Improving access to effective care for people with chronic respiratory symptoms in low and middle income countries.

Chronic respiratory symptoms are amongst the most common complaints among low and middle-income country (LMICs) populations and they are expected to remain common over the 10 to 20 year horizon. The underlying diseases (predominantly chronic obstructive pulmonary disease, asthma and tuberculosis) cause, and threaten to increasingly cause, substantial morbidity and mortality. Effective treatment is available for these conditions but LMICs health systems are not well set up to provide accessible clinical diagnostic pathways that lead to sustainable and affordable management plans especially for the chronic non communicable respiratory diseases. There is a need for clinical and academic capacity building together with well-conducted health systems research to underpin health service strengthening, policy and decision-making. There is an opportunity to integrate solutions for improving access to effective care for people with chronic respiratory symptoms with approaches to tackle other major population health issues that depend on well-functioning health services such as chronic communicable (e.g. HIV) and non-communicable (e.g. cardiovascular and metabolic) diseases

'Pneumonia has gone': exploring perceptions of health in a cookstove intervention trial in rural Malawi

Introduction Air pollution through cooking on open fires or inefficient cookstoves using biomass fuels has been linked with impaired lung health and with over 4 million premature deaths per annum. However, use of cleaner cookstoves is often sporadic and there are indications that longer-term health benefits are not prioritised by users. There is also limited information about how recipients of cookstoves perceive the health benefits of clean cooking interventions. We therefore conducted a qualitative study alongside the Cooking and Pneumonia Study (CAPS). Methods Qualitative methods and the participatory methodology Photovoice were used in an in-depth examination of health perceptions and understandings of CAPS trial participants. Fifty participants in five CAPS intervention villages collected images about cooking. These were discussed in village-level focus groups and in interviews with 12 representative participants. Village community representatives were also interviewed. Four female and eight male CAPS fieldworkers took part in gender-specific focus groups and two female and two male fieldworkers were interviewed. A thematic content approach was used for data analysis. Results We found a disconnect between locally situated perceptions of health and the biomedically focused trial model. This included the development of potentially harmful understandings such as that pneumonia was no longer a threat and potential confusion between the symptoms of pneumonia and malaria. Study participants perceived health and well-being benefits including: cookstoves saved bodily energy; quick cooking helped maintain family harmony. Conclusion A deeper understanding of narratives of health within CAPS showed how context-specific perceptions of the health benefits of cookstoves were developed. This highlighted the conflicting priorities of cookstove intervention researchers and participants, and unintended and potentially harmful health understandings. The study also emphasises the importance of including qualitative explorations in similar complex interventions where potential pathways to beneficial (and harmful) effects, cannot be completely explicated through biomedical models alone

'Cooking is for everyone?': Exploring the complexity of gendered dynamics in a cookstove intervention study in rural Malawi

BACKGROUND Household air pollution (HAP) resulting from cooking on open fires has been linked to considerable ill-health in women and girls, including chronic respiratory diseases, and has been identified as a contributor to climate change. It has been suggested that cleaner burning cookstoves can mitigate these risks, and that time saved through speedier cooking can lead to the economic empowerment of women. Despite these and other potential advantages of cookstoves, sustained use is difficult to achieve. OBJECTIVE We used qualitative methods (focus groups, interviews, observation) and the participatory methodology Photovoice in order to inform a deeper understanding of gendered social relationships within the Cooking and Pneumonia Study (CAPS) in rural Malawi. METHODS Over five CAPS villages, forty women and ten men were recruited for Photovoice activities, including image collection, village-level focus group discussion and interviews. Data were also collected from interviews with village-based community representatives. RESULTS This study facilitated a rich exploration of context-specific gendered household roles and power relations which found that there was space for contestation in seemingly entrenched and 'traditional' household responsibilities. The results suggest that the introduction of cookstoves through CAPS provided a focus for this contestation. It was evident that men and children also cooked, and that cooking played a central role in the gendered socialisation of children. However, there were no indications that time saved resulted in the empowerment of women. CONCLUSION Our findings suggest that dominant narratives of the links between gender and cookstoves are often reductive and fail to reflect the complexity of gender power relations. The use of qualitative methods incorporating Photovoice helped to facilitate an alternative 'bottom-up' view of cookstove use which demonstrated that while cookstoves may disrupt gendered relationships in target communities, positive impacts for women and girls cannot be assumed

Commentary - Key stakeholders’ perspectives on prioritization of services for chronic respiratory diseases (CRDs) in Tanzania and Sudan: Implications in the COVID-19 era

Key Messages● Despite significant morbidity and mortality and socioeconomic consequences, chronic respiratory diseases (CRDs) are underprioritized in public health programs, especially in low-and middle income countries (LMICs)● COVID-19 is compounding this lack of prioritization and negatively impacting CRD-related (and other) health-care access, diagnosis, and management● Risk factors for exposure to untreated COVID-19, other respiratory infections, and CRDs overlap and could be addressed in concert● Prioritization of COVID-19 within the health system is likely to last for years, potentially allowing advocates to reframe the prioritization of CRDs as part of the pandemic preparedness and integration of health care. This includes advocating for approaches that integrate CRDs into existing programs and services systems strengthening

Key stakeholders’ perspectives on prioritization of services for chronic respiratory diseases (CRDs) in Tanzania and Sudan: Implications in the COVID-19 era

Key Messages ● Despite significant morbidity and mortality and socioeconomic consequences, chronic respiratory diseases (CRDs) are underprioritized in public health programs, especially in low-and middle income countries (LMICs) ● COVID-19 is compounding this lack of prioritization and negatively impacting CRD-related (and other) health-care access, diagnosis, and management ● Risk factors for exposure to untreated COVID-19, other respiratory infections, and CRDs overlap and could be addressed in concert ● Prioritization of COVID-19 within the health system is likely to last for years, potentially allowing advocates to reframe the prioritization of CRDs as part of the pandemic preparedness and integration of health care. This includes advocating for approaches that integrate CRDs into existing programs and services systems strengthenin

Management of chronic lung diseases in Sudan and Tanzania: how ready are the country health systems?

Background Chronic lung diseases (CLDs), responsible for 4 million deaths globally every year, are increasingly important in low- and middle-income countries where most of the global mortality due to CLDs currently occurs. As existing health systems in resource-poor contexts, especially sub-Saharan Africa (SSA), are not generally oriented to provide quality care for chronic diseases, a first step in re-imagining them is to critically consider readiness for service delivery across all aspects of the existing system. Methods We conducted a mixed-methods assessment of CLD service readiness in 18 purposively selected health facilities in two differing SSA health system contexts, Tanzania and Sudan. We used the World Health Organization’s (WHO) Service Availability and Readiness Assessment checklist, qualitative interviews of key health system stakeholders, health facility registers review and assessed clinicians’ capacity to manage CLD using patient vignettes. CLD service readiness was scored as a composite of availability of service-specific tracer items from the WHO service availability checklist in three domains: staff training and guidelines, diagnostics and equipment, and basic medicines. Qualitative data were analysed using the same domains. Results One health facility in Tanzania and five in Sudan, attained a CLD readiness score of ≥ 50 % for CLD care. Scores ranged from 14.9 % in a dispensary to 53.3 % in a health center in Tanzania, and from 36.4 to 86.4 % in Sudan. The least available tracer items across both countries were trained human resources and guidelines, and peak flow meters. Only two facilities had COPD guidelines. Patient vignette analysis revealed significant gaps in clinicians’ capacity to manage CLD. Key informants identified low prioritization as key barrier to CLD care. Conclusions Gaps in service availability and readiness for CLD care in Tanzania and Sudan threaten attainment of universal health coverage in these settings. Detailed assessments by health systems researchers in discussion with stakeholders at all levels of the health system can identify critical blockages to reimagining CLD service provision with people-centered, integrated approaches at its heart

Study protocol: analysis of regional lung health policies and stakeholders in Africa

Background Lung health is a critical area for research in sub-Saharan Africa. The International Multidisciplinary Programme to Address Lung Health and TB in Africa (IMPALA) is a collaborative programme that seeks to fill evidence gaps to address high-burden lung health issues in Africa. In order to generate demand for and facilitate use of IMPALA research by policy-makers and other decision-makers at the regional level, an analysis of regional lung health policies and stakeholders will be undertaken to inform a programmatic strategy for policy engagement. Methods and analysis This analysis will be conducted in three phases. The first phase will be a rapid desk review of regional lung health policies and stakeholders that seeks to understand the regional lung health policy landscape, which issues are prioritised in existing regional policy, key regional actors, and opportunities for engagement with key stakeholders. The second phase will be a rapid desk review of the scientific literature, expanding on the work in the first phase by looking at the external factors that influence regional lung health policy, the ways in which regional bodies influence policy at the national level, investments in lung health, structures for discussion and advocacy, and the role of evidence at the regional level. The third phase will involve a survey of IMPALA partners and researchers as well as interviews with key regional stakeholders to further shed light on regional policies, including policy priorities and gaps, policy implementation status and challenges, stakeholders, and platforms for engagement and promoting uptake of evidence. Discussion Health policy analysis provides insights into power dynamics and the political nature of the prioritisation of health issues, which are often overlooked. In order to ensure the uptake of new knowledge and evidence generated by IMPALA, it is important to consider these complex factors

Genomic epidemiology of SARS-CoV-2 in a UK university identifies dynamics of transmission

AbstractUnderstanding SARS-CoV-2 transmission in higher education settings is important to limit spread between students, and into at-risk populations. In this study, we sequenced 482 SARS-CoV-2 isolates from the University of Cambridge from 5 October to 6 December 2020. We perform a detailed phylogenetic comparison with 972 isolates from the surrounding community, complemented with epidemiological and contact tracing data, to determine transmission dynamics. We observe limited viral introductions into the university; the majority of student cases were linked to a single genetic cluster, likely following social gatherings at a venue outside the university. We identify considerable onward transmission associated with student accommodation and courses; this was effectively contained using local infection control measures and following a national lockdown. Transmission clusters were largely segregated within the university or the community. Our study highlights key determinants of SARS-CoV-2 transmission and effective interventions in a higher education setting that will inform public health policy during pandemics.</jats:p

The Cooking and Pneumonia Study (CAPS) in Malawi: A Nested Pilot of Photovoice Participatory Research Methodology.

The Cooking and Pneumonia Study (CAPS) is a village-level randomised controlled trial of an advanced cookstove intervention to prevent pneumonia in children under the age of 5 in rural Malawi (www.capstudy.org). The trial offers a unique opportunity to gain understanding about the social and cultural factors that may facilitate sustained use of improved cookstoves. In January 2015, the use of Photovoice as a participatory research methodology was piloted at the CAPS Chikhwawa site. Photovoice is a photographic technique that allows communities (including women and marginalised groups) to share knowledge about their perspectives and priorities. Four households were given digital cameras and asked to collect images over 24-48 hours and were then interviewed on film about their selection. This resulted in over 400 images and a one hour long film that revealed community concerns and could be thematically analysed. The collection of interview data through film was useful for capturing discussion and was acceptable to participants. Photovoice is a feasible participatory research methodology that can play a valuable role in qualitative studies of improved cookstove adoption in challenging resource poor settings