The Institute for Global Health and Development

Permanent URI for this collectionhttps://eresearch.qmu.ac.uk/handle/20.500.12289/7193

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Alleviating psychosocial suffering: an analysis of approaches to coping with war-related distress in Angola.
(Queen Margaret University, 2001) Eyber, Carola
This study investigates the role that the notions of trauma and culture play in relation to the alleviation of distress within an war-affected population. It analyses how local, cultural conceptions of distress and those held by psychological service providers relate to one another, and how they contribute to improving the well-being of the displaced. Fieldwork was conducted with urban and rural displaced populations in the south-eastern province of Huila in Angola. Ethnographic, psychometric and participatory methods were used to examine issues of health, illness and distress amongst the displaced. Local idioms of distress in the form of pensamentos, mutima, madness and high and low blood pressure are common ways of expressing suffering related to war. The different explanatory models held about these illnesses and the various resources available in the popular, folk and professionals sectors of the health care system were explored. The religious and spiritual domains were found to be influential in the treatment of distress-related illnesses. The psychological services available in the war-displaced communities were examined in terms of their common theoretical and practical elements. These were then analysed in relation to the conceptualisations held by local populations, and points of similarity and difference were noted. Specifically, the conceptualisation of suffering as trauma and the cultural misunderstandings that arise as a result of this, and the representation of the displaced as traumatised and therefore dependent and passive people, are discussed. A particular subgroup in the community, the adolescents, was identified and participatory methods were employed to investigate the strategies and resources this group uses for coping with war-related distress. The youths predominantly make use of distraction, conselho, religious and cultural resources. The application of a PTSD scale, the EARAT, suggests that 71% of the adolescents had symptoms of trauma consistent with a diagnosis of PTSD. It is argued that for the vast majority such a conceptualisation does not reflect the adolescents' abilities to function on social, vocational, educational and physical levels. The implications of these findings for research and practice in the field of psychosocial work are discussed.
Unfolding tragedies: the impact of a mother's death on her kin and community. An ethnography from Southern Malawi.
(Queen Margaret University, 2003) Putter, C.
In examining the specific impact of a mother's death on her surviving family and community, the thesis highlights the social devastation resulting from such an event. Crucially, it argues that the increased frequency of maternal death associated with the HIV/AIDS epidemic, and the associated increase in numbers of orphaned children, have the potential to provoke full-scale destruction of traditional kinship structures and coping mechanisms. The study contributes to a gendered study of death and the resultant coping mechanisms as well as emphasizing the importance of sibling bonds in Malawian kinship. Furthermore, it provides an analysis of the current trends relating to orphan care, and suggests how these goals could be improved within the specific cultural context. The findings are based on 14 months of in situ fieldwork, during which time a totla of 78 interviews were conducted with 66 individuals, 46 of whom are case studies. Further interviews were conducted with hospital personnel, workers with orphans, and teachers, i.e. those in positions to provide social commentary. Nudist N4 software was used for data management of the interview transcripts and fieldnotes, and facilitated access to the coded data as analysis proceeded. An historical understanding of Malawi's cultural context is outlined in the introductory chapter and the entire discussion is grounded within this context. More detailed anthropological data is provided in the chapter on kinship, which emphasizes the importance of maternal kin in looking after orphans subsequent to a mother's death. Chapters on HIV and death outline how communities are besieged by illnesses surrounding HIV-infection, and how the increased death rates associated with HIV have undermined the traditional bereavement processes, and, hence, the associated coping mechanisms. The thesis concludes with a discussion of the kinds of orphan care currently available in Malawi, followed by recommendations on how the needs of orphans could better be met by development initiatives that are more suited to working with community-based organizations.
Rhetoric or reality? Cross-sector policy and practice at the UK Government Department for International Development (DFID) in the UK and Nepal: an exploration of reproductive health and women's education linkages
(Queen Margaret University, 2005) Bovill, Catherine
Within the international development community, global agreement around a poverty elimination target and the Millenium Development Goals (MDGs) has led to renewed emphasis on partnership and cross-sectoral approaches. Similarly the UK Government aims to ensure policies are coherent in an increasingly complex global arena and has called for joined-up working. In response to both of these influences, the UK Government Department for International Development (DFID) stresses partnership, joining-up and cross-sectoral approaches within departmental documents. This research explores cross-sector policy and practice at DFID in the UK and Nepal and focuses particularly on cross-sectoral relationships between reproductive health and women's education. The research employs a social constructionist epistemology and utilises Critical Inquiry and Feminist theories, elements of grounded theory and narrative analysis methodologies, informing the use of numerous data collection methods. These methods include literature searches, document analysis, semi-structured interviews (incorporating Participatory Learning and Action techniques), informal meetings and critical reflection. Data was gathered in the UK and Nepal from DFID staff, Nepali Government staff, DFID-funded project staff, external development consultants and other stakeholders. A 'cross-sector continuum model' is presented to facilitate understanding of the different definitions and possible levels of cross-sectoral engagement. Examples of cross-sector policy and practice are presented and discussed. Key factors facilitation cross-sector policy and practice are also identified. The greatest levels of cross-sectoral engagement were found at project-level in Nepal, although the DFID offices had also made some significant efforts to improve cross-sectoral approaches. Poor knowledge and selective use of the reproductive health and women's education research, however, exposed a gap between research and policy. In addition, the reality of cross-sector policy and practice often did not match the rhetoric within DFID's documents. According to respondents, DFID faces some substantial challenges that contribute to these research-to-policy and policy-to-implementation gaps. Despite the increased calls for cross-sectorality, there is little evidence of the benefits of cross-sector policy and practice, suggesting the need for research clarifying the added value of cross-sectoral approaches. Finally, the lack of agreement over cross-sector definitions, the lack of operational guidance and DFID's strong emphasis on outcomes all suggest the need for a reorientation of focus towards cross-sectoral processes. Based on these findings and conclusions, recommendations are made for DFID and other organisations wishing to pursue cross-sectoral approaches.
Decentralisation in the post-conflict environment of Guatemala: a critical examination of the evaluation process of community participation in a health sector reform context
(Queen Margaret University, 2007) De Leon Estrada, Mario Sergio
This thesis focuses on a critical and comprehensive analysis of community participation within a health sector reform process in a post-conflict environment. The aim is to examine how evaluation of such processes should be guided, how decentralising policies should be implemented, and how the assumptions of existing evaluations limit their relevance and effectiveness. The thesis argues that comprehensive analysis demonstrates the need for a much deeper and more extensive understanding of the multiple complexities present in post-conflict environments than is often achieved. It is necessary to carry out a historical, comparative and analytical evaluative exercise, beyond mainstream structural-functionalist evaluations, because the latter generally do not address relevant external and internal variables affecting the conditions of the community. Utilising this proposed approach fieldwork in the communities of San Juan Chamelco and San Miguel Tucurú (in the northern department of Alta Verapaz) examined examples of the limitations of and potentials for the incorporation of traditional medicine into the institutional healthcare system. This fieldwork is used to inform development of a comprehensive framework for evaluation with wide potential as a technical-conceptual tool. The Guatemalan case is presented as an illustrative example of how this tool can be developed and elaborated within a specific historical, political, social and cultural context. Building on the findings of a sectoral evaluation carried out under the auspices of the Ministry of Health the comprehensive evaluation presented identifies key problems that prevented health decentralisation policies from having a significant and positive impact at the local level. In this complex post-conflict environment, local organisation and community participation are shown to be still in their infancy having been obliterated by the counter-insurgency policies during the course of prolonged conflict.
Responding to the health needs of the internally displaced persons: an analysis of the Indonesian health system
(Queen Margaret University, 2008) Massie, R.
Since 1998, several provinces in Indonesia have suffered a number of violent conflicts causing massive destruction, several thousand deaths and creating over a million displaced people. This happened in North Maluku and Central Kalimantan Provinces. In 1999 the displaced people from North Maluku took flight to Manado municipality and in 2001 those from Central Kalimantan fled to Sampang District. These recipient areas were selected for this study because of their differing characteristics, including presence of IDPs; urban/rural; and levels of development. While the central government was initially responsible for providing adequate support in the first two -three years of their displacement in both areas, this changed at the end of 2003 when the central government terminated their support for the IDPs. During this period, authority for developing health programmes and services had been devolved to local government by central government through the health decentralisation policy in 2001, which created additional challenges to their meeting the needs of the incoming IDP population and particularly after the removal of government support for IDPs in 2003. This research was designed to contribute to a policy or model to be developed by the Indonesian health authorities to provide services for IDPs. The research questions were: what are the key health needs of the displaced population in the two selected recipient areas in Indonesia; what are the problems experienced by services in the municipality and district in seeking to meet these needs; to what extent has the public sector identified and responded to the health needs of the IDPs in the context of the health decentralisation policy that was currently being implemented in these two areas; on the basis of the preceding analysis, what are appropriate recommendations for the provision of health services to the displaced populations of Indonesia? The research employed mixed methods in handling the above questions. It was conducted through direct observation, surveys and focus group discussions (FGD) with IDPs. Semi-structured interviews were conducted with the Heads of the Municipal/District Health Offices and Heads of selected puskesmas in the recipient IDP areas. Respondents for surveys were selected by using a formula for estimating statistical proportions. 71 respondents in Manado and 116 respondents in Sampang were selected and respondents for FGD were selected through purposive sampling. This thesis presents the effect of the reception of IDPs on the local health systems and the responses of the areas that received them. It argues that IDPs, trapped in complex emergency situations with consequent increased health needs, added a burden to the health systems in the recipient areas The findings indicated that the local health authorities were unable to fully meet the health needs of the IDPs and therefore suggested that local health systems need to be improved at the same time as the implementation of the health decentralisation policy. This thesis provides recommendations for the public health sector capacity in the areas that received the IDPs. These are intended to enable the national health system to fill the gap between the health needs of the IDPs and the local authority health system. Recommendations include: redefinition of functions of local health institutions, ensuring a better quality of health service and strengthening the referral system.
An assessment of the capacity of faculty-based youth friendly reproductive health services to promote sexual and reproductive health among unmarried adolescents: evidence from rural Malawi
(Queen Margaret University, 2009) Jimmy-Gama, Dixon
Despite the recognition of the influence of cultural norms on adolescent sexual behaviours in most societies (Kaler 2004; Chege 2005), less attention has been paid to the link between social norms and effectiveness of health facilities to promote adolescent sexual and reproductive health (ASRH). This thesis therefore examines the capacity of facilitybased youth-friendly reproductive health services (YFRHS) to promote ASRH in rural Malawian societies where culture strongly influences adolescent sexual behaviours. The study employs a social constructionist epistemology and a social interactionism theory to understand the capacity of YFRHS in ASRH promotion in rural Malawi. Qualitative and quantitative data were collected using a sequential exploratory design. Semi-structured in-depth interviews, participant observations, client exit interviews, survey, focus group discussions and review of health strategic and service utilisation documents/records were conducted. The results were generated by triangulating both qualitative and quantitative data. The findings of the study illuminate how social norms related to social identities influence adolescent sexual behaviours and ASRH promotion. An exploration of the cultural context reveals a major disjuncture between an ideal norm - no premarital sex - and a modelled norm where unmarried adolescents are expected to engage in unsafe sex. It also shows the conflicts between the cultural and scientific models of ASRH promotion. Structural gender asymmetry that emphasises subservience in females and hegemonic masculinity also reduces adolescents' rights and agency in SRH promotion. The health providers are cultural agents. They manage diverse roles both as 'moral guardians' and as 'health promoters' in a way that limits their effectiveness as health promoters. The thesis concludes that the way facility-based YFRHS is implemented has limited impact on SRH promotion among unmarried adolescents of rural Malawi. The study recommends that appropriate health promotion interventions based on conscientisationoriented empowerment theories directed at adolescents, community and health workers should be used in ASRH promotion in societies with strong cultural influence on sexual behaviours.
Understanding public private partnerships: the discourse, the practice, and the system wide effects of the global fund to fight AIDS, tuberculosis, and malaria.
(Queen Margaret University, 2010) Kapilashrami, A.
This thesis aims to deconstruct the monotheism of public private partnerships (PPP) for health and demonstrate the polytheism of practices enabled by it. It contributes to the body of knowledge on PPP in two respects: theoretical and substantive. At a theoretical level, using a critical enquiry lens, I deconstruct the partnership phenomenon and the notion of shared power within these interactions. This diverges from the traditional problem solving approach intrinsic to ‘good’ governance literature on PPP, which focuses on how partnerships can be made more effective. The thesis gives a plural account of the rationale and emerging paradoxes and examines the role of structural (institutions and mechanisms) and ideational (ideas and discourse) factors in constituting and constructing the practice of PPPs. The substantive aim of the thesis is to advance the study on PPP by understanding the contingencies and plurality of practices as a departure from the rhetoric on global health PPPs. Drawing on the case of Global Fund to fight AIDS TB and Malaria (GFATM), one of the three largest global health partnerships, and its country wide operations with respect to HIV and AIDS in India, I also discuss the implications of the discursive practices for the management of HIV and equity in health care. Through a critical examination of the governance mechanisms and arrangements of GFATM it is argued that these have instilled an environment characterised by a proliferation of multiple unaccountable entities which emerge as sites where principles of partnership are subsumed by competition for resources, power and individual and organisational gains. This raises an important question that the thesis attempts to answer: How despite the tensions and ruptures is it possible for the global health PPPs to rise to prominence as a key mechanism in global and national health governance? In response to this, I focus on the role of the development brokers and street level bureaucrats who act at the interface of the global discourse and the local perspectives and create “order” by negotiating dissent, building coherent representations and translating common meanings into individual and collective objectives.
The implications of contracting out health care provision to private not-for-profit health care providers: the case of service level agreements in Malawi
(Queen Margaret University, 2013) Gama, Elvis Sitithana Mpakati
Background: The Malawi government in 2002 embarked on an innovative health care financing mechanism called Service Level Agreement (SLA) with Christian Health Association of Malawi (CHAM) institutions that are located in areas where people with low incomes reside. The rationale of SLA was to increase access, equity and quality of health care services as well as to reduce the financial burden of health expenditure faced by poor and rural communities. This thesis evaluates the implications of SLA contracting out mechanism on access, utilization and financial risk protection, and determines factors that might have affected the performance of SLAs in relation to their objectives. Methods: The study adopted a triangulation approach using qualitative and quantitative methods and case studies to investigate the implications of contracting out in Malawi. Data sources included documentary review, in-depth, semi-structured interviews and questionnaire survey. The principal agent model guided the conceptual framework of the study. Results: We find positive impact on overall access to health care services, qualitative evidence of perverse incentives for both parties to the contracting out programme and that some intended beneficiaries are still exposed to financial risk. Conclusion: An important conclusion of this study is that contracting out has succeeded in improving access to maternal and child health care as well as provided financial risk protection associated with out of pocket expenditure. However, despite this improvement in access and reduction in financial risk, we observe little evidence of meaningful improvement in quality and efficiency, perhaps because SLA focused on demand side factors, and paid little attention to supply factors: resources, materials and infrastructure continued to be inadequate.
The social construction of justice: searching for connection and credibility in Sri Lanka.
(Queen Margaret University, Edinburgh, 2013) Salih, Maleeka
Research in Sri Lanka suggests that many people experience a deep scepticism about the chances of achieving justice. This is true not only of those who had suffered the most gross forms of human rights violations in the country’s past conflicts but, surprisingly, also of those caught up in more ordinary forms of everyday disputes and grievances. The prevalence of this sentiment of pervasive ‘injustice’ – captured in one informant’s pithy statement that “only the powerful get justice in Sri Lanka” – compels closer scrutiny of the broader processes and politics of justice-seeking. This thesis, based on research carried out in 2008 and 2009 and on the analysis of detailed accounts from 110 informants in 3 geographical locations, studies this quotidian experience of justice-seeking and dispute settlement work in Sri Lanka. It provides insights into how the broader political and social environment shapes the possibilities of a just outcome for any of its citizens. The thesis reveals the overriding power of social and political factors in the justice-seeking process. Becoming ‘known’ in a way that establishes the credibility of disputants is important. This is an inherently social exercise in which dominant notions about credibility and legitimacy as defined by the state are reinforced. The thesis illustrates the crucial role of the state in everyday dispute management. The police are a key resource for mediators and disputants, who seem to rely most notably on the police’s acknowledged potential and actual capability for violence. Persons who are seen to be politically suspicious are especially vulnerable to such violence. Who constitutes a ‘suspicious’ person, however, is in flux. The thesis shows that attempts which focus narrowly on law reform and human rights advocacy will be in vain unless the social and political processes driving the implementation of justice are acknowledged and addressed.
Stigma in access to antiretroviral treatment in Abuja, Nigeria: the importance of social connections
(Queen Margaret University, 2013) Otura, Kingsley
Access to anti-retroviral drug (ARV) therapy in Nigeria has been a big challenge. Despite the fact that ARVs have been demonstrated to improve quality of life, reduce AIDS prevalence and AIDS deaths, many people in Nigeria still do not have access to ARV therapy. At the time this study was started, the ARV access rate was 16.6%. This Grounded Theory study examines the experiences of HIV positive people accessing ARVs in Abuja, Nigeria. 30 Patients living with HIV/AIDS were interviewed in an iterative manner. The results of the Grounded Theory analysis were triangulated with the documentary analysis of preliminary and secondary literature. As reported by the participants of the study, patients initially found it very difficult to access treatment. Stigma emerged as the main concern of the research participants. Although access to anti retroviral treatment has improved over the years, different forms of stigma still pose important barriers to access in this group of participants. The results of this research suggest that stigma occurs at individual, familial, community, organisational and national levels. The main concern of research participants was resolved mainly through the use of social connections. The contribution to knowledge is the development of the Social Connection Theory. 5 main stages that patients pass through when they attempt to access ARVs were identified in this study. During each of these stages, the patient may experience barriers through stigma or other forms of structural issues such as poverty. They may also move from one stage to another through social connectors who assist them to access ARVs. In the Social Connection Theory, it is argued that in African settings, social connectors play a vital role in influencing the way that patients access antiretroviral treatment. Social connectors are social acquaintances of the patient who help shape their health care seeking decisions. They play a vital role in supporting and linking HIV positive persons to where they can access ARVS. Social connection serves as a useful tool for empowering HIV patients to overcome different obstacles and access treatment. However, these processes do not occur in a structural vacuum. Structural factors such as religion, gender, politics and the economy were also found to shape the way stigma is experienced in Nigeria and how people access HIV treatment. To improve access to ARVs, it is suggested that while taking cognisance of structural forces, multidisciplinary strategies should be developed that integrate social connectors at different critical points in the access continuum.
Social connections and trust among destitute, undocumented African migrants in Barcelona, Spain.
(Queen Margaret University, 2014) Bermúdez, Keven E.
This PhD research is based on a 5 month-long participant observation with a total of 18 undocumented migrants of African origin that were residing at an emergency accommodation in Barcelona, Spain between February and July 2010. Study participants had arrived at this flat, managed by a migrant support association, after their available social networks, on which they depended for shared accommodation arrangements, disbanded under negative pressure caused by the 2008 global economic crisis. They were consequently left without the possibility of relying on familiar support to cope with the effects of the economic recession. In this adverse economic context, it was, therefore, essentially important for them to rebuild their relational support systems, to facilitate their exit from destitution. They could not depend on public supports beyond room and board offered at the emergency accommodation because of their undocumented status. However, in this new life setting, study participants faced the challenge of having to consider relationship opportunities with individuals at the flat or in the community who were previously socially distant, as they did not belong to their tight-knit social networks. The fact that study participants showed marked differences in social connectivity while facing this challenge, stimulated research interest in understanding the reasons behind these differences. The social-ecological paradigm of community psychology was selected as an appropriate theoretical framework to approach this topic, as it draws attention to the multilevel factors that could influence study participants' attitudes towards social connection across ethnic boundaries. Application of participant observation methodology as the core data collection strategy allowed use of complementary methods of data collection as were deemed useful to answer the research questions, like informal conversations with different study participants, a weekly support group with all residents, weekend outings with all who wished to participate and, finally, Focus Group Interviews on the topic of interpersonal trust. The research found that undocumented migrants hold high expectations on trust in their social relationships in response to perceived risk in the transnational context, where they face continuous threats of arrest, detention, and deportation. For this reason, they concentrate their social relationships on available undocumented migrant social networks, which, because members usually belong to the same country of origin, allow them to activate culturally-bound social mechanisms that ensure satisfaction of their high trust expectations. When these networks are no longer available, some undocumented migrants may experience difficulties to adjust their trust expectations as necessary to form relationships with non-network members. However, some display a fundamental willingness to cooperate with others over and above usual trust considerations, which appears to constitute a key personal asset to maintain social connection in crisis situations. This research concludes by outlining the implications of this finding for psychosocial support practice with undocumented migrants and members of other socially vulnerable groups, like refugees and asylum seekers, who could benefit from heightened cooperation to enhance social connectivity in critical situations.
The impact of the Global Fund programmes on HIV prevention policy and services in Ukraine in 2003-2012
(Queen Margaret University, Edinburgh, 2014) McGill, Svetlana
Ukraine is home to one of the world's fastest growing HIV epidemic and has received significant amounts of foreign aid to help it tackle the crisis. This study is an enquiry into the implementation of the Global Fund against AIDS, Tuberculosis and Malaria (GFATM) programmes in Ukraine, during the second decade of this country's post-Soviet economic and political transition. The discussion is positioned within a broader debate on aid effectiveness. By looking at the GFATM as an aid institution whose establishment was purported to improve the aid delivery process, the thesis offers a critical insight on the GFATM aid delivery model in the context of Ukraine. The thesis investigates the conduct and practice of INGO and national NGOs in their role as Principal Recipients of GFATM grants targeting HIV prevention in Ukraine. Based on ethnographical enquiry conducted in three oblasts in Ukraine, and in capital Kyiv, the thesis aims to understand how NGOs have implemented HIV prevention services in context of state-owned health care system and to determine the perceived effects of the GF programmes on the ground. The thesis situates analysis of NGOs into a broader socio-political context of post-Soviet Ukraine and questions their role as central actors in delivering essential HIV programmes in parallel with or instead of the state, as well as the consequences for sustainability of such programmes. Using the particular experience in Ukraine, the thesis shows the influence of global funding institutions on relationships between state and civil society and altering of civil society's roles in aid programmes. The thesis includes a comprehensive literature analysis about the Global Fund and other donor programmes working in Ukraine in the area of HIV/AIDS.
Impact of the performance-based payments on health workers in contracting out government health services: Cambodia's experience
(Queen Margaret University, Edinburgh, 2014) Abe, Kimiko
Contracting out government health services has been increasing in low and middle income countries (LMICs) and highly valued in improving health service delivery. In some cases, government health workers have been paid performance-based payments; such payments have been quoted to contribute to the achievement. However, impacts of the payments on the health workers' total income including income from their private practice and the government salaries have been little studied, while their private practice have posed serious issues in the service delivery with the constraint from low government salaries. The impacts at the household level have been unstudied.
An economic analysis Of retail pharmaceutical market In Nigeria: towards access expansion and policy
(Queen Margaret University, 2014) Usar, Joseph Iornumbe
Rural areas in much of sub-Saharan Africa access needed health care from untrained and often poorly regulated drug vendor shops with concerns over the quality of products and services provided and their public health implications. The thesis undertook to understand market relationships in a rural retail drug market in the light of the structure-conduct-performance paradigm and isolate opportunities for potential policy interventions for improved access to quality and safer medicines. Data was collected from a sample of patent medicine vendors and drug purchasers in Katsina-Ala Local Government Area of Benue State, north central Nigeria, over 9 months in 2012. Information from drug vendors and drug consumers was generated through semi-structured questionnaires, in-depth interviews and systematic business transaction observations. Key state and national drug regulatory officials were also interviewed in-depth and related documentary data collected and evaluated. Data analysis focussed mainly on the relationships between market structure, provider conduct, consumer behaviour and the nature of regulation, with the aim of understanding market performance in relation to access to medicines and their rational use. The study established that patent medicine vendors were an important source of medicines for inhabitants of the local government for ambulatory primary health care. Drug retailers were said to be a reliable source of a wide range of drugs provided at relatively more affordable prices and in a convenient way that satisfied consumer expectations. However, a number of market failures existed: low quality of treatment due to poor provider knowledge of diseases and drugs and therefore inappropriate prescription and dispensing practices. Ineffective regulation was also demonstrated by way of inappropriate and inadequate regulatory regime, occasioned by wide spread regulatory infractions. To attain the desirable public health objective of sustained improvement in the quality of products and services obtainable at patent medicine vendor outlets, regulatory strategies must be contextually relevant, providers must be trained and offered financial and business incentives and consumers must be empowered by accessible and timely health information for informed choices against the backdrop of strengthened and better incentivized inspectorate unit in a systematically intertwined approach.
Delivering ART service in Thailand: predicting future workforce requirements and deployment patterns enabling and sustaining universal access through different models of care
(Queen Margaret University, 2014) Jirawattanapisal, Thidaporn
Thailand introduced universal access to Anti-retroviral treatment (ART) service in 2003. This became the main factor increasing demands for services with increasing numbers of People living with the Human Immunodeficiency Virus (HIV) and the Acquired Immune Deficiency Syndrome (AIDS), (PLHIV) and those people living longer. Since 2011, two other factors altered the ART service provision: changes in enrolment criteria to allow PLHIV with high CD4 count (a blood test that establishes the stage of immunosuppression), access to the ART service, and decentralisation changes allowing easier access to ART at peripheral levels. This study therefore examined how service providers at all levels of care deliver ART services, and developed a tool to estimate future requirements for those providers. The case study uses mixed methods including both quantitative and qualitative approaches. Two stages of data collection were conducted; fieldwork to collect data on activities and flow of ART services, and time required for each type of service provider. These become the input data for a second stage to project staffing requirements based on Markov and Monte Carlo analysis to 2025. Three models of ART services were found, across all levels of facility in the public sector operating in high HIV/AIDS prevalence settings,: community-based, doctor-led and mixed-comprehensive. All models adapted their ART services from the national guidelines by applying HR strategies: task shifting, skill mix and community-based approach, to maintain/increase accessibility and quality of care. The estimation of time required to provide ART service of providers was estimated. 60 full time equivalent (FTE) providers (doctors, nurses, pharmacists, pharmacy technicians and non-healthcare providers) in 2012, projected to almost double in 2015. This study found negligible gaps (0.02-0.05%) between needs and availability of healthcare providers to deliver ART service. The HR strategies investigated, were sufficiently widespread to be worth recommending for wide application in human resource planning. Moreover, the tool developed to estimate the requirements for healthcare providers from this study could further support forward towards planning for HIV/AIDS services in Thailand and possibly elsewhere.
Elderly carers: the experiences of the elderly caring for orphans and vulnerable children in the context of the HIV/Aids epidemic in Chiradzuru district, Malawi
(Queen Margaret University, Edinburgh, 2015) Kachale, Blessings
PURPOSE: This qualitative study explores the day-to-day care experiences and livelihoods challenges of the elderly carers of orphan and vulnerable children (OVCs) in rural Chiradzuru district in Malawi. The study aims to highlight the impact of AIDS mortality on Elderly Households' livelihood assets. METHOD: Using case study approach data was collected from 43 cases comprised of 23 individuals and 3 Focus Groups. The main study participants were elderly-headed households caring for OVCs. Data was collected and the evidence converged using the Sustainable Livelihood Framework (SLF) to analyse findings. FINDINGS: The main ten study participants were between the ages 55-90+ caring for thirty-eight OVCs; seven of whom were single females caring for OVCs aged between 2-16 years old-some of them caring for second generation of orphans(great grandchildren). Although this is crisis-led fostering, most of the elderly have accepted the responsibility regardless of their capabilities. This highlights the value of family based care in these families. Six of the ten elderly carers had lost a significant number of assets to AIDS sickness and death of family members. A few had given up their wage earning livelihoods to care for OVCs while for the very old (71-90) their physical old-age disabilities affected pursuance of livelihoods impacting their food security and acquisition of basic needs. There was mutual reciprocity between the OVCs and their carers to pursue livelihoods which increased household resilience. Conclusion: The elderly in Chiradzuru need social security support so that they must not give up care of their children to alternative care arrangements which can contribute to trauma on OVCs.
The impact of information and communication technology on the marketing performance of Jordanian hotels
(Queen Margaret University, Edinburgh, 2015) Al-Adamat, Abdullah
Purpose – This thesis proposes to address the research gap of understanding the relationshipbetween ‘Information Communication Technology (ICT)’ and ‘marketing performance’ in upscale hotels in Jordan. Design/methodology/approach – Extensive literature that links both ICT and marketing performance forms the framework of this research. This research examines the level of ICT usage by hotels as well as their marketing performance to support the theoretical framework that can be used for practical application in the hospitality industry and provides direction for both practising managers and theoreticians. The quantitative survey technique, using structured closed questions, was the main method applied to test the theoretical framework and all of its hypotheses as well as to provide answers to all the research questions. The quantitative survey was undertaken of 61 Jordanian hotels in Amman, Aqaba, the Dead Sea and Petra over the time period from May to July 2013. The senior managers including CEOs, managing directors, and general managers or marketing directors of the hotels, who are responsible for making decisions regarding the hotel marketing activities, were selected to provide the primary data regarding the use of ICT in their hotels and their marketing performance. Findings – The findings demonstrate that the majority of Jordanian hotels have a high level of ICT adoption, however, the integrated (i.e. interconnectivity) level and the usage level of ICT are significantly less. Moreover, the availability, interconnectivity and the usage extent of ICT vary according to the size of the hotel, star-rating, and the experience of hotel management in ICT. The findings also suggest that Jordanian hoteliers are to some extent satisfied with their marketing performance and particularly with the financial aspect of marketing performance. Additionally, the results exhibited important differences in the contribution that each technology makes to the marketing performance. For example, the electronic-points-of-sales systems (EPOS) and the booking-enabled hotel Website are the highest individual ICT systems that impact the marketing performance. Finally, the invention measures (e.g. the ability of launching new products/ services) are the most affected aspect of marketing performance when adopting interconnected ICT systems in hotel establishments. Practical implications – There are multiple areas and issues that need to be considered in making and implementing ICT investment decisions if they are to contribute to the hotel marketing performance. Hotel companies need to be selective in their ICT adoption decisions and look at each ICT system from the marketing management perspective. The Electronic Distribution Systems (e.g. Booking-Enabled Website), and Hotel Front-Office Systems (e.g. PMS) are some of the most differentiating technologies, which may be implemented by 3-, 4- and 5-star hotels to improve marketing performance, especially; the non-financial aspects of marketing performance (e.g. the ability to launch new processes and services and the perceived quality of these processes and services). Originality/value – This is one of the first studies in the hospitality field that offers practical evidence on how ICT systems affect the marketing performance. This research identifies the most discriminating ICT solutions across three, four, and five-star hotels, and discusses their potential for improving marketing performance. It also provides recommendations for Jordanian hotels to improve their marketing effectiveness by using the appropriate technologies in the hospitality industry.
Crossing boundaries for maternal health: a qualitative investigation into the role of community health workers as frontline providers of maternal care in the Peruvian Andes
(Queen Margaret University, Edinburgh, 2015) Vidal, Nicole L.
Despite its status as a middle income country, Peru has one of the highest maternal mortality rates in the Americas. In the Andes region, poor, rural indigenous women are more likely to die from pregnancy related complications than their urban counterparts because they are denied the same level of maternal health services other women in the country receive. Barriers to care include geographic isolation, health staff members who do not speak indigenous languages, and cultural and ethnic discrimination. As a result, indigenous Andean women in need of maternal health services face a significant degree of social exclusion and institutionalized racism which hinders the accessibility, acceptability, and quality of maternal health services offered to them. One approach to improving access to health services has been through the use of Community Health Worker (CHW) programs. Although CHWs are recognized as an important frontline health source, there is a significant lack of literature concerning their role as community level providers of maternal health services. Using a combined grounded theory and case study methodology, this qualitative study investigates the experiences of CHWs working in Andean communities and their relationships with other community members and health and social service professionals. Findings from this study suggest that CHWs can be enabled to bring care directly to their communities in a way that community members can relate to and feel comfortable with while also forming part of the wider health system. Focusing on participants' reports of challenging cultural and ethnic boundaries through a process of ethnic bargaining and adopting professional affiliation, this study identifies CHWs as a potentially vital link between rural community members and other providers of these services. If the right factors are met, such as finding ways to navigate the tensions between traditional and biomedical health care models, CHWs can be considered critical community level health providers who can communicate the value of both models, thereby improving the accessibility, acceptability and quality of maternal health services. However, the root causes leading to social, structural and institutional boundaries to care still need to be addressed. As such, this study aims to fill a significant gap in current research on the role of CHWs in Peru, specifically in the ways they are enabled to negotiate ethnic discrimination within the health system.
Understanding the power relations in health policy implementation in Pakistan
(Queen Margaret University, Edinburgh, 2016) Bajwa, Fatima
Policy implementation is a complex, technical and political process. It is shaped by the capacity of the government, political patronage, influence of diverse actors, power relationships, role of the state, nature of the political systems and their mechanisms for participation in the policy subsystem. Tackling the implementation gap is a health policy concern in Low and Middle Income Countries (LMICs). In these countries, governments frequently fail to achieve effective policy implementation. The government of Pakistan has over six decades introduced many health initiatives and plans to improve the health status of its population. Still, the implementation process remains arduous. To identify the implementation gaps and their drivers, forty-two semi-structured interviews were conducted with the key policy actors from general political sphere and health policy subsystem in Pakistan, to explore their knowledge, perspectives and experience. The key informants were mainly politicians, bureaucrats, health ministry officials, and technocrats from Islamabad, Punjab, Khyber Pakhtunkhwa and Sind provinces in Pakistan. The data was analysed using thematic analysis. This qualitative exploratory study using an inductive approach draws on the concepts of power, policy networks and path dependency. Findings suggest that the factors influencing the policy-action relationship in the health sector in Pakistan operate at two levels: actors and institutional or structural. Political history as a part of the structure plays an important role as well. The power relations within the health sector are a complex interplay of ideas, interests and incentives resulting in policy networks or iron triangles at different levels. The underlying power relations remain the same and policy implementation process is path dependent. Due to this, most health policies remain in long periods of stasis or equilibrium. The stalemate over these policies was seen because of the elitist system of interest groups' hold over policy choices. Frequently, policies are caught in a web of interests.
Occupational Therapy Service redesign for care of the elderly: Measuring up to a joint future?
(Queen Margaret University, Edinburgh, 2016) Ait-Hocine, Nadia
Partnership working between Health and Social Care is the Scottish Government's strategy to affect major policy and practice level changes within public services in order to meet the fiscal challenges arising from the ageing demographic profile within our society. The Joint Future Group Report, published by the Scottish Government in 2002, specifically identified the profession of occupational therapy as central to the strategy for public service reform and inspired an inter-organisational occupational therapy service redesign within Lanarkshire. The practice and system service redesign transcended Acute, Primary Care and Local Authority care of the elderly occupational therapy services, introducing measures to promote patient continuity of care at an informational, management and relational level. The aim was to promote longitudinal models of patient care that minimised the incidence of patients being transitioned between occupational therapy services. This PhD adopted a critical realism research approach with a mixed method sequential explanatory research design. The aim was to develop a theoretical understanding of the structural and agential influences at the macro meso and micro levels that gave rise to the service redesign outcomes. The results provided illuminating insights as to the agential and structural barriers to partnership working. Service specific patterns emerged that suggested structural and cultural influences on occupational therapy practice resulted in service specific variation in the ability to deliver on the continuity of care service redesign intentions. The agency of the occupational therapists was explored through mechanism based theorising in order to identify morphogenetic influences (facilitators to change) and morphostatic influences (barriers to change) in engaging in the service redesign measures in practice. The results reflect that the occupational therapists within all three service sectors enacted their agency to preserve their respective pre-existing organisational service structures. These results suggest that the learning strategies and associated behaviours of the participating occupational therapists were not conducive to transformational change. The practical insights of the conditioning power of structure vis a vis the discrete reflexive power of agency outlined within this thesis offers the profession of occupational therapy within public services the means of exploring and conceptualising the complex implications of partnership working.