Introduction Anthropological Knowledge and Practice in Global Health

Since the turn of the millennium, conceptual and practice-oriented shifts in global health have increasingly given emphasis to health indicator production over research and interventions that emerge out of local social practices, environments and concerns. In this special issue of Anthropology in Action, we ask whether such globalised contexts allow for, recognise and sufficiently value the research contributions of our discipline. We question how global health research, ostensibly inter-or multi-disciplinary, generates knowledge. We query ‘not-knowing’ practices that inform and shape global health evidence as influenced by funders’ and collaborators’ expectations. The articles published here provide analyses of historical and ethnographic field experiences that show how sidelining anthropological contributions results in poorer research outcomes for the public. Citing experiences in Latin America, Angola, Senegal, Nigeria and the domain of global health evaluation, the authors consider anthropology’s roles in global health

Study protocol: Evaluation of the Mamás del Río programme - a community-based, maternal and neonatal health intervention in Rural Amazonian Peru

Study protocol for the outcome and process evaluation of the Mamás del Río programme – a community-based, maternal and neonatal health intervention aiming to improve ENC practices and healthcare seeking in rural Amazonian Peru through educational home visits by community-health workers, sensitization of traditional birth attendants and supportive facility strengthening

Barriers and facilitators to the implementation of a community-based hypertension improvement project in Ghana: a qualitative study of ComHIP.

BACKGROUND: Globally, hypertension is a leading cause of cardiovascular disease and mortality, with the majority of deaths occurring in low- and middle-income countries. Because the burden of hypertension is increasing in low resource settings with restricted infrastructure, it is imperative that new models for hypertension care are realised. One such model is the Community-based Hypertension Improvement Project (ComHIP) which employs a community-based method of task-shifting for managing hypertension. This study is a qualitative analysis of the barriers and facilitators of the main components of ComHIP. METHODS: We purposively selected 55 informants for semi-structured interviews or focus group discussions, which were carried out bythree trained local researchers in Krobo, Twi or English. Informants included patients enrolled in ComHIP, health care providers and Licensed Chemical Sellers trained by ComHIP, and Ghana Health Service employees. Data were analysed using a multi-step thematic analysis. RESULTS: While results of the effectiveness of the intervention are pending, overall, patients and nurses reported positive experiences within ComHIP, and found that it helped enable them to manage their hypertension. Healthcare providers appreciated the additional training, but had some gaps in their knowledge. Ghana Health Service employees were cautiously optimistic about the programme, but expressed some worries about the sustainability of the programme. Many informants expressed concerns over the inability of community nurses and workers to dispense anti-hypertensives, due to legal restrictions. CONCLUSIONS: The WHO recommends task-sharing as a technique for managing chronic conditions such as hypertension in resource constrained settings. ComHIP presents an example of a task-sharing programme with a high level of acceptability to all participants. Going forward, we recommend greater levels of communication and dialogue to allow community-based health workers to be allowed to dispense anti-hypertensives

Losing women along the path to safe motherhood: why is there such a gap between women's use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda.

BACKGROUND: Thousands of women and newborns still die preventable deaths from pregnancy and childbirth-related complications in poor settings. Delivery with a skilled birth attendant is a vital intervention for saving lives. Yet many women, particularly where maternal mortality ratios are highest, do not have a skilled birth attendant at delivery. In Uganda, only 58 % of women deliver in a health facility, despite approximately 95 % of women attending antenatal care (ANC). This study aimed to (1) identify key factors underlying the gap between high rates of antenatal care attendance and much lower rates of health-facility delivery; (2) examine the association between advice during antenatal care to deliver at a health facility and actual place of delivery; (3) investigate whether antenatal care services in a post-conflict district of Northern Uganda actively link women to skilled birth attendant services; and (4) make recommendations for policy- and program-relevant implementation research to enhance use of skilled birth attendance services. METHODS: This study was carried out in Gulu District in 2009. Quantitative and qualitative methods used included: structured antenatal care client entry and exit interviews [n = 139]; semi-structured interviews with women in their homes [n = 36], with health workers [n = 10], and with policymakers [n = 10]; and focus group discussions with women [n = 20], men [n = 20], and traditional birth attendants [n = 20]. RESULTS: Seventy-five percent of antenatal care clients currently pregnant reported they received advice during their last pregnancy to deliver in a health facility, and 58 % of these reported having delivered in a health facility. After adjustment for confounding, women who reported they received advice at antenatal care to deliver at a health facility were significantly more likely (aOR = 2.83 [95 % CI: 1.19-6.75], p = 0.02) to report giving birth in a facility. Despite high antenatal care coverage, a number of demand and supply side barriers deter use of skilled birth attendance services. Primary barriers were: fear of being neglected or maltreated by health workers; long distance and other difficulties in access; poverty, and material requirements for delivery; lack of support from husband/partner; health systems deficiencies such as inadequate staffing/training, work environment, and referral systems; and socio-cultural and gender issues such as preferred birthing position and preference for traditional birth attendants. CONCLUSIONS: Initiatives to improve quality of client-provider interaction and respect for women are essential. Financial barriers must be abolished and emergency transport for referrals improved. Simultaneously, supply-side barriers must be addressed, notably ensuring a sufficient number of health workers providing skilled obstetric care in health facilities and creating habitable conditions and enabling environments for them

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

What maternal morbidities are and what they mean for women: A thematic analysis of twenty years of qualitative research in low and lower-middle income countries.

BACKGROUND: With an estimated 27 million annual incidents of maternal morbidity globally, how they are manifested or experienced is diverse and shaped by societal, cultural and personal influences. Using qualitative research to examine a woman's perception of her pregnancy, its complications, and potential long-term impact on her life can inform public health approaches and complement and inform biomedical classifications of maternal morbidities, historically considered a neglected dimension of safe motherhood. As part of the WHO's Maternal Morbidity Working Group's efforts to define and measure maternal morbidity, we carried out a thematic analysis of the qualitative literature published between 1998 and 2017 on how women experience maternal morbidity in low and lower-middle income countries. RESULTS AND CONCLUSIONS: Analysis of the 71 papers included in this study shows that women's status, their marital relationships, cultural attitudes towards fertility and social responses to infertility and pregnancy trauma are fundamental to determining how they will experience morbidity in the pregnancy and postpartum periods. We explore the physical, economic, psychological and social repercussions pregnancy can produce for women, and how resource disadvantage (systemic, financial and contextual) can exacerbate these problems. In addition to an analysis of ten themes that emerged across the different contexts, this paper presents which morbidities have received attention in different regions and the trends in researching morbidities over time. We observed an increase in qualitative research on this topic, generally undertaken through interviews and focus groups. Our analysis calls for the pursuit of high quality qualitative research that includes repeat interviews, participant observation and triangulation of sources to inform and fuel critical advocacy and programmatic work on maternal morbidities that addresses their prevention and management, as well as the underlying systemic problems for women's status in society

Correction to: Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study

Following publication of the original article [1], the authors identified an error in the author name of Julie Barnet. The incorrect author name is: Julie Barnett The correct author name is: Julie Barnet The author group has been updated above and the original article [1] has been corrected

Correction to: Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study.

Following publication of the original article [1], the authors identified an error in the author name of Julie Barnet. The incorrect author name is: Julie Barnett The correct author name is: Julie Barnet The author group has been updated above and the original article [1] has been corrected

Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study

BACKGROUND: Healthcare associated infections (HAIs) are the most frequent adverse outcome in healthcare delivery worldwide. In conflict-affected settings HAIs, in particular surgical site infections, are prevalent. Effective infection prevention and control (IPC) is crucial to ending avoidable HAIs and an integral part of safe, effective, high quality health service delivery. However, armed conflict and widespread violence can negatively affect the quality of health care through workforce shortages, supply chain disruptions and attacks on health facilities and staff. To improve IPC in these settings it is necessary to understand the specific barriers and facilitators experienced locally. METHODS: In January and February of 2020, we conducted semi-structured interviews with hospital staff working for the International Committee of the Red Cross across eight conflict-affected countries (Central African Republic, South Sudan, Democratic Republic of the Congo, Mali, Nigeria, Lebanon, Yemen and Afghanistan). We explored barriers and facilitators to IPC, as well as the direct impact of conflict on the hospital and its' IPC programme. Data was analysed thematically. RESULTS: We found that inadequate hospital infrastructure, resource and workforce shortages, education of staff, inadequate in-service IPC training and supervision and large visitor numbers are barriers to IPC in hospitals in this study, similar to barriers seen in other resource-limited settings. High patient numbers, supply chain disruptions, high infection rates and attacks on healthcare infrastructures, all as a direct result of conflict, exacerbated existing challenges and imposed an additional burden on hospitals and their IPC programmes. We also found examples of local strategies for improving IPC in the face of limited resources, including departmental IPC champions and illustrated guidelines for in-service training. CONCLUSIONS: Hospitals included in this study demonstrated how they overcame certain challenges in the face of limited resources and funding. These strategies present opportunities for learning and knowledge exchange across contexts, particularly in the face of the current global coronavirus pandemic. The findings are increasingly relevant today as they provide evidence of the fragility of IPC programmes in these settings. More research is required on tailoring IPC programmes so that they can be feasible and sustainable in unstable settings