Reviews

Martin Oliver (ed.), Innovation in the Evaluation of Learning Technology, London: University of North London, 1998. ISBN: 1–85377–256–9. Softback, 242 pages, £15.00

Prohibition, persecution, performance

A preponderance of the ethnographies published by researchers working in Haiti during the 1930s and 1940s focus on the Vodou religion. Yet the fact that many Haitian popular ritual practices were officially prohibited by penal law, first as «sortilèges» and later as «pratiques superstitieuses», and, on this basis, subject to US Marine, Protestant missionary, Catholic Church, and Haitian state offensives  during these same years, is not always well-acknowledged or documented in this ethnographic literature. Focusing on the writings of Melvillle J. Herskovits, George Eaton Simpson, Jacques Roumain and Alfred Métraux, this article argues that the persecution of Haitian popu­lar religious practices played a key role in propelling ethnographic work on Haiti and Vodou during this period and also influenced the methodological forms that this research took. In particular, the article examines the ways in which officially prohibited rituals were restaged and reframed as ethnographic «performances» in the context of this repression.Alors qu’un grand nombre des études ethnographiques de chercheurs travaillant sur Haïti pendant les années 1930-1950 porte sur la religion vodou, cette littérature ne fait que peu état ni n’approfondit le fait que la plupart des pratiques rituelles populaires, considérées comme «sortilèges» ou «pratiques superstitieuses», étaient alors officiellement interdites par la loi et furent de ce fait violemment réprimées, tant par l’armée américaine d’occupation, que par les missions protestantes, l’Église catholique et l’État haïtien. Se basant sur les écrits de Melville J. Herskovits, George Eaton Simpson, Jacques Roumain et Alfred Métraux, l’auteur souligne que la persécution qu’ont subie les pratiques religieuses populaires a cependant joué un rôle majeur dans la dynamique prise par les études ethnographiques sur Haïti et le vodou et a également influencé les formes méthodologiques qu’ont prises ces recherches. L’article se penche plus particulièrement sur la façon dont les rituels, officiellement interdits, furent pourtant remis en scène et réélaborés dans le cadre de «représentations» ethnographiques

Understanding the origins of a social catastrophe: Mistreatment in childbirth as normalized organizational deviance

Mistreatment experienced by women delivering in healthcare institutions is a concerning pattern reproduced and normalized in health systems globally, causing widespread harm. Women’s reports and observations of childbirth practices in institutions have revealed that disturbing proportions of deliveries are characterized by indignity, humiliation, and neglect. The enormity of the problem constitutes a social catastrophe, as potentially hundreds of thousands are affected daily at a profoundly important moment of personal, family, and social life. Growing global concern has elicited research on mistreatment’s prevalence and characteristics, with limited attention to developing explanatory theory. The observed patterns indicate that mistreatment is systemic; therefore, social theory is required to understand why mistreatment persists, despite official norms that prohibit mistreatment and promulgate respectful care. Diane Vaughan’s normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. The theory posits that organizational structures and processes are distorted due to resource scarcity combined with production pressures resulting in normalized organizational deviance in daily micro-level transactions. Furthermore, regulatory systems are unable to capture and mitigate the problem. Vaughan’s multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance.To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case because it was the site of a seminal study to measure the prevalence of mistreatment, explore its causes, and develop and test interventions to reduce its occurrence. My participation in designing and conducting this study provided understanding of the phenomenon which formed the foundation of this dissertation. Novel theory was first elaborated through a systematic review of literature on maternal health care and the government health system in Tanzania. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan’s theory and additional organizational theories, resulting in a nascent theory. A qualitative theory-driven approach was then applied to verify and expand the nascent theory using qualitative exploratory data from the study in Tanzania described above. The data included eight focus group discussions and 37 in-depth interviews involving 91 individuals representing community and health system stakeholders. Data were analyzed deductively and inductively using the theory’s framework while allowing for emergent constructs. Analysis based on the literature review revealed that normalized scarcity at the macro-level combined with production pressures that emphasized biomedical care and imbalanced power-dependence on limited financial sources altered values, structures, and processes in the health system. Meso-level actors strove to achieve production goals with limited autonomy and insufficient resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. The nascent theory developed through literature review was largely supported by the qualitative data, while providing further nuance and elucidating new components. Moral distress, which occurs when one knows the right thing to do but is prevented from taking the right action due to institutional constraints, emerged as an important systems effect of organizational dysfunction. In addition, the qualitative data revealed that managers coped with dual roles as both managers and providers and that the service interaction includes families, not solely providers, women, and newborns. The challenges in the regulatory environment also were clarified, highlighting that monitoring and observing mistreatment was hindered due to structural secrecy and the nature of mistreatment. The nascent theory revealed the importance of emotional labor and emotion work in understanding mistreatment. Emotional labor has been widely acknowledged as an important aspect of healthcare provision, especially for a positive patient experience; yet there has been limited attention to emotion work as the underlying effort required to provide respectful maternity care and prevent mistreatment. Qualitative data from the exploratory formative research were further analyzed to explore the characteristics of emotion work. 22 interviews and 3 focus groups with 44 maternity providers from different levels of care provision in two districts were analyzed using thematic analysis combined with affinity diagramming. Six key themes were identified that provide a deeper understanding of the emotion work required of maternity providers, including 1) expected to love and care for patients; 2) controlling emotions; 3) managing patient expectations in the face of system shortages; 4) providers are human beings too; 5) nurses are perceived as harsh; and 6) limited system support for emotion work. The themes and corresponding sub-themes highlight that the nature of childbirth care, the context, and gender norms influence the ability to exert emotion work and thus provide respectful care. Emotion work was expected but good performance was unacknowledged by the system. Additional resources are required, not only to ensure the most basic of resources to provide quality of care, but to ensure sufficient organizational support to address the emotional demands of providers. Systems need to acknowledge the extra effort required for emotion work and support and train providers to provide this care, as well as help them to manage difficult emotions that they experience due to the nature of their work. Analogical comparison with another case of organizational deviance enabled a novel approach to elaborate theory. Normalization of organizational deviance proved useful for understanding mistreatment. This theory and others from organizational sociology that explore why things go wrong in organizations may be relevant for other areas of persistent systems failure and underperformance. Further theory testing in different contexts and types of health systems is needed to understand the generalizability of the nascent theory and advance its development. In addition, many of the constructs, such as emotional labor and moral distress, have not been widely applied in low- and middle-income settings and require deeper study. This theory reveals the systemic factors driving mistreatment and can guide the identification of system leverage points to transform health systems towards ensuring a respectful experience during childbirth for women and their newborns. Ensuring that adequate resources are provided to achieve targets is essential, but organizational support to address the emotional demands of providers must also be provided. These changes will ease the burden among providers and managers struggling to provide care in under-resourced health systems. The extra effort required for emotion work should be acknowledged and appropriate training provided, as well as support for providers to manage the difficult emotions that they experience due to the nature of their work. The findings may also have implications beyond childbirth, as the theory highlights the conditions that may lead to burnout and poor mental health among providers, an ongoing problem worldwide that was exacerbated by the COVID-19 pandemic

Nonclassical crystallization of dipicolinic acid in microemulsions

Dipicolinic acid (DPA) was crystallised in microemulsions to investigate the effect of 3D nanoconfinement on the crystallisation process. The microemulsions were acidified with 2M HCl to prevent the formation of DPA metal salts, which occurs due to a pH shift towards neutrality arising from the nanoconfinement. TEM analysis showed that 30-100 nm square-plate nanoaggregates crystallised from these acidified microemulsions. Higher resolution TEM images revealed that the nanoaggregates consisted of smaller 3-10 nm nanocrystals. The FFT’s obtained from images of these nanocrystals were similar to the diffraction pattern arising from the whole nanoaggregate confirming that the nanocrystals exhibited ordered packing and resembled mesocrystals. The crystallisation of the nanoaggregates is aided by the suppression of Ostwald ripening of the nanocrystals in the nm-sized microemulsion droplets and surfactant adsorption onto the nanocrystals

Poverty identification for a pro-poor health insurance scheme in Tanzania: reliability and multi-level stakeholder perceptions.

BACKGROUND: Many low income countries have policies to exempt the poor from user charges in public facilities. Reliably identifying the poor is a challenge when implementing such policies. In Tanzania, a scorecard system was established in 2011, within a programme providing free national health insurance fund (NHIF) cards, to identify poor pregnant women and their families, based on eight components. Using a series of reliability tests on a 2012 dataset of 2,621 households in two districts, this study compares household poverty levels using the scorecard, a wealth index, and monthly consumption expenditures. METHODS: We compared the distributions of the three wealth measures, and the consistency of household poverty classification using cross-tabulations and the Kappa statistic. We measured errors of inclusion and exclusion of the scorecard relative to the other methods. We also gathered perceptions of the scorecard criteria through qualitative interviews with stakeholders at multiple levels of the health system. FINDINGS: The distribution of the scorecard was less skewed than other wealth measures and not truncated, but demonstrated clumping. There was a higher level of agreement between the scorecard and the wealth index than consumption expenditure. The scorecard identified a similar number of poor households as the "basic needs" poverty line based on monthly consumption expenditure, with only 45 % errors of inclusion. However, it failed to pick up half of those living below the "basic needs" poverty line as being poor. Stakeholders supported the inclusion of water sources, income, food security and disability measures but had reservations about other items on the scorecard. CONCLUSION: In choosing poverty identification strategies for programmes seeking to enhance health equity it's necessary to balance between community acceptability, local relevance and the need for such a strategy. It is important to ensure the strategy is efficient and less costly than alternatives in order to effectively reduce health disparities

Implementation and effectiveness of free health insurance for the poor pregnant women in Tanzania: A mixed methods evaluation.

Demand side financing strategies have been a popular means of increasing coverage and availability of effective maternal and child health services in low and middle income countries (LMIC). However, most research to date has focused on the effects of demand side financing on the use and costs of care with less attention being paid to how they work to achieve outcomes. This study used a mixed methods evaluation to determine the effect of a targeted health insurance scheme on access to affordable quality maternal and child care, and assess implementation fidelity and how this affected programme outcomes. Programme effects on service access, affordability and quality were evaluated using difference in difference regression analysis, with outcomes being measured through facility, patient and household surveys and observations of care before the intervention started and eighteen months later. A simultaneous process evaluation was designed as a case study of the implementation experience. A total of 90 in-depth interviews (IDIs) and five focus group discussions were conducted during three rounds of data collection among respondents from management, facility and community. The scheme achieved high coverage among the target population and reduced the amount paid for antenatal and delivery care; however, there was no effect on service coverage and limited effects on quality of care. The lack of programme effects was partly due to the late timing of first antenatal care visits and registration for the scheme together with limited understanding of entitlements among beneficiaries and providers. Better communication of programme benefits is needed to enhance effects together with integration of such schemes within existing purchasing mechanisms and in financially decentralised health systems

Protocol for the evaluation of a free health insurance card scheme for poor pregnant women in Mbeya region in Tanzania: a controlled-before and after study.

BACKGROUND: The use of demand-side financing mechanisms to increase health service utilisation among target groups and enhance service quality is gaining momentum in many low- and middle-income countries. However, there is limited evidence on the effects of such schemes on equity, financial protection, quality of care, and cost-effectiveness. A scheme providing free health insurance cards to poor pregnant women and their households was first introduced in two regions of Tanzania in 2011 and gradually expanded in 2012. METHODS: A controlled before and after study will examine in one district the effect of the scheme on utilization, quality, and cost of healthcare services accessed by poor pregnant women and their households in Tanzania. Data will be collected 4 months before implementation of the scheme and 17 months after the start of implementation from a survey of 24 health facilities, 288 patients exiting consultations and 1500 households of women who delivered in the previous year in one intervention district (Mbarali). 288 observations of provider-client interactions will also be carried out. The same data will be collected from a comparison district in a nearby region. A process evaluation will ascertain how the scheme is implemented in practice and the level of implementation fidelity and potential moderators. The process evaluation will draw from impact evaluation data and from three rounds of data collection at the national, regional, district, facility and community levels. An economic evaluation will measure the cost-effectiveness of the scheme relative to current practice from a societal perspective. DISCUSSION: This evaluation will generate evidence on the impact and cost-effectiveness of targeted health insurance for pregnant women in a low income setting, as well as building a better understanding of the implementation process and challenges for programs of this nature

Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga Region, Tanzania: A comparative before-and-after study

Background Abusive treatment of women during childbirth has been documented in low-resource countries and is a deterrent to facility utilization for delivery. Evidence for interventions to address women’s poor experience is scant. We assessed a participatory community and health system intervention to reduce the prevalence of disrespect and abuse during childbirth in Tanzania. Methods and findings We used a comparative before-and-after evaluation design to test the combined intervention to reduce disrespect and abuse. Two hospitals in Tanga Region, Tanzania were included in the study, 1 randomly assigned to receive the intervention. Women who delivered at the study facilities were eligible to participate and were recruited upon discharge. Surveys were conducted at baseline (December 2011 through May 2012) and after the intervention (March through September 2015). The intervention consisted of a client service charter and a facility-based, quality-improvement process aimed to redefine norms and practices for respectful maternity care. The primary outcome was any self-reported experiences of disrespect and abuse during childbirth. We used multivariable logistic regression to estimate a difference-in-difference model. At baseline, 2,085 women at the 2 study hospitals who had been discharged from the maternity ward after delivery were invited to participate in the survey. Of these, 1,388 (66.57%) agreed to participate. At endline, 1,680 women participated in the survey (72.29% of those approached). The intervention was associated with a 66% reduced odds of a woman experiencing disrespect and abuse during childbirth (odds ratio [OR]: 0.34, 95% CI: 0.21–0.58, p < 0.0001). The biggest reductions were for physical abuse (OR: 0.22, 95% CI: 0.05–0.97, p = 0.045) and neglect (OR: 0.36, 95% CI: 0.19–0.71, p = 0.003). The study involved only 2 hospitals in Tanzania and is thus a proof-of-concept study. Future, larger-scale research should be undertaken to evaluate the applicability of this approach to other settings. Conclusions After implementation of the combined intervention, the likelihood of women’s reports of disrespectful treatment during childbirth was substantially reduced. These results were observed nearly 1 year after the end of the project’s facilitation of implementation, indicating the potential for sustainability. The results indicate that a participatory community and health system intervention designed to tackle disrespect and abuse by changing the norms and standards of care is a potential strategy to improve the treatment of women during childbirth at health facilities. The trial is registered on the ISRCTN Registry, ISRCTN 48258486