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Awuor AO, Wambura G, Ngere I, Hunsperger E, Onyango C, Bigogo G, Blum LS, Munyua P, Njenga MK, Widdowson MA. A mixed methods assessment of knowledge, attitudes and practices related to aflatoxin contamination and exposure among caregivers of children under 5 years in western Kenya. Public Health Nutr 2023; 26:3013-3022. [PMID: 36871962 PMCID: PMC10755389 DOI: 10.1017/s1368980023000150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 11/22/2022] [Accepted: 12/01/2022] [Indexed: 03/07/2023]
Abstract
OBJECTIVE Identifying factors that may influence aflatoxin exposure in children under 5 years of age living in farming households in western Kenya. DESIGN We used a mixed methods design. The quantitative component entailed serial cross-sectional interviews in 250 farming households to examine crop processing and conservation practices, household food storage and consumption and local understandings of aflatoxins. Qualitative data collection included focus group discussions (N 7) and key informant interviews (N 13) to explore explanations of harvesting and post-harvesting techniques and perceptions of crop spoilage. SETTING The study was carried out in Asembo, a rural community where high rates of child stunting exist. PARTICIPANTS A total of 250 female primary caregivers of children under 5 years of age and thirteen experts in farming and food management participated. RESULTS Study results showed that from a young age, children routinely ate maize-based dishes. Economic constraints and changing environmental patterns guided the application of sub-optimal crop practices involving early harvest, poor drying, mixing spoiled with good cereals and storing cereals in polypropylene bags in confined quarters occupied by humans and livestock and raising risks of aflatoxin contamination. Most (80 %) smallholder farmers were unaware of aflatoxins and their harmful economic and health consequences. CONCLUSIONS Young children living in subsistence farming households may be at risk of exposure to aflatoxins and consequent ill health and stunting. Sustained efforts to increase awareness of the risks of aflatoxins and control measures among subsistence farmers could help to mitigate practices that raise exposure.
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Affiliation(s)
- Abigael O Awuor
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Gati Wambura
- Washington State University Global Health Program, Nairobi, Kenya
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Isaac Ngere
- Washington State University Global Health Program, Nairobi, Kenya
- Paul G Allen School of Global Animal Health, Washington State University, Pullman99164, USA
| | - Elizabeth Hunsperger
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Clayton Onyango
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Godfrey Bigogo
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Lauren S Blum
- Paul G Allen School of Global Animal Health, Washington State University, Pullman99164, USA
| | - Peninah Munyua
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - M Kariuki Njenga
- Washington State University Global Health Program, Nairobi, Kenya
- Paul G Allen School of Global Animal Health, Washington State University, Pullman99164, USA
| | - Marc-Alain Widdowson
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Nairobi, Kenya
- Institute of Tropical Medicine, Antwerp, Belgium
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Blum LS, Swartz H, Olisenekwu G, Erhabor I, Gonzalez W. Social and economic factors influencing intrahousehold food allocation and egg consumption of children in Kaduna State, Nigeria. Matern Child Nutr 2022; 19:e13442. [PMID: 36353982 PMCID: PMC9749605 DOI: 10.1111/mcn.13442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 09/10/2022] [Accepted: 09/24/2022] [Indexed: 11/11/2022]
Abstract
Adequate intake of high-quality nutritious foods during infancy and early childhood is critical to achieving optimal growth, cognitive and behavioural development, and economic productivity later in life. Integrating high-quality and nutrient-dense animal source foods (ASFs), a major source of protein and micronutrients, into children's diets is increasingly considered essential to reducing the global burden of malnutrition in low- and middle-income countries. While eggs are an ASF that shows promise for mitigating child undernutrition, interventions promoting egg consumption among children have had mixed results in improving egg intake and child growth outcomes. As part of an evaluation of a demand creation campaign promoting egg consumption, qualitative research was carried out in September 2019 to assess sociocultural and household factors affecting egg intake among young children living in Kaduna State, Nigeria, where a thriving egg industry and childhood stunting rates of 50% exist. Methods included freelisting exercises (11), key informant interviews (11), in-depth interviews (25) and FGDs (4). Results illuminated cultural rules that restrict egg consumption among children living in low-income households. These rules and norms reflect social and economic valuations that foster male dominance in household decision-making and guide food purchasing and intrahousehold food allocation that allow men to consume eggs more regularly. Study results highlight sociocultural considerations when selecting food interventions to address child malnutrition in low-income contexts. Interventions encouraging increased consumption of ASFs, and specifically eggs in young children, should be informed by formative research to understand sociocultural norms and beliefs guiding egg consumption.
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Affiliation(s)
- Lauren S. Blum
- Global Alliance for Improved Nutrition (GAIN)GenevaSwitzerland
| | - Haley Swartz
- Global Alliance for Improved Nutrition (GAIN)GenevaSwitzerland
| | | | - Irowa Erhabor
- Global Alliance for Improved Nutrition (GAIN)AbujaNigeria
| | - Wendy Gonzalez
- Global Alliance for Improved Nutrition (GAIN)GenevaSwitzerland
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Neufeld LM, Andrade EB, Ballonoff Suleiman A, Barker M, Beal T, Blum LS, Demmler KM, Dogra S, Hardy-Johnson P, Lahiri A, Larson N, Roberto CA, Rodríguez-Ramírez S, Sethi V, Shamah-Levy T, Strömmer S, Tumilowicz A, Weller S, Zou Z. Food choice in transition: adolescent autonomy, agency, and the food environment. Lancet 2022; 399:185-197. [PMID: 34856191 DOI: 10.1016/s0140-6736(21)01687-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 02/07/2023]
Abstract
Dietary intake during adolescence sets the foundation for a healthy life, but adolescents are diverse in their dietary patterns and in factors that influence food choice. More evidence to understand the key diet-related issues and the meaning and context of food choices for adolescents is needed to increase the potential for impactful actions. The aim of this second Series paper is to elevate the importance given to adolescent dietary intake and food choice, bringing a developmental perspective to inform policy and programmatic actions to improve diets. We describe patterns of dietary intake, then draw on existing literature to map how food choice can be influenced by unique features of adolescent development. Pooled qualitative data is then combined with evidence from the literature to explore ways in which adolescent development can interact with sociocultural context and the food environment to influence food choice. Irrespective of context, adolescents have a lot to say about why they eat what they eat, and insights into factors that might motivate them to change. Adolescents must be active partners in shaping local and global actions that support healthy eating patterns. Efforts to improve food environments and ultimately adolescent food choice should harness widely shared adolescent values beyond nutrition or health.
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Affiliation(s)
| | - Eduardo B Andrade
- Brazilian School of Public and Business Administration (EBAPE), Getulio Vargas Foundation (FGV), Rio de Janeiro, Brazil
| | | | - Mary Barker
- NIHR Southampton Biomedical Research Centre, University of Southampton, Southampton, UK; MRC Lifecourse Epidemiology Centre, Southampton General Hospital, Southampton, UK; School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Ty Beal
- Global Alliance for Improved Nutrition, Washington, DC, USA
| | - Lauren S Blum
- Global Alliance for Improved Nutrition, Washington, DC, USA
| | | | - Surabhi Dogra
- Lancet Standing Commission on Adolescent Health and Wellbeing, Noida, India
| | - Polly Hardy-Johnson
- MRC Lifecourse Epidemiology Centre, Southampton General Hospital, Southampton, UK
| | | | - Nicole Larson
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Christina A Roberto
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | - Sofia Strömmer
- NIHR Southampton Biomedical Research Centre, University of Southampton, Southampton, UK; MRC Lifecourse Epidemiology Centre, Southampton General Hospital, Southampton, UK
| | | | - Susie Weller
- Clinical Ethics and Law at Southampton (CELS), Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Zhiyong Zou
- Institute of Child and Adolescent Health, Peking University School of Public Health, Beijing, China; National Health Commission Key Laboratory of Reproductive Health, Beijing, China
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Blum LS, Karia FP, Msoka EF, Oshosen Mwanga M, Crump JA, Rubach MP. An In-Depth Examination of Reasons for Autopsy Acceptance and Refusal in Northern Tanzania. Am J Trop Med Hyg 2020; 103:1670-1680. [PMID: 32748779 DOI: 10.4269/ajtmh.20-0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Uncertainty about the causes of death (COD) in low- and middle-income countries (LMICs) has been recognized as a constraint to global health and development. Although complete diagnostic autopsy (CDA) is the best way to assess COD, it is uncommon in LMICs because of low investment priority and assumptions about poor acceptability. Social science research was conducted from May 2016 through July 2017 to examine issues related to acceptability of CDAs in northern Tanzania where autopsy was being offered in two referral hospitals to assess COD associated with febrile illness. Initial formative research entailed 29 key informant interviews, seven observations of burial practices, and four group discussions. In-depth interviews were conducted with families of deceased, including nine families that accepted and 11 families that refused CDA. The formative research identified concepts related to death, understandings of CDA, and cultural practices and psychosocial considerations associated with death that informed the authorization process. Most families who accepted CDA cited the desire to get clarity regarding the COD as a primary reason for acceptance. An unexpected finding was that CDA is perceived as a means to determine witchcraft involvement, a common explanation for COD and a common reason for postmortem acceptance. Death resulting from chronic illness or conditions presumed to have a clinical diagnosis were reasons for CDA to be viewed as unnecessary. The timing, way families were approached, and content of information shared during authorization influenced acceptance and refusal of CDA. Findings show that CDAs can be acceptable in settings where traditional disease models prevail.
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Affiliation(s)
| | - Francis P Karia
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | | | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand.,Duke Global Health Institute, Duke University, Durham, North Carolina.,Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Matthew P Rubach
- Duke Global Health Institute, Duke University, Durham, North Carolina.,Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Snavely ME, Oshosen M, Msoka EF, Karia FP, Maze MJ, Blum LS, Rubach MP, Mmbaga BT, Maro VP, Crump JA, Muiruri C. "If You Have No Money, You Might Die": A Qualitative Study of Sociocultural and Health System Barriers to Care for Decedent Febrile Inpatients in Northern Tanzania. Am J Trop Med Hyg 2020; 103:494-500. [PMID: 32314691 DOI: 10.4269/ajtmh.19-0822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Infectious diseases are a leading cause of mortality in low- and middle-income countries (LMICs) despite effective treatments. To study the sociocultural and health system barriers to care, we conducted a qualitative social autopsy study of patients who died from febrile illness in northern Tanzania. From December 2016 through July 2017, we conducted in-depth interviews in Arusha and Kilimanjaro regions with a purposive sample of 20 family members of patients who had died at two regional referral hospitals. Of the deceased patients included in this study, 14 (70%) were adults and 10 (50%) were female. Patients identified their religion as Catholic (12, 60%), Lutheran (six, 30%), and Muslim (two, 10%), and their ethnicity as Chagga (14, 70%) and Sambaa (two, 10%), among others. Family members reported both barriers to and facilitators of receiving health care. Barriers included a perceived lack of capacity of local health facilities, transportation barriers, and a lack of formal referrals to higher levels of care. Family members also reported the cost of health care as a barrier. However, one facilitator of care was access to financial resources via families' social networks-a phenomenon we refer to as social capital. Another facilitator of care was families' proactive engagement with the health system. Our results suggest that further investment in lower level health facilities may improve care-seeking and referral patterns and that future research into the role of social capital is needed to fully understand the effect of socioeconomic factors on healthcare utilization in LMICs.
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Affiliation(s)
- Michael E Snavely
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | | | - Elizabeth F Msoka
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Francis P Karia
- Duke Office of Clinical Research, Duke University School of Medicine, Durham, North Carolina.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Michael J Maze
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | | | - Matthew P Rubach
- Programme in Emerging Infectious Diseases, Duke-National University of Singapore, Singapore, Singapore.,Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Venance P Maro
- Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Charles Muiruri
- Department of Population Health, Duke University, Durham, North Carolina.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Duke Global Health Institute, Duke University, Durham, North Carolina
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Blum LS, Yemweni A, Trinies V, Kambere M, Tolani F, Allen JV, Handzel T, Cookson S, Ram PK. Programmatic implications for promotion of handwashing behavior in an internally displaced persons camp in North Kivu, Democratic Republic of Congo. Confl Health 2019; 13:54. [PMID: 31832088 PMCID: PMC6868763 DOI: 10.1186/s13031-019-0225-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 08/21/2019] [Indexed: 11/16/2022] Open
Abstract
Background Diarrhea and acute respiratory infections (ARI) account for 30% of deaths among children displaced due to humanitarian emergencies. A wealth of evidence demonstrates that handwashing with soap prevents both diarrhea and ARI. While socially- and emotionally-driven factors are proven motivators to handwashing in non-emergency situations, little is known about determinants of handwashing behavior in emergency settings. Methods We conducted a qualitative investigation from June to August 2015 in a camp for internally displaced persons with a population of 6360 in the war-torn eastern region of the Democratic Republic of Congo. We held key informant interviews with 9 non-governmental organizations and camp officials, in-depth interviews and rating exercises with 18 mothers of children < 5 years, and discussions with 4 groups of camp residents and hygiene promoters to identify motivators and barriers to handwashing. Results At the time of the study, hygiene promotion activities lacked adequate resources, cultural acceptability, innovation, and adaptation for sustained behavioral change. Lack of ongoing provision of hygiene materials was a major barrier to handwashing behavior. When hygiene materials were available, camp residents reported that the primary motivator to handwashing was to prevent illness, particularly diarrheal disease, with many mentioning an increased need to wash hands during diarrhea outbreaks. Emotionally- and socially-related motivators such as “maintaining a good image” and social pressure to follow recommended camp hygiene practices were also reported to motivate handwashing with soap. Residents who engaged in day labor outside the camp had limited exposure to hygiene messages and handwashing facilities. Interviewees indicated that the harsh living conditions forced residents to prioritize obtaining basic survival needs over good hygiene. Conclusions Hygiene promotion in camp settings must involve preparedness of adequate resources and supplies and ongoing provision of hygiene materials so that vulnerable populations affected by emergencies can apply good hygiene behaviors for the duration of the camp’s existence. Compared to non-emergency contexts, illness-based messages may be more effective in emergency settings where disease poses a current and ongoing threat. However, failure to use emotive and social drivers that motivate handwashing may present missed opportunities to improve handwashing in camps.
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Affiliation(s)
- Lauren S Blum
- 1Consultant, University at Buffalo, Buffalo, NY 14214 USA
| | - Anicet Yemweni
- 2University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | | | | | | | - Jelena V Allen
- 1Consultant, University at Buffalo, Buffalo, NY 14214 USA
| | - Thomas Handzel
- Centers for Disease Prevention and Control, Atlanta, GA 30333 USA
| | - Susan Cookson
- Centers for Disease Prevention and Control, Atlanta, GA 30333 USA
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Blum LS, Mellisa A, Kurnia Sari E, Novitasari Yusadiredja I, van Liere M, Shulman S, Izwardy D, Menon R, Tumilowicz A. In-depth assessment of snacking behaviour in unmarried adolescent girls 16-19 years of age living in urban centres of Java, Indonesia. Matern Child Nutr 2019; 15:e12833. [PMID: 31042814 PMCID: PMC6852566 DOI: 10.1111/mcn.12833] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 03/22/2019] [Accepted: 04/24/2019] [Indexed: 12/21/2022]
Abstract
Adolescence is a critical period characterized by physical, social, and developmental changes that impact on health and eating behaviour. Indonesia is experiencing dramatic economic and infrastructural changes, causing greater access to the global food industry and media. This transition is influencing food intake trends, leading to new nutritional challenges in adolescent girls. Qualitative research was conducted between November 2016 and January 2017 in five urban sites in Java, Indonesia, to examine individual, social, environmental, and macrosystem factors affecting snacking behaviours in unmarried adolescent girls 16–19 years of age. Methods entailed 30 freelisting exercises, nine key informant interviews, and 16 in‐depth interviews. Freelisting results identified over 200 snack foods, with the most salient processed convenience foods such as chips and cookies. Respondents typically snacked multiple times daily. Widespread availability of affordable and “tasty” snacks makes snack foods appealing meal substitutes. Snacks provide a distraction to boredom and loneliness and an enhancement to social gatherings. Girls exhibited limited understanding or concern about potential negative effects of snacking. Parents facilitate acquisition of nutrient‐poor snacks, whereas friends exert pressure for routine consumption of snack foods. Social media infiltrated with promotions of eateries and snack foods is likely contributing to the preponderance of snack food consumption. Routine consumption of snack foods high in sugar, salt, and fat and skipping meals will likely have long‐term consequences on the nutritional status and health of Indonesian adolescent girls. Findings underline the urgent need to develop contextually relevant, targeted behavioural change strategies to modify the potentially harmful eating and activity patterns of adolescent girls identified in this study and to curb the trajectory of overweight in urban Indonesia.
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Affiliation(s)
- Lauren S Blum
- Global Alliance for Improved Nutrition (GAIN), Jakarta, Indonesia
| | - Ayu Mellisa
- PT Kadence International, Jakarta, Indonesia
| | - Eny Kurnia Sari
- Global Alliance for Improved Nutrition (GAIN), Jakarta, Indonesia
| | | | - Marti van Liere
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Susan Shulman
- Global Alliance for Improved Nutrition (GAIN), Jakarta, Indonesia
| | - Doddy Izwardy
- Directorate of Public Health, Ministry of Health Republic of Indonesia, Jakarta, Indonesia
| | - Ravi Menon
- Global Alliance for Improved Nutrition (GAIN), Jakarta, Indonesia
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Blum LS, Khan R, Sultana M, Soltana N, Siddiqua Y, Khondker R, Sultana S, Tumilowicz A. Using a gender lens to understand eating behaviours of adolescent females living in low-income households in Bangladesh. Matern Child Nutr 2019; 15:e12841. [PMID: 31083774 PMCID: PMC6852560 DOI: 10.1111/mcn.12841] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/22/2019] [Accepted: 04/24/2019] [Indexed: 01/22/2023]
Abstract
Adolescence is a critical period characterized by rapid physical, psychological, and social development and growth. In Bangladesh, high rates of undernutrition persist among adolescent females living in low‐income households. Prevalence of adolescent marriage and pregnancy is extremely high, with almost half of Bangladeshi women giving birth by 18 years of age. Qualitative research was carried out from April to June 2017 to examine individual, social, and environmental factors influencing eating behaviours of female adolescents between 15 and 19 years of age living in low‐income families in urban and rural settings in Bangladesh. Methods included freelisting exercises (33), key informant interviews (11), in‐depth interviews (24), direct observations (16), and focus group discussions (12). Findings show that household food insecurity necessitates adjustments in meal food quality and frequency. Gender norms prescribe that females receive small meal portions and make sacrifices in food consumption so that male family members can eat more. Work and school schedules cause long breaks between meal consumption, restricting food intake of adolescent females for extended periods. Gender discrimination and its manifestations likely amplify susceptibility to psychological stresses in adolescent females. An inferior social position makes adolescent females living in food insecure households vulnerable to undernutrition, with factors affecting food deprivation increasing as they approach childbearing. Policies to increase age of marriage and reduce adolescent pregnancy must continue. Programmes must ensure that school‐going adolescents eat adequately during the school day. Prolonging school education and strengthening the economic viability of women should alter cultural expectations regarding marriage age and normative female roles.
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Affiliation(s)
- Lauren S Blum
- Global Alliance for Improved Nutrition (GAIN), House 20, Road 99, Level 4, Gulshan 2, Dhaka, 1212, Bangladesh
| | - Rasheda Khan
- Global Alliance for Improved Nutrition (GAIN), House 20, Road 99, Level 4, Gulshan 2, Dhaka, 1212, Bangladesh
| | - Marzia Sultana
- Global Alliance for Improved Nutrition (GAIN), House 20, Road 99, Level 4, Gulshan 2, Dhaka, 1212, Bangladesh
| | - Nahian Soltana
- Global Alliance for Improved Nutrition (GAIN), House 20, Road 99, Level 4, Gulshan 2, Dhaka, 1212, Bangladesh
| | | | - Rudaba Khondker
- Global Alliance for Improved Nutrition (GAIN), House 20, Road 99, Level 4, Gulshan 2, Dhaka, 1212, Bangladesh
| | - Sabiha Sultana
- Global Alliance for Improved Nutrition (GAIN), House 20, Road 99, Level 4, Gulshan 2, Dhaka, 1212, Bangladesh
| | - Alison Tumilowicz
- Global Alliance for Improved Nutrition (GAIN), House 20, Road 99, Level 4, Gulshan 2, Dhaka, 1212, Bangladesh
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Horton S, Blum LS, Diouf M, Ndiaye B, Ndoye F, Niang K, Greig A. Delivering Vitamin A Supplements to Children Aged 6-59 Months: Comparing Delivery through Campaigns and through Routine Health Services in Senegal. Curr Dev Nutr 2018; 2:nzy006. [PMID: 30019030 PMCID: PMC6041955 DOI: 10.1093/cdn/nzy006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 10/10/2017] [Accepted: 01/11/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Using twice-yearly campaigns such as Child Health Days to deliver vitamin A supplements has been a key strategy over the last 2 decades, and was an important component in helping reach the Millennium Development Goals in child health. As countries move to strengthen their routine health services under the Sustainable Development Goals, efforts are underway to shift supplementation from campaign to routine delivery. OBJECTIVE The aim of this study was to compare cost, coverage, and user satisfaction between twice-yearly campaigns and routine delivery of vitamin A supplements in Senegal. METHODS Information was collected on cost, coverage, and user satisfaction with both types of delivery, using administrative data, interviews at various levels in the health system, and focus group discussions with caregivers. Both qualitative and quantitative information were obtained, for 2 regions using routine delivery and 2 regions using campaign delivery. RESULTS Routine delivery receives fewer dedicated resources. Coverage is lower, especially of children >12 mo of age. Districts undertake outreach ("mini-campaigns") to try to improve coverage in regions using routine delivery, in effect using a hybrid approach. Some mothers prefer the administration of supplements at a health facility as it is perceived as more hygienic and involving professional health workers, but others, especially those living further away, prefer house-to-house delivery which was the norm for the campaign mode. CONCLUSIONS Advance planning for the shift to routine delivery is important in maintaining coverage, as is strengthening the primary health care system by having an appropriate ratio of salaried workers to population. When the system relies heavily on volunteers, and the small incentive payments to volunteers are discontinued, coverage suffers. Routine delivery also relies on good record-keeping and hence literacy. Community understanding of, and support for, supplementation are even more important for routine than for campaign delivery.
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Affiliation(s)
- Susan Horton
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
| | | | | | | | | | - Khadim Niang
- Institut de Santé en Développement, Université Chaikh Anta Diop de Dakar, Dakar, Senegal
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Phillips RM, Vujcic J, Boscoe A, Handzel T, Aninyasi M, Cookson ST, Blanton C, S Blum L, Ram PK. Soap is not enough: handwashing practices and knowledge in refugee camps, Maban County, South Sudan. Confl Health 2015; 9:39. [PMID: 26702295 PMCID: PMC4689052 DOI: 10.1186/s13031-015-0065-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 12/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provision of soap, handwashing stations, and latrines. We conducted a study 1 year after the outbreak to assess the knowledge, attitudes, and practices of the refugees in Maban County. METHODS We conducted a cross sectional survey of female heads of households in three refugee camps in Maban County. We performed structured observations on a subset of households to directly observe their handwashing practices at times of possible pathogen transmission. RESULTS Of the 600 households interviewed, nearly all had soap available and 91 % reported water was available "always" or "sometimes". Exposure to handwashing promotion was reported by 85 % of the respondents. Rinsing hands with water alone was more commonly observed than handwashing with soap at critical handwashing times including "before eating" (80 % rinsing vs. 7 % washing with soap) and "before preparing/cooking food" (72.3 % vs 23 %). After toilet use, 46 % were observed to wash hands with soap and an additional 38 % rinsed with water alone. CONCLUSIONS Despite intensive messaging regarding handwashing with soap and access to soap and water, rinsing hands with water alone rather than washing hands with soap remains more common among the refugees in Maban County. This practice puts them at continued risk for communicable disease transmission. Qualitative research into local beliefs and more effective messaging may help future programs tailor handwashing interventions.
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Affiliation(s)
| | | | | | - Thomas Handzel
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Susan T Cookson
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Curtis Blanton
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Blum LS, Dentz H, Chingoli F, Chilima B, Warne T, Lee C, Hyde T, Gindler J, Sejvar J, Mintz ED. Formative investigation of acceptability of typhoid vaccine during a typhoid fever outbreak in Neno District, Malawi. Am J Trop Med Hyg 2014; 91:729-37. [PMID: 25002303 PMCID: PMC4183395 DOI: 10.4269/ajtmh.14-0067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 05/02/2014] [Indexed: 11/07/2022] Open
Abstract
Typhoid fever affects an estimated 22 million people annually and causes 216,000 deaths worldwide. We conducted an investigation in August and September 2010 to examine the acceptability of typhoid vaccine in Neno District, Malawi where a typhoid outbreak was ongoing. We used qualitative methods, including freelisting exercises, key informant and in-depth interviews, and group discussions. Respondents associated illness with exposure to "bad wind," and transmission was believed to be airborne. Typhoid was considered extremely dangerous because of its rapid spread, the debilitating conditions it produced, the number of related fatalities, and the perception that it was highly contagious. Respondents were skeptical about the effectiveness of water, sanitation, and hygiene (WaSH) interventions. The perceived severity of typhoid and fear of exposure, uncertainty about the effectiveness of WaSH measures, and widespread belief in the efficacy of vaccines in preventing disease resulted in an overwhelming interest in receiving typhoid vaccine during an outbreak.
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Affiliation(s)
- Lauren S Blum
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, (NCEZID), CDC, Atlanta, Georgia; Strengthening Immunization Systems Branch, Global Immunization Division, Center for Global Health (CGH), CDC, Atlanta, Georgia; Neno District Health Office, Neno, Malawi; Community Health Services Unit, MOH, Lilongwe, Malawi; Global AIDS Program Malawi, Division of Global HIV AIDS, CGH, CDC, Lilongwe, Malawi; Office of the Director, Division of High Consequence Pathogens and Pathology, NCEZID, CDC, Atlanta, Georgia
| | - Holly Dentz
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, (NCEZID), CDC, Atlanta, Georgia; Strengthening Immunization Systems Branch, Global Immunization Division, Center for Global Health (CGH), CDC, Atlanta, Georgia; Neno District Health Office, Neno, Malawi; Community Health Services Unit, MOH, Lilongwe, Malawi; Global AIDS Program Malawi, Division of Global HIV AIDS, CGH, CDC, Lilongwe, Malawi; Office of the Director, Division of High Consequence Pathogens and Pathology, NCEZID, CDC, Atlanta, Georgia
| | - Felix Chingoli
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, (NCEZID), CDC, Atlanta, Georgia; Strengthening Immunization Systems Branch, Global Immunization Division, Center for Global Health (CGH), CDC, Atlanta, Georgia; Neno District Health Office, Neno, Malawi; Community Health Services Unit, MOH, Lilongwe, Malawi; Global AIDS Program Malawi, Division of Global HIV AIDS, CGH, CDC, Lilongwe, Malawi; Office of the Director, Division of High Consequence Pathogens and Pathology, NCEZID, CDC, Atlanta, Georgia
| | - Benson Chilima
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, (NCEZID), CDC, Atlanta, Georgia; Strengthening Immunization Systems Branch, Global Immunization Division, Center for Global Health (CGH), CDC, Atlanta, Georgia; Neno District Health Office, Neno, Malawi; Community Health Services Unit, MOH, Lilongwe, Malawi; Global AIDS Program Malawi, Division of Global HIV AIDS, CGH, CDC, Lilongwe, Malawi; Office of the Director, Division of High Consequence Pathogens and Pathology, NCEZID, CDC, Atlanta, Georgia
| | - Thomas Warne
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, (NCEZID), CDC, Atlanta, Georgia; Strengthening Immunization Systems Branch, Global Immunization Division, Center for Global Health (CGH), CDC, Atlanta, Georgia; Neno District Health Office, Neno, Malawi; Community Health Services Unit, MOH, Lilongwe, Malawi; Global AIDS Program Malawi, Division of Global HIV AIDS, CGH, CDC, Lilongwe, Malawi; Office of the Director, Division of High Consequence Pathogens and Pathology, NCEZID, CDC, Atlanta, Georgia
| | - Carla Lee
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, (NCEZID), CDC, Atlanta, Georgia; Strengthening Immunization Systems Branch, Global Immunization Division, Center for Global Health (CGH), CDC, Atlanta, Georgia; Neno District Health Office, Neno, Malawi; Community Health Services Unit, MOH, Lilongwe, Malawi; Global AIDS Program Malawi, Division of Global HIV AIDS, CGH, CDC, Lilongwe, Malawi; Office of the Director, Division of High Consequence Pathogens and Pathology, NCEZID, CDC, Atlanta, Georgia
| | - Terri Hyde
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, (NCEZID), CDC, Atlanta, Georgia; Strengthening Immunization Systems Branch, Global Immunization Division, Center for Global Health (CGH), CDC, Atlanta, Georgia; Neno District Health Office, Neno, Malawi; Community Health Services Unit, MOH, Lilongwe, Malawi; Global AIDS Program Malawi, Division of Global HIV AIDS, CGH, CDC, Lilongwe, Malawi; Office of the Director, Division of High Consequence Pathogens and Pathology, NCEZID, CDC, Atlanta, Georgia
| | - Jacqueline Gindler
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, (NCEZID), CDC, Atlanta, Georgia; Strengthening Immunization Systems Branch, Global Immunization Division, Center for Global Health (CGH), CDC, Atlanta, Georgia; Neno District Health Office, Neno, Malawi; Community Health Services Unit, MOH, Lilongwe, Malawi; Global AIDS Program Malawi, Division of Global HIV AIDS, CGH, CDC, Lilongwe, Malawi; Office of the Director, Division of High Consequence Pathogens and Pathology, NCEZID, CDC, Atlanta, Georgia
| | - James Sejvar
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, (NCEZID), CDC, Atlanta, Georgia; Strengthening Immunization Systems Branch, Global Immunization Division, Center for Global Health (CGH), CDC, Atlanta, Georgia; Neno District Health Office, Neno, Malawi; Community Health Services Unit, MOH, Lilongwe, Malawi; Global AIDS Program Malawi, Division of Global HIV AIDS, CGH, CDC, Lilongwe, Malawi; Office of the Director, Division of High Consequence Pathogens and Pathology, NCEZID, CDC, Atlanta, Georgia
| | - Eric D Mintz
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, (NCEZID), CDC, Atlanta, Georgia; Strengthening Immunization Systems Branch, Global Immunization Division, Center for Global Health (CGH), CDC, Atlanta, Georgia; Neno District Health Office, Neno, Malawi; Community Health Services Unit, MOH, Lilongwe, Malawi; Global AIDS Program Malawi, Division of Global HIV AIDS, CGH, CDC, Lilongwe, Malawi; Office of the Director, Division of High Consequence Pathogens and Pathology, NCEZID, CDC, Atlanta, Georgia
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Khan R, Blum LS, Sultana M, Bilkis S, Koblinsky M. An examination of women experiencing obstetric complications requiring emergency care: perceptions and sociocultural consequences of caesarean sections in Bangladesh. J Health Popul Nutr 2012; 30:159-71. [PMID: 22838158 PMCID: PMC3397327 DOI: 10.3329/jhpn.v30i2.11309] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Little is known about the physical and socioeconomic postpartum consequences of women who experience obstetric complications and require emergency obstetric care (EmOC), particularly in resource-poor countries such as Bangladesh where historically there has been a strong cultural preference for births at home. Recent increases in the use of skilled birth attendants show socioeconomic disparities in access to emergency obstetric services, highlighting the need to examine birthing preparation and perceptions of EmOC, including caesarean sections. Twenty women who delivered at a hospital and were identified by physicians as having severe obstetric complications during delivery or immediately thereafter were selected to participate in this qualitative study. Purposive sampling was used for selecting the women. The study was carried out in Matlab, Bangladesh, during March 2008-August 2009. Data-collection methods included in-depth interviews with women and, whenever possible, their family members. The results showed that the women were poorly informed before delivery about pregnancy-related complications and medical indications for emergency care. Barriers to care-seeking at emergency obstetric facilities and acceptance of lifesaving care were related to apprehensions about the physical consequences and social stigma, resulting from hospital procedures and financial concerns. The respondents held many misconceptions about caesarean sections and distrust regarding the reason for recommending the procedure by the healthcare providers. Women who had caesarean sections incurred high costs that led to economic burdens on family members, and the blame was attributed to the woman. The postpartum health consequences reported by the women were generally left untreated. The data underscore the importance of educating women and their families about pregnancy-related complications and preparing families for the possibility of caesarean section. At the same time, the health systems need to be strengthened to ensure that all women in clinical need of lifesaving obstetric surgery access quality EmOC services rapidly and, once in a facility, can obtain a caesarean section promptly, if needed. While greater access to surgical interventions may be lifesaving, policy-makers need to institute mechanisms to discourage the over-medicalization of childbirth in a context where the use of caesarean section is rapidly rising.
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Affiliation(s)
| | | | | | | | - Marge Koblinsky
- icddr,b, GPO Box 128, Dhaka 1000, Bangladesh
- John Snow, Inc., Arlington, VA, USA
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Naved RT, Blum LS, Chowdhury S, Khan R, Bilkis S, Koblinsky M. Violence against women with chronic maternal disabilities in rural Bangladesh. J Health Popul Nutr 2012; 30:181-92. [PMID: 22838160 PMCID: PMC3397329 DOI: 10.3329/jhpn.v30i2.11312] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
This study explored violence against women with chronic maternal disabilities in rural Bangladesh. During November 2006-July 2008, in-depth interviews were conducted with 17 rural Bangladeshi women suffering from uterine prolapse, stress incontinence, or fistula. Results of interviews showed that exposure to emotional abuse was almost universal, and most women were sexually abused. The common triggers for violence were the inability of the woman to perform household chores and to satisfy her husband's sexual demands. Misconceptions relating to the causes of these disabilities and the inability of the affected women to fulfill gender role expectations fostered stigma. Emotional and sexual violence increased their vulnerability, highlighting the lack of life options outside marriage and silencing most of them into accepting the violence. Initiatives need to be developed to address misperceptions regarding the causes of such disabilities and, in the long-term, create economic opportunities for reducing the dependence of women on marriage and men and transform the society to overcome rigid gender norms.
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Blum LS, Oria PA, Olson CK, Breiman RF, Ram PK. Examining the use of oral rehydration salts and other oral rehydration therapy for childhood diarrhea in Kenya. Am J Trop Med Hyg 2012; 85:1126-33. [PMID: 22144457 DOI: 10.4269/ajtmh.2011.11-0171] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Reductions in the use of oral rehydration therapy (ORT) in sub-Saharan Africa highlight the need to examine caregiver perceptions of ORT during diarrheal episodes. Qualitative research involving group discussions with childcare providers and in-depth interviews with 45 caregivers of children < 5 years of age who had experienced diarrhea was conducted in one rural and urban site in Kenya during July-December 2007. Diarrhea was considered a dangerous condition that can kill young children. Caregivers preferred to treat diarrhea with Western drugs believed to be more effective in stopping diarrhea than ORT. Inconsistent recommendations from health workers regarding use of oral rehydration solution (ORS) caused confusion about when ORS is appropriate and whether it requires a medical prescription. In the rural community, causal explanations about diarrhea, beliefs in herbal remedies, cost, and distance to health facilities presented additional barriers to ORS use. Health communication is needed to clarify the function of ORT in preventing dehydration.
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Olson CK, Blum LS, Patel KN, Oria PA, Feikin DR, Laserson KF, Wamae AW, Bartlett AV, Breiman RF, Ram PK. Community case management of childhood diarrhea in a setting with declining use of oral rehydration therapy: findings from cross-sectional studies among primary household caregivers, Kenya, 2007. Am J Trop Med Hyg 2011; 85:1134-40. [PMID: 22144458 PMCID: PMC3225166 DOI: 10.4269/ajtmh.2011.11-0178] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 07/12/2011] [Indexed: 11/07/2022] Open
Abstract
We sought to determine factors associated with appropriate diarrhea case management in Kenya. We conducted a cross-sectional survey of caregivers of children < 5 years of age with diarrhea in rural Asembo and urban Kibera. In Asembo, 61% of respondents provided oral rehydration therapy (ORT), 45% oral rehydration solution (ORS), and 64% continued feeding. In Kibera, 75% provided ORT, 43% ORS, and 46% continued feeding. Seeking care at a health facility, risk perception regarding death from diarrhea, and treating a child with oral medications were associated with ORT and ORS use. Availability of oral medication was negatively associated. A minority of caregivers reported that ORS is available in nearby shops. In Kenya, household case management of diarrhea remains inadequate for a substantial proportion of children. Health workers have a critical role in empowering caregivers regarding early treatment with ORT and continued feeding. Increasing community ORS availability is essential to improving diarrhea management.
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Affiliation(s)
- Christine K Olson
- Epidemic Intelligence Service and Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30329, USA.
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Abstract
Cultural explanations and management strategies for specific signs and symptoms of vitamin A deficiency are explored in a Hausa-speaking community in northern Niger. Their interpretations of the etiology of nightblindness in young children and pregnant women focus on food-related causes, in which "lack of good food" is central. In parallel with the significance of food in the etiology of nightblindness, the recommended treatments are home food remedies, primarily involving liver, meat, or green leaves. The locally attributed etiology for the more severe manifestation of vitamin A deficiency, xerophthalmia, stands in sharp contrast to this. People believe the primary cause is "heat" produced by acute infectious disease (particularly measles). A trip to the medical dispensary or a reliance upon home remedies are the preferred treatment options for this condition. We explore the striking correspondence between local interpretations of nightblindness and contemporary medical knowledge and treatment in relation to the very different explanations and curative measures offered for more serious manifestations of vitamin A deficiency.
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Affiliation(s)
- Lauren S Blum
- ICDDR, B: Centre for Health and Population Research, Dhaka, Bangladesh
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Arifeen SE, Hoque DME, Akter T, Rahman M, Hoque ME, Begum K, Chowdhury EK, Khan R, Blum LS, Ahmed S, Hossain MA, Siddik A, Begum N, Sadeq-ur Rahman Q, Haque TM, Billah SM, Islam M, Rumi RA, Law E, Al-Helal ZAM, Baqui AH, Schellenberg J, Adam T, Moulton LH, Habicht JP, Scherpbier RW, Victora CG, Bryce J, Black RE. Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial. Lancet 2009; 374:393-403. [PMID: 19647607 DOI: 10.1016/s0140-6736(09)60828-x] [Citation(s) in RCA: 169] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND WHO and UNICEF launched the Integrated Management of Childhood Illness (IMCI) strategy in the mid-1990s to reduce deaths from diarrhoea, pneumonia, malaria, measles, and malnutrition in children younger than 5 years. We assessed the effect of IMCI on health and nutrition of children younger than 5 years in Bangladesh. METHODS In this cluster randomised trial, 20 first-level government health facilities in the Matlab subdistrict of Bangladesh and their catchment areas (total population about 350 000) were paired and randomly assigned to either IMCI (intervention; ten clusters) or usual services (comparison; ten clusters). All three components of IMCI-health-worker training, health-systems improvements, and family and community activities-were implemented beginning in February, 2002. Assessment included household and health facility surveys tracking intermediate outputs and outcomes, and nutrition and mortality changes in intervention and comparison areas. Primary endpoint was mortality in children aged between 7 days and 59 months. Analysis was by intention to treat. This study is registered, number ISRCTN52793850. FINDINGS The yearly rate of mortality reduction in children younger than 5 years (excluding deaths in first week of life) was similar in IMCI and comparison areas (8.6%vs 7.8%). In the last 2 years of the study, the mortality rate was 13.4% lower in IMCI than in comparison areas (95% CI -14.2 to 34.3), corresponding to 4.2 fewer deaths per 1000 livebirths (95% CI -4.1 to 12.4; p=0.30). Implementation of IMCI led to improved health-worker skills, health-system support, and family and community practices, translating into increased care-seeking for illnesses. In IMCI areas, more children younger than 6 months were exclusively breastfed (76%vs 65%, difference of differences 10.1%, 95% CI 2.65-17.62), and prevalence of stunting in children aged 24-59 months decreased more rapidly (difference of differences -7.33, 95% CI -13.83 to -0.83) than in comparison areas. INTERPRETATION IMCI was associated with positive changes in all input, output, and outcome indicators, including increased exclusive breastfeeding and decreased stunting. However, IMCI implementation had no effect on mortality within the timeframe of the assessment. FUNDING Bill & Melinda Gates Foundation, WHO's Department of Child and Adolescent Health and Development, and US Agency for International Development.
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Affiliation(s)
- Shams E Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh.
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Kalim N, Anwar I, Khan J, Blum LS, Moran AC, Botlero R, Koblinsky M. Postpartum haemorrhage and eclampsia: differences in knowledge and care-seeking behaviour in two districts of Bangladesh. J Health Popul Nutr 2009; 27:156-69. [PMID: 19489413 PMCID: PMC2761783 DOI: 10.3329/jhpn.v27i2.3328] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
In high- and low-performing districts of Bangladesh, the study explored the demand-side of maternal healthcare by looking at differences in perceived knowledge and care-seeking behaviours of women in relation to postpartum haemorrhage or eclampsia. Haemorrhage and eclampsia are two major causes of maternal mortality in Bangladesh. The study was conducted during July 2006-December 2007. Both postpartum bleeding and eclampsia were recognized by women of different age-groups as severe and life-threatening obstetric complications. However, a gap existed between perception and actual care-seeking behaviours which could contribute to the high rate of maternal deaths associated with these conditions. There were differences in care-seeking practices among women in the two different areas of Bangladesh, which may reflect sociocultural differences, disparities in economic and educational opportunities, and a discrimination in the availability of care.
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Affiliation(s)
- Nahid Kalim
- Public Health Sciences Division, ICDDR,B, G.P.O. Box 128, Dhaka 1000, Bangladesh.
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Blum LS, Khan R, Nahar N, Breiman RF. In-depth assessment of an outbreak of Nipah encephalitis with person-to-person transmission in Bangladesh: implications for prevention and control strategies. Am J Trop Med Hyg 2009; 80:96-102. [PMID: 19141846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Continued Nipah encephalitis outbreaks in Bangladesh highlight the need for preventative and control measures to reduce transmission from bats to humans and human-to-human spread. Qualitative research was conducted at the end of an encephalitis outbreak in Faridpur, Bangladesh in May 2004 and continued through December 2004. Methods included in-depth interviews with caretakers of cases, case survivors, neighbors of cases, and health providers. Results show contrasts between local and biomedical views on causal explanations and appropriate care. Social norms demanded that family members maintain physical contact with sick patients, potentially increasing the risk of human-to-human transmission. Initial treatment strategies by community members involved home remedies, and public health officials encouraged patient hospitalization. Over time, communities linked the outbreak to supernatural powers and sought care with spiritual healers. Differing popular and medical views of illness caused conflict and rejection of biomedical recommendations. Future investigators should consider local perceptions of disease and treatment when developing outbreak strategies.
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Affiliation(s)
- Lauren S Blum
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
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Blum LS, Nahar N, Khan R, Breiman RF. In-Depth Assessment of an Outbreak of Nipah Encephalitis with Person-to-Person Transmission in Bangladesh: Implications for Prevention and Control Strategies. Am J Trop Med Hyg 2009. [DOI: 10.4269/ajtmh.2009.80.96] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Ram PK, Choi M, Blum LS, Wamae AW, Mintz ED, Bartlett AV. Declines in case management of diarrhoea among children less than five years old. Bull World Health Organ 2008; 86:E-F. [PMID: 18368194 DOI: 10.2471/blt.07.041384] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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22
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Sibley LM, Blum LS, Kalim N, Hruschka D, Edmonds JK, Koblinsky M. Women's descriptions of postpartum health problems: preliminary findings from Matlab, Bangladesh. J Midwifery Womens Health 2007; 52:351-60. [PMID: 17603957 DOI: 10.1016/j.jmwh.2007.02.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Complications of childbirth kill more than 500,000 women each year. Postpartum hemorrhage (PPH) is the leading cause of death. Because nearly half the women who give birth at home in developing countries are cared for by unskilled attendants, it is critical to understand how women and their caregivers recognize bleeding and decide to seek help when needed. Using an approach that combined systematic qualitative data collection and multivariate analysis, we identified local cultural theories that women and traditional birth attendants in rural Bangladesh use to recognize and care for postpartum problems, including PPH. These preliminary findings will be used to further explore cultural norms related to PPH and their possible modes of transmission. The overall approach may be used to develop or improve birth preparedness and complication readiness, a core global safe motherhood intervention.
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Affiliation(s)
- Lynn M Sibley
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, USA.
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Luby SP, Rahman M, Hossain MJ, Blum LS, Husain MM, Gurley E, Khan R, Ahmed BN, Rahman S, Nahar N, Kenah E, Comer JA, Ksiazek TG. Foodborne transmission of Nipah virus, Bangladesh. Emerg Infect Dis 2007; 12:1888-94. [PMID: 17326940 PMCID: PMC3291367 DOI: 10.3201/eid1212.060732] [Citation(s) in RCA: 283] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We investigated an outbreak of encephalitis in Tangail District, Bangladesh. We defined case-patients as persons from the outbreak area in whom fever developed with new onset of seizures or altered mental status from December 15, 2004, through January 31, 2005. Twelve persons met the definition; 11 (92%) died. Serum specimens were available from 3; 2 had immunoglobulin M antibodies against Nipah virus by capture enzyme immunoassay. We enrolled 11 case-patients and 33 neighborhood controls in a case-control study. The only exposure significantly associated with illness was drinking raw date palm sap (64% among case-patients vs. 18% among controls, odds ratio [OR] 7.9, p = 0.01). Fruit bats (Pteropus giganteus) are a nuisance to date palm sap collectors because the bats drink from the clay pots used to collect the sap at night. This investigation suggests that Nipah virus was transmitted from P. giganteus to persons through drinking fresh date palm sap.
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Affiliation(s)
- Stephen P Luby
- International Centre for Diarrheal Disease Research, Dhaka, Bangladesh.
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Borghi J, Sabina N, Blum LS, Hoque ME, Ronsmans C. Household costs of healthcare during pregnancy, delivery, and the postpartum period: a case study from Matlab, Bangladesh. J Health Popul Nutr 2006; 24:446-55. [PMID: 17591341 PMCID: PMC3001148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
A household survey was undertaken in Matlab, a rural area of Bangladesh, to estimate the costs incurred during pregnancy, delivery, and the postpartum period for women delivering at home and in a health facility. Those interviewed included 121 women who delivered at home, 120 who delivered in an ICDDR,B basic obstetric care (BEOC) facility, 27 who delivered in a public comprehensive obstetric care (CEOC) hospital, and 58 who delivered in private hospitals. There was no significant difference in total costs incurred by those delivering at home and those delivering in a BEOC facility. Costs for those delivering in CEOC facilities were over nine times greater than for those delivering in BEOC facilities. Costs of care during delivery were predominant. Antenatal and postnatal care added between 7% and 30% to the total cost. Services were more equitable at home and in a BEOC facility compared to services provided at CEOC facilities. The study highlights the regressive nature of the financing of CEOC services and the need for a financing strategy that covers both the costs of referral and BEOC care for those in need.
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Affiliation(s)
- Josephine Borghi
- Infectious Disease and Epidemiology Unit, London School of Hygiene & Tropical Medicine, London, UK.
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Hadley MB, Blum LS, Mujaddid S, Parveen S, Nuremowla S, Haque ME, Ullah M. Why Bangladeshi nurses avoid 'nursing': social and structural factors on hospital wards in Bangladesh. Soc Sci Med 2006; 64:1166-77. [PMID: 16890336 DOI: 10.1016/j.socscimed.2006.06.030] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2005] [Indexed: 11/16/2022]
Abstract
In response to concerns that nurses spend less than 6% of their time on direct patient care, this study explored factors that influence nurses' behaviour in the provision of 'hands on' care in hospitals in Bangladesh. Through in-depth interviews with female nurses and patients and their co-workers in six hospitals, we identified conflicts between the inherited British model of nursing and Bangladeshi societal norms. This was most evident in the areas of night duty, contact with strangers, and involvement in 'dirty' work. The public was said to associate nursing activities with commercial sex work. As a consequence, their value on the 'bride market' decreases. To minimise the stigma associated with their profession, nurses in government hospitals distance themselves from patients, using nurse surrogates in the form of patients' relatives and hospital support workers to carry out their work. These adaptations are supported and sustained through unofficial activities developed over time within hospitals. In contrast nurses in NGO hospitals give more direct patient care themselves and do not rely on carers as much because of tight supervision and limited visitor hours. Initiatives undertaken to improve the quality of patient care, such as enlarging the nursing workforce or providing clinical instruction, which do not take into account the prevailing culture in hospitals and social conflicts faced by nurses, are unlikely to succeed. Fundamental decisions on how to care for the sick in Bangladesh are required. If the present nursing curriculum is followed, adequate supplies, supervision and accountability are prerequisites for its implementation.
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Affiliation(s)
- Mary B Hadley
- Ministry of Health/DFID, Copperbelt Province, Zambia.
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Blum LS, Sharmin T, Ronsmans C. Attending Home vs. Clinic-Based Deliveries: Perspectives of Skilled Birth Attendants in Matlab, Bangladesh. Reproductive Health Matters 2006; 14:51-60. [PMID: 16713879 DOI: 10.1016/s0968-8080(06)27234-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In an effort to make skilled attendance at birth more accessible, some countries in Asia have begun major initiatives to promote the option of home delivery with a midwife. Yet there is little empirical evidence from the region to suggest that home-based care is as safe or effective as care in medical facilities. Qualitative research involving key informant and in-depth interviews and group discussions was carried out in 2003 and 2004 in Matlab, a rural area of Bangladesh, to examine the feasibility of home- vs. facility-based delivery from the perspective of 13 skilled birth attendants. The findings illuminate major constraints encountered during home deliveries, including poor transportation, inappropriate environment for delivery, insufficient supplies and equipment, lack of security, and inadequate training and medical supervision, which may prevent the provision of skilled care. Most difficult was the pressure by families to adhere to traditional childbirth norms and convincing families to accept the need for referral. The advantages highlighted of attending births in a health facility were the safe, clean environment, availability of supplies, ability to accommodate other work activities and make quick referrals, and higher coverage. The study illuminates practical, cultural and medical issues that need to be taken into consideration when choosing between home- and facility-based strategies and designing safe motherhood interventions.
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Affiliation(s)
- Lauren S Blum
- Centre for Health and Population Research, Dhaka, Bangladesh.
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Chowdhury ME, Ronsmans C, Killewo J, Anwar I, Gausia K, Das-Gupta S, Blum LS, Dieltiens G, Marshall T, Saha S, Borghi J. Equity in use of home-based or facility-based skilled obstetric care in rural Bangladesh: an observational study. Lancet 2006; 367:327-32. [PMID: 16443040 DOI: 10.1016/s0140-6736(06)68070-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Few studies have assessed whether the poorest people in developing countries benefit from giving birth at home rather than in a facility. We analysed whether socioeconomic status results in differences in the use of professional midwives at home and in a basic obstetric facility in a rural area of Bangladesh, where obstetric care was free of charge. METHODS We routinely obtained data from Matlab, Bangladesh between 1987 and 2001. We compared the benefits of home-based and facility-based obstetric care using a multinomial logistic and binomial log link regression, controlling for multiple confounders. FINDINGS Whether or not a midwife was used at home or in a facility differed significantly with wealth (adjusted odds ratio comparing the wealthiest and poorest quintiles 1.94 [95% CI 1.69-2.24] for home-based care, and 2.05 [1.72-2.43] for facility-based care). The gap between rich and poor widened after the introduction of facility-based care in 1996. The risk ratio (RR) between the wealthiest and poorest quintiles was 1.91 (adjusted RR 1.49 [95% CI 1.16-1.91] when most births with a midwife took place at home compared with 2.71 (1.66 [1.41-1.96]) at the peak of facility-based care. INTERPRETATION In this area of Bangladesh, a shift from home-based to facility-based basic obstetric care is feasible but might lead to increased inequities in access to health care. However, there is also evidence of substantial inequities in home births. Before developing countries reinforce home-based births with a skilled attendant, research is needed to compare the feasibility, cost, effectiveness, acceptability, and implications for health-care equity in both approaches.
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El Arifeen S, Blum LS, Hoque DME, Chowdhury EK, Khan R, Black RE, Victora CG, Bryce J. Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study. Lancet 2004; 364:1595-602. [PMID: 15519629 DOI: 10.1016/s0140-6736(04)17312-1] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We report the preliminary findings from a continuing cluster randomised evaluation of the Integrated Management of Childhood Illness (IMCI) strategy in Bangladesh. METHODS 20 first-level outpatient facilities in the Matlab sub-district and their catchment areas were randomised to either IMCI or standard care. Surveys were done in households and in health facilities at baseline and were repeated about 2 years after implementation. Data on use of health facilities were recorded. IMCI implementation included health worker training, health systems support, and community level activities guided by formative research. FINDINGS 94% of health workers in the intervention facilities were trained in IMCI. Health systems supports were generally available, but implementation of the community activities was slow. The mean index of correct treatment for sick children was 54 in IMCI facilities compared with 9 in comparison facilities (range 0-100). Use of the IMCI facilities increased from 0.6 visits per child per year at baseline to 1.9 visits per child per year about 21 months after IMCI introduction. 19% of sick children in the IMCI area were taken to a health worker compared with 9% in the non-IMCI area. INTERPRETATION 2 years into the assessment, the results show improvements in the quality of care in health facilities, increases in use of facilities, and gains in the proportion of sick children taken to an appropriate health care provider. These findings are being used to strengthen child health care nationwide. They suggest that low levels of use of health facilities could be improved by investing in quality of care and health systems support.
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Affiliation(s)
- Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
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Blum LS, Nahar N. Cultural and social context of dysentery: implications for the introduction of a new vaccine. J Health Popul Nutr 2004; 22:159-169. [PMID: 15473519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Dysentery, a severe form of diarrhoeal disease, is a major cause of morbidity and mortality. Paradoxically, virtually no studies have been conducted to examine beliefs and behaviours associated with dysentery. The explanatory model of dysentery was explored in a community in Dhaka, Bangladesh, to understand the acceptability of a vaccine against dysentery. A local term for bloody dysentery is widely known, and residents describe a progression of symptoms, which closely mirrors the biomedical model of the disease. Due to the symbolic significance of blood loss and the fact that there is much uncertainty regarding treatment, bloody dysentery is perceived to be extremely serious. Causal interpretations most commonly relate to humoral theories, and remedies involve the consumption of 'cooling' foods that will reduce the heat associated with dysentery. Despite many misconceptions about vaccines and the fact that this approach contradicts aetiological explanations, the perceived severity of the illness makes vaccines attractive compared to other preventative measures. The results illuminate relevant information for the implementation of a new vaccine.
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Affiliation(s)
- Lauren S Blum
- Social and Behavioural Sciences Unit, ICDDR,B: Centre for Health and Population Research, GPO Box 128, Dhaka 1000, Bangladesh.
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