Changing stigmatisation of leprosy: an exploratory, qualitative life course study in Western Nigeria.

INTRODUCTION: Renewed interest in health-related stigma has invigorated calls to understand factors and processes underlying stigma. However, few empirical studies explore the influences of structural discrimination and moral status on leprosy-related stigma. We investigated how sociocultural context and organisational policies and practices influenced the connotations of leprosy, sources of stigma and the changing social responses to leprosy in Western Nigeria. METHODOLOGY: Ethnographic research conducted between 2008 and 2012 combined documents review with life history interviews of 21 individuals affected by leprosy and semistructured interviews with 26 community members in Western Nigeria. Interviews were audiotaped, transcribed verbatim and coded. Theoretical frameworks used to deepen social understandings of leprosy and responses to stigma included Link's and Phelan's conceptualisation of stigma and the concepts of structural discrimination and moral status. RESULTS: Findings showed that connotations of leprosy in Yorùbá culture included the following: (i) perception of leprosy as the most shameful and detested condition and (ii) symbolic association with filth and immoral behaviour that is dishonouring to Yorùbá identity. Secondary analysis of archival materials revealed four sources of stigma: cultural beliefs about leprosy, health promotion messages embedded in primary school books, religious teachings about leprosy and campaigns conducted by the leprosy service in 1950s. Contrary to the portrayal of Yorùbá attitudes to leprosy as entirely negative, we identified that people affected by leprosy were creating new life courses to counter existing cultural accounts of marginalisation. Emerging narratives of inclusion outlined five facilitators of acceptance namely, antileprosy treatment, good moral character, supportive family networks, livelihoods, and contribution to community survival. CONCLUSION: Gaps highlighted by this study suggest that the global target of zero stigma and discrimination of leprosy will remain unattainable without better understanding of cultural significance(s) of leprosy and the local sources and underlying drivers of stigma that are crucial for developing context-specific stigma reduction interventions.

"Who Will Marry a Diseased Girl?" Marriage, Gender, and Tuberculosis Stigma in Asia.

In a qualitative study on the stigma associated with tuberculosis (TB), involving 73 interviews and eight focus groups conducted in five sites across three countries (Bangladesh, Nepal, and Pakistan), participants spoke of TB's negative impact on the marriage prospects of women in particular. Combining the approach to discovering grounded theory with a conceptualization of causality based on a realist ontology, we developed a theory to explain the relationships between TB, gender, and marriage. The mechanism at the heart of the theory is TB's disruptiveness to the gendered roles of wife (or daughter-in-law) and mother. It is this disruptiveness that gives legitimacy to the rejection of marriage to a woman with TB. Whether or not this mechanism results in a negative impact of TB on marriage prospects depends on a range of contextual factors, providing opportunities for interventions and policies.

Capacity to conduct health research among NGOs in Malawi: Diverse strengths, needs and opportunities for development.

BACKGROUND: The role of non-governmental organisations (NGOs) in health research has attracted growing attention. NGOs are important service providers and advocates in international health, and conducting research can help NGOs to strengthen these service delivery and advocacy activities. However, capacity to conduct research varies among NGOs. There is currently limited evidence on NGOs' research capacity that can explain why capacity varies or indicate potential areas for support. We examined NGOs' capacity to conduct research, identifying factors that affect their access to the funds, time and skills needed to undertake research. METHODS: We examined research capacity through qualitative case studies of three NGOs in Malawi, including one national and two international NGOs. Data were generated through interviews and focus groups with NGO staff, observation of NGO activities, and document reviews. RESULTS: Availability of funding, skills and time to conduct research varies considerably between the case NGOs. Access to these resources is affected by internal processes such as sources of funding and prioritisation of research, and by the wider environment and external relationships, including the nature of donor support. Constraints include limited ability to apply for research funding, a perception that donors will not support research costs, lack of funding to hire or train research staff, and prioritisation of service delivery over research in funding proposals and staff schedules. CONCLUSION: The findings suggest strategies for NGOs and for donors interested in supporting NGOs' research capacity. Above all, the findings reinforce the importance of initial capacity assessments to identify organisational needs and opportunities. In addition, the need for time and funding as well as skills suggests that strengthening NGOs' research capacity will often require more than research training.

Can "realist" randomised controlled trials be genuinely realist?

In this paper, we respond to a paper by Jamal and colleagues published in Trials in October 2015 and take an opportunity to continue the much-needed debate about what applied scientific realism is. The paper by Jamal et al. is useful because it exposes the challenges of combining a realist evaluation approach (as developed by Pawson and Tilley) with the randomised controlled trial (RCT) design.We identified three fundamental differences that are related to paradigmatic differences in the treatment of causation between post-positivist and realist logic: (1) the construct of mechanism, (2) the relation between mediators and moderators on one hand and mechanisms and contexts on the other hand, and (3) the variable-oriented approach to analysis of causation versus the configurational approach.We show how Jamal et al. consider mechanisms as observable, external treatments and how their approach reduces complex causal processes to variables. We argue that their proposed RCT design cannot provide a truly realist understanding. Not only does the proposed realist RCT design not deal with the RCT's inherent inability to "unpack" complex interventions, it also does not enable the identification of the dynamic interplay among the intervention, actors, context, mechanisms and outcomes, which is at the core of realist research. As a result, the proposed realist RCT design is not, as we understand it, genuinely realist in nature.

Health system decentralisation in Nepal: identifying the issues.

PURPOSE: The purpose of this paper is to describe and discuss policy analysis in Nepal and review the wide range of choices feasible in decentralisation decision making. DESIGN/METHODOLOGY/APPROACH: In this paper an iterative qualitative method was developed and used in the research, which consisted of focus group interviews, key informant interviews, document analysis, including descriptive statistics, and analysis of the policy context. Participants in the research reflected the urban/rural mix of districts and the geography of Nepal. Analysis combined transcribed interviews with findings from document searches and analysis of the policy context. Coding was pre-determined during the training workshop and further codes were generated during and after the fieldwork. FINDINGS: The paper finds that Nepal is in the process of decentralising public services from the central level to the local level, particularly to local bodies: District Development Committees (DDCs), Village Development Committees (VDCs) and Municipalities. Key contextual factors referred to are the overall structure of decentralisation, the social context of poverty and the political instability leading to a fluid political situation characterised by political tension, armed conflict, controversies and agreements while carrying out the research. The key issues identified and discussed in the paper are the policy process leading to decentralisation, the organisational structure and tension in the proposed system, the systems of resource generation, allocation, planning and management and lastly the forms of accountability, participation, public-private relations and collaborative strategies. ORIGINALITY/VALUE: The paper discusses the challenges faced in conducting such a policy analysis, the broad ranging and unremitting nature of the decentralisation process, and the contextual setting of the process of change.

Perceptions of the health effects of stoves in Mongolia.

PURPOSE: The purpose of this paper is to evaluate the views of stove users in Ulaanbaatar, Mongolia on how stoves affect their health. DESIGN/METHODOLOGY/APPROACH: In this paper focus groups were conducted with improved stove users; traditional stove users; and a mix of traditional and improved stove users. Individual interviews were also held with various types of stove users. A translator moderated all discussions with a questioning route. All discussions were fully transcribed and translated. The transcripts were analysed by identifying common themes in responses to form an emerging theory. FINDINGS: The findings in the paper are that all stove users recognised respiratory symptoms caused by stove smoke and other health effects such as warmth, dirt and workload, which they perceived to be important. Stove users had a lack of knowledge about the diseases caused by the smoke. Public health was a key driver for the improved stove project, yet has been neglected in improved stove marketing. RESEARCH LIMITATIONS/IMPLICATIONS: The study used in this paper was limited by the language barrier. Some of the meanings of participants' responses may have been lost in translation. PRACTICAL IMPLICATIONS: This paper has highlighted the importance of the health effects of stove smoke to stove users. Uptake of the improved stoves has been low. Public health should be included in marketing strategies for improved stoves to increase their uptake. ORIGINALITY/VALUE: The paper shows that acute respiratory infections are a major cause of mortality world-wide. Indoor air pollution from burning biomass fuels in household stoves causes a significant proportion of respiratory infections. No qualitative research has been published exploring stove users' views on the health effects of stoves. This paper provides an insight into stove users' perceptions for those interested in people-centred approaches to tackling international health issues.

International health in medical education: students' experiences and views.

PURPOSE: The purpose of this paper is to describe the experiences and views of the first group of medical students to complete the intercalated International Health BSc in Leeds. DESIGN/METHODOLOGY/APPROACH: The paper draws on experiences of international health and draws parallels with those of other international health students. The paper also discusses how studying international health may benefit future doctors and considers how medical education can take a more international approach. FINDINGS: The paper finds that international health education can help future doctors acquire knowledge and skills in refugees' health, patients' cultural differences, the multifactoral influences on health, policymaking, the interests of various stakeholders, problem-solving skills and evidence-based medicine. PRACTICAL IMPLICATIONS: The paper shows that international health teaching is both relevant and valuable in medical education. The medical profession should give more recognition to its worth. ORIGINALITY/VALUE: This is the first paper to reflect on medical students' experiences of studying for an intercalated BSc at Leeds. It makes some important points about international health education for doctors and medical students world-wide.