Kenneth Maes

Becoming and remaining community health workers: perspectives from Ethiopia and Mozambique.

Many global health practitioners are currently reaffirming the importance of recruiting and retaining effective community health workers (CHWs) in order to achieve major public health goals. This raises policy-relevant questions about why people become and remain CHWs. This paper addresses these questions, drawing on ethnographic work in Addis Ababa, the capital of Ethiopia, between 2006 and 2009, and in Chimoio, a provincial town in central Mozambique, between 2003 and 2010. Participant observation and in-depth interviews were used to understand the life histories that lead people to become CHWs, their relationships with intended beneficiaries after becoming CHWs, and their social and economic aspirations. People in Ethiopia and Mozambique have faced similar political and economic challenges in the last few decades, involving war, structural adjustment, and food price inflation. Results suggest that these challenges, as well as the socio-moral values that people come to uphold through the example of parents and religious communities, influence why and how men and women become CHWs. Relationships with intended beneficiaries strongly influence why people remain CHWs, and why some may come to experience frustration and distress. There are complex reasons why CHWs come to seek greater compensation, including desires to escape poverty and to materially support families and other community members, a sense of deservingness given the emotional and social work involved in maintaining relationships with beneficiaries, and inequity vis-à-vis higher-salaried elites. Ethnographic work is needed to engage CHWs in the policy process, help shape new standards for CHW programs based on rooting out social and economic inequities, and develop appropriate solutions to complex CHW policy problems.

Water Insecurity In 3 Dimensions: An Anthropological Perspective On Water And Women’s Psychosocial Distress In Ethiopia

Water insecurity is a primary underlying determinant of global health disparities. While public health research on water insecurity has focused mainly on two dimensions, water access and adequacy, an anthropological perspective highlights the cultural or lifestyle dimension of water insecurity, and its implications for access/adequacy and for the phenomenology of water insecurity. Recent work in Bolivia has shown that scores on a water insecurity scale derived from ethnographic observations are associated with emotional distress. We extend this line of research by assessing the utility of a locally developed water insecurity scale, compared with standard measures of water access and adequacy, in predicting womens psychosocial distress in Ethiopia. In 2009-2010 we conducted two phases of research. Phase I was mainly qualitative and designed to identify locally relevant experiences of water insecurity, and Phase II used a quantitative survey to test the association between womens reported water insecurity and the Falk Self-Reporting Questionnaire (SRQ-F), a measure of psychosocial distress. In multiple regression models controlling for food insecurity and reported quantity of water used, womens water insecurity scores were significantly associated with psychosocial distress. Including controls for time required to collect water and whether water sources were protected did not further predict psychosocial distress. This approach highlights the social dimension of water insecurity, and may be useful for informing and evaluating interventions to improve water supplies.

Food insecurity and mental health: Surprising trends among community health volunteers in Addis Ababa, Ethiopia during the 2008 food crisis

The 2008 food crisis may have increased household food insecurity and caused distress among impoverished populations in low-income countries. Policy researchers have attempted to quantify the impact that a sharp rise in food prices might have on population wellbeing by asking what proportion of households would drop below conventional poverty lines given a set increase in prices. Our understanding of the impact of food crises can be extended by conducting micro-level ethnographic studies. This study examined self-reported household food insecurity (FI) and common mental disorders (CMD) among 110 community health AIDS care volunteers living in Addis Ababa, Ethiopia during the height of the 2008 food crisis. We used generalized estimating equations that account for associations between responses given by the same participants over 3 survey rounds during 2008, to model the longitudinal response profiles of FI, CMD symptoms, and socio-behavioral and micro-economic covariates. To help explain the patterns observed in the response profiles and regression results, we examine qualitative data that contextualize the cognition and reporting behavior of AIDS care volunteers, as well as potential observation biases inherent in longitudinal, community-based research. Our data show that food insecurity is highly prevalent, that is it associated with household economic factors, and that it is linked to mental health. Surprisingly, the volunteers in this urban sample did not report increasingly severe FI or CMD during the peak of the 2008 food crisis. This is a counter-intuitive result that would not be predicted in analyses of population-level data such as those used in econometrics simulations. But when these results are linked to real people in specific urban ecologies, they can improve our understanding of the psychosocial consequences of food price shocks.

The Impact of Polio Eradication on Routine Immunization and Primary Health Care: A Mixed-Methods Study

Background. After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC). Methods. Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review. Results. Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year. Conclusions. Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.

Examining health-care volunteerism in a food- and financially-insecure world.

The problem of severe shortages in global health workforces is addressed in many places by using community volunteers. Whether it is unjust and/or unsustainable to rely on volunteerism in low-income set-tings, particularly in sub-Saharan Africa, has become a major concern for a widen-ing group of researchers and community health practitioners, particularly in the wake of the 2008 food and financial crises.The World Health Organization (WHO) recommends that “essential health services cannot be provided by people working on a voluntary basis if they are to be sustainable. While volun-teers can make a valuable contribution on a short-term or part-time basis, trained health workers…should receive adequate wages and/or other appropriate and com-mensurate incentives”.

Methods for evaluating the impact of vertical programs on health systems: protocol for a study on the impact of the global polio eradication initiative on strengthening routine immunization and primary health care

BackgroundThe impact of vertical programs on health systems is a much-debated topic, and more evidence on this complex relationship is needed. This article describes a research protocol developed to assess the relationship between the Global Polio Eradication Initiative, routine immunization, and primary health care in multiple settings.Methods/DesignThis protocol was designed as a combination of quantitative and qualitative research methods, making use of comparative ethnographies. The study evaluates the impact of the Global Polio Eradication Initiative on routine immunization and primary health care by: (a) combining quantitative and qualitative work into one coherent study design; (b) using purposively selected qualitative case studies to systematically evaluate the impact of key contextual variables; and (c) making extensive use of the method of participant observation to create comparative ethnographies of the impact of a single vertical program administered in varied contexts.DiscussionThe study design has four major benefits: (1) the careful selection of a range of qualitative case studies allowed for systematic comparison; (2) the use of participant observation yielded important insights on how policy is put into practice; (3) results from our quantitative analysis could be explained by results from qualitative work; and (4) this research protocol can inform the creation of actionable recommendations. Here, recommendations for how to overcome potential challenges in carrying out such research are presented. This study illustrates the utility of mixed-methods research designs in which qualitative data are not just used to embellish quantitative results, but are an integral component of the analysis.

A new global monitoring system for food insecurity

www.thelancet.com Vol 374 October 10, 2009 1223 7 Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF, for the QUOROM Group. Improving the quality of reporting of meta-analysis of randomized controlled trials: the QUOROM statement. Lancet 1999; 354: 1896–900. 8 EQUATOR Network. Enhancing the QUAlity and Transparency Of health Research. http://www.equator-network.org (accessed Aug 1, 2009). 9 Liberati A, Altman DG, Tetzlaff J, Mulrow C, the PRISMA Group. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6: e1000100. 10 The Lancet. Information for authors [updated March, 2009]. http:// download.thelancet.com/fl atcontentassets/authors/lancet-informationfor-authors.pdf (accessed Aug 1, 2009).

The Global Context of Vaccine Refusal: Insights from a Systematic Comparative Ethnography of the Global Polio Eradication Initiative.

Many of medical anthropologys most pressing research questions require an understanding how infections, money, and ideas move around the globe. The Global Polio Eradication Initiative (GPEI) is a

Per Diems in Polio Eradication: Perspectives From Community Health Workers and Officials

9 billion project that has delivered 20 billion doses of oral polio vaccine in campaigns across the world. With its array of global activities, it cannot be comprehensively explored by the traditional anthropological method of research at one field site. This article describes an ethnographic study of the GPEI, a collaborative effort between researchers at eight sites in seven countries. We developed a methodology grounded in nuanced understandings of local context but structured to allow analysis of global trends. Here, we examine polio vaccine acceptance and refusal to understand how global phenomena-in this case, policy decisions by donors and global health organizations to support vaccination campaigns rather than building health systems-shape local behavior.

Food Insecurity among Volunteer AIDS Caregivers in Addis Ababa, Ethiopia Was Highly Prevalent but Buffered from the 2008 Food Crisis

Nearly all global health initiatives give per diems to community health workers (CHWs) in poor countries for short-term work on disease-specific programs. We interviewed CHWs, supervisors, and high-level officials (n = 95) in 6 study sites across sub-Saharan Africa and South Asia in early 2012 about the per diems given to them by the Global Polio Eradication Initiative. These per diems for CHWs ranged from