Dilemma with the local perception of causes of illnesses in central Africa: muted concept but prevalent in everyday life

Intersectionality on the perception of health in two cross-national surveys (WVS and EVS)

This article focuses on the health perceptions of people across social strata and nations using the combined dataset of the World Values Survey and the European Values Study (EVS/WVS). An intercategorical intersectional analysis model was developed to examine the social determinants underlying differences in health perceptions. Using logistic regression of the interactions between sex, age, level of educational attainment and income, we calculated the impact of these variables (main effects) and their interactions within the intersecting categories on health perceptions. The group with the best perception of their health includes men aged 16-49, with a high income and an upper-middle level of education. Comparative analysis has been carried out to identify differences in the influence of intersectional categories across countries. Of particular relevance is the number of Eastern European countries where the perception of people aged 50 and over with low income is very poor.

An exploratory study on the perceptions of rabies and ill-health causations and health seeking behaviours of school children and local communities in southern Bhutan

BACKGROUND

The perception of illness and health-seeking behaviours, including rabies differ from one culture to another. Depending on the cultural setting of the society in which people live, the definition of the causal factors of illness may range from natural biological causes to supernational causes which greatly influence subsequent health-seeking behaviour. To ensure best health practices and plan effective health interventions for the control of dog-mediated-human rabies, we explored how school children and adult communities perceive and respond to illnesses, including rabies in southern Bhutan.

METHODS

We collected quantitative data related to the causes of illness and health-seeking practices of school children using a questionnaire survey (QS). Qualitative data were collected through focus group discussions (FGDs) and in-depth interviews (IDIs) with older members of communities (≥ 18 years) that work closely with school children. Descriptive analysis was performed for the quantitative data and thematic analysis was performed for the qualitative data.

RESULTS

The participants during the FDGsand IDIshave linked the illnesses to past actions, spirits, energy channels, planetary movement, sorcery, black magic, food, physical or environmental factors, individual habits and social factors. The survey of the school children reported microorganisms (75%), past actions (16.8%), spirits (9.6%) and black magic (9.1%) as causal factors for illnesses. Health seeking behaviours reported by the participants included visiting hospitals, performing spiritual or religious rituals and local treatments. Similarly, school children also mentioned that illnesses can be treated by visiting hospitals (98%), performing rituals (59.1%), and seeking traditional treatments practices (18.8%). Both school children and adult members of the communities that we interviewed were well aware on the causes of rabies and need for allopathic treatments rather than seeking spiritual or local treatments.

CONCLUSION

There is a need for the consideration of the socio-cultural context in the planning and implementation of health-related policies, including the rabies prevention programs in Bhutan, by involving traditional healers and religious entities with "One Health" public health sectors.

Misconceptions and Rumors about Ebola Virus Disease in Sub-Saharan Africa: A Systematic Review

We sought to summarize knowledge, misconceptions, beliefs, and practices about Ebola that might impede the control of Ebola outbreaks in Africa. We searched Medline, EMBASE, CINAHL, and Google Scholar (through May 2019) for publications reporting on knowledge, attitudes, and practices (KAP) related to Ebola in Africa. In total, 14 of 433 articles were included. Knowledge was evaluated in all 14 articles, and they all highlighted that there are misconceptions and risk behaviors during an Ebola outbreak. Some communities believed that Ebola spreads through the air, mosquito bites, malice from foreign doctors, witchcraft, and houseflies. Because patients believe that Ebola was caused by witchcraft, they sought help from traditional healers. Some people believed that Ebola could be prevented by bathing with salt or hot water. Burial practices where people touch Ebola-infected corpses were common, especially among Muslims. Discriminatory attitudes towards Ebola survivors or their families were also prevalent. Some Ebola survivors were not accepted back in their communities; the possibility of being ostracized from their neighborhoods was high and Ebola survivors had to lead a difficult social life. Most communities affected by Ebola need more comprehensive knowledge on Ebola. Efforts are needed to address misconceptions and risk behaviors surrounding Ebola for future outbreak preparedness in Africa.

Health-Seeking Behaviors in Mozambique: A Mini-Study of Ethnonursing

In settings where traditional medicine is a crucial part of the healthcare system, providing culturally competent healthcare services is vital to improving patient satisfaction and health outcomes. Therefore, this study sought to gain insight into how cultural beliefs influence health-seeking behaviors (HSBs) among Mozambicans. Participant observation and in-depth interviews (IDIs) were undertaken using the ethnonursing method to investigate beliefs and views that Mozambicans (living in Pemba City) often take into account to meet their health needs. Data were analyzed in accordance with Leininger’s ethnonursing guidelines. Twenty-seven IDIs were carried out with 12 informants from the Makonde and Makuwa tribes. The choice of health service was influenced by perceptions of health and illness through a spiritual lens, belief in supernatural forces, dissatisfaction with and dislike of the public medical system on grounds of having received poor-quality treatment, perceived poor communication skills of health professionals, and trust in the indigenous medical system. This study confirmed the need for health professionals to carefully take cultural influences into consideration when providing care for their patients. We recommend an educational intervention that emphasizes communication skills training for healthcare workers to ensure successful physician/nurse–patient relationships.

'What the herbal medicine can do for me in a week, the orthodox does in a year': Perceived efficacy of local alternative therapies influences medication adherence in patients with atherosclerotic cardiovascular disease

Background

There is strong evidence that anti‐platelet therapy, ACE inhibitors, beta‐blockers and statins are cost‐effective in reducing subsequent cardiovascular disease (CVD) events in patients with atherosclerotic cardiovascular disease (ACVD). In some settings, only a low proportion of people have access to these medications, and even lower adhere to them. The current study explored and presents data on the causes of poor adherence to orthodox medication and motivations for alternative therapies in patients with established atherosclerotic cardiovascular disease (ACVD).

Methods

The study was conducted among city‐dwelling adults with ACVD in Accra – Ghana's capital city. Eighteen interviews were conducted with patients with established ACVD. A follow‐up focus group discussion was conducted with some of them. The protocol was approved by two ethics review committees based in Ghana and in the United Kingdom. All participants were interviewed after informed consent. Analysis was done with the Nvivo qualitative data analysis software.

Results

We identified motivations for use of alternatives to orthodox therapies. These cover the five dimensions of adherence: social and economic, health‐care system, condition‐related, therapy‐related, and patient‐related dimensions. Perceived inability of an orthodox medication to provide immediate benefit is an important motivator for use of alternative forms of medication.

Conclusions

A multiplicity of factors precipitate non‐adherence to orthodox therapies. Perceived efficacy and easy access to local alternative therapies such as herbal and faith‐based therapies are important motivators.

Ebola virus disease in the eyes of a rural, agrarian community in Western Nigeria: a mixed method study

Background

Ebola virus disease (EVD) is a severe hemorrhagic disease caused by Ebola virus. Several outbreaks have been reported in Africa and often originated from remote agrarian communities where there are enormous misconceptions of the disease, refusal of early isolation and quarantine, and unsafe burial rites practices which aggravates the epidemics. It is on this basis that this study was conducted to (assess) the knowledge, perceptions, beliefs and preventive practices against EVD in a predominantly agrarian rural community in Southwest Nigeria.

Methods

This was a cross-sectional study conducted in Igbogila town, Yewa North Local Government Area of Ogun State, Southwest Nigeria in the latter part of 2014 during the EVD outbreak. Mixed methods were used for data collection. Quantitative data collection was done using a pre-tested interviewer administered questionnaire. Four hundred and seven respondents selected by multi-stage sampling technique were interviewed. Descriptive and inferential statistics were done, and the level of significance was set at 0.05. Qualitative data collection involved four focus group discussions a year after the epidemic was declared over in the country. The discussions were recorded, transcribed and analyzed along major themes.

Results

All respondents were aware of EVD with radio and television being the major sources of information. Knowledge of the disease was however very poor with many misconceptions and it was significantly influenced by educational level of respondent. EVD survivors will be welcomed back into the community by few residents (36.8%) and a much fewer proportion (27.2%) will freely entertain a survivor in their house. Most would prefer local herbalists over orthodox medical practitioners to care for their loved one in case they contract EVD. Although respondents knew that burying a victim is dangerous, they opposed cremation.

Conclusion

There was poor knowledge of EVD with a lot of misconceptions. Community members were not pro-active about prevention with dire consequences in the event of an outbreak. Continuous public education should be done via mass media, traditional institutions and other community-based channels as part of emergency preparedness.

Health Beliefs and Patient Perspectives of Febrile Illness in Kilombero, Tanzania

This qualitative study assessed the knowledge and beliefs surrounding fever syndrome among adult febrile patients seeking health care in Kilombero, Tanzania. From June 11 to July 13, 2014, 10% of all adult (≥ 15 years) febrile patients enrolled in the larger syndromic study, who presented with an axillary temperature ≥ 37.5°C and symptom onset ≤ 5 days prior, were randomly selected to participate in an in-depth physician-patient interview, informed by Health Belief Model constructs. Interviews were audio recorded, translated, and transcribed. Transcripts were coded using NVivo Version 11.1, and the thematic content was analyzed by two separate researchers. Blood and nasopharyngeal/oralpharyngeal specimens were collected and analyzed using both acute febrile illness and respiratory TaqMan Array Cards for multipathogen detection of 56 potential causative agents. A total of 18 participants provided 188 discrete comments. When asked to speculate the causative agent of febrile illness, 33.3% cited malaria and the other 66.6% offered nonbiomedical responses, such as "mosquitoes" and "weather." Major themes emerging related to severity and susceptibility to health hazards included lack of bed net use, misconceptions about bed nets, and mosquito infestation. Certain barriers to treatment were cited, including dependence on traditional healers, high cost of drugs, and poor dispensary services. Overall, we demonstrate low concurrence in speculations of fever etiology according to patients, clinicians, and laboratory testing. Our findings contribute to the important, yet limited, base of knowledge surrounding patient risk perceptions of febrile illness and underscore the potential utility of community-based participatory research to inform disease control programs.

Experiences and perceptions of infant dental enucleation among Somali immigrants in Sweden: a phenomenographic study

Objective: The aim of this study was to explore and describe ways of experiencing and perceiving the Eastern African practice of infant dental enucleation (IDE) among immigrants of Somali origin living in Sweden. Material and methods: Six informants, three men and three women aged 26-54 years, were recruited for semi-structured individual interviews. Phenomenographic analysis of the interview transcripts was performed. Findings: Informants described four ways of experiencing and perceiving IDE: as an effective, necessary treatment; as a disputed tradition; as an alternative to failure; and as a desperate measure. The experiences and perceptions were highly influenced by the contexts the informants had been in, namely, communities in which traditional treatments were used frequently, in which other people were influential over their daily lives, and in which negative experiences of formal health care were common, as well as other difficult circumstances beyond the informants' individual control. Conclusions: The findings contribute to deepened understanding of IDE and the importance of context to the practice of it. Further, the findings deepen understanding of the decision to have the practice performed on infants, which may help dental and health care personnel to adequately communicate with individuals of Somali origin about the harmfulness of IDE.

Who are the real community health workers in Tshopo Province, Democratic Republic of the Congo?

Recent years have seen increasing momentum towards task shifting of basic health services, including using community health workers (CHW) to diagnose and treat common childhood illnesses. Yet few studies have examined the role of traditional healers in meeting families’ and communities’ health needs and liaising with the formal health system. We examine these issues in Tshopo Province in the Democratic Republic of the Congo, a country with high rates of child mortality (104 deaths per 1000 live births). We conducted 127 in-depth interviews and eight focus group discussions with a range of community members (mothers, fathers and grandmothers of children under 5 years of age) and health providers (CHWs, traditional healers, doctors and nurses) on topics related to care seeking and case management for childhood illness and malnutrition, and analysed them iteratively using thematic content analysis. We find significant divergence between biomedical descriptions of child illness and concepts held by community members, who distinguished between local illnesses and so-called ‘white man’s diseases.’ Traditional healers were far less costly and more geographically accessible to families than were biomedical health providers, and usually served as families’ first recourse after home care. Services provided by traditional healers were also more comprehensive than services provided by CHWs, as the traditional medicine sphere recognised and encompassed care for ‘modern’ diseases (but not vice versa). Meanwhile, CHWs did not receive adequate training, supervision or supplies to provide child health services. Considering their accessibility, acceptability, affordability and ability to recognise all domains of illness (biomedical and spiritual), traditional healers can be seen as the de facto CHWs in Tshopo Province. National and international health policymakers should account for and involve this cadre of health workers when planning child health services and seeking to implement policies and programmes that genuinely engage with community health systems.

Burden of diabetic foot ulcer in Nigeria: Current evidence from the multicenter evaluation of diabetic foot ulcer in Nigeria

BACKGROUND

Nigeria bears the greatest burden of diabetes prevalence in Sub-Saharan Africa. Diabetic foot ulcer (DFU) is a serious and potentially life-threatening complication of diabetes. Significant improvements in diabetic foot incidence and outcomes have been recorded in many Western countries in the past decade. However, the current burden of DFU in Nigeria is largely unknown.

AIM

To evaluate the patients’ profile, ulcer characteristics, associated co-morbidities and outcome of patients with DFU in Nigeria.

METHODS

Multicenter evaluation of diabetic foot ulcer in Nigeria was a one year multicenter observational study of patients hospitalized for DFU in six tertiary health institutions in Nigeria from March 2016 to March 2017. Demographic and diabetes information, ulcer characteristics and associated co-morbidities were assessed. Relevant laboratory and imaging studies were performed. All patients received appropriate multi-disciplinary care and were followed up until discharge or death. Outcome variables of interest were ulcer healing, lower extremity amputation (LEA), duration of hospitalization and mortality.

RESULTS

A total of 336 patients (55.1% male) with mean age of 55.9 ± 12.5 years were enrolled into this study. Majority (96.1%) had type 2 diabetes. Only 25.9% of the subjects had prior foot care knowledge. Most of the subjects presented late to the hospital and median (IQR) duration of ulcer at presentation was 39 (28-54) d. Ulcers were already advanced (Wagner grades ≥ 3) in 79.2% of the subjects while 76.8% of the ulcers were infected at the time of admission. The commonest co-morbidities were systemic hypertension, anemia and hyperglycemic emergencies. One hundred and nineteen subjects (35.4%) suffered LEA while 10.4% left against medical advice. The median (IQR) duration of hospitalization was 52.0 (29-66) d with case fatality rate of 20.5%.

CONCLUSION

The burden of DFU in Nigeria is very high. The major gaps include low level of foot care knowledge among diabetic patients, overdependence on self-medication and unorthodox medicine following development of foot ulceration, late hospital presentation, and high amputation and mortality rates. Extensive foot care education within the framework of a multi-disciplinary foot care team is highly desirable.

Heart Failure Etiologies and Challenges to Care in the Developing World: An Observational Study in the Democratic Republic of Congo

BACKGROUND

Limited data are available regarding causes and outcomes of heart failure as well as organization of care in the developing world.

METHODS AND RESULTS

We included consecutive patients diagnosed with heart failure from November 2014 to September 2016 in a university and private hospital of Lubumbashi, Democratic Republic Congo. Baseline data, including echocardiography, were analyzed to determine factors associated with mortality. Cost of hospitalization as well as challenges for care regarding follow-up were determined. A total of 231 patients (56 ± 17 years, 47% men, left ventricular ejection fraction 29 ± 15%, 20% atrial fibrillation) were diagnosed, more during heart failure hospitalizations (69%) than as outpatients (31%). Main risk factors for heart failure included hypertension (59%), chronic kidney disease (51%), alcohol abuse (38%), and obesity (32%). Dilated cardiomyopathy was the most prevalent etiology (48%), with ischemic cardiomyopathy being present in only 4%. In-hospital mortality rate was 19% and associated with an estimated glomerular filtration rate of <60 mL·min^-1·1.73 m^-2 (P < .01) and atrial fibrillation (P = .02). One hundred six patients (46%) were lost to follow-up, which was mainly related to lack of organization of care, poverty, and poor health literacy. Of the remaining 95 subjects, another 33 (35%) died within 1 year after presentation. The average cost of care for a 10-day hospitalization was higher in a private than in a university hospital (885 vs 409 USD).

CONCLUSIONS

Patients admitted for heart failure in DRC have a high incidence of nonischemic cardiomyopathy and present late during their disease, with limited resources being available accounting for a high mortality rate and very high loss to follow-up.

Exploring the knowledge, explanatory models of illness, and patterns of healthcare-seeking behaviour of Fang culture-bound syndromes in Equatorial Guinea

In 1994, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) included "culture-bound syndromes" in its classification of psychiatric disorders and associated them with disease processes that manifest in behavioural or thought disorders that develop within a given cultural context. This study examines the definitions, explanatory models, signs and symptoms, and healthcare-seeking behaviours common to Fang culture-bound syndromes (i.e., kong, eluma, witchcraft, mibili, mikug, and nsamadalu). The Fang ethnic group is the majority ethnic group in Equatorial Guinea. From September 2012 to January 2013, 45 key Fang informants were selected, including community leaders, tribal elders, healthcare workers, traditional healers, and non-Catholic pastors in 39 of 724 Fang tribal villages in 6 of 13 districts in the mainland region of Equatorial Guinea. An ethnographic approach with an emic-etic perspective was employed. Data were collected using semi-structured interviews, participant observation and a questionnaire that included DHS6 key indicators. Interviews were designed based on the Cultural Formulation form in the DSM-5 and explored the definition of Fang cultural syndromes, symptoms, cultural perceptions of cause, and current help-seeking. Participants defined "Fang culture-bound syndromes" as those diseases that cannot be cured, treated, or diagnosed by science. Such syndromes present with the same signs and symptoms as diseases identified by Western medicine. However, they arise because of the actions of enemies, because of the actions of spirits or ancestors, as punishments for disregarding the law of God, because of the violation of sexual or dietary taboos, or because of the violation of a Fang rite of passage, the dzas, which is celebrated at birth. Six Fang culture-bound syndromes were included in the study: 1) Eluma, a disease that is targeted at the victim out of envy and starts out with sharp, intense, focussed pain and aggressiveness; 2) Witchcraft, characterized by isolation from the outside, socially maladaptive behaviour, and the use of hallucinogenic substances; 3) Kong, which is common among the wealthy class and manifests as a disconnection from the environment and a lack of vital energy; 4) Mibili, a possession by evil spirits that manifests through visual and auditory hallucinations; 5) Mikug, which appears after a person has had contact with human bones in a ritual; and 6) Nsamadalu, which emerges after a traumatic process caused by violating traditions through having sexual relations with one's sister or brother. The therapeutic resources of choice for addressing Fang culture-bound syndromes were traditional Fang medicine and the religious practices of the Bethany and Pentecostal churches, among others. Among African ethnic groups, symbolism, the weight of tradition, and the principle of chance in health and disease are underlying factors in the presentation of certain diseases, which in ethno-psychiatry are now referred to as culture-bound syndromes. In this study, traditional healers, elders, healthcare professionals, religious figures, and leaders of the Fang community in Equatorial Guinea referred to six such cultural syndromes: eluma, witchcraft, kong, mibili, mikug, and nsamadalu. In the absence of a multidisciplinary approach to mental illness in the country, the Fang ethnic group seeks healthcare for culture-bound syndromes from traditional healing and religious rites in the Evangelical faiths.

Detection of Emerging Zoonotic Pathogens: An Integrated One Health Approach

The emergence of novel zoonotic pathogens is one of the greatest challenges to global health security. The advent of increasingly sophisticated diagnostics tools has revolutionized our capacity to detect and respond to these health threats more rapidly than ever before. Yet, no matter how sophisticated these tools become, the initial identification of emerging infectious diseases begins at the local community level. It is here that the initial human or animal case resides, and it is here that early pathogen detection would have maximum benefit. Unfortunately, many areas at highest risk of zoonotic disease emergence lack sufficient infrastructure capacity to support robust laboratory diagnostic systems. Multiple factors are essential for pathogen detection networks, including an understanding of the complex sociological and ecological factors influencing disease transmission risk, community engagement, surveillance along high-risk human-animal interfaces, and a skilled laboratory workforce. Here we discuss factors relevant to the emerging disease paradigm, recent technical advances in diagnostic methods, and strategies for comprehensive and sustainable approaches to rapid zoonotic disease detection.

'I think my body has become addicted to those tablets'. Chronic heart failure patients' understanding of and beliefs about their illness and its treatment: A qualitative longitudinal study from Uganda

BACKGROUND

Patients with heart failure in Uganda present for health care with advanced structural heart disease, have repeated hospitalizations and poorly controlled disease symptoms. The reasons for these are unclear. Literature from other settings shows that patients' understanding of their illness and their beliefs influence their health related behaviour. The study aimed to explore the beliefs of patients with heart failure, their understanding of their illness and its treatment, and how this influenced their health related behaviour to inform future health education programs, information and palliative care services.

METHODS

Serial qualitative in-depth interviews were conducted with Heart Failure patients who were purposively sampled and recruited in Mulago National Referral Hospital until thematic saturation was reached. In-depth interviews were conducted at three time points over the course of their illness with intervals of 3 months between interviews. A grounded theory approach was used in data analysis. The University of Edinburgh ethics committee, Mulago Hospital Research Ethics committee and the Uganda National Council of Science and Technology (Reference numbers D/GC/178; MREC 33, SS 3083 respectively) approved the research.

RESULTS

A total of 40 face to face qualitative longitudinal interviews (36-patient alone, 4 paired-patient and family carer), were conducted with 21 patients. The findings revealed that heart failure patients were unaware of the symptoms of the illness and their definition of illness differed from that of health professionals. Patients understood their diagnosis, cause of illness, prognosis and the importance of the medicines differently from health professionals, and had insufficient information on self-care. Lay beliefs were used to explain many aspects of the illness and treatments. All these influenced where patients sought care and their adherence to treatment, self-care and follow up leading to uncontrolled disease.

CONCLUSION

There is a high level of health illiteracy among heart failure patients in Uganda. Patients rely on lay beliefs to make health decisions and medical information is often miscomprehended. There is an urgent need for health education using culturally appropriate information.

Local terms and understandings of mental health problems in Burundi

A pilot study and two intensive studies were conducted to document the local vocabularies used by Burundians to describe mental health problems and their understandings about the causes. The pilot study-in which 14 different large groups of community members awaiting appointments at a village health clinic were engaged in open-ended discussions of the local terminology and causal beliefs about mental health problems-suggested three key syndromes: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms). In Study 1 ( N = 542), individual interviews or surveys presented participants with the names of these syndromes and asked what they considered to be the symptoms and causes of them. Study 2 ( N = 143) cross-validated these terms with a different sample (also in individual interviews/surveys), by presenting the symptom clusters and asking what each would be called and about their causes. Findings of both studies validated this set of terms and yielded a rich body of data about causal beliefs. The influence of education level and gender on familiarity with these terms was also assessed. Implications for the development of mental health services and directions for future research are discussed.

Mental health treatment outcome expectancies in Burundi

Best practices in global mental health stress the importance of understanding local values and beliefs. Research demonstrates that expectancies about the effectiveness of a given treatment significantly predicts outcome, beyond the treatment effect itself. To help inform the development of mental health interventions in Burundi, we studied expectancies about the effectiveness of four treatments: spiritual healing, traditional healing, medication, and selected evidence-based psychosocial treatments widely used in the US. Treatment expectancies were assessed for each of three key syndromes identified by previous research: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms) . In individual interviews or written surveys in French or Kirundi with patients ( N = 198) awaiting treatment at the clinic, we described each disorder and the treatments in everyday language, asking standard efficacy expectations questions about each ("Would it work?" "Why or why not?"). Findings indicated uniformly high expectancies about the efficacy of spiritual treatment, relatively high expectancies for western evidence-based treatments (especially cognitive behavior therapy [CBT] for depression-like symptoms), lower expectancies for medicine, and especially low expectancies for traditional healing (except for traditional healing for psychosis-like symptoms). There were significant effects of gender but not of education level. Qualitative analyses of explanations provide insight into the basis of people's beliefs, their explanations about why a given treatment would or would not work varied by type of disorder, and reflected beliefs about underlying causes. Implications for program development and future research are discussed.

Health-Seeking Behaviour towards Poverty-Related Disease (PRDs): A Qualitative Study of People Living in Camps and on Campuses in Cameroon

Poverty-Related Diseases (PRDs) emphasize poverty as a ‘breeding-ground’ for a range of diseases. The study presented here starts from the premise that poverty is a general condition that can limit people’s capacity to prevent, mitigate or treat diseases. Using an interpretation of health seeking behaviour (HSB), inspired by the salutogenic approach, we investigated how people deal with PRDs, their ability and strategies put in place to cope. We collected HSB data from two groups of respondents in Cameroon: labourers of the Cameroon Development Corporation (CDC) living in settlements called camps and students of the state universities of Buea and Yaoundé living in settlements we refer to as campuses. By selecting these groups, the study offers a unique view of how different people cope with similar health challenges. We carried out semi-structured interviews with 21 camp dwellers and 21 students in a cross-sectional study. Our findings revealed 1) respondents use multiple resources to cope with PRDs. 2) Respondents’ perceptions of diseases and connection with poverty closely ties to general hygienic conditions of their living environment. 3) Utilisation of health facilities is not strongly dependent on financial resources. 4) Volatile health facilities are a major challenge and reason for people to revert to other health resources. The study brings out the need for organisations (governmental and non-governmental) to strengthen people’s capacities to cope with health situations through better health and housing policies geared at incorporating practices currently used by the people and supporting pro-hygienic initiatives.

People’s living conditions are a crucial factor for health and diseases. In developing countries like Cameroon, poverty is a major condition affecting the way people deal with health issues. We studied people’s a health-seeking behaviour action in two settings: camps, housing labourers of the Cameroon Development Cooperation, and campuses, places where students of the state universities of Buea and Yaoundé reside. We interviewed 21 camp dwellers and 21 students about their health challenges and responses. The results show health challenges not only relate to exposure to diseases but also to the reliability, affordability and functionality of medical services, the hygienic conditions in the living environment and money. For treatment of common diseases, foremost malaria and typhoid, the last resort was going to a clinic or hospital. More prominent responses were cleaning and other hygienic measures, self-medication using available tablets, herbs or other traditional medicine, consultation at small pharmacies or unofficial ‘doctors’. Public health services should anticipate people’s health behaviour to better address the health challenges of people living in poor conditions.

Qualitative study exploring surgical team members' perception of patient safety in conflict-ridden Eastern Democratic Republic of Congo

OBJECTIVE

To identify potential barriers to patient safety (PS) interventions from the perspective of surgical team members working in an operating theatre in Eastern Democratic Republic of Congo (DRC).

DESIGN

In-depth interviews were conducted and analysed using qualitative content analysis.

SETTING

Governmental referral teaching hospital in Eastern DRC.

PARTICIPANTS

We purposively selected 2-4 national and expatriate surgical team members from each specialisation. Of the 31 eligible surgical health workers (HWs), 17 volunteered to be interviewed.

RESULTS

Economics issues affected PS throughout the entire health system, from human resources and hospital management, to access to healthcare for patients. Surgical team members seemed embedded in a paternalistic organisational structure and blame culture accompanied by perceived inefficient support services and low salaries. The armed conflict did not only worsen these system failures, it also carried direct threats to patients and HWs, and resulted in complex indirect consequences compromising PS. The increased corruption within health organisations, and population impoverishment and substance abuse among health staff adversely altered safe care. Simultaneously, HWs' reported resilience and resourcefulness to address barrier to PS. Participants had varying views on external aid depending on its relevance.

CONCLUSIONS

The complex links between war and PS emphasise the importance of a comprehensive approach including occupational health to strengthen HWs' resilience, external clinical audits to limit corruption, and educational programmes in PS to support patient-centred care and address blame culture. Finally, improvement of equity in the health financing system seems essential to ensure access to healthcare and safe perioperative outcomes for all.

Home Care of Children With Diarrhea in Bangui's Therapeutic Landscape (Central African Republic)

We explore how the therapeutic landscape of Bangui, capital of the Central African Republic, shaped and reflected caregivers' home care of childhood diarrhea. Using interviews, group discussions, and participant observation, we found that caregivers described several categories of diarrhea, but in practice, adopted an experimental approach to home diarrheal care. Many managed incertitude by initially dosing children with street medicines and herbal infusions; they delayed seeking professional medical care to avoid expenses, observed their children's symptoms, consulted social networks, and used therapeutic foods. The logics underpinning these practices emerged from caregivers' conviction that diarrhea necessitated medical therapy and restricted choices within Bangui's therapeutic landscape, a consequence of lengthy political economic crisis. This crisis impoverished Bangui populations, eroded formal health care, and sharpened religious differences, discouraging care seeking from traditional healers. Analyses of therapeutic landscapes illuminate why caregivers embraced specific practices and logics and should guide the elaboration of more effective public health interventions.

Community acceptability and adoption of integrated community case management in Uganda

Integrated community case management (iCCM) is a recommended strategy to curb child mortality. Drawing on diffusion of innovations (DOIs), the acceptability and adoption of iCCM were qualitatively explored. Data from focus group discussions and interviews with community members, community health workers (CHWs), and supervisors conducted in seven communities were analyzed using content analysis. Perceived relative advantage and compatibility of the program with sociocultural beliefs and healthcare expectations of the communities positively affected acceptability and adoption of iCCM. The degree of stringency, quality, and cost of access to healthcare were crucial to adoption. Failure of the health system to secure regular drug supplies, monetary support, and safe referrals globally hindered adoption. Individual CHW characteristics like undesired behavior, demotivation, and lack of reciprocated trust deterred adoption in some areas. Optimal functioning of iCCM programs will require community sensitization and targeted health systems strengthening to enhance observable program benefits like reduced child mortality.

[Psychosocial impact of sickle cell disease in the parents of children living in Kinshasa, Democratic Republic of Congo: a qualitative study]

Introduction

L'insuffisance des moyens de base pour le dépistage et la prise en charge de la socioculturel Africain. D'où la nécessité de réaliser un travail de mise en sens du vécu et des émotions en vue d'information et de soutien psychologique des familles des drépanocytaires. Cette étude a eu pour objectif d'identifier la nature des répercussions psychosociales de la drépanocytose chez les parents et chez les malades.

Méthodes

Une approche qualitative a été utilisée. Des entretiens ont été menés auprès des parents et des patients drépanocytaires. Nos résultats ont fait l'objet d'une analyse thématique articulée sur les circonstances de découvertes de la maladie, les répercussions de la maladie et la perception de la prise en charge.

Résultats

Nos interviews ont montré des répercussions psychosociales importantes chez les parents d'enfants drépanocytaires et de stigmatisation des difficultés d'insertion sociale et scolaire pour les enfants drépanocytaires. Ces derniers sont les grands oubliés des récits de parents. La prise en charge est uniquement médicale avec des ressources très limitées et aucun accompagnement psychologique de la famille n'est assuré.

Conclusion

La prise en charge de cette maladie nécessite la mise en place d'une politique de prise en charge basée sur une approche globale de la maladie.

The challenges of caring for children with nephrotic syndrome in a tertiary institution in the Democratic Republic of Congo

AIM

The care of children with resistant nephrotic syndrome (NS) in the Democratic Republic of Congo is compromised by resource deficiencies that range from inadequate healthcare budgets, to scarce laboratory facilities and inconsistent drug supplies. The aim of this study was to describe the clinical profile and management of children with nephrotic syndrome in Kinshasa, the country's capital and its largest city.

METHODS

We retrospectively reviewed the medical records of 62 patients with a diagnosis of NS, who were seen in the Paediatric Nephrology Unit at the University Hospital of Kinshasa between January 1983 and January 2008.

RESULTS

Of the 62 children diagnosed with nephrotic syndrome, 33 were boys and 29 were girls, giving a male to female ratio of 1.14:1. Their median age at initial presentation was 7.5 years (range: 1.5-13 years) with a peak incidence at six to nine years of age (38.7%). No cases of plasmodium malariae were isolated in our series. Sixteen (25.8%) of the children had resistant corticoid nephrotic syndrome and six of the children (9.7%) died.

CONCLUSION

Age, the prevalence of steroid-resistant NS and the mortality rate in our series were higher than those reported in Asian and Western countries.

Intellectual and developmental disabilities in Kinshasa, Democratic Republic of the Congo: causality and implications for resilience and support

This article reports results of a 7-month qualitative study on intellectual and related developmental disabilities in Kinshasa, Democratic Republic of the Congo, particularly as they relate to the causes and meaning of intellectual and developmental disabilities (IDD). This study raises important questions related to the understanding of resilience of persons affected by IDD and the nature and purpose of support they use or desire.

Infant dental enucleation: A literature review on a traditional remedial practice in East Africa

OBJECTIVE

To summarize and review the literature on infant dental enucleation, a traditional remedial procedure prevalent mainly in East Africa.

MATERIALS AND METHODS

Literature searches were made electronically using general and specialized search engines. The main search was performed through a systematic strategy in PubMed, comprising tabulated keywords, search codes, and translated and transliterated terms. Criteria for the selection of studies were designed to provide a general understanding of the procedure. The findings were synthesized into two sections: a summary of the population prevalence studies, and a thematic literature review.

RESULTS

An overview of the known prevalence and clinical specifications was established. Insight was gained into the purpose of the procedure and the factors influencing its performance. Diverging suggestions were seen with regard to the rationale for use of infant dental enucleation between different populations. Moreover, reports of complications and consequences involving the general health and the dentoalveolar structures of patients were examined.

CONCLUSIONS

Prevalence, clinical features and risks of infant dental enucleation point to a need for greater awareness of the procedure. Further, there is a need for specific guidelines regarding management of suspected cases within dental and healthcare communities.

Comparing local perspectives on women's health with statistics on maternal mortality: an ethnobotanical study in Bénin and Gabon

BACKGROUND

According to the World Health Organization (WHO), reproductive health problems are the leading cause of morbidity and mortality for women in Africa. In spite of this scenario and the importance of plants in African health care, limited research has been conducted linking maternal health and plant-based medicine. The objective of our research was to examine how closely Beninese and Gabonese women's health perspectives, medicinal plant knowledge, and plant use practices reflect the statistical causes of maternal mortality.

METHODS

In Bénin (2011) and Gabon (2012), we conducted 87 ethnobotanical questionnaires with the corresponding collection of 800 botanical specimens. We used free-listing analysis, citation frequency and species counts to determine women's top health concerns. We also interviewed 18 biomedical healthcare providers in national hospitals and local clinics.

RESULTS

Informants' perceptions of the main causes of maternal suffering included malaria, infertility, and menstruation and pregnancy concerns. Women were knowledgeable on plants to treat the top causes of maternal morbidity, but knew more plants for conditions such as anemia, infertility, breast milk production, and the maintenance of menstruation and pregnancy. The biomedical staff recognized the role of traditional medicine in their patients' lives and expressed concern for herbal remedies to facilitate birth, but were restricted by national policies on advising on medicinal plant use.

CONCLUSIONS

Plants serve as an entry point to understanding Beninese and Gabonese women's perceptions of common health concerns and local health management strategies. Plant use practices in both countries did not closely parallel the top statistical causes of maternal mortality, but highlighted key issues such as menstruation and infertility as salient health concerns for women. More research is needed on the role of plants in women's gynecological healthcare.

Socio-cultural determinants of health-seeking behaviour on the Kenyan coast: a qualitative study

Background

Severe childhood illnesses present a major public health challenge for Africa, which is aggravated by a suboptimal response to the child's health problems with reference to the health-seeking behaviour of the parents or guardians. We examined the health-seeking behaviour of parents at the Kenyan coast because understanding impediments to optimal health-seeking behaviour could greatly contribute to reducing the impact of severe illness on children's growth and development.

Methods and Results

Health-seeking behaviour, and the factors influencing this behaviour, were examined in two traditional communities. We held in-depth interviews with 53 mothers, fathers and caregivers from two rural clinics at the Kenyan Coast. Biomedical medicine (from health facilities and purchased over the counter) was found to be the most popular first point of treatment. However, traditional healing still plays a salient role in the health care within these two communities. Traditional healers were consulted for various reasons: a) attribution of causation of ill-health to supernatural sources, b) chronic illness (inability of modern medicine to cure the problem) and c) as prevention against possible ill-health. In developing an explanatory model of decision-making, we observed that this was a complex process involving consultation at various levels, with elders, but also between both parents, depending on the perceived nature and chronicity of the illness. However, it was reported that fathers were the ultimate decision makers in relation to decisions concerning where the child would be taken for treatment.

Conclusions

Health systems need to see traditional healing as a complementary system in order to ensure adequate access to health care. Importantly, fathers also need to be addressed in intervention and education programs.

Comparing actual and perceived causes of fever among community members in a low malaria transmission setting in northern Tanzania

OBJECTIVE

To compare actual and perceived causes of fever in northern Tanzania.

METHODS

In a standardised survey, heads of households in 30 wards in Moshi, Tanzania, were asked to identify the most common cause of fever for children and for adults. Responses were compared to data from a local hospital-based fever aetiology study that used standard diagnostic techniques.

RESULTS

Of 810 interviewees, the median (range) age was 48 (16, 102) years and 509 (62.8%) were women. Malaria was the most frequently identified cause of fever, cited by 353 (43.6%) and 459 (56.7%) as the most common cause of fever for children and adults, respectively. In contrast, malaria accounted for 8 (2.0%) of adult and 6 (1.3%) of paediatric febrile admissions in the fever aetiology study. Weather was the second most frequently cited cause of fever. Participants who identified a non-biomedical explanation such as weather as the most common cause of fever were more likely to prefer a traditional healer for treatment of febrile adults (OR 2.7, P < 0.001). Bacterial zoonoses were the most common cause of fever among inpatients, but no interviewees identified infections from animal contact as the most common cause of fever for adults; two (0.2%) identified these infections as the most common cause of fever for children.

CONCLUSIONS

Malaria is perceived to be a much more common cause of fever than hospital studies indicate, whereas other important diseases are under-appreciated in northern Tanzania. Belief in non-biomedical explanations of fever is common locally and has important public health consequences.

Treatment of rheumatoid arthritis with methotrexate in Congolese patients

Methotrexate (MTX) is the anchor drug in the treatment of rheumatoid arthritis (RA) but data concerning the effectiveness of treatment with this compound are lacking in the Congolese population. In the present study, the evolution of RA in Congolese patients on MTX treatment is reported from before disease-modifying antirheumatic drug (DMARD) initiation till 20 months later. All consecutive DMARD-naïve RA patients (ACR 1987 criteria) attending the rheumatology unit of the University Hospital of Kinshasa from January 2008 to September 2010 were included. All were treated with MTX (started at 7.5 mg/week) and bridging steroids (started at 30mg/day). Treatment adaptations of MTX and concomitant drugs are reported as well as evolution of disease activity (DAS28-ESR), functionality (Health Assessment Questionnaire), radiological damage, and safety over 20 months. Of 98 patients recruited, more than one third were lost at follow-up. A follow-up visit at 20 months was available for 51 patients. These 48 women and 3 men had a mean age of 51.2 ± 13 years and a mean delay from symptom onset till their first visit of 3.2 years. At 20 months, the average MTX dose was 9.7 mg weekly. A second DMARD was added in three patients. The average dose of prednisone at 20 months was 7.5 mg daily. A significant improvement of DAS28 and functional disability was observed and 35.3 % of patients entered remission (DAS28 <2.6). A progression of X-ray damage was observed in one third of patients. Two patients had to stop MTX because of severe side effects and two patients developed diabetes. Methotrexate and bridging steroids therapy is effective also in sub-Saharan Africa but the average weekly MTX dose remains low. Implementation of a regular follow-up is a major issue.

Understanding careseeking for child illness in sub-Saharan Africa: a systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria

Diarrhoea, pneumonia and malaria are the largest contributors to childhood mortality in sub-Saharan Africa. While supply side efforts to deliver effective and affordable interventions are being scaled up, ensuring timely and appropriate use by caregivers remains a challenge. This systematic review synthesises qualitative evidence on the factors that underpin household recognition and response to child diarrhoea, pneumonia and malaria in sub-Saharan Africa. For this review, we searched six electronic databases, hand searched 12 journals from 1980 to 2010 using key search terms, and solicited expert review. We identified 5104 possible studies and included 112. Study quality was appraised using the Critical Appraisal Skills Program (CASP) tool. We followed a meta-ethnographic approach to synthesise findings according to three main themes: how households understand these illnesses, how social relationships affect recognition and response, and how households act to prevent and treat these illnesses. We synthesise these findings into a conceptual model for understanding household pathways to care and decision making. Factors that influence household careseeking include: cultural beliefs and illness perceptions; perceived illness severity and efficacy of treatment; rural location, gender, household income and cost of treatment. Several studies also emphasise the importance of experimentation, previous experience with health services and habit in shaping household choices. Moving beyond well-known barriers to careseeking and linear models of pathways to care, the review suggests that treatment decision making is a dynamic process characterised by uncertainty and debate, experimentation with multiple and simultaneous treatments, and shifting interpretations of the illness and treatment options, with household decision making hinging on social negotiations with a broad variety of actors and influenced by control over financial resources. The review concludes with research recommendations for tackling remaining gaps in knowledge.

[Acute renal failure and severe malaria in Congolese children living in Kinshasa, Democratic Republic of Congo]

BACKGROUND

Data on acute renal failure in complicated malaria in children in the Democratic Republic of Congo are sparse. The objective of this study was to document the profile of acute renal failure in severe malaria in admitted patients in pediatric hospitals from Kinshasa.

METHODS

A prospective cohort study was conducted from January 2008 to December 2008 in children admitted in emergency units of five hospitals in Kinshasa for severe malaria.

RESULTS

In our series, 378 children with severe malaria were included. There were 226 boys and 152 girls (sex ratio 1.49). One hundred and ninety four (194) of these patients were under 5 years old. Acute renal failure was observed in 89 children (23.6%) and 87 of them had blackwater fever (BWF). This form of severe malaria was predominant in children older than 5 years. Quinine was the commonest antimalarial drug involved in the genesis of BWF. Dialysis was indicated in 23 children (24.0%) and was effective (acute peritoneal dialysis) in 21 patients. The death rate in children with ARF was 12.6% (n=87). Recovery of renal function was obtained by conservative treatment in the remained group.

CONCLUSION

This study confirmed the emergence of BWF in seemed protected autochthon children older than 5 years. BWF remained the leading cause of acute renal failure in complicated malaria among Congolese children in Kinshasa.

Acute renal failure in Congolese children: a tertiary institution experience

AIM

Published data on acute renal failure in children from the Democratic Republic of Congo are rare. The objective of this study was to review clinical manifestations, aetiologies and outcome in hospitalized children with acute renal failure.

METHODS

A retrospective study at Pediatric Nephrology Unit of University Hospital of Kinshasa was carried out.

RESULTS

Fifty-six children with acute renal failure were eligible. There were 31 boys (55.4%) and 25 girls (44.6%) with a sex ratio of 1.24. The median age was 6.7 years (range 1-13 years). Fever (80.3%), oligo-anuria (73.2%), jaundice (67.9%) were the common clinical presentation. Blackwater fever (42.8%) was the leading cause of Acute Renal Failure. The incidence of severe dehydration because of gastroenteritis was low (5.3%). Around 12.5% of patients' misused herbal plants. Acute Peritoneal Dialysis was indicated in 15/56 children and only performed in four patients. Fourteen children (25%) died.

CONCLUSION

A wide spectrum of features was seen in hospitalized Acute Renal Failure children and limited access to Acute Peritoneal Dialysis remained an important mortality risk factor.

Retinoblastoma in the democratic republic of congo: 20-year review from a tertiary hospital in kinshasa

Background. To determine clinical profile and management of retinoblastoma among children at Kinshasa in Democratic Republic of Congo. Patients and methods. The medical records of patients with a diagnosis of retinoblastoma seen at the University Hospital of Kinshasa from January 1985 till December 2005 were retrospectively reviewed. Demographic profile, clinical data, modes of treatment and outcome were analysed. Results. A total of 49 children, of whom 40 had adequate data on record were identified as retinoblastoma (28 males and 12 females). Nine cases had bilateral disease. The median age at the first symptoms was 9 months (range, 1 month to 6 years) for unilateral retinoblastoma and 18 months (range, 1 month to 3.5 years) for bilateral retinoblastoma. The median age at the first oncology consultation was 2.4 years (range, 6 months to 6 years) for unilateral retinoblastoma and 2.4years (range, 9 months to 4 years) for bilateral disease. Leukokoria was present in 67.5% of subjects. Seventy-five percent abandoned the treatment. The mortality was 92.5%. Conclusion. In Democratic Republic of Congo, retinoblastoma remains a life threatening disease characterized by late referral to a specialized unit and affordability of chemotherapy; all leading to an extension of the disease and high mortality.

Evidence-based African first aid guidelines and training materials

Stijn Van de Velde and colleagues describe the African First Aid Materials project, which developed evidence-based guidelines on administering first aid in the African context as well as training materials to support the implementation of the guidelines.

Elder authority and the situational diagnosis of diarrheal disease as normal infant development in northeast Thailand

Research was conducted in rural Northeast Thailand to understand how mothers perceive children's acute illness episodes, and their resulting illness management strategies. Although diarrheal disease is one of the leading causes of illness among young children in Thailand, interviews revealed that mothers frequently do not classify infantile diarrhea as an "illness." Infantile diarrhea is commonly labeled thai su, a type of diarrhea believed necessary to "lighten the body" so that the infant can attain a new developmental stage, such as sitting up, standing, or walking. Consequently, mothers do not perceive infection-related diarrheal illness as common in infants, and therefore do not direct much attention to prevention, nor manage diarrheal cases in a manner consistent with biomedical recommendations. In this article I describe local explanatory models of diarrheal illness, and discuss the role of situational factors and elder authority in determining how illness episodes are assessed and managed.