'The System is Not Set up for the Benefit of Women': Women's Experiences of Decision-Making During Pregnancy and Birth in Ireland.

In this article, I draw on in-depth qualitative interviews with 23 women, conducted in 2019/2020, focusing on their involvement in decision-making during pregnancy and birth. The study is located in Ireland, where comparably progressive national policies regarding informed choice in labour and birth clash with the day-to-day reality of a heavily medicalised, paternalistic maternity care system. I represent the subjective experiences of a diverse group of women through in-depth interview excerpts. In my analysis, I move beyond describing what is happening in the Irish maternity system to discussing why this is happening - relating the findings of the research to the international literature on authoritative knowledge, technocratic hospital cultures and risk-based discourses around birth. In the last section of the article, I offer concrete, empirically grounded and innovative recommendations how to enhance women's involvement in decision-making.

Barriers to the use of trained interpreters in consultations with refugees in four resettlement countries: a qualitative analysis using normalisation process theory.

BACKGROUND: Increasing numbers of primary care practitioners in refugee resettlement countries are providing care to refugees. Access to trained interpreters is a priority for these practitioners, but there are many barriers to the implementation of interpreted consultations in routine care. There is a lack of international, theoretically informed research. The purpose of this paper is to understand barriers to interpreter use in primary care consultations in four resettlement countries using Normalisation Process Theory. METHOD: We conducted a cross-sectional online survey with networks of primary care practitioners (PCPs) who care for refugees in Australia, Canada, Ireland and the US (n = 314). We analysed qualitative data from the survey about barriers to interpreter use (n = 178). We completed an inductive thematic analysis, iteratively developed a Normalisation Process Theory (NPT)-informed coding frame and then mapped the emergent findings onto the theory's construct about enacting interpreted consultations. RESULTS: In all four countries, the use of an interpreter presented communication and interaction challenges between providers and patients, which can impede the goals of primary care consultations. Primary care practitioners did not always have confidence in interpreted consultations and described poor professional practice by some interpreters. There was variation across countries, and inconsistency within countries, in the availability of trained interpreters and funding sources. CONCLUSION: There are shared and differential barriers to implementation of interpreted consultations in a consistent and sustained way in the four countries studied. These findings can be used to inform country-specific and international level policies and interventions focusing on improving skills and resources for interpreted consultations to improve implementation of interpreted primary care consultations.

Sex work and condom use in Soweto, South Africa: a call for community-based interventions with clients.

Despite public health interventions targeting sex workers in an attempt to increase condom use, HIV still remains a significant health issue for those involved in the sex industry in many countries. In this paper, we analyse data collected as part of an ethnographic study of sex work in Soweto, South Africa. We show that the main problems with consistent condom use are clients who threaten violence if sex workers insist on condoms, clients who are 'rough' and refuse to stop intercourse when the condom breaks, and clients who offer to pay more money for unprotected sex. These issues relate to unequal gender norms that disempower female sex workers and dismiss the importance of consent in sexual relationships. The criminalisation of sex work increases vulnerability and reduces sex workers' agency as sex workers are reluctant to report crimes committed against them. Persistent 'whore stigma' adds to this dynamic by dehumanising sex workers. In conclusion, we advocate for decriminalisation and posit that public health interventions aimed at increasing condom use and reducing HIV rates need to specifically engage clients, address unequal gender norms and involve local communities to tackle stigma directed against sex workers.

Challenges with seeking HIV care services: perspectives of older adults infected with HIV in western Kenya.

BACKGROUND: While younger adults (15-49 years) form the majority of the population living with HIV, older adults (≥50 years) infected with HIV face multiple challenges related to the aging process and HIV. We explored the experiences of older persons infected with HIV at the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya to understand the challenges faced when seeking HIV care services. METHODS: Between November 2016 and April 2017, a total of 57 adults aged 50 years and above were recruited from two AMPATH facilities - one rural and one urban facility. A total of 25 in-depth interviews and four focus group discussions were conducted, audio-recorded, transcribed and thematic analysis performed. RESULTS: Study participants raised unique challenges with seeking HIV care that include visits to multiple healthcare providers to manage HIV and comorbidities and as a result impact on their adherence to medication and clinical visits. Challenges with inadequate quality of facilities and poor patient-provider communication were also raised. Participants' preference for matched gender and older age for care providers that serve older patients were identified. CONCLUSION: Results indicate multiple challenges faced by older adults that need attention in ensuring continuous engagement in HIV care. Targeted HIV care for older adults would, therefore, significantly improve their access to and experience of HIV care. Of key importance is the integration of other chronic diseases into HIV care and employing staff that matches the needs of older adults.

HIV testing and counselling experiences: a qualitative study of older adults living with HIV in western Kenya.

BACKGROUND: Finding HIV infected persons and engaging them in care is crucial in achieving UNAIDS 90-90-90 targets; diagnosing 90% of those infected with HIV, initiating 90% of the diagnosed on ART and achieving viral suppression in 90% of those on ART. To achieve the first target, no person should be left behind in their access to HIV testing services. In Kenya, HIV prevention and testing services give less emphasis on older adults. This article describes HIV testing experiences of older adults living with HIV and how their age shaped their interaction and treatment received during HIV testing and diagnosis. METHODS: We conducted a qualitative study in two HIV clinics (rural and urban) in western Kenya, and recruited 57 HIV infected persons aged ≥50 years. We conducted in depth interviews (IDIs) with 25 participants and 4 focus group discussions (FGDs) with a total of 32 participants and audio recorded all the sessions. Participants recruited were aged between 54 and 79 years with 43% being females. We transcribed audio records and analyzed the data using thematic content analysis method. RESULTS: Older persons' experiences with HIV testing depended on where they tested (hospital or community setting); whether they actively sought the testing or not; and the age and gender of the healthcare provider who conducted the test. Participants expressed concerns with ageist discrimination when actively seeking HIV care testing services in hospital settings, characterized by providers' reluctance or refusal to test. The testing and counseling sessions were described as short and hurried within the hospital settings, whereas the interactions with service providers in home-based testing were experienced as appropriate and supportive. Participants in this study expressed preference for healthcare providers who were older and of similar gender. CONCLUSION: HIV testing services are still not tailored to target older adults' needs in our setting resulting in late diagnosis among older persons. We argue that a scale-up of community level testing services that provide adequate testing and counselling time and actively reach out to older adults is key to attaining the UNAIDS targets of having 90% of PLWH know their status.

Subjective health of undocumented migrants in Germany - a mixed methods approach.

BACKGROUND: Health of migrants is known to be above-average in the beginning of the migration trajectory. At the same time reports from non-government organisations (NGOs) suggest that undocumented migrants in Germany tend to present late and in poor health at healthcare facilities. In this paper, we explore the health status of undocumented migrants with a mixed method approach including complementary qualitative and quantitative datasets. METHODS: Undocumented migrants attending a NGO based in Hamburg, Germany, were asked to fill in the SF-12v2, a standardized questionnaire measuring health-related quality of life (HRQOL). The SF-12v2 was analyzed in comparison to the U.S. American norm sample and a representative German sample. Differences in mean scores for HRQOL were evaluated with a t-test and with a generalized linear model analyzing the impact of living without legal status on HRQOL. The quantitative research was complemented by a qualitative ethnographic study on undocumented migration and health in Berlin, Germany. The study included semi-structured interviews, informal conversations and participant observation with Latin American migrants over the course of three years. The study focused on subjective experiences of illness and health and the impact of illegality on migrants' health and access to health care. RESULTS: HRQOL was significantly worse in the sample of undocumented migrants (n = 96) as compared to the U.S. American sample (p < 0.005). Living without legal status displayed a significant negative effect on subjective mental and physical health (p ≤ 0.003) in the generalized linear model when adjusted for age and gender compared to the representative German population sample. The ethnographic study, which included 35 migrants, identified socio-economic conditions, the subjective experiences of criminalization, and late presentation at healthcare-facilities as the three main factors impacting on health from migrant perspective. DISCUSSION: The present research suggests a high morbidity and mortality in this comparatively young population. The ethnographic research confirms negative impacts on health of social determinants in general and stress associated with living without legal status in particular, both are further aggravated by exclusion from health care services. In addition to the provision of health care it appears to be important to structurally tackle the underlying social conditions which affect undocumented migrants' health. CONCLUSIONS: Living without legal status has a negative impact on health and well-being. Limited access to care may further exacerbate physical and mental illness. Possibilities to claim basic rights and protection as well as access to care without legal status appear to be important measures to improve health and well-being.

Service User and Service Provider Perceptions of Enablers and Barriers for Refugee and Asylum-Seeking Women Accessing and Engaging with Perinatal Mental Health Care Services in the WHO European Region: A Scoping Review Protocol.

There is a need to understand the specific perinatal mental health care needs of migrant subgroups who often have differing health care needs and specific barriers to accessing and engaging with health care services. It is important to have evidence about the WHO European context given the rising numbers of refugees and asylum seekers in the region. The aim of this scoping review is to map the factors that enable and prevent access and engagement of refugee and asylum-seeking women with perinatal mental health care services in the WHO European Region, from the perspectives of service providers and service users. The database search will include PsycINFO, Cochrane, Web of Science, MEDLINE, EMBASE, CINAHL complete, Scopus, Academic Search Complete, and Maternity and Infant Care (OVID). Search results will be exported to an online tool that provides a platform to help manage the review process, including title, abstract, and full-text screening and voting by reviewers independently. Data concerning access and engagement with health care services will be mapped on to the candidacy framework. Systematically searching evidence within the WHO European region and examining this evidence through the candidacy lens will help develop a more comprehensive and a deeper conceptual understanding of the barriers and levers of access and engagement with perinatal mental health care services, whilst identifying gaps in existing evidence. Exploring factors that influence access and engagement for refugee and asylum-seeking women from the perspective of key stakeholders in the service provision and/or service utilisation of perinatal mental health care services will add a more comprehensive understanding of the recursive relationship between service provision and use.

Perinatal mental health in Ireland: A scoping review.

BACKGROUND: The international literature clearly indicates that perinatal mental health issues affect many women, and can have profound negative consequences for both the mother, infant and family, and that the causes of perinatal mental health issues are multifaceted and complex. AIM: This scoping review explores the existing research on perinatal mental health in Ireland to provide a baseline and to guide further research as well as inform the implementation of the recent policy strategies. DESIGN: Scoping Review METHODS: We conducted a structured literature search on Science Direct, Web of Science, PubMed, PsychInfo and Scopus, using key words to search for publications up to December 2018. All publications based on empirical studies on perinatal mental health in Ireland (regardless of research design, sample size, and methods used) were included. Exclusion criteria were: study location not the Republic of Ireland; not relating to the perinatal period (pregnancy up to the first 12 months after birth); not relating to mental health; and not relating to maternal mental health, not relating to human subjects; not an empirical study; international study with generalised results. Data were mapped onto a charting form, allowing us to a) conduct a basic numerical analysis of prevalent research questions and designs, and b) to identify key themes within the data, utilising Braun and Clarke's (2006) thematic analysis. RESULTS: The search resulted in 623 unique references. 29 publications were included in this review. Our analysis resulted in three main findings. (1) A significant number of women in Ireland are affected by perinatal mental health problems, but prevalence rates vary significantly between studies. (2) A history of mental health problems and lack of social support were identified as key risk factors. (3) The existing perinatal mental health services in Ireland are generally inadequate. We further noted a focus on quantitative approaches and a medicalisation of perinatal mental health, resulting in an absence of women's voices and their lived experiences, particularly those of women of colour, migrant women and ethnic minorities. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: We conclude that in order to further the vision of woman-centred maternity care, we need to conduct woman-centred research that puts women's subjective experiences of perinatal mental health and well-being at the centre, including those of marginalised women in an increasingly diverse Irish society.

Empowering sex workers? Critical reflections on peer-led risk-reduction workshops in Soweto, South Africa.

Background: Sex workers in South Africa face various forms of structural and interpersonal violence, including police violence, exclusion from health services, and stigmatization and marginalization within their communities. In an attempt to counteract the harmful health effects of criminalization and exclusion, risk-reduction workshops are a key component of HIV prevention programs globally. This paper offers a critical investigation of Creative Space workshops - a South African model of risk-reduction workshops for sex workers - taking place in Soweto, Johannesburg. Drawing on Paulo Freire's work, the paper explores the potential of these workshops to contribute to the empowerment, health and well-being of sex workers. Objectives: The aim of this paper is to investigate the social and psychological effects of peer-led risk-reduction workshops for sex workers in Soweto, South Africa, with a particular focus on the ways in which they might contribute to community empowerment. Methods: This paper is based on in-depth interviews and focus group discussions with 32 sex workers conducted as part of a 20-month ethnographic study (December 2015 to July 2017). Data was analyzed combining inductive thematic analysis with a theoretical frame based on Freire's theory of community empowerment. Results: Peer-led risk-reduction workshops can serve as a 'safe space' for sex workers and distribute empowering forms of knowledge, particularly regarding health issues and rights. However, divisions between different groups of sex workers and between sex workers and non-sex workers counteract the potential benefits of the workshops. Conclusions: Peer-led sex worker programs are likely to be more empowering when they are committed to raising critical consciousness and creating solidarity, and embedded in community action, focusing on common issues such as institutionalized racism, livelihood insecurity, and lack of access to safe and secure housing. Such actions would have positive outcomes on health and well-being.

Giving back: activist research with undocumented migrants in Berlin.

In this article, I draw on my doctoral field work in Berlin (2008-2010), on the illness experiences of undocumented Latin American labor migrants, and on my work as an activist for the Berlin-based nongovernmental organization Medibüro, an anti-racist migrant health organization. I highlight how my attempts to 'give back,' and the various forms of engagements and commitments that resulted from it, shaped my relationships with actors in the field, the data I gathered, and the analytical framework I employed. I offer solutions on how to address these (unintended) effects of activism, and highlight the unique potential of activist research in regard to the forms of data available to the researcher and in gaining and retaining field access. By probing into some of its concrete methodological and analytical implications, I explore how to do activist research.

Performing deservingness. Humanitarian health care provision for migrants in Germany.

In this paper, I critically investigate humanitarian aid for migrant populations in Germany. I aim to enhance the existing literature on migrant deservingness and humanitarian aid by focusing on the performative aspects of concrete face-to-face interactions between physicians/volunteers and patients. I argue that despite efforts of volunteers to provide non-discriminatory care, the encounters between patients as aid-receivers and volunteers/physicians as aid-providers are inevitably shaped by power inequalities. These immanent power inequalities may lead patients to perform their deservingness, that is, to present themselves as helpless sufferers rather than empowered subjects. Simultaneously, patient-solicitants are prevented from feeling and enacting a sense of entitlement. Those patients who do not heed to the social mechanisms of humanitarian aid, such as being thankful and humble, cause disenchantment on the side of some medical professionals who provide care as part of humanitarian networks and subsequently, they may be turned away. The research project focused on the migration trajectories and illness experiences of undocumented Latin American migrants and their access to healthcare. The analysis draws on my long-term ethnographic fieldwork with 35 Latin American migrants in Berlin (2008-2011), 22 interviews with healthcare providers, and my experience as an activist/volunteer for a Berlin-based humanitarian NGO (2008-2012).