Jana Fried

Endurance, resistance and resilience in the South African health care system: case studies to demonstrate mechanisms of coping within a constrained system

BackgroundSouth Africa is at present undertaking a series of reforms to transform public health services to make them more effective and responsive to patient and provider needs. A key focus of these reforms is primary care and its overburdened, somewhat dysfunctional and hierarchical nature. This comparative case study examines how patients and providers respond in this system and cope with its systemic demands through mechanisms of endurance, resistance and resilience, using coping and agency literatures as the theoretical lenses.MethodsAs part of a larger research project carried out between 2009 and 2010, this study conducted semi-structured interviews and observations at health facilities in three South African provinces. This study explored patient experiences of access to health care, in particular, ways of coping and how health care providers cope with the health care system’s realities. From this interpretive base, four cases (two patients, two providers) were selected as they best informed on endurance, resistance and resilience. Some commentary from other respondents is added to underline the more ubiquitous nature of these coping mechanisms.ResultsThe cases of four individuals highlight the complexity of different forms of endurance and passivity, emotion- and problem-based coping with health care interactions in an overburdened, under-resourced and, in some instances, poorly managed system. Patients’ narratives show the micro-practices they use to cope with their treatment, by not recognizing victimhood and sometimes practising unhealthy behaviours. Providers indicate how they cope in their work situations by using peer support and becoming knowledgeable in providing good service.ConclusionsResistance and resilience narratives show the adaptive power of individuals in dealing with difficult illness, circumstances or treatment settings. They permit individuals to do more than endure (itself a coping mechanism) their circumstances, though resistance and resilience may be limited. These are individual responses to systemic forces. To transform health care, mutually supportive interactions are required among and between both patients and providers but their nature, as micro-practices, may show a way forward for system change.

Acceptable Care? Illness Constructions, Healthworlds, and Accessible Chronic Treatment in South Africa

Achieving equitable access to health care is an important policy goal, with access influenced by affordability, availability, and acceptability of specific services. We explore patient narratives from a 5-year program of research on health care access to examine relationships between social constructions of illness and the acceptability of health services in the context of tuberculosis treatment and antiretroviral therapy in South Africa. Acceptability of services seems particularly important to the meanings patients attach to illness and care, whereas—conversely—these constructions appear to influence what constitutes acceptability and hence affect access to care. We highlight the underestimated role of individually, socially, and politically constructed healthworlds; traditional and biomedical beliefs; and social support networks. Suggested policy implications for improving acceptability and hence overall health care access include abandoning patronizing approaches to care and refocusing from treating “disease” to responding to “illness” by acknowledging and incorporating patients’ healthworlds in patient–provider interactions.

Stakeholder engagement in the study and management of invasive alien species

Invasive alien species are a major driver of global environmental change and a range of management interventions are needed to manage their effects on biodiversity, ecosystem services, human well-being and local livelihoods. Stakeholder engagement is widely advocated to integrate diverse knowledge and perspectives in the management of invasive species and to deal with potential conflicts of interest. We reviewed the literature in the ISI Web of Science on stakeholder engagement (the process of involving stakeholders (actors) in decision making, management actions and knowledge creation) in invasion science to assess and understand what has been done (looking at approaches and methodologies used, stakeholders involved, and outcomes from engagement) and to make recommendations for future work. Research on stakeholder engagement in invasion science has increased over the last decade, helping to improve scientific knowledge and contributing towards policy formulation and co-implementation of management. However, many challenges remain and engagement could be made more effective. For example, most studies engage only one stakeholder group passively using questionnaires, primarily for assessing local knowledge and perceptions. Although useful for management and policy planning, these stakeholders are not active participants and there is no two-way flow of knowledge. To make stakeholder involvement more useful, we encourage more integrative and collaborative engagement to (1) improve co-design, co-creation and co-implementation of research and management actions; (2) promote social learning and provide feedback to stakeholders; (3) enhance collaboration and partnerships beyond the natural sciences and academia (interdisciplinary and transdisciplinary collaboration); and (4) discuss some practical and policy suggestions for improving stakeholder engagement in invasion science research and management. This will help facilitate different stakeholders to work better together, allowing problems associated with biological invasions to be tackled more holistically and successfully.

Welcome waste -- interpreting narratives of radioactive waste disposal in two small towns in Ontario, Canada

After briefly reviewing the production of nuclear energy and waste in Canada, this paper uses two small Ontario towns as case studies to examine the treatment of low-level radioactive waste and the communities’ responses and narratives to it. Both towns, Port Hope and Kincardine, have long histories of dealing with such waste. Using interviews, relevant websites and past accounts, this paper employs a discourse analysis to understand the differences in risk perceptions and living with the presence of these materials. Ideas from landscape narratives are employed to show that responses in Port Hope are dominated by death, elegy and crime, whereas those in Kincardine are predominately linked to progressivism and optimism. We explore the characteristics of each case to highlight the reasons for these differences. We conclude by emphasizing the potential role of narrative analysis in informing policymaking.

Exploring Perceptions of Credible Science Among Policy Stakeholder Groups: Results of Focus Group Discussions About Nuclear Energy

How do different stakeholder groups define credible science? Using original qualitative focus group data, this exploratory study suggests that while nuclear energy stakeholder groups consider the same factors when assessing credibility (specifically, knowledge source, research funding, research methods, publication, and replication), groups differ in their assessments of what constitutes expertise, what demonstrates (or reduces) trustworthiness, and the relative prioritization of expertise versus trustworthiness. Overall, these results suggest it is important for science communication to consider audience-specific credibility, and raise questions about the potential impact of both funding sources and predatory journals on the perceived credibility of scientists.

The Anatomy of a Brand: Shaping Nuclear Discourse to Create the Perception of a “Clean World”

We examine how over the past 25 years the Canadian nuclear industry has used various strategies to diminish or remove perceptions of any environmental health risks that emanate from its practice and activities. Using both industry and critical website materials, we demonstrate how the industry “removes” risk by emphasizing its own safety culture in a complex process, its green credentials, its role in producing local energy options, and the scientific ignorance of its critics, the suppression of opposing views, and a narrow risk assessment approach to potential environmental and health hazards in the marketing of a specific brand. We suggest that the same strategies are being used after the recent Japanese nuclear disaster.

Support, opposition, emotion and contentious issue risk perception

Purpose – Research on emotion in the context of risk perception has historically focused on negative emotions, and has emphasized the effect of these negative emotions on the perception of risk amongst those who oppose (rather than support) contentious issues. Drawing on theory, the purpose of this paper is to hypothesize that both positive and negative emotions are correlated with risk perceptions regarding contentious public issues and that this occurs amongst supporters and opponents alike. Design/methodology/approach – The paper explores the relationship between emotions and perceived risk through consideration of the highly contentious case of nuclear energy in Saskatchewan, Canada. The analysis uses data from a representative telephone survey of 1,355 residents. Findings – The results suggest that positive emotions, like negative emotions, are related to nuclear energy risk perceptions. Emotions are related to risk perception amongst both supporters and opponents. Research limitations/implications –...

The reason that I did not go – determinants of the use of antenatal care services in South Africa, two decades after the end of apartheid

According to South Africas new constitution, access to health care is a fundamental right. Equitable provision of maternal health care is important in redressing past legacies and achieving the Millennium Development Goals. We analyse the utilisation of antenatal care (ANC) services under South Africas public health system to inform policy concerned with equity of access. We conceptualise access to care as covering three distinct but interacting dimensions: availability, affordability and acceptability. We explain variations in the number of ANC visits among women giving birth in four selected communities, two urban and two rural. Results indicate that more-marginalised women were significantly less likely to have the minimum recommended number of ANC visits whereas being older, in a stable or married relationship and more highly educated and having no previous deliveries were positive influences. Further analysis revealed variations between facilities in the determinants of sufficient ANC visits. These results are discussed using insights based on qualitative patient interviews. Our findings show inequalities in utilisation which may indicate remaining inequities in access.

Knowledge Utilization by Policy Makers: Is There a Role for Marketing?

While most university settings expect and aspire for researchers to share their findings with policy makers, industry, and society (Tatari et al. 2012), there are several barriers within this process (Sa et al. 2011). In this conceptual chapter, we describe findings from an interdisciplinary investigation of existing work on knowledge use by policy makers and identify opportunities to incorporate marketing theory to facilitate knowledge transfer.

Breaking the connections: reducing and removing environmental health risk in the Canadian nuclear power industry

In this paper, we examine how over the past twenty five years the nuclear industry has used various strategies to diminish or remove any environmental health risks that emanate from its practice and activities. Using both industry and critical website materials, we demonstrate how risk is removed by emphasizing its own safety culture in a complex process, its ‘clean energy’ credentials, its role in producing national energy options, close co-operation with its regulators, the ignorance of its critics, the suppression of opposing views and a narrowing risk assessment approach to potential environmental and health hazards. We suggest that the same strategies will be used after the recent Japanese nuclear disaster.