Mothers' involvement in providing care for their hospitalised sick newborns in Kenya: a focused ethnographic account.

INTRODUCTION: There is growing evidence that parental participation in the care of small and sick newborns benefits both babies and parents. While studies have investigated the roles that mothers play in newborn units in high income contexts (HIC), there is little exploration of how contextual factors interplay to influence the ways in which mothers participate in the care of their small and sick newborn babies in very resource constrained settings such as those found in many countries in sub-Saharan Africa. METHODS: Ethnographic methods (observations, informal conversations and formal interviews) were used to collect data during 627 h of fieldwork between March 2017 and August 2018 in the neonatal units of one government and one faith-based hospital in Kenya. Data were analysed using a modified grounded theory approach. RESULTS: There were marked differences between the hospitals in the participation by mothers in the care of their sick newborn babies. The timing and types of caring task that the mothers undertook were shaped by the structural, economic and social context of the hospitals. In the resource constrained government funded hospital, the immediate informal and unplanned delegation of care to mothers was routine. In the faith-based hospital mothers were initially separated from their babies and introduced to bathing and diaper change tasks slowly under the close supervision of nurses. In both hospitals appropriate breast-feeding support was lacking, and the needs of the mothers were largely ignored. CONCLUSION: In highly resource constrained hospitals with low nurse to baby ratios, mothers are required to provide primary and some specialised care to their sick newborns with little information or support on how undertake the necessary tasks. In better resourced hospital settings, most caring tasks are initially performed by nurses leaving mothers feeling powerless and worried about their capacity to care for their babies after discharge. Interventions need to focus on how to better equip hospitals and nurses to support mothers in caring for their sick newborns, promoting family centred care.

Imported malaria among people who travel to visit friends and relatives: is current UK policy effective or does it need a strategic change?

BACKGROUND: The proportion of all imported malaria reported in travellers visiting friends and relatives (VFRs) in the UK has increased over the past decade and the proportion of Plasmodium falciparum malaria affecting this group has remained above 80% during that period. The epidemiological data suggest that the strategies employed in the UK to prevent imported malaria have been ineffective for VFRs. This paper attempts to identify possible reasons for the failure of the malaria prevention strategy among VFRs and suggest potential alternatives. METHODS: A review of the current UK malaria prevention guidelines was undertaken and their approach was compared to the few data that are available on malaria perceptions and practices among VFRs. RESULTS: The current UK malaria prevention guidelines focus on educating travellers and health professionals using messages based on the personal threat of malaria and promoting the benefits of avoiding disease through the use of chemoprophylaxis. While malaria morbidity disproportionately affects VFRs, the mortality rates from malaria in VFRs is eight times, and severe disease eight times lower than in tourist and business travellers. Recent research into VFR malaria perceptions and practices has highlighted the complex socio-ecological context within which VFRs make their decisions about malaria. These data suggest that alternative strategies that move beyond a knowledge-deficit approach are required to address the burden of malaria in VFRs. DISCUSSION: Potential alternative strategies include the use of standby emergency-treatment (SBET) for the management of fevers with an anti-malarial provided pre-travel, the provision of rapid diagnostic testing and treatment regimen based in general-practitioner surgeries, and urgent and walk-in care centres and local accident and emergency (A&E) departments to provide immediate diagnosis and accessible ambulatory treatment for malaria patients. This latter approach would potentially address some of the practical barriers to reducing the burden of malaria in VFRs by moving the process nearer to the community.

"You cannot know if it's a baby or not a baby": uptake, provision and perceptions of antenatal care and routine antenatal ultrasound scanning in rural Kenya.

BACKGROUND: Antenatal care early in pregnancy enables service providers to identify and manage risks to mother and fetus. In the global north, ultrasound scans are routinely offered in pregnancy to provide an accurate estimate of gestational age and identify potential problems. In sub-Saharan Africa, such services are rarely available and women often delay initiating antenatal care. This study describes the uptake and provision of antenatal care in a rural Kenyan hospital and explores how pregnant women and healthcare providers perceived the provision of ultrasound scanning, following its introduction in an international foetal growth study. METHODS: A descriptive study, using qualitative and quantitative methods, was conducted in Kilifi District Hospital, Kenya, between June 2011 and April 2012. In-depth interviews were conducted with 10 nurses working in the antenatal clinic (ANC) and 59 pregnant women attending ANC. Structured observations of 357 ANC consultations and 30 ultrasound scans were made. RESULTS: Women sought antenatal care for information about the health of their baby and the protection provided by the ANC services. Uncertainty about pregnancy status contributed to delay in ANC attendance; more than 78 % of women were over 20 weeks' gestation at their first visit. Healthcare workers found it difficult to detect pregnancies below 16 weeks gestation and, accurate assessment of gestational age below 20 weeks' gestation could be problematic. Provision of services depended on the pregnancy being detected and gestational age assessed. The "seeing", made possible through ultrasound scanning was perceived by pregnant women and healthcare workers to be beneficial: confirming the pregnancy, and providing reassurance about the fetus' condition. Few participants raised concerns about ultrasound scanning. CONCLUSIONS: Uncertainty about pregnancy status and gestational age for women and healthcare providers is a key factor influencing timing of ANC attendance, contributing to delays and restricting early provision of ANC services. Ultrasound scanning was perceived to enhance antenatal care through confirmation of pregnancy status and enabling more accurate estimation of gestational age and the health status of the fetus. There is a need to make available more affordable means of pregnancy testing as a strategy towards encouraging early attendance, and delivery of antenatal care.

"You're losing your Ghanaianess": understanding malaria decision-making among Africans visiting friends and relatives in the UK.

BACKGROUND: In the UK, the majority of imported malaria infections occur in the London area among UK residents of African origin who travel to Africa visiting friends and relatives (VFRs). Effective malaria prevention measures are available but there is little understanding of the factors that enhance and constrain their use among VFRs. METHODS: Semi-structured interviews were undertaken with Africans resident in London who visited friends and relatives in Nigeria and Ghana (n = 20) and with African VFRs recently treated for malaria (n = 6). Data collection took place between December 2007 and February 2011. Information on migration patterns and travel of respondents was collected and the data were analysed using a framework analysis approach. RESULTS: Knowledge of the link between mosquitoes and malaria was high. Factors influencing the use of mosquito avoidance methods included knowledge about the local environment, perceptions of the inevitability of contracting malaria, and a desire to fit with the norms of host families. Previous experience of bed nets, and the belief that more modern ways of preventing mosquito bites were available deterred people from using them. Chemoprophylaxis use was varied and influenced by: perceptions about continuing immunity to malaria; previous experiences of malaria illness; the cost of chemoprophylaxis; beliefs about the likely severity of malaria infections; the influence of friends in the UK; and, the way malaria is perceived and managed in Nigeria and Ghana. Malaria treatment was considered by many to be superior in Nigeria and Ghana than in the UK. A conceptual framework was developed to illustrate the manner in which these factors interact to affect malaria decisions. CONCLUSIONS: The use of malaria prevention among VFRs needs to be understood not only in terms of individual risk factors but also in relation to the context in which decisions are made. For VFRs, malaria decisions are undertaken across two distinct social and environmental contexts and within the structural constraints associated with each. Strategies for reducing the burden of malaria among VFRs that ignore this complexity are likely to face challenges. New approaches that take account of contextual as well as individual factors are required.

Challenges facing providers of imported malaria-related healthcare services for Africans visiting friends and relatives (VFRs).

BACKGROUND: In many non-malarious countries, imported malaria disproportionately affects Africans visiting friends and relatives (VFRs). Most previous research has focused on understanding the knowledge, attitudes and practices of these travellers, but has not examined the quality of prevention, diagnosis and treatment services provided. The aim of this study was to understand the perspective of providers of malaria-related healthcare services to VFRs about factors impacting on the quality of these and to make recommendations about improvements. METHODS: Thirty semi-structured interviews were conducted with practice nurses providing pre-travel health advice (n = 10), general practitioners (GPs) (n = 10), hospital consultants (n = 3), and community pharmacists (n = 7) working in areas of London with large African communities and a relatively high burden of imported malaria. A thematic analysis of the results was undertaken. RESULTS: Time constraints in GPs' surgeries and competing priorities, lack of confidence in issuing advice on mosquito avoidance, the cost of chemoprophylaxis and travel at short notice prevented the provision of adequate malaria prevention advice. Long GP waiting times, misdiagnoses, lack of disclosure by VFRs about recent travel, and the issue of where malaria treatment should be provided were raised as potential barriers to diagnosis and treatment. CONCLUSIONS: Some issues raised by respondents are relevant to all travellers, irrespective of their reason for travel. The challenge for healthcare providers to reduce the burden of imported malaria in VFRs is to provide services of sufficient quality to persuade them to adopt these in preference to those with which they may be familiar in their country of birth. Although no single intervention will significantly lower the burden of imported malaria, addressing the issues raised in this research could make a significant impact.

Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation and knowledge diffusion.

BACKGROUND: Antimicrobial resistance (AMR) is a global health priority. Leading UK and global strategy papers to fight AMR recognise its social and behavioural dimensions, but current policy responses to improve the popular use of antimicrobials (eg, antibiotics) are limited to education and awareness-raising campaigns. In response to conceptual, methodological and empirical weaknesses of this approach, we study people's antibiotic-related health behaviour through three research questions.RQ1: What are the manifestations and determinants of problematic antibiotic use in patients' healthcare-seeking pathways?RQ2: Will people's exposure to antibiotic awareness activities entail changed behaviours that diffuse or dissipate within a network of competing healthcare practices?RQ3: Which proxy indicators facilitate the detection of problematic antibiotic behaviours across and within communities? METHODS: We apply an interdisciplinary analytical framework that draws on the public health, medical anthropology, sociology and development economics literature. Our research involves social surveys of treatment-seeking behaviour among rural dwellers in northern Thailand (Chiang Rai) and southern Lao PDR (Salavan). We sample approximately 4800 adults to produce district-level representative and social network data. Additional 60 cognitive interviews facilitate survey instrument development and data interpretation. Our survey data analysis techniques include event sequence analysis (RQ1), multilevel regression (RQ1-3), social network analysis (RQ2) and latent class analysis (RQ3). DISCUSSION: Social research in AMR is nascent, but our unprecedentedly detailed data on microlevel treatment-seeking behaviour can contribute an understanding of behaviour beyond awareness and free choice, highlighting, for example, decision-making constraints, problems of marginalisation and lacking access to healthcare and competing ideas about desirable behaviour. TRIAL REGISTRATION NUMBER: NCT03241316; Pre-results.

The social burden of malaria: what are we measuring?

Definitions of the burden of malaria vary by public health discipline. Epidemiologists and economists commonly use a quantitative approach to measure risk factors and associate them with disease outcomes. In contrast, since burden is itself a cultural construct, an anthropologic perspective of the burden of disease considers the sociocultural context in which these risk factors exist. This broader concept of burden is rarely tackled, most likely stemming from a lack of understanding of what is meant by the term social burden. This report describes the concept from an anthropologic perspective. The aim is to provide a better understanding of the process through which social and cultural factors affect the biomedical burden of malaria. The consequences of adopting this perspective for public health in general and malaria interventions in particular are discussed.

A critical review of behavioral issues related to malaria control in sub-Saharan Africa: what contributions have social scientists made?

In 1996, Social Science & Medicine published a review of treatment seeking for malaria (McCombie, 1996). Since that time, a significant amount of socio-behavioral research on the home management of malaria has been undertaken. In addition, recent initiatives such as Roll Back Malaria have emphasized the importance of social science inputs to malaria research and control. However, there has been a growing feeling that the potential contributions that social science could and should be making to malaria research and control have yet to be fully realized. To address these issues, this paper critically reviews and synthesizes the literature (published, unpublished and technical reports) pertaining to the home management of illness episodes of malaria in sub-Saharan Africa from 1996 to the end of 2000, and draws conclusions about the use of social science in malaria research and control. The results suggest that while we have amassed increasing quantities of descriptive data on treatment seeking behavior, we still have little understanding of the rationale of drug use from the patient perspective and, perhaps more importantly, barely any information on the rationale of provider behaviors. However, the results underline the dynamic and iterative nature of treatment seeking with multiple sources of care frequently being employed during a single illness episode; and highlight the importance in decision making of gender, socio-economic and cultural position of individuals within households and communities. Furthermore, the impact of political, structural and environmental factors on treatment seeking behaviors is starting to be recognised. Programs to address these issues may be beyond single sector (malaria control programme) interventions, but social science practice in malaria control needs to reflect a realistic appraisal of the complexities that govern human behavior and include critical appraisal and proposals for practical action. Major concerns arising from the review were the lack of evidence of 'social scientist' involvement (particularly few from endemic countries) in much of the published research; and concerns with methodological rigor. To increase the effective use of social science, we should focus on a new orientation for field research (including increased methodological rigor), address the gaps in research knowledge, strengthen the relationship between research, policy and practice; and concentrate on capacity strengthening and advocacy.

"Even if you know everything you can forget": health worker perceptions of mobile phone text-messaging to improve malaria case-management in Kenya.

This paper presents the results of a qualitative study to investigate the perceptions and experiences of health workers involved in a a cluster-randomized controlled trial of a novel intervention to improve health worker malaria case-management in 107 government health facilities in Kenya. The intervention involved sending text-messages about paediatric outpatient malaria case-management accompanied by "motivating" quotes to health workers' mobile phones. Ten malaria messages were developed reflecting recommendations from the Kenyan national guidelines. Two messages were delivered per day for 5 working days and the process was repeated for 26 weeks (May to October 2009). The accompanying quotes were unique to each message. The intervention was delivered to 119 health workers and there were significant improvements in correct artemether-lumefantrine (AL) management both immediately after the intervention (November 2009) and 6 months later (May 2010). In-depth interviews with 24 health workers were undertaken to investigate the possible drivers of this change. The results suggest high acceptance of all components of the intervention, with the active delivery of information in an on the job setting, the ready availability of new and stored text messages and the perception of being kept 'up to date' as important factors influencing practice. Applying the construct of stages of change we infer that in this intervention the SMS messages were operating primarily at the action and maintenance stages of behaviour change achieving their effect by creating an enabling environment and providing a prompt to action for the implementation of case management practices that had already been accepted as the clinical norm by the health workers. Future trials testing the effectiveness of SMS reminders in creating an enabling environment for the establishment of new norms in clinical practice as well as in providing a prompt to action for the implementation of the new case-management guidelines are justified.

Social acceptability and durability of two different house screening interventions against exposure to malaria vectors, Plasmodium falciparum infection, and anemia in children in the Gambia, West Africa.

The social acceptability and durability of two house screening interventions were addressed using focus group discussions, questionnaires, indoor climate measurements, and durability surveys. Participants recognized that screening stopped mosquitoes (79-96%) and other insects (86-98%) entering their houses. These and other benefits were appreciated by significantly more recipients of full screening than users of screened ceilings. Full screened houses were 0.26°C hotter at night (P = 0.05) than houses with screened ceilings and 0.51°C (P < 0.001) hotter than houses with no screening (28.43°C), though only 9% of full screened house users and 17% of screened ceiling users complained about the heat. Although 71% of screened doors and 85% of ceilings had suffered some damage after 12 months, the average number of holes of any size was < 5 for doors and < 7 for ceilings. In conclusion, house screening is a well-appreciated and durable vector control tool.

Who needs 'pukka anthropologists'? A study of the perceptions of the use of anthropology in tropical public health research.

Over the past 50 years, there have been considerable changes both in how medical anthropologists view their relationship to tropical public health and in how tropical public health professionals view the role of anthropologists. In particular, in recent decades critical currents have emerged from an anthropology of medicine, calling for an examination of biomedicine and its conceptualisation of public health. There are parallel debates in public health about a narrow disease-focused or broader socio-cultural approach to improving population health. Based on a review of the literature and a qualitative study of the views of public health professionals and anthropologists working in tropical public health, the data presented in this paper suggest that public health professionals remain unaware of many of the contributions anthropology could make to tropical public health theory and practice. However, the objectives of a critical social science are not dissimilar to those of the broader concept of public health. We suggest that there are grounds for optimism. For those of us concerned not just with disease but also with inequities in health, the challenge is to work towards a critical tropical public health which draws as much from social science as from biomedicine, in theory and practice.