Thilde Rheinländer

Keeping Up Appearances: Perceptions of Street Food Safety in Urban Kumasi, Ghana

The growing street food sector in low-income countries offers easy access to inexpensive food as well as new job opportunities for urban residents. While this development is positive in many ways, it also presents new public health challenges for the urban population. Safe food hygiene is difficult to practice at street level, and outbreaks of diarrheal diseases have been linked to street food. This study investigates local perceptions of food safety among street food vendors and their consumers in Kumasi, Ghana in order to identify the most important aspects to be included in future public health interventions concerning street food safety. This qualitative study includes data from a triangulation of various qualitative methods. Observations at several markets and street food vending sites in Kumasi were performed. Fourteen street food vendors were chosen for in-depth studies, and extensive participant observations and several interviews were carried out with case vendors. In addition, street interviews and Focus Group Discussions were carried out with street food customers. The study found that although vendors and consumers demonstrated basic knowledge of food safety, the criteria did not emphasize basic hygiene practices such as hand washing, cleaning of utensils, washing of raw vegetables, and quality of ingredients. Instead, four main food selection criteria could be identified and were related to (1) aesthetic appearance of food and food stand, (2) appearance of the food vendor, (3) interpersonal trust in the vendor, and (4) consumers often chose to prioritize price and accessibility of food—not putting much stress on food safety. Hence, consumers relied on risk avoidance strategies by assessing neatness, appearance, and trustworthiness of vendor. Vendors were also found to emphasize appearance while vending and to ignore core food safety practices while preparing food. These findings are discussed in this paper using social and anthropological theoretical concepts such as ‘purity’, ‘contamination’, ‘hygiene puzzles’, and ‘impression behaviors’ from Douglas, Van Der Geest, and Goffman. The findings indicate that educating vendors in safe food handling is evidently insufficient. Future public health interventions within the street food sector should give emphasis to the importance of appearance and neatness when designing communication strategies. Neglected aspects of food safety, such as good hand hygiene and cleanliness of kitchen facilities, should be emphasized. Local vendor networks can be an effective point of entry for future food hygiene promotion initiatives.

Sanitation behavior among schoolchildren in a multi-ethnic area of Northern rural Vietnam

BackgroundIn Vietnam, efforts are underway to improve latrine use in rural and remote areas with particular focus on increasing coverage of sanitation in schools. However, there is a lack of information on how the school program affects latrine use by schoolchildren and at community level. This paper analyzes sanitation use among schoolchildren in a multi-ethnic area to inform future school-based sanitation promotion programmes.MethodsA combination of quantitative and qualitative methods was applied during a 5 months period in six primary and secondary schools and in the homes of schoolchildren in four different ethnic villages in Northern rural Vietnam. Using a structured questionnaire, 319 children were interviewed face-to-face to collect quantitative data. Qualitative methods included extensive observations at schools and in the homes of 20 children, a single days diary writings of 234 children, in-depth interviews with children (20), their parents (20) and school staff (10), and focus group discussions with parents (4) and teachers (6), and picture drawing with children (12).ResultsAll surveyed schools had student latrines. However, the observed schoolchildren most commonly urinated and defecated in the open. Main barriers for latrine use included inadequate number of latrines, limited accessibility to latrines, lack of constant water supply in latrines and lack of latrine maintenance by school management. Programs promoting latrine use for children were not conducted in either schools or communities and were not established as a preferred social norm in such settings. Children perceived existing school latrines as unappealing and expressed a wish to have basic, functional, clean, and colorful school latrines with privacy.ConclusionsThe paper shows that the current school based sanitation promotion is insufficient to change sanitation behavior of school children irrespective of their ethnicity. It is important that schools, households and communities work more closely together to increase use and uptake of latrine use among schoolchildren. Also, the contractors of latrine facilities must work more closely with local school management when constructing latrines, including identifying location, design and appropriate systems of water supply. A separate budget needs to be allocated to allow the school to maintain the sanitation infrastructure and keep it hygienic and appealing for users.

Redefining shared sanitation.

PerspectivesAs the Millennium Development Goals reach their deadline, it is clear that the world is not on track to achieve global sanitation targets. With sanitation trends, global developments and local contexts in mind, it is time to adopt a more flexible approach to achieving universal functional sanitation. By functional sanitation, we mean toilet facilities that protect human health by preventing contamination of the envi-ronment with human faecal waste.According to the latest estimates from the World Health Organization/United Nations Children’s Fund Joint Monitoring Programme for water and sanitation (JMP), 2.5billion people worldwide do not have access to any type of improved sanitation. To meet the JMP definition of improved sanita-tion, toilets must be used by only one household, as well as meeting certain design standards that prevent human contact with faeces. Of this 2.5billion, 732million use a facility that does not meet minimum hygiene standards and one billion people practise open def-ecation (i.e. defecation without using a toilet facility).

Teaching handwashing with soap for schoolchildren in a multi-ethnic population in northern rural Vietnam

Background In Vietnam, initiatives have been started aimed at increasing the practice of handwashing with soap (HWWS) among primary schoolchildren. However, compliance remains low. Objective This study aims to investigate responses to a teacher-centred participatory HWWS intervention in a multi-ethnic population of primary schoolchildren in northern rural Vietnam. Design This study was implemented in two phases: a formative research project over 5 months (July–November 2008) and an action research project with a school-based HWWS intervention study in two rural communes during 5 months (May, September–December 2010). Based upon knowledge from the formative research in 2008, schoolteachers from four selected schools in the study communes actively participated in designing and implementing a HWWS intervention. Qualitative data was collected during the intervention to evaluate the responses and reaction to the intervention of teachers, children and parents. This included semi-structured interviews with children (15), and their parents (15), focus group discussions (FGDs) with schoolchildren (32) and school staff (20) and observations during 15 HWWS involving children. Results Observations and interview data from children demonstrated that children were visibly excited and pleased with HWWS sessions where teachers applied active teaching methods including rewards, games and HWWS demonstrations. All children, schoolteachers and parents also viewed the HWWS intervention as positive and feasible, irrespective of ethnicity, gender of schoolchildren and background of schoolteachers. However, some important barriers were indicated for sustaining and transferring the HWWS practice to the home setting including limited emphasis on hygiene in the standard curriculum of schools, low priority and lack of time given to practical teaching methods and lack of guidance and reminding HWWS on a regular basis at home, in particular by highland parents, who spend most of their time working away from home in the fields. Access to soap and water at the household level did not seem a barrier for the uptake of HWWS but continuous access to these might be a challenge at schools. Conclusions This study demonstrated that it is feasible to engage teachers and implement active teaching methods for behaviour change of HWWS in a group of multi-ethnic primary schoolchildren without the need for major investments in water and hygiene infrastructures. However, in those areas there was limited transfer of practice from school promotion to home. Continuous access to soaps at schools needs to be invested.Background In Vietnam, initiatives have been started aimed at increasing the practice of handwashing with soap (HWWS) among primary schoolchildren. However, compliance remains low. Objective This study aims to investigate responses to a teacher-centred participatory HWWS intervention in a multi-ethnic population of primary schoolchildren in northern rural Vietnam. Design This study was implemented in two phases: a formative research project over 5 months (July-November 2008) and an action research project with a school-based HWWS intervention study in two rural communes during 5 months (May, September-December 2010). Based upon knowledge from the formative research in 2008, schoolteachers from four selected schools in the study communes actively participated in designing and implementing a HWWS intervention. Qualitative data was collected during the intervention to evaluate the responses and reaction to the intervention of teachers, children and parents. This included semi-structured interviews with children (15), and their parents (15), focus group discussions (FGDs) with schoolchildren (32) and school staff (20) and observations during 15 HWWS involving children. Results Observations and interview data from children demonstrated that children were visibly excited and pleased with HWWS sessions where teachers applied active teaching methods including rewards, games and HWWS demonstrations. All children, schoolteachers and parents also viewed the HWWS intervention as positive and feasible, irrespective of ethnicity, gender of schoolchildren and background of schoolteachers. However, some important barriers were indicated for sustaining and transferring the HWWS practice to the home setting including limited emphasis on hygiene in the standard curriculum of schools, low priority and lack of time given to practical teaching methods and lack of guidance and reminding HWWS on a regular basis at home, in particular by highland parents, who spend most of their time working away from home in the fields. Access to soap and water at the household level did not seem a barrier for the uptake of HWWS but continuous access to these might be a challenge at schools. Conclusions This study demonstrated that it is feasible to engage teachers and implement active teaching methods for behaviour change of HWWS in a group of multi-ethnic primary schoolchildren without the need for major investments in water and hygiene infrastructures. However, in those areas there was limited transfer of practice from school promotion to home. Continuous access to soaps at schools needs to be invested.

Smell: an overlooked factor in sanitation promotion

Bad smell from human waste carries so many social, moral, aesthetic, and disease-related concerns that it represents a major barrier to successful sanitation adaptation for people all over the world. This paper summarizes the authors experiences from sanitation research in low- and middle-income settings from several continents and research disciplines, and addresses the often-overlooked issue of reduction of smell for effective sanitation promotion. The paper argues that people therefore have developed strategies to avoid smell, some of these being of concern to public health specialists. It is recommended that smell and smellavoiding strategies are integrated into all phases of sanitation promotion programmes, from investigatory, to design, and maintenance planning.

Indirect causes of maternal death

Comprehensive analyses of the causes of maternal mortality have been published by WHO and the Institute for Health Metrics and Evaluation. These analyses strikingly show the increasing importance of indirect causes of maternal death. Say and colleagues noted that 27·5% of all maternal deaths result from these indirect causes, with the highest proportion of such deaths in south Asia and sub-Saharan Africa. Kassebaum and colleagues similarly show the growing direct and indirect eff ects of non-communicable diseases on maternal mortality. The authors conclude that indirect causes of maternal deaths cannot be ignored and that eff orts should be focused on their reduction. The greater relative importance of indirect causes could be a result of successful addressing of direct complications of pregnancy and childbirth, and of a change in risk factors and disease patterns. Indirect causes of death include the eff ects of pre-existing disorders, such as HIV infection, mental disease, and diabetes, when aggravated by pregnancy. Unfortunately, this range of indirect causes is yet to be fully explored. Prompt action to thoroughly understand these causes of death and develop appropriate responses is crucial to continue worldwide progress in maternal mortality reduction. Despite the importance of these indirect causes, key policy and strategy documents of leading international maternal health nongovernmental organisations and UN organisations do not focus much on indirect causes of maternal mortality, except for HIV infection. Predominant attention is still given to direct causes of adverse pregnancy outcomes. In particular, poor mental health as an underlying causal factor for maternal mortality and morbidity has been ignored and remains outside the stated agenda of these organisations. This omission is despite the fact that many studies have shown that poor maternal mental health has far-reaching adverse eff ects on mother and infant. Furthermore, suicide, as the most severe eff ect of poor mental health, is a leading contributor to maternal mortality worldwide and is strongly associated with violence and abuse. The situation might be helped by the WHO guidelines on recording of maternal mortality cause: the International Classif ication of Disease—Maternal Mortality. These guidelines now deem suicides during pregnancy and 12 months postpartum as direct maternal deaths, even if underlying obstetric psychiatric disorders are not diagnosed. This revision provides hope for improved future data on suicide as a cause of maternal death and provides reason for organisations to add mental health to their agenda. Implementation of several internationally ratified human rights conventions that require governments to take action to address maternal mental health as part of health services could improve the situation somewhat. Maternal mental health is essential to safe motherhood. The worldwide maternal health community should update their agendas to ensure programme eff ectiveness by giving attention to indirect causes of maternal death, including mental health. We declare no competing interests.

Teaching minority children hygiene: investigating hygiene education in kindergartens and homes of ethnic minority children in northern Vietnam.

Objectives. Ethnic minority children in Vietnam experience high levels of hygiene- and sanitation-related diseases. Improving hygiene for minority children is therefore vital for improving child health. The study objective was to investigate how kindergarten and home environments influence the learning of hygiene of pre-school ethnic minority children in rural Vietnam. Design. Eight months of ethnographic field studies were conducted among four ethnic minority groups living in highland and lowland communities in northern Vietnam. Data included participant observation in four kindergartens and 20 homes of pre-school children, together with 67 semi-structured interviews with caregivers and five kindergarten staff. Thematic analysis was applied and concepts of social learning provided inputs to the analysis. Findings. This study showed that poor living conditions with lack of basic sanitation infrastructures were important barriers for the implementation of safe home child hygiene. Furthermore, the everyday life of highland villages, with parents working away from the households resulted in little daily adult supervision of safe child hygiene practices. While kindergartens were identified as potentially important institutions for improving child hygiene education, essential and well-functioning hygiene infrastructures were lacking. Also, hygiene teaching relied on theoretical and non-practice-based learning styles, which did not facilitate hygiene behaviour change in small children. Minority children were further disadvantaged as teaching was only provided in non-minority language. Conclusions. Kindergartens can be important institutions for the promotion of safe hygiene practices among children, but they must invest in the maintenance of hygiene and sanitation infrastructures and adopt a strong practice-based teaching approach in daily work and in teachers education. To support highland minority children in particular, teaching styles must take local living conditions and caregiver structures into account and teach in local languages. Creating stronger links between home and institutional learning environments can be vital to support disadvantaged highland families in improving child health.

Factors influencing timely initiation and completion of gestational diabetes mellitus screening and diagnosis - a qualitative study from Tamil Nadu, India

BackgroundIn 2007, universal screening for gestational diabetes mellitus (GDM) was introduced in Tamil Nadu, India. To identify factors hindering or facilitating timely initiation and completion of the GDM screening and diagnosis process, our study investigated how pregnant women in rural and urban Tamil Nadu access and navigate different GDM related health services.MethodsThe study was carried out in two settings: an urban private diabetes centre and a rural government primary health centre. Observations of the process of screening and diagnosis at the health centres as well as semi-structured interviews with 30 pregnant women and nine health care providers were conducted. Data was analysed using qualitative content analysis.ResultsThere were significant differences in the process of GDM screening and diagnosis in the urban and rural settings. Several factors hindering or facilitating timely initiation and completion of the process were identified. Timely attendance required awareness, motivation and opportunity to attend. Women had to attend the health centre at the right time and sometimes at the right gestational age to initiate the test, wait to complete the test and obtain the test report in time to initiate further action. All these steps and requirements were influenced by factors within and outside the health system such as getting right information from health care providers, clinic timings, characteristics of the test, availability of transport, social network and support, and social norms and cultural practices.ConclusionsMinimising and aligning complex stepwise processes of prenatal care and GDM screening delivery and attention to the factors influencing it are important for further improving and expanding GDM screening and related services, not only in Tamil Nadu but in other similar low and middle income settings. This study stresses the importance of guidelines and diagnostic criteria which are simple and feasible on the ground.

An investigation into the role of alcohol in self-harm in rural Sri Lanka: a protocol for a multimethod, qualitative study

Introduction Sri Lanka has one of the highest suicide and self-harm rates in the world and although alcohol has been found to be a risk factor for self-harm in Sri Lanka, we know little about the connection between the two. This paper comprises a protocol for a qualitative study investigating alcohols role in self-harm in rural Sri Lanka at three levels: the individual, community and policy level. The analysis will bring new understanding of the link between alcohol and self-harm in Sri Lanka, drawing on structural, cultural and social concepts. It will equip researchers, health systems and policy makers with vital information for developing strategies to address alcohol-related problems as they relate to self-harm. Methods and analysis To capture the complexity of the link between alcohol and self-harm in the Anuradhapura district in the North Central Province in Sri Lanka, qualitative methods will be utilised. Specifically, the data will consist of serial narrative life-story interviews with up to 20 individuals who have non-fatally self-harmed and where alcohol directly or indirectly was involved in the incidence as well as with their significant others; observations in communities and families; six focus group discussions with community members; and key-informant interviews with 15–25 stakeholders who have a stake in alcohol distribution, marketing, policies, prevention and treatment as they relate to self-harm. Ethics and dissemination The study has received ethical approval from the Ethical Review Committee of the Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka. A sensitive data collection technique will be used and ethical issues will be considered throughout the study. Results The results will be disseminated in scientific peer-reviewed articles in collaboration with Sri Lankan and other international research partners.

‘We lost because of his drunkenness’: the social processes linking alcohol use to self-harm in the context of daily life stress in marriages and intimate relationships in rural Sri Lanka

Introduction Harmful alcohol use has been found to cause detriment to the consumers and those around them. Research carried out in Sri Lanka has described the socioeconomic consequences to families owing to alcohol consumption. However, the social processes around alcohol use and how it could result in behaviour such as self-harm was unclear. With an outset in daily life stressors in marriages and intimate relationships we explored alcohol use in families with a recent case of self-harm. Methods Qualitative data were collected for 11 months in 2014 and 2015 in the North Central and North Western provinces of Sri Lanka. Narrative life story interviews with 19 individuals who had self-harmed where alcohol was involved and 25 of their relatives were conducted. Ten focus group discussions were carried out in gender and age segregated groups. An inductive content analysis was carried out. Results Participants experienced two types of daily life stressors: non-alcohol-related stressors, such as violence and financial difficulties, and alcohol-related stressors. The alcohol-related stressors aggravated the non-alcohol-related daily life stressors within marriages and intimate relationships, which resulted in conflict between partners and subsequent self-harm. Women were disproportionately influenced by daily life stressors and were challenged in their ability to live up to gendered norms of marriage. Further, women were left responsible for their own and their husband’s inappropriate behaviour. Self-harm appeared to be a possible avenue of expressing distress. Gendered alcohol and marriage norms provided men with acceptable excuses for their behaviour, whether it was alcohol consumption, conflicts or self-harm. Conclusions This study found that participants experienced both alcohol-related and non-alcohol-related daily life stressors. These two categories of daily life stressors, gender inequalities and alcohol norms should be considered when planning alcohol and self-harm prevention in this setting. Life situations also reflected larger community and structural issues.