization and ultimately improve reproductive health outcomes for women in South Sudan.</p>
<p><img src="https://pachodo.org/images/Dr_Emmanuel_Timothy_THWOL.png" alt="DR. EMMANUEL TIMOTHY THWOL" title="DR. EMMANUEL TIMOTHY THWOL" /></p>
<p><em><strong>By DR. EMMANUEL TIMOTHY THWOL (PhD)</strong></em></p>
<p><em>© OCTOBER 2023</em></p>
<p>Despite comprising only about one-tenth of the global population in Africa, the region accounts for a disproportionate 20 per cent of worldwide births and nearly half of all maternal deaths during pregnancy and childbirth. Poor reproductive health is a significant contributor to the global disease burden, particularly affecting women of reproductive age. This dire situation is partly attributed to limited access to essential reproductive health interventions. For example, contraceptive use among married women in Sub-Saharan Africa is notably low at 13 per cent, leading to a high total fertility rate of 5.5 children per woman and an elevated adult lifetime risk of maternal death, with Africa having the highest risk at 1 in 26, while developed countries have the lowest risk at 1 in 7,300.</p>
<p>The study's objective was to investigate the factors influencing the uptake and utilization of reproductive health services among women of reproductive age in South Sudan's public health facilities.</p>
<p>The study employed a mixed-methods approach, including a longitudinal ecological study and an analytical cross-sectional study, conducted in selected States - Western Equatoria and Central Equatoria. The target population included women aged 15 to 49 visiting health facilities during the study period and key informants involved in reproductive health services and policy implementation. Data collection methods included structured questionnaires, in-depth interviews, focus group discussions, and data abstraction tools. Quantitative data analysis involved descriptive statistics and inferential analyses, while qualitative data underwent content and thematic analysis to identify common patterns and trends.</p>
<p>The study's findings in South Sudan's public health facilities indicate that a significant portion of respondents (72.5%) utilized reproductive health services, with family planning and STI prevention being the most used (25.1% each), followed by maternal and newborn care (18.1%) and HIV counselling and testing (15.3%). While overall uptake of reproductive health services increased over the years, there were declines during the third quarter from 2015 to 2020, coinciding with the rainy season.</p>
<p>Extreme weather events, like flooding and drought, hindered access to services for over 35% of women surveyed. Socio-cultural factors played a role, with age, place of residence, and educational level influencing utilization. Furthermore, awareness of nearby clinics, distance from clinics, and the availability of specific contraceptives were related to service utilization. Adequate and qualified healthcare staff, education levels, manageable workloads, and fair compensation were identified as crucial factors in improving reproductive health service delivery and access in South Sudan's public health facilities.</p>
<p>To enhance the uptake and utilization of RHS among women of reproductive age in South Sudan's public health facilities, several recommendations should be implemented. These include improving the availability of RHS by ensuring a consistent supply of essential resources and adequate staffing, raising awareness about free RHS through targeted campaigns, addressing seasonal variations and climate-related challenges, mitigating socio-cultural barriers, enhancing health facility characteristics to improve geographical accessibility, strengthening the health workforce through training and capacity-building, and providing competitive compensation packages and a supportive work environment for healthcare providers.</p>
<p>These measures collectively aim to improve reproductive health outcomes and access to services for women in South Sudan. Top of Form Further research can delve deeper into specific interventions and their effectiveness in overcoming these determinants to enhance RHS utilization and ultimately improve reproductive health outcomes for women in South Sudan.</p>
Keep Music Alive & 1,200+ Locations to Celebrate 8th Annual Kids Music Day – Friday, October 6th
2023-09-29T04:53:30+01:00
2023-09-29T04:53:30+01:00
https://pachodo.org/latest-news-articles/pachodo-english-articles/42579-keep-music-alive-1%2C200-locations-to-celebrate-8th-annual-kids-music-day-%E2%80%93-friday%2C-october-6th
Joann Pierdomenico
LamArop@pachodo.org
<p> <img src="https://pachodo.org/images/annual-kids-music-2023.jpg" alt="8th Annual Int'l Kids Music Day banner1" title="8th Annual Int'l Kids Music Day banner1" /></p>
<p><img src="https://pachodo.org/images/annual-kids-music-2023-AmbassadorsSupporters-2023-NEW.jpg" alt="8th Annual Int'l Kids Music Day banner 2" title="8th Annual Int'l Kids Music Day banner 2" /></p>
<p> </p>
<p><strong>PHILADELPHIA, PA</strong> – Over 1,200 locations in all 50 US states, Canada and a dozen other countries will participate in the <strong>8th Annual Kids Music Day</strong> this year with special events & promotions that benefit & celebrate kids playing music. Kids Music Day events & promotions will be held between Friday, September 29<sup>th</sup> and Sunday,October 8<sup>th</sup>. Families can locate Kids Music Day activities in their community by entering their zip code on the <a href="http://www.KidsMusicDay.org" data-saferedirecturl="https://www.google.com/url?q=http://www.KidsMusicDay.org&source=gmail&ust=1696066225221000&usg=AOvVaw1Wg8UMRoYjDu4rwwhac4bU">www.KidsMusicDay.org</a> locator page.</p>
<p><strong>Keep Music Alive</strong> is excited to, once again, partner with the <strong>Music & Arts</strong> & <strong>Guitar Center </strong>retail chains who are making it easier and more fun than ever to give music a try! Both chains are offering a FREE group guitar lesson on Saturday, October 7th to celebrate Kids Music Day. Included is a special promotion “Buy 3 Lessons, Get 1 Free” + Free Registration for those who attend & sign up at the event.</p>
<p><strong>Saturday 10/7 @ 11 AM </strong>- <strong>Free Group Guitar Class at your local Music & Arts</strong></p>
<p><strong>RSVP</strong> - <a href="http://www.MusicArts.com/Lessons-Open-House" data-saferedirecturl="https://www.google.com/url?q=http://www.MusicArts.com/Lessons-Open-House&source=gmail&ust=1696066225221000&usg=AOvVaw0659vaGZr2rPiPPyQZq_hr">www.MusicArts.com/Lessons-Open-House</a> </p>
<p><strong>Saturday 10/7 @ 11 AM</strong> - <strong>Free Group Guitar Class at your local Guitar Center </strong></p>
<p><strong>RSVP</strong> - <a href="http://www.GuitarCenter.com/Lessons-Open-House.gc" data-saferedirecturl="https://www.google.com/url?q=http://www.GuitarCenter.com/Lessons-Open-House.gc&source=gmail&ust=1696066225221000&usg=AOvVaw11a5k4fEt0iQQ2n42jHvan">www.GuitarCenter.com/Lessons-Open-House.gc</a> </p>
<p>“<em>Music education creates lifelong benefits that can enrich a child’s life, including increased social skills to higher levels of confidence and self-esteem</em>,” said <strong>Donny Gruendler, VP of Education at Guitar Center</strong>. “<em>From the guitar to the drums, it doesn’t matter what instrument a child learns to play— the experience will allow them to cultivate their identity and kindle a life-long passion for learning. As a result, we are so proud to partner with Keep Music Alive and Kids Music Day to promote the value of music</em>.”</p>
<p>Over a dozen celebrity artists are showing their support for Music Education by lending their name as Kids Music Day Ambassadors including: <strong>Julie Andrews, Jack Black, Ann & Nancy Wilson of Heart, Pat Benatar & Neil Giraldo, Michael Feinstein, Kenny Loggins, Richie Sambora, Sarah McLachlan, Vanessa Williams, Victor Wooten, Todd Rundgren, Neil Nayyar, Philip Lawrence, Bernie Williams, Damien Escobar and Mandy Harvey.</strong></p>
<p> </p>
<p>Kids Music Day is also supported by a number of music industry brands including <strong>Alfred Music, CASIO EMI, Conn-Selmer, D’Addario Foundation, Guitars in the Classroom, Kala Brand Music, Hungry for Music, Les Paul Foundation, Make Music, Music Nomad Equipment Care, Music for Minors II, Panyard, Remo Percussion and The Spirit of Harmony Foundation.</strong> Keep Music Alive is honored to welcome these partners helping to share the Kids Music Day message, inspiring more kids to start their musical journey. </p>
<p><strong>Keep Music Alive</strong> is a national 501(c)(3) on a mission to help more kids & adults reap the educational, therapeutic and social benefits of playing music. Major programs include Teach Music Week in March, Kids Music Day in October and year-round Musical Instrument Petting Zoo events. For more information, please call (610) 874-6312 or visit <a href="http://www.KeepMusicAlive.org" data-saferedirecturl="https://www.google.com/url?q=http://www.KeepMusicAlive.org&source=gmail&ust=1696066225221000&usg=AOvVaw02sRbe9WzEXVdkb-HJtPCF">www.KeepMusicAlive.org</a> and <a href="http://www.KidsMusicDay.org" data-saferedirecturl="https://www.google.com/url?q=http://www.KidsMusicDay.org&source=gmail&ust=1696066225221000&usg=AOvVaw1Wg8UMRoYjDu4rwwhac4bU">www.KidsMusicDay.org</a>.</p>
<p> <img src="https://pachodo.org/images/annual-kids-music-2023.jpg" alt="8th Annual Int'l Kids Music Day banner1" title="8th Annual Int'l Kids Music Day banner1" /></p>
<p><img src="https://pachodo.org/images/annual-kids-music-2023-AmbassadorsSupporters-2023-NEW.jpg" alt="8th Annual Int'l Kids Music Day banner 2" title="8th Annual Int'l Kids Music Day banner 2" /></p>
<p> </p>
<p><strong>PHILADELPHIA, PA</strong> – Over 1,200 locations in all 50 US states, Canada and a dozen other countries will participate in the <strong>8th Annual Kids Music Day</strong> this year with special events & promotions that benefit & celebrate kids playing music. Kids Music Day events & promotions will be held between Friday, September 29<sup>th</sup> and Sunday,October 8<sup>th</sup>. Families can locate Kids Music Day activities in their community by entering their zip code on the <a href="http://www.KidsMusicDay.org" data-saferedirecturl="https://www.google.com/url?q=http://www.KidsMusicDay.org&source=gmail&ust=1696066225221000&usg=AOvVaw1Wg8UMRoYjDu4rwwhac4bU">www.KidsMusicDay.org</a> locator page.</p>
<p><strong>Keep Music Alive</strong> is excited to, once again, partner with the <strong>Music & Arts</strong> & <strong>Guitar Center </strong>retail chains who are making it easier and more fun than ever to give music a try! Both chains are offering a FREE group guitar lesson on Saturday, October 7th to celebrate Kids Music Day. Included is a special promotion “Buy 3 Lessons, Get 1 Free” + Free Registration for those who attend & sign up at the event.</p>
<p><strong>Saturday 10/7 @ 11 AM </strong>- <strong>Free Group Guitar Class at your local Music & Arts</strong></p>
<p><strong>RSVP</strong> - <a href="http://www.MusicArts.com/Lessons-Open-House" data-saferedirecturl="https://www.google.com/url?q=http://www.MusicArts.com/Lessons-Open-House&source=gmail&ust=1696066225221000&usg=AOvVaw0659vaGZr2rPiPPyQZq_hr">www.MusicArts.com/Lessons-Open-House</a> </p>
<p><strong>Saturday 10/7 @ 11 AM</strong> - <strong>Free Group Guitar Class at your local Guitar Center </strong></p>
<p><strong>RSVP</strong> - <a href="http://www.GuitarCenter.com/Lessons-Open-House.gc" data-saferedirecturl="https://www.google.com/url?q=http://www.GuitarCenter.com/Lessons-Open-House.gc&source=gmail&ust=1696066225221000&usg=AOvVaw11a5k4fEt0iQQ2n42jHvan">www.GuitarCenter.com/Lessons-Open-House.gc</a> </p>
<p>“<em>Music education creates lifelong benefits that can enrich a child’s life, including increased social skills to higher levels of confidence and self-esteem</em>,” said <strong>Donny Gruendler, VP of Education at Guitar Center</strong>. “<em>From the guitar to the drums, it doesn’t matter what instrument a child learns to play— the experience will allow them to cultivate their identity and kindle a life-long passion for learning. As a result, we are so proud to partner with Keep Music Alive and Kids Music Day to promote the value of music</em>.”</p>
<p>Over a dozen celebrity artists are showing their support for Music Education by lending their name as Kids Music Day Ambassadors including: <strong>Julie Andrews, Jack Black, Ann & Nancy Wilson of Heart, Pat Benatar & Neil Giraldo, Michael Feinstein, Kenny Loggins, Richie Sambora, Sarah McLachlan, Vanessa Williams, Victor Wooten, Todd Rundgren, Neil Nayyar, Philip Lawrence, Bernie Williams, Damien Escobar and Mandy Harvey.</strong></p>
<p> </p>
<p>Kids Music Day is also supported by a number of music industry brands including <strong>Alfred Music, CASIO EMI, Conn-Selmer, D’Addario Foundation, Guitars in the Classroom, Kala Brand Music, Hungry for Music, Les Paul Foundation, Make Music, Music Nomad Equipment Care, Music for Minors II, Panyard, Remo Percussion and The Spirit of Harmony Foundation.</strong> Keep Music Alive is honored to welcome these partners helping to share the Kids Music Day message, inspiring more kids to start their musical journey. </p>
<p><strong>Keep Music Alive</strong> is a national 501(c)(3) on a mission to help more kids & adults reap the educational, therapeutic and social benefits of playing music. Major programs include Teach Music Week in March, Kids Music Day in October and year-round Musical Instrument Petting Zoo events. For more information, please call (610) 874-6312 or visit <a href="http://www.KeepMusicAlive.org" data-saferedirecturl="https://www.google.com/url?q=http://www.KeepMusicAlive.org&source=gmail&ust=1696066225221000&usg=AOvVaw02sRbe9WzEXVdkb-HJtPCF">www.KeepMusicAlive.org</a> and <a href="http://www.KidsMusicDay.org" data-saferedirecturl="https://www.google.com/url?q=http://www.KidsMusicDay.org&source=gmail&ust=1696066225221000&usg=AOvVaw1Wg8UMRoYjDu4rwwhac4bU">www.KidsMusicDay.org</a>.</p>
A response to the concocted allegations labelled against the Speaker of TNLA Hon. Jemma Nunu by the illiterate Governor of Western Equatoria State
2023-09-18T04:00:13+01:00
2023-09-18T04:00:13+01:00
https://pachodo.org/latest-news-articles/pachodo-english-articles/42383-a-response-to-the-concocted-allegations-labelled-against-the-speaker-of-tnla-hon-jemma-nunu-by-the-illiterate-governor-of-western-equatoria-state
Meen Gabriel Chol Kuac
LamArop@pachodo.org
<figure data-wf-figure="1"><img src="https://pachodo.org/images/Jemma_Nunu_Kumba.jpeg" alt="Hon. Jemma Nunu (File Photo)" title="Hon. Jemma Nunu (File Photo)" /><figcaption><em>Hon. Jemma Nunu (File Photo)</em></figcaption></figure>
<p> </p>
<p><em><strong>By Cde Meen Gabriel Chol</strong></em></p>
<p>On 31st August 2023, The illiterate Governor of Western Equatoria State Gen. Alfred Futiyo Karaba who doubles as militia commander of SPLA IO Sector Six, penned a malicious and misleading letter to the President of the Republic, requesting him to remove the incumbent Speaker of the NTLA Hon. Jemma Nunu Kumba from the speakership. The Former Head of Yambio Butcher Union, later turned into Militia General, falsely accused the peace loving Speaker of funding tribal conflicts in Tambura County as well as border conflicts . </p>
<p>Before disputing the allegations raised against the Speaker in the letter, let us bring to the attention of our citizens that the national legislature is an independent organ of the government and he as a Governor of the State has no constitutional right to appeal for the removal of the NTLA Speaker. Gen. Alfred Futiyo Karaba wrote a letter to the president after he was summoned by the Parliament to answer the questions regarding the salaries of the employees of defunct Amadi, Maridi and Tambura States. After receiving the summon letter, the warmonger Gen. Alfred Futiyo Karaba suspected Rt Hon. Nunu Kumba was behind his summon and quickly rushed to coin allegations against her. The governor is incapable of differentiating the parliament as an institution from Hon. Jemma Nunu as an individual. The corrupt and illiterate governor was summoned by the parliament as an institution not Hon. Nunu Kumba.</p>
<p>Gen. Alfred Futiyo Karaba in his letter accused the Honourable Speaker of laying off the civil servants from Baka and Moru ethnic groups in 2008 when she was a Governor of Western Equatoria State. The issues to do with the government employees in the state are the constitutional responsibilities of the national Ministry of Public Service in collaboration with the State Ministry of Public Service and Human Resource Development. The State Governor has no constitutional powers to either recruit or lay off civil servants. Hon. Nunu Kumba as the governor of Western Equatoria State by then never involved herself in the issues to do with the employees leave alone downsizing them.</p>
<p>Regarding the allegations of ordering the military to shoot the school girls after the celebration of CPA Day in 2009. All the citizens of Western Equatoria State can recall that the CPA Day of 2009 was celebrated peacefully and no such incident of shooting occurred during the celebrations or after the celebrations.</p>
<p>The War Loving Governor of Western Equatoria further accused the Honourable Speaker of funding the tribal conflicts between Azande and Balanda ethnic groups in Tambura County in 2021. Every Citizen of Western Equatoria is aware that the tribal conflicts between the peaceful tribes of Azande and Balanda in Tambura County were instigated by the forces of SPLA IO under the command of Gen. Alfred Futiyo Karaba himself. Futiyo is a coin of two faces. He is a commander of SPLA IO Sector Six militias and a Governor at the same time. Hon. Nunu Kumba is a civilian politician with not even a single armed personnel under her authority unlike Mr governor who still commands thousands of rebel militias in Western Equatoria State. </p>
<p>The communities of Azande and Balanda in Tambura County were coexisting peacefully during the gubernatorial tenure of Hon. Jemma Nunu Kumba. If she is a tribalist then the conflict between these two tribes would have broken out during her tenure as Governor of Western Equatoria State ( 2008-2010). Hon. Jemma Nunu has no hand in the conflict between Azande and Balanda tribes. In addition, the ongoing conflicts along the borders of South Sudan, Democratic Republic of Congo and Central African Republic emerged as a result of the failure of the state government under his leadership. As a head of security in the state, Gen. Alfred Futiyo has totally failed to maintain security and resorted to pointing his hands at the innocent and peace loving leaders like Hon. Jemma Nunu Kumba.</p>
<p>Gen. Alfred Futiyo Karaba is a founder of all the ongoing conflicts in the Western Equatoria State and any citizen of Western Equatoria State can attest to this and no need for him to put blame on others. As an African proverb says " whenever a man fails to control his house, he should refrain from blaming others for the mess in the house". Gen. Futiyo should resign from the governorship and resume his previous business of selling meat in the butchery and give a chance to someone with leadership skills.</p>
<p>Otherwise he will be accountable for all the messes that are occuring in Western Equatoria State. In addition the governor should order his Press Secretary Alex Daniel Digi to stop abusing the President of the Republic on social media. Up to day, Mr. Governor is still seeing himself as a rebel commander in the bush and that's why his Press Secretary is always insulting the President of the Republic in the social media on daily bases. </p>
<p>In conclusion, the UNMISS and all the citizens who might have come across the letter are urged to disregard whatever the illiterate governor has rebelled against the Hon. Speaker Jemma Nunu and other leaders of Western Equatoria. The governor should be advised to focus on peace building initiatives and refrain from anti peace activities in the State. </p>
<p> </p>
<p><strong><em>The Author is. </em></strong></p>
<p><strong><em> </em></strong></p>
<p><strong><em>Cde, Meen Gabriel Chol Kuac </em></strong></p>
<p><strong><em>The SPLM Senior Political Activist</em></strong></p>
<figure data-wf-figure="1"><img src="https://pachodo.org/images/Jemma_Nunu_Kumba.jpeg" alt="Hon. Jemma Nunu (File Photo)" title="Hon. Jemma Nunu (File Photo)" /><figcaption><em>Hon. Jemma Nunu (File Photo)</em></figcaption></figure>
<p> </p>
<p><em><strong>By Cde Meen Gabriel Chol</strong></em></p>
<p>On 31st August 2023, The illiterate Governor of Western Equatoria State Gen. Alfred Futiyo Karaba who doubles as militia commander of SPLA IO Sector Six, penned a malicious and misleading letter to the President of the Republic, requesting him to remove the incumbent Speaker of the NTLA Hon. Jemma Nunu Kumba from the speakership. The Former Head of Yambio Butcher Union, later turned into Militia General, falsely accused the peace loving Speaker of funding tribal conflicts in Tambura County as well as border conflicts . </p>
<p>Before disputing the allegations raised against the Speaker in the letter, let us bring to the attention of our citizens that the national legislature is an independent organ of the government and he as a Governor of the State has no constitutional right to appeal for the removal of the NTLA Speaker. Gen. Alfred Futiyo Karaba wrote a letter to the president after he was summoned by the Parliament to answer the questions regarding the salaries of the employees of defunct Amadi, Maridi and Tambura States. After receiving the summon letter, the warmonger Gen. Alfred Futiyo Karaba suspected Rt Hon. Nunu Kumba was behind his summon and quickly rushed to coin allegations against her. The governor is incapable of differentiating the parliament as an institution from Hon. Jemma Nunu as an individual. The corrupt and illiterate governor was summoned by the parliament as an institution not Hon. Nunu Kumba.</p>
<p>Gen. Alfred Futiyo Karaba in his letter accused the Honourable Speaker of laying off the civil servants from Baka and Moru ethnic groups in 2008 when she was a Governor of Western Equatoria State. The issues to do with the government employees in the state are the constitutional responsibilities of the national Ministry of Public Service in collaboration with the State Ministry of Public Service and Human Resource Development. The State Governor has no constitutional powers to either recruit or lay off civil servants. Hon. Nunu Kumba as the governor of Western Equatoria State by then never involved herself in the issues to do with the employees leave alone downsizing them.</p>
<p>Regarding the allegations of ordering the military to shoot the school girls after the celebration of CPA Day in 2009. All the citizens of Western Equatoria State can recall that the CPA Day of 2009 was celebrated peacefully and no such incident of shooting occurred during the celebrations or after the celebrations.</p>
<p>The War Loving Governor of Western Equatoria further accused the Honourable Speaker of funding the tribal conflicts between Azande and Balanda ethnic groups in Tambura County in 2021. Every Citizen of Western Equatoria is aware that the tribal conflicts between the peaceful tribes of Azande and Balanda in Tambura County were instigated by the forces of SPLA IO under the command of Gen. Alfred Futiyo Karaba himself. Futiyo is a coin of two faces. He is a commander of SPLA IO Sector Six militias and a Governor at the same time. Hon. Nunu Kumba is a civilian politician with not even a single armed personnel under her authority unlike Mr governor who still commands thousands of rebel militias in Western Equatoria State. </p>
<p>The communities of Azande and Balanda in Tambura County were coexisting peacefully during the gubernatorial tenure of Hon. Jemma Nunu Kumba. If she is a tribalist then the conflict between these two tribes would have broken out during her tenure as Governor of Western Equatoria State ( 2008-2010). Hon. Jemma Nunu has no hand in the conflict between Azande and Balanda tribes. In addition, the ongoing conflicts along the borders of South Sudan, Democratic Republic of Congo and Central African Republic emerged as a result of the failure of the state government under his leadership. As a head of security in the state, Gen. Alfred Futiyo has totally failed to maintain security and resorted to pointing his hands at the innocent and peace loving leaders like Hon. Jemma Nunu Kumba.</p>
<p>Gen. Alfred Futiyo Karaba is a founder of all the ongoing conflicts in the Western Equatoria State and any citizen of Western Equatoria State can attest to this and no need for him to put blame on others. As an African proverb says " whenever a man fails to control his house, he should refrain from blaming others for the mess in the house". Gen. Futiyo should resign from the governorship and resume his previous business of selling meat in the butchery and give a chance to someone with leadership skills.</p>
<p>Otherwise he will be accountable for all the messes that are occuring in Western Equatoria State. In addition the governor should order his Press Secretary Alex Daniel Digi to stop abusing the President of the Republic on social media. Up to day, Mr. Governor is still seeing himself as a rebel commander in the bush and that's why his Press Secretary is always insulting the President of the Republic in the social media on daily bases. </p>
<p>In conclusion, the UNMISS and all the citizens who might have come across the letter are urged to disregard whatever the illiterate governor has rebelled against the Hon. Speaker Jemma Nunu and other leaders of Western Equatoria. The governor should be advised to focus on peace building initiatives and refrain from anti peace activities in the State. </p>
<p> </p>
<p><strong><em>The Author is. </em></strong></p>
<p><strong><em> </em></strong></p>
<p><strong><em>Cde, Meen Gabriel Chol Kuac </em></strong></p>
<p><strong><em>The SPLM Senior Political Activist</em></strong></p>
The Pride of the Land
2023-09-11T14:50:28+01:00
2023-09-11T14:50:28+01:00
https://pachodo.org/latest-news-articles/pachodo-english-articles/42217-the-pride-of-the-land
Ogeryath Oger
LamArop@pachodo.org
<p><img src="https://pachodo.org/images/south-sudan-basket-nets-news-royal-ivey-leads-south-sudan-to-2023-fiba-basketball-world-cup.jpg" alt="South Sudan BasketBall Team " title="South Sudan BasketBall Team " /></p>
<p> </p>
<p><em><strong>By: Ogeryath Oger</strong></em></p>
<p>Unfortunately for nearly a decade, South Sudan was portrayed by the world media as the land of violence and backwardness, luckily in just less than three years, the Basketball National Team under the leadership of the great Deng Lual, elevated the land into the Galaxy of the giants in the sports (basketball). What an amazing greatness and hard work brought in by the sons of South Sudan to the nation never known for something incredible on its soils from the time of its emergence (Independence) until the time it was engulfed by conflict a decade ago, never was it in anyone’s assumption or imagination for South Sudan to rise and stand upright, decent and presentable to the world in greatness and power.</p>
<p>As the country struggled in all the types of sports to deep down keep the roots strong just like its neighbors Kenya and Ethiopia known for their greatness in Marathon on the world stage, and Democratic Republic of Congo (DRC) known for greatness in football across Africa, far away from home in the Western World (USA) appeared a lion known as Deng Lual with optimistic and great followers willing to make their motherland dominate in a sport never known to the nation before.</p>
<p>The leadership of the great Deng Lual and the great performance of his team (National Basketball Team) in the world cup, will go down to be remembered and studied as the third most unifying factor among the South Sudanese after the great struggle for Twenty One Years under the Leadership of Dr. John Garang and the Independence Day under comrade Salva Kiir. The qualification of South Sudan Basketball National Team for the France Olympics 2024 was an event that brought the nation down to its knees full of happiness and greatness. The news as it spread across the world about unknown nations challenging the great nations, The Basketball National Team will always be studied before the kickoff of the France Olympics by its opponents with fear and care.</p>
<p>The South Sudan National Basketball Team is an icon and symbol of courage that the country can march out strongly of all the challenges it faces today in case pragmatism and unity are employed in our conduct in all the political, economic and social sectors. The great leadership of Deng Lual didn’t emerge out of magic and the great performance displayed by the National Basketball Team wasn’t accidental but a hard work and hope practiced for years in the tough circumstances of life far away from home in order to come back and lift the home. What a great combination to have a great team in Africa united from its roots by the great Deng Lual. This is a justification for all the South Sudanese that South Sudan can be a prosperous country in sports and strong in unity under sports. </p>
<p>Never were we respected before on the African continent and world at large. The greatness achieved by the National Basketball Team shouldn't be left hanging but more energy and investment injected in until the great team achieves more than the recent achievements. Participation in the Basketball World Cup was an incredible show for South Sudan at large. Facing the tournament favorites Serbia was challenging but a great show of progress and wisdom from the sons of South Sudan, the victory against China was great and perfect and the show against Puerto Rico was a sign that we can come back next tournament.</p>
<p>A story can be put down about the South Sudan Basketball National Team as follows: “ A collection of generous and hardworking children (Now great men) who disappeared into the forests due to the tough circumstances of life in their own land, worked hard under the tense conditions of life and later emerged out of poverty and suffering as great, rich and passionate men but instead of keeping their riches, talents and greatness to themselves, their eyes were full of mercy and compassion for their suffering nation and decided to put aside their own satisfaction to come and lift a nation once broken into a galaxy of the greats in sports on the African continent”. </p>
<p><img src="https://pachodo.org/images/south-sudan-basket-nets-news-royal-ivey-leads-south-sudan-to-2023-fiba-basketball-world-cup.jpg" alt="South Sudan BasketBall Team " title="South Sudan BasketBall Team " /></p>
<p> </p>
<p><em><strong>By: Ogeryath Oger</strong></em></p>
<p>Unfortunately for nearly a decade, South Sudan was portrayed by the world media as the land of violence and backwardness, luckily in just less than three years, the Basketball National Team under the leadership of the great Deng Lual, elevated the land into the Galaxy of the giants in the sports (basketball). What an amazing greatness and hard work brought in by the sons of South Sudan to the nation never known for something incredible on its soils from the time of its emergence (Independence) until the time it was engulfed by conflict a decade ago, never was it in anyone’s assumption or imagination for South Sudan to rise and stand upright, decent and presentable to the world in greatness and power.</p>
<p>As the country struggled in all the types of sports to deep down keep the roots strong just like its neighbors Kenya and Ethiopia known for their greatness in Marathon on the world stage, and Democratic Republic of Congo (DRC) known for greatness in football across Africa, far away from home in the Western World (USA) appeared a lion known as Deng Lual with optimistic and great followers willing to make their motherland dominate in a sport never known to the nation before.</p>
<p>The leadership of the great Deng Lual and the great performance of his team (National Basketball Team) in the world cup, will go down to be remembered and studied as the third most unifying factor among the South Sudanese after the great struggle for Twenty One Years under the Leadership of Dr. John Garang and the Independence Day under comrade Salva Kiir. The qualification of South Sudan Basketball National Team for the France Olympics 2024 was an event that brought the nation down to its knees full of happiness and greatness. The news as it spread across the world about unknown nations challenging the great nations, The Basketball National Team will always be studied before the kickoff of the France Olympics by its opponents with fear and care.</p>
<p>The South Sudan National Basketball Team is an icon and symbol of courage that the country can march out strongly of all the challenges it faces today in case pragmatism and unity are employed in our conduct in all the political, economic and social sectors. The great leadership of Deng Lual didn’t emerge out of magic and the great performance displayed by the National Basketball Team wasn’t accidental but a hard work and hope practiced for years in the tough circumstances of life far away from home in order to come back and lift the home. What a great combination to have a great team in Africa united from its roots by the great Deng Lual. This is a justification for all the South Sudanese that South Sudan can be a prosperous country in sports and strong in unity under sports. </p>
<p>Never were we respected before on the African continent and world at large. The greatness achieved by the National Basketball Team shouldn't be left hanging but more energy and investment injected in until the great team achieves more than the recent achievements. Participation in the Basketball World Cup was an incredible show for South Sudan at large. Facing the tournament favorites Serbia was challenging but a great show of progress and wisdom from the sons of South Sudan, the victory against China was great and perfect and the show against Puerto Rico was a sign that we can come back next tournament.</p>
<p>A story can be put down about the South Sudan Basketball National Team as follows: “ A collection of generous and hardworking children (Now great men) who disappeared into the forests due to the tough circumstances of life in their own land, worked hard under the tense conditions of life and later emerged out of poverty and suffering as great, rich and passionate men but instead of keeping their riches, talents and greatness to themselves, their eyes were full of mercy and compassion for their suffering nation and decided to put aside their own satisfaction to come and lift a nation once broken into a galaxy of the greats in sports on the African continent”. </p>
US Sanctions High-Ranking Leader of Sudan’s Rapid Support Forces
2023-09-08T04:28:01+01:00
2023-09-08T04:28:01+01:00
https://pachodo.org/latest-news-articles/pachodo-english-articles/42180-us-sanctions-high-ranking-leader-of-sudan%E2%80%99s-rapid-support-forces
The Sentry
LamArop@pachodo.org
<p><img src="https://pachodo.org/images/Sentry.jpg" alt="Sentry Logo" title="Sentry Logo" /></p>
<p> </p>
<p><strong>US Sanctions High-Ranking Leader of Sudan’s Rapid Support Forces </strong></p>
<p><em>Treasury Department Cites Responsibility for Civilian Massacres, Sexual Violence, Human Rights Abuses</em><br /> </p>
<p><strong>September 6, 2023 (Washington DC)</strong> - Today, the U.S. Treasury Department <a href="https://u7061146.ct.sendgrid.net/ls/click?upn=4tNED-2FM8iDZJQyQ53jATUYrILUvwE81Y0T60YQ3ncW2vsAGX-2F5JrIyO9-2F9dPY200t6-2BfEfO-2By7XK8zLGq1HPVg-3D-3D-2CM_r95Xg7-2BqhKQOvO-2B4rh9LgsQzS8tkUAunKqWItQRaZ6t5ke6aBFnuH-2Fd5o4-2FjWzB2MSg1stZgmsB5U-2F3IaWA-2BwOY2RpHEqJw8L805-2FQogcaoQCxWTMa2tp0ULgh762vf-2Bhy6VqhRrktPrGzzJrNwowSOTiGBiKwF8ugvSoLd8pP9ISupuMee4YbahdsHgQoKnmVKMmqX2pzdWMUUlEFwPAKpL2GKaLyPlFByvzlSNZcrInYQrx80r8qVawdMDLVe6s0EckW38YUbCfXD-2BpFAG8jZ1br1SfEUThhAdv3myJLDBYBs7-2F3m1-2B5XhXnTQQXdvvmHu4p09bC0h8sF7OlDpFg-3D-3D" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://u7061146.ct.sendgrid.net/ls/click?upn%3D4tNED-2FM8iDZJQyQ53jATUYrILUvwE81Y0T60YQ3ncW2vsAGX-2F5JrIyO9-2F9dPY200t6-2BfEfO-2By7XK8zLGq1HPVg-3D-3D-2CM_r95Xg7-2BqhKQOvO-2B4rh9LgsQzS8tkUAunKqWItQRaZ6t5ke6aBFnuH-2Fd5o4-2FjWzB2MSg1stZgmsB5U-2F3IaWA-2BwOY2RpHEqJw8L805-2FQogcaoQCxWTMa2tp0ULgh762vf-2Bhy6VqhRrktPrGzzJrNwowSOTiGBiKwF8ugvSoLd8pP9ISupuMee4YbahdsHgQoKnmVKMmqX2pzdWMUUlEFwPAKpL2GKaLyPlFByvzlSNZcrInYQrx80r8qVawdMDLVe6s0EckW38YUbCfXD-2BpFAG8jZ1br1SfEUThhAdv3myJLDBYBs7-2F3m1-2B5XhXnTQQXdvvmHu4p09bC0h8sF7OlDpFg-3D-3D&source=gmail&ust=1694247652978000&usg=AOvVaw0zLXsCGJYT42nyRSfssUVR">announced sanctions</a> on Abdelrahim Hamdan Dagalo, a high-ranking leader of Sudan’s Rapid Support Forces (RSF). Dagalo was designated by The Treasury Department’s Office of Foreign Assets Control (OFAC) “for his leadership of an entity whose members have engaged in acts of violence and human rights abuses, including the massacre of civilians, ethnic killings, and use of sexual violence.”</p>
<p>Dagalo is the brother of RSF commander Lieutenant General Mohamed Hamdan Dagalo, widely known as “Hemedti.”</p>
<blockquote>
<p><strong>John Prendergast, Co-Founder of The Sentry</strong>, said: "The strategy to end Sudan's destructive civil war is broken, in part due to the lack of leverage for the various mediation efforts. Imposing a widening circle of sanctions like the ones the U.S. Treasury Department issued today will provide the U.S. and other mediators the beginnings of influence over the calculations of the warring parties. But quick follow-up is required, sanctioning broader networks on both sides who stand to profit from the conflict and who are responsible for massive human rights abuses."</p>
<p><strong>Brian Adeba, Senior Policy Advisor at The Sentry, </strong>said: "Sanctioning a top leader of the Rapid Support Forces is a move other states should consider replicating to increase the pressure on the warring sides in the Sudan conflict and put an end to the ongoing violence and human suffering. If the European Union, Britain, and other countries impose similar measures on the key perpetrators of violence, the momentum for peace would be accelerated."</p>
</blockquote>
<p><strong>For media inquiries or interview requests</strong>, please contact: Greg Hittelman, Director of Communications, <a href="mailto:gh@thesentry.org" target="_blank"></a><a href="mailto:gh@thesentry.">gh@thesentry.</a><wbr />org</p>
<p><strong>About The Sentry</strong><br /> <em>(Short descriptor for press use: “The Sentry, an investigative organization that tracks corruption”)</em></p>
<p>The Sentry is an investigative and policy organization that seeks to disable multinational predatory networks that benefit from violent conflict, repression, and kleptocracy. Pull back the curtain on wars, mass atrocities, and other human rights abuses, and you’ll find grand corruption and unchecked greed. These tragedies persist because the perpetrators rarely face meaningful consequences. The Sentry aims to alter the warped incentive structures that continually undermine peace and good governance. Our investigations follow the money as it is laundered from war zones to financial centers around the world. We provide evidence and strategies for governments, banks, and law enforcement to hold the perpetrators and enablers of violence and corruption to account. These efforts provide new leverage for human rights, peace, and anti-corruption efforts. Learn more: <a href="https://u7061146.ct.sendgrid.net/ls/click?upn=TeZUXWpUv-2B6TCY38pVLo9nU9uzqTCYheAT9RUTS-2B-2B78p24pj7cw7zn7rvZ73QWHQYiuC_r95Xg7-2BqhKQOvO-2B4rh9LgsQzS8tkUAunKqWItQRaZ6t5ke6aBFnuH-2Fd5o4-2FjWzB2MSg1stZgmsB5U-2F3IaWA-2BwOY2RpHEqJw8L805-2FQogcaoQCxWTMa2tp0ULgh762vf-2Bhy6VqhRrktPrGzzJrNwowSOTiGBiKwF8ugvSoLd8pP9ISupuMee4YbahdsHgQoKnmnYzuhZG8YwL8pTSMxUl-2FKcBtbkykdBQeZXoY2RIRMD7tWhqA4CNunNP3Lu2RZf003GS7LCXt5EOF5744CdFRR2E-2FfLyzZG4T0pkvBRznOZFfG9yA9G6x0I1uhrxqqESsKyNtEGuKGVfEcfYhN7nyQ-3D-3D" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://u7061146.ct.sendgrid.net/ls/click?upn%3DTeZUXWpUv-2B6TCY38pVLo9nU9uzqTCYheAT9RUTS-2B-2B78p24pj7cw7zn7rvZ73QWHQYiuC_r95Xg7-2BqhKQOvO-2B4rh9LgsQzS8tkUAunKqWItQRaZ6t5ke6aBFnuH-2Fd5o4-2FjWzB2MSg1stZgmsB5U-2F3IaWA-2BwOY2RpHEqJw8L805-2FQogcaoQCxWTMa2tp0ULgh762vf-2Bhy6VqhRrktPrGzzJrNwowSOTiGBiKwF8ugvSoLd8pP9ISupuMee4YbahdsHgQoKnmnYzuhZG8YwL8pTSMxUl-2FKcBtbkykdBQeZXoY2RIRMD7tWhqA4CNunNP3Lu2RZf003GS7LCXt5EOF5744CdFRR2E-2FfLyzZG4T0pkvBRznOZFfG9yA9G6x0I1uhrxqqESsKyNtEGuKGVfEcfYhN7nyQ-3D-3D&source=gmail&ust=1694247652978000&usg=AOvVaw1mRL2BXEmQP-j3TIxHcIMN">www.TheSentry.org</a></p>
<p><img src="https://pachodo.org/images/Sentry.jpg" alt="Sentry Logo" title="Sentry Logo" /></p>
<p> </p>
<p><strong>US Sanctions High-Ranking Leader of Sudan’s Rapid Support Forces </strong></p>
<p><em>Treasury Department Cites Responsibility for Civilian Massacres, Sexual Violence, Human Rights Abuses</em><br /> </p>
<p><strong>September 6, 2023 (Washington DC)</strong> - Today, the U.S. Treasury Department <a href="https://u7061146.ct.sendgrid.net/ls/click?upn=4tNED-2FM8iDZJQyQ53jATUYrILUvwE81Y0T60YQ3ncW2vsAGX-2F5JrIyO9-2F9dPY200t6-2BfEfO-2By7XK8zLGq1HPVg-3D-3D-2CM_r95Xg7-2BqhKQOvO-2B4rh9LgsQzS8tkUAunKqWItQRaZ6t5ke6aBFnuH-2Fd5o4-2FjWzB2MSg1stZgmsB5U-2F3IaWA-2BwOY2RpHEqJw8L805-2FQogcaoQCxWTMa2tp0ULgh762vf-2Bhy6VqhRrktPrGzzJrNwowSOTiGBiKwF8ugvSoLd8pP9ISupuMee4YbahdsHgQoKnmVKMmqX2pzdWMUUlEFwPAKpL2GKaLyPlFByvzlSNZcrInYQrx80r8qVawdMDLVe6s0EckW38YUbCfXD-2BpFAG8jZ1br1SfEUThhAdv3myJLDBYBs7-2F3m1-2B5XhXnTQQXdvvmHu4p09bC0h8sF7OlDpFg-3D-3D" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://u7061146.ct.sendgrid.net/ls/click?upn%3D4tNED-2FM8iDZJQyQ53jATUYrILUvwE81Y0T60YQ3ncW2vsAGX-2F5JrIyO9-2F9dPY200t6-2BfEfO-2By7XK8zLGq1HPVg-3D-3D-2CM_r95Xg7-2BqhKQOvO-2B4rh9LgsQzS8tkUAunKqWItQRaZ6t5ke6aBFnuH-2Fd5o4-2FjWzB2MSg1stZgmsB5U-2F3IaWA-2BwOY2RpHEqJw8L805-2FQogcaoQCxWTMa2tp0ULgh762vf-2Bhy6VqhRrktPrGzzJrNwowSOTiGBiKwF8ugvSoLd8pP9ISupuMee4YbahdsHgQoKnmVKMmqX2pzdWMUUlEFwPAKpL2GKaLyPlFByvzlSNZcrInYQrx80r8qVawdMDLVe6s0EckW38YUbCfXD-2BpFAG8jZ1br1SfEUThhAdv3myJLDBYBs7-2F3m1-2B5XhXnTQQXdvvmHu4p09bC0h8sF7OlDpFg-3D-3D&source=gmail&ust=1694247652978000&usg=AOvVaw0zLXsCGJYT42nyRSfssUVR">announced sanctions</a> on Abdelrahim Hamdan Dagalo, a high-ranking leader of Sudan’s Rapid Support Forces (RSF). Dagalo was designated by The Treasury Department’s Office of Foreign Assets Control (OFAC) “for his leadership of an entity whose members have engaged in acts of violence and human rights abuses, including the massacre of civilians, ethnic killings, and use of sexual violence.”</p>
<p>Dagalo is the brother of RSF commander Lieutenant General Mohamed Hamdan Dagalo, widely known as “Hemedti.”</p>
<blockquote>
<p><strong>John Prendergast, Co-Founder of The Sentry</strong>, said: "The strategy to end Sudan's destructive civil war is broken, in part due to the lack of leverage for the various mediation efforts. Imposing a widening circle of sanctions like the ones the U.S. Treasury Department issued today will provide the U.S. and other mediators the beginnings of influence over the calculations of the warring parties. But quick follow-up is required, sanctioning broader networks on both sides who stand to profit from the conflict and who are responsible for massive human rights abuses."</p>
<p><strong>Brian Adeba, Senior Policy Advisor at The Sentry, </strong>said: "Sanctioning a top leader of the Rapid Support Forces is a move other states should consider replicating to increase the pressure on the warring sides in the Sudan conflict and put an end to the ongoing violence and human suffering. If the European Union, Britain, and other countries impose similar measures on the key perpetrators of violence, the momentum for peace would be accelerated."</p>
</blockquote>
<p><strong>For media inquiries or interview requests</strong>, please contact: Greg Hittelman, Director of Communications, <a href="mailto:gh@thesentry.org" target="_blank"></a><a href="mailto:gh@thesentry.">gh@thesentry.</a><wbr />org</p>
<p><strong>About The Sentry</strong><br /> <em>(Short descriptor for press use: “The Sentry, an investigative organization that tracks corruption”)</em></p>
<p>The Sentry is an investigative and policy organization that seeks to disable multinational predatory networks that benefit from violent conflict, repression, and kleptocracy. Pull back the curtain on wars, mass atrocities, and other human rights abuses, and you’ll find grand corruption and unchecked greed. These tragedies persist because the perpetrators rarely face meaningful consequences. The Sentry aims to alter the warped incentive structures that continually undermine peace and good governance. Our investigations follow the money as it is laundered from war zones to financial centers around the world. We provide evidence and strategies for governments, banks, and law enforcement to hold the perpetrators and enablers of violence and corruption to account. These efforts provide new leverage for human rights, peace, and anti-corruption efforts. Learn more: <a href="https://u7061146.ct.sendgrid.net/ls/click?upn=TeZUXWpUv-2B6TCY38pVLo9nU9uzqTCYheAT9RUTS-2B-2B78p24pj7cw7zn7rvZ73QWHQYiuC_r95Xg7-2BqhKQOvO-2B4rh9LgsQzS8tkUAunKqWItQRaZ6t5ke6aBFnuH-2Fd5o4-2FjWzB2MSg1stZgmsB5U-2F3IaWA-2BwOY2RpHEqJw8L805-2FQogcaoQCxWTMa2tp0ULgh762vf-2Bhy6VqhRrktPrGzzJrNwowSOTiGBiKwF8ugvSoLd8pP9ISupuMee4YbahdsHgQoKnmnYzuhZG8YwL8pTSMxUl-2FKcBtbkykdBQeZXoY2RIRMD7tWhqA4CNunNP3Lu2RZf003GS7LCXt5EOF5744CdFRR2E-2FfLyzZG4T0pkvBRznOZFfG9yA9G6x0I1uhrxqqESsKyNtEGuKGVfEcfYhN7nyQ-3D-3D" target="_blank" rel="noopener" data-saferedirecturl="https://www.google.com/url?q=https://u7061146.ct.sendgrid.net/ls/click?upn%3DTeZUXWpUv-2B6TCY38pVLo9nU9uzqTCYheAT9RUTS-2B-2B78p24pj7cw7zn7rvZ73QWHQYiuC_r95Xg7-2BqhKQOvO-2B4rh9LgsQzS8tkUAunKqWItQRaZ6t5ke6aBFnuH-2Fd5o4-2FjWzB2MSg1stZgmsB5U-2F3IaWA-2BwOY2RpHEqJw8L805-2FQogcaoQCxWTMa2tp0ULgh762vf-2Bhy6VqhRrktPrGzzJrNwowSOTiGBiKwF8ugvSoLd8pP9ISupuMee4YbahdsHgQoKnmnYzuhZG8YwL8pTSMxUl-2FKcBtbkykdBQeZXoY2RIRMD7tWhqA4CNunNP3Lu2RZf003GS7LCXt5EOF5744CdFRR2E-2FfLyzZG4T0pkvBRznOZFfG9yA9G6x0I1uhrxqqESsKyNtEGuKGVfEcfYhN7nyQ-3D-3D&source=gmail&ust=1694247652978000&usg=AOvVaw1mRL2BXEmQP-j3TIxHcIMN">www.TheSentry.org</a></p>
Opinion: Minimize Reliance On The United Nations Agencies
2023-08-21T19:09:18+01:00
2023-08-21T19:09:18+01:00
https://pachodo.org/latest-news-articles/pachodo-english-articles/41871-opinion-minimize-reliance-on-the-united-nations-agencies
Ogeryath Oger
LamArop@pachodo.org
<figure data-wf-figure="1"><img src="https://pachodo.org/images/Ogeryath_Oger5.jpg" alt="By: Ogeryath Oger" title="By: Ogeryath Oger" /><figcaption><em><strong>By: Ogeryath Oger</strong></em></figcaption></figure>
<p> </p>
<p>The United Nations (UN) as an International Organization with various branches dealing in Health, Children, Culture, Refugees, and Food etc. matters is essential to the entire world in terms of all the services the Organization offers especially to the Low Developing Countries (LDC) in Africa, Europe and Asia. However, the continuous reliance on the UN is a setback to the development of Africa in terms of poverty eradication and economic development because the UN houses the agenda of the Western colonial powers whose intentions are to keep Africa poor and unable to make positive steps towards development.</p>
<p>The UN armed forces in various parts of Africa especially in South Sudan (SSD) and Democratic Republic of Congo (DRC) have helped the conflict affected masses but the conflicts that affected people seem to be used as the reason for the intervention in the affairs of these countries and imposing Western agenda by the colonial members of the Security Council of the United Nations (UN) who are careless and only work for their interests.</p>
<p>The continuous presence of the UN armed forces in the African continent shall inject difficulty on the host countries to allow their masses the ability to establish settlements, grow their own food and have their own national armies protect them. Having the UN providing food to the African masses for years yet the continent is able to produce more than the provided food seems to be another way of subjecting the continent to extreme poverty because without the UN the food supply is affected and therefore rises to poverty again.</p>
<p>African governments should inject too much energy in establishing medical facilities, police forces and prioritize revival of agriculture in order to reduce dependence on the UN health agencies, armed forces and FAO (Food and Agriculture Organization). Continuous reliance on the UN agencies to provide security and Food to the African masses is an indication of continuous stay under foreign powers that make decisions that do not favor the continent.</p>
<p>For Africa to develop and avoid migration of its masses to Europe and Asia for better living conditions, our governments together with the masses need to set clear agenda that is based on transparency and progress in order to develop our own infrastructures like roads and power plants that shall reduce costs of production and attract investments, settle and resolve tribal conflicts and create peace with the armed forces (rebels) in order to create security that will allow the civilians have confidence in building their own lives without fear and avoid massive migration to other continents, invest highly in development of the health and education sectors in order to combat spread of various diseases and make people have confidence in the health system. Education should be made practical in order to send productive graduates to the job markets and have the graduates able to create their own jobs as well. </p>
<p>On top of developing infrastructures (roads, power plants, hospitals, schools), the politicians should be honest enough to be transparent and honest in their acts so as to avoid corruption and military coups in the continent. Having governments set up isn’t enough but the governments should be functional in terms of providing services to the masses.</p>
<p>With the implementation of agricultural revival agenda to ensure availability of food, development of independent armed forces to protect the masses and keep the territorial integrity as well as setting up governments that truly represent the voice of the people (Africans), the African continent and South Sudan in particular shall be able to minimize reliance on the UN agencies and avoid the intervention of the foreign powers in the affairs of Africa.</p>
<p>The journey of real independence is a long one but we must walk and take courage because slavery is bitter and real. There is no superpower in this world that keeps its interests aside. Remember colonialism in another form exists.</p>
<figure data-wf-figure="1"><img src="https://pachodo.org/images/Ogeryath_Oger5.jpg" alt="By: Ogeryath Oger" title="By: Ogeryath Oger" /><figcaption><em><strong>By: Ogeryath Oger</strong></em></figcaption></figure>
<p> </p>
<p>The United Nations (UN) as an International Organization with various branches dealing in Health, Children, Culture, Refugees, and Food etc. matters is essential to the entire world in terms of all the services the Organization offers especially to the Low Developing Countries (LDC) in Africa, Europe and Asia. However, the continuous reliance on the UN is a setback to the development of Africa in terms of poverty eradication and economic development because the UN houses the agenda of the Western colonial powers whose intentions are to keep Africa poor and unable to make positive steps towards development.</p>
<p>The UN armed forces in various parts of Africa especially in South Sudan (SSD) and Democratic Republic of Congo (DRC) have helped the conflict affected masses but the conflicts that affected people seem to be used as the reason for the intervention in the affairs of these countries and imposing Western agenda by the colonial members of the Security Council of the United Nations (UN) who are careless and only work for their interests.</p>
<p>The continuous presence of the UN armed forces in the African continent shall inject difficulty on the host countries to allow their masses the ability to establish settlements, grow their own food and have their own national armies protect them. Having the UN providing food to the African masses for years yet the continent is able to produce more than the provided food seems to be another way of subjecting the continent to extreme poverty because without the UN the food supply is affected and therefore rises to poverty again.</p>
<p>African governments should inject too much energy in establishing medical facilities, police forces and prioritize revival of agriculture in order to reduce dependence on the UN health agencies, armed forces and FAO (Food and Agriculture Organization). Continuous reliance on the UN agencies to provide security and Food to the African masses is an indication of continuous stay under foreign powers that make decisions that do not favor the continent.</p>
<p>For Africa to develop and avoid migration of its masses to Europe and Asia for better living conditions, our governments together with the masses need to set clear agenda that is based on transparency and progress in order to develop our own infrastructures like roads and power plants that shall reduce costs of production and attract investments, settle and resolve tribal conflicts and create peace with the armed forces (rebels) in order to create security that will allow the civilians have confidence in building their own lives without fear and avoid massive migration to other continents, invest highly in development of the health and education sectors in order to combat spread of various diseases and make people have confidence in the health system. Education should be made practical in order to send productive graduates to the job markets and have the graduates able to create their own jobs as well. </p>
<p>On top of developing infrastructures (roads, power plants, hospitals, schools), the politicians should be honest enough to be transparent and honest in their acts so as to avoid corruption and military coups in the continent. Having governments set up isn’t enough but the governments should be functional in terms of providing services to the masses.</p>
<p>With the implementation of agricultural revival agenda to ensure availability of food, development of independent armed forces to protect the masses and keep the territorial integrity as well as setting up governments that truly represent the voice of the people (Africans), the African continent and South Sudan in particular shall be able to minimize reliance on the UN agencies and avoid the intervention of the foreign powers in the affairs of Africa.</p>
<p>The journey of real independence is a long one but we must walk and take courage because slavery is bitter and real. There is no superpower in this world that keeps its interests aside. Remember colonialism in another form exists.</p>