Towards a Unified Theory of Health-Disease: I. Health as a complex model-object

Improving access to maternal health services among rural hard-to-reach fishing communities in Uganda, the role of community health workers

OBJECTIVES

To explore whether community health worker household-based maternal health visits improve antenatal care and skilled birth attendance among hard-to-reach fishing villages on Lake Victoria, Uganda.

METHODS

This quasi-experimental 18-month prospective study involved 486 consenting women aged 15-49 years, who were pregnant or had a pregnancy outcome in the past 6 months, from 6 island fishing communities. The community health worker household-based intervention (community health workers' household visits to provide counseling, blood pressure measurement, anemia, and HIV testing) involved 243 women from three fishing communities. Random effects logistic regression was used to determine the association between the community health worker intervention and antenatal care and skilled birth attendance among women who had at least 5 months of pregnancy or childbirth at follow-up.

RESULTS

Almost all women accepted the community health worker intervention (90.9% (221/243)). Hypertension was at 12.5% (27/216) among those who accepted blood pressure measurements, a third (33.3% (9/27)) were pregnant. HIV prevalence was 23.5% (52/221). Over a third (34.2% (69/202)) of women tested had anemia (hemoglobin levels less than 11 g/dL). The community health worker intervention was associated with attendance of first antenatal care visit within 20 weeks of pregnancy (adjusted odd ratio = 2.1 (95% confidence interval 0.6-7.6)), attendance of at least four antenatal care visits (adjusted odd ratio = 0.9 (95% confidence interval 0.4-2.0)), and skilled birth attendance (adjusted odd ratio = 0.5 (95% confidence interval 0.1-1.5)), though not statistically significant.

CONCLUSION

Community health workers have a crucial role in improving early antenatal care attendance, early community-based diagnosis of anemia, hypertensive disorders, and HIV among women in these hard-to-reach fishing communities.

'Protective' silence surrounding AIDS: Reasons and implications of non-disclosure among pregnant women living with HIV in Rio de Janeiro (Brazil)

The persistence of stigma surrounding AIDS remains a challenge in the epidemic's fourth decade. Based on qualitative research, this study analyses how pregnant women living with HIV/AIDS (PWLHA) experience and cope with AIDS stigma. A total of 29 semi-structured interviews were conducted with PWLHA focusing on socioeconomic profiles, the contexts in which they discovered HIV infection, experiences with health-care sites and ways of dealing with AIDS-related stigma. We recruited PWLHA at two prevention of mother-to-child transmission sites in Rio de Janeiro, Brazil. The PWLHA's testimony indicates that access to care and treatment has a profound effect on the deconstruction of their understanding of AIDS as a fatal disease. However, fear of AIDS stigma is still predominant. The law guarantees HIV non-disclosure, and women see it as a way to protect themselves from discrimination. We argue, however, that the silence surrounding HIV diagnosis perpetuates the psychosocial and structural mechanisms that reproduce stigma. We conclude that diverse sectors of society, including health-care facilities, must be involved in confronting stigma by demystifying AIDS, improving patients' knowledge of their rights, and increasing their access to material and symbolic goods.

Towards a unified theory of health-disease: II. Holopathogenesis

This article presents a systematic framework for modeling several classes of illness-sickness-disease named as Holopathogenesis. Holopathogenesis is defined as processes of over-determination of diseases and related conditions taken as a whole, comprising selected facets of the complex object Health. First, a conceptual background of Holopathogenesis is presented as a series of significant interfaces (biomolecular-immunological, physiopathological-clinical, epidemiological-ecosocial). Second, propositions derived from Holopathogenesis are introduced in order to allow drawing the disease-illness-sickness complex as a hierarchical network of networks. Third, a formalization of intra- and inter-level correspondences, over-determination processes, effects and links of Holopathogenesis models is proposed. Finally, the Holopathogenesis frame is evaluated as a comprehensive theoretical pathology taken as a preliminary step towards a unified theory of health-disease.