"Mothers get really exhausted!" The lived experience of pregnancy in extreme heat: Qualitative findings from Kilifi, Kenya

Heat exposure in pregnancy is associated with a range of adverse health and wellbeing outcomes, yet research on the lived experience of pregnancy in high temperatures is lacking. We conducted qualitative research in 2021 in two communities in rural Kilifi County, Kenya, a tropical savannah area currently experiencing severe drought. Pregnant and postpartum women, their male spouses and mothers-in-law, community health volunteers, and local health and environment stakeholders were interviewed or participated in focus group discussions. Pregnant women described symptoms that are classically regarded as heat exhaustion, including dizziness, fatigue, dehydration, insomnia, and irritability. They interpreted heat-related tachycardia as signalling hypertension and reported observing more miscarriages and preterm births in the heat. Pregnancy is conceptualised locally as a 'normal' state of being, and women continue to perform physically demanding household chores in the heat, even when pregnant. Women reported little support from family members to reduce their workload at this time, reflecting their relative lack of autonomy within the household, but also potentially the 'normalisation' of heat in these communities. Climate change risk reduction strategies for pregnant women in low-resource settings need to be cognisant of local household gender dynamics that constrain women's capacity to avoid heat exposures

Using environmental monitoring to complement in-depth qualitative interviews in cold homes research

Cold homes contribute to twenty to forty thousand excess winter deaths each year in the UK and approximately 300,000 hospital admissions. Using fuel poverty as an identifier for those at risk does not always capture everyday exposure to cold homes due to variations in financial trade-offs and behavioural factors. Few fuel poverty studies have combined environmental measurements with qualitative data on lived experiences of fuel poverty and cold homes. This paper looks at the strengths and limitations of using a mixed method, environmental and qualitative interviewing approach. A series of six discreet studies were conducted between 2001 and 2015 using a similar methodology with a mixed methods design where in-depth interviews were conducted alongside temperature and humidity measurements. The research studies found that combining environmental monitoring with qualitative research methods allows both cross validation and triangulation of data in order to provide a richer and more insightful examination into the lives of people living in cold homes. The studies demonstrate how a combined methodological approach can help explain the choices, decisions and behaviour of households experiencing cold homes and fuel poverty. The paper concludes with recommendations for future development and implementation of the research method

Strategies to enhance routine physical activity in care home residents: the REACH research programme including a cluster feasibility RCT

This is the final version. Available from NIHR via the DOI in this record. Background: Care home residents are mainly inactive, leading to increased dependency and low mood. Although exercise classes may increase activity, a more sustainable model is to engage staff and residents in increasing routine activity. Objectives: The objectives were to develop and preliminarily test strategies to enhance the routine physical activity of care home residents to improve their physical, psychological and social well-being through five overlapping workstreams. Design: This trial had a mixed-methods research design to develop and test the feasibility of undertaking an evaluative study consisting of gaining an understanding of the opportunities for and barriers to enhancing physical activity in care homes (workstream 1); testing physical activity assessment instruments (workstream 2); developing an intervention through a process of intervention mapping (workstream 3); refining the provisional intervention in the care home setting and clarifying outcome measurement (workstream 4); and undertaking a cluster randomised feasibility trial of the intervention [introduced via three facilitated workshops at baseline (with physiotherapist input), 2 weeks (with artist input) and 2 months], with embedded process and health economic evaluations (workstream 5). Setting: The trial was set in 12 residential care homes differing in size, location, ownership and provision in Yorkshire, UK. Participants: The participants were elderly residents, carers, managers and staff of care homes. Intervention: The intervention was MoveMore, designed for the whole home, to encourage and support the movement of residents in their daily routines. Main outcome measures: The main outcome measures related to the feasibility and acceptability of implementing a full-scale trial in terms of recruitment and retention of care homes and residents, intervention delivery, completion and reporting of baseline data and outcomes (including hours of accelerometer wear, hours of sedentary behaviour and hours and type of physical activity), and safety and cost data (workstream 5). Results: Workstream 1 – through a detailed understanding of life in a care home, a needs assessment was produced, and barriers to and facilitators of activity were identified. Key factors included ethos of care; organisation, management and delivery of care; use of space; and the residents’ daily routines. Workstream 2 – 22 (73.3%) out of 30 residents who wore a hip accelerometer had valid data (≥ 8 hours on ≥ 4 days of the week). Workstream 3 – practical mechanisms for increasing physical activity were developed, informed by an advisory group of stakeholders and outputs from workstreams 1 and 2, framed by the process of intervention mapping. Workstream 4 – action groups were convened in four care homes to refine the intervention, leading to further development of implementation strategies. The intervention, MoveMore, is a whole-home intervention involving engagement with a stakeholder group to implement a cyclical process of change to encourage and support the movement of residents in their daily routines. Workstream 5 – 12 care homes and 153 residents were recruited to the cluster randomised feasibility trial. Recruitment in the care homes varied (40–89%). Five care homes were randomised to the intervention and seven were randomised to usual care. Predetermined progression criteria were recruitment of care homes and residents (green); intervention delivery (amber); and data collection and follow-up – 52% of residents provided usable accelerometer data at 9 months (red), > 75% of residents had reported outcomes at 9 months (green, but self-reported resident outcomes were red), 26% loss of residents to follow-up at 9 months [just missing green criterion (no greater than 25%)] and safety concerns (green). Limitations: Observations of residents’ movements were not conducted in private spaces. Working with care home residents to identify appropriate outcome measures was challenging. Take-up of the intervention was suboptimal in some sites. It was not possible to make a reliably informed decision on the most appropriate physical activity end point(s) for future use in a definitive trial. Conclusions: A whole-home intervention was developed that was owned and delivered by staff and was informed by residents and staff. The feasibility of conducting a cluster randomised controlled trial was successfully tested: the target numbers of care homes and residents were recruited, demonstrating that it is possible to recruit care home residents to a cluster randomised trial, although this process was time-consuming and resource heavy. A large data set was collected, which provided a comprehensive picture of the environment, residents and staff in care homes. Extensive quantitative and qualitative work comprehensively explored a neglected area of health and social care research. Completion of ethnographic work in a range of settings enabled the production of an in-depth picture of life in care homes that will be helpful for other researchers considering organisational change in this setting. Future work: The content and delivery of the intervention requires optimisation and the outcome measurement requires further refinement prior to undertaking a full trial evaluation. Consideration could be given to a recommended, simplified, core outcome set, which would facilitate data collection in this population.National Institute for Health Researc

What do we know about maternal and perinatal mortality and morbidity audits in sub-Saharan Africa? A scoping literature review

Purpose The purpose of this paper is to provide a situational overview of the facility-based maternal and perinatal morbidity and mortality audits (MPMMAs) in SSA, their current efficacy at reducing mortality and morbidity rates related to childbirth. Design/methodology/approach This is a scoping literature review based on the synthesis of secondary literature. Findings Not all countries in SSA conduct MPMMAs. Countries where MPMMAs are conducted have not instituted standard practice, MPMMAs are not done on a national scale, and there is no clear best practice for MPMMAs. In addition, auditing process of pediatrics and maternal deaths is flawed by human and organizational barriers. Thus, the aggregated data collected from MPMMAs are not adequate enough to identify and correct systemic flaws in SSA childbirth-related health care. Research limitations/implications There are a few published literature on the topic in sub-Saharan Africa. Practical implications This review exposes serious gaps in literature and practice. It provides a platform upon which practitioners and policy makers must begin to discuss ways of embedding mortality audits in SSA in their health systems as well as health strategies. Social implications The findings of this paper can inform policy in sub-Saharan Africa that could lead toward better outcomes in health and well-being. Originality/value The paper is original.</p

Honour based violence and wellbeing of women and girls of Pakistani heritage in South Yorkshire (abstract only)

Background Honour Based Violence (HBV), a sub-category of gender based violence, is increasing in the UK and has a significant impact on well-being, particularly for women and girls. In the Independent Inquiry into Child Sexual Exploitation: 1997–2013 in Rotherham, South Yorkshire the 1,400 victims were reported to be mostly white British girls and the perpetrators mostly South Asian men. It is believed however there were also a number of unreported South Asian victims and that cultural sensitivity was prioritised over the wellbeing of girls subject to abuse in raising awareness of the problem for both ethnic groups. Methods Mixed method study incorporating a) A literature review on HBV and wellbeing links; b) interviews (n = 16), Focus groups (n = 4), with women and girls of Pakistani origin in Rotherham and Sheffield and WEMWBS wellbeing scale (n = 40). Results This study explores the relationship between HBV and wellbeing of women and girls in Rotherham and Sheffield whilst employing culturally sensitive methodologies. The results of the literature review are presented regarding evidence for and against the role of equality and diversity dimensions, such as ethnicity, disability, gender, age and sexuality in HBV. Risk and protective factors and the evidence around any causal links between health (public and individual) and HBV are also presented. The results of the qualitative interviews identify where HBV may have been experienced in these two locations, what women and girls perceive to be HBV and how they believe their health and wellbeing is affected. Conclusions Understanding of women and girls experience of HBV in Pakistani community by looking at socio-economic, political, individual, cultural and religious factors could be used as a pilot study for a larger, future study on prevention HBV in the UK. A greater understanding of the root causes of HBV could reduce the stereotyping of HBV being a purely cultural phenomenon

'It is a disease which comes and kills directly' : what refugees know about COVID-19 and key influences of compliance with preventive measures

Background: Refugees are at increased risk for COVID-19 infection in part due to their living conditions, which make it harder to adopt and adhere to widely accepted preventive measures. Little empirical evidence exists about what refugees know about COVID-19 and what they do to prevent infection. This study explored what refugee women and their health care workers understand about COVID-19 prevention, the extent of their compliance to public health recommendations, and what influences the adoption of these measures. Methods: In October 2020, we conducted 25 in-depth interviews with facility and community health care staff (n = 10) and refugee women attending antenatal and postnatal care services (n = 15) in Eastleigh, Nairobi. Findings: While researchers found a high level of awareness about COVID-19 and related prevention and control measures among refugee women, various barriers affected compliance with such measures, due in part to poverty and in part to rampant misconceptions informed by religious beliefs and political narratives about the virus. Conclusions: These findings indicated that Kenya's Ministry of Health needs to institute a concerted and continuous education program to bring refugee communities up to speed about COVID-19 and its prevention. In addition to disseminating information about the need to wear masks and repeatedly wash hands, supplies-masks, soap and access to water-need to be made available to poor refugee communities. Future research could explore which measures for disseminating factual information work best in refugee populations with different cultural norms and how best to target interventions to these groups

An Iceberg I can’t handle: A qualitative inquiry on perceptions towards paediatric rheumatology among healthcare workers in Kenya.

Delay in diagnosis and access to specialist care are huge problems for many children and young people with rheumatic disease in sub-Saharan Africa. Most children with symptoms of rheumatic disease present to non-specialists for care. There is an urgent need to understand and scale-up paediatric rheumatology knowledge and skills amongst non-specialist clinicians, to promote early diagnosis, prompt referral, and management. Purpose We evaluated the knowledge, attitudes and practices towards diagnosis and care of paediatric rheumatology patients among health care workers in Kenya. Methods We conducted 12 focus group discussions with clinical officers (third-tier community health workers) nurses, general practitioners and paediatricians across 6 regions in Kenya. Interviews were conducted on zoom, audio-recorded, transcribed, and analysed using NVIVO software. Results A total of 68 individuals participated; 11 clinical officers, 12 nurses, 10 general practitioners, 27 paediatricians and 7 others. Most (n = 53) were female, and the median age was 36 years (range 31–40 years). Half the participants (34 of 68) worked in public health facilities. Our study revealed gaps in knowledge of paediatric rheumatology amongst healthcare workers, which contributes to late disease diagnosis and poor management. Healthcare workers reported both positive and negative attitudes towards diagnosis and care of paediatric rheumatological diseases. Perceived complexity and lack of knowledge in the diagnosis and management, in addition to unclear health system clinical pathways, made all cadres of healthcare workers feel helpless, frustrated, inadequate and incompetent to manage paediatric rheumatology patients. Positive attitudes arose from a perceived feeling that paediatric rheumatology patients pose unique challenges and learning opportunities. Conclusion There is an urgent need to educate healthcare workers and improve health systems for paediatric rheumatology patients

How do high ambient temperatures affect infant feeding practices? A prospective cohort study of postpartum women in Bobo-Dioulasso, Burkina Faso.

OBJECTIVE: To examine the effects of high ambient temperature on infant feeding practices and childcare. DESIGN: Secondary analysis of quantitative data from a prospective cohort study. SETTING: Community-based interviews in the commune of Bobo-Dioulasso, Burkina Faso. Exclusive breastfeeding is not widely practised in Burkina Faso. PARTICIPANTS: 866 women (1:1 urban:rural) were interviewed over 12 months. Participants were interviewed at three time points: cohort entry (when between 20 weeks' gestation and 22 weeks' postpartum), three and nine months thereafter. Retention at nine-month follow-up was 90%. Our secondary analysis focused on postpartum women (n=857). EXPOSURE: Daily mean temperature (°C) measured at one weather station in Bobo-Dioulasso. Meteorological data were obtained from publicly available archives (TuTiempo.net). PRIMARY OUTCOME MEASURES: Self-reported time spent breastfeeding (minutes/day), exclusive breastfeeding of infants under 6 months (no fluids other than breast milk provided in past 24 hours), supplementary feeding of infants aged 6-12 months (any fluid other than breast milk provided in past 24 hours), time spent caring for children (minutes/day). RESULTS: The population experienced year-round high temperatures (daily mean temperature range=22.6°C-33.7°C). Breastfeeding decreased by 2.3 minutes/day (95% CI -4.6 to 0.04, p=0.05), and childcare increased by 0.6 minutes/day (0.06 to 1.2, p=0.03), per 1°C increase in same-day mean temperature. Temperature interacted with infant age to affect breastfeeding duration (p=0.02), with a stronger (negative) association between temperature and breastfeeding as infants aged (0-57 weeks). Odds of exclusive breastfeeding very young infants (0-3 months) tended to decrease as temperature increased (OR=0.88, 0.75 to 1.02, p=0.09). There was no association between temperature and exclusive breastfeeding at 3-6 months or supplementary feeding (6-12 months). CONCLUSIONS: Women spent considerably less time breastfeeding (~25 minutes/day) during the hottest, compared with coolest, times of the year. Climate change adaptation plans for health should include advice to breastfeeding mothers during periods of high temperature

Retrofitting social housing : reflections by tenants on adopting and living with retrofit technology

Retrofit has been described as one of the major engineering challenges of the twenty-first century (Kelly 2009). However, the industry needs to look beyond regarding the problem as restricted to the physical upgrade of properties. Asset managers, engineers and installers work on and in people’s homes and, in many cases, are subsequently changing the way householders use their homes to meet their comfort and wider energy needs. Here we consider how the twin issues of adopting and living with retrofit technologies have affected groups of residents in social housing. We discuss issues of trust, social norms, engagement and concern that have shaped the adoption process, as well as investigating the everyday experience of living with new configurations of energy consumption. The findings have relevance not only for the social housing sector but also raise questions as to how to effectively deliver programmes such as the Green Deal and the Energy Company Obligation within the UK