“Who are you?” About experiences from a course in qualitative research

“You are you?” asked the professor. I sat there puzzled by the question. “I am Sara” I thought, “a researcher, a colleague, a friend, a…” But that was not the answer the professor was looking for. What was my epistemological position?  Was I a constructionist believing that everything is relative and that there are several realities all socially constructed? Or perhaps a positivist certain that the reality is static and directly measurable? During the course I have attended for the past two weeks titled “Advanced course in qualitative research in global public health” we as participants have been challenged to position ourselves within these theories. The course is organized in collaboration between the University of Copenhagen, the University of Bergen and the Norwegian Research School of Public Health. During the course we have learned that epistemology is the underlying assumption or belief about how knowledge is generated. Ontology is the study of the nature of being, becoming, or reality. It is grounded in the philosophical idea that everything around us is subjective and based on our individual reality. We have also learnt that as a qualitative researcher it is important to be transparent to our readers about who we are as researchers; our epistemological position and the theoretical approach we use to collect and analyze data. “But wait a minuteI thought “aren’t we as researchers supposed to generate some sort of objective truth completely separated from who we are as human beings and what we believe in?”

Later on in the course, during a group exercise about qualitative thematic analysis, participants were separated into groups at random and instructed to extract key features of a text and condense it into key words, a process called coding. These codes would eventually be developed into interpretative themes that would be presented to the class by each group at the end of the exercise. The text was about health-seeking behaviors of HIV positive men in Zimbabwe. Course participants were from multiple professional backgrounds such as medicine, anthropology and philosophy and came from various corners of the globe. Therefore, the multidisciplinary environment permitted rich discussions and interpretations from diverse perspectives. When each group presented their interpretative themes that they felt summed up the most important aspects of the text, it turned out we had all focused on different aspects of the text. The health professional had focused on issues such as adherence- the men´s ability to follow the treatment regimen, while the anthropologist had spent more time focusing on the experiences of the men and the context within which they lived their lives. The exercise was a lesson in how we all interpret the world around us from a unique position which influence who we are as researchers.

So who am I? I still need some more time on that one. But definitively not a positivist, I think…

Sara Rivenes Lafontan is a PhD student at the University of Oslo. Her PhD project is about adaptation of new technology among birth attendants and laboring women in Tanzania. She recently published a scientific article about laboring women´s experience using a newly developed electronic fetal heart rate monitor.

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About stereotypes, traditional practices and culture: Experiences from field work in Malawi

Written by Hanneke Pot, PhD candidate at Centre for Development and the Environment, University of Oslo 

To Malawi for fieldwork

During my first weeks in Malawi, I met with a staff member of an International Non-Governmental Organization (INGO). Over a cup of tea, we discussed a possible location for my fieldwork. I was interested in studying the dynamic relationships between NGOs and local communities and how this shaped the implementation of a project aiming to reduce teenage pregnancies and keep girls in school.  The Malawian INGO staff member was fascinated by Mangochi, a district which he described as having ‘bad’ indicators in the fields of health and education compared to the national average, but which on the other hand was quite developed in terms of economic activity. He mentioned that cultural values and practices were the main reason for these bad indicators. In other districts, he argued, people were more accepting towards programs. However, the ‘bad’ status of Mangochi was relative, as nationwide as much as 29 per cent of girls between the ages of 15 and 19 have begun child bearing and the median years of completed education for women aged 15-49 is 5.6 (for men 6.6) [1]. In Malawi, young motherhood was the norm.

Hanneke 4

Stereotypes at several levels

The more NGO staff and senior government officials I spoke to, the more I became aware of people’s strong stereotypical ideas about Mangochi: The dominant tribe in Mangochi – the Yao – did not value education because they were Muslims. They highly valued traditional practices such as initiation ceremonies and early marriages, aimed to protect their culture and therefore resisted development discourses. Having some prior knowledge of Islam, the logic of resisting western education out of religious conviction did not make sense to me. I knew Islam as a religion in which knowledge and education were highly valued. This puzzle fascinated me. How could elite Malawians’ perception of Islam be so different from mine? And why were traditional practices and culture so central in the explanation for the ‘bad’ indicators in Mangochi district?

A couple of weeks later I was on my way to Mangochi, a four-hour drive from the capital Lilongwe, crossing the mountains and fertile lands of Dedza district. The beautiful and peaceful scenery was somewhat in contrast with the immensely busy and vibrant atmosphere in Mangochi, located at the southern end of Lake Malawi. There were bicycles everywhere, transporting people, but also merchandise, between markets. On one side of the lake there were tourist lodges, the larger ones had conference halls, which were used for NGO-organized meetings. The population was ethnically mixed and residence to people from different parts of Malawi. The other side of the lake was calmer in terms of economic activity, and the population was more homogeneous Yao. I chose a village on the side with the mixed population as fieldwork location.

Conducting participant observation in the implementation of an INGO project with a behavior change approach and studying in-depth one rural area in which it was meant to make a difference, provided me with unique insights. I learned how the INGO staff ‘translated’ the content of the project to specificities of the district, how INGO staff and government stakeholders talked about the project and the target population during project meetings, but also how the project related to local realities in rural Malawi. One finding that stood out was the stereotypical portrayal of the Yao tribe, the overemphasis on a static uniform culture to explain bad indicators, and how this was in discordance with local realities shaped by poverty, daily uncertainties and lack of options to formal employment.

Hanneke 2

Emphasis on cultural and behavioral factors amongst INGO staff

Whereas the INGO staff attributed the Yao’s low educational attendance to a distant past in which they had resisted missionary education out of refusal to convert to Christianity, INGO staff completely passed over the influence of more recent events. The 1994 Free Primary Education policy had doubled the enrollment but deteriorated the quality of education. In the southern region of Malawi, this reinforced the idea that education was insignificant to secure livelihoods that were severely affected by the AIDS crisis [2]. There seemed to be no collective cultural or religious resistance towards education. Rather, to many villagers the importance of education was related to various notions of development. For some this meant a strong focus on tangibles, such as iron sheet houses, sleeping on a mattress, or having braided hair. To others, development meant envisioning getting an education and formal employment. Yet, achieving these dreams proved to be challenging.

When implementing interventions with a behavior change approach, discussions during INGO-community meetings were almost inevitably steered towards those factors that could be changed by the project: behavioral determinants. Although in private conversations INGO staff acknowledged the structural inequalities that characterized village life, they could not address these issues with the project. It was their job to convince local communities that education would lead to a better future, thereby constructing education and teenage pregnancies as oppositional. What therefore became the topic of discussion during INGO-community meetings were the behavioral and cultural factors that could be changed to achieve these aims. As such, poverty became a superficial factor, and culture the deeper layered problem, instead of the other way around.

Hanneke 1

Hanneke 3

Focus on culture reflects dichotomies

Through such meetings, INGO staff talked about tradition and culture as something static, as an entity in itself, uninfluenced over time. The fuss about ‘harmful cultural practices’ in Malawi seemed to reflect dichotomies between elites and villagers, modernity and tradition, urban and rural, educated and ignorant. As such, a project about reducing teenage pregnancies and keeping girls in school that appeared to be morally neutral due to its scientific underpinnings, played out as a moral discourse for rural girls and communities to abandon their traditional practices and become modern educated Malawians, blaming culture in its course.

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Hanneke Pot with research assistants Gertrude Finyiza and Beatrice Chibayo

  1. NSO and ICF, Malawi Demographic and Health Survey 2015-16. 2017, National Statistical Office [NSO] Malawi and ICF: Zomba, Malawi and Rockville, Maryland, USA.
  2. Kendall, N., Education for All Meets Political Democratization: Free Primary Education and the Neoliberalization of the Malawian School and State. Comparative Education Review, 2007. 51(3): p. 281-305.

Improving the quality of reproductive healthcare in Georgia – About the creation of a Georgian birth registry

Written by Ingvild Hersoug Nedberg (MPH), Natia Skhvitaridze (MD, MBA) and Tinatin Manjavidze (DD, MPH) from UiT The Arctic University of Norway  

Maternal and perinatal mortality and morbidity are frequently referred to as the most important indicators related to the health of a nation and is used as a measure of quality of the reproductive health care system. One of the major challenges to improve a health care system is unreliable patient-data and methods of collecting data. A country can improve the quality and efficiency of their reproductive health care system with the use of a medical birth registry with high quality and accurate data, as has been done in Georgia.   

 

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Health data in Georgia

Georgia is a developing country with several problems related to their healthcare system. Among the challenges are how to improve the quality of care and its effectiveness. Reduction of maternal and children morbidity and mortality has been an important goal for the United Nations Millennium Development Goals (MDG) and is now the priority for the Sustainable Development Goals (SDG). Maternal and newborns deaths are crucial to report accurately. However, Georgia has been lacking precise and longitudinal data dealing with maternal and newborns mortality and morbidity. Until 2016, data on reproductive health services came from sporadic on-demand surveys. Routine info on mortality and morbidity was available as aggregated data with a lack of epidemiological analysis.

 

Using data for research and education

The Georgian Birth Registry (GBR) was implemented 1January 2016 with the aim of collecting reliable information and ensuring accurate reporting of data with high quality and completeness. It is the first developing country to implement a national, digital medical birth registry, and it was made possible by the initiative and great enthusiasm from the involved actors.

The introduction of the GBR in Georgia has made it possible to create a database, which can be used for epidemiological analysis and recommend evidence-based findings. We are three PhD-students (two Georgians living in Georgia and one Norwegian) accepted at UiT The Arctic University of Norway in the Department of Community Medicine to work and develop our studies. We are all using data from the GBR and our projects deal with maternal and perinatal mortality and morbidity, and cesareans sections.

The supervising team consists of main supervisors in Norway and co-supervisors in Georgia from different scientific backgrounds and clinical experience.

 

How it works

We started our PhD in January 2017 and we all study full-time. We attend relevant PhD-courses together in Norway and gather for common supervision either in Norway or in Georgia at least four times a year. We also have weekly communication by Skype. We arranged a writing gathering in February 2018 where supervisors and PhD-students came together for a week in the mountains of Georgia to write the outline of our first paper, a highly effective way of working and something we would recommend for other PhD-students working on common data material. The Norwegian and Georgian partners in the project also organize annual conferences to review progress and challenges with the birth registry and other parts of the project.

Due to the recent implementation of the GBR, we have spent much time reviewing the quality of the variables in the registry, trying to find out why some are poorly filled out while others seem to be misunderstood. It is also important to make a detailed and up-to-date codebook of all the 470 variables with detailed explanations of coding and meaning, to avoid misunderstandings and provide a working tool for all those involved in using the GBR data. This work is not directly related to our projects, but is valuable to understand how a national registry is set up, what it takes to make it work and not the least how much time it takes to clean a dataset before it is ready for analyses!

 

Outcomes

We believe that our studies, through our PhD-projects, can contribute to the improvement of the Georgian reproductive health system by providing descriptions and analyses of data never published before and suggestions for improving maternal and newborn health.

 

For more information contact:

Ingvild Hersoug Nedberg – ingvild.h.nedberg@uit.no

Natia Skhvitaridze – natia.skhvitaridze@uit.no

Tinatin Manjavidze – tinatin.manjavidze@uit.no

 

The Norwegian Center for International Cooperation in Education (SIU) funded the project ”Georgian-Norwegian Collaborative in Public Health (GeNoC-PH)” in 2016 with the following participants:

  • UiT The Arctic University of Norway (UiT)
  • University of Georgia (UG)
  • Ivane Javakhishvili Tbilisi State University (TSU)
  • National Center for Disease Control and Public Health of Georgia (NCDC)
  • United Nations Children’s Fund (UNICEF)
  • Consulting & IT Innovations (CiTi)

Country of focus: Malawi

Written by Maria Lisa Odland, PhD Candidate, Norwegian University of Science and Technology (NTNU)

 

About research, medical training and other experiences from Malawi

 

First time in Malawi

People´s knowledge on Malawi varies a lot. Some people don’t know the difference between Mali and Malawi, some people know it’s one of the poorest countries in the world, some people don’t know it exists, and some people know it is a popular place to do research and aid work, and some people even know it as a tourist destination. For me I didn’t have a clue before the first time I travelled down there, but now I can safely say that Blantyre is my second hometown and Malawi will always have a special place in my heart.

I went to Malawi for the first time as a medical student and did rotations in Obstetrics and Gynecology, Pediatrics and Nephrology. There was a lot of impressions, both good and bad. Doing rounds at the ward for malnourished children and participating in a data collection on underfed children was probably one of the most difficult things I have ever done. I more or less saw children die from lack of food. Additionally, seeing patients with chronic kidney disease without money to buy drugs or the possibility to get a transplant or dialysis also made a very big impression on me and is something I will never forget. The bright side were seeing all these talented and dedicated doctors doing everything they could with very little resources. It made me a little bit hopeful that some of these patients could be saved, and maybe get better lives.

 

 

Unsafe abortions, complications and maternal mortality

Personally, my interest was always in Gynecology and naturally my further work went in this direction. It was devastating seeing girls even younger than me that had done horrible things to induce an abortion. An abortion is not legal in Malawi unless to save a pregnant woman’s life. Still, there is estimated around 140 000 induced abortions in the country every year. Considering the abortion law most of these are unsafe which leads to many complications that have to be treated.  Retained products of conception in the uterus, referred to as incomplete abortions, consists of more than 50% of the patients in a gynecological or female ward in Malawi, and takes up a lot time and resources. If incomplete abortions are left untreated it can lead to hemorrhage, sepsis and in worst case scenario death. One thing I noticed as a medical student was that they were treating all these patients with sharp curettage, while in Norway we mostly use medical treatment with misoprostol or electrical vacuum if surgical treatment is necessary. Treatment with curettage requires more resources like general anesthetics, a doctor or clinical officers, and electricity. Also, it is known to lead to more complications such as bleeding, uterine perforation and Asherman Syndrom. Potentially complications after this treatment can make women infertile in the future which can be devastating for a 16-year-old girl who maybe would have wanted a child later in life. In Malawi, they prefer to treat patients surgically for different reasons. If medical treatment is given out it can be used to induce abortions illegally. Additionally, medical treatment is not as efficient as surgical treatment and patients are supposed to return for follow up to ensure the uterus is empty. In Malawi, this is difficult due to lack of transport and money, and the woman can end up with more dangerous septic abortions. Manual vacuum aspiration (MVA) is therefore the preferred surgical method of treatment in Malawi, and recommended by the WHO, FIGO and the Ministry of Health in Malawi. The method is cheap, safe and can be done without electricity by nurses/midwives in addition to doctors.

Research on the treatment of incomplete abortions – My PhD

A fellow medical student, Hanne Rasmussen, had made similar observations with curettage in Ecuador, and came up with the idea to investigate this further. Since I had previous experiences from Malawi we travelled down together in early 2013 to go through all the hospital files on women treated for incomplete abortions the last 4 years in three public hospitals in Malawi. The findings were striking. Even though, the recommendations from WHO and the Ministry of Health was to increase the use of MVA, they were using less and less MVA, and more curettage. This development was in contrast to the guidelines, and curettage is a more costly and dangerous procedure. Malawi already has a high maternal mortality ratio, and a health system that is very low on resources and personnel, and this development would only make things worse, or at least not better. So, we decided to do something about it. Over the last few years I have with my collaborators conducted trainings at three public hospitals in Malawi to increase the use of MVA. We achieved a 21.3% increase in the use of MVA at the intervention hospitals, while there was only a 3% increase at the control hospitals during the same time period. This indicates that simple trainings should be done on a regular basis to sustain the use of MVA rather than curettage. However, it is essential that donors and policy makers make the equipment available and this is something that has to be dealt with.

More trips to Malawi in the future?

So, after living in Malawi three times already I still don’t feel it’s over. When you identify a problem, you can’t just leave it and expect someone else to sort things out. I therefore think my research in Malawi will continue to try and make things better for young women in the country. At the same time, Malawi is captivating and it sucks you in. First of all, it’s a beautiful place, and most importantly the people are amazing. So, you push through the power cuts, lack of water, the broken-down cars, the fear of malaria and different parasites. If you have a rough day you soon forget everything when you are going for run or having a gin and tonic with your friends in the amazing African sunset. To conclude, Malawi is maybe not for everyone, but it’s definitely for me.

 

 

Facts about Malawi

Population 18.09 millions
Gross Domestic Product 5.43 billions
Human Development Index 0.476, Place 170
Life Expectancy at birth 63
Mortality rate (under 5) per 1000 55
Maternal Mortality Ratio per 100 000 births 439
Prevalence of HIV, total (% of population ages 15-49) 9.2

Resource: The World Bank 2016 and Malawi Demographic and Health Survey 2015-2016.

A personal experience from Nepal Earthquake in 2015: Lesson learned from a local hospital

Written by Samita Giri, PhD candidate at NTNU, the Norwegian University of Science and Technology

This is a story about how a collaborative project between Dhulikhel hospital (DH) in Nepal, the Norwegian University of Science and Technology (NTNU) and St. Olav’s Hospital, University Hospital Trondheim, Norway, showed fruitful and life-saving result during the Nepal earthquake in 2015.

On 25 April 2015, middle of the day at 11:56, I felt a very high intensity shake. I was inside the house with my husband. My husband told me that it is an earthquake and he immediately ran out of the house and asked me to run with him. I was unable to move for a few seconds, I rather tried to hide under the bed instead of running out. I was seven months pregnant expecting our first baby in July.  My husband came back to take me out. I could hear people screaming and running to the safest place that they would think of. My family and I was safe and our house was still standing. Within an hour after this first quake, the ambulances, motorbikes, trucks, cars or any kind of transport system that were available started rushing towards the hospital. Some of the victims were even carried by their family members & neighbors with some heavy bleeding. I was living in a few minutes distance from the Dhulikhel Hospital (DH). DH is one of the tertiary level hospital for the Kavrepalanchok district and for few other neighboring districts.

Most of the regular health facilities were closed because of the weekend. My husband decided to go to the hospital the first day. After a while, I received a phone call and it was my supervisor (Prof. Erik Solligård) who was asking if we were safe. I was very happy to hear him. We were outside the whole day. I was very scared to go back to the house and the same feeling was with my family members and my neighbors. We bought some dry foods from the local shops and spend that night in a public bus that was parked in the bus station. We spend our nights outside under the tents and sometimes inside the bus for almost a month after the first earthquake. I started to go to the hospital from the second day to help in the areas that I could. Personally, I also felt more safe being in the hospital and making myself busy. I usually started my work from 8:00 in the morning until 20:00.

I still remember, the second day after the earthquake when I was in the hospital, the number of earthquake injuries escalated in the hospital, all the beds and almost all the space in the courtyard was occupied. The working conditions were continuously demanding. No one was prepared to deal with such a large number of injured patients. This was Nepal’s first experience in responding to a major disaster almost after eight decades and DH had never been the first-line health care provider after an earthquake. However, the hospital was in the process of improving emergency health care through the “Dhulikhel Hospital Patient Care (DHPCARE)” project, a collaborative project initiated in 2013 between DH, the Norwegian University of Science and Technology (NTNU) and St. Olav’s Hospital, University Hospital Trondheim, Norway [1]. The main interventions in this project were the introduction of a systematic emergency registry, a systematic triage system, and simulator training among health personnel in the emergency department (ED). As part of the project, the ED was reorganized to separate patients into three treatment zones (red, orange/yellow, and green) according to four triage categories (red, orange, yellow and green), with separate staff attending each zone since Feb 2015. I was the coordinator from the DH in implementing the project.

DH located in one of the most earthquake-affected districts of Nepal started providing 24 hours health services from day one to the earthquake victims. The hospital set up immediate medical direction, 24-hour surgical services, infection control teams, and logistical management teams, who had a vital role in managing unexpected workloads and providing efficient and quality health care. One of the major task force was the establishment of triage zone at the main entrance of the hospital consisting of medical team and volunteers. We started a systematic screening of patients arriving at the hospital using a simplified triage system, and prioritized patients for effective surgical services. We used color ribbons (red, orange, yellow and green) to distinguish the patient according to the severity and were treated in respective treatment zones. This was evaluated as a useful tool by the staffs at the hospital. I believe this is a great example of teamwork in a local hospital with dedicated staffs working 24 hours prioritizing their profession and humanity rather than their family. On the other hand, collaborations between the two institutions could deliver the quality of health service to the people on right time. At the same time, I was collecting the patient information from the triage zone and the treatment area. I thought this would be useful to report for the future preparedness in similar disasters. I find very challenging to have patients’ information during this emergency phase because the situation was very emotional, hospital had large number of caseloads, and in the first few days the hospital was not able to establish the systematic patient registry system. My two dedicated and hardworking research nurses helped me to accomplish this tremendous work.

DH provided emergency health services to more than 2,000 patients. The caseload was unexpected and was almost five times higher during the first five days than the pre-incident daily average. The majority of injuries were lower limb fractures and over 100 severely injured patients were treated. The proportion of severely injured and in-hospital deaths were relatively low indicating that the most severely injured did not reach the hospital. Most earthquake-affected regions in Nepal were rural and mountainous and there were continuous landslides, which affect transportation and prevent timely access to health facilities. The burden of emergency cases was high before the international field hospitals could be established. The international medical teams need some days after a disaster to initiate their services in the disaster affected areas. Until they arrive, patients are often treated by the poorly developed local health system, and many severely injured likely die prior to receiving medical treatment. Our study result and the local hospital experience underline the importance of developing own consistent and robust local health services capable of managing natural disasters such as an earthquake.

I am a PhD student at the Medical Faculty at NTNU under the supervision of Erik Solligård and Kari Risnes who are the project leaders in the DHECARE project. We had presented the experiences from DH including follow-up of earthquake victims in the article “Impact of 2015 Earthquakes on a local hospital in Nepal: A Prospective Hospital-based Study” in “PLOS ONE”, 2 February 2018.

Samita Giri, NTNU

Welcome to the blog of the Norwegian Research School of Global Health!

Being a PhD candidate in global health is not only about research. On this blog the members of the research school are invited to share stories, pictures and anecdotes from seminars, field works, travels, lectures and other relevant activities.

All members are encouraged to contribute to the blog, so don’t hesitate to get in touch. Contact Turid Austin Wæhler, blog coordinator in NRSGH, or Elin Yli Dvergsdal, coordinator in NRSGH.

 

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