Publications by authors named "Gilles de Wildt"

24 Publications

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Exploring women's decisions of where to give birth in the Peruvian Amazon; why do women continue to give birth at home? A qualitative study.

PLoS One 2021 10;16(9):e0257135. Epub 2021 Sep 10.

Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.

Background: Despite improvements in maternal mortality globally, hundreds of women continue to die daily. The World Health Organisation therefore advises all women in low-and-middle income countries to give birth in healthcare facilities. Barriers to seeking intrapartum care have been described in Thaddeus and Maine's Three Delays Model, however these decisions are complex and often unique to different settings. Loreto, a rural province in Peru has one of the highest homebirth rates in the country at 31.8%. The aim of this study was to explore facilitators and barriers to facility births and explore women's experiences of intrapartum care in Amazonian Peru.

Methods: Through purposive sampling, postnatal women were recruited for semi-structured interviews (n = 25). Interviews were transcribed verbatim and thematically analysed. A combination of deductive and inductive coding was used. Analytical triangulation was undertaken, and data saturation was used to determine when no further interviews were necessary.

Results: Five themes were generated from the data: 1) Financial barriers; 2) Accessing care; 3) Fear of healthcare facilities; 4) Importance of seeking care and 5) Comfort and traditions of home. Generally, participants realised the importance of seeking skilled care however barriers persisted, across all areas of the Three Delays Model. Barriers identified included fear of healthcare facilities and interventions, direct and indirect costs, continuation of daily activities, distance and availability of transport. Women who delivered in healthcare facilities had mixed experiences, many reporting good attention, however a selection experienced poor treatment including abusive behaviour.

Conclusion: Despite free care, women continue to face barriers seeking obstetric care in Amazonian Peru, including fear of hospitals, cost and availability of transport. However, women accessing care do not always receive positive care experiences highlighting implications for changes in accessibility and provision of care. Minimising these barriers is critical to improve maternal and neonatal outcomes in rural Peru.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257135PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432815PMC
September 2021

Implementing trachoma control programmes in marginalised populations in Tanzania: A qualitative study exploring the experiences and perspectives of key stakeholders.

PLoS Negl Trop Dis 2021 Sep 10;15(9):e0009727. Epub 2021 Sep 10.

Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom.

Background: Despite aspects of the SAFE strategy for reducing trachoma in Tanzania have been somewhat successful, the disease still persists in marginalised communities even with repeated trachoma control interventions. This study aims to understand the facilitators and barriers associated with implementing trachoma control programmes in these communities, from the perspective of non-governmental organisations (NGOs).

Methods: Participants were the representatives of NGOs who had knowledge and experience in the implementation of trachoma control programmes. Data was collected using in-depth, semi-structured interviews guided by a topic guide, which was updated after each interview using a constant comparative method. Interviews were audio-recorded and then transcribed verbatim. Thematic analysis was done inductively. Codes were generated from the transcripts and then clustered into themes.

Findings: The context within marginalised communities often acted as a perceived barrier to successful implementation of control programmes. This included poor environmental cleanliness, lack of trust, poor disease knowledge and traditional lifestyles. Community values could either be a facilitator or a barrier, depending on the scenario. The anatomical location of the disease and the poor understanding of the disease progression also served as barriers. Considerations affecting decision-making among NGO's include financial feasibility, community needs and whether the quality of the intervention could be improved. NGOs felt that the collaboration and the opportunity to learn from other organisations were beneficial aspects of having different actors. However, this also resulted in variability in the effectiveness of interventions between districts.

Conclusion: NGOs should focus on behaviour change and health education that is tailored to marginalised communities and seek innovative ways to implement trachoma intervention programmes whilst being minimally intrusive to the traditional way of life. Partners should also implement ways to ensure high quality programmes are being provided, by increasing staff accountability and compensating volunteers fairly.
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http://dx.doi.org/10.1371/journal.pntd.0009727DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432809PMC
September 2021

Nurses' and teachers' perceived barriers and facilitators to the uptake of the Human Papilloma Virus (HPV) vaccination program in Iquitos, Peru: A qualitative study.

PLoS One 2021 29;16(7):e0255218. Epub 2021 Jul 29.

Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.

Globally, over 300,000 women die of cervical cancer annually. Given that human papillomavirus vaccines are highly effective in the primary prevention of cervical cancer, it is important to explore the barriers and facilitators to vaccination uptake in areas where the burden of disease remains high. This study, informed by the socio-ecological model, aimed to qualitatively explore vaccination uptake via in-depth interviews with eleven nurses and ten teachers involved in vaccine delivery in Iquitos, Peru. The results highlighted that vaccine uptake was influenced by multiple factors including individuals' knowledge and attitudes, community beliefs, geography, and policy level variables. Findings suggested that professionals were informed and supportive of the HPV vaccination program but perceived that parents were uninformed about the vaccine. There is a need for community education programs, for a revision of the process of obtaining parental consent, for improved communication between professionals and for involvement of grassroots staff in policy making.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255218PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8320989PMC
July 2021

Exploring Perceptions of Female Genital Mutilation/Cutting Abandonment (FGM/C) in Kenyan Health Care Professionals.

Qual Health Res 2021 Jun 4:10497323211015967. Epub 2021 Jun 4.

University of Birmingham, Birmingham, United Kingdom.

Female genital mutilation/cutting (FGM/C) remains a global problem. We aimed to explore Kenyan health care professionals' (HCPs) perceptions of FGM/C abandonment and, in particular, those focused on those serving Maasai communities who continue to practice FGM/C. Using a grounded theory Straussian approach, 18 interviews were conducted with HCPs in Kajiado County, Kenya, to understand perceptions of FGM/C as a cultural practice, identify barriers and facilitators to abandonment, and explore attitudes to medicalization (FGM/C conducted by HCPs) and alternatives of FGM/C. Within a substantive theory, one core category ("FGM/C persists but can be abandoned") comprised two subcategories: "exploring the influencers of persistence" and the "roadmap to abandonment." HCPs believed collaborative multilateral efforts were necessary to support successful abandonment and that "enlightening" the community needed to focus on changing the perception of FGM/C as a social norm alongside a health risk educational approach. Future effective intervention is needed to support the abandonment of FGM/C in Kenya.
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http://dx.doi.org/10.1177/10497323211015967DOI Listing
June 2021

Patients' perspectives on factors facilitating adherence to tuberculosis treatment in Iquitos, Peru: a qualitative study.

BMC Health Serv Res 2021 Apr 14;21(1):345. Epub 2021 Apr 14.

College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.

Background: Tuberculosis is a major global health problem and one of the greatest barriers to its control is poor adherence to treatment. Peru has one of the highest burdens of TB in South America, with an incidence rate of 123 per 100,000 populations. There is currently a lack of evidence in South America about factors that facilitate adherence to treatment, with most previous research focusing on factors that negatively influence adherence to TB treatment.

Setting: This study was conducted in Iquitos, the capital city of the Loreto region, north-eastern Peru. Loreto has a high incidence of tuberculosis, estimated at 99 per 100,000 population, and a high poverty rate.

Methods: Twenty face-to-face, semi-structured interviews were conducted at two healthcare centres. Data collected from the interviews was analysed using thematic content analysis.

Results: Three main themes emerged from the data set. Personal Qualities, such as responsibility and determination, were perceived as important factors facilitating adherence. Participants described their Trust in Healthcare Providers positively, particularly focusing on their trust in clinical staff, although knowledge of tuberculosis and its treatment was limited. Social Support, from a variety of sources, was also seen as a driving factor for continued adherence.

Conclusions: The results suggest that more emphasis should be placed on educating tuberculosis patients about their disease and its treatment. Additionally, consideration should be given to improving the social support available to patients, for example with tuberculosis support groups involving 'expert' tuberculosis patients.
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http://dx.doi.org/10.1186/s12913-021-06329-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048224PMC
April 2021

Improving treatment outcomes for leprosy in Pernambuco, Brazil: a qualitative study exploring the experiences and perceptions of retreatment patients and their carers.

BMC Infect Dis 2021 Mar 19;21(1):282. Epub 2021 Mar 19.

Instituto Lauro de Souza Lima, São Paulo, Brazil.

Background: Brazil has a high leprosy burden and poor treatment outcomes (TOs), manifesting in high relapse rates. Pernambuco, an impoverished Brazilian state suffering notable geographical health inequalities, has 'hyperendemic' leprosy. Although current literature identifies barriers and facilitators influencing leprosy treatment compliance, inadequate investigation exists on other factors influencing TOs, including carers' roles and psycho-dermatological impact. This qualitative study explores experiences and perceptions of leprosy patients and their carers in Pernambuco, Brazil; to identify location-specific factors influencing TOs, and consequently inform future management.

Methods: 27, semi-structured, in-depth interviews were conducted with 14 patients and 13 carers. Participants were recruited using maximum variation and snowball sampling from three clinics in Petrolina, Pernambuco. Transcripts and field notes from both participant groups were separately analysed using conventional thematic and deviant case analysis. The University of Birmingham Internal Research Ethics Committee and Instituto Lauro de Souza Lima provided ethical approval.

Results: Two homologous sets of four, primary, interdependent themes influencing leprosy TOs emerged: 'personal factors'; 'external factors'; 'clinical factors'; and 'the healthcare professional (HCP)-patient-carer relationship'. Poor participant knowledge and lack of symptomatic relief caused patients to distrust treatment. However, because participants thought HCP-led interventions were vital for optimal TOs, patients were effectively persuaded to adhere to pharmaceutical treatments. High standard patient and population education facilitated treatment engagement by encouraging evidence-based medicine belief, and dispelling health myths and stigma. Healthcare, on occasions, was perceived as disorganised, particularly in resource-scarce rural areas, and for those with mental health needs. Participants additionally experienced incorrect/delayed diagnoses and poor contact tracing. Leprosy's negative socio-economic impact on employment - together with stigma, dependency and changing relationships - caused altered senses of identity, negatively impacting TOs. Better dialogue between patients, HCPs and carers facilitated individualised patient support.

Conclusion: This study highlights the importance of: effective evidence-based leprosy education; communication between HCPs, patients and carers; state-funded support; and healthcare resource distribution. These findings, if prioritised on governmental scales, provide the valuable insight needed to inform location-specific management strategies, and consequently improve TOs. Future research should evaluate the effectiveness of these implementations. Failure to address these findings will hinder regional elimination efforts.
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http://dx.doi.org/10.1186/s12879-021-05980-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7980336PMC
March 2021

Views and Experiences of Adults who are Overweight and Obese on the Barriers and Facilitators to Weight Loss in Southeast Brazil: A Qualitative Study.

Int J Qual Stud Health Well-being 2020 Dec;15(1):1852705

College of Medical and Dental Sciences, University of Birmingham , Birmingham, UK.

: Obesity in Brazil is increasing with 54% of the Brazilian population being overweight, of which 20% is obese. Obesity is a risk factor for non-communicable diseases such as cardiovascular disease: the leading cause of mortality in Brazil. This study aims to identify the barriers and facilitators to weight loss as perceived by patients with a view to reducing the burden of obesity-related diseases on patients and healthcare services. : Fifteen qualitative, semi-structured, in-depth interviews were conducted in the preventive medicine department in a private health clinic in Bauru, Southeast Brazil. Inductive thematic analysis was conducted. : The barriers and facilitators were classified into three themes: lifestyle, motivation and education. Barriers include cost of a healthy lifestyle, time management, personal safety, mobility, junk food advertising, sustaining weight loss, mental health, lack of support and health education. Facilitators include change in eating habits, sleep quality, cooperative food networks, access to the multidisciplinary team and expert patients as health educators. : Expert patients should be utilized as an education method, as they increase motivation, promote the facilitators and provide realistic expectations of the weight loss process. Barriers such as junk food advertising and accessibility to treatment need to be addressed. : BMI: Body Mass Index; NCD: Non-Communicable Disease; SUS: Sistema Único de Saúde; WHO: World Health Organization.
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http://dx.doi.org/10.1080/17482631.2020.1852705DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717597PMC
December 2020

HIV understanding, experiences and perceptions of HIV-positive men who have sex with men in Amazonian Peru: a qualitative study.

BMC Public Health 2020 May 19;20(1):728. Epub 2020 May 19.

Department of Infectious Diseases, Regional Hospital of Loreto, Iquitos, Peru.

Background: HIV-related incidence and mortality is increasing across Peru, with highest mortality rates recorded in the Amazonian region of Loreto. This epidemic is concentrated in men who have sex with men, a population with 14% HIV treatment adherence despite free national provision. This study investigates barriers and facilitators to following healthcare advice through experiences and perceptions of HIV-positive men who have sex with men and healthcare professionals in Loreto.

Methods: Twenty qualitative interviews with HIV-positive men who have sex with men and one focus group with HIV-specialist healthcare professionals were conducted in Loreto, January-February 2019. Interviews were transcribed per verbatim. Thematic content analysis and deviant case analysis were used.

Results: A culture of isolation and discrimination was identified, propagated by poor public knowledge surrounding HIV transmission and treatment. Employment potential was hampered and 7/20 patients had suicidal thoughts post-diagnosis. Barriers to care included: shame, depression, travel cost/times, a preference for traditional plant-based medicine and side-effects of antiretroviral therapy. Facilitators included: education, family and clinic support, disease acceptance and lifestyle changes.

Conclusion: More effective, focussed community education and workplace discrimination investigations are recommended to reduce stigma and increase adherence to treatment in this population.
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http://dx.doi.org/10.1186/s12889-020-08745-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238527PMC
May 2020

The timing and quality of antenatal care received by women attending a primary care centre in Iquitos, Peru: A facility exit survey.

PLoS One 2020 5;15(3):e0229852. Epub 2020 Mar 5.

Bristol Medical School, Population Health Sciences, Southmead Hospital, University of Bristol, Bristol, United Kingdom.

Background: Maternal mortality is high in Loreto, Peru, but can be reduced by high quality antenatal care. Indicators for the quality of antenatal care received include the timing (with respect to gestational age) and number of antenatal appointments attended, the delivery of antenatal services and health information, and women's perceptions about their care. This study investigated these indicators amongst women receiving antenatal care in predominantly the San Juan Bautista district of Iquitos, Loreto. This was to identify areas for improvement through comparison with antenatal guidelines published by the Ministry of Health, Peru, and the World Health Organization.

Methods: A total of 134 women were recruited at the Centro de Salud, San Juan-a primary care centre in Iquitos. Information about the delivery of antenatal services and the number of and gestational ages at appointments attended was collected from 121/134 women's hand-held antenatal cards. The delivery of health information and women's perceptions about their antenatal care were investigated through questionnaires (133/134 completed). Descriptive statistics, such as frequencies and valid percentages, were determined.

Results: Hand-held antenatal cards revealed that 52.9% of participants began their antenatal care in the first trimester. Compared to national guidelines, 42.1% attended appointments at recommended gestational ages and no women received all recommended antenatal services. Most women received information about identifying complications in pregnancy and health and lifestyle topics. Over 85% of women reported satisfaction with their antenatal care.

Conclusions: Timely antenatal attendance and delivery of services should be encouraged to meet national and global standards. Although all services were not delivered in a combined manner according to national guidelines, individual services were mostly delivered to a high standard and therefore a high proportion of women were satisfied with their antenatal care.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229852PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058332PMC
June 2020

Improving outcomes for multi-drug-resistant tuberculosis in the Peruvian Amazon - a qualitative study exploring the experiences and perceptions of patients and healthcare professionals.

BMC Health Serv Res 2019 Aug 22;19(1):594. Epub 2019 Aug 22.

Facultad de Medicina Humana, Universidad Nacional de la Amazonia Peruana, Iquitos, Peru.

Background: Management for multi-drug-resistant tuberculosis (MDR-TB) is challenging and has poor patient outcomes. Peru has a high burden of MDR-TB. The Loreto region in the Peruvian Amazon is worst affected for reasons including high rates of poverty and poor healthcare access. Current evidence identifies factors that influence MDR-TB medication adherence, but there is limited understanding of the patient and healthcare professional (HCP) perspective, the HCP-patient relationship and other factors that influence outcomes. A qualitative investigation was conducted to explore and compare the experiences and perceptions of MDR-TB patients and their dedicated HCPs to inform future management strategies.

Method: Twenty-six, semi-structured in-depth interviews were conducted with 15 MDR-TB patients and 11 HCPs who were purposively recruited from 4 of the worst affected districts of Iquitos (capital of the Loreto region). Field notes and transcripts of the two groups were analysed separately using thematic content analysis. Ethics approval was received from the Institutional Research Ethics Committee, Department of Health, Loreto, and the University of Birmingham Internal Research Ethics Committee.

Results: Four key themes influencing patient outcomes emerged in each participant group: personal patient factors, external factors, clinical factors, and the HCP-patient relationship. Personal factors included high standard patient and population knowledge and education, which can facilitate engagement with treatment by encouraging belief in evidence-based medicine, dispelling belief in natural medicines, health myths and stigma. External factors included the adverse effect of the financial impact of MDR-TB on patients and their families. An open, trusting and strong HCP-patient relationship emerged as a vitally important clinical factor influencing of patient outcomes. The results also provide valuable insight into the dynamic of the relationship and ways in which a good relationship can be fostered.

Conclusions: This study highlights the importance of financial support for patients, effective MDR-TB education and the role of the HCP-patient relationship. These findings add to the existing evidence base and provide insight into care improvements and policy changes that could improve outcomes if prioritised by local and national government.
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http://dx.doi.org/10.1186/s12913-019-4429-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704631PMC
August 2019

A qualitative exploration of women's experiences of antenatal and intrapartum care: The need for a woman-centred approach in the Peruvian Amazon.

PLoS One 2019 7;14(1):e0209736. Epub 2019 Jan 7.

Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.

Objective: To explore women's experiences and perceptions of antenatal and intrapartum care in the Peruvian Amazon, including their perceived motivators, enablers and barriers to accessing care.

Design: Interpretive descriptive qualitative study using semi-structured face-to-face interviews.

Setting: Primary healthcare centre, Iquitos, Peru.

Participants: Women (n = 20) attending the healthcare centre who had given birth in the past 6 months.

Measures: Interviews were conducted using a female interpreter, transcribed clean verbatim and thematically analysed.

Findings: Four core themes relating to antenatal care were interpreted. (1) Perceived knowledge of antenatal care and its importance: women generally understood the importance of care, mainly for their baby's health rather than their own. (2) Appointments and information received: women wanted more appointments to facilitate greater depth of information relating to their pregnancy. (3) Interaction with healthcare practitioners: women felt they received inadequate attention, care lacked continuity and they were often uncomfortable with male practitioners. (4) Perceived motivators, barriers and enablers to accessing antenatal care: Knowledge of the importance of care acted as the main motivator. Few direct barriers were identified, other than employment. Free care and ease of access enabled attendance. Two core themes were interpreted relating to intrapartum care. (1) Expectations and preferences for labour and delivery: the need for a safe environment for childbirth was acknowledged. (2) Actual experiences of labour and delivery: for most women labour and delivery experiences were not as they had expected. Women objected less to male professionals during labour than antenatal care.

Conclusions And Implications For Practice: Women reported negative experiences of both antenatal and intrapartum care. There is clearly a need for a more woman-centred approach to care and service provision. Ideally, this would involve employing more staff, acknowledging the implications on resources, improving attitudes towards women, facilitating continuity of care, and allowing patient choice to give women greater involvement.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0209736PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6322728PMC
September 2019

Perceptions and experiences regarding the impact of race on the quality of healthcare in Southeast Brazil: a qualitative study.

Ethn Health 2020 04 24;25(3):436-452. Epub 2018 Jan 24.

University of Birmingham, Birmingham, UK.

To explore the impact of race on the quality of healthcare received by patients attending a primary care centre in Brazil. This was a qualitative study consisting of 19 semi-structured interviews conducted on patients from six racial groups (as defined in Brazil as white, yellow, brown, black and indigenous and one self-identified 'other' group). The interviews were analysed using thematic analysis. Four main themes were identified during analysis; factors affecting the access to healthcare, experiences regarding quality of healthcare, discrimination in healthcare and deep-rooted societal discrimination, which were categorised into a number of sub-themes. Within these themes, interviewees reported (1) experiences of racism in society towards the black racial group, (2) one personal perception and two observations of racial discrimination in healthcare, (3) perceived racial discrimination due to healthcare professional behaviour and (4) other factors, such as delays in appointments and long waiting times in health facilities were felt to impact access to care. The findings suggest that racial discrimination exists in Brazilian society but its direct impact on healthcare access was felt to be less obvious. Instead, organisational level factors were felt to contribute to difficulty accessing care. Interviewees perceived that racial discrimination may affect the quality of care, particularly for those designated as 'black'. Socio-economic factors were felt to influence discrimination in healthcare. The findings can help inform further studies and educational initiatives to help address discrimination and access to healthcare in Brazil.
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http://dx.doi.org/10.1080/13557858.2018.1431206DOI Listing
April 2020

Preventing malaria in the Peruvian Amazon: a qualitative study in Iquitos, Peru.

Malar J 2018 Jan 16;17(1):31. Epub 2018 Jan 16.

College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.

Background: In Peru, despite decades of concerted control efforts, malaria remains a significant public health burden. Peru has recently exhibited a dramatic rise in malaria incidence, impeding South America's progress towards malaria elimination. The Amazon basin, in particular the Loreto region of Peru, has been identified as a target for the implementation of intensified control strategies, aiming for elimination. No research has addressed why vector control strategies in Loreto have had limited impact in the past, despite vector control elsewhere being highly effective in reducing malaria transmission. This study employed qualitative methods to explore factors limiting the success of vector control strategies in the region.

Methods: Twenty semi-structured interviews were conducted among adults attending a primary care centre in Iquitos, Peru, together with 3 interviews with key informants (health care professionals). The interviews focussed on how local knowledge, together with social and cultural attitudes, determined the use of vector control methods.

Results: Five themes emerged. (a) Participants believed malaria to be embedded within their culture, and commonly blamed this for a lack of regard for prevention. (b) They perceived a shift in mosquito biting times to early evening, rendering night-time use of bed nets less effective. (c) Poor preventive practices were compounded by a consensus that malaria prevention was the government's responsibility, and that this reduced motivation for personal prevention. (d) Participants confused the purpose of space-spraying. (e) Participants' responses also exposed persisting misconceptions, mainly concerning the cause of malaria and best practices for its prevention.

Conclusion: To eliminate malaria from the Americas, region-specific strategies need to be developed that take into account the local social and cultural contexts. In Loreto, further research is needed to explore the potential shift in biting behaviour of Anopheles darlingi, and how this interacts with the population's social behaviours and current use of preventive measures. Attitudes concerning personal responsibility for malaria prevention and long-standing misconceptions as to the cause of malaria and best preventive practices also need to be addressed.
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http://dx.doi.org/10.1186/s12936-018-2177-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5771103PMC
January 2018

The prevalence and risk factors for acute respiratory infections in children aged 0-59 months in rural Malawi: A cross-sectional study.

Influenza Other Respir Viruses 2017 11 30;11(6):489-496. Epub 2017 Sep 30.

Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.

Background: Acute Respiratory Infections (ARI) are a leading cause of childhood mortality and morbidity. Malawi has high childhood mortality but limited data on the prevalence of disease in the community.

Methods: A cross-sectional study of children aged 0-59 months. Health passports were examined for ARI diagnoses in the preceding 12 months. Children were physically examined for malnutrition or current ARI.

Results: 828 children participated. The annual prevalence of ARI was 32.6% (95% CI 29.3-36.0%). Having a sibling with ARI (OR 1.44, P = .01), increasing household density (OR 2.17, P = .02) and acute malnutrition (OR 1.69, P = .01) were predictors of infection in the last year. The point prevalence of ARI was 8.3% (95% CI 6.8-10.4%). Risk factors for current ARI were acute-on-chronic malnutrition (OR 3.06, P = .02), increasing household density (OR1.19, P = .05) and having a sibling with ARI (OR 2.30, P = .02).

Conclusion: This study provides novel data on the high prevalence of ARI in Malawi. This baseline data can be used in the monitoring and planning of future interventions in this population.
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http://dx.doi.org/10.1111/irv.12481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5705682PMC
November 2017

"We need people to collaborate together against this disease": A qualitative exploration of perceptions of dengue fever control in caregivers' of children under 5 years, in the Peruvian Amazon.

PLoS Negl Trop Dis 2017 Sep 5;11(9):e0005755. Epub 2017 Sep 5.

Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.

Background: Dengue Fever presents a significant and growing burden of disease to endemic countries, where children are at particular risk. Worldwide, no effective anti-viral treatment has been identified, thus vector control is key for disease prevention, particularly in Peru where no vaccine is currently available. This qualitative study aimed to explore the perceptions of dengue control in caregivers' of children under 5 years in Peru, to help direct future mosquito control programmes and strategy.

Methods: Eighteen semi-structured interviews were conducted in one health centre in Iquitos, Peru. Interviews were audio-recorded, transcribed and translated by an independent translator. Data were analysed using an inductive thematic approach.

Findings: Three core analytic themes were interpreted: (1) awareness of dengue and its control, (2) perceived susceptibility of children, rural riverside communities and city inhabitants, and (3) perceived responsibility of vector control. Participants were aware of dengue symptoms, transmission and larvae eradication strategies. Misconceptions about the day-time biting behaviour of the Aedes aegypti mosquito and confusion with other mosquito-borne diseases influenced preventative practice. Community-wide lack of cooperation was recognised as a key barrier. This was strengthened by attitudes that the government or health centre were responsible for dengue control and a belief that the disease cannot be prevented through individual actions. Participants felt powerless to prevent dengue due to assumed inevitability of infection and lack of faith in preventative practices. However, children and rural communities were believed to be most vulnerable.

Conclusions: Perceptions of dengue control amongst caregivers to under 5's were important in shaping their likelihood to participate in preventative practices. There is a need to address the perceived lack of community cooperation through strategies creating a sense of ownership of community control and enhancing social responsibility. The belief that dengue cannot be prevented by individual actions in a community also warrants attention. Specific misconceptions about dengue should be addressed through the community health worker system and further research directed to identify the needs of certain vulnerable groups.
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http://dx.doi.org/10.1371/journal.pntd.0005755DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5600389PMC
September 2017

Hepatitis B: A cross-sectional survey of knowledge, attitudes and practices amongst backpackers in Thailand.

Travel Med Infect Dis 2017 Jan - Feb;15:57-62. Epub 2016 Nov 23.

University of Birmingham, Edgbaston, Birmingham, West Midlands, B15 2TT, England.

Background: In 2013, 200 million tourists visited countries that are endemic for hepatitis B virus (HBV). Backpackers are potentially at greater risk of hepatitis B than other travellers yet exposure to HBV remains under researched in this population.

Method: A cross-sectional survey of backpackers visiting two islands in Thailand was performed during early 2015. Participation in activities with high HBV exposure risk was recorded, alongside rates of vaccination and an evaluation of knowledge and attitudes towards the risk of HBV.

Results: 1680 questionnaires were completed and analysed; the median participant age was 24 (range: 18-68) and 47.9% were male. 20.8% took part in activities with a high risk of HBV exposure. Over two-thirds of the sample were not protected against HBV. 24% were able to correctly identify HBV transmission methods. 44.1% underestimated the risk of HBV in Thailand.

Conclusions: The proportion of backpackers participating in high-risk activities was double the level found in previous studies that have examined the HBV exposure risk amongst travellers to endemic countries. Voluntary risk activities were the largest source of potential exposure to HBV and rates of vaccination are low. Backpackers should be considered for routine vaccination and education on risk behaviours should be included in the pre-travel consultation.
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http://dx.doi.org/10.1016/j.tmaid.2016.11.008DOI Listing
May 2017

Factors Contributing to the Delay in Diagnosis and Continued Transmission of Leprosy in Brazil--An Explorative, Quantitative, Questionnaire Based Study.

PLoS Negl Trop Dis 2016 Mar 15;10(3):e0004542. Epub 2016 Mar 15.

Department of Clinical Immunology, School of Infection and Immunity, University of Birmingham, Birmingham, United Kingdom.

Background: Leprosy is a leading cause of preventable disability worldwide. Delay in diagnosis of patients augments the transmission of infection, and allows progression of disease and more severe disability. Delays in diagnosis greater than ten years have been reported in Brazil. To reduce this delay, it is important to identify factors that hinder patients from presenting to doctors, and those that delay doctors from diagnosing patients once they have presented. This study aimed to explore factors associated with the delayed diagnosis of leprosy in Brazil.

Methodology/ Principal Findings: This is an exploratory study using a self-constructed questionnaire delivered to patients attending three leprosy referral clinics across three states in Brazil. Data were analysed to determine associations between variables and the time taken for participants to present to the health-service, and between variables and the time taken for doctors to diagnose participants once they had presented. Participants who suspected they had leprosy but feared community isolation were 10 times more likely to wait longer before consulting a doctor for their symptoms (OR 10.37, 95% CI 2.18-49.45, p = 0.003). Participants who thought their symptoms were not serious had a threefold greater chance of waiting longer before consulting than those who did (OR 3.114, 95% CI 1.235-7.856, p = 0.016). Forty-two point six per cent of participants reported initially receiving a diagnosis besides leprosy. These had a three times greater chance of receiving a later diagnosis of leprosy compared to those not misdiagnosed or not given a diagnosis (OR 2.867, 95% CI 1.288-6.384, p = 0.010).

Conclusions/ Significance: This study implies a need for patient education regarding leprosy symptoms and the reduction of stigma to encourage patients to present. The high rate of misdiagnosis reported suggests a need to increase clinician suspicion of leprosy. Further education regarding disease symptoms in medical school curriculums may be advisable.
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http://dx.doi.org/10.1371/journal.pntd.0004542DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4792453PMC
March 2016

The patient perspective of the diagnostic process for leprosy in Brazil. An exploratory study.

Lepr Rev 2015 Mar;86(1):21-36

Objectives: To explore the patient experience of being diagnosed with leprosy and the support provided during this process in selected populations in Brazil. To understand the information needs of patients during diagnosis. To identify characteristics of patients with different diagnostic experiences. To add to the evidence base used for improving the diagnostic process for leprosy patients.

Design: A self-constructed questionnaire delivered to 116 participants, at three leprosy health centres, across three states in Brazil.

Results: Most participants felt under-informed during diagnosis; 68.1% wanted more information about leprosy. Nearly one-quarter of patients reported feeling unable to ask questions at diagnosis. Almost half of patients reported being worried about treatment, yet 43.3% reported not having the chance to talk about their concerns. Younger participants were significantly more likely to report feeling unable to ask questions and talk about their worries. The majority of participants (59.5%) reported not being given any written information to take away with them. 36.5% reported not being given advice about how to reduce the chance of other family members becoming ill with leprosy. Older males were most likely to be given this advice despite females being in most contact with family members in most cultures.

Conclusions: It is recommended that patients are encouraged to ask questions and invited to talk about their concerns, particularly younger patients. It is recommended that a simple information leaflet be provided to all patients. These suggestions may require some financial input, more staff and longer consultations but should significantly improve the diagnostic process.
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March 2015

An assessment of surgical and anesthesia staff at 10 government hospitals in Sierra Leone.

JAMA Surg 2015 Mar;150(3):237-44

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: Strengthening workforce capacity to deliver essential surgical and anesthesia care has been identified as a strategy for addressing the unmet burden of morbidity and mortality in under-resourced countries. Sierra Leone is one of the poorest countries in the world and faces the challenge of stretching limited resources to provide appropriate health care for a population of 6 million.

Objectives: To investigate the training of surgical and anesthesia staff in Sierra Leone and to build an evidence base for future health care policy and training programs tailored to local needs.

Design, Setting, And Participants: Health care professionals who conduct surgery or deliver anesthesia at 10 of the 23 government hospitals in Sierra Leone were surveyed regarding training and clinical practices. This study surveyed 36 of 70 surgical staff (51%) and 38 of 68 nurse specialists (56%) nationally.

Main Outcomes And Measures: Descriptive analysis of demographic details, training levels, and reported needs for future development.

Results: Thirty-six surgeons were surveyed in study hospitals, of whom the majority had limited surgical specialization training, whereas most anesthesia was provided by 47 nurse specialists. All consultants had postgraduate qualifications, but 4 of 6 medical superintendents (67%) and all medical officers lacked postgraduate surgical qualifications or formal surgical specialist training. The number of trained anesthesia staff increased after the introduction of the Nurse Anesthesia Training Program in 2008, funded by the United Nations Fund for Population Activities, increasing the number from 2 to 47 anesthesia staff based at the study hospitals. Although 32 of 37 nurse anesthetists (86%) reported having attended training workshops, 30 of 37 (>80%) described anesthesia resources as "poor," reporting a critical need for anesthesia machines and continual oxygen supply. Of the 37, 25 specifically mentioned the need for a better-functioning anesthesia machine and 16 mentioned the need for oxygen.

Conclusions And Relevance: To address unmet surgical need in the long term, accredited local surgical specialization programs are required; training of nonphysician surgical practitioners may offer a short-term solution. To develop safe anesthesia care, governments and donors should focus on providing health care professionals with essential equipment and resources.
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http://dx.doi.org/10.1001/jamasurg.2014.2246DOI Listing
March 2015

Health-seeking behaviour for schistosomiasis: a systematic review of qualitative and quantitative literature.

Pan Afr Med J 2013 5;16:130. Epub 2013 Dec 5.

School of Health and Population Sciences, Primary Care Clinical Sciences, University of Birmingham, UK.

Schistosomiasis is a chronic and debilitating parasitic disease acquired through contact with infested freshwater. An essential component of its control is passive case finding, which, in order to be effective, requires a detailed understanding of health-seeking behaviour. This study aimed to systematically review evidence on health-seeking behaviour for schistosomiasis, in order to determine factors influencing use or non-use of modern health services for the infection. Quantitative, qualitative and mixed method studies reporting on factors related to seeking treatment from modern health services for schistosomiasis were obtained, combining electronic and hand searching. Data extraction and quality assessment of the included articles were performed, with all studies qualitatively analysed using thematic synthesis. A total of 19 studies were included in the review. Six themes were identified from the analysis: biomedical knowledge on schistosomiasis, perceptions of modern treatment and health services, financial considerations of treatment, perceptions on the symptoms, stigma of the infection, and physical location and community. These findings were consistent across studies of different design, setting and quality. Many of the themes identified echo existing literature on health-seeking behaviour. The synthesis also highlighted the role of stigma, and aspects of the physical location and community that may affect treatment-seeking for schistosomiasis. Health education programmes that intend to improve the utilisation of modern health services for the infection need to acknowledge the multiple determinants influencing their use. Future research should move beyond describing health-seeking behaviour to identifying the factors that underlay such behaviour.
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http://dx.doi.org/10.11604/pamj.2013.16.130.3078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4021984PMC
November 2014

Patents or patients? Global access to pharmaceuticals and social justice.

Med Confl Surviv 2008 Apr-Jun;24 Suppl 1:S52-61

Jiggins Lane Medical Centre, Birmingham, UK.

Innovation, vaccine development, and world-wide equitable access to necessary pharmaceuticals are hindered by current patenting arrangements and the orientation of pharmaceutical research. Plausible alternatives exist, including instituting the right of national or international agencies to act in the public interest and to buy patents selectively with a view to innovation and equitable access. Alternatives could partly or wholly finance themselves and lower pharmaceutical prices globally. Countries, individuals or groups of patients could help promote alternatives by calling into question the current emphasis on commercialization and profit, and by demanding globally equitable arrangements when sharing data that are important for research or when individuals or communities volunteer as research participants.
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http://dx.doi.org/10.1080/13623690801957380DOI Listing
October 2008
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