Effects of self-esteem and stress on self-assessed health: a Swiss study from adolescence to early adulthood.

PURPOSE: A large literature shows important effects of self-esteem and stress on mental and physical health in young adulthood. Negative life events are one type of stressor associated with poor health, but it is less clear whether more neutral stressors are also associated with poor health. This study contributes to the existing literature by investigating the association between different types of stressful life events, self-esteem, and health during the transition from adolescence to early adulthood in Switzerland. METHODS: We draw on the "Transitions from Education to Employment" (TREE) panel study, a nationally representative longitudinal survey of a cohort of Swiss young adults, using logistic regression analysis. The study includes eight waves over a 10-year period, from 2001, average age 16, to 2010, average age 26. Our dependent variable is a dichotomized health self-assessment, and key independent variables include self-esteem and three measures of cumulative significant life events (SLEs): total cumulative SLEs, cumulative negative SLEs, and cumulative neutral SLEs. RESULTS: Self-esteem had a significant positive impact on health, whereas cumulative SLEs had a significant negative impact. Negative SLEs had a larger negative impact than total SLEs, and neutral SLEs had a smaller impact. Considered individually, negative SLEs were more likely to have a significant negative impact on health. CONCLUSIONS: In addition to their known influence on mental health, stress and self-esteem are important factors influencing individuals' general health, even in adolescence and young adulthood. While all types of stressors have a negative impact on health, the negative stressors seem to have more prominent effects than neutral stressors.

Towards improved health service quality in Tanzania: contribution of a supportive supervision approach to increased quality of primary healthcare.

BACKGROUND: Universal Health Coverage only leads to the desired health outcomes if quality of health services is ensured. In Tanzania, quality has been a major concern for many years, including the problem of ineffective and inadequate routine supportive supervision of healthcare providers by council health management teams. To address this, we developed and assessed an approach to improve quality of primary healthcare through enhanced routine supportive supervision. METHODS: Mixed methods were used, combining trends of quantitative quality of care measurements with qualitative data mainly collected through in-depth interviews. The former allowed for identification of drivers of quality improvements and the latter investigated the perceived contribution of the new supportive supervision approach to these improvements. RESULTS: The results showed that the new approach managed to address quality issues that could be solved either solely by the healthcare provider, or in collaboration with the council. The new approach was able to improve and maintain crucial primary healthcare quality standards across different health facility level and owner categories in various contexts. CONCLUSION: Together with other findings reported in companion papers, we could show that the new supportive supervision approach not only served to assess quality of primary healthcare, but also to improve and maintain crucial primary healthcare quality standards. The new approach therefore presents a powerful tool to support, guide and drive quality improvement measures within council. It can thus be considered a suitable option to make routine supportive supervision more effective and adequate.

Towards improved health service quality in Tanzania: appropriateness of an electronic tool to assess quality of primary healthcare.

BACKGROUND: Progress in health service quality is vital to reach the target of Universal Health Coverage. However, in order to improve quality, it must be measured, and the assessment results must be actionable. We analyzed an electronic tool, which was developed to assess and monitor the quality of primary healthcare in Tanzania in the context of routine supportive supervision. The electronic assessment tool focused on areas in which improvements are most effective in order to suit its purpose of routinely steering improvement measures at local level. METHODS: Due to the lack of standards regarding how to best measure quality of care, we used a range of different quantitative and qualitative methods to investigate the appropriateness of the quality assessment tool. The quantitative methods included descriptive statistics, linear regression models, and factor analysis; the qualitative methods in-depth interviews and observations. RESULTS: Quantitative and qualitative results were overlapping and consistent. Robustness checks confirmed the tool's ability to assign scores to health facilities and revealed the usefulness of grouping indicators into different quality dimensions. Focusing the quality assessment on processes and structural adequacy of healthcare was an appropriate approach for the assessment's intended purpose, and a unique key feature of the electronic assessment tool. The findings underpinned the accuracy of the assessment tool to measure and monitor quality of primary healthcare for the purpose of routinely steering improvement measures at local level. This was true for different level and owner categories of primary healthcare facilities in Tanzania. CONCLUSION: The electronic assessment tool demonstrated a feasible option for routine quality measures of primary healthcare in Tanzania. The findings, combined with the more operational results of companion papers, created a solid foundation for an approach that could lastingly improve services for patients attending primary healthcare. However, the results also revealed that the use of the electronic assessment tool outside its intended purpose, for example for performance-based payment schemes, accreditation and other systematic evaluations of healthcare quality, should be considered carefully because of the risk of bias, adverse effects and corruption.

Social Resilience and Mental Health Among Eritrean Asylum-Seekers in Switzerland.

Eritreans comprise the largest group of asylum-seekers in Switzerland. Gaining recognized refugee status can take up to 36 months, during which time asylum-seekers live in a state of legal limbo, intensifying threats to their well-being. Resilience and mental health among this population is poorly understood. We interviewed 10 asylum-seekers residing in Switzerland using qualitative, in-depth interviews. Data were analyzed using the Framework Method. Results indicated that mental health was understood as a binary state rather than a continuum and that trusted friends and family were responsible for recognizing and attempting to treat mental health problems. Pathways to care were potentially interrupted for asylum-seekers. Capital building, considered through the lens of social resilience, consisted of language learning, establishing of new individual- and community-level social networks, and proactive symbolic capital building through volunteering. We contextualize the asylum-seekers' experience into a resilience framework and offer practical recommendations for improving mental health care access.

Linking gender, extramarital affairs, and HIV: a mixed methods study on contextual determinants of extramarital affairs in rural Tanzania.

BACKGROUND: Extramarital sex is a potential driver of human immunodeficiency virus (HIV) transmission for long-term couples in sub-Saharan Africa. It is increasingly recognized that preventing sexual risk behaviours requires an understanding and adjustment of sexual relationship factors beyond the individual level. We investigated the association between extramarital affairs and HIV status, factors associated with extramarital affairs, and created insights in the context and pathways for married men and women in rural Tanzania who engage in extramarital affairs. METHODS: A cross-sectional sequential explanatory mixed method design was employed. The WHO-Social determinants of health perspective guided the study. Using logistic regression, we analysed the MZIMA project community surveillance representative sample of 3884 married partners aged 15+ residing in Ifakara town, Tanzania (2012-2013). Multinomial logistic regression analysis established the relative risk ratio (RRR) of different social and economic factors with lifetime (proxy) and recent (12 months prior to survey) extramarital affairs. Logistic regression analysis determined the association between extramarital affairs and HIV status. Semi-structured interviews and focus group discussions explored the quantitative findings, capturing the experiences and norms regarding extramarital affairs. RESULTS: We found a significant association between lifetime (proxy) extramarital affairs and HIV infection among women only. The RRR of having extramarital affairs (lifetime proxy) was significantly higher among Village Community Bank (VICOBA) members, the re-married, consumers of alcohol, those from southern regions, non-Muslims, and those with older age. In the case of recent extramarital affairs (12 months prior to survey), associations were significant for the same variables except for religion, having an income was also associated with the outcome. Qualitative narratives reflected that, desire to prove manhood (masculinity) supported by societal normative beliefs such as; 'it is not realistic for a man to stay without extramarital partner' and religious beliefs; 'a man shall dominate a woman' encouraged men's extramarital affairs. For women, striving for financial autonomy, obligations to pay back debts borrowed from several VICOBA, and limited support from their husbands encouraged their engagement in extramarital affairs. Low relationship quality (conflict and sexual dissatisfaction) were reported to encourage both men and women's extramarital affairs. CONCLUSIONS: The findings show that the link between extramarital affairs and HIV has a gender dimension in which women are more likely to acquire HIV through extramarital affairs (case of recent extramarital affairs (12 months prior to survey). Future programs seeking to address risk sexual behaviors in Tanzanian marriages can consider context-sensitive interventions which address aspects beyond 'individual risk' and women's financial uncertainties, and include couple's relationship quality, excessive alcohol behaviors, normative masculinity ideology and societal norms, that encourage women's economic dependence and men's engagement in multiple sexual partnerships. Microfinance projects (e.g. VICOBA) could be a platform for gender-transformative approaches, combining economic empowerment and HIV risk protection strategies.

Assessing policy-makers', academics' and experts' satisfaction with the performance of the Palestinian health research system: a qualitative study.

BACKGROUND: There is a growing demand within international health agencies to ensure health research systems (HRSs) are strengthened and well-functioning to support healthcare systems (HCSs). Understanding HRS performance through system actors is an indispensable move in analysing this system. This study aims to examine policy-makers', academics' and experts' satisfaction with overall HRS performance, while also investigating their perceptions about political will and attention towards health research. Ultimately, we want to identify gaps related to performance and generate insights on how to move forward for HRS performance strengthening. METHODS: This study was carried out in Palestine, targeting three sectors, namely government institutions, public health universities, and major local and international health non-governmental organisations (NGOs). Semi-structured, in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted with participants. The institutions from the three sectors were selected based on stated criteria and peer reviews. Data were translated from Arabic into English, transcribed, content checked by the principal investigator, imported to a software programme (MAXQDA 12), and then coded. Thematic content analysis was used. RESULTS: A total of 104 experts participated in 52 IDIs and 52 experts participated in 6 FGDs. Findings revealed three principal domains. First, the HRS in Palestine is remarkably underperforming, and the majority of experts were unsatisfied. Participants perceived the system as ineffective and inefficient, poorly managed and lacking systematic assessment. Second, the factors behind system underperformance were (1) an unstructured system and the lack of a research culture as well as of a governing body or policies; (2) health research was seen as individualistic, non-development driven and unutilised in policy decisions; and (3) considerably deficient coordination and essential resources. The third finding showed inadequate political support and engagement, which then also related to system underperformance. CONCLUSIONS: The Palestinian HRS is perceived as underperforming by health experts at different levels, where research is not on the leadership agendas. Potential actions should be taken to actively engage the state health decision-makers and inform them of the importance, uses and impacts of performance assessment. Findings urge policy-makers and legislators to build an inclusive and national body of governance with agreed strategies including fundamentally hybrid and aligned performance assessment mechanisms, such as a research observatory platform. In addition, it is recommended to establish a strategic plan to expand professionals' research awareness and abilities, as well as empower the institution's research monitoring and evaluation capacities.

Understanding the concept and importance of the health research system in Palestine: a qualitative study.

BACKGROUND: The importance of a health research system (HRS), namely an instrument for developing and enabling health systems, is increasing, particularly in developing countries. Assessing the perceptions of system performers is a necessary part of system analysis, which seeks to recognize a system's strengths and limitations aiming towards improvement. This study assesses the perceptions of policy-makers, academicians and experts regarding the HRS concept and its importance to generate insights for system strengthening. In Palestine, HRS is just emerging, helping to address the many public health-related challenges faced by the country. METHODS: The study was implemented from January until July 2016, targeting three sectors, namely relevant government institutions, schools of public health, and major local and international health agencies. Data was collected through 52 in-depth interviews and six focus group discussions (FGDs) with policy-makers, academics, directors and experts. Participants and institutions were selected based on stated criteria and peer review. Data were translated, transcribed, checked and then imported to a software program (MAXQDA 12) for thematic and content analysis. RESULTS: A total of 104 experts participated, wherein 52 were interviewed and 52 participated in the six FGDs. The HRS concept, as defined by WHO, was conceptualized differently among participants with unclear delineations between various components. Inconsistencies appeared when participants attempted to conceptualize HRS in broader contexts, though HRS goals and functions were sufficiently delineated. The majority of participants agreed that HRS correlates with notions of 'improvement' and recognized HRS 'as a significant gain'. Neglect of HRS was perceived as a big loss. CONCLUSIONS: The study revealed that the level of understanding of HRS among health experts in Palestine is inadequate and not sufficiently conceptualized for its application. Findings also underlined the need to establish a central governance coordination body that promotes HRS understanding, awareness and culture as an enabler for HRS strengthening.

The Palestinian health research system: who orchestrates the system, how and based on what? A qualitative assessment.

BACKGROUND: In 2011, the WHO Eastern Mediterranean Region committee launched a strategy for scaling up research in the region to address the countries' health needs through formulating and analysing the National Health Research System (HRS). Stewardship comprises three functions, namely governance, policy and priorities, and is a central pillar of this system to ensure a well-organised and functioning HRS. This study aims to examine the perceptions of the HRS performers to understand these functions and to generate insights for system strengthening. METHODS: The study was carried out in Palestine, targetting three sectors in the health field, including relevant governmental health institutions, schools of public health, and major local and international health agencies. The data were collected through 52 in-depth interviews (IDIs) and 6 focus group discussions (FGDs) with policy-makers, academics, directors, and experts. Participants and institutions were selected purposively based on a set of criteria and peer review. RESULTS: A total of 104 experts participated in the IDIs (52 participants) and FGDs (52 participants in 6 FGDs), highlighting that stewardship functions remain problematic and insufficiently performed, mainly due to a missing health research structural and regulatory framework and dispersed health research work. Despite the limited good practices, the majority of the participants described the Ethical Review and Clearance as weak due to the lack of an agreed-upon national committee and procedural quality and ethics guidelines for non-compliance. A policy or strategy dedicated to health research is lacking. The exercises of research priority-setting appear to be evolving despite the lack of consensus and the low levels of knowledge and experience in research prioritisation. Common gaps, such as weak political will and capacity support, the absence of a national unified regulating body, and the indirect effects of political conditions on strengthening the HRS as well as other sectors, also emerged. CONCLUSIONS: The stewardship functions of the Palestinian HRS remain weak along with substantial political, structural, and resources and capacity gaps. The study emphasises the imperative need to initiate strategic efforts led by the MOH and the Palestinian National Institute of Public Health alongside with other players to strengthen a national HRS through improving the stewardship functions. To achieve this, attention and support of decision-makers, involvement, mobilisation and strategic dialogue are indispensable, in order to embark on building a well-regulated and coordinated structure, operational research policy, and prioritisation of essential research.

The effect of small solar powered 'Bͻkͻͻ' net fans on mosquito net use: results from a randomized controlled cross-over trial in southern Ghana.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are ineffective malaria transmission prevention tools if they are unused. Discomfort due to heat is the most commonly reported reason for not using nets, but this problem is largely unaddressed. With increasing rural electrification and the dropping price of solar power, fans could improve comfort inside nets and be affordable to populations in malaria endemic areas. Here, results are presented from a pilot randomized controlled cross-over study testing the effect of fans on LLIN use. METHODS: Eighty-three households from two rural communities in Greater Accra, Ghana, randomized into three groups, participated in a 10-month cross-over trial. After a screening survey to identify eligible households, all households received new LLINs. BÍ»kͻͻ net fan systems (one fan per member) were given to households in Group 1 and water filters were given to households in Group 2. At mid-point, Group 1 and 2 crossed over interventions. Households in Group 1 and 2 participated in fortnightly surveys on households' practices related to nets, fans and water filters, while households in Group 3 were surveyed only at screening, mid-point and study end. Entomological and weather data were collected throughout the study. Analysis took both 'per protocol' (PP) and 'intention to treat' (ITT) approaches. The mid- and end-point survey data from Group 1 and 2 were analysed using Firth logistic regressions. Fortnightly survey data from all groups were analysed using logistic regressions with random effects. RESULTS: Provision of fans to households appeared to increase net use in this study. Although the increase in net use explained by fans was not significant in the primary analyses (ITT odds ratio 3.24, p > 0.01; PP odds ratio = 1.17, p > 0.01), it was significant in secondary PP analysis (odds ratio = 1.95, p < 0.01). Net use was high at screening and even higher after provision of new LLINs and with follow up. Fan use was 90-100% depending on the fortnightly visit. CONCLUSIONS: This pilot study could not provide definitive evidence that fans increase net use. A larger study with additional statistical power is needed to assess this association across communities with diverse environmental and socio-demographic characteristics.

Understanding resilience of female adolescents towards teenage pregnancy: a cross-sectional survey in Dar es Salaam, Tanzania.

BACKGROUND: In Tanzania, teenage pregnancy rates are still high despite the efforts being made to reduce them. Not enough is known about how adolescents experience and cope with sexuality and teenage pregnancy. Over the past few decades, most studies have focused on vulnerability and risk among youth. The concept of 'reproductive resilience' is a new way of looking at teenage pregnancy. It shifts the perspective from a deficit-based to a strength-based approach. The study presented here aimed to identify factors that could contribute to strengthening the reproductive resilience of girls in Dar es Salaam, Tanzania. METHODS: Using a cross-sectional cluster sampling approach, 750 female adolescents aged 15-19 years were interviewed about how they mobilize resources to avoid or deal with teenage pregnancy. The main focus of the study was to examine how social capital (relations with significant others), economic capital (command over economic resources), cultural capital (personal dispositions and habits), and symbolic capital (recognition and prestige) contribute to the development of adolescent competencies for avoiding or dealing with teenage pregnancy and childbirth. RESULTS: A cumulative competence scale was developed to assess reproductive resilience. The cumulative score was computed based on 10 competence indicators that refer to the re- and pro-active mobilization of resources. About half of the women who had never been pregnant fell into the category, 'high competence' (50.9%), meaning they could get the information and support needed to avoid pregnancies. Among pregnant women and young mothers, most were categorized as 'high competence' (70.5%) and stated that they know how to avoid or deal with health problems that might affect them or their babies, and could get the information and support required to do so. Cultural capital, in particular, contributed to the competence of never-pregnant girls [OR = 1.80, 95% CI = 1.06 to 3.07, p = 0.029], pregnant adolescents and young mothers [OR = 3.33, 95% CI = 1.15 to 9.60, p = 0.026]. CONCLUSIONS: The reproductive resilience framework provides new insights into the reproductive health realities of adolescent girls from a strength-based perspective. While acknowledging that teenage pregnancy has serious negative implications for many female adolescents, the findings presented here highlight the importance of considering girls' capacities to prevent or deal with teenage pregnancy.

Perceptions on the effect of small electric fans on comfort inside bed nets in southern Ghana: a qualitative study.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are known to be highly effective in reducing malaria transmission, morbidity and mortality. However, among those owning an LLIN, use rates are often suboptimal. A reported barrier to bed net use is discomfort due to heat. This qualitative study was part of a larger evaluation conducted in communities without electricity in rural Ghana to assess whether 0.8 W solar powered net fans can increase net use. METHODS: Twenty-three key informant interviews with household heads in the study communities in Shai-Osudoku District, southern Ghana, were conducted from July to August 2015. The purpose of the interviews was to obtain insight into perceptions of participants about the net fan system in relation to LLIN use. RESULTS: While all study participants reported using LLINs, with mosquito nuisance prevention as the prime motivation, heat was also mentioned as a key barrier to net use. Respondents appreciated the net fans because they improved comfort inside bed nets. The LED light on the fan stand became the main source of light at night and positively influenced the perception of the intervention as a whole. CONCLUSION: The general acceptance of the net fan system by the study participants highlights the potential of the intervention to improve comfort inside mosquito nets. This, therefore, has a potential to increase bed net use in areas with low access to electricity.

Can smartphones and tablets improve the management of childhood illness in Tanzania? A qualitative study from a primary health care worker's perspective.

BACKGROUND: The impact of the Integrated Management of Childhood Illness (IMCI) strategy has been less than anticipated because of poor uptake. Electronic algorithms have the potential to improve quality of health care in children. However, feasibility studies about the use of electronic protocols on mobile devices over time are limited. This study investigated constraining as well as facilitating factors that influence the uptake of a new electronic Algorithm for Management of Childhood Illness (ALMANACH) among primary health workers in Dar es Salaam, Tanzania. METHODS: A qualitative approach was applied using in-depth interviews and focus group discussions with altogether 40 primary health care workers from 6 public primary health facilities in the three municipalities of Dar es Salaam, Tanzania. Health worker's perceptions related to factors facilitating or constraining the uptake of the electronic ALMANACH were identified. RESULTS: In general, the ALMANACH was assessed positively. The majority of the respondents felt comfortable to use the devices and stated that patient's trust was not affected. Most health workers said that the ALMANACH simplified their work, reduced antibiotic prescription and gave correct classification and treatment for common causes of childhood illnesses. Few HWs reported technical challenges using the devices and complained about having had difficulties in typing. Majority of the respondents stated that the devices increased the consultation duration compared to routine practice. In addition, health system barriers such as lack of staff, lack of medicine and lack of financial motivation were identified as key reasons for the low uptake of the devices. CONCLUSIONS: The ALMANACH built on electronic devices was perceived to be a powerful and useful tool. However, health system challenges influenced the uptake of the devices in the selected health facilities.

Socio-cultural and economic factors influencing adolescents' resilience against the threat of teenage pregnancy: a cross-sectional survey in Accra, Ghana.

BACKGROUND: Adolescent pregnancy exposes female adolescents to medical, social and economic risks. In Ghana, adolescent mothers are more likely to experience complications during pregnancy and delivery as compared to older mothers. This study examined the competencies of adolescent girls to either proactively prevent teenage pregnancy or reactively cope effectively with it. METHODS: A cross-sectional survey approach was used to interview 820 adolescent girls aged 15-19 years in Accra, Ghana. The main focus of the study was to examine how social capital (various kinds of valued relations with significant others), economic capital (command over economic resources, mainly cash and assets), cultural capital (personal dispositions and habits; knowledge and tradition stored in material forms and institutionalized) and symbolic capital (honour, recognition and prestige) contribute to the development of competencies of adolescents to deal with the threat of teenage pregnancy and childbirth. RESULTS: Out of 820 adolescents interviewed, 128 (16%) were pregnant or mothers. Adolescents in both groups (62% never pregnant girls and 68% pregnant/young mothers) have access to social support, especially from their parents. Parents are taking the place of aunts and grandmothers in providing sexual education to their adolescent girls due to changing social structures where extended families no longer reside together in most cases. More (79%) pregnant girls and young mothers compared to never pregnant girls (38%) have access to economic support (P = <0.001). Access to social, economic and cultural capitals was associated with high competence to either prevent or deal with pregnancy among adolescent girls. CONCLUSION: Findings showed that adolescent girls, especially those that get pregnant should not be viewed as weak and vulnerable because many of them have developed competencies to cope with pregnancy and childbirth effectively. Thus, focusing on developing the competencies of girls to access social, economic and cultural capitals may be an effective way of tackling the threat of teenage pregnancy than focusing only on their vulnerability and associated risks.

The use of social media among adolescents in Dar es Salaam and Mtwara, Tanzania.

Social media form part of the rapid worldwide digital development that is re-shaping the life of many young people. While the use of social media by youths is increasingly researched in the North, studies about youth in the South are missing. It therefore remains unclear how social media can be included in interventions that aim at informing young people in many countries of the global South about sexual and reproductive health. This paper presents findings of a mixed-methods study of young people's user behaviour on the internet and specifically of social media as a platform for sexual health promotion in Tanzania. The study used questionnaires with 60 adolescents and in-depth interviews with eight students aged 15 to 19 years in Dar es Salaam, and in Mtwara, Southern Tanzania. Findings show that youth in Dar es Salaam and Mtwara access the internet mainly through mobile phones. Facebook is by far the most popular internet site. Adolescents highlighted their interest in reproductive and sexual health messages and updates being delivered through humorous posts, links and clips, as well as by youth role models like music stars and actors that are entertaining and reflect up-to-date trends of modern youth culture.

Delivering at home or in a health facility? health-seeking behaviour of women and the role of traditional birth attendants in Tanzania.

BACKGROUND: Traditional birth attendants retain an important role in reproductive and maternal health in Tanzania. The Tanzanian Government promotes TBAs in order to provide maternal and neonatal health counselling and initiating timely referral, however, their role officially does not include delivery attendance. Yet, experience illustrates that most TBAs still often handle complicated deliveries. Therefore, the objectives of this research were to describe (1) women's health-seeking behaviour and experiences regarding their use of antenatal (ANC) and postnatal care (PNC); (2) their rationale behind the choice of place and delivery; and to learn (3) about the use of traditional practices and resources applied by traditional birth attendants (TBAs) and how they can be linked to the bio-medical health system. METHODS: Qualitative and quantitative interviews were conducted with over 270 individuals in Masasi District, Mtwara Region and Ilala Municipality, Dar es Salaam, Tanzania. RESULTS: The results from the urban site show that significant achievements have been made in terms of promoting pregnancy- and delivery-related services through skilled health workers. Pregnant women have a high level of awareness and clearly prefer to deliver at a health facility. The scenario is different in the rural site (Masasi District), where an adequately trained health workforce and well-equipped health facilities are not yet a reality, resulting in home deliveries with the assistance of either a TBA or a relative. CONCLUSIONS: Instead of focusing on the traditional sector, it is argued that more attention should be paid towards (1) improving access to as well as strengthening the health system to guarantee delivery by skilled health personnel; and (2) bridging the gaps between communities and the formal health sector through community-based counselling and health education, which is provided by well-trained and supervised village health workers who inform villagers about promotive and preventive health services, including maternal and neonatal health.

"Workhood"-a useful concept for the analysis of health workers' resources? An evaluation from Tanzania.

BACKGROUND: International debates on improving health system performance and quality of care are strongly coined by systems thinking. There is a surprising lack of attention to the human (worker) elements. Although the central role of health workers within the health system has increasingly been acknowledged, there are hardly studies that analyze performance and quality of care from an individual perspective. Drawing on livelihood studies in health and sociological theory of capitals, this study develops and evaluates the new concept of workhood. As an analytical device the concept aims at understanding health workers' capacities to access resources (human, financial, physical, social, cultural and symbolic capital) and transfer them to the community from an individual perspective. METHODS: Case studies were conducted in four Reproductive-and-Child-Health (RCH) clinics in the Kilombero Valley, south-eastern Tanzania, using different qualitative methods such as participant observation, informal discussions and in-depth interviews to explore the relevance of the different types of workhood resources for effective health service delivery. Health workers' ability to access these resources were investigated and factors facilitating or constraining access identified. RESULTS: The study showed that lack of physical, human, cultural and financial capital constrained health workers' capacity to act. In particular, weak health infrastructure and health system failures led to the lack of sufficient drug and supply stocks and chronic staff shortages at the health facilities. However, health workers' capacity to mobilize social, cultural and symbolic capital played a significant role in their ability to overcome work related problems. Professional and non-professional social relationships were activated in order to access drug stocks and other supplies, transport and knowledge. CONCLUSIONS: By evaluating the workhood concept this study highlights the importance of understanding health worker performance by looking at their resources and capacities. Rather than blaming health workers for health system failures, applying a strength-based approach offers new insights into health workers' capacities and identifies entry points for target actions.

Antenatal care in practice: an exploratory study in antenatal care clinics in the Kilombero Valley, south-eastern Tanzania.

BACKGROUND: The potential of antenatal care for reducing maternal morbidity and improving newborn survival and health is widely acknowledged. Yet there are worrying gaps in knowledge of the quality of antenatal care provided in Tanzania. In particular, determinants of health workers' performance have not yet been fully understood. This paper uses ethnographic methods to document health workers' antenatal care practices with reference to the national Focused Antenatal Care guidelines and identifies factors influencing health workers' performance. Potential implications for improving antenatal care provision in Tanzania are discussed. METHODS: Combining different qualitative techniques, we studied health workers' antenatal care practices in four public antenatal care clinics in the Kilombero Valley, south-eastern Tanzania. A total of 36 antenatal care consultations were observed and compared with the Focused Antenatal Care guidelines. Participant observation, informal discussions and in-depth interviews with the staff helped to identify and explain health workers' practices and contextual factors influencing antenatal care provision. RESULTS: The delivery of antenatal care services to pregnant women at the selected antenatal care clinics varied widely. Some services that are recommended by the Focused Antenatal Care guidelines were given to all women while other services were not delivered at all. Factors influencing health workers' practices were poor implementation of the Focused Antenatal Care guidelines, lack of trained staff and absenteeism, supply shortages and use of working tools that are not consistent with the Focused Antenatal Care guidelines. Health workers react to difficult working conditions by developing informal practices as coping strategies or "street-level bureaucracy". CONCLUSIONS: Efforts to improve antenatal care should address shortages of trained staff through expanding training opportunities, including health worker cadres with little pre-service training. Attention should be paid to the identification of informal practices resulting from individual coping strategies and "street-level bureaucracy" in order to tackle problems before they become part of the organizational culture.

'Problem patients and physicians' failures': What it means for doctors to counsel vaccine hesitant patients in Switzerland.

This article reports on our qualitative inquiry into the meanings biomedically trained doctors in Switzerland attach to treating vaccine hesitant (VH) and underimmunized patients. With support from social science literature on 'good' and 'bad' patients and doctors, we explore how both doctors and patients cross the boundaries of these conceptual categories in situations involving vaccine hesitancy and underimmunization. The doctors we interviewed (N = 20) and observed (N = 16 observations, subsample of 6 doctors from the interview sample) described how they screened, measured, and diagnosed patients' levels of vaccine hesitancy. Our results emphasize the meanings doctors associated with counseling hesitant patients, especially while managing their own professional responsibilities, legitimacy, and reputations among colleagues and patients. Doctors' discourses constructed the figure of 'problem patients,' characterized through their (potential) non-adherence to vaccination recommendations, desire for lengthy consultations and individualized counseling, and dogmatic ideologies running contra to biomedicine. Discussions around the dilemmas faced by doctors in vaccination consultations brings to the fore several key, yet underdiscussed, paradoxes concerning VH, patient-doctor relationships, and the constructs of 'good'/'bad' doctors and patients. These paradoxes revolve around expectations in Western societies for 'good' patients to be autonomous health-information seekers and active participants in clinical encounters, which research shows to be the case for many VH and underimmunizing individuals. However, in the eyes of many vaccination advocates and proponents of biomedical approaches, VH patients become 'bad' patients thru their risk of non-adherence, which has implications for the population at large. In these consultations, doctors find themselves conflicted around the expectations to promote vaccination while, at the same time, being active listeners and good communicators with those who question their biomedical training and legitimacy. Understanding these paradoxes highlights the need to better support HCPs in addressing VH in clinical practice.

A vision to strengthen resources and capacity of the Palestinian health research system: a qualitative assessment.

BACKGROUND: The World Health Organization has proposed a global strategy to build a robust Health Research System Resources and Infrastructural Capacity (HRSRIC). Despite the growing research productivity, HRSRIC in Palestine has rarely been investigated. AIMS: To analyse perceptions of health research system performers to understand the status of HRSRIC, identify its gaps, and propose policy solutions to strengthen HRSRIC. METHODS: This qualitative study targeted 3 health sectors: government, academia, and local and international organizations. Fifty-two in-depth interviews and 6 focus group discussions were conducted with key informants who were selected purposively. Data were analysed using MAXQDA 12. RESULTS: Despite the availability of competent personnel, the overall HRSRIC, such as human and financial resources, and facilities, forms a central challenge. HR financing is limited, unsustainable, and flows from external and individual sources. The public and private funds are largely in shortage with resources misallocation and donors' conditionality. HR quality is moderate while knowledge transfer and translation are not well conceptualized and inappropriately performed. Lack of governance, coordination, HRSRIC strategy, resource allocation, systematic and reliable data, evidence-informed culture, and environmental impacts are the main common gaps. CONCLUSIONS: The overall status of HRSRIC in Palestine is still lacking and major challenges persist where the pace of strengthening efforts is steady. There is an emphasis that strengthening HRSRIC is an imperative step and real investment opportunity for building a successful health research system. Political commitment, consolidated leadership structure, operational capacity building strengthening strategy, resources mobilization, and sovereignty are key requirements.

Mapping stakeholders of the Palestinian Health Research System: a qualitative study.

BACKGROUND: There is a growing international and regional interest in Health Research Systems (HRSs) in light of a global strategy for HRS stakeholders' (HRSSHs) active involvement. HRSSHs in Palestine have rarely been investigated with regard to uncertainties. AIMS: This study aimed to analyse perceptions of HRSSHs in order to understand their roles and involvement, identify gaps, and offer policy solutions for stakeholders' engagement in the Palestinian HRS. METHODS: This qualitative study targeted three local Palestinian health sectors, government, academia, and local and international agencies. Data were collected through 52 in-depth interviews (IDIs) and 6 focus group discussions (FGDs) and then analysed using MAXQDA 12 software. Participants and institutions were selected purposively based on a set of criteria and peer review. RESULTS: The overall HRS stakeholders' roles were unsatisfactory, with low involvement from society, the private sector, local and international sectors. The role of academia and the Ministry of Health is vital but observed moderate in health research while that of international agencies is weak due to conflicting agendas and lack of a guiding body. Most universities have poor representation in public decision-making and scarcity in health research potential and capacity. Interest-power imbalance among stakeholders is reported where political, organizational, and technical shortfalls were indicative of weak roles and low involvement, along with a lack of health research culture, structure, resources, defined roles, and network. CONCLUSIONS: Tackling the inadequate roles, interests' disparity, and poor involvement of HRSSHs is imperative for HRS strengthening. Redefining HRSSHs' roles and involving all stakeholders is key through strategic dialogue, consolidated leadership, and resource mobilization.