Looking within the household: gender roles and responses to malaria in Ghana

Unveiling the significance of women's role in health-seeking behavior during suspected malaria fever in risk populations of Nepal: Mixed methods cross-sectional study

Malaria remains a substantial global health challenge, causing preventable illnesses and fatalities. In Nepal, the government has ambitiously targeted achieving malaria-free status by 2025. This study aims to assess the impact of women's roles on health-seeking behavior during suspected malaria fever in the high-risk area of Kanchanpur district, Nepal. This is a cross-sectional analytical design with a mixed-method approach, the research focused on Kanchanpur district, selected from 20 high-risk malaria districts of Nepal. Belauri Municipality within Kanchanpur, identified for its concentration of high and moderate-risk wards, was the specific study area. A random selection process identified 387 households for a comprehensive survey. Face-to-face interviews with household heads were conducted after obtaining written informed consent and ethical approval from the Nepal Health Research Council (March 3, 2023/Ref no.-2041). Data analysis, employing statistical measures such as percentages, frequency, mean, and the Chi-square test, was performed using SPSS version 20. Cultural beliefs regarding women's use of bed nets during menstruation significantly predicted health-seeking behavior (p-value < 0.05). Those endorsing bed net use during menstruation were nearly twice as likely to choose modern health facilities (COR = 1.975, 95% C.I. = 1.134 to 3.439, p = 0.016). Women's involvement in malaria treatment decisions strongly correlated with health-seeking behavior (p-value = 0.001). However, women participating in household decisions for suspected malaria treatment were less likely to choose modern health facilities (COR = 0.327, 95% CI = 0.171-0.627, p = 0.001) compared to those without such a role. The study underscores the complex influence of cultural beliefs and women's decision-making roles on health-seeking behavior. Recognizing and comprehending these factors are vital for crafting effective malaria interventions that align with cultural contexts and consider the nuanced roles of women in health-related decisions.

Self-Reported Symptoms at Last Febrile Illness as a Predictor of Treatment-Seeking in Western Kenya: A Cross-Sectional Study

Timely treatment-seeking behavior can reduce morbidity and mortality due to infectious diseases. Patterns of treatment-seeking behavior can differ by access to health care, and perceptions of disease severity and symptoms. We evaluated the association between self-reported symptoms at last illness and the level of treatment-seeking behaviors. We analyzed cross-sectional data from 1,037 participants from the lowlands and highlands of Western Kenya from 2015 using logistic regression models. There was considerable heterogeneity in the symptoms and treatment-seeking behaviors reported among individuals who were febrile at their last illness. A greater number of self-reported categories of symptoms tended to be associated with a higher likelihood of treatment-seeking in both sites. Participants were significantly more likely to seek treatment if they reported fever, aches, and digestive symptoms at last illness than just fever and aches or fever alone, but the frequency of treatment-seeking for fever in combination with aches and respiratory symptoms did not follow a consistent pattern. Among those who sought treatment, most used a formal source, but the patterns were inconsistent across sites and by the number of symptoms categories. Understanding the drivers of treatment-seeking behavior after febrile illness is important to control and treat infectious diseases in Kenya.

[Husbands' involvement in antenatal-related care in the Bosomtwe District of Ghana: inquiry into the facilitators and barriers]

BACKGROUND

This paper explored the facilitators and barriers to husbands' involvement in antenatal-related care in the Bosomtwe District of Ghana from the perspectives of husbands, pregnant women with and without delivery experience, nursing mothers, midwives and traditional birth attendants.

METHODS

The study relied on the qualitative research design to collect and analyse data on the facilitators and barriers to husbands' involvement in antenatal-related care. The unit of analysis was made up of 36 participants-husbands (14), pregnant women with delivery experience and, nursing mothers (8), pregnant women without delivery experience (6), male and female midwives (6) and traditional birth attendants (2) who were purposively selected. The study's data was gathered using in-depth interviews and analysed through the content approach.

RESULTS

Various economic [work and time constraint], cultural [the association of childbearing and its allied duties to women] and health-system factors [lack of antenatal services targeted at husbands and health professionals' attitude] hinder husbands' active participation in antenatal care. Despite these, some husbands participated in antenatal care owing to the importance they accord to the health and safety of their wives and the foetus; changing gender roles and preferential treatments received by their wives at antenatal clinics [as a result of the involvement of their husbands in prenatal care].

CONCLUSION

The implementation of alternative strategies, like, couple counselling, prolonging operating times of health centres to accommodate working men are recommended to provide a more accommodative and attractive avenue for husbands to support their wives during pregnancy. These efforts must be reinforced by the entire society through modifying the "ill-held view" that pregnancy and childcare is the sole duty of a woman.

Associations between women’s empowerment, care seeking, and quality of malaria care for children: A cross-sectional analysis of demographic and health surveys in 16 sub-Saharan African countries

Background

Methods

Results

Conclusions

Are Malaria Risk Factors Based on Gender? A Mixed-Methods Survey in an Urban Setting in Ghana

Malaria still represents one of the most debilitating and deadly diseases in the world. It has been suggested that malaria has different impacts on women and men due to both social and biological factors. A gender perspective is therefore important to understand how to eliminate malaria. This study aimed to investigate malaria from a gender perspective in a non-for-profit private health facility, HopeXchange Medical Centre, based in Kumasi (Ghana). A sequential mixed-methods design, comprising quantitative and qualitative methods, was used. This study found low ownership (40%) and use (19%) of insecticide-treated nets (ITNs). Most malaria cases were women (62%), who were less educated and had more external risk factors associated with infection. Our study reported a trend of preferring malaria self-medication at home, which was practiced mostly by men (43%). Our data suggest that women are more likely to be exposed to malaria infections than men, especially due to their prolonged exposure to mosquito bites during the most dangerous hours. Our study highlighted the need for future malaria control policies to be more focused on social and behavioral aspects and from a gender perspective.

Applying a gender lens to understand pathways through care for acutely ill young children in Kenyan urban informal settlements

Background

In many African settings, gender strongly influences household treatment-seeking and decision-making for childhood illnesses. While mothers are often the primary engagers with health facilities, their independence in illness-related decisions is shaped by various factors. Drawing on a gender lens, we explored treatment-seeking pathways pre- and post-hospital admission for acutely ill young children living in low income settlements in Nairobi, Kenya; and the gendered impact of child illness both at the household and health system level.

Methods

Household members of 22 children admitted to a public hospital were interviewed in their homes several times post hospital discharge. In-depth interviews covered the child’s household situation, health and illness; and the family’s treatment-seeking choices and experiences. Children were selected from an observational cohort established by the Childhood Acute Illness and Nutrition (CHAIN) Network.

Results

Treatment-seeking pathways were often long and complex, with mothers playing the key role in caring for their children and in treatment decision-making. Facing many anxieties and dilemmas, mothers often consulted with significant influencers - primarily women - particularly where illnesses were prolonged or complex. In contrast to observations in rural African contexts, fathers were less prominent as influencers than (often female) neighbours, grandparents and other relatives. Mothers were sometimes blamed for their child’s condition at home and at health facilities. Children’s illness episode and associated treatment-seeking had significant gendered socio-economic consequences for households, including through mothers having to take substantial time off work, reduce their working hours and income, or even losing their jobs.

Conclusion

Women in urban low-income settings are disproportionately impacted by acute child illness and the related treatment-seeking and recovery process. The range of interventions needed to support mothers as they navigate their way through children’s illnesses and recovery include: deliberate engagement of men in child health to counteract the dominant perception of child health and care as a ‘female-domain’; targeted economic strategies such as cash transfers to safeguard the most vulnerable women and households, combined with more robust labour policies to protect affected women; as well as implementing strategies at the health system level to improve interactions between health workers and community members.

A multicenter study of the prevalence and risk factors of malaria and anemia among pregnant women at first antenatal care visit in Ghana

BACKGROUND

Malaria in pregnancy remains a major public health problem in Africa and Ghana and has been associated with a variety of pregnancy-related adverse complications. The development of effective and timely health policies for the prevention and control of malaria and anemia in pregnancy; requires current and consistent data on the prevalence and risk factors. We report the prevalence and risk factors of malaria and anemia from three major hospitals across three regions in Ghana.

METHODS

This multicenter cross-sectional study comprising a total of 628 pregnant women was conducted at the antenatal care units of the Achimota Hospital in the Greater Accra Region (n = 199), St. Michael's Hospital in the Ashanti Region (n = 221), and Effia Nkwanta Regional Hospital in the Western Region (n = 211). Questionnaires were administered to obtain socio-demographic, obstetrics and clinical data. Venous blood, stool and urine samples were collected for hematological profile and parasite identification using microscopy. Risk factors were evaluated using logistic regression models.

RESULTS

The overall prevalence of P. falciparum malaria was 8.9%. Factors independently associated with malaria were self-reported mosquito exposure (moderate exposure: aOR = 3.11, 95% CI (1.12-8.61) and severe exposure: aOR = 10.46, 95% CI (3.86-28.34)) and non-use mosquito repellents (aOR = 3.29, 95% CI (1.70-6.39)). Multiparty (parity of 2: aOR = 0.19, 95% CI (0.05-0.70) and parity ≥3: aOR = 0.11, 95% CI (0.03-0.45)) and age (20-30 years old: aOR = 0.22, 95% CI (0.09-0.56)) reduced the odds of infection. The overall prevalence of anemia was 42.4%. The prevalence of mild, moderate and severe anemia were 35.7%, 6.1% and 0.6%, respectively. The use of water other than purified water (tap water: aOR = 3.05, 95% CI (2.06-4.51) and well water: aOR = 2.45, 95% CI (1.35-4.44)), increasing gestational age (second trimester: aOR = 2.05, 95% CI (1.41-2.97) and third trimester: aOR = 7.20, 95% CI (3.06-16.92)) and malaria (aOR = 2.40, 95% CI (1.27-4.53)) were independent risk factors for anemia.

CONCLUSIONS

Although the prevalence of malaria is relatively low, that of anemia remains high. We recommend increasing efforts to make ITNs more available to strengthen malaria prevention. Public health education programs could help improve uptake and proper use of ITNs. To help reduce anemia in pregnancy, women should be empowered economically and interventions that reduce malnutrition should be encouraged. Women should be educated on early initiation of antenatal care to enhance surveillance, identification and treatment of anemia.

'I also take part in caring for the sick child': a qualitative study on fathers' roles and responsibilities in seeking care for children in Southwest Ethiopia

OBJECTIVES

Fathers play an important role in household decision-making processes and child health development. Nevertheless, they are under-represented in child health research, especially in low-income settings. Little is known about what roles fathers play in the care-seeking processes or how they interact with the health system when their child is sick. This study aimed to understand Ethiopian fathers' roles and responsibilities in caring for their children when they are or become ill.

DESIGN

Qualitative study using semistructured interviews with fathers.

SETTING

This study was conducted in three rural districts of the Southern Nations, Nationalities and People's Region of Ethiopia.

PARTICIPANTS

Twenty-four fathers who had at least one child between 2 and 59 months who visited a health extension worker with fever.

RESULTS

The overarching theme of this study was 'changing perceptions of paternal responsibilities during children's ill health'. It constituted three subthemes, namely, 'fathers' burden of earning money for care', 'fatherhood entails advocating children's healthcare needs' and 'investing in children's health can benefit the family in the future'. Fathers described that they were the ones mainly responsible for the financial arrangement of care and that this financial responsibility can involve stress when resources are scarce. Fathers knew what health services were available and accessible to them and were involved in different ways in the care seeking of the child. Changes in the importance ascribed to child health were expressed by fathers who described being more alert to children's ill-health.

CONCLUSION

Fathers play various roles in the care-seeking process during children's illness episodes. This included, for instance, arranging resources to seek care, (co)-deciding where to seek care as well as accompanying the child to the health facility. The inability to organise necessary resources for care can lead to involuntary delays in care seeking for the child. This demonstrates the importance of including fathers in future interventions on maternal and child health.

'I wanted to go, but they said wait': Mothers' bargaining power and strategies in care-seeking for ill newborns in Ethiopia

Introduction

To prevent the 2.6 million newborn deaths occurring worldwide every year, health system improvements and changes in care-taker behaviour are necessary. Mothers are commonly assumed to be of particular importance in care-seeking for ill babies; however, few studies have investigated their participation in these processes. This study explores mothers’ roles in decision making and strategies in care-seeking for newborns falling ill in Ethiopia.

Methods

A qualitative study was conducted in Butajira, Ethiopia. Data were collected during the autumn of 2015 and comprised 41 interviews and seven focus group discussions. Participants included primary care-takers who had experienced recent newborn illness or death, health care workers and community members. Data were analysed using thematic analysis.

Results

Choices about whether, where and how to seek care for ill newborns were made through cooperation and negotiation among household members. Mothers were considered the ones that initially identified or recognised illness, but their actual opportunities to seek care were bounded by structural and cultural constraints. Mothers’ limited bargaining power, contained by financial resources and gendered decision making, shaped their roles in care-seeking. We identified three strategies mothers took on in decision making for newborn illness: (a) acceptance and adaptation (to the lack of options), (b) negotiation and avoidance of advice from others, and (c) active care-seeking and opposition against the husband’s or community’s advice.

Conclusion

While the literature on newborn health and parenting emphasizes the key role of mothers in care-seeking, their actual opportunities to seek care are shaped by factors commonly beyond their control. Efforts to promote care-seeking for ill children should recognise that mothers’ capabilities to make decisions are embedded in gendered social processes and financial power structures. Thus, policies should not only target individual mothers, but the wider decision making group, including the head of households and extended family.

Re-conceptualising gender and power relations for sexual and reproductive health: contrasting narratives of tradition, unity, and rights

Sexual and reproductive health interventions in sub-Saharan Africa will be most effective if grounded in emic (insider) perspectives of gender and power in intimate relationships. We conducted eight focus group discussions with 62 young adults in Malawi to explore conceptions of gender and power relations and areas of tension between different perspectives. We framed our enquiry according to the three social structures of the Theory of Gender and Power: the sexual division of labour, the sexual division of power, and social norms and affective attachments around femininity and masculinity. Young adults drew on interrelated and competing narratives to describe the state of gender relations, which we named tradition, unity, and rights. Participants used tradition narratives most frequently to describe patriarchal gender roles, norms and ideals. Some participants challenged this predominant discourse using unity and rights narratives. Unity narratives illustrated how love and couple reciprocity were essential sources of 'power with' as opposed to 'power over'. Rights narratives were more contested than other narratives, with some participants acknowledging that women's rights were important to the family's survival and others viewing women's rights as problematic for gender relations. Gender-responsive interventions should consider the tensions and intersections between multiple narratives on gender and power, including unity as a gender-equitable form of power.

Ausencia de perspectiva de género en la educación médica. Implicaciones en pacientes mujeres y LGBT+, estudiantes y profesores

La Salud corresponde a un estado de bienestar completo, donde interactúan factores biológicos, socioculturales y psicosociales. El género es uno de ellos. Actualmente está demostrado que las diferencias entre sexos y géneros tienen efectos en múltiples enfermedades, diferencias que tienden a omitirse en la educación médica. Entre las principales consecuencias a dicha omisión se encuentra la atención inadecuada a pacientes y la existencia de distintas discriminaciones dentro de la enseñanza médica.La siguiente revisión bibliográfica abordará cómo la ausencia de perspectiva de género en la educación en la salud afecta a los pacientes y estudiantes de medicina, sean femeninas o LGBT+. Se concluye que han existido mejoras tanto en la atención como en la enseñanza, pero debe continuarse el trabajo, en particular, en la formación inicial de los profesionales de la medicina.

Prevalence of malarial recurrence and hematological alteration following the initial drug regimen: a retrospective study in Western Thailand

Background

The hematological changes following the initial drug regimen has been poorly understood in Thailand. This study was designed to determine the prevalence of malaria parasite recurrence and hematological alteration of patients during the initial drug regimen.

Methods

A retrospective study was conducted at Phop Phra Hospital, Tak Province, located in northwestern Thailand. All data from patients who were diagnosed with Plasmodium spp. infection – including types of Plasmodium spp., clinical characteristics, and hematological parameters – were retrieved and analyzed.

Results

The results demonstrated that during years 2012–2018, 95 out of 971 patients (9.78%) were infected with malaria two or more times. The gender, nationality, symptom of headache, type of Plasmodium spp., and career of each patient were associated with recurrence (P-value< 0.05). Among patients treated with malarial drug, the leukocyte count and red cell distribution width (RDW) were significantly changed when compared to untreated patients with recurrence (P-value< 0.05).

Conclusion

This study indicated the high prevalence of malarial recurrence in Tak Province, Western Thailand, and its relationship to certain characteristics of individuals. Patients who were treated with antimalarial drugs exhibited leukocyte and RDW changes following the initial drug regimen. This data could be useful for prompt detection, treatment, and prevention of malarial recurrence in endemic areas of Thailand.

The gendered impact of Buruli ulcer on the household production of health and social support networks: Why decentralization favors women

Background

Buruli ulcer [BU] is a chronic and debilitating neglected tropical skin disease caused by Mycobacterium ulcerans. The treatment of moderate to severe BU affects the well-being of entire households and places a strain on both gender relations within households and social relations with kin asked for various types of support. In this paper, we employ the conceptual lenses provided by the Household Production of Health approach to understanding the impact of illness on the household as a unit of analysis, gender studies, and social support related research to better understand BU health care decision making and the psychosocial experience of BU hospitalization.

Methods

An ethnography attentive to circumstance and the nested contexts within which stakeholders respond to BU was conducted employing semi-structured interviews, illness narratives, and case studies. An iterative process of data collection with preliminary analyses and reflection shaped subsequent interviews. Interviews were conducted with 45 women in households having a member afflicted with BU in two communes of Benin with high prevalence rates for BU. The first commune [ZE] has a well-established decentralized BU treatment program and a well-functioning referral network linked to the Allada reference hospital specializing in the care of BU and other chronic ulcers. The second commune [Ouinhi] is one of the last regions of the country to introduce a decentralized BU treatment program. A maximum variation purposeful sample was selected to identify information-rich health care decision cases for in-depth study.

Principal findings

Study results demonstrated that although men are the primary decision makers for healthcare decisions outside the home, women are largely responsible for arranging care for the afflicted in hospital in addition to managing their own households. A woman’s agency and ability to influence the decision-making process is largely based on whatever social support and substitute labor she can mobilize from her own network of kin relations. When support wanes, women are placed in a vulnerable position and often end up destitute. Decentralized BU treatment is preferred because it enables a woman to remain in her own household as a patient or caretaker of an ill family member while engaging in child care and petty revenue earing activities. Remaining in the hospital (a liminal space) as either patient or caretaker also renders a woman vulnerable to rumor and innuendo about sexual liaisons and constitutes a form of social risk. Social risk in some cases eclipses the physical risk of the disease in what we would describe as a hierarchy of risks.

Conclusion

This study illustrates the importance of decentralized treatment programs for NTDs such as BU. Such programs enable patients to remain in their homes while being treated, and do not displace women responsible for the welfare of the entire household. When women are displaced the well-being of the entire household is placed in jeopardy.

In this gender-focused study of the neglected tropical disease Buruli ulcer (BU) in Benin, West Africa, we document how seeking care for BU is influenced by broad-based concerns about the household production of health and the availability of resources women can mobilize from their social support networks. Women and girls shoulder a disproportionate share of the burdens incurred by BU treatment and prefer decentralized treatment from local health stations to free hospital care. Long term and often-indeterminate residence in hospital threatens the integrity of households and results in marital stress, economic vulnerability, school and vocational training dropout, and loss of essential income-generating activities. The case study of BU clearly demonstrates the necessity of recognizing the household, and not just the patient, as a unit of analysis in public health and the need to consider the ripple effect of serious illness beyond the household to one’s social network. We draw attention to the fact that while men are the decision makers about health care in patrilineal Beninese society, a women’s agency in influencing decision making is tied to her accumulation of social capital, capital that is taxed by long term medical treatment weakening her safety net in the future.

Regular Antenatal Attendance and Education Influence the Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy: A Cross-Sectional Study at the University Hospital, Kumasi, Ghana

Background

The World Health Organization (WHO) recommends the use of Insecticide Treated Bed-Nets and Intermittent Preventive Treatment (IPT) with Sulphadoxine-Pyrimethamine (SP) as interventions in curbing malaria during pregnancy. However, increasing evidence shows a gap in coverage where not all pregnant women receive the recommended SP dose. This study evaluated the factors influencing uptake of IPTp-SP among pregnant women in Kumasi, Ghana.

Methodology

This cross-sectional study was conducted among 280 pregnant women attending the Kwame Nkrumah University of Science and Technology Hospital in Kumasi, Ghana. Validated structured questionnaires were administered to obtain sociodemographic, medical/reproductive information, and IPTp-SP uptake among participants. Statistical analyses were performed using IBM SPSS 25.0 statistics.

Results

The mean age of respondents was 29.7±4.9 years. Of the 280 women interviewed, 74.6% attended the antenatal care (ANC) clinic at least four times with only 31.8% completing the recommended doses. Tertiary education [aOR=3.15, 95% CI (0.94 -10.97), and p=0.042] and ≥ 4 ANC visits [aOR=24.6, 95% CI (5.87-103.07), p<0.0001] had statistically significant higher odds of completing the recommended IPTp-SP dose. However, participants employed by the formal sector [aOR=0.28, 95% CI (0.09 - 0.79), p=0.016] and participants with more than four children [aOR=0.14, 95% CI (0.03 - 0.63), and p=0.011] had statistically significant lower odds of completing the recommended IPT dose.

Conclusion

ANC attendance is critical in IPTp uptake. The results emphasize the need for the Health Policy Makers in Kumasi to encourage pregnant women, especially women working in the formal sector and women having more than four children to patronize ANC attendance to ensure high coverage of the recommended IPTp dose.

Knowledge, attitude, and practice about malaria: Socio-demographic implications for malaria control in rural Ghana

Despite continuing international attention to malaria prevention, the disease remains a global public health problem. We investigated socio-demographic factors influencing knowledge, attitudes, and practices about malaria in rural Ghana. Our survey looked at 354 households. Mean knowledge score was higher among individuals with a history of volunteers having visited their households to educate them about malaria; families with 4-6 members; and males. Households with at least one under-five-aged child also had significantly higher knowledge scores. Households with at least one pregnant woman evinced a positive attitude towards malaria prevention. National malaria control strategies have achieved positive results in the fight against malaria. Nonetheless, multipronged community-based health strategies that integrate malaria programs and population growth control initiatives may be able to reach by 2030 the sustainable development goal of eliminating malaria.

Hematological abnormalities in patients with malaria and typhoid in Tamale Metropolis of Ghana

Objective

Anemia, Leukopenia, and thrombocytopenia are commonly observed hematological abnormalities in malaria and typhoid patients. In this study, we evaluated the prevalence of cytopenias in patients with mono-infections of plasmodium parasites (malaria group) or salmonella bacteria (typhoid group). Full blood counts from 79 patients (age ranging from 18 to 77 years) categorized into malaria and typhoid groups at the Tamale Central Hospital were assessed.

Results

Data generated were entered and analyzed using SPSS version 20 and Graphpad Prism 6. Values were observed to be significant at p < 0.05. The prevalence of cytopenias were; 29.6, 48.0% for anemia, 38.9, 12.0% for thrombocytopenia, 20.4, 12.0% for leukopenia, 13.0, 8.0% for bicytopenia and 5.6, 4.0% for pancytopenia in both malaria and typhoid groups respectively. Between the two groups of patients, thrombocytopenia was significantly associated with those in the malaria group (χ² = 5.84, p < 0.016). No association was found between cytopenias and gender in patients in the malaria group; however, the middle aged group, 36–55 years, was significantly associated with anemia (χ² = 12.97, p < 0.002). Cytopenias were not associated with gender, and with different age categories in patients in the typhoid group.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3456-9) contains supplementary material, which is available to authorized users.

Unravelling the Contextual Factors Mediating Illness Response Using Mixed Methodology

The re-emergence of infectious diseases has been a rampant public health challenge in the state of Kerala over the past one decade with high rates of mortality and morbidity. In an exploration of the contextual factors determining illness response associated with these diseases, this study employed a mixed methodology including a cross sectional survey of 430 respondents and 30 in-depth interviews. Individuals having one or more cases of selected re-emerging infectious diseases (Chikungunya, Dengue, Malaria and Leptospirosis) from various socio-spatial locations were included in the study to understand the patterns and determinants of illness response across different categories. The findings demonstrated that respondents’ response to illness is jointly determined by individual and household level factors such as gender, parenthood, illness context and spatiality. The article explains the ways in which these factors have interacted and intersected at varying points to create and reinforce multiple layers of vulnerability. Results are pertinent in understanding the pathways and mechanisms through which health inequities are created and sustained among different categories in the population. The findings demonstrate that only interventions concomitantly dealing with these factors and their interactions will produce more equitable results in improving access to health services and management of morbidity associated with re-emerging infectious diseases.

The role of gender relations in uptake of mass drug administration for lymphatic filariasis in Alor District, Indonesia

Background

The Global Programme to Eliminate Lymphatic Filariasis has set 2020 as a target to eliminate lymphatic filariasis (LF) as a public health problem through mass drug administration (MDA) to all eligible people living in endemic areas. To obtain a better understanding of compliance with LF treatment, a qualitative study using 43 in-depth interviews was carried out in Alor District, Indonesia to explore factors that motivate uptake of LF treatment, including the social and behavioural differences between compliant and non-compliant individuals. In this paper, we report on the findings specific to the role of family and gender relations and how they affect compliance.

Results

The sample comprised 21 men and 22 women; 24 complied with treatment while 19 did not. Gender relations emerged as a key theme in access, uptake and compliance with MDA. The view that the husband, as head of household, had the power, control, and in some cases the responsibility to influence whether his wife took the medication was common among both men and women. Gender also affected priorities for health care provision in the household as well as overall decision making regarding health in the household. Four models of responsibility for health decision making emerged: (i) responsibility resting primarily with the husband; (ii) responsibility resting primarily with the wife; (iii) responsibility shared equally by both husband and wife; and (iv) responsibility autonomously assumed by each individual for his or her own self, regardless of the course of action of the other spouse.

Conclusions

(i) Gender relations and social hierarchy influence compliance with LF treatment because they inherently affect decisions taken within the household regarding health; (ii) health care interventions need to take account of the complexity of gender roles; (iii) the fact that women’s power tends to be implicit and not overtly recognised in the household or the community has important implications for health care interventions; (iv) campaigns and other preventive interventions need to take account of the diversity of patterns of health care decision-making and responsibility in specific communities so that social mobilisation messages can be tailored appropriately.

Equal Opportunity, Equal Work: Increasing Women's Participation in the U.S. President's Malaria Initiative Africa Indoor Residual Spraying Project

BACKGROUND

One of the primary control measures for malaria transmission is indoor residual spraying (IRS). Historically, few women have worked in IRS programs, despite the income-generating potential. Increasing women's roles in IRS requires understanding the barriers to women's participation and implementing measures to address them. The U.S. President's Malaria Initiative (PMI) Africa Indoor Residual Spraying (AIRS) Project is the largest implementer of IRS globally. To address gender inequity in IRS operations, PMI AIRS assessed the barriers to the participation of women and developed and implemented policies to address these barriers.

METHODS

The PMI AIRS Project initially identified barriers through a series of informal assessments with key stakeholders. PMI AIRS then implemented a series of gender-guided policies, starting in 2015, in Benin, Ethiopia, Ghana, Mali, Madagascar, Mozambique, Rwanda, Senegal, Zambia, and Zimbabwe. The policies included adapting physical work environments to ensure privacy for women; ensuring the safety of women in the workplace; guaranteeing safety and job security of women during pregnancy; and encouraging qualified women to apply for supervisory positions. The project collected routine programmatic data on staff, spray quality, and spray efficiency; data from 2012 through the end of 2015 were analyzed (up through 1 year after implementation of the gender policies). In addition, PMI AIRS conducted surveys in 2015, 2016, and 2017 before and after the spray campaigns in 4 countries to determine changes in gender norms among spray operators through questions about decision making and agency.

RESULTS

The PMI AIRS Project increased women's employment with the program. Specifically, women's employment increased overall from 23% in 2012 to 29% in 2015, with a 2015 range from 16% (Mali) to 40% (Madagascar). Growth among supervisor roles was even stronger, with the percentage of women in supervisory roles increasing from 17% in 2012 to 46% in 2015, with a 2015 range from 9% (Mali) to 50% (Madagascar). While the data showed that in most countries women sprayed fewer houses per day than men in 2015, the differences were not meaningful, ranging from 0.1 to 1.2 households per day. Gender norms shifted toward more egalitarian views in 2 of the 4 countries with survey data.

CONCLUSION

Preliminary results suggest the PMI AIRS Project gender policies are increasing the engagement of women in all aspects of spray operations, especially in supervisory roles. Expansion of these policies to all countries implementing IRS and to malaria control implementation more broadly is recommended.

"If it's issues to do with nutrition…I can decide…": gendered decision-making in joining community-based child nutrition interventions within rural coastal Kenya

Gender roles and relations play an important role in child health and nutritional status. While there is increasing recognition of the need to incorporate gender analysis in health planning and programme development, there has been relatively little attention paid to the gendered nature of child nutrition interventions. This qualitative study undertaken in rural Coastal Kenya aimed to explore the interaction between household gender relations and a community-based child nutrition programme, with a focus on household decision-making dynamics related to joining the intervention. Fifteen households whose children were enrolled in the programme were followed up over a period of 12 months. Over a total of 60 household visits, group and individual in-depth interviews were conducted with a range of respondents, supplemented by non-participant observations. Data were analysed using a framework analysis approach. Engagement with the intervention was highly gendered with women being the primary decision-makers and engagers. Women were responsible for managing child feeding and minor child illnesses in households. As such, involvement in community-based nutrition interventions and particularly one that targeted a condition perceived as non-serious, fell within women's domain. Despite this, the nutrition programme of interest could be categorized as gender-blind. Gender was not explicitly considered in the design and implementation of the intervention, and the gender roles and norms in the community with regards to child nutrition were not critically examined or challenged. In fact, the intervention might have inadvertently reinforced existing gender divisions and practices in relation to child nutrition, by (unintentionally) excluding men from the nutrition discussions and activities, and thereby supporting the notion of child feeding and nutrition as "women's business". To improve outcomes, community-based nutrition interventions need to understand and take into account gendered household dynamics, and incorporate strategies that promote behaviour change and attitude shifts in relation to gendered norms and child nutrition.

"It is good to take her early to the doctor" - mothers' understanding of childhood pneumonia symptoms and health care seeking in Kilimanjaro region, Tanzania

Background

Pneumonia is among the leading causes of avoidable deaths for young children globally. The main burden of mortality falls on children from poor and rural families who are less likely to obtain the treatment they need, highlighting inequities in access to effective care and treatment. Caretakers’ illness perceptions and care-seeking practices are of major importance for children with pneumonia to receive adequate care. This study qualitatively explores the caretaker concepts of childhood pneumonia in relation to treatment seeking behaviour and health worker management in Moshi urban district, Tanzania.

Methods

In May - July 2013 data was gathered through different qualitative data collection techniques including five focus group discussions (FGDs) with mothers of children under-five years of age. The FGDs involved free listing of pneumonia symptoms and video presentations of children with respiratory symptoms done, these were triangulated with ten case narratives with mothers of children admitted with pneumonia and eleven in-depth interviews with hospital health workers. Transcripts were coded and analysed using qualitative content analysis.

Results

Mothers demonstrated good awareness of common childhood illnesses including pneumonia, which was often associated with symptoms such as cough, flu, chest tightness, fever, and difficulty in breathing. Mothers had mixed views on causative factors and treatments options but generally preferred modern medicine for persisting and severe symptoms. However, all respondent reported access to health facilities as a barrier to care, associated with transport, personal safety and economic constraints.

Conclusion

Local illness concepts and traditional treatment options did not constitute barriers to care for pneumonia symptoms. Poor access to health facilities was the main barrier. Decentralisation of care through community health workers may improve access to care but needs to be combined with strengthened referral systems and accessible hospital care for those in need.

A qualitative exploration of care-seeking pathways for sick children in the rural Oromia region of Ethiopia

BACKGROUND

Ethiopia has experienced rapid improvements in its healthcare infrastructure, such as through the recent scale up of integrated community case management (iCCM) delivered by community-based health extension workers (HEWs) targeting children under the age of five. Despite notable improvements in child outcomes, the use of HEWs delivering iCCM remains very low. The aim of our study was to explain this phenomenon by examining care-seeking practices and treatment for sick children in two rural districts in the Oromia Region of Ethiopia.

METHODS

Using qualitative methods, we explored perceptions of child illness, influences on decision-making processes occurring over the course of a child's illness and caregiver perceptions of available community-based sources of child illness care. Sixteen focus group discussions (FGDs) and 40 in-depth interviews (IDIs) were held with mothers of children under age five. For additional perspective, 16 IDIs were conducted fathers and 22 IDIs with health extension workers and community health volunteers.

RESULTS

Caregivers often described the act of care-seeking for a sick child as a time of considerable uncertainty. In particular, mothers of sick children described the cultural, social and community-based resources available to minimize this uncertainty as well as constraints and strategies for accessing these resources in order to receive treatment for a sick child. The level of trust and familiarity were the most common dynamics noted as influencing care-seeking strategies; trust in biomedical and government providers was often low.

CONCLUSIONS

Overall, our research highlights the multiple and dynamic influences on care-seeking for sick children in rural Ethiopia. An understanding of these influences is critical for the success of existing and future health interventions and continued improvement of child health in Ethiopia.

Increasing understanding of the relationship between geographic access and gendered decision-making power for treatment-seeking for febrile children in the Chikwawa district of Malawi

Background

This study used qualitative methods to investigate the relationship between geographic access and gendered intra-household hierarchies and how these influence treatment-seeking decision-making for childhood fever within the Chikwawa district of Malawi. Previous cross-sectional survey findings in the district indicated that distance from facility and associated costs are important determinants of health facility attendance in the district. This paper uses qualitative data to add depth of understanding to these findings by exploring the relationship between distance from services, anticipated costs and cultural norms of intra-household decision-making, and to identify potential intervention opportunities to reduce challenges experienced by those in remote locations. Qualitative data collection included 12 focus group discussions and 22 critical incident interviews conducted in the local language, with primary caregivers of children who had recently experienced a febrile episode.

Results

Low geographic accessibility to facilities inhibited care-seeking, sometimes by extending the ‘assessment period’ for a child’s illness episode, and led to delays in seeking formal treatment, particularly when the illness occurred at night. Although carers attempted to avoid incurring costs, cash was often needed for transport and food. Whilst in all communities fathers were normatively responsible for treatment costs, mothers generally had greater access to and control over resources and autonomy in decision-making in the matrilineal and matrilocal communities in the central part of the district, which were also closer to formal facilities.

Conclusions

This study illustrates the complex interplay between geographic access and gender dynamics in shaping decisions on whether and when formal treatment is sought for febrile children in Chikwawa District. Geographic marginality and cultural norms intersect in remote areas both to increase the logistical and anticipated financial barriers to utilising services and to reduce caretakers’ autonomy to act quickly once they recognize the need for formal care. Health education campaigns should be based within communities, engaging all involved in treatment-seeking decision-making, including men and grandmothers, and should aim to promote the ability of junior women to influence the treatment-seeking process. Both mothers’ financial autonomy and fathers financial contributions are important to enable timely access to effective healthcare for children with malaria.

KAP Surveys and Dengue Control in Colombia: Disentangling the Effect of Sociodemographic Factors Using Multiple Correspondence Analysis

During the last few decades, several studies have analyzed and described knowledge, attitudes, and practices (KAP) of populations regarding dengue. However, few studies have applied geometric data analytic techniques to generate indices from KAP domains. Results of such analyses have not been used to determine the potential effects of sociodemographic variables on the levels of KAP. The objective was to determine the sociodemographic factors related to different levels of KAP regarding dengue in two hyper-endemic cities of Colombia, using a multiple correspondence analysis (MCA) technique. In the context of a cluster randomized trial, 3,998 households were surveyed in Arauca and Armenia between 2012 and 2013. To generate KAP indexes, we performed a MCA followed by a hierarchical cluster analysis to classify each score in different groups. A quantile regression for each of the score groups was conducted. KAP indexes explained 56.1%, 79.7%, and 83.2% of the variance, with means of 4.2, 1.4, and 3.2 and values that ranged from 1 to 7, 7 and 11, respectively. The highest values of the index denoted higher levels of knowledge and practices. The attitudes index did not show the same relationship and was excluded from the analysis. In the quantile regression, age (0.06; IC: 0.03, 0.09), years of education (0.14; IC: 0.06, 0.22), and history of dengue in the family (0.21; IC: 0.12, 0.31) were positively related to lower levels of knowledge regarding dengue. The effect of such factors gradually decreased or disappeared when knowledge was higher. The practices indexes did not evidence a correlation with sociodemographic variables. These results suggest that the transformation of categorical variables into a single index by the use of MCA is possible when analyzing knowledge and practices regarding dengue from KAP questionnaires. Additionally, the magnitude of the effect of socioeconomic variables on the knowledge scores varies according to the levels of knowledge, suggesting that other factors might be influencing higher levels of knowledge.

Perceptions of childhood undernutrition among rural households on the Kenyan coast - a qualitative study

BACKGROUND

Nutrition plays an important role in child survival and development. Treatment action in the management of child health and nutrition is influenced by perceptions of illness, and gender plays an important role. However, little is known about if and how moderate undernutrition is recognised among lay populations, or how local social norms and intra-household dynamics affect decisions to seek biomedical assistance for nutritional concerns. In this paper we describe how childhood nutritional problems are recognised and understood within rural households. We demonstrate how context influences local constructs of 'normal', and suggest the centrality of gender in the management of child health and nutrition in our research context.

METHODS

This qualitative study was undertaken in Kilifi County on the Kenyan Coast. A set of 15 households whose children were engaged in a community-based nutrition intervention were followed up over a period of twelve months. Over a total of 54 household visits, group and individual in-depth interviews were conducted with a range of respondents, supplemented by non-participant observations. Eight in-depth interviews with community representatives were also conducted.

RESULTS

Local taxonomies of childhood undernutrition were found to overlap with, but differ from, biomedical categories. In particular, moderate undernutrition was generally not recognised as a health problem requiring treatment action, but rather as routine and manageable, typically seasonal, weight-loss. Where symptoms were considered more serious and requiring remedial action, household management strategies were typically based on perceived aetiology of the illness. Additionally, gender emerged as a potentially central theme in childhood nutrition problems and related management. Women reported that they have primary responsibility for ensuring children's good health and nutritional status, and that they are often held accountable when their children are of sub-optimal health.

CONCLUSION

Perceptions of child nutrition and illness and gendered roles within households influence treatment action, and engagement with nutrition interventions. Community-based nutrition interventions must recognise these complex realities.

Factors likely to affect community acceptance of a malaria vaccine in two districts of Ghana: a qualitative study

Malaria is a leading cause of morbidity and mortality among children in Ghana. As part of the effort to inform local and national decision-making in preparation for possible malaria vaccine introduction, this qualitative study explored community-level factors that could affect vaccine acceptance in Ghana and provides recommendations for a health communications strategy. The study was conducted in two purposively selected districts: the Ashanti and Upper East Regions. A total of 25 focus group discussions, 107 in-depth interviews, and 21 semi-structured observations at Child Welfare Clinics were conducted. Malaria was acknowledged to be one of the most common health problems among children. While mosquitoes were linked to the cause and bed nets were considered to be the main preventive method, participants acknowledged that no single measure prevented malaria. The communities highly valued vaccines and cited vaccination as the main motivation for taking children to Child Welfare Clinics. Nevertheless, knowledge of specific vaccines and what they do was limited. While communities accepted the idea of minor vaccine side effects, other side effects perceived to be more serious could deter families from taking children for vaccination, especially during vaccination campaigns. Attendance at Child Welfare Clinics after age nine months was limited. Observations at clinics revealed that while two different opportunities for counseling were offered, little attention was given to addressing mothers’ specific concerns and to answering questions related to child immunization. Positive community attitudes toward vaccines and the understanding that malaria prevention requires a comprehensive approach would support the introduction of a malaria vaccine. These attitudes are bolstered by a well-established child welfare program and the availability in Ghana of active, flexible structures for conveying health information to communities. At the same time, it would be important to improve the quality of Child Welfare Clinic services, particularly in relation to communication around vaccination.

Antenatal care visit attendance, intermittent preventive treatment during pregnancy (IPTp) and malaria parasitaemia at delivery

Background

The determinants and barriers for delivery and uptake of IPTp vary with different regions in sub-Saharan Africa. This study evaluated the determinants of ANC clinic attendance and IPTp-SP uptake among parturient women from Mount Cameroon Area and hypothesized that time of first ANC clinic attendance could influence uptake of IPTp-SP/dosage and consequently malaria parasite infection status at delivery.

Methods

Two cross sectional surveys were carried out at the Government Medical Centre in the Mutengene Health Area, Mt Cameroon Area from March to October 2007 and June 2008 to April 2009. Consented parturient women were consecutively enrolled in both surveys. In 2007, socio-demographic data, ANC clinic attendance, gestational age, fever history and reported use/dosage of IPTp-SP were documented using a structured questionnaire. In the second survey only IPT-SP usage/dosage was recorded. Malaria parasitaemia at delivery was determined by blood smear microscopy and placental histology.

Results and discussion

In 2007, among the 287 women interviewed, 2.2%, 59.7%, and 38.1% enrolled in the first, second and third trimester respectively. About 90% of women received at least one dose SP but only 53% received the two doses in 2007 and by 2009 IPTp-two doses coverage increased to 64%. Early clinic attendance was associated (P = 0.016) with fever history while being unmarried (OR = 2.2; 95% CI: 1.3-3.8) was significantly associated with fewer clinic visits (<4visits). Women who received one SP dose (OR = 3.7; 95% CI: 2.0-6.8) were more likely not to have attended ≥ 4visits. A higher proportion (P < 0.001) of women with first visit during the third trimester received only one dose, meanwhile, those who had an early first ANC attendance were more likely (OR = 0.4; 95% CI = 0.2 - 0.7) to receive two or more doses. Microscopic parasitaemia at delivery was frequent (P = 0.007) among women who enrolled in the third trimester and had received only one SP dose than in those with two doses.

Conclusion

In the study area, late first ANC clinic enrolment and fewer clinic visits may prevent the uptake of two SP doses and education on early and regular ANC clinic visits can increase IPTp coverage.

A gendered users' perspective on decentralized primary health services in rural Tanzania

Since the 1990s, Tanzania has been implementing health sector reforms including decentralization of primary healthcare services to districts and users. The impact of the reforms on the access, quality and appropriateness of primary healthcare services from the viewpoint of users is, however, not clearly documented. This article draws on a gendered users' perspective to address the question of whether the delivery of gender-sensitive primary health services has improved after the reforms. The article is based on empirical data collected through a household survey, interviews, focus group discussions, case studies and analysis of secondary data in two rural districts in Tanzania. The analysis shows that the reforms have generated mixed effects: they have contributed to improving the availability of health facilities in some villages but have also reinforced inter-village inequalities. Men and women hold similar views on the perceived changes and appropriateness to women on a number of services. Gender inequalities are, however, reflected in the significantly low membership of female-headed households in the community health fund and their inability to pay the user fees and in the fact that women's reproductive and maternal health needs are as yet insufficiently addressed. Although over half of users are satisfied with the services, more women than men are dissatisfied. The reforms appear to have put much emphasis on building health infrastructure and less on quality issues as perceived by users.

Ghana's National Health Insurance Scheme: a national level investigation of members' perceptions of service provision

Background

Ghana’s National Health Insurance Scheme (NHIS), established into law in 2003 and implemented in 2005 as a ‘pro-poor’ method of health financing, has made great progress in enrolling members of the general population. While many studies have focused on predictors of enrolment this study offers a novel analysis of NHIS members’ perceptions of service provision at the national level.

Methods

Using data from the 2008 Ghana Demographic Health Survey we analyzed the perceptions of service provision as indicated by members enrolled in the NHIS at the time of the survey (n = 3468; m = 1422; f = 2046). Ordinal Logistic Regression was applied to examine the relationship between perceptions of service provision and theoretically relevant socioeconomic and demographic variables.

Results

Results demonstrate that wealth, gender and ethnicity all play a role in influencing members’ perceptions of NHIS service provision, distinctive from its influence on enrolment. Notably, although wealth predicted enrolment in other studies, our study found that compared to the poorest men and uneducated women, wealthy men and educated women were less likely to perceive their service provision as better/same (more likely to report it was worse). Wealth was not an important factor for women, suggesting that household gender dynamics supersede household wealth status in influencing perceptions. As well, when compared to Akan women, women from all other ethnic groups were about half as likely to perceive the service provision to be better/same.

Conclusions

Findings of this study suggest there is an important difference between originally enrolling in the NHIS because one believes it is potentially beneficial, and using the NHIS and perceiving it to be of benefit. We conclude that understanding the nature of this relationship is essential for Ghana’s NHIS to ensure its longevity and meet its pro-poor mandate. As national health insurance systems are a relatively new phenomenon in sub-Saharan Africa little is known about their long term viability; understanding user perceptions of service provision is an important piece of that puzzle.

Household roles and care-seeking behaviours in response to severe childhood illness in Mali

Malaria is a major cause of under-five mortality in Mali and many other developing countries. Malaria control programmes rely on households to identify sick children and either care for them in the home or seek treatment at a health facility in the case of severe illness. This study examines the involvement of mothers and other household members in identifying and treating severely ill children through case studies of 25 rural Malian households. A wide range of intra-household responses to severe illness were observed among household members, both exemplifying and contravening stated social norms about household roles. Given their close contact with children, mothers were frequently the first to identify illness symptoms. However, decisions about care-seeking were often taken by fathers and senior members of the household. As stewards of the family resources, fathers usually paid for care and thus significantly determined when and where treatment was sought. Grandparents were frequently involved in diagnosing illnesses and directing care towards traditional healers or health facilities. Relationships between household members during the illness episode were found to vary from highly collaborative to highly conflictive, with critical effects on how quickly and from where treatment for sick children was sought. These findings have implications for the design and targeting of malaria and child survival programming in the greater West African region.

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.

Measuring women's perceived ability to overcome barriers to healthcare seeking in Burkina Faso

Background

In sub-Saharan Africa, women must overcome numerous barriers when they need modern healthcare. Respect of gender norms within the household and the community may still influence women's ability to obtain care. A lack of gender-sensitive instruments for measuring women's ability to overcome barriers compromises attempts to adequately quantify the burden and risk of exclusion they face when seeking modern healthcare. The aim of this study was to create and validate a synthetic measure of women's access to healthcare from a publicly available and possibly internationally comparable population-based survey.

Method

Seven questionnaire items from the Burkina Faso 2003 DHS were combined to create the index. Cronbach's alpha coefficient was used to test the reliability of the index. Exploratory factor analyses (EFA) and confirmatory factor analyses (CFA) were applied to evaluate the factorial structure and construct validity of the index while taking into account the hierarchical structure of the data.

Results

The index has a Cronbach's alpha of 0.75, suggesting adequate reliability. In EFA, three correlated factors fitted the data best. In CFA, the construct of perceived ability to overcome barriers to healthcare seeking emerged as a second-order latent variable with three domains: socioeconomic barriers, geographical barriers and psychosocial barriers. Model fit indices support the index's global validity for women of reproductive age in Burkina Faso. Evidence for construct validity comes from the finding that women's index scores increase with household living standard.

Conclusion

The DHS items can be combined into a reliable and valid, gender-sensitive index quantifying reproductive-age women's perceived ability to overcome barriers to healthcare seeking in Burkina Faso. The index complies conceptually with the sector-cross-cutting capability approach and enables measuring directly the perceived access to healthcare. Therefore it can help to improve the design and evaluation of interventions that aim to facilitate healthcare seeking in this country. Further analyses may examine how far the index applies to similar contexts.

Improving access to health care for malaria in Africa: a review of literature on what attracts patients

BACKGROUND

Increasing access to health care services is considered central to improving the health of populations. Existing reviews to understand factors affecting access to health care have focused on attributes of patients and their communities that act as 'barriers' to access, such as education level, financial and cultural factors. This review addresses the need to learn about provider characteristics that encourage patients to attend their health services.

METHODS

This literature review aims to describe research that has identified characteristics that clients are looking for in the providers they approach for their health care needs, specifically for malaria in Africa. Keywords of 'malaria' and 'treatment seek*' or 'health seek*' and 'Africa' were searched for in the following databases: Web of Science, IBSS and Medline. Reviews of each paper were undertaken by two members of the team. Factors attracting patients according to each paper were listed and the strength of evidence was assessed by evaluating the methods used and the richness of descriptions of findings.

RESULTS

A total of 97 papers fulfilled the inclusion criteria and were included in the review. The review of these papers identified several characteristics that were reported to attract patients to providers of all types, including lower cost of services, close proximity to patients, positive manner of providers, medicines that patients believe will cure them, and timeliness of services. Additional categories of factors were noted to attract patients to either higher or lower-level providers. The strength of evidence reviewed varied, with limitations observed in the use of methods utilizing pre-defined questions and the uncritical use of concepts such as 'quality', 'costs' and 'access'. Although most papers (90%) were published since the year 2000, most categories of attributes had been described in earlier papers.

CONCLUSION

This paper argues that improving access to services requires attention to factors that will attract patients, and recommends that public services are improved in the specific aspects identified in this review. It also argues that research into access should expand its lens to consider provider characteristics more broadly, especially using methods that enable open responses. Access must be reconceptualized beyond the notion of barriers to consider attributes of attraction if patients are to receive quality care quickly.

Improving access to health care for malaria in Africa: a review of literature on what attracts patients

BACKGROUND

Increasing access to health care services is considered central to improving the health of populations. Existing reviews to understand factors affecting access to health care have focused on attributes of patients and their communities that act as 'barriers' to access, such as education level, financial and cultural factors. This review addresses the need to learn about provider characteristics that encourage patients to attend their health services.

METHODS

This literature review aims to describe research that has identified characteristics that clients are looking for in the providers they approach for their health care needs, specifically for malaria in Africa. Keywords of 'malaria' and 'treatment seek*' or 'health seek*' and 'Africa' were searched for in the following databases: Web of Science, IBSS and Medline. Reviews of each paper were undertaken by two members of the team. Factors attracting patients according to each paper were listed and the strength of evidence was assessed by evaluating the methods used and the richness of descriptions of findings.

RESULTS

A total of 97 papers fulfilled the inclusion criteria and were included in the review. The review of these papers identified several characteristics that were reported to attract patients to providers of all types, including lower cost of services, close proximity to patients, positive manner of providers, medicines that patients believe will cure them, and timeliness of services. Additional categories of factors were noted to attract patients to either higher or lower-level providers. The strength of evidence reviewed varied, with limitations observed in the use of methods utilizing pre-defined questions and the uncritical use of concepts such as 'quality', 'costs' and 'access'. Although most papers (90%) were published since the year 2000, most categories of attributes had been described in earlier papers.

CONCLUSION

This paper argues that improving access to services requires attention to factors that will attract patients, and recommends that public services are improved in the specific aspects identified in this review. It also argues that research into access should expand its lens to consider provider characteristics more broadly, especially using methods that enable open responses. Access must be reconceptualized beyond the notion of barriers to consider attributes of attraction if patients are to receive quality care quickly.

Parents' perceptions, attitudes and acceptability of treatment of childhood malaria with artemisinin combination therapies in ghana

BACKGROUND

There is little information on sociocultural and contextual factors that may influence attitudes of patients to new treatments, such as artemisinin combination therapies (ACT).

METHODS

Semi-structured questionnaires and focus group discussions were used to assess views of parents of children with uncomplicated malaria treated with ACT in a low socio-economic area in Accra, Ghana.

RESULTS

The majority of parents reported a favourable experience, in terms of perceived i) rapidity of symptom resolution, compared to their previous experience of other therapies for childhood malaria, or ii) when their experience was compared that of parents of children treated with monotherapy. The parents of children treated with ACT were more willing to pay for the treatment, or adhere to the full treatment course. The explanations given for adherence were consistent with conventional biomedical explanations. Although care-seeking practices for childhood malaria were considered appropriate, perceived or real barriers to accessible health care were also important factors in the decision to seek treatment. Household dynamics and perceived inequities at the care-provider-patient interface were identified as having potential negative impact on care-seeking practices and adherence.

CONCLUSIONS

Health education messages aimed at improving the response to childhood febrile illness should include other strategic stakeholders, such as decision-makers at the household level. The effectiveness and implementation success of the ACT policy could be enhanced by highlighting and reinforcing messages intrinsic to these regimens. Integrating the views of caretakers during the clinical encounter was validated as an empowerment tool that could aid in the appropriate responses to childhood illness.

Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya

BACKGROUND

Malaria is a leading cause of morbidity and mortality in children younger than 5 years in Kenya. Within the context of planning for a vaccine to be used alongside existing malaria control methods, this study explores sociocultural and health communications issues among individuals who are responsible for or influence decisions on childhood vaccination at the community level.

METHODS

This qualitative study was conducted in two malaria-endemic regions of Kenya--South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted.

RESULTS

Participants understand that malaria is a serious problem that no single tool can defeat. Communities would welcome a malaria vaccine, although they would have questions and concerns about the intervention. While support for local child immunization programs exists, limited understanding about vaccines and what they do is evident among younger and older people, particularly men. Even as health care providers are frustrated when parents do not have their children vaccinated, some parents have concerns about access to and the quality of vaccination services. Some women, including older mothers and those less economically privileged, see themselves as the focus of health workers' negative comments associated with either their parenting choices or their children's appearance. In general, parents and caregivers weigh several factors--such as personal opportunity costs, resource constraints, and perceived benefits--when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers.

CONCLUSIONS

The study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunization focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender. It should involve influential community members and provide needed information and reassurances about immunization. Efforts also should be made to address concerns about the quality of immunization services--including health workers' interpersonal communication skills.

Treatment-seeking for febrile illness in north-east India: an epidemiological study in the malaria endemic zone

BACKGROUND

This paper studies the determinants of utilization of health care services, especially for treatment of febrile illness in the malaria endemic area of north-east India.

METHODS

An area served by two districts of Upper Assam representing people living in malaria endemic area was selected for household survey. A sample of 1,989 households, in which at least one member of household suffered from febrile illness during last three months and received treatment from health service providers, were selected randomly and interviewed by using the structured questionnaire. The individual characteristics of patients including social indicators, area of residence and distance of health service centers has been used to discriminate or group the patients with respect to their initial and final choice of service providers.

RESULTS

Of 1,989 surveyed households, initial choice of treatment-seeking for febrile illness was self-medication (17.8%), traditional healer (Vaidya)(39.2%), government (29.3%) and private (13.7%) health services. Multinomial logistic regression (MLR) analysis exhibits the influence of occupation, area of residence and ethnicity on choice of health service providers. The traditional system of medicine was commonly used by the people living in remote areas compared with towns. As all the febrile cases finally received treatment either from government or private health service providers, the odds (Multivariate Rate Ratio) was almost three-times higher in favour of government services for lower households income people compared to private.

CONCLUSION

The study indicates the popular use of self-medication and traditional system especially in remote areas, which may be the main cause of delay in diagnosis of malaria. The malaria training given to the paramedical staff to assist the health care delivery needs to be intensified and expanded in north-east India. The people who are economically poor and living in remote areas mainly visit the government health service providers for seeking treatment. So, the improvement of quality health services in government health sector and provision of health education to people would increase the utilization of government health services and thereby improve the health quality of the people.

"I never had the money for blood testing" - caretakers' experiences of care-seeking for fatal childhood fevers in rural Uganda - a mixed methods study

Background

The main killer diseases of children all manifest as acute febrile illness, yet are curable with timely and adequate management. To avoid a fatal outcome, three essential steps must be completed: caretakers must recognize illness, decide to seek care and reach an appropriate source of care, and then receive appropriate treatment. In a fatal outcome some or all of these steps have failed and it remains to be elucidated to what extent these fatal outcomes are caused by local disease perceptions, inappropriate care-seeking or inadequate resources in the family or health system. This study explores caretakers' experiences of care-seeking for childhood febrile illness with fatal outcome in rural Uganda to elucidate the most influential barriers to adequate care.

Methods

A mixed methods approach using structured Verbal/Social autopsy interviews and in-depth interviews was employed with 26 caretakers living in Iganga/Mayuge Demographic Surveillance Site who had lost a child 1–59 months old due to acute febrile illness between March and June 2006. In-depth interviews were analysed using content analysis with deductive category application.

Results

Final categories of barriers to care were: 1) "Illness interpretation barriers" involving children who received delayed or inappropriate care due to caretakers' labelling of the illness, 2) "Barriers to seeking care" with gender roles and household financial constraints hindering adequate care and 3) "Barriers to receiving adequate treatment" revealing discontents with providers and possible deficiencies in quality of care. Resource constraints were identified as the underlying theme for adequate management, both at individual and at health system levels.

Conclusion

The management of severely ill children in this rural setting has several shortcomings. However, the majority of children were seen by an allopathic health care provider during the final illness. Improvements of basic health care for children suffering from acute febrile illness are likely to contribute to a substantial reduction of fatal outcomes. Health care providers at all levels and private as well as public should receive training, support, equipment and supplies to enable basic health care for children suffering from common illnesses.

The influence of parents' marital relationship and women's status on children's age at first sex in Cebu, Philippines

This study examines the intergenerational effects of parents' marital relationship and the status of women on children's age at first sexual intercourse in Cebu, Philippines. Matched longitudinal data for 1,661 mothers and their children are analyzed. The mothers were interviewed in 1994, when their children were aged 9 to 11, about sociodemographic characteristics, their marital relationships, and women's status. Cox proportional hazards models are used to assess unmarried children's age at first sex as reported by the children in 2005 at ages 20 to 22. After multivariate adjustment, the analysis indicates that when parents make household decisions jointly, sons report delaying first sex. In households in which mothers have higher status, daughters report delayed first sex. The results demonstrate that long-term positive effects on children, particularly delaying first sex, occur in families in which parental decisionmaking is cooperative and in which women have high status.

Differences in hospital admissions for males and females in northern Uganda in the period 1992–2004: a consideration of gender and sex differences in health care use

To inform our understanding of male and female health care use, we assessed sex differences in hospital admissions by diagnosis and for in-patient mortality using discharge records for 210319 patients admitted to the Lacor Hospital in northern Uganda in the period 1992-2004. These differences were interpreted using a gender framework. The overall number of admissions was similar by sex, yet differences emerged among age groups. In children (0-14 years), malaria was the leading cause of admission, and the distribution of diseases was similar between sexes. Among 15-44 year olds, females had more admissions, overall, and for malaria, cancer and anaemia, in addition to delivery and gynaeco-obstetrical conditions (25.7% of female admissions). Males had more admissions for injuries, liver disease and tuberculosis in the same age group. In older persons (>or=45 years), women had more admissions for cancer, hypertension, malaria and diarrhoea, while, as for the previous age group, males had more admissions for injuries, liver disease and tuberculosis. This study provides insight into sex- and gender-related differences in health. The analysis and documentation of these differences are crucial for improving service delivery and for assessing the achievement of the dual goals of improving health status and reducing health inequalities.

Influences on uptake of reproductive health services in Nsangi community of Uganda and their implications for cervical cancer screening

Background

Cervical cancer is the most common female cancer in Uganda. Over 80% of women diagnosed or referred with cervical cancer in Mulago national referral and teaching hospital have advanced disease. Plans are underway for systematic screening programmes based on visual inspection, as Pap smear screening is not feasible for this low resource country. Effectiveness of population screening programmes requires high uptake and for cervical cancer, minimal loss to follow up. Uganda has poor indicators of reproductive health (RH) services uptake; 10% postnatal care attendance, 23% contraceptive prevalence, and 38% skilled attendance at delivery. For antenatal attendance, attendance to one visit is 90%, but less than 50% for completion of care, i.e. three or more visits.

Methods

We conducted a qualitative study using eight focus group discussions with a total of 82 participants (16 men, 46 women and 20 health workers). We aimed to better understand factors that influence usage of available reproductive health care services and how they would relate to cervical cancer screening, as well as identify feasible interventions to improve cervical cancer screening uptake.

Results

Barriers identified after framework analysis included ignorance about cervical cancer, cultural constructs/beliefs about the illness, economic factors, domestic gender power relations, alternative authoritative sources of reproductive health knowledge, and unfriendly health care services. We discuss how these findings may inform future planned screening programmes in the Ugandan context.

Conclusion

Knowledge about cervical cancer among Ugandan women is very low. For an effective cervical cancer-screening programme, awareness about cervical cancer needs to be increased. Health planners need to note the power of the various authoritative sources of reproductive health knowledge such as paternal aunts (Sengas) and involve them in the awareness campaign. Cultural and economic issues dictate the perceived reluctance by men to participate in women's reproductive health issues; men in this community are, however, potential willing partners if appropriately informed. Health planners should address the loss of confidence in current health care units, as well as consider use of other cervical cancer screening delivery systems such as mobile clinics/camps.

Gender, equity: new approaches for effective management of communicable diseases

This editorial article examines what is meant by sex, gender and equity and argues that these are critical concepts to address in the effective management of communicable disease. Drawing on examples from the three major diseases of poverty (HIV, tuberculosis [TB] and malaria), the article explores how, for women and men, gender and poverty can lead to differences in vulnerability to illness; access to quality preventive and curative measures; and experience of the impact of ill health. This exploration sets the context for the three companion papers which outline how gender and poverty shape responses to the three key diseases of poverty in different geographical settings: HIV/AIDS in Kenya; TB in India; and malaria in Ghana.