After more than two decades of the Safe Motherhood Initiative and Millennium Development Goals aimed at reducing maternal mortality, women continue to die in childbirth at unacceptably high rates in ...Pakistan. While an extensive literature describes various programmatic strategies, it neglects the rigorous analysis of the reasons these strategies have been unsuccessful, especially for women living at the economic and social margins of society. A critical gap in current knowledge is a detailed understanding of the root causes of disparities in maternal health care, and in particular, how gender and class influence policy formulation and the design and delivery of maternal health care services. Taking Pakistan as a case study, this research builds upon two distinct yet interlinked conceptual approaches to understanding the phenomenon of inequity in access to maternal health care: social exclusion and health systems as social institutions.
This four year project consists of two interrelated modules that focus on two distinct groups of participants: (1) poor, disadvantaged women and men and (2) policy makers, program managers and health service providers. Module one will employ critical ethnography to understand the key axes of social exclusion as related to gender, class and zaat and how they affect women's experiences of using maternal health care. Through health care setting observations, interviews and document review, Module two will assess policy design and delivery of maternal health services.
This research will provide theoretical advances to enhance understanding of the power dynamics of gender and class that may underlie poor women's marginalization from health care systems in Pakistan. It will also provide empirical evidence to support formulation of maternal health care policies and health care system practices aimed at reducing disparities in maternal health care in Pakistan. Lastly, it will enhance inter-disciplinary research capacity in the emerging field of social exclusion and maternal health and help reduce social inequities and achieve the Millennium Development Goal No. 5.
A key aim of countries with high maternal mortality rates is to increase availability of competent maternal health care during pregnancy and childbirth. Yet, despite significant investment, countries ...with the highest burdens have not reduced their rates to the expected levels. We argue, taking Pakistan as a case study, that improving physical availability of services is necessary but not sufficient for reducing maternal mortality because gender inequities interact with caste and poverty to socially exclude certain groups of women from health services that are otherwise physically available.
Using a critical ethnographic approach, two case studies of women who died during childbirth were pieced together from information gathered during the first six months of fieldwork in a village in Northern Punjab, Pakistan.
Shida did not receive the necessary medical care because her heavily indebted family could not afford it. Zainab, a victim of domestic violence, did not receive any medical care because her martial family could not afford it, nor did they think she deserved it. Both women belonged to lower caste households, which are materially poor households and socially constructed as inferior.
The stories of Shida and Zainab illustrate how a rigidly structured caste hierarchy, the gendered devaluing of females, and the reinforced lack of control that many impoverished women experience conspire to keep women from lifesaving health services that are physically available and should be at their disposal.
To evaluate the effectiveness of a 3-year human immunodeficiency virus (HIV) prevention program for adolescents attending secondary school in Mongolia.
Comparisons of knowledge, attitudes, ...self-efficacy and safe sex practices of grade 10 students from schools with a peer education prevention program to grade 10 students from schools without the intervention. Peer education programs were launched in 2000 across Mongolia. In 2004, survey data was collected among 720 randomly selected students from eight schools with the peer education prevention program and compared with those of 647 students from eight schools without this intervention. Data was collected in Ulaanbaatar and three Mongolian provinces and analyzed using multilevel regression methods.
Students of schools with the program were statistically significantly more knowledgeable, had less traditional attitudes, and had greater awareness of their self-efficacy in regards to HIV and sexual health. Students from schools with the peer education program were more likely to practice safe sex, though the difference was not statistically significant. However, safe sex practice was found to be statistically significantly safer in a subset of schools that had small teams of peer educators.
Adolescents in Mongolia are sexually active and at risk for infection with HIV and other STIs. Peer education programs, particularly those that are managed by small teams, appear effective and should be implemented more broadly.
This paper presents critical realism (CR) as an innovative system for research in tobacco prevention and control. CR argues that underlying mechanisms are considered and explored to ensure effective ...implementation of any program/policy or intervention. Any intervention or program/policy that is transposed from one country to another or one setting to another is complex.
The research was undertaken and analyzed through a critical ethnography lens using CR as a philosophical underpinning. The study relied upon the following components: original fieldwork in Nigeria including participant observation of smokers, in-depth interviews and focus groups with smokers, and in-depth interviews with health professionals working in the area of tobacco control in Nigeria.
Findings from this small ethnographic study in Nigeria, suggest that Critical Realism holds promise for addressing underlying mechanism that links complex influences on smoking.
This paper argues that understanding the underlying mechanisms associated with smoking in different societies will enable a platform for effective implementation of tobacco control policies that work in various settings.
Recent political, economic, and cultural changes in Mongolia make its large proportion of young people vulnerable to HIV infection. While there had been only two clinical cases of HIV in Mongolia by ...the year 2000, the incidence of sexually transmitted infections (STIs) is on the rise, especially among people aged 15–24. Little is known about the social and cultural context in which the sexual knowledge, attitudes, and behaviour of Mongolian young people are created and negotiated. This context must be better understood in order to promote safer sex practices. This study employed qualitative research methods to explore and describe the social and cultural context in which sexual behaviour is negotiated among secondary school students in Ulaanbaatar, Mongolia. Students and teachers from two schools in Ulaanbaatar and health professionals were selected by purposeful sampling to participate in six semi-structured focus group interviews in autumn 2000. Thematic content analysis was conducted on the focus group transcripts. Seven themes were extracted including embarrassment, lack of knowledge, concepts of sex, perceptions of condoms, gender roles, peer norms, and the influence of drinking on sexual activity. Results presented are the first description of the social and cultural context of sexual health and highlight the combined impact of these themes on safer sex practices in Mongolia. These findings are not generalizable, but their agreement with the Mongolian and the international literature indicates that they may be transferable. Implications for STI and HIV/AIDS prevention efforts and further research in Mongolia are discussed.
Illicit and prescription drug use disorders are two to four times more prevalent among Aboriginal peoples in North America than the general population. Research suggests Aboriginal cultural ...participation may be protective against substance use problems in rural and remote Aboriginal communities. As Aboriginal peoples continue to urbanize rapidly around the globe, the role traditional Aboriginal beliefs and practices may play in reducing or even preventing substance use problems in cities is becoming increasingly relevant, and is the focus of the present study. Mainstream acculturation was also examined. Data were collected via in-person surveys with a community-based sample of Aboriginal adults living in a mid-sized city in western Canada (N = 381) in 2010. Associations were analysed using two sets of bootstrapped linear regression models adjusted for confounders with continuous illicit and prescription drug problem scores as outcomes. Psychological mechanisms that may explain why traditional culture is protective for Aboriginal peoples were examined using the cross-products of coefficients mediation method. The extent to which culture served as a resilience factor was examined via interaction testing. Results indicate Aboriginal enculturation was a protective factor associated with reduced 12-month illicit drug problems and 12-month prescription drug problems among Aboriginal adults in an urban setting. Increased self-esteem partially explained why cultural participation was protective. Cultural participation also promoted resilience by reducing the effects of high school incompletion on drug problems. In contrast, mainstream acculturation was not associated with illicit drug problems and served as a risk factor for prescription drug problems in this urban sample. Findings encourage the growth of programs and services that support Aboriginal peoples who strive to maintain their cultural traditions within cities, and further studies that examine how Aboriginal cultural practices and beliefs may promote and protect Aboriginal health in an urban environment.
•This study provides much needed information about the protective role of traditional Aboriginal culture in cities.•Aboriginal cultural participation was protective against prescription and illicit drug problems for urban-based Aboriginal.•Increased self-esteem partially explained why cultural participation was protective for Aboriginal peoples.•Aboriginal culture also promoted resilience.•Mainstream acculturation was not associated illicit drug problems and was a risk factor for prescription drug problems.
Objectives
: 1) To examine associations between racial discrimination and drug problems among urban-based Aboriginal adults; and 2) to determine whether these associations are best explained by ...symptoms of psychological stress, distress or post-traumatic stress disorder (PTSD).
Methods
: Data were collected through in-person surveys with a community-based sample of Aboriginal adults (
N
= 372) living in a mid-sized city in western Canada in 2010. Associations were examined using bootstrapped linear regression models adjusted for confounders, with continuous prescription and illicit drug problem scores as outcomes. Mediation was examined using the cross-products of coefficients method.
RESULTS
: More than 80% of Aboriginal adults had experienced racial discrimination in the past year, with the majority reporting high levels in that period. Past-year discrimination was a risk factor for PTSD symptoms and prescription drug problems in models adjusted for confounders and other forms of psychological trauma. In mediation models, PTSD symptoms explained the association between discrimination and prescription drug problems; psychological stress and distress did not. PTSD symptoms also explained this association when the covariance between mediators was controlled. The results also indicate that participation in Aboriginal cultural traditions was associated with increased discrimination.
CONCLUSIONS
: Most efforts to address Aboriginal health inequities in Canada have focused on the role Aboriginal people play in these disparities. The current findings combine with others to call for an expanded focus. Non-Aboriginal Canadians may also play a role in the health inequities observed. The findings of this study suggest efforts to reduce discrimination experienced by Aboriginal adults in cities may reduce PTSD symptomology and prescription drug problems in these populations.
Purpose.
Investigate whether TV viewing and recognition of snack food advertisements were associated with snack food consumption and the odds of being overweight or obese.
Design.
Cross-sectional ...internet-based survey.
Setting.
University of Alberta, Edmonton, Canada.
Subjects.
Undergraduate university students aged 18 to 25 years (N = 613).
Measures.
Self-reported TV viewing, energy-dense snack consumption, snacking while viewing TV, and body weight.
Analysis.
Hypothesis testing was completed using multiple analysis of variance, analysis of covariance, and logistic regression.
Results.
Students reporting medium or high TV viewership snacked more frequently while watching TV and recognized more advertising than students who were considered low viewers. High viewers also reported more consumption of energy-dense snacks than low viewers. Snacking frequency appeared to be related to TV viewing and place of residence, but the association between snacking frequency and TV viewing was not accounted for by advertising. Conversely, the association between TV viewing and consumption of energy-dense snacks was accounted for by advertising recognition. Finally, male students (odds ratio OR, 2.78; 99% confidence interval CI, 1.68–4.59) and medium (OR, 3.11;99% CI, 1.37–7.08) and high (OR, 5.47; 99% CI, 1.97–15.16) TV viewers had higher odds of being overweight or obese.
Conclusions.
Associations were found among TV viewing, energy-dense snack consumption, and snacking behavior, and between TV viewing and body weight status.
Evidence suggests national- and community-level interventions are not reaching women living at the economic and social margins of society in Pakistan. We conducted a 10-month qualitative study (May ...2010-February 2011) in a village in Punjab, Pakistan. Data were collected using 94 in-depth interviews, 11 focus group discussions, 134 observational sessions, and 5 maternal death case studies. Despite awareness of birth complications and treatment options, poverty and dependence on richer, higher-caste people for cash transfers or loans prevented women from accessing required care. There is a need to end the invisibility of low-caste groups in Pakistani health care policy. Technical improvements in maternal health care services should be supported to counter social and economic marginalization so progress can be made toward Millennium Development Goal 5 in Pakistan.
Objectives:
Racial discrimination is an established life course social determinant of health associated with adverse psychological outcomes among minority populations. However, little is known about ...the extent to which Aboriginal people in Canada may experience racial discrimination and consequent adverse psychological effects. This study sought to measure the extent to which Aboriginal university students living in an urban area of Canada experienced racism, to triangulate this evidence with US data and qualitative findings, and to examine the impact of these experiences on mental health.
Methods:
Data for this mixed method study were collected via in-person surveys with a volunteer sample of Aboriginal university students (n = 60) living in a mid-sized city in central Canada in 2008–2009.
Results:
Results indicate Aboriginal university students experienced more frequent racism across a greater number of life situations than African- and Latino-American adults in the United States. Student reactions to these experiences were symptomatic of what has been termed racial battle fatigue in the United States. Students who considered themselves traditional or cultural Aboriginal persons were significantly more likely to experience discrimination.
Conclusions:
Results underline the need for policies aimed at reducing racism directed at Aboriginal people in urban areas and the growth of services to help Aboriginal people cope with these experiences. Results highlight the need for further research to determine the potential pathogenic consequences of racial discrimination for Aboriginal people in Canada.
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