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Gregg C, Valdez M, Stollak I, Martin S, Story WT, Perry HB. Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 7. The empowering effect of Care Groups. Int J Equity Health 2023; 21:199. [PMID: 36855142 PMCID: PMC9976358 DOI: 10.1186/s12939-022-01759-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND While there is extensive published evidence regarding the effectiveness of the Care Group Approach in promoting community-wide health behavior change, there is no published evidence regarding its empowering effect on its participants. Our study aimed to understand if the Care Group Approach as applied in the Curamericas/Guatemala Maternal and Child Health Project in isolated rural mountainous communities in Guatemala produced evidence of empowerment among the female participants. This is the seventh of 10 papers describing the expanded Census-Based, Impact-Oriented (CBIO+) Approach in improving the health and well-being of mothers and children in the rural highlands of the Department of Huehuetenango, Guatemala. METHODS We conducted semi-structured individual and group interviews with 96 female Care Group participants -including Level-1 Care Group Promoters, Care Group Volunteers, and Self-Help Group participants. The participants were from six communities - two from each of the three municipalities making up the Project Area. Data were analyzed both using deductive thematic and by exploring the following social constructs: perceived social status, self-efficacy, decision-making autonomy, and formation of social capital. RESULTS The findings supported the hypothesis that Care Group participation was an empowering process. The primary themes that emerged included increased respect accorded to women in the community, women's willingness and ability to make decisions and their confidence in making those decisions, and the development of stronger bonds among Care Group members, with other community members, and with community leaders. CONCLUSION Through increased theoretical and practical knowledge about important maternal and child health matters and through the social experience of obtaining this knowledge and sharing it with other community members, participation in the Care Group Approach empowered participants to make positive health behavior changes for themselves and for their children and families. This, in turn, led many participants to become more engaged in community activities for improved health and beyond, thereby enhancing social capital in the community. We conclude that the Care Group Approach, as applied in this setting, has made it possible for marginalized indigenous women living in a male-dominated society to become more empowered.
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Affiliation(s)
- Corey Gregg
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Mario Valdez
- Curamericas/ Guatemala, Calhuitz, San Sebastián Coatán, Huehuetenango, Guatemala
| | - Ira Stollak
- Curamericas Global, Raleigh, North Carolina, USA
| | - Shayanne Martin
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - William T Story
- Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Stollak I, Valdez M, Story WT, Perry HB. Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 8. Impact on women's empowerment. Int J Equity Health 2023; 21:200. [PMID: 36855052 PMCID: PMC9976544 DOI: 10.1186/s12939-022-01760-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Indigenous Maya women in the rural highlands of Guatemala have traditionally faced constraints to decision-making and participation in community affairs. Anecdotal experiences from previous Curamericas Global projects in Guatemala and Liberia have suggested that interventions using the CBIO+ Approach (which consists of implementing together the Census-Based, Impact-Oriented Approach, the Care Group Approach, and Community Birthing Centers), can be empowering and can facilitate improvements in maternal and child health. This paper, the eighth in a series of 10 papers examining the effectiveness of CBIO+ in improving the health and well-being of mothers and children in an isolated mountainous rural area of the Department of Huehuetenango, explores changes in women's empowerment among mothers of young children associated with the Curamericas/Guatemala Maternal and Child Health Project, 2011-2015. METHODS Knowledge, practice, and coverage (KPC) surveys and focus group discussions (FGDs) were used to explore six indicators of women's empowerment focusing on participation in health-related decision-making and participation in community meetings. KPC surveys were conducted at baseline (January 2012) and endline (June 2015) using standard stratified cluster sampling. Seventeen FGDs (9 with women, 3 with men, 2 with mothers-in-law, and 3 with health committees), approximately 120 people in all, were conducted to obtain opinions about changes in empowerment and to identify and assess qualitative factors that facilitate and/or impede women's empowerment. RESULTS The KPC surveys revealed statistically significant increases in women's active participation in community meetings. Women also reported statistically significant increases in rates of participation in health-related decision-making. Further, the findings show a dose-response effect for two of the six empowerment indicators. The qualitative findings from FGDs show that the Project accelerated progress in increasing women's empowerment though women still face major barriers in accessing needed health care services for themselves and their children. CONCLUSION The Project achieved some notable improvements in women's decision-making autonomy and participation in community activities. These improvements often translated into making decisions to practice recommended health behaviors. Traditional cultural norms and the barriers to accessing needed health services are not easily overcome, even when empowerment strategies are effective.
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Affiliation(s)
- Ira Stollak
- Curamericas Global, Raleigh, North Carolina, USA
| | - Mario Valdez
- Curamericas/Guatemala, Calhuitz, San Sebastián Coatán, Huehuetenango, Guatemala
| | - William T Story
- Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Story WT, Pyle DF. A blueprint for engaging communities to reduce inequities in maternal and child health: evidence from rural Guatemala. Int J Equity Health 2023; 21:151. [PMID: 36855138 PMCID: PMC9976359 DOI: 10.1186/s12939-022-01753-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Affiliation(s)
- William T Story
- Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City, Iowa, USA.
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Sarriot E, Story WT. On Learning About Efforts to Strengthen (and Reduce Harm to) Systems for Health. Health Policy Plan 2022; 37:535-538. [PMID: 35137084 DOI: 10.1093/heapol/czac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 01/03/2022] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
We comment on two embedded case studies of systems effects of successive mid-size projects looking back over 7-10 years, published in Health Policy and Planning. The papers examine humanitarian projects in Sudan and Pakistan and development projects (integrated Community Case Management) in Ethiopia, Malawi, and Mozambique. In this commentary, we summarize the two papers and discuss the overarching substantive and methodological lessons learned. In both development and humanitarian/emergency practice, projects navigate a dynamic space between gap-filling, systems support, and systems strengthening. In this, their contribution to systems strengthening depends heavily on the eco-system of government, development partners, and donors. Systems strengthening presents great challenges in definition, implementation, and measurement. Nonetheless, project implementers can and should renew their commitment to strengthening systems for health. This comes with a fundamental requirement for learning and evaluation.
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Affiliation(s)
- Eric Sarriot
- Formerly Save the Children, Department of Global Health, 899 North Capitol Street NE #900, Washington, DC 20002, USA
- Gavi, The Vaccine Alliance, Health Systems and Immunisation Strengthening Team, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva 1218, Switzerland
| | - William T Story
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N Riverside Dr, Iowa City, IA 52242, USA
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Osinuga A, Janssen B, Fethke NB, Story WT, Imaledo JA, Baker KK. Understanding Rural Women's Domestic Work Experiences (DWE) in Ibadan, Nigeria: Development of a Measurement Tool Using Confirmatory Factor Analysis. Int J Environ Res Public Health 2021; 18:ijerph182111043. [PMID: 34769564 PMCID: PMC8582860 DOI: 10.3390/ijerph182111043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/14/2021] [Accepted: 10/14/2021] [Indexed: 11/16/2022]
Abstract
Gender norms prescribe domestic labor as primarily a female's responsibility in developing countries. Many domestic tasks depend on access to water, so the physical, emotional, and time demands of domestic labor may be exacerbated for women living in water-insecure environments. We developed a set of domestic work experience (DWE) measures tailored to work in rural areas in developing countries, assessed rural Nigerian women's DWE, and examined relationships among the measures. Interviewer-administered survey data were collected between August and September from 256 women in four rural Nigerian communities. Latent factors of DWE were identified by analyzing survey items using confirmatory factor analysis. Pearson's correlation was used to examine relationships among latent factor scores, and multivariate linear regression models were used to determine if factor scores significantly differed across socio-demographic characteristics. The DWE measures consisted of latent factors of the physical domain (frequency of common domestic tasks, water sourcing and carriage, experience of water scarcity), the psychosocial domain (stress appraisal and demand-control), and the social domain (social support). Significant correlations were observed among the latent factors within and across domains. Results revealed the importance of measuring rural Nigerian women's DWE using multiple and contextual approaches rather than relying solely on one exposure measure. Multiple inter-related factors contributed to women's DWE. Water insecurity exacerbated the physical and emotional demands of domestic labor DWE varied across age categories and pregnancy status among rural Nigerian women.
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Affiliation(s)
- Abisola Osinuga
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, IA 52242, USA; (B.J.); (N.B.F.); (K.K.B.)
- Correspondence: ; Tel.: +1-3195126701
| | - Brandi Janssen
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, IA 52242, USA; (B.J.); (N.B.F.); (K.K.B.)
| | - Nathan B Fethke
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, IA 52242, USA; (B.J.); (N.B.F.); (K.K.B.)
| | - William T Story
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA 52242, USA;
| | - John A Imaledo
- Department of Health Promotion and Education, University of Ibadan, Ibadan 200212, Nigeria;
| | - Kelly K Baker
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, IA 52242, USA; (B.J.); (N.B.F.); (K.K.B.)
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Hasan MZ, Story WT, Bishai DM, Ahuja A, Rao KD, Gupta S. Does social capital increase healthcare financing's projection? Results from the rural household of Uttar Pradesh, India. SSM Popul Health 2021; 15:100901. [PMID: 34466652 PMCID: PMC8383105 DOI: 10.1016/j.ssmph.2021.100901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/23/2021] [Accepted: 08/19/2021] [Indexed: 11/19/2022] Open
Abstract
In the absence of adequate social security, out-of-pocket health expenditure compels households to adopt coping strategies, such as utilizing savings, selling assets, or acquiring external financial support (EFS) by borrowing with interest. Households' probability of acquiring EFS and its amount (intensity) depends on its social capital – the nature of social relationships and resources embedded within social networks. This study examines the effect of social capital on the probability and intensity of EFS during health events in Uttar Pradesh (UP), India. The analysis used data from a cross-sectional survey of 6218 households, reporting 3066 healthcare events, from two districts of UP. Household heads (HH) reported demographic, socioeconomic, and health-related information, including EFS, for each household member. Self-reported data from Shortened and Adapted Social Capital Assessment Tool in India (SASCAT-I) was used to generate four unique social capital measures (organizational participation, social support, trust, and social cohesion) at HH and community-level, using multilevel confirmatory factor analysis. After descriptive analysis, two-part mixed-effect models were implemented to estimate the probability and intensity of EFS as a function of social capital measures, where multilevel mixed-effects probit regression was used as the first-part and multilevel mixed-effects linear model with log link and gamma distribution as the second-part. Controlling for all covariates, the probability of acquiring EFS significantly increased (p = 0.04) with higher social support of the HH and significantly decreased (p = 0.02) with higher community social cohesion. Conditional to receiving any EFS, higher social trust of the HH resulted in higher intensity of EFS (p = 0.09). Social support and trust may enable households to cope up with financial stress. However, controlling for the other dimensions of social capital, high cohesiveness with the community might restrict a household's access to external resources demonstrating the unintended effect of social capital exerted by formal or informal social control. Social support assists household head to acquire external financing for healthcare payment. But higher social support may not secure higher intensity of receiving external financing. However, trust is a catalyst to acquire more financing conditional of any external financing was acquire in the first place. Living in a cohesive community may restrict access to external financial resources.
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Affiliation(s)
- Md Zabir Hasan
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Corresponding author. 2206 E Mall, Vancouver, BC V6T 1Z3, Canada.
| | - William T. Story
- Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, USA
| | - David M. Bishai
- Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Krishna D. Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shivam Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Story WT, Pritchard S, Hejna E, Olivas E, Sarriot E. The role of integrated community case management projects in strengthening health systems: case study analysis in Ethiopia, Malawi and Mozambique. Health Policy Plan 2021; 36:900-912. [PMID: 33930137 DOI: 10.1093/heapol/czaa177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 11/14/2022] Open
Abstract
Integrated community case management (iCCM) has now been implemented at scale globally. Literature to-date has focused primarily on the effectiveness of iCCM and the systems conditions required to sustain iCCM. In this study, we sought to explore opportunities taken and lost for strengthening health systems through successive iCCM programmes. We employed a systematic, embedded, multiple case study design for three countries-Ethiopia, Malawi and Mozambique-where Save the Children implemented iCCM programmes between 2009 and 2017. We used textual analysis to code 62 project documents on nine categories of functions of health systems using NVivo 11.0. The document review was supplemented by four key informant interviews. This study makes important contributions to the theoretical understanding of the role of projects in health systems strengthening by not only documenting evidence of systems strengthening in multi-year iCCM projects, but also emphasizing important deficiencies in systems strengthening efforts. Projects operated on a spectrum, ranging from gap-filling interventions, to support, to actual strengthening. While there were natural limits to the influence of a project on the health system, all successive projects found constructive opportunities to try to strengthen systems. Alignment with the Ministry of Health was not always static and simple, and ministries themselves have shown pluralism in their perspectives and orientations. We conclude that systems strengthening remains 'everybody's business' and places demands for realism and transparency on government and the development architecture. While mid-size projects have limited decision space, there is value in better defining where systems strengthening contributions can actually be made. Furthermore, systems strengthening is not solely about macro-level changes, as operational and efficiency gains at meso and micro levels can have value to the system. Claims of 'systems strengthening' are, however, bounded within the quality of evaluation and learning investments.
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Affiliation(s)
- William T Story
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Susannah Pritchard
- Formerly Save the Children, Health Department, 1 St. John's Lane, London EC1M 4AR, UK
| | - Emily Hejna
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Elijah Olivas
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Eric Sarriot
- Formerly Save the Children, Department of Global Health, 899 North Capitol St NE #900, Washington, DC 20002, USA
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Sarriot E, Olivas E, Khalsa S, Ashraf S, Hejna E, Hinds G, Story WT. Health systems effects of successive emergency health and nutrition projects: an embedded retrospective case study analysis in Sudan and Pakistan. Health Policy Plan 2021; 36:176-186. [PMID: 33462605 DOI: 10.1093/heapol/czaa096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2020] [Indexed: 01/23/2023] Open
Abstract
Despite increasing attention to the concept of a humanitarian-development nexus in recent years, limited research is available to improve health systems strengthening practice within humanitarian programmes. We used an exploratory, systematic, embedded, multiple case study design to discern systems effects of successive Save the Children chronic emergency health and nutrition projects implemented in Sudan and Pakistan between 2011 and 2018. We used textual analysis to code 63 documents focused on eight themes using NVivo 11.0. This was supplemented by six key informant interviews. Findings offer a complex and mixed picture, with contributions to systems strengthening in community systems, their linkages to health management structures, and human resources for health. Projects with primary mandates for urgent service delivery progressively found systems strengthening opportunities, through a combination of tacit choices and explicit objectives. In both countries, some 'parallel systems' were set in place initially, with immediate gains (e.g. quality of services) only occasionally accompanied by enhanced systems capacity to sustain them. Cycles of implementation, however, achieved financial transition of 'macro-costs' to the government (e.g. facilities in Sudan, staff in Pakistan) through indirect pathways and the influence of pluralistic governmental structures themselves. Opportunities were taken, or missed, based on dynamic relationships within the government-development partners eco-system. Transition steps also came with unintended effects and drops in intensity. Both project contributions to systems strengthening and our own study were limited by substantial gaps in evaluation and documentation processes. We provide cautious recommendations based on the literature and our two case studies. Even mid-size chronic emergency projects can and should make meaningful and explicit contributions to systems strengthening. This contribution will, however, depend on the development eco-system context, and development of better collective intelligence (coordination, evaluation and learning, benchmarking, accountability) to improve individual projects' adaptive management efforts to improve fit with evolving national systems.
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Affiliation(s)
- Eric Sarriot
- Save the Children, Department of Global Health, 899 North Capitol St NE #900, Washington, DC 20002, USA
| | - Elijah Olivas
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N Riverside Dr, Iowa City, IA 52242, USA
| | - Saraswati Khalsa
- Save the Children, Department of Global Health, 899 North Capitol St NE #900, Washington, DC 20002, USA
| | - Sarah Ashraf
- Save the Children, Department of Global Health, 899 North Capitol St NE #900, Washington, DC 20002, USA
| | - Emily Hejna
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N Riverside Dr, Iowa City, IA 52242, USA
| | - Givan Hinds
- Independent Consultant, 4553 Lake Chapin Shores, Berrien Springs, MI 49103, USA
| | - William T Story
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N Riverside Dr, Iowa City, IA 52242, USA
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Ajjarapu A, Story WT, Haugsdal M. Addressing Obstetric Health Disparities among Refugee Populations: Training the Next Generation of Culturally Humble OB/GYN Medical Providers. Teach Learn Med 2021; 33:326-333. [PMID: 33956548 DOI: 10.1080/10401334.2020.1813585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Issue: The burden of increasing obstetric morbidity and mortality in the United States disproportionately affects marginalized and vulnerable populations, including refugees. Many factors have been attributed to this disparity in birth outcomes, such as linguistic, cultural, and health system limitations. However, refugee health disparities have received little attention in the U.S., especially as it relates to the training of healthcare providers. Evidence: Poor obstetric outcomes among refugee communities have been historically attributed to delayed initiation of prenatal care, failure to detect co-morbidities, as well as higher rates of Cesarean sections in comparison to host-country mothers. These inequities are often linked to poor communication due to cultural misunderstandings, which ultimately leads to mistrust and reduced utilization of healthcare services. In 2017, a Midwest academic hospital, refugee community, and health system came together to form the Congolese Health Partnership (CHP). The CHP was formed to improve access to quality healthcare for expecting Congolese mothers and their families experiencing poor quality of obstetric care. Discussions that arose from this partnership identified issues of mistrust in healthcare providers within the community, worry about misjudgment and overuse of C-sections, and a lack of understanding about health insurance during pregnancy and childbirth. Therefore, it is apparent that understanding the contextual nuances that play a role in these poor outcomes among refugee communities in the U.S. is critical in order to narrow the healthcare gap. Implications: Since pregnancy and its surrounding events are intricately tied to the ways in which different societies define culture, we argue for a focus on culture when training future healthcare providers to work with refugees in the U.S. Specifically, we focus on the necessity of cultural humility, rather than cultural competence, when caring for obstetric patients from diverse backgrounds. Cultural humility forces providers to think about power imbalances that exist between a patient and provider when cultural differences exist. We describe specific barriers to care among Congolese refugees living in eastern Iowa and explore ways to utilize community-provider partnership and cultural humility training to address obstetric morbidity. Finally, we propose ways to incorporate cultural humility training among OB/GYN residents to address community-identified barriers to improve overall health outcomes locally with implications for refugee communities across the U.S.
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Affiliation(s)
- Avanthi Ajjarapu
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - William T Story
- Department of Community and Behavioral Health, University of Iowa, Iowa City, Iowa, USA
| | - Michael Haugsdal
- Department of Obstetrics and Gynecology, University of Iowa, Iowa City, Iowa, USA
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Story WT, Amare Y, Vaz LME, Gardner H, Tura H, Snetro G, Kinney MV, Wall S, Bekele A. Changes in attitudes and behaviors supportive of maternal and newborn health in Ethiopia: an evaluative case study. BMC Pregnancy Childbirth 2021; 21:407. [PMID: 34049509 PMCID: PMC8161997 DOI: 10.1186/s12884-021-03865-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/07/2021] [Indexed: 11/29/2022] Open
Abstract
Background Ethiopia’s high neonatal mortality rate led to the government’s 2013 introduction of Community-Based Newborn Care (CBNC) to bring critical prevention and treatment interventions closer to communities in need. However, complex behaviors that are deeply embedded in social and cultural norms continue to prevent women and newborns from getting the care they need. A demand creation strategy was designed to create an enabling environment to support appropriate maternal, newborn, and child health (MNCH) behaviors and CBNC. We explored the extent to which attitudes and behaviors during the prenatal and perinatal periods varied by the implementation strength of the Demand Creation Strategy for MNCH-CBNC. Methods Using an embedded, multiple case study design, we purposively selected four kebeles (villages) from two districts with different levels of implementation strength of demand creation activities. We collected information from a total of 150 key stakeholders across kebeles using multiple qualitative methods including in-depth interviews, focus group discussions, and illness narratives; sessions were transcribed into English and coded using NVivo 10.0. We developed case reports for each kebele and a final cross-case report to compare results from high and low implementation strength kebeles. Results We found that five MNCH attitudes and behaviors varied by implementation strength. In high implementation strength kebeles women felt more comfortable disclosing their pregnancy early, women sought antenatal care (ANC) in the first trimester, families did not have fatalistic ideas about newborn survival, mothers sought care for sick newborns in a timely manner, and newborns received care at the health facility in less than an hour. We also found changes across all kebeles that did not vary by implementation strength, including male engagement during pregnancy and a preference for giving birth at a health facility. Conclusions Findings suggest that a demand creation approach—combining participatory approaches with community empowering strategies—can promote shifts in behaviors and attitudes to support the health of mothers and newborns, including use of MNCH services. Future studies need to consider the most efficient level of intervention intensity to make the greatest impact on MNCH attitudes and behaviors. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03865-8.
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Affiliation(s)
- William T Story
- Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, 52242, USA.
| | - Yared Amare
- Independent Consultant, Addis Ababa, Ethiopia
| | - Lara M E Vaz
- Save the Children US, Washington, DC, 20001, USA
| | | | - Halkeno Tura
- Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, 52242, USA
| | - Gail Snetro
- Save the Children US, Washington, DC, 20001, USA
| | | | - Steve Wall
- Save the Children US, Washington, DC, 20001, USA
| | - Abeba Bekele
- Ethiopia Country Office, Save the Children International, Addis Ababa, Ethiopia
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Afifi RA, Abdulrahim S, Betancourt T, Btedinni D, Berent J, Dellos L, Farrar J, Nakkash R, Osman R, Saravanan M, Story WT, Zombo M, Parker E. Implementing Community-Based Participatory Research with Communities Affected by Humanitarian Crises: The Potential to Recalibrate Equity and Power in Vulnerable Contexts. Am J Community Psychol 2020; 66:381-391. [PMID: 32797639 DOI: 10.1002/ajcp.12453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Worldwide, over 70.8 million people are forcibly displaced from their homes as a result of persecution, conflict, violence, or human rights violation. In humanitarian crises, protection and the provision of basic needs are often prioritized. Research may be seen as opportunistic. However, without documenting and researching humanitarian responses, knowledge is not shared and does not accumulate, limiting the application of evidence-based interventions where they are most needed. Research in humanitarian crises is complex, both ethically and methodologically. Community-engaged research, and specifically community-based participatory research (CBPR), can address some of the challenges of research in these settings. Using case studies of research we have conducted with communities affected by humanitarian crises, we highlight challenges and opportunities of the application of the ten core principles of CBPR in humanitarian settings. Despite some challenges and barriers, CBPR is a highly effective approach to use when engaging these populations in research. We argue that the application of CBPR in these settings has the potential to recalibrate the scales of equity and power among vulnerable populations.
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Affiliation(s)
- Rima A Afifi
- Community and Behavioral Health Department, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Sawsan Abdulrahim
- Health Promotion and Community Health Department, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Theresa Betancourt
- Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA
| | - Dima Btedinni
- Health Promotion and Community Health Department, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Jenna Berent
- Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA
| | - Laura Dellos
- Obstetrics and Gynecology Department, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Jordan Farrar
- Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA
| | - Rima Nakkash
- Health Promotion and Community Health Department, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Rilwan Osman
- Maine Immigrant and Refugee Services, Lewiston, ME, USA
| | - Monisa Saravanan
- Community and Behavioral Health Department, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - William T Story
- Community and Behavioral Health Department, College of Public Health, University of Iowa, Iowa City, IA, USA
| | | | - Edith Parker
- Community and Behavioral Health Department, College of Public Health, University of Iowa, Iowa City, IA, USA
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Story WT, Tura H, Rubin J, Engidawork B, Ahmed A, Jundi F, Iddosa T, Abrha TH. Social capital and disaster preparedness in Oromia, Ethiopia: An evaluation of the “Women Empowered” approach. Soc Sci Med 2020; 257:111907. [DOI: 10.1016/j.socscimed.2018.08.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 08/09/2018] [Accepted: 08/23/2018] [Indexed: 10/28/2022]
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Tura HT, Story WT, Licoze A. Community-based savings groups, women's agency, and maternal health service utilisation: Evidence from Mozambique. Glob Public Health 2020; 15:1119-1129. [PMID: 32274971 DOI: 10.1080/17441692.2020.1751232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This study, using data collected as part of an ongoing programme evaluation, investigates whether participation in Saving Groups (SGs)-a community-owned microfinance intervention focused on poor households - is associated with maternal health service utilisation, and whether this association is mediated by women's agency - as measured by self-efficacy and decision-making autonomy. We compared maternal health service utilisation among SG members (n=105) and non-members (n=100) in rural Mozambique. We estimated prevalence ratios for SG membership and women's agency using Poisson regression while controlling for confounding factors. We also estimated mediation effects for women's agency. The results showed that SG membership is associated with four or more antenatal care (ANC) visits, skilled birth attendant (SBA) use, and postnatal care within 48 h of delivery. Self-efficacy mediated the relationship between SG membership and ANC vists and SBAuse, but not postnatal care; whereas women's decision-making autonomy mediated the relationship with SBA use and postnatal care, but not ANC visits. This study suggests that the impact of SG membership on use of maternal health services goes beyond improvements in household income and may operate through women's agency by giving women the ability to realize their preference for quality health care.
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Affiliation(s)
- Halkeno T Tura
- Department of Community and Behavioural Health, College of Public Health, University of Iowa, Iowa City, USA
| | - William T Story
- Department of Community and Behavioural Health, College of Public Health, University of Iowa, Iowa City, USA
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Hasan MZ, Leoutsakos JM, Story WT, Dean LT, Rao KD, Gupta S. Exploration of Factor Structure and Measurement Invariance by Gender for a Modified Shortened Adapted Social Capital Assessment Tool in India. Front Psychol 2019; 10:2641. [PMID: 31920771 PMCID: PMC6918543 DOI: 10.3389/fpsyg.2019.02641] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/08/2019] [Indexed: 11/23/2022] Open
Abstract
Social capital is defined as the nature of the social relationship between individuals or groups and the embedded resources available through their social network. It is considered as a critical determinant of health and well-being. Thus, it is essential to assess the performance of any tool when meaningfully comparing social capital between specific groups. Using measurement invariance (MI) analysis, this paper explored the factor structure of the social capital of men and women measured by a modified Shortened Adapted Social Capital Assessment Tool (SASCAT-I) in rural Uttar Pradesh (UP), India. The study sample comprised 5,287 men (18-101 years) and 7,186 women (15-45 years) from 6,218 randomly selected households who responded to SASCAT-I during a community-level cross-sectional survey. Social capital factor structure was examined by both exploratory and confirmatory factor analysis (CFA), and MI across genders was investigated using multigroup CFA. While disregarding gender, four unique factors (Organizational Participation, Social Support, Trust, and Social Cohesion) represented the structure of social capital. The MI analysis presented a partial metric-invariance indicating factor loadings for Organizational Participation and Social Support were the same across genders. The gender-stratified analysis demonstrated that a four-factor solution was best fitted for both men and women. Men and women of rural UP interpreted social capital differently as the perception of Trust and Social Cohesion varied across genders. For any future applications of SASCAT-I, we recommend gender-stratified factor analysis to quantify social capital's measure, acknowledging its multidimensionality.
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Affiliation(s)
- Md Zabir Hasan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - William T. Story
- Department of Community and Behavioral Health, The University of Iowa, Iowa City, IA, United States
| | - Lorraine T. Dean
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Krishna D. Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Shivam Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Story WT, Glanville JL. Comparing the association between social capital and self-rated health in poor and affluent nations. SSM Popul Health 2019; 9:100508. [PMID: 31998830 PMCID: PMC6978489 DOI: 10.1016/j.ssmph.2019.100508] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/25/2019] [Accepted: 10/27/2019] [Indexed: 10/25/2022] Open
Abstract
Country context has been shown to influence the association between social capital and health; however, few studies have examined how the level of societal affluence affects the relationship between social capital and health. Drawing on the study of individual-level socioeconomic variation in the returns to social capital by Uphoff and colleagues (2013), we examine two possible explanations about the differential impact of social capital on health based on country-level socioeconomic variation. The buffer hypothesis posits that social capital will have a greater benefit for poorer (versus more affluent) nations, whereas the dependency hypothesis suggests that social capital will be more beneficial in more affluent (versus poorer) nations. Using Waves 5 and 6 of the World Values Survey, we employed multilevel ordered logistic regression to examine whether national wealth moderates the association between social capital-as measured by particularized and generalized trust-and self-rated health across 72 countries. We also assessed five potential explanations for the moderating role of economic context based on the buffer and dependency hypotheses: institutional effectiveness, economic inequality, coverage of health services, human capital, and access to clean water and sanitation services. In support of the dependency hypothesis, we found that both particularized and generalized trust were associated with self-rated health to a greater extent in more affluent countries than in poorer countries; however, none of the potential explanations that we tested accounted for this pattern. Further, we found that particularized trust was more strongly associated with self-rated health compared to generalized trust across all countries. Future research should focus on the mechanisms by which economic context modifies the relationship between social capital and self-rated health.
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Affiliation(s)
- William T Story
- Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, 52242, USA
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Sacks E, Morrow M, Story WT, Shelley KD, Shanklin D, Rahimtoola M, Rosales A, Ibe O, Sarriot E. Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all. BMJ Glob Health 2019; 3:e001384. [PMID: 31297243 PMCID: PMC6591791 DOI: 10.1136/bmjgh-2018-001384] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 05/23/2019] [Accepted: 05/25/2019] [Indexed: 11/03/2022] Open
Abstract
Achieving ambitious health goals-from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of 'health for all'-necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers-particularly the well-known WHO 'building blocks' framework-only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.
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Affiliation(s)
- Emma Sacks
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Melanie Morrow
- Community Health Team, USAID Maternal and Child Survival Program/ICF, Washington, District of Columbia, USA
| | - William T Story
- Department of Community and Behavioral Health, University of Iowa, Iowa City, Iowa, USA
| | | | - D Shanklin
- CORE Inc, Washington, District of Columbia, USA
| | - Minal Rahimtoola
- Independent Health Systems Consultant, Boston, Massachusetts, USA
| | | | - Ochiawunma Ibe
- Community Health Team, USAID Maternal and Child Survival Program/ICF, Washington, District of Columbia, USA
| | - Eric Sarriot
- Global Health, Save the Children Federation Inc, Washington, District of Columbia, USA
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Baker KK, Story WT, Walser-Kuntz E, Zimmerman MB. Impact of social capital, harassment of women and girls, and water and sanitation access on premature birth and low infant birth weight in India. PLoS One 2018; 13:e0205345. [PMID: 30296283 PMCID: PMC6175511 DOI: 10.1371/journal.pone.0205345] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 09/24/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes. METHODS AND FINDINGS This cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification. CONCLUSIONS The relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affects PTB and LBW among Indian women. Interventions that reduce domestic responsibilities related to water and sanitation and change social norms related to gender-based harassment may reduce rates of PTB and LBW in India.
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Affiliation(s)
- Kelly K. Baker
- Department of Occupational and Environmental Health, University of Iowa College of Public Health, IA, United States of America
| | - William T. Story
- Department of Community and Behavioral Health, University of Iowa College of Public Health, IA, United States of America
| | - Evan Walser-Kuntz
- Department of Biostatistics, University of Iowa College of Public Health, IA, United States of America
| | - M. Bridget Zimmerman
- Department of Biostatistics, University of Iowa College of Public Health, IA, United States of America
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Story WT, LeBan K, Altobelli LC, Gebrian B, Hossain J, Lewis J, Morrow M, Nielsen JN, Rosales A, Rubardt M, Shanklin D, Weiss J. Institutionalizing community-focused maternal, newborn, and child health strategies to strengthen health systems: A new framework for the Sustainable Development Goal era. Global Health 2017; 13:37. [PMID: 28651632 PMCID: PMC5485706 DOI: 10.1186/s12992-017-0259-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/08/2017] [Indexed: 09/03/2023] Open
Abstract
Background Stronger health systems, with an emphasis on community-based primary health care, are required to help accelerate the pace of ending preventable maternal and child deaths as well as contribute to the achievement of the Sustainable Development Goals (SDGs). The success of the SDGs will require unprecedented coordination across sectors, including partnerships between public, private, and non-governmental organizations (NGOs). To date, little attention has been paid to the distinct ways in which NGOs (both international and local) can partner with existing national government health systems to institutionalize community health strategies. Discussion In this paper, we propose a new conceptual framework that depicts three primary pathways through which NGOs can contribute to the institutionalization of community-focused maternal, newborn, and child health (MNCH) strategies to strengthen health systems at the district, national or global level. To illustrate the practical application of these three pathways, we present six illustrative cases from multiple NGOs and discuss the primary drivers of institutional change. In the first pathway, “learning for leverage,” NGOs demonstrate the effectiveness of new innovations that can stimulate changes in the health system through adaptation of research into policy and practice. In the second pathway, “thought leadership,” NGOs disseminate lessons learned to public and private partners through training, information sharing and collaborative learning. In the third pathway, “joint venturing,” NGOs work in partnership with the government health system to demonstrate the efficacy of a project and use their collective voice to help guide decision-makers. In addition to these pathways, we present six key drivers that are critical for successful institutionalization: strategic responsiveness to national health priorities, partnership with policymakers and other stakeholders, community ownership and involvement, monitoring and use of data, diversification of financial resources, and longevity of efforts. Conclusion With additional research, we propose that this framework can contribute to program planning and policy making of donors, governments, and the NGO community in the institutionalization of community health strategies.
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Affiliation(s)
- William T Story
- The University of Iowa, College of Public Health, Iowa City, IA, USA.
| | - Karen LeBan
- Independent Consultant (formerly CORE Group), Washington, DC, USA
| | | | - Bette Gebrian
- University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Judy Lewis
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Melanie Morrow
- Maternal and Child Survival Program and ICF, Washington, DC and Rockville, MD, USA
| | | | | | - Marcie Rubardt
- Independent Consultant (formerly CARE USA), Vashon, WA, USA
| | - David Shanklin
- Independent Consultant (formerly CORE Group), Washington, DC, USA
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Story WT, Carpiano RM. Household social capital and socioeconomic inequalities in child undernutrition in rural India. Soc Sci Med 2017; 181:112-121. [DOI: 10.1016/j.socscimed.2017.03.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 03/16/2017] [Accepted: 03/19/2017] [Indexed: 11/29/2022]
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Pettit KA, Kundert JR, VanBuren JM, Story WT, Buresh CT. Close Together, Far Apart: an Assessment of the Public Health Needs of Three Geographically Proximate Communities in Central Haiti. J Health Care Poor Underserved 2017; 28:739-753. [DOI: 10.1353/hpu.2017.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Story WT, Barrington C, Fordham C, Sodzi-Tettey S, Barker PM, Singh K. Male Involvement and Accommodation During Obstetric Emergencies in Rural Ghana: A Qualitative Analysis. Int Perspect Sex Reprod Health 2016; 42:211-219. [PMID: 28825900 PMCID: PMC6771418 DOI: 10.1363/42e2616] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
CONTEXT Although men potentially play an important role in emergency obstetric care in Sub-Saharan Africa, few studies have examined the ways in which men are involved in such emergencies, the consequences of their involvement or the degree to which health facilities accommodate men. METHODS Qualitative interviews were conducted with 39 mothers and fathers in two districts in Northern and Central Ghana who had experienced obstetric emergencies, such as severe birth complications, to obtain narratives about those experiences. In addition, interviews with six health facility workers and eight focus group discussions with community members were conducted. Transcripts were analyzed using an inductive analytic approach. RESULTS Although some men had not been involved at all during their partner's obstetric emergency, two-thirds had provided some combination of financial, emotional and instrumental support. On the other hand, several men had acted as gatekeepers, and their control of resources and decisions had resulted in care-seeking delays. Although many respondents reported that health facilities accommodated male partners (e.g., by providing an appropriate space for men during delivery), others found that facilities were not accommodating, in some cases ignoring or disrespecting men. A few respondents had encountered improper staff expectations, notably that men would accompany their partner to the facility, a requirement that limits women's autonomy and delays care. CONCLUSIONS Policies and programs should promote supportive behavior by men during obstetric emergencies while empowering women. Health facility policies regarding accommodation of men during obstetric emergencies need to consider women's and men's preferences. Research should examine whether particular forms of support improve maternal and newborn health outcomes.
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Affiliation(s)
- William T Story
- assistant professor, Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA, USA,
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Abstract
Despite the growing evidence linking social capital to improvements in health and health behaviors, reliable measures of social capital are lacking in low-income countries. To accurately measure social capital in new contexts, there is a need to validate social capital survey questions in each new cultural setting. In this article, we examine the content validity of the measurement of social capital in Bangladesh using qualitative methods. In December 2012, we conducted four focus group discussions and 32 cognitive interviews in one rural subdistrict (Durgapur) and one urban slum (Mirpur). We used the findings from the focus groups and cognitive interviews to create a new social capital survey instrument that can be used by health and development organizations in Bangladesh. Furthermore, in this article, we provide insight into social capital survey research in general, including suggestions for the measurement of group membership, social support, collective action, and social trust.
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Affiliation(s)
- William T Story
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Fahmida Taleb
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - S M Monirul Ahasan
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Nabeel A Ali
- International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
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Speizer IS, Story WT, Singh K. Factors associated with institutional delivery in Ghana: the role of decision-making autonomy and community norms. BMC Pregnancy Childbirth 2014; 14:398. [PMID: 25427853 PMCID: PMC4247879 DOI: 10.1186/s12884-014-0398-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 11/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Ghana, the site of this study, the maternal mortality ratio and under-five mortality rate remain high indicating the need to focus on maternal and child health programming. Ghana has high use of antenatal care (95%) but sub-optimum levels of institutional delivery (about 57%). Numerous barriers to institutional delivery exist including financial, physical, cognitive, organizational, and psychological and social. This study examines the psychological and social barriers to institutional delivery, namely women's decision-making autonomy and their perceptions about social support for institutional delivery in their community. METHODS This study uses cross-sectional data collected for the evaluation of the Maternal and Newborn Referrals Project of Project Fives Alive in Northern and Central districts of Ghana. In 2012 and 2013, a total of 2,527 women aged 15 to 49 were surveyed at baseline and midterm (half in 2012 and half in 2013). The analysis sample of 1,606 includes all women who had a birth three years prior to the survey date and who had no missing data. To determine the relationship between institutional delivery and the two key social barriers-women's decision-making autonomy and community perceptions of institutional delivery-we used multi-level logistic regression models, including cross-level interactions between community-level attitudes and individual-level autonomy. All analyses control for the clustered survey design by including robust standard errors in Stata 13 statistical software. RESULTS The findings show that women who are more autonomous and who perceive positive attitudes toward facility delivery (among women, men and mothers-in-law) were more likely to deliver in a facility. Moreover, the interactions between autonomy and community-level perceptions of institutional delivery among men and mothers-in-law were significant, such that the effect of decision-making autonomy is more important for women who live in communities that are less supportive of institutional delivery compared to communities that are more supportive. CONCLUSIONS This study builds upon prior work by using indicators that provide a more direct assessment of perceived community norms and women's decision-making autonomy. The findings lead to programmatic recommendations that go beyond individuals and engaging the broader network of people (husbands and mothers-in-law) that influence delivery behaviors.
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Affiliation(s)
- Ilene S Speizer
- />Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
- />Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - William T Story
- />Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Kavita Singh
- />Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
- />Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
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Abstract
Research on the linkage between social capital and health has grown in recent years; however, there is a dearth of evidence from resource-poor countries. This review examines the association between social capital and physical health (including health behaviours) in the least developed countries (LDCs). Citations were searched using three databases from 1990 to 2011 using the keyword 'social capital' combined with the name of each of the 48 LDCs. Of the 14 studies reviewed, 12 took place in Africa and 2 in South Asia. All used cross-sectional study designs, including five qualitative and nine quantitative studies. The literature reviewed suggests that social capital is an important factor for improving health in resource-poor settings; however, more research is needed in order to determine the best measures for social capital and elucidate the mechanisms through which social capital affects health in the developing world. Future research on social capital and health in the developing world should focus on applying appropriate theoretical conceptualisations of social capital to the developing country context, adapting and validating instruments for measuring social capital, and examining multilevel models of social capital and health in developing countries.
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Affiliation(s)
- William T. Story
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, 48109-2029, USA Tel.: + 16163894437; Fax: + 17347644338;
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Story WT, Burgard SA. Couples' reports of household decision-making and the utilization of maternal health services in Bangladesh. Soc Sci Med 2012; 75:2403-11. [PMID: 23068556 DOI: 10.1016/j.socscimed.2012.09.017] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 07/17/2012] [Accepted: 09/13/2012] [Indexed: 10/27/2022]
Abstract
This study examines the association between maternal health service utilization and household decision-making in Bangladesh. Most studies of the predictors of reproductive health service utilization focus on women's reports; however, men are often involved in these decisions as well. Recently, studies have started to explore the association between health outcomes and reports of household decision-making from both husbands and wives as matched pairs. Many studies of household decision-making emphasize the importance of the wife alone making decisions; however, some have argued that joint decision-making between husbands and wives may yield better reproductive health outcomes than women making decisions without input or agreement from their partners. Husbands' involvement in decision-making is particularly important in Bangladesh because men often dominate household decisions related to large, health-related purchases. We use matched husband and wife reports about who makes common household decisions to predict use of antenatal and skilled delivery care, using data from the 2007 Bangladesh Demographic and Health Survey. Results from regression analyses suggest that it is important to consider whether husbands and wives give concordant responses about who makes household decisions since discordant reports about who makes these decisions are negatively associated with reproductive health care use. In addition, compared to joint decision-making, husband-only decision-making is negatively associated with antenatal care use and skilled delivery care. Finally, associations between household decision-making arrangements and health service utilization vary depending on whose report is used and the type of health service utilized.
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Affiliation(s)
- William T Story
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI 48109-2029, USA.
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Story WT, Burgard SA, Lori JR, Taleb F, Ali NA, Hoque DME. Husbands' involvement in delivery care utilization in rural Bangladesh: A qualitative study. BMC Pregnancy Childbirth 2012; 12:28. [PMID: 22494576 PMCID: PMC3364886 DOI: 10.1186/1471-2393-12-28] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 04/11/2012] [Indexed: 11/30/2022] Open
Abstract
Background A primary cause of high maternal mortality in Bangladesh is lack of access to professional delivery care. Examining the role of the family, particularly the husband, during pregnancy and childbirth is important to understanding women's access to and utilization of professional maternal health services that can prevent maternal mortality. This qualitative study examines husbands' involvement during childbirth and professional delivery care utilization in a rural sub-district of Netrokona district, Bangladesh. Methods Using purposive sampling, ten households utilizing a skilled attendant during the birth of the youngest child were selected and matched with ten households utilizing an untrained traditional birth attendant, or dhatri. Households were selected based on a set of inclusion criteria, such as approximate household income, ethnicity, and distance to the nearest hospital. Twenty semi-structured interviews were conducted in Bangla with husbands in these households in June 2010. Interviews were transcribed, translated into English, and analyzed using NVivo 9.0. Results By purposefully selecting households that differed on the type of provider utilized during delivery, common themes--high costs, poor transportation, and long distances to health facilities--were eliminated as sufficient barriers to the utilization of professional delivery care. Divergent themes, namely husbands' social support and perceived social norms, were identified as underlying factors associated with delivery care utilization. We found that husbands whose wives utilized professional delivery care provided emotional, instrumental and informational support to their wives during delivery and believed that medical intervention was necessary. By contrast, husbands whose wives utilized an untrained dhatri at home were uninvolved during delivery and believed childbirth should take place at home according to local traditions. Conclusions This study provides novel evidence about male involvement during childbirth in rural Bangladesh. These findings have important implications for program planners, who should pursue culturally sensitive ways to involve husbands in maternal health interventions and assess the effectiveness of education strategies targeted at husbands.
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Affiliation(s)
- William T Story
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI 48109-2029, USA.
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Einolf HJ, Story WT, Marcus CB, Larsen MC, Jefcoate CR, Greenlee WF, Yagi H, Jerina DM, Amin S, Park SS, Gelboin HV, Baird WM. Role of cytochrome P450 enzyme induction in the metabolic activation of benzo[c]phenanthrene in human cell lines and mouse epidermis. Chem Res Toxicol 1997; 10:609-17. [PMID: 9168260 DOI: 10.1021/tx960174n] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The environmental contaminant benzo[c]phenanthrene (B[c]Ph) has weak carcinogenic activity in rodent bioassays; however, the fjord region diol epoxides of B[c]Ph, B[c]Ph-3,4-diol 1,2-epoxides (B[c]PhDE), are potent carcinogens. To determine the role of cytochrome P450 isozymes in the activation of B[c]Ph in MCF-7 cells and the low activation of B[c]Ph in mouse skin, cells of the MCF-7 and the human hepatoma HepG2 cell lines were treated with the potent Ah receptor agonist 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) prior to exposure to B[c]Ph for 24 h. Mice were treated topically with 1 microg of TCDD or vehicle (control) for 73 h and then with 2 micromol of B[c]Ph for 24 h. In MCF-7 cells, TCDD exposure increased B[c]PhDE-DNA adduct levels more than 3-fold with a 10-fold increase in the (-)-B[c]PhDE-2-dA(t) adduct. Treatment of HepG2 cells with TCDD prior to B[c]Ph application did not increase B[c]PhDE-DNA binding. Total B[c]PhDE-DNA adducts increased 3-fold in TCDD-treated mouse epidermis: the majority of the increase resulted from (+)-B[c]PhDE-1-dA adducts. Analysis of P450 enzymes by Western blotting detected a large increase of P4501B1 but almost no increase in P4501A1 in MCF-7 cells exposed to 10 microM B[c]Ph for 24 or 48 h. In HepG2 cells, there were no detectable levels of P4501A1 or P4501B1 after treatment with 10 microM B[c]Ph for 24 h. In contrast, topical application of 2 micromol of B[c]Ph to mouse skin for 48 or 72 h increased P4501A1, but no P4501B1 was detected. As a measure of P450 activity, the metabolism of 7,12-dimethylbenz[a]anthracene (DMBA) was analyzed in microsomes prepared from MCF-7 and HepG2 cells exposed to 0.1% DMSO, 10 microM B[c]Ph, or 10 nM TCDD for 24 or 48 h and from mouse epidermis treated with 1 microg of TCDD, or vehicle control for 72 h, or 2 micromol of B[c]Ph for 48 h. The levels of DMBA metabolites were low or undetectable in microsomes from B[c]Ph-treated MCF-7 and HepG2 cells, but a metabolite pattern consistent with P4501A1 metabolism of DMBA was present in B[c]Ph-exposed mouse epidermal microsomes. TCDD-treated MCF-7 cells, HepG2 cells, and mouse epidermis had DMBA metabolism patterns characteristic of P4501A1 activity. Microsomes from TCDD-treated human cells formed a higher proportion of the proximate carcinogenic metabolite DMBA-3,4-dihydrodiol (16% of total identified metabolites) than TCDD-treated mouse epidermis (2%). In mouse epidermis, the weak ability of B[c]Ph to increase hydrocarbon-metabolizing activity and the increase in mainly P4501A1, leading to formation of the less carcinogenic stereoisomer B[c]PhDE-1, may explain the low carcinogenic activity of B[c]Ph. In a human mammary carcinoma cell line, treatment with B[c]Ph increases mainly P4501B1 and results in formation of a higher proportion of the more carcinogenic B[c]PhDE-2. This indicates that cells in which B[c]Ph treatment increases P4501B1 levels effectively activate B[c]Ph to potent carcinogenic metabolites.
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Affiliation(s)
- H J Einolf
- Department of Medicinal Chemistry & Molecular Pharmacology, Purdue University, West Lafayette, Indiana 47907, USA
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