Responses of rural agricultural households to agricultural policies in South Africa.

Thesis (M.Soc.Sc.)-University of Natal, Pietermaritzburg, 1997.No abstract available

Seeking referral care for newborns in eastern Uganda : community health workers' role, caretakers' compliance and provision of care

Background: Newborn deaths contribute 44% of all under-five deaths. Community health worker (CHW) during home-visits may identify and refer newborns to health facilities for postnatal care and treatment of danger signs. However, little is known on the care seeking practices and health system capacity to care for healthy and sick newborns in sub Saharan Africa. Objective: The overall objective of the studies was to assess newborn referral care seeking practices, compliance, and associated community and health systems factors in order to inform scale up of newborn care programs in Uganda and other low income countries with high newborn mortality. Methods: Four studies (I-IV) nested within a cluster randomized trial were conducted between 2011 and 2013 at the Iganga-Mayuge Health Demographic Surveillance Site in eastern Uganda. In Study I, focus group discussions (n=12) with men and women and in-depth interviews (n=11) with mothers and traditional birth attendants were used to obtain a deeper understanding of the social and cultural factors that affect caretakers’ compliance with community newborn referrals. Case vignettes, observations through role plays and record reviews were used in a cross sectional study to assess the ability of 57 trained community health workers to identify and refer sick newborns to health facilities (Study II). Study (III) was retrospective cohort of all referred newborns, during which interviews were held with 700 caretakers to determine compliance rate to seek health facility based care within 24-hours of a referral. In a cross sectional study, capacity to provide newborn care was assessed in all the 20 health facilities within the cluster randomized trial, using observations and interviews with of health workers (Study IV). Results: Community members understood the newborn period differently from health workers. A seclusion period observed immediately after birth restricted movement of the mother and newborn until the umbilical cord dropped off, but was not binding in case of illness (Study I). Of the 57 CHWs assessed, 68% were considered knowledgeable with a median knowledge score of 100% (IQR 94%-100%), and 36 (63%) considered skilled in identifying sick newborns (Study II). A total of 724 newborns were referred, of which 700 were successfully traced. Fifty three percent (373/700) were referred for postnatal care/immunization and 47% because they had at least one danger sign (Study III). Overall, 63% of the caretakers of referred newborns complied within less than24 hours, but more caretakers of sick newborns (243/327, 74%) complied, compared with 196/373 (53%) of those referred for immunization and postnatal care (p<0.001). A majority, (493, 77%) sought care from lower level health facilities. The determinants of compliance were: referred for danger signs Adjusted Odds Ratio (AOR) = 2.3, (95% CI: 1.6-3.5); CHW making a reminder visit to the referred newborn shortly after referral (AOR =1.7; 95% CI: 1.2 –2.7); and age of mother being 25-29 or 30-34 years, (AOR =0.4; 95% CI: 0.2 - 0.8) and (AOR = 0.4; 95% CI: 0.2 - 0.8) respectively; compared to the age group of less than 20 years (Study III). Fifteen of the 20 health facilities offered newborn care but level II facilities had the lowest availability score for resuscitation equipment (31%,) or newborn sepsis drugs (8%), and none offered kangaroo mother care. Two-thirds (33/50, 66%) of the health facility workers were considered knowledgeable in newborn care, but less than a half (17/42, 41%) skilled in newborn resuscitation (Study IV). Conclusion: Trained community health workers when engaged in maternal-newborn programs can assist caretakers to recognize sick newborns, change long held norms like the ‘seclusion’ and achieve good referral care seeking for newborns. There was high compliance with referrals, and caretakers mainly sought care from first level facilities which lacked capacity to care for sick newborns. Health workers had good knowledge about newborn care but unsatisfactory skills for resuscitation of newborns. Wherever deliveries are conducted there must also be health service readiness to care for newborn asphyxia and low-birth weight/prematurity. Policy and practice needs to change to enable lowest level health centres (HCII) to care for newborns with possible septicemia

Atypical hematological manifestation of celiac disease: A case report of aplastic anemia in a 2-year-old child and review of the literature.

Celiac disease typically presents with symptoms of malabsorption, but extraintestinal manifestations are increasingly reported. Aplastic anemia as the mode of celiac disease presentation is extremely rare in children. We report a 2-year-old boy who presented with loose stools, loss of appetite, and bicytopenia with severe aregenerative normocytic anemia. Investigations, including bone marrow aspirate and biopsy, revealed aplastic anemia. Screening for malabsorption showed increased plasma concentrations of anti-transglutaminase and anti-gliadin antibodies. A duodenal biopsy confirmed the histologic features of celiac disease. The child received a packed red cell transfusion and was started on a gluten-free diet, with a very good prognosis and normalization of both his blood and histological parameters. To the best of our knowledge, our report is the sixth pediatric case in the literature. Screening for celiac disease should be performed in children with unexplained hematological abnormalities such as aplastic anemia with or without gastrointestinal symptoms

A systematic review of community-to-facility neonatal referral completion rates in Africa and Asia

Background An estimated 2.8 million neonatal deaths occur annually worldwide. The vulnerability of newborns makes the timeliness of seeking and receiving care critical for neonatal survival and prevention of long-term sequelae. To better understand the role active referrals by community health workers play in neonatal careseeking, we synthesize data on referral completion rates for neonates with danger signs predictive of mortality or major morbidity in low- and middle-income countries. Methods A systematic review was conducted in May 2014 of the following databases: Medline-PubMed, Embase, and WHO databases. We also searched grey literature. In addition, an investigator group was established to identify unpublished data on newborn referral and completion rates. Inquiries were made to the network of research groups supported by Save the Children’s Saving Newborn Lives project and other relevant research groups. Results Three Sub-Saharan African and five South Asian studies reported data on community-to-facility referral completion rates. The studies varied on factors such as referral rates, the assessed danger signs, frequency of home visits in the neonatal period, and what was done to facilitate referrals. Neonatal referral completion rates ranged from 34 to 97 %, with the median rate of 74 %. Four studies reported data on the early neonatal period; early neonatal completion rates ranged from 46 to 97 %, with a median of 70 %. The definition of referral completion differed by studies, in aspects such as where the newborns were referred to and what was considered timely completion. Conclusions Existing literature reports a wide range of neonatal referral completion rates in Sub-Saharan Africa and South Asia following active illness surveillance. Interpreting these referral completion rates is challenging due to the great variation in study design and context. Often, what qualifies as referral and/or referral completion is poorly defined, which makes it difficult to aggregate existing data to draw appropriate conclusions that can inform programs. Further research is necessary to continue highlighting ways for programs, governments, and policymakers to best aid families in low-resource settings in protecting their newborns from major health consequences

The Ambiguity Imperative: "Success" in a Maternal Health Program in Uganda

Global health programs are compelled to demonstrate impact on their target populations. We study an example of social franchising - a popular healthcare delivery model in low/middle-income countries - in the Ugandan private maternal health sector. The discrepancies between the program's official profile and its actual operation reveal the franchise responded to its beneficiaries, but in a way incoherent with typical evidence production on social franchises, which privileges simple narratives blurring the details of program enactment. Building on concepts of not-knowing and the production of success, we consider the implications of an imperative to maintain ambiguity in global health programming and academia

Abortion decision-making trajectories and factors influencing such trajectories in low- and middle-income countries: a protocol for mixed-methods systematic review.

Introduction Globally, about half of all pregnancies are unintended and/or unwanted and three-fifths of these end in induced abortion. When faced with a choice to terminate pregnancy, women’s abortion decision-making processes are often complex and multiphasic and maybe amplified in low- and middle-income countries (LMICs) which bear the major burden of abortion-related morbidity and mortality. Our review aims to (1) describe abortion decision-making trajectories for women in LMICs and (2) investigate factors influencing the choice of abortion decision-making trajectories in LMICs. Methods and analysis We will search and retrieve published and unpublished qualitative, quantitative and mixed-methods, community and/or hospital-based studies conducted in LMICs from 1 January 2000 up to 16 February 2021. We will search Ovid Medline, Ovid EMBASE, Ovid PsycInfo, Ovid Global Health, Web of Science (including Social Science Citation Index), Scopus, IBSS, CINAHL via EBSCO, WHO Global Index Medicus, the Cochrane Library, WHO website, ProQuest and Google Scholar. We will search reference lists of eligible studies and contact experts for additional data/information, if required. We will extract all relevant data to answer our research questions and assess study quality using the appropriate appraisal tools. Depending on the extracted data, our analysis will use sequential or convergent synthesis methods proposed by Hong et al. For qualitative studies, we will synthesise evidence using thematic synthesis, meta-ethnography or ‘best-fit’ framework synthesis; and for quantitative findings, we will provide a narrative synthesis and/or meta-analysis. We will do sensitivity analyses and assess confidence in our findings using Grades of Recommendation, Assessment, and Evaluation –Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQUal) for qualitative findings and Grades of Recommednation, Assessment, and Evaluation (GRADE) for quantitative findings. Ethics and dissemination We did not require ethics approval for this systematic review. We will publish our findings in an open-access peer-reviewed journal with global and maternal health readership. We will also present our findings at national and international scientific conferences

Abortion decision-making process trajectories and determinants in low- and middle-income countries: A mixed-methods systematic review and meta-analysis.

Background: About 45.1% of all induced abortions are unsafe and 97% of these occur in low- and middle-income countries (LMICs). Women's abortion decisions may be complex and are influenced by various factors. We aimed to delineate women's abortion decision-making trajectories and their determinants in LMICs. Methods: We searched Medline, EMBASE, PsychInfo, Global Health, Web of Science, Scopus, IBSS, CINAHL, WHO Global Index Medicus, the Cochrane Library, WHO website, ProQuest, and Google Scholar for primary studies and reports published between January 1, 2000, and February 16, 2021 (updated on June 06, 2022), on induced abortion decision-making trajectories and/or their determinants in LMICs. We excluded studies on spontaneous abortion. Two independent reviewers extracted and assessed quality of each paper. We used "best fit" framework synthesis to synthesise abortion decision-making trajectories and thematic synthesis to synthesise their determinants. We analysed quantitative findings using random effects model. The study protocol is registered with PROSPERO number CRD42021224719. Findings: Of the 6960 articles identified, we included 79 in the systematic review and 14 in the meta-analysis. We identified nine abortion decision-making trajectories: pregnancy awareness, self-reflection, initial abortion decision, disclosure and seeking support, negotiations, final decision, access and information, abortion procedure, and post-abortion experience and care. Determinants of trajectories included three major themes of autonomy in decision-making, access and choice. A meta-analysis of data from 7737 women showed that the proportion of the overall women's involvement in abortion decision-making was 0.86 (95% CI:0.73-0.95, I2 = 99.5%) and overall partner involvement was 0.48 (95% CI:0.29-0.68, I2 = 99.6%). Interpretation: Policies and strategies should address women's perceptions of safe abortion socially, legally, and economically, and where appropriate, involvement of male partners in abortion decision-making processes to facilitate safe abortion. Clinical heterogeneity, in which various studies defined "the final decision-maker" differentially, was a limitation of our study. Funding: Nuffield Department of Population Health DPhil Scholarship for PL, University of Oxford, and the Medical Research Council Career Development Award for MN (Grant Ref: MR/P022030/1)

Public/community engagement in health research with men who have sex with men in sub-Saharan Africa: challenges and opportunities

Abstract Background Community engagement, incorporating elements of the broader concepts of public and stakeholder engagement, is increasingly promoted globally, including for health research conducted in developing countries. In sub-Saharan Africa, community engagement needs and challenges are arguably intensified for studies involving gay, bisexual and other men who have sex with men, where male same-sex sexual interactions are often highly stigmatised and even illegal. This paper contextualises, describes and interprets the discussions and outcomes of an international meeting held at the Kenya Medical Research Institute-Wellcome Trust in Kilifi, Kenya, in November 2013, to critically examine the experiences with community engagement for studies involving men who have sex with men. Discussion We discuss the ethically charged nature of the language used for men who have sex with men, and of working with ‘representatives’ of these communities, as well as the complementarity and tensions between a broadly public health approach to community engagement, and a more rights based approach. We highlight the importance of researchers carefully considering which communities to engage with, and the goals, activities, and indicators of success and potential challenges for each. We suggest that, given the unintended harms that can emerge from community engagement (including through labelling, breaches in confidentiality, increased visibility and stigma, and threats to safety), representatives of same-sex populations should be consulted from the earliest possible stage, and that engagement activities should be continuously revised in response to unfolding realities. Engagement should also include less vocal and visible men who have sex with men, and members of other communities with influence on the research, and on research participants and their families and friends. Broader ethics support, advice and research into studies involving men who have sex with men is needed to ensure that ethical challenges – including but not limited to those related to community engagement – are identified and addressed. Summary Underlying challenges and dilemmas linked to stigma and discrimination of men who have sex with men in Africa raise special responsibilities for researchers. Community engagement is an important way of identifying responses to these challenges and responsibilities but itself presents important ethical challenges

Integrated community case management in a peri-urban setting: a qualitative evaluation in Wakiso District, Uganda.

Integrated community case management (iCCM) strategies aim to reach poor communities by providing timely access to treatment for malaria, pneumonia and diarrhoea for children under 5 years of age. Community health workers, known as Village Health Teams (VHTs) in Uganda, have been shown to be effective in hard-to-reach, underserved areas, but there is little evidence to support iCCM as an appropriate strategy in non-rural contexts. This study aimed to inform future iCCM implementation by exploring caregiver and VHT member perceptions of the value and effectiveness of iCCM in peri-urban settings in Uganda.A qualitative evaluation was conducted in seven villages in Wakiso district, a rapidly urbanising area in central Uganda. Villages were purposively selected, spanning a range of peri-urban settlements experiencing rapid population change. In each village, rapid appraisal activities were undertaken separately with purposively selected caregivers (n = 85) and all iCCM-trained VHT members (n = 14), providing platforms for group discussions. Fifteen key informant interviews were also conducted with community leaders and VHT members. Thematic analysis was based on the 'Health Access Livelihoods Framework'.iCCM was perceived to facilitate timely treatment access and improve child health in peri-urban settings, often supplanting private clinics and traditional healers as first point of care. Relative to other health service providers, caregivers valued VHTs' free, proximal services, caring attitudes, perceived treatment quality, perceived competency and protocol use, and follow-up and referral services. VHT effectiveness was perceived to be restricted by inadequate diagnostics, limited newborn care, drug stockouts and VHT member absence - factors which drove utilisation of alternative providers. Low community engagement in VHT selection, lack of referral transport and poor availability of referral services also diminished perceived effectiveness. The iCCM strategy was widely perceived to result in economic savings and other livelihood benefits.In peri-urban areas, iCCM was perceived as an effective, well-utilised strategy, reflecting both VHT attributes and gaps in existing health services. Depending on health system resources and organisation, iCCM may be a useful transitional service delivery approach. Implementation in peri-urban areas should consider tailored community engagement strategies, adapted selection criteria, and assessment of population density to ensure sufficient coverage