BackgroundDespite targeted indoor residual spraying (IRS) over a six-year period and free mass distribution of long-lasting insecticide-treated nets (ITNs), malaria rates in northern Ghana remain high. Outdoor sleeping and other night-time social, cultural and economic activities that increase exposure to infective mosquito bites are possible contributors. This study was designed to document these phenomena through direct observation, and to explore the context in which they occur.MethodsDuring the late dry season months of February and March 2014, study team members carried out continuous household observations from dusk to dawn in one village in Ghana’s Northern Region and one in Upper West Region. In-depth interviews with health workers and community residents helped supplement observational findings.ResultsStudy team members completed observations of 182 individuals across 24 households, 12 households per site. Between the two sites, they interviewed 14 health workers, six community health volunteers and 28 community residents. In early evening, nearly all study participants were observed to be outdoors and active. From 18.00-23.00 hours, socializing, night school, household chores, and small-scale economic activities were common. All-night funerals, held outdoors and attended by large numbers of community members, were commonly reported and observed. Outdoor sleeping was frequently documented at both study sites, with 42% of the study population sleeping outdoors at some time during the night. While interviewees mentioned bed net use as important to malaria prevention, observed use was low for both indoor and outdoor sleeping. Net access within households was 65%, but only 17% of those with access used a net at any time during the night. Participants cited heat as the primary barrier and reported higher net use during the rainy season.DiscussionOutdoor sleeping and other night-time activities were extensive, and could significantly increase malaria risk. These findings suggest that indoor-oriented control measures such as ITNs and IRS are insufficient to eliminate malaria in this setting, especially given the low net use observed. Development and evaluation of complementary outdoor control strategies should be prioritized. A research agenda is proposed to quantify the relative risk of outdoor night-time activities and test potential vector control interventions that might reduce that risk.

BackgroundDespite increased access and ownership, barriers to insecticide-treated bed net (ITN) use persist. While barriers within the home have been well documented, the challenges to net use when sleeping away from home remain relatively unexplored. This study examines common situations in which people sleep away from home and the barriers to ITN use in those situations.MethodsTo explore these issues, a group of researchers conducted 28 in-depth interviews and four focus groups amongst adults from net-owning households in four Ugandan districts.ResultsIn addition to sleeping outside during hot season, participants identified social events, livelihood activities, and times of difficulty as circumstances in which large numbers of people sleep away from home. Associated challenges to ITN use included social barriers such as fear of appearing proud, logistical barriers such as not having a place to hang a net, and resource limitations such as not having an extra net with which to travel. Social disapproval emerged as an important barrier to ITN use in public settings.ConclusionsUnique barriers to ITN use exist when people spend the night away from home. It is essential to identify and address these barriers in order to reduce malaria exposure in such situations. For events like funerals or religious “crusades” where large numbers of people sleep away from home, alternative approaches, such as spatial repellents may be more appropriate than ITNs. Additional research is required to identify the acceptability and feasibility of alternative prevention strategies in situations where ITNs are unlikely to be effective.

BackgroundAccess to insecticide-treated bed nets has increased substantially in recent years, but ownership and use remain well below 100% in many malaria endemic areas. Understanding decision-making around net allocation in households with too few nets is essential to ensuring protection of the most vulnerable. This study explores household net allocation preferences and practices across four districts in Uganda.MethodsData collection consisted of eight focus group discussions, twelve in-depth interviews, and a structured questionnaire to inventory 107 sleeping spaces in 28 households.ResultsIn focus group discussions and in-depth interviews, participants almost unanimously stated that pregnant women, infants, and young children should be prioritized when allocating nets. However, sleeping space surveys reveal that heads of household sometimes receive priority over children less than five years of age when households have too few nets to cover all members.ConclusionsWhen asked directly, most net owners highlight the importance of allocating nets to the most biologically vulnerable household members. This is consistent with malaria behaviour change and health education messages. In actual allocation, however, factors other than biological vulnerability may influence who does and does not receive a net.

The rising salinity of land and water is an important, but understudied, climate change-sensitive trend that can exert devastating impacts on food security. This mixed methods investigation combines salinity testing with qualitative research methods to explore these impacts in one of the most salinity-affected regions in the world—the Ganges River Delta. Data collection in 2015 and 2016 undertaken in Bangladesh’s southwest coastal region and Dhaka consisted of 83 in-depth household and stakeholder interviews, six community focus groups, and salinity testing of 27 soil and 45 surface and groundwater samples. Results show that household food production is a multifaceted cornerstone of rural livelihood in the southwest coastal region, and virtually every component of it—from rice plantation and homestead gardening to livestock cultivation and aquaculture—is being negatively affected by salinity. Although households have attempted multiple strategies for adapting food production, effective adaptation remains elusive. At the community level, improved irrigation and floodplain management, as well as restrictions on saltwater aquaculture to abate salinity, are viewed as promising interventions. However, the potential of such measures remains unrealized on a broad scale, as they require a level of external resources and regulation not yet provided by the NGO and government sectors. This study elucidates issues of accessibility, equity, and governance surrounding agricultural interventions for climate change-related salinity adaptation, and its findings can help inform the community of organizations that will increasingly need to grapple with salinity in order to guarantee food security in the context of environmental change.

BackgroundIncreased insecticide-treated net (ITN) use over the last decade has contributed to dramatic declines in malaria transmission and mortality, yet residual transmission persists even where ITN coverage exceeds 80%. This article presents observational data suggesting that complex human net use patterns, including multiple entries to and exits from ITNs by multiple occupants throughout the night, might be a contributing factor.MethodsThe study included dusk-to-dawn observations of bed net use in 60 households in the Peruvian Amazon. Observers recorded number of net occupants and the time and number of times each occupant entered and exited each net. The study team then tabulated time of first entry, total times each net was lifted, and, where possible, minutes spent outside by each occupant.ResultsThe sample included 446 individuals and 171 observed sleeping spaces with nets. Household size ranged from 2 to 24 occupants; occupants per net ranged from 1 to 5. Nets were lifted a mean 6.1 times per night (SD 4.35, range 1–22). Observers captured substantial detail about time of and reasons for net entry and exit as well as length of time and activities undertaken outside.ConclusionsThese findings suggest that the ITN use patterns observed in this study may contribute to residual transmission. As a result, respondents to net use surveys may truthfully report that they slept under a net the previous night but may not have received the anticipated protection. More research is warranted to explore the impact of this phenomenon. Concurrent entomological data would help assess the magnitude of the effect.

IntroductionResearch suggests that literacy plays a key role in mediating the relationship between formal education and care-seeking among women in developing countries. However, little research has examined literacy’s role independently from formal education. This differentiation is important, as literacy programs and formal schooling entail distinct intervention designs and resources, and may target different groups. To assess the relationship between literacy and healthcare-seeking among Nepali women of low educational attainment, we analyzed data from the 2011 Nepal Demographic and Health Survey (DHS).MethodsFrom the 2011 Nepal DHS, our sample consisted of 7,020 women who had attained at most a primary school level of education, and a subsample of 4,875 women with no formal schooling whatsoever. We assessed associations between literacy and four healthcare-seeking outcomes: whether women identified “getting permission” as a barrier to accessing care; whether women identified “not wanting to go alone” as a barrier; whether among women who were married/partnered, the woman had some say in making decisions about her own health; and whether among women who experienced symptoms related to sexually-transmitted infections (STIs) in the past year, treatment was sought. We performed simple and multiple logistic regressions, which adjusted for several socio-demographic covariates.ResultsLiteracy was associated with some aspects of healthcare-seeking, even after adjusting for socio-demographic covariates. Among women with no more than primary schooling, literate women’s odds of identifying “getting permission” as a barrier to healthcare were 23% less than illiterate women’s odds (p = 0.04). For married/partnered women, odds of having some say in making decisions related to their health were 37% higher (p = 0.002) in literate than illiterate women. Comparing literate to illiterate women in the subsample with no formal schooling, odds of reporting “getting permission” as a barrier were 35% lower (p = 0.01), odds of having a decision-making say were 57% higher (p < 0.001), and odds of having sought care for experiences of STI-related symptoms were 86% higher (p = 0.04).ConclusionsFurther research should be undertaken to determine whether targeted literacy programs for those past normal schooling age lead to improved healthcare-seeking among Nepali women with little or no formal education.

Background Industrial food animal production (IFAP) is characterized by dense animal housing, high throughput, specialization, vertical integration, and corporate consolidation. Research in high-income countries has documented impacts on public health, the environment, and animal welfare. IFAP is proliferating in some low- and middle-income countries (LMICs), where increased consumption of animal-source foods has occurred alongside rising incomes and efforts to address undernutrition. However, in these countries IFAP’s negative externalities could be amplified by inadequate infrastructure and resources to document issues and implement controls. Methods Using UN FAOSTAT data, we selected ten LMICs where food animal production is expanding and assessed patterns of IFAP growth. We conducted a mixed methods review to explore factors affecting growth, evidence of impacts, and information gaps; we searched several databases for sources in English, Spanish, and Portuguese. Data were extracted from 450+ sources, comprising peer-reviewed literature, government documents, NGO reports, and news articles. Results In the selected LMICs, not only has livestock production increased, but the nature of expansion appears to have involved industrialized methods, to varying extents based on species and location. Expansion was promoted in some countries by explicit government policies. Animal densities, corporate structure, and pharmaceutical reliance in some areas mirrored conditions found in high-income countries. There were many reported weaknesses in regulation and capacity for enforcement surrounding production and animal welfare. Global trade increasingly influences movement of and access to inputs such as feed. There was a nascent, compelling body of scientific literature documenting IFAP’s negative environmental and public health externalities in some countries. Conclusions LMICs may be attracted to IFAP for economic development and food security, as well as the potential for increasing access to animal-source foods and the role these foods can play in alleviating undernutrition. IFAP, however, is resource intensive. Industrialized production methods likely result in serious negative public health, environmental, and animal welfare impacts in LMICs. To our knowledge, this is the first systematic effort to assess IFAP trends through an environmental public health lens for a relatively large group of LMICs. It contributes to the literature by outlining urgent research priorities aimed at informing national and international decisions about the future of food animal production and efforts to tackle global undernutrition.

Despite the existence of highly active antiretroviral therapy, HIV/AIDS morbidity and mortality continue to be public health burdens in the United States due to difficulties in engaging people living with HIV/AIDS (PLWHA) in continuous, effective care. In comparison to studies investigating patient-level characteristics associated with starting and remaining in care, there is relatively little research on how structural factors, such as those pertaining to healthcare providers and the infrastructure for delivery of health services, influence patients’ engagement in HIV care. Our study, based in the city of Baltimore, Maryland, uses qualitative research methods with a population of predominantly African American PLWHA who have a history of drug abuse, to examine facilitators and barriers regarding adherence to antiretroviral therapy (ART) and HIV care appointment attendance. Data collection involved conducting one-on-one, in-depth interviews with 31 study participants, and data analysis entailed thematic coding of interview transcripts and writing analytic memos to develop ideas and concepts. Among other findings, factors described as influential by our study participants related to appointment reminders and scheduling, the attitudes and communication styles of HIV clinicians, and the disposition and availability of other healthcare workers on the care “team.” Thus, improving quality of HIV care and means of delivering it may help mitigate the numerous points in the continuum of HIV care when a patient may disengage.