Development, coinfection, and the syndemics of pregnancy in Sub-Saharan Africa

Compounding vulnerabilities: Syndemics and the social determinants of disease in the past

OBJECTIVE

This article explores the theory and utility of a syndemic approach for the study of disease in the past. Syndemic principles are examined alongside other theoretical developments within bioarchaeology. Two case studies are provided to illustrate the efficacy of this approach: Tuberculosis and vitamin D deficiency in 18th and 19th century England, and malaria and helminth infections in Early Medieval England.

MATERIALS

Public health studies of present syndemics, in addition to published bioarchaeological, clinical and social information relating to the chosen case studies.

METHODS

The data from these two historical examples are revisited within a syndemic framework to draw deeper conclusions about disease clustering and heterogeneity in the past.

RESULTS

A syndemic framework can be applied to past contexts using clinical studies of diseases in a modern context and relevant paleopathological, archaeological, and historical data.

CONCLUSIONS

This approach provides a means for providing a deeper, contextualised understanding ancient diseases, and integrates well with extant theoretical tools in bioarchaeology SIGNIFICANCE: Syndemics provides scholars a deep-time perspective on diseases that still impact modern populations.

LIMITATIONS

Many of the variables essential for a truly syndemic approach cannot be obtained from current archaeological, bioarchaeological, or historical methods.

SUGGESTIONS FOR FURTHER RESEARCH

More detailed and in-depth analysis of specific disease clusters within the past and the present, which draws on a comprehensive analysis of the social determinants of health.

Individual Freedom in the Initial Response to Covid-19

The COVID-19 pandemic has been a phenomenal challenge to global health care and will continue to be so in the upcoming months. Beyond its medical toll, COVID-19 has also exacerbated pre-existing social issues and created new inequalities. This has generated a series of ethical problems that will need to be carefully analyzed to avoid repeating similar mistakes in the context of other crises. Among those, we discuss here the bioethical implications of preserving individual freedom in the context of the early response to a pandemic and propose a global approach to the issue that could be applied in future health challenges.

Astrocytes and Microglia in Stress-Induced Neuroinflammation: The African Perspective

Background: Africa is laden with a youthful population, vast mineral resources and rich fauna. However, decades of unfortunate historical, sociocultural and leadership challenges make the continent a hotspot for poverty, indoor and outdoor pollutants with attendant stress factors such as violence, malnutrition, infectious outbreaks and psychological perturbations. The burden of these stressors initiate neuroinflammatory responses but the pattern and mechanisms of glial activation in these scenarios are yet to be properly elucidated. Africa is therefore most vulnerable to neurological stressors when placed against a backdrop of demographics that favor explosive childbearing, a vast population of unemployed youths making up a projected 42% of global youth population by 2030, repressive sociocultural policies towards women, poor access to healthcare, malnutrition, rapid urbanization, climate change and pollution. Early life stress, whether physical or psychological, induces neuroinflammatory response in developing nervous system and consequently leads to the emergence of mental health problems during adulthood. Brain inflammatory response is driven largely by inflammatory mediators released by glial cells; namely astrocytes and microglia. These inflammatory mediators alter the developmental trajectory of fetal and neonatal brain and results in long-lasting maladaptive behaviors and cognitive deficits. This review seeks to highlight the patterns and mechanisms of stressors such as poverty, developmental stress, environmental pollutions as well as malnutrition stress on astrocytes and microglia in neuroinflammation within the African context.

Malaria and Helminthic Co-Infection during Pregnancy in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Malaria and helminthic co-infection during pregnancy causes fetomaternal haemorrhage and foetal growth retardation. This study determined the pooled burden of pregnancy malaria and helminthic co-infection in sub-Saharan Africa. CINAHL, EMBASE, Google Scholar, Scopus, PubMed, and Web of Science databases were used to retrieve data from the literature, without restricting language and publication year. The Joanna Briggs Institute’s critical appraisal tool for prevalence studies was used for quality assessment. STATA Version 14.0 was used to conduct the meta-analysis. The I² statistics and Egger’s test were used to test heterogeneity and publication bias. The random-effects model was used to estimate the pooled prevalence at a 95% confidence interval (CI). The review protocol has been registered in PROSPERO, with the number CRD42019144812. In total, 24 studies (n = 14,087 participants) were identified in this study. The pooled analysis revealed that 20% of pregnant women were co-infected by malaria and helminths in sub-Saharan Africa. The pooled prevalence of malaria and helminths were 33% and 35%, respectively. The most prevalent helminths were Hookworm (48%), Ascaris lumbricoides (37%), and Trichuris trichiura (15%). Significantly higher malaria and helminthic co-infection during pregnancy were observed. Health systems in sub-Saharan Africa must implement home-grown innovative solutions to underpin context-specific policies for the early initiation of effective intermittent preventive therapy.

Syndemic Perspectives to Guide Black Maternal Health Research and Prevention During the COVID-19 Pandemic

The coronavirus 2019 (COVID-19) pandemic and related policies have led to an unequal distribution of morbidity and mortality in the U.S. For Black women and birthing people, endemic vulnerabilities and disparities may exacerbate deleterious COVID-19 impacts. Historical and ongoing macro-level policies and forces over time have induced disproportionately higher rates of maternal morbidity and mortality among Black women and birthing people, and contemporary macroeconomic and healthcare policies and factors continue to hold particular consequence. These factors induce detrimental psychological, health, and behavioral responses that contribute to maternal health disparities. The COVID-19 pandemic is likely to disproportionately impact Black women and birthing people, as policy responses have failed to account for the their unique socioeconomic and healthcare contexts. The resulting consequences may form a ‘vicious cycle’, with upstream impacts that exacerbate upstream macro-level policies and forces that can further perpetuate the clustering of maternal morbidity and mortality in this population. Understanding the impacts of COVID-19 among Black women and birthing people requires theoretical frameworks that can sufficiently conceptualize their multi-level, interacting, and dynamic nature. Thus, we advocate for the proliferation of syndemic perspectives to guide maternal disparities research and prevention during the COVID-19 pandemic. These perspectives can enable a holistic and nuanced understanding of the intersection of endemic and COVID-19-specific vulnerabilities and disparities experienced by Black women and birthing people. Syndemic-informed research can then lead to impactful multi-level prevention strategies that simultaneously tackle both endemic and COVID-19-specific factors and outcomes that lead to the clustering of vulnerabilities and disparities over time.

What maternal morbidities are and what they mean for women: A thematic analysis of twenty years of qualitative research in low and lower-middle income countries

Background

With an estimated 27 million annual incidents of maternal morbidity globally, how they are manifested or experienced is diverse and shaped by societal, cultural and personal influences. Using qualitative research to examine a woman's perception of her pregnancy, its complications, and potential long-term impact on her life can inform public health approaches and complement and inform biomedical classifications of maternal morbidities, historically considered a neglected dimension of safe motherhood. As part of the WHO’s Maternal Morbidity Working Group’s efforts to define and measure maternal morbidity, we carried out a thematic analysis of the qualitative literature published between 1998 and 2017 on how women experience maternal morbidity in low and lower-middle income countries.

Results and conclusions

Analysis of the 71 papers included in this study shows that women’s status, their marital relationships, cultural attitudes towards fertility and social responses to infertility and pregnancy trauma are fundamental to determining how they will experience morbidity in the pregnancy and postpartum periods. We explore the physical, economic, psychological and social repercussions pregnancy can produce for women, and how resource disadvantage (systemic, financial and contextual) can exacerbate these problems. In addition to an analysis of ten themes that emerged across the different contexts, this paper presents which morbidities have received attention in different regions and the trends in researching morbidities over time. We observed an increase in qualitative research on this topic, generally undertaken through interviews and focus groups. Our analysis calls for the pursuit of high quality qualitative research that includes repeat interviews, participant observation and triangulation of sources to inform and fuel critical advocacy and programmatic work on maternal morbidities that addresses their prevention and management, as well as the underlying systemic problems for women’s status in society.

Mapping a Syndemic of Psychosocial Risks During Pregnancy Using Network Analysis

BACKGROUND

Psychosocial risks during pregnancy impact maternal health in resource-limited settings, and HIV-positive women often bear a heavy burden of these factors. This study sought to use network modeling to characterize co-occurring psychosocial risks to maternal and child health among at-risk pregnant women.

METHODS

Two hundred pregnant HIV-positive women attending antenatal care in South Africa were enrolled. Measured risk factors included younger age, low income, low education, unemployment, unintended pregnancy, distress about pregnancy, antenatal depression, internalized HIV stigma, violence exposure, and lack of social support. Network analysis between risk factors was conducted in R using mixed graphical modeling. Centrality statistics were examined for each risk node in the network.

RESULTS

In the resulting network, unintended pregnancy was strongly tied to distress about pregnancy. Distress about pregnancy was most central in the network and was connected to antenatal depression and HIV stigma. Unintended pregnancy was also associated with lack of social support, which was itself linked to antenatal depression, HIV stigma, and low income. Finally, antenatal depression was connected to violence exposure.

CONCLUSIONS

Our results characterize a network of psychosocial risks among pregnant HIV-positive women. Distress about pregnancy emerged as central to this network, suggesting that unintended pregnancy is particularly distressing in this population and may contribute to further risks to maternal health, such as depression. Prevention of unintended pregnancies and interventions for coping with unplanned pregnancies may be particularly useful where multiple risks intersect. Efforts addressing single risk factors should consider an integrated, multilevel approach to support women during pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03069417.

PrEP and the syndemic of substance use, violence, and HIV among female and male sex workers: a qualitative study in Kisumu, Kenya

INTRODUCTION

Female and male sex workers experience heightened vulnerability to HIV and other health harms that are compounded by substance use, physical and sexual violence, and limited access to health services. In Kisumu, Kenya, where sex work is widespread and substance use is a growing public health concern, offering pre-exposure prophylaxis (PrEP) for HIV prevention could help curtail the HIV epidemic. Our study examines "syndemics," or mutually reinforcing epidemics of substance use, violence and HIV, in relation to PrEP acceptability and feasibility among female and male sex workers in Kenya, one of the first African countries to approve PrEP for HIV prevention.

METHODS

From 2016 to 2017, sex workers in Kisumu reporting recent alcohol or drug use and experiences of violence participated in qualitative interviews on HIV risk and perspectives on health service needs, including PrEP programming. Content analysis identified themes relating to PrEP knowledge, acceptability, access challenges and delivery preferences.

RESULTS

Among 45 female and 28 male sex workers, median age was 28 and 25 respectively. All participants reported past-month alcohol use and 91% of women and 82% of men reported past-month drug use. Violence was pervasive, with most women and men reporting past-year physical (96% women, 86% men) and sexual (93% women, 79% men) violence. Concerning PrEP, interviews revealed: (1) low PrEP knowledge, especially among women; (2) high PrEP acceptability and perceived need, particularly within syndemic contexts of substance use and violence; and (3) preferences for accessible, non-stigmatizing PrEP delivery initiatives designed with input from sex workers.

CONCLUSIONS

Through a syndemic lens, substance use and violence interact to increase HIV vulnerability and perceived need for PrEP among female and male sex workers in Kisumu. Although interest in PrEP was high, most sex workers in our sample, particularly women, were not benefiting from it. Syndemic substance use and violence experienced by sex workers posed important barriers to PrEP access for sex workers. Increasing PrEP access for sex workers will require addressing substance use and violence through integrated programming.

Multiple morbidities in pregnancy: Time for research, innovation, and action

In a Guest Editorial, James Beeson and colleagues discuss the contribution of nonobstetric morbidity to mortality during and around pregnancy and what needs to be done to address this global health challenge.

Public Health Activist Skills Pyramid: A Model for Implementing Health in All Policies

Affecting public health for society requires various competencies. In fact, the prerequisite for the implementation of health in all policies should be effectiveness of public health activists (PHAs) in these competencies. This study aims to determine the competencies of the activists in public health. The present qualitative study reviewed the literature and adopted qualitative methods like content analysis, stakeholder interviews, and conducted focus group discussions with related experts. In each stage, the required competencies were extracted through drawing the main action processes of a PHA. Thereafter, the authors reached an ultimately best-suited working model by classifying and approving extracted competencies. The competencies comprise a pyramid set of three main categories of basic, specialized/professional, and individual updating competencies. Personal management, communication, teamwork, project management, ability to apply principles and concepts of public health, anatomy, physiology, and pathology in the organizations of the society should be included in the basic category. Specialized skills should include ability to plan, public participation, intersectoral collaboration, social marketing, working with the media/media friendly attitude, advocacy, research management and knowledge translation, evaluation of health programs, network establishment and management, deployment and institutionalization, operational research, empowerment and consultation, and protocol and service pack design. Last but not least, individual updating is defined as being informed of the latest scientific articles and reports about health and its situation in different countries as well as determinants that affect health. Implementation of this pyramid requires design and establishment of specific centers for transferring effective public health competencies. This pyramid has also functional use for the revision of educational curriculums in all health study fields. Moreover, it is helpful in designing virtual health education courses and the update of employees in entire parts of society pertaining to the health sector.

A Qualitative Study of Substance use during Pregnancy: Implications for Reproductive Healthcare in Western Kenya

Women who use alcohol and drugs are often in their childbearing years, creating a need for integrated substance abuse and reproductive health services. However, our understanding of the social context and drivers of substance use during pregnancy, particularly in developing countries, is limited and largely unaddressed in clinical care. Our qualitative research explored the reproductive health of women of childbearing age who inject drugs and its implications for healthcare in Kisumu, Kenya. We used in-depth, semi-structured qualitative interviews with 17 women who inject drugs to explore reproductive health topics including knowledge, practices, and clinical interactions related to substance use during pregnancy. All but one woman had a prior pregnancy and two were pregnant during our study. Alcohol and drug use was prevalent throughout pregnancy, often described as a coping mechanism for stress. Women received mixed advice from family and social contacts regarding alcohol use during pregnancy, leading to differing perceptions of its health effects. Healthcare providers infrequently screened women for alcohol or drug use. Our analysis highlights the need for culturally appropriate alcohol and drug screening and counseling to be included in integrated reproductive health services in western Kenya.

The reproductive ecology of iron in women

Reproductive ecology focuses on the sensitivity of human reproduction to environmental variation. While reproductive ecology has historically focused on the relationship between energy status and reproductive outcomes, iron status is equally critical to women's reproductive health, given the wide-ranging detrimental effects of iron-deficiency anemia on maternal and infant well-being. This review interprets the vast literature on iron status and women's reproduction through an evolutionary framework. First, it will critique the evidence for iron deficiency caused by blood loss during menstruation, reinterpreting the available data as ecological variation in menses within and between populations of women. Second, it will highlight the scant but growing evidence that iron status is implicated in fertility, a relationship that has deep evolutionary roots. Third, this review proposes a new hypothesis for the transfer of iron from mother to infant via pregnancy and breastfeeding: reproductive iron withholding. In this hypothesis, mothers transfer iron to infants in a manner that helps infants avoid iron-mediated infection and oxidative stress, but trades off with potential risk of maternal and infant iron deficiency. Finally, this review explores two main factors that can modify the relationship between iron status and the gestation-lactation cycle: (1) the relationship between long-term reproductive effort (parity) and iron status and (2) supplementation schemes before and during pregnancy. The review concludes by suggesting continued research into iron homeostasis in women using evolutionary, ecological, and biocultural frameworks.

Impact of co-infections with enteric pathogens on children suffering from acute diarrhea in southwest China

Background

Acute diarrhea is a global health problem, resulting in high morbidity and mortality in children. It has been suggested that enteric pathogen co-infections play an important role in gastroenteritis, but most research efforts have only focused on a small range of species belonging to a few pathogen groups. This study aimed to assess the impact of co-infections with a broad range of enteric pathogens on children aged below five years who suffer from acute diarrhea in southwest China.

Method

A total of 1020 subjects (850 diarrhea cases and 170 healthy controls) were selected from four sentinel hospitals in Kunming, Yunnan province, southwest China, from June 2014 to July 2015. Stool specimens were collected to detect five virus (rotavirus group A, RVA; norovirus, NoV; Sapovirus, SaV; astrovirus, As; and adenovirus, Ad), seven bacterial (diarrheagenic Escherichia coli, DEC; non-typhoidal Salmonella, NTS; Shigella spp.; Vibrio cholera; Vibrio parahaemolyticus; Aeromonas spp.; and Plesiomonas spp.), and three protozoan (Cryptosporidium spp., Giardia lamblia, and Blastocystis hominis, B. hominis) species using standard microbiologic and molecular methods. Data were analyzed using the partial least square regression technique and chi-square test.

Results

At least one enteric pathogen was detected in 46.7 % (n = 397) of acute gastroenteritis cases and 13.5 % (n = 23) of healthy controls (χ² = 64.4, P < 0.05). Single infection with RVA was associated with acute diarrhea (26.5 % vs. 5.8 %, P < 0.05). The prevalence of a single infection with B. hominis in diarrhea cases was higher than in healthy controls (3.1 % vs. 0.5 %, OR = 4.7, 95 % CI: 1.01–112.0). Single infection with NoV GII was not associated with diarrhea (4.4 % vs. 3.5 %, OR = 1.2, 95 % CI: 0.5–3.3). Single infections with bacterial species were not observed. The prevalence of co-infections with two enteric pathogens in diarrhea cases was higher than in asymptomatic children (20.1 % vs. 5.3 %, P < 0.05). RVA-NoV GII was the most common co-infection in symptomatic children (4.4 %), with it aggravating the severity of diarrhea.

Conclusions

Although it is clear that RVA has an overwhelming impact on diarrhea illnesses in children, co-infection with other enteric pathogens appears to also aggravate diarrhea severity. These findings should serve as evidence for public health services when planning and developing intervention programs.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0157-2) contains supplementary material, which is available to authorized users.

Interactions among urogenital, intestinal, skin, and oral infections in pregnant and lactating Panamanian Ngäbe women: a neglected public health challenge

Interrelationships among bacteria, protozoa, helminths, and ectoparasites were explored in a cross-sectional survey of 213 pregnant and 99 lactating indigenous women. Prevalences in pregnancy and lactation, respectively, were: vaginitis (89.2%; 46.8%), vaginal trichomoniasis (75.3%; 91.1%), bacterial vaginosis (BV; 60.6%; 63.3%), hookworm (56.6%; 47.8%), asymptomatic bacteriuria/urinary tract infection (AB/UTI; 56.2%; 36.2%), cervicitis (33.3%; 6.3%), vaginal yeast (24.9%; 11.4%), Ascaris (32.5%; 17.4%), vaginal diplococci (20.4%; 31.6%), caries (19.7%; 18.2%), scabies (17.4%; 8.1%), and Trichuris (12.5%; 8.7%). Multiple regressions revealed positive associations during pregnancy (trichomoniasis and AB/UTI; diplococci and Ascaris) and lactation (yeast and scabies). Negative associations were detected in pregnancy (BV and trichomoniasis; hookworm and diplococci) and lactation (BV and yeast). Vaginal Lactobacillus reduced odds of diplococci in pregnancy and lactation, but increased Ascaris eggs per gram (epg) and odds of trichomoniasis in pregnancy and yeast in lactation. These associations raised a concern that treatment of one condition may increase the risk of another.