'It is the child with the big head' - Primary healthcare providers' perceptions of paediatric hydrocephalus in Blantyre, Malawi: A qualitative study.

Children in Africa are disproportionately burdened by the neurosurgical condition hydrocephalus. In Blantyre, Malawi, paediatric hydrocephalus represents the majority of surgical procedures performed in the neurosurgical department at Queen Elizabeth Central Hospital. To reduce morbidity and mortality, timely detection followed by referral from surrounding primary health centres is crucial. Aiming to explore perceptions and identify enablers and barriers to detection and referral, we conducted a qualitative study among primary healthcare providers (n = 30) from ten health centres in Blantyre district. Using a semi-structured interview-guide, we audio-recorded and transcribed the interviews before conducting a thematic analysis. One main finding is that there is a potential to improve detection through head circumference measurements, which is the recommended way to detect hydrocephalus early, yet healthcare providers did not carry this out systematically. They described the health passport provided by the Malawian Ministry of Health as an important tool for clinical communication. However, head circumference growth charts are not included. To optimise outcomes for paediatric hydrocephalus we suggest including head circumference growth charts in the health passports. To meet the need for comprehensive management of paediatric hydrocephalus, we recommend more research from the continent, focusing on bridging the gap between primary care and neurosurgery.

Use of emergency primary care among pregnant undocumented migrants over ten years: an observational study from Oslo, Norway.

OBJECTIVE: To compare consultations with pregnant undocumented migrants at emergency primary health care to consultations with pregnant residents of Norway. DESIGN: A cross-sectional study of consultations at several time points. SETTING: The study was conducted at the Oslo Accident and Emergency Outpatient Clinic (OAEOC), the main emergency primary care service in Oslo, Norway. SUBJECTS: Consultations with pregnant patients without a Norwegian identity number seeking care at the Department of Emergency General Practice at the OAEOC were identified through a manual search of registration lists from 2009 to 2019. The consultations were categorized by women's residency status as 'probably documented migrant', 'uncertain migrant status', or 'probably undocumented migrant'. We also extracted aggregated data for women with a Norwegian identity number (i.e. residents) presenting in consultations with pregnancy-related (ICPC-2 chapter W) conditions. MAIN OUTCOME MEASURES: Manchester Triage System urgency level at presentation, and hospitalization. RESULTS: Among 829 consultations with female patients categorized as probably undocumented migrants, we found 27.1% (225/829) with pregnant women. About half of the pregnant women (54.6% (123/225)) presented with a pregnancy-related condition. Pregnant women that were probably undocumented migrants had an increased risk of being triaged with a high level of urgency at presentation (relative risk (RR) 1.86, 95% CI 1.14-3.04) and being hospitalized (RR 1.68, 95% CI 1.21-2.34), compared to pregnant residents. CONCLUSION: Pregnant undocumented migrants were more severely sick when presenting to emergency primary care services than pregnant residents. Increased access to primary care and emergency primary care services for pregnant undocumented migrants is urgently needed.

Restricted access to primary care may increase the use of primary care facilities intended for emergency care.A considerable proportion of the consultations with undocumented migrant women at the emergency primary care services are related to pregnancy.Consultations with pregnant undocumented migrants more often contained severe pregnancy-related conditions compared to consultations with pregnant residents of Norway.Interventions to increase access to primary care for pregnant undocumented migrants are urgently needed.

Chasing dön spirits in Tibetan medical encounters: Transcultural affordances and embodied psychiatry in Amdo, Qinghai.

Although spirit possession is generally considered a psychiatric illness, the class of conditions designated as dön (Tib. gdon, "afflictive external influences," often glossed as "spirit affliction") in Tibetan medicine represents a distinctive paradigm for an etiology where physical and mental facets inhere in every illness. This study draws upon ethnographic fieldwork in eastern Tibet to examine two conditions that represent illness presentations at both ends of the dön spectrum: one that maps onto a biomedical etiology of stroke and another that presents in a way similar to schizophrenia. The case studies illuminate the forms of harmful external influences that (1) have physiological and psychological impacts that present as symptoms and (2) contribute to a pathogenesis common to both conditions. Our analysis considers the dual role of cultural affordances and bio-looping in the cultural presentation of the two conditions, as well as how the Tibetan medical tradition draws upon cultural, social, biological, and psychological determinants to understand this class of conditions. We also explore the implications the dön illness category has for biomedically oriented paradigms through the way in which it accounts for cultural models for both diagnosis and treatment of several chronic inflammatory conditions that have significant concomitant mental health presentations.

Aetiology and diagnostics of paediatric hydrocephalus across Africa: a systematic review and meta-analysis.

BACKGROUND: We aimed to identify the aetiological distribution and the diagnostic methods for paediatric hydrocephalus across Africa, for which there is currently scarce evidence. METHODS: In this systematic review and meta-analysis, we searched MEDLINE (Ovid), the Cochrane Database of Systematic Reviews (Wiley), Embase (Ovid), Global Health (Ovid), Maternity & Infant Care (Ovid), Scopus, African Index Medicus (Global Index Medicus, WHO) and Africa-Wide Information (EBSCO) from inception to Nov 29, 2021. We included studies from any African country reporting on the distribution of hydrocephalus aetiology in children aged 18 years and younger, with no language restrictions. Hydrocephalus was defined as radiological evidence of ventriculomegaly or associated clinical symptoms and signs of the disorder, or surgical treatment for hydrocephalus. Exclusion criteria were studies only reporting on one specific subgroup or one specific cause of hydrocephalus. We also excluded conference and meetings abstracts, grey literature, editorials, commentaries, historical reviews, systematic reviews, case reports and clinical guidelines, as well as studies on non-humans, fetuses, or post-mortem reports. The proportions of postinfectious hydrocephalus, non-postinfectious hydrocephalus, and hydrocephalus related to spinal dysraphism were calculated using a random-effects model. Additionally, we included a category for unclear cases. Diagnostic methods were described qualitatively. To assess methodological study quality, we applied critical appraisal checklists provided by the Joanna Briggs Institute. The study was registered in Prospero (CRD42020219038). FINDINGS: Our search yielded 3783 results, of which 1880 (49·7%) were duplicates and were removed. The remaining 1903 abstracts were screened and 122 (6·4%) full articles were sought for retrieval; of these, we included 38 studies from 18 African countries that studied a total of 6565 children. The pooled proportion of postinfectious hydrocephalus was 28% (95% CI 22-36), non-postinfectious hydrocephalus was 21% (95% CI 13-30), and of spinal dysraphism was 16% (95% CI 12-20), with substantial heterogeneity. The pooled proportion of hydrocephalus of unclear aetiology was 20% (95% CI 13-28). INTERPRETATION: Our findings suggest that postinfectious hydrocephalus is the single most common cause of paediatric hydrocephalus in Africa. For targeted investments to be optimal, there is a need for consensus regarding the aetiological classification of hydrocephalus and improved access to diagnostic services. FUNDING: Rikshospitalet, Oslo University Hospital, Oslo, Norway.

Use of non-governmental maternity services and pregnancy outcomes among undocumented women: a cohort study from Norway.

BACKGROUND: In 2011 Norway granted undocumented women the right to antenatal care and to give birth at a hospital but did not include them in the general practitioner and reimbursement schemes. As a response to limited access to health care, Non-Governmental Organizations (NGO) have been running health clinics for undocumented migrants in Norway's two largest cities. To further facilitate universal health coverage, there is a need to investigate how pregnant undocumented women use NGO clinics and how this affects their maternal health. We therefore investigated the care received, occurrence of pregnancy-related complications and pregnancy outcomes in women receiving antenatal care at these clinics. METHODS: In this historic cohort study we included pregnant women aged 18-49 attending urban NGO clinics from 2009 to 2020 and retrieved their medical records from referral hospitals. We compared women based on region of origin using log-binominal regression to estimate relative risk of adverse pregnancy outcomes. RESULTS: We identified 582 pregnancies in 500 women during the study period. About half (46.5%) the women sought antenatal care after gestational week 12, and 25.7% after week 22. The women had median 1 (IQR 1-3) antenatal visit at the NGO clinics, which referred 77.7% of the women to public health care. A total of 28.4% of women were referred for induced abortion. In 205 retrieved deliveries in medical records, there was a 45.9% risk for any adverse pregnancy outcome. The risk of stillbirth was 1.0%, preterm birth 10.3%, and emergency caesarean section 19.3%. CONCLUSION: Pregnant undocumented women who use NGO clinics receive substandard antenatal care and have a high risk of adverse pregnancy outcomes despite low occurrence of comorbidities. To achieve universal health coverage, increased attention should be given to the structural vulnerabilities of undocumented women and to ensure that adequate antenatal care is accessible for them.

Coming of age: a qualitative study of adolescent girls' menstrual preparedness in Palestinian refugee camps in the West Bank and Jordan.

Menstrual health is important for adolescent girls and is particularly compromised in displaced communities due to restricted access to information and lack of private spaces to manage menstruation. Menarche is the biological and social milestone of girls' adolescence, marking the onset of puberty and confirming womanhood in many communities. It also marks a difficult transitional period influenced by socio-cultural beliefs and expectations. Menstrual preparedness is critical for this transition, and the lack of accurate, timely, age-appropriate information might impact current, and future reproductive health and well-being. This paper investigates the menstrual preparedness status of adolescents living in Palestinian refugee camps in the West Bank and Jordan. These are long-term refugee camps characterised by a variety of social, economic, and political constraints affecting the health of women and girls. We conducted 39 in-depth interviews and 23 focus-group discussions with adolescent girls. The study reveals inadequate menstrual preparedness among the participants, especially in pre-menarche. Among the barriers to adequate menstrual preparedness is a predominance of practical concerns, such as the use of sanitary pads and hygienic practices, socio-cultural norms that promote secrecy and taboo around menstruation, and divergent notions of timeliness of information among girls, their mothers, and teachers. The study contends that addressing the taboo around menstruation requires joint efforts by the family, school, and social services. Menstrual preparedness should begin early and encompass biological, practical, emotional, and psychological components. The paper advocates for Comprehensive, Contextually Relevant, Timely Menstrual Preparedness (CCTMP) policies and initiatives, empowering adolescent girls, their mothers, and educators.

Food-based nutrition counselling and education intervention for improved diets of pregnant women in rural Malawi: a qualitative study of factors influencing dietary behaviour change.

OBJECTIVE: We wanted to identify factors related to dietary behavioural change among impoverished pregnant women in the face of nutrition education and counselling, describing what creates an enabling environment and barriers for dietary change. DESIGN: We used qualitative data from a cluster-randomised maternal education trial and conducted a thematic analysis using a social ecological framework to describe the factors that influenced dietary adherence. SETTING: Mangochi district in rural Malawi. PARTICIPANTS: We interviewed ten pregnant women and conducted four sets of focus group discussions with twenty-two significant family members (husbands and mothers-in-law) and twelve counsellors. RESULTS: The participants' experiences showed that the main barriers of adherence to the intervention were taste, affordability and poverty. The use of powders and one-pot dishes, inclusion of both women and significant family members and a harmonisation with local food practices enabled adherence to the intervention. We found it crucial to focus the dietary education and counselling intervention on locally available ingredients and food processing methods. CONCLUSIONS: Use of contextualised food-based solutions to combat maternal malnutrition was observed to be relatively cheap and sustainable. However, there is need for more research on local foods used as nutrition supplements. We suggest that investments need to be directed not only to nutrition education and counselling but also to the enabling factors that enhance adherence. The original cluster-randomised controlled trial was registered with Clinical trials.gov ID: NCT03136393.

Pediatric Hydrocephalus in Northwest Tanzania: A Descriptive Cross-Sectional Study of Clinical Characteristics and Early Surgical Outcomes from the Bugando Medical Centre.

OBJECTIVES: In this study, we present data from a neurosurgical training program in Tanzania for the treatment of pediatric hydrocephalus. The objectives of the study were to identify the demographics and clinical characteristics of pediatric patients with hydrocephalus who were admitted to Bugando Medical Centre in Mwanza, Tanzania, as well as to describe their surgical treatment and early clinical outcomes. METHODS: This cross-sectional study included 38 pediatric patients. Physical examinations were conducted pre- and postoperatively, and their mothers completed a questionnaire providing demographic and clinical characteristics. RESULTS: There was a slight preponderance of male sex (21/38; 55.3%) with median age at the time of admission of 98.5 days. The majority of patients were surgically treated (33/38; 86.8%). Among those surgically treated, most received a ventriculoperitoneal shunt (23/33; 69.7%), whereas 7 were treated with an endoscopic third ventriculostomy (7/33; 21.2%). At the time of admission, the majority of patients (86%) had head circumferences that met criteria for macrocephaly. The median time between admission and surgery was 23 days (2-49 days). Overall, 5 patients (13.2%) died, including 2 who did not receive surgical intervention. CONCLUSIONS: We found that in our population, pediatric patients with hydrocephalus often present late for treatment with additional significant delays prior to receiving any surgical intervention. Five patients died, of whom 2 had not undergone surgery. Our study reinforces that targeted investments in clinical services are needed to enable access to care, improve surgical capacity, and alleviate the burden of neurosurgical disease from pediatric hydrocephalus in sub-Saharan Africa.

Enhancing nutrition knowledge and dietary diversity among rural pregnant women in Malawi: a randomized controlled trial.

BACKGROUND: In many sub-Saharan African countries, such as Malawi, antenatal care (ANC) services do not deliver sufficient nutrition awareness to improve adequate dietary intake in pregnancy. We therefore compared the effects of supplementary nutrition education and dietary counselling with routine ANC service on nutrition knowledge and dietary intakes among Malawian pregnant women. METHODS: We used data from a two-armed cluster randomised controlled trial (RCT) of which the intervention group received supplementary nutrition education, dietary counselling and routine ANC services whereas the controls received only routine ANC services. The RCT was conducted in 10 control and 10 intervention villages in Mangochi, Southern Malawi and included pregnant women between their 9th and 16th gestational weeks. We examined the changes in nutrition knowledge and dietary diversity from enrolment (baseline) to study end-point of the RCT (two weeks before expected delivery). We used three linear multilevel regression models with random effects at village level (cluster) to examine the associations between indicators of nutrition knowledge and diet consumption adjusted for selected explanatory variables. RESULTS: Among 257 pregnant women enrolled to the RCT, 195 (76%) were available for the current study. The supplementary nutrition education and counselling led to significant improvements in nutrition knowledge, dietary diversity and nutrition behaviour in the intervention group compared with controls. Most women from both study groups had a moderate consumption of diversified foods at study end-point. A significant positive association between nutrition knowledge and consumption of a diversified diet was only observed in the intervention group. CONCLUSIONS: Nutrition knowledge and dietary diversity improved in both study groups, but higher in the intervention group. Increased nutrition knowledge was associated with improved dietary diversity only in the intervention women, who also improved their nutrition perceptions and behaviour. Antenatal nutrition education needs strengthening to improve dietary intakes in pregnancy in this low resource-setting. TRIAL REGISTRATION: Clinical trials.gov ID: NCT03136393 (registered on 02/05/2017).