Diagnosing norms and norm change in rural Bangladesh: an exploration of gendered social norms and women's empowerment.

BACKGROUND: Gender-transformative public health programs often aim to address power inequities between men and women and promote women's empowerment. However, to achieve transformative change, it is necessary to first identify the underlying norms that perpetuate these power imbalances. The objective of our study was to use Bicchieri's theory of social norms and model of norm change to identify gendered norms and evidence of norm change amongst participants of the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) trial in rural Sylhet Division, Bangladesh. METHODS: We conducted ten life history interviews, 16 key informant interviews, and four focus group discussions with women and men in communities within the FAARM study site in rural, north-eastern Bangladesh. We performed a thematic analysis as well as a relational analysis of the data. RESULTS: We found that social norms dictated the extent and ways in which women participated in household decisions, the locations they could visit, and their autonomy to use household resources. We also found evidence of changes to gendered social norms over time and the desire amongst some men and women to abandon restrictive norms. Certain intersecting factors, such as education and employment, were identified as facilitators and barriers to women's empowerment and the related gendered expectations. CONCLUSIONS: Our findings corroborate existing norms literature, which highlights the strong role social norms play in influencing women's empowerment and behaviour. Our study provides an example of rigorous qualitative methodology that others may follow to assess gendered social norms that can be targeted for transformative change.

Chronic Stress and Preconception Health Among Latina Women in Metro Atlanta.

BACKGROUND: Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta. DESIGN: We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma. RESULTS: Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2-1.1)). CONCLUSIONS: Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.

PrEP and sexual well-being: a qualitative study on PrEP, sexuality of MSM, and patient-provider relationships.

Most new diagnoses of HIV in the United States are among men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) is a medication that mitigates risk of HIV acquisition and requires regular STI testing and prescription refills with PrEP providers. Because PrEP care monitors sexual behavior, there is a need to understand how PrEP providers approach sexual health care for MSM patients. In this study, semi-structured qualitative interviews were conducted with 20 MSM in Atlanta, Georgia with current or past prescriptions for PrEP. Data were analyzed with thematic analysis using four major steps: (1) code and codebook development, (2) assigning codes to segments of interviews, (3) code-based and comparative analysis methods, and (4) developing thematic findings. Findings from interviews about changes in sexuality while using PrEP include decreased anxiety surrounding sex, increased feelings of control over personal health, and experiencing less stigma towards sexual partners with HIV. Participants indicated needs for tailored health advice based on individual sexual preferences, sexual health care free from stereotypical assumptions, and improved access to PrEP providers identifying as gay men or who practice in LGBT-friendly settings. Study findings support a call for a gain-frame approach to sexual health in PrEP care for MSM.

Neonatal care and community-level treatment seeking for possible severe bacterial infection (PSBI) in Amhara, Ethiopia.

BACKGROUND: In Ethiopia, neonatal mortality accounts for approximately 54% of under-five deaths with the majority of these deaths driven by infections. Possible Severe Bacterial Infection (PSBI) in neonates is a syndromic diagnosis that non-clinical health care providers use to identify and treat newborns with signs of sepsis. In low- and middle-income countries, referral to a hospital may not be feasible due to transportation, distance or finances. Growing evidence suggests health extension workers (HEWs) can identify and manage PSBI at the community level when referral to a hospital is not possible. However, community-based PSBI care strategies have not been widely scaled-up. This study aims to understand general determinants of household-level care as well as household care seeking and decision-making strategies for neonatal PSBI symptoms. METHODS: We conducted eleven focus group discussions (FGDs) to explore illness recognition and care seeking intentions from four rural kebeles in Amhara, Ethiopia. FGDs were conducted among mothers, fathers and households with recruitment stratified among households that have had a newborn with at least one symptom of PSBI (Symptomatic Group), and households that have had a newborn regardless of the child's health status (Community Group). Data were thematically analyzed using MAXQDA software. RESULTS: Mothers were described as primary caretakers of the newborn and were often appreciated for making decisions for treatment, even when the father was not present. Type of care accessed was often dependent on conceptualization of the illness as simple or complex. When symptoms were not relieved with clinical care, or treatments at facilities were perceived as ineffective, alternative methods were sought. Most participants identified the health center as a reliable facility. While designed to be the first point of access for primary care, health posts were not mentioned as locations where families seek clinical treatment. CONCLUSIONS: This study describes socio-contextual drivers for PSBI treatment at the community level. Future programming should consider the role community members have in planning interventions to increase demand for neonatal care at primary facilities. Encouragement of health post utilization could further allow for heightened accessibility-acceptability of a simplified PSBI regimen.

A Public Health of Consequence: Shifting the Cultural Narrative From Churning Grants to a Scholarship of Consequence.

A confluence of challenges is impeding faculty members' ability to prioritize research with the goal of achieving a public health of consequence: research designed to improve conditions to produce a healthier society. Together, these challenges create a "churn" culture in which faculty focus on generating new business (i.e., grant funding and associated incentives) to replace lost revenue (i.e., expiring grants); this culture can relegate public health impact to a back seat.We share three strategies and related insights from our efforts to shift our department's cultural narrative from churn to a "scholarship of consequence": crafting research proposals of consequence, fostering thought leadership through collaborative writing, and mentoring faculty with a view to a scholarship of consequence.We describe each of the strategies and interim progress. Although they are a work in progress, we conclude that despite initial concerns, our evaluation metrics indicate improvement.

Student and faculty perceptions on the rapid scale-up of medical students in Ethiopia.

BACKGROUND: Ethiopia is a country of over 94 million people that has a severe physician shortage with approximately only 2.5 physicians per 100,000 persons. Recently, the Ethiopian government implemented a "flood and retain" initiative to rapidly increase the quantity of physicians in Ethiopia. Consequently, medical student enrollment at Addis Ababa University (AAU) School of Medicine increased from 100 to approximately 300-400 students per class. This study evaluated the impact of the rapid scale-up in the number of medical students on the quality of medical education at AAU and the impact of the U.S. government-funded Medical Education Partnership Initiative (MEPI) grant awarded to AAU to provide resources to strengthen the quality of medical education at AAU. METHODS: Qualitative, semi-structured, in-depth interviews were conducted with 22 key informants including faculty members, administrators and medical students at AAU. The audio recordings were transcribed verbatim and interview data were analyzed with thematic analysis. RESULTS: Four key themes emerged from the data. Overall, participants perceived a decrease in the quality of medical education at AAU due to challenges created by the rapid scale-up in the number of medical students. Positive learning environments were described as difficult to achieve due to overcrowding in classrooms and the limited numbers of textbooks. Overall, participants stated that infrastructure improvement is needed to provide adequate medical student training. The medical education initiatives implemented and funded by MEPI have provided significant resources to support the medical student curriculum but additional resources are required to accommodate a large student body. CONCLUSIONS: The unprecedented rapid scale-up of medical students has impacted multiple facets of medical education at AAU. It is important to consider the perspectives of students and faculty in order to focus future medical education policies, MEPI programming and the allocation of resources.

MATERNAL PERCEPTIONS OF PARENTING FOLLOWING AN EVIDENCE-BASED PARENTING PROGRAM: A QUALITATIVE STUDY OF LEGACY FOR CHILDRENTM.

This article presents the findings of a qualitative study of maternal perceptions of parenting following participation in Legacy for ChildrenTM (Legacy), an evidence-based parenting program for low-income mothers of young children and infants. To further examine previous findings and better understand participant experiences, we analyzed semistructured focus-group discussions with predominantly Hispanic and Black, non-Hispanic Legacy mothers at two sites (n = 166) using thematic analysis and grounded theory techniques. The qualitative study presented here investigated how mothers view their parenting following participation in Legacy, allowing participants to describe their experience with the program in their own words, thus capturing an "insider" perspective. Mothers at both sites communicated knowledge and use of positive parenting practices targeted by the goals of Legacy; some site-specific differences emerged related to these parenting practices. These findings align with the interpretation of quantitative results from the randomized controlled trials and further demonstrate the significance of the Legacy program in promoting positive parenting for mothers living in poverty. This study emphasizes the importance of understanding real-world context regarding program efficacy and the benefit of using qualitative research to understand participant experiences.

Perceptions of diet, physical activity, and obesity-related health among black daughter-mother pairs in Soweto, South Africa: a qualitative study.

BACKGROUND: The prevalence of overweight and obesity is on the rise in South Africa, particularly among females living in urban environments. The purpose of this qualitative study was to explore the emic perspectives of black young adult daughter and mother pairs living in Soweto, South Africa on diet, physical activity, and obesity-related health within their social and cultural context. METHODS: Purposeful sampling was used to recruit daughters with a normal body mass index (BMI) who have obese mothers. Individual semi-structured in-depth interviews were conducted with 17 daughters (age 24 years) and 15 of their mothers in Soweto, South Africa. Interview questions related to: a) eating and physical activity behaviors and perceptions, b) perceptions of social and community level factors, c) cultural beliefs about diet and body image, and d) intergenerational relationships. Data were analyzed using four-phases of thematic analysis and the constant comparison approach. RESULTS: Daughters and mothers had similar ideas of the definition of healthy food and the importance of eating healthy, but mothers were more likely to report eating healthy because of their age, adverse health experiences, and a desire to live longer. Daughters and mothers engaged in physical activity for reasons related to weight maintenance and feeling better, but mothers reported being more likely to start exercising as a result of a health concern. Daughters and mothers had comparable views of what makes a person healthy. Daughters and mothers relied on each other for food purchasing and food preparation. CONCLUSION: Daughters and mothers shared some similar perceptions of diet, physical activity, and health that were rooted in their daily life in Soweto. However, mothers generally reported being more likely to exhibit healthy eating and physical activity behaviors despite being obese. The mothers may have adopted these perceptions and behaviors later in life linked to ageing and ill-health. It is possible that through exposure, their daughters have assimilated these perceptions earlier in childhood or adolescence. It is important to focus health promotion efforts around preventing the otherwise expected increase of obesity among the young adult generation.

Assessing the lived experiences of females with phenylketonuria in their health management.

Introduction: The present study is a mixed-methods exploratory study aiming to understand the lived experiences of females with phenylketonuria (PKU) in managing their health. The study aims to identify what individual, interpersonal, and environmental factors serve as facilitators and inhibitors, and how PKU intrudes on different realms of health. Methods: Attendees of Emory's Metabolic Camp and female users of Medical Nutrition Therapy for Prevention (MNT4P) were recruited. Participants were administered the Illness Intrusiveness Ratings Scale (IIRS) survey and qualitatively interviewed. The IIRS survey was analyzed using descriptive statistics and the interviews were coded and assessed using inductive and deductive analysis. Results: In total, 25 participants were included in analysis (adults, n = 20; adolescents, n = 5). In the IIRS survey, diet had the highest average impact score of 5.74 (SD = 2.05) and religious expression had the lowest average impact score of 1.74 (SD = 1.65). The most salient themes that arose from the qualitative interviews were related to concerns of pregnancy (n = 25), interactions with health care providers relative to PKU care (n = 23) and independent of PKU care (n = 21), social support (n = 21) and isolation (n = 12), financial issues (n = 22), and illness intrusiveness on general health management (n = 22). Discussion: Adolescent and adult female participants with PKU identified significant concerns in individual, interpersonal, and environmental factors affecting the management of their health. Additionally, the illness intrusiveness of PKU impacted their physical, mental, and gynecological health. Future research should further assess the unique challenges faced by females with PKU and potential interventions to better address these barriers.

Opportunities and barriers for maternal nutrition behavior change: an in-depth qualitative analysis of pregnant women and their families in Uttar Pradesh, India.

Background: Maternal undernutrition during pregnancy remains a critical public health issue in India. While evidence-based interventions exist, poor program implementation and limited uptake of behavior change interventions make addressing undernutrition complex. To address this challenge, Alive & Thrive implemented interventions to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in Uttar Pradesh, India. Objective: This qualitative study aimed to: (1) examine pregnant women's experiences of key nutrition-related behaviors (ANC attendance, consuming a diverse diet, supplement intake, weight gain monitoring, and breastfeeding intentions); (2) examine the influence of family members on these behaviors; and (3) identify key facilitators and barriers that affect behavioral adoption. Methods: We conducted a qualitative study with in-depth interviews with 24 pregnant women, 13 husbands, and 15 mothers-in-law (MIL). We analyzed data through a thematic approach using the Capability-Opportunity-Motivation-Behavior (COM-B) framework. Results: For ANC checkups and maternal weight gain monitoring, key facilitators were frontline worker home visits, convenient transportation, and family support, while the primary barrier was low motivation and lack understanding of the importance of ANC checkups. For dietary diversity, there was high reported capability (knowledge related to the key behavior) and most family members were aware of key recommendations; however, structural opportunity barriers (financial strain, lack of food availability and accessibility) prevented behavioral change. Opportunity ranked high for iron and folic acid supplement (IFA) intake, but was not consistently consumed due to side effects. Conversely, lack of supply was the largest barrier for calcium supplement intake. For breastfeeding, there was low overall capability and several participants described receiving inaccurate counseling messages. Conclusion: Key drivers of maternal nutrition behavior adoption were indicator specific and varied across the capability-opportunity-motivation behavior change spectrum. Findings from this study can help to strengthen future program effectiveness by identifying specific areas of program improvement.

Mentor training for junior faculty: a brief evaluation report from the Georgia Clinical and Translational Science Alliance.

To provide a foundation for mentoring, junior faculty participated in a mentor training workshop informed by the Mentoring Clinical and Translational Researchers curriculum. The goal was to develop skills and behaviors that engender more rewarding and inclusive mentoring practices. Attendees responded to baseline and follow-up surveys assessing perceived mentoring skills. Follow-up surveys included closed- and open-ended questions about the value and satisfaction of the training, and intended behavior changes. Junior faculty respondents (n = 39) reported significantly higher overall mentoring skills after the training (t = -2.6, p = 0.012) with a medium effect size (Cohen's D = 0.59). Domains with statistically significant improvement from baseline to follow-up included aligning mentor-mentee expectations and assessing understanding. Thirty-eighty (97%) found the training valuable, and 32 (82%) indicated they would change mentoring-related behaviors because of the training. Intended behavior changes described in open-ended responses aligned with mentoring skills assessed (e.g., aligning expectations). An additional competency domain of evaluating mentoring relationships was also described. A mentor training workshop for junior faculty appeared to contribute to changes in mentoring skills and intended behaviors. Mentor training has the potential to enhance mentorship, which is critical to strengthening a diverse pipeline of clinical and translational science researchers.

A mixed-methods study of factors influencing postpartum intrauterine device uptake after family planning counseling among women in Kigali, Rwanda.

INTRODUCTION: Rwanda has high unmet need for family planning (FP), especially in the postpartum period when women are advised to space pregnancies at least two years for improved maternal-child health. Despite interest in the copper intrauterine device (IUD), a highly cost-effective method, access and uptake remain low. This study aimed to determine factors associated with postpartum IUD (PPIUD) uptake after postpartum family planning (PPFP) counseling as well as provider perceptions of facilitators and barriers to clients' PPIUD uptake. METHODS: Postpartum women who received PPFP counseling and were less than 6 weeks postpartum were recruited for a case-control study in Kigali, Rwanda in 2018. We recruited n = 74 women who had accepted and n = 91 women who had declined the PPIUD. Multivariate logistic regression analyses evaluated associations between women's socio-demographics, FP knowledge and decision-making, and the outcome of PPIUD uptake. Six focus groups (FGs) were conducted with FP providers (n = 24) and community health workers (n = 17) trained to deliver PPFP counseling to assess perceptions of PPFP counseling and facilitators and barriers to PPIUD uptake. FG discussions were recorded, translated, and analyzed for themes. RESULTS: Factors associated (P<0.1) with PPIUD uptake included citing its non-hormonal nature, effectiveness, and duration of protection against pregnancy as advantages. Exclusive male partner control over FP decisions (relative to women's control or joint decision-making) was associated with non-use. Overall, limited knowledge about some aspects of the PPIUD persisted among clients even after counseling. Provider FGs highlighted client concerns, inconsistent FP messaging, and lack of male partner involvement as factors influencing non-use. CONCLUSIONS: Knowledge of the IUD and its benefits was associated with PPIUD uptake. There is need to refine PPFP counseling messages to address remaining knowledge gaps and concerns. Additionally, male partner involvement in FP counseling and decisions with their partners could be a key strategy to increase both PPIUD and FP uptake in Rwanda.

Perceptions of stress and resilience among Latina women enrolled in prenatal care in Metro Atlanta through an ecosocial lens.

Stress across the life course is highly prevalent, particularly among immigrant and racial/ethnic minority women who face adversities associated with structural and interpersonal racism. Understanding how women perceive and describe stress and resilience can provide cultural context to inform interventions to improve health among pregnant women facing adversity. The goal of this project was to examine how external stressors and coping strategies prior to and during pregnancy are reflected in Latina women's narratives about their lives through an Ecosocial framework. This mixed methods research study explores pregnant Latina women's psychosocial well-being before and during pregnancy based on Ecosocial theory. We conducted 111 surveys with Latina women receiving prenatal care in Atlanta, Georgia in 2017-2018. We conducted 24 in-depth interviews, chosen purposively from survey respondents, collecting narratives of stress and resilience over the course of pregnancy. We purposively sampled equal numbers of women who did and did not report an ongoing stressor in the survey. The survey and interview guide were focused on domains of stress, psychosocial being, coping and resilience. The majority of survey participants spoke Spanish (86%) and were born in Mexico (42%) or Guatemala (27%). Less than half (37%) reported ongoing stress, most commonly from a loved one's illness or work-related problem. The majority of women felt they should control emotional responses to external stressors during pregnancy to protect their baby's health. Women described motherhood and previous challenges as sources of maturity and improved coping. Familial financial and emotional support were perceived as critical to women's successful coping.

A qualitative study of risks and protective factors against pregnancy among sexually-active adolescents in Soweto, South Africa.

Risky sexual behaviors contribute to increased risk of adolescent pregnancy. This qualitative study sought to understand risks and protective factors against pregnancy amongst sexually-active adolescents in Soweto, South Africa. We used purposive sampling to recruit women at age 24 years from Soweto, who self-reported having sexual debut by age 15 years. Twenty women were recruited: (i) women who did not become pregnant before 18 years (n = 10) and (ii) women who became pregnant before 18 years (n = 10). In-depth interviews were conducted to understand their family backgrounds, conversations about sex, sexual behaviors, and initiatives taken (or not) during adolescence to prevent pregnancy. Both groups of women reported predisposing risks to early pregnancy including influence from peers to engage in early sex, unstable family relationships and limited conversations about sex. We found that the family is a key institution in supporting adolescents' decisions regarding their behaviors and choices, as are peers and exposures to information. Community Youth Centers, high schools and Youth Friendly Health Services should ensure that adolescents have access to relevant information, including sex education and contraceptives.

Spatial Variation in Very Preterm Birth to Hispanic Women Across the United States: The Role of Intensified Immigration Enforcement.

Introduction: Limited existing research suggests that immigration climate and enforcement practices represent a social determinant of health for immigrants, their families, and communities. However, national research on the impact of specific policies is limited. The goal of this article is to estimate the effect of county-level participation in a 287(g) immigration enforcement agreement on very preterm birth (VPTB, <32 weeks' gestation) rates between 2005-2016 among US-born and foreign-born Hispanic women across the United States. Methods: We fit spatial Bayesian models to estimate the effect of local participation in a 287(g) program on county VPTB rates, accounting for variation by maternal nativity, county ethnic density, and controlling for individual specific Hispanic background and nativity and county-level confounders. Results: While there was no global effect of county participation in a 287(g) program on county VPTB rates, rates were slightly increased in some counties, primarily in the Southeast (Virginia, North Carolina, South Carolina). Future Directions: Future research should consider the mechanisms through which immigration policies and enforcement may impact health of both immigrants and wider communities.

Community Perceptions of a Multilevel Sanitation Behavior Change Intervention in Rural Odisha, India.

While latrine coverage is increasing in India, not all household members use their latrines. Cost-effective, culturally appropriate, and theory-informed behavior change interventions are necessary to encourage sustained latrine use by all household members. We qualitatively examined community perceptions of sanitation interventions broadly, along with specific impressions and spillover of community-level activities of the Sundara Grama latrine use behavior change intervention in rural Odisha, India. We conducted sixteen sex-segregated focus group discussions (n = 152) in three intervention and three nonintervention villages and thematically analyzed the data. We found Sundara Grama was well-received by community members and considered educative, but perceptions of impact on latrine use were mixed and varied by activity. Intervention recruitment challenges prevented some, such as women and households belonging to lower castes, from attending activities. Spillover occurred in one of two nonintervention villages, potentially due to positive relations within and between the nonintervention village and nearby intervention village. Community-level sanitation initiatives can be hindered by community divisions, prioritization of household sanitation over community cleanliness, and perceptions of latrine use as a household and individual issue, rather than common good. Community-centered sanitation interventions should assess underlying social divisions, norms, and perceptions of collective efficacy to adapt intervention delivery and activities.

A Review of Qualitative Data Analysis Practices in Health Education and Health Behavior Research.

Data analysis is one of the most important, yet least understood, stages of the qualitative research process. Through rigorous analysis, data can illuminate the complexity of human behavior, inform interventions, and give voice to people's lived experiences. While significant progress has been made in advancing the rigor of qualitative analysis, the process often remains nebulous. To better understand how our field conducts and reports qualitative analysis, we reviewed qualitative articles published in Health Education & Behavior between 2000 and 2015. Two independent reviewers abstracted information in the following categories: data management software, coding approach, analytic approach, indicators of trustworthiness, and reflexivity. Of the 48 ( n = 48) articles identified, the majority ( n = 31) reported using qualitative software to manage data. Double-coding transcripts was the most common coding method ( n = 23); however, nearly one third of articles did not clearly describe the coding approach. Although the terminology used to describe the analytic process varied widely, we identified four overarching trajectories common to most articles ( n = 37). Trajectories differed in their use of inductive and deductive coding approaches, formal coding templates, and rounds or levels of coding. Trajectories culminated in the iterative review of coded data to identify emergent themes. Few articles explicitly discussed trustworthiness or reflexivity. Member checks ( n = 9), triangulation of methods ( n = 8), and peer debriefing ( n = 7) were the most common procedures. Variation in the type and depth of information provided poses challenges to assessing quality and enabling replication. Greater transparency and more intentional application of diverse analytic methods can advance the rigor and impact of qualitative research in our field.

Study Design and Use of Inquiry Frameworks in Qualitative Research Published in Health Education & Behavior.

Qualitative methods help us understand context, explore new phenomena, identify new research questions, and uncover new models of change. To better understand how researchers in health education and health behavior use qualitative methods, we reviewed qualitative articles published in Health Education & Behavior from 2000 to 2015. We identified 48 articles that met our inclusion criteria and extracted information on the qualitative inquiry framework, use of theory, data collection methods, sampling strategy, general analysis approach, and reporting of results. Use of common qualitative inquiry frameworks was rare, with just one grounded theory study, five ethnographies, and one case study. No studies were framed using phenomenological or narrative inquiry approaches. Theory was used most commonly to select sensitizing constructs for analysis (41.7%) and to inform development of data collection instruments (27.1%). Interviews were the most common data collection method (66.7%), with focus groups next most common (39.6%). Sampling was typically purposive (87.5%), although often not labeled as such. Almost all (95.8%) the articles used quotes to illustrate themes and more than half (58.3%) used descriptors of magnitude (e.g., most, some) to report findings. The use of qualitative methods by health education and behavior researchers could be enriched with more intentional application of a broader range of inquiry frameworks. More deliberate application of a range of inquiry frameworks has the potential to broaden the types of research questions asked, application and generation of theory, study design, analytic strategies, and reporting of results.

The rapid scale up of medical education in Ethiopia: Medical student experiences and the role of e-learning at Addis Ababa University.

BACKGROUND: In response to a physician shortage in Ethiopia, the number of medical students admitted to public universities was rapidly increased through a "flooding" policy. OBJECTIVES: To assess medical student perceptions on the impact of the "flooding" policy on medical education and e-learning initiatives, as well as plans for future emigration. DESIGN: A cross-sectional survey of medical students at AAU was implemented in 2014. Attitude and practice items were assessed using a Likert scale. Logistic regression analysis was performed to identify characteristics associated with an interest in future emigration. RESULTS: 673 (99.6%) of 676 students approached completed the survey, representing 39.5% of all 1705 medical students enrolled at AAU in 2014. Most students felt the "flooding" policy had a negative impact on their medical education and >90% felt there was not adequate infrastructure to support the increased student body. E-learning activities to accommodate increased class size included distribution of electronic tablets, but at the time of the survey only 34.8% of students still had a working tablet and 82.3% reported problems with internet connectivity. Most preclinical students (85.1%) who had attended live-streamed lectures preferred traditional classroom lectures. Half of the students (49.5%) intended to practice medicine in Ethiopia. Independent risk factors for planning to emigrate included age <21 years (aOR = 1.30, 95% CI 1.04, 1.97); having applied to medical school for reasons other than "wanting to be a physician" (aOR = 1.55, 95% CI 1.14, 2.20), and not believing that "flooding" policy would increase the number of physicians working in Ethiopia (aOR = 1.87, 95% CI 1.33, 2.58). CONCLUSIONS: The "flooding" policy lead to significant educational challenges that were not fully alleviated by e-learning initiatives. Concomitant increases in resources for infrastructure development and faculty expansion are needed to maintain quality medical education. Additional research is needed on factors that influence medical graduates decision to emigrate.