Burden of chronic pain among adult pastoralists in Ethiopia: a cross-sectional household survey.

ABSTRACT: Chronic pain is a major global health problem. Untreated pain causes particular suffering in marginalized communities. Most studies investigating chronic pain in sub-Saharan Africa stem from South Africa and Nigeria. Pastoralists are particularly underrepresented in pain research. The main objective of this study is to investigate the burden of chronic pain in adult pastoralists in the Somali Regional State of Ethiopia. We conducted a cross-sectional household survey among adult pastoralists (aged 18 years or older, N = 299) by face-to-face interviews. To randomly select households, we applied GPS-based household localization and recruitment. Chronic pain was self-reported by 17.0% (95% CI: 10.8-25.7) of male and 34.7% (95% CI: 28.4-41.5) of female adult pastoralists. The prevalence of chronic pain increased with age from 5.4% (95% CI: 0.8-30.1; 18-34 years) to 27.1% (95% CI: 15.1-43.7; 35-54 years) to 69.1% (95% CI: 53.7-81.1; 55 years and older). The body sites most commonly affected among those with chronic pain were knees (37.2%), followed by lower back (33.7%) and head (23.3%). The data for the first time provide insights into the burden of chronic pain among Somali pastoralists and reveal associated risk factors. The results support the planning of locally adapted health interventions for pastoralist-specific pain management considering the effects of chronic pain on pastoralists' daily lives.

Operational Differences between Product Development Partnership, Pharmaceutical Industry, and Investigator Initiated Clinical Trials.

Medicine development is a lengthy endeavour. Increasing regulatory stringency and trial complexity might lead to reduced efficiency, dwindled output, and elevated costs. However, alternative models are possible. We compared the operational differences between pharmaceutical industry sponsored trials, product development partnership trials, and investigator-initiated trials to identify key drivers of inefficiency in clinical research. We conducted an exploratory mixed-methods study with stakeholders, including clinical trial sponsors, contract research organisations, and investigators. The qualitative component included 40 semi-structured interviews, document reviews of 12 studies and observations through work shadowing in research institutions in Burkina Faso, Mali, and Switzerland. The findings were triangulated with an online survey polling clinical research professionals. The operational differences were grouped under five categories: (i) trial start-up differences including governance and management structure; (ii) study complexity; (iii) site structural and organisational differences; (iv) study conduct, quality approaches, and standard operating procedures; and (v) site capacity strengthening and collaboration. Early involvement of sites in the planning and tailored quality approaches were considered critical for clinical operations performance. Differences between the types of trials reviewed pertained to planning, operational complexities, quality approaches, and support to the sites. Integration of quality-by-design components has the potential to alleviate unnecessary process burden.

"I could not bear it": Perceptions of chronic pain among Somali pastoralists in Ethiopia. A qualitative study.

BACKGROUND: Pain is a major public health problem in the Global South, particularly among marginalized communities, such as Somali pastoralists. Yet, the topic of chronic pain has not yet been comprehensively studied in Sub-Saharan Africa, specifically in the Somali region of Ethiopia. Therefore, this study aims to explore the perceptions and notions of chronic pain among Somali pastoralists in this context. METHODS: This study used an explorative qualitative design. We performed semi-structured, face-to-face interviews with 20 purposively selected female and male Somali pastoralists with chronic pain. For data analysis, we applied the Framework Method by Gale et al. and explained patterns drawing on the Enactive Approach to Pain proposed by Stilwell and Harman. FINDINGS: Six different themes emerged: (1) "Pain as a symptom of harsh daily life", (2) "Pain descriptions and dimensions", (3) "Temporality of pain", (4) "Pain-related stigma and stoicism" (5) "Mediating role of spirituality", and (6) "Impact of pain on daily life activities". CONCLUSIONS: Somali pastoralists described their chronic pain as a multicausal and relational experience. Pastoralists (especially women) commonly refrained from communicating their pain and represented aspects of social stigma and stoicism. The mediating role of spirituality aided pastoralists to make sense of their pain and to ease its impact on their harsh daily life. The findings of this study can contribute to raise awareness of chronic pain issues among pastoralists. They highlight the need for policymakers to prioritize the improvement of pastoralist-specific pain management. Necessary resources and skills should be available within health care facilities. Pain management should be accessible, affordable and culturally acceptable for this population.

Opportunities and challenges for decentralised clinical trials in sub-Saharan Africa: a qualitative study.

INTRODUCTION: Digital health has gained traction in research and development, and clinical decision support systems. The COVID-19 pandemic accelerated the adoption of decentralised clinical trials (DCTs) as a mitigation and efficiency improvement strategy. We assessed the opportunities and challenges of a digital transformation in clinical research in sub-Saharan Africa from different stakeholders' perspectives. METHODS: A qualitative study, including 40 in-depth semi structured interviews, was conducted with investigators of three leading research institutions in sub-Saharan Africa and Switzerland, contract research organisations and sponsors managing clinical trials in sub-Saharan Africa. A thematic approach was used for the analysis. RESULTS: Interviewees perceived DCTs as an opportunity for trial efficiency improvement, quality improvement and reducing the burden of people participating in clinical trials. However, to gain and maintain an optimal quality of clinical trials, a transition period is necessary to tackle contextual challenges before DCTs are being implemented. The main challenges are categorised into four themes: (1) usability and practicability of the technology; (2) paradigm shift and trial data quality; (3) ethical and regulatory hurdles and (4) contextual factors (site-specific research environment and sociocultural aspects). CONCLUSION: The transformation from a site to a patient-centric model with an increased responsibility of participants should be context adapted. The transformation requires substantial investment, training of the various stakeholders and an efficient communication. Additionally, commitment of sponsors, investigators, ethics and regulatory authorities and the buy-in of the communities are essential for this change.

"It is difficult for us to treat their pain". Health professionals' perceptions of Somali pastoralists in the context of pain management: a conceptual model.

Pain is one of the most neglected areas of care in sub-Saharan Africa. Access to adequate pain management is important, especially in marginalised populations, such as pastoralists. Little is known about health professionals' perceptions of pain-related care for Somali pastoralists. This study seeks to understand health professionals' perceptions of Somali pastoralists in the context of pain management in Eastern Ethiopia. Within the scope of this qualitative multicentre study, we conducted semi-structured interviews with 17 health professionals (mainly nurses) experienced in treating Somali pastoralists with pain. Data analysis was based on the coding paradigm proposed by Strauss and Corbin within Grounded Theory methodology and resulted in a conceptual model of pastoralist-specific pain management. We gave voice to pastoralists in the study design, for example, through focus group discussions conducted prior to this study. Our study is part of a larger ongoing research project involving health professionals and pastoralist communities. The perspective of pastoralists is explored in a consecutive study. 'Patient-professional relationship' was the core category we identified within the conceptual model. This category was closely linked with issues of '(mis)trust' and 'communication (barriers)'. 'Patient-related conditions' (eg, (under)-reporting of pain, care preferences and beliefs) and 'health professional-related' conditions' (eg, insufficient training, (under)exposure to local culture) had an influence on the core category. Contextual factors proved to be relevant as well, such as age and gender. The study highlights the complexity of pain management among marginalised communities, such as pastoralists. Health professionals perceive Somali pastoralists to have distinct illness beliefs and pain concepts influencing their health-seeking behaviour. The study highlights the importance of reaching this patient group with culturally acceptable and comprehensive pain management strategies.

Defining clinical trial quality from the perspective of resource-limited settings: A qualitative study based on interviews with investigators, sponsors, and monitors conducting clinical trials in sub-Saharan Africa.

BACKGROUND: Increasing clinical trial cost and complexity, as well as a high waste of clinical trial investment over the past decades, have changed the way clinical trial quality is managed. Recent evidence has highlighted that the lack of a clear clinical trial quality definition may have contributed to previous inefficiencies. This study aims to support the understanding of what clinical trial quality entails from the perspective of resource-limited settings. METHODOLOGY/PRINCIPAL FINDINGS: We conducted 46 semi-structured interviews involving investigators, sponsors, and monitors with experience in conducting clinical trials in 27 countries in sub-Saharan Africa. The questionnaire addressed the overall meaning of clinical trial quality and a conclusive clinical trial quality definition, as well as specific aspects of resource-limited settings across the clinical trial process. We held the interviews either in person, via Skype or by phone. They were recorded and transcribed verbatim, and we performed the analysis using The Framework Method. The analysis of clinical trial quality definitions resulted in 11 elements, which were summarised into a clinical trial quality concept consisting of two components: 1) clinical trial quality building factors (Scientific factors and Moral factors) and 2) promoting factors (Context adaptation; Infrastructure; Partnership; Operational excellence; Quality system). 12 resource-limited settings specific themes were identified. These themes were all categorised under the promoting factors "Context adaptation", "Infrastructure", and "Partnership". CONCLUSIONS/SIGNIFICANCE: We found that in order to enable comprehensive clinical trial quality management, clinical trial quality should be defined by a multidimensional concept that includes not only scientific and ethical, but also quality-promoting factors. Such a concept is of general relevance and not limited to clinical trials in resource-limited settings, where it naturally carries particular weight. In addition, from the perspective of sub-Saharan Africa, we identified specific categories that appear to be critical for the conduct of clinical trials in resource-limited settings, and we propose respective changes to a particular existing clinical trial quality framework (i.e., INQUIRE).

Medical Anthropology in, of, for and with Africa: Three Hotspots.

Medical anthropologists offer an empirically rich and conceptually nuanced account of how and why people in Africa engage with diverse forces influencing their ways of experiencing illness and practicing medicine in an unequal world. Expanding the research focus from healers to patients and, since 2000, to biomedicine and global health, they have deepened our understanding of the intricate, though not immediately visible networks of connecting, diverging and crisscrossing healing routes within and beyond Africa. In this review article, we revisit three much debated issues in this burgeoning research field: making African global health, framing traditional medicine, and tackling culturalism.

Parental satisfaction with quality of neonatal care in different level hospitals: evidence from Vietnam.

BACKGROUND: Most health systems provide the most specialized, and presumably also the highest quality of care at a central level. This study assessed parental satisfaction and its determinants in the context of neonatal care in a provincial as well as a national hospital of Vietnam. METHODS: In this cross-sectional quantitative study, parents of 340 preterm infants admitted to neonatal care units of a national and a provincial hospital in 2018 were interviewed using structured questionnaires. Unadjusted and adjusted linear regression models were used to assess the relationship between parental satisfaction and hospital rank. RESULTS: The mean parental satisfaction score was 3.74 at the provincial, and 3.56 at the national hospital. These satisfaction differences persisted when parent and child characteristics were adjusted for in multivariate analysis. Longer length of stay and worsening infant health status were associated with parents reporting lower levels of satisfaction with the quality of care being provided at the healthcare facility. CONCLUSIONS: This study suggests that parents of preterm infants admitted in a provincial hospital were more satisfied with the quality of care received than those in a specialized national hospital. Length of stay and infant health status were the two most important determinants of level of parental satisfaction.

Precarity, Assemblages, and Indonesian Elder Care.

The provision (or failure) of care reflects and produces vulnerability in old age. Reliable and appropriate care widely affects the imagination of "good care" of older Indonesians in North Sulawesi. Yet, their striving for better life goes with the growing chronification of conditions and processes with unpredictable endings. Three factors shape such uncertainty in elder care in North Sulawesi: (1) unsustainable, fragile care arrangements; (2) progressive-degenerative non-communicable diseases and aging impairments; and (3) structural insecurity in elder care and health-care institutions. Older persons mitigate the degree of chronifying care uncertainty by expanding social spaces, but often in normatively less accepted ways.

Use of herbal remedies in the management of sleeping sickness in four northern provinces of Angola.

ETHNOPHARMACOLOGICAL RELEVANCE: This study reports for the first time on the use of folk medicine to treat sleeping sickness and its symptoms in four endemic provinces in northern Angola. By interviewing both traditional practitioners and confirmed patients, it highlights reasons to recourse to folk medicine, the plant species used for this affection as well as arises awareness about the use of particular plants showing potential risks. AIM OF THE STUDY: The aims of this explorative study were three-fold. Firstly, it informed on access to, and use of plant-based medicine as first-choice treatment by infected persons. Secondly, it aimed at collecting comprehensive data from patients and traditional healers on herbal remedies in order to identify plant species used in the management of the disease. Thirdly, it served as contribution for primary indication of potential risk of use associated with the studied plants and their preparation. MATERIALS AND METHODS: The study was conducted in 4 endemic provinces of Angola, namely Bengo, Zaire, Kwanza Norte and Uíge. We explored the use of herbal remedies by conducting structured and semi-structured interviews within two distinct study populations. The first group comprises 30 patients who had been diagnosed for trypanosomiasis and treated by the reference treatment. The second group included 9 traditional practitioners who had already treated sleeping sickness. The plants that were cited during the interviews were collected during field walks under supervision of a traditional healer, then authenticated and deposited at the National Herbarium in Luanda. RESULTS: Of the 30 included patients, 12 (40%) had turned to folk medicine in the management of trypanosomiasis and related symptoms. 7 medicinal plants were reported by this group. Considering the key motivation to consult a traditional practitioner, two main factors accounted for half of the cases: "past experience with folk medicine" and "family habit". Out of 9 traditional practitioners' interviewees, 26 medicinal plants were cited. Roots and leaves were the most used plant parts, and decoction was the common mode of preparation. Evidence for antitrypanosomal activity in the scientific literature was found for 56% (17 of 30) of the identified plant species. The most cited plant was Crossopteryx febrifuga (UR = 6). Some of the cited plants, as for example Aristolochia gigantea, raised concern about potential toxicity. CONCLUSIONS: With 40% of infected persons having turned first to folk medicine before consulting a medical doctor, this explorative study points out that plant-based medicines play an important role in local dynamics of health care. It highlights the need for primary assessment of potential risk of use related to the herbal recipes, and for reporting it to the concerned population. This first ethnobotanical study on trypanosomiasis in endemic provinces of Angola provides information on 30 plants, of which some had been identified as promising for further pharmacological research. Our results provide a first step towards the validation and valorization of Angolan herbal remedies for sleeping sickness.

Perceived illness drives participation in mass deworming campaigns in Laos.

Multiple helminth infections are very common in communities of southern Laos. Preventive chemotherapy in combination with health education is the mainstay of control. We assessed the knowledge, perceptions and practices of rural communities related to endemic helminthiasis and their control during a mass drug administration (MDA) campaign. Short interviews with household heads (n=192), direct observations and discussions with attendees of MDAs, and in-depth interviews with local opinion leaders (n=21) were carried out. Quantitative and qualitative data analysis was performed. Results showed that opinion leaders and villagers were well aware of the importance of attending MDA. Leaders perceived the effectiveness of MDA against severe schistosomiasis and appreciated that it was provided for free and in their village. They encouraged villagers to attend it. Anticipated adverse events of praziquantel was a barrier for participation. A majority of leaders purchased deworming tablet (mebendazole, albendazole) in a local pharmacy for deworming when MDA is absent in their villages (19/21). Most leaders (20/21) had a good knowledge on severe schistosomiasis though only a few of them (5/21) described its cause correctly. They knew little about the disease consequences of liver fluke (3/21) and soil-transmitted helminth (4/21) infections but more about their causes. A high risk for worm infection was observed: consumption of raw or insufficiently cooked fish (100%), frequent physical contacts with Mekong River water (76.0%) and low number of latrines (14.5%). In conclusion, MDA is widely accepted in affected communities. Avoiding severe schistosomiasis was the main motivation to comply. Participation rates increased significantly with drugs provided free of charge in the villages. Better knowledge on the consequences of worm infections and on its modes of transmission will foster the distribution and acceptance of appropriate preventive treatment and other measures in helminth-endemic communities. Where multiple infections require several drugs for MDA, preceding health education and information about MDA and its benefits are a prior condition.

Raw fish consumption in liver fluke endemic areas in rural southern Laos.

Consumption of raw or insufficiently cooked fish is a major public health concern in Southeast Asia, and in Lao People's Democratic Republic (Lao PDR), in particular. We aimed to assess the knowledge, attitudes, perceptions and practices of villagers in liver fluke endemic areas related to raw fish preparation, consumption and its health consequences. In February 2010, eight focus group discussions (FGDs, 35 men and 37 women total) and direct observations were conducted in four randomly selected villages in Saravane District, Saravane Province (Lao PDR). FGDs distilled the knowledge, attitudes, perceptions and practices of adult community members on raw fish preparation, consumption and its consequences for health. Conversations were transcribed from notes and tape-recorders. MaxQDA software was used for content analysis. Knowledge regarding the health effects of raw fish consumption was heterogeneous. Some participants did not associate liver fluke infection with any ill health, while others linked it to digestive problems. Participants also associated vegetables and tree leave consumption with liver fluke infection. The majority of FGD participants considered fish flesh that had been prepared with weaver ant extract to be safe for consumption. Visual appearance, taste, smell and personal preference were given as reasons for consuming raw fish dishes. Moreover, participants considered it a traditional way of food preparation, practiced for generations in Laos. Ten different fish dishes that use raw or fermented fish were identified. All FGD participants reported consuming dishes with raw fish. This study reveals a low degree of knowledge among local people on the health risks related to frequent consumption of raw or insufficiently cooked fish. Fish dishes were considered to be 'well-prepared' (that is, 'cooked') even though the fish had not been heated. In future, successful health education campaigns will have to address the specific knowledge, attitudes, perceptions and practices of the concerned population.

Helminth infection in southern Laos: high prevalence and low awareness.

BACKGROUND: Helminthiasis is a public health concern in Lao People's Democratic Republic (Lao PDR, Laos). This study aimed to understand helminth infection and associated risk factors in relation to existing local knowledge, attitudes and practices regarding worm infections in endemic communities. METHODS: A cross-sectional survey was conducted in 10 randomly selected villages in Saravane district, Southern Laos. Two stool samples obtained from 574 members (aged ≥2 years) of selected households were examined using the Kato Katz method. Household heads (n = 130) were interviewed. Eight focus group discussions (FGDs) and direct observations were performed. Uni- and multivariate logistic regression analyses were conducted to predict infection. Content analysis was conducted for qualitative data. RESULTS: The prevalence of Opisthorchis viverrini, hookworm, Trichuris trichiura, Ascaris lumbricoides and Taenia sp. was 88.7%, 86.6%, 32.9%, 9.8% and 11.5%, respectively. Most individuals were co-infected with O. viverrini and hookworm. More men had multiple helminth infections than did women. Only one-third of household heads had heard about liver fluke before, of which 59.2% associated it with eating raw fish dish. Among the soil-transmitted helminths, roundworm was the most well known (70.8%) but was attributed to raw food consumption (91.3%). Eating raw fish was a common practice (75.4%); few households possessed a latrine (16.1%); less than half of the study participants mentioned health benefits from latrine use and personal hygiene. Focus group discussion participants had a low level of awareness of worm infections; more men liked eating raw fish than did women; some disliked using latrines because they were not used to it and because of their bad smell. Poor personal and village hygiene practices were observed. CONCLUSIONS: This study highlights a high helminth infection rate and poor community awareness of worm infections and associated risk factors. Only a sound awareness of worm infection and the underlying risk factors may prevent infection and re-infection after treatment.

Health anthropology and urban health research.

We live in a rapidly urbanising world. According to the 2001 statistics of the United Nations,a the proportion of urban dwellers rose from 30% in 1950 to 47% in 2000 and will probably attain 60% in 2030. Almost 70% of these urban dwellers live in cities of developing regions. At the current rates of urbanisation, the number of city dwellers in the world will equal that of their rural counterparts by 2007. In the late 1980s, researchers became increasingly concerned about the combined impact of rapid urban growth and economic recession on the health of a majority of people in African and Asian cities. Several books established urban health research with a focus on developing countries as a multidisciplinary field of inquiry (Harpham et al., 1988; Salem &Jeannée, 1989). It is now widely recognised that urbanisation per se is not necessarily bad for health, but it becomes so if urban governments fail to establish and support necessary infrastructure and services to protect citizens from environmental hazards and from social, economic and political insecurity.

Urban elderly with chronic illness: local understandings and emerging discrepancies in North Sulawesi, Indonesia.

Old-age research in developing countries is at its beginning in the social sciences and particularly in anthropology, which has focused on other vulnerable groups, but has not sufficiently addressed emerging health issues of elderly urban dwellers in developing countries. This study investigates the health status of aged people living in cities (i.e. the 'burden of disease'), and how urban elderly experience and give meaning to chronic illnesses in context (i.e. the 'burden of illness'). It correlates the conceptual framework of 'health transition' with prevailing theoretical concepts and models of medical anthropology. The research project was carried out in three cities of North Sulawesi Province; it encompasses elderly people (≥ 60 years) suffering from one or more chronic illnesses. Elderly people experience chronic illnesses in three qualitative ways: illnesses that (1) disturb, (2) threaten, or (3) cause worry. The harsh urban setting reinforces these afflictions, and may lead to economic hardships and social destitution. The meaning of chronic illness of elderly varies distinctly from that of biomedicine and results in divergent health priorities. This article examines patterns of meaning developed by urban elderly with chronic illnesses, and explores how these emic classifications mirror afflictions of city life for these elderly in daily practice.