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Understanding key drivers of performance in the provision of maternal health services in eastern cape, South Africa: a systems analysis using group model building.
BMC Health Services Research. 2018 Nov 29; 18(1):912.BACKGROUND: The Eastern Cape Province reports among the poorest health service indicators in South Africa with some of its districts standing out as worst performing as regards maternal health indicators. To understand key drivers and outcomes of this underperformance and to explore whether a participatory analysis could deepen action-oriented understanding among stakeholders, a study was conducted in one of the chronically poorly performing districts. METHODS: The study used a systems analysis approach to understand the drivers and outcomes affecting maternal health in the district in order to identify key leverage points for addressing the situation. The approach included semi-structured interviews with a total of 24 individuals consisting health system managers at various levels, health facility staff and patients. This was followed by a participatory group model building exercise with 23 key stakeholders to analyze system factors and their interrelationships affecting maternal health in the district using rich pictures and interrelationship diagraphs (IRDs) and finally the development of causal loop diagrams (CLDs). RESULTS: The stakeholders were able to unpack the complex ways in which factors were interrelated in contributing to poor maternal health performance and identified the feedback loops which resulted in the situation being intractable, suggesting strategies for sustainable improvement. Quality of leadership was shown to have a pervasive influence on overall system performance by linking to numerous factors and feedback loops, including staff motivation and capacity building. Staff motivation was linked to quality of care in turn influencing patient attendance and feeding back into staff motivation through its impact on workload. Without attention to workload, patient waiting times and satisfaction, the impact of improved leadership and staff support on staff competence and attitudes would be diminished. CONCLUSION: Understanding the complex interrelationships of factors in the health system is key to identifying workable solutions especially in the context of chronic health systems challenges. Systems modelling using group model building methods can be an efficient means of supporting stakeholders to recognize valuable resources within the context of a dysfunctional system to strengthen systems performance.
Effective Collaboration for Scaling Up Health Technologies: A Case Study of the Chlorhexidine for Umbilical Cord Care Experience.
Global Health, Science and Practice. 2018 Mar 21; 6(1):178-191.The global health field is replete with examples of cross-organizational collaborative partnerships, such as networks, alliances, coalitions, task forces, and working groups, often established to tackle a shared global health concern, condition, or threat affecting low-income countries or communities. The purpose of this article is to review factors influencing the effectiveness of a multi-agency global health collaborative effort using the Chlorhexidine Working Group (CWG) as our case study. The CWG was established to accelerate the introduction and global scale-up of chlorhexidine for umbilical cord care to reduce infection-related neonatal morbidity and mortality in low-income countries. Questions included: how current and past CWG members characterized the effectiveness, productivity, collaboration, and leadership of the CWG; what factors facilitated or hindered group function; institutional or individual reasons for participating and length of participation in the CWG; and lessons that might be relevant for future global collaborative partnerships. Data were collected through in-depth, semistructured individual interviews with 19 group members and a review of key guiding documents. Six domains of internal coalition functioning (leadership, interpersonal relationships, task focus, participant benefits and costs, sustainability planning, and community support) were used to frame and describe the functioning of the CWG. Collaboration effectiveness was found to depend on: (1) leadership that maintained a careful balance between discipline and flexibility, (2) a strong secretariat structure that supported the evolution of trust and transparent communication in interpersonal relationships, (3) shared goals that allowed for task focus, (4) diverse membership and active involvement from country-level participants, which created a positive benefit-cost ratio for participants, (5) sufficient resources to support the partnership and build sustainable capacity for members to accelerate the transfer of knowledge, and (6) support from the global health community across multiple organizations. Successful introduction and scale-up of new health interventions require effective collaboration across multiple organizations and disciplines, at both global and country levels. The participatory collaborative partnership approach utilized by the Chlorhexidine Working Group offers an instructive learning case.
The relationship between leadership style and health worker motivation, job satisfaction and teamwork in Uganda.
Journal of Healthcare Leadership. 2018; 10:21-32.Background: Leadership is key to strengthening performance of Health Systems. Leadership styles are important organizational antecedents, especially in influencing employee's motivation, job satisfaction, and teamwork. There is limited research exploring this relationship among health workers in resource-limited settings such as Uganda. The aim of this study was to examine the relationship between transformational, transactional, and laissez-faire leadership styles and motivation, job satisfaction, and teamwork of health workers in Uganda. Method: We conducted a cross-sectional study in 3 geographic regions of Uganda in November 2015, using self-administered questionnaires with 564 health workers from 228 health facilities. Data were collected on health workers' perception of leadership styles displayed by their facility leaders, their level of motivation, job satisfaction, and team work. Using Pearson correlation, relationships among variables were identified and associations of the components of leadership styles with motivation, job satisfaction, and teamwork was found using multivariable logistic regression. Results: Health workers in Uganda preferred leaders who were transformational (62%) compared with being transactional (42%) or laissez-faire (14%). Transformational leadership was positively correlated with motivation (r=0.32), job satisfaction (r=0.38), and team work (r=0.48), while transactional leadership was positively correlated with job satisfaction (r=0.21) and teamwork (r=0.18). Motivation was positively associated with leaders who displayed idealized influence-behavior (odds ratio [OR]=3.7; 95% CI, 1.33-10.48) and intellectual stimulation (OR=2.4; 95% CI, 1.13-5.15) but negatively associated with management by exception (OR=0.4; 95% CI, 0.19-0.82). Job satisfaction was positively associated with intellectual stimulation (OR=5.7; 95% CI, 1.83-17.79). Teamwork was positively associated with idealized influence-behavior (OR=1.07-8.57), idealized influence-attributed (OR=3.9; 95% CI, 1.24-12.36), and contingent reward (OR=5.6; 95% CI, 1.87-17.01). Conclusion: Transformational styles had a positive impact on stimulating motivation, assuring job satisfaction, and consolidating teamwork among health workers compared with those who demonstrated transactional skills or laissez-faire styles. Recommendation: Supporting transformational leadership skills development in health facility leaders could encourage health worker motivation, strengthen job satisfaction, and maintain cohesion among health workers for better service delivery.
Centering contraception: postpartum contraceptive choices of women enrolled in Centering group prenatal care versus traditional prenatal care.
BMJ Sexual and Reproductive Health. 2018 Feb 10; 1-6.Objective To assess postpartum contraceptive choices of women participating in group versus traditional prenatal care. Methods This is a retrospective cohort study assessing postpartum contraceptive choices of women participating in group versus traditional prenatal care. Patients were derived from a database of all deliveries from 1 January 2009 to 31 December 2014 at Christiana Hospital in Newark, Delaware, USA. Within this database, group prenatal care patients were identified and a two-to-one matched set of similar traditional prenatal care patients was created. Contraceptive methods utilized by these women were ascertained via chart review. The proportion of women using each method in each care model was calculated. Multinomial logistic regression was carried out for statistical analysis. Results Included in the final analysis were 867 patients: 289 group and 587 traditional prenatal care participants. Groups were similar in selection of sterilization, condoms, injection, and other short-acting hormonal contraceptive methods (a composite of patch, vaginal ring, and pills). Group prenatal care patients were more likely to utilize contraception postpartum (as measured by use of no method with AOR 0.50, 95% CI 0.32 to 0.78, P=0.002), particularly long-acting reversible contraceptives (LARCs) (OR 1.67, 95% CI 1.16 to 2.40, P=0.005). This difference was most pronounced for women aged 20-24 years (AOR 1.98, 95% CI 1.10 to 3.56). Conclusion Participation in group prenatal care as opposed to traditional prenatal care increases use of postpartum contraception and increases uptake of LARCs. The association of group prenatal care participation with LARC use is particularly apparent for women aged 20-24 years.
Group cell phones are feasible and acceptable for promoting optimal breastfeeding practices in a women's microcredit program in Nigeria.
Maternal and Child Nutrition. 2017 Jan; 13(1)As part of a breastfeeding promotion intervention trial in Nigeria, we provided one cell phone per group of 5-7 microcredit clients and instructed the group's cell phone recipient to share weekly breastfeeding voice and text messages with group members. We measured the feasibility and acceptability of using group cell phones by conducting semi-structured exit interviews with 195 microcredit clients whose babies were born during the intervention (target group), in-depth interviews with eight phone recipients and nine non-phone recipients, and 16 focus group discussions with other microcredit clients. Women in the target group said the group phone worked well or very well (64%). They were motivated to try the recommended practices because they trusted the information (58%) and had support from others (35%). Approximately 44% of target women reported that their groups met and shared messages at least once a week. Women in groups that met at least weekly had higher odds of exclusive breastfeeding up to 6 months (OR 5.6, 95% CI 1.6, 19.7) than women in groups that never met. In-depth interviews and focus group discussions indicated that non-phone recipients had positive feelings towards phone recipients, the group phone met participants' needs, and messages were often shared outside the group. In conclusion, group cell phone messaging to promote breastfeeding among microcredit clients is feasible and acceptable and can be part of an effective behaviour change package. (c) 2016 John Wiley & Sons Ltd.
Vulnerable Children and Youth Studies. 2017 May 9; 1-14.Past studies on pediatric HIV disclosure have not investigated the variations across childcare settings. This study explored pediatric HIV disclosure for children living in the community with their birthparents or relatives and those living in orphanages in Addis Ababa, Ethiopia, to highlight the variations in reasons, processes and outcomes of disclosure across childcare settings. Semi-structured interviews were conducted with children and their caregivers attending an HIV clinic in Addis Ababa, Ethiopia. Among children living in orphanages, the proportion with disclosure was significantly higher (p < 0.001) and age at disclosure was younger (p = 0.09). Although the proportions of children with unplanned disclosure were similar in orphanages and the community, there were notable differences between children’s experiences. Children living in the community often found out their status alone through exposure to antiretroviral therapy advertisements in the media, unbeknownst to their caregivers and healthcare providers and suffered silently without any support. Orphans, on the other hand, experienced unplanned disclosure after the death of their birthparents and subsequently received significant emotional support. Healthcare professionals need to consider these variations with childcare settings in disclosure processes. Practices in orphanages may be important models for developing adequate support system for caregivers and children in the community.
Washington, D.C., United States Agency for International Development [USAID], 2016 Oct. 7 p. (High Impact Practices in Family Planning [HIP] Brief; Social and Behavior Change: Promising Practice)This brief describes the evidence on and experience with community group engagement (CGE) interventions that aim to foster healthy sexual and reproductive health (SRH) behaviors. The distinguishing characteristic of CGE interventions from other social and behavior change (SBC) interventions is that they work with and through community groups to influence individual behaviors and/or social norms rather than shifting behavior by targeting individuals alone. Specifically, community support can shift individual behaviors, including contraceptive behaviors, either by changing norms or individual knowledge and attitudes.
Scaling-up impact in perinatology through systems science: Bridging the collaboration and translational divides in cross-disciplinary research and public policy.
Seminars In Perinatology. 2015 Aug; 39(5):416-23.Despite progress over the past decade in reducing the global burden of newborn deaths, gaps in the knowledge base persist, and means of translating empirical findings into effective policies and programs that deliver life-saving interventions remain poorly understood. Articles in this issue highlight the relevance of transdisciplinary research in perinatology and calls for increased efforts to translate research into public policy and to integrate interventions into existing primary care delivery systems. Given the complexity and multi-causality of many of the remaining challenges in newborn health, and the effects that social and economic factors have over many newborn conditions, it has further been proposed that integrated, multi-sector public policies are also required. In this article, we discuss the application of systems science methods to advance transdisciplinary research and public policy-making in perinatology. Such approaches to research and public policy have been used to address various global challenges but have rarely been implemented in developing country settings. We propose that they hold great promise to improve not only our understanding of complex perinatology problems but can also help translate research-based insights into effective, multi-pronged solutions that deliver positive, intended effects. Examples of successful transdisciplinary science exist, but successes and failures are context specific, and there are no universal blueprints or formulae to reproduce what works in a specific context into different social system settings. Group model building is a tool, based in the field of System Dynamics, that we have used to facilitate transdisciplinary research and, to a lesser extent, policy formulation in a systematic and replicable way. In this article, we describe how group model building can be used and argue for scaling its use to further the translation of empirical evidence and insights into policy and action that increase maternal and neonatal survival and well-being. Copyright (c) 2015 Elsevier Inc. All rights reserved.
Psychological and behavioral interventions to reduce HIV risk: Evidence from a randomized control trial among orphaned and vulnerable adolescents in South Africa.
AIDS Care. 2016; 28(S1):8-15.Evidence-based approaches are needed to address the high levels of sexual risk behavior and associated HIV infection among orphaned and vulnerable adolescents. This study recruited adolescents from a support program for HIV-affected families and randomly assigned them by cluster to receive one of the following: (1) a structured group-based behavioral health intervention; (2) interpersonal psychotherapy group sessions; (3) both interventions; or (4) no new interventions. With 95% retention, 1014 adolescents were interviewed three times over a 22-month period. Intent-to-treat analyses, applying multivariate difference-in-difference probit regressions, were performed separately for boys and girls to assess intervention impacts on sexual risk behaviors. Exposure to a single intervention did not impact behaviors. Exposure to both interventions was associated with risk-reduction behaviors, but the outcomes varied by gender: boys reported fewer risky sexual partnerships (ß = -.48, p = .05) and girls reported more consistent condom (ß = 1.37, p = .02). There was no difference in the likelihood of sexual debut for either gender. Providing both psychological and behavioral interventions resulted in long-term changes in sexual behavior that were not present when either intervention was provided in isolation. Multifaceted approaches for reducing sexual risk behaviors among vulnerable adolescents hold significant promise for mitigating the HIV epidemic among this priority population. © 2016 The Author(s). Published by Taylor & Francis. Open Access.
Culture Health and Sexuality. 2015 Nov; 17(Suppl 2):S223-S237.There are a number of persuasive arguments as to why sexual pleasure should be included in sexual health work with young people, including the suggestion that this would provide young people with accounts of gender and sexuality that are more critical and holistic than those presented in the popular media, pornography and current sex education curricula. This paper considers the possibilities for engaging young men in critical group work about sexual pleasure in research and education contexts, drawing on a mixed-methods study of young people's understandings and experiences of ‘good sex’. The paper provides a reflexive account of one focus group conducted with a group of heterosexual young men and two youth educators. It explores some of the challenges to building relationships with young men and creating ‘safe spaces’ in which to engage in critical sexuality education in socially unequal contexts. In this case study, adult-led discussion elicits rebellious, ‘hyper-masculine’ performances that close down opportunities for critical or reflective discussion. Although there are some opportunities for critical work that move beyond limited public health or school-based sex education agendas, there is also space for collusion and the reinforcement of oppressive social norms. The paper concludes by imagining possibilities for future research and practice.
Community Collectivization and Consistent Condom Use Among Female Sex Workers in Southern India: Evidence from Two Rounds of Behavioral Tracking Surveys.
AIDS and Behavior. 2016 Apr; 20(4):776-87.Community collectivization is an integral part of condom use and HIV risk reduction interventions among key population. This study assesses community collectivization among female sex workers (FSWs), and explores its relationship with sex workers' consistent condom use (CCU) with different partners considering the interaction effect of time and collectivization. Data were drawn from two rounds of cross-sectional surveys collected during 2010 (N1 = 1986) and 2012 (N2 = 1973) among FSWs in Andhra Pradesh, India. Results of the multiple logistic regression analysis show that, CCU with regular and occasional clients increased over the inter-survey period among FSWs with a high collective efficacy (AOR 2.9 and 6.1) and collective agency (AOR 14.4 and 19.0) respectively. The association of high levels of collectivization with CCU and self-efficacy for condom use are central to improve the usefulness and sustainability of HIV prevention programs worldwide.
Social capital and the utilization of maternal and child health services in India: A multilevel analysis.
Health and Place. 2014 Jul; 28:73-84.This study examines the association between social capital and the utilization of antenatal care, professional delivery care, and childhood immunizations using a multilevel analytic sample of 10,739 women who recently gave birth and 7403 children between one and five years of age in 2293 communities and 22 state-groups from the 2005 India Human Development Survey. Exploratory factor analysis was used to create and validate six social capital measures that were used in multilevel logistic regression models to examine whether each form of social capital had an independent, contextual effect on health care use. Results revealed that social capital operated at the community level in association with all three care-seeking behaviors; however, the results differed based on the type of health care utilized. Specifically, components of social capital that led to heterogeneous bridging ties were positively associated with all three types of health care use, whereas components of social capital that led to strong bonding ties were negatively associated with the use of preventive care, but positively associated with professional delivery care.
'Trust and teamwork matter' : community health workers' experiences in integrated service delivery in India.
Global Public Health. 2014 Jul 15; 1-15.A comprehensive and integrated approach to strengthen primary health care has been the major thrust of the National Rural Health Mission (NRHM) that was launched in 2005 to revamp India’s rural public health system. Though the logic of horizontal and integrated health care to strengthen health systems has long been acknowledged at policy level, empirical evidence on how such integration operates is rare. Based on recent (2011-2012) ethnographic fieldwork in Odisha, India, this article discusses community health workers’ experiences in integrated service delivery through village level outreach sessions within the NRHM. It shows that for health workers, the notion of integration goes well beyond a technical lens of mixing different health services. Crucially, they perceive ‘teamwork’ and ‘building trust with the community’ (beyond trust in health services) to be critical components of their practice. However, the comprehensive NRHM primary health care ideology -which the health workers espouse -is in constant tension with the exigencies of narrow indicators of health system performance. Our ethnography shows how monitoring mechanisms, the institutionalized privileging of statistical evidence over field-based knowledge and the highly hierarchical health bureaucratic structure that rests on top-down communications mitigate efforts towards sustainable health system integration.
Prevalence and predictors of problematic alcohol use, risky sexual practices and other negative consequences associated with alcohol use among safety and security employees in the Western Cape, South Africa.
Substance Abuse: Treatment, Prevention, and Policy. 2014; 9(1)Introduction: Harmful alcohol use can compromise worker health and productivity. Persons employed in safety-sensitive occupations are particularly vulnerable to hazardous alcohol use and its associated risks. This study describes the patterns of harmful alcohol use, related HIV risks and risk factors for the harmful use of alcohol among a sample of employees in South Africa working in the safety and security sector.Methods: A cross-sectional study that formed the baseline for a clustered randomized control trial was undertaken in 2011. A random sample of 325 employees employed within a safety and security sector of a local municipality in the Western Cape Province of South Africa participated in the study. Data were collected by means of an 18-page self-administered structured questionnaire and analyzed using SAS/STAT software version 9.2. For all significance testing, the F-statistic and p-values are reported.Results: Three hundred and twenty-five employees were surveyed. Findings suggest that more than half (76.1%) of the 78.9% of participants who consumed alcohol engaged in binge drinking, with close to a quarter reporting a CAGE score greater than the cut-off of 2, indicating potentially hazardous drinking patterns. The study further found that employees who use alcohol are more likely to engage in risky sexual practices when under the influence. A favorable drinking climate (p < 0.001) and poor levels of group cohesion (p = 0.009) were significantly correlated to binge drinking.Conclusion: This study identifies alcohol-related behaviors and associated risks in the context of safety-sensitive occupations at the workplace. It suggests that persons employed within such positions are at high risk for developing alcohol-related disorders and for contracting HIV. This study highlights the need for testing a comprehensive package of services designed to prevent hazardous alcohol use among safety and security employees.
A group-based counselling intervention for depression comorbid with HIV/AIDS using a task shifting approach in South Africa: A randomized controlled pilot study.
Journal of Affective Disorders. 2014; 158:78-84.Background Co-morbid depression in HIV-positive patients on anti-retroviral (ART) treatment poses a public health threat. It compromises treatment adherence and accelerates disease progression. This study aimed to assess the feasibility of a group-based counselling intervention for depressed HIV-positive patients in primary health care (PHC) in South Africa using a task shifting approach. Methods Using a randomized control design, 76 HIV-positive patients with co-morbid depression were initially recruited. This reduced to 34 in the final cohort. Participants were assessed using the Patient Health Questionnaire (PHQ9), Hopkins Symptom Checklist (HSCL-25) and Multidimensional Scale of Perceived Social Support (MSPSS) at baseline and 3-month follow-up. The intervention was adapted from a local group-based Interpersonal Therapy (IPT) intervention. Process evaluation interviews were held with the HIV counsellors who delivered the intervention and a sub-sample of participants. Results Repeated measures ANOVA analysis showed significantly greater improvement on depression scores on the PHQ9 in the intervention group compared to the control group. A significant decline in the mean scores on the HSCL-25 was found for both groups although this was more pronounced for the intervention group. There was no significant improvement in the MSPSS scores. Limitations The small sample size of the final cohort affected the power of the study to detect significant differences between the intervention and control groups on the MSPSS. Longer term impact of the intervention is unknown. Conclusions These preliminary findings suggest that group-based counselling for depression in HIV-positive patients can potentially be effectively delivered by appropriately trained and supported lay HIV counsellors. The need for a larger trial is indicated.
Culture, Health and Sexuality. 2013 Nov; 15(Suppl 4):S567-S580.Psychosocial support groups offer an important space for people living with HIV to pursue greater wellbeing as they learn how to accept and live with their HIV status. They are critical for the cultivation of responsible and adherent patients. Occasionally, support groups provide spaces where members are encouraged to discuss sexual struggles related to being HIV-positive, including sexual performance issues, sexual relationships, fertility desires and communicating with sexual partners. This paper examines an HIV-positive men’s sex therapy support group at Kenyatta National Hospital in Nairobi, Kenya, where HIV-positive men access information about HIV and treatment, while getting tips on restoring sexual functioning and improving sexual gratification from medical experts, peer counselors and fellow group members. In the group setting, members worked to rediscover and reconstruct masculinity under the guidance of a range of experts, while focusing on regaining or improving sexual prowess.
Journal of Community Health. 2013 Oct; 38(5):885-893.South African townships have high HIV prevalence and a strong need for collective action to change normative sexual risk behaviors. This study investigated the relationship between perceptions of individuals about collective efficacy in the community's ability to prevent HIV and their personal HIV risk behaviors. Men (n = 1,581) and women (n = 718) completed anonymous surveys within four Black African Townships in Cape Town, South Africa from June 2008 to December 2010. Measures included demographics, alcohol use, attitudinal and behavioral norms, sexual health communications, and sexual risk behaviors. In multivariate logistic regressions, men were more likely to endorse collective efficacy if they were married, drank less often in alcohol serving establishments, believed that fewer men approve of HIV risk behaviors, talk more with others about HIV/AIDS, and had more sex partners in the past month. Women were more likely to endorse collective efficacy if they drank alcohol less often, talked more with others about HIV/AIDS, had more sex partners in the past month, but reported fewer unprotected sex acts in the past month. Community level interventions that strengthen collective efficacy beliefs will have to consider both protective and risk behaviors associated with believing that the community is ready and capable of preventing HIV.
International Journal of Knowledge Management. 2007 Jan-Mar; 3(1):29-48.The study aims to understand the social and organizational factors that influence knowledge sharing. A model of knowledge management and knowledge sharing was developed inspired by the work of Nahapiet and Ghoshal. Data on KM processes and various social capital measures were collected from a sample of 262 members of a tertiary educational institution in Singapore. Rewards and incentives, open-mindedness, and cost-benefit concerns of knowledge hoarding turned out to be the strongest predictors of knowledge sharing rather than prosocial motives or organizational care. Individuals who are highly competent in their work abilities are less likely to share what they know when they perceive that there are few rewards or when sharing is not recognized by the organization. The findings provide evidence for the importance of social capital as a lubricant of knowledge sharing and engaging performance management systems in knowledge-intensive organizations.
AIDS Care. 2012; 24(5):649-57.HIV care and treatment providers across sub-Saharan Africa are integrating livelihood interventions to improve food security of their clientele. Many integrated HIV and livelihood programmes (IHLPs) require the formation and use of groups of HIV-infected/affected individuals as the operational target for programme interventions, indeed, virtually without exception the group is the focal point for material and intellectual inputs of IHLPs. We sought to critically examine the group approach to programming among IHLPs in Uganda, and to explore and problematise the assumptions underpinning this model. A case study approach to studying 16 IHLPs was adopted. Each IHLP was treated as a case comprising multiple in-depth interviews conducted with staff along the livelihood programme chain. Additionally, in-depth interviews were conducted with staff from The AIDS Support Organization (TASO), and with members of 71 HIV-infected TASO-registered client households. Our analysis reveals three important considerations in IHLP programming regarding the group-centred approach: (1) Group membership is widely held to confer benefits in the form of psycho-social and motivational support, particularly in empowering individuals to access HIV services and handle stigma. This is contrasted with the problem of stigma inherent in joining groups defined by HIV-status; (2) Membership in groups can bring economic benefits through the pooling of labour and resources. These benefits however need to be set against the costs of membership, when members are required to make contributions in the form of money, goods or labour; (3) Sharing of goods and labour in the context of group membership allow members to access benefits which would otherwise be inaccessible. In exchange, individual choice and control are diminished and problems of resources held in common can arise. While the group model can bring benefits to IHLP efficiency and by extension to food security, and other outcomes, its application needs to be carefully scrutinised at the individual programme level, in terms of whether it is an appropriate approach, and in terms of mitigating potentially adverse effects.
Journal of Asian and African Studies. 2011; 46(2):169-83.This paper examines the influence of informal banking club participation on family planning practices in rural Ghana. Research from Asia suggests that family planning practices are improved by club participation. This study examines this thesis in an African context, using rural Ghana as a case study. A sample of 204 women (19 years and older) was drawn from Abokobi village, Ghana. Multivariate analyses of direct, mediating and moderating effects of women's demographic background characteristics, membership status and length, and women's empowerment status as predictors of family planning practices are assessed. Findings suggest that club membership and membership length is not associated with family planning practices; however, age, education level, number of children and empowerment status are.
Reflections on the practice of facilitating group-based antenatal education: should a midwife wear a uniform in the hospital setting?
International Journal of Nursing Practice. 2011 Dec; 17(6):628-35.The first author of this paper, a Thai midwife, conducted a feminist action research project aimed at collaboratively developing a model for group-based antenatal education in Thailand. Should a midwife wear a uniform when facilitating midwife-led group-based antenatal education sessions in the hospital setting? This paper reports on a single example of reflection in and on midwifery practice that aimed to answer the guiding question. The practice and reflection occurred over a number of months at the beginning of the feminist action research project. The midwife should wear normal clothes when facilitating group-based antenatal education as a symbol of equality in power relationships within the group. When power relationships between women and the midwife are equalized, women are more able to take responsibility for their health as they are less likely to defer to the 'expert'. Reflection in and on practice is a powerful tool to allow the midwife to understand and change her own practice as required to meet those goals. Self-change is a critical first step because there can be no change in the way maternity care is provided without each midwife being willing to be self-aware and open to appropriate self-change. (c) 2011 Blackwell Publishing Asia Pty Ltd.
Intergenerational participatory discussion groups foster knowledge exchange to improve child nutrition and food security in northern Malawi.
Ecology of Food and Nutrition. 2009 Sep-Oct; 48(5):369-82.This article assesses the effectiveness of a participatory, intergenerational, dialogue approach in addressing gender and generational conflicts related to both child nutrition and agriculture. Analysis of 46 interviews and 3 focus groups with smallholder farmers in rural agrarian communities with high rates of child malnutrition in northern Malawi suggested that participatory discussion can lead to positive change, including increasing child feeding frequency and dietary diversity. An intergenerational, transformative, and holistic approach to nutrition education which integrates agricultural and gender issues can effectively address sensitive conflicts within households and communities that affect child nutrition, and come up with local solutions.
Knowledge exchange processes in organizations and policy arenas: a narrative systematic review of the literature.
Milbank Quarterly. 2010; 88(4):444-483.Context: This article presents the main results from a large-scale analytical systematic review on knowledge exchange interventions at the organizational and policymaking levels. The review integrated two broad traditions, one roughly focused on the use of social science research results and the other focused on policymaking and lobbying processes. Methods: Data collection was done using systematic snowball sampling. First, we used prospective snowballing to identify all documents citing any of a set of thirty-three seminal papers. This process identified 4,102 documents, 102 of which were retained for in-depth analysis. The bibliographies of these 102 documents were merged and used to identify retrospectively all articles cited five times or more and all books cited seven times or more. All together, 205 documents were analyzed. To develop an integrated model, the data were synthesized using an analytical approach. Findings: This article developed integrated conceptualizations of the forms of collective knowledge exchange systems, the nature of the knowledge exchanged, and the definition of collective-level use. This literature synthesis is organized around three dimensions of context: level of polarization (politics), cost-sharing equilibrium (economics), and institutionalized structures of communication (social structuring). Conclusions: The model developed here suggests that research is unlikely to provide context-independent evidence for the intrinsic efficacy of knowledge exchange strategies. To design a knowledge exchange intervention to maximize knowledge use, a detailed analysis of the context could use the kind of framework developed here.
Spread of PMTCT and ART better care practices through collaborative learning in Tanzania. Research and evaluation report.
Bethesda, Maryland, University Research Company [URC], Health Care Improvement Project [HCI], 2011 Jun.  p. (Research and Evaluation Report; USAID Contract No. GHN-I-01-07-00003-00; USAID Contract No. GHN-I-03-07-00003-00)The Tanzania National AIDS Control Program (NACP) and PEPFAR initiated the Partnership for Quality Improvement (PQI) in 2007 to develop and promote a harmonized quality improvement (QI) plan for antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) services countrywide. The partnership included PEPFAR’s HIV/AIDS care and treatment implementing partners, with technical leadership from the USAID Health Care Improvement Project (HCI), implemented by University Research Co., LLC (URC), and PharmAccess International (PAI). The PQI introduced the “Improvement Collaborative” strategy to generate better care practices to improve care provided to those needing HIV and AIDS services and has developed improvement collaboratives in four regions. Collaborative improvement is built on multiple teams working on a common aim and sharing learning about what works to achieve results more rapidly. This study evaluates peer-to-peer learning among health workers and the spread of better care practices within regions and across regions in the PQI ART/PMTCT collaboratives in Tanzania.This cross-sectional evaluation used quantitative and qualitative methods to measure use of mechanisms for exposure and sharing of change ideas, changes implemented, and factors that facilitated or hindered sharing and uptake of change ideas. Data were collected in three regions (Tanga, Morogoro, and Mtwara) in a total of 25 sites.
Population Briefs. 2011 May; 17(1):5.Gender inequities can hinder women's and men's ability to protect themselves from HIV infection. The Population Council's Horizons Program sought to better understand gender inequities and their consequences, developing tools to measure gender-based power dynamics and designing and testing programs to reduce gender-based biases. Our research showed that it is possible to reduce gender-based biases and HIV risk when programs engage men in thinking critically about gender inequality; include interactive, small-group sessions and community-based activities; use the media to promote gender equity and HIV prevention; and reach men when their partners are pregnant. (excerpt)