Narratives of symbolic objects : exploring relational wellbeing of young refugees living in Scotland, Finland, and Norway

Background: In this study, objects are used as a representation of relational wellbeing to help young refugees living in Norway, Scotland, and Finland to talk about important persons who make them feel well. At the time of this research, there is no known study that uses objects to facilitate narratives of how young refugees and members of their social networks generate relational wellbeing. Methods: Using a qualitative approach, young refugees participated in individual interviews about the objects they brought to art workshops to understand their experiences, feelings, and acts of wellbeing. Results: Treating each object as unique to the owner was powerful in revealing how relational wellbeing is experienced and expressed. There were overlaps in experiences and expressions of wellbeing, hence our themes of discussion: overlaps between old and new social ties; between time and space; and between the three constructs of relational wellbeing. Old ties were not forgotten; instead, they evolved to a different form, supporting young refugees from a distance, while new ties contributed to what is needed in their present and at their current age. Experiences of relational wellbeing transcended time and space between their disrupted places of origin, their experiences on the journey, and settling in their new countries. The constructs of relational wellbeing—feeling good, being connected, and having enough—were inseparable in the participants’ experiences. Conclusions: We conclude that these overlaps have implications for a relational wellbeing approach in theory and practice. The results leave a challenge for both researchers and practitioners to develop complex research and intervention methods that can capture these tapestries of young refugees’ experiences of relational wellbeing

The power of context in health partnerships:Exploring synergy and antagony between external and internal ideologies in mplementing Safe Male Circumcision (SMC) for HIV prevention in Botswana

Background The aim of this thesis is to explore partnership functioning and the power of context in a North-South partnership in Botswana whose mission is to promote sexual health via Safe Male Circumcision (SMC) for HIV prevention. Specifically the study explores the power of cultural relevance as well as elements that bring synergy and antagony in a partnership. The Botswana SMC partnership comprised Ministry of Health (MH) and two international organisations, US Centers for Disease Control (CDC) and African Comprehensive HIV/AIDS Partnership (ACHAP), both funded by unseen international donors. The mission of this partnership was to circumcise 80% of HIV negative men (100,000 per year) over a five year period. Partnerships between the global North and the global South are a tool used in global governance of aid to mobilise resources to particularly assist developing countries where the poor and vulnerable are concentrated. HIV/AIDS is a global disease, with efforts to fight it coordinated by international institutions like UNAIDS and World Health Organisation (WHO). The global organisations and donors are commended for supporting global scientific efforts in prevention and cure for infectious and chronic diseases and for being a platform that facilitates funding efforts to the developing countries. The view of HIV/AIDS as a global disease has been observed to bring some good but has also generated ‘local pain’ as approaches used to combat it are applied with assumptions of universal effectiveness. Some partnerships have faced disappointing shortfalls and many fail before fulfilling their goals. There are few studies that analyse partnership functioning and processes, especially in Africa. Most of these studies explore what brings about synergy - producing more results than those of a single entity operation. Thus far, very few studies identified ‘antagony’ in partnerships and few address partnership context issues in a more generalised way. There are, to my knowledge, few studies that explore global and local contextual environments that cause antagony and the underlying causes thereof. This thesis aims to bridge this gap and to add to the knowledge of partnership functioning. Methods This study used qualitative ethnographic design to explore the Botswana SMC partnership over three years. Data were collected in three research sites in Botswana; Gaborone city where national officers to the program operate; Hukuntsi and Mochudi villages which have two contrasting cultures to the tradition of initiation. The methods for data collection were observation, in-depth interviews (IDIs), focus group discussion (FGDs) and informal discussions. Thirty national and district SMC officers were observed in a three-day meeting. I also observed two SMC public campaigns where I interacted with a range of stakeholders. All in all, 39 IDIs and five FGDs were conducted for the whole study. Paper I and III draw on data from observation of the 30 officers, IDIs and FDGs while paper II adds experiences of program campaigns to the list. Results Results of Paper I reveal that the Botswana SMC partnership experienced a range of partnership outcomes; additive – Botswana Government had been doing SMC without partnership, synergistic – more was achieved through the partnership and antagonistic – resistance that caused counter-productivity. A combination of inputs – planning together, developing training and implementing materials, giving financial resources, sharing skills, donating capital and medical equipment – helped push their target of circumcising 100,000 HIV negative men in a given year. However, the same resources brought tensions in the partnership, especially where there was no transparency and where international organisations used different reporting tools. Although there are tensions between partners, they are working together in strategising to address some challenges of the partnership and implementation. Pressure to meet the target caused tension and challenges between the in- country partners to the extent of international organisations retreating and not pursuing the mission further. Paper II shows that program officers’ consultation with traditional leaders was done in a seemingly superficial, non-participatory manner. While SMC implementers reported pressure to deliver numbers to the WHO, traditional leaders promoted circumcision through their routine traditional initiation ceremonies at breaks of two-year intervals. There are conflicting views on public SMC demand creation campaigns in relation to the traditional secrecy of circumcision within initiation. Paper III reveals that the partnership experienced antagonistic results during operational processes and as the ultimate outcome. Target setting, financial power of the North, superficial ownership given to the South, and ignoring local traditional realities result in antagony. There are three underlying causes of antagony identified: 1. therapeutic domination – medical expertise given with arrogance; 2. iatrogenic violence – good intentions that cause unintended harm; 3. the Trojan horse – deceptive power positioned under the pretext of benevolence. To tie the three papers together, I identify three main findings that were given less attention. First, all three in-country partners had attitudes that were counterproductive to the success of the partnership. Second, there was resistance at different levels by the recipient government and communities. Third, it was the international donors rather than the in-country partners who put pressure in partnership. Discussion Results of Paper I reveal that external influences that come from the unseen international donors influenced the working of the in-country partnership, unfortunately crippling it from resolving implementation challenges as experienced within the context of partnership functioning. Global mechanisms used for accountability are sabotaged by the same global context where the exercise of power and financial leverage by international donors reign. A combination of inputs by partners brought some progress towards achieving set program goals. However, prioritising externally formulated programs and lack of appreciation for local symbolic funding undermined local efforts and gave blurriness in leadership and ownership of the program. Externally formulated goals and targets, as well as subsequent expectations from external donors placed the functioning and contextual interaction of the partnership at risk. Tensions around target, ownership, financial contribution and accounting caused antagony, resulting in international partners withdrawing before accomplishing the mission. Results for Papers II and III reveal that antagony can be experienced at two levels: during the collaborative process and as the ultimate outcome of the partnership. The two papers also show that the local and global context has not been harmonised in a way that inspires collaboration rather it create tensions. Ignoring to address contextual issues like the ideology of neoliberalism and traditional practices of collectivism caused continuous conflict and resistance. Lack of genuine community consultation and SMC program implementers’ unwillingness to address traditional leaders’ views of locally appropriate approaches to program implementation caused tensions and resistance. Paper III specifically showed that inputs such as finance and oversupply of medical equipment can be a source of antagony. It is also observed that attitudes of the international donors bring antagony: Therapeutic domination – was shown in prioritising external approaches such as the MOVE project which was more concerned about numbers than other implementation realities, side-lining the local government’s approach of integration. The international partners’ lack of acknowledgment for Ministry of Health’s (MH’s) non- financial contribution indicated their belief in the superiority of their modes of involvement; Iatrogenic violence – was evident when MH was left with the sole financial and operational responsibility for all aspects of the program once the DPs pulled out; The Trojan horse – is illustrated by the international donors’ approach that brought false hope of victory but was a vehicle for donor control. Consistent throughout the three papers is that more can be achieved through partnerships than single actors acting alone or parallel, but attention needs to be given to partners’ inherent attitudes as well as global and local contexts of partnerships to minimise antagony. Also, consultation at all levels would better be done in a genuine, participatory manner. Community’s initial cooperation was a loud message for openness and flexibility while the ultimate resistance was a cry to be heard. The main conclusion of this study is that North- South partnerships should not only be between organisations but also between organisations and people in order to account for the context of local realities

Exploring the roots of antagony in the safe male circumcision partnership in Botswana

Background Partnerships in global health and development governance have been firmly established as a tool to achieve effective outcomes. Botswana implements Safe Male Circumcision (SMC) for HIV prevention through a North-South partnership comprising the local Ministry of Health, US Centers for Disease Control and Prevention (funded by PEPFAR) and Africa Comprehensive HIV/AIDS Partnership (funded by the Bill and Melinda Gates Foundation). The SMC partnership experienced significant antagony and the aim of this paper is to illuminate the actions and processes in the SMC program that contributed to that antagony. Methods Methods used to gather data include observation of the partners’ planning and strategic meeting in 2012, in-depth interviews with lead officers at national level, focus group discussions with district officers and implementers, younger male officers and old community members as recipients of the service. Results The findings reveal that the partnership experienced antagony during operational processes and as the ultimate outcome. Target setting, financial power of the North, superficial ownership given to the South, ignoring local traditional realities results in antagony. Three roots of antagony have been identified: 1. therapeutic domination–medical expertise given with arrogance; 2.iatrogenic violence–good intentions that cause unintended harm; 3. the Trojan horse–Reckless acceptance of the gift as well as deceptive power positioned under the pretext of benevolence. Conclusion The three roots of antagony; therapeutic domination, iatrogenic violence and the Trojan horse, constitute attitudes, hidden intentions and unintended consequences that influence program implementation and cause harm at different levels. Examples of therapeutic domination and the Trojan horse have highlighted the need for vigilance at the stage of establishing a partnership, to prevent more powerful partners from developing and applying hidden agendas and to strengthen accountability from the local partner. Iatrogenic violence has highlighted the need for partnership interventions to prevent good partner intentions accidentally producing bad outcomes

Exploring the roots of antagony in the safe male circumcision partnership in Botswana

Background: Partnerships in global health and development governance have been firmly established as a tool to achieve effective outcomes. Botswana implements Safe Male Circumcision (SMC) for HIV prevention through a North-South partnership comprising the local Ministry of Health, US Centers for Disease Control and Prevention (funded by PEPFAR) and Africa Comprehensive HIV/AIDS Partnership (funded by the Bill and Melinda Gates Foundation). The SMC partnership experienced significant antagony and the aim of this paper is to illuminate the actions and processes in the SMC program that contributed to that antagony. Methods: Methods used to gather data include observation of the partners’ planning and strategic meeting in 2012, in-depth interviews with lead officers at national level, focus group discussions with district officers and implementers, younger male officers and old community members as recipients of the service. Results: The findings reveal that the partnership experienced antagony during operational processes and as the ultimate outcome. Target setting, financial power of the North, superficial ownership given to the South, ignoring local traditional realities results in antagony. Three roots of antagony have been identified: 1. therapeutic domination–medical expertise given with arrogance; 2.iatrogenic violence–good intentions that cause unintended harm; 3. the Trojan horse–Reckless acceptance of the gift as well as deceptive power positioned under the pretext of benevolence. Conclusion: The three roots of antagony; therapeutic domination, iatrogenic violence and the Trojan horse, constitute attitudes, hidden intentions and unintended consequences that influence program implementation and cause harm at different levels. Examples of therapeutic domination and the Trojan horse have highlighted the need for vigilance at the stage of establishing a partnership, to prevent more powerful partners from developing and applying hidden agendas and to strengthen accountability from the local partner. Iatrogenic violence has highlighted the need for partnership interventions to prevent good partner intentions accidentally producing bad outcomes

Exploring the roots of antagony in the safe male circumcision partnership in Botswana

Background Partnerships in global health and development governance have been firmly established as a tool to achieve effective outcomes. Botswana implements Safe Male Circumcision (SMC) for HIV prevention through a North-South partnership comprising the local Ministry of Health, US Centers for Disease Control and Prevention (funded by PEPFAR) and Africa Comprehensive HIV/AIDS Partnership (funded by the Bill and Melinda Gates Foundation). The SMC partnership experienced significant antagony and the aim of this paper is to illuminate the actions and processes in the SMC program that contributed to that antagony. Methods Methods used to gather data include observation of the partners’ planning and strategic meeting in 2012, in-depth interviews with lead officers at national level, focus group discussions with district officers and implementers, younger male officers and old community members as recipients of the service. Results The findings reveal that the partnership experienced antagony during operational processes and as the ultimate outcome. Target setting, financial power of the North, superficial ownership given to the South, ignoring local traditional realities results in antagony. Three roots of antagony have been identified: 1. therapeutic domination–medical expertise given with arrogance; 2.iatrogenic violence–good intentions that cause unintended harm; 3. the Trojan horse–Reckless acceptance of the gift as well as deceptive power positioned under the pretext of benevolence. Conclusion The three roots of antagony; therapeutic domination, iatrogenic violence and the Trojan horse, constitute attitudes, hidden intentions and unintended consequences that influence program implementation and cause harm at different levels. Examples of therapeutic domination and the Trojan horse have highlighted the need for vigilance at the stage of establishing a partnership, to prevent more powerful partners from developing and applying hidden agendas and to strengthen accountability from the local partner. Iatrogenic violence has highlighted the need for partnership interventions to prevent good partner intentions accidentally producing bad outcomes.publishedVersio

Safe male circumcision in Botswana: Tension between traditional practices and biomedical marketing

Botswana has been running Safe Male Circumcision (SMC) since 2009 and has not yet met its target. Donors like the US Centers for Disease Control and Prevention and Africa Comprehensive HIV/AIDS Partnership (funded by the Gates Foundation) in collaboration with Botswana's Ministry of Health have invested much to encourage HIV-negative men to circumcise. Demand creation strategies make use of media and celebrities. The objective of this paper is to explore responses to SMC in relation to circumcision as part of traditional initiation practices. More specifically, we present the views of two communities in Botswana on SMC consultation processes, implementation procedures and campaign strategies. The methods used include participant observation, in-depth interviews with key stakeholders (donors, implementers and Ministry officials), community leaders and men in the community. We observe that consultation with traditional leaders was done in a seemingly superficial, non-participatory manner. While SMC implementers reported pressure to deliver numbers to the World Health Organization, traditional leaders promoted circumcision through their routine traditional initiation ceremonies at breaks of two-year intervals. There were conflicting views on public SMC demand creation campaigns in relation to the traditional secrecy of circumcision. In conclusion, initial cooperation of local chiefs and elders turned into resistance

Aspirations and realities in a North-South partnership for health promotion: lessons from a program to promote safe male circumcision in Botswana

Background: International donors support the partnership between the Government of Botswana and two international organisations: U.S. Centers for Disease Control and Prevention and Africa Comprehensive HIV/AIDS Partnership to implement Voluntary Medical Male Circumcision with the target of circumcising 80 % of HIV negative men in 5 years. Botswana Government had started integration of the program into its health system when international partners brought in the Models for Optimizing Volume and Efficiency to strengthen delivery of the service and push the target. The objective of this paper is to use a systems model to establish how the functioning of the partnership on Safe Male Circumcision in Botswana contributed to the outcome. Methods: Data were collected using observations, focus group discussions and interviews. Thirty participants representing all three partners were observed in a 3-day meeting; followed by three rounds of in-depth interviews with five selected leading officers over 2 years and three focus group discussions. Results: Financial resources, “ownership” and the target influence the success or failure of partnerships. A combination of inputs by partners brought progress towards achieving set program goals. Although there were tensions between partners, they were working together in strategising to address some challenges of the partnership and implementation. Pressure to meet the expectations of the international donors caused tension and challenges between the in-country partners to the extent of Development Partners retreating and not pursuing the mission further. Conclusion: Target achievement, the link between financial contribution and ownership expectations caused antagonistic outcome. The paper contributes enlightenment that the functioning of the visible in-country partnership is significantly influenced by the less visible global context such as the target setters and donors

Intergenerational perspectives on refugee children and youth's adapatation to life in Norway

Refugees from the Global South face many challenges when they arrive in Europe, not least having their subjectivities and beliefs questioned as part of requests for them to adapt to the norms of the destination context. Although there has been much critical research on migrant integration and adaptation, few of these studies have used an intergenerational lens to investigate the experiences of refugee children and youth. This article addresses this research gap using a social navigation theoretical framework and qualitative data obtained from focus group discussions with Eritrean and Afghan unaccompanied minors, young adults, and parents. The findings demonstrate how challenges and resources associated with adaptation identified across generations were related to (a) the frequency and nature of interactions between refugees, their compatriots, and Norwegians; (b) learning the Norwegian language; (c) comprehension of Norway's bureaucratic welfare systems; and (d) accepting Norwegian cultural values while maintaining transnational cultural ties. Notably, unaccompanied minors, young adults, and parents all navigated dual cultures as part of efforts to achieve normative Norwegian markers of successful migrant adaptation. Significantly, the older generational groups had the most difficulty “breaking” into Norwegian society. Overall, it is argued that to understand better the challenges migrants face when they are required to adapt to a new life in a destination context and the implications of these challenges for their aspirations, it is important to include both a focus on how they move through the society (social navigation) and the interactivity between generations (intergenerational perspective)

Intergenerational perspectives on refugee children and youth's adaptation to life in Norway

Refugees from the Global South face many challenges when they arrive in Europe, not least having their subjectivities and beliefs questioned as part of requests for them to adapt to the norms of the destination context. Although there has been much critical research on migrant integration and adaptation, few of these studies have used an intergenerational lens to investigate the experiences of refugee children and youth. This article addresses this research gap using a social navigation theoretical framework and qualitative data obtained from focus group discussions with Eritrean and Afghan unaccompanied minors, young adults, and parents. The findings demonstrate how challenges and resources associated with adaptation identified across generations were related to (a) the frequency and nature of interactions between refugees, their compatriots, and Norwegians; (b) learning the Norwegian language; (c) comprehension of Norway's bureaucratic welfare systems; and (d) accepting Norwegian cultural values while maintaining transnational cultural ties. Notably, unaccompanied minors, young adults, and parents all navigated dual cultures as part of efforts to achieve normative Norwegian markers of successful migrant adaptation. Significantly, the older generational groups had the most difficulty “breaking” into Norwegian society. Overall, it is argued that to understand better the challenges migrants face when they are required to adapt to a new life in a destination context and the implications of these challenges for their aspirations, it is important to include both a focus on how they move through the society (social navigation) and the interactivity between generations (intergenerational perspective)