Socio-Cultural Determinants of Health-Seeking Behaviour on the Kenyan Coast: A Qualitative Study

Background

Severe childhood illnesses present a major public health challenge for Africa, which is aggravated by a suboptimal response to the child''s health problems with reference to the health-seeking behaviour of the parents or guardians. We examined the health-seeking behaviour of parents at the Kenyan coast because understanding impediments to optimal health-seeking behaviour could greatly contribute to reducing the impact of severe illness on children''s growth and development.

Methods and Results

Health-seeking behaviour, and the factors influencing this behaviour, were examined in two traditional communities. We held in-depth interviews with 53 mothers, fathers and caregivers from two rural clinics at the Kenyan Coast. Biomedical medicine (from health facilities and purchased over the counter) was found to be the most popular first point of treatment. However, traditional healing still plays a salient role in the health care within these two communities. Traditional healers were consulted for various reasons: a) attribution of causation of ill-health to supernatural sources, b) chronic illness (inability of modern medicine to cure the problem) and c) as prevention against possible ill-health. In developing an explanatory model of decision-making, we observed that this was a complex process involving consultation at various levels, with elders, but also between both parents, depending on the perceived nature and chronicity of the illness. However, it was reported that fathers were the ultimate decision makers in relation to decisions concerning where the child would be taken for treatment.

Conclusions

Health systems need to see traditional healing as a complementary system in order to ensure adequate access to health care. Importantly, fathers also need to be addressed in intervention and education programs.     

Recent contributions of behavioural and biomedical scientists in applied anthropology of hygiene practices and management of diarrhoea in Bangladesh

In the past few years anthropologists, sociologists and biostatisticians have made contributions on hygiene practices and management of diarrhoea in relation to young children in rural Bangladesh. The cultural practices of caregivers with regard to washing hands after cleansing the anus of young children following defectation and disposing of the stool often do not fulfil the biomedical criteria for prevention of the transmission of diarrhoea-causing pathogens. These practices, being important determinants of prevention of transmission, were studied in the rural communities of Matlab, Bangladesh. Data were collected by observing the practices of caregivers of 404 children with diarrhoea chosen from 444 community cases recruited from the neighbourhood of the 218 hospitalized index cases. Observations were made regarding the cleansing of the anus of these children, washing of the hands of the caregivers, and disposal of the stool. It was observed that all the caregivers used bare hands and most used only water in cleaning the anus of the child. Also following the cleaning, most of the caregivers used only water to wash the soiled hand. Most of them used water collected in a pot, and only a small proportion used water from the direct source. The majority of caregivers disposed of the faeces in an unhygienic way. The caregivers classified diarrhoeal illness into 5 types based on stool characteristics and perceived specific causation. Their management approach was determined by the type and cause of the diarrhoea. The oral rehydration approach to management was not considered for diarrhoeas which were believed to be caused by supernatural and certain other cultural factors.     

Breast feeding,nutritional state,and child survival in rural Bangladesh

The effect of breast feeding on nutritional state, morbidity, and child survival was examined prospectively in a community in rural Bangladesh. Every month for six months health workers inquired about breast feeding and illness and measured arm circumference in an average of 4612 children aged 12-36 months. Data from children who died within one month of a visit were compared with those from children who survived. Roughly one third of the deaths in the age range 18-36 months were attributable to absence of breast feeding. Within this age range protection conferred by breast feeding was independent of age but was evident only in severely malnourished children.In communities with a high prevalence of malnutrition breast feeding may substantially enhance child survival up to 3 years of age.     

Gender differences in child survival in contemporary rural China: a county study

Using data from a survey of deaths of children less than 5 years old conducted in 1997 in a county in Shaanxi Province, China, this paper examines gender differences in child survival in contemporary rural China. First, excess female child mortality in the county in 1994-96 is described, followed by an analysis of the mechanisms whereby the excess mortality takes place, and the underlying social, economic and cultural factors behind it. Excess female child mortality in this county is probably caused primarily by discrimination against girls in curative health care rather than in preventive health care or food and nutrition. Although discrimination occurs in all kinds of families and communities, discrimination itself is highly selective, and is primarily against girls with some specific characteristics. It is argued that the excess mortality of girls is caused fundamentally by the strong son preference in traditional Chinese culture, but exacerbated by the government-guided family planning programme and regulations. This suggests that it is crucial to raise the status of girls within the family and community so as to mitigate the pressures to discriminate against girls in China's low fertility regime. Finally, the possible policy options to improve female child survival in contemporary rural China are discussed.     

Operationalising Contemporary Rural Development: Socio-Cultural Determinants Arising from a Strong Local Fishing Culture

A transition to programmes adopting a governance-based approach in encouraging value-added and innovation in rural economies is often described as offering new opportunities for marginalised rural communities that have not benefited from top-down development policies. In practice, however, it is noted in Ireland and elsewhere in the EU that traditional fishers and farmers have been slow to engage in economic activities favoured by contemporary policies. I discuss how traditional small-scale fishing communities can be estranged from contemporary rural development policies that are focused primarily on providing high value-added service-oriented and processed goods. I approach the problem of poor integration of fishing communities by focusing on how contemporary rural development programmes - though shrouded in language of local participation, governance, and indigenisation - can fail to actively engage with indigenous socio-cultural identity and resources. Exploring how intricate human ecological relationships involving custom and local knowledge of physical resources are not readily commoditised, I raise questions in relation to some of the central claims of the governance and rural development model, such as that it has the capacity to empower and generate confidence through locally appropriate economic activity.     

Breastfeeding behavior and infant survival with emphasis on reverse causation bias: some evidence from Nigeria

The possibility of selection bias in the estimation of the effects of breastfeeding on subsequent survival is implied by the clinical evidence that children who are healthier at birth are more likely to be breastfed than their less healthy counterparts who may be prone to difficulties in sustaining breastfeeding. This paper addresses an important problem in understanding the association of breastfeeding and child survival with regard to reverse causation. It utilizes data on the reported reason for weaning to assess the degree to which reverse causality may be responsible for observed associations. The analysis indicates that children who are weaned in the neonatal period because of illness or weakness to suckle, experience a much higher risk of dying than others. This is not mainly because of the cessation of breastfeeding, but because of the original factor, being their illness. Any biases imparted by an initial selection mechanism appear, therefore, to have influence on the effectiveness of breastfeeding behavior.     

Ethnomedical pathogenesis and Hmong immigrants' sudden nocturnal deaths

Scores of seemingly healthy Hmong immigrants have died mysteriously and without warning from what has come to be known as Sudden Unexpected Nocturnal Death Syndrome (SUNDS). To date medical research has provided no adequate explanation for these sudden deaths. This study is an investigation into the role of powerful traditional beliefs in illness causation. In Stockton, California, 118 Hmong men and women were interviewed regarding their awareness of and personal experience with a traditional nocturnal spirit encounter. An analysis of this data reveals that the supranormal encounter acts as a trigger for Hmong SUNDS.     

Rural Livelihood Variation and its Effects on Child Growth in Timor-Leste

Economic development introduces opportunities for subsistence households to diversify income sources. Timor-Leste is undergoing this transition; however, little is known about the patterns of household strategies and the effects of rural development on child wellbeing. We derive strategies from 190 households in two rural Timor-Leste communities and examine the links between resource strategies and child growth using linear mixed modeling. Children’s z-height, z-weight, and z-BMI are well below international standards. We find agriculture remains predominantly subsistence-based, with some reliance on cash flow from government pensions and salaries. Households with stable income sources are better able to accumulate wealth, and children living in salaried households have better z-height. However, child growth is best predicted by individual-level factors rather than household ecology. Substantial variation in household strategy and little association of strategy with growth indicates there is no ‘best’ strategy in this transitioning environment.     

Closing the rural-urban gap in child malnutrition: Evidence from Paraguay, 1997–2012

Between 1997 and 2012, Paraguay achieved not only remarkable improvements in child nutrition, but also a surprising elimination of the rural-urban differential in child height-for-age Z score (HAZ) and stunting. Our decomposition analysis, applied to four rounds of Paraguayan National Household Surveys, allows us to directly infer not only the contributions of changes in determinants of child nutritional status to the improvements in child nutritional status in rural and urban areas, but also their contribution to closing the rural-urban gap. We find that while common determinants of child nutritional status such as income, maternal education, sanitation, and access to piped water are strongly associated with improvements in child nutrition, they have contributed little to reducing the rural-urban gap (10%, p < 0.05). Improvements in health care utilization, family planning, and demographics have been the main drivers in closing the rural-urban gap in child nutritional status in Paraguay (32%, p < 0.05). The results highlight the potential need for multipronged nutritional strategies that consider the distinct needs of rural and urban communities.     

Social economics of childhood glucocorticoid stress response and health

This study examines socioeconomic conditions, psychosocial stress, and health among 264 infants, children, adolescents, and young adults aged 2 months to 18 years residing in a rural Caribbean village. Fieldwork was conducted over a 9 year period (1988–1996). Research methods and techniques include salivary cortisol radioimmunoassay (N = 22,438), systematic behavioral observations, psychological questionnaires, health evaluations, medical records, informal interviews, and participant observation. Analyses of data indicate complex relations among socioeconomic conditions, stress, and health. Household income, land ownership, parental education, and other socioeconomic measures are weakly associated with child illness. There is no evidence that apparent material benefits of high socioeconomic status—such as improved housing, diet, work loads, and access to private healthcare—have important direct effects on child health in this population. However, social relationships, especially family environment, may have important effects on childhood psychosocial stress and illness. Abnormal glucocorticoid response profiles, diminished immunity, and frequent illness are associated with unstable mating relationships of parents/caretakers and household composition. We suggest that family relationships and concomitant stress and immunosuppression are important intermediary links between socioeconomic conditions and child health. Am J Phys Anthropol 102:33–53, 1997. © 1997 Wiley-Liss, Inc.     

Covariates of child mortality in Mali: does the health-seeking behaviour of the mother matter?

This paper uses data from the 1995/96 Mali DHS survey to examine the importance of a wide range of socioeconomic, behavioural and biodemographic factors in the determination of child mortality in Mali, with a special focus on maternal education and behaviour. The central hypothesis of the study is that advances in maternal education would contribute little to child survival in settings such as Mali's urban and rural communities where progress in educational attainment is not matched with improvements in other aspects of socioeconomic development such as economic growth, job creation, financial security and public health and medical resources. Units of analysis are children born in the past 5 years to DHS respondents (women aged 15-45) who were married at the time of the survey. The Cox proportional hazards regression technique has been used to estimate the net effects of variables included as covariates. The findings indicate that the health-seeking behaviour of the mother matters more than maternal education in explaining the observed differences in infant and child mortality in Mali's urban and rural areas.     

Etiology in psychiatry: embracing the reality of poly‐gene‐environmental causation of mental illness

Intriguing findings on genetic and environmental causation suggest a need to reframe the etiology of mental disorders. Molecular genetics shows that thousands of common and rare genetic variants contribute to mental illness. Epidemiological studies have identified dozens of environmental exposures that are associated with psychopathology. The effect of environment is likely conditional on genetic factors, resulting in gene‐environment interactions. The impact of environmental factors also depends on previous exposures, resulting in environment‐environment interactions. Most known genetic and environmental factors are shared across multiple mental disorders. Schizophrenia, bipolar disorder and major depressive disorder, in particular, are closely causally linked. Synthesis of findings from twin studies, molecular genetics and epidemiological research suggests that joint consideration of multiple genetic and environmental factors has much greater explanatory power than separate studies of genetic or environmental causation. Multi‐factorial gene‐environment interactions are likely to be a generic mechanism involved in the majority of cases of mental illness, which is only partially tapped by existing gene‐environment studies. Future research may cut across psychiatric disorders and address poly‐causation by considering multiple genetic and environmental measures across the life course with a specific focus on the first two decades of life. Integrative analyses of poly‐causation including gene‐environment and environment‐environment interactions can realize the potential for discovering causal types and mechanisms that are likely to generate new preventive and therapeutic tools.     

Insights from Characterizing Extinct Human Gut Microbiomes

In an effort to better understand the ancestral state of the human distal gut microbiome, we examine feces retrieved from archaeological contexts (coprolites). To accomplish this, we pyrosequenced the 16S rDNA V3 region from duplicate coprolite samples recovered from three archaeological sites, each representing a different depositional environment: Hinds Cave (∼8000 years B.P.) in the southern United States, Caserones (1600 years B.P.) in northern Chile, and Rio Zape in northern Mexico (1400 years B.P.). Clustering algorithms grouped samples from the same site. Phyletic representation was more similar within sites than between them. A Bayesian approach to source-tracking was used to compare the coprolite data to published data from known sources that include, soil, compost, human gut from rural African children, human gut, oral and skin from US cosmopolitan adults and non-human primate gut. The data from the Hinds Cave samples largely represented unknown sources. The Caserones samples, retrieved directly from natural mummies, matched compost in high proportion. A substantial and robust proportion of Rio Zape data was predicted to match the gut microbiome found in traditional rural communities, with more minor matches to other sources. One of the Rio Zape samples had taxonomic representation consistent with a child. To provide an idealized scenario for sample preservation, we also applied source tracking to previously published data for Ötzi the Iceman and a soldier frozen for 93 years on a glacier. Overall these studies reveal that human microbiome data has been preserved in some coprolites, and these preserved human microbiomes match more closely to those from the rural communities than to those from cosmopolitan communities. These results suggest that the modern cosmopolitan lifestyle resulted in a dramatic change to the human gut microbiome.     

Feasibility assessment and implementation strategies of green care in rural Taiwan

Pursuing the rural idyll for retirement is especially a popular age-old dream for Taiwan people. Farming for health is an emerging trend, which drivers to initiate a green care service based on a combination of agriculture resources and traditional care. The purposes of this study were to assess the feasibility of green care in rural communities and to propose implementation strategies for varied rural area types in Taiwan. This study was conducted with two stags. A feasibility study comprising two aspects of political and environmental feasibilities was assessed in the first stage. The political feasibility was assessed based on social demand and government policies. Accordingly, three alternative models for senior green care participation were proposed, including green occupational therapy (for residents), rural long-stay tourism (for tourists), and agricultural working holiday (for volunteers). The environmental feasibility assessment was conducted in 102 rural communities in northern Taiwan. Five indexes, including the natural environment, rural resources, public facilities, senior care, and community capacity, were used to evaluate the potential of communities for developing green care. The results showed that green care implementing active aging in place in rural areas is feasible. Seventeen communities with plentiful or unique rural resources and high-quality community capacity were recommended as potential communities. In the second stage, a multiple case study was conducted in three communities representing different alternative models of green care. The community leader interviews, on-site investigations, vision forum, and operation workshop were adopted to propose the implementation strategies of green care for three communities, respectively, including human resource, volunteer or tourist management, revenue distribution, and marketing.

     

Impact of Preventive Responses to Epidemics in Rural Regions

Various epidemics have arisen in rural locations through human-animal interaction, such as the H1N1 outbreak of 2009. Through collaboration with local government officials, we have surveyed a rural county and its communities and collected a dataset characterizing the rural population. From the respondents’ answers, we build a social (face-to-face) contact network. With this network, we explore the potential spread of epidemics through a Susceptible-Latent-Infected-Recovered (SLIR) disease model. We simulate an exact model of a stochastic SLIR Poisson process with disease parameters representing a typical influenza-like illness. We test vaccine distribution strategies under limited resources. We examine global and location-based distribution strategies, as a way to reach critical individuals in the rural setting. We demonstrate that locations can be identified through contact metrics for use in vaccination strategies to control contagious diseases.     

Addressing the concerns of rural communities about access to plants and knowledge in a<Emphasis Type="Italic">sui generis</Emphasis> legislation in Cameroon

This article assesses the traditional systems of accessing and using plant genetic resources as well as the benefit sharing and systems of sanctioning infringement in the context of biodiversity related activities in specific areas in the Northwest province of Cameroon. The article also addresses the type research and development activities using plant genetic resources and associated traditional knowledge in the context of Cameroon, the current laws regulating such activities and the extent to which these activities and laws affect and/or protect the customary biodiversity rights of rural communities. The article uses these assessments to suggest the context under which asui generis legislation for the protection of the biodiversity rights of rural communities can be established in Cameroon.     

Explanatory Models and Mental Health Treatment: Is Vodou an Obstacle to Psychiatric Treatment in Rural Haiti?

Vodou as an explanatory framework for illness has been considered an impediment to biomedical psychiatric treatment in rural Haiti by some scholars and Haitian professionals. According to this perspective, attribution of mental illness to supernatural possession drives individuals to seek care from houngan-s (Vodou priests) and other folk practitioners, rather than physicians, psychologists, or psychiatrists. This study investigates whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study comprised 31 semi-structured interviews with community leaders, traditional healers, religious leaders, and biomedical providers, 10 focus group discussions with community members, community health workers, health promoters, community leaders, and church members; and four in-depth case studies of individuals exhibiting mental illness symptoms conducted in Haiti's Central Plateau. Respondents invoked multiple explanatory models for mental illness and expressed willingness to receive treatment from both traditional and biomedical practitioners. Folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. At the same time, respondents perceived the biomedical system as largely ineffective for treating mental health problems. Explanatory models rooted in Vodou ethnopsychology were not primary barriers to pursuing psychiatric treatment. Rather, structural factors including scarcity of treatment resources and lack of psychiatric training among health practitioners created the greatest impediments to biomedical care for mental health concerns in rural Haiti.     

Telemedicine may help change the face of medical care in Eastern Canada

Pilot projects in eastern Canada that use personal computers and telephone lines to link patients and rural physicians with specialists in urban centres indicate that telemedicine may be a cost-effective adjunct to clinical medicine. Dermatology, radiology, cardiology and oncology are among the areas that have been tested in Nova Scotia. Although physicians say telemedicine may have many useful applications, such as providing efficient continuing medical education for doctors in remote communities, they say it must respect traditional referral patterns.     

Role of health-seeking behaviour in child mortality in the slums of Karachi,Pakistan

The role of family health-seeking behaviour in under-five-year child mortality was explored through the combined approach of examining health-seeking behaviour regarding treatment generally, and in specific in relation to illness before death. A population-based case control study was carried out during the period 1993-1994 using 222 deaths from diarrhoea and acute respiratory illness (ARI) in children under five years of age in six slums of Karachi as cases, and 419 controls matched on age, disease (diarrhoea and ARI) and slum. Factors significantly associated (p<0.05) with child mortality in the multivariate analysis were: mothers changing healers quickly, using a traditional healer or an unqualified doctor and mothers to whom doctors did not explain the treatment, even when maternal education was controlled for. Seeking effective medical services is highly influential on whether the child survives or succumbs to ARI or diarrhoea. As mothers are the first providers of care, an attempt should be made to try and improve their skills through health education so that they can use simple and effective treatments for minor illnesses. They should also be taught to recognize potentially life-threatening conditions, to seek care early and to persist with treatment.