Table 4.

Users’ and providers’ perspectives of syphilis services (key findings, IDI and FGD)

Key issues	Challenges		Explanation (reasons)	Key quotes
	Users (IDI)	Providers (FGD)
Testing difficulties	When test kits run out, PW screening and treatment were moved to the next day. Spend much time waiting for the result after being tested. Partners refused to support PW, for example, to take the test because they wonder why they have syphilis.	Lack of testing kits and medicine. Difficult to confirm and follow-up PW and partner. Challenges to test infants at maternity wards (stockout of kits and double tasks).	When the titre was not available on site for both PW and syphilis-exposed infants, they were referred to other sites and had to pay test fees. Still need more efforts to encourage PW (and partners) to take syphilis test, and if positive get treatment and follow up.	“Sometimes when they [health staff] are out of test kits, we [PW] must go back home without getting tested.” (IDI2, Siem Reap)
Referral system (RPR test and syphilis treatment)	PW did not comply with referral due to long distances to health facilities, spending long time at the health facility and did not understand the provider’s advice.	Patient did not return when referred to district hospital. Stockouts of benzathine penicillin G.	Lack of recording system in the register book. Problems related to the reporting system mentioned in most sites.	“The referral system or following-up cases outside the hospitals have issues.” (FGD, MCH, Siem Reap)
Follow-up and treatment issues	PW faced financial problems, distance from health services and (oral) medication side effects.	PW and partners are lost to follow-up. PW seeking service late leads to challenges to providing treatment. Paediatric staff lacked drugs or skills to properly treat infants.	Side effects of (oral) medication prevent PW from coming to their next appointment. No contact information or sometimes the patient changes health service location. For example, penicillin G had to be retrieved from other hospitals or searched for. Paediatric staff not fully aware of treatment guidelines.	“(…) The only problem is when we transfer the PW with Syphilis out to other hospitals, and we do not hear back from PW at all…. We do not know where the mother goes to give birth and get treatment….” (FGD, provincial level)
Follow-up system issues		Lack of communication. The mechanism to follow-up PW was not clear and well understood by the staff.	Challenges to access PW and their child’s health record in logbook and referral letter from one health facility to another. Besides, many patients had never received any feedback information.	“The follow-up system is not clear because it depends on the patients themselves and depends on a health center that refers to the patient. And I think that this system does not work well because there is not clear communication.” (FGD, Banteay Meanchey)

FGD, focus group discussion; IDI, indepth interview; PW, pregnant women; RPR, rapid plasma reagin.