From idea to systems solution: enhancing access to primary care in Malawi.

Malawi, like many other countries, faces challenges in providing accessible, affordable, and quality health services to all people. The Malawian policy framework recognizes the value of communities and citizens, as co-creators of health and leaders of localized and innovative initiatives, such as social innovations.Social innovations involve and include communities and citizens, as well as bring about changes in the institutions responsible for care delivery. In this article, we describe the institutionalization process of a citizen-initiated primary care social innovation, named Chipatala Cha Pa Foni, focused on extending access to health information and appropriate service-seeking behavior.An interdisciplinary multi-method qualitative case study design was adopted, drawing on data collected from key informant interviews, observations, and documents over an 18-month period. A composite social innovation framework, informed by institutional theory and positive organizational scholarship, guided the thematic content analysis. Institutional-level changes were analyzed in five key dimensions as well as the role of actors, operating as institutional entrepreneurs, in this process.A subset of actors matched the definition of operating as Institutional Entrepreneurs. They worked in close collaboration to bring about changes in five institutional dimensions: roles, resource flows, authority flows, social identities and meanings. We highlight the changing role of nurses; redistribution and decentralization of health information; shared decision-making, and greater integration of different technical service areas.From this study, the social innovation brought about key institutional and socio-cultural changes in the Malawi health system. These changes supported strengthening the system's integrity for achieving Universal Health Coverage by unlocking and cultivating dormant human-based resources. As a fully institutionalized social innovation, Chipatala Cha Pa Foni has enhanced access to primary care and especially as part of the Covid-19 response.

"It's my secret": barriers to paediatric HIV treatment in a poor rural South African setting.

In South Africa, a third of children born are exposed to HIV, while fewer undergo an HIV confirmatory test. Anti-retroviral therapy (ART) coverage among children remains low-despite roll-out of the national ART programme in South Africa in 2004. This study sought to understand critical barriers to seeking HIV-related care for children in rural South Africa. Data presented in this article derive from community-based qualitative research in poor rural villages in north-east South Africa; this includes 21 in-depth interviews in 2008 among caregivers of children identified as HIV-positive in 2007 from a randomly selected community-based sample. Using NVIVO 8, data were coded and analysed, using a constant comparative method to identify themes and their repetitions and variations. Structural barriers leading to poor access to health care, and social and systems barriers, all influenced paediatric HIV treatment seeking. Of concern was the expressed need to maintain secrecy regarding a child's HIV status to avoid stigma and discrimination, and misconceptions regarding the course of HIV disease in children; this led to a delay in seeking appropriate care. These barriers need to be addressed, including through focused awareness campaigns, improved access to health care and interventions to address rural poverty and development at both household and community levels. In addition, training of health care professionals to improve their attitudes and practice may be necessary. However, this study only provides the perspective of the caregivers; further studies with health care providers are needed to gain a fuller picture for appropriate policy and practice guidance.

Understanding antibiotic use: practices, structures and networks.

In this article, we consider how social sciences can help us to understand the rising use of antibiotics globally. Drawing on ethnography as a way to research how we are in the world, we explore scholarship that situates antibiotic use in relation to interactions of pathogens, humans, animals and the environment in the context of globalization, changes in agriculture and urbanization. We group this research into three areas: practices, structures and networks. Much of the public health and related social research concerning antimicrobial resistance has focused on antibiotic use as a practice, with research characterizing how antibiotics are used by patients, farmers, fishermen, drug sellers, clinicians and others. Researchers have also positioned antibiotic use as emergent of political-economic structures, shedding light on how working and living conditions, quality of care, hygiene and sanitation foster reliance on antibiotics. A growing body of research sees antibiotics as embedded in networks that, in addition to social and institutional networks, comprise physical, technical and historical connections such as guidelines, supply chains and reporting systems. Taken together, this research emphasizes the multiple ways that antibiotics have become built into daily life. Wider issues, which may be invisible without explication through ethnographic approaches, need to be considered when addressing antibiotic use. Adopting the complementary vantage points of practices, networks and structures can support the diversification of our responses to AMR.

Infant feeding practices in Soweto, South Africa: Implications for healthcare providers.

BACKGROUND: The 2011 Tshwane Declaration for the Promotion of Breastfeeding in South Africa ended the country's longstanding support for promoting either exclusive breastfeeding (EBF) or exclusive formula feeding for HIV-positive mothers. However, South Africa's EBF rate is only 32%. OBJECTIVES: To describe multilevel factors associated with different infant feeding practices among HIV-positive and negative mothers of infants aged <6 months in an HIV-endemic community. METHODS: A cross-sectional survey was administered to 298 HIV-positive and negative mothers accessing care in one of five community health clinics in Soweto, Johannesburg, between September 2015 and May 2016. Infant feeding practices and associated factors were explored through descriptive and multivariate analysis. RESULTS: Excluding HIV-positive mothers who chose formula feeding (n=97), breastfeeding initiation was almost universal (99.5%). Caesarean section (CS) was the most common reason mothers delayed breastfeeding. HIV-positive mothers were significantly more likely to report prolonged EBF (and formula feeding) practices than their HIV-negative counterparts. Breastfeeding mothers were significantly more likely to be unemployed than mothers who formula fed. Mixed feeding was common. CONCLUSIONS: EBF remains strongly associated with HIV status as opposed to infant health and development. Breastfeeding support for working mothers is needed. While breastfeeding increased following the Declaration, more should be done in the health setting to communicate the risks of mixed feeding in the first 6 months. The high rate of CSs reported by mothers, linked to late initiation of breastfeeding, also needs the medical community's attention.

Infectious disease research and the gender gap.

Historically, women have been less likely to be supported through higher degree training programmes, and they continue to hold more junior positions in science. This paper reviews the current gender research and gender capacity-building efforts led by the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR). Created more than 40 years ago as the only United Nations-based Special Programme dedicated to research and research capacity building on infectious diseases, TDR has a longstanding track record both in supporting research into gender-specific questions and in research capacity strengthening among women scientists. We provide an overview of these approaches, then describe a recent pilot programme on Women in Science, designed to understand and remedy the gender gaps in health research. The programme focused on Africa, but it is hoped that the replication of such schemes in TDR and other international funding agencies will lead to more attention being given to women in infectious diseases research in other continents. This article may not be reprinted or reused in any way in order to promote any commercial products or services.

Evaluating agency initiatives: building social science capability in tropical disease research.

In recent years, in an endeavour to increase social and economic research in tropical diseases, WHO/TDR has used a number of alternative models to develop social science research capability in countries endemic for the designated tropical diseases. These have included small grants schemes to encourage junior researchers to gain familiarity with the subject area and methods, and protocol development and methodology workshops, either for specific research topics (e.g. adolescent women's health; community perceptions of schistosomiasis) or for any topic of interest to the participants. Participants have included medical researchers, social science researchers, and interdisciplinary teams (e.g. a medical researcher and a collaborating social scientist). This paper develops a typology and critically analyses these alternative approaches to developing research capability, and assesses their effectiveness in terms of cost, short-term effectiveness, and sustainability of the initiative.

Schistosomiasis and the social patterning of infection.

Social, cultural, behavioural and economic factors interact with local environmental and ecological factors to produce extraordinary variation in the epidemiology of schistosomiasis, including with respect to prevalence and intensity of infection and the potential for control. This article reviews the literature on schistosomiasis infection, primarily derived from African studies, to identify its major social themes. Research has demonstrated a strong link between economic development strategies, where irrigation has been introduced to boost agricultural production, and the increased transmission of infection. Water-contact studies have provided the fullest and most detailed descriptions of social risk factors, and have isolated age, sex, religion and occupation as primary risk factors. However, fuller explorations of the social and cultural context of infection have yet to be undertaken. The social context of water-related behaviour and patterns of water use within communities and households, the intersection of social and economic activities, and the significance that people give to these activities, remains poorly explored, and although research papers concerned with community-based interventions refer to poor community understanding of the cause, prevention and treatment of the disease, this domain has also received little scholarly attention. Finally, economic studies have focused primarily on working capacity, and extrapolated these findings to generalize about the impact that this might have on productivity, but have yet to address either household or community costs of schistosomiasis infection.

The diagnosis and management of fever at household level in the Greater Accra Region, Ghana.

> Qualitative research methods were used in rural and urban areas of the Greater Accra Region to generate data to describe the folk diagnosis, etiology and management of malaria. Respondents defined as fever a set of symptoms loosely concordant with clinical malaria. Primary cause of fever as heat and particularly in rural areas, an understanding of the role of mosquitos in transmitting fever was limited. First- and second-line treatments adopted by caretakers, when either they or their children were sick, involved considerable self-medication with chloroquine and paracetamol. Ethnographic data were supplemented and tested for generalizability through a cross-sectional survey, and the paper discusses this methodological approach.

PIP: In the course of developing a manual for the rapid ethnographic assessment of social and cultural aspects of malaria, community understandings, diagnosis, and treatment of malaria in Ghana were explored through limited focused ethnographic research supplemented by a cross-sectional survey. The research took place during August-September 1992 and November 1992-January 1993 and involved urban and rural residents of two sub-districts of the Greater Accra Region. In both regions, residents use the term "fever" for the set of symptoms that approximate the clinical definition of malaria. The symptoms of "fever" in children are tabulated for rural and urban respondents by order of frequency as are the symptoms in adults (which differ from those in children). Most respondents used two or more symptoms to diagnose "fever." The causes of "fever" are said to include heat exposure, diet, mosquitos, or unhygienic surroundings, and most survey respondents gave more than one cause. The fact that 33% of respondents mentioned mosquitos is in opposition to the qualitative data which indicate that rural Ghanians are unaware of the connection. Knowledge of the cause of malaria was a major point of difference between the urban and rural population, with more of the rural residents attributing it to the sun. The treatment given is very similar for children and adults in both areas. The primary first course of treatment is self-medication, including the use of pharmaceutical products such as paracetamol and chloroquine. When it becomes necessary, medical attention is sought, and adults expect injections for themselves. This delay in treatment is particularly significant for sick infants, because malaria remains a primary cause of death during the first year of life. This research indicates the necessity for health education and control program activities.

Perceptions of malaria in a low endemic area in the Philippines: transmission and prevention of disease.

Qualitative methods were used to gather data on community perceptions of malaria in Morong, Bataan. People recognised an illness which they called "malarya' through a discrete set of symptoms: high fever and intense chills, with or without a severe headache. Self-medication was common. Enquiry into perceptions of cause and prevention of the disease revealed a complex mixture of beliefs involving environmental conditions, the mosquito vector and parasites, but included also various ideas about dirty water, diet, hunger and conditions of hygiene. The implications of these findings for disease control, and the relationship between knowledge and practices, are discussed.

Social aspects of malaria in Heping, Hainan.

This paper presents findings from a study conducted in Heping Town, Qiongzhong County, Hainan Province, China. The study, conducted in 1992, used qualitative as well as quantitative methods to gather social, cultural and behavioural data associated with the acquisition, transmission and prevention of malaria, and the diagnosis and treatment of disease. These methods included focus groups, key informant and other in-depth interviews, and observations, a household survey and tests of school children of knowledge of malaria. The study is among the first to our knowledge that has utilized this broad mix of methods for tropical disease research in China.

PIP: Malaria continues to be a major public health problem worldwide. Although there is only a low level of malaria endemicity in China, Hainan Island is endemic for malaria. Qiongzhong County was long hyperendemic for malaria. The authors used focus groups, key informant and other in-depth interviews, observations, a household survey, and tests of school children knowledge of malaria to gather social, cultural, and behavioral data associated with the acquisition, transmission, and prevention of malaria, and the diagnosis and treatment of disease in six villages of Heping Town and three production teams of Chengpo Farm, Qiongzhong County. This 1992 study is groundbreaking in its use of such a broad array of methods to research tropical disease in China. Findings are based upon the input of 1100 persons in 226 households. The open walls of the bamboo-slat houses allow easy mosquito access, but the cost of more substantial, and protective, housing is beyond the means of most villagers. The study found no statistically significant association between literacy and bed net use, while income was neither predictive of nor related to bed net use. Some malaria knowledge and being younger than ten years old were, however, predictive of bed net use. Residents tend to use bed nets without understanding the rationale for such behavior. They do so in adherence to the general message that bed nets will prevent mosquito bites. The authors note the need to address the odor and heat discomfort from sleeping under bed nets, the lack of association among villagers between net use and disease prevention, the lack of understanding that mosquitoes are the vector of malaria, confusion between general health status and vulnerability to malaria infection, the nature of sleeping patterns by sex, and the lack of understanding that one bite suffices to transmit disease.

Drugs, sex and social science: social science research and health policy in Australia.

Social science health research in Australia has undergone considerable expansion through government sponsorship of projects that complement or address issues related directly to policy and program concerns. In examining the rationale for supporting social science research, and the difficulties that social scientists often face in return in presenting their work in ways that might optimize funding, the paper first explores the paradigmatic tensions between social and biomedical scientists, that in turn influence funding decisions and potentially the receipt and uptake of social research. It also addresses the incorporation of the language and concepts of social science within policy documents, using 'ethnicity' as an exemplar of this. The paper then documents and analyses federal targeted-funding programs for health research, and the measures taken to encourage policy-relevant research. In particular, the paper discusses the funding programs that operate for drug and alcohol use and HIV/AIDS.

'These are modern times': infant feeding practice in Peninsular Malaysia.

Traditionally, Malaysian women (Malay, Indian and Chinese) breastfed their infants as a matter of course and for an extended period of time; only elite Chinese women might have resorted to a wet-nurse. But the introduction of condensed and dehydrated milk in colonial Malaya from the late nineteenth century, and the later marketing also of commercially manufactured baby foods, led to some variation in traditional practice. Structural changes, industrialiZation and urbanisation affected social as well as economic life, and again these broad changes had an impact on infant feeding. Today, few women remain unfamiliar with the wide range of infant food products sold in the most isolated provision shops. This paper focuses on key sociological factors that might predict the frequency and duration of breastfeeding and weaning patterns. The data analysed below, collected during semi-structured interviews with 278 women presenting at Maternal and Child Health Clinics in Peninsular Malaysia, are in part confusing. They suggest that the women most likely to bottle feed only or to breast feed for a short period, and to use commercial baby foods, are young, with one child only, who reside in urban or peri-urban areas and have a reasonable household income. Higher educated women, and women whose husbands are in non-traditional occupations, are also less likely to breast feed or to do so for an extended period. But the profile of infant feeding practices is by no means clear. One of the shortcomings of the study relates to the method of collection of data, and highlights the need for detailed ethnographic studies to better explore the variability and complexity of the patterns of infant feeding.

Perceptions of menopause in northeast Thailand: contested meaning and practice.

This paper draws on data collected from village-based ethnographic research conducted in northeast Thailand in 1990-1991 and highlights the polarities and contradictions of perceptions of menopause that exist between village women and health personnel with whom these women interact. For village women until recently, the menopause has been regarded as a simple and natural biological event; for health professionals, it is consistently represented as a 'medical problem' indicating treatment. The paper highlights women's construction of menopause, and their recognition and management of its physical symptoms. It draws attention too to differences among women and to the dynamic nature of their understandings and consequent health-seeking behaviour. The paper also describes the way in which health providers, through their own training and reading of professional and popular journals, increasingly represent the menopause as a pathological process and treatable condition. Through the exploration of conflicting perceptions of the menopause among contemporary Thai women, the paper draws attention to the heterogeneity and fluidity in understandings of biological processes that are related to and reflect the wider social and economic changes to which they are subject.

An epidemic in the field? Rapid assessment procedures and health research.

This paper reviews the development of various methods designed to generate relevant social information, pertaining to health and disease control, quickly and accurately. In so doing, we examine the use of KAP surveys and the subsequent development of community diagnosis, rapid appraisal methods, rapid epidemiological assessment, and rapid assessment procedures (RAP) for anthropological studies. Our focus is on the development of anthropological RAPs, in response to the lack of professionally trained social scientists to work with disease control programmes and ministries of health, and in light of the demonstrable need for social science input in the development of health policies and programmes. These developments are assessed in terms of scope and method. Issues relating to the representativeness, reliability and validity of RAP studies are discussed, and mechanisms by which to maximise the yield of valid data are presented.

Treatment seeking for malaria in Morong, Bataan, the Philippines.

Early diagnosis and treatment for malaria has a significant impact on the severity of the disease and contributes to the interruption of its transmission. Fourteen high-risk families and nine locality-matched families, with no recent history of malaria, participated in an ethnographic study which aimed to document malaria episodes and to examine treatment paths for fevers locally termed malaria and perceived to be malaria. The study, conducted in Morong, Bataan, a low malaria endemic area in the Philippines, used a combination of qualitative and quantitative methods over a period of 12 months. Six treatment categories were identified; self-treatment with Western medicines and clinic consultations had almost equal frequencies. Twenty-six treatment paths were recognised which consisted of the six categories singly or in combination. More than 80% of the undiagnosed malarya illnesses were treated with antimalarials of inappropriate dosages. More adult men than women self-treated, but there was no significant difference by gender in terms of clinic consultation for illness. The majority of clinic consultations were made for young children. The implications for control are discussed.

The social life of bonding theory.

'Bonding' as a crucial factor of the early post-partum entered obstetric and paediatric practice after the publication of Maternal and Infant Bonding in 1976 by Klaus and Kennell. The concept has held its place since, as witnessed by medical textbook accounts of it, and the perception of 'instantaneous bonding' as a vital component of the ideal birth experience has dominated media representations of childbirth and, until very recently, feminist writing. Only during the last few years has this literature taken into account research findings concerning the guilt and anxiety experienced by women whose expectations regarding 'bonding' are not realised. While it is now generally acknowledged that maternal attachment develops over an extended period of time, 'bonding' as used extensively in both popular and scientific literature conflates a wide range of meanings and blurs the boundaries between process and outcome. This facilitates the entry of ideological elements into a field which is, by its very nature, deeply significant for human experience. We therefore argue for a continuing critical appraisal of the role of 'bonding' in both general and scientific research.

Local knowledge and treatment of malaria in Agusan del Sur, The Philippines.

Information about local knowledge of malaria, its transmission, treatment and prevention were gathered at the outset of a Malaria Control Program in order to incorporate this information into community interventions. Data were collected using focus groups and indepth interviews with caretakers of children who had had a recent episode of malaria. These were supplemented as baseline data through a survey and the ongoing participation of researchers in the intervention. Local knowledge of malaria was influenced by clinical diagnosis and was based on the coexistence of signs of illness. People conventionally self-medicated or used herbs for symptomatic relief prior to seeking clinical diagnosis and treatment, with treatment delay influenced by the logistic difficulties within the region, direct and indirect costs associated with treatment seeking, and delays in the return of results once a blood film for diagnosis was made. People were familiar with mosquito control activities conducted by the Malaria Control Service and, as a result, most respondents associated malaria with mosquitos. However, the role of the mosquito as the sole vector, and the means by which malaria was transmitted, were not well appreciated.

Responding to cough: Boholano illness classification and resort to care in response to childhood ARI.

A qualitative study into the health seeking behaviour of caretakers in response to ARI in children under five years of age was conducted in the province of Bohol, the Philippines. The study was designed to compliment survey data generated from a long running ARI intervention project, specifically to explain behaviours identified as problematic by the project. Results indicate the importance of folk diagnosis as a basis for selection of first resort for care in the management of childhood ARI. A cultural category, piang, was identified as a major factor influencing health seeking behaviour and delay in consulting the biomedical system where serious ARI exists. In addition, caretakers' financial situation and social contacts are important in their decision to seek biomedical assistance and are often implicated in delay in presentation and acting upon referral to hospital.

Indigenous women's perceptions of breast cancer diagnosis and treatment in Queensland.

OBJECTIVE: To identify social, structural and personal factors among indigenous women in Queensland associated with the detection of breast cancer, and the treatment and post-treatment care and support of cancer. METHODS: Qualitative research including interviews, case studies and focus group discussions were conducted, among Aboriginal women and service providers in urban, rural and remote areas of Queensland over nine months in 1998/99. RESULTS: A range of factors were identified as influencing women's willingness to perform BSE, receive screening mammograms, and receive and complete treatment compared to the non-indigenous population. Personal history of health services, provision of information about mammography, the cost of treatment and care, and availability of personal support, all influenced women's willingness to access services and maintain treatment. Indigenous women in Queensland experience various barriers to effective and appropriate detection, treatment and care of breast cancer. CONCLUSION: Barriers to diagnosis, treatment and care can be addressed by increasing women's awareness of breast cancer and the benefits of preventative health behaviour, and improving the quality and appropriateness of health care and counselling services for Indigenous women and their families. IMPLICATIONS: Indigenous women's knowledge and practice relating to the early diagnosis and prevention of breast cancer may improve through outreach work with women, to encourage their confidence in preventative health. Women's commitment to preventive health will also be enhanced by improved quality and access to health care, and improved relationships between practitioners and patients.