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The article draws on the Cynefin framework to illuminate how distinct sensemaking boundaries appeared to co-exist among the two main group of actors, health experts and political leaders, during the crucial early response phase of the COVID-19 outbreak in Denmark. The Danish government was in a chaotic sensemaking frame where major decisions needed to be made fast to avoid an impending disaster, and where scientific evidence was not pivotal to the decision-making process. The leading health authorities, on the other hand, appeared to be in a complicated sensemaking frame where evidence-based decision-making was still the modus operandum, and where policy recommendations were continuously reassessed in light of new scientific data. These two sensemaking frames clashed both publicly and internally, exposing a lack of understanding and communication across different sensemaking frames. Based on the analysis, we recommend two overarching initiatives to bridge contradictory sensemaking boundaries in times of major crises: (i) training in identifying and acknowledging different sensemaking frames; (ii) communication strategies that are sensitive to the sensemaking frames of other actors in the decision-making process.

Abstract In 1999 Hurricane Floyd pummeled the eastern portion of North Carolina (NC, U.S.A.), and in its wake many localities participated in federal home acquisition-relocation programs in flood-prone areas, with shared and devolved governance. This article reports on one such program that was conducted in the City of Kinston, where a historical African-American neighborhood called Lincoln City was badly flooded by water containing raw sewage from a compromised wastewater treatment plant upstream. Afterwards, some of the acquired homes were relocated to an adjacent area populated by middle-class, African-American families. The article explores to what extent political devolution of flood mitigation disempowered residents to deal with this crisis in their waterscape. Combining a framework from medical anthropology regarding the logics of choice and care with historical political ecology, it illustrates how devolved government policy led to a continuation of the waterscape's discriminatory history after the buyout program, with no recourse for local citizens as the program worked through a logic of choice that demarcated responsibilities. Understanding this case requires a historically informed assessment of social impact, in which the chosen flood mitigation measures are critically assessed using tools from historically-informed political ecology, leading to a longerterm logic of care where needed. Keywords: Devolution, flooding, path-dependency, waterscape, buyout, mitigation, care, choice

Abstract In 1999 Hurricane Floyd pummeled the eastern portion of North Carolina (NC, U.S.A.), and in its wake many localities participated in federal home acquisition-relocation programs in flood-prone areas, with shared and devolved governance. This article reports on one such program that was conducted in the City of Kinston, where a historical African-American neighborhood called Lincoln City was badly flooded by water containing raw sewage from a compromised wastewater treatment plant upstream. Afterwards, some of the acquired homes were relocated to an adjacent area populated by middle-class, African-American families. The article explores to what extent political devolution of flood mitigation disempowered residents to deal with this crisis in their waterscape. Combining a framework from medical anthropology regarding the logics of choice and care with historical political ecology, it illustrates how devolved government policy led to a continuation of the waterscape's discriminatory history after the buyout program, with no recourse for local citizens as the program worked through a logic of choice that demarcated responsibilities. Understanding this case requires a historically informed assessment of social impact, in which the chosen flood mitigation measures are critically assessed using tools from historically-informed political ecology, leading to a longerterm logic of care where needed. Keywords: Devolution, flooding, path-dependency, waterscape, buyout, mitigation, care, choice

Since the 1990s, the United States Federal Emergency Management Agency (FEMA) has promoted voluntary "buyout" programs to relocate property owners out of floodplains. In this paper we evaluate perceived voluntariness of these initiatives. We use local mitigation official interviews and property owner surveys conducted in four post-disaster buyout program sites. We show that there is considerable variability in property-owner's experience of buyout programs and their sense of voluntariness, despite high buyout acceptance rates. We find that the paradox facing program managers is that buyout participants perceive the process to be less voluntary compared to those who did not accept the offer. Because local mitigation officials simultaneously act in the interest of the government while working with flooded property owners, voluntariness is not guaranteed. Low social capital of flood victims tends to lead to situations where buyouts are successfully expedited during post-crisis, temporal "windows of opportunity" and local perceptions of voluntariness are compromised.

What was the impact of physical distancing on socially vulnerable groups needing care during the first COVID-19 pandemic lockdown in the Netherlands? We conducted repeated qualitative interviews with 141 people in care relationships and 106 professionals, and two repeated surveys among older populations outside (n = 1697) and inside long-term care facilities (n = 2619). Findings show a diversity of experiences, ranging from relative calmness and feeling socially normal, to loneliness and loss of perspective. Care must be seen as essential social traffic needed to guarantee basic quality of life for these groups during disease outbreaks. Findings emphasise an empirical ethics approach to policy interventions.

Background: This paper describes a participatory methodology that supports investigation of the synergistic collaboration between communities affected by infectious disease outbreak events and relevant official institutions. The core principle underlying the methodology is the recognition that synergistic relationships, characterised by mutual trust and respect, between affected communities and official institutions provide the most effective means of addressing outbreak situations. Methods: The methodological approach and lessons learned were derived from four qualitative case studies including (i) two tick-borne disease events (Crimean-Congo haemorrhagic fever in Spain, 2016, and tick-borne encephalitis in the Netherlands, 2016); and (ii) two outbreaks of acute gastroenteritis (norovirus in Iceland, 2017, and verocytotoxin-producing Escherichia coli [VTEC] in Ireland, 2018). An after-event qualitative case study approach was taken using mixed methods. The studies were conducted in collaboration with the respective national public health authorities in the affected countries by the European Centre for Disease Prevention and Control (ECDC). The analysis focused on the specific actions undertaken by the participating countries' public health and other authorities in relation to community engagement, as well as the view from the perspective of affected communities. Results: Lessons highlight the critical importance of collaborating with ECDC National Focal Points during preparation and planning and with anthropological experts. Field work for each case study was conducted over one working week, which although limiting the number of individuals and institutions involved, still allowed for rich data collection due to the close collaboration with local authorities. The methodology enabled efficient extraction of synergies between authorities and communities. Implementing the methodology required a reflexivity among fieldworkers that ackowledges that different versions of reality can co-exist in the social domain. The method allowed for potential generalisability across studies. Issues of extra attention included insider-outsider perspectives, politically sensitivity of findings, and how to deal with ethical and language issues. Conclusions: The overall objective of the assessment is to identify synergies between institutional decision-making bodies and community actors and networks before, during and after an outbreak response to a given public health emergency. The methodology is generic and could be applied to a range of public health emergencies, zoonotic or otherwise.

BackgroundHIV is an important factor affecting healthcare workforce capacity in high‐prevalence countries, such as Swaziland. It contributes to loss of valuable healthcare providers directly through death and absenteeism and indirectly by affecting family members, increasing work volume and decreasing performance. This study explored perceived barriers to accessing HIV/AIDS care and prevention services among health workers in Swaziland. We asked health workers about their views on how HIV affects Swaziland's health workforce and what barriers and strategies health workers have for addressing HIV and using healthcare treatment facilities.MethodsThirty‐four semi‐structured, in‐depth interviews, including a limited set of quantitative questions, were conducted among health workers at health facilities representing the mixture of facility type, level and location found in the Swaziland health system. Data were collected by a team of Swazi nurses who had received training in research methods. Study sites were selected using a purposive sampling method while health workers were sampled conveniently with attention to representing a mixture of different cadres. Data were analyzed using Nvivo qualitative analysis software and Excel.ResultsHealth workers reported that HIV had a range of negative impacts on their colleagues and identified HIV testing and care as one of the most important services to offer health workers. They overwhelmingly wanted to know their own HIV status. However, they also indicated that in general, health workers were reluctant to access testing or care as they feared stigmatization by patients and colleagues and breaches of confidentiality. They described a self‐stigmatization related to a professional need to maintain a HIV‐free status, contrasting with the HIV‐vulnerable general population. Breaching of this boundary included feelings of professional embarrassment and fear of colleagues' and patients' judgements.ConclusionsWhile care is available and relatively accessible, Swaziland health workers still face unique usage barriers that relate to a self‐stigmatizing process of boundary maintenance ‐ described here as a form of "othering" from the HIV‐vulnerable general population ‐ and a lack of trust in privacy and confidentiality. Interventions that target health workers should address these issues.

BACKGROUND: Although many success stories exist of Village Health Workers (VHWs) improving primary health care, critiques remain about the medicalisation of their roles in disease-specific interventions. VHWs are placed at the bottom of the health system hierarchy as cheap and low-skilled volunteers, irrespective of their highly valued social and political status within communities. In this paper, we shed light on the political role VHWs play and investigate how this shapes their social and medical roles, including their influence on community participation. METHOD: The study was carried out within the context of a malaria elimination trial implemented in rural villages in the North Bank of The Gambia between 2016 and 2018. The trial aimed to reduce malaria prevalence by treating malaria index cases and their potentially asymptomatic compound members, in which VHWs took an active role advocating their community and the intervention, mobilising the population, and distributing antimalarial drugs. Mixed-methods research was used to collect and analyse data through qualitative interviews, group discussions, observations, and quantitative surveys. RESULTS AND DISCUSSION: We explored the emic logic of participation in a malaria elimination trial and found that VHWs played a pivotal role in representing their community and negotiating with the Medical Research Council to bring benefits (e.g. biomedical care service) to the community. We highlight this representative role of VHWs as 'health diplomats', valued and appreciated by community members, and potentially increasing community participation in the trial. We argue that VHWs aspire to be politically present and be part of the key decision-makers in the community through their health diplomat role. CONCLUSION: It is thus likely that in the context of rural Gambia, supporting VHWs beyond medical roles, in their social and political roles, would contribute to the improved performance of VHWs and to enhanced community participation in activities the community perceive ...

This open access book explores the intersection of property law, relocation, and resettlement processes in the United States and among communities that grapple with migration as an adaptation strategy. As communities face the prospect of relocating because of rising seas, policy makers, disaster specialists, and community leaders are scrambling to understand what adaptation pathways are legally possible. While in its ideal application, law functions blindly and without variation, the authors find that legal contradictions come to bear on resettlement processes and place certain communities further in harm's way. This book will unearth these contradictions in order to understand why successful community-based resettlement has presented such a challenge to communities that are experiencing increasing land deterioration as a result of climate change.

Background: Communities affected by infectious disease outbreaks are increasingly recognised as partners with a significant role to play during public health emergencies. This paper reports on a qualitative case study of the interactions between affected communities and public health institutions prior to, during, and after two emerging tick-borne disease events in 2016: Crimean-Congo Haemorrhagic Fever in Spain, and Tick-Borne Encephalitis in the Netherlands. The aim of the paper is to identify pre-existing and emergent synergies between communities and authorities, and to highlight areas where synergies could be facilitated and enhanced in future outbreaks. Methods: Documentary material provided background for a set of semi-structured interviews with experts working in both health and relevant non-health official institutions (13 and 21 individuals respectively in Spain and the Netherlands), and focus group discussions with representatives of affected communities (15 and 10 individuals respectively). Data from all sources were combined and analysed thematically, initially independently for each country and then for both countries together. Results: Strong synergies were identified in tick surveillance activities in both countries, and the value of pre-existing networks of interest groups for preparedness and response activities was recognised. However, authorities also noted that there were hard-to-reach and potentially vulnerable groups, such as hikers, foreign tourists, and volunteers working in green areas. While the general population received preventive information about the two events, risk communication or other community engagement efforts were not seen as necessary specifically for these sub-groups. Post-event evaluations of community engagement activities during the two events were limited, so lessons learned were not well documented. Conclusions: A set of good practices emerged from this study, that could be applied in these and other settings. They included the potential value of conducting stakeholder analyses of community actors with a stake in tick-borne or other zoonotic diseases; of utilising pre-existing stakeholder networks for information dissemination; and of monitoring community perceptions of any public health incident, including through social media. Efforts in the two countries to build on the community engagement activities that are already in place could contribute to better preparedness planning and more efficient and timely responses in future outbreaks.

Background: Conducting health impact assessments (HIAs) is a growing practice in various organizations and countries, yet scholarly interest in HIAs has primarily focused on the synergies between exposure and health outcomes. This limits our understanding of what factors influence HIAs and the uptake of their outcomes. This paper presents a framework for conducting participatory quantitative HIA (PQHIA) in low- and middle-income countries (LMICs), including integrating the outcomes back into society after an HIA is conducted. The study responds to the question: what are the different components of a participatory quantitative model that can influence HIA implementation in LMICs? Methods: To build the framework, we used a case study from a PQHIA fieldwork model developed in Port Louis (Mauritius). To explore thinking on the participatory components of the framework, we extract and analyze data from ethnographic material including fieldnotes, interviews, focus group discussions and feedback exercises with 14 stakeholders from the same case study. We confirm the validity of the ethnographic data using five quality criteria: credibility, transferability, dependability, confirmability, and authenticity. We build the PQHIA framework connecting the main HIA steps with factors influencing HIAs. Results: The final framework depicts the five standard HIA stages and summarizes participatory activities and outcomes. It also reflects key factors influencing PQHIA practice and uptake of HIA outcomes: costs for participation, HIA knowledge and interest of stakeholders, social responsibility of policymakers, existing policies, data availability, citizen participation, multi-level stakeholder engagement and multisectoral coordination. The framework suggests that factors necessary to complete a participatory HIA are the same needed to re-integrate HIA results back into the society. There are three different areas that can act as facilitators to PQHIAs: good governance, evidence-based policy making, and access to resources. Conclusions: The framework has several implications for research and practice. It underlines the importance of applying participatory approaches critically while providing a blueprint for methods to engage local stakeholders. Participatory approaches in quantitative HIAs are complex and demand a nuanced understanding of the context. Therefore, the political and cultural contexts in which HIA is conducted will define how the framework is applied. Finally, the framework underlines that participation in HIA does not need to be expensive or time consuming for the assessor or the participant. Yet, participatory quantitative models need to be contextually developed and integrated if they are to provide health benefits and be beneficial for the participants. This integration can be facilitated by investing in opportunities that fuel good governance and evidence-based policy making.

Background: Conducting health impact assessments (HIAs) is a growing practice in various organizations and countries, yet scholarly interest in HIAs has primarily focused on the synergies between exposure and health outcomes. This limits our understanding of what factors influence HIAs and the uptake of their outcomes. This paper presents a framework for conducting participatory quantitative HIA (PQHIA) in low- and middle-income countries (LMICs), including integrating the outcomes back into society after an HIA is conducted. The study responds to the question: what are the different components of a participatory quantitative model that can influence HIA implementation in LMICs?. Methods: To build the framework, we used a case study from a PQHIA fieldwork model developed in Port Louis (Mauritius). To explore thinking on the participatory components of the framework, we extract and analyze data from ethnographic material including fieldnotes, interviews, focus group discussions and feedback exercises with 14 stakeholders from the same case study. We confirm the validity of the ethnographic data using five quality criteria: credibility, transferability, dependability, confirmability, and authenticity. We build the PQHIA framework connecting the main HIA steps with factors influencing HIAs. Results: The final framework depicts the five standard HIA stages and summarizes participatory activities and outcomes. It also reflects key factors influencing PQHIA practice and uptake of HIA outcomes: costs for participation, HIA knowledge and interest of stakeholders, social responsibility of policymakers, existing policies, data availability, citizen participation, multi-level stakeholder engagement and multisectoral coordination. The framework suggests that factors necessary to complete a participatory HIA are the same needed to re-integrate HIA results back into the society. There are three different areas that can act as facilitators to PQHIAs: good governance, evidence-based policy making, and access to resources. Conclusions: The framework has several implications for research and practice. It underlines the importance of applying participatory approaches critically while providing a blueprint for methods to engage local stakeholders. Participatory approaches in quantitative HIAs are complex and demand a nuanced understanding of the context. Therefore, the political and cultural contexts in which HIA is conducted will define how the framework is applied. Finally, the framework underlines that participation in HIA does not need to be expensive or time consuming for the assessor or the participant. Yet, participatory quantitative models need to be contextually developed and integrated if they are to provide health benefits and be beneficial for the participants. This integration can be facilitated by investing in opportunities that fuel good governance and evidence-based policy making.