The rite of passage of becoming a humanitarian health worker: experiences of retention in Sweden.

BACKGROUND: Low retention of humanitarian workers poses constraints on humanitarian organisations' capacity to respond effectively to disasters. Research has focused on reasons for humanitarian workers leaving the sector, but little is known about the factors that can elucidate long-term commitment. OBJECTIVE: To understand what motivates and supports experienced humanitarian health workers to remain in the sector. METHODS: Semi-structured interviews were conducted with 10 experienced nurses who had been on at least three field missions with Médecins Sans Frontières Sweden. Interviews explored factors influencing the decision to go on missions, how nurses were supported and how they looked back on those experiences. Transcripts were analysed through content analysis informed by van Gennep's concept of 'Rite of Passage', combined with elements of the self-determination theory. RESULTS: The findings indicate that their motivations and how nurses thought of themselves, as individuals and professionals, changed over time. For initiation and continued engagement in humanitarian work, participants were motivated by several personal and professional ambitions, as well as altruistic principles of helping others. When starting their first humanitarian missions, nurses felt vulnerable and had low self-esteem. However, through experiencing feelings of autonomy, competence and relatedness during missions, they underwent a process of change and gradually adjusted to new roles as humanitarian health workers. Reintegration in their home community, while maintaining the new roles and skills from the missions, proved very challenging. They individually found their own ways of overcoming the lack of social support they experienced after missions in order to sustain their continuation in the sector. CONCLUSIONS: The findings highlight the importance of social environments that facilitate and support the adjustment of individuals during and after field missions. Learning from positive examples, such as nurses with several years of experience, can strengthen strategies of retention, which can ultimately improve the delivery of humanitarian assistance.

Health care workers' perceptions of point-of-care testing in a low-income country-A qualitative study in Southwestern Uganda.

BACKGROUND: Point-of-care (POC) tests have become increasingly available and more widely used in recent years. They have been of particular importance to low-income settings, enabling them with clinical capacities that had previously been limited. POC testing programs hold a great potential for significant improvement in low-income health systems. However, as most POC tests are developed in high-income countries, disengagement between developers and end-users inhibit their full potential. This study explores perceptions of POC test end-users in a low-income setting, aiming to support the development of novel POC tests for low-income countries. METHODS: A qualitative study was conducted in Mbarara District, Southwestern Uganda, in October 2014. Fifty health care workers were included in seven focus groups, comprising midwives, laboratory technicians, clinical and medical officers, junior and senior nurses, and medical doctors. Discussions were audio-recorded and transcribed verbatim. Transcripts were coded through a data-driven approach for qualitative content analysis. RESULTS: Nineteen different POC tests were identified as currently being in use. While participants displayed being widely accustomed to and appreciative of the use of POC tests, they also assessed the use and characteristics of current tests as imperfect. An ideal POC test was characterized as being adapted to local conditions, thoughtfully implemented in the specific health system, and capable of improving the care of patients. Tests for specific medical conditions were requested. Opinions differed with regard to the ideal distribution of POC tests in the local health system. CONCLUSION: POC tests are commonly used and greatly appreciated in this study setting. However, there are dissatisfactions with current POC tests and their use. To maximize benefit, stakeholders need to include end-user perspectives in the development and implementation of POC tests. Insights from this study will influence our ongoing efforts to develop POC tests that will be particularly usable in low-income settings.

Experience of intimate partner violence among young pregnant women in urban slums of Kathmandu Valley, Nepal: a qualitative study.

BACKGROUND: Intimate partner violence (IPV) is an urgent public health priority. It is a neglected issue in women's health, especially in urban slums in Nepal and globally. This study was designed to better understand the IPV experienced by young pregnant women in urban slums of the Kathmandu Valley, as well as to identify their coping strategies, care and support seeking behaviours. Womens' views on ways to prevent IPV were also addressed. METHODS: 20 young pregnant women from 13 urban slums in the Kathmandu valley were recruited purposively for this qualitative study, based on pre-defined criteria. In-depth interviews were conducted and transcribed, with qualitative content analysis used to analyse the transcripts. RESULTS: 14 respondents were survivors of violence in urban slums. Their intimate partner(s) committed most of the violent acts. These young pregnant women were more likely to experience different forms of violence (psychological, physical and sexual) if they refused to have sex, gave birth to a girl, or if their husband had alcohol use disorder. The identification of foetal gender also increased the experience of physical violence at the prenatal stage. Interference from in-laws prevented further escalation of physical abuse. The most common coping strategy adopted to avoid violence among these women was to tolerate and accept the husbands' abuse because of economic dependence. Violence survivors sought informal support from their close family members. Women suggested multiple short and long term actions to reduce intimate partner violence such as female education, economic independence of young women, banning identification of foetal gender during pregnancy and establishing separate institutions within their community to handle violence against young pregnant women. CONCLUSIONS: Diversity in the design and implementation of culturally and socially acceptable interventions might be effective in addressing violence against young pregnant women in humanitarian settings such as urban slums. These include, but are not limited to, treatment of alcohol use disorder, raising men's awareness about pregnancy, addressing young women's economic vulnerability, emphasising the role of health care professionals in preventing adverse consequences resulting from gender selection technologies and working with family members of violence survivors.

Changes in pregnancy and childbirth practices in remote areas in Lao PDR within two generations of women: implications for maternity services.

This paper sheds light on the inter-generational changes in pregnancy and childbirth practices in remote areas of Lao PDR over a period of 30 years. The study consisted of focus group discussions with pregnant women aged 14-30, mothers and fathers of small children, and older women aged 40+ in six rural communities in two districts. Childbirth practices were gradually evolving and changing - most dramatically illustrated by the transition from forest-based to home-based delivery, and a few health facility-based deliveries when complications occurred. Today's generation of women aged 40+ did not recommend all the practices of their mothers, but saw the need to adapt due to the social and medical risks they had experienced, especially high rates of neonatal death. Their daughters are doing the same. The increase in home-based deliveries should be regarded as significant progress in this setting in rural Laos. Understanding how young women interpret their options and incorporating that knowledge and the experience of successful local outreach programmes into health system policy and practice for maternity care, e.g. by strengthening the skills of community-based health workers, could contribute to improving maternal and neonatal survival and reducing health inequalities.

Coping with uncertainty during healthcare-seeking in Lao PDR.

BACKGROUND: Uncertainty is regarded as a central dimension in the experience of illness and in the processes of alleviating it. Few studies from resource-poor settings have investigated this and how it interacts with other factors. This study aims to shed light on how healthcare-seeking develops in the context of multiple medical alternatives and to understand what bearing uncertainty has on this process. METHODS: The study was conducted in six purposively selected rural communities in Lao PDR. In each community, two focus group discussions were held: first with mothers and then with fathers of children younger than five years old. Eleven in-depth interviews with caregivers of severely sick children were conducted. Subsequently, traditional healers, drug vendors, community health workers, nurses and medical doctors were recruited for interviews or group discussions. The data were transcribed and key themes and similarities were identified. Additional readings were conducted to better understand the interactions of factors during which uncertainty was identified as one of several factors mentioned during interviews and focus group discussions. RESULTS: Care-seekers expressed a strong preference for initially seeking local providers. Subsequently, multiple providers were consulted to increase the chances of recovery. This resulted in patients leaving the health facilities before recovery and in ending the recommended treatment regime prematurely. These healthcare-seeking decisions reflect the social significance of being a responsible caregiver and of showing respect for household norms. In general, healthcare-seeking was shrouded in uncertainty when it came to selecting the right provider, the likelihood of finding the real cause of the illness, spending savings on treatments and ultimately the likelihood of recovery. CONCLUSIONS: Care-seekers' initial strong preference for local providers irrespective of the providers' legitimacy indicates the need for a robust primary healthcare system. Care-seekers' subsequent consultations must be understood in the light of their uncertainty regarding the skills of the available providers. The social connotations of seeking healthcare including the vulnerability of poor households in public health facilities were taken into account to only a limited extent by health workers. Health workers should have greater awareness of the social and cultural aspects of seeking care.

Shaping healthcare-seeking processes during fatal illness in resource-poor settings. A study in Lao PDR.

BACKGROUND: There are profound social meanings attached to bearing children that affect the experience of losing a child, which is akin to the loss of a mother in the household. The objective of this study is to comprehend the broader processes that shape household healthcare-seeking during fatal illness episodes or reproductive health emergencies in resource-poor communities. METHODS: The study was conducted in six purposively selected poor, rural communities in Lao PDR, located in two districts that represent communities with different access to health facilities and contain diverse ethnic groups. Households having experienced fatal cases were first identified in focus group discussions with community members, which lead to the identification of 26 deaths in eleven households through caregiver and spouse interviews. The interviews used an open-ended anthropological approach and followed a three-delay framework. Interpretive description was used in the data analysis. RESULTS: The healthcare-seeking behavior reported by caregivers revealed a broad range of providers, reflecting the mix of public, private, informal and traditional health services in Lao PDR. Most caregivers had experienced multiple constraints in healthcare-seeking prior to death. Decisions regarding care-seeking were characterized as social rather than individual actions. They were constrained by medical costs, low expectations of recovery and worries about normative expectations from healthcare workers on how patients and caregivers should behave at health facilities to qualify for treatment. Caregivers raised the difficulties in determining the severity of the state of the child/mother. Delays in reaching care related to lack of physical access and to risks associated with taking a sick family member out of the local community. Delays in receiving care were affected by the perceived low quality of care provided at the health facilities. CONCLUSIONS: Care-seeking is influenced by family- and community-based relations, which are integrated parts of people's everyday life. The medical and normative responses from health providers affect the behavior of care-seekers. An anthropological approach to capture the experience of caregivers in relation to deciding, seeking and reaching care reveals the complexity and socio-cultural context surrounding maternal and child mortality and has implications for how future mortality data should be developed and interpreted.