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Kok M, Munthali A, Mvula P, Chisiza Z, Mat ML. Community bylaws concerning sexual and reproductive health and rights in Machinga District, Malawi: to what extent are they responsive to young people's needs? Int J Equity Health 2023; 22:237. [PMID: 37964291 PMCID: PMC10647080 DOI: 10.1186/s12939-023-02054-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Community bylaws are commonly accepted mechanisms to influence behaviour change to achieve better health and development outcomes in sub-Saharan Africa. However, the uses, benefits, and potential downsides of community bylaws are largely unclear, especially regarding sexual and reproductive health and rights (SRHR) of young people. The objective of this study was to determine the extent to which community bylaws in Machinga District in southern Malawi are responsive to young people's realities and SRHR needs. METHODS In Phase 1 of this qualitative study, 35 community members were interviewed, including 14 young people (15-24 years), five parents, five traditional leaders, and eleven key informants. Based on findings from Phase 1, eleven members from local youth groups co-created a drama performance that covered issues concerning bylaws and young people's SRHR (Phase 2). The drama was performed in the community, after which young women (18-24 years), young men (17-24 years), female and male parents discussed on what they saw in the drama, focusing on young people's SRHR, in four focus group discussions (Phase 3). All transcripts were coded and thematically analysed and narratives were written on main themes. RESULTS Three community SRHR bylaws, related to teenage pregnancy, child marriage, and sexual harassment and rape were identified and commonly accepted in the community. While these bylaws intend to reduce SRHR-related issues among young people, they are often not involved in bylaw formulation. The bylaws were associated with protection of girls, and a good reputation for boys, young men and traditional leaders. Bylaw enforcement faced problems, as fines were not in line with national laws, and wealthy offenders could avoid them through bribes. Effects of bylaws on teenage pregnancy rates seemed limited, while some positive effects on school readmission, prevention of child marriage, and reporting sexual harassment were reported. CONCLUSIONS The study revealed that community bylaws were accepted but not owned by young people, and had different effects on the rich versus the poor, and girls versus young men. Bylaws were associated with punishment in terms of money, which seemed to overpower their potential to promote rights and address social norms underlying SRHR issues of the youth.
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Affiliation(s)
- Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, the Netherlands.
| | | | | | - Zindaba Chisiza
- Department of Drama and Theatre Studies, University of Malawi, Zomba, Malawi
| | - Marielle Le Mat
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, the Netherlands
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Pindani M, Chilinda I, Botha J, Chorwe-Sungani G. Exploring community support on safe motherhood: A case of Lilongwe District, Malawi. Afr J Prim Health Care Fam Med 2021; 13:e1-e7. [PMID: 34342479 PMCID: PMC8424708 DOI: 10.4102/phcfm.v13i1.2907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Malawi is grappling with a high maternal mortality of 439 per 100 000 live births. It is estimated that 80% of maternal deaths can be prevented by actively engaging the community in the country. However, community support on safe motherhood remains unknown. AIM This study, therefore, explored community support rendered to mothers and babies during antenatal, intrapartum and postpartum periods. SETTING This study was conducted in the Lilongwe District, Malawi. METHODS This was a qualitative study that collected data from 30 village health committee members through Focus Group Discussions (FGDs). Data were analysed using thematic analysis. RESULTS This study found that community support on safe motherhood rendered to women varied. The following five themes emerged from FGDs data on community support on safe motherhood: antenatal support, intrapartum support, postpartum support, bylaws reinforced by chiefs in the community and safe motherhood support groups. Community members encourage pregnant women to attend antenatal care, escorted pregnant women to the hospital for delivery and assisted women to care for a child and go for postpartum checkups. Community bylaws were considered as a necessary tool for encouraging women to attend antenatal care, deliver at the health facility and attend postpartum checkups. CONCLUSION This study suggests that community members play a crucial role in providing support to women and newborns during antenatal, intrapartum and postpartum periods.
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Affiliation(s)
- Mercy Pindani
- School of Nursing, Kamuzu University of Health Sciences, Blantyre.
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Makwinja AK, Maida ZM, Nyondo-Mipando AL. Delivery strategies for optimizing uptake of contraceptives among adolescents aged 15-19 years in Nsanje District, Malawi. Reprod Health 2021; 18:15. [PMID: 33472646 PMCID: PMC7818728 DOI: 10.1186/s12978-020-01065-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/29/2020] [Indexed: 11/23/2022] Open
Abstract
Background Despite documented benefits of contraceptives, uptake among young people aged 20–24 years is high compared to adolescents aged 15–19 years in Malawi. As the world’s population of 15–19-year-olds continues to grow the need to meet the increasing demand for contraceptive services and information that address adolescent-specific needs cannot be underestimated. To inform Sexual and Reproductive health services for the youth, we explored strategies for optimizing uptake of contraceptives among this age group. Methods An exploratory qualitative cross-sectional study was conducted at Nsanje District Hospital and Nyamadzere Community Day Secondary School guided by Social-Ecological Framework to understand strategies that may optimize the uptake of contraceptives among adolescents aged 15–19. Nsanje district was purposively selected based on the reason that it is the second district in Malawi with the highest rate of adolescent childbearing of girls aged 15–19 years. We conducted a Focus Group Discussion (FGD) with 9 traditional leaders, 11 Key Informant Interviews (KIIs) with health workers, 20 In-depth Interviews (IDIs) with 12 adolescents, 4 teachers, and 4 parents. All data were digitally recorded, transcribed verbatim into English. The data was analyzed and managed using deductive thematic analysis guided by Social-Ecological Framework. Results Adolescents suggested accessing contraceptives from local drug stores, pharmacies and hospitals at a health system level and through Youth Centres, clubs, and corners at a Community level. There is a need to ensure a continuous supply of various kinds of contraceptives and the presence of youth-friendly health care workers in the specified areas. Conclusion There is no one way of delivering contraceptives to adolescents. Multiple avenues existent at the health facility and community could be leveraged to optimize delivery and uptake of contraceptives in a manner that is not intimidating to an adolescent while involving key stakeholders.
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Affiliation(s)
- Andrew Kondaine Makwinja
- Department of Health Systems and Policy, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Chichiri, Private Bag 360, Blantyre, Malawi. .,College of Medicine, African Centre of Excellence in Public Health and Herbal Medicine (ACEPHEM), University of Malawi, Blantyre, Malawi. .,Medecins Sans Frontieres-Belgium Malawi Mission, Blantyre, Malawi.
| | | | - Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Chichiri, Private Bag 360, Blantyre, Malawi
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Iliyasu Z, Galadanci HS, Muhammad B, Yadudu FZ, Kwaku AA, Salihu HM, Aliyu MH. Correlates of HIV-Positive Fathers' Involvement in Prevention of Mother-to-child Transmission Programs in Northern Nigeria. Curr HIV Res 2020; 18:443-457. [PMID: 32778029 DOI: 10.2174/1570162x18666200810133347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/08/2020] [Accepted: 07/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The involvement of men in prevention of mother-to-child HIV transmission (PMTCT) programs could accelerate the elimination of vertical transmission. Yet, little research has focused on HIV-positive male partners. This study determined the predictors of male partners' PMTCT knowledge and involvement in a tertiary hospital in northern Nigeria. METHODS A clinic-based sample of 401 HIV-positive male partners of women who delivered within 12 months prior were interviewed using structured questionnaires. PMTCT knowledge and involvement scores were computed. Adjusted odd ratios (AOR) for predictors were derived from multivariate logistic regression models. RESULTS The proportion of respondents with adequate PMTCT knowledge was 40.9%. Less than half (43.6%) of the respondents participated in PMTCT, with median involvement score of 2.00 (interquartile range, IQR = 0, 5.0). One quarter of respondents (25.7%, n =103) reported >1 sex partners, 10.5% consistently used condoms, and 20.7% had disclosed to all partners. Fathers' involvement in PMTCT was predicted by paternal education (AOR = 0.30; 95% Confidence Interval (CI): 0.12-0.77, no formal vs. post-secondary), HIV-positive child (AOR = 3.85; 95%CI: 1.41-10.54, yes vs. no), treatment duration (AOR = 4.17; 95%CI: 1.67-10.41, ≤1 vs. ≥10 years), disclosure to partner(s) (AOR = 1.21; 95%CI: 1.15-3.52, 'disclosed to all' vs. 'not disclosed'), condom use (AOR = 5.81; 95%CI: 3.07-11.0, always vs. never), and PMTCT knowledge (AOR = 0.62; 95%CI: 0.31-0.92, inadequate versus adequate). CONCLUSION The involvement of fathers in HIV PMTCT programs was low and predicted by paternal education, HIV-positive child, duration of antiretroviral treatment, disclosure to partner, consistent condom use, and level of PMTCT knowledge. Our findings will inform the development of policies to increase male partner involvement in PMTCT in Nigeria.
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Affiliation(s)
- Zubairu Iliyasu
- Epidemiology & Biostatistics Division, Department of Community Medicine, Faculty of Clinical Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
| | | | - Bashir Muhammad
- Epidemiology & Biostatistics Division, Department of Community Medicine, Faculty of Clinical Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
| | - Fatima Z Yadudu
- School of Medicine, University of Kentucky, Lexington, KY, United States
| | - Aminatu A Kwaku
- Epidemiology & Biostatistics Division, Department of Community Medicine, Faculty of Clinical Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
| | - Hamisu M Salihu
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, United States
| | - Muktar H Aliyu
- Department of Health Policy and Vanderbilt Institute for Global Health,Vanderbilt University Medical Center, Tennessee, United States
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Karp C, Wood SN, Galadanci H, Sebina Kibira SP, Makumbi F, Omoluabi E, Shiferaw S, Seme A, Tsui A, Moreau C. 'I am the master key that opens and locks': Presentation and application of a conceptual framework for women's and girls' empowerment in reproductive health. Soc Sci Med 2020; 258:113086. [PMID: 32521413 PMCID: PMC7369639 DOI: 10.1016/j.socscimed.2020.113086] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/30/2020] [Accepted: 05/22/2020] [Indexed: 11/18/2022]
Abstract
RATIONALE A renewed focus on women's and girls' empowerment in the era of Sustainable Development Goals reflects the belief that empowerment is central to health and development. Sexual and reproductive health (SRH) outcomes, including pregnancy and contraceptive use, may contribute to and result from empowerment. However, enhanced understanding of how women become empowered for SRH requires clear conceptualization of empowerment. OBJECTIVE We aimed to assess the applicability of a proposed framework for women's and girls' SRH empowerment (WGE-SRH) in sub-Saharan Africa. We sought to understand what shapes and motivates preferences for childbearing and contraception, exploring how women and girls navigate external pressures or rewards to exercise and achieve their reproductive goals. METHODS Grounded in the WGE-SRH framework, we conducted a qualitative study in four distinct contexts (Ethiopia, Kano and Anambra States in Nigeria, and Uganda). We implemented and analyzed 120 in-depth interviews and 38 focus group discussions with 440 women and men and translated results to refine the WGE-SRH framework. RESULTS Findings demonstrate the salience of women's internal motivations, including the social value and joys of motherhood, in shaping existence of reproductive choices. However, existence of choice was limited by couples' economic situations, pressures from providers, partners, and family members, and women's fears of contraceptive side effects or relationship dissolution. Despite these constraints, many found ways to exercise their reproductive choices through negotiation with partners, third party involvement in reproductive discussions, non-verbal communication, and covert use of contraception. CONCLUSIONS The WGE-SRH framework is useful for exploring SRH empowerment, embracing the multilevel, dynamic nature of empowerment, as a process transitioning from existence of choice (autonomy) to exercise of choice (self-efficacy, decision-making, negotiation), and, ultimately, to achievement of choice. Future research and programs related to SRH empowerment should distinguish between existence and exercise of choices to promote the health and well-being of women and girls.
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Affiliation(s)
- Celia Karp
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA.
| | - Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Hadiza Galadanci
- Center for Advanced Medical Research and Training, Bayero University Kano, Nigeria
| | - Simon Peter Sebina Kibira
- Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University, Uganda
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Uganda
| | | | - Solomon Shiferaw
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Ethiopia
| | - Assefa Seme
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Ethiopia
| | - Amy Tsui
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA; Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, F-94805, Villejuif, France
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Mochache V, Wanje G, Nyagah L, Lakhani A, El-Busaidy H, Temmerman M, Gichangi P. Religious, socio-cultural norms and gender stereotypes influence uptake and utilization of maternal health services among the Digo community in Kwale, Kenya: a qualitative study. Reprod Health 2020; 17:71. [PMID: 32448327 PMCID: PMC7245746 DOI: 10.1186/s12978-020-00919-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 05/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background Maternal health outcomes in resource-limited settings are typically influenced by supply-side factors affecting the provision of quality health services. The extent to which demand-side factors contribute to this influence is unclear. We aimed to explore how individual and community-wide factors influenced uptake and utilization of maternal health services among the Digo community residing in Kwale County of coastal Kenya. Methods Between March and December 2015, we conducted 5 focus group discussions (FGDs) and 15 in-depth interviews (IDIs) with members of the Digo community predominant in Kwale county, Kenya. Respondents were sampled purposively and included female (pregnant and postpartum) as well as male adult community members. A thematic content analytic approach was used. Results There were a total of 47 FGD respondents, including 15 (32%) females with a median (interquartile, IQR) age of 38 (27–55) years and 6 (3–8) children. Majority (40%) reported attaining secondary-level education. All IDI respondents were female with a median (IQR) age of 27 (24–35) years and 4 (2–5) children. Majority (80%) had attained primary-level education. We found that religious and socio-cultural norms as well as gender stereotypes were important influences on the uptake and utilization of maternal health services, including facility-based delivery and contraception. Key amongst this was the unspoken deference to the counsel of a prominent matriarchal figure in the decision-making process. Conclusions Among the Digo community of coastal Kenya, a unique social-cultural context comprising of a religious and gendered value belief system influences women’s reproductive health and rights. These findings highlight the important role of demand-side factors in influencing maternal health outcomes. In addition to addressing supply-side factors, programs in such settings should aim to address factors that leverage inherent social capital to drive demand for maternal health services ensuring that they are not only effective, but also responsive to the local context.
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Affiliation(s)
- Vernon Mochache
- International Centre for Reproductive Health, P.O. Box 91109-80103, Mombasa, Kenya. .,University of Ghent, Ghent, Belgium.
| | - George Wanje
- Department of Medical Microbiology, University of Nairobi, Mombasa Field Site, P.O Box 91276-80103, Mombasa, Kenya
| | - Lucy Nyagah
- Community Health Department, Aga Khan University, P.O Box 83013-80100, Mombasa, Kenya
| | - Amyn Lakhani
- Community Health Department, Aga Khan University, P.O Box 83013-80100, Mombasa, Kenya
| | - Hajara El-Busaidy
- Department of Health, County Government of Kwale, P.O Box 6-80403, Kwale, Kenya
| | - Marleen Temmerman
- International Centre for Reproductive Health, P.O. Box 91109-80103, Mombasa, Kenya.,University of Ghent, Ghent, Belgium.,Community Health Department, Aga Khan University, P.O Box 83013-80100, Mombasa, Kenya.,Aga Khan University Hospital, 3rd Parklands Avenue, Limuru Road, Nairobi, Kenya
| | - Peter Gichangi
- International Centre for Reproductive Health, P.O. Box 91109-80103, Mombasa, Kenya.,University of Ghent, Ghent, Belgium.,Technical University of Mombasa, P.O Box 90420-80100, Mombasa, Kenya
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Aliyu MH, Sam-Agudu NA, Shenoi S, Goga AE, Ramraj T, Vermund SH, Audet CM. Increasing male engagement in the prevention of vertical transmission of HIV: what works in sub-Saharan Africa? BMJ 2019; 365:l1965. [PMID: 31171558 PMCID: PMC6598674 DOI: 10.1136/bmj.l1965] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Muktar Aliyu and colleagues discuss barriers, enablers, and research gaps in engaging male partners in prevention of vertical HIV transmission in sub-Saharan Africa
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Affiliation(s)
- Muktar H Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, USA
| | - Nadia A Sam-Agudu
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, USA
- Institute of Human Virology, Abuja, Nigeria
| | | | - Ameena E Goga
- South African Medical Research Council, Pretoria, South Africa
- Department of Paediatrics, University of Pretoria, South Africa
| | - Trisha Ramraj
- South African Medical Research Council, Pretoria, South Africa
| | | | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, USA
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Sochas L. Women who break the rules: Social exclusion and inequities in pregnancy and childbirth experiences in Zambia. Soc Sci Med 2019; 232:278-288. [PMID: 31112919 DOI: 10.1016/j.socscimed.2019.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/11/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
Health inequities are a growing concern in low- and middle-income countries, but reducing them requires a better understanding of underlying mechanisms. This study is based on 42 semi-structured interviews conducted in June 2018 with women who gave birth in the previous year, across rural and urban clinic sites in Mansa district, Zambia. Findings show that health facility rules regulating women's behaviour during pregnancy and childbirth create inequities in women's maternity experiences. The rules and their application can be understood as a form of social exclusion, discriminating against women with fewer financial and social resources. This study extends existing frameworks of social exclusion by demonstrating that the rules do not only originate in, but also reinforce, the structural processes that underpin inequitable social institutions. Legitimising the rules supports a moral order where women with fewer resources are constructed as "bad women", while efforts to follow the rules widen existing power differentials between socially excluded women and others. This study's findings have implications for the literature on reversed accountability and the unintended consequences of global and national safe motherhood targets, and for our understanding of disrespectful maternity care.
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Affiliation(s)
- Laura Sochas
- Department of Social Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
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Topp SM, Scott K, Ruano AL, Daniels K. Showcasing the contribution of social sciences to health policy and systems research. Int J Equity Health 2018; 17:145. [PMID: 30244676 PMCID: PMC6151940 DOI: 10.1186/s12939-018-0862-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/11/2018] [Indexed: 11/10/2022] Open
Abstract
Background This Special Issue represents a critical response to the frequent silencing of qualitative social science research approaches in mainstream public health journals, particularly in those that inform the field of health policy and systems research (HPSR), and the study of equity in health. Methods This collection of articles is presented by SHAPES, the thematic working group of Health Systems Global focused on social science approaches to research and engagement in health policy and systems. The issue aims to showcase how qualitative and theory-driven approaches can contribute to better promoting equity in health within the field of HPSR. Results This issue builds on growing recognition of the complex social nature of health systems. The articles in this collection underscore the importance of employing methods that can uncover and help explain health system complexities by exploring the dynamic relationships and decision-making processes of the human actors within. Articles seek to highlight the contribution that qualitative, interpretivist, critical, emancipatory, and other relational methods have made to understanding health systems, health policies and health interventions from the perspective of those involved. By foregrounding actor perspectives, these methods allow us to explore the impact of vital but difficult-to-measure concepts such as power, culture and norms. Conclusion This special issue aims to highlight the critical contribution of social science approaches. Through the application of qualitative methods and, in some cases, development of theory, the articles presented here build broader and deeper understanding of the way health systems function, and simultaneously inform a more people-centred approach to collective efforts to build and strengthen those systems.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, 4810, QLD, Australia. .,Nossal Institute for Global Health, University of Melbourne, Melbourne, 3002, VIC, Australia.
| | - Kerry Scott
- Research Consultant, Bengaluru, Karnataka, India.,Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205, USA
| | - Ana Lorena Ruano
- Center for the Study of Equity and Governance in Health Systems, Guatemala, Guatemala.,Center for International Health University of Bergen, Bergen, Norway
| | - Karen Daniels
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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