Social risks, economic dynamics and the local politics of COVID-19 prevention in Eldoret town, Kenya.

A steady and consistent national and local government leadership is crucial in times of crisis. The trust in government - which can be so fragile - was strong in Eldoret town, a large municipal in western Kenya widely known for ethnic conflicts. In our interviews with 20 business people and 30 community members from Eldoret town, we found that the trust built early in the pandemic was broken due to individual leaders who eventually dismissed public health promotion and engaged in politics and corruption of funds for COVID-19 relief. When leadership was strong, locals in Eldoret town (and especially business owners) engaged in public health prevention measures for the greater good. But when leadership slipped, people complained and eventually ignored public health prevention measures at home, on the bus, and in businesses around town, causing the intensification of outbreaks. This was most common among those engaged in the formal economy as those in the informal economy were more likely to mistrust the government altogether. We show who falls through the cracks when government policy targets viral threats and suggest how local government and public health agencies might work to control COVID-19 infections while ensuring that all Eldoret residents are cared for.

The anthropology of health systems: A history and review.

Ethnographies of health systems are a theoretically rich and rapidly growing area within medical anthropology. Critical ethnographic work dating back to the 1950s has taken policymakers and health staff as points of entry into the power structures that run through the global health enterprise. In the last decade, there has been a surge of ethnographic work on health systems. We conceptualize the anthropology of health systems as a field; review the history of this body of knowledge; and outline emergent literatures on policymaking, HIV, hospitals, Community Health Workers, health markets, pharmaceuticals, and metrics. High-quality ethnographic work is an excellent way to understand the complex systems that shape health outcomes, and provides a critical vantage point for thinking about global health policy and systems. As theory in this space develops and deepens, we argue that anthropologists should look beyond the discipline to think through what their work does and why it matters.

Flourishing: migration and health in social context.

Health and the capacity to flourish are deeply intertwined. For members of vulnerable migrant groups, systemic inequalities and structural forms of marginalisation and exclusion create health risks, impede access to needed care and interfere with the ability to achieve one's full potential. Migrants often have limited access to healthcare, and they frequently are portrayed as less deserving than others of the resources needed to lead a healthy and flourishing life. Under these circumstances, clinicians, healthcare institutions and global health organisations have a moral and ethical obligation to consider the role they can-and do-play in either advancing or impeding migrants' health and their capacity to flourish. Drawing on case studies from three world regions, we propose concrete steps clinicians and health institutions can take in order to better serve migrant patients. These include recommendations that can help improve understanding of the complex circumstances of migrants' lives, strengthen collaboration between care providers and non-medical partners and transform the social, economic and structural circumstances that impede flourishing and harm health. Developing new strategies to promote the flourishing of precarious migrants can strengthen our collective ability to re-envision and redesign health systems and structures to value the health, dignity and bodily integrity of all patients-especially the most vulnerable-and to promote flourishing for all.

A Systematic Review of Medical-Legal Partnerships Serving Immigrant Communities in the United States.

The medical-legal partnership addresses social and political determinants of health. Yet, relatively little is known about best practices for these two service providers collaborating to deliver integrated services, particularly to im/migrant communities. To investigate evaluations of existing medical-legal partnerships in order to understand how they function together, what they provide, and how they define and deliver equitable, integrated care. We searched five databases (PubMed, Medline, Web of Science, HeinOnline, and Nexus Uni) using search terms related to "medical-legal partnerships", "migrants", and "United States". We systematically evaluated ten themes related to how medical and legal teams interacted, were situated, organized, and who they served. Articles were published in English between 2010 and 2019; required discussion about a direct partnership between medical and legal professionals; and focused on providing clinical care and legal services to im/migrant populations. Eighteen articles met our inclusion criteria. The most common form of partnership was a model in which legal clinics make regular referrals to medical clinics, although the reverse was also common. Most services were not co-located. Partnerships often engaged in advocacy work, provided translation services, and referred clients to non-medical providers and legal services. This review demonstrates the benefits of a legal-medical partnership, such as enhancing documentation and care for im/migrants and facilitating a greater attention to political determinants of health. Yet, this review demonstrates that, despite the increasing salience of such partnership, few have written up their lessons learned and best practices.

Nurses' perceptions of mental healthcare in primary-care settings in Kenya.

Kenya maintains an extraordinary treatment gap for mental health services because the need for and availability of mental health services are extraordinarily misaligned. One way to narrow the treatment gap is task-sharing, where specialists rationally distribute tasks across the health system, with many responsibilities falling upon frontline health workers, including nurses. Yet, little is known about how nurses perceive task-sharing mental health services. This article investigates nurses' perceptions of mental healthcare delivery within primary-care settings in Kenya. We conducted a cross-sectional study of 60 nurses from a public urban (n = 20), private urban (n = 20), and public rural (n = 20) hospitals. Nurses participated in a one-hour interview about their perceptions of mental healthcare delivery. Nurses viewed mental health services as a priority and believed integrating it into a basic package of primary care would protect it from competing health priorities, financial barriers, stigma, and social problems. Many nurses believed that integrating mental healthcare into primary care was acceptable and feasible, but low levels of knowledge of healthcare providers, especially in rural areas, and few specialists, would be barriers. These data underscore the need for task-sharing mental health services into existing primary healthcare in Kenya.

Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations.

The co-occurrence of health burdens in transitioning populations, particularly in specific socioeconomic and cultural contexts, calls for conceptual frameworks to improve understanding of risk factors, so as to better design and implement prevention and intervention programmes to address comorbidities. The concept of a syndemic, developed by medical anthropologists, provides such a framework for preventing and treating comorbidities. The term syndemic refers to synergistic health problems that affect the health of a population within the context of persistent social and economic inequalities. Until now, syndemic theory has been applied to comorbid health problems in poor immigrant communities in high-income countries with limited translation, and in low-income or middle-income countries. In this Series paper, we examine the application of syndemic theory to comorbidities and multimorbidities in low-income and middle-income countries. We employ diabetes as an exemplar and discuss its comorbidity with HIV in Kenya, tuberculosis in India, and depression in South Africa. Using a model of syndemics that addresses transactional pathophysiology, socioeconomic conditions, health system structures, and cultural context, we illustrate the different syndemics across these countries and the potential benefit of syndemic care to patients. We conclude with recommendations for research and systems of care to address syndemics in low-income and middle-income country settings.

Stress, diabetes, and infection: Syndemic suffering at an urban Kenyan hospital.

The complexity of sickness among Kenya's urban poor cannot be dissociated from how social and health problems become syndemic. Increasingly diabetes and other non-communicable diseases (NCDs) are emerging among low-income populations that also are most afflicted by social stress and infection. This article examines how social stress, psychological distress, and physical illness among patients in a public hospital in Nairobi, Kenya, produce syndemic suffering, defined by lived experiences of syndemic clustering such as diabetes with depression and infection. We recruited 100 urban public hospital patients, of which half were women, and half had type 2 diabetes from June to August 2014. We administered written informed consent and collected anthropometrics and blood samples before we conducted lengthy mixed qualitative and survey interviews. We analyzed social stress in narrative interviews using content analysis and evaluated social and physical contributors to mental distress with frequency tables and logistic regression. We found that people experienced diabetes through a complex social and medical framework, where social problems were cause and consequence to psychological and physical suffering. Women's narratives revealed more social suffering as well as more mental distress and somatic symptoms, including multi-morbidities, than men's. People with diabetes reported not only concurrent anxiety and depression but also common infections, including malaria, tuberculosis, and HIV/AIDS. Narratives reveal how NCDs concurrent with infections, and HIV in particular, produce financial challenges for patients, especially when HIV treatment is free and patients must pay out-of-pocket for diabetes care. Future studies should investigate syndemic clustering of infections and NCDs among low-income populations at the population-level.

A mixed methods exploration of patterns of healthcare utilization of urban women with non-communicable disease in South Africa.

BACKGROUND: Despite the growing burden of NCDs in South Africa, very little is known about how people living in urban townships manage these illnesses. In this article we expound upon the findings of a study showing that only one-third of women with an NCD participating in the Birth to Twenty (Bt20) cohort study of Soweto-Johannesburg, South Africa, had sought biomedical services in the previous six months. METHODS: We evaluated quantitative data from a cross sectional health access survey conducted with adult women (mean age = 44.8) and examined 25 in-depth narrative interviews with twelve women who self-reported at least one NCD from the larger study. RESULTS: The qualitative findings highlight the potential role of negative experiences of healthcare services and biomedicine in delaying the seeking of healthcare. Multivariate analysis of the quantitative findings found that the possession of medical aid (OR = 1.7, CI = 1.01-2.84) and the self-reported use of patient strategies in negotiating healthcare access (OR = 1.6, CI = 1.04-2.34) were positively associated with the utilization of healthcare services. Belief in the superior efficacy of traditional healers over doctors was associated with delay of NCD treatment (OR = 2.4, CI = 1.14-4.18). CONCLUSION: Our data suggest that low healthcare utilization is due in part to low rates of expectation for consistent and high-quality care and potential mistrust of the medical system. We conclude that both demand-side and supply-side measures focusing on high trust management practices will prove essential in ensuring access to healthcare services.

Global health research in narrative: a qualitative look at the FICRS-F experience.

For American professional and graduate health sciences trainees, a mentored fellowship in a low- or middle-income country (LMIC) can be a transformative experience of personal growth and scientific discovery. We invited 86 American trainees in the Fogarty International Clinical Research Scholars and Fellows Program and Fulbright-Fogarty Fellowship 2011-2012 cohorts to contribute personal essays about formative experiences from their fellowships. Nine trainees contributed essays that were analyzed using an inductive approach. The most frequently addressed themes were the strong continuity of research and infrastructure at Fogarty fellowship sites, the time-limited nature of this international fellowship experience, and the ways in which this fellowship period was important for shaping future career planning. Trainees also addressed interaction with host communities vis-à-vis engagement in project implementation. These qualitative essays have contributed insights on how a 1-year mentored LMIC-based research training experience can influence professional development, complementing conventional evaluations. Full text of the essays is available at http://fogartyscholars.org/.

Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda.

Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs.

Association of somatoform disorders with anxiety and depression in women in low and middle income countries: a systematic review.

BACKGROUND: Across cultures, women are more likely than men to report somatoform disorders (SD), depression and anxiety. The aim of this article is to describe the co-morbidity of SD with depression/anxiety and to investigate the possible mechanisms of this relationship in women in low and middle income countries (LMIC). METHODS: We reviewed two databases: MEDLINE and PsycINFO from 1994 to 2012 for studies which assessed the association between any SD and depression/ anxiety in women from LMIC. Our focus was on community and primary healthcare based studies. Both quantitative and qualitative studies were included. RESULTS: A total of 21 studies covering eight LMICs were included in our analysis. Our findings suggest a strong association between SD and depression/anxiety (with odds ratios ranging from 2.5-3.5), though we also observed that the majority of women with SD did not have depression/anxiety. The likely mechanisms for this association are multidimensional, and may include shared aetiologies, that both conditions are in fact variants of the same primary mental disorder, and that one disorder is a risk factor for the other. Anthropological research offers a number of frameworks through which we can view these mechanisms. CONCLUSION: The current evidence indicates that service providers at the primary care level should be sensitized to consider SD in women as variants of CMD (Common Mental Disorders) and address both groups of disorders concurrently. Further research should explicitly seek to unpack the mechanisms of the relationship between SD and CMD.

Stress and diabetes in socioeconomic context: a qualitative study of urban Indians.

Type 2 diabetes has escalated in urban India in the past two decades. Historically a disease of the affluent, recent epidemiological evidence indicates rising diabetes incidence and prevalence in urban India's middle class and working poor. Although there is substantial qualitative data about people with diabetes from high-income countries, scant resources provide insight into diabetes experiences among those in India, and lower-income groups specifically. In this article, we use individual-level analysis of illness narratives to understand how people experience and understand diabetes across income groups in Delhi, India. We conducted in-depth qualitative interviews and administered the Hopkins Symptoms Check-List (HSCL-25) to evaluate depression among 59 people with diabetes in northeast Delhi between December 2011 and February 2012. We analyzed their responses to: 1) what caused your diabetes?; 2) what do you find most stressful in your daily life?; and 3) where do you seek diabetes care? We found few people held diabetes beliefs that were congruent with socio-spiritual or biomedical explanatory models, and higher income participants commonly cited "tension" as a contributor to diabetes. Stress associated with children's futures, financial security, and family dynamics were most commonly reported, but how these subjective stresses were realized in people's lives varied across income groups. Depression was most common among the poorest income group (55%) but was also reported among middle- (38%) and high-income (29%) participants. One-quarter of respondents reported diabetes distress, but only those from the low-income community reported co-occurring depression and these respondents often revealed poor access to diabetes care. These data suggest that lower-income populations not only have higher rates of depression but also may be more likely to delay health care and therefore develop diabetes complications. This research has many implications for public health care in India as diabetes prevalence shifts to affect lower income groups who concurrently experience higher rates of depression and poorer access to medical care.

An exploratory study of how trust in health care institutions varies across African American, Hispanic and white populations.

BACKGROUND: Minority and non-minority patients in the United States have different levels of trust in health care; however, few studies have examined how determinants of trust and distrust in health care vary across diverse groups. OBJECTIVE: To explore how trust in health care institutions varies across diverse populations. METHODS: We conducted 17 focus groups with 117 participants in Chicago: 9 with African American, 5 with Hispanic, and 3 with white participants. Discussions were audiotaped, transcribed verbatim and coded using grounded theory analysis to identify dominant themes. RESULTS: We found a core set of factors that contribute to trust and distrust across racial/ethnic groups. In addition, there were unique factors that contributed to distrust among African Americans and Hispanics. Both of these groups discussed expectations of discrimination in the health care setting and African Americans discussed expectations of being experimented on as determinants of distrust. Based on these findings, we developed a hypothetical model of how different factors influence trust and distrust in health care across these different racial/ethnic groups. CONCLUSIONS: Contributors to trust and distrust in health care institutions are not always uniform across racial/ethnic groups. These differences should be addressed in future research and efforts to enhance trust in health care institutions.

Speaking through diabetes: Rethinking the significance of lay discourses on diabetes.

The disproportionate prevalence of Type II diabetes mellitus among the poor suggests that, in addition to lifestyle factors, social suffering may be embodied in diabetes. In this article, we examine the role of social distress in narratives collected from 26 Mexican Americans seeking diabetes care at a public hospital in Chicago. By linking social suffering with diabetes causality, we argue that our participants use diabetes much like an "idiom of distress," leveraging somatic symptoms to disclose psychological distress. We argue that diabetes figures both as an expression and a product of social suffering in these narratives. We propose that increasingly prevalent chronic diseases, like diabetes, which are closely associated with social disparities in health, may function as idioms for psychological and social suffering. Such findings inform the anthropological literature and emerging clinical and scientific discourse about the roles of stress and psychological distress in diabetes experiences among underserved groups.