Speaking of Hunger: Food Shortages, Poverty and Community Assistance in Urban South Africa.

How people speak of hunger extends beyond statements about food adequacy; people's remarks may reflect experiences of poverty and feelings of vulnerability, and may be used to request help. In this article, we build on the idea of idioms of distress to conceptualize hunger talk as expressing more than an empty belly. We draw on ethnographic data gathered in two settings in South Africa: one a peri-urban area under traditional jurisdiction in the Eastern Cape Province; the other an inner-city suburb of the largest city, Johannesburg, in Gauteng. Hunger-related idioms of distress help illustrate the complex interplay of social, economic, and cultural factors, and allow people to speak of various affective and material aspects of their lives.

Risk, lifestyle and non-communicable diseases of poverty.

Common discourse in public health and preventive medicine frames non-communicable diseases, including cardiovascular and metabolic diseases, as diseases of 'lifestyle'; the choice of terminology implies that their prevention, control and management are amenable to individual action. In drawing attention to global increases in the incidence and prevalence of non-communicable disease, however, we increasingly observe that these are non-communicable diseases of poverty. In this article, we call for the reframing of discourse to emphasize the underlying social and commercial determinants of health, including poverty and the manipulation of food markets. We demonstrate this by analysing trends in disease, which indicate that diabetes- and cardiovascular-related DALYS and deaths are increasing particularly in countries categorized as low-middle to middle levels of development. In contrast, countries with very low levels of development contribute least to diabetes and document low levels of CVDs. Although this might suggest that NCDs track increased national wealth, the metrics obscure the ways in which the populations most affected by these diseases are among the poorest in many countries, and hence, disease incidence is a marker of poverty not wealth. We also illustrate variations in five countries - Mexico, Brazil, South Africa, India and Nigeria - by gender, and argue that these differences are associated with gender norms that vary by context rather than sex-specific biological pathways.We tie these trends to shifts in food consumption from whole foods to ultra-processed foods, under colonialism and with continued globalization. Industrialization and the manipulation of global food markets influence food choice in the context of limited household income, time, and household and community resources. Other factors that constitute risk factors for NCDs are likewise constrained by low household income and the poverty of the environment for people with low income, including the capacity of individuals in sedentary occupations to engage in physical activity. These contextual factors highlight extremely limited personal power over diet and exercise. In acknowledging the importance of poverty in shaping diet and activity, we argue the merit in using the term non-communicable diseases of poverty and the acronym NCDP. In doing so, we call for greater attention and interventions to address structural determinants of NCDs.

Social innovation in health: strengthening Community Systems for Universal Health Coverage in rural areas.

BACKGROUND: In seeking the attainment of Universal Health Coverage (UHC), there has been a renewed emphasis on the role of communities. This article focuses on social innovation and whether this concept holds promise to enhance equity in health services to achieve UHC and serve as a process to enhance community engagement, participation, and agency. METHODS: A cross-country case study methodology was adopted to analyze three social innovations in health in three low- and middle-income countries (LMICs): Philippines, Malawi, and Colombia. Qualitative methods were used in data collection, and a cross-case analysis was conducted with the aid of a simplified version of the conceptual framework on social innovation as proposed by Cajaiba-Santana. This framework proposes four dimensions of social innovation as a process at different levels of action: the actors responsible for the idea, the new idea, the role of the institutional environment, and the resultant changes in the health and social system. RESULTS: The study found that each of the three social innovation case studies was based on developing community capacities to achieve health through community co-learning, leadership, and accountability. The process was dependent on catalytic agents, creating a space for innovation within the institutional context. In so doing, these agents challenged the prevailing power dynamics by providing the communities with respect and the opportunity to participate equally in creating and implementing programs. In this way, communities were empowered; they were not simply participants but became active agents in conceptualizing, implementing, monitoring, and sustaining the social innovation initiatives. CONCLUSION: The study has illustrated how three creative social innovation approaches improved access and quality of health services for vulnerable rural populations and increased agency among the intervention communities. The processes facilitated empowerment, which in turn supported the sustained strengthening of the community system and the achievement of community goals in the domain of health and beyond.

What factors shape quality of life for women affected by gynaecological cancer in South, South East and East Asian countries? A critical review.

BACKGROUND: Gynaecological cancers are among the most prevalent cancers worldwide, with profound effects on the lives of women and their families. In this critical review, we explore the impacts of these cancers on quality of life (QOL) of women in Asian countries, and highlight areas for future inquiry. METHODS: A systematic search of the literature was conducted in six electronic databases: Web of Science, Scopus, Global Health (CAB Direct), PsycINFO (Ovid), EBMR (Ovid), and Medline (Ovid). Screening resulted in the inclusion of 53 relevant articles reporting on 48 studies. RESULTS: Most studies were conducted in high and upper-middle income countries in East Asia and used quantitative approaches. Women had predominantly been diagnosed with cervical or ovarian cancer, and most had completed treatment. Four key interrelated domains emerged as most relevant in shaping QOL of women affected by gynaecological cancer: support, including identified needs, sources and forms; mental health, covering psychological distress associated with cancer, risk and protective factors, and coping strategies; sexual function and sexuality, focused on physiological, emotional and relational changes caused by gynaecological cancers and treatments, and the impacts of these on women's identities; and physical health, covering the physical conditions associated with gynaecological cancers and their impacts on women's daily activities. CONCLUSION: QOL of women affected by gynaecological cancer is shaped by their mental and physical health, support, and changes in sexual function and sexuality. The limited number of studies from lower- and middle-income countries in South and Southeast Asia highlights important knowledge gaps requiring future research.

Multiple factors shape the quality of life of women affected by gynaecological cancers in Asian countries as elsewhere. We identified 53 articles reporting on 48 studies, most conducted in high- and upper-middle income East Asian countries, with much less attention to women in lower income countries in South and Southeast Asia. Most studies used quantitative research methods to gain an understanding of the impact on women diagnosed with cervical or ovarian cancer who had completed treatment. Women's quality of life was shaped by their mental and physical health, their support needs, and the changes they experienced in sexual function and sexuality.

PROXEMICS, COVID-19, AND THE ETHICS OF CARE IN SOUTH AFRICA.

In South Africa, lockdown and its excesses have opened up questions on the limits of an ethics of care, whose ethics are privileged, how care is delivered, and what care means. We show how an ethics of proxemics and its operationalization as distance highlight everyday inequalities and limit the provision of care. Constraints on physical distancing in line with public health measures intended to limit the spread of the coronavirus echo the controls enforced under apartheid, showing how inequality is both embodied and legally entrenched.

Adolescents living with HIV, complex needs and resilience in Blantyre, Malawi.

BACKGROUND: Adolescents living with HIV (ALHIV) in Malawi experience multiple challenges associated with their illness and various social, environmental, economic and cultural factors. In exploring their various medical concerns and social vulnerabilities, we consider the role of multiple services in creating a pathway for resilience. METHODS: Multiple methods and case studies allowed for triangulation of evidence and provided a holistic understanding of resilience among adolescents with complex needs. The research methods included: (1) a survey to identify examples of young people with complex needs, (2) qualitative interviews and field notes to further explore these needs, (3) patient files and health passports to identify clinical challenges, and (4) ecomapping exercises to personalize cases and identify resilience-enabling resources and supports. We present four case studies to highlight the complex experiences and access to services of ALHIV, and to illustrate their growing power and decision-making capacity over time. RESULTS: Adversity experienced by ALHIV varied by gender, family situation, years of schooling, and use of teen-clubs for support. The two female adolescents emphasised their need to be accepted and how this impacted sexuality and reproduction. The two males illustrated how ideas of masculinity influenced their sexual practice and involvement with health services and the correctional justice system. Multiple risks (alcohol use, sexual activities) and complex needs (belonging, having a purpose in life/productive activities, autonomy, desire for offspring) influence pathways to resilience. ALHIV were able to strengthen their own wellbeing by resisting negative behaviours and peer pressure and caregiver interactions through 'strategic silence'. CONCLUSION: ALHIV experienced self-transformation as a result of taking ART, with fewer severe episodes of illness and distressing skin conditions. Continuous engagement at the teen-club clinic transformed both productive activities and social relationships among ALHIV as they set life goals, gained a sense of empowerment, requested SRH services, and formed intimate relationships. These transformative opportunities allowed them to learn ways of minimizing risk of reinfection and violence, and of navigating health worker-caregiver-adolescent interactions.

Conflict and care in sexual and reproductive health services for young mothers in urban South Africa.

In South Africa, sexual and reproductive health services aim to facilitate access to and utilisation of care to young people. We draw on narrative interviews with 45 young mothers and six health care providers delivering sexual and reproductive health services at an urban health centre, to understand how young mothers experienced services in relation to ante- and post-natal care, including termination services. Although health care providers emphasised what they considered young women's 'ignorance' and 'irresponsibility' as central to early and unintended pregnancy; they also expressed their sympathy and concern. In a resource-limited health care setting, with health system inefficiencies and lack of specialised training, there was little opportunity to deliver high-quality care to young women. We draw attention to the need to prioritise the training of health care providers to expand early pregnancy testing and termination services and to deliver patient-centred family planning services to young women.

"But this is a good cancer:" Patient perceptions of endometrial cancer in Denmark.

AIMS AND OBJECTIVES: To explore endometrial cancer patients' perceptions of the disease and the influence of favourable prognoses on their experiences. BACKGROUND: Endometrial cancer is associated with favourable prognoses, which may imply that patients experience distress to a lesser extent than other cancer patients with less positive treatment outcomes. However, most people with cancer report reduced quality of life and, despite endometrial cancer being prevalent worldwide, experiences of the disease have been little explored. DESIGN: Ethnographic fieldwork with participant observations and interviews. METHODS: Observations during clinical consultations at two Danish hospitals and interviews with women with endometrial cancer (n = 18) over a period of 6 months. The article adheres to the COREQ guidelines for reporting qualitative research. RESULTS: We identify how patients consider cancer in general very likely to be fatal, while clinicians in contrast characterise endometrial cancer specifically as "good" because of favourable prognoses. We employ the concept of bricolage to illustrate how bits and pieces of biomedical knowledge and statistical evidence become intertwined with patients' past experiences and subjective ways of knowing, suggesting that patients' perceptions of endometrial cancer as a disease are somewhat dynamic. CONCLUSIONS: Public stories and everyday life experiences of cancer provide a central framework for illness perceptions. As a result, patients retain the idea of a close connection between cancer and death, while also adopting the notion of endometrial cancer as "good". This influenced how women responded to treatment and care. Framing endometrial cancer as "good" is not always helpful, as the impact of a cancer diagnosis per se is rarely favourable. RELEVANCE TO CLINICAL PRACTICE: In providing women with endometrial cancer with optimal support through diagnosis and treatment, clinicians should attend to the complexity of patients' illness understandings and be aware that assuring patients of a good prognosis not always has the expected impact.

Outdoor malaria transmission risks and social life: a qualitative study in South-Eastern Tanzania.

BACKGROUND: Behaviour changes in mosquitoes from indoor to outdoor biting result in continuing risk of malaria from outdoor activities, including routine household activities and occasional social and cultural practices and gatherings. This study aimed to identify the range of social and cultural gatherings conducted outdoors and their associated risks for mosquito bites. METHODS: A cross-sectional study was conducted in four villages in the Kilombero Valley from November 2015 to March 2016. Observations, focus group discussions, and key informant interviews were conducted. The recorded data were transcribed and translated from Swahili to English. Thematic content analysis was used to identify perspectives on the importance of various social and cultural gatherings that incidentally expose people to mosquito bites and malaria infection. RESULTS: Religious, cultural and social gatherings involving the wider community are conducted outdoors at night till dawn. Celebrations include life course events, religious and cultural ceremonies, such as Holy Communion, weddings, gatherings at Easter and Christmas, male circumcision, and rituals conducted to please the gods and to remember the dead. These celebrations, at which there is minimal use of interventions to prevent bites, contribute to individual satisfaction and social capital, helping to maintain a cohesive society. Bed net use while sleeping outdoors during mourning is unacceptable, and there is minimal use of other interventions, such as topical repellents. Long sleeve clothes are used for protection from mosquito bites but provide less protection. CONCLUSION: Gatherings and celebrations expose people to mosquito bites. Approaches to prevent risks of mosquito bites and disease management need to take into account social, cultural and environmental factors. Area specific interventions may be expensive, yet may be the best approach to reduce risk of infection as endemic countries work towards elimination. Focusing on single interventions will not yield the best outcomes for malaria prevention as social contexts and vector behaviour vary.

Talking about sex in pregnancy: reflections from the field in urban South Africa.

Qualitative research with close engagement in the field allows researchers and participants to build relationships and establish trust, enabling researchers to collect meaningful and sensitive information. Drawing on findings from a study conducted in an urban setting in South Africa, we discuss the challenges faced when interviewing pregnant women with HIV infection, retaining them in the study, and extending the study to include their partners. We discuss the dynamics of pregnancy and draw lessons from interviews concerned with personal, sensitive issues. The study on which we draw was conducted in Johannesburg, South Africa, and was nested in a larger prospective cohort study of women and their infants, which in turn was part of a case control study. Sensitive topics are difficult and complex, but to ignore these and stay in safe territory is to ignore some of the most pressing questions of our time. It is important that those who conduct interviews are well trained and able to engage empathetically with participants, and that some form of counselling is available for both participants and researchers.

Social determinants of disability-based disadvantage in Solomon islands.

Development discourse widely recognises that disability is the result of economic and social processes and structures that fail to accommodate persons with disabilities. Empirical work on the relationship between disability and poverty however, conceptualize poverty through an economic resource lens in high-income countries. To address this conceptual gap this article uses a social determinants of health perspective to examine how socio-cultural, economic and political contexts shape disability-based disadvantage. This article draws upon ethnographic research and supplementary data collected using rapid assessment techniques in Solomon Islands. Findings suggest that the disability-poverty nexus and inequalities in health, wellbeing and quality of life must be understood within broader patterns of social vulnerability that are institutionalised in landownership and patterns of descent, gendered power relations and disability specific stigmas that preclude social and productive engagement . This article demonstrates how a social determinant of health perspective that closely examines lived experiences of disability provides critical analytical insights into the structural mechanisms that constitute disability-based disadvantage. This article provides foundation knowledge on which policies and further research to promote disability-inclusion and equity can be based.

Changes in mood after screening for antenatal anxiety and depression.

BACKGROUND: Screening programmes with referral are a valuable strategy for mitigating consequences of perinatal depression on mothers and their families. The effectiveness of these screening programmes needs to be measured. One potential problem in assessing outcomes is measurement reactivity where the actual measure results in changes in the people being measured. AIM: The aim of this article is to explain the mechanisms and circumstances by which measurement reactivity occurred in a sample of antenatal women who participated in a screening interview. METHODS: Fifty-five women who participated in an antenatal screening interview in their second trimester were re-interviewed in their third trimester. These qualitative interviews were conducted between September 2015 and April 2016. RESULTS: The qualitative data suggested that measurement reactivity occurred through mechanisms such as the disclosure, gaining self-knowledge, validation of experiences, and personal agency which resulted in them seeking out support from others. CONCLUSION: Although the screening interview appeared to improve women's outcomes, this may have occurred through measurement reactivity. This needs to be considered when designing studies that aim to assess the effectiveness of screening with intervention for antenatal depression.

Community perceptions on outdoor malaria transmission in Kilombero Valley, Southern Tanzania.

BACKGROUND: The extensive use of indoor residual spraying (IRS) and insecticide-treated nets (ITNs) in Africa has contributed to a significant reduction in malaria transmission. Even so, residual malaria transmission persists in many regions, partly driven by mosquitoes that bite people outdoors. In areas where Anopheles gambiae s.s. is a dominant vector, most interventions target the reduction of indoor transmission. The increased use of ITNs/LLINs and IRS has led to the decline of this species. As a result, less dominant vectors such as Anopheles funestus and Anopheles arabiensis, both also originally indoor vectors but are increasingly biting outdoors, contribute more to residual malaria transmission. The study reports the investigated community perceptions on malaria and their implications of this for ongoing outdoor malaria transmission and malaria control efforts. METHODS: This was a qualitative study conducted in two rural villages and two peri-urban areas located in Kilombero Valley in south-eastern Tanzania. 40 semi-structured in-depth interviews and 8 focus group discussions were conducted with men and women who had children under the age of five. The Interviews and discussions focused on (1) community knowledge of malaria transmission, and (2) the role of such knowledge on outdoor malaria transmission as a contributing factor to residual malaria transmission. RESULTS: The use of bed nets for malaria prevention has been stressed in a number of campaigns and malaria prevention programmes. Most people interviewed believe that there is outdoor malaria transmission since they use interventions while indoors, but they are unaware of changing mosquito host-seeking behaviour. Participants pointed out that they were frequently bitten by mosquitoes during the evening when outdoors, compared to when they were indoors. Most participants stay outdoors in the early evening to undertake domestic tasks that cannot be conducted indoors. House structure, poor ventilation and warm weather conditions were reported to be the main reasons for staying outdoors during the evening. Participants reported wearing long sleeved clothes, fanning and slapping themselves, using repellents, and burning cow dung and neem tree leaves to chase away mosquitoes. CONCLUSIONS: Community understanding of multiple prevention strategies is crucial given changes in mosquito host seeking behaviour and the increased incidence of outdoor biting. The current low use of outdoor control measures is attributed largely to limited awareness of outdoor transmission. Improved community understanding of outdoor malaria transmission is critical: efforts to reduce or eliminate malaria transmission will not be successful if the control of outdoor transmission is not emphasized.

Policy perspectives on post pandemic influenza vaccination in Ghana and Malawi.

BACKGROUND: In the late 1990s, in the context of renewed concerns of an influenza pandemic, countries such as Ghana and Malawi established plans for the deployment of vaccines and vaccination strategies. A new pandemic was declared in mid-June 2009, and by April 2011, Ghana and Malawi vaccinated 10% of the population. We examine the public health policy perspectives on vaccination as a means to prevent the spread of infection under post pandemic conditions. METHODS: In-depth interviews were conducted with 46 policymakers (Ghana, n = 24; Malawi, n = 22), identified through snowballing sampling. Interviews were supplemented by field notes and the analysis of policy documents. RESULTS: The use of vaccination to interrupt the pandemic influenza was affected by delays in the procurement, delivery and administration of vaccines, suboptimal vaccination coverage, refusals to be vaccinated, and the politics behind vaccination strategies. More generally, rolling-out of vaccination after the transmission of the influenza virus had abated was influenced by policymakers' own financial incentives, and government and foreign policy conditionality on vaccination. This led to confusion about targeting and coverage, with many policymakers justifying that the vaccination of 10% of the population would establish herd immunity and so reduce future risk. Ghana succeeded in vaccinating 2.3 million of the select groups (100% coverage), while Malawi, despite recourse to force, succeeded only in vaccinating 1.15 million (74% coverage of select groups). For most policymakers, vaccination coverage was perceived as successful, despite that vaccination delays and coverage would not have prevented infection when influenza was at its peak. CONCLUSIONS: While the vaccination strategy was problematic and implemented too late to reduce the effects of the 2009 epidemic, policy makers supported the overall goal of pandemic influenza vaccination to interrupt infection. In this context, there was strong support for governments engaging in contracts with pharmaceutical companies to ensure the timely supply of vaccines, and developing well-defined guidelines to address vaccination delays, refusals and coverage.

Cultural beliefs about TBI in Botswana.

Cultural differences have been shown to have an influence on outcome following traumatic brain injury (TBI). This study examined illness representations and the nature of beliefs about TBI in Botswana, a small middle income country in southern Africa. Participants included 26 people who had sustained moderate to severe TBI, 18 caregivers (all significant others) and 27 healthcare workers. A mixed-methods approach was utilised. Illness representations were assessed using the revised Illness Perception Questionnaire (IPQ-R), and beliefs and perceptions about cause of injury were established through semi-structured qualitative interviews. Results indicated that participants considered TBI to be chronic in nature and accompanied by serious consequences. Participants held positive attitudes about the manageability of symptoms despite having little understanding about TBI and its consequences. People with TBI tended to report fewer symptoms than did their caregivers. In addition, although some participants held concrete beliefs about the causes of injury, many participants attributed the injury to supernatural causes. Religious interpretations were also commonly held. Although age appeared to be associated with beliefs, no significant relationships existed between demographic factors and beliefs about the injury. This study highlights the importance of understanding the cultural perspectives of patients and their families in order to provide effective care.

Mental Ill Health, Recovery and the Family Assemblage.

The recovery approach is now among the most influential paradigms shaping mental health policy and practice across the English-speaking world. While recovery is normally presented as a deeply personal process, critics have challenged the individualism underpinning this view. A growing literature on "family recovery" explores the ways in which people, especially parents with mental ill health, can find it impossible to separate their own recovery experiences from the processes of family life. While sympathetic to this literature, we argue that it remains limited by its anthropocentricity, and therefore struggles to account for the varied human and nonhuman entities and forces involved in the creation and maintenance of family life. The current analysis is based on an ethnographic study conducted in Australia, which focused on families in which the father experiences mental ill health. We employ the emerging concept of the "family assemblage" to explore how the material, social, discursive and affective components of family life enabled and impeded these fathers' recovery trajectories. Viewing families as heterogeneous assemblages allows for novel insights into some of the most basic aspects of recovery, challenging existing conceptions of the roles and significance of emotion, identity and agency in the family recovery process.

Barriers and challenges affecting the contemporary church's engagement in health promotion.

Issue addressed Christian churches have historically undertaken welfare and community service activities to practise faith and increase their relevance to communities. However, the church in Australia has received little attention from health promotion practitioners and researchers. The objective of this qualitative study was to explore the barriers and challenges that affect church engagement in health promotion to assist practitioners' understanding of the potential for these civil society organisations to play a role in health promotion programs and partnerships. Methods The research was based on interviews with five directors of church-affiliated organisations and with the church leaders (ministers, pastors, priests) of 30 churches in urban and rural Victoria. Analysis was iterative using open, axial and thematic coding. Results The challenges to church involvement in health promotion, as articulated by church leaders, fell under the themes of the social context of churches and the attributes of congregations. Major issues raised were perceived relevance, mistrust, contested agendas, discordant values within congregations, and risk management. Conclusion Although churches may take a different stance to health promotion agencies on a range of social and health issues, many have experience addressing social disadvantage and are prepared to commit resources to meet the needs of people outside their congregations. However, several factors inhibit the engagement of churches in health promotion including perceived irrelevance and community mistrust, agendas of conversion and values that conflict with health promotion. So what? Churches have a history of addressing social determinants of health such as housing, employment and food security. Deeper understanding of the challenges and barriers church leaders experience in undertaking health promotion work will facilitate more realistic and effective engagement by practitioners with these organisations.

Emotional Well-Being Following Religious Conversion Among Women in Northeast Thailand.

Religious conversion can have a profound impact on individual mental health and emotional well-being. These changes may need specific nursing care. In this article, we describe the lived experiences of 21 women who converted from Buddhism to Islam and who live in Isan, the northeast region of Thailand. The data derive from in-depth interviews, natural conversations, and observations. Thematic analysis revealed two dominant themes: women's sense of happiness in their new faith, and their suffering following from and as a result of their conversion. To provide appropriate care to and prevent mental health problems among Isan women who convert from Buddhism to Islam, and other women in similar contexts, health providers need to enhance their understanding of conversion and to be aware of life experiences that impact on their emotional well-being.

Fragility, fluidity, and resilience: caregiving configurations three decades into AIDS.

HIV and AIDS have impacted on social relations in many ways, eroding personal networks, contributing to household poverty, and rupturing intimate relations. With the continuing transmission of HIV particularly in resource-poor settings, families and others must find new ways to care for those who are living with HIV, for those who are ill and need increased levels of personal and medical care, and for orphaned children. These needs occur concurrently with changes in family structure, as a direct result of HIV-related deaths but also due to industrialization, urbanization, and labor migration. In this special issue, the contributing authors draw on ethnographies from South Africa, Swaziland, Lesotho, Zambia, and - by way of contrast - China, to illustrate how people find new ways of constituting families, or of providing alternatives to families, in order to provide care and support to people infected with and afflicted by HIV.

Community health workers, recipients' experiences and constraints to care in South Africa - a pathway to trust.

Community health workers (CHWs) affiliated with community-based organisations are central to the implementation of primary health care in district health services in South Africa. Here, we explore factors that affect the provision of and access to care in two provinces - Gauteng and Eastern Cape. Drawing on narratives of care recipients and the CHWs who support them, we illustrate the complex issues surrounding health maintenance and primary care outreach in poor communities, and describe how the intimate interactions between providers and recipients work to build trust. In the study we report here, householders in Gauteng Province had poor access to health care and other services, complicating the impoverished circumstances of their everyday lives. The limited resources available to CHWs hindered their ability to meet householders' needs and for householders to benefit from existing services. CHWs in the Eastern Cape were better able to address the needs of poor householders because of the organisational support available to them. Based on an ethos of integrated and holistic care, this enabled the CHWs to address the recipients' context-related needs, and health and medical needs, while building greater levels of trust with their clients.