1
|
Emile R, Krisjanous J, Banga M, Kadirov D. Healthcare access for pregnant women in a rural developing country context: Formal and informal institutional challenges. Health Mark Q 2024:1-19. [PMID: 38733354 DOI: 10.1080/07359683.2024.2347047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
This study examines healthcare access for pregnant women in a rural developing country context. Drawing upon institutional theory and Levesque et al's model of access, the study finds pregnant women face challenges both of a formal and informal nature in accessing healthcare. The findings suggest the need for integrated and collaborative workings across formal and informal institutional networks. Theoretically, the study makes two contributions. First, it adds value to institutional theory by incorporating a dimension of access. Second, it builds upon Levesque et al.'s healthcare access framework by highlighting the role and significance of a third dimension-that is informal institutions, in addition to the current two-formal institutions and individual factors.
Collapse
Affiliation(s)
- Renu Emile
- Jindal Global Law School, O.P. Jindal Global University, Sonipat (NCR of Delhi), Haryana, India
| | - Jayne Krisjanous
- School of Marketing and International Business, Victoria University of Wellington, New Zealand
| | | | - Djavlonbek Kadirov
- School of Marketing and International Business, Victoria University of Wellington, New Zealand
| |
Collapse
|
2
|
Chirgwin H, Cairncross S, Zehra D, Sharma Waddington H. Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1194. [PMID: 36951806 PMCID: PMC8988822 DOI: 10.1002/cl2.1194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Background Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged. Objectives Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews. Methods This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis. Results There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation. Conclusion Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.
Collapse
Affiliation(s)
- Hannah Chirgwin
- International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
| | | | | | - Hugh Sharma Waddington
- London School of Hygiene and Tropical Medicine and International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
| |
Collapse
|
3
|
Bombak AE, Colotti TE, Raji D, Riediger ND. Exploring attitudes toward taxation of sugar-sweetened beverages in rural Michigan. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2021; 40:36. [PMID: 34344480 PMCID: PMC8329609 DOI: 10.1186/s41043-021-00259-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND While policies to address "obesity" have existed for decades, they have commonly focused on behavioral interventions. More recently, the taxation of sugar-sweetened beverages is gaining traction globally. This study sought to explore individuals' attitudes and beliefs about sugar-sweetened beverages being taxed in a rural Michigan setting. METHODS This qualitative study was conducted using critical policy analysis. Data were collected in 25 semi-structured, audio-recorded interviews with adult Michiganders. Following data collection, transcripts were coded into themes using NVivo software. RESULTS Four themes emerged in participants' perspectives regarding sugar-sweetened beverages being taxed: resistance, unfamiliarity, tax effects, and need for education. While some participants were unfamiliar with sugar-sweetened beverage taxes, many viewed taxation as a "slippery slope" of government intervention, which invoked feelings of mistrust. In addition, participants predicted a sugar-sweetened beverage tax would be ineffective at reducing intake, particularly among regular consumers, who were frequently perceived as mostly low income and/or of higher weight. CONCLUSIONS Further research is needed to explore perceptions of sugar-sweetened beverage taxes in different geographic areas in the USA to examine how perceptions vary. Policymakers should be aware of the potential implications of this health policy with respect to government trust and stigma towards lower income and higher-weight individuals.
Collapse
Affiliation(s)
- Andrea E. Bombak
- Department of Sociology, University of New Brunswick, Tilley Hall, Room 9, Fredericton, NB E3B 5A3 Canada
- School of Health Sciences, Community Health Division, Central Michigan University, 1280 E Campus Dr, Mt Pleasant, MI 48859 USA
| | - Taylor E. Colotti
- School of Health Sciences, Community Health Division, Central Michigan University, 1280 E Campus Dr, Mt Pleasant, MI 48859 USA
| | - Dolapo Raji
- School of Health Sciences, Community Health Division, Central Michigan University, 1280 E Campus Dr, Mt Pleasant, MI 48859 USA
| | - Natalie D. Riediger
- Department of Food and Human Nutritional Sciences, Faculty of Agricultural and Food Sciences, University of Manitoba, 407 Human Ecology Building, Winnipeg, MB R3T 2N2 Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
| |
Collapse
|
4
|
Parvez SM, Rahman MJ, Azad R, Rahman M, Unicomb L, Ashraf S, Mondol MH, Jahan F, Winch PJ, Luby SP. Achieving equitable uptake of handwashing and sanitation by addressing both supply and demand-based constraints: findings from a randomized controlled trial in rural Bangladesh. Int J Equity Health 2021; 20:16. [PMID: 33407549 PMCID: PMC7789645 DOI: 10.1186/s12939-020-01353-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels. Methods The current analysis selected 4 indicators from the WASH Benefits trial— presence of water and soap in household handwashing stations, observed mother’s hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline. Results For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (− 4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, − 25% (− 35, − 15) Q2: − 34% (− 44, − 23%)] than the wealthiest household [Q5 DID: − 1% (− 11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1–4 DID: 50–54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%). Conclusion By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program. Trial registration WASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095. Date of registration: April 30, 2012 ‘Retrospectively registered’. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-020-01353-7.
Collapse
Affiliation(s)
- Sarker Masud Parvez
- Environmental Intervention Unit, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
| | - Musarrat Jabeen Rahman
- Environmental Intervention Unit, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rashidul Azad
- Environmental Intervention Unit, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mahbubur Rahman
- Environmental Intervention Unit, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Leanne Unicomb
- Environmental Intervention Unit, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sania Ashraf
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Farjana Jahan
- Environmental Intervention Unit, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Peter J Winch
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| |
Collapse
|
5
|
Inauen J, Lilje J, Mosler HJ. Refining hand washing interventions by identifying active ingredients: A cluster-randomized controlled trial in rural Zimbabwe. Soc Sci Med 2019; 245:112712. [PMID: 31846857 DOI: 10.1016/j.socscimed.2019.112712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/17/2019] [Accepted: 11/30/2019] [Indexed: 11/17/2022]
Abstract
RATIONALE Consistent hand washing with soap can reduce the risk of diarrhea, but changing hand-washing behavior is difficult. Systematic behavior change approaches promise to enhance hand washing with soap effectively, and allow the identification of active intervention ingredients using mediation analysis. This knowledge can then be used to derive hypotheses for systematically refining the intervention. OBJECTIVE We demonstrate this at the example of a behavior change intervention to promote hand washing with soap based on the RANAS approach (risk, attitudes, norms, ability, and self-regulation). METHODS Sixteen wards of Masvingo province in Zimbabwe were randomly allocated to the RANAS-based intervention or a wait-list control group. Hand washing at baseline and follow-up was observed for 224 randomly selected caregivers of young children. They additionally participated in quantitative face-to-face interviews assessing psychosocial factors. RESULTS At baseline, hand washing with soap was <3% on average, and did not differ between groups (p = .526). At follow-up, intervention participants washed hands with soap more frequently than controls (in 29.4% vs. 8.2% of all stool- and food-related situations, B = 1.88, SE = 0.32, OR = 6.6, p < .001). Mediation analyses revealed that the intervention enhanced several of the targeted psychosocial factors; return, descriptive and injunctive norms, action knowledge, action self-efficacy, maintenance self-efficacy, action planning, and remembering. The intervention effect was mediated through increased remembering. CONCLUSION This study supports the efficacy of a systematic approach to behavior change to promote hand washing with soap. The analyses of the mechanisms revealed important insights into the active ingredients of the intervention, which will facilitate its future refinement.
Collapse
Affiliation(s)
- Jennifer Inauen
- Institute of Psychology, University of Bern, Bern, Switzerland; Department of Environmental Social Sciences, Eawag: Swiss Federal Institute of Aquatic Science & Technology, Duebendorf, Switzerland.
| | - Jonathan Lilje
- Department of Environmental Social Sciences, Eawag: Swiss Federal Institute of Aquatic Science & Technology, Duebendorf, Switzerland
| | - Hans-Joachim Mosler
- Department of Environmental Social Sciences, Eawag: Swiss Federal Institute of Aquatic Science & Technology, Duebendorf, Switzerland
| |
Collapse
|
6
|
Luca NR, Hibbert S, McDonald R. Understanding behaviour change in context: examining the role of midstream social marketing programmes. SOCIOLOGY OF HEALTH & ILLNESS 2019; 41:1373-1395. [PMID: 31099093 DOI: 10.1111/1467-9566.12951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This research examines how midstream social marketing programmes that adopt a relational and community-based approach create opportunities for individuals to make incremental changes to health behaviour. Specifically, it applies Bourdieusian theory to explore how interactions between community healthcare workers (CHWs) and members of the public generate impetus for change and foster individual agency for improved health. Qualitative interviews were carried out with members of the public and CHWs engaged in a Smokefree home and cars initiative. The findings suggest that although CHWs are challenged by resource constraints, their practices in working with individuals and families build trust and enable dialogue that bridges smoking-related health insight with home logics. These interactions can promote individual agency with a transformative effect through small changes to smoking-related dispositions, norms and practices. However, tensions with the habitus of other household members and other capital deficits can inhibit progress towards embedding new practices. The study concludes that interventions built upon community relationships show potential for addressing limitations of information-focused campaigns but there is a need to also respond to key social structures relating to the field of action for new health dispositions to become embedded in practice.
Collapse
Affiliation(s)
- Nadina R Luca
- York Management School, University of York, York, UK
| | - Sally Hibbert
- Nottingham University Business School, University of Nottingham, Nottingham, UK
| | - Ruth McDonald
- Manchester Business School, University of Manchester, Manchester, UK
| |
Collapse
|
7
|
Denyer Willis L, Chandler C. Quick fix for care, productivity, hygiene and inequality: reframing the entrenched problem of antibiotic overuse. BMJ Glob Health 2019; 4:e001590. [PMID: 31497315 PMCID: PMC6703303 DOI: 10.1136/bmjgh-2019-001590] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/05/2019] [Accepted: 07/12/2019] [Indexed: 11/04/2022] Open
Abstract
Antimicrobial resistance (AMR) is a major challenge of our time. A key global objective is to reduce antibiotic use (ABU), in order to reduce resistance caused by antimicrobial pressure. This is often set as a 'behaviour change' issue, locating intervention efforts in the knowledge and attitudes of individual prescribers and users of medicines. Such approaches have had limited impact and fall short of addressing wider drivers of antibiotic use. To address the magnitude of antibiotic overuse requires a wider lens to view our relationships with these medicines. This article draws on ethnographic research from East Africa to answer the question of what roles antibiotics play beyond their immediate curative effects. We carried out interviews, participant observation and documentary analysis over a decade in northeast Tanzania and eastern and central Uganda. Our findings suggest that antibiotics have become a 'quick fix' in our modern societies. They are a quick fix for care in fractured health systems; a quick fix for productivity at local and global scales, for humans, animals and crops; a quick fix for hygiene in settings of minimised resources; and a quick fix for inequality in landscapes scarred by political and economic violence. Conceptualising antibiotic use as a 'quick fix' infrastructure shifts attention to the structural dimensions of AMR and antimicrobial use (AMU) and raises our line of sight into the longer term, generating more systemic solutions that have greater chance of achieving equitable impact.
Collapse
Affiliation(s)
- Laurie Denyer Willis
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Clare Chandler
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
8
|
Brewis A, Wutich A, du Bray MV, Maupin J, Schuster RC, Gervais MM. Community hygiene norm violators are consistently stigmatized: Evidence from four global sites and implications for sanitation interventions. Soc Sci Med 2019; 220:12-21. [DOI: 10.1016/j.socscimed.2018.10.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 10/28/2022]
|
9
|
Harvey M, McGladrey M. Explaining the origins and distribution of health and disease: an analysis of epidemiologic theory in core Master of Public Health coursework in the United States. CRITICAL PUBLIC HEALTH 2018. [DOI: 10.1080/09581596.2018.1535698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Michael Harvey
- Department of Health Science and Recreation, San José State University, San Jose, CA, USA
| | - Margaret McGladrey
- Tisch College of Civic Life and Department of Sociology, Tufts University, Medford, USA
| |
Collapse
|
10
|
Harvey SA. Observe Before You Leap: Why Observation Provides Critical Insights for Formative Research and Intervention Design That You'll Never Get From Focus Groups, Interviews, or KAP Surveys. GLOBAL HEALTH: SCIENCE AND PRACTICE 2018; 6:299-316. [PMID: 29794000 PMCID: PMC6024634 DOI: 10.9745/ghsp-d-17-00328] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 02/06/2018] [Indexed: 12/12/2022]
Abstract
Four case studies show how observation can uncover issues critical to making a health intervention succeed or, sometimes, reveal reasons why it is likely to fail. Observation can be particularly valuable for interventions that depend on mechanical or clinical skills; service delivery processes; effects of the built environment; and habitual tasks that practitioners find difficult to articulate. Formative research is essential to designing both study instruments and interventions in global health. While formative research may employ many qualitative methods, focus group discussions and in-depth interviews are the most common. Observation is less common but can generate insights unlikely to emerge from any other method. This article presents 4 case studies in which observation revealed critical insights: corralling domestic poultry to reduce childhood diarrhea, promoting insecticide-treated bed nets (ITNs) to prevent malaria, evaluating skilled birth attendant competency to manage life-threatening obstetric and neonatal complications, and assessing community health worker (CHW) ability to use malaria rapid diagnostic tests (RDTs). Observation of Zambian CHWs to design malaria RDT training materials revealed a need for training on how to take finger-stick blood samples, a procedure second nature to many health workers but one that few CHWs had ever performed. In Lima, Peru, study participants reported keeping their birds corralled “all the time,” but observers frequently found them loose, a difference potentially explained by an alternative interpretation of the phrase “all the time” to mean “all the time (except at some specific seemingly obvious times).” In the Peruvian Amazon, observation revealed a potential limitation of bed net efficacy due to the built environment: In houses constructed on stilts, many people sleep directly on the floor, allowing mosquitoes to bite from below through gaps in the floorboards. Observation forms and checklists from each case study are included as supplemental files; these may serve as models for designing new observation guides. The case studies illustrate the value of observation to clearly understanding clinical practices and skills, details about how people carry out certain tasks, routine behaviors people would most likely not think to describe in an interview, and environmental barriers that must be overcome if an intervention is to succeed. Observation provides a way to triangulate for social desirability bias and to measure details that interview or focus group participants are unlikely to recognize, remember, or be able to describe with precision.
Collapse
Affiliation(s)
- Steven A Harvey
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| |
Collapse
|
11
|
Whelan E. Working up a lather: the rise (and fall?) of hand hygiene in Canadian newspapers, 1986–2015. CRITICAL PUBLIC HEALTH 2018. [DOI: 10.1080/09581596.2018.1453126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Emma Whelan
- Department of Sociology & Social Anthropology, Dalhousie University , Halifax, Canada
| |
Collapse
|
12
|
Greenland K, Chipungu J, Chilekwa J, Chilengi R, Curtis V. Disentangling the effects of a multiple behaviour change intervention for diarrhoea control in Zambia: a theory-based process evaluation. Global Health 2017; 13:78. [PMID: 29041941 PMCID: PMC5645837 DOI: 10.1186/s12992-017-0302-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 10/05/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diarrhoea is a leading cause of child death in Zambia. As elsewhere, the disease burden could be greatly reduced through caregiver uptake of existing prevention and treatment strategies. We recently reported the results of the Komboni Housewives intervention which tested a novel strategy employing motives including affiliation and disgust to improve caregiver practice of four diarrhoea control behaviours: exclusive breastfeeding; handwashing with soap; and correct preparation and use of oral rehydration salts (ORS) and zinc. The intervention was delivered via community events (women's forums and road shows), at health clinics (group session) and via radio. A cluster randomised trial revealed that the intervention resulted in a small improvement in exclusive breastfeeding practices, but was only associated with small changes in the other behaviours in areas with greater intervention exposure. This paper reports the findings of the process evaluation that was conducted alongside the trial to investigate how factors associated with intervention delivery and receipt influenced caregiver uptake of the target behaviours. METHODS Process data were collected from the eight peri-urban and rural intervention areas throughout the six-month implementation period and in all 16 clusters 4-6 weeks afterwards. Intervention implementation (fidelity, reach, dose delivered and recruitment strategies) and receipt (participant engagement and responses, and mediators) were explored through review of intervention activity logs, unannounced observation of intervention events, semi-structured interviews, focus groups with implementers and intervention recipients, and household surveys. Evaluation methods and analyses were guided by the intervention's theory of change and the evaluation framework of Linnan and Steckler. RESULTS Intervention reach was lower than intended: 39% of the surveyed population reported attending one or more face-to-face intervention event, of whom only 11% attended two or more intervention events. The intervention was not equally feasible to deliver in all settings: fewer events took place in remote rural areas, and the intervention did not adequately penetrate communities in several peri-urban sites where the population density was high, the population was slightly higher socio-economic status, recruitment was challenging, and numerous alternative sources of entertainment existed. Adaptations made by the implementers affected the fidelity of implementation of messages for all target behaviours. Incorrect messages were consequently recalled by intervention recipients. Participants were most receptive to the novel disgust and skills-based interactive demonstrations targeting exclusive breastfeeding and ORS preparation respectively. However, initial disgust elicitation was not followed by a change in associated psychological mediators, and social norms were not measurably changed. CONCLUSIONS The lack of measured behaviour change was likely due to issues with both the intervention's content and its delivery. Achieving high reach and intensity in community interventions delivered in diverse settings is challenging. Achieving high fidelity is also challenging when multiple behaviours are targeted for change. Further work using improved tools is needed to explore the use of subconscious motives in behaviour change interventions. To better uncover how and why interventions achieve their measured effects, process evaluations of complex interventions should develop and employ frameworks for investigation and interpretation that are structured around the intervention's theory of change and the local context. TRIAL REGISTRATION The study was registered as part of the larger trial on 5 March 2014 with ClinicalTrials.gov: NCT02081521 .
Collapse
Affiliation(s)
- Katie Greenland
- Department for Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, UK
| | - Jenala Chipungu
- Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Rd, Lusaka, Zambia
| | - Joyce Chilekwa
- Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Rd, Lusaka, Zambia
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Plot 5032 Great North Rd, Lusaka, Zambia
| | - Val Curtis
- Department for Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, UK
| |
Collapse
|
13
|
Abstract
Globally, 2.4 billion people lack adequate sanitation, and open defecation remains common. In this article, I present the qualitative findings from an evaluation of a water, sanitation, and hygiene intervention in remote, mid-West Nepal. The evaluation, conducted in 2014, involved villagers from eight wards in Kotgaun Village Development Committee. Drawing on the concept of the "toilet tripod," I argue as follows: multi-scalar political will provide an important foundation for construction and sustained use of toilets, proximate social pressures contributed significantly to toilet adoption and efforts to eliminate open defecation, and water insecurity constrained improved sanitation and hygiene.
Collapse
Affiliation(s)
- Celia McMichael
- a School of Geography, University of Melbourne , Carlton , Victoria , Australia
| |
Collapse
|
14
|
Acharya D, Singh JK, Adhikari M, Gautam S, Pandey P, Dayal V. Association of water handling and child feeding practice with childhood diarrhoea in rural community of Southern Nepal. J Infect Public Health 2017; 11:69-74. [PMID: 28576344 DOI: 10.1016/j.jiph.2017.04.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 03/15/2017] [Accepted: 04/28/2017] [Indexed: 11/18/2022] Open
Abstract
Diarrhoea is a major cause of childhood morbidity and mortality globally. While the childhood diarrhoea and its association with child feeding, and hygiene, hand washing and water treatment are studied elsewhere, the association of water handling and child feeding with childhood diarrhoea is an understudied area in Nepal. This study aimed to investigate the association of water handling and child feeding practice with childhood diarrhoea among children of one to five years of age in Southern, Nepal. A cross-sectional study was conducted in the Dhanusha district of Southern Nepal in 2013. A total of 284 mother-child pairs were selected using systemic random sampling. A four-week prevalence of childhood diarrhoea was reported using frequency distribution. The association of childhood diarrhoea with water handling and child feeding practices was ascertained using multiple logistic regressions after adjusting for potential confounders. The result of the study demonstrated that the four-week prevalence of childhood diarrhoea was 36.6%. Our finding showed that unsafe water handling practices were associated independently with childhood diarrhoea: untreated water (aOR 3.55; 95% CI: 1.13-11.10), uncovered water (aOR 2.14; 95% CI: 1.09-4.19). Similarly, partial breast feeding (aOR 4.35; 95% CI: 1.87-10.12) was also associated with higher odds of childhood diarrhoea. One third of children in Southern Nepal still had diarrhoea within the four weeks preceding the survey. As poor water handling and sub optimal infant feeding practice were major risk factors contributing to such a high burden of the disease, health promotion strategies such as promotion of safe water handling, improved hygiene and child feeding practices are recommended for the prevention of childhood diarrhoea in Southern Terai of Nepal.
Collapse
Affiliation(s)
- Dilaram Acharya
- Department of Community Medicine, Kathmandu University, Devdaha Medical College and Research Institute, Devdaha Municipality-10, Rupandehi, Nepal.
| | - Jitendra K Singh
- Department of Community Medicine & Public Health, Tribhuvan University, Janaki Medical College, Janakpur, Nepal; Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, India.
| | | | - Salila Gautam
- Department of Public Health, Purbanchal University, Sanjeevani College of Medical Sciences, Butwal, Rupandehi, Nepal.
| | - Pragya Pandey
- Faculty of Nursing, Janaki Medical College, Tribhuvan University, Janakpur, Nepal.
| | - Vinita Dayal
- Population Services International, New Delhi, India.
| |
Collapse
|
15
|
Pleasure: An under-utilised ‘P’ in social marketing for healthy eating. Appetite 2016; 104:60-9. [DOI: 10.1016/j.appet.2015.10.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 08/23/2015] [Accepted: 10/05/2015] [Indexed: 12/31/2022]
|
16
|
Drivers of sustained hygiene behaviour change: A case study from mid-western Nepal. Soc Sci Med 2016; 163:28-36. [PMID: 27391250 DOI: 10.1016/j.socscimed.2016.06.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 06/28/2016] [Accepted: 06/28/2016] [Indexed: 11/20/2022]
Abstract
Behaviour change is central to the prevention of many population health problems, yet it is typically difficult to initiate and sustain. This paper reports on an evaluation of a water, sanitation and hygiene (WASH) intervention in mid-western Nepal, with particular focus on the drivers and barriers for handwashing with soap/ash and elimination of open defecation. The research was conducted during October-November 2014, two and half years following the intervention's end-point. Qualitative data were collected from the target community (n = 112) via group discussions, interviews and drawings/stories of 'most significant change'. Households' handwashing/water facilities and toilets were observed. Analysis was informed by a model that highlights environmental, psychosocial and technological factors that shape hygiene behaviours across multiple levels, from the habitual to the structural (Dreibelbis et al. 2013). Findings indicate the intervention has supported development of new norms around hygiene behaviours. Key drivers of sustained hygiene behaviour were habit formation, emotional drivers (e.g. disgust, affiliation), and collective action and civic pride; key constraints included water scarcity and socio-economic disadvantage. Identifying and responding to the drivers and constraints of hygiene behaviour change in specific contexts is critical to sustained behaviour change and population health impact.
Collapse
|
17
|
Impact of a social media campaign targeting men who have sex with men during an outbreak of syphilis in Winnipeg, Canada. ACTA ACUST UNITED AC 2016; 42:45-49. [PMID: 29770003 DOI: 10.14745/ccdr.v42i02a04] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background The city of Winnipeg has experienced a surge of infectious syphilis cases since the fall of 2012, concentrated among men who have sex with men (MSM) and who use social media technologies-including phone applications-to meet sexual contacts. Objective To evaluate the acceptability, cost and effectiveness of a campaign promoting syphilis testing on popular websites and applications used by MSM in the Winnipeg Health Region (WHR). Methods The Winnipeg Regional Health Authority developed a campaign in March 2014 highlighting the syphilis outbreak and the importance of seeking testing. Over one month, advertisements appeared on four web-platforms: Grindr, Facebook, Squirt and the Gay Ad Network. When clicked, ads would direct the user to an information website. Acceptability was assessed using the number of 'clicks' elicited by advertisements on each platform. The cost of each platform's run of advertisements was compared to the number clicks elicited to produce a cost-per-click ratio for each platform. Effectiveness was assessed by comparing the number of syphilis tests ordered for male residents of the Winnipeg Health Region in the seven-week period before and after the campaign, as well as to the same time periods in 2012 and 2013. Results Out of 800,000 appearances purchased, the advertisements elicited 2,166 clicks, suggesting good acceptability. Grindr and Squirt advertisements had a better cost-per-click ratio than Facebook or the Gay Ad Network. There was no significant difference in testing before (2,049 tests) versus after (2,025 tests) the campaign and these findings were similar to testing trends in 2012 and 2013. Conclusion Although this web-based campaign showed good acceptability and low cost, it did not appear to increase syphilis testing. This may be due to a poor campaign design; it also suggests that an education campaign alone may be insufficient to change behaviour.
Collapse
|
18
|
Wallington SF, Dash C, Sheppard VB, Goode TD, Oppong BA, Dodson EE, Hamilton RN, Adams-Campbell LL. Enrolling Minority and Underserved Populations in Cancer Clinical Research. Am J Prev Med 2016; 50:111-117. [PMID: 26470805 PMCID: PMC4691547 DOI: 10.1016/j.amepre.2015.07.036] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 07/14/2015] [Accepted: 07/30/2015] [Indexed: 10/22/2022]
Abstract
Research suggests that community involvement is integral to solving public health problems, including involvement in clinical trials-a gold standard. Significant racial/ethnic disparities exist in the accrual of participants for clinical trials. Location and cultural aspects of clinical trials influence recruitment and accrual to clinical trials. It is increasingly necessary to be aware of defining characteristics, such as location and culture of the populations from which research participants are enrolled. Little research has examined the effect of location and cultural competency in adapting clinical trial research for minority and underserved communities on accrual for clinical trials. Utilizing embedded community academic sites, the authors applied cultural competency frameworks to adapt clinical trial research in order to increase minority participation in nontherapeutic cancer clinical trials. This strategy resulted in successful accrual of participants to new clinical research trials, specifically targeting participation from minority and underserved communities in metropolitan Washington, DC. From 2012 to 2014, a total of 559 participants enrolled across six nontherapeutic clinical trials, representing a 62% increase in the enrollment of blacks in clinical research. Embedding cancer prevention programs and research in the community was shown to be yet another important strategy in the arsenal of approaches that can potentially enhance clinical research enrollment and capacity. The analyses showed that the capacity to acquire cultural knowledge about patients-their physical locales, cultural values, and environments in which they live-is essential to recruiting culturally and ethnically diverse population samples.
Collapse
Affiliation(s)
- Sherrie F Wallington
- Georgetown-Lombardi Comprehensive Cancer Center, Washington, District of Columbia.
| | - Chiranjeev Dash
- Georgetown-Lombardi Comprehensive Cancer Center, Washington, District of Columbia
| | - Vanessa B Sheppard
- Georgetown-Lombardi Comprehensive Cancer Center, Washington, District of Columbia
| | - Tawara D Goode
- National Center for Cultural Competence, Department of Pediatrics, Georgetown University Medical Center, Washington, District of Columbia
| | - Bridget A Oppong
- Georgetown-Lombardi Comprehensive Cancer Center, Washington, District of Columbia; Georgetown University Medical Center, Department of Surgery, Washington, District of Columbia
| | - Everett E Dodson
- Georgetown-Lombardi Comprehensive Cancer Center, Washington, District of Columbia
| | - Rhonda N Hamilton
- Georgetown-Lombardi Comprehensive Cancer Center, Washington, District of Columbia
| | | |
Collapse
|
19
|
McDonald E, Cunningham T, Slavin N. Evaluating a handwashing with soap program in Australian remote Aboriginal communities: a pre and post intervention study design. BMC Public Health 2015; 15:1188. [PMID: 26614522 PMCID: PMC4662811 DOI: 10.1186/s12889-015-2503-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 11/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The No Germs on Me (NGoM) Social Marketing Campaign to promote handwashing with soap to reduce high rates of infection among children living in remote Australian Aboriginal communities has been ongoing since 2007. Recently three new television commercials were developed as an extension of the NGoM program. This paper reports on the mass media component of this program, trialling an evaluation design informed by the Theory of Planned Behaviour (TPB). METHODS A survey questionnaire taking an ecological approach and based on the principals and constructs of the TPB was developed. Surveys were completed in six discrete Aboriginal communities immediately before and on completion of four weeks intensive televising of the three new commercials. RESULTS Across the six communities access in the home to a television that worked ranged from 49 to 83 % (n = 415). Seventy-seven per cent (n = 319) of participants reported having seen one or more of the new commercials. Levels of acceptability and comprehension of the content of the commercials was high (97 % n = 308). Seventy-five per cent (n = 651) of participants reported they would buy more soap, toilet paper and facial tissues if these were not so expensive in their communities. For TPB constructs demonstrated to have good internal reliability the findings were mixed and these need to be interpreted with caution due to limitations in the study design. CONCLUSIONS Cultural, social-economic and physical barriers in remote communities make it challenging to promote adults and children wash their hands with soap and maintain clean faces such that these behaviours become habit. Low levels of access to a television in the home illustrate the extreme level of disadvantage experienced in these communities. Highlighting that social marketing programs have the potential to increase disadvantage if expensive items such as television sets are needed to gain access to information. This trial of a theory informed evaluation design allowed for new and rich information to be obtained about community members' beliefs, attitudes and intentions towards teaching and assisting children so safe hygiene behaviours become habit. Findings will support an evidence-based approach is taken to plan future NGoM program activities.
Collapse
Affiliation(s)
- Elizabeth McDonald
- Child Health Division, Menzies School of Health Research, Post Office Box 41096, Casuarina, NT, 0811, Australia.
| | - Teresa Cunningham
- Centre for Child Development and Education, Menzies School of Health Research, Menzies School of Health Research, Post Office Box 41096, Casuarina, NT, 0811, Australia.
| | - Nicola Slavin
- Northern Territory Government Environmental Health Branch, Post Office Box 40596, Casuarina, NT, 0811, Australia.
| |
Collapse
|
20
|
Rajaraman D, Varadharajan KS, Greenland K, Curtis V, Kumar R, Schmidt WP, Aunger R, Biran A. Implementing effective hygiene promotion: lessons from the process evaluation of an intervention to promote handwashing with soap in rural India. BMC Public Health 2014; 14:1179. [PMID: 25407695 PMCID: PMC4251686 DOI: 10.1186/1471-2458-14-1179] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 11/03/2014] [Indexed: 11/30/2022] Open
Abstract
Background An intervention trial of the ‘SuperAmma’ village-level intervention to promote handwashing with soap (HWWS) in rural India demonstrated substantial increases in HWWS amongst the target population. We carried out a process evaluation to assess the implementation of the intervention and the evidence that it had changed the perceived benefits and social norms associated with HWWS. The evaluation also aimed to inform the design of a streamlined shorter intervention and estimate scale up costs. Methods Intervention implementation was observed in 7 villages. Semi-structured interviews were conducted with the implementation team, village leaders and representatives of the target population. A questionnaire survey was administered in 174 households in intervention villages and 171 households in control villages to assess exposure to intervention activities, recall of intervention components and evidence that the intervention had produced changes in perceptions that were consistent with the intervention core messages. Costs were estimated for the intervention as delivered, as well as for a hypothetical scale-up to 1,000 villages. Results We found that the intervention was largely acceptable to the target population, maintained high fidelity (after some starting problems), and resulted in a high level of exposure to most components. There was a high recall of most intervention activities. Subjects in the intervention villages were more likely than those in control villages to cite reasons for HWWS that were in line with intervention messaging and to believe that HWWS was a social norm. There were no major differences between socio-economic and caste groups in exposure to intervention activities. Reducing the intervention from 4 to 2 contact days, in a scale up scenario, cut the estimated implementation cost from $2,293 to $1,097 per village. Conclusions The SuperAmma intervention is capable of achieving good reach across men and women of varied social and economic status, is affordable, and has the potential to be effective at scale, provided that sufficient attention is given to ensuring the quality of intervention delivery.
Collapse
Affiliation(s)
- Divya Rajaraman
- Division of Epidemiology and Biostatistics, St John's Research Institute, St John's National Academy of Health Sciences, Sarjapur Road, Bangalore 560034, India.
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Panter-Brick C. Health, Risk, and Resilience: Interdisciplinary Concepts and Applications. ANNUAL REVIEW OF ANTHROPOLOGY 2014. [DOI: 10.1146/annurev-anthro-102313-025944] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
22
|
Guillemin F, Carruthers E, Li LC. Determinants of MSK health and disability – Social determinants of inequities in MSK health. Best Pract Res Clin Rheumatol 2014; 28:411-33. [DOI: 10.1016/j.berh.2014.08.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
23
|
Panter-Brick C, Eggerman M, Tomlinson M. How might global health master deadly sins and strive for greater virtues? Glob Health Action 2014; 7:23411. [PMID: 24685169 PMCID: PMC3970118 DOI: 10.3402/gha.v7.23411] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 02/13/2014] [Accepted: 02/15/2014] [Indexed: 11/23/2022] Open
Abstract
In the spirit of critical reflection, we examine how the field of global health might surmount current challenges and prioritize its ethical mandate, namely to achieve, for all people, equity in health. We use the parlance of mastering deadly sins and striving for greater virtues in an effort to review what is needed to transform global health action. Global health falls prey to four main temptations: coveting silo gains, lusting for technological solutions, leaving broad promises largely unfulfilled, and boasting of narrow successes. This necessitates a change of heart: to keep faith with the promise it made, global health requires a realignment of core values and a sharper focus on the primacy of relationships with the communities it serves. Based on the literature to date, we highlight six steps to re-orienting global health action. Articulating a coherent global health agenda will come from principled action, enacted through courage and prudence in decision-making to foster people-centered systems of care over the entire lifespan.
Collapse
Affiliation(s)
| | - Mark Eggerman
- MacMillan Center for International and Area Studies, Yale University, New Haven, CT, USA
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa;
| |
Collapse
|
24
|
Can technology be effective in interventions targeting sexual health and substance use in young people; a systematic review. HEALTH AND TECHNOLOGY 2013. [DOI: 10.1007/s12553-013-0059-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|