How using light touch immersion research revealed important insights into the lack of progress in malaria elimination in Eastern Indonesia

BACKGROUND

By 2022, the Government of Indonesia had successfully eliminated malaria in 389 out of 514 districts but continues to face a challenge in Eastern Indonesia where 95% of the total 2021 malaria cases were reported from Papua, West Papua and Nusa Tenggara Timur provinces. There is an increased recognition that malaria elimination will require a better understanding of the human behavioural factors hindering malaria prevention and treatment, informed by local context and local practice.

METHODS

This research used a light-touch immersion research approach. Field researchers lived in communities over several days to gather data through informal conversations, group-based discussions using visual tools, participant observation and direct experience. The study was conducted in four high malaria endemic areas in Papua, West Papua, and Sumba Islands in Nusa Tenggara Timur.

RESULTS

The research highlights how people's perception of malaria has changed since the introduction of effective treatment which, in turn, has contributed to a casual attitude towards early testing and adherence to malaria treatment. It also confirms that people rarely accept there is a link between mosquitoes and malaria based on their experience but nevertheless take precautions against the annoyance of mosquitoes. There is widespread recognition that babies and small children, elderly and incomers are more likely to be seriously affected by malaria and separately, more troubled by mosquitoes than indigenous adult populations. This is primarily explained by acclimatization and strong immune systems among the latter.

CONCLUSIONS

Using immersion research enabled behaviour research within a naturalistic setting, which in turn enabled experiential-led analysis of findings and revealed previously unrecognized insights into attitudes towards malaria in Eastern Indonesia. The research provides explanations of people's lack of motivation to consistently use bed nets, seek early diagnosis or complete courses of treatment. The felt concern for the wellbeing of vulnerable populations highlighted during light touch immersion provides an entry point for future social behaviour change communication interventions. Rather than trying to explain transmission to people who deny this connection, the research concludes that it may be better to focus separately on the two problems of malaria and mosquitoes (especially for vulnerable groups) thereby resonating with local people's own experience and felt concerns.

Contemporary pathways to adolescent pregnancy in Indonesia: A qualitative investigation with adolescent girls in West Java and Central Sulawesi

In the last decade, reduction in adolescent fertility rates in Indonesia has slowed despite national programmes and policies focused on addressing child marriage. Indonesia currently has the highest number of births to adolescent girls aged 15-19 years in Southeast Asia. There is a need to develop a more nuanced understanding of the drivers of adolescent pregnancy in Indonesia to inform programmes and policies tailored to young people's needs and priorities. This study explored adolescent girls' pathways to pregnancy across two provinces (Central Sulawesi and West Java) in Indonesia. We conducted participatory timeline interviews with 79 girls aged 15-21 years from urban, peri-urban, and rural communities and inquired about their relationships and life experiences leading up to pregnancy. We conducted follow-up interviews with 19 selected participants to validate and clarify preliminary findings. We identified six pathways to adolescent pregnancy which were broadly differentiated by the timing of pregnancy relative to marriage. Three pregnancy pathways within marriage were further differentiated by the main motivation for marriage-financial reasons, protecting the girl and family's reputation, or to progress a romantic relationship. Three pregnancy pathways outside marriage were distinguished by the nature of the sexual relationship preceding pregnancy-consensual sex, unwanted or pressured sex, and forced sex. Drivers of adolescent pregnancy include the acceptability of child marriage and stigma surrounding premarital pregnancy, family and social expectations of pregnancy following marriage, harmful gender-based norms and violence, and lack of sexual and reproductive health information and access to services. Adolescents follow varied pathways to pregnancy in Indonesia. The idealisation and acceptance of child marriage is both a catalyst and outcome of adolescent pregnancy, which is occurring amid stigma surrounding premarital sex and pregnancy, harmful gender-based norms and violence, and barriers to contraceptive access and use. Our findings emphasise that there are many drivers of adolescent pregnancy and different pathways will require intervention approaches that address child marriage alongside other key contributors.

System mapping with adolescents: Using group model building to map the complexity of obesity

Public health research and practice is increasingly employing systems thinking to help grapple with complex issues, from obesity to HIV treatment. At the same time, there is growing recognition that to address a given problem it is essential collaborate with those most at risk of or affected by it. Group model building (GMB), a process grounded in system dynamics, combines systems thinking and participatory methods to structure and address complex issues. As part of the CO-CREATE project we conducted GMB sessions with young people in six countries to create causal loop diagrams showing the factors that they believe drive obesity. This paper describes the background to GMB and the process we used to construct causal loop diagrams; it discusses how GMB contributed to generating noteworthy and useful findings, and the strengths and limitations of the method. Using GMB, we identified areas of concern to adolescents in relation to obesity that have so far had little attention in obesity research and policy: mental health and online activity. In using GMB, we also helped answer calls for a more participatory approach to youth involvement in research and policy development.

Ethical considerations in engaging young people in European obesity prevention research: The CO-CREATE experience

Engaging youth in obesity prevention research and policy action is essential to develop strategies that are relevant and sensitive to their needs. Research with young people requires critical reflection to safeguard their rights, dignity, and well-being. The CO-CREATE project used various methods to engage approximately 300 European youth aged 15-19 years in the development of policies to prevent adolescent obesity. This paper discusses ethical considerations made in the project pertaining to the youth's voluntary participation, their protection from obesity stigma, respect for their time, data privacy and confidentiality, power balance, and equality of opportunity to participate in the research. We describe measures implemented to prevent or limit the emergence of ethical challenges in our interaction with youth and discuss their relevance based on our experience with implementation. While some challenges seemingly were prevented, others arose related to the youth's voluntary participation, time burdens on them, and the sustainability of participation under the Covid-19 pandemic. Concrete and ongoing ethical guidance may be useful in projects aiming to interact and build collaborative relationships with youth for long periods of time.

Recruiting and engaging adolescents in creating overweight and obesity prevention policies: The CO-CREATE project

The CO-CREATE project aims to collaborate with adolescents across Europe in developing policy ideas that contribute to overweight and obesity prevention. In this paper, we present the theoretical basis and methodological approach to recruitment and engagement in the project. The principles of youth-led participatory action research were employed to design Youth Alliances in which adolescents and adults could collaborate. These Alliances should serve to promote and support adolescent participation and to develop policy ideas that would contribute to obesity prevention. Alliance members were recruited in two local geographical areas per country with a focus on reaching out to underrepresented youth. We started with fieldwork to assess locally relevant forms of inclusion and exclusion. The methodology entailed a handbook combining existing tools which could be used flexibly, a collaborative organization, and budgets for the alliances. Engagement started in local organizations, that is, schools and scouts, and with peers. Health- and overweight-related challenges were addressed in their immediate surroundings and supported the inclusion of experiential knowledge. Adolescents were then supported to address the wider obesogenic system when designing policy ideas. The CO-CREATE Alliances provide a concrete example of how to engage youth in public health, in a manner that strives to be participatory, transformative, and inquiry based.

Youth Alliance - a new model for health policy development

The work of the “Youth Alliance” (as part of the EU funded CO-CREATE project) introduces a new model for health policy development which sees young people and health policy experts from academia coalesce to form a ‘Youth Alliance’ considering the broader social and commercial environments which result in childhood obesity and other health problems, and what this means for policy development. The CO-CREATE project is a partnership between 14 European health and academic institutions and civil societies in five countries. The project will demonstrate the democratic engagement of youth in facilitating intergenerational and interorganisational cooperation.

Presenters: Christian Bröer and Sherria Ayuandini, University of Amsterdam

How variability in hymenoplasty recommendations leads to contrasting rates of surgery in the Netherlands: an ethnographic qualitative analysis

Hymenoplasty is surgery to alter the shape of the hymen membrane in the vaginal canal, commonly performed to minimise the aperture. This medical operation is often requested by women who expect that their virginity will be under scrutiny, particularly during their first sexual encounter on their wedding night. Despite increasing demand for the surgery all over the globe, there is no one standard of practice in performing hymenoplasty. In the Netherlands, the manner in which medical consultations concerning the procedure take place depends heavily on the consulting physician. This paper looks at two different approaches to hymenoplasty consultation in the Netherlands: a pedagogical philosophy adopted in a public hospital and a practical approach employed by a private clinic. Each approach culminates in a contrasting result: patients in one medical establishment are twice as likely to undergo hymenoplasty than those visiting the other.

Finger Pricks and Blood Vials: How doctors medicalize 'cultural' solutions to demedicalize the 'broken' hymen in the Netherlands

This paper provides new perspectives on the scholarship on medicalization and demedicalization, building on an ethnography of hymenoplasty consultations in the Netherlands. By examining how doctors can play an active role in demedicalization, this paper presents novel insights into Dutch physicians' attempt to demedicalize the "broken" hymen. In their consultations, Dutch doctors persuade hymenoplasty patients to abandon the assumed medical definition of the "broken" hymen and offer nonmedical solutions to patients' problems. Drawing from unique ethnographical access from 2012 to 2015 to 70 hymenoplasty consultations in the Netherlands, this paper's original contribution comes from closely examining how demedicalization can be achieved through the process of medicalization. It investigates how Dutch physicians go even further in their efforts to demedicalize by medicalizing "cultural" solutions as an alternative course of action to surgery.