In/dependent Collaborations: Perceptions and Experiences of African Scientists in Transnational HIV Research.

This article examines collaboration in transnational medical research from the viewpoint of African scientists working in partnerships with northern counterparts. It draws on ethnographic fieldwork in an HIV laboratory of an East African state university, with additional data from interviews with scientists working in related research institutions. Collaboration is today the preferred framework for the mechanisms by which northern institutions support research in the south. The concept signals a shift away from the legacy of unequal (post-) colonial power relations, although, amid persisting inequalities, the rhetorical emphasis on equality might actually hinder critical engagement with conflicts of interest and injustice. To collaborate, African scientists engage various strategies: They establish a qualified but flexible, non-permanent workforce, diversify collaborators and research areas, source complementary funding to assemble infrastructures, and maintain prospective research populations to attract transnational clinical trials. Through this labor of collaboration, they sustain their institutions under prevailing conditions of scarcity.

Factors influencing uptake of HIV care and treatment among children in South Africa - a qualitative study of caregivers and clinic staff.

Despite antiretroviral therapy rollout in South Africa, fewer children than expected are accessing HIV care services. Our objectives were to describe barriers and facilitators of uptake of HIV care among children. Our study involved six private-sector clinics which provide HIV care free-of-charge in and around Gauteng province, South Africa. In-depth interviews were conducted in July 2008 with 21 caregivers of HIV-infected children attending these clinics, 21 clinic staff members and three lead members of staff from affiliated care centres. Many children were only tested for HIV after being recurrently unwell. The main facility-related barriers reported were long queues, negative staff attitudes, missed testing opportunities at healthcare facilities and provider difficulties with paediatric counselling and venesection. Caregivers reported lack of money for transport, food and treatments for opportunistic infections, poor access to welfare grants and lack of coordination amongst multiple caregivers. Misperceptions about HIV, maternal guilt and fear of negative repercussions from disclosure were common. Reported facilitators included measures implemented by clinics to help with transport, support from family and day-care centres/orphanages, and seeing children's health improve on treatment. Participants felt that better public knowledge about HIV would facilitate uptake. Poverty and the implications of children's HIV infection for their families underlie many of these factors. Some staff-related and practical issues may be addressed by improved training and simple measures employed at clinics. However, changing caregiver attitudes may require interventions at both individual and societal levels. Healthcare providers should actively promote HIV testing and care-seeking for children.

Effects on haemoglobin of multi-micronutrient supplementation and multi-helminth chemotherapy: a randomized, controlled trial in Kenyan school children.

OBJECTIVE: To assess the effects of multi-micronutrient supplementation and multi-helminth chemotherapy on haemoglobin concentration (Hb), using schools as a health delivery system. STUDY AREA AND POPULATION: Nine hundred seventy-seven children between 9 and 18 y of age from 19 primary schools in Bondo District, western Kenya, were included in the trial. The 746 (76.4%) children on whom baseline Hb was available were included in this study. DESIGN: The study was a randomized, placebo-controlled, double-blind, two-by-two factorial trial of the effects of multi-micronutrient supplementation and multi-helminth chemotherapy on Hb after 8 months. INTERVENTION: Single treatment of infected children with albendazole (600 mg) for geohelminths and praziquantel (40 mg/kg) for Schistosoma mansoni and daily supplementation with 13 micronutrients. RESULTS: : Multi-micronutrient supplementation (3.5 g/l, 95% CI 1.7, 5.3; P=0.0002) and anthelminthic treatment (2.0 g/l, 95% CI 0.2, 3.9; P=0.03) increased Hb independently (interaction, P=0.33). The effects were also independent of baseline Hb and general nutritional status. The treatment effect was due to reductions in S. mansoni and hookworm intensities of infection, in that Hb increased by 0.4 and 0.2 g/l, respectively, per 100 epg reductions in egg output. Interestingly, among S. mansoni-infected children, the effect of treatment seemed stronger in those with compared to those without co-existing malaria parasitaemia (interaction, P=0.09). CONCLUSION: Multi-micronutrient supplementation and multi-helminth chemotherapy increased Hb among school children, irrespective of initial Hb and nutritional status.

Effects on serum retinol of multi-micronutrient supplementation and multi-helminth chemotherapy: a randomised, controlled trial in Kenyan school children.

OBJECTIVE: To assess the effects of multi-micronutrient supplementation and multi-helminth chemotherapy on serum retinol concentration, using schools as a health delivery system. STUDY AREA AND POPULATION: From 19 primary schools in Bondo District, western Kenya, 977 children between 9 and 18 y were included in the trial. The 644 (65.9%) children on whom baseline serum retinol was available were included in this study. DESIGN: A randomised, placebo-controlled, double-blind, two-by-two factorial trial on the effects of multi-micronutrient supplementation and multi-helminth chemotherapy on serum retinol after 8 months. INTERVENTION: Single treatment with albendazole (600 mg) and praziquantel (40 mg/kg of body weight) and daily multi-micronutrient supplementation with tablet containing 1000 microg vitamin A. RESULTS: Micronutrient supplementation (0.08 micromol/l, 95% CI 0.01, 0.14; P=0.025), but not treatment (0.03 micromol/l, 95% CI -0.04, 0.10; P=0.38), increased serum retinol. However, treatment did increase serum retinol in S. mansoni-infected (0.09, 95% CI 0.02, 0.16; P=0.009), but not in uninfected children (-0.07, 95% CI -0.18, 0.03; P=0.18; interaction, P=0.01). Similarly, reduction in egg output of S. mansoni, but none of the geohelminth, was a predictor, corresponding to a 0.008 micromol/l (95% CI 0.00002, 0.02; P=0.049) increase in serum retinol per 100 epg reduction. Interestingly, interactions were found between age and sex (P=0.046), and malaria parasitaemia and sickle cell phenotype (P=0.04). CONCLUSION: Multi-micronutrient supplementation and reduction in S. mansoni egg output increased serum retinol, irrespective of initial serum retinol. SPONSORSHIP: The Danish International Development Assistance.

Self-treatment by Kenyan and Ugandan schoolchildren and the need for school-based education.

Studies on Kenyan and Ugandan primary schoolchildren's knowledge of medicines and self-treatment practices show that children aged between 10 and 18 years have a broad knowledge of herbal and biomedical remedies and that they use them frequently, often without adults' involvement. They use pharmaceuticals, including prescription-only drugs, but lack knowledge about indications and dosages. There is a gap between the children's life worlds and the school health education as it is presently designed and taught in Kenya and Uganda. It limits itself to disease prevention and health promotion, and does not teach treatment or medicine-use. Self-treatment based on insufficient knowledge poses a threat to children's health and to the health of the wider community. Therefore, education on the critical and appropriate use of medicines needs to be developed and tested for possible use in Kenya, Uganda and other countries in which home-treatment is common. The proposed education on medicines should go beyond providing information on accurate dosage and indication: it should create critical awareness with regard to medicine-use, enabling children to use them appropriately and cautiously. Kenyan and Ugandan primary schoolchildren are active agents within pluralistic medical fields. By taking the children seriously as competent health care agents, the dangers of self-treatment could be reduced, and the potential of children could be guided to fruitful use. Educational interventions cannot solve the problems of self-treatment, which are related to the wider social and economic context, but they could contribute to increased awareness as a necessary condition for change.

Children and medicines: self-treatment of common illnesses among Luo schoolchildren in western Kenya.

In a rural area of western Kenya, primary schoolchildren's health seeking behaviour in response to common illnesses was investigated. 57 primary schoolchildren (age 11-17 years, median 13 years) were interviewed weekly about their health status and health seeking activities for 30 weeks. The children each experienced on average 25 illness episodes during this period. Most episodes could be categorised into 4 groups: 'cold', 'headache', 'abdominal complaints' and 'injuries'. One fifth (21%) of the illness episodes were serious enough to keep the children from school. In 28% of them, an adult was consulted, while 72% were not reported to an adult caretaker. Of the episodes without adult involvement, 81% remained untreated, while 19% were treated by the children themselves with either herbal or Western medicines. Of all the medicines taken by the children, two thirds were provided or facilitated by adults (assisted treatment) and one third taken by the children themselves without adult involvement (self-treatment). Among boys, the proportion of illnesses, which were self-treated increased with age from 12% in the youngest age group (< 13 years) to 34% in the oldest (> 14 years). In girls, the proportion of illnesses which were self-treated was consistently lower than among boys and remained constant around 9% for all age groups. The proportion of Western pharmaceuticals used for self-treatment increased with age from 44% in the youngest age group to 63% in the oldest (average 52% Western pharmaceuticals). Again, there were differences between boys and girls: among the youngest age group, boys were twice as likely to use pharmaceuticals than girls (62 versus 32% of the self-treatments, respectively) and in the oldest age group they were nearly three times more likely (75 versus 25%, respectively). These differences in self-treatment practices and choice of medicines between girls and boys may reflect the higher income potential of boys, who can earn money by fishing. Pharmaceuticals were generally preferred for the treatment of headache and fevers, or colds, while herbal remedies were the preferred choice for the treatment of abdominal complaints and wounds. The most commonly used pharmaceuticals were antimalarials (mainly chloroquine), painkillers and antipyretics (mainly aspirin and paracetamol), which were stocked in most small shops in the village at low prices and readily sold to children. Throughout primary school age Kenyan children are growing into a pluralistic medical practice, integrating Western pharmaceuticals into the local herbal medical system, and gradually become autonomous agents in their health care.

Perceptions of soil-eating and anaemia among pregnant women on the Kenyan coast.

After a clinical study at Kilifi District hospital had shown a high prevalence of geophagy among pregnant women, and a strong association of geophagy, anaemia and iron depletion, 52 pregnant women from the same hospital, and 4 traditional healers from the surroundings of Kilifi in Kenya were interviewed on the topic of soil-eating and its perceived causes and consequences. The findings were substantiated by results from an earlier anthropological study on maternal health and anaemia in the same study area. Most of the pregnant women (73%) ate soil regularly. They mainly ate the soil from walls of houses, and their estimated median daily ingestion was 41.5 g. They described soil-eating as a predominantly female practice with strong relations to fertility and reproduction. They made associations between soil-eating, the condition of the blood and certain bodily states: pregnancy, lack of blood (upungufu wa damu), an illness called safura involving "weak" blood, and worms (minyolo). The relationships the women described between soil-eating and illness resemble to some extent the causalities explored in biomedical research on soil-eating, anaemia and intestinal worm infections. However the women did not conceptualise the issue in terms of the single causal links characteristic of most scientific thought. Instead, they acknowledged the existence of multiple links between phenomena which they observed in their own and other women's bodies. The women's ideas about soil-eating and their bodies shows the significance of both social and cultural context on the ways in which women derive knowledge from, and make sense of their bodily states. The cultural associations of soil-eating with blood, fertility and femininity exist alongside knowledge of its links to illness. Our findings show that soil-eating is more than just a physiologically induced behaviour; it is a rich cultural practice.

Geophagy, iron status and anaemia among pregnant women on the coast of Kenya.

In a cross sectional survey based in an antenatal clinic at Kilifi District Hospital, Coast Province, Kenya, 154 of 275 pregnant women (56%) reported eating soil regularly. Geophagous women had lower haemoglobin and serum ferritin concentrations than non-geophagous women (mean haemoglobin level 9.1 vs. 10.0 g/dL, P < 0.001; median ferritin level 4.5 vs. 9.0 micrograms/L, P < 0.001). In multiple linear regression analyses, geophagy was a significant predictor of haemoglobin (beta = -6.4, P = 0.01) and serum ferritin concentrations (beta = -6.6, P = 0.002), while controlling for gestational age and malaria and hookworm infection. Another 38 pregnant women, who reported eating soil regularly, participated in focus group discussions and were interviewed on geophagy. The most commonly eaten soil was from the walls of houses. The median estimated daily intake was 41.5 g (range 2.5-219.0 g). Twenty-seven of these women assisted in the collection of soil samples which were then analysed for their content of iron, zinc and aluminium after extraction with 0.1 M HC1. The average daily soil intake supplied the geophagous women with 4.3 mg of iron, corresponding to 14% of the recommended dietary allowance of iron for pregnant women. The study revealed a strong negative association between geophagy and both haemoglobin and ferritin status. At the same time it demonstrated the potential of soil as a source of dietary iron for geophagous women. These seemingly contradictory results might be due to other components in the soil interfering with iron uptake or metabolism. Alternatively, it may be that the geophagous women had extremely depleted iron stores before starting to eat soil. From these cross-sectional data, no inference about causality could be made.

Geophagy as a risk factor for geohelminth infections: a longitudinal study of Kenyan primary schoolchildren.

Geophagy among primary schoolchildren and its impact on geohelminth infection were studied in western Kenya. In a cross-sectional survey, 204 children aged 10-18 years were interviewed about geophagy and examined for helminth infections (Ascaris lumbricoides, Trichuris trichiura, Schistosoma mansoni, hookworm). Children found infected were treated with albendazole (600 mg in a single dose) and/or praziquantel (40 mg/kg in a single dose). The children were re-examined after 4, 8 and 11 months. In the initial cross-sectional survey, 77% of the children ate soil daily and 48% of all soil samples were contaminated with eggs of A. lumbricoides (median egg count in contaminated samples was 3/2 g of soil; range 1-15). Twenty-nine children (14.2%) were infected with A. lumbricoides and 87 (42.6%) with T. trichiura. Significant associations between geophagy and infection intensity with A. lumbricoides and T. trichiura, but not S. mansoni or hookworm, were found. Re-infection with A. lumbricoides was twice as common among geophagous children as among non-geophagous children (27.4% vs. 12.0%; P = 0.030). The intensity of reinfections was higher in geophagous children (median 773 eggs/g vs. 95 eggs/g; P = 0.027). The relative risk for A. lumbricoides reinfection was 2.28 for geophagous children (95% confidence interval [95% CI] 1.02-5.11), and the fraction of reinfection attributable to geophagy was 56.0% (95% CI 1.7%-80.4%). There was a significant difference in T. trichiura infection intensity between geophagous and non-geophagous children (median no. of eggs/g 68 vs. 20; P = 0.049), but not in reinfection rates. No difference between the groups was seen in S. mansoni or hookworm reinfection rate or intensity, or in the families' socioeconomic or educational status. Geophagy was associated with an increased risk of reinfection with A. lumbricoides and possibly with T. trichiura. Neither family background nor infection with non-orally transmitted helminths was associated with geophagy, suggesting that this association was not due to confounding, but causal. Geophagy is therefore likely to be a source of ascariasis and possibly trichiuriasis among primary schoolchildren.

Geophagy, iron status and anaemia among primary school children in Western Kenya.

As part of a cross-sectional study among 156 primary school children (median age 13 years, range 10-18) in Western Kenya, geophagy was assessed through interviews. 114 (73.1%) of these children reported eating soil daily. Haemoglobin levels were determined in all 156 children and serum ferritin concentrations in 135. The mean haemoglobin (Hb) concentration was 12.7 g/dl, and median ferritin concentration 27.2 microg/l. Both the proportion of anaemic (Hb < 11.0 g/dl) and of iron-depleted (ferritin < 12 microg/l) children was significantly higher among the geophageous children than among the nongeophageous (9.6% vs. 0% anaemia; P = 0.037; 18.4% vs. 5.4% iron depletion; P = 0.046). Serum ferritin and haemoglobin concentrations were not correlated (r = 0. 13 5; P = 0. 100). Multiple regression analysis showed that geophagy, hookworm eggs per gram faeces and malaria parasite counts per microl blood were independent predictors of serum ferritin, when controlling for other helminth infections, age and sex, and socio-economic and educational background of the children's families and family size (y = 36.038-11.247(geophagy) -- 0.010(hookworm epg) + 0.001(malaria parasite counts); R2 = 0.17). Multiple regression analysis with haemoglobin as dependent variable and the same independent variables did not reveal any significant predictors. Analysis of the soil eaten by the children revealed a mean HCl-extractable iron content of 168.9 mg/kg (SD 44.9). Based on the data on the amounts eaten daily and this mean iron content, soil could provide on average 4.7 mg iron to a geophageous child (interquartile range 2.1-7.1 mg), which is equivalent to 32% of the Recommended Nutrient Intake (RNI) for girls (interquartile range 14-48%) or 42% of the RNI for boys (interquartile range 19-63%). Iron depletion and anaemia are associated with geophagy, but only serum ferritin concentrations were shown to be dependent upon geophagy in the regression model. From the cross-sectional data no inference about causality can be made. To clarify the possible causal relationships involved, longitudinal studies and iron-supplementation intervention studies are needed.

'Worms are our life', part I: Understandings of worms and the body among the Luo of western Kenya.

Perceptions of worms and their role in the body were studied among the people in a Luo village in western Kenya. Worms were found to be prominent in people's body-image and ideas about illness. Two models applied to worms were distinguished analytically as 'traditional' and 'biomedical', referring to their sources, modes of transmission and relation to wider understandings of life. The first acknowledged worms as positive agents of both digestion and illness and aimed at maintaining a balanced relationship with them. The latter saw worms as dangerous intruders into bodily order and demanded their expulsion. Both models were used side by side or alternately by most people in the village, according to their individual preferences or to the specific context. The different attitudes to worms-one inclusive, the other exclusive-were related to wider concepts of dirt, pollution, affliction and evil, and shed light on people's understandings of the body and life.

Geophagy among school children in western Kenya.

A cross-sectional study was conducted among 285 school children aged 5-18 years in Nyanza Province, Western Kenya, to determine the prevalence of geophagy and the types and amounts of soil eaten. Stool samples were taken from a subsample of 53 (19%) and their silica content determined to compare the results with the reported geophagy. Geophagy was practised by 73% of the children. The prevalence decreased with age for both sexes up to age 15, then remained stable for girls between 15 and 18 years but continued to decrease for boys in that age range. Most children ate soil from the surface of termitaria; others preferred the edges of paths and gullies, material from the wall of huts, and a chalk-like, soft stone commonly found in the area. The soil was eaten dry and was occasionally ground, but not processed in other ways. All but 4 of the children practising geophagy reported to eat soil at least once daily. The median amount reported eaten was 28 g daily, ranging from 8 to 108 g. The reported amount of soil eaten daily was significantly correlated to the results of the stool silica determinations. Using the median of 1% silica of faecal wet weight as a cut-off point to distinguish geophageous children from non-geophageous, the examination of a single stool sample had a sensitivity of 76% and a specificity of 80% to detect a geophageous child compared to the interview method. The cultural context of geophagy and its potential health impact in terms of infection and nutrition need to be further investigated, and it is suggested that more school and community-based studies on geophagy in different societies should be undertaken.