Socio-cultural determinants of anticipated acceptance of an oral cholera vaccine in Western Kenya.

Determinants of anticipated acceptance of an oral cholera vaccine (OCV) were studied in urban and rural communities of Western Kenya. An explanatory model interview administered to 379 community residents assessed anticipated vaccine acceptance at various prices from no cost to full-cost recovery, socio-cultural features of cholera and social characteristics. Nearly all (99%) residents indicated willingness to accept a no-cost OCV, 95% at a price of US$ 0·8, 73% at US$ 4·2 and 59% at US$ 8·4. Logistic regression models analysed socio-cultural determinants of anticipated OCV acceptance. Prominence of non-specific symptoms for cholera was negatively associated with acceptance. A cholera-specific symptom (thirst), self-help referring to prayer, income and education were positively associated. In the high-cost model, education was no longer significant and reliance on herbal treatment was a significant determinant of vaccine non-acceptance. Findings suggest high motivation for OCVs, if affordable. Socio-cultural determinants are better predictors of anticipated acceptance than socio-demographic factors alone.

Stakeholders perspectives on perceived needs and priorities for leprosy control and care, Tamil Nadu, India.

Although leprosy has been declared as eliminated in India, treated patients with persisting disabilities still require care. With the shift from vertical to integrated services, questions remain about case detection and maintaining the quality of patient care. We conducted a qualitative study to clarify the perceived status of elimination, patient care and other aspects of leprosy control from the perspective of various stakeholders. We interviewed leprosy programme managers, Non-governmental organization directors, healthcare providers, patients and community leaders from Kanchipuram district, Tamil Nadu. Consensus endorsed the current approach to integration of leprosy in primary healthcare, but healthcare personnel acknowledged problems from shortage of medicines and failure to fill key positions. Patients were concerned about limited clinic hours, long waits and delayed treatment. Disabled patients indicated how they were troubled by stigmatization of their condition. Programme managers mentioned limited support for needed research and some emphasized the potential threat of emerging drug resistance. Although consensus supports an integrated approach for leprosy services in primary care, the relative priority of different aspects of leprosy control vary among stakeholders. Perspectivist approaches to methodologically sound operational research could guide planning for effective case detection and patient care during the post-elimination era.

Cultural epidemiology of TB with reference to gender in Bangladesh, India and Malawi.

SETTING: TB control programmes in Bangladesh, India and Malawi. OBJECTIVE: To identify and compare socio-cultural features of tuberculosis (TB) and the distribution of TB-related experiences, meanings and behaviours with reference to gender across cultures in three high-endemic low-income countries. DESIGN: Approximately 100 patients at three sites were interviewed with in-depth semi-structured Explanatory Model Interview Catalogue (EMIC) interviews inquiring about patterns of distress, perceived causes and help-seeking behaviours in the context of illness narratives. RESULTS: Female patients reported more diverse symptoms and men more frequently focused on financial concerns. Most patients reported psychological and emotional distress. Men emphasised smoking and drinking alcohol as causes of TB, and women in Malawi reported sexual causes associated with HIV/AIDS. In Bangladesh, exaggerated concerns about the risk of spread despite treatment contributed to social isolation of women. Public health services were preferred in Malawi, and private doctors in India and Bangladesh. CONCLUSION: Cross-site analysis of these studies has identified features of TB that influence the burden of disease and are likely to affect timely help seeking and adherence to treatment. Health systems benefit from sex-disaggregated epidemiological data complemented by cultural epidemiological study, which together clarify the role of gender and contribute to the knowledge base for TB control at various levels.

Gender and socio-cultural determinants of delay to diagnosis of TB in Bangladesh, India and Malawi.

SETTING: Tuberculosis (TB) control programmes in Bangladesh, India and Malawi. OBJECTIVE: To compare the interval from symptom onset to diagnosis of TB for men and women, and to assess socio-cultural and gender-related features of illness explaining diagnostic delay. DESIGN: Semi-structured Explanatory Model Interview Catalogue (EMIC) interviews were administered to 100 or more patients at each site, assessing categories of distress, perceived causes and help seeking. Based on time from initial symptoms to diagnosis of TB, patients were classified with problem delay (>90 days), timely diagnosis (< or =30 days) or moderate delay. EMIC interview data were analysed to explain problem delay. RESULTS: The median interval from symptom onset to diagnosis was longest in India and shortest in Malawi. With adjustment for confounding, female sex (Bangladesh), and status of married woman (India) and housewife (Malawi) were associated with problem delay. Prominent non-specific symptoms--chest pain (Bangladesh) and breathlessness (Malawi)--were also significant. Cough in India, widely associated with TB, was associated with timely diagnosis. Sanitation as a perceived cause linked to poor urban conditions was associated with delayed diagnosis in India. Specific prior help seeking with circuitous referral patterns was identified. CONCLUSION: The study identified gender- and illness-related features of diagnostic delay. Further research distinguishing patient and provider delay is needed.

Gender and socio-cultural determinants of TB-related stigma in Bangladesh, India, Malawi and Colombia.

SETTING: Tuberculosis (TB) control programmes in Bangladesh, India, Malawi and Colombia. OBJECTIVE: Assess indicators of TB-related stigma and socio-cultural and gender-related features of illness associated with stigma. DESIGN: Semi-structured Explanatory Model Interview Catalogue (EMIC) interviews were administered to 100 or more patients at each site, assessing categories of distress, perceived causes and help seeking. Indicators of self-perceived stigma were analysed individually and in a validated index, which was compared across sites and between men and women at each site. Cultural epidemiological explanatory variables for stigma and interactions with female sex were analysed at each site. Qualitative illness narratives were examined to explain the role and context of explanatory variables. RESULTS: The overall stigma index was highest in India, lowest in Malawi and greater for women in Bangladesh. In India and Malawi, women were more likely to be concerned about impact on marital prospects. Associations with HIV/AIDS were linked to TB stigma in Malawi, where sexual contact as a perceived cause was more associated with stigma for men and less for women. CONCLUSION: Stigma both influences and indicates the effectiveness of TB control. Cultural epidemiological methods clarify cross-cutting and local features of stigma and gender for TB control.

Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain.

OBJECTIVE: To establish beginning evidence of clinical validity and reliability of the Neonatal Pain, Agitation and Sedation Scale (N-PASS) in neonates with prolonged pain postoperatively and during mechanical ventilation. STUDY DESIGN: Prospective psychometric evaluation. Two nurses administered the N-PASS simultaneously and independently before and after pharmacologic interventions for pain or sedation. One nurse also administered the premature infant pain profile (PIPP) concurrently with the N-PASS. The setting consisted of 50-bed level III neonatal intensive care unit. Convenience sample of 72 observations of 46 ventilated and/or postoperative infants, 0 to 100 days of age, gestational age 23 to 40 weeks was used. Outcome measures comprised convergent and construct validity, interrater reliability and internal consistency. RESULT: Interrater reliability measured by intraclass coefficients of 0.85 to 0.95 was high (P<0.001 to 0.0001). Convergent validity was demonstrated by correlation with the PIPP scores (Spearman's rank correlation coefficient of 0.83 at high pain scores, 0.61 at low pain scores). Internal consistency, measured by Cronbach's alpha, was evident with pain scores (0.82), and with sedation scores (0.87). Construct validity was established via the Wilcoxon signed-rank test, comparing the distribution of N-PASS scores before and after pharmacologic intervention showing pain scores of 4.86 (3.38) and 1.81 (1.53) (mean (s.d.), P<0.0001) and sedation scores of 0.85 (1.66) and -2.78 (2.81) (P<0.0001) for pre- and postintervention assessments, respectively. CONCLUSIONS: This research provides beginning evidence that the N-PASS is a valid and reliable tool for assessing pain/agitation and sedation in ventilated and/or postoperative infants 0 to 100 days of age, and 23 weeks gestation and above.

Heated humidified high-flow nasal cannula: use and a neonatal early extubation protocol.

OBJECTIVE: Respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD) are frequent complications of prematurity. To decrease ventilator-induced lung injury, we evaluated the safety, efficacy and neonatal outcomes of a heated humidified high-flow nasal cannula (HFNC) system and an early extubation protocol (EEP) designed for preterm infants 25 to 29 weeks' gestational age (GA). STUDY DESIGN: The Vapotherm (VT) high-flow humidification system was introduced to our unit in March 2004. After 10 months of VT use, an EEP was developed to begin January 2005. Infants 25 to 29 weeks of GA, intubated for RDS, were enrolled in January-December 2005 to extubate to VT following the EEP. Exclusion criteria were: major congenital anomalies, asphyxia and a 5 min Apgar score <5. Variables examined included BPD, growth and infection. Subjects were compared to historical controls, admitted January to December 2003, prior to the use of VT. RESULT: Inclusion criteria were met by 49/57 infants in the control group and 65/75 infants in the HFNC group. The groups had similar demographics, perinatal conditions, birthweight, GA, timing and total doses of surfactant. There were no differences in rates of extubation failure, patent ductus arteriosus, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, laser eye surgery, sepsis, BPD at 28 days and 36 weeks and death. The groups did not differ in oxygen use, i.v. steroid days, or parenteral nutrition days. Days to reach full feeds were similar. Infants in the HFNC group were extubated from a higher ventilator rate (32.6+/-8.5 vs 28+/-7.5, P=0.003) and spent fewer days on the ventilator (11.4+/-12.8 vs 18.5+/-21, P=0.028). Rates of ventilator-associated pneumonia were higher in the control group (P=0.018). Discharge weights were greater in the HFNC group (P=0.016) despite similar length of stay and GA at discharge. CONCLUSION: High-flow nasal cannula use appears safe and well-tolerated. Infants extubated to HFNC spent fewer days on the ventilator. Additional benefits may include a decreased rate of ventilator associated with pneumonia and improved growth.

Pesticide practices and suicide among farmers of the sundarban region in India.

BACKGROUND: Deliberate self-poisoning by ingesting pesticides is a serious health problem among farmers, especially in low- and middle-income countries. Preventing these suicides is a priority for a public mental health agenda. OBJECTIVE: To examine the role of pesticide poisoning in suicide and nonfatal deliberate self-harm, and clarify awareness of risks, safe practices concerning storage and use of pesticides, and associated self-injury, both unintentional and intentional, within farmer households of the Sundarban region, India. METHODS: Retrospective record review of adult cases of deliberate self-poisoning at the Block Primary Health Centres of 13 Sundarban Blocks was performed to analyze the relative roles of various methods of self-harm and their lethality. Focus group discussions, questionnaires, and in-depth interviews were undertaken in a community study of farmer households to examine pesticide-related views and practices, with particular attention to storage, use, and health impact. RESULTS: Pesticide poisoning was the most common method of deliberate self-harm in both men and women. Pesticide storage in most households was unsafe and knowledge was inadequate concerning adverse effects of pesticides on health, crops, and the environment. CONCLUSIONS: An intersectoral approach linking the interests of public health, mental health, and agriculture is well suited to serve the collective interests of all three agendas better than each in isolation. Such an approach is needed to reduce morbidity and mortality from unintentional and intentional self-injury in low-income agricultural communities like those of the Sundarban region.

Use of army weapons and private firearms for suicide and homicide in the region of Basel, Switzerland.

OBJECTIVES: Switzerland has one of the highest rates of firearm suicides in the world. International studies show a positive correlation between the rate of households with guns and femicides with guns. Because its defense system requires a militia to keep personal firearms at home, Switzerland has a high rate of households with a gun. METHODS: Records of suicides in the region of Basel between 1992 and 1996 were reviewed. Suicides with either army weapons or private firearms and suicides by other means were compared. Methods and types of homicides that occurred in the region at the same time were also analyzed. FINDINGS: Firearm suicides were clearly the most frequent means of suicide. They were also used in 30.0% of domestic homicides, although other means were used at similar rates. Firearms for suicide were mainly used by men, especially army weapons. These men were younger, professionally better qualified, and fewer had ever been treated in one of the local state psychiatric services. DISCUSSION: The use of firearms for suicide, rather than homicide, and particularly of army weapons by young, well-educated men, requires more attention in debates and informed policy regarding access to firearms and suicide prevention in Switzerland.

Impact of migration on illness experience and help-seeking strategies of patients from Turkey and Bosnia in primary health care in Basel.

Migration, particularly among refugees and asylum seekers, poses many challenges to the health system of host countries. This study examined the impact of migration history on illness experience, its meaning and help-seeking strategies of migrant patients from Bosnia and Turkey with a range of common health problems in general practice in Basel, Switzerland. The Explanatory Model Interview Catalogue, a data collection instrument for cross-cultural research which combines epidemiological and ethnographic research approaches, was used in semi-structured one-to-one patient interviews. Bosnian patients (n=36) who had more traumatic migration experiences than Turkish/Kurdish (n=62) or Swiss internal migrants (n=48) reported a larger number of health problems than the other groups. Psychological distress was reported most frequently by all three groups in response to focussed queries, but spontaneously reported symptoms indicated the prominence of somatic, rather than psychological or psychosocial, problems. Among Bosnians, 78% identified traumatic migration experiences as a cause of their illness, in addition to a range of psychological and biomedical causes. Help-seeking strategies for the current illness included a wide range of treatments, such as basic medical care at private surgeries, outpatients department in hospitals as well as alternative medical treatments among all groups. Findings provide a useful guide to clinicians who work with migrants and should inform policy in medical care, information and health promotion for migrants in Switzerland as well as further education of health professionals on issues concerning migrants health.

Community Psychiatry Clinics at Sundarban: a clinical and cultural experience.

A series of Community Psychiatric Clinics were conducted in different blocks of Sundarban region of West Bengal. One of the primary objectives of this was to collect clinical epidemiological data on psychiatric morbidity in the region. A total of 26 clinics were conducted in Sagar, Kakdwip, Canning and Gosaba block of the Sundarban region during the period from end 1998 to end 2000. A total of 451 psychiatric cases with diagnostic categories (male 239, female 212) and 215 non-psychiatric cases (male 107 and female 108) were seen in these clinics. Diagnostic Interview Schedules (SCID) and Clinical rating scales like Hamilton Depression Rating Scale and Brief Psychiatric Rating Scales were used to ascertain clinical diagnosis quantitatively. Special emphasis was given on common psychiatric disorders.

Stigma, depression, and somatization in South India.

OBJECTIVE: The relationships of stigma to both depression and somatization were studied in psychiatric patients in South India to test the hypothesis that stigma is positively related to depressive symptoms and negatively related to somatoform symptoms. METHOD: Illness experience, symptom prominence, and indicators of stigma for 80 psychiatric outpatients were addressed with the Explanatory Model Interview Catalogue. Stigma scores and ratings of symptom prominence were derived. The Structured Clinical Interview for DSM-III-R and the Hamilton Depression Rating Scale were administered to assess psychiatric diagnoses and symptoms of depression. Clinical narratives were analyzed to clarify the nature of relationships between stigma and symptom prominence. RESULTS: The mean stigma scores were 18.2 (SD = 13.0) for patients with somatoform disorders only, 36.0 (SD = 19.0) for patients with depressive disorders only, and 26.8 (SD = 16.0) for those with mixed depressive and somatoform disorders. The stigma scores were positively related to depressive symptoms, as indicated by Hamilton scale scores and prominence ratings for depressive symptoms, but stigma was inversely related to somatoform symptoms, as indicated by ratings of symptom prominence. Although both depressive and somatic symptoms were distressing, qualitative analysis clarified meanings of perceived stigma, showing that depressive symptoms, unlike somatic symptoms, were construed as socially disadvantageous. CONCLUSIONS: The tendency to perceive and report distress in psychological or somatic terms is influenced by various social and cultural factors, including the degree of stigma associated with particular symptoms. This study with the Explanatory Model Interview Catalogue demonstrates how quantitative and qualitative methods can be effectively combined to examine key issues in cultural psychiatry.

Psychiatric morbidity and illness experience of primary care patients with chronic fatigue in Hong Kong.

OBJECTIVE: The authors' goal was to examine the prevalence and experience of psychiatric morbidity among primary care patients with chronic fatigue in Hong Kong. METHOD: One hundred adult patients with medically unexplained fatigue for 6 or more months were assessed with the Explanatory Model Interview Catalogue, psychopathological rating scales, and an enhanced version of the Structured Clinical Interview for DSM-III-R. RESULTS: The lifetime prevalence of DSM-III-R depressive and anxiety disorders was 54%. Current depressive and anxiety disorders were identified in 28 patients, who exhibited more psychopathology and functional impairment than other patients. Thirty-three patients had somatoform pain disorder, and 30 had undifferentiated somatoform disorder, but most of them could also be diagnosed as having shenjing shuairuo (weakness of nerves) and, to a lesser extent, ICD-10 neurasthenia. Chronic fatigue syndrome diagnosed according to the 1988 Centers for Disease Control criteria was rare (3%) and atypical. Generally, patients mentioned fatigue if asked, but pains (36%), insomnia (20%), and worries (13%) were the most troublesome symptoms. Most patients attributed illness onset to psychosocial sources. CONCLUSIONS: Psychiatric morbidity was common among primary care patients with chronic fatigue. Subthreshold psychiatric morbidity was very common and was more validly represented by the disease construct of shenjing shuairuo or neurasthenia than somatoform disorder.

Attention to gender issues in tuberculosis control.

Although a seventy per cent excess of male over female TB cases are reported globally each year, the reasons for this difference are unclear. Generally, women in poor countries confront more barriers than men in accessing health care services. Yet, research is lacking to explain the impact of gender inequalities in access to care on reported sex ratios for TB. A review of the limited available literature and field visits to TB programmes offered insights and suggested a framework to study gender differentials in TB. This paper considers the role of gender at various steps in effective TB care. A research strategy to study and account for gender differences in TB control is proposed.

Bovine tuberculosis: an old disease but a new threat to Africa.

Bovine tuberculosis (TB) is a disease characterised by progressive development of specific granulomatous lesions or tubercles in lung tissue, lymph nodes or other organs. Mycobacterium bovis is the causative agent of the disease. Bovine species, including bison and buffaloes, are susceptible to the disease, but nearly all warm-blooded animals can be affected. All species are not equally susceptible to the disease; some are spill-over (end) hosts and others maintenance hosts. In Africa, bovine TB primarily affects cattle; however, infection in other farm and domestic animals, such as sheep, goats, pigs, dogs and cats, is not uncommon. Wild ruminants and carnivores are also affected and are the natural reservoirs of the infectious agent in the wild. Man is also susceptible to the disease, the highest risk groups being individuals with concomitant HIV/AIDS infection. In Africa, human TB is widely known to be caused by M. tuberculosis; however, an unknown proportion of cases are due to M. bovis. This infection in humans is under-reported as a result of the diagnostic limitations of many laboratories in distinguishing M. bovis from M. tuberculosis. None of the national reports submitted to the OIE and WHO by African member states mention the importance of M. bovis in human TB cases. Consumption of unpasteurised milk and poorly heat-treated meat and close contact with infected animals represent the main sources of infection for humans. This review attempts to examine the impact of bovine TB on the health of animals and humans.

Eating disorders and disordered eating in different cultures.

Clinical experience and research have moved the field toward greater recognition and differentiation of eating disorders as independent categories of mental disorder. Shorter's historical analysis, however, suggests that it may be useful to reconsider the relationship of AN and BN to the broader class of somatoform disorders. Also, by conferring legitimacy on this socially and culturally constructed disorder, mental health professionals may have seriously underestimated their unanticipated influence in propagating eating disorders with publicity aimed at preventing and curing them. Inasmuch as it offers an alternative or complement to the prevailing cultural hypothesis, which focuses on the effect of Western esthetics rather than the sociology of health care institutions, and has important implications for policy and publicity about eating disorders, the question of how culture and Westernization affect the epidemiology and experience of eating disorders also requires further study.

Genioglossal recruitment during acute hypoxia and hypercapnia in kittens.

We examined genioglossal and diaphragmatic EMG activities in one- and two-month-old anesthetized kittens during acute exposures to hypoxic (13% or 10% O2) and hyperoxic hypercapnic (8% CO2/50% O2/balanced N2) gas mixtures. Phasic genioglossal EMG activity, frequently characterized by a combined inspiratory-expiratory discharge pattern, was observed in 3 of 8 one-month-old vs. 7 of 7 two-month-old kittens during hypercapnia (Chi-square P less than 0.05). The percentage of kittens recruiting genioglossal activity during hypoxic exposures was similar at both ages (1 month, 75%; 2 month, 83%). Analysis of the breath-by-breath response during trials of hypoxia in which genioglossal recruitment was observed, however, revealed that the one-month-old kittens exhibited phasic genioglossal activity in only 40 +/- 27% of the stimulated breaths, compared to 63 +/- 26% for the two-month-old ones (P less than 0.05) at each level of hypoxia. In this regard, the genioglossal response to hypoxia in one-month-old kittens was frequently characterized by early and only transient recruitment (when diaphragmatic activity was at its peak), while genioglossal recruitment was more sustained in two-month-old animals. These data indicate that genioglossal activity in kittens is often recruited during exposures to hypercapnia and hypoxia, and suggest that such recruitment is more frequent with increasing postnatal age.

Cultural models of diarrheal illness: conceptual framework and review.

Health planning for diarrheal diseases must be responsive to both epidemiological patterns and local perceptions of health, illness and need. A conceptual framework that relates patterns of distress, explanatory models, help seeking and treatment practices to knowledge and use of oral rehydration therapy (ORT), dietary management, other specific treatments and health policy issues provides the basis for our review of research on diarrheal illness-related beliefs and practices. The ethnomedical model asserts that efforts to secure the compliance of target populations are likely to be inadequate without an alliance between health professionals and communities to identify and address mutually comprehensible objectives that are perceived locally as meaningful and relevant. An appreciation of local cultural models and the diversity of cultural contexts enables health professionals to (1) recognize the significance of local perceptions of diarrheal illness with respect to pertinent outcomes and perceived needs, (2) develop ways to introduce recommendations that communities will accept, and (3) make appropriate use of existing community resources representing local traditions. An agenda for needed research concludes the review.

Humoral concepts of mental illness in India.

Based on interviews with patients at three allopathic psychiatric clinics in Bombay, Bangalore and Varanasi, employing a preliminary version of the Explanatory Model Interview for Classification (EMIC) to elicit indigenous explanations of illness and patterns of prior help seeking, we discuss popular humoral theories of mental disorder. Even though most laypersons are unfamiliar with the content of the classical treatises of Ayurveda, the humoral traditions which they represent influence current perceptions. Case vignettes clarify the nature of the relationship between cultural, familial and personal factors that influence the experience of illness.