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Tikkanen RS, Closser S, Prince J, Chand P, Justice J. An anthropological history of Nepal's Female Community Health Volunteer program: gender, policy, and social change. Int J Equity Health 2024; 23:70. [PMID: 38614976 PMCID: PMC11015651 DOI: 10.1186/s12939-024-02177-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/06/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history-even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs). METHODS We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources. RESULTS Looking across four decades of the program's history illuminates that issues of gender, workload, and pay-hotly debated in the CHW literature now-have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system. CONCLUSIONS Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment.
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Affiliation(s)
- Roosa Sofia Tikkanen
- Institute of Sociology and Political Science, Faculty of Social and Educational Sciences, Norwegian University of Science and Technology, Edvard Bulls veg 1, 7491, Trondheim, Norway.
| | - Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, Maryland, 21205, USA
| | - Justine Prince
- Zanvyl Krieger School of Arts & Sciences, Johns Hopkins University, 3400 N. Charles Street, Baltimore, Maryland, 21218, USA
| | - Priyankar Chand
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, Maryland, 21205, USA
| | - Judith Justice
- Institute for Health & Aging, School of Nursing, University of California at San Francisco, 490 Illinois Street, San Francisco, CA, 94143, USA
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Park S, Thrul J, Cooney EE, Atkins K, Kalb LG, Closser S, McDonald KM, Schneider-Firestone S, Surkan PJ, Rushton CH, Langhinrichsen-Rohling J, Veenema TG. Betrayal-Based Moral Injury and Mental Health Problems Among Healthcare and Hospital Workers Serving COVID-19 Patients. J Trauma Dissociation 2024; 25:202-217. [PMID: 38047579 DOI: 10.1080/15299732.2023.2289195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 06/13/2023] [Indexed: 12/05/2023]
Abstract
One factor potentially driving healthcare and hospital worker (HHW)'s declining mental health during the COVID-19 pandemic is feeling betrayed by institutional leaders, coworkers, and/or others' pandemic-related responses and behaviors. We investigated whether HHWs' betrayal-based moral injury was associated with greater mental distress and post-traumatic stress disorder (PTSD) symptoms related to COVID-19. We also examined if these associations varied between clinical and non-clinical staff. From July 2020 to January 2021, cross-sectional online survey data were collected from 1,066 HHWs serving COVID-19 patients in a large urban US healthcare system. We measured betrayal-based moral injury in three groups: institutional leaders, coworkers/colleagues, and people outside of healthcare. Multivariate logistic regression analyses were performed to investigate whether betrayal-based moral injury was associated with mental distress and PTSD symptoms. Approximately one-third of HHWs reported feeling betrayed by institutional leaders, and/or people outside healthcare. Clinical staff were more likely to report feelings of betrayal than non-clinical staff. For all respondents, 49.5% reported mental distress and 38.2% reported PTSD symptoms. Having any feelings of betrayal increased the odds of mental distress and PTSD symptoms by 2.9 and 3.3 times, respectively. These associations were not significantly different between clinical and non-clinical staff. As health systems seek to enhance support of HHWs, they need to carefully examine institutional structures, accountability, communication, and decision-making patterns that can result in staff feelings of betrayal. Building trust and repairing ruptures with HHWs could prevent potential mental health problems, increase retention, and reduce burnout, while likely improving patient care.
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Affiliation(s)
- Soim Park
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Johannes Thrul
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
| | - Erin E Cooney
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kaitlyn Atkins
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Luther G Kalb
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kathryn M McDonald
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Pamela J Surkan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Cynda H Rushton
- Johns Hopkins School of Nursing, Berman Institute of Bioethics, Baltimore, Maryland, USA
| | | | - Tener G Veenema
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Ahmed ST, Haider SS, Hanif S, Anwar HB, Mehjabeen S, Closser S, Bazant E, Sarker M. A scoping review on integrated health campaigns for immunization in low- and middle-income countries. Health Policy Plan 2023; 38:1198-1224. [PMID: 37699072 PMCID: PMC10752386 DOI: 10.1093/heapol/czad082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 07/19/2023] [Accepted: 09/01/2023] [Indexed: 09/14/2023] Open
Abstract
Health campaign integration is a key implementation strategy outlined by the World Health Organization to achieve universal health coverage. This scoping review synthesizes the evidence on Integrated Health Campaigns (IHC) in the field of immunization in low- and middle-income countries (LMICs) regarding the most common strategies, facilitators and barriers. Four reviewers followed a systematic approach to identify, screen and analyse relevant articles. The team used three search engines (PubMed, Scopus and Google Scholar) to identify peer-reviewed journal articles as well as select institutional websites for grey literature publications. Full-text articles using any study design and across any time frame were included. Data were extracted following a predefined matrix, analysed deductively and presented in a narrative synthesis. Thirty articles (20 academic and 10 grey) were included in the final review. All studies included identified IHCs as effective when planning or implementation is integrated. The common strategies were: using resources efficiently in remote locations; using national immunization days to maximize impact; targeting specific age groups by selecting intervention sites that are frequented by that age group; building community ownership over the integrated program; and integrating programs that already share common elements. The key facilitators were: closing the gap between services and communities; planning, coordination and resource management both before and during integration; cost-effectiveness; and utilization of pre-existing infrastructure. The common barriers included seemingly optimized initial cost to appear feasible only in the short term and additional responsibilities on the field staff. This review finds IHCs a common practice in immunization and identifies gaps in evidence on evaluation; indicating the need for additional research. Strong evidence accounts IHCs to increase coverage, improve community acceptance of health services and strengthen the community models of health service delivery.
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Affiliation(s)
- Syeda Tahmina Ahmed
- BRAC James P Grant School of Public Health, BRAC University, 6th Floor, Medona Tower, 28 Mohakhali Commercial Area, Bir Uttom A K Khandakar Road, Dhaka 1213, Bangladesh
| | - Shams Shabab Haider
- BRAC James P Grant School of Public Health, BRAC University, 6th Floor, Medona Tower, 28 Mohakhali Commercial Area, Bir Uttom A K Khandakar Road, Dhaka 1213, Bangladesh
| | - Suhi Hanif
- BRAC James P Grant School of Public Health, BRAC University, 6th Floor, Medona Tower, 28 Mohakhali Commercial Area, Bir Uttom A K Khandakar Road, Dhaka 1213, Bangladesh
| | - Humayra Binte Anwar
- BRAC James P Grant School of Public Health, BRAC University, 6th Floor, Medona Tower, 28 Mohakhali Commercial Area, Bir Uttom A K Khandakar Road, Dhaka 1213, Bangladesh
| | - Saima Mehjabeen
- BRAC James P Grant School of Public Health, BRAC University, 6th Floor, Medona Tower, 28 Mohakhali Commercial Area, Bir Uttom A K Khandakar Road, Dhaka 1213, Bangladesh
| | - Svea Closser
- John Hopkins University, Bultimore, Maryland 21218, US
| | - Eva Bazant
- The Task Force for Global Health, 330 W. Ponce de Leon Ave., Decatur, GA 30030, US
| | - Malabika Sarker
- BRAC James P Grant School of Public Health, BRAC University, 6th Floor, Medona Tower, 28 Mohakhali Commercial Area, Bir Uttom A K Khandakar Road, Dhaka 1213, Bangladesh
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Park S, Closser S, Cooney EE, Atkins K, Thrul J, McDonald KM, Langhinrichsen-Rohling J, Veenema TG. "A slap in the face": Institutional betrayal, burnout, and career choice regret among frontline health care workers serving COVID-19 patients. J Trauma Stress 2023; 36:980-992. [PMID: 37671574 DOI: 10.1002/jts.22967] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 06/14/2023] [Accepted: 06/25/2023] [Indexed: 09/07/2023]
Abstract
The COVID-19 pandemic has exacted a physical and mental health toll on health care and hospital workers (HHWs). To provide COVID-19 care, HHWs expected health care institutions to support equipment and resources, ensure safety for patients and providers, and advocate for employees' needs. Failure to do these acts has been defined as institutional betrayal. Using a mixed-methods approach, this study aimed to explore the experience of institutional betrayal in HHWs serving COVID-19 patients and the associations between self-reported institutional betrayal and both burnout and career choice regret. Between July 2020 and January 2021, HHWs working in an urban U.S. health care system participated in an online survey (n = 1,189) and semistructured interview (n = 67). Among 1,075 quantitative participants, 57.8% endorsed institutional betrayal. Qualitative participants described frustration when the institution did not prioritize their safety while reporting they perceived receiving inadequate compensation from the system and felt that leadership did not sufficiently respond to their needs. Participants who endorsed prolonged breaches of trust reported more burnout and stronger intent to quit their job. Quantitatively, institutional betrayal endorsement was associated with 3-fold higher odds of burnout, aOR = 2.94, 95% CI [2.22, 3.89], and 4-fold higher odds of career choice regret, aOR = 4.31, 95% CI [3.15, 5.89], compared to no endorsement. Developing strategies to prevent, address, and repair institutional betrayal in HHWs may be critical to prevent and reduce burnout and increase motivation to work during and after public health emergencies.
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Affiliation(s)
- Soim Park
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Erin E Cooney
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kaitlyn Atkins
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Johannes Thrul
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
| | - Kathryn M McDonald
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Tener Goodwin Veenema
- Department of Environmental Health and Engineering, Center for Health Security, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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5
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Atkins K, Cooney EE, Park S, Closser S, Surkan PJ, Marker HC, Schneider-Firestone S, Kalb LG, Thrul J, Veenema TG. Day to Day and Environmental Risk Factors for Psychological Distress Among Healthcare Workers: A Mixed Methods Analysis. J Occup Environ Med 2023; 65:e593-e603. [PMID: 37367694 DOI: 10.1097/jom.0000000000002909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Despite a growing literature on mental health among clinical staff during COVID-19, factors shaping distress for nonclinical staff are understudied and may be driven by inequalities at work. We aimed to discuss the role of workplace factors in shaping psychological distress for a diverse group of clinical, nonclinical, and other health and hospital workers (HHWs). METHODS This convergent parallel mixed-methods study with HHWs in a US hospital system included an online survey ( n = 1127) and interviews ( n = 73) collected from August 2020 to January 2021. We thematically analyzed interviews; findings informed log binomial regression estimating risk factors for severe psychological distress (Patient Health Questionnaire - 4 item version [PHQ-4] scores of 9 or greater). RESULTS Qualitatively, day-to-day stressors fostered fear and anxiety, and concerns about work environments manifest as betrayal and frustration with leadership. Distress was associated with burnout, financial concerns, and feeling betrayed or unsupported by the institution and leadership. Staff in service versus clinical roles had higher risk for severe distress (adjusted prevalence ratio = 2.04, 95% confidence interval = 1.13-2.66); HHWs receiving workplace mental health support had lower risk (adjusted prevalence ratio = 0.52, 95% confidence interval = 0.29-0.92. CONCLUSIONS Our mixed-methods study underscores how the pandemic brought inequalities to the surface to increase distress for vulnerable HHWs. Workplace mental health activities can support HHWs now and during future crises.
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Affiliation(s)
- Kaitlyn Atkins
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.A.); Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.A., E.E.C., S.P., S.C., P.J.S., H.C.M.); Johns Hopkins School of Nursing, Baltimore, Maryland (S.S.-F.); Department of Mental Health, Johns Hopkins Bloomberg School of Public Health (L.G.K., J.T.); Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland (L.G.K.); Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (T.G.V.); and Center for Health Security, Johns Hopkins University, Baltimore, Maryland (T.G.V.)
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Sultan MA, Closser S, Majidulla A, Ahmed S, Naz F, Nayyab S, Zaman A, Shafique M, Sohail A. How to eradicate polio in Pakistan: Insights from community health workers. PLOS Glob Public Health 2023; 3:e0002289. [PMID: 37643151 PMCID: PMC10464965 DOI: 10.1371/journal.pgph.0002289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023]
Abstract
Pakistan, along with Afghanistan, is one of two countries where wild poliovirus is still endemic. Frontline workers (FLWs) are the staff most intimately familiar with both implementation challenges and community context. Harnessing their expertise may be a way to improve the community-polio program interface, which has been a persistent and shifting challenge in polio-endemic areas of both countries. From 2020-2022, we engaged frontline workers in 18 Super High-Risk Union Councils (SHRUCs) in Pakistan through a Human-Centered Design ideas competition. In that competition, teams of polio FLWs identified the most significant barriers they faced in conducting their work, and suggested solutions to those problems-a window into the issues the program faces by the people who know it best. The suggestions of FLWs on how to eradicate polio fell into four main categories. First, there were suggestions to tackle community fatigue by reducing touchpoints, particularly visits solely for data collection. Second, there were calls to improve Primary Health Care in SHRUCs, as a way of addressing community frustrations over an intense focus on just one disease in the context of numerous acute needs. Third, there were suggested ways to increase community engagement through locally relevant channels. Finally, many workers suggested improvements to Human Resources processes and workplace dynamics. Across these ideas, one repeated concept is the need for balance between the intensity of polio activities required for eradication and the provision of other government services, including health services. FLWs engaged the process deeply, providing well thought out problem statements and ideas for change. It is our view that there is no one more qualified to speak to the issues on the ground than FLWs. There are critical insights available if we listen to people who are instrumental to the success of health programs, but not commonly involved with creating policy.
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Affiliation(s)
- Marium A. Sultan
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Svea Closser
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Arman Majidulla
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Dhaliwal BK, Seth R, Thankachen B, Qaiyum Y, Closser S, Best T, Shet A. Leading from the frontlines: community-oriented approaches for strengthening vaccine delivery and acceptance. BMC Proc 2023; 17:5. [PMID: 37391823 DOI: 10.1186/s12919-023-00259-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Although immunization is one of the most successful public health interventions, vaccine hesitancy and the COVID-19 pandemic have strained health systems, contributing to global reductions in immunization coverage. Existing literature suggests that involving community members in vaccine interventions has been beneficial, but efforts to facilitate community ownership to motivate vaccine acceptance have been limited. METHODS Our research leveraged community-based participatory research to closely involve the community from conception to implementation of an intervention to facilitate vaccine acceptance in Mewat District in Haryana, an area in India with extremely low vaccination coverage. Through the development of a community accountability board, baseline data collection on vaccination barriers and facilitators, and two human-centered design workshops, our team co-created a six-pronged intervention with community leaders and community health workers. This intervention included involving religious leaders in vaccine discussions, creating pamphlets of local vaccine champions for dissemination to parent and child caregivers, creating short videos of local leaders advocating for vaccines, implementing communication training exercises for community health workers, and implementing strategies to strengthen coordination between health workers and supervisors. RESULTS Post-intervention data suggested parents and child caregivers had improvements in knowledge of the purpose of vaccines and side effects of vaccines. They noted that the involvement of religious leaders was beneficial, they were more willing to travel to vaccinate their children, and they had fewer non-logistical reasons to refuse vaccination services. Interviews with community leaders and community health workers who were involved in the creation of the intervention suggested that they experienced higher levels of ownership, they were better equipped to address community concerns, and that vaccine misinformation decreased in the post-intervention period. CONCLUSION Through this unique intervention to strengthen vaccine uptake that incorporated the needs, interests, and expertise of local community members, we developed a community-driven approach to strengthen vaccine acceptance in a population with low uptake. This comprehensive approach is essential to amplify local voices, identify local concerns and advocates, and leverage bottom-up strategies to co-design successful interventions to facilitate long-term change.
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Affiliation(s)
- Baldeep K Dhaliwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | | | | | - Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tyler Best
- Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anita Shet
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Closser S, Sultan M, Tikkanen R, Singh S, Majidulla A, Maes K, Gerber S, Rosenthal A, Palazuelos D, Tesfaye Y, Finley E, Abesha R, Keeling A, Justice J. Breaking the silence on gendered harassment and assault of community health workers: an analysis of ethnographic studies. BMJ Glob Health 2023; 8:bmjgh-2023-011749. [PMID: 37208121 DOI: 10.1136/bmjgh-2023-011749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/21/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Across a variety of settings, women in tenuous financial circumstances are drawn to community health work as a way to advance themselves in the context of limited employment options. Female Community Health Workers (CHWs) are often preferred because they can more easily access mothers and children; at the same time, gender norms are at the heart of many of the challenges and inequities that these workers encounter. Here, we explore how these gender roles and a lack of formal worker protections leave CHWs vulnerable to violence and sexual harassment, common occurrences that are frequently downplayed or silenced. METHODS We are a group of researchers who work on CHW programmes in a variety of contexts globally. The examples here are drawn from our ethnographic research (participant observation and in-depth interviews). RESULTS CHW work creates job opportunities for women in contexts where such opportunities are extremely rare. These jobs can be a lifeline for women with few other options. Yet the threat of violence can be very real: women may face violence from the community, and some experience harassment from supervisors within health programmes. CONCLUSION Taking gendered harassment and violence seriously in CHW programmes is critical for research and practice. Fulfilling CHWs' vision of health programmes that value them, support them and give them opportunities may be a way for CHW programmes to lead the way in gender-transformative labour practices.
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Affiliation(s)
- Svea Closser
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marium Sultan
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Roosa Tikkanen
- Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
| | - Shalini Singh
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Arman Majidulla
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kenneth Maes
- Anthropology, Oregon State University, Corvallis, Oregon, USA
| | - Sue Gerber
- Independent Consultant, Truchas, New Mexico, USA
| | - Anat Rosenthal
- Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Southern, Israel
| | - Daniel Palazuelos
- Blavatnik Institute of Global Health and Social Medicine, Harvard University, Cambridge, Massachusetts, USA
| | | | - Erin Finley
- Psychiatry and Behavioral Sciences, UT Health San Antonio, San Antonio, Texas, USA
| | - Roza Abesha
- Independent Consultant, Gondar, Amhara, Ethiopia
| | | | - Judith Justice
- Institute for Health and Aging, University of California at San Francisco, Berkeley, California, USA
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Finley EP, Closser S, Sarker M, Hamilton AB. Editorial: The theory and pragmatics of power and relationships in implementation. Front Health Serv 2023; 3:1168559. [PMID: 37033898 PMCID: PMC10076820 DOI: 10.3389/frhs.2023.1168559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/09/2023] [Indexed: 04/11/2023]
Affiliation(s)
- Erin P. Finley
- VA Greater Los Angeles Healthcare System, Veterans Health Administration, United States Department of Veterans Affairs, Los Angeles, CA, United States
- Center for Research to Advance Community Health, Joe R. & Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Correspondence: Erin P. Finley
| | - Svea Closser
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Malabika Sarker
- Center of Excellence for the Science of Implementation and Scale-Up, BRAC University, Dhaka, Bangladesh
- Heidelberg Institute of Global Health, University of Heidelberg, Germany
| | - Alison B. Hamilton
- VA Greater Los Angeles Healthcare System, Veterans Health Administration, United States Department of Veterans Affairs, Los Angeles, CA, United States
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
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Kalbarczyk A, Closser S, Hirpa S, Cintyamena U, Azizatunnisa L, Agrawal P, Rahimi AO, Akinyemi OO, Mafuta EM, Deressa W, Alonge OO. A light touch intervention with a heavy lift - gender, space and risk in a global vaccination programme. Glob Public Health 2022; 17:4087-4100. [PMID: 35849627 DOI: 10.1080/17441692.2022.2099930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Frontline workers (FLWs) in the Global Polio Eradication Initiative go door-to-door delivering polio vaccine to children. They have played a pivotal role in eliminating wild polio from most countries on earth; at the same time, they face significant bodily risk. STRIPE, an international consortium, conducted a mixed-methods study exploring the knowledge and experiences of polio staff in seven countries (Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Indonesia and Nigeria). We surveyed 826 polio FLWs and conducted semi-structured interviews with 22 of them. We used a body work framework to guide analysis. Polio workers perform a different kind of body work than many other FLWs. Delivering a few drops of oral vaccine takes a light touch, but gendered spaces can make the work physically dangerous. Polio's FLWs must bend or break gendered space norms as they move from house-to-house. Navigating male spaces carries risk for women, including lethal risk, particularly in conflict settings. Workers manoeuvre between skeptical community members and the demands of supervisors which generates emotional labour. Providing FLWs with more power to make operational decisions and providing them with robust teams and remuneration would improve the likelihood that they could act to improve their working conditions.
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Affiliation(s)
- Anna Kalbarczyk
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Selamawit Hirpa
- Department of Preventive Medicine, School of Public Health, College of Health Sciences Addis Ababa University, Addis Ababa, Ethiopia
| | - Utsamani Cintyamena
- Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Lutfhi Azizatunnisa
- Department of Health Behavior, Environment, and Social Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Priyanka Agrawal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Oluwaseun O Akinyemi
- Department of Health Policy and Management, University of Ibadan College of Medicine, Ibadan Nigeria
| | - Eric M Mafuta
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, DRC
| | - Wakgari Deressa
- Department of Preventive Medicine, School of Public Health, College of Health Sciences Addis Ababa University, Addis Ababa, Ethiopia
| | - Olakunle O Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Neill R, Neel AH, Cardona C, Bishai D, Gupta S, Mohan D, Jain N, Basu S, Closser S. Everyday capabilities were a path to resilience during COVID-19: a case study of five countries. Health Policy Plan 2022; 38:192-204. [PMID: 36222381 PMCID: PMC9619747 DOI: 10.1093/heapol/czac085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/14/2022] Open
Abstract
COVID-19 demanded urgent responses by all countries, with wide variations in the scope and sustainability of those responses. Scholarship on resilience has increasingly emphasized relational considerations such as norms and power and how they influence health systems' responses to evolving challenges. In this study, we explored what influenced countries' national pandemic responses over time considering a country's capacity to test for COVID-19. To identify countries for inclusion, we used daily reports of COVID-19 cases and testing from 184 countries between 21st January 2020 and 31st December 2020. Countries reporting test data consistently and for at least 105 days were included, yielding a sample of 52 countries. We then sampled five countries representing different geographies, income levels and governance structures (Belgium, Ethiopia, India, Israel and Peru) and conducted semi-structured key informant interviews with stakeholders working in, or deeply familiar with, national responses. Across these five countries, we found that existing health systems capacities and political leadership determined how responses unfolded, while emergency plans or pandemic preparedness documents were not fit-for-purpose. While all five countries were successful at reducing COVID-19 infections at a specific moment in the pandemic, political economy factors complicated the ability to sustain responses, with all countries experiencing larger waves of the virus in 2021 or 2022. Our findings emphasize the continued importance of foundational public health and health systems capacities, bolstered by clear leadership and multisectoral coordination functions. Even in settings with high-level political leadership and a strong multisectoral response, informants wished that they-and their country's health system-were more prepared to address the pandemic and maintain an effective response over time. Our findings challenge emergency preparedness as the dominant frame in pandemic preparedness and call for a continued emphasis on health systems strengthening to respond to future health shocks and a pandemic moving to endemic status.
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Affiliation(s)
- Rachel Neill
- Corresponding author. Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA. E-mail:
| | - Abigail H Neel
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Carolina Cardona
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - David Bishai
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Shivam Gupta
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Nishant Jain
- Indo-German Social Security Program, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, 5/1, Second Floor, Safdarjung Enclave, New Delhi 110029, India
| | - Sharmishtha Basu
- Indo German Programme on Universal Health Coverage ((IGUHC), Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, 5/1, Second Floor, Safdarjung Enclave, New Delhi 110029, India
| | - Svea Closser
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
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Banerjee P, Seth R, Dhaliwal BK, Sullivan A, Qiayum Y, Thankachen B, Closser S, Shet A. Vaccine acceptance in rural India: Engaging faith leaders as vaccine ambassadors. Front Public Health 2022; 10:979424. [PMID: 36203681 PMCID: PMC9531688 DOI: 10.3389/fpubh.2022.979424] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/05/2022] [Indexed: 01/25/2023] Open
Abstract
Introduction Religious faith is a key marker of identity and shapes community perspectives and trust. Faith leader involvement in vaccine campaigns in India have been beneficial to counter misinformation regarding infectious diseases such as polio. Faith leaders are influential stakeholders who bear potential to enhance public confidence in vaccine campaigns. Context While vaccine coverage has been increasing in India, inequities abound, especially in populations with historically low vaccine confidence. The COVID-19 pandemic has led to major disruptions in delivery of routine immunization services for children. To address these challenges, we co-designed interventions aimed at contextual communication strategies and peer support. Engaging faith leaders was an important part of this intervention. In this report we describe our experience and highlight the perspectives of faith leaders and their expectations of the outcomes for this intervention. Programmatic elements The CIVIC Project, conducted from January to December 2021 aimed to engage caregivers, community health workers and key stakeholders, particularly, faith leaders in co-designing interventions to address vaccine hesitancy in Mewat. The project, deeply rooted in community based participatory research, used a three-E approach (Exploration of community perspectives, Establishment of vaccine trust and awareness, Engagement in vaccine promotion activities) to successfully engage faith leaders in the design and dissemination of media messages advocating for vaccine acceptance and uptake. Lessons learned The involvement of faith leaders in the intervention benefited the community in two ways. First, faith leaders were spotlighted via videos, often disseminating advice and personal anecdotes about vaccines, thus reassuring caregivers and community members who previously expressed distrust in vaccines. Second, involvement of trusted faith leaders provided a platform for a two-way dialogue for the community to openly discuss and address myths and misconceptions regarding vaccines. This project provided the learning that co-creating interventions with faith leaders who are often gatekeepers of close-knit communities can lead to the development of vaccine positive messaging that community members relate with, motivating increased vaccine confidence.
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Affiliation(s)
- Preetika Banerjee
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Baldeep K. Dhaliwal
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Alexis Sullivan
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | | | - Svea Closser
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Anita Shet
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States,*Correspondence: Anita Shet
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13
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Dhaliwal BK, Chandrashekhar R, Rattani A, Seth R, Closser S, Jain A, Bloom DE, Shet A. Community perceptions of vaccination among influential stakeholders: qualitative research in rural India. BMC Public Health 2021; 21:2122. [PMID: 34794415 PMCID: PMC8600485 DOI: 10.1186/s12889-021-12188-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 11/08/2021] [Indexed: 11/20/2022] Open
Abstract
Background In India and other low- and middle-income countries, multiple family and community members are influential in caregivers’ perceptions of vaccination. Existing literature indicates the primary caregiver, typically the mother, is instrumental in vaccine decision-making, but this may vary in contexts. We investigated the role of stakeholders in India who influence caregivers’ vaccination perceptions, as this is essential to developing strategies to promote vaccine acceptance and improve uptake. Methods This research was conducted in 2019 in Mewat District in Haryana, an area in India with extremely low vaccination coverage. We conducted six focus group discussions with 60 participants in the following categories: fathers of children under-5 years old, expectant mothers, mothers-in-law, community health workers, and community influencers such as locally elected officials and religious leaders. Results Our results highlighted four themes that influence vaccine uptake. First, while caregivers associated vaccination with reductions in specific diseases, they also noted that vaccination services brought broad health gains, including improved nutrition, antenatal guidance, and social support. Second, community health workers critically influenced, positively or negatively, caregivers’ vaccination perceptions. Third, community health workers faced gaps in their education such as limited training on vaccine side-effects, placing them at a disadvantage when dealing with families. Finally, we found that mothers-in-law, fathers, and religious leaders influence caregivers’ perceptions of vaccination. Conclusions Communication of broader benefits of vaccines and vaccination services by community health workers could be impactful in increasing vaccine acceptance. Vaccine uptake could potentially be improved by facilitating community health workers’ ownership over vaccine acceptance and uptake by involving them in the design and implementation of interventions to target mothers and mothers-in-law. A ‘bottom-up’ approach, leveraging community health workers’ knowledge to design interventions, and giving a voice to key members of the household and society beyond mothers alone, may sustain health improvement in low vaccine coverage areas. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-12188-4.
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Affiliation(s)
- Baldeep K Dhaliwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA. .,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, 415 N. Washington Street, Baltimore, MD, USA.
| | - Riti Chandrashekhar
- Bal Umang Drishya Sanstha, E-10, Block X, Green Park Extension, New Delhi, India
| | - Ananya Rattani
- Bal Umang Drishya Sanstha, E-10, Block X, Green Park Extension, New Delhi, India
| | - Rajeev Seth
- Bal Umang Drishya Sanstha, E-10, Block X, Green Park Extension, New Delhi, India
| | - Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA
| | - Anika Jain
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA
| | - David E Bloom
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Anita Shet
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, 415 N. Washington Street, Baltimore, MD, USA
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14
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Kalbarczyk A, Closser S, Rao A, Akinyemi O, Anwar HB, Mafuta E, Majumdar P, Alonge OO. Translating Implementation Experiences and Lessons Learned From Polio Eradication Into a Global Health Course: Insights From an International Consortium. Glob Health Sci Pract 2021; 9:682-689. [PMID: 34593590 PMCID: PMC8514025 DOI: 10.9745/ghsp-d-20-00460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 05/18/2021] [Indexed: 12/03/2022]
Abstract
Using international collaborations to develop educational materials presents several challenges but offers enormous benefits in gleaning a wealth of information, perspectives, and context. The global course that resulted from this collaboration mirrors the goals of implementation science more broadly—to bring the findings of research into routine practice to improve health services. Lessons learned from one global health program can inform responses to challenges faced by other programs. One way to disseminate these lessons is through courses. However, such courses are often delivered by and taught to people based in high-income countries and thus may not present a truly global perspective. The Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) is a consortium of 8 institutions in Afghanistan, Bangladesh, the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria, and the United States that seeks to carry out such a transfer of the lessons learned in polio eradication. This short report describes the collaborative process of developing content and curriculum for an international course, the learnings that emerged, the barriers we faced, and recommendations for future similar efforts. Various parts of our course were developed by teams of researchers from countries across South Asia and sub-Saharan Africa. We held a series of regional in-person team meetings hosted in different countries to improve rapport and provide a chance to work together in person. The course content reflects the diversity of team members’ knowledge in a variety of contexts. Challenges to this effort included team coordination (e.g., scheduling across time zones); hierarchies across and between countries; and the coronavirus disease (COVID-19) pandemic. We recommend planning for these hierarchies ahead of time and ensuring significant in-person meeting time to make the most of international collaboration.
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Affiliation(s)
- Anna Kalbarczyk
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Svea Closser
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Aditi Rao
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Oluwaseun Akinyemi
- Department of Health Policy and Management, College of Medicine University of Ibadan, Ibadan, Nigeria
| | - Humarya Binte Anwar
- BRAC James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Eric Mafuta
- University of Kinshasa School of Public Health, Kinshasa, The Democratic Republic of the Congo
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15
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Abstract
Across the literature on CHWs globally, the role of CHWs' families remains largely unexplored. This article focuses on ASHAs and Anganwadi Workers in a town in rural Rajasthan, India. We interviewed all twenty ASHAs and Anganwadi Workers in this town, and ten of their families; we also conducted participant observation in Anganwadi Centers, health centres, and family settings. ASHA and Anganwadi work was in high demand, despite being low paying, because of an overall lack of jobs for educated women. Every aspect of CHW work, from recruitment to selection to training to the number of hours spent on the job, was heavily determined by families. Women's mobility, income, and workload was tied up in family structures. ASHA and Anganwadi Work increased the mobility and autonomy of the women who held those jobs in significant ways. But mostly, women stayed in these extremely low paying jobs because they and their families hoped that one day they would become permanent jobs with salaries and benefits. By providing honourable work, and keeping the idea of permanent employment in view but always just out of reach, the ASHA and Anganwadi programmes both exploited and strengthened gendered inequalities in the rural Rajasthani labour market.
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Affiliation(s)
- Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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16
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Closser S, Mendenhall E, Brown P, Neill R, Justice J. The anthropology of health systems: A history and review. Soc Sci Med 2021; 300:114314. [PMID: 34400012 DOI: 10.1016/j.socscimed.2021.114314] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 12/17/2022]
Abstract
Ethnographies of health systems are a theoretically rich and rapidly growing area within medical anthropology. Critical ethnographic work dating back to the 1950s has taken policymakers and health staff as points of entry into the power structures that run through the global health enterprise. In the last decade, there has been a surge of ethnographic work on health systems. We conceptualize the anthropology of health systems as a field; review the history of this body of knowledge; and outline emergent literatures on policymaking, HIV, hospitals, Community Health Workers, health markets, pharmaceuticals, and metrics. High-quality ethnographic work is an excellent way to understand the complex systems that shape health outcomes, and provides a critical vantage point for thinking about global health policy and systems. As theory in this space develops and deepens, we argue that anthropologists should look beyond the discipline to think through what their work does and why it matters.
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Affiliation(s)
- Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Rm E5545, Baltimore, MD, 21205, USA.
| | - Emily Mendenhall
- Science, Technology and International Affairs Program, Edmund A. Walsh School of Foreign Service, Georgetown University, USA
| | - Peter Brown
- Department of Anthropology, Emory University, USA
| | - Rachel Neill
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Judith Justice
- Institute for Health and Aging, School of Nursing, University of California, San Francisco, USA
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17
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Neel AH, Closser S, Villanueva C, Majumdar P, Gupta SD, Krugman D, Akinyemi OO, Deressa W, Kalbarczyk A, Alonge O. 30 years of polio campaigns in Ethiopia, India and Nigeria: the impacts of campaign design on vaccine hesitancy and health worker motivation. BMJ Glob Health 2021; 6:bmjgh-2021-006002. [PMID: 34344665 PMCID: PMC8336205 DOI: 10.1136/bmjgh-2021-006002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/11/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction The debate over the impact of vertical programmes, including mass vaccination, on health systems is long-standing and often polarised. Studies have assessed the effects of a given vertical health programme on a health system separately from the goals of the vertical programme itself. Further, these health system effects are often categorised as either positive or negative. Yet health systems are in fact complex, dynamic and tightly linked. Relationships between elements of the system determine programme and system-level outcomes over time. Methods We constructed a causal loop diagram of the interactions between mass polio vaccination campaigns and government health systems in Ethiopia, India and Nigeria, working inductively from two qualitative datasets. The first dataset was 175 interviews conducted with policymakers, officials and frontline staff in these countries in 2011–2012. The second was 101 interviews conducted with similar groups in 2019, focusing on lessons learnt from polio eradication. Results Pursuing high coverage in polio campaigns, without considering the dynamic impacts of campaigns on health systems, cost campaign coverage gains over time in weaker health systems with many campaigns. Over time, the systems effects of frequent campaigns, delivered through parallel structures, led to a loss of frontline worker motivation, and an increase in vaccine hesitancy in recipient populations. Co-delivery of interventions helped to mitigate these negative effects. In stronger health systems with fewer campaigns, these issues did not arise. Conclusion It benefits vertical programmes to reduce the construction of parallel systems and pursue co-delivery of interventions where possible, and to consider the workflow of frontline staff. Ultimately, for health campaign designs to be effective, they must make sense for those delivering and receiving campaign interventions, and must take into account the complex, adaptive nature of the health systems in which they operate.
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Affiliation(s)
- Abigail H Neel
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Svea Closser
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Catherine Villanueva
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Piyusha Majumdar
- SDG School of Public Health, Indian Institute of Health Management Research, Jaipur, Rajasthan, India
| | - S D Gupta
- SDG School of Public Health, Indian Institute of Health Management Research, Jaipur, Rajasthan, India
| | - Daniel Krugman
- Anthropology, Middlebury College, Middlebury, Vermont, USA
| | | | - Wakgari Deressa
- Preventive Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Anna Kalbarczyk
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Olakunle Alonge
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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18
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Haenssgen MJ, Closser S, Alonge O. Impact and effect mechanisms of mass campaigns in resource-constrained health systems: quasi-experimental evidence from polio eradication in Nigeria. BMJ Glob Health 2021; 6:bmjgh-2020-004248. [PMID: 33685940 PMCID: PMC7942242 DOI: 10.1136/bmjgh-2020-004248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/12/2021] [Accepted: 02/10/2021] [Indexed: 12/04/2022] Open
Abstract
Background Mass campaigns are a key strategy for delivering life-saving interventions under Global Health Initiatives, especially in weak health system contexts. They are frequently designed parallel to the health system to rapidly achieve programme targets such as vaccination coverage, but we lack quantitative evidence demonstrating their impact and effect mechanisms on health system performance at sub-/national level. This longitudinal study responds to this gap through an analysis of polio eradication campaigns in Nigeria. Methods Using four rounds of Demographic and Health Surveys in Nigeria between October 2000 and December 2017, we created a longitudinal dataset containing 88 881 under-5 children/pregnancies. We estimated the relationships between individuals’ campaign exposure and health system performance indices (full RI schedule attainment, maternal healthcare services utilisation and child survival) using multilevel, mixed-effects regression models applied nationally and stratified by the six geopolitical zones in Nigeria. Results Nationally, high-frequency mass campaigns had detrimental health systems effects that potentially left 3.6 million children deprived of full immunisation. The frequency of campaigns was most concentrated in regions with weak health systems, where the operations of RI were disrupted, alongside negative effects on child survival and institutional delivery. In contrast, regions with relatively strong health systems and few campaigns experienced beneficial effects on maternal healthcare service utilisation. Conclusions As we provide evidence that well-functioning health systems can benefit from mass campaigns under Global Health Initiatives, our work also challenges the established wisdom to intensify mass campaigns in weaker health systems to bypass service provision bottlenecks. Mass campaigns do not inherently benefit or damage a health system, but frequent campaigns in weak health system contexts can impede service provision. We call for an additional burden of proof and active efforts to integrate mass campaigns into routine health services by harmonising implementation plans and service delivery in weak health system contexts.
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Affiliation(s)
- Marco J Haenssgen
- Department of Global Sustainable Development, School of Cross-Faculty Studies, University of Warwick, Coventry, UK.,Institute of Advanced Study, Milburn House, University of Warwick, Coventry, UK
| | - Svea Closser
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Olakunle Alonge
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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19
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Closser S. The Corruption Game: Health Systems, International Agencies, and the State in South Asia. Med Anthropol Q 2019; 34:268-285. [PMID: 31573104 DOI: 10.1111/maq.12549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 08/26/2019] [Accepted: 09/06/2019] [Indexed: 12/01/2022]
Abstract
Drawing on ethnographic material collected in Pakistan, India, and Nepal, this article analyzes patterns of corruption in vaccination programs in South Asia. Corrupt practices-which required substantial work-were deeply shaped by both the money and systems of accountability of the global health system. Bilateral and multilateral donors provided substantial funding for immunization programs across South Asia. International agencies and governments instituted systems of accountability, including documentation requirements and a parallel UN bureaucracy in problematic districts, to try to ensure that health workers did what they wanted. Some immunization program staff skillfully bent these systems of accountability to their own ends, diverting vaccination funding into their own pockets. Corruption operates not in opposition to the official rules, but in spaces opened up by them. These practices sometimes transform Weber's rational bureaucracy into a sophisticated game with many players, whose aims are more complex than the stated goals of the bureaucracy.
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Affiliation(s)
- Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health
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20
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Closser S, Napier H, Maes K, Abesha R, Gebremariam H, Backe G, Fossett S, Tesfaye Y. Does volunteer community health work empower women? Evidence from Ethiopia’s Women’s Development Army. Health Policy Plan 2019; 34:298-306. [DOI: 10.1093/heapol/czz025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Of the millions of Community Health Workers (CHWs) serving their communities across the world, there are approximately twice as many female CHWs as there are male. Hiring women has in many cases become an ethical expectation, in part because working as a CHW is often seen as empowering the CHW herself to enact positive change in her community. This article draws on interviews, participant observation, document review and a survey carried out in rural Amhara, Ethiopia from 2013 to 2016 to explore discourses and experiences of empowerment among unpaid female CHWs in Ethiopia’s Women’s Development Army (WDA). This programme was designed to encourage women to leave the house and gain decision-making power vis-à-vis their husbands—and to use this power to achieve specific, state-mandated, domestically centred goals. Some women discovered new opportunities for mobility and self-actualization through this work, and some made positive contributions to the health system. At the same time, by design, women in the WDA had limited ability to exercise political power or gain authority within the structures that employed them, and they were taken away from tending to their individual work demands without compensation. The official rhetoric of the WDA—that women’s empowerment can happen by rearranging village-level social relations, without offering poor women opportunities like paid employment, job advancement or the ability to shape government policy—allowed the Ethiopian government and its donors to pursue ‘empowerment’ without investments in pay for lower-level health workers, or fundamental freedoms introduced into state-society relations.
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Affiliation(s)
- Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, USA
| | - Harriet Napier
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, USA
| | - Kenneth Maes
- Department of Anthropology, Oregon State University, 2250 SW Jefferson Way, Corvallis, OR, USA
| | - Roza Abesha
- Department of Sociology/Anthropology, Middlebury College, 201 Munroe Hall, Middlebury, VT, USA
| | - Hana Gebremariam
- Department of Sociology/Anthropology, Middlebury College, 201 Munroe Hall, Middlebury, VT, USA
| | - Grace Backe
- Department of Sociology/Anthropology, Middlebury College, 201 Munroe Hall, Middlebury, VT, USA
| | - Sarah Fossett
- Department of Sociology/Anthropology, Middlebury College, 201 Munroe Hall, Middlebury, VT, USA
| | - Yihenew Tesfaye
- Department of Anthropology, Oregon State University, 2250 SW Jefferson Way, Corvallis, OR, USA
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21
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Maes K, Closser S, Tesfaye Y, Abesha R. Psychosocial distress among unpaid community health workers in rural Ethiopia: Comparing leaders in Ethiopia's Women's Development Army to their peers. Soc Sci Med 2019; 230:138-146. [PMID: 31009880 DOI: 10.1016/j.socscimed.2019.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 11/28/2022]
Abstract
There is a growing critical social science literature on volunteering in health programs in non-western, low-income countries, yet few have mixed quantitative and qualitative methods to examine the psychological and social wellbeing of unpaid community health workers in such contexts. We address this issue with data from unpaid community health workers (CHWs) and other women who comprise Ethiopia's state-organized Women's Development Army. We draw on qualitative and cross-sectional survey data collected between 2013 and 2016 to test links between various aspects of psychosocial and economic wellbeing and volunteer status in a rural context. We surveyed 422 adult women in Amhara state, 73 of whom were unpaid CHWs in the "Army". We also conducted interviews and focus group discussions with health officials, salaried Health Extension Workers, volunteer CHWs, and other adult women. Analyses of our qualitative and quantitative datasets show that volunteer CHWs are actually worse off than their peers in various psychosocial and economic respects, and that CHW recruitment processes are the most likely explanation for this difference. Additionally, the unpaid CHW position adds work to already burdened shoulders, and makes women-especially unmarried women-vulnerable to negative gossip and high levels of psychological distress. To a limited extent, the volunteer CHW position also bolsters married women's subjective socioeconomic status and confidence in achieving future gains in status. By showing that unpaid CHWs do not necessarily enjoy psychosocial benefits, and may experience harm as a result of their work, these findings reinforce the recommendation that CHWs in contexts of poverty be paid and better supported.
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Affiliation(s)
- Kenneth Maes
- Department of Anthropology, Oregon State University, Corvallis, OR, USA.
| | - Svea Closser
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Yihenew Tesfaye
- Department of Anthropology, Oregon State University, Corvallis, OR, USA
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Schaaf M, Fox J, Topp SM, Warthin C, Freedman LP, Robinson RS, Thiagarajan S, Scott K, Maboe T, Zanchetta M, Ruano AL, Kok M, Closser S. Community health workers and accountability: reflections from an international "think-in". Int J Equity Health 2018; 17:66. [PMID: 29801493 PMCID: PMC5970525 DOI: 10.1186/s12939-018-0781-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/20/2018] [Indexed: 12/02/2022] Open
Abstract
Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several propositions for further conceptual development and research related to the question of CHWs and accountability.
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Affiliation(s)
- Marta Schaaf
- Averting Maternal Death and Disability Program, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B3, New York, NY, 10032, USA.
| | - Jonathan Fox
- Accountability Research Center, School of International Service, American University, 4400 Massachusetts Ave NW, Washington, DC, 20016, USA
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, James Cook Dr, Townsville, QLD, 4812, Australia
| | - Caitlin Warthin
- Averting Maternal Death and Disability Program, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B3, New York, NY, 10032, USA
| | - Lynn P Freedman
- Averting Maternal Death and Disability Program, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B3, New York, NY, 10032, USA
| | - Rachel Sullivan Robinson
- School of International Service, American University, 4400 Massachusetts Ave NW, Washington, DC, 20016, USA
| | - Sundararaman Thiagarajan
- School of Health Systems Studies, Tata Institute of Social Sciences, VN Purav Marg, Deonar, Mumbai, 400088, India
| | - Kerry Scott
- Independent Consultant, Bangalore, India and Research Associate, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Thoko Maboe
- Qondisa Institute Training for Community Health Care Workers, Monument Road, Duncanville, Vereeniging, 1939, South Africa
| | - Margareth Zanchetta
- Daphne Cockwell School of Nursing, Faculty of Community Services, Ryerson University, 350 Victoria St, Office POD 474A, Toronto, ON, M5B 2K3, Canada
| | - Ana Lorena Ruano
- Center for the Study of Equity and Governance in Health Systems, Guatemala and Center for International Health University of Bergen, Bergen, Norway
| | - Maryse Kok
- KIT
- Royal Tropical Institute, P.O. Box 95001, 1090, HA, Amsterdam, The Netherlands
| | - Svea Closser
- Middlebury College, 301 Munroe Hall, Middlebury, VT, 05753, USA
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Schaaf M, Fox J, Topp SM, Warthin C, Freedman LP, Robinson RS, Thiagarajan S, Scott K, Maboe T, Zanchetta M, Ruano AL, Kok M, Closser S. Community health workers and accountability: reflections from an international "think-in". Int J Equity Health 2018. [PMID: 29801493 DOI: 10.1186/s12939-018-0781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a 'think in', held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger "accountability ecosystem." This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs' social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several propositions for further conceptual development and research related to the question of CHWs and accountability.
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Affiliation(s)
- Marta Schaaf
- Averting Maternal Death and Disability Program, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B3, New York, NY, 10032, USA.
| | - Jonathan Fox
- Accountability Research Center, School of International Service, American University, 4400 Massachusetts Ave NW, Washington, DC, 20016, USA
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, James Cook Dr, Townsville, QLD, 4812, Australia
| | - Caitlin Warthin
- Averting Maternal Death and Disability Program, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B3, New York, NY, 10032, USA
| | - Lynn P Freedman
- Averting Maternal Death and Disability Program, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B3, New York, NY, 10032, USA
| | - Rachel Sullivan Robinson
- School of International Service, American University, 4400 Massachusetts Ave NW, Washington, DC, 20016, USA
| | - Sundararaman Thiagarajan
- School of Health Systems Studies, Tata Institute of Social Sciences, VN Purav Marg, Deonar, Mumbai, 400088, India
| | - Kerry Scott
- Independent Consultant, Bangalore, India and Research Associate, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Thoko Maboe
- Qondisa Institute Training for Community Health Care Workers, Monument Road, Duncanville, Vereeniging, 1939, South Africa
| | - Margareth Zanchetta
- Daphne Cockwell School of Nursing, Faculty of Community Services, Ryerson University, 350 Victoria St, Office POD 474A, Toronto, ON, M5B 2K3, Canada
| | - Ana Lorena Ruano
- Center for the Study of Equity and Governance in Health Systems, Guatemala and Center for International Health University of Bergen, Bergen, Norway
| | - Maryse Kok
- KIT | Royal Tropical Institute, P.O. Box 95001, 1090, HA, Amsterdam, The Netherlands
| | - Svea Closser
- Middlebury College, 301 Munroe Hall, Middlebury, VT, 05753, USA
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Maes K, Closser S, Tesfaye Y, Gilbert Y, Abesha R. Volunteers in Ethiopia's women's development army are more deprived and distressed than their neighbors: cross-sectional survey data from rural Ethiopia. BMC Public Health 2018; 18:258. [PMID: 29444660 PMCID: PMC5813408 DOI: 10.1186/s12889-018-5159-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 02/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many Community Health Workers (CHWs) experience the same socioeconomic and health needs as their neighbors, given that they are by definition part of their communities. Yet very few studies aim to measure and characterize experiences of deprivation, poverty, and wellbeing among community health workers. This study quantitatively examines deprivation and wellbeing in Ethiopia's Women's Development Army (WDA), a massive unpaid community health workforce intended to improve population health and modernize the country. METHODS We conducted a survey of 422 volunteer WDA leaders and community members in rural Amhara state, part of a mixed-methods ethnographic study of the experiences of women in the WDA. The survey asked a variety of questions about respondents' demographics, education, assets, and access to government services. We also used survey measures to evaluate respondents' levels of household food and water security, stressful life events, social support, work burden, and psychological distress. RESULTS Volunteer WDA leaders and community members alike tend to have very low levels of schooling and household assets, and to be heavily burdened with daily work in several domains. Large proportions are food and water insecure, many are in debt, and many experience stretches of time with no money at all. Our survey also revealed differences between volunteer WDA leaders and other women that warrant attention. Leaders are less likely to be married and more likely to be divorced or separated. Leaders are also more likely to experience some aspects of food insecurity and report greater levels of psychological distress and more stressful life events. They also report slightly less social support than other women. CONCLUSIONS In rural Amhara, women who seek out and/or are sought and recruited for leader roles in the WDA are a population living in precarity. In several domains, they experience even more hardship than their neighbors. These findings highlight a need for careful attention and further research into processes of volunteer CHW selection, and to determine whether or not volunteering for CHW programs increases socioeconomic and health risks among volunteers. CHW programs in settings of poverty should stop using unpaid labor and seek to create more paid CHW jobs.
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Affiliation(s)
- Kenneth Maes
- Department of Anthropology, Oregon State University, Corvallis, OR USA
| | - Svea Closser
- Department of Anthropology, Middlebury College, Middlebury, VT USA
| | - Yihenew Tesfaye
- Department of Anthropology, Oregon State University, Corvallis, OR USA
| | - Yasmine Gilbert
- Department of Anthropology, Middlebury College, Middlebury, VT USA
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Closser S. Compound Solutions: Pharmaceutical Alternatives for Global Health. Susan Craddock, Minneapolis: University of Minnesota Press, 2017, 166 pp. Med Anthropol Q 2017. [DOI: 10.1111/maq.12413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Closser S, Rosenthal A, Justice J, Maes K, Sultan M, Banerji S, Amaha HB, Gopinath R, Omidian P, Nyirazinyoye L. Per Diems in Polio Eradication: Perspectives From Community Health Workers and Officials. Am J Public Health 2017; 107:1470-1476. [PMID: 28727538 DOI: 10.2105/ajph.2017.303886] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Nearly all global health initiatives give per diems to community health workers (CHWs) in poor countries for short-term work on disease-specific programs. We interviewed CHWs, supervisors, and high-level officials (n = 95) in 6 study sites across sub-Saharan Africa and South Asia in early 2012 about the per diems given to them by the Global Polio Eradication Initiative. These per diems for CHWs ranged from $1.50 to $2.40 per day. International officials defended per diems for CHWs with an array of arguments, primarily that they were necessary to defray the expenses that workers incurred during campaigns. But high-level ministry of health officials in many countries were concerned that even small per diems were unsustainable. By contrast, CHWs saw per diems as a wage; the very small size of this wage led many to describe per diems as unjust. Per diem polio work existed in the larger context of limited and mostly exploitative options for female labor. Taking the perspectives of CHWs seriously would shift the international conversation about per diems toward questions of labor rights and justice in global health pay structures.
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Affiliation(s)
- Svea Closser
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Anat Rosenthal
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Judith Justice
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Kenneth Maes
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Marium Sultan
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Sarah Banerji
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Hailom Banteyerga Amaha
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Ranjani Gopinath
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Patricia Omidian
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
| | - Laetitia Nyirazinyoye
- Svea Closser, Marium Sultan, and Sarah Banerji are with the Department of Sociology/Anthropology, Middlebury College, Middlebury, VT. Anat Rosenthal is with the Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheva, Israel. Judith Justice is with the Philip R. Lee Institute for Health Policy Studies, University of California, Berkeley. Kenneth Maes is with the Department of Anthropology, Oregon State University, Corvallis. Hailom Banteyerga Amaha is with Addis Ababa University, Addis Ababa, Ethiopia. Ranjani Gopinath is an independent consultant based in Hyderabad, India. Patricia Omidian is an independent consultant based in Corvallis, OR. Laetitia Nyrazinyoye is with the School of Public Health, Kigali, Rwanda
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Closser S, Finley EP. A New Reflexivity: Why Anthropology Matters in Contemporary Health Research and Practice, and How to Make It Matter More. American Anthropologist 2016. [DOI: 10.1111/aman.12532] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Svea Closser
- Department of Sociology and Anthropology; Middlebury College; Middlebury Vermont United States
| | - Erin P. Finley
- Department of Psychiatry and Division of Hospital Medicine, Department of Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-based Research, Dissemination, and Implementation Center (VERDICT); South Texas Veterans Health Care System; San Antonio Texas United States
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Closser S, Rosenthal A, Maes K, Justice J, Cox K, Omidian PA, Mohammed IZ, Dukku AM, Koon AD, Nyirazinyoye L. The Global Context of Vaccine Refusal: Insights from a Systematic Comparative Ethnography of the Global Polio Eradication Initiative. Med Anthropol Q 2016; 30:321-41. [DOI: 10.1111/maq.12254] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Svea Closser
- Department of Sociology/Anthropology; Middlebury College
| | - Anat Rosenthal
- Department of Health Systems Management; Ben Gurion University of the Negev
| | - Kenneth Maes
- Department of Anthropology; Oregon State University
| | - Judith Justice
- Philip R. Lee Institute for Health Policy Studies; University of California at San Francisco
| | - Kelly Cox
- Department of Sociology/Anthropology; Middlebury College
| | | | | | | | - Adam D. Koon
- Department of Global Health and Development; London School of Hygiene and Tropical Medicine
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Closser S, Rosenthal A, Maes K, Justice J, Cox K, Omidian PA, Mohammed IZ, Dukku AM, Koon AD, Nyirazinyoye L. The Global Context of Vaccine Refusal: Insights from a Systematic Comparative Ethnography of the Global Polio Eradication Initiative. Med Anthropol Q 2015:n/a-n/a. [PMID: 26084915 DOI: 10.1111/maq.12229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Many of medical anthropology's most pressing research questions require an understanding how infections, money and ideas move around the globe. The Global Polio Eradication Initiative (GPEI) is a $9 billion project that has delivered 20 billion doses of oral polio vaccine in campaigns across the world. With its array of global activities, it cannot be comprehensively explored by the traditional anthropological method of research at one field site. This paper describes an ethnographic study of the GPEI, a collaborative effort between researchers at eight sites in seven countries. We developed a methodology grounded in nuanced understandings of local context but structured to allow analysis of global trends. Here, we examine polio vaccine acceptance and refusal to understand how global phenomena-in this case, policy decisions by donors and global health organizations to support vaccination campaigns rather than building health systems-shape local behavior. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Svea Closser
- Middlebury College, Sociology/Anthropology, Middlebury, Vermont, USA.
| | - Anat Rosenthal
- Ben Gurion University of the Negev, Department of Health Systems Management, Faculty of Health Sciences, Beer - Sheva, Israel
| | - Kenneth Maes
- Oregon State University, Anthropology, Corvallis, Oregon, USA
| | - Judith Justice
- University of California at San Francisco, Philip R. Lee Institute for Health Policy Studies, San Francisco, California, USA
| | - Kelly Cox
- Middlebury College, Sociology/Anthropology, Middlebury, Vermont, USA
| | | | | | | | - Adam D Koon
- London School of Hygiene and Tropical Medicine, Global Health and Development, London, United Kingdom
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Maes K, Closser S, Kalofonos I. Listening to community health workers: how ethnographic research can inform positive relationships among community health workers, health institutions, and communities. Am J Public Health 2014; 104:e5-9. [PMID: 24625167 PMCID: PMC3987580 DOI: 10.2105/ajph.2014.301907] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2014] [Indexed: 11/04/2022]
Abstract
Many actors in global health are concerned with improving community health worker (CHW) policy and practice to achieve universal health care. Ethnographic research can play an important role in providing information critical to the formation of effective CHW programs, by elucidating the life histories that shape CHWs' desires for alleviation of their own and others' economic and health challenges, and by addressing the working relationships that exist among CHWs, intended beneficiaries, and health officials. We briefly discuss ethnographic research with 3 groups of CHWs: volunteers involved in HIV/AIDS care and treatment support in Ethiopia and Mozambique and Lady Health Workers in Pakistan. We call for a broader application of ethnographic research to inform working relationships among CHWs, communities, and health institutions.
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Affiliation(s)
- Kenneth Maes
- At the time of writing, Kenneth Maes was with the Department of Anthropology, School of Language, Culture, and Society, Oregon State University, Corvallis. Svea Closser was with the Department of Sociology and Anthropology, Middlebury College, Middlebury, VT. Ippolytos Kalofonos was with the Department of Psychiatry and Behavioral Health, University of Washington, Seattle
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Closser S, Cox K, Parris TM, Landis RM, Justice J, Gopinath R, Maes K, Banteyerga Amaha H, Mohammed IZ, Dukku AM, Omidian PA, Varley E, Tedoff P, Koon AD, Nyirazinyoye L, Luck MA, Pont WF, Neergheen V, Rosenthal A, Nsubuga P, Thacker N, Jooma R, Nuttall E. The impact of polio eradication on routine immunization and primary health care: a mixed-methods study. J Infect Dis 2014; 210 Suppl 1:S504-13. [PMID: 24690667 PMCID: PMC4197907 DOI: 10.1093/infdis/jit232] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background. After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC). Methods. Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review. Results. Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year. Conclusions. Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.
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Affiliation(s)
- Svea Closser
- Department of Sociology and Anthropology, Middlebury College, Middlebury
| | - Kelly Cox
- Department of Sociology and Anthropology, Middlebury College, Middlebury
| | | | | | - Judith Justice
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco
| | | | - Kenneth Maes
- Department of Anthropology, Oregon State University
| | | | | | | | | | - Emma Varley
- MNCH-RH Department, Health Services Academy, Islamabad
| | - Pauley Tedoff
- Department of Sociology and Anthropology, Middlebury College, Middlebury
| | - Adam D Koon
- Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom
| | | | | | | | - Vanessa Neergheen
- Department of Sociology and Anthropology, Middlebury College, Middlebury
| | - Anat Rosenthal
- Department of Biomedical Ethics, McGill University, Montreal, Canada
| | | | - Naveen Thacker
- Deep Children Hospital and Research Centre, Gandhidham, India
| | - Rashid Jooma
- Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Elizabeth Nuttall
- Department of Sociology and Anthropology, Middlebury College, Middlebury
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Mounier-Jack S, Griffiths UK, Closser S, Burchett H, Marchal B. Measuring the health systems impact of disease control programmes: a critical reflection on the WHO building blocks framework. BMC Public Health 2014; 14:278. [PMID: 24666579 PMCID: PMC3974593 DOI: 10.1186/1471-2458-14-278] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 03/12/2014] [Indexed: 02/05/2023] Open
Abstract
Background The WHO health systems Building Blocks framework has become ubiquitous in health systems research. However, it was not developed as a research instrument, but rather to facilitate investments of resources in health systems. In this paper, we reflect on the advantages and limitations of using the framework in applied research, as experienced in three empirical vaccine studies we have undertaken. Discussion We argue that while the Building Blocks framework is valuable because of its simplicity and ability to provide a common language for researchers, it is not suitable for analysing dynamic, complex and inter-linked systems impacts. In our three studies, we found that the mechanical segmentation of effects by the WHO building blocks, without recognition of their interactions, hindered the understanding of impacts on systems as a whole. Other important limitations were the artificial equal weight given to each building block and the challenge in capturing longer term effects and opportunity costs. Another criticism is not of the framework per se, but rather how it is typically used, with a focus on the six building blocks to the neglect of the dynamic process and outcome aspects of health systems. We believe the framework would be improved by making three amendments: integrating the missing “demand” component; incorporating an overarching, holistic health systems viewpoint and including scope for interactions between components. If researchers choose to use the Building Blocks framework, we recommend that it be adapted to the specific study question and context, with formative research and piloting conducted in order to inform this adaptation. Summary As with frameworks in general, the WHO Building Blocks framework is valuable because it creates a common language and shared understanding. However, for applied research, it falls short of what is needed to holistically evaluate the impact of specific interventions on health systems. We propose that if researchers use the framework, it should be adapted and made context-specific.
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Affiliation(s)
- Sandra Mounier-Jack
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Abstract
Svea Closser and Rashid Jooma argue that achieving polio eradication and strengthening Pakistan's health system must focus not just on international engagement but also on local partnerships with Lady Health Workers and other ground-level staff. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Svea Closser
- Department of Sociology and Anthropology, Middlebury College, Middlebury, Vermont, United States of America
- * E-mail:
| | - Rashid Jooma
- Department of Surgery, Aga Khan University, Karachi, Pakistan
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Closser S, Rosenthal A, Parris T, Maes K, Justice J, Cox K, Luck MA, Landis RM, Grove J, Tedoff P, Venczel L, Nsubuga P, Kuzara J, Neergheen V. Methods for evaluating the impact of vertical programs on health systems: protocol for a study on the impact of the global polio eradication initiative on strengthening routine immunization and primary health care. BMC Public Health 2012; 12:728. [PMID: 22938708 PMCID: PMC3499151 DOI: 10.1186/1471-2458-12-728] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 08/24/2012] [Indexed: 05/26/2023] Open
Abstract
Background The impact of vertical programs on health systems is a much-debated topic, and more evidence on this complex relationship is needed. This article describes a research protocol developed to assess the relationship between the Global Polio Eradication Initiative, routine immunization, and primary health care in multiple settings. Methods/Design This protocol was designed as a combination of quantitative and qualitative research methods, making use of comparative ethnographies. The study evaluates the impact of the Global Polio Eradication Initiative on routine immunization and primary health care by: (a) combining quantitative and qualitative work into one coherent study design; (b) using purposively selected qualitative case studies to systematically evaluate the impact of key contextual variables; and (c) making extensive use of the method of participant observation to create comparative ethnographies of the impact of a single vertical program administered in varied contexts. Discussion The study design has four major benefits: (1) the careful selection of a range of qualitative case studies allowed for systematic comparison; (2) the use of participant observation yielded important insights on how policy is put into practice; (3) results from our quantitative analysis could be explained by results from qualitative work; and (4) this research protocol can inform the creation of actionable recommendations. Here, recommendations for how to overcome potential challenges in carrying out such research are presented. This study illustrates the utility of mixed-methods research designs in which qualitative data are not just used to embellish quantitative results, but are an integral component of the analysis.
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Affiliation(s)
- Svea Closser
- Department of Sociology and Anthropology, Middlebury College, 306 Munroe Hall, Middlebury, VT 05753, USA.
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Maes KC, Kohrt BA, Closser S. Culture, status and context in community health worker pay: pitfalls and opportunities for policy research. A commentary on Glenton et al. (2010). Soc Sci Med 2010; 71:1375-8; discussion 1379-80. [PMID: 20667639 PMCID: PMC6211553 DOI: 10.1016/j.socscimed.2010.06.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 06/03/2010] [Indexed: 11/25/2022]
Affiliation(s)
- Kenneth C Maes
- Department of Anthropology, Emory University, 1557 Dickey Drive, Atlanta, GA, USA.
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Closser S. BOOK REVIEWS: Textbook of International Health, Third Edition. by Anne-Emanuelle Birn, Yogan Pilay, and Timothy H. Holtz
The Practice of International Health: A Case-Based Orientation. by Daniel Perlman and Ananya Roy. Med Anthropol Q 2010. [DOI: 10.1111/j.1548-1387.2010.01116.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Closser S, McManus M. Outbreak: An Activity to Foster Awareness of Everyday Public Health Issues. American Journal of Health Education 2005. [DOI: 10.1080/19325037.2005.10608203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Svea Closser
- a Emory University's Department of Anthropology , 1557 Dickey Drive, Atlanta , GA , 30322 , USA
| | - Maureen McManus
- b Southside High School , 801 Glenwood Avenue, S.E., Atlanta , GA , 30312 , USA
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