Zelee Hill

Recognizing childhood illnesses and their traditional explanations: exploring options for care‐seeking interventions in the context of the IMCI strategy in rural Ghana

Objectives Interventions that promote appropriate care‐seeking for severely ill children have the potential to substantially reduce child mortality in developing countries, but little is known about the best approach to address the issue. This paper explores the relative importance of illness recognition as a barrier to care‐seeking and the feasibility and potential impact of improving recognition.

Informed consent in Ghana: what do participants really understand?

Objectives: To explore how subjects in a placebo-controlled vitamin A supplementation trial among Ghanaian women aged 15–45 years perceive the trial and whether they know that not all trial capsules are the same, and to identify factors associated with this knowledge. Methods: 60 semistructured interviews and 12 focus groups were conducted to explore subjects’ perceptions of the trial. Steps were taken to address areas of low comprehension, including retraining fieldworkers. 1971 trial subjects were randomly selected for a survey measuring their knowledge that not all trial capsules are the same. The subjects’ fieldworkers were also interviewed about their characteristics and trial knowledge. Factors associated with knowledge were explored using multi-level modeling. Results: Although subjects knew they were taking part in research, most thought they were receiving an active and beneficial medication. Variables associated with knowledge were education and district of residence. Radio broadcasts benefited those with some schooling. Fieldworkers’ characteristics were not associated with subjects’ knowledge. Conclusions: Research and debate on new or improved consent procedures are urgently required, particularly for subjects with little education.

Patterns of adherence to antiretrovirals: why adherence has no simple measure.

The goal of this study was to explore patterns and explanations of adherence to antiretroviral therapies from the patients perspective. It consisted of 78 in-depth interviews with patients attending an HIV clinic in New Orleans, Louisiana, to whom combination therapy had been prescribed. Interviews explored patients definitions of adherence, beliefs about consequences of nonadherence, reasons for current and past adherence behavior, and contextual issues such as drug and alcohol use and social support. Respondents reported nine distinct patterns of adherence, which they perceived to have different consequences and causes. These patterns hid variations because respondents could have more than one pattern simultaneously and patterns were not stable over time. Although there are gold standards for adherence measurement, such as directly observed therapy, these measurements are most frequently used to classify respondents as adherers or nonadherers based on whether they take a certain percentage of their medication. Such a categorization is simplistic and does not reflect the complexity of adherence patterns.

Religious affiliation and extramarital sex among men in Brazil

CONTEXTnSince 1990, HIV infection in Brazil has spread among the heterosexual population, particularly in the north. Containment of the epidemic can be informed by a better understanding of mens sexual risk behavior.nnnMETHODSnLogistic, Poisson and multilevel logit models were applied to data on married and cohabiting men who had participated in the 1996 Brazilian Demographic and Health Survey.nnnRESULTSnTwelve percent of married or cohabiting men reported having had at least one extramarital partner in the previous 12 months; half of these had had two or more. The majority (77%) of partners were described as friends or lovers; 4% had been prostitutes and 15% strangers. Among men who had had sex with an extramarital partner in the last year, 40% reported having used condoms during last extramarital sex. Compared with members of evangelical religions, other men were significantly more likely to report having had an extramarital partner (odds ratios, 3.0-4.7) and unprotected extramarital sex in the last 12 months (3.4-7.9). Region of residence was also strongly correlated with extramarital sex: Compared with men in southern or central Brazil, those in the north had more than three times the odds of having had extramarital sex and unprotected extramarital sex in the last year (3.1-3.8).nnnCONCLUSIONnIn Brazil, religious affiliation and region of residence exert a major influence on risk behavior.

Factors that affect the adoption and maintenance of weekly vitamin A supplementation among women in Ghana

OBJECTIVEnTo identify regimen, individual, community and cultural factors that affect adoption and adherence to weekly vitamin A supplementation in Ghana.nnnDESIGNnFifty semi-structured interviews were conducted with women who would be eligible for vitamin A supplementation, 30 with husbands, and 13 with drug sellers, birth attendants and health workers. Six focus group discussions were also conducted with women. These interviews were followed by a 4-month capsule trial with 60 women. Data from a previously conducted communication channel survey of 332 women were also reviewed.nnnSETTINGnThe study was conducted in Kintampo District in central Ghana.nnnSUBJECTSnParticipants for the semi-structured interviews and focus groups were selected from four villages and the district capital, and women in the capsule trial were selected at random from two villages.nnnRESULTSnKnowledge of vitamins was low and taking medicines for long periods and when healthy is a new concept. In spite of this, long-term supplementation will be accepted if motives are explained, specific questions answered and clear instructions are given. Potential barriers included the idea of doctor medicines as curative, false expectations of the supplement, forgetting to take the supplement, losing the supplement, travelling, lack of motivation, perceived side-effects, concerns that the supplement is really family planning or will make delivery difficult, and concerns about taking the supplement with other doctor or herbal medicine, or when pregnant or breast-feeding, or if childless.nnnCONCLUSIONnSuccessful supplementation programmes require appropriately designed information, education and communication strategies. Designing such strategies requires pre-programme formative research to uncover barriers and facilitators for supplementation.

Nothing new: responses to the introduction of antiretroviral drugs in South Africa

Interviews conducted in South Africa found that awareness of antiretroviral therapy was generally poor. Antiretroviral drugs were not perceived as new, but one of many alternative therapies for HIV/AIDS. Respondents had more detailed knowledge of indications, effects and how to access alternative treatments, which is bolstered by the active promotion and legitimization of alternative treatments. Many expressed a lack of excitement about the introduction of antiretroviral therapy, and little change in their attitudes concerning the epidemic.

Evaluating the implementation of community volunteer assessment and referral of sick babies: lessons learned from the Ghana Newhints home visits cluster randomized controlled trial

A World Health Organization (WHO)/United Nations Childrens Fund (UNICEF) (2009) joint statement recommended home visits by community-based agents as a strategy to improve newborn survival, based on promising results from Asia. This article presents detailed evaluation of community volunteer assessment and referral implemented within the Ghana Newhints home visits cluster-Randomized Controlled Trial (RCT). It highlights the lessons learned to inform implementation/scale-up of this model in similar settings. The evaluation used a conceptual framework adopted for increasing access to care for sick newborns and involves three main steps, each with a specific goal and key requirements to achieving this. These steps are: sick newborns are identified within communities and referred; families comply with referrals and referred babies receive appropriate management at health facilities. Evaluation data included interviews with 4006 recently delivered mothers; records on 759 directly observed volunteer assessments and 52 validation of supervisors’ assessments; newborn care quality assessment in 86 health facilities and in-depth interviews (IDIs) with 55 mothers, 21 volunteers and 15 health professionals. Assessment accuracy of volunteers against supervisors and physician was assessed using Kappa (agreement coefficient). IDIs were analysed by generating and indexing into themes, and exploring relationships between themes and their contextual interpretations. This evaluation demonstrated that identifying, understanding and implementing the key requirements for success in each step of volunteer assessment and referrals was pivotal to success. In Newhints, volunteers (CBSVs) were trusted by families, their visits were acceptable and they engaged mothers/families in decisions, resulting in unprecedented 86% referral compliance and increased (55–77%) care seeking for sick newborns. Poor facility care quality, characterized by poor health worker attitudes, limited the mortality reduction. The important implication for future implementation of home visits in similar settings is that, with 100% specificity but 80% sensitivity of referral decisions, volunteers might miss some danger signs but if successful implementation must translate into mortality reductions, concurrent improvement in facility newborn care quality is imperative.

Effect of vitamin A supplementation on cause-specific mortality in women of reproductive age in Ghana: A secondary analysis from the ObaapaVitA trial | Effet de la supplémentation en vitamine A sur la mortalité relative chez les femmes en âge de procréer au Ghana: Une analyse secondaire de l'étude ObaapaVitA

OBJECTIVEnTo determine the effect of weekly low-dose vitaminxa0A supplementation on cause-specific mortality in women of reproductive age in Ghana.nnnMETHODSnA cluster-randomized, triple-blind, placebo-controlled trial was conducted in seven districts of the Brong Ahafo region of Ghana. Women aged 15-45 years who were capable of giving informed consent and intended to live in the trial area for at least 3xa0months were enrolled and randomly assigned, according to their cluster of residence, to receive oral vitaminxa0A (7500 μg) or placebo once a week. Randomization was blocked, with two clusters in each fieldwork area allocated to vitaminxa0A and two to placebo. Every 4xa0weeks, fieldworkers distributed capsules and collected data during home visits. Verbal autopsies were conducted by field supervisors and reviewed by physicians, who assigned a cause of death. Cause-specific mortality rates in both arms were compared by means of random-effects Poisson regression models to allow for the cluster randomization. Analysis was by intention-to-treat, based on cluster of residence, with women eligible for inclusion once they had consistently received the supplement or placebo capsules for 6xa0months.nnnFINDINGSnThe analysis was based on 581u2009870 woman-years and 2624 deaths. Cause-specific mortality rates were found to be similar in the two study arms.nnnCONCLUSIONnLow-dose vitaminxa0A supplements administered weekly are of no benefit in programmes to reduce mortality in women of childbearing age.