The Institute for Global Health and Development
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Item Tutor motivation and retention in public health training institutions in Ghana: An exploration sequential mixed methods study(Queen Margaret University, Edinburgh, 2019) Beyere, Christopher BaasongtiPolicymakers in the health sector continue to look for ways to improve the staffing of rural health facilities. However, only when they are equitably distributed and accessible by the population, when they possess the required competency, and are motivated and empowered to deliver quality care that is appropriate and acceptable to the sociocultural expectations of the society (WHO, 2016). Extensive research has been conducted on health worker motivation and retention in the clinical settings, but relatively little is known of the situation of staff in the Ministry of Health training institutions. Health-training institutions play a significant role in strengthening the health workforce of the country by training all the middle-level cadres of health professions like Nurses, midwives, and other affiliated health professionals (MoH, 2015). This thesis reports on a mixed-methods study of health tutors in some selected public health training schools in the northern part of the country, predominantly rural-based and some in the southern region, primarily urban-based. Focus group discussions engaged 100 health tutors from across rural and urban schools. Five in-depth interviews and five key informant interviews were conducted with past health tutors and principals, respectively. Focus group discussions and interviews informed the development of a structured questionnaire comprising closed and opened ended questions. The quantitative study used a representative sample of 329 health tutors. Non-parametric (Spearman ranked correlation, Pearson Chi-Square, and Wilcoxon-Mann Whitney) and parametric (t-test and ordered logistic regression) statistical tests were run. Findings suggest that most tutors actively compare their income, benefits, qualification to that of their colleagues in other schools, and with other general health workers in the clinical area and lecturers within the ministry of education. From the findings of the results, personal characteristics of the health tutors, such as his or her place of origin, rural or urban, gender, age, and family background, have a significant impact on their employment decisions. There was evidence from this research demonstrating that rural upbringing increases the chances of rural practice. While rural and urban health tutors equated motivation with money, those working in urban settings ranked accommodation as a significant factor influencing employment choice. In conclusion, the study examined differences in health tutors’ motivation and retention and some recommendations.Item Humanitarian workers in South Sudan: Mental health, gender, and organizational staff support(Queen Margaret University, Edinburgh, 2019) Strohmeier, HannahThis study focused on humanitarian workers in South Sudan and the interrelation of mental health, gender, and organizational staff support. Based on the propositions of Job Demands- Resources (JDR) theory, I applied mixed methods research in three research phases to 1) investigate prevalence and predictors of common mental health problems among national and international humanitarian workers; 2) examine international humanitarian workers’ lived experiences, particularly with respect to gender; and 3) crystallize implications of these findings for humanitarian stakeholders, particularly with respect to organizational staff support. The survey phase estimated prevalence rates of post-traumatic stress disorder (24%), depression (39%), anxiety disorder (38%), hazardous alcohol consumption in men (35%) and women (36%), and the burnout components emotional exhaustion (24%) and depersonalization (19%). Chronic stress was most consistently associated with mental health problems. Dysfunctional coping predicted mental health problems among humanitarian workers, but emotion-focused and problem-focused coping were neither protective nor predictive of the outcomes studied. Surprisingly, gender was significantly associated with anxiety only, with women being more likely to experience symptoms associated with anxiety diagnosis. However, the focused qualitative phase indicated that gender substantially influenced international humanitarian workers’ lived experiences. Men perceived Juba as a convenient duty station. Women experienced a feeling of loneliness on site, and considered it challenging to combine their profession with family life. There was a gap between international humanitarian workers’ needs for psychosocial support, and the attention paid to these needs by themselves and their organizations. The evaluation phase showed that organizational staff support provided by NGOs was insufficient to address employees’ needs. As expected, national staff had less access to services than international staff, and organizations neglected gender in their staff support programs. This study provides tailored recommendations to address the identified challenges and gaps in staff support. It demonstrates that a more nuanced version of JDR theory is required to be applicable to humanitarian settings.Item Agency and wellbeing in the context of early marriage: A qualitative inquiry into the northern Nigerian context(Queen Margaret University, Edinburgh, 2018) Zasha, DoosuurAccording to the literature, early marriage remains a problem due to the limitations it places on the educational and economic opportunities of the young girls involved, as well as the variety of health complications they suffer as a result of this. Although early marriage is prevalent in Nigeria, regional differences indicate the northern part of the country as having a higher percentage of girls who marry before the age of 18 compared to the south. Most research and advocacy efforts, as well as related programmes and policies, rightfully focus on the prevention of early marriage but neglect the adolescent girls who are already married. This study focuses on the lives of young married girls, highlighting the process through which they get married as told from their own perspective, and explores their accounts of life after marriage particularly illuminating their health needs and overall wellbeing. Using semi-structured interviews, focus group discussions participatory techniques, and participant observations, 24 young married girls between the ages of 15-25 from Nasarawa state in Nigeria, were recruited for this study, adopting a mixture of principles borrowed from ethnography and grounded theory. The analysis highlights the personal agency exercised by some of the girls in their decisions to get married but also demonstrates how said agency is constrained by the context in which it is exercised. Analysis further reveals the underlying influences behind the constructions of health and illness held by young girls and explores ways in which they primarily seek to address their health and wellbeing. The accounts of these girls also point to strong associations between their wellbeing, economic factors, relationships and experiencing self-worth. This dissertation will contribute to knowledge around early marriage in Nigeria and Sub-Saharan Africa and highlight nuances around the decision-making process at the time of marriage. It also offers insights as to how young girls construct wellbeing in the context of marriage hereby contributing to knowledge around wellbeing in poorer populations in Nigeria and arguably, similar African contexts.Item LADY HEALTH WORKERS IN PAKISTAN: TRACING PERSONAL AND PROFESSIONAL TRAJECTORIES WITHIN A PATRIARCHAL CONTEXT(Queen Margaret University, Edinburgh, 2019) Chaudhry, AmjadIn Pakistan, the Lady Health Workers (LHWs) a cadre of Community Health Workers (CHWs) are providing health services to communities in rural areas and disadvantaged urban area since 1994. Introduced to enhance women‟s access to PHC, they countered gender barriers of segregation and restrictions on the mobility of women. Currently 100,000 LHWs are deployed in the country. The LHW have been granted the status of regular government employees recently following nationwide campaign including protests. Generally the interest in the LHWs has been largely confined to monitoring and evaluation of their activities. The perspectives of LHWs as a female workforce on the margins of formal health system within a patriarchal context, has never been explored. This qualitative study was designed with the aim to explore and describe how the experiences of the LHWs shape the process of their development as female health workers in the Pakistani health system. The three objectives of the study were to explore how the LHWs‟ life and work experiences influenced their development as health workers, to examine the process by which LHWs constructed and defined their personhood and to understand how community- and workplace-based gender dynamics influenced the LHWs in the Pakistani health system. This qualitative study was carried out two in four union councils of a district in Pakistan. It involved 32 indepth interviews conducted with 27 LHWs, while six FGDs were conducted with this cadre of women. Interviews were also conducted with other health professionals including eight health managers, two medical assistants, two Lady Health Visitors (LHVs), three Lady Health Supervisors (LHSs) and three Vaccinators. The results showed that both community and health system were important contexts for the LHWs‟ socialisation and formation of professional identity. The transitions, turning points and trajectories of the LHWs show that the LHWs have used their agency to make the best use of available resources and are proud of their achievements. The analysis of findings gave useful insights about the practices which led to the development of identity through professional socialisation process. Gender was pervasive in all spheres of personal and professional lives of the LHWs, and lack of health system support such as referral rendered the LHWs‟ services ineffective. The LHWs attributed community health improvement to their contributions, and identified with the government health team after regularisation.Item Understanding prescribing behaviour of Tuberculosis doctors in the context of integrated service delivery: a case study of two designated hospitals of Zhejiang province, China(2018) Zou, GuanyangThere is on-going debate regarding if and how integrated service delivery might affect quality of care for infectious diseases traditionally delivered through vertical programmes. In China, tuberculosis (TB) care has recently been integrated into ‘designated’ public hospitals at the county level. However, the integration initiative has caused concerns among hospital providers about cost recovery for poorly funded public hospitals. These concerns are partially reflected in the prescription of non-standardized, non-free auxiliary treatment for TB patients, which increases patients’ financial burden and compromises quality of care. This study applies Complex Adaptive Systems (CAS) thinking to understand providers’ prescribing behaviour in the context of integrated service delivery in TB designated hospitals in Zhejiang province, China. A case study approach was applied to research conducted in two designated hospitals, where the TB clinic was subsidized through local government or the hospital respectively. This study started with a retrospective review of 340 medical charts of uncomplicated TB patients. Informed by the results of this review, 47 semi-structured interviews were conducted with health officials, public health officers, and hospital staff members such as managers and TB clinicians, radiologists, laboratory staff and nurses. The working environment of the TB health workers was also observed. A thematic approach was used to formulate the initial coding frame, as guided by the conceptual framework. Hospital-based integrated TB care is highly medicalised due to strong medical culture and values associated with the integrated care. In both hospitals, non-standardised, non-free prescription of drugs and interventions for uncomplicated TB is common, with no consistent patterns for the two hospitals. This can also be attributed to lack of clear guidelines, weak doctor-patient relationship and hidden financial incentives of TB doctors. Staff motivation is low due to the perceived poor opportunities for professional development in TB work, the perceived gap in salaries as compared to other clinical staff, and the limited provision of risk protection measures for TB health workers. Welfare of TB health workers, who generate limited income for hospitals, is accorded low priority. Professional differences and tension between public health and medical professionals remain the biggest barrier to ensuring clinical governance for TB control in the hospitals. This study suggests that non-standardised prescribing behaviour is a dynamic response to the systemic conditions generated by the current model of integrated service delivery in the designated hospitals in China. Delivering free and standardised integrated TB care in the designated hospitals is challenging in the context of highly fragmented disease control and clinical structures and market-orientated health services. Using CAS thinking has helped to shift attention from a functional analysis of the health systems ‘building blocks’ and their mechanical interactions towards a more dynamic way of examining emergence, feedback loops, adaptation and relationship management in the study of integrating a public health function (TB care) within a hospital setting. The study will inform the on-going discussion of strengthening the quality of integrated service delivery model in China and public-private mix for TB control in other similar contexts.Item Social and structural factors affecting the culture of medical migration in Nigeria: insights from four public medical schools(2017) Awire, Eddy IgheleBackground: The loss of doctors from low income countries through migration is a major concern. In Nigeria, one of several ’push’ factors implicated in the migration of doctors is a ‘culture of migration’ prevalent in medical schools. This culture has policy implications; retention schemes and policies are less likely to be effective if the targets of such schemes are being prepared for export during their medical school training. Little is known about the drivers of a ‘culture of migration’ in Nigeria and their influence on the aspirations of medical students to emigrate after graduation. Aim and Objectives: The aim of the thesis is to define and assess the scope of a ‘culture of migration’ in Nigerian medical schools. Objectives are: (1) To examine attitudes and intentions to migrate among medical students in Nigerian medical schools (2) To examine medical education in Nigeria and its influence on medical students’ aspirations to migrate after graduation, (3) To understand the influence of social networks on medical students’ aspirations and intentions to migrate after graduation in Nigeria. Methods: A two-phased mixed methods design was employed. In the first phase of the study, a structured questionnaire survey was conducted to assess the defining features and extent of a ‘culture of migration’ in four medical schools in Nigeria. In the second phase, a flexible, embedded multiple case study of two schools was employed to explore in-depth the reasons and the mechanisms through which a ‘culture of migration’ is propagated. Results: 211 out of a total of 580 final year students in six medical schools participated in the survey, aged between 20 and 45 years. Almost two-thirds (63.5%) of respondents had positive views on medical migration, while close to half (41.7%) showed a positive aspiration to migrate after graduation. Respondents’ ‘views on migration’, ‘gender’, and ‘family migration history’ were found to be the predictors of respondents’ aspirations to migrate after graduation. This study found evidence of factors characteristic of the existence of a culture of migration in the medical schools studied: a long history of migration, positive attitudes towards migration, and high aspirations to migrate. However, the strength of this evidence varies across the schools depending on the availability of support structures for migration; one school showed compelling evidence, another showed little, while the other two showed characteristics that were between those two extremes. Students’ dissatisfaction with the general situation in Nigeria, and a dysfunctional medical education system, leaves them feeling inadequate, and in need of further training abroad. These aspirations are furthered by students’ day-to-day interactions with the medical school faculty, and by the backing they receive from social institutions. Students and young medical graduates prepare for their migration projects by taking advantage of the support provided by their family, social networks, and support of their training institutions. Discussion/Conclusion: Medical students and medical graduates will continue to migrate from Nigeria because the culture in their training institutions encourages them to do so; the stronger the institutional support for migration the stronger the evidence of a culture of migration. Retention schemes aimed at keeping doctors in Nigeria must therefore include concerted efforts to change the institutional support for migration and the resulting ’culture of migration’. This will require policies that introduce exit requirements for medical school graduates, as well as improvements in funding for both medical education and the healthcare systems and revamping of the national social infrastructure in Nigeria. Better training facilities, better treatment of resident doctors, and greater availability of residency training places might encourage medical students and graduates to consider a professional future in Nigeria.Item Corporate social responsibility in the Ugandan alcohol industry: its contribution towards the prevention and mitigation of HIV and Aids.(2017) Bakojja, Nabulya Ninah DianaThis thesis sets out to determine the contribution made by the Alcohol Industry in Uganda towards HIV and AIDS treatment, care and prevention through Corporate Social Responsibility (CSR) activities. Adopting a qualitative case study approach from two multinational breweries; Diageo and AB InBev, data was collected during fieldwork in Uganda using individual interviews, participant observation, two group interviews and secondary data from breweries and partners’ annual and media reports. The main study participants were brewery managers, health workers from partner health centres and beneficiaries including farmers and people living with HIV at the health centres. It is argued that the CSR activities of companies are established as a response to the perception that the high alcohol consumption in Uganda leads to greater risk behaviours for HIV. The study adopts Corporate Social Performance Framework (Ten Pierick et al. 2004) to identify the motivation of breweries to engage in HIV related CSR and the key activities that the breweries engage in. CSR activities include awareness raising, testing and counselling for HIV and AIDS. In addition, the breweries have improved the livelihoods of farmers through the provision of regular contracts to buy grain for brewing. This is perceived by stakeholders to have both a beneficial and detrimental effect: the regular income lifts poor populations out of extreme poverty. However, improved livelihoods can also enable access to social activities which have the potential to increase the risk of HIV infection. Findings from this research highlight the stakeholders’ views that the CSR activities are perceived as strategic due to the fact they have greater benefit for the breweries themselves rather than being largely altruistic. Furthermore, the most significant contribution of the CSR activities is the improved livelihood for farmers, which results from regular and consistent contracts for purchasing grain. This study makes a significant contribution to the field by carrying out a stakeholder perspective of CSR activities in a resource poor setting in the global South. Two distinct disciplines, business studies and global health, have been brought together in order to deepen understandings and provide a rich insight into the ways in which CSR activities can contribute to global health issues with both intended and unintended consequences.Item 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.Item Occupational Therapy Service redesign for care of the elderly: Measuring up to a joint future?(Queen Margaret University, Edinburgh, 2016) Ait-Hocine, NadiaPartnership 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.Item Philippine nurse migration to the Canadian prairies: challenges and opportunities(Queen Margaret University, Edinburgh, 2017) Baxter, Catherine ElizabethInternationally Educated Nurses (IENs) from the Philippines comprise the highest proportion of IENs working as regulated nurses in Canada, yet many report challenges integrating into the Canadian nursing workforce. The purpose of this mixed methods study was to explore and describe the integration of Registered Nurses (RNs) from the Philippines into the nursing workforce in the Canadian Prairies. A total of 182 IENs from the Philippines who had migrated to Manitoba, Saskatchewan or Alberta between 2008 and 2013 participated. Data were collected through an online survey comprised primarily of fixed response questions and through semi-structured interviews. The findings of the mixed analysis revealed that participants identified four main reasons for migrating to Canada and the Prairie Provinces. These included the presence of family in Canada, the demand for nurses in the Prairie Provinces, ease of migration, and the opportunity for a better life. Upon entry into Canada, IENs encountered challenges in both the pre-licensure and post-employment phases. Financial constraints, obtaining the necessary English language proficiency levels, and meeting the RN licensure requirements were the key pre-licensure challenges identified. Post-employment, IENs reported challenges with language and sociocultural communication, obtaining the required knowledge and skills, adjusting to different resources, conflicting values, and professional and collaborative practice. IENs from the Philippines were employed in the Prairie nursing workforce as RNs, Licensed Practical Nurses (LPNs), and unregulated health workers (URHWs). IENs pursued LPN practice as a Stepping Stone, Parallel Process, or Alternate Career Path, to RN practice. The main reason cited for working as a URHW was the need to find a survival job while working through the nursing licensure process. Nursing workforce integration was a complex process and the cultural, financial, and social capital the IEN possessed, along with the availability of the host country programs and supports, were important resources to facilitate the process.
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