Conceptualisations of "good care" within informal caregiving networks for older people in rural South Africa

Good care in social policy statements is commonly implied as familial and person-centred, provided by family members and focused on upholding the autonomy, dignity and respect of the care recipient. Policy consideration of the relational nature of caregiving, the sociomaterial determinants of good care, the practical knowledge of caregivers and responsibilities of the state, is limited. Drawing on the ethics of care theory and a care ecology framework, which conceptualises the dynamic interactions between formal and informal care "systems," we analysed ethnographic data of the interactions of 21 caregivers and their older care recipients in South Africa to understand how they conceptualised good care. Conceptualisations of good care included: having the right, altruistic and reciprocal, motivations; providing care frequently and consistently; and demonstrating hope for a better future through practical action. Caregivers also considered restricting autonomy a feature of good care, when doing so was perceived to be in the care recipient's best interest. Conceptualisations of good care were influenced by but also countered policy and cultural ideals. When they subverted policy values and practices, by overriding autonomy, for instance, caregivers' conceptualisations reflected their practical experiences of caregiving amidst gross material inadequacies, underpinned by deficiencies in the formal care system. We highlight the need for policies, interventions and theories of care that focus broadly on the care ecology and particularly on the "carescape" (formal care system). We advocate relational approaches that consider and balance the needs, desires and rights of caregivers and care recipients, and recognise caregivers' experiential knowledge, rather than person-centred approaches that focus exclusively on the care recipient.

Ethnographic understandings of sexual and reproductive health and HIV care for adolescents in Blantyre, Malawi

Sexual and reproductive health (SRH) care and support are provided to adolescents living with HIV, with the aim to build safer sex negotiation skills, sexual readiness and reproductive preparedness while reducing unintended pregnancies and sexually transmitted infections. We consider how different settings might either constrain or facilitate access to resources and support. Ethnographic research was conducted in Malawi in teen club clinic sessions at an enhanced antiretroviral clinic from November 2018 to June 2019. Twenty-one individual and five group interviews were conducted with young people, caregivers, and healthcare workers, and were digitally recorded, transcribed, and translated into English for thematic analysis. Drawing on socio-ecological and resilience theories, we considered the different ways in which homes, schools, teen club clinics, and community settings all functioned as interactional, relational, and transformational spaces to allow young people to talk about and receive information on sexuality and health. Young people perceived that comprehensive SRH support enhanced their knowledge, sexual readiness, and reproductive preparedness. However, their desire to reproduce at an early age complicated their adoption of safer sex negotiation skills and SRH care. Engaging and talking about SRH and related issues varied according to physical and social space, suggesting the value of multiple locations for support and resources for young people with HIV.

From idea to systems solution: enhancing access to primary care in Malawi

Malawi, like many other countries, faces challenges in providing accessible, affordable, and quality health services to all people. The Malawian policy framework recognizes the value of communities and citizens, as co-creators of health and leaders of localized and innovative initiatives, such as social innovations.Social innovations involve and include communities and citizens, as well as bring about changes in the institutions responsible for care delivery. In this article, we describe the institutionalization process of a citizen-initiated primary care social innovation, named Chipatala Cha Pa Foni, focused on extending access to health information and appropriate service-seeking behavior.An interdisciplinary multi-method qualitative case study design was adopted, drawing on data collected from key informant interviews, observations, and documents over an 18-month period. A composite social innovation framework, informed by institutional theory and positive organizational scholarship, guided the thematic content analysis. Institutional-level changes were analyzed in five key dimensions as well as the role of actors, operating as institutional entrepreneurs, in this process.A subset of actors matched the definition of operating as Institutional Entrepreneurs. They worked in close collaboration to bring about changes in five institutional dimensions: roles, resource flows, authority flows, social identities and meanings. We highlight the changing role of nurses; redistribution and decentralization of health information; shared decision-making, and greater integration of different technical service areas.From this study, the social innovation brought about key institutional and socio-cultural changes in the Malawi health system. These changes supported strengthening the system's integrity for achieving Universal Health Coverage by unlocking and cultivating dormant human-based resources. As a fully institutionalized social innovation, Chipatala Cha Pa Foni has enhanced access to primary care and especially as part of the Covid-19 response.

Addressing coloniality of power to improve HIV care in South Africa and other LMIC

We describe the appropriateness and potential for effectiveness of three strategic approaches for improving HIV care in South Africa: community-based primary healthcare, local/community-based stakeholder engagement, and community-engaged research. At their core, these approaches are related to overcoming health inequity and inequality resulting from coloniality of power's heterogenous structural processes impacting health care in many low- and middle-income countries (LMIC). We turn to South Africa, a middle-income country, as an example. There the HIV epidemic began in the 1980s and its ending is as elusive as achieving universal healthcare. Despite impressive achievements such as the antiretroviral treatment program (the largest in the world) and the country's outstanding cadre of HIV experts, healthcare workers and leaders, disadvantaged South Africans continue to experience disproportionate rates of HIV transmission. Innovation in global public health must prioritize overcoming the coloniality of power in LMIC, effected through the imposition of development and healthcare models conceived in high-income countries (HIC) and insufficient investment to address social determinants of health. We advocate for a paradigm shift in global health structures and financing to effectively respond to the HIV pandemic in LMIC. We propose ethically responsive, local/community-based stakeholder engagement as a key conceptual approach and strategy to improve HIV care in South Africa and elsewhere. We join in solidarity with local/community-based stakeholders' longstanding efforts and call upon others to change the current status quo characterized by global public health power concentrated in HIC.

Social innovation in health: strengthening Community Systems for Universal Health Coverage in rural areas

BACKGROUND

In seeking the attainment of Universal Health Coverage (UHC), there has been a renewed emphasis on the role of communities. This article focuses on social innovation and whether this concept holds promise to enhance equity in health services to achieve UHC and serve as a process to enhance community engagement, participation, and agency.

METHODS

A cross-country case study methodology was adopted to analyze three social innovations in health in three low- and middle-income countries (LMICs): Philippines, Malawi, and Colombia. Qualitative methods were used in data collection, and a cross-case analysis was conducted with the aid of a simplified version of the conceptual framework on social innovation as proposed by Cajaiba-Santana. This framework proposes four dimensions of social innovation as a process at different levels of action: the actors responsible for the idea, the new idea, the role of the institutional environment, and the resultant changes in the health and social system.

RESULTS

The study found that each of the three social innovation case studies was based on developing community capacities to achieve health through community co-learning, leadership, and accountability. The process was dependent on catalytic agents, creating a space for innovation within the institutional context. In so doing, these agents challenged the prevailing power dynamics by providing the communities with respect and the opportunity to participate equally in creating and implementing programs. In this way, communities were empowered; they were not simply participants but became active agents in conceptualizing, implementing, monitoring, and sustaining the social innovation initiatives.

CONCLUSION

The study has illustrated how three creative social innovation approaches improved access and quality of health services for vulnerable rural populations and increased agency among the intervention communities. The processes facilitated empowerment, which in turn supported the sustained strengthening of the community system and the achievement of community goals in the domain of health and beyond.

Reproductive materialism and justice for women with abortion care needs in Uganda

While reproductive health justice is often assumed to be inherent in reproductive health interventions, the nature of injustices, and the reasons for and mechanisms of concealment, are often unclear. In this article, we draw on an ethnography of priority setting and healthcare practice in eastern Uganda to illuminate these injustices and the mechanisms of concealement. We focus on discursive practices as the mechanisms through which power is activated and navigated, such that health practitioners are able to evade state surveillance and retribution. While language discourses conceal and normalise reproductive health injustices, discursive practices of care and priority setting enable reproductive controls to be navigated in ways that amplify these injustices and create new ones. In interventions, precarious conditions that impact women's reproductive health and living circumstances are often overlooked or concealed. We illustrate the convergence of biopower and necropolitical strategies to illuminate these conditions. Using the concept of reproductive materialism, we show how neoliberalism cultivates particular conditions of everyday life, in which populations are positioned as instruments for pecuniary motives, and normative controls are used to further financial gain.

Containing COVID-19 and the social costs on human rights in African countries

Multiple social interventions were introduced to contain the COVID-19 pandemic across Africa, limiting social engagement, school and workplace attendance, and travel. In anticipation of negative economic consequences and social impact, many governments introduced cash transfers, social pensions, food aid, and utility and tax waivers. However, people living precariously and/or under conditions of structural vulnerability were often unable to access to this support. A rapid review was undertaken on COVID-19 and the effects of interventions on human rights in African countries, examining primary studies, editorial notes, opinion papers, and literature reviews, with focus on qualitative approaches and discussions. In examining the links between health, human rights and non-pharmaceutical interventions on vulnerable populations, the review identified that: (1) people who were vulnerable were excluded from or not adequately represented in policy responses to COVID-19; (2) the precarious socio-economic conditions of these populations were not adequately addressed by dominant policy responses; and (3) only partial support was offered to those whose relationship with the state was ambiguous or conditional, so compromising human rights. Interactions between health, human rights, and underlying social and economic conditions amplified poor health and impoverishment of those who were already vulnerable. The challenge is to find a balance between stopping the spread of COVID-19 and the protection of human rights; to implement population-specific responses to supplement uniform public health responses; and to address causes (structural vulnerability) rather than symptoms. There is a need to plan rather than react to pandemics, and to co-construct interventions with rather than delivering instructions to populations. These recommendations serve as instruments to be considered when designing new policies, to incorporate a human rights perspective in responses to current and future pandemics.

The double-edged role of accessed status on health and well-being among middle- and older-age adults in rural South Africa: The HAALSI study

Background

Social capital theory conceptualizes accessed status (the socioeconomic status of social contacts) as interpersonal resources that generate positive health returns, while social cost theory suggests that accessed status can harm health due to the sociopsychological costs of generating and maintaining these relationships. Evidence for both hypotheses has been observed in higher-income countries, but not in more resource-constrained settings.

We therefore investigated whether the dual functions of accessed status on health may be patterned by its interaction with network structure and functions among an older population in rural South Africa.

Method

We used baseline survey data from the HAALSI study (“Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa”) among 4,379 adults aged 40 and older. We examined the direct effect of accessed status (measured as network members’ literacy), as well as its interaction with network size and instrumental support, on life satisfaction and self-rated health.

Results

In models without interactions, accessed status was positively associated with life satisfaction but not self-rated health. Higher accessed status was positively associated with both outcomes for those with fewer personal contacts. Interaction effects were further patterned by gender, being most health-protective for women with a smaller network and most health-damaging for men with a larger network.

Conclusions

Supporting social capital theory, we find that having higher accessed status is associated with better health and well-being for older adults in a setting with limited formal support resources. However, the explanatory power of both theories appears to depending on other key factors, such as gender and network size, highlighting the importance of contextualizing theories in practice.

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We investigated the double-edged role of accessed status on self-rated health and life satisfaction among older South Africans in a rural setting.

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Accessed status was overall positively associated with life satisfaction.

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Accessed status was positively associated with health and well-being for women, unemployed respondents, and people with fewer social contacts.

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We found an inverse association between accessed status and life satisfaction among men with a larger personal network.

Protocol: the complexity of informal caregiving for Alzheimer's disease and related dementias in rural South Africa

BACKGROUND

 With aging, many people develop Alzheimer's disease or related dementias (ADRD) as well as chronic physical health problems. The consequent care needs can be complicated, with heavy demands on families, households and communities, especially in resource-constrained settings with limited formal care services. However, research on ADRD caregiving is largely limited to primary caregivers and high-income countries. Our objectives are to analyse in a rural setting in South Africa: (1) how extended households provide care to people with ADRD; and (2) how the health and wellbeing of all caregivers are affected by care roles.

METHODS

 The study will take place at the Agincourt health and socio-demographic surveillance system site of the MRC/Wits Rural Public Health and Health Transitions Research Unit in Mpumalanga Province, northeast South Africa. We will recruit 100 index individuals predicted to currently have ADRD or cognitive impairment using data from a recent dementia survey. Quantitative surveys will be conducted with each index person's nominated primary caregiver, all other household members aged over 12, and caregiving non-resident kin and non-kin to determine how care and health are patterned across household networks. Qualitative data will be generated through participant observation and in-depth interviews with caregivers, select community health workers and key informants. Combining epidemiological, demographic and anthropological methods, we will build a rich picture of households of people with ADRD, focused on caregiving demands and capacity, and of caregiving's effects on health.

DISCUSSION

 Our goal is to identify ways to mitigate the negative impacts of long-term informal caregiving for ADRD when formal supports are largely absent. We expect our findings to inform the development of locally relevant and community-oriented interventions to improve the health of caregivers and recipients, with implications for other resource-constrained settings in both higher- and lower-income countries.

What factors shape quality of life for women affected by gynaecological cancer in South, South East and East Asian countries? A critical review

Background

Gynaecological cancers are among the most prevalent cancers worldwide, with profound effects on the lives of women and their families. In this critical review, we explore the impacts of these cancers on quality of life (QOL) of women in Asian countries, and highlight areas for future inquiry.

Methods

A systematic search of the literature was conducted in six electronic databases: Web of Science, Scopus, Global Health (CAB Direct), PsycINFO (Ovid), EBMR (Ovid), and Medline (Ovid). Screening resulted in the inclusion of 53 relevant articles reporting on 48 studies.

Results

Most studies were conducted in high and upper-middle income countries in East Asia and used quantitative approaches. Women had predominantly been diagnosed with cervical or ovarian cancer, and most had completed treatment. Four key interrelated domains emerged as most relevant in shaping QOL of women affected by gynaecological cancer: support, including identified needs, sources and forms; mental health, covering psychological distress associated with cancer, risk and protective factors, and coping strategies; sexual function and sexuality, focused on physiological, emotional and relational changes caused by gynaecological cancers and treatments, and the impacts of these on women’s identities; and physical health, covering the physical conditions associated with gynaecological cancers and their impacts on women’s daily activities.

Conclusion

QOL of women affected by gynaecological cancer is shaped by their mental and physical health, support, and changes in sexual function and sexuality. The limited number of studies from lower- and middle-income countries in South and Southeast Asia highlights important knowledge gaps requiring future research.

Multiple factors shape the quality of life of women affected by gynaecological cancers in Asian countries as elsewhere. We identified 53 articles reporting on 48 studies, most conducted in high- and upper-middle income East Asian countries, with much less attention to women in lower income countries in South and Southeast Asia. Most studies used quantitative research methods to gain an understanding of the impact on women diagnosed with cervical or ovarian cancer who had completed treatment. Women’s quality of life was shaped by their mental and physical health, their support needs, and the changes they experienced in sexual function and sexuality.

Reproductive travel to, from and within sub-Saharan Africa: A scoping review

Scholarly interest in reproductive travel has increased in recent years, but travel within, to and from the African continent has received much less attention. We reviewed the literature on cross-border reproductive travel to and from countries of sub-Saharan Africa in order to understand the local forms of this trade. Access to fertility care remains deeply stratified, which is an ongoing concern in a region with some of the highest rates of infertility. We found a wide variety of reasons for reproductive travel, including a lack of trusted local clinics. Destinations were chosen for reasons including historical movements for medical treatment broadly, diasporic circulations, pragmatic language reasons, and ties of former colonial relations. We describe the unique tempos of treatment in the region, ranging from some intended parents staying in receiving countries for some years to the short-term contingent support networks that reprotravellers develop during their treatment and travel. Unique to the region is the movement of medical professionals, such as the 'fly-in, fly-out' clinic staff to deliver fertility care. Future research should include practices and movements to presently neglected 'reprohubs', particularly Kenya and Nigeria; the impact of pandemic-related lockdowns and border closures on the movements of intended parents, reproductive assistors and reproductive material; and the impact of low-cost protocols on treatment access within the region. This scoping review provides insight into the relevant work on cross-border reproductive care in sub-Saharan Africa, where a unique combination of access factors, affordability, and sociocultural and geopolitical issues fashion individuals' and couples' cross-border reproductive travel within, to and from Africa.

Understanding antibiotic use: practices, structures and networks

In this article, we consider how social sciences can help us to understand the rising use of antibiotics globally. Drawing on ethnography as a way to research how we are in the world, we explore scholarship that situates antibiotic use in relation to interactions of pathogens, humans, animals and the environment in the context of globalization, changes in agriculture and urbanization. We group this research into three areas: practices, structures and networks. Much of the public health and related social research concerning antimicrobial resistance has focused on antibiotic use as a practice, with research characterizing how antibiotics are used by patients, farmers, fishermen, drug sellers, clinicians and others. Researchers have also positioned antibiotic use as emergent of political-economic structures, shedding light on how working and living conditions, quality of care, hygiene and sanitation foster reliance on antibiotics. A growing body of research sees antibiotics as embedded in networks that, in addition to social and institutional networks, comprise physical, technical and historical connections such as guidelines, supply chains and reporting systems. Taken together, this research emphasizes the multiple ways that antibiotics have become built into daily life. Wider issues, which may be invisible without explication through ethnographic approaches, need to be considered when addressing antibiotic use. Adopting the complementary vantage points of practices, networks and structures can support the diversification of our responses to AMR.

Strengthening the Mentorship and Leadership Capacity of HIV/AIDS and Tuberculosis Researchers in South Africa

Programs to increase emerging and established HIV and tuberculosis (TB) researchers' capacity to be more effective leaders and mentors are urgently needed in low- and middle-income countries (LMICs). Although conceptual frameworks of mentoring and mentoring toolkits have been developed by and for researchers in LMIC settings, few mentor training programs have been implemented and evaluated in these settings. We created, implemented, and evaluated a 9-month, certificate-level mentorship training program to strengthen the pipeline of HIV and TB researchers in South Africa. Differentiating features of the program included careful contextualization of mentorship tools and approaches, inclusion of a leadership curriculum to improve participant ability to work effectively in teams and organizations, and attention to processes that promote interinstitutional collaboration in mentorship. Twelve mid-career researchers graduated from the first cohort of the program. Among participants, we observed significant longitudinal improvement in mentorship competencies, increased numbers of network connections in multiple domains of collaboration, and high levels of satisfaction. We anticipate that the program description and results will be useful to researchers, research institutions, and funders seeking to build research mentorship and leadership capacity in LMIC settings.

PROXEMICS, COVID-19, AND THE ETHICS OF CARE IN SOUTH AFRICA

In South Africa, lockdown and its excesses have opened up questions on the limits of an ethics of care, whose ethics are privileged, how care is delivered, and what care means. We show how an ethics of proxemics and its operationalization as distance highlight everyday inequalities and limit the provision of care. Constraints on physical distancing in line with public health measures intended to limit the spread of the coronavirus echo the controls enforced under apartheid, showing how inequality is both embodied and legally entrenched.

Power, policy and abortion care in Uganda

Unsafe abortion practices remain the major contributor to maternal death in Uganda, impeding the achievement of universal health coverage and quality of maternal health care. Using an ethnographic design and critical discourse analysis, we explored the operations of power in setting maternal healthcare priorities, as evident at the 2018 Reproductive, Maternal, Neonatal, Child and Adolescents Health Conference. Observational data were collected of the policy-making activities, processes and events and key informant interviews were conducted with 27 participants. We describe how neoliberal and state governance through the structure and organization of policy-making, epistemic governance and universal concepts of ‘high-impact’ interventions, results-based financing, cost-effectiveness and accountability converge to suppress the articulation of local conditions associated with unsafe and risky abortion. By defining maternity along the continuum of birth and emphasizing birthing women, priority-setting was directed towards interventions promoting women’s normative role as mothers while suppressing unmet abortion care needs. Finally, discursive and communicative materials controlled how women of reproductive age in Uganda managed reproduction.

Planetary healthy publics after COVID-19

COVID-19 is a sign of a global malaise. The pandemic is an outcome of what we term a planetary dysbiosis, for which underlining drivers include inequality and the exploitation and extraction of human and non-human labours. The implication is that the usual fixes to outbreaks of infectious diseases (ie, surveillance, pharmaceutical measures, and non-pharmaceutical measures) will be insufficient without a thorough reappraisal of and investment in planetary health. Given the heterogeneity and diversity of environments and populations, we envisage these actions as a matter for the generation of new kinds of public, requiring widespread and multiple forms of engagement to generate lasting solutions. We use and extend the concept of healthy publics to suggest a movement that can start to reclaim planetary health as a collective and ongoing issue.

Community participation in the collaborative governance of primary health care facilities, Uasin Gishu County, Kenya

INTRODUCTION

Community participation in the governance of health services is an important component in engaging stakeholders (patients, public and partners) in decision-making and related activities in health care. Community participation is assumed to contribute to quality improvement and goal attainment but remains elusive. We examined the implementation of community participation, through collaborative governance in primary health care facilities in Uasin Gishu County, Western Kenya, under the policy of devolved governance of 2013.

METHODS

Utilizing a multiple case study methodology, five primary health care facilities were purposively selected. Study participants were individuals involved in the collaborative governance of primary health care facilities (from health service providers and community members), including in decision-making, management, oversight, service provision and problem solving. Data were collected through document review, key informant interviews and observations undertaken from 2017 to 2018. Audio recording, notetaking and a reflective journal aided data collection. Data were transcribed, cleaned, coded and analysed iteratively into emerging themes using a governance attributes framework.

FINDINGS

A total of 60 participants representing individual service providers and community members participated in interviews and observations. The minutes of all meetings of five primary health care facilities were reviewed for three years (2014-2016) and eight health facility committee meetings were observed. Findings indicate that in some cases, structures for collaborative community engagement exist but functioning is ineffective for a number of reasons. Health facility committee meetings were most frequent when there were project funds, with discussions focusing mainly on construction projects as opposed to the day-to-day functioning of the facility. Committee members with the strongest influence and power had political connections or were retired government workers. There were no formal mechanisms for stakeholder forums and how these worked were unclear. Drug stock outs, funding delays and unclear operational guidelines affected collaborative governance performance.

CONCLUSION

Implementing collaborative governance effectively requires that the scope of focus for collaboration include both specific projects and the routine functioning of the primary health care facility by the health facility committee. In the study area, structures are required to manage effective stakeholder engagement.

The application of social innovation in healthcare: a scoping review

BACKGROUND

Social innovation has been applied increasingly to achieve social goals, including improved healthcare delivery, despite a lack of conceptual clarity and consensus on its definition. Beyond its tangible artefacts to address societal and structural needs, social innovation can best be understood as innovation in social relations, in power dynamics and in governance transformations, and may include institutional and systems transformations.

METHODS

A scoping review was conducted of empirical studies published in the past 10 years, to identify how social innovation in healthcare has been applied, the enablers and barriers affecting its operation, and gaps in the current literature. A number of disciplinary databases were searched between April and June 2020, including Academic Source Complete, CIHAHL, Business Source Complete Psych INFO, PubMed and Global Health. A 10-year publication time frame was selected and articles limited to English text. Studies for final inclusion was based on a pre-defined criteria.

RESULTS

Of the 27 studies included in this review, the majority adopted a case research methodology. Half of these were from authors outside the health sector working in high-income countries (HIC). Social innovation was seen to provide creative solutions to address barriers associated with access and cost of care in both low- and middle-income countries and HIC settings in a variety of disease focus areas. Compared to studies in other disciplines, health researchers applied social innovation mainly from an instrumental and technocratic standpoint to foster greater patient and beneficiary participation in health programmes. No empirical evidence was presented on whether this process leads to empowerment, and social innovation was not presented as transformative. The studies provided practical insights on how implementing social innovation in health systems and practice can be enhanced.

CONCLUSIONS

Based on theoretical literature, social innovation has the potential to mobilise institutional and systems change, yet research in health has not yet fully explored this dimension. Thus far, social innovation has been applied to extend population and financial coverage, principles inherent in universal health coverage and central to SDG 3.8. However, limitations exist in conceptualising social innovation and applying its theoretical and multidisciplinary underpinnings in health research.

Aging, Care, and Isolation in the Time of COVID-19

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Validating a Child Youth Resilience Measurement (CYRM-28) for Adolescents Living With HIV (ALHIV) in Urban Malawi

Resilience as a strength-based notion, measured across cultures, age groups, and sub-populations, contributes to understanding health and well-being. Yet, there is limited evidence of how the construct performs in resource-limited countries. We explored the psychometric properties of the CYRM-28 and validated the scale with adolescents living with HIV (ALHIV), a key sub-population. The participants included members of an advisory panel and 406 ALHIV, aged 15–19 years, attending an antiretroviral therapy and teen-club clinic in Blantyre, Malawi. This study employed a mixed-method study using an exploratory sequential design. The advisory panel discussed the CYRM-28, and select ALHIV then translated it into Chichewa, pilot-tested it using cognitive interviews, and back-translated it for clarity and appropriateness. The resultant CYRM-28 was tested using a survey with purposefully selected ALHIV. The overall median score was 123, with an interquartile range of 110–130. Minimum and maximum scores were 53 and 140. Cronbach’s alpha of 0.863 and Kaiser–Meyer–Olkin measure (0.866) confirmed internal consistency and the sample size adequacy, respectively. Bartlett’s tests of sphericity (p < 0.001) informed factor analysis. Exploratory factor analysis determined possible dimensions of resilience and the sub-scales. The confirmatory factor analysis (CFA) confirmed the construct validity and supported a three-factor model consistent with the conceptualization of resilience as a multi-dimensional construct. Structural equation modeling was applied to perform CFA to measure model of resilience. Multiple fit indices showed a good fit for the model. The CYRM-28 has good internal consistency, test and re-test reliability, and moderate convergent validity which render it useful as a self-report resilience measure to inform and evaluate interventions for the health and well-being of adolescents in Malawi.

Age and Gender Differences in Social Network Composition and Social Support Among Older Rural South Africans: Findings From the HAALSI Study

Objectives

Drawing on the “Health and Aging in Africa: A Longitudinal Study of an INDEPTH community in South Africa” (HAALSI) baseline survey, we present data on older adults’ social networks and receipt of social support in rural South Africa. We examine how age and gender differences in social network characteristics matched with patterns predicted by theories of choice- and constraint-based network contraction in older adults.

Method

We used regression analysis on data for 5,059 South African adults aged 40 and older.

Results

Older respondents reported fewer important social contacts and less frequent communication than their middle-aged peers, largely due to fewer nonkin connections. Network size difference between older and younger respondents was greater for women than for men. These gender and age differences were explicable by much higher levels of widowhood among older women compared to younger women and older men. There was no evidence for employment-related network contraction or selective retention of emotionally supportive ties.

Discussion

Marriage-related structural constraints impacted on older women’s social networks in rural South Africa, but did not explain choice-based network contraction. These findings suggest that many older women in rural Africa, a growing population, may have an unmet need for social support.

Social innovation for health: engaging communities to address infectious diseases

Universal health coverage emphasises the value of the community-based delivery of health services to ensure that underserved populations have access to care. In areas where infectious diseases are endemic, there are often few resources and limited capacity, and the introduction of effective and accessible strategies require innovation. In this special issue, the contributing authors emphasise the power of local responses to the circumstances that underpin diseases of poverty, and highlight the methodological and programme innovations necessary to support and sustain these responses. Through case studies, the authors illustrate how social innovations can address health inequities, and they identify the role of academics in the Social Innovation in Health Initiative to support this approach.

The Percussive Effects of Pandemics and Disaster

In this special issue, we note the percussive - immediate, disruptive and urgent - effects of the coronavirus pandemic, while anticipating its longer term repercussions. As social institutions, global and local economies,  political relations, and everyday social lives are being remade, we highlight the implications of this microbial infection and its virulence. In doing so, we illustrate how medical anthropology both illuminates the present and warns of COVID-19's unequal unfolding.

Adolescents living with HIV, complex needs and resilience in Blantyre, Malawi

BACKGROUND

Adolescents living with HIV (ALHIV) in Malawi experience multiple challenges associated with their illness and various social, environmental, economic and cultural factors. In exploring their various medical concerns and social vulnerabilities, we consider the role of multiple services in creating a pathway for resilience.

METHODS

Multiple methods and case studies allowed for triangulation of evidence and provided a holistic understanding of resilience among adolescents with complex needs. The research methods included: (1) a survey to identify examples of young people with complex needs, (2) qualitative interviews and field notes to further explore these needs, (3) patient files and health passports to identify clinical challenges, and (4) ecomapping exercises to personalize cases and identify resilience-enabling resources and supports. We present four case studies to highlight the complex experiences and access to services of ALHIV, and to illustrate their growing power and decision-making capacity over time.

RESULTS

Adversity experienced by ALHIV varied by gender, family situation, years of schooling, and use of teen-clubs for support. The two female adolescents emphasised their need to be accepted and how this impacted sexuality and reproduction. The two males illustrated how ideas of masculinity influenced their sexual practice and involvement with health services and the correctional justice system. Multiple risks (alcohol use, sexual activities) and complex needs (belonging, having a purpose in life/productive activities, autonomy, desire for offspring) influence pathways to resilience. ALHIV were able to strengthen their own wellbeing by resisting negative behaviours and peer pressure and caregiver interactions through 'strategic silence'.

CONCLUSION

ALHIV experienced self-transformation as a result of taking ART, with fewer severe episodes of illness and distressing skin conditions. Continuous engagement at the teen-club clinic transformed both productive activities and social relationships among ALHIV as they set life goals, gained a sense of empowerment, requested SRH services, and formed intimate relationships. These transformative opportunities allowed them to learn ways of minimizing risk of reinfection and violence, and of navigating health worker-caregiver-adolescent interactions.

After illness, under diagnosis

A vast portion of the world’s population live with ill health following acute infection or disease and its emergency management. This reflects the increased capacity of technological innovations and pharmaceuticals to interrupt decline or complications, even when cure is unlikely. The authors in this Special Section illustrate how, in different localities, people live with risk for themselves or their offspring; with non-communicable, degenerative, autoimmune, and congenital conditions; with the after-effects of diagnostic procedures and surgical interventions; and with continued treatment and surveillance. We attend to the value of conceptualising this as ‘living under’ diagnosis or description. We illustrate how diagnostic labels overdetermine subsequent embodied states of being, structuring interactions and social relations with family, friends, and health professionals. Living under diagnosis, we argue, impacts on self-care, care for and by others, everyday lives, and anticipations of the future.

Chronic Living in a Communicable World

By April 2020, COVID-19 lockdowns had restricted the movements of over half the world's population. As health authorities advise people living with chronic conditions to self-isolate because they are at particular risk of serious complications and death, the epidemiological split between communicable and noncommunicable disease is tenuous. We argue that much more is at stake for people living with (multiple) medical conditions than being "at risk" of infection of coronavirus. We emphasize the need to attend to the long-term effects of COVID-19, but also the importance of the continued care of people living with other lifelong medical conditions.

Innovations in maternal and child health: case studies from Uganda

Background

Nearly 300 children and 20 mothers die from preventable causes daily, in Uganda. Communities often identify and introduce pragmatic and lasting solutions to such challenging health problems. However, little is known of these solutions beyond their immediate surroundings. If local and pragmatic innovations were scaled-up, they could contribute to better health outcomes for larger populations. In 2017 an open call was made for local examples of community-based solutions that contribute to improving maternal and child health in Uganda. In this article, we describe three top innovative community-based solutions and their contributions to maternal health.

Main text

In this study, all innovations were implemented by non-government entities. Two case studies highlight the importance of bringing reproductive health and maternal delivery services closer to populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service, through task-shifting certain sonography services to midwives. Various health system and policy relevant lessons are highlighted.

Conclusions

The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Emphasis should be put on identification, capacity building and research to support the scale up of these community-based health solutions.

Conflict and care in sexual and reproductive health services for young mothers in urban South Africa

In South Africa, sexual and reproductive health services aim to facilitate access to and utilisation of care to young people. We draw on narrative interviews with 45 young mothers and six health care providers delivering sexual and reproductive health services at an urban health centre, to understand how young mothers experienced services in relation to ante- and post-natal care, including termination services. Although health care providers emphasised what they considered young women's 'ignorance' and 'irresponsibility' as central to early and unintended pregnancy; they also expressed their sympathy and concern. In a resource-limited health care setting, with health system inefficiencies and lack of specialised training, there was little opportunity to deliver high-quality care to young women. We draw attention to the need to prioritise the training of health care providers to expand early pregnancy testing and termination services and to deliver patient-centred family planning services to young women.

Anthropologists Respond to The Lancet EAT Commission

The Lancet Commissions are widely known as aspirational pieces, providing the mechanisms for consortia and networks of researchers to organize, collate, interrogate and publish around a range of subjects. Although the Commissions are predominantly led by biomedical scientists and cognate public health professionals, many address social science questions and involve social science expertise. Medical anthropologist David Napier was lead author of the Lancet Commission on Culture and Health (2014), for example, and all commissions on global health (https://www.thelancet.com/global-health/commissions) address questions of social structure, everyday life, the social determinants of health, and global inequalities.

Medical technologies and abortion care in Eastern Uganda

Manual Vacuum Aspirators (MVA), Dilation and Curettage (D&C), and medical abortifacients (Misoprostol, Mifepristone and Divabo) are available in clinical settings that offer abortion and post-abortion care in Uganda. While these technologies imply appropriate and safe abortion care, legal and policy ambiguities impact health outcomes. In this article, we draw on an ethnography of abortion care delivery practice conducted in one district in Eastern Uganda between August 2018 and March 2019, with data from interviews and observations, both of interactions and during quality of care improvement and training meetings. We illuminate how, in the context of a financialized healthcare system and legal restrictions, the meanings and use of medical technologies and abortion care vary across different health facility types. In public health facilities, health workers become state agents in the control of women's bodies. In private health facilities, they become transgressors, who use medical technologies to help women attain termination surreptitiously. Health workers offset risks associated with any involvement in termination, such that pecuniary interests dominate their motivation. Normalized and disciplinary power enact and reproduce unsafe and risky conditions, leading to poor abortion care outcomes. We illustrate the mechanisms of domination and tactics of resistance in abortion care, and expose conditions upon which unsafe and risky outcomes are contingent.

Disaggregating diabetes

Interest in disaggregating diabetes into numerous subtypes is growing as patients and providers recognize the limitations of standard diabetes typologies. As anthropologists, we draw attention to how ‘subtyping’ may reduce stigma derived from the connection between obesity and ‘type 2 diabetes’. We highlight the complexities that drive diabetes and argue that an exclusive or dominant focus on diet and obesity obfuscates other underlying risks. Yet, we warn that subtyping may promote unnecessary pharmaceuticalization, especially for other subtypes of diabetes that may be associated with stress and inflammation. We call upon providers to continue to closely attend to patients’ lived experiences. While we recognize the shortcomings of the existing classificatory scheme, patients’ outcomes and prognoses are often more closely connected to the social and medical support they receive than to the underlying metabolic classification.

Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: A mixed-methods systematic review

BACKGROUND

In 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016.

OBJECTIVES

The aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods.

METHODS

We applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980-2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analysed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework.

RESULTS

From an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce.

CONCLUSIONS

From a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed.

Linking human behaviours and malaria vector biting risk in south-eastern Tanzania

To accelerate malaria elimination in areas where core interventions such as insecticide-treated nets (ITNs) are already widely used, it is crucial to consider additional factors associated with persistent transmission. Qualitative data on human behaviours and perceptions regarding malaria risk was triangulated with quantitative data on Anopheles mosquito bites occurring indoors and outdoors in south-eastern Tanzania communities where ITNS are already used but lower level malaria transmission persists. Each night (18:00h-07:00h), trained residents recorded human activities indoors, in peri-domestic outdoor areas, and in communal gatherings. Host-seeking mosquitoes were repeatedly collected indoors and outdoors hourly, using miniaturized exposure-free double net traps (DN-Mini) occupied by volunteers. In-depth interviews were conducted with household representatives to explore perceptions on persistent malaria and its control. Higher proportions of people stayed outdoors than indoors in early-evening and early-morning hours, resulting in higher exposures outdoors than indoors during these times. However, exposure during late-night hours (22:00h–05:00h) occurred mostly indoors. Some of the popular activities that kept people outdoors included cooking, eating, relaxing and playing. All households had at least one bed net, and 83.9% of people had access to ITNs. Average ITN use was 96.3%, preventing most indoor exposure. Participants recorgnized the importance of ITNs but also noted that the nets were not perfect. No complementary interventions were reported being used widely. Most people believed transmission happens after midnight. We conclude that insecticide-treated nets, where properly used, can still prevent most indoor exposures, but significant risk continues unabated before bedtime, outdoors and at communal gatherings. Such exposure is greatest for rural and low-income households. There is therefore an urgent need for complementary interventions, particularly those targeting outdoor-biting and are applicable for all people including the marginalised populations such as migratory farmers and fishermen. Besides, the differences in community understanding of ongoing transmission, and feedback on imperfections of ITNs should be considered when updating malaria-related communication and interventions.

Spatial and socio-economic correlates of effective contraception among women seeking post-abortion care in healthcare facilities in Kenya

Introduction

Information, counseling, availability of contraceptives, and their adoption by post-abortion care (PAC) patients are central to the quality of PAC in healthcare facilities. Effective contraceptive adoption by these patients reduces the risks of unintended pregnancy and repeat abortion.

Methods

This study uses data from the Incidence and Magnitude of Unsafe Abortion Study of 2012 to assess the level and determinants of highly effective contraception among patients treated with complications from an unsafe abortion in healthcare facilities in Kenya. Highly effective contraception was defined as any method adopted by a PAC patient that reduces pregnancy rate by over 99%.

Results

Generally, contraceptive counseling was high among all PAC patients (90%). However, only 54% of them received a modern family planning method—45% a short-acting method and 9% a long-acting and permanent method. Adoption of highly effective contraception was determined by patient’s previous exposure to unintended pregnancies, induced abortion and modern family planning (FP). Facility level factors associated with the uptake of highly effective contraceptives included: facility ownership, availability of evacuation procedure room, whether the facility had a specialized obstetric-gynecologist, a facility that also had maternity services and the number of FP methods available for PAC patients.

Discussion and conclusion

For better adoption of highly effective FP, counseling of PAC patients requires an understanding of the patient’s past experience with contraception and their future fertility intentions and desires in order to meet their reproductive needs more specifically. Family planning integration with PAC can increase contraceptive uptake and improve the reproductive health of post-abortion care patients.

Impairment in Activities of Daily Living, Care Receipt, and Unmet Needs in a Middle-Aged and Older Rural South African Population: Findings From the HAALSI Study

Objectives: The objective of this study is to analyze the degree to which care needs are met in an aging rural African population. Method: Using data from the Health and Aging in Africa: Longitudinal Study of an INDEPTH Community (HAALSI) baseline survey, which interviewed 5,059 adults aged older than 40 years in rural South Africa, we assessed the levels of limitations in activities of daily living (ADLs) and in unmet care for these ADLs, and evaluated their association with sociodemographic and health characteristics. Results: ADL impairment was reported by 12.2% of respondents, with the proportion increasing with age. Among those with ADL impairment, 23.9% reported an unmet need and 51.4% more a partially met need. Relatives provided help most often; formal care provision was rare. Unmet needs were more frequent among younger people and women, and were associated with physical and cognitive deficits, but not income or household size. Discussion: Unmet care needs in rural South Africa are often found among individuals less expected to require care.

Focus Groups in Rapid Assessment Procedures

Focus groups are an instrument designed to gather information primarily about beliefs, values, and understanding. The participants are specifically selected to explore the range of these beliefs in a study population. Croup dynamics facilitate the collection of relatively detailed information on prevalent attitudes and ideas, conflicts and contradictions. Focus groups are guided by relatively strict rules of structure and procedure. This paper examines the need for flexibility in the conduct of these groups in developing-country settings and argues for their applicability in research on tropical diseases.

Talking about sex in pregnancy: reflections from the field in urban South Africa

Qualitative research with close engagement in the field allows researchers and participants to build relationships and establish trust, enabling researchers to collect meaningful and sensitive information. Drawing on findings from a study conducted in an urban setting in South Africa, we discuss the challenges faced when interviewing pregnant women with HIV infection, retaining them in the study, and extending the study to include their partners. We discuss the dynamics of pregnancy and draw lessons from interviews concerned with personal, sensitive issues. The study on which we draw was conducted in Johannesburg, South Africa, and was nested in a larger prospective cohort study of women and their infants, which in turn was part of a case control study. Sensitive topics are difficult and complex, but to ignore these and stay in safe territory is to ignore some of the most pressing questions of our time. It is important that those who conduct interviews are well trained and able to engage empathetically with participants, and that some form of counselling is available for both participants and researchers.

Outdoor malaria transmission risks and social life: a qualitative study in South-Eastern Tanzania

Background

Behaviour changes in mosquitoes from indoor to outdoor biting result in continuing risk of malaria from outdoor activities, including routine household activities and occasional social and cultural practices and gatherings. This study aimed to identify the range of social and cultural gatherings conducted outdoors and their associated risks for mosquito bites.

Methods

A cross-sectional study was conducted in four villages in the Kilombero Valley from November 2015 to March 2016. Observations, focus group discussions, and key informant interviews were conducted. The recorded data were transcribed and translated from Swahili to English. Thematic content analysis was used to identify perspectives on the importance of various social and cultural gatherings that incidentally expose people to mosquito bites and malaria infection.

Results

Religious, cultural and social gatherings involving the wider community are conducted outdoors at night till dawn. Celebrations include life course events, religious and cultural ceremonies, such as Holy Communion, weddings, gatherings at Easter and Christmas, male circumcision, and rituals conducted to please the gods and to remember the dead. These celebrations, at which there is minimal use of interventions to prevent bites, contribute to individual satisfaction and social capital, helping to maintain a cohesive society. Bed net use while sleeping outdoors during mourning is unacceptable, and there is minimal use of other interventions, such as topical repellents. Long sleeve clothes are used for protection from mosquito bites but provide less protection.

Conclusion

Gatherings and celebrations expose people to mosquito bites. Approaches to prevent risks of mosquito bites and disease management need to take into account social, cultural and environmental factors. Area specific interventions may be expensive, yet may be the best approach to reduce risk of infection as endemic countries work towards elimination. Focusing on single interventions will not yield the best outcomes for malaria prevention as social contexts and vector behaviour vary.

Policy, law and post-abortion care services in Kenya

BACKGROUND

Unsafe abortion is still a leading cause of maternal death in most Sub-Saharan African countries. Post-abortion care (PAC) aims to minimize morbidity and mortality following unsafe abortion, addressing incomplete abortion by treating complications, and reducing possible future unwanted pregnancies by providing contraceptive advice. In this article, we draw on data from PAC service providers and patients in Kenya to illustrate how the quality of PAC in healthcare facilities is impacted by law and government policy.

METHODS

A cross-sectional design was used for this study, with in-depth interviews conducted to collect qualitative data from PAC service providers and seekers in healthcare facilities. Data were analyzed both deductively and inductively, with diverse sub-themes related to specific components of PAC quality.

RESULTS

The provision of quality PAC in healthcare facilities in Kenya is still low, with access hindered by restrictions on abortion. Negative attitudes towards abortion result in the continued undirected self-administration of abortifacients. Intermittent service interruptions through industrial strikes and inequitable access to care also drive unsafe terminations. Poor PAC service availability and lack of capacity to manage complications in primary care facilities result in multiple referrals and delays in care following abortion, leading to further complications. Inefficient infection control exposes patients and caregivers to unrelated infections within facilities, and the adequate provision of contraception is a continued challenge.

DISCUSSION

Legal, policy and cultural restrictions to access PAC increase the level of complications. In Kenya, there is limited policy focus on PAC, especially at primary care level, and no guidelines for health providers to provide legal, safe abortion. Discrimination at the point of care discourages women from presenting for care, and discourages providers from freely offering post-abortion contraceptive guidance and services. Poor communication between facilities and communities continues to result in delayed care and access-related discrimination.

CONCLUSION

Greater emphasis should be placed on the prevention of unsafe abortion and improved access to post-abortion care services in healthcare facilities. There is a definite need for service guidelines for this to occur.

Anticipation and response: pandemic influenza in Malawi, 2009

Background: In 2006, Malawi developed a national influenza plan to mitigate, prevent and manage the burden of infection should an outbreak occur. In 2009, it translated its contingency plan to respond to the unfolding influenza pandemic. However, little is known of how Malawi translated its national influenza plan into response actions, or the success of these responses.

Objective: To investigate how Malawi translated its preparedness plan and so broaden our understanding of the outcomes of the responses.

Methods: We draw on data from 22 in-depth interviews with government policymakers and people working at a policy level in various non-governmental organisations, conducted to assess the level of preparedness and the challenges of translating this.

Results: Through a number of public health initiatives, authorities developed communication strategies, strengthened influenza surveillance activities and updated overall goals in pandemic training and education. However, without influenza drills, exercises and simulations to test the plan, activating the pandemic plan, including coordinating and deploying generic infection control measures, was problematic. Responses during the pandemic were at times ‘weak and clumsy’ and failed to mirror the activities and processes highlighted in the preparedness plan.

Conclusions: Participants stressed that in order to achieve a coordinated and successful response to mitigate and prevent the further transmission of pandemic influenza, good preparation was critical. The key elements which they identified as relevant for a rapid response included effective communications, robust evidence-based decision-making, strong and reliable surveillance systems and flexible public health responses. To effectively articulate a viable trajectory of pandemic responses, the potential value of simulation exercises could be given more consideration as a mean of sustaining good levels of preparedness and responses against future pandemics. These all demand a well-structured planning for and response to pandemic influenza strategy developed by a functioning scientific and policy advisory committee.