Listening to Caregivers: Narratives of Health Seeking for Children Under Five with Pneumonia and Diarrhea: Insights from the NIGRAAN Trial in Pakistan

Background

Understanding health-seeking behaviors of caregivers is important to reduce child mortality. Several factors influence decision-making related to childhood illnesses.

Objective

The objective of this study was to gather caretaker narratives to develop a comprehensive understanding of the context and process of caregiving at household level during all stages of an episode of diarrhea and pneumonia in children <5.

Methods

Using a narrative interview approach, stories from caregivers of children <5 were collected from a rural district in Sindh Pakistan. Eleven households with children <5 were randomly selected and purposive sampling was done to interview 20 caregivers. All data collection was conducted privately in participants' homes and informed consent taken. Manual content analysis was carried out by three independent researchers and emerging themes drawn.

Results

The role of joint family system is integral in making decisions and the child's paternal grandmother, is an important and trusted source of information regarding child sickness in the household. They often promote home remedies with considerable authority prior to formal consultation with the health care system. Caregivers were generally dissatisfied with doctors in the public sector who were perceived to be providing free consultation with a poor quality of care and long waiting time as compared to private doctors. Financial considerations and child support were favorably addressed in households with a joint family system.

Conclusion

The joint family system provides a strong support system, but also tends to reduce parental autonomy in decision-making and delay first contact with formal health providers. Prevalent home remedies, and authority of elders in the family influence management practices. Interventions for reducing improving child mortality should be cognizant of the context of decision-making and social influences at the household level.

The Politics of Transnational Advocacy Against Chinese, Indian, and Brazilian Extractive Projects in the Global South

Activists in the global South have been navigating two powerful trends since the mid-1990s: intensifying state repression and rising investment in extractive projects from the emerging economies of Brazil, Russia, India, China, and South Africa (BRICS). In this context, this article explores the underlying forces determining the formation, endurance, and power of BRICS-South transnational advocacy networks (TANs) opposed to BRICS-based corporate extraction in the global South. By analyzing activism against Chinese, Indian, and Brazilian extractive projects in Ecuador, Ethiopia, and Mozambique, respectively, the research reveals the critical importance of domestic politics and civil society characteristics in both the BRICS and host states for shaping BRICS-South TANs, including which groups assume leadership, the extent of cross-national cooperation, and the role of nonprofits headquartered in the global North. The findings uncover core reasons for the variable resiliency and capacity of BRICS-South TANs, opening up new avenues of research and offering valuable insights for activists and policymakers.

"Get Your Child in Order:" Illustrations of Courtesy Stigma from Fathers Raising Both Autistic and Non-autistic Children

Parents of autistic children report relatively high levels of parenting stress that includes experiencing stigma. Yet, research about stigma experienced by parents of autistic children is limited, and in particular, fathers' experiences are rarely documented. The purpose of this study is to illuminate courtesy stigma experiences of fathers of autistic children. We conducted a secondary analysis of narrative data from a subset of 16 fathers raising both autistic and non-autistic children. Fathers participated in in-depth interviews about successes and struggles in raising autistic children. Fathers experienced "felt stigma" in forms of censorship, isolation, guilt and defying stigma. Fathers navigate ableist stereotypes, which are interwoven with stereotypes of traditional masculinity. Fathers defy stigma but are also part of processes that perpetuate stigma. Further, understandings of the complexities of courtesy stigma are needed, particularly through studies that target fathers from diverse cultural, racial, family structural and socio-economic backgrounds. 

Meta-synthesis of fathers' experiences raising children on the autism spectrum

Parents raising children with autism have distinct experiences that influence their well-being, relationships, engagement with the public, and interaction with education and healthcare systems. However, experiences of fathers of children with autism have been largely overlooked by researchers. This meta-synthesis is our synthesis of qualitative accounts of fathers' experiences and we included peer reviewed and gray literature articles that: (1) reported primary qualitative research, (2) included fathers of children with autism as participants, and (3) reported qualitative findings on the first-hand experiences of fathers of children with autism. Studies were appraised for quality and many theoretical and methodological deficiencies identified. Six studies met quality appraisal criteria and three main themes of findings from these studies were generated: (1) adaptation and concern with the future, (2) the importance of cultural context, and (3) reverence for one's child and new opportunities. Fathers' experiences illuminate a need for father-oriented resources that recognize fathers' value in children's lives.

Canadian mining and ill health in Latin America: a call to action

This commentary argues that Canada's public and global health communities have a special ethical and political responsibility to act to reverse the harms associated with Canadian mining activities in Latin America and beyond through advocacy, research, and using their public voice. We begin with an overview of the direct and indirect health effects of mining, drawing especially on Latin America where 50-70% of mining activity involves Canadian companies. Then we examine the judicial, legislative, financial, and diplomatic contexts that make Canada such a welcome host and champion of the mining sector. Finally, we turn to the responsibility of the public and global health communities, offering concrete recommendations for using research, practical expertise public health solidarity networks, and political clout to speak out and advocate for policies that redress the harms caused by mining.

Fathers Raising Children with Autism Spectrum Disorder: Stories of Marital Stability as Key to Parenting Success

Using media reports of high divorce rates among couples of children with ASD as a point of departure, our purpose in this paper is to examine how married fathers of children with ASD understand their marriages relative to the demands of ASD and in the context of media reports of elevated divorce rates among parents raising children with ASD. We begin with a review of select literature pertaining to the impact of ASD on marriages and we include a brief account of popular media portrayals of the influence of having a child with a developmental disability, and ASD in particular, on marriages. We then describe our qualitative examination of narrative interview data from 26 married fathers raising children with ASD aged 2-13 beginning with our theoretical anchoring in social comparison to focus our attention on how fathers compare themselves with media accounts of elevated divorce rates among parents of children and also with other hypothetical family configurations. Our findings are evidence of fathers' strong and strengthened commitments to marriages and we illustrate a re-purposing of inflated portrayals of divorce rates to shore up fathers' sense of their own effectiveness as husbands and fathers.

Exploring health care seeking knowledge, perceptions and practices for childhood diarrhea and pneumonia and their context in a rural Pakistani community

Background

Where access to facilities for childhood diarrhea and pneumonia is inadequate, community case management (CCM) is an effective way of improving access to care. In Pakistan, utilization of CCM for these diseases through the Lady Health Worker Program remains low. Challenges of access to facilities persist leading to delayed care and poor outcomes. Estimating caregiver knowledge, understanding their perceptions and practices, and recognizing how these are related to care seeking decisions about childhood diarrhea and pneumonia is crucial to bring about coherence between supply and demand-side practices.

Methods

Data was collected from family caregivers to explore their knowledge, perceptions and practices regarding childhood diarrhea and pneumonia. Data from a household survey with 7025 caregivers, seven focus group discussion (FGDs), seven in-depth interviews (IDIs), and 20 detailed narrative interviews are used to explore caregiver knowledge, perceptions and practices.

Results

Household survey shows that most family caregivers recognize main signs and symptoms of diarrhea such as loose stools (76%). Fewer recognize signs and symptoms of pneumonia such as breathing problems (21%). Few caregivers (18%) have confidence in lady health workers’ (LHWs) ability to treat childhood diarrhea and pneumonia. Care seeking from LHWs remains negligible (< 1%). Caregivers overwhelmingly prefer to seek care from doctors (97%). Seventy-five percent caregivers sought care from private providers and 45% from public providers.

FGDs, IDIs, and narrative interviews show that care mostly begins with home remedies and sometimes self-prescribed medicines. Treatment delays occur because of caregiver inability to recognize disease, use of home remedies, financial constraints, and low utilization of community based LHW services. Caregivers do not seek care from LHWs because of lack of trust and LHWs’ inability to provide medicines. If finances allow, private doctors, who caregivers perceive as more responsive, are preferred over public sector doctors. Financial resources, availability of time, support for household chores by family and community determine whether, when, and from whom caregivers seek care.

Conclusions

Many children do not receive recommended diarrhea and pneumonia treatment on time. Taking into consideration caregiver concerns, adequate supply of medicines to LHWs, improved facility level care could improve care seeking practices and child health outcomes.

Trial registration

The trial is registered with ‘Australian New Zealand Clinical Trials Registry’. Registration Number: ACTRN12613001261707. Registered 18 November 2013.

Motivating and Demotivating Factors for Community Health Workers Engaged in Maternal, Newborn and Child Health Programs in Low and Middle-Income Countries: A Systematic Review

This systematic review aimed to synthesize primary research on motivating factors of community health workers (CHWs) for maternal, neonatal, and child health (MNCH) in low and middle-income countries (LMICs). Peer-reviewed literatures were systematically searched in five databases. Identified studies were then screened and selected for inclusion. The eligibility criteria were reported primary qualitative, quantitative, or mixed methods research, with participants being CHWs in LMICs who address MNCH, which investigated motivation or related concepts of retention, attrition, and performance. A thematic synthesis process was used to analyze findings of motivating factors, reported by included studies. Seventeen qualitative, quantitative, or mixed methods studies met inclusion criteria. Two overarching themes were developed: Levels of motivation (i.e. individual, community, and health system) and stages of motivation (i.e. recruitment, retention, and attrition). Nine sub-themes were further developed at the intersection of each level and stage of motivation. Each subtheme comprises the motivating factors that are influential to community health workers at each stage and level. These themes and sub-themes are presented in a Community Health Worker Motivation Model. The motivation model can be used to identify what motivating factors are relevant to community health workers motivation and the stakeholders necessary to address each motivating factor. Recruitment of community health workers for maternal, neonatal, and child health relies largely on individual level of motivation. At retention, individual level motivating factors remain influential; and community and health system begin to influence motivation positively. But, overall health systems in low and middleincome countries are demotivating the health workers rather than motivating them.

Quality Group Home Care for Adults with Developmental Disabilities and/or Mental Health Disorders: Yearning for Understanding, Security and Freedom

BACKGROUND

The purpose of this study was to uncover and understand factors influencing quality of care received by adults with developmental disabilities and/or mental health disorders living in group homes.

METHODS

The present authors conducted a secondary analysis of data from nine focus group discussions with adults with developmental disabilities and/or mental health disorders, and their family and paid caregivers (N = 52). To focus the analysis, the present authors drew on the research literature to craft a model of quality of group home care using concepts of social inclusion and self-determination, and corresponding staff approaches that include active support and person-centred care.

RESULTS

Social inclusion and self-determination for adults in group homes are facilitated by staff approaches and manifest in residents being understood and experiencing security and freedom.

CONCLUSIONS

The present authors offer recommendations for group home resources, training, communication and outcome measures that promote residents' being understood and experiencing security and freedom.

Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?

BACKGROUND

Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasized the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualizing a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005-2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges.

MAIN TEXT

The challenges faced by LMICs include rapid urbanization, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs).

CONCLUSION

SPHs in LMICs can contribute to overcoming several public health challenges being faced by LMICs, including achieving SDGs. Most importantly they can develop cadres of competent and well-motivated public health professionals: educators, practitioners and researchers who ask questions that address fundamental health determinants, seek solutions as agents of change within their mandates, provide specific services and serve as advocates for multilevel partnerships. Funding support, human resources, and agency are unfortunately often limited or curtailed in LMICs, and this requires constructive collaboration between LMICs and counterpart institutions from high income countries.

Inspiring health worker motivation with supportive supervision: a survey of lady health supervisor motivating factors in rural Pakistan

Background

Community health worker motivation is an important consideration for improving performance and addressing maternal, newborn, and child health in low and middle-income countries. Therefore, identifying health system interventions that address motivating factors in resource-strained settings is essential. This study is part of a larger implementation research project called Nigraan, which is intervening on supportive supervision in the Lady Health Worker Programme to improve community case management of pneumonia and diarrhea in rural Pakistan. This study explored the motivation of Lady Health Supervisors, a cadre of community health workers, with particular attention to their views on supportive supervision.

Methods

Twenty-nine lady health supervisors enrolled in Nigraan completed open-ended structured surveys with questions exploring factors that affect their motivation. Thematic analysis was conducted using a conceptual framework categorizing motivating factors at individual, community, and health system levels.

Results

Supportive supervision, recognition, training, logistics, and salaries are community and health system motivating factors for lady health supervisors. Lady health supervisors are motivated by both their role in providing supportive supervision to lady health workers and by the supervisory support received from their coordinators and managers. Family support, autonomy, and altruism are individual level motivating factors.

Conclusions

Health system factors, including supportive supervision, are crucial to improving lady health supervisor motivation. As health worker motivation influences their performance, evaluating the impact of health system interventions on community health worker motivation is important to improving the effectiveness of community health worker programs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1641-x) contains supplementary material, which is available to authorized users.