Strategic traditions. changing livelihoods, access to food and child malnutrition in the Zambian Kafue Flats

Zambia has experienced a burst of industrial development which started already in the 1920s. Large-scale copper-mining made the country to one of the most rapidly ‘modernizing’ states, and during the 1960s and 1970s it was ranked as “middle-income country”. When the terms of trade for copper declined sharply after the oil-shock in the 1970s, the Zambian economy began to deteriorate. After the millenium turn, Zambia figured among the ten poorest countries of the world. The economic collapse has left the promises of modernity unfulfilled. Meanwhile a world of plural values and modes of life had emerged. The crisis was mirrored on the local level in urban and rural areas. When agricultural cashcrop production, supported by subsidies, as well as veterinary services were established (starting during colonial administration), the Kafue Flats’ agro-pastoralists profited from these achievements. At the same time the state took over the control of natural resources. With the beginning economic crisis the state failed to maintain its services, leading to a declining agrarian production. Also the use of natural resources (fish, wildlife) was only marginally controlled. This “open access” constellation attracted migratory fishermen and hunters from the urban areas. These developments jeopardized the local food basis. ,45674899:;?@4AB!CD:!D?A@4A49D! Nutrition in the rural areas of the Zambian Kafue Flats still depends to a large extent on subsistence production. But several pillars of the diversified livelihoods of the local Ila/Balundwe and Tonga people, the former once famous for their wealth in cattle, have recently been undermined by rapid economic and environmental change. Nevertheless, local livelihoods still heavily rely on natural resources of the surrounding area. Vulnerability of specific parts of the population in times of food shortages cannot be separated from social transformations due to changes in political power, institutions, economic and environmental setting and demography. Indirect consequences, such as the splitting up of large extended families into many individual small households without the old liabilities leading to a new power-equilibrium and a decline in social security, gave rise to a local “traditionalism” among both the wealthy and the poor. The affluent are primarily trying to maintain favourable local inheritance and marriage regulations (polygyny) in order to legitimise their inherited and acquired property and access rights to pasture and fisheries, referring to an ethnicity and cultural heritage discourse. Meanwhile, many among the impoverished equally follow the traditional lifestyle, lacking practicable alternatives and hoping to restore at least partly their former wealth. The participation in agricultural intensification programs was not considered profitable enough during the last few years, seen the low market prices and lack of former subsidies. Hence, local livelihood strategies and experiences are often contesting the dominant development discourse. This is also shown in the contradictory way how local people and NGO representatives were interpreting the 2002/3 food crisis. While local rural people perceived the traditional pastoralists households as most resilient to the crisis, extensive pastoralism was made responsible for the lack of staple crops in the prevailing development rhetoric. But our data analysis of food consumption and caloric intake equally support the local interpretation that traditional pastoralists (including the majority of the polygynous households) were least affected by the crisis, as were households with more diversified strategies. These local experiences, contradicting dominant agricultural and development policies, have to be considered as reasons for low adherence to programs aimed at mitigating food insecurity. Apart from recurrent droughts over the last years and a decreasing maize production, the main staple and cash crop, many additional food items are no longer available due to the increasingly limited access to natural resources such as wildlife or fisheries, and because of a cattle disease (theileria parva), which killed large parts of the livestock in the area. In addition, the consumption of wild bush-plants (fruits, nuts, tubers and leaves) has decreased. Alternative food items need to be purchased at the cost of selling part of the maize yields. This led to a nutritional transition towards a less diversified diet in addition to periodical famines, promoting chronic as well as acute malnutrition. .C7D?A@4A49D!E6AF66D!79>C7!CD:!;>46DA4=4>!>9D>6GA;! While child malnutrition is a recognised problem and affects many families, most mothers are well aware of how they should complement the foods for their children with purchased products. However, many mothers cannot afford to buy food on a regular basis, or they might not have the bargaining power to convince their husbands to spend money on expensive foods for their children, implying that child malnutrition is not limited to poor families. Although only few mothers have not been exposed to health education encompassing information about a “balanced diet”, many remain with little possibility to actually provide it. Women are responsible for infant and child feeding, but do not necessarily control the allocation of money, and only partly the purpose of subsistence products – whether they are produced for consumption or for sale. This does not remain without impact on child nutrition, neither on the interpretation of malnutrition symptoms as socially produced. It is partly in the view of these constraints that it has to be understood how many parents interpret signs of malnutrition as masoto, a traditional illness, which is perceived as being caused by a transgression of one of the parents, such as the violation of the postpartum abstinence rule. Contrary to malnutrition, which can be prevented only if diverse food items can be provided on a regular basis implying the availability of cash, masoto can be prevented by respectable behaviour. It has however been shown that masoto did not interfere with the provision of an adequate diet taking up information of health professionals. It neither prevented the consultation of health facilities in the vast majority of the cases. But the possibilities to obtain assistance from the health sector were limited, as only few children could be included in special feeding programmes. There are several aspects of masoto, which help to understand the persisting attractiveness of the concept. The relatively recent impoverishment has left people with the hope to restore the lost wealth, only partly admitting their poverty, which is evoking shame. Illegitimate behaviour, although equally associated with shame, is easier to deal with than poverty in a region, which was known to be rich throughout the country until recently. In addition, it draws on a well-established way of solving potential intra-household conflicts involving both parents under the custody of other community members (e.g. traditional healers), satisfying moral and religious concerns. On the contrary, conflicts about money rather remain to be solved between husbands and wives alone, whereby men are in the decision-making position. Masoto as a clear representation of an illness asking for defined action, provides mothers with more bargaining power towards husbands and relatives, than a mere begging for food. In order to understand why the reference to a local illness concept such as masoto is widespread despite health education on infant nutrition, this situational framework has to be considered. %H6@I4DI!86C7A8!4HGC>A;!9=!G956@AB!CD:!=99:!4D;6>?@4ABJ!=4;8K=9@K;6L!6L>8CDI6! The impoverishment and recent livelihood changes have led to an increasing attractiveness of the fisheries as a resource exploitable for everyone to meet everyday livelihood needs. For many households in the Kafue Flats, fish became an important protein source to rely on. Due to the increasing prices of fish in the urban and rural centres compared to other goods (increasing relative price), the area is facing a massive immigration of fishermen from other areas of the country and from urban centres, and especially fish trade has become a lucrative income generating option for local men and women. In the Kafue Flats, many women are relying on an own income. Fish trade, due to the good market price and the low investments needed, provides good opportunities especially in the late dry and early rainy season, when maize prices begin to increase. Partly, though, fish is traded in form of fish-for-sex exchange, a form of transactional sex, exposing female fish traders and fishermen to a high risk for HIV transmission. Despite the increasing awareness of HIV/AIDS in the permanent villages, where people are visibly dying from AIDS, the mobile fishing community along the river and lagoons is widely ignoring the risk. First, HIV/AIDS prevention campaigns primarily rely on a Abstinence, Be faithful, or Condom use approach (ABC campaigns). For many of the mobile fishermen, often coming from other areas of the country and from urban areas, A and B do not provide an attractive option, and condoms are hardly available in the fishing camps. Lacking the visibility of AIDS patients due to high mobility, the risk is underestimated. Local female fish traders, on the other hand, are increasingly exposed to stigmatisation in their villages, as they are seen as a threat to the community. Despite their awareness of the risk to become infected with the HI-virus, women’s options to protect themselves are very limited; it has to be acknowledged that many women cannot afford to turn down an offer where they can get free fish, worth several weeks of maize consumption, in exchange for sex. Seen the good opportunities of fish trade, and especially fish-for-sex exchange throughout the year without any long-term commitment needed, it is unlikely that income-generating projects will be able to completely substitute fish-for-sex deals. Moreover, the increasing moral pressure on women rather motivates them to hide their activities than to stop. Women who get involved in such arrangements have different strategies to escape the increasing moral pressure of their communities as well as of health professionals and churches. First of all, they deny any involvement in fish-for-sex exchange. In a local setting, where “traditions” are still valorised, some women may refer to a transformed traditional institution regulating extramarital sexual relations, thus avoiding the association with prostitution, in order to gain legitimacy towards the community and themselves, and to maintain their reputation. In the Kafue Flats setting, HIV/AIDS prevention approaches, which primarily rely on moral messages and empowerment, are showing a low impact. Condoms, on the other hand, are hardly available in the fishing camps, although there is a clearly expressed demand. Meanwhile, the HIV/AIDS prevention discourse is taken up by diverse other local actors who have their own agenda. Apart from a real concern with HIV/AIDS, which is of course a main worry, prevention messages are additionally used to give legitimacy to own interests especially in relation to the planning of interventions strengthening economic alternatives to the fisheries. Hence, the narrative of the dangers, which fish-for-sex deals are encompassing, is locally used as an argument to serve heterogeneous purposes, and to attract donors, while it does not always include the interests of those who are most exposed to HIV, namely the female fish traders and the fishermen

Non-uptake of HIV testing in children at risk in two urban and rural settings in Zambia: a mixed-methods study

This article investigates reasons why children who were considered at risk of HIV were not taken for HIV testing by their caregivers. Qualitative and quantitative data collected in Zambia from 2010-11 revealed that twelve percent of caregivers who stated that they had been suspecting an HIV infection in a child in their custody had not had the child tested. Fears of negative reactions from the family were the most often stated reason for not testing a child. Experience of pre-existing conflicts between the couple or within the family (aOR 1.35, 95% CI 1.00-1.82) and observed stigmatisation of seropositive children in one's own neighbourhood (aOR 1.69, 95% CI1.20-2.39) showed significant associations for not testing a child perceived at risk of HIV. Although services for HIV testing and treatment of children have been made available through national policies and programmes, some women and children were denied access leading to delayed diagnosis and treatment-not on the side of the health system, but on the household level. Social norms, such as assigning the male household head the power to decide over the use of healthcare services by his wife and children, jeopardize women's bargaining power to claim their rights to healthcare, especially in a conflict-affected relationship. Social norms and customary and statutory regulations that disadvantage women and their children must be addressed at every level-including the community and household-in order to effectively decrease barriers to HIV related care

Crafting Our Own Rules: Constitutionality as a Bottom-Up Approach for the development of By-Laws in Zambia

This paper details the process of bottom-up crafting of by-laws to the state fishery laws in Zambia, the initial empirical case informing the development of the constitutionality concept. It explores the historical, political as well as environmental and economic conditions on which the process of sense of ownership of the institution building process came to be. The role of the researchers as well as the process of crafting new rules in a situation of an absent state but which is ideologically present as the owner of the resource are discussed. Furthermore, we underline that for this process the issue of bargaining power in communities that are very heterogeneous is a major challenge to a fair process for the crafting of institutions. The paper explains the main factors leading to what Haller et al. have labeled “constitutionality” addressing these power disparities. However, a clear examination of the process of the by-law crafting, including the content of the by-laws themselves, reveals that newly crafted institutions developed by local actors a) go beyond pure resource governance issues to include other areas related to fisheries (health and sanitation), b) address vital gender and power relations, and c) show high innovation potential to interrelate governance issues that are locally important but not addressed in fragmented state governance

The fight against lymphatic filariasis: perceptions of community drug distributors during mass drug administration in coastal Kenya

Lymphatic filariasis (LF), a neglected tropical disease (NTD) and leading cause of global disability, is endemic in 32 countries in Africa with almost 350 million people requiring regular drug administration, and only 16 countries achieving target coverage. Community Drug Distributors (CDDs) are critical for the success of NTD programs, and the distribution of medicines during mass drug administration (MDA) in Africa; however they could also be a weak link. The primary aim of this study is to explore and describe perceptions of CDDs during MDA for LF in Mvita sub-county in Mombasa county and Kaloleni sub-county in Kilifi county, Kenya; and provide recommendations for the effective engagement of communities and CDDs in low-resource settings.; In September 2018, we conducted six focus group discussions with community members in each sub-county, three with men aged 18-30, 31-50, and 51 years and above and three with women stratified into the same age groups. In each sub-county, we also conducted semi-structured interviews with nine community health extension workers (CHEWs), the national LF focal point, the county NTD focal points, and seven community leaders. Content analysis of the data was conducted, involving a process of reading, coding, and displaying data in order to develop a codebook.; We found that several barriers and facilitators impact the engagement between CDDs and community members during MDA. These barriers include poor communication and trust between CDDs and communities; community distrust of the federal government; low community knowledge and perceived risk of LF, poor timing of MDA, fragmented supervision of CDDs during MDA; and CDD bias when distributing medicines. We also found that CDD motivation was a critical factor in their ability to successfully meet MDA targets. It was acknowledged that directly observed treatment and adequate health education were often not executed by CDDs. The involvement of community leaders as informal supervisors of CDDs and community members improves MDA.; In order to achieve global targets around the elimination of LF, CDDs and communities must be effectively engaged by improving planning and implementation of MDA

Parental attitudes towards measles vaccination in the canton of Aargau, Switzerland: a latent class analysis

Despite the successes of routine national childhood vaccination programmes, measles remains a public health concern. The purpose of this paper is to investigate how patterns of parental attitudes are linked to the decision-making process for or against MMR vaccination. This exploratory study was designed to identify distinct patterns of attitudes towards or against measles vaccination through Latent Class Analysis (LCA) in a sub-sample of mothers living in the canton of Aargau in Switzerland.; Parents of young children below 36 months of age were randomly selected through parents' counsellors' registries. Among other questions, respondents were asked to state their agreement in response to 14 belief statements regarding measles vaccination on a 5-point Likert scale. To identify groups of parents showing distinct patterns of attitudes and beliefs regarding measles vaccination, we used Latent Class Analysis (LCA).; The LCA showed three classes of parents with different attitudes and believes towards measles vaccination: The biggest group (class 1) are those having positive attitudes towards immunisation, followed by the second biggest group (class 2) which is characterised by having fearful attitudes and by showing uncertainty about immunisation. The third group (class 3) shows distinct patterns of critical attitudes against immunisation. Within this group over 90 % agree or totally agree that immunisation is an artificial intrusion into the natural immune system and therefore want to vaccinate their children only if necessary.; We find that parents in the Canton Aargau who hesitate to vaccinate their children against measles, mumps and rubella show distinct opinions and attitudes. Health professionals should be aware of these perceptions to tailor their messages accordingly and positively influence these parents to vaccinate their children. Special attention needs to be given to those parents who are planning to vaccinate their children but are not following the national guidelines

Caesarean sections and breastfeeding initiation among migrants in Switzerland

Summary: Objectives:: Twenty-six percent of all women giving birth in Switzerland are of non-Swiss nationality. Differences in reproductive health outcomes such as preterm deliveries, Caesarean sections, and breastfeeding initiation for mother-child pairs of various nationalities are investigated, and the influence of the educational level was assessed. In order to identify trans-national differences, national breastfeeding rates from 22 countries and Caesarean section rates from 24 countries were compared to the rates in Swiss hospitals. Study Sample:: Drawing on routinely collected monitoring data, 37 332 mother-child pairs from various nationalities, who delivered in Swiss Baby-Friendly hospitals between 2000 and 2002, were included in the study. All nationalities with at least 150 deliveries were coded individually, while the remaining were summarised in regional groups. Results:: Sub-Saharan African, Latin American and Asian mothers had higher rates of Caesarean sections compared to Swiss mothers (OR = 1.77, 95 % CI 1.49-2.22; OR = 1.80, 1.51-2.17; OR = 1.37, 1.18.1.59). African and Asian children were at an increased risk of being transferred to neonatal care units (OR = 1.48, 95 % CI 1.19-1.83; OR = 1.45, 1.21-1.73;). In addition, infants from Balkan countries, who showed lowest Caesarean section rates, were also more likely to be transferred to an ICU (OR = 1.30, 95 % CI 1.12-1.52). Apart from the country or region of origin, the maternal educational level was an important influence and modified the effect of the mother's nationality. Mothers from all regions, apart from Western Europe, were significantly more likely to breastfeed their children after being discharged. Established determinants for breastfeeding duration, including feeding exclusively with breast milk in maternity wards, early initiation of breastfeeding, rooming-in and pacifier use, varied according to nationality. The comparison of Caesarean section and breastfeeding rates with the rates in the mother's country of origin additionally investigates the relation between reproductive health outcomes of migrant women in Switzerland compared to their country of origin. In both cases, a significant rank correlation (Spearman) could be established between the rate in Swiss hospitals and the rate in the mother's country of origin (P < 0.001, P = 0.04). Conclusions:: Our data confirms inequalities in reproductive health outcomes and responses to health promotion programmes among migrant women in Switzerland. These differences are dependent on educational level and on the mothers' nationality. The large variation suggests that different trans-national experiences play some role in health-related decision-making and access to health care. This should be considered when planning health promotion programs and the individual counselling of pregnant mothers in Switzerlan

Networked Spaces: Benefits of Mobile Phones in the Treatment and Referral Process within iCCM

Kenya is still lagging behind regional and global averages in child mortality rates despite the fact that substantial progress has been made in reducing child mortality through child health programs since 1990. Furthermore, Kenya like other developing countries faces constraints in health system performance and access to services in hard-to-reach areas. Studies on the use of mobile phones in iCCM have mainly focused on malaria and neglected other common childhood illnesses, yet there is evidence to show the potential for the integration of mobile phones in iCCM to address the challenges of reducing under-five child morbidity and mortality due to common childhood illnesses. This paper aims to assess the informal uses of mobile phones in community case management of childhood illnesses in Nyaguda sub-location, Western Kenya. Ethnographic study design was employed. The study population consisted of 25 CHVs trained and supervised in ICCM and having access to basic mobile phones, selected caregivers, KIIs with Nyaguda dispensary incharge, CHEW Nyaguda sub-location, a clinical officer and matron in-charge of MCH at Bondo sub-County hospital, FGDs with caregivers, community health workers, CHEWs within the intervention sites of iCCM and Bondo sub-county health management team. Data collection methods included; in-depth interviews, KIIs, FGDs, and direct observation.  Data was analyzed through latent content analysis by theoretically relating the emerging themes from the texts as per the specific objectives. Ethical standards were followed by obtaining informed consent and respecting confidentiality.  This study found that the integration of mobile phone within iCCM opened further the existing and new spaces of care hence improving the healthcare system and health policy. Keywords:  iCCM, Informal uses, Mobile phones, Health worker

Baby-friendly hospital designation has a sustained impact on continued breastfeeding

The Baby-Friendly Hospital (BFH) Initiative has led to an increase in breastfeeding rates and duration worldwide. But little is known about whether the beneficial effects persist beyond a facility's designation as a BFH. To investigate the association of BFH designation (current, former, and never) and compliance with Baby-Friendly (BF) practices on breastfeeding in Switzerland, this study combined nationwide survey data on breastfeeding with BFH monitoring data. In this cross-sectional study, 1,326 children were born in 34 current (N = 508), 28 former (N = 425), and 34 never designated BFHs (N = 393). We compared exclusive and any breastfeeding according to BFH designation over the first year of life, using Kaplan-Meyer Survival curves. Logistic regression models were applied to analyse breastfeeding prevalence, and Cox-regression models were used for exclusive (0-6 months) and continued (6-12 months) breastfeeding duration. Average duration of exclusive breastfeeding (13.1 weeks, 95% confidence interval [12.0, 17.4]) and any breastfeeding (32.7 weeks, 95% confidence interval [30.5, 39.2]) were the longest for babies born in currently accredited BFHs. Exclusive breastfeeding was associated with high compliance with monitored BF practices in current BFHs and with the number of BF practices experienced in all hospitals. Continued breastfeeding was significantly longer when babies were born in current BFHs (cessation hazard ratio 0.60, 95% confidence interval [0.42, 0.84]) or in former BFHs (cessation hazard ratio 0.68, 95% confidence interval [0.48, 0.97]). Overall, the results support continued investment into BFHs, because babies born in current BFHs are breastfed the most and the longest, whereas a former BFH designation shows a sustained effect on continued breastfeeding

Baby-friendly hospital designation has a sustained impact on continued breastfeeding

The Baby-Friendly Hospital (BFH) Initiative has led to an increase in breastfeeding rates and duration worldwide. But little is known about whether the beneficial effects persist beyond a facility's designation as a BFH. To investigate the association of BFH designation (current, former, and never) and compliance with Baby-Friendly (BF) practices on breastfeeding in Switzerland, this study combined nationwide survey data on breastfeeding with BFH monitoring data. In this cross-sectional study, 1,326 children were born in 34 current (N = 508), 28 former (N = 425), and 34 never designated BFHs (N = 393). We compared exclusive and any breastfeeding according to BFH designation over the first year of life, using Kaplan-Meyer Survival curves. Logistic regression models were applied to analyse breastfeeding prevalence, and Cox-regression models were used for exclusive (0-6 months) and continued (6-12 months) breastfeeding duration. Average duration of exclusive breastfeeding (13.1 weeks, 95% confidence interval [12.0, 17.4]) and any breastfeeding (32.7 weeks, 95% confidence interval [30.5, 39.2]) were the longest for babies born in currently accredited BFHs. Exclusive breastfeeding was associated with high compliance with monitored BF practices in current BFHs and with the number of BF practices experienced in all hospitals. Continued breastfeeding was significantly longer when babies were born in current BFHs (cessation hazard ratio 0.60, 95% confidence interval [0.42, 0.84]) or in former BFHs (cessation hazard ratio 0.68, 95% confidence interval [0.48, 0.97]). Overall, the results support continued investment into BFHs, because babies born in current BFHs are breastfed the most and the longest, whereas a former BFH designation shows a sustained effect on continued breastfeeding