Abstract
BACKGROUND: Africa accounts for 56% of maternal syphilis and 62% of congenital syphilis cases globally. The high prevalence of syphilis in this region is particularly concerning in the context of a generalized HIV epidemic, as syphilis infection increases potential for sexual transmission of HIV. The present study qualitatively explores perceptions of syphilis risk, transmission, testing and treatment, and experiences accessing antenatal care from the perspectives of currently pregnant people residing in communities across two Ugandan districts: Wakiso and Hoima. METHODS: We conducted focus group discussions (k = 10) with pregnant women (n = 82) across six communities. FGDs were audio recorded. Data analysis involved transcription and translation, coding (by two qualitative researchers), and thematic analysis. We promoted trustworthiness through various methodological strategies (e.g. purposive sampling, reflexivity). RESULTS: Many women described barriers to care seeking at government ANC clinics that centered around poor treatment by providers, long wait times for appointments, high out of pocket costs (due to travel and fees) and the expectation that male partners should accompany them to appointments. This led many to seek their antenatal care from traditional birth attendants instead. From these themes we identified several salient barriers to both syphilis testing and treatment, leading us to identify four critical and modifiable targets: [1] structural barriers to care seeking that reflect facility and provider policies that are not necessarily in line with governmental policies; [2] untapped opportunities to leverage alternative care providers (such as traditional birth attendants) to bolster ANC attendance and syphilis treatment uptake [3] improve health literacy around syphilis through education campaigns within the community to increase demand of timely syphilis screening and treatment and [4] sub-optimal patient-provider interactions in government run healthcare facilities. CONCLUSION: The study provides practical suggestions for enhancing syphilis awareness, engagement in care, and women's experiences in ANC within a resource-limited, high-burden context. Future efforts should concentrate on extending syphilis education beyond clinics, utilizing Village Health Teams (VHTs) as trusted sources, and identifying barriers to improving healthcare quality for women, informing quality improvement programming.