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Desmond N.,International Health Group | Desmond N.,Malawi Liverpool Wellcome Trust Research Programme | Desmond N.,Medical Research Council | Prost A.,Medical Research Council | And 2 more authors.
Health, Risk and Society | Year: 2012

This paper examines how risk is perceived by lay populations in response to two aetiologically connected but conceptually divided diseases - malaria and nzoka. Using case study data from an ethnographic study of risk perceptions in north-western Tanzania, we explore the relevance of risk as a concept within a community exposed to traditional and modern value systems, a pluralistic health care system and syncretic treatment-seeking behaviour. We found that the concept of risk was a useful heuristic device, but that what was categorised as risk reflected different social circumstances. The findings reinforce the evidence for risk and risk perception as cultural products. Using empirical examples of experiences with malaria and nzoka, we highlight difficulties in illness recognition, particularly with common symptoms such as high fevers and convulsions in this case. We show how risky decisions over appropriate treatment-seeking were informed by processes of categorisation and re-categorisation as the patient and their family negotiate a solution to illness. We show how this process of risk re-categorisation is framed by social context, hinges on peer and professional advice and responses to treatment, and how this process often continues after treatment ends through recovery or death. We conclude by emphasising the way in which awareness of categorisation as a risky practice in illness management increases the salience of treatment-seeking considered as risk, exacerbating the 'actual' risks of experiencing illness. © 2012 Copyright Taylor and Francis Group, LLC. Source


Chikovore J.,Sexually Transmitted Infections and Tuberculosis Unit | Chikovore J.,Malawi Liverpool Wellcome Trust Research Programme | Nystrom L.,Umea University | Lindmark G.,Uppsala University Hospital | And 2 more authors.
PLoS ONE | Year: 2013

Young people face sexual and reproductive health (SRH) problems including Human immunodeficiency virus (HIV) and Acquired immunodeficiency syndrome (AIDS). It is critical to continue documenting their situation including the contexts they live in. As part of a larger study that explored perspectives of men to SRH and more specifically abortion and contraceptive use, 546 pupils (51% female; age range 9-25 years) from a rural area in Zimbabwe were invited to write anonymously questions about growing up or other questions they could not ask adults for fear or shame. The pupils were included following descriptions by adults of the violence that is unleashed on unmarried young people who engaged in sex, used contraceptives, or simply suggested doing so. The questions by the young people pointed to living in a context of prohibitive silence; their sexuality was silenced and denied. As a consequence they had poor knowledge and their fears and internal conflicts around sexuality and pregnancy were not addressed. Current action suggests concerted effort at the policy level to deal with young people's SRH in Zimbabwe. It nevertheless remains necessary, as a way to provide support to these efforts, to continue examining what lessons can be drawn from the past, and how the past continues to reflect in and shape present dynamics and relations. There is also need to look more critically at life skill education, which has previously been described as having failed to address adequately the practical needs of young people. Life skill education in Zimbabwe has rarely been systematically evaluated. A fuller understanding is also needed of the different factors co-existing in contemporary African societies and how they have been and continue to be constituted within history, and the implications to the promotion of adolescent SRH. © 2013 Chikovore et al. Source


Desmond N.A.,Malawi Liverpool Wellcome Trust Research Programme | Nyirenda D.,Malawi Liverpool Wellcome Trust Research Programme | Dube Q.,University of Malawi | Mallewa M.P.,Malawi Liverpool Wellcome Trust Research Programme | And 2 more authors.
PLoS ONE | Year: 2013

Objective: High mortality burden from Acute Bacterial Meningitis (ABM) in resource-poor settings has been frequently blamed on delays in treatment seeking. We explored treatment-seeking pathways from household to primary health care and referral for ABM in Malawi. Design: A cross-sectional qualitative study using narrative in-depth interviews, semi-structured interviews and focus group discussions. Participants: Adults and children with proven and probable acute bacterial meningitis and/or their carers; adults from urban and peri-urban communities; and primary health care workers (HCW). Setting: Queen Elizabeth Central Hospital (QECH), urban and peri-urban private and government primary health centres and communities in Blantyre District, Malawi. Results: Whilst communities associated meningitis with a stiff neck, in practice responses focused on ability to recognise severe illness. Misdiagnosis of meningitis as malaria was common. Subsequent action by families depended on the extent to which normal social life was disrupted by the illness and depended on the age and social position of the sufferer. Seizures and convulsions were considered severe symptoms but were often thought to be malaria. Presumptive malaria treatment at home often delayed formal treatment seeking. Further delays in treatment seeking were caused by economic barriers and perceptions of inefficient or inadequate primary health services. Conclusions: Given the difficulties in diagnosis of meningitis where malaria is common, any intervention for ABM at primary level must focus on recognising severe illness, and encouraging action at the household, community and primary health levels. Overcoming barriers to recognition and social constraints at community level require broad community-based strategies and may provide a route to addressing poor clinical outcomes. © 2013 Desmond et al. Source


Ngwira L.G.,Malawi Liverpool Wellcome Trust Research Programme | Khundi M.,Malawi Liverpool Wellcome Trust Research Programme | Harawa T.,Malawi Liverpool Wellcome Trust Research Programme | Corbett E.L.,Malawi Liverpool Wellcome Trust Research Programme | And 2 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2015

Objective: New tools, including light-emitting diode (LED) fluorescence microscopy and the molecular assay Xpert MTB/RIF, offer increased sensitivity for tuberculosis (TB) in persons with HIV but come with higher costs. Using operational data from rural Malawi, we explored the potential cost-effectiveness of on-demand screening for TB in low-income countries of Sub-Saharan Africa. Design and Methods: Costs were empirically collected in 4 clinics and in 1 hospital using a microcosting approach, through direct interview and observation from the national TB program perspective. Using decision analysis, newly diagnosed persons with HIV were modeled as being screened by 1 of the 3 strategies: Xpert, LED, or standard of care (ie, at the discretion of the treating physician). Results: Cost-effectiveness of TB screening among persons newly diagnosed with HIV was largely determined by 2 factors: prevalence of active TB among patients newly diagnosed with HIV and volume of testing. In facilities screening at least 50 people with a 6.5% prevalence of TB, or at least 500 people with a 2.5% TB prevalence, Xpert is likely to be cost-effective. At lower prevalence - including that observed in Malawi - LED microscopy may be the preferred strategy, whereas in settings of lower TB prevalence or small numbers of eligible patients, no screening may be reasonable (such that resources can be deployed elsewhere). Conclusions: TB screening at the point of HIV diagnosis may be cost-effective in low-income countries of Sub-Saharan Africa, but only if a relatively large population with high prevalence of TB can be identified for screening. © 2015 Wolters Kluwer Health, Inc. Source


Dowdy D.W.,Center for Tuberculosis Research | Gounder C.R.,Center for Tuberculosis Research | Corbett E.L.,London School of Hygiene and Tropical Medicine | Corbett E.L.,Malawi Liverpool Wellcome Trust Research Programme | And 3 more authors.
Clinical Infectious Diseases | Year: 2012

In the last decade, many new rapid diagnostic tests for infectious diseases have been developed. In general, these new tests are developed with the intent to optimize feasibility and population health, not accuracy alone. However, unlike drugs or vaccines, diagnostic tests are evaluated and licensed on the basis of accuracy, not health impact (eg, reduced morbidity or mortality). Thus, these tests are sometimes recommended or scaled up for purposes of improving population health without randomized evidence that they do so. We highlight the importance of randomized trials to evaluate the health impact of novel diagnostics and note that such trials raise distinctive ethical challenges of equipoise, equity, and informed consent. We discuss the distinction between equipoise for patient-important outcomes versus diagnostic accuracy, the equity implications of evaluating health impact of diagnostics under routine conditions, and the importance of offering reasonable choices for informed consent in diagnostic trials. © 2012 The Author. Source

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