‘As soon as they can hold a glass, they begin taking alcohol’: a qualitative study on early childhood substance use in Mbale District, Uganda

Background Globally, substance use is a leading contributor to the burden of disease among young people, with far reaching social, economic and health effects. Following a finding of harmful alcohol use among 5-8-year-old children in Mbale District, Uganda, this study aims to investigate community members’ views on early childhood substance use among children below the age of 10 years. Methods In 2016, we conducted eight focus group discussions with 48 parents and 26 key informant interviews with teachers, health workers, alcohol distributors, traditional healers, religious leaders, community leaders and youth workers. We used thematic content analysis. Four participants and two research assistants reviewed and confirmed the findings. Results Alcohol in everyday life: ‘Even children on laps taste alcohol’: Almost all participants confirmed the existence of and concern for substance use before age 10. They described a context where substance use was widespread in the community, especially intake of local alcoholic brews. Children would access substances in the home or buy it themselves. Those living in poor neighbourhoods or slums and children of brewers were described as particularly exposed. Using substances to cope: ‘We don’t want them to drink’: Participants explained that some used substances to cope with a lack of food and resources for childcare, as well as traumatic experiences. This made children in deprived families and street-connected children especially vulnerable to substance use. Participants believed this was a result of seeing no alternative solution. Conclusions To our knowledge, this is the first study to describe the context and conditions of childhood substance use before age 10 in Mbale District, Uganda. The study shows that community members attributed early childhood substance use to a social context of widespread use in the community, which was exacerbated by conditions of material and emotional deprivation. These social determinants for this practice deserve public health attention and intervention.publishedVersio

Kvinners erfaringer med abortnemnder

Denne rapporten presenterer resultatene fra en amfunnsvitenskapelig studie om kvinners erfaringer med abortnemnder. Rapporten bygger på 13 dybdeintervju med kvinner som hadde erfaring med å søke om og gjennomleve andretrimesterabort innenfor et abortnemndsystem. Kvinnene hadde fått sine abortbegjæringer behandlet i nemnd ved åtte ulike sykehus i hele landet. Studien undersøkte kvinnenes helhetlige prosess med å søke andretrimesterabort innen rammene av et abortnemndsystem, opplevelser knyttet til selve møtet med nemnden og kvinnenes erfaringer knyttet til nemndenes myndighet til å fatte beslutning om deres liv samtidig som de skal ivareta kvinnenes rett til informasjon og veiledning. Kvinnene fortalte sine historier fra de oppdaget svangerskapet til tiden etter at abortfødsel var overstått. Analysen som presenteres i denne rapporten fokuserer på temaene 1) Forventninger og forberedelser til nemndsmøtet, 2) Å møte abortnemnden og 3) Tidsrammer og oppfølging. Studien viser at tiden før selve nemndsmøtet preges av varierende forkunnskaper og ulik og mangelfull informasjon til kvinnene om plikter og rettigheter ved nemndsbehandling. Muligheten for å få avslag preget kvinnene i forkant av nemndsmøtet, og gjorde kvinnenes beslutningsprosess vanskeligere. Videre viser studien at abortnemndene organiseres svært ulikt fra sykehus til sykehus. Noen kvinner opplevde at nemnden ga råd og støtte utover det å avklare om aborten oppfylte lovens kriterier. Mens noen opplevde nemndsmøtet som både belastende og meningsløst, opplevde andre det som en støtte. Metaforer som «eksamen» eller «avhør» ble brukt til å beskrive noen av kvinnenes møte med nemnden. Kvinner som hadde søkt om å få avslutte et ønsket svangerskap var frustrert over at partner ikke hadde plass som part i nemndsystemet. Tidsaspektet formet kvinnenes opplevelser med nemndsbehandling. For noen var det å vente på nemnden en belastning. For andre gjorde lovens grenser for svangerskapets avslutning at vanskelige avgjørelser måtte tas på kort tid. Kvinnene hadde et stort behov for støtte og oppfølging etter abortfødsel, og i dag er det ikke noe system som sikrer dette. Abortnemndene utgjør bare én del av et større system som aktiveres når en kvinne søker en andretrimesterabort. Kvinnenes erfaringer med abortnemndsystemet preges av skjevheten i makt mellom dem selv og nemnden. Denne skjevheten begrenser rommet for tvil og muligheten for en god og opplysende dialog. Noen kvinner opplever at møtet med nemnd gir dem større kontroll over egen situasjon. Slik det fungerer i dag favoriserer nemndsystemet ressurssterke kvinner og kan bidra til å ytterligere marginalisere sårbare kvinner. Uklarhet og ulik praksis knyttet til abortnemndens oppgave utover det å fatte et vedtak om andretrimesterabort, skaper risiko for at viktig informasjon ikke formidles. Dette svekker kvinners rett til å ikke delta i nemndsmøte samt hennes mulighet til å handle på bakgrunn av riktig informasjon. Dagens system tar i liten grad høyde for at de fleste andrestrimesteraborter er avbrudd av ønskede svangerskap. For kvinner som opplever dette virker abortnemdsystemet fremmedgjørende og lite forståelsesfullt. Dette kan gjøre den vanskelige tiden etter en gjennomført abort ekstra krevende. Dagens helsesystem sikrer ikke god oppfølging til kvinnene som gjennomgår en andretrimesterabort. Tiden etter en gjennomført abortfødsel er den mest sårbare for kvinnene som har vært gjennom abortnemndsystemet. Det er grunn til å stille spørsmål til ressursbruken knyttet til nemndsmøtene i kontrast til få ressurser til oppfølgingstjenester

Stakeholders' Participation in Planning and Priority Setting in the Context of a Decentralised Health Care system: the case of prevention of mother to child Transmission of HIV Programme in Tanzania.

In Tanzania, decentralisation processes and reforms in the health sector aimed at improving planning and accountability in the sector. As a result, districts were given authority to undertake local planning and set priorities as well as allocate resources fairly to promote the health of a population with varied needs. Nevertheless, priority setting in the health care service has remained a challenge. The study assessed the priority setting processes in the planning of the prevention of mother to child transmission of HIV (PMTCT) programme at the district level in Tanzania. This qualitative study was conducted in Mbarali district, south-western Tanzania. The study applied in-depth interviews and focus group discussions in the data collection. Informants included members of the Council Health Management Team, regional PMTCT managers and health facility providers. Two plans were reported where PMTCT activities could be accommodated; the Comprehensive Council Health Plan and the Regional PMTCT Plan that was donor funded. As donors had their own globally defined priorities, it proved difficult for district and regional managers to accommodate locally defined PMTCT priorities in these plans. As a result few of these were funded. Guidelines and main priority areas of the Ministry of Health and Social Welfare (MoHSW) also impacted on the ability of the districts and regions to act, undermining the effectiveness of the decentralisation policy in the health sector. The challenges in the priority setting processes revealed within the PMTCT initiative indicate substantial weaknesses in implementing the Tanzania decentralisation policy. There is an urgent need to revive the strategies and aims of the decentralisation policy at all levels of the health care system with a view to improving health service delivery

Increased waterborne blaNDM-1 resistance gene abundances associated with seasonal human pilgrimages to the Upper Ganges River

Antibiotic resistance (AR) is often rooted in inappropriate antibiotic use, but poor water quality and inadequate sanitation exacerbate the problem, especially in emerging countries. An example is increasing multi-AR due to mobile carbapenemases, such as NDM-1 protein (coded by blaNDM-1 genes), which can produce extreme drug-resistant phenotypes. In 2010, NDM-1 positive isolates and blaNDM-1 genes were detected in surface waters across Delhi and have since been detected across the urban world. However, little is known about blaNDM-1 levels in more pristine locations, such as the headwaters of the Upper Ganges River. This area is of particular interest because it receives massive numbers of visitors during seasonal pilgrimages in May/June, including visitors from urban India. Here we quantified blaNDM-1 abundances, other AR genes (ARG) and coliform bacteria in sediments and water column samples from seven sites in the Rishikesh-Haridwar region of the Upper Ganges and five sites on the Yamuna River in Delhi to contrast blaNDM-1 levels and water quality conditions between season and region. Water quality in the Yamuna was very poor (e.g., anoxia at all sites), and blaNDM-1 abundances were high across sites in water (5.4 ± 0.4 log(blaNDM-1·mL-1); 95% confidence interval) and sediment (6.3 ± 0.7 log(blaNDM-1·mg-1)) samples from both seasons. In contrast, water column blaNDM-1 abundances were very low across all sites (2.1 ± 0.6 log(blaNDM-1·mL-1)) in February in the Upper Ganges and water quality was good (e.g., near saturation oxygen). However, per capita blaNDM-1 levels were 20 times greater in June in the Ganges water column relative to February and blaNDM-1 levels significantly correlated with fecal coliform levels (r=0.61; p=0.007). Given waste management infrastructure is limited in Rishikesh-Haridwar; data imply blaNDM-1 levels are higher in visitor's wastes than local residents, which results in seasonally higher blaNDM-1 levels in the river. Pilgrimage areas without adequate waste treatment are possible "hot spots" for AR transmission, and waste treatment must be improved to reduce broader AR dissemination via exposed returning visitors

Improvement in the Reproducibility and Accuracy of DNA Microarray Quantification by Optimizing Hybridization Conditions

BACKGROUND: DNA microarrays, which have been increasingly used to monitor mRNA transcripts at a global level, can provide detailed insight into cellular processes involved in response to drugs and toxins. This is leading to new understandings of signaling networks that operate in the cell, and the molecular basis of diseases. Custom printed oligonucleotide arrays have proven to be an effective way to facilitate the applications of DNA microarray technology. A successful microarray experiment, however, involves many steps: well-designed oligonucleotide probes, printing, RNA extraction and labeling, hybridization, and imaging. Optimization is essential to generate reliable microarray data. RESULTS: Hybridization and washing steps are crucial for a successful microarray experiment. By following the hybridization and washing conditions recommended by an oligonucleotide provider, it was found that the expression ratios were compressed greater than expected and data analysis revealed a high degree of non-specific binding. A series of experiments was conducted using rat mixed tissue RNA reference material (MTRRM) and other RNA samples to optimize the hybridization and washing conditions. The optimized hybridization and washing conditions greatly reduced the non-specific binding and improved the accuracy of spot intensity measurements. CONCLUSION: The results from the optimized hybridization and washing conditions greatly improved the reproducibility and accuracy of expression ratios. These experiments also suggested the importance of probe designs using better bioinformatics approaches and the need for common reference RNA samples for platform performance evaluation in order to fulfill the potential of DNA microarray technology

The science of european marine reserves: Status, efficacy, and future needs

The ecologically and socio-economically important marine ecosystems of Europe are facing severe threats from a variety of human impacts. To mitigate and potentially reverse some of these impacts, the European Union (EU) has mandated the implementation of the Marine Strategy Framework Directive (MSFD) in order to achieve Good Environmental Status (GES) in EU waters by 2020. The primary initiative for achieving GES is the implementation of coherent networks of marine protected areas (MPAs). Marine reserves are an important type of MPA in which no extraction is allowed, but their usefulness depends upon a number of ecological, management, and political factors. This paper provides a synthesis of the ecological effects of existing European marine reserves and the factors (social and ecological) underlying their effectiveness. Results show that existing European marine reserves foster significant positive increases in key biological variables (density, biomass, body size, and species richness) compared with areas receiving less protection, a pattern mirrored by marine reserves around the globe. For marine reserves to achieve their ecological and social goals, however, they must be designed, managed, and enforced properly. In addition, identifying whether protected areas are ecologically connected as a network, as well as where new MPAs should be established according to the MSFD, requires information on the connectivity of populations across large areas. The adoption of the MSFD demonstrates willingness to achieve the long-term protection of Europe’s marine ecosystems, but whether the political will (local, regional, and continent wide) is strong enough to see its mandates through remains to be seen. Although the MSFD does not explicitly require marine reserves, an important step towards the protection of Europe’s marine ecosystems is the establishment of marine reserves within wider-use MPAs as connected networks across large spatial scales

"I am nothing": experiences of loss among women suffering from severe birth injuries in Tanzania

\ud Despite the increased attention on maternal mortality during recent decades, which has resulted in maternal health being defined as a Millennium Development Goal (MDG), the disability and suffering from obstetric fistula remains a neglected issue in global health. Continuous leaking of urine and the physical, emotional and social suffering associated with it, has a profound impact on women's quality of life. This study seeks to explore the physical, cultural and psychological dimensions of living with obstetric fistula, and demonstrate how these experiences shape the identities of women affected by the condition. A cross-sectional study with qualitative and quantitative components was used to explore the experiences of Tanzanian women living with obstetric fistula and those of their husbands. The study was conducted at the Comprehensive Community Based Rehabilitation Tanzania hospital in Dar es Salaam, Bugando Medical Centre in Mwanza, and Mpwapwa district, in Dodoma region. Conveniently selected samples of 16 women were interviewed, and 151 additional women responded to a questionnaire. In addition, 12 women affected by obstetric fistula and six husbands of these affected women participated in a focus group discussions. Data were analysed using content data analysis framework and statistical package for the social sciences (SPSS) version 15 for Microsoft windows. The study revealed a deep sense of loss. Loss of body control, loss of the social roles as women and wives, loss of integration in social life, and loss of dignity and self-worth were located at the core of these experiences. The women living with obstetric fistula experience a deep sense of loss that had negative impact on their identity and quality of life. Acknowledging affected women's real-life experiences is important in order to understand the occurrence and management of obstetric fistula, as well as prospects after treatment. This knowledge will help to improve women's sense of self-worth and maintain their identity as women, wives, friends and community members. Educational programmes to empower women socially and economically and counselling of families of women living with obstetric fistula may help these women receive medical and social support that is necessary.\u

Action to protect the independence and integrity of global health research

Storeng KT, Abimbola S, Balabanova D, et al. Action to protect the independence and integrity of global health research. BMJ GLOBAL HEALTH. 2019;4(3): e001746

Translating global recommendations on HIV and infant feeding to the local context: the development of culturally sensitive counselling tools in the Kilimanjaro Region, Tanzania

BACKGROUND: This paper describes the process used to develop an integrated set of culturally sensitive, evidence-based counselling tools (job aids) by using qualitative participatory research. The aim of the intervention was to contribute to improving infant feeding counselling services for HIV positive women in the Kilimanjaro Region of Tanzania. METHODS: Formative research using a combination of qualitative methods preceded the development of the intervention and mapped existing practices, perceptions and attitudes towards HIV and infant feeding (HIV/IF) among mothers, counsellors and community members. Intervention Mapping (IM) protocol guided the development of the overall intervention strategy. Theories of behaviour change, a review of the international HIV/IF guidelines and formative research findings contributed to the definition of performance and learning objectives. Key communication messages and colourful graphic illustrations related to infant feeding in the context of HIV were then developed and/or adapted from existing generic materials. Draft materials were field tested with intended audiences and subjected to stakeholder technical review. RESULTS: An integrated set of infant feeding counselling tools, referred to as 'job aids', was developed and included brochures on feeding methods that were found to be socially and culturally acceptable, a Question and Answer Guide for counsellors, a counselling card on the risk of transmission of HIV, and an infant feeding toolbox for demonstration. Each brochure describes the steps to ensure safer infant feeding using simple language and images based on local ideas and resources. The brochures are meant to serve as both a reference material during infant feeding counselling in the ongoing prevention of mother to child transmission (pMTCT) of HIV programme and as take home material for the mother. CONCLUSION: The study underscores the importance of formative research and a systematic theory based approach to developing an intervention aimed at improving counselling and changing customary feeding practices. The identification of perceived barriers and facilitators for change contributed to developing the key counselling messages and graphics, reflecting the socio-economic reality, cultural beliefs and norms of mothers and their significant others