Alison Swartz

Understanding careseeking for child illness in sub-Saharan Africa: A systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria

Diarrhoea, pneumonia and malaria are the largest contributors to childhood mortality in sub-Saharan Africa. While supply side efforts to deliver effective and affordable interventions are being scaled up, ensuring timely and appropriate use by caregivers remains a challenge. This systematic review synthesises qualitative evidence on the factors that underpin household recognition and response to child diarrhoea, pneumonia and malaria in sub-Saharan Africa. For this review, we searched six electronic databases, hand searched 12 journals from 1980 to 2010 using key search terms, and solicited expert review. We identified 5104 possible studies and included 112. Study quality was appraised using the Critical Appraisal Skills Program (CASP) tool. We followed a meta-ethnographic approach to synthesise findings according to three main themes: how households understand these illnesses, how social relationships affect recognition and response, and how households act to prevent and treat these illnesses. We synthesise these findings into a conceptual model for understanding household pathways to care and decision making. Factors that influence household careseeking include: cultural beliefs and illness perceptions; perceived illness severity and efficacy of treatment; rural location, gender, household income and cost of treatment. Several studies also emphasise the importance of experimentation, previous experience with health services and habit in shaping household choices. Moving beyond well-known barriers to careseeking and linear models of pathways to care, the review suggests that treatment decision making is a dynamic process characterised by uncertainty and debate, experimentation with multiple and simultaneous treatments, and shifting interpretations of the illness and treatment options, with household decision making hinging on social negotiations with a broad variety of actors and influenced by control over financial resources. The review concludes with research recommendations for tackling remaining gaps in knowledge.

‘It’s in our veins’: caring natures and material motivations of community health workers in contexts of economic marginalisation

Khayelitsha, an economically marginal peri-urban settlement in Cape Town, is home to a number of ‘flagship’ public health interventions aimed at HIV/AIDS and TB. Alongside these high-profile, foreign donor-driven treatment and care programmes are a plethora of NGOs that provide a wide range of community-based carework. Some of these organisations are large, well funded and well connected globally, while others are run by a few unemployed women responding to care needs in their neighbourhoods. This article explores the ways that community health workers (CHWs) who work for these organisations understand and speak about their involvement in carework as volunteers, employees or managers of community-based care organisations. Many CHWs framed their work through discourses of gender, religion or culture (‘African-ness’). They also described forms of material or economic benefits of providing carework, but many were concerned that these might be seen as existing in tension with more socially accepted, altruistic motivations for care. We explore here how CHWs narrate and understand their roles and motivations as carers and members of a resource-constrained community.

Theorising beyond the individual: Adherence to antiretroviral therapy in resource-constrained societies

Adherence to antiretroviral therapy, while often conceptualised as an individual or community-level concern, needs to be understood in the context of political and historical developments that have characterised many resource-constrained societies. This article identifies some of these dimensions of antiretroviral therapy adherence in South Africa and outlines the implications for community health psychology in taking this perspective. Using the conceptual apparatus of therapeutic citizenship, we demonstrate the importance of historical, political and other structural barriers to adherence. We conclude by examining the implications of these debates for community health psychology that go beyond the individual as the unit of intervention and analysis.

Self-management of medical abortion : a qualitative evidence synthesis.

Abstract Medical abortion is a method of pregnancy termination that by its nature enables more active involvement of women in the process of managing, and sometimes even administering the medications for, their abortions. This qualitative evidence synthesis reviewed the global evidence on experiences with, preferences for, and concerns about greater self-management of medical abortion with lesser health professional involvement. We focused on qualitative research from multiple perspectives on women’s experiences of self-management of first trimester medical abortion (< 12 weeks gestation). We included research from both legal and legally-restricted contexts whether medical abortion was accessed through formal or informal systems. A review team of four identified 36 studies meeting inclusion criteria, extracted data from these studies, and synthesized review findings. Review findings were organized under the following themes: general perceptions of self-management, preparation for self-management, logistical considerations, issues of choice and control, and meaning and experience. The synthesis highlights that the qualitative evidence base is still small, but that the available evidence points to the overall acceptability of self-administration of medical abortion. We highlight particular considerations when offering self-management options, and identify key areas for future research. Further qualitative research is needed to strengthen this important evidence base. Résume L’avortement médicamenteux est une méthode d’interruption de grossesse qui, par sa nature, permet une participation plus active des femmes à la gestion, et parfois même l’administration des médicaments pour leur propre avortement. Cette synthèse de données qualitatives a examiné les données mondiales sur les expériences, les préférences et les préoccupations relatives à une autogestion croissante de l’avortement médicamenteux, avec une moindre participation des professionnels de santé. Nous nous sommes concentrés sur la recherche qualitative, depuis de multiples perspectives, sur la manière dont les femmes ont vécu l’autogestion d’un avortement médicamenteux du premier trimestre (< 12 semaines) de gestation. Nous avons inclus la recherche portant sur des environnements légaux et juridiquement restrictifs, que l’avortement médicamenteux ait été obtenu par des systèmes formels ou informels. Une équipe de quatre personnes a sélectionné 36 études réunissant les critères d’inclusion, en a extrait des données et rédigé un projet de synthèse. Les résultats ont été organisés d’après les thèmes suivants : perceptions générales de l’autogestion, préparation à l’autogestion, considérations logistiques, questions de choix et contrôle, et signification et expérience. La synthèse montre que la base de données qualitative est encore mince, mais que ces informations indiquent une acceptabilité globale de l’auto-administration. Nous soulignons des points particuliers à prendre en compte lors de l’application des options d’autogestion, et nous identifions des domaines clés pour de futures recherches. Il faut poursuivre les recherches qualitatives pour étoffer cette base de données importante. Resumen El aborto con medicamentos es un método de interrupción del embarazo que por su naturaleza permite una participación más activa de las mujeres en el proceso de manejar, y en algunos casos incluso administrar los medicamentos, para su aborto. Esta síntesis de evidencia cualitativa revisó la evidencia mundial de experiencias, preferencias e inquietudes relacionadas con mayor automanejo del aborto con medicamentos y menos participación de profesionales de la salud. Nos enfocamos en investigaciones cualitativas, desde múltiples puntos de vista sobre las experiencias de las mujeres con el automanejo del aborto con medicamentos en el primer trimestre de embarazos (< 12 semanas) de gestación. Incluimos investigaciones de contextos donde es legal y donde es restringido por la ley, ya sea que los servicios de aborto con medicamentos hayan sido accedidos por medio de sistemas formales o informales. Un equipo de revisión integrado por cuatro personas identificó 36 estudios que reunían los criterios de inclusión, extrajó datos de estos estudios y redactó los hallazgos de la revisión sintetizada. Los hallazgos fueron organizados bajo las siguientes temáticas: percepciones generales del automanejo, preparación para el automanejo, consideraciones logísticas, asuntos de elección y control, y significado y experiencia. La síntesis destaca que la base de evidencia cualitativa aún es pequeña, pero que la evidencia existente indica la aceptación general de la autoadministración. Destacamos asuntos específicos que deben ser considerados al aplicar las opciones de automanejo, e identificamos áreas clave para futuras investigaciones. Se necesitan más investigaciones cualitativas para fortalecer esta importante base de evidencia.

The Cape Town boyfriend and the Joburg boyfriend: women’s sexual partnerships and social networks in Khayelitsha, Cape Town

In South Africa, young people’s “multiple” or “concurrent” partnerships have been increasingly prominent in public health discourses – as drivers of HIV transmission. Multiple partnerships are typically framed in moralising, negative terms and depicted primarily as male-driven, within a broader framework of women’s vulnerability and use of sex for survival and material gain. Based on ethnographic fieldwork with adolescents and young adults in Khayelitsha township near Cape Town, this article investigates young women’s partnerships by exploring their complex interpersonal and social dynamics. We unpack women’s multiple motivations for, and careful management strategies of, both sexual and social relationships in a broader context of socio-economic exclusion, threats to health and well-being, social obligations and relationships of care. The meanings and practices associated with young people’s relationships are more than the sum of individual sexual behaviours, rigid cultural scripts or simply a locus of “risk.” The data presented here highlight some of the limitations of “prevention” approaches that do not take into account this nuanced and multilayered view of such relationships. The affective and empathetic dimensions of young peoples’ relationships, as well as the socio-economic contexts in which they occur should also be considered. Without accounting for this context, standard “prevention” approaches are less likely to succeed.

“Contract to Volunteer”: South African Community Health Worker Mobilization for Better Labor Protection:

In this paper, we explore the increasing activity around labor rights for South African community health workers (CHWs). Contextualizing this activity within broader policy and legal developments, we track the emergence of sporadic mobilizations for decent work (supported by local health activist organizations) and subsequently, the formation of a CHW union. The National Union of Care Workers of South Africa (NUCWOSA) was inaugurated in 2016, hoping to secure formal and secure employment through government and the consequent labor and occupational health protections. Various tensions were observed during fieldwork in the run up to NUCWOSAs formation and raise important questions about representation, legitimacy, and hierarchies of power. We close by offering suggestions for future research in this developing space.

Toxic layering through three disciplinary lenses: childhood poisoning and street pesticide use in Cape Town, South Africa

This article focuses on the devastating hidden perils of agricultural pesticides repurposed by informal sellers in urban South African townships to kill rats and other unwanted pests. Drawing on collaborative research techniques, we investigate the causal relationship between child poisoning episodes and the household use of illegal street pesticides. Such pesticides are used to safeguard homes from pests in an attempt to protect children from the harmful consequences of rodent bites and vectorborne diseases. Here, we consider the social injustice and economic inequality of episodes of child pesticide poisoning in the Western Cape from three disciplinary perspectives: public health, medical anthropology and fine art. We ultimately seek to demonstrate the complex relationship between the political economy of sanitation, waste removal and insecure housing, and the proliferation of rodents and other pests in urban townships. As a contribution to the medical humanities, the paper leans into different disciplines to highlight the toxic layering at play in a child pesticide poisoning event. The public health perspective focuses on the circulation of illegal street pesticides, the anthropologists focus on the experiences of the children and caregivers who are victims of poisoning, and the fine artist centres the rat within a broader environmental context. While non-toxic methods to eliminate rats and household pests are critical, longer term structural changes, through environmental and human rights activism, are necessary to ameliorate the suffering caused by poisoning. The medical and health humanities is well poised to highlight creative ways to draw public attention to these challenges, as well as to bridge the divide between science and the humanities through collaborative research efforts. With this paper we set the stage for discussing and balancing perspectives when addressing pest control in poor urban communities.

What will it really take to end the HIV epidemic

Gaining access to medication against HIV is just the first step towards creating health for PLWHIV and those at risk of it, it is not the last step … PLWHIV need health services, not just disease s...