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 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.Item 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.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.
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