Unpacking the role of transport inequalities among older adults for accessing healthcare in Bengaluru, India.

Mobility, access to transport and healthcare play a crucial part in healthy ageing. However, these often posechallenges for older adults in the global South. This study applies the three concepts of 'motility' (access, competence and appropriation), to explore transport inequalities and barriers to access healthcare services for older adults in Bengaluru, India. The paper draws on interviews with sixty adults, aged 50 years and over, residing in urban Bengaluru. A semi-structured in-depth interview guide was employed to explore the transport inequalities. Applying thematic analysis, we present the mobility and transport barriers to access healthcare. Restricted access to healthcare services due to unavailable and unaffordable transportation resulted in missed appointments, delayed care and deterioration of health conditions. To cope with the barriers, older adults often visited less specialised clinics for regular check-ups and those with financial constraints resorted to self-medication. These actions further deteriorated health and led to adverse health outcomes. Our findings suggest that integrated health and transport policies must be designed to ensure equitable access to transportation services. Enabling older adults to have more independent lives and improve access to preventive healthcare is essential for better health outcomes.

"When I Need to Travel, I Feel Feverish": Everyday Experiences of Transport Inequalities Among Older Adults in Dhaka, Bangladesh.

BACKGROUND AND OBJECTIVES: Buses are the most common form of public transport for older adults in developing countries. With over 37% of total trips, buses are the principal mode of transport in Dhaka. The majority of older adults are dependent on buses because of their affordability relative to other modes such as auto-rickshaws, rideshares, and taxis. This study aims to investigate key barriers in accessing buses in Dhaka and the consequences of these barriers to the everyday mobility of older adults. RESEARCH DESIGN AND METHODS: Thirty participants aged 60 and older were recruited from 2 socioeconomically different neighborhoods in Dhaka. We employed a thematic analysis of visual surveys and in-depth interviews to understand older adults' spatial and cultural context and their experiences using buses in their everyday lives. RESULTS: Boarding and deboarding buses were common barriers for older adults due to overcrowding and traffic congestion. In addition, older adults faced challenges such as ageism, gender discrimination, and undesirable behavior by transport personnel and co-passengers. These barriers affected their independent mobility and influenced their access to work and social life, contributing to their social exclusion. DISCUSSION AND IMPLICATIONS: This study illustrates the challenges faced by older adults when accessing public transport and the need to improve access to work, health care, and social life. Inclusive transport policies are essential in low- and middle-income countries to improve the well-being of older adults.

Evaluating and strengthening the health system of CuraÒ«ao to improve its performance for future outbreaks of vector-borne diseases.

BACKGROUND: Vector-borne diseases (VBDs) such as dengue, chikungunya, and Zika pose a significant challenge to health systems in countries they affect, especially countries with less developed healthcare systems. Therefore, countries are encouraged to work towards more resilient health systems. This qualitative study aims to examine the performance of the health system of the Dutch Caribbean island of CuraÒ«ao regarding the prevention and control of VBDs in the last decade by using the WHO health system building blocks. METHODS: From November 2018 to December 2020, a multi-method qualitative study was performed in Curaçao, applying content analysis of documents (n = 50), five focus group discussions (n = 30), interviews with experts (n = 11) and 15 observation sessions. The study was designed based on the WHO framework: health system building blocks. Two cycles of inductive and deductive coding were employed, and Nvivo software was used to analyse the data. RESULTS: This study's data highlighted the challenges (e.g. insufficient oversight, coordination, leadership skills, structure and communication) that the departments of the health system of CuraÒ«ao faced during the last three epidemics of VBDs (2010-2020). Furthermore, low levels of collaboration between governmental and non-governmental organisations (e.g. semi-governmental and private laboratories) and insufficient capacity building to improve skills (e.g. entomological, surveillance skills) were also observed. Lastly, we observed how bottlenecks in one building block negatively influenced other building blocks (e.g. inadequate leadership/governance obstructed the workforce's performance). CONCLUSIONS: This study uncovers potential organisational bottlenecks that have affected the performance of the health system of CuraÒ«ao negatively. We recommend starting with the reinforcement of oversight of the integrated vector management programme to ensure the development, implementation and evaluation of related legislation, policies and interventions. Also, we recommend evaluating and reforming the existing administrative and organisational structure of the health system by considering the cultural style, challenges and barriers of the current health system. More efforts are needed to improve the documentation of agreements, recruitment and evaluation of the workforce's performance. Based on our findings, we conceptualised actions to strengthen the health system's building blocks to improve its performance for future outbreaks of infectious diseases.

'He usually has what we call normal fevers': Cultural perspectives on healthy child growth in rural Southeastern Tanzania: An ethnographic enquiry.

INTRODUCTION: While parents' construction of and actions around child growth are embedded in their cultural framework, the discourse on child growth monitoring (CGM) has been using indicators grounded in the biomedical model. We believe that for CGM to be effective, it should also incorporate other relevant socio-cultural constructs. To contribute to the further development of CGM to ensure that it reflects the local context, we report on the cultural conceptualization of healthy child growth in rural Tanzania. Specifically, we examine how caregivers describe and recognize healthy growth in young children, and the meanings they attach to these cultural markers of healthy growth. METHODS: Caregivers of under-five children, including mothers, fathers, elderly women, and community health workers, were recruited from a rural community in Kilosa District, Southeastern Tanzania. Using an ethnographic approach and the cultural schemas theory, data for the study were collected through 19 focus group discussions, 30 in-depth interviews, and five key informant interviews. Both inductive and deductive approaches were used in the data analysis. RESULTS: Participants reported using multiple markers for ascertaining healthy growth. These include 'being bonge' (chubby), 'being free of illness', 'eating well', 'growing in height', as well as 'having good kilos' (weight). Despite the integration of some biomedical concepts into the local conceptualization of growth, the meanings attached to these concepts are largely rooted in the participants' cultural framework. For instance, a child's weight is ascribed to the parents' adherence to postpartum sex taboos and to the nature of a child's bones. The study noted conceptual differences between the meanings attached to height from a biomedical and a local perspective. Whereas from a biomedical perspective the height increment is considered an outcome of growth, the participants did not see height as linked to nutrition, and did not believe that they have control over their child's height. CONCLUSIONS: To provide context-sensitive advice to mothers during CGM appointments, health workers should use a tool that takes into account the mothers' constructs derived from their cultural framework of healthy growth. The use of this approach should facilitate communication between health professionals and caregivers during CGM activities, increase the uptake and utilization of CGM services, and, eventually, contribute to reduced levels of childhood malnutrition in the community.

Long-term Chikungunya Sequelae in Curaçao: Burden, Determinants, and a Novel Classification Tool.

Background: Beyond the acute illness phase, chikungunya constitutes a public health problem given its chronic disease phase, which may include long-term arthralgia, arthritis, fatigue, and depression. Currently, there is no consensus on how to define chikungunya chronicity. Methods: A comprehensive cross-sectional survey was performed in Curaçao in June and July 2015 to evaluate 304 adult laboratory-confirmed chikungunya patients 3-16 months after diagnosis. We developed a novel tool, the Curaçao Long-Term Chikungunya Sequelae (CLTCS) score, to classify chronic chikungunya disease and estimate its burden regarding disease duration, clinical presentation, and impact on quality of life. Results: Disease persistence was estimated to be 79% one month after symptom onset and 64% after 400 days. Chikungunya persistence was characterized by higher proportions of arthralgia, weakness, myalgia, and age 41-60 years. Individuals were classified as "highly affected," "mildly affected," and "recovered." "Highly affected" disease status was associated with clinical complaints (arthralgia, weakness, loss of vitality, and being diabetic) and major decreases in quality-of-life scores. Conclusions: In the Caribbean, a high proportion of chikungunya patients remains chronically affected. We propose the CLTCS as a suitable score to easily and rapidly classify the severity of chikungunya chronic disease and to assess the need for symptom-alleviating treatment.

Community participation in mosquito breeding site control: an interdisciplinary mixed methods study in Curaçao.

BACKGROUND: As the arboviral diseases dengue, chikungunya and Zika emerge in the Americas, so does the need for sustainable vector control policies. To successfully achieve mosquito control, joint efforts of both communities and governments are essential. This study investigates this important, but by-and-large neglected topic. METHODS: In June and July 2015, a cross-sectional mixed methods study applying a survey questionnaire (response rate of 82.5%; n = 339), in-depth interviews (n = 20) and focus group discussions (n = 7; 50 participants) was performed in Curaçao. The study was designed based on an integrated theoretical framework of the Health Belief Model and the Theory of Planned Behaviour. RESULTS: Participants showed a good knowledge of, and a high-level performance of mosquito breeding site control (MBSC) practices. Personal protection against mosquitoes (e.g. topical repellents) was perceived as relatively less effective thus practiced to lower extent compared to MBSC practices (i.e. larval source management). A lower intention to perform MBSC was independently associated with: (i) satisfaction on governmental MBSC (P = 0.012); (ii) barriers to perform MBSC practices, i.e. 'Government doesn't control other breeding sites' (P = 0.005), 'Don't know how to control breeding sites' (P = 0.041), and 'a mosquito does not transmit dengue' (P = 0.016), (iii) attitudes towards MBSC (P = 0.001) and self-efficacy (person's perceived ability to act) to perform MBSC (P = 0.002). Mixed-methods evidence highlights three possible ways of improving community participation in MBSC. First, it highlights the need for ongoing media coverage, targeting (i) communities' perceptions on transmission routes of dengue and chikungunya, and (ii) presence of car tires in yards. Secondly, it shows that promotion of governmental activities in MBSC can enhance MBSC of communities, if people develop a sense of responsibility to perform MBSC at their own properties. Thirdly, this study describes the presence of key persons in communities, who could be engaged in mosquito control policies to improve MBSC in neighbourhoods. CONCLUSION: This study reveals gaps between policy and communities' lived realities. These gaps might be overcome with the proposed interventions, resulting in a higher performance of MBSC in the community in Curaçao. Furthermore, this study shows how interdisciplinary mixed methods research can provide important, comprehensive, and in-depth insights to inform mosquito control policies.

Illness experiences of diabetes in the context of malaria in settings experiencing double burden of disease in southeastern Tanzania.

BACKGROUND: Tanzania is doubly burdened with both non-communicable and infectious diseases, but information on how Tanzanians experience the co-existence of these conditions is limited. Using Kleinman's eight prompting questions the study synthesizes explanatory models from patients to describe common illness experiences of diabetes in a rural setting where malaria is the predominant health threat. METHODS: We conducted 17 focus group discussions with adult members of the general community, diabetes patients, neighbours and relatives of diabetes patients to gain insight into shared experiences. To gain in-depth understanding of the individual illness experiences, we conducted 41 in-depth interviews with malaria or diabetes patients and family members of diabetes patients. The analysis followed grounded theory principles and the illness experiences were derived from the emerging themes. RESULTS: The illness experiences showed that malaria and diabetes are both perceived to be severe and fatal conditions, but over the years people have learned to live with malaria and the condition is relatively manageable compared with diabetes. In contrast, diabetes was perceived as a relatively new disease, with serious life-long consequences. Uncertainty, fear of those consequences, and the increased risk for severe malaria and other illnesses impacted diabetes patients and their families' illness experiences. Unpredictable ailments and loss of consciousness, memory, libido, and functional incapability were common problems reported by diabetes patients. These problems had an effect on their psychological and emotional health and limited their social life. Direct and indirect costs of illness pushed individuals and their families further into poverty and were more pronounced for diabetes patients. CONCLUSION: The illness experiences revealed both malaria and diabetes as distressing conditions, however, diabetes showed a higher level of stress because of its chronicity. Strategies for supporting social, emotional, and psychological well-being that build on the patient accounts are likely to improve illness experiences and quality of life for the chronically ill patient.

"It is the medicines that keep us alive": lived experiences of diabetes medication use and continuity among adults in Southeastern Tanzania.

BACKGROUND: Diabetes is a chronic condition which requires many patients to use medications for the remainder of their lives. While this regimen is demanding, little research has been done on the experiences individuals have with diabetes medication use and the continuity of use, especially patients from rural areas of Tanzania. This study explores the lived experiences of diabetes medication use and the continuity of use among adult diabetes patients from rural communities with limited access to diabetes medicines. METHODS: We conducted 19 in-depth interviews to explore patients' experiences with diabetes medication use and the continuity of use. We employed the 5As of access to care to situate the behavioral practices surrounding diabetes medication use in the study settings. The data analysis followed grounded theory principles, and was conducted with the help of NVivo 9. RESULTS: Study participants expressed positive attitudes toward the use of diabetes medicines, but also concerns about affordability. The patients employed two main strategies for dealing with the cost. The first was to increase their available funds by spending less money on family needs, selling household property, asking family and friends for money, or borrowing cash. They also reported sourcing medicines from pharmacies to save on consultation and laboratory costs. Second, participants reported using less than the recommended dosage or skipping doses, and sharing medicines. The geographic accessibility of diabetes service providers, the availability of medication, and the organization of the diabetes services were also cited as barriers to taking medications and to using them continuously. CONCLUSIONS: The strategies employed by the people in this study illustrate their resilience in the face of poverty and failing health care systems. More comprehensive strategies are therefore needed to encourage consistent medication use among people with chronic conditions. These strategies could include the reduction of prices by pharmaceuticals, the strengthening of community risk-pooling mechanisms and sustained health campaigns aimed at patients and the community.

Cultural heuristics in risk assessment of HIV/AIDS.

Behaviour change models in HIV prevention tend to consider that risky sexual behaviours reflect risk assessments and that by changing risk assessments behaviour can be changed. Risk assessment is however culturally constructed. Individuals use heuristics or bounded cognitive devices derived from broader cultural meaning systems to rationalize uncertainty. In this study, we identify some of the cultural heuristics used by migrant men in Goa, India to assess their risk of HIV infection from different sexual partners. Data derives from a series of in-depth interviews and a locally informed survey. Cultural heuristics identified include visual heuristics, heuristics of gender roles, vigilance and trust. The paper argues that, for more culturally informed HIV/AIDS behaviour change interventions, knowledge of cultural heuristics is essential.