The knowledge, the will and the power : a plan of action to meet the HIV prevention needs of Africans living in England

The Knowledge, The Will and The Power is a statement of what we, the NAHIP Partners, plan to do to prevent HIV transmissions occurring during sexual activity among the diverse population of Africans living in England (Chapter 1). We describe the size and context of Africans living in England (Chapter 2), the size of the HIV epidemic and the number of new infections occurring (Chapter 3), as well as the behaviours and facilitators of new infections (Chapter 4). We then articulate how the NAHIP partners intend to influence future behaviours (Chapter 5). The final three chapters describe what is required in order to meet the HIV prevention needs of individual African people (Chapter 6), of NAHIP partner organisations (Chapter 7) and of those undertaking decisions related to policy, planning and research (Chapter 8)

African migrant women acquisition of clay for ingestion during pregnancy in London: a call for action

Objectives This study aimed to explore how African migrant women go about acquiring clay for ingestion during pregnancy in London against a backdrop of restrictions and warnings by the Food Standard Agency and Public Health England due to the potential health risks to expectant mothers and their unborn babies. Study design This was a qualitative study using an interpretative phenomenological approach. Methods Individual in-depth interviews and a focus group discussion were used for data collection. Data collection took place between May and August 2020. Results Participants acquired clay from African shops and markets in London, countries of origin and online/social media platforms. Due to official restrictions and warnings, transactions were conducted under the counter based on trust between sellers and the women underpinned by shared community identities. However, clay was acquired, social networks emerged as crucial facilitators. The current top-down approach, which is also lacking a regulatory policy framework, has pushed clay transactions underground, thereby leaving pregnant women potentially ingesting toxic clay with little chances of dictation by authorities. Conclusion We call on the UK Health Security Agency (UKHSA) and public health practitioners to collaborate with communities to design multilevel/multisectoral interventions as well as the Food Standards Agency (FSA) to consider an appropriate regulatory policy framework

Remote fieldwork with African migrant women during COVID-19 pandemic in London: a reflection

As coronavirus disease 2019 (COVID-19) pandemic unraveled, state-led preventative restrictions created a "new" normal through remote home-working. A long-planned follow-up qualitative research study on risk perceptions and experiences regarding Clay Ingestion among black African women during pregnancy, in London, was disrupted as England went into lockdown. Against this backdrop, we shifted to remote data collection which raised pertinent concerns around access to technology and participant digital skills. We share our experiences of navigating through remote fieldwork during the pandemic with black African mothers with caring responsibilities as well as the extra burden of homeschooling, the challenges we encountered and how we mitigate these and the lessons learnt. Thus, drawing from our remote qualitative research experiences, we refer to notable examples of challenges, mitigating strategies applied and potential lessons to inform future practice

Experiences of geophagy during pregnancy among African migrant women in London: implications for public health interventions

This study explored African migrant women's clay ingestion experiences during pregnancy against a backdrop of health risks warnings in order, to inform public health interventions by the UK Food Standards Agency and Public Health England, now known as the UK Health Security Agency. An interpretative phenomenological approach (IPA) was utilized, and data were collected with a total of 30 participants through individual in-depth interviews and one focus group discussion. Findings showed clay ingestion is a fluid and widely accepted cultural practice among African communities with most participants having been socialized into ingestion during childhood, through family influences and current social networks in their adulthood. Vomiting, nausea, spitting, appetite challenges, and cravings were cited as the main reasons for clay ingestion during pregnancy. With strong claims regarding its effectiveness, clay was ingested every day by most participants, and at times in large quantities despite the potential health risks. This calls for innovative and culturally sensitive public health interventions starting with the inclusion of clay ingestion health risk messages in maternal health nutrition information within antenatal settings. This can be done as part of multilevel interventions informed by life course approaches, which also consider community health messages and an enabling regulatory policy framework focusing on clay sold for human ingestion

Nigerian doctors’ experiences of guideline-based asthma management: a qualitative study

Background The Global Initiative for Asthma (GINA) report sets out an updated evidence-based strategy for asthma management. Little is known about how this report is perceived and implemented in low-income and middle-income countries (LMICs) like Nigeria. We explored the experiences of asthma management as informed by the current GINA guideline among doctors in Lagos, Nigeria. Methods Using a qualitative research approach, in-depth interviews were conducted among doctors in Lagos, Nigeria to explore their experiences of asthma management in the context of the current GINA report. The thematic framework approach was used for data analysis. Results Eleven doctors aged 28-46 years (five general practitioners (GPs) and six family physicians (FPs) took part. Four overarching themes were identified: (i) knowledge of, and attitude towards the GINA strategy – whilst most doctors were aware of the existence of the GINA report, there was limited knowledge about its content including current recommendations for mild asthma treatment; (ii) asthma diagnosis and treatment – there was limited access to lung function testing facilities, and its role in asthma diagnosis was underappreciated; (iii) barriers to managing asthma according to GINA recommendations – these included complexity of the GINA report, unavailability and unaffordability of asthma medicines and poor patient adherence to medications, driven by socio-cultural factors; and (iv) enablers of GINA-recommended asthma management – improvement in asthma education for doctors and the general population and better access to diagnostic tests and medicines. Conclusions Whilst there was awareness of the existence of the GINA report, there was limited knowledge about its content and several barriers to its implementation were reported. Education about the GINA report, investment in diagnostic and treatment services and simplification of recommendations were identified as possible solutions

Nigerian doctors’ experiences of guideline-based asthma management: a qualitative study

# Background The Global Initiative for Asthma (GINA) report sets out an updated evidence-based strategy for asthma management. Little is known about how this report is perceived and implemented in low-income and middle-income countries (LMICs) like Nigeria. We explored the experiences of asthma management as informed by the current GINA guideline among doctors in Lagos, Nigeria. # Methods Using a qualitative research approach, in-depth interviews were conducted among doctors in Lagos, Nigeria to explore their experiences of asthma management in the context of the current GINA report. The thematic framework approach was used for data analysis. # Results Eleven doctors aged 28-46 years (five general practitioners (GPs) and six family physicians (FPs) took part. Four overarching themes were identified: (i) *knowledge of, and attitude towards the GINA strategy* -- whilst most doctors were aware of the existence of the GINA report, there was limited knowledge about its content including current recommendations for mild asthma treatment; (ii) *asthma diagnosis and treatment* -- there was limited access to lung function testing facilities, and its role in asthma diagnosis was underappreciated; (iii) *barriers to managing asthma according to GINA recommendations* -- these included complexity of the GINA report, unavailability and unaffordability of asthma medicines and poor patient adherence to medications, driven by socio-cultural factors; and (iv) *enablers of GINA-recommended asthma management* -- improvement in asthma education for doctors and the general population and better access to diagnostic tests and medicines. # Conclusions Whilst there was awareness of the existence of the GINA report, there was limited knowledge about its content and several barriers to its implementation were reported. Education about the GINA report, investment in diagnostic and treatment services and simplification of recommendations were identified as possible solutions

“We threw away the stones”: a mixed method evaluation of a simple cookstove intervention in Malawi

Background: Air pollution exposure is responsible for a substantial burden of respiratory disease globally. Household air pollution from cooking using biomass is a major contributor to overall exposure in rural low-income settings. Previous research in Malawi has revealed how precarity and food insecurity shape individuals’ daily experiences, contributing to perceptions of health. Aiming to avoid a mismatch between research intervention and local context, we introduced a simple cookstove intervention in rural Malawi, analysing change in fine particulate matter (PM2.5) exposures, and community perceptions. Methods: Following a period of baseline ethnographic research, we distributed ‘chitetezo mbaula’, locally-made cookstoves, to all households (n=300) in a rural Malawian village. Evaluation incorporated village-wide participant observation and concurrent exposure monitoring using portable PM2.5 monitors at baseline and follow-up (three months post-intervention). Qualitative data were thematically analysed. Quantitative analysis of exposure data included pre-post intervention comparisons, with datapoints divided into periods of combustion activity (almost exclusively cooking) and non-combustion periods. Findings were integrated at the interpretation stage, using a convergent design mode of synthesis. Results: Individual exposure monitoring pre- and post-cookstove intervention involved a sample of 18 participants (15 female; mean age 43). Post-intervention PM2.5 exposures (median 9.9μg/m3 [interquartile range: 2.2–46.5]) were not significantly different to pre-intervention (11.8μg/m3 [3.8–44.4]); p=0.71. On analysis by activity, background exposures were found to be reduced post-intervention (from 8.2μg/m3 [2.5–22.0] to 4.6μg/m3 [1.0–12.6]; p=0.01). Stoves were well-liked and widely used by residents as substitutes for previous cooking methods (mainly three-stone fires). Commonly cited benefits related to fuel saving and shorter cooking times. Conclusions: The cookstove intervention had no impact on cooking-related PM2.5 exposures. A significant reduction in background exposures may relate to reduced smouldering emissions. Uptake and continued use of the stoves was high amongst community members, who preferred using the stoves to cooking over open fires

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

Personal exposures to fine particulate matter and carbon monoxide in relation to cooking activities in rural Malawi.

Background: Air pollution is a major environmental risk factor for cardiorespiratory disease. Exposures to household air pollution from cooking and other activities, are particularly high in Southern Africa. Following an extended period of participant observation in a village in Malawi, we aimed to assess individuals' exposures to fine particulate matter (PM ) and carbon monoxide (CO) and to investigate the different sources of exposure, including different cooking methods. Methods: Adult residents of a village in Malawi wore personal PM and CO monitors for 24-48 hours, sampling every 1 (CO) or 2 minutes (PM ). Subsequent in-person interviews recorded potential exposure details over the time periods. We present means and interquartile ranges for overall exposures and summaries stratified by time and activity (exposure). We employed multivariate regression to further explore these characteristics, and Spearman rank correlation to examine the relationship between paired PM and CO exposures. Results: Twenty participants (17 female; median age 40 years, IQR: 37-56) provided 831 hours of paired PM and CO data. Concentrations of PM during combustion activity, usually cooking, far exceeded background levels (no combustion activity): 97.9μg/m (IQR: 22.9-482.0), vs 7.6μg/m , IQR: 2.5-20.6 respectively. Background PM concentrations were higher during daytime hours (11.7μg/m [IQR: 5.2-30.0] vs 3.3μg/m at night [IQR: 0.7-8.2]). Highest exposures were influenced by cooking location but associated with charcoal use (for CO) and firewood on a three-stone fire (for PM ). Cooking-related exposures were higher in more ventilated places, such as outside the household or on a walled veranda, than during indoor cooking. Conclusions: The study demonstrates the value of combining personal PM exposure data with detailed contextual information for providing deeper insights into pollution sources and influences. The finding of similar/lower exposures during cooking in seemingly less-ventilated places should prompt a re-evaluation of proposed clean air interventions in these settings

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