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1.  Community perceptions of mental health needs: a qualitative study in the Solomon Islands 
Background
Psychosocial and mental health needs in the aftermath of conflict and disaster have attracted substantial attention. In the Solomon Islands, the conceptualisation of mental health, for several decades regarded by policy makers as primarily a health issue, has broadened and been incorporated into the national development and social policy agendas, reflecting recognition of the impact of conflict and rapid social change on the psychosocial wellbeing of the community as a whole. We sought to understand how mental health and psychosocial wellbeing were seen at the community level, the extent to which these issues were identified as being associated with periods of 'tension', violence and instability, and the availability of traditional approaches and Ministry of Health services to address these problems.
Methods
This article reports the findings of qualitative research conducted in a rural district on the island of Guadalcanal in the Solomon Islands. Key informant interviews were conducted with community leaders, and focus groups were held with women, men and young people. Wellbeing was defined broadly.
Results
Problems of common concern included excessive alcohol and marijuana use, interpersonal violence and abuse, teenage pregnancy, and lack of respect and cooperation. Troubled individuals and their families sought help for mental problems from various sources including chiefs, church leaders and traditional healers and, less often, trauma support workers, health clinic staff and police. Substance-related problems presented special challenges, as there were no traditional solutions at the individual or community level. Severe mental illness was also a challenge, with few aware that a community mental health service existed. Contrary to our expectations, conflict-related trauma was not identified as a major problem by the community who were more concerned about the economic and social sequelae of the conflict.
Conclusion
Communities identify and are responding to a wide range of mental health challenges; the health system generally can do more to learn about how this is being done, and build more comprehensive services and policy on this foundation. The findings underscore the need to promote awareness of those services which are available, to extend mental health care beyond urban centres to rural villages where the majority of the population live, and to promote community input to policy so as to ensure that it 'fits' the context.
doi:10.1186/1752-4458-3-6
PMCID: PMC2667440  PMID: 19284638
2.  Listening to local voices: adapting rapid appraisal to assess health and social needs in general practice. 
BMJ : British Medical Journal  1994;308(6930):698-700.
OBJECTIVES--To explore the use of rapid appraisal in defining the health and social needs of a community and to formulate joint action plans between the residents and service providers. DESIGN--Collection of data by an extended primary care team from three sources: existing documents about the neighbourhood, interviews with a range of informants, and direct observations to build a profile of the community. SETTING--Council estate of 670 homes in Edinburgh. MAIN OUTCOME MEASURES--Perceived problems of the community and suggestions for change. RESULTS--The interviews and focus groups identified six priorities for change, many of which were not health related. These changes have been or are being implemented. CONCLUSIONS--An expanded primary care team can use rapid appraisal as a first step in identifying and meeting local health needs. It facilitates a multidisciplinary approach and complements quantitative methods of assessing need.
PMCID: PMC2539376  PMID: 8142796
3.  Accelerators/decelerators of achieving universal access to sexual and reproductive health services: a case study of Iranian health system 
Background
At the 1994 International Conference on Population and Development (ICPD), held in Cairo, the global community agreed to the goal of achieving universal access to sexual and reproductive health (SRH) and rights by 2015. This research explores the accelerators and decelerators of achieving universal access to the sexual and reproductive health targets and accordingly makes some suggestions.
Method
We have critically reviewed the latest national reports and extracted the background data on each SRH indicator. The key stakeholders, both national and international, were visited and interviewed at two sites. A total of 55 in-depth interviews were conducted with religious leaders, policy-makers, senior managers, senior academics, and health care managers. Six focus-group discussions were also held among health care providers. The study was qualitative in nature.
Results
Obstacles on the road to achieving universal access to SRH can be viewed from two perspectives. One gap exists between current achievements and the targets. The other gap arises due to age, marital status, and residency status. The most recently observed trends in the indicators of the universal access to SRH shows that the achievements in the “unmet need for family planning” have been poor. Unmet need for family planning could directly be translated to unwanted pregnancies and unwanted childbirths; the former calls for sexual education to underserved people, including adolescents; and the latter calls for access to safe abortion. Local religious leaders have not actively attended international goal-setting programs. Therefore, they usually do not presume a positive attitude towards these goals. Such negative attitudes seem to be the most important factors hindering the progress towards universal access to SRH. Lack of international donors to fund for SRH programs is also another barrier. In national levels both state and the society are interactively playing their roles. We have used a cascade model for presenting the barriers at the state levels from the strategic planning to implementation. Social factors are to be considered as a background for other factors at all stages.
Conclusion
Accelerating universal access to SRH requires adequate funding, firm political commitment, creative programming, and the involvement of diverse actors, including faith-based, civil society, and private sector partners.
doi:10.1186/1472-6963-13-241
PMCID: PMC3750448  PMID: 23816259
Iran; Health system; Sexual and reproductive health; Universal access; Millennium development goal
4.  Using consecutive Rapid Participatory Appraisal studies to assess, facilitate and evaluate health and social change in community settings 
BMC Public Health  2006;6:68.
Background
To investigate how a relatively socio-economically deprived community's needs have changed over time, assess which recommendations from an earlier assessment were implemented and sustained, and consider whether serial Rapid Participatory Appraisal is an effective health research tool that can promote community development and has utility in assessing longitudinal change.
Methods
Rapid Participatory Appraisal involves communities in identifying and challenging their own health-related needs. Information on ten health and social aspects was collated from existing documentation, neighbourhood observations, and interviews with a range of residents and key informants, providing a composite picture of the community's structure, needs and services.
Results
The perceived needs after 10 years encompassed a wide construct of health, principally the living environment, housing, and lack of finance. Most identified upstream determinants of health rather than specific medical conditions as primary concerns. After the initial Rapid Participatory Appraisal many interviewees took the recommendations forward, working to promote a healthier environment and advocate for local resources. Interventions requiring support from outwith the community were largely not sustained.
Conclusion
Rapid Participatory Appraisal proved valuable in assessing long-term change. The community's continuing needs were identified, but they could not facilitate and sustain change without the strategic support of key regional and national agencies. Many repeatedly voiced concerns lay outwith local control: local needs assessment must be supported at higher levels to be effective.
doi:10.1186/1471-2458-6-68
PMCID: PMC1435890  PMID: 16539712
5.  Untreated Reproductive Morbidities among Ever Married Women of Slums of Rajkot City, Gujarat: The Role of Class, Distance, Provider Attitudes, and Perceived Quality of Care 
It is a common problem in India for women in the reproductive age group to suffer from reproductive illnesses and not seek care. This paper is an attempt to assess untreated reproductive morbidities and to study factors affecting treatment-seeking behavior among ever married women of urban slums. We selected 1,046 women of the reproductive age group (15–49 years) using two-stage cluster sampling for a community-based, cross-sectional study. From this sample, 593 responses reporting reproductive morbidity were analyzed for treatment-seeking behavior and its correlates. Information was collected on demographics, socioeconomic status, self-reported reproductive morbidity, and treatment-seeking patterns, along with reasons for not utilizing available health services, all using a pretested, structured interview schedule. Univariate and multivariate analyses were done in SPSS 15.0. In our sample, 57% of women had at least one reproductive morbidity; of these, only one third sought health care. Women belonging to the Scheduled Castes/Scheduled Tribes caste group (OR = 3.92, 95% CI 1.44–10.64), at a distance of more than 2 km from a health facility (OR = 2.67, 95% CI 1.28–5.58), and whose duration of illness was more than 1 year (OR = 14.44, 95% CI 3.66–56.87) accessed fewer reproductive health services compared to their counterparts. The present study found that a lower sense of need, the cost of care, and societal barriers were the reasons for not seeking care. Providers’ poor attitudes, poor quality of services, and long waiting times were found to be the reasons for not utilizing health facilities. The determinants for accessing reproductive health care were resources available at the household level, social factors, the availability of services, and behaviors related to health. Government facilities remained underutilized.
doi:10.1007/s11524-009-9423-y
PMCID: PMC2845825  PMID: 20108049
Reproductive health; Urban slums; Gujarat; India; Surat; Maternal and child health; Health policy; Untreated morbidity; Health seeking
6.  Facilitators and barriers to accessing reproductive health care for migrant beer promoters in Cambodia, Laos, Thailand and Vietnam: A mixed methods study 
Background
The purpose of the research was to assess access to sexual and reproductive health services for migrant women who work as beer promoters. This mixed methods research was conducted in Phnom Penh, Cambodia, Bangkok, Thailand, Vientiane, Laos, and Hanoi, Vietnam during 2010 to 2011.
Methods
Focus groups were held with beer promoters and separate focus groups or interviews with key informants to explore the factors affecting beer promoters’ access to health care institutions for reproductive health care. The findings of the focus groups were used to develop a survey for beer promoters. This survey was conducted in popular health institutions for these women in each of the four Asian cities.
Results
Several common themes were evident. Work demands prevented beer promoters from accessing health care. Institutional factors affecting care included cost, location, environmental factors (e.g. waiting times, cleanliness and confidentiality) and service factors (e.g. staff attitudes, clinic hours, and availability of medications). Personal factors affecting access were shyness and fear, lack of knowledge, and support from family and friends.
The survey of the beer promoters confirmed that cost, location and both environmental and service factors impact on access to health care services for beer promoters. Many beer promoters are sexually active, and a significant proportion of those surveyed rely on sex work to supplement their income. Many also drink with their clients. Despite a few differences amongst the surveyed population, the findings were remarkably similar across the four research sites.
Conclusions
Recommendations from the research include the provision of evening and weekend clinic hours to facilitate access, free or low cost clinics, and health insurance through employer or government plans which are easy to access for migrants. Other improvements that would facilitate the access of beer promoters to these services include increased funding to hire more staff (reducing waiting times) and to stock more needed medications, mobile clinics to come to the workplace or free transportation for beer promoters to the clinics, improved training to reduce health care provider stigma against beer promoters, and public education about the importance of reproductive health care, including preventative services.
doi:10.1186/1744-8603-8-21
PMCID: PMC3475045  PMID: 22747607
Beer promoters; Migrants; Sexual health; Reproductive health; Access to health services; Southeast Asia; Cambodia; Laos; Thailand; Vietnam
7.  In the face of war: examining sexual vulnerabilities of Acholi adolescent girls living in displacement camps in conflict-affected Northern Uganda 
Background
Adolescent girls are an overlooked group within conflict-affected populations and their sexual health needs are often neglected. Girls are disproportionately at risk of HIV and other STIs in times of conflict, however the lack of recognition of their unique sexual health needs has resulted in a dearth of distinctive HIV protection and prevention responses. Departing from the recognition of a paucity of literature on the distinct vulnerabilities of girls in time of conflict, this study sought to deepen the knowledge base on this issue by qualitatively exploring the sexual vulnerabilities of adolescent girls surviving abduction and displacement in Northern Uganda.
Methods
Over a ten-month period between 2004–2005, at the height of the Lord’s Resistance Army insurgency in Northern Uganda, 116 in-depth interviews and 16 focus group discussions were held with adolescent girls and adult women living in three displacement camps in Gulu district, Northern Uganda. The data was transcribed and key themes and common issues were identified. Once all data was coded the ethnographic software programme ATLAS was used to compare and contrast themes and categories generated in the in-depth interviews and focus group discussions.
Results
Our results demonstrated the erosion of traditional Acholi mentoring and belief systems that had previously served to protect adolescent girls’ sexuality. This disintegration combined with: the collapse of livelihoods; being left in camps unsupervised and idle during the day; commuting within camp perimeters at night away from the family hut to sleep in more central locations due to privacy and insecurity issues, and; inadequate access to appropriate sexual health information and services, all contribute to adolescent girls’ heightened sexual vulnerability and subsequent enhanced risk for HIV/AIDS in times of conflict.
Conclusions
Conflict prevention planners, resettlement programme developers, and policy-makers need to recognize adolescent girls affected by armed conflict as having distinctive needs, which require distinctive responses. More adaptive and sustainable gender-sensitive reproductive health strategies and HIV prevention initiatives for displaced adolescent girls in conflict settings must be developed.
doi:10.1186/1472-698X-12-38
PMCID: PMC3536565  PMID: 23270488
Adolescent girls; Conflict; Sexual vulnerability; Displacement camps; Northern Uganda; Acholi; Qualitative; HIV/AIDS
8.  Domestic violence and its predictors among married women in reproductive age in Fagitalekoma Woreda, Awi zone, Amhara regional state, North Western Ethiopia 
Reproductive Health  2013;10:63.
Background
Violence against women is one of the most systematic and prevalent human rights abuses in the world. It is a form of discrimination and deeply rooted in power imbalances and structural inequality between women and men. Documenting the extent of the problem and associated factors is essential to develop public health interventions to tackle violence against women. Therefore, the objective of this study was to determine magnitude of domestic violence and identify its predictors among married women in the reproductive age in north western Ethiopia.
Methods
Community-based cross-sectional study was conducted from February 15 to March 15, 2011 among 682 married women and 46 key informants. Systematic sampling technique was used to select respondents for the quantitative method. Purposive sampling was used to select in-depth interview key informants for and focus group discussants. Data were analyzed using SPSS window version 16.0. Binary logistic regression and multivariable logistic regression analysis were carried out to determine the prevalence and identify independent predictors of domestic violence against women. Statistical association was measured by adjusted odds ratios and 95% confidence intervals. Statistical significance was declared at P < 0.05.
Result
The prevalence of domestic violence was 78.0%. About 73.3%, 58.4% and 49.1% of women reported different forms of psychological, physical and sexual violence, respectively. Alcohol consumption by husband (AOR = 1.9, 95%CI = 1.3, 2.8), being pregnant (AOR = 2.1, 95% CI = 1.4, 3.4), decision making power (AOR = 2.3, 95% CI = 1.5, 3.4) and annual income (AOR = 1.9, 95% CI = 1.1, 3.3) were predictors of domestic violence.
Conclusion
The prevalence of domestic violence was very high as compared to other studies. Women’s husband alcohol consumption, decision making power annual household income and being pregnant are some of the predictors of domestic violence against women.
doi:10.1186/1742-4755-10-63
PMCID: PMC3879008  PMID: 24308763
Domestic; Violence; Women; Ethiopia
9.  Infertility and childlessness: a qualitative study of the experiences of infertile couples in Northern Ghana 
Background
Infertility is a global reproductive health issue that affects many individuals and couples. Despite the high prevalence of infertility in Ghana, no study has been done on the experiences of infertile couples in Northern Ghana. This study therefore explored the experiences of infertile couples in Northern Ghana using the Upper West Region as a case study.
Methods
We interviewed fifteen childless couples, forty-five couples with children, and eight key informants using a semi-structured interview guide. We also carried out three focus group discussions; one for childless women, one for women with children and one for men with children. The data were transcribed, coded, arranged and analyzed for categories and themes.
Results
Infertile couples are socially stigmatised and excluded from leadership roles in their communities. Couples without children are denied membership in the ancestral world thereby losing the opportunity to live again. Both males and females are engaged in sex with multiple partners to prove their fertility.
Conclusions
Both men and women suffer from the social effects of childlessness. The desire to have biological children in a pronatalist society results in unhealthy practices. Health policy makers and gender advocates should be more concerned about infertility.
doi:10.1186/1471-2393-13-72
PMCID: PMC3610195  PMID: 23517021
10.  Key informant perspectives on policy- and service-level challenges and opportunities for delivering integrated sexual and reproductive health and HIV care in South Africa 
Background
Integration of sexual and reproductive health (SRH) and HIV services is a policy priority, both globally and in South Africa. Recent studies examining SRH/HIV integration in South Africa have focused primarily on the SRH needs of HIV patients, and less on the policy and service-delivery environment in which these programs operate. To fill this gap we undertook a qualitative study to elicit the views of key informants on policy-and service-level challenges and opportunities for improving integrated SRH and HIV care in South Africa. This study comprised formative research for the development of an integrated service delivery model in KwaZulu-Natal (KZN) Province.
Methods
Semi-structured in-depth interviews were conducted with 21 expert key informants from the South African Department of Health, and local and international NGOs and universities. Thematic codes were generated from a subset of the transcripts, and these were modified, refined and organized during coding and analysis.
Results
While there was consensus among key informants on the need for more integrated systems of SRH and HIV care in South Africa, a range of inter-related systems factors at policy and service-delivery levels were identified as challenges to delivering integrated care. At the policy level these included vertical programming, lack of policy guidance on integrated care, under-funding of SRH, program territorialism, and weak referral systems; at the service level, factors included high client load, staff shortages and insufficient training and skills in SRH, resistance to change, and inadequate monitoring systems related to integration. Informants had varying views on the best way to achieve integration: while some favored a one-stop shop approach, others preferred retaining sub-specialisms while strengthening referral systems. The introduction of task-shifting policies and decentralization of HIV treatment to primary care provide opportunities for integrating services.
Conclusion
Now that HIV treatment programs have been scaled up, actions are needed at both policy and service-delivery levels to develop an integrated approach to the provision of SRH and HIV services in South Africa. Concurrent national policies to deliver HIV treatment within a primary care context can be used to promote more integrated approaches.
doi:10.1186/1472-6963-12-48
PMCID: PMC3311559  PMID: 22369041
HIV; Family planning; Reproductive health; Sexual health; Integrated delivery of healthcare; South Africa
11.  Practice based health needs assessment: use of four methods in a small neighbourhood. 
BMJ : British Medical Journal  1995;310(6992):1443-1448.
OBJECTIVE--To explore the use of four methods to define health needs in a community, with a view to formulating guidelines for practice based assessment of health needs. DESIGN--Collection of data on health needs for a specific neighbourhood with four complementary methods: rapid participatory appraisal, postal survey, analysis of routinely available small area statistics, and collation of practice held information. SETTING--Council estate of 670 homes in Edinburgh. MAIN OUTCOME MEASURES--Description and comparison of health needs found by the different methods. RESULTS--Each method yielded particular insights into both health and health care needs. CONCLUSIONS--An extended primary care team with public health support can assess health and health care needs in a neighbourhood by means of a mixture of quantitative and qualitative methods. Different methods may be more suitable to assess different health needs or to explore potential service provision in the community or in primary or secondary care. A composite method may be most informative.
PMCID: PMC2549816  PMID: 7613279
12.  Knowledge and communication needs assessment of community health workers in a developing country: a qualitative study 
Background
Primary health care is a set of health services that can meet the needs of the developing world. Community health workers act as a bridge between health system and community in providing this care. Appropriate knowledge and communication skills of the workers are key to their confidence and elementary for the success of the system. We conducted this study to document the perceptions of these workers on their knowledge and communication needs, image building through mass media and mechanisms for continued education.
Methods
Focus group discussions were held with health workers and their supervisors belonging to all the four provinces of the country and the Azad Jammu & Kashmir region. Self-response questionnaires were also used to obtain information on questions regarding their continued education.
Results
About four fifths of the respondents described their communication skills as moderately sufficient and wanted improvement. Knowledge on emerging health issues was insufficient and the respondents showed willingness to participate in their continued education. Media campaigns were successful in building the image of health workers as a credible source of health information.
Conclusion
A continued process should be ensured to provide opportunities to health workers to update their knowledge, sharpen communication skills and bring credibility to their persona as health educators.
doi:10.1186/1478-4491-7-59
PMCID: PMC2720909  PMID: 19622172
13.  Paying health workers for performance in Battagram district, Pakistan 
Background
There is a growing interest in using pay-for-performance mechanisms in low and middle-income countries in order to improve the performance of health care providers. However, at present there is a dearth of independent evaluations of such approaches which can guide understanding of their potential and risks in differing contexts. This article presents the results of an evaluation of a project managed by an international non-governmental organisation in one district of Pakistan. It aims to contribute to learning about the design and implementation of pay-for-performance systems and their impact on health worker motivation.
Methods
Quantitative analysis was conducted of health management information system (HMIS) data, financial records, and project documents covering the period 2007-2010. Key informant interviews were carried out with stakeholders at all levels. At facility level, in-depth interviews were held, as were focus group discussions with staff and community members.
Results
The wider project in Battagram had contributed to rebuilding district health services at a cost of less than US$4.5 per capita and achieved growth in outputs. Staff, managers and clients were appreciative of the gains in availability and quality of services. However, the role that the performance-based incentive (PBI) component played was less clear--PBI formed a relatively small component of pay, and did not increase in line with outputs. There was little evidence from interviews and data that the conditional element of the PBIs influenced behaviour. They were appreciated as a top-up to pay, but remained low in relative terms, and only slightly and indirectly related to individual performance. Moreover, they were implemented independently of the wider health system and presented a clear challenge for longer term integration and sustainability.
Conclusions
Challenges for performance-based pay approaches include the balance of rewarding individual versus team efforts; reflecting process and outcome indicators; judging the right level of incentives; allowing for very different starting points and situations; designing a system which is simple enough for participants to comprehend; and the tension between independent monitoring and integration in a national system. Further documentation of process and cost-effectiveness, and careful examination of the wider impacts of paying for performance, are still needed.
doi:10.1186/1478-4491-9-23
PMCID: PMC3196684  PMID: 21982330
14.  An assessment of attitudes toward gender inequitable sexual and reproductive health norms in South Sudan: a community-based participatory research approach 
Conflict and Health  2013;7:24.
Background
Communities in South Sudan have endured decades of conflict. Protracted conflict exacerbated reproductive health disparities and gender inequities. This study, conducted prior to the country’s 2011 independence, aimed to assess attitudes toward gender inequitable norms related to sexual relationships and reproductive health and the effects of sex, age, and education on these attitudes.
Methods
Applying a community-based participatory research approach and quota sampling, 680 adult male and female respondents were interviewed in seven sites within South Sudan in 2009–2011. The verbally administered survey assessed attitudes using the Gender Equitable Men scale. Data were stratified by sex, age (≤35 years and >35 years), and education.
Results
Of 680 respondents, 352 were female, 326 were male, and 2 did not indicate their sex. The majority of women (77%) and men (74%) agreed “a man needs other women, even if things with his wife are fine”. Respondents who reported no education (60%) were more likely than those who reported any education (45%) to agree “if a woman is married, she should have sex with her husband whenever he wants to, even if she doesn’t want to” (p = 0.002). The majority of women (74%) and men (73%) agreed “it is a woman’s responsibility to avoid getting pregnant”. Respondents who reported no education (81%) were more likely than those who reported any education (72%) to agree with this statement (p = 0.04). When asked about condom use, the majority of respondents, across both sexes and both age groups, agreed “it would be outrageous for a wife to ask her husband to use a condom” and “women who carry condoms are easy”. There were no statistically significant differences between the two age groups for any of the assessed gender inequitable norms.
Conclusion
The study reveals differences in attitudes toward gender inequitable sexual and reproductive health norms among those surveyed in South Sudan when stratified by sex and education. As a new nation seeks to strengthen its health system, these data can inform sexual and reproductive health policies and programming in South Sudan.
doi:10.1186/1752-1505-7-24
PMCID: PMC3826838  PMID: 24209789
South Sudan; Conflict; Sexual health; Reproductive health; Gender; Inequitable norms; Gender Inequitable Men scale
15.  Local Perceptions, Cultural Beliefs and Practices That Shape Umbilical Cord Care: A Qualitative Study in Southern Province, Zambia 
PLoS ONE  2013;8(11):e79191.
Background
Global policy regarding optimal umbilical cord care to prevent neonatal illness is an active discussion among researchers and policy makers. In preparation for a large cluster-randomized control trial to measure the impact of 4% chlorhexidine as an umbilical wash versus dry cord care on neonatal mortality in Southern Province, Zambia, we performed a qualitative study to determine local perceptions of cord health and illness and the cultural belief system that shapes umbilical cord care knowledge, attitudes, and practices.
Methods and Findings
This study consisted of 36 focus group discussions with breastfeeding mothers, grandmothers, and traditional birth attendants, and 42 in-depth interviews with key community informants. Semi-structured field guides were used to lead discussions and interviews at urban and rural sites. A wide variation in knowledge, beliefs, and practices surrounding cord care was discovered. For home deliveries, cords were cut with non-sterile razor blades or local grass. Cord applications included drying agents (e.g., charcoal, baby powder, dust), lubricating agents (e.g., Vaseline, cooking oil, used motor oil) and agents intended for medicinal/protective purposes (e.g., breast milk, cow dung, chicken feces). Concerns regarding the length of time until cord detachment were universally expressed. Blood clots in the umbilical cord, bulongo-longo, were perceived to foreshadow neonatal illness. Management of bulongo-longo or infected umbilical cords included multiple traditional remedies and treatment at government health centers.
Conclusion
Umbilical cord care practices and beliefs were diverse. Dry cord care, as recommended by the World Health Organization at the time of the study, is not widely practiced in Southern Province, Zambia. A cultural health systems model that depicts all stakeholders is proposed as an approach for policy makers and program implementers to work synergistically with existing cultural beliefs and practices in order to maximize effectiveness of evidence-based interventions.
doi:10.1371/journal.pone.0079191
PMCID: PMC3820671  PMID: 24244447
16.  Using a Mixed-Methods Approach to Identify Health Concerns in an African American Community 
American journal of public health  2011;101(11):2087-2092.
Objectives
We used qualitative and quantitative data collection methods to identify the health concerns of African American residents in an urban community and analyzed the extent to which there were consistencies across methods in the concerns identified.
Methods
We completed 9 focus groups with 51 residents, 27 key informant interviews, and 201 community health surveys with a random sample of community residents to identify the health issues participants considered of greatest importance. We then compared the issues identified through these methods.
Results
Focus group participants and key informants gave priority to cancer and cardiovascular diseases, but most respondents in the community health survey indicated that sexually transmitted diseases, substance abuse, and obesity were conditions in need of intervention. How respondents ranked their concerns varied in the qualitative versus the quantitative methods.
Conclusions
Using qualitative and quantitative approaches simultaneously is useful in determining community health concerns. Although quantitative approaches yield concrete evidence of community needs, qualitative approaches provide a context for how these issues can be addressed. Researchers should develop creative ways to address multiple issues that arise when using a mixed-methods approach.
doi:10.2105/AJPH.2010.191775
PMCID: PMC3107882  PMID: 21330592
17.  Malaria control under the Taliban regime: insecticide-treated net purchasing, coverage, and usage among men and women in eastern Afghanistan 
Malaria Journal  2010;9:7.
Background
Scaling up insecticide-treated mosquito net (ITN) coverage is a key malaria control strategy even in conflict-affected countries [1,2]. Socio-economic factors influence access to ITNs whether subsidized or provided free to users. This study examines reported ITN purchasing, coverage, and usage in eastern Afghanistan and explores women's access to health information during the Taliban regime (1996-2001). This strengthens the knowledge base on household-level health choices in complex-emergency settings.
Methods
Fifteen focus group discussions (FGDs) and thirty in-depth interviews were conducted with men and women from ITN-owning and non-owning households. FGDs included rank ordering, pile sorting and focused discussion of malaria knowledge and ITN purchasing. Interviews explored general health issues, prevention and treatment practices, and women's malaria knowledge and concerns. Seven key informant interviews with health-related workers and a concurrent survey of 200 ITN-owning and 214 non-owning households were used to clarify or quantify findings.
Results
Malaria knowledge was similar among men and women and ITN owners and non-owners. Women reported obtaining health information through a variety of sources including clinic staff, their husbands who had easier access to information, and particularly female peers. Most participants considered ITNs very desirable, though not usually household necessities. ITN owners reported more household assets than non-owners. Male ITN owners and non-owners ranked rugs and ITNs as most desired, while women ranked personal assets such as jewellery highest. While men were primarily responsible for household decision-making and purchasing, older women exerted considerable influence. Widow-led and landless households reported most difficulties purchasing ITNs. Most participants wanted to buy ITNs only if they could cover all household members. When not possible, preferential usage was given to women and children.
Conclusions
Despite restricted access to health facilities and formal education, Afghan women were surprisingly knowledgeable about the causes of malaria and the value of ITNs in prevention. Inequities in ITN usage were noted between rather than within households, with some unable to afford even one ITN and others not wanting ITNs unless all household members could be protected. Malaria knowledge thus appears a lesser barrier to ITN purchasing and coverage in eastern Afghanistan than are pricing and distribution strategies.
doi:10.1186/1475-2875-9-7
PMCID: PMC2817706  PMID: 20053281
18.  Tracking Official Development Assistance for Reproductive Health in Conflict-Affected Countries 
PLoS Medicine  2009;6(6):e1000090.
Preeti Patel and colleagues report inequity in the disbursement of official development assistance for reproductive health between countries affected by conflict and those unaffected.
Background
Reproductive health needs are particularly acute in countries affected by armed conflict. Reliable information on aid investment for reproductive health in these countries is essential for improving the efficiency and effectiveness of aid. The purpose of this study was to analyse official development assistance (ODA) for reproductive health activities in conflict-affected countries from 2003 to 2006.
Methods and Findings
The Creditor Reporting System and the Financial Tracking System databases were the chosen data sources for the study. ODA disbursement for reproductive health activities to 18 conflict-affected countries was analysed for 2003, 2004, 2005, and 2006. An average of US$20.8 billion in total ODA was disbursed annually to the 18 conflict-affected countries between 2003 and 2006, of which US$509.3 million (2.4%) was allocated to reproductive health. This represents an annual average of US$1.30 disbursed per capita in the 18 sampled countries for reproductive health activities. Non-conflict-affected least-developed countries received 53.3% more ODA for reproductive health activities than conflict-affected least-developed countries, despite the latter generally having greater reproductive health needs. ODA disbursed for HIV/AIDS prevention and treatment increased by 119.4% from 2003 to 2006. The ODA disbursed for other direct reproductive health activities declined by 35.9% over the same period.
Conclusions
This study provides evidence of inequity in disbursement of reproductive health ODA between conflict-affected countries and non-conflict-affected countries, and between different reproductive health activities. These findings and the study's recommendations seek to support initiatives to make aid financing more responsive to need in the context of armed conflict.
Editors' Summary
Background
Reproductive health concerns the bodily functions and systems that are involved in conceiving and bearing offspring. A reproductively healthy person is able to have a responsible, satisfying and safe sex life and to reproduce if and when they chose to do so. More specifically, to ensure their reproductive health, both men and women need access to safe and effective birth control methods, they need to know how to avoid sexually transmitted diseases (including HIV/AIDS), and they need access to treatment should they become infected. Women also need access to appropriate health-care services to safeguard their own health and their offspring's health during pregnancy and childbirth. Reproductive health is essential for the wellbeing of individuals and families and for the social and economic development of nations. Consequently, some of the official development assistance (ODA) given to developing countries by wealthier nations and by international agencies is being used to improve reproductive health. Indeed, several of the Millennium Development Goals (internationally agreed targets designed to eradicate global poverty by 2015) are directly related to reproductive health, including the improvement of maternal health and the control of HIV/AIDS.
Why Was This Study Done?
Many developing countries, such as Afghanistan, the Democratic Republic of Congo, Iraq, and Sudan, are experiencing violent conflicts. Such conflicts tend to slow down the development of low-income countries, and can also cause harm to reproductive health by damaging the health-service infrastructure and by increasing exposure to sexual violence. Although conflict-affected low-income countries rely heavily on international and humanitarian aid for basic health-care provision, there is little reliable information about how much of this aid is invested in reproductive health in such countries. This information is needed to ensure that development aid is used effectively. In this study, therefore, the researchers analyze the amount of ODA disbursed (the amount of official development money paid to recipient countries) for reproductive health activities in conflict-affected countries between 2003 and 2006.
What Did the Researchers Do and Find?
The researchers identified eighteen countries (mostly “least-developed” countries as defined by the Organisation for Economic Co-operation and Development; OEDC) that had been at war at sometime during the study period. They obtained information on ODA disbursements for reproductive health activities mainly from the Creditor Reporting System (CRS) database, which is maintained by the OECD, but also from the Financial Tracking System (FTS) database, which is maintained by the United Nations Office for the Coordination of Humanitarian Affairs. An average of US$20.8 billion in ODA was disbursed annually to the 18 conflict-affected countries between 2003 and 2006. Only US$509.3 million (2.4%) of this was allocated to reproductive health. Put another way, each person living in these conflict-affected countries received US$1.30 per year for their reproductive health needs. By contrast, people in non-conflict-affected least-developed countries each received 50% more ODA for reproductive health activities, even though these countries often had better reproductive health indicators than the conflict-affected countries. The researchers also found that nearly half of ODA disbursed for reproductive health was used for HIV/AIDS-related activities. This portion of ODA increased slightly during the study period in the conflict-affected countries whereas ODA disbursed for other reproductive health activities fell by a third.
What Do These Findings Mean?
Although these findings do not take into account money provided to conflict-affected developing countries for reproductive health activities by large philanthropic organizations, they nevertheless reveal an inequality between conflict-affected and non-conflict affected countries in terms of the development money provided for reproductive health. This is a worrying finding given that reproductive health tends to suffer in countries affected by war and poor reproductive health can slow down development. The findings of this study also suggest that funding for non-HIV reproductive health activities is declining in conflict-affected countries. Importantly, they also highlight additional research that is needed to ensure that donors of development aid can be more responsive in future to the reproductive health needs of conflict-affected countries.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000090.
This study is further discussed in a PLoS Medicine Perspective by Paul Spiegel and colleagues
The World Health organization provides information about reproductive health, including information on its 2004 global strategy for reproductive health (in several languages)
The US Centers for Disease Control and Prevention also provides information on reproductive health (in English and Spanish)
Wikipedia has a page on reproductive health (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages
The United Nations provides information on the Millennium Development Goals
The Organisation for Economic Cooperation and Development provides information on ODA through its Creditor Reporting System database; the United Nations Office for the Coordination of Humanitarian Affairs provides similar information for other donors through its Financial Tracking System database
The Reproductive Health Response in Conflict Consortium promotes access to reproductive health programs in emergencies and advocates for policies that support reproductive health of persons affected by armed conflict
doi:10.1371/journal.pmed.1000090
PMCID: PMC2682761  PMID: 19513098
19.  Identifying priority healthcare trainings in frozen conflict situations: The case of Nagorno Karabagh 
Conflict and Health  2010;4:21.
Introduction
Health care in post-war situations, where the system's human and fixed capital are depleted, is challenging. The addition of a frozen conflict situation, where international recognition of boundaries and authorities are lacking, introduces further complexities.
Case description
Nagorno Karabagh (NK) is an ethnically Armenian territory locked within post-Soviet Azerbaijan and one such frozen conflict situation. This article highlights the use of evidence-based practice and community engagement to determine priority areas for health care training in NK. Drawing on the precepts of APEXPH (Assessment Protocol for Excellence in Public Health) and MAPP (Mobilizing for Action through Planning and Partnerships), this first-of-its-kind assessment in NK relied on in-depth interviews and focus group discussions supplemented with expert assessments and field observations. Training options were evaluated against a series of ethical and pragmatic principles.
Discussion and Evaluation
A unique factor among the ethical and pragmatic considerations when prioritizing among alternatives was NK's ambiguous political status and consequent sponsor constraints. Training priorities differed across the region and by type of provider, but consensus prioritization emerged for first aid, clinical Integrated Management of Childhood Illnesses, and Adult Disease Management. These priorities were then incorporated into the training programs funded by the sponsor.
Conclusions
Programming responsive to both the evidence-base and stakeholder priorities is always desirable and provides a foundation for long-term planning and response. In frozen conflict, low resource settings, such an approach is critical to balancing the community's immediate humanitarian needs with sponsor concerns and constraints.
doi:10.1186/1752-1505-4-21
PMCID: PMC3022565  PMID: 21143931
20.  “Everyone just keeps their eyes closed and their fingers crossed”: Sexual health communication among black parents and children in Nova Scotia, Canada 
Background
Black Canadian youth remain disproportionally affected by an array of social and health issues, including sexually transmitted infections. While research exists in support of the involvement of parents as a key means to prevent or modify harmful behaviours among youth, less is known about how parent–child communication can serve as a prevention intervention strategy within Black families in Canada. This study explores sexual health communication between Black parents and youth in Nova Scotia and identifies facilitators, obstacles and issues that families face in dialoguing about sexual health.
Methods
Focus groups and in-depth interview sessions were held with a diverse sample of parents of Black youth, health and education professionals, and Black youth in Nova Scotia, as part of a larger study aimed at exploring parent–child communication on sexual health and HIV. The research team worked in partnership with and received feedback from key informants and a community advisory committee throughout the various stages of this study. All sessions were audio-taped with permission and thematic analysis was carried out on the verbatim transcripts.
Results
Six key themes emerged from the data analysis in relation to parent–child communication within Black families in Nova Scotia: 1. the gendered nature of [sexual] health communication; 2. fear and uncertainty as obstacles; 3. open and honest dialogue from an early age as a facilitator; 4. media as both a catalyst and a barrier; 5. peers as a catalyst; and 6. time constraints as an obstacle.
Conclusions
The findings of this study reveal that parent–child communication regarding sexual health promotion within Black families in Nova Scotia remains varied and is heavily affected by a myriad of intersecting determinants of health faced by Black youth and their parents. Health promotion interventions aimed at fostering and supporting parent–child communication on sexual health must simultaneously target both parents and youth and further, such efforts must engage a high level of cultural competency in order to better meet the needs of this population.
doi:10.1186/1475-9276-12-55
PMCID: PMC3765904  PMID: 23876177
Sexual health; Black youth; Parents; Qualitative research; Nova Scotia; Communication
21.  Stakeholders’ participation in planning and priority setting in the context of a decentralised health care system: the case of prevention of mother to child transmission of HIV programme in Tanzania 
Background
In Tanzania, decentralisation processes and reforms in the health sector aimed at improving planning and accountability in the sector. As a result, districts were given authority to undertake local planning and set priorities as well as allocate resources fairly to promote the health of a population with varied needs. Nevertheless, priority setting in the health care service has remained a challenge. The study assessed the priority setting processes in the planning of the prevention of mother to child transmission of HIV (PMTCT) programme at the district level in Tanzania.
Methods
This qualitative study was conducted in Mbarali district, south-western Tanzania. The study applied in-depth interviews and focus group discussions in the data collection. Informants included members of the Council Health Management Team, regional PMTCT managers and health facility providers.
Results
Two plans were reported where PMTCT activities could be accommodated; the Comprehensive Council Health Plan and the Regional PMTCT Plan that was donor funded. As donors had their own globally defined priorities, it proved difficult for district and regional managers to accommodate locally defined PMTCT priorities in these plans. As a result few of these were funded. Guidelines and main priority areas of the Ministry of Health and Social Welfare (MoHSW) also impacted on the ability of the districts and regions to act, undermining the effectiveness of the decentralisation policy in the health sector.
Conclusion
The challenges in the priority setting processes revealed within the PMTCT initiative indicate substantial weaknesses in implementing the Tanzania decentralisation policy. There is an urgent need to revive the strategies and aims of the decentralisation policy at all levels of the health care system with a view to improving health service delivery.
doi:10.1186/1472-6963-13-273
PMCID: PMC3720200  PMID: 23849730
Planning; Priority setting; PMTCT; Decentralisation; Donor influence; Tanzania
22.  Increasing access to quality health care for the poor: Community perceptions on quality care in Uganda 
This paper examines the community’s perspectives and perceptions on quality of health care delivery in two Uganda districts. The paper addresses community concerns on service quality. It focuses on the poor because they are a vulnerable group and often bear a huge burden of disease. Community views were solicited and obtained using eight focus group discussions, six in-depth and 12 key informant interviews. User perceptions and definitions of the quality of health services depended on a number of variables related to technical competence, accessibility to services, interpersonal relations and presence of adequate drugs, supplies, staff, and facility amenities. Results indicate that service delivery to the poor in the general population is perceived to be of low quality. The factors that were mentioned as affecting the quality of services delivered were inadequate trained health workers, shortage of essential drugs, poor attitude of the health workers, and long distances to health facilities. This paper argues that there should be an improvement in the quality of health services with particular attention being paid to the poor. Despite wide focus on improvement of the existing infrastructure and donor funding, there is still low satisfaction with health services and poor perceived accessibility.
PMCID: PMC2778436  PMID: 19936148
quality; health care; poor; community; perceptions; utilization
23.  Post-conflict mental health needs: a cross-sectional survey of trauma, depression and associated factors in Juba, Southern Sudan 
BMC Psychiatry  2009;9:7.
Background
The signing of the Comprehensive Peace Agreement in January 2005 marked the end of the civil conflict in Sudan lasting over 20 years. The conflict was characterised by widespread violence and large-scale forced migration. Mental health is recognised as a key public health issue for conflict-affected populations. Studies revealed high levels of post-traumatic stress disorder (PTSD) amongst populations from Southern Sudan during the conflict. However, no studies have been conducted on mental health in post-war Southern Sudan. The objective of this study was to measure PTSD and depression in the population in the town of Juba in Southern Sudan; and to investigate the association ofdemographic, displacement, and past and recent trauma exposure variables, on the outcomes of PTSD and depression.
Methods
A cross-sectional, random cluster survey with a sample of 1242 adults (aged over 18 years) was conducted in November 2007 in the town of Juba, the capital of Southern Sudan. Levels of exposure to traumatic events and PTSD were measured using the Harvard Trauma Questionnaire (original version), and levels of depression measured using the Hopkins Symptom Checklist-25. Multivariate logistic regression was used to analyse the association ofdemographic, displacement and trauma exposure variables on the outcomes of PTSD and depression. Multivariate logistic regression was also conducted to investigate which demographic and displacement variables were associated with exposure to traumatic events.
Results
Over one third (36%) of respondents met symptom criteria for PTSD and half (50%) of respondents met symptom criteria for depression. The multivariate logistic regression analysis showed strong associations of gender, marital status, forced displacement, and trauma exposure with outcomes of PTSD and depression. Men, IDPs, and refugees and persons displaced more than once were all significantly more likely to have experienced eight or more traumatic events.
Conclusion
This study provides evidence of high levels of mental distress in the population of Juba Town, and associated risk-factors. Comprehensive social and psychological assistance is urgently required in Juba.
doi:10.1186/1471-244X-9-7
PMCID: PMC2656503  PMID: 19261192
24.  The appropriateness of gatekeeping in the provision of reproductive health care for adolescents in Lithuania:the general practice perspective 
BMC Family Practice  2006;7:16.
Background
Adolescents' consultation of primary health care services remains problematic despite their accessibility. The reproductive health service seeking behavior of adolescents is the object of much research but little is known about how this behavior is influenced by the gatekeeping system. This study aimed to explore general practitioners' perceptions of the appropriateness of gatekeeping in adolescent reproductive health care.
Methods
Twenty in-depth interviews regarding factors affecting adolescent reproductive health care were carried out on a diverse sample of general practitioners and analyzed using grounded theory.
Results
The analysis identified several factors that shaped GPs' negative attitude to gatekeeping in adolescent reproductive health care. Its appropriateness in this field was questionable due to a lack of willingness on the part of GPs to provide reproductive health services for teenagers, their insufficient training, inadequately equipped surgeries and low perceived support for reproductive health service provision.
Conclusion
Since factors for improving adolescent reproductive health concern not only physicians but also the health system and policy levels, complex measures should be designed to overcome these barriers. Discussion of a flexible model of gatekeeping, encompassing both co-ordination of care provided by GPs and the possibility of patients' self-referral, should be included in the political agenda. Adolescents tend to under-use rather than over-use reproductive health services and every effort should be made to facilitate the accessibility of such services.
doi:10.1186/1471-2296-7-16
PMCID: PMC1431546  PMID: 16536876
25.  Sociocultural and individual determinants for motivation of sexual and reproductive health workers in Papua New Guinea and their implications for male circumcision as an HIV prevention strategy 
Background
The motivation of health workers (HWs) to deliver services in developing countries has been described as a critical factor in the success of health systems in implementing programmes. How the sociocultural context of Papua New Guinea (PNG) affects the values, motivation and actions of HWs involved in sexual and reproductive health services is important for policy development and programme planning. With interest in male circumcision (MC) as an HIV prevention option in PNG, this study explored the perceptions and motivations of HWs involved in sexual and reproductive health services in PNG, examining their implications for the possible future roll out of a national MC programme.
Methods
A multi-method qualitative study was conducted with HWs across a range of health care professions working in sexual health facilities. A total of 29 in-depth interviews and one focus group discussion were completed. Qualitative thematic analysis of the transcripts and field notes was undertaken using a social constructivist approach and complemented by documentary organizational, programme and policy analysis.
Results and discussions
Introduction of new health programmes, such as a MC programme for HIV prevention, are likely to impact upon one or more of the many motivational determinants. Social–cultural and individual factors influencing HW motivation to be involved in sexual and reproductive health services in PNG included community expectation and concern, sense of accomplishment and religious conviction. Strong links to community responsibility outweighed organizational ties. Faced with an often dysfunctional work environment, HWs perceived themselves as responsible to compensate for the failed health system. The impact of community influence and expectation needs to be considered when introducing a MC programme, particularly to communities in PNG where penile foreskin cutting is a common and accepted practice.
Conclusions
The potential contribution to the success of a MC programme that HWs may have means that taking into account the differing needs of communities as well as the motivational influences on HWs that exist within the sociocultural environment is important. These findings will assist not only in programme planning for MC, but also in the expansion of other existing sexual and reproductive health services.
doi:10.1186/1478-4491-11-7
PMCID: PMC3602021  PMID: 23418879

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