3,761 research outputs found
Public Health Banner to Counter Stigma through Awareness of Treatment, at Brigade Road Construction Site, Bangalore, India.
No full text<p>Photograph: M. G. Weiss, 1992.</p
MITCHELL CHAPPLE, Joe
No full textPaper by Joel Mitchell Chapple about President Warren G. Harding’s life and time. This work was dedicated to Gen. Plutarco Elías Calles by its author (See library). / Obra de Joe Mitchell Chapple sobre el tiempo y vida del Presidente Warren G. Harding, dedicada por el autor al Gral. PEC (Ver Biblioteca)
Federic G. Renner with Mitchell Wilder at the Amon Carter Museum of Western Art
No full textImage of Frederic G. Renner of Washington, author of the catalog for the exhibition of Russell Illustrated letters. Mr. Renner is photographed having a conversation with Mitchell Wilder, director of the museum. The two men are photographed looking at the Russell letters. Fort Worth Star-Telegram Evening edition January 23, 1962.https://mavmatrix.uta.edu/specialcollections_startelegram1960s/1735/thumbnail.jp
Sociocultural concepts of pandemic influenza and determinants of community vaccine acceptance in Pune, India
No full textVaccines are considered one of public health’s greatest achievements. Yet, public concerns and hesitancy towards acceptance of vaccines has been noted around the world for various vaccines. Limited vaccine uptake against influenza A (H1N1) was a problem during the 2009-2010 pandemic. Ensuring the ability to rapidly produce large quantities of an efficacious vaccine has been a focus of pandemic preparedness at the global and national levels. Notwithstanding the importance of these preparedness measures, its availability and clinical efficacy alone may not be sufficient for the vaccine to be effective at a community level.
Culture has a powerful influence on the understanding of sickness and illness-related behaviour. The framework of cultural epidemiology used in this thesis integrates the local validity of anthropology and the explanatory power of epidemiology to clarify the cultural basis of vaccine hesitancy and acceptance.
Despite cross-cultural differences and an acknowledged need for country-specific studies, relatively little research has focussed on pandemic influenza vaccine hesitancy in lower income settings. A mixed-methods research study was conducted in urban and rural Pune, a hotspot of the influenza pandemic in India. The aim was to study local sociocultural features of illness and determinants of pandemic influenza vaccine acceptance from a community perspective.
This work is a contribution to global advances in the study of vaccine hesitancy and it underscores the value of sociocultural study and community preferences in planning effective vaccine action
Key elements of HIV/AIDS control in the Arab world
No full textHIV/AIDS remains one of the most pressing health challenges more than three decades after the first documented case in 1981. The Middle East and North Africa region (MENA) is one of lowest regions in terms of HIV/AIDS prevalence. At the end of 2011 there were 300,000 PLWHA in the region (adult prevalence was estimated at 0.2%). For the same year, 37,000 people were newly infected with the HIV virus, while 23,000 deaths were AIDS-related. Low prevalence, however, does not necessarily mean low risk, and the MENA region is affected in various ways. The burden of HIV/AIDS in the region is strongly believed to be underestimated. The number of new infections in the region is on the rise despite the overall global decrease. Concentrated epidemics are emerging among high-risk groups (HRG), mainly men who have sex with men (MSM) and injecting drug users (IDU).
Attitudes about HIV/AIDS in the MENA region have largely been influenced by Islamic views. It is widely believed that certain sociocultural values, reflected in Islamic practices, provide protection against HIV/AIDS and that people are mainly infected because of misbehaviour. Therefore, the initial response to HIV/AIDS was denial. Despite acknowledging the influence of sociocultural features on HIV/AIDS control in the region, consideration of cultural aspects on control efforts has been very limited.
This study was conducted in Jordan and is the first to study the cultural epidemiology of HIV/AIDS in the MENA region. The aims were, first, to gain a better understanding of the local perceptions of HIV/AIDS by assessing its priority in the local health agenda and in scientific research, and, second, to study sociocultural factors that are associated with HIV/AIDS control from the perspectives of PLWHA and HRGs.
To address the first aim we clarified regional control policies and assessed the priority of HIV/AIDS through an exploratory observational study, involving discussions with policy makers, and a systematic review of literature and policy documents. The second aim was addressed by using the mixed-methods approach of cultural epidemiology among PLWHA and MSM.
Findings showed that approaches to control in the region focus mainly on standard international approaches such as VCT services, promoting HIV testing, and condom use. Even though cultural norms have notable implications for HIV/AIDS control in the region, their impact is neither represented in the literature nor well-integrated into control strategies. This could explain, to a great extent, the failure of control interventions in the region. Studies on HIV/AIDS in the MENA region are very limited, particularly studies that focus on sociocultural aspects of the disease. There is a need for more comprehensive academic research and political commitment. Control programmes must consider sociocultural features of HIV/AIDS with regard to priority, prevention, and treatment.
Thirty PLWHA from Jordan were interviewed to address the second aim. Thirty-three per cent were diagnosed with HIV through mandatory testing required to obtain residence permits in neighbouring countries. Forty-seven per cent sought help voluntarily and 67% were adherent to ART at the time of the study. The context in which patients are diagnosed and requirements for mandatory testing limited appropriate help-seeking and adherence to ART; voluntary testing and willingness to seek help were associated with better adherence. Side effects of prolonged medication, perceived stigma, access to treatment, anticipated ineffectiveness of treatment and religious beliefs were all found to affect adherence to ART.
PLWHA reported adverse effects of stigma on social life, medical treatment, and their work life. A few respondents referred to experience of enacted stigma, mainly arising from health care workers. Most respondents reported concerns about felt or anticipated stigma. Sadness, anxiety, reduced social status, social isolation, reduced income, and job loss were illness-related experiences associated with higher levels of stigma. Perceived causes of HIV/AIDS associated with higher stigma included socially-mediated effects of specific behaviours such as sharing shaving blades and various sexual acts including masturbation.
A second interview survey involved a sample of 97 MSM from the four main cities of Jordan. Approximately 25% of the respondents reported using a condom during their most recent sexual intercourse, and 38% had been tested at least once for HIV. Positive determinants of condom use were higher education level, acknowledging MSM as a HRG, seeking advice from a medical doctor, and the perceived cause of sex with prostitutes. Awareness of available treatment was a positive determinant of HIV testing. Blood transfusion as a perceived cause and asking advice from friends were negative determinants.
Control of HIV/AIDS in Jordan and the wider MENA region is generally inadequate, unsustainable, and challenged by cultural values and religious teachings. HIV/AIDS prevention and control should be higher prioritised in national and regional public health agendas in terms of both resources and political commitment. Surveillance systems should be strengthened strategically to reduce the gap in HIV/AIDS-related data in the MENA region. The HIV testing policy, which currently depends heavily on mandatory or pre-marital testing, should be reformed to reach HRGs; and travel restrictions on PLWHA should be minimised to mitigate stigma. Most importantly, the recognition of local, sociocultural illness-related features should be essential in the design of interventions to enhance HIV/AIDS control. In addition, all stakeholders, and especially religious leaders, should be involved in the design and implementation of control strategies and their implementation
The Geneva Gay Men's Health Project: A community-research collaboration to assess and improve the health of gay men in Geneva, Switzerland
No full textComprehensive overviews of research in the late 1990s on health issues relevant to gay men, lesbians, bisexuals, and transgender people (LGBT) identified issues which appear to affect sexual minorities disproportionately, but the quality of the available data was deemed too poor to translate into policy initiatives. Dialogai, a gay organization in Geneva active in HIV prevention work, embarked on a community-research partnership with the Institute for Social and Preventive Medicine, University of Zurich, for the Geneva Gay Men's Health Project with the following objectives: gather information on gay men's health in order to educate itself and others, set priorities based on evidence, and introduce new interventions in response to community needs.
After two rounds of focus groups and an extensive literature review phase, the first Geneva Gay Men's Health Survey (GGMHS)-patterned on national health interview surveys-was carried out in 2002 among 571 gay men recruited using randomized time-space sampling. In order to explore the possible existence of distinctive health needs among gay men along key public health indicators of health status, health-related behaviors, and health care utilization, we performed a post-hoc comparison with matched general population controls from the 2002 Swiss Health Survey. Gay men reported significantly more and severe physical symptoms (AOR=1.72-9.21), short-term disability (AOR=2.56), risk factors for chronic disease-i.e., high cholesterol, high blood pressure, high glucose, and smoking-(AOR=1.67-3.89), and greater health services utilization (AOR=1.62-4.28), even after adjustment for socio-demographic characteristics and health behaviors. The only exceptions to greater morbidity were greater attention to food choices (AOR=1.66) and less obesity (AOR=0.54) among gay men.
GGMHS assessed common psychiatric disorders using the WHO Composite International Diagnostic Interview Short Form (CIDI-SF). Nearly half (43.7%) of the sample fulfilled diagnostic criteria for at least one of five DSM-IV disorders in the past 12 months: major depression 19.2%, specific and/or social phobia 21.9%, and alcohol and/or drug dependence 16.7%. Over one quarter of cases were comorbid with another kind of disorder. Despite chronicity, half the men with major depression and a third of the men with social and/or specific phobia actually self-reported the condition. Such men were 5 times more likely to have sought treatment, underscoring the importance of recognition in help-seeking. In all, only 35.7% of cases consulted a health care professional in the past 12 months for mental health.
GGMHS assessed various forms of suicidality. Suicidal ideation (12 months/lifetime) was reported by 22%/55%, suicide plans 12%/38%, and suicide attempts 4%/19%. While lifetime prevalences and ratios are similar across age groups, men under 25 years reported the highest 12-month prevalences for suicidal ideation (35.4%) and suicide attempts (11.5%) and the lowest attempt ratio (1:3.1 for attempt to ideation). In order to bolster the findings for the youngest age group, we performed secondary analyses of two national adolescent health surveys from 2002-i.e., Swiss Multicenter Adolescent Survey on Health (SMASH) and Swiss Recruit Survey
(ch-x)-comparing homo- and bisexually attracted young men directly with their heterosexual counterparts. Homo/bisexual men aged 16-20 years were significantly more likely to report 12-month suicidal ideation, plans, and attempts (OR=2.09-2.26) and lifetime suicidal ideation (OR=2.15) and suicide attempts (OR=4.68-5.36).
GGMHS was repeated in 2007 and 2011 with a focus on mental health and assessed the understanding and experience of gay men using mental health literacy with features of cultural epidemiology. A depression vignette was labelled as such by 44.1% of the entire sample, and 61.9% of the men with major depression in the past 12 months. Discrimination (33.2%), acceptance/rejection by others (21.4%), and loneliness (24.9%) were the most common reasons given for greater susceptibility among gay men, yet men with major depression reported problems with love/relationship (32.5%) and work (28.9%) as the most common perceived causes of recent depression, and problems with love/relationship (21.9%), accepting one's homosexuality (21.1%), and family (20.2%) at initial outset. The highest proportions of gay men rated non-medical options such as a close friend (91.6%), relaxation exercises or meditation (84.4%), and physical activity (83.5%) as being helpful for the depression vignette, and seeing friends (17.2%) and doing sports (17.2%) were the most common non-professional activities mentioned spontaneously by men with major depression. While gay men share many commonalities in labelling, perceived causes, and help-seeking with general populations, several specificities in understanding and experience were identified.
As the first mental health intervention for a gay community, Blues-out is a depression awareness campaign modelled after the evidence-based European Alliance Against Depression. The pre-post intervention evaluation confirmed levels of recognition of depression and Blues-out comparable to those found in general populations. A third of the respondents (32.9%) recognized Blues-out in 2011. Such men were more likely to find specialists and psychological therapies helpful and correctly identify depression and gay men's greater risk for depression. Despite small effect sizes, significant net decreases (18 - 28%) were seen in lifetime suicide plans, 12-month suicidal ideation, self-reported lifetime depression, and 4-week psychological distress between 2007 and 2011. It should be a priority to test and implement public mental health interventions in such high prevalence populations
Socio-cultural features of Buruli ulcer and implications for control in Ghana
No full textBuruli ulcer (BU) infection, caused by Mycobacterium ulcerans, an environmental pathogen, is a disfiguring disease of the skin and occasionally the bones. Although mortality is rare, morbidity is high. All age groups are affected but children less than 17 years-of-age are at highest risk. BU has been reported in several tropical and sub-tropical regions of the world, particularly among poor, rural populations with limited access to basic water, sanitation and health facilities. However, most cases are from West-Africa and Ghana reports about 1,000 cases annually.
Since the mode of transmission for BU is unclear and considering the extent of BU-related morbidity, public health programmes to control BU are very important. This research examined the role of demographic, gender-related and socio-cultural features of BU and how these features affect the quality of timely treatment for BU clinical management and control in Ghana. The research was conducted in the Ga-West and Ga-South municipalities of Ghana. These areas are the fifth most endemic for BU in Ghana, yet they have the highest burden in terms of healed and active lesions.
The research had three components. A community study surveyed 504 heads of households, conducted 7 focus group discussions and assessed knowledge, attitudes and practices (KAP) of BU-affected persons in 2005. This study was motivated by the paucity of base-line socio-cultural data in the study areas and provided the rational for the inception of a Buruli ulcer prevention and treatment programme (BUPaT). A cultural epidemiological (CE) study, focusing on illness experience, meaning and help-seeking was carried out from November 2008 to July 2009 among 181 affected persons from 67 endemic communities and in 3 major health treatment centres in the study area. During this same period, the health system performance in the first phase of the BUPaT phase 1 programme was assessed.
The KAP study found a low level of knowledge about the causes of BU: only 5.5% of respondents mentioned swimming and wading in ponds as a risk factor; 5.2% mentioned witchcraft, and 53% did not know the cause. There was considerable use of herbalists as the first recourse after infection, and medical treatment was often considered as a last alternative. Reasons for delayed medical treatment included a fear of prolonged hospitalisation, delays in treatment at the hospital, difficulty in obtaining transport for medical treatment, high transport costs and loss of income because of time spent in seeking medical treatment. There was a high level of compassion and acceptance of BU-affected persons, more among adults than children. Children’s discrimination of BU-affected persons was based on fear of contagion. It was widely believed that BU-affected persons stayed away from public because they were embarrassed about their illness.
The KAP study suggested the need for community health education specifically on the risk factors for BU infection, and recognition of early stages of BU infection. It showed that improved access to health services and facilities was needed, and that access would benefit from community-based surveillance and a referral system to encourage timely medical treatment. The study also recommended the inclusion of information about BU in the school curriculum to allay fears of contagion among children. Because of the community preference for herbal treatment, it was suggested that herbalists should be trained to recognise all clinical features of BU and integrated in the health system so they could recognise and refer cases.
Results of the CE study showed the influence of illness experience, meaning and health system factors on help- seeking for BU. Findings revealed the extent of anxiety about anticipated illness outcomes and immense physical suffering of persons with pre-ulcers and ulcers. Study findings also drew attention to the socio-economic impact of BU illness both on affected persons and their family; many affected persons lost their livelihoods and had their education interrupted. The welfare of the family was further compromised when the main income-earner was infected with BU.
The demands for care for BU-affected sick relatives in the hospital and at home required mothers and adult female family members to make very difficult decisions. Work was often affected and young children were left unattended at home, when mothers were in the hospital, either seeking treatment for themselves or providing care for others. Younger female children were more likely than male children to suffer from school absenteeism to provide care for sick relatives. These findings suggest far-reaching implications for welfare, development and economic empowerment.
Additional findings from the CE study indicated that although the use of herbalists was extensive, awareness of features of BU had increased since the KAP study in 2005. Consequently, a high proportion of respondents sought medical care for ulcers (66.9%) although the proportion who sought help for pre-ulcers was comparatively low (17.1%). Findings showed that affected persons used private health practitioners hoping that this would enable them continue with work and school.
Nevertheless, difficulties in diagnosing early lesions and progression of pre-ulcer lesions to large, slow-healing ulcers supported local concepts of witchcraft as a perceived cause of BU. Ideas of witchcraft did not prevent respondents from seeking medial care, but it prejudiced them against health messages that emphasised water contact as a risk factor for BU infection. Furthermore, respondents were sceptical of health education messages that failed to explain disease contagion in persons who appeared to have had no water contact. Some respondents also requested explanations for the absence of BU disease in persons who had frequent exposure to water, yet had no illness.
Help-seeking included substantial use of herbs at home for treatment of pre-ulcer lesions and the local excision of nodules to expose infected tissues, after which herbs were placed on sores. Analgesics, balms, blood tonics and antibiotics - particularly Terramycin and Phenxymethylpenicillin (commonly known as penicillin v) - were purchased from local chemists and itinerant drug peddlers. Herbalists were used extensively as the first-line treatment provider because of their consanguine relationship with respondents, easy access to their itinerant services and anticipation that their treatment would enable respondents to continue with work and school.
The main aim of the health system in the BuPaT phase 1 programme was to reduce BU-related suffering and disability through early detection and treatment of cases. Various community-based approaches and improved case management strategies were used to achieve this aim. Five main achievements of the health system were notable: (1) Extensive collaboration of all stakeholders across all levels, (national, municipal and community), which helped to strengthen the health system. (2) Enhanced capacity of health staff in antibiotic treatment and wound care. (3). A cadre of teachers, municipal environmental health officers, community health nurses and community-based surveillance volunteers were trained to give correct health education messages and to screen and refer infected persons for medical treatment. (4) The creation of a patient database using recommended WHO forms. (5) The introduction of antibiotics recommended by the WHO for improved treatment and cure, particularly for early lesions, thus preventing recurrences. Notwithstanding these achievements, problems remained with access, accommodation (lack of sufficient ward space), inappropriate use of traditional treatment, loss to follow-up and non-adherence to treatment.
In conclusion, this thesis has clarified the extent and nature of the substantial suffering and burden of BU-affected persons and their families. Although findings indicate an increase in awareness and the increased use of medical treatment, they also highlight pervasive ideas of witchcraft as a perceived cause which seemed to explain illness experience and burden of disease, and which reflected scepticism of health education messages that emphasise contact with rivers, ponds and lakes as risk factors for contagion.
The study showed that health system features such as collaboration among stakeholders and the use of community-based initiatives such as surveillance, community and school education, screening and referral of infected persons, and improving access to treatment were necessary for BU control.
To reduce the use of herbalists as first-line providers, access to medical treatment, particularly antibiotic treatment recommended by WHO is critical. Since community residents use private health practitioners, training and incorporating them in the health system should improve access to antibiotic treatment. The health system should also devise innovative ways to include traditional healers, particularly herbalists, in the health system to improve referral.
However, illness experience, meaning and help-seeking behaviors are influenced by the socio-cultural contexts of affected persons, which are likely to change with exposure to health information and improved socio-economic status. Regular socio-cultural assessments are needed to guide public health programmes to address current treatment needs and gaps. Since the mode of transmission remains unclear, re is no known method of prevention, there is the need for further interdisciplinary research on the role of environmental, socio-cultural and genetic factors that explain in BU contagion is needed. clarify
Zusammenfassung
Buruli-Ulkus (BU) ist eine durch das Umweltpathogen Mycobacterium ulcerans verursachte Infektionskrankheit, welche zu Haut verunstaltenden Geschwüren führt und gelegentlich auch die Knochen befällt. Obwohl die Morbidität hoch ist, führt BU selten zum Tod. Obwohl alle Altersgruppen davon betroffen sind, tragen Kinder unter 17 Jahren das höchste Erkrankungsrisiko. BU ist vor allem in tropischen und subtropischen Gegenden verbreitet, wobei vor allem arme, ländliche Bevölkerungsschichten mit beschränktem Zugang zu Wasser, sanitärer Infrastruktur und Gesundheitsdiensten betroffen sind. Die meisten Fälle treten jedoch in Westafrika auf, wo in Ghana alleine 1'000 Erkrankungen pro Jahr gemeldet werden.
Da die Übertragungsarten von BU noch nicht geklärt sind, und angesichts der hohen durch BU verursachten Morbidität, sind Gesundheitsprogramme zur BU-Bekämpfung von höchster Priorität. Die vorliegende Forschungsarbeit untersuchte den Einfluss demografischer, genderspezifischer und soziokultureller Merkmale von BU in Bezug auf die Qualität rechtzeitiger medizinischer Behandlung und die Bekämpfung von BU in Ghana. Diese Forschungsarbeit wurde in den Munizipalitäten Ga-West und Ga-South in Ghana durchgeführt. Beide Munizipalitäten gehören zum fünfthöchsten Endemiegebiet für BU in Ghana; sie sind aber von der höchsten Anzahl an geheilten und aktiven Läsionen betroffen.
Diese Forschungsarbeit beinhaltete drei Komponenten. Im Jahr 2005 wurden in einer Gemeindebasierte Studie 504 Haushaltsoberhäupter befragt, 7 Fokusgruppendiskussionen durchgeführt und der Wissenstand, die Einstellungen und Verhaltensweisen von durch BU betroffenen Personen mittels einer „KAP-Studie“ ermittelt. Diese Studie war durch den Mangel an soziokulturellen Grundlagedaten in den untersuchten Gemeinden motiviert und lieferte den Anlass für die Lancierung eines Buruli-Ulkus Präventions- und Behandlungsprogramms („BUPaT“). Zwischen November 2008 und Juli 2009 wurden Krankheitserfahrungen, Ursachenzuschreibungen und das Hilfesuchverhalten aus Sicht von 181 von BU betroffenen Personen mittels einer sogenannten kulturell-epidemiologischen Studie („CE-Studie“) erhoben. Die Teilnehmenden dieser Studie wurden aus 67 endemischen Gemeinden und den drei grossen Gesundheitszentren im Studiengebiet rekrutiert. Gleichzeitig wurde die Leistung des Gesundheitssystems in der erste Phase von „BUPaT“ evaluiert.
Die „KAP-Studie“ ermittelte einen tiefen Wissenstand bezüglich der Ursachen von BU: bloss 5.5% der Studienteilnehmenden erwähnten Schwimmen und Waten in Teichen als Risikofaktor; während 5.2% Hexerei als Ursache erwähnten, konnten 53% keine Ursache identifizieren. Herbalisten wurden von vielen als erste Hilfemassnahme nach einer Infektion aufgesucht, während die medizinische Behandlung als letzte Alternative angeschaut wurde. Gründe für die verspätete medizinische Behandlung bezogen sich auf Ängste bezüglich einer verlängerten Hospitalisation, Verzögerungen bei Behandlungen im Spital, Schwierigkeiten hinsichtlich Transportmöglichkeiten ins Spital, hohen Transportkosten und Einkommensausfällen wegen der langwierigen medizinischen Behandlung. Von BU betroffene Personen konnten auf viel Mitgefühl und Akzeptanz zählen, und zwar mehr unter Erwachsenen als unter Kindern. Diskriminierung von Personen mit BU durch Kinder basierte auf deren Angst vor Ansteckungen. Es wurde allgemein angenommen, dass von BU betroffene Personen die Öffentlichkeit meiden, weil ihnen ihre Erkrankung peinlich ist.
Die Resultate der „KAP-Studie“ deuteten auf einen Bedarf an Gesundheitsaufklärung in der Gemeinde hin, vor allem bezüglich Risikofaktoren und Erkennung von frühen Stadien von BU-Infektionen. Der Zugang zu Gesundheitsdiensten und –zentren wurde als weiteres Bedürfnis erkannt; dieser Zugang würde von einem in der Gemeinde verankerten Überwachungs- und Überweisungssystem profitieren, das eine rechtzeitige medizinische Behandlung ermöglichen würde. Zusätzlich empfiehlt diese Studie, Informationen über BU in die Lehrpläne an Schulen aufzunehmen, um Kinder hinsichtlich deren Befürchtungen zur Ansteckungsgefahr zu beschwichtigen. Wegen der Wichtigkeit der Kräuterheikunde in den untersuchten Gemeinden sollen Herbalisten bezüglich klinischer Merkmale von BU trainiert und auch vermehrt in das Gesundheitssystem integriert werden. Dadurch werden sie besser in der Lage sein, Personen mit BU zu diagnostizieren und diese an die Gesundheitszentren zu überweisen.
Die „CE-Studie“ präsentierte den Einfluss von Krankheitserfahrungen, Ursachenzuschreibungen und Aspekte des Gesundheitssystems auf das Hilfesuchverhalten für BU. Resultate zeigten die Besorgnis über die Konsequenzen dieser Erkrankung auf und das damit verbundene immense physische Leiden von Personen mit Läsionen und Geschwüren. Zusätzlich zeigte diese Studie die negativen sozioökonomischen Auswirkungen von BU auf betroffene Personen und deren Familien auf; viele betroffene Personen hatten ihren Lebensunterhalt verloren und ihre Ausbildung wurde durch die Erkrankung unterbrochen. Familien, wo die für das Haushaltseinkommen hauptsächlich zuständige Person mit BU infiziert war, hatten besonders unter prekären finanziellen Verhältnissen zu leiden.
Mütter und andere weibliche Familienmitglieder mussten schwerwiegende Entscheidungen treffen, um die pflegerischen Bedürfnisse ihrer von BU betroffenen Verwandten im Spital zu befriedigen. Die tägliche Arbeit wurde vernachlässigt und junge Kinder wurden zu Hause nicht mehr beaufsichtigt, weil ihre Mütter zur Behandlung im Spital waren oder dort andere von BU betroffene Familienmitglieder pflegen mussten. Jüngere Mädchen hatten mehr Schulabsenzen zu erleiden als Knaben, da sie vermehrt Verwandte pflegen mussten. Die Resultate dieser Studie deuten auf weit reichende Konsequenzen bezüglich Wohlergehen, Entwicklung und ökonomischer Unterstützung hin.
Obwohl Herbalisten sehr begehrt waren, hat die „CE-Studie“ auch aufgezeigt, dass sich das Bewusstsein zu Merkmalen von BU seit der „KAP-Studie“ im Jahr 2005 erhöht hat. Entsprechend hatte ein hoher Anteil der Studienteilnehmenden, die an Geschwüren litten, medizinische Hilfe in Anspruch genommen (66.9%); aber nur 17.1% der Teilnehmenden, die an Vorstadien zu Geschwüren litten, hatten solche Hilfe bezogen.
Nichtsdestotrotz deuteten Schwierigkeiten in der Diagnose von Läsionen im Frühstadium und das Fortschreiten von kleineren zu grossflächigen, langsam heilenden Geschwüren darauf hin, dass lokale Konzepte, die Hexerei als Ursache von BU annehmen, immer noch wirksam sind. Obwohl Teilnehmende, die an Hexerei glaubten, dennoch medizinische Pflege benutzten, waren sie gegenüber Gesundheitsbotschaften, welche Kontakt mit Wasser als Risikofaktor für BU betonten, voreingenommen. Dazu waren Teilnehmende auch skeptisch gegenüber Gesundheitsbotschaften, welche die Ansteckung von Personen ohne Wasserkontakt nicht erklären konnten. Einige Teilnehmende verlangten auch eine Erklärung, warum Personen mit häufigem Wasserkontakt nicht an BU erkrankt waren.
Hilfe zu Hause beinhaltete vor allem die kräutermedizinische Behandlung von Läsionen bevor sie zu Geschwüren wurden; auch wurde infiziertes Gewebe nach der lokalen Entfernung von Knötchen mit Kräutern behandelt. Analgetika, Balsam, Bluttonika und Antibiotika, vor allem Tetramycin und Phenoxymethylpenicillin (bekannt als Penicillin V), wurden in lokalen Drogerien und von fliegenden Medikamentenhändlern gekauft. Als erste Behandlungserbringer wurden hauptsächlich Herbalisten, die in Blutsverwandtschaft mit den Studienteilnehmenden stehen, aufgesucht. Herbalisten waren als Herumziehende auch einfach zu kontaktieren und nach deren Behandlung wurde erwartet, dass mit der Arbeit oder der Schule weiter gefahren werden kann.
Das Hauptziel der ersten Phase von „BuPaT“, das auf der Ebene des Gesundheitssystems ansetzte, bestand darin, durch frühe Wahrnehmung und Behandlung von Fällen zur Verminderung von durch BU verursachtem Leiden und Behinderung beizutragen. Zur Erreichung dieses Ziels wurden verschiedene Ansätze auf Gemeindeebene und verbesserte Strategien zum Fallmanagement eingesetzt. Die fünf Haupterrungenschaften im Gesundheitssystem waren folgende: (1) Umfangreiche Zusammenarbeit aller Akteure auf allen Ebenen (national, Munizipalität und Gemeinde) zur Stärkung des Gesundheitssystems. (2) Verbesserte Fähigkeiten des Gesundheitspersonals bezüglich Antibiotikaeinsatz und Wundpflege. (3) Lehrerkader, zuständige Beamte für Umwelt und Gesundheit auf Munizipalitätsstufe und Pflegepersonal und Freiwillige zur Überwachung in Gemeinden wurden trainiert, um korrekte Gesundheitsbotschaften zu vermitteln und um infizierte Personen zu erkennen und zur medizinischen Behandlung zu überweisen. (4) Es wurde eine Patientendatenbank geschaffen, die mit den offiziell empfohlenen WHO-Formularen arbeitete. (5) Es wurden neuerdings Antibiotika eingesetzt, die von der WHO zur besseren Behandlung und Heilung empfohlen sind. Diese werden vor allem bei Läsionen im Frühstadium eingesetzt, um deren Wiederauftreten zu verhindern. Ungeachtet dessen bestehen weiterhin Probleme hinsichtlich des Zugangs zur Behandlung und bezüglich fehlender Unterkünfte (nicht genügend Plätze auf Stationen), inadäquater Behandlungen mit traditioneller Medizin, Follow-Up-Verlusten und Nichtbefolgung der Behandlung.
Fazit: Diese Arbeit hat das substanzielle Ausmass und die Natur des Leidens und der Belastung von an BU erkrankten Personen und deren Familien aufgezeigt. Obwohl die Resultate auf ein verbessertes Bewusstsein und vermehrte Inanspruchnahme von medizinischer Behandlung hinweisen, wurde Hexerei weit verbreitet als Ursache wahrgenommen. Diese Ursachenzuschreibung könnte die Krankheitserfahrung und -belastung und den Skeptizismus gegenüber Gesundheitsbotschaften, welche Kontakt mit Flüssen, Weihern und Seen als Risikofaktoren für eine Ansteckung betonen, erklären.
Diese Studie zeigte, dass die Berücksichtigung folgender Faktoren im Gesundheitssystem wichtig war für die Bekämpfung von BU: die Zusammenarbeit zwischen Akteuren und die in Gemeinden verankerten Initiativen zur Überwachung, zur Gesundheitsbildung in Schulen, zur Erkennung und Überweisung von infizierten Personen und für einen verbesserten Zugang zur Behandlung. Um die Attraktivität von Herbalisten als Erstanbieter zu vermindern, sind der Zugang zu medizinischer Behandlung, insbesondere mit Antibiotika, wie von der WHO empfohlen, entscheidend. Da die Bevölkerung private Therapeuten konsultiert, sollten diese entsprechend ausgebildet und in das Gesundheitssystem integriert werden, damit der Zugang zu Antibiotika verbessert werden kann. Ausserdem sollten innovative Wege erdacht werden, um traditionelle Heiler, insbesondere Herbalisten, in das Gesundheitssystem zu integrieren und um die Überweisungsrate zu verbessern.
Allerdings werden Krankheitserfahrungen, Ursachenzuschreibungen und das Hilfesuchverhalten durch die soziokulturellen Kontexte der betroffenen Personen beeinflusst, welche sich wahrscheinlich nach der Vermittlung von Gesundheitsinformationen und mit verbessertem sozioökonomischem Status verändern. Somit sind regelmässige soziokulturelle Beurteilungen nötig, um den Programmen im öffentlichen Gesundheitswesen geeignete Informationen bereitzustellen; damit können aktuelle Behandlungsprobleme und -lücken angegangen werden. Da die Art der Übertragung von BU weiterhin unklar ist, sind weitere interdisziplinäre Forschungen auf diesem Gebiet nötig, um die Rolle von umweltrelevanten, soziokulturellen und genetischen Faktoren hinsichtlich einer Ansteckung mit BU zu erklären
Gender and the cultural context of urban mental health in Mumbai
No full textBy 2015 it is expected there will be 23 megacities, and all but four will be in developing countries. Mumbai, which now has a population in its metropolitan area of 16.4 million (Census of India, 2001), will then be the world’s second largest city after Tokyo. Three other cities in India (Kolkata, Delhi, and Hyderabad) and two more in South Asia (Dhaka and Karachi) will also join the ranks of these megacities. In Asia and Africa such demographic shifts into cities have been especially challenging, and the environmental and social impact of unbridled urban expansion on infrastructures affecting health status has become a priority for public health. It is recognised that the urban poor are especially vulnerable to these adverse effects of urbanisation, but the topics of culture and gender have attracted far too little interest, especially in mental health research and policymaking. Various accounts of international health agencies concerning the needs and approaches to the mental health of populations highlight the broader social, cultural, and economic contexts, for which clinical experience alone is an inadequate guide. Changing social values and the influence of globalisation require timely consideration of the role of gender. Mainstream psychiatric priorities advocate a model of mental disorders that has become less attentive to the impact of social conditions than many aspects of clinical practice and effective community mental health programmes require. Such considerations indicate the need to re-establish the balance between these interests and current research priorities in psychiatry, which emphasize the biological basis of mental disorders and criteria-based definitions based on clinical, rather than community, experience and research. Informed policy, which is attentive to the local contexts of needed mental health actions, requires more relevant research as a guide, responsive to recommendations of major policy reviews reported in the World Mental Health Report (Desjarlais et al.,
1995) and the WHO’s (2001) world health report on mental health.
The field of cultural psychiatry has long been grappling with a tension between
needs to pursue psychiatric epidemiological study of mental disorders in Asia and
Africa, which have long motivated developments in transcultural psychiatry, and
questions about the limitations of dominant paradigms of psychiatry, which motivated
subsequent rethinking of the new cross-cultural psychiatry. Questions about
interactions between gender and culture, however, have been for the most part
subordinate among priorities in the field. Research is needed on mental health
problems to examine explain interrelationships among gender and culture as a
complement and integral feature of psychiatric epidemiology—addressing questions
of why, how, and what to do—and to make languages and priorities of patients,
communities and professionals more mutually comprehensible.
A common theme links the various studies that comprise this thesis. It is a
focus on local representations of various mental health problems in both clinic and
community settings in urban Mumbai, with particular attention to questions of gender.
Formulating these studies in both clinical and community settings provided valuable
opportunities to consider a broader agenda of mental health interventions rooted in,
and aiming to restore, a more contextual formulation of a biopsychosocial model.
The research reported in this thesis has been motivated by the clinical professional
and personal experience of the author in Mumbai, focussing the work on particular
themes of cultural context, gender and common mental health problems. These
studies highlight the concept of common mental health problems because the nature
of the problems that arise in the course of evaluating deliberate self harm (DSH) and
the mental health-related issues that arise in dealing with both clinic patients and community residents are not restricted to the formal professional concepts of
psychiatric disorder. Our studies of DSH have examined underlying sociocultural and
psychiatric problems and identified triggers of suicidal actions. Expected genderspecific
contexts were identified, such as alcohol and other substance dependence
disorders among men and victimisation among women. Furthermore, a number of
individuals also described their problems in terms that contradicted the gender
stereotypes. For some conditions, such as substance use disorders, mental health
problems had substantial impact on people living with affected person, indicating a
hidden burden.
The research has been especially attentive to the influence of social and
cultural factors in Mumbai that affect mental health—factors such as economy,
unemployment, poverty, and the gendered dynamics of family interactions. The
nature and formulation of categories of distress, perceived causes, and health
seeking were clarified in community dialogues through ethnographic community
study, clinical interactions and clinical cultural epidemiological study using locally
adapted EMIC interviews. Our cultural epidemiology provides an account of the
distribution of the categories of experience, meaning and behaviour, which constitute
locally valid representations of mental health problems. These studies proceeded at
two different sites in Mumbai. The ethnographic community study was undertaken in
the Malavani slum, 35 kms north of central Mumbai in a western suburb. The study
of DSH was based at the second site in the KEM Hospital, which is the largest
hospital in Mumbai. It proceeded in cooperation with colleagues in the emergency
medical department to ensure systematic referrals of all patients who met criteria for
study. The research reported in this thesis demonstrated how cultural epidemiology
supported by ethnography may complement psychiatric epidemiology to guide
clinical practice and mental health policy. Collectively, the studies in this volume
suggest the value of ethnographic data for identifying categories of experience,
meaning, and behavior, which clarify locally important features of common mental
health problems. The research on DSH examined the relationship between clinical
diagnoses based on DSM-IV criteria and patient-perceived determinants of suicidal
behavior ascertained in EMIC interviews. This perspectivism has guided
complementary psychiatric and cultural epidemiological assessments of suicidal
behavior. Locally relevant features, attentive to the impact on suicidal behavior of
psychopathology, underlying problems patients relate to their DSH, and stressors
that constitute triggers of suicidal behavior should all inform suicide prevention,
community mental health interventions, and clinical practice.
The research reported in this thesis contributes to a novel approach that
provides gender-sensitive information of practical significance for designing services
and programmes in urban settings of low-income countries. Individually and
collectively, these studies are addressing practical and highly relevant issues that
mental health policy must address in India’s cities, both in communities and clinics of
slums and in middle-class neighbourhoods. In addition to their contribution to mental
health at these sites, it is hoped that the example of these studies will also clarify an
approach to cultural epidemiological research that will be useful in other settings
Social and cultural features of vaccine acceptance and cost-effectiveness of an oral cholera mass vaccination campaign in Zanzibar
No full textClassical cholera control is based on prevention—safe water, sanitation and education of people on the importance of hygiene and diarrheal diseases—health system preparedness and a timely response to provide appropriate treatment in the event of an outbreak. The World Health Organization (WHO) recommends vaccination with an oral cholera vaccine (OCV) as a supplement for prevention and control of epidemic and endemic cholera. Consideration of local cultural concepts of illness among potential vaccine recipients and how these may affect vaccine acceptance is crucial. To date, no published studies have examined the influence of social and cultural features of cholera on vaccine acceptance in African settings. The aims of the research presented here were to study social and cultural features of OCV acceptance and to assess the cost-effectiveness of the 2009 OCV mass campaign in Zanzibar.
The integrated-methods approach of cultural epidemiology was used to study local views of cholera-like illness and to examine their influence on OCV acceptance in endemic communities in Zanzibar before and after the OCV mass campaign. Public and private costs of illness due to cholera and costs of the vaccination campaign were estimated to assess the cost-effectiveness of using OCVs from a health care provider and a societal perspective.
A random sample of 356 unaffected adults from a periurban and a rural community was studied with a vignette-based, locally adapted semi-structured interview based on the Explanatory Model Interview Catalogue (EMIC). This descriptive study showed that cholera was more often recognized as serious illness that may be fatal without appropriate treatment than shigellosis. Features of distress were primarily related to the negative social and financial impact cholera can have on a patient’s life. Interference with work- or income-related activities was the most prominent category of distress. The most prominent somatic symptoms were related to dehydration and to general gastrointestinal features. Cholera was mainly attributed to a dirty environment and microbiological contamination while causes unrelated to the biomedical basis were also identified, but with less prominence. Even though rehydration of the patient (primarily in the periurban community) and use of herbal treatment and antibiotics (rural community) were the preferred self-treatment options, professional health facilities were universally recommended at both sites. This survey showed that cholera represented a significant perceived illness burden in periurban and rural Zanzibar.
Subsequent analysis showed that community willingness for a free OCV was almost universal (94%), but declined with increasing price to 61% if the OCV was offered at a low price (~USD 0.9), to 19% if offered at a medium price (~USD 4.5) and to 15% if offered at a high price (~USD 9). Logistic regression models including somatic symptoms (low and high price), social impact (low and medium price) and perceived causes (medium and high price) explained anticipated OCV acceptance better than models containing only sociodemographic characteristics. This showed that prevaccination assessments of community demand for OCV should not only consider the social epidemiology, but also examine local sociocultural features of cholera-like illness.
Since only 50% of the interviewed respondents had drunk two doses of the free OCV—with higher priority in the rural (59%) than in the periurban (41%) community (p<0.01)—study of social and cultural determinants of OCV uptake was deemed necessary. Similar to the previous study of determinants of anticipated OCV acceptance, this study showed that consideration of sociocultural features of illness explained uptake better than a purely social epidemiological analysis. Loss of appetite and nausea, both nonspecific features of cholera were negative determinants. Recognition of unconsciousness as a sign of serious dehydration and concern that cholera outbreaks could negatively impact the local health care system in the rural area were positive determinants of acceptance. Female gender, rural residence and older age were also positive determinants of OCV uptake.
A sample of 367 vaccinated and unvaccinated adults from the same two communities was studied in a postvaccination survey with a revised EMIC interview. Factors associated with uptake indicated a positive impact of the vaccination campaign and of sensitization activities on vaccine acceptance behavior. Analysis of barriers among unvaccinated people identified logistical issues as main reasons for the low community coverage, with people’s own busy daily schedules as the most prominent feature. Unlike communities opposed to cholera control or in settings where public confidence in vaccines is lacking, this study indicated a good campaign implementation and trust in the health system.
The incremental cost-effectiveness ratio (ICER) of USD 119,339 per disability-adjusted life-year averted exceeded three times the Tanzanian per capita gross domestic product; thus, use of OCVs was not considered a cost-effective strategy in comparison to the current practice based on decentralized cholera treatment centers in Zanzibar.
In conclusion, the research presented here suggests little community opposition to vaccination and good prospects to use OCVs for endemic cholera control in Zanzibar. From an economic perspective, prospects to use OCV mass campaigns under current conditions seem to be limited. However, at a subsidized purchase price and subsidized delivery costs of ~USD 1 each per immunized individual, OCV mass campaigns may become economically and financially feasible for cholera control in high-incidence areas of Zanzibar
The air quality impact of cordon and distance based road user charging: an empirical study of Leeds, U.K
No full textTraffic assignment, pollutant emission and dispersion models were applied to a major UK city so as to assess the air quality impacts of five road pricing schemes. Schemes were evaluated with reference to: exceedence of air quality standards for six pollutants; greenhouse gas emission; redistribution of pollution, an environmental justice concern; and road network performance as traffic speed and trip distance. Results were compared to alternatives of do nothing, network development and clean fuel promotion. The air quality benefits of a modest distance based charge are highlighted. However, whilst road pricing shows potential as an air quality management tool, its value and suitability are strongly sensitive to prior air quality and emission source apportionment in the application city
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