Conference Material > Abstract
Hadiuzzaman M, Yantzi R, van den Boogaard W, Lim SY, Gupta PS, et al.
MSF Scientific Days International 2022. 2022 May 12; DOI:10.57740/2hjs-zc19
INTRODUCTION
Maternal health indicators remain unacceptably poor within the densely populated Rohingya refugee camps in Cox’s Bazar, Bangladesh. With a high prevalence of home births, we sought to explore perceptions, experiences, and expectations around delivery care of women of reproductive age. We also examined the potential roles of family and key community members within Camp 22, a relatively isolated camp with 23,000 refugees where MSF is the only provider of facility-based maternity care.
METHODS
In 2021, we selected 45 participants from Camp 22 through purposive and snowball sampling for in-depth interviews. Participants included 36 Rohingya women and their family members, three traditional birth attendants (TBA’s) and six community and religious leaders. Interviews were recorded, translated and transcribed into English by trained staff fluent in Rohingya. Thematic-content analysis was performed, whereby codes and emerging themes were identified.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and by the ERB of Bangladesh University of Health Sciences.
RESULTS
Findings showed that delivery choices were made as a family, with husband and parents-in-law being primary decision makers. An uncomplicated birth was not perceived as requiring facility-based assistance; many women preferred to give birth at home assisted by TBA’s, family, or local healers, due to placing greater trust in their own community. Lack of security and transport were crucial determinants in repudiating facility-based care at night. Concerns about male staff and being undressed during facility-based births, as well as the possibility of onward referrals should surgery or episiotomies be required, drove hesitancy. Separation from family and children added more anxiety. Lack of understanding by facility staff towards Rohingya birthing practices and beliefs, and the Rohingya’s unfamiliarity with formally-trained midwives and medical procedures, featured heavily in decisions for home births. Factors such as utilising birthing ropes and guaranteed privacy at home were key influencers for choosing home births. Additionally, perceived inexperience of midwives and lack of autonomy while in the facility, were other common reasons for apprehension.
CONCLUSION
This study emphasizes community trust as a factor in collective decision-making regarding birth choices. Trust was higher in TBA’s than in formally-trained midwives and this negatively affected perceptions regarding competence. Perceptions may also be affected by rapid midwife turnover, a factor endemic to non-governmental organizations working in Cox’s Bazar. The persistent gap in cultural understanding and adaptation by facility-based staff, even after three years of presence, suggests the need for a more iterative, inclusive and reflective approach, with community engagement strategies founded on beneficiaries own explicitly stated needs, beliefs and practices.
CONFLICTS OF INTEREST
None declared
Maternal health indicators remain unacceptably poor within the densely populated Rohingya refugee camps in Cox’s Bazar, Bangladesh. With a high prevalence of home births, we sought to explore perceptions, experiences, and expectations around delivery care of women of reproductive age. We also examined the potential roles of family and key community members within Camp 22, a relatively isolated camp with 23,000 refugees where MSF is the only provider of facility-based maternity care.
METHODS
In 2021, we selected 45 participants from Camp 22 through purposive and snowball sampling for in-depth interviews. Participants included 36 Rohingya women and their family members, three traditional birth attendants (TBA’s) and six community and religious leaders. Interviews were recorded, translated and transcribed into English by trained staff fluent in Rohingya. Thematic-content analysis was performed, whereby codes and emerging themes were identified.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and by the ERB of Bangladesh University of Health Sciences.
RESULTS
Findings showed that delivery choices were made as a family, with husband and parents-in-law being primary decision makers. An uncomplicated birth was not perceived as requiring facility-based assistance; many women preferred to give birth at home assisted by TBA’s, family, or local healers, due to placing greater trust in their own community. Lack of security and transport were crucial determinants in repudiating facility-based care at night. Concerns about male staff and being undressed during facility-based births, as well as the possibility of onward referrals should surgery or episiotomies be required, drove hesitancy. Separation from family and children added more anxiety. Lack of understanding by facility staff towards Rohingya birthing practices and beliefs, and the Rohingya’s unfamiliarity with formally-trained midwives and medical procedures, featured heavily in decisions for home births. Factors such as utilising birthing ropes and guaranteed privacy at home were key influencers for choosing home births. Additionally, perceived inexperience of midwives and lack of autonomy while in the facility, were other common reasons for apprehension.
CONCLUSION
This study emphasizes community trust as a factor in collective decision-making regarding birth choices. Trust was higher in TBA’s than in formally-trained midwives and this negatively affected perceptions regarding competence. Perceptions may also be affected by rapid midwife turnover, a factor endemic to non-governmental organizations working in Cox’s Bazar. The persistent gap in cultural understanding and adaptation by facility-based staff, even after three years of presence, suggests the need for a more iterative, inclusive and reflective approach, with community engagement strategies founded on beneficiaries own explicitly stated needs, beliefs and practices.
CONFLICTS OF INTEREST
None declared
Journal Article > ResearchFull Text
BMC Prim Care. 2023 January 26; Volume 24 (Issue 1); 34.; DOI:10.1186/s12875-022-01957-8
Nhemachena T, Späth C, Arendse KD, Lebelo K, Zokufa N, et al.
BMC Prim Care. 2023 January 26; Volume 24 (Issue 1); 34.; DOI:10.1186/s12875-022-01957-8
BACKGROUND & OBJECTIVES
The benefits of long-term adherence to antiretroviral therapy (ART) are countered by interruptions in care or disengagement from care. Healthcare workers (HCWs) play an important role in patient engagement and negative or authoritarian attitudes can drive patients to disengage. However, little is known about HCWs’ perspectives on disengagement. We explored HCWs’ perspectives on ART disengagement in Khayelitsha, a peri-urban area in South Africa with a high HIV burden.
METHOD
Semi-structured interviews were conducted with 30 HCWs in a primary care HIV clinic to explore their perspectives of patients who disengage from ART. HCWs interviewed included clinical (doctors and nurses) and support staff (counsellors, social workers, data clerks, security guards, and occupational therapists). The interview guide asked HCWs about their experience working with patients who interrupt treatment and return to care. Transcripts were audio-recorded, transcribed, and analysed using an inductive thematic analysis approach.
RESULTS
Most participants were knowledgeable about the complexities of disengagement and barriers to sustaining engagement with ART, raising their concerns that disengagement poses a significant public health problem. Participants expressed empathy for patients who interrupted treatment, particularly when the challenges that led to their disengagement were considered reasonable by the HCWs. However, many also expressed feelings of anger and frustration towards these patients, partly because they reported an increase in workload as a result. Some staff, mainly those taking chronic medication themselves, perceived patients who disengage from ART as not taking adequate responsibility for their own health.
CONCLUSION
Lifelong engagement with HIV care is influenced by many factors including disclosure, family support, and HCW interactions. Findings from this study show that HCWs had contradictory feelings towards disengaged patients, experiencing both empathy and anger. Understanding this could contribute to the development of more nuanced interventions to support staff and encourage true person-centred care, to improve patient outcomes.
The benefits of long-term adherence to antiretroviral therapy (ART) are countered by interruptions in care or disengagement from care. Healthcare workers (HCWs) play an important role in patient engagement and negative or authoritarian attitudes can drive patients to disengage. However, little is known about HCWs’ perspectives on disengagement. We explored HCWs’ perspectives on ART disengagement in Khayelitsha, a peri-urban area in South Africa with a high HIV burden.
METHOD
Semi-structured interviews were conducted with 30 HCWs in a primary care HIV clinic to explore their perspectives of patients who disengage from ART. HCWs interviewed included clinical (doctors and nurses) and support staff (counsellors, social workers, data clerks, security guards, and occupational therapists). The interview guide asked HCWs about their experience working with patients who interrupt treatment and return to care. Transcripts were audio-recorded, transcribed, and analysed using an inductive thematic analysis approach.
RESULTS
Most participants were knowledgeable about the complexities of disengagement and barriers to sustaining engagement with ART, raising their concerns that disengagement poses a significant public health problem. Participants expressed empathy for patients who interrupted treatment, particularly when the challenges that led to their disengagement were considered reasonable by the HCWs. However, many also expressed feelings of anger and frustration towards these patients, partly because they reported an increase in workload as a result. Some staff, mainly those taking chronic medication themselves, perceived patients who disengage from ART as not taking adequate responsibility for their own health.
CONCLUSION
Lifelong engagement with HIV care is influenced by many factors including disclosure, family support, and HCW interactions. Findings from this study show that HCWs had contradictory feelings towards disengaged patients, experiencing both empathy and anger. Understanding this could contribute to the development of more nuanced interventions to support staff and encourage true person-centred care, to improve patient outcomes.
Journal Article > ResearchFull Text
BMC Infect Dis. 2020 March 20; Volume 20 (Issue 1); DOI:10.1186/s12879-020-04968-x
Murray J, Whitehouse K, Ousley J, Bermudez E, Soe TT, et al.
BMC Infect Dis. 2020 March 20; Volume 20 (Issue 1); DOI:10.1186/s12879-020-04968-x
BACKGROUND:
Adolescents living with HIV/AIDS (ALHIV) are a particularly vulnerable but often overlooked group in the HIV response despite additional disease management challenges.
METHODS:
All ALHIV (10-19 years), on ART for ≥6 months, presenting to care at a Médecins Sans Frontières (MSF) clinic in Myanmar from January-April 2016 were eligible for the quantitative study component (clinical history, medical examination, laboratory investigation). A subset of these respondents were invited to participate in qualitative interviews. Interviews and focus groups were also conducted with other key informants (care givers, clinicians).
RESULTS:
Of 177 ALHIV, 56% (100) were aged 9-13 years and 77 (44%) were 14-19. 49% (86) had been orphaned by one parent, and 19% (33) by both. 59% (104) were severely underweight (BMI < 16). 47% presented with advanced HIV (WHO stage III/IV). 93% were virally supressed (< 250 copies/mL). 38 (21%) of ALHIV were on a second-line ART after first-line virological failure. Qualitative interviewing highlighted factors limiting adherence and the central role that HIV counsellors play for both ALHIV patients and caregivers.
CONCLUSIONS:
Our study shows good clinical, immunological, and virological outcomes for a cohort of Myanmar adolescents living with HIV, despite a majority being severely underweight, presenting with Stage III or IV illness, and the prevalence of comorbid infections (TB). Many treatment and adherence challenges were articulated in qualitative interviewing but emphasized the importance of actively engaging adolescents in their treatment. Comprehensive HIV care for this population must include routine viral load testing and social support programs.
Adolescents living with HIV/AIDS (ALHIV) are a particularly vulnerable but often overlooked group in the HIV response despite additional disease management challenges.
METHODS:
All ALHIV (10-19 years), on ART for ≥6 months, presenting to care at a Médecins Sans Frontières (MSF) clinic in Myanmar from January-April 2016 were eligible for the quantitative study component (clinical history, medical examination, laboratory investigation). A subset of these respondents were invited to participate in qualitative interviews. Interviews and focus groups were also conducted with other key informants (care givers, clinicians).
RESULTS:
Of 177 ALHIV, 56% (100) were aged 9-13 years and 77 (44%) were 14-19. 49% (86) had been orphaned by one parent, and 19% (33) by both. 59% (104) were severely underweight (BMI < 16). 47% presented with advanced HIV (WHO stage III/IV). 93% were virally supressed (< 250 copies/mL). 38 (21%) of ALHIV were on a second-line ART after first-line virological failure. Qualitative interviewing highlighted factors limiting adherence and the central role that HIV counsellors play for both ALHIV patients and caregivers.
CONCLUSIONS:
Our study shows good clinical, immunological, and virological outcomes for a cohort of Myanmar adolescents living with HIV, despite a majority being severely underweight, presenting with Stage III or IV illness, and the prevalence of comorbid infections (TB). Many treatment and adherence challenges were articulated in qualitative interviewing but emphasized the importance of actively engaging adolescents in their treatment. Comprehensive HIV care for this population must include routine viral load testing and social support programs.
Conference Material > Slide Presentation
Hadiuzzaman M, Yantzi R, van den Boogaard W, Lim SY, Gupta PS, et al.
MSF Scientific Days International 2022. 2022 May 12; DOI:10.57740/qwgn-be73
Journal Article > CommentaryFull Text
Lancet Global Health. 2020 April 1; Volume 8 (Issue 4); DOI:10.1016/S2214-109X(20)30030-9
Smith JS, Whitehouse K, Blanchet K
Lancet Global Health. 2020 April 1; Volume 8 (Issue 4); DOI:10.1016/S2214-109X(20)30030-9
Journal Article > Case Report/SeriesFull Text
Oxf Med Case Reports. 2023 July 18; Volume 2023 (Issue 7); omad053.; DOI:10.1093/omcr/omad053
Bublitz A, Manirakiza C, Whitehouse K, Chara A, Musa T, et al.
Oxf Med Case Reports. 2023 July 18; Volume 2023 (Issue 7); omad053.; DOI:10.1093/omcr/omad053
The management of kwashiorkor disease (KD) in children is challenging in resource-limited settings, especially for those cases with severe skin lesions and its complications. There are no evidenced-based management protocols specific to KD. This article describes the clinical presentation and case management of two children with different presentations of complicated kwashiorkor skin lesions and explores kwashiorkor from the perspective of the children’s caretakers in Maiduguri, Nigeria. Our experience shows that a well-structured approach and careful skin care are crucial. This includes simplified wound care guidance, training of medical staff, strict hygiene measures and the correct choice of antibiotics and antifungals, taking into the account low immunity and vulnerability to opportunistic infections amongst malnourished children. Limited knowledge of kwashiorkor amongst caretakers negatively impacts health-seeking behaviour, resulting in late presentation. Engaging caretakers in the process of care is essential to successful treatment.
Journal Article > ResearchFull Text
Int J Migr Health Soc Care. 2021 August 1; Volume 17 (Issue 3); 241-258.; DOI:10.1108/IJMHSC-08-2020-0082
Whitehouse K, Lambe E, Rodriguez S, Pellecchia U, Ponthieu A, et al.
Int J Migr Health Soc Care. 2021 August 1; Volume 17 (Issue 3); 241-258.; DOI:10.1108/IJMHSC-08-2020-0082
PURPOSE
Prolonged exposure to daily stressors can have long-term detrimental implications for overall mental health. For asylum seekers in European Union transit or destination countries, navigating life in reception centres can represent a significant burden. The purpose of this study was to explore post-migration stressors during residency in reception centres, and to formulate recommendations for adequate service provision in Belgium.
DESIGN/METHODOLOGY/APPROACH
Research was conducted in two reception centres in Belgium. A total of 41 in-depth interviews were carried out with asylum seeker residents (n = 29) and staff (n = 12). Purposive recruitment was used for asylum seekers (for variation in length of centre residency and family status) and staff (variation in job profiles). Interviews were conducted in English, French or with a translator in Arabic or Dari. Interviews were audio-recorded, transcribed verbatim and manually coded using thematic analysis.
FINDINGS
Asylum seekers face significant constraints with regard to their living conditions, including total absence of privacy, overcrowding and unhygienic conditions. These act as continuous and prolonged exposure to daily stressors. Several barriers to accessing activities or integration opportunities prevent meaningful occupation, contribute towards eroded autonomy and isolation of asylum seeker residents. Inadequate capacity and resources for the provision of psychosocial support in reception centres leads to a sense of abandonment and worthlessness.
ORIGINALITY/VALUE
Analysis indicates that structural and practical challenges to adequately support asylum seekers are rooted in policy failures necessary for appropriate resourcing and prioritization of preventative measures. Such deliberate decisions contribute towards state deterrence strategies, eroding both individual well-being and manufacturing a crisis in the systems of support for asylum seekers.
Prolonged exposure to daily stressors can have long-term detrimental implications for overall mental health. For asylum seekers in European Union transit or destination countries, navigating life in reception centres can represent a significant burden. The purpose of this study was to explore post-migration stressors during residency in reception centres, and to formulate recommendations for adequate service provision in Belgium.
DESIGN/METHODOLOGY/APPROACH
Research was conducted in two reception centres in Belgium. A total of 41 in-depth interviews were carried out with asylum seeker residents (n = 29) and staff (n = 12). Purposive recruitment was used for asylum seekers (for variation in length of centre residency and family status) and staff (variation in job profiles). Interviews were conducted in English, French or with a translator in Arabic or Dari. Interviews were audio-recorded, transcribed verbatim and manually coded using thematic analysis.
FINDINGS
Asylum seekers face significant constraints with regard to their living conditions, including total absence of privacy, overcrowding and unhygienic conditions. These act as continuous and prolonged exposure to daily stressors. Several barriers to accessing activities or integration opportunities prevent meaningful occupation, contribute towards eroded autonomy and isolation of asylum seeker residents. Inadequate capacity and resources for the provision of psychosocial support in reception centres leads to a sense of abandonment and worthlessness.
ORIGINALITY/VALUE
Analysis indicates that structural and practical challenges to adequately support asylum seekers are rooted in policy failures necessary for appropriate resourcing and prioritization of preventative measures. Such deliberate decisions contribute towards state deterrence strategies, eroding both individual well-being and manufacturing a crisis in the systems of support for asylum seekers.
Journal Article > CommentaryFull Text
Forced Migr Rev. 2021 March 1
Venables E, Whitehouse K, Spissu C, Pizzi L, Al Rousan A, et al.
Forced Migr Rev. 2021 March 1
Journal Article > ResearchFull Text
Refugee Survey Quarterly. 2020 February 20; Volume 39 (Issue 1); 26-55.; DOI:10.1093/rsq/hdz018
Schockaert L, Venables E, Gil-Bazo M-T, Barnwell G, Gerstenhaber R, et al.
Refugee Survey Quarterly. 2020 February 20; Volume 39 (Issue 1); 26-55.; DOI:10.1093/rsq/hdz018
Despite the difficulties experienced by asylum-seekers in South Africa, little research has explored long-term asylum applicants. This exploratory qualitative study describes how protracted asylum procedures and associated conditions are experienced by Congolese asylum-seekers in Tshwane, South Africa. Eighteen asylum-seekers and eight key informants participated in the study. All asylum-seekers had arrived in South Africa between 2003 and 2013, applied for asylum within a year of arrival in Tshwane, and were still in the asylum procedure at the time of the interview, with an average of 9 years since their application. Thematic analysis was used to analyse the data. The findings presented focus on the process of leaving the Democratic Republic of Congo, applying for asylum and aspirations of positive outcomes for one’s life. Subsequently, it describes the reality of prolonged periods of unfulfilled expectations and how protracted asylum procedures contribute to poor mental health. Furthermore, coping mechanisms to mitigate these negative effects are described. The findings suggest that protracted asylum procedures in South Africa cause undue psychological distress. Thus, there is both a need for adapted provision of mental health services to support asylum-seekers on arrival and during the asylum process, and systemic remediation of the implementation of asylum procedures.
Journal Article > Meta-AnalysisFull Text
Lancet HIV. 2016 October 1; Volume 3 (Issue 10); e473-e481.; DOI:10.1016/S2352-3018(16)30050-9
Cohn J, Whitehouse K, Tuttle J, Lueck K, Tran TH
Lancet HIV. 2016 October 1; Volume 3 (Issue 10); e473-e481.; DOI:10.1016/S2352-3018(16)30050-9