"We threw away the stones": a mixed method evaluation of a simple cookstove intervention in Malawi.

Background: Air pollution exposure is responsible for a substantial burden of respiratory disease globally. Household air pollution from cooking using biomass is a major contributor to overall exposure in rural low-income settings. Previous research in Malawi has revealed how precarity and food insecurity shape individuals' daily experiences, contributing to perceptions of health. Aiming to avoid a mismatch between research intervention and local context, we introduced a simple cookstove intervention in rural Malawi, analysing change in fine particulate matter (PM 2.5) exposures, and community perceptions. Methods: Following a period of baseline ethnographic research, we distributed 'chitetezo mbaula', locally-made cookstoves, to all households (n=300) in a rural Malawian village. Evaluation incorporated village-wide participant observation and concurrent exposure monitoring using portable PM 2.5 monitors at baseline and follow-up (three months post-intervention). Qualitative data were thematically analysed. Quantitative analysis of exposure data included pre-post intervention comparisons, with datapoints divided into periods of combustion activity (almost exclusively cooking) and non-combustion periods. Findings were integrated at the interpretation stage, using a convergent design mode of synthesis. Results: Individual exposure monitoring pre- and post-cookstove intervention involved a sample of 18 participants (15 female; mean age 43). Post-intervention PM 2.5 exposures (median 9.9µg/m 3 [interquartile range: 2.2-46.5]) were not significantly different to pre-intervention (11.8µg/m 3 [3.8-44.4]); p=0.71. On analysis by activity, background exposures were found to be reduced post-intervention (from 8.2µg/m 3 [2.5-22.0] to 4.6µg/m 3 [1.0-12.6]; p=0.01). Stoves were well-liked and widely used by residents as substitutes for previous cooking methods (mainly three-stone fires). Commonly cited benefits related to fuel saving and shorter cooking times. Conclusions: The cookstove intervention had no impact on cooking-related PM 2.5 exposures. A significant reduction in background exposures may relate to reduced smouldering emissions. Uptake and continued use of the stoves was high amongst community members, who preferred using the stoves to cooking over open fires.

Personal exposures to fine particulate matter and carbon monoxide in relation to cooking activities in rural Malawi.

Background: Air pollution is a major environmental risk factor for cardiorespiratory disease. Exposures to household air pollution from cooking and other activities, are particularly high in Southern Africa. Following an extended period of participant observation in a village in Malawi, we aimed to assess individuals' exposures to fine particulate matter (PM 2.5) and carbon monoxide (CO) and to investigate the different sources of exposure, including different cooking methods. Methods: Adult residents of a village in Malawi wore personal PM 2.5 and CO monitors for 24-48 hours, sampling every 1 (CO) or 2 minutes (PM 2.5). Subsequent in-person interviews recorded potential exposure details over the time periods. We present means and interquartile ranges for overall exposures and summaries stratified by time and activity (exposure). We employed multivariate regression to further explore these characteristics, and Spearman rank correlation to examine the relationship between paired PM 2.5 and CO exposures. Results : Twenty participants (17 female; median age 40 years, IQR: 37-56) provided 831 hours of paired PM 2.5 and CO data. Concentrations of PM 2.5 during combustion activity, usually cooking, far exceeded background levels (no combustion activity): 97.9µg/m 3 (IQR: 22.9-482.0), vs 7.6µg/m 3, IQR: 2.5-20.6 respectively. Background PM 2.5 concentrations were higher during daytime hours (11.7µg/m 3 [IQR: 5.2-30.0] vs 3.3µg/m 3 at night [IQR: 0.7-8.2]). Highest exposures were influenced by cooking location but associated with charcoal use (for CO) and firewood on a three-stone fire (for PM 2.5). Cooking-related exposures were higher in more ventilated places, such as outside the household or on a walled veranda, than during indoor cooking. Conclusions : The study demonstrates the value of combining personal PM 2.5 exposure data with detailed contextual information for providing deeper insights into pollution sources and influences. The finding of similar/lower exposures during cooking in seemingly less-ventilated places should prompt a re-evaluation of proposed clean air interventions in these settings.

Shifting Positionalities in a Time of COVID-19: The Transnational Public Health Doctor and Ethnographer.

Ethnographic research is characterised by in-person engagement with individuals and groups within a social setting, usually over an extended timeframe. These elements provide valuable insights which cannot be gained through other forms of research. In addition, such levels of involvement in "the field" create complex, shifting researcher-participant relationships which themselves shape the course of the project and its findings. The COVID-19 pandemic disrupted many research projects, but impacts on ethnographic research, with its emphasis on physical presence in the field and interpersonal relationships, reveals much about these key elements of our praxis. I discuss how the pandemic influenced the progress of an ethnographic research project, based in Malawi, including consideration of how, as lead for the project, my clinical/"public health" positionalities interacted with relationships in the village and the arrival of COVID-19 in Malawi. This account reveals shifting intersubjectivities of researchers and participants as the pandemic brought changes in the nature of the engagement, from ethnographic explorations into the roles of smoke in everyday life, through fieldwork suspension, and contextualised COVID-19 response. These experiences demonstrate how a basis of reflexive ethnographic engagement with communities can underpin thoughtful responses to upcoming challenges, with implications for future "global health" work, both within and beyond the pandemic context.

Exploring smoke: an ethnographic study of air pollution in rural Malawi.

Air pollution adversely affects human health, and the climate crisis intensifies the global imperative for action. Low-/middle-income countries (LMIC) suffer particularly high attributable disease burdens. In rural low-resource settings, these are linked to cooking using biomass. Proposed biomedical solutions to air pollution typically involve 'improved cooking technologies', often introduced by high-income country research teams. This ethnography, set in a rural Malawian village, aimed to understand air pollution within its social and environmental context. The results provide a multifaceted account through immersive participant observations with concurrent air quality monitoring, interviews and participatory workshops. Data included quantitative measures of individuals' air pollution exposures paired with activity, qualitative insights into how smoke is experienced in daily life throughout the village, and participants' reflections on potential cleaner air solutions. Individual air quality monitoring demonstrated that particulate levels frequently exceeded upper limits recommended by the WHO, even in the absence of identified sources of biomass burning. Ethnographic findings revealed the overwhelming impact of economic scarcity on individual air pollution exposures. Scarcity affected air pollution exposures through three pathways: daily hardship, limitation and precarity. We use the theory of structural violence, as described by Paul Farmer, and the concept of slow violence to interrogate the origins of this scarcity and global inequality. We draw on the ethnographic findings to critically consider sustainable approaches to cleaner air, without re-enacting existing systemic inequities.

Participant compensation in global health research: a case study.

BACKGROUND: Compensation for research participants can be provided for reasons including reimbursement of costs; compensation for time lost, discomfort or inconvenience; or expression of appreciation for participation. This compensation involves numerous ethical complexities, at times entailing competing risks. In the context of transnational research, often incorporating contexts of economic inequality, power differentials and post-colonialism, these issues extend into wider questions of ethical research conduct. METHODS: We describe experiences of conducting a community-based study of air pollution in southern Malawi incorporating ethnographic, participatory and air quality monitoring elements. Decisions surrounding participant compensation evolved in response to changing circumstances in the field. RESULTS: Attention to careful researcher-participant relationships and responsiveness to community perspectives allowed dynamic, contextualised decision-making around participant compensation. Despite widely cited risks, including but not restricted to undue influence of monetary compensation on participation, we learned that failure to adequately recognise and compensate participants has its own risks, notably the possibility of 'ethics dumping'. CONCLUSIONS: We recommend active engagement with research participants and communities with integration of contextual insights throughout, including participant compensation, as for all elements of research conduct. Equitable research relationships encompass four central values: fairness, care, honesty and respect.

Health seeking for chronic lung disease in central Malawi: Adapting existing models using insights from a qualitative study.

BACKGROUND: Chronic lung diseases contribute to the growing non-communicable disease (NCD) burden and are increasing, particularly in many low and middle-income countries (LMIC) in sub-Saharan African. Early engagement with health systems in chronic lung disease management is critical to maintain quality of life and prevent further damage. Our study sought to understand health seeking behaviour in relation to chronic lung disease and TB in a rural district in Malawi. METHODS: Qualitative data was collected between March-May 2015, exploring patterns of health seeking for lung disease amongst residents of two districts in rural Malawi. Participants included those with and without lung disease, health workers and village leaders. Participants with a history of TB were included in the sample due to similarities in clinical presentation and in view of potential to cause long-term damage to lung tissue. RESULTS: Our findings are ordered around a specific model of health seeking devised by adapting previous models. The model and findings span three broad areas that were found to influence health seeking: understandings of health and disease which shaped whether, when and where to seek care; the care seeking decision which was influenced by social and structural factors; and the care seeking experience which impacted future care decisions creating 'feedback loops'. DISCUSSION: Efforts to improve effective and accessible healthcare provision for chronic lung disease need to address all the determinants of health seeking behaviour identified. This may include: enhancing the structural and financial accessibility of health services, through the strengthening of community linkages; improving communication between formal health providers, patients and communities around symptoms, diagnosis and management of chronic lung diseases; and improving the quality of diagnostic and management services through the strengthening of health systems 'hardware' (equipment availability) and 'software' (development of trusting and respectful relationships between providers and patients).

Questionnaires for Lung Health in Africa across the Life Course.

Respiratory infections remain a leading cause of morbidity and mortality in many low and middle-income countries but non-communicable disease rates are rising fast. Prevalence studies have been primarily symptom-focused, with tools developed in countries in the Global North such as the United States and the United Kingdom. Systematic study in sub-Saharan African populations is necessary to accurately reflect disease risk factors present in these populations. We present tools for such studies, developed as part of the International Multidisciplinary Programme to Address Lung Health and TB in Africa ('IMPALA'), which includes lay representatives. At a preliminary meeting, the adequacy and suitability of existing tools was discussed and a new questionnaire set proposed. Individual questionnaires were developed, and an expert panel considered content and criterion validity. Questionnaires underwent a cross-cultural adaptation process, incorporating translation and contextual 'sense-checking', through the use of pre-established lay focus groups in Malawi, before consensus-approval by project collaborators. The complete set of research questionnaires, providing information on lung health symptoms and a relevant range of potential risk factors for lung disease, is now available online. In developing the tools, cultural and contextual insights were important, as were translational considerations. The process benefitted from a foundation in expert knowledge, starting with validated tools and internationally respected research groups, and from a coordinated collaborative approach. We present and discuss a newly devised, contextually appropriate set of questionnaires for non-communicable lung disease research in Africa that are now available in open access for all to use.

Novel application of the matched case-control design to compare food supply chains during an Escherichia coli O157 outbreak, United Kingdom, 2016.

There is a need for innovative methods to investigate outbreaks of food-borne infection linked to produce with a complex distribution network. The investigation of a large outbreak of Escherichia coli O157 PT34 infection in the United Kingdom in 2016 indicated that catering venues associated with multiple cases had used salad leaves sourced from one supplier. Our aim was to investigate whether catering venues linked to cases were more likely to have used salad leaves from this supplier. We conducted a matched case-control study, with catering venues as the units of analysis. We compared venues linked to cases to those without known linked cases. We included 43 study pairs and obtained information on salad leaf products received by each venue. The odds of a case venue being supplied with salad leaves by Supplier A were 7.67 times (95% confidence interval: 2.30-25.53) those of control venues. This association provided statistical evidence to support the findings of the other epidemiological investigations undertaken for this outbreak. This is a novel approach which is labour-intensive but which addresses the challenge of investigating exposures to food across a complex distribution network.

"Like a rabbit from a hat!"--a case of a sacrocolpopexy mesh being taken out by a patient.

Sacrocolpopexy, be it laparoscopic or abdominal, is associated with a risk of mesh extrusion. We report an interesting case of mesh extrusion with subsequent removal of the mesh from the vagina by the patient. We take this opportunity to review the literature regarding incidence, predisposing factors and complications of sacrocolpopexy mesh extrusion with specific reference to this case.

Inpatient bladder retraining: is it beneficial on its own?

INTRODUCTION AND HYPOTHESIS: Urinary incontinence is a common problem with serious effect on the quality of life. Bladder training aims to increase the interval between voids, either by a mandatory or self-adjustable schedule, so that incontinence is avoided. This study aimed to assess the effectiveness of inpatient bladder retraining. METHODS: A retrospective case-note analysis was conducted over a period of 24 months. Outcome measures were decrease in incontinence episode frequency (IEF) and nocturia and increase in interval between voids. Subjective improvement was assessed on a four-point scale. RESULTS: The study revealed statistically significant decrease in IEF and nocturia and increase in the interval between voids. Twenty-three percent was cured of their symptoms, 36% reported improvement, 27% did not find any change, whereas 14% reported that they were worse off their after bladder retraining. CONCLUSION: The study confirms the usefulness of inpatient bladder retraining as a treatment option, especially in people refractory to outpatient management.