[Show abstract][Hide abstract] ABSTRACT: Task shifting in response to the health workforce shortage has resulted in community-based health workers taking on increasing responsibility. Community health workers are expected to work collaboratively, though they are often a heterogeneous group with a wide range of training and experience. Interpersonal relationships are at the very core of effective teamwork, yet relational variables have seldom been the focus of health systems research in low resource, rural settings. This article helps fill this knowledge gap by exploring the dyadic level, or relational, characteristics of community maternal and newborn health workers and the individual and collective influence of these characteristics on interaction patterns. Network data were collected from community health workers (N ¼ 194) in seven rural kebeles of Amhara region, Ethiopia from November 2011 to January 2012. Multiple Regression Quadratic Assignment Procedure was used to fit regression models for frequency of work interactions, a proxy for teamwork. Strong and consistent evidence was found in support of Trust and Past training together as important relational factors for work interactions; less consistent evidence was found across sites in support of Homophily, Distance and Shared motivations. Our findings also point to a typology of network structure across sites, where one set of networks was characterized by denser and stronger health worker ties relative to their counterparts. Our results suggest that the development of interventions that promote trust and incorporate cross-cadre training is an important step in encouraging collective action. Moreover, assessing the structure of health worker networks may be an effective means of evaluating health systems strengthening efforts in rural, low-resource settings.
Health Policy and Planning 10/2014; · 2.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Worldwide, a shortage of skilled health workers has prompted a shift toward community-based health workers taking on greater responsibility in the provision of select maternal and newborn health services. Research in mid- and high-income settings suggests that coworker collaboration increases productivity and performance. A major gap in this research, however, is the exploration of factors that influence teamwork among diverse community health worker cadres in rural, low-resource settings. The purpose of this study is to examine how sociodemographic and structural factors shape teamwork among community-based maternal and newborn health workers in Ethiopia.
A cross-sectional survey was conducted with health extension workers, community health development agents, and traditional birth attendants in 3 districts of the West Gojam Zone in the Amhara region of Ethiopia. Communities were randomly selected from Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) sites; health worker participants were recruited using a snowball sampling strategy. Fractional logit modeling and average marginal effects analyses were carried out to identify the influential factors for frequency of work interactions with each cadre.
One hundred and ninety-four health workers participated in the study. A core set of factors-trust in coworkers, gender, and cadre-were influential for teamwork across groups. Greater geographic distance and perception of self-interested motivations were barriers to interactions with health extension workers, while greater food insecurity (a proxy for wealth) was associated with increased interactions with traditional birth attendants.
Interventions that promote trust and gender sensitivity and improve perceptions of health worker motivations may help bridge the gap in health services delivery between low- and high-resource settings. Inter-cadre training may be one mechanism to increase trust and respect among diverse health workers, thereby increasing collaboration. Large-scale, longitudinal research is needed to understand how changes in trust, gender norms, and perceptions of motivations influence teamwork over time.
Journal of midwifery & women's health 01/2014; 59 Suppl 1:S32-43. · 1.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper explores the expected outcome of maternal nutritional "buffering," namely that children's diets will be more adequate than mothers' diets under conditions of food scarcity. Data on Amazonian mothers and their children, household demography and economics and direct, weighed measures of household food availability and dietary intakes of mother-child pairs were collected from 51 households to address the following research questions: (1) is there evidence of food scarcity in this setting?; (2) are there differences in energy and protein adequacy between children and their mothers?; and, (3) which individual and household-level factors are associated with these mother-child differences in energy and protein adequacy? In this context of food scarcity, we found that the majority of children had more adequate energy (p < 0.001) and protein (p < 0.001) intakes than their mothers. Multivariate OLS regression models showed that of the individual-level factors, child age and height-for-age were negatively associated with maternal-child energy and protein inequalities while maternal reproductive status (lactation) was positively associated with energy inequality. While there were no gender differences in dietary adequacy among children, boys had a larger advantage over their mothers in terms of protein adequacy than girls. Household food availability was related to maternal-child energy and protein inequalities in a curvilinear fashion with the lowest inequalities found in households with extremely low food availability and those with adequate food resources. This is the first study to quantify maternal-child dietary inequalities in a setting of food scarcity and demonstrates the importance of the household context and individual characteristics in understanding the degree to which mothers protect their children from resource scarcity.
Social Science [?] Medicine 11/2013; 96:183-91. · 2.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Although many studies showed that adolescent food insecurity is a pervasive phenomenon in Southwest Ethiopia, its effect on the linear growth of adolescents has not been documented so far. This study therefore aimed to longitudinally examine the association between food insecurity and linear growth among adolescents. METHODS: Data for this study were obtained from a longitudinal survey of adolescents conducted in Jimma Zone, which followed an initial sample of 2084 randomly selected adolescents aged 13--17 years. We used linear mixed effects model for 1431 adolescents who were interviewed in three survey rounds one year apart to compare the effect of food insecurity on linear growth of adolescents. RESULTS: Overall, 15.9% of the girls and 12.2% of the boys (P=0.018) were food insecure both at baseline and on the year 1 survey, while 5.5% of the girls and 4.4% of the boys (P=0.331) were food insecure in all the three rounds of the survey. In general, a significantly higher proportion of girls (40%) experienced food insecurity at least in one of the survey rounds compared with boys (36.6%) (P=0.045).The trend of food insecurity showed a very sharp increase over the follow period from the baseline 20.5% to 48.4% on the year 1 survey, which again came down to 27.1% during the year 2 survey.In the linear mixed effects model, after adjusting for other covariates, the mean height of food insecure girls was shorter by 0.87 cm (P<0.001) compared with food secure girls at baseline. However, during the follow up period on average, the heights of food insecure girls increased by 0.38 cm more per year compared with food secure girls (P<0.066). However, the mean height of food insecure boys was not significantly different from food secure boys both at baseline and over the follow up period. Over the follow-up period, adolescents who live in rural and semi-urban areas grew significantly more per year than those who live in the urban areas both for girls (P<0.01) and for boys (P<0.01). CONCLUSIONS: Food insecurity is negatively associated with the linear growth of adolescents, especially on girls. High rate of childhood stunting in Ethiopia compounded with lower height of food insecure adolescents compared with their food secure peers calls for the development of direct nutrition interventions targeting adolescents to promote catch-up growth and break the intergenerational cycle of malnutrition.
[Show abstract][Hide abstract] ABSTRACT: We are delighted that our article has stimulated novel analyses regarding the relationship between food insecurity and well-being. Theall et al. describe how there were no significant associations found between food security and inflammation among a younger age group (adolescents aged 12-17 years) of the National Health and Nutrition Examination Survey study population 1999-2006 that we used to investigate these relationships in adults (aged ≥ 18 years). (Am J Public Health. Published online ahead of print January 17, 2013: e1. doi:10.2105/AJPH.2012.301187).
American Journal of Public Health 01/2013; · 3.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Research on trust, and its influence on teamwork, among health workers in low-resource settings has been understudied. We, therefore, undertook a formative study of trust among three diverse cadres of frontline health workers in Amhara region, Ethiopia. We aimed to develop a comprehensive description of trust in this setting and generate a tool to measure levels of trust within and between cadres. In-depth interviews with 30 frontline workers uncovered a core set of items that seem to define trust in this setting (character/ability/communication), including novel conceptualizations (oneness). Twenty-five items developed from formative data were pilot tested with 92 health workers. The final 10-item scale exhibited strong internal consistency across cadres (alpha>0.83).
In support of criterion validity, the scale was positively associated with the sense-of-team scale (p<0.001) and accounted for greater variance in health workers’ sense-of-team (Adj.R2 =0.67) than did a composite of single trust items (Adj.R2=0.28). For contrasting group validity, respondents had greater within-group agreement compared to between-group agreement on trust items and displayed higher competence in answering questions about their own cadre. Results demonstrate that the Rural Health Worker Trust Scale can be validly and reliably used to measure trust among diverse cadres. The scale may be used to develop and evaluate trust-building
interventions that aim to encourage and sustain collaboration among heterogeneous frontline workers.
Human organization 01/2013; 72(3):230-241. · 0.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This article draws on qualitative and quantitative research to examine the relationship between the consumption of khat, symptoms of depression and anxiety and the experience of time among young men in urban Ethiopia. Young men claim that khat, a mild stimulant, both causes and alleviates symptoms of depression and anxiety. However, our quantitative data indicate that there is not a direct relationship between khat and symptoms of depression and anxiety. We analyze this apparent contradiction in terms of young men's experiences of time. Long-term ethnographic research indicates that khat consumption and mental distress have a close relationship with young men's temporal problems. In a context of high urban unemployment, young men struggle to negotiate overabundant amounts of unstructured time in the present and place themselves within a narrative in which they are progressing toward future aspirations. These temporal struggles generate symptoms of depression and anxiety. For young men, khat consumption functions to reposition them in relation to time, both in the present and the future. Ultimately, we argue that the relationship between khat and time has implications for the economic issues that underlie young people's symptoms of depression and anxiety.
Culture Medicine and Psychiatry 11/2012; · 1.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We thank Dodge for highlighting the potential environmental factors that may impact food insecurity upstream of the mechanistic pathway between food insecurity and health. Our work demonstrated that food insecurity is associated with C-reactive protein, a marker of inflammation associated with chronic health conditions such as diabetes, hyperlipidemia, and cardiovascular disease. In our exploratory study, we focused primarily on associations at the individual and household level between socioeconomic conditions and biological processes such as nutritional deficiencies, susceptibility to infection, and increased inflammation. (Am J Public Health. Published online ahead of print November 15, 2012: e1. doi:10.2105/AJPH.2012.301099).
American Journal of Public Health 11/2012; · 3.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Food insecurity is common among HIV-infected populations in resource-rich and resource-poor countries. We hypothesized that food insecurity would be associated with risky sexual behaviors. We examined this hypothesis among all sexually active participants (n = 154) in the Research on Access to Care in the Homeless (REACH) cohort in San Francisco. The outcomes were unprotected vaginal or anal sex and multiple sexual partners during the prior 90 days. Associations were examined using repeated measures multivariable logistic regression analyses. Food insecurity was independently associated with unprotected sexual activity (AOR = 2.01 for each five point increase in HFIAS scale, 95 % CI 1.31-3.10) and multiple sexual partners (AOR = 1.54 for each five-point increase in HFIAS scale, 95 % CI 1.05-2.29). Food insecurity is a risk factor for unprotected sexual activity and multiple sexual partners among homeless and marginally housed HIV-infected individuals in San Francisco. Measures to alleviate food insecurity may play a role in decreasing secondary HIV transmission.
[Show abstract][Hide abstract] ABSTRACT: The rise in food prices since 2007 is widely recognized as signaling a crisis of food insecurity among the world's poor. Scholars sought to chart the impacts of the crisis on food insecurity by conducting simulation studies, assessing anthropometric outcomes, and evaluating shifts in experience-based measures of food security. Few studies, however, have investigated the broader impacts on those most vulnerable and how rapid rises in food prices play out in the everyday lives of those most impacted. We used qualitative methods to investigate the impact of the rise in food prices on the urban poor in Ethiopia. Twenty semi-structured interviews were conducted in August 2011, in the provincial town of Jimma. Themes identified in these interviews included coping strategies, consumption priorities, and impacts on institutional networks of sharing. Our results suggest that several important cultural practices, including funerals and coffee ceremonies, were undermined by the rise in prices, and that respondents linked food prices to increasing food insecurity, which they in turn linked to high levels of stress, poor mental health, and reduced physical health. Our results are consistent with several other studies that suggest that food insecurity has a range of non-nutritional consequences, and that these are due in part to the highly social nature of food. Recognizing the effects of food insecurity on dimensions of everyday life such as interaction with neighbors, and feelings of shame, draws attention to the potential for food price increases to have erosive effects on communal social capital, and to increase the vulnerability of affected peoples to future shocks.
Social Science [?] Medicine 09/2012; · 2.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The concept of acculturation is widely used in the health and social sciences to explain various health and behavioral outcomes. A review of the literature highlights weaknesses in current acculturation research including the failure to ground the concept in a theory of culture, failure to specify the pathways through which acculturation impacts on outcomes and reliance on methodological tools that do not measure the core construct of interest. Building on cognitive and evolutionary anthropological theories and methods of measuring the distribution of cultural beliefs, we suggest that a research program focused on acculturation needs to initially aim at measuring beliefs, attitudes, and norms, and not on behavior. Researchers should empirically examine the distribution of beliefs across presumed cultural groups, and specify how these might impact on outcomes of interest. By parceling beliefs as distinct from behavior, our approach advances culture as but one possible hypothesis to account for outcomes.
The Social Science Journal. 09/2012; 49(3):375–385.
[Show abstract][Hide abstract] ABSTRACT: To expand the understanding of potential pathways through which food insecurity is associated with adverse health outcomes, we investigated whether food insecurity is associated with nutritional levels, inflammatory response, and altered immune function.
We performed a cross-sectional analysis of the National Health and Nutrition Examination Survey (1999-2006) with 12,191 participants. We assessed food insecurity using the US Department of Agriculture food security scale module and measured clinical biomarkers from blood samples obtained during participants' visits to mobile examination centers.
Of the study population, 21.5% was food insecure. Food insecurity was associated with higher levels of C-reactive protein (adjusted odds ratio [AOR]=1.21; 95% confidence interval [CI]=1.04, 1.40) and of white blood cell count (AOR=1.36; 95% CI=1.11, 1.67). White blood cell count partly mediated the association between food insecurity and C-reactive protein.
These findings show that food insecurity is associated with increased inflammation, a correlate of chronic diseases. Immune response also appears to be a potential mediator in this pathway.
American Journal of Public Health 06/2012; 102(8):1579-86. · 3.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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 women's 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 women's 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, women's 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.
Social Science [?] Medicine 04/2012; 75(2):392-400. · 2.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: While the global number of resettled refugees rises annually, the summaries of research on refugee health needs in countries of asylum remain sparse. We conducted a systematic review of published research on refugee health in Canada in order to: (i) identify studies addressing health outcomes among refugees recently resettled in Canada; (ii) identify general trends in health research conducted in Canada among refugee populations; (iii) identify significant gaps in current knowledge of health-related issues among refugees recently resettled in Canada; (iv) evaluate the quality and consistency of available information; (v) develop a summary of available research results; and (vi) identify priorities for future research. A search of several major citation indices resulted in the analysis of 196 research reports after reviewing more than 5,000 articles. This review is timely, systematic and inclusive; furthermore, potential biases in methodology are clearly assessed. The results indicate an immediate need to address specific gaps in health knowledge for refugee populations and lead us to draw five primary conclusions. First, mental health outcomes dominate the research landscape. Second, cross-sectional studies are most commonly the study design of choice. Third, studies examining some aspect of health among refugees from Asia dominate the literature. Fourth, there is a notable lack of information on cardiovascular diseases and its antecedents. Fifth, indications show that screenings for pre-existing conditions are biased towards communicable diseases. These findings have implications for health monitoring, evaluation and policy affecting the health of refugees resettled in Canada and elsewhere.
International Migration 02/2012; · 0.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is considerable interest in the link between household food insecurity and child wellbeing, and the extent to which caregiver wellbeing mediates the relationship between food insecurity and child wellbeing. The aim of this was to assess these relationships among a rural population in Ethiopia.
We used existing survey data from a maximum of 1,006 children under 5 years of age with matched data on household-level data on food insecurity, caregiver distress, and asset ownership, along with other sociodemographic information. All respondents lived in a predominately rural, primarily subsistence-based area in southwest Ethiopia. Multivariable regression models were used to test hypothesized associations.
Household food insecurity, distress, and socioeconomic status predicted children's weight for age and undernutrition, defined as weight for age Z (WAZ) less than -2SD from the reference median. A small portion of the household food insecurity effect was mediated by caregiver distress but these were largely independent effects. Maternal distress was associated with greater odds of a child having any illness, and any illness was associated with lower WAZ and higher odds of being undernourished. The effect of maternal distress on undernutrition was mediated by diarrhea.
This study suggests that household food insecurity, maternal distress, and household SES are independent contributors to children's undernutrition. Our results are consistent with others but are not generally consistent with the hypothesis that maternal distress is a primary pathway through which food insecurity impacts on child nutritional wellbeing.
American Journal of Human Biology 11/2011; 24(2):149-57. · 2.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The global food crisis of 2008 led to renewed interest in global food insecurity and how macro-level food prices impact household and individual level wellbeing. There is debate over the extent to which food price increases in 2008 eroded food security, the extent to which this effect was distributed across rural and urban locales, and the extent to which rural farmers might have benefited. Ethiopia's food prices increased particularly dramatically between 2005 and 2008 and here we ask whether there was a concomitant increase in household food insecurity, whether this decline was distributed equally across rural, urban, and semi-urban locales, and to what extent pre-crisis household capacities and vulnerabilities impacted 2008 household food insecurity levels. Data are drawn from a random sample of 2610 households in Southwest Ethiopia surveyed 2005/6 and again in mid to late 2008. Results show broad deterioration of household food insecurity relative to baseline but declines were most pronounced in the rural areas. Wealthier households and those that were relatively more food secure in 2005/6 tended to be more food secure in 2008, net of other factors, and these effects were most pronounced in urban areas. External shocks, such as a job loss or loss of crops, experienced by households were also associated with worse food insecurity in 2008 but few other household variables were associated with 2008 food insecurity. Our results also showed that rural farmers tended to produce small amounts for sale on markets, and thus were not able to enjoy the potential benefits that come from greater crop prices. We conclude that poverty, and not urban/rural difference, is the important variable for understanding the risk of food insecurity during a food crisis and that many rural farmers are too poor to take advantage of rapid rises in food prices.
Social Science [?] Medicine 11/2011; 73(10):1534-42. · 2.73 Impact Factor