Indigence and access to health care in sub‐Saharan Africa

Access to health care services for the poor and indigent is hampered by current policies of health care financing in sub‐Saharan Africa. This paper reviews the issue as it is discussed in the international literature. No real strategies seem to exist for covering the health care of the indigent. Frequently, definitions of poverty and indigence are imprecise, the assessment of indigence is difficult for conceptual and technical reasons, and, therefore, the actual extent of indigence in Africa is not well known. Explicit policies rarely exist, and systematic evaluation of experiences is scarce. Results in terms of adequately identifying the indigent, and of mechanisms to improve indigents' access to health care, are rather deceiving. Policies to reduce poverty, and improve indigents' access to health care, seem to pursue strategies of depoliticizing the issue of social injustice and inequities. The problem is treated in a ‘technical’ manner, identifying and implementing ‘operational’ measures of social assistance. This approach, however, cannot resolve the problem of social exclusion, and, consequently, the problem of excluding large parts of African populations from modern health care. Therefore, this approach has to be integrated into a more ‘political’ approach which is interested in the process of impoverishment, and which addresses the macro‐economic and social causes of poverty and inequity. Copyright © 1999 John Wiley & Sons, Ltd.     

Stalls in Fertility Transitions in sub‐Saharan Africa: Revisiting the Evidence

Stalls in fertility decline were first identified in Ghana and Kenya in the early 2000s, and since then as many as 20 African countries have been classified in the “stall” category at some point. The countries and time periods in which they occurred are not well established, however, and whether stalls in sub‐Saharan Africa are pervasive or not remains an open question. This article identifies where and when fertility stalls have occurred in sub‐Saharan Africa. I combine a variety of data sources and methods to identify cases of fertility stalls strongly supported by the data. I find unambiguous support for stalls in two countries (Namibia and Zimbabwe), very strong support in three additional countries (Congo, Kenya, and Zambia), and fairly strong support in Cameroon, in the early 2000s. Stalls are possible in seven cases in six other countries (Côte d'Ivoire, Gabon, Madagascar, Nigeria, South Africa, and Tanzania), where evidence is moderate. Fertility stalls in sub‐Saharan Africa are thus not widespread, but they are not exceptional either. Further research on the causes of these stalls is key to a better understanding of the future paths of fertility in sub‐Saharan Africa.     

Exploring the Paradox of Intimate Partner Violence and Increased Contraceptive Use in sub‐Saharan Africa

We question the positive effect of intimate partner violence on women's modern contraceptive use in sub‐Saharan Africa found in previous studies. The explanations offered for this counter‐intuitive result are either that women make greater efforts to avoid childbearing in conflictual relationships, or that endogeneity bias exists. Endogeneity bias stems from the inability of researchers to attribute a specific cause to one variable when they are unable to control for related missing covariates. Demographic and Health Survey data from 13 countries in sub‐Saharan Africa provide evidence for the latter but not the former. Indeed, using simple probit regression models, we observe a positive relationship between intimate partner violence and modern contraceptive use in Burkina Faso, Mali, Nigeria, Tanzania, and Zimbabwe. This effect remains unchanged when controlling for various measures of women's autonomy in the household, showing that these two variables interact with contraceptive use independently. However, the use of recursive bivariate probit and Rosenbaum bounds sensitivity analysis to control for endogeneity biases erodes the initial positive effect in the five countries, although only partially in Burkina Faso. Our research shows that the previously reported findings arise from poor model specification and highlights the need for more appropriate data to assess the effect of intimate partner violence on modern contraceptive use in sub‐Saharan Africa.     

The Africa Center for Biostatistical Excellence: a proposal for enhancing biostatistics capacity for sub‐Saharan Africa

Sub‐Saharan Africa has a shortage of well‐trained biomedical research methodologists, in particular, biostatisticians. In July 2014, a group of biostatisticians and researchers from the region attended a brainstorming workshop to identify ways in which to reduce the deficit in this critical skill. The workshop recognized that recommendations from previous workshops on building biostatistics capacity in sub‐Saharan Africa had not been implemented. The discussions culminated with a proposal to setup an Africa Center for Biostatistical Excellence, a collaborative effort across academic and researcher institutions within the region, as a vehicle for promoting biostatistics capacity building through specialized academic masters programs as well as regular workshops targeting researchers. Copyright © 2015 John Wiley & Sons, Ltd.     

Improving Data Concerning Women's Empowerment in Sub‐Saharan Africa

This study assesses the utility of Demographic and Health Survey (DHS) questions regarding women's empowerment in the context of sub‐Saharan Africa. We examine the use of, and need for improvements to, women's empowerment data in Ghana, Mozambique, Senegal, and Uganda. Drawing on interviews conducted among gender and health experts and on context‐specific literature, our findings reveal that although DHS data are widely used, data needs remain in five areas: economic empowerment, knowledge of legal rights and recourse, participation in decisionmaking, attitudes and social norms, and adolescent girls. We recommend that Demographic and Health Surveys be modified—for example, through adding specific survey items—to fulfill some but not all of these emerging women's empowerment data needs. We also suggest that other surveys fill known gaps and that data users carefully consider the meaning and relative weight of the women's empowerment items according to the cultural context in which the data are collected.     

Recent Trends in Premarital Fertility across Sub‐Saharan Africa

The rising age of first marriage across sub‐Saharan Africa over the past 25 years has led many scholars to predict a concurrent increase in premarital childbearing. We examine whether this anticipated increase has materialized using data from 27 countries. Our results reveal considerable heterogeneity. Although levels of premarital fertility have risen by up to 13 percent in recent years in some African countries, other countries have experienced a 7 percent decline. Adolescent premarital childbearing, in particular, has shown marked decline in several countries. Furthermore, although the rising age of marriage exerts clear upward pressure on premarital fertility, decomposition analyses indicate that in half of the countries examined, other factors such as delayed sexual debut and use of contraception counteract this effect. These results temper concerns about the rising numbers of unwed mothers and demonstrate that countries can simultaneously delay marriage and achieve relatively stable, or even declining, levels of premarital childbearing.     

Good sex/bad sex: the individualised focus of US HIV prevention policy in sub‐Saharan Africa, 1995–2005

The expanding reliance on the health sciences to address social problems is well documented, as are the effects of the social construction of public (health) problems on ‘target’ populations, intervention design and broader social systems. Less attention has been given in the literature to the cultural meanings that configure public health efforts themselves. This study demonstrates how the cultural understandings of sex and sexuality that inform US human immunodeficiency virus (HIV) prevention policy in sub‐Saharan Africa shape policy recommendations. Based on an analysis of 119 US policy documents, a relatively stable and highly gendered narrative of sexual risk was found across the Clinton and (G.W.) Bush administrations. This narrative locates HIV risk in (what is constructed to be) the inevitable clash between women’s sexuality and men’s sexuality, and delineates HIV risk by the form of relationship in which sex occurs. The two narratives diverge at this point, offering different definitions of ‘bad’ sex and ‘good’ sex. This divergence helps to explain the different prevention foci of the administrations – condoms during the Clinton era and abstinence‐outside‐of‐marriage during the Bush administration. In both cases, the sexual risk narrative points to individual targeted prevention strategies, even as the policy identifies structural factors as driving global HIV epidemics.     

Family Planning Outcomes and Primary School Attendance in Sub‐Saharan Africa

This study examines the relationship between women's family planning outcomes and primary school enrollment among their 8‐11‐year‐old children. We analyze household‐ and wider‐context‐level data for 103,000 children in 30 sub‐Saharan African countries. Negative associations with school enrollment are found for those who have short preceding or succeeding birth intervals, a young sibling, or a mother who is pregnant. These findings remain unchanged after controlling for socioeconomic and demographic characteristics. Analysis of interaction effects shows that many associations with family planning outcomes depend on the context in which the household is living, revealing the importance of a situation‐specific approach. Findings indicate that helping families improve their pregnancy planning will increase children's schooling opportunities and lead to more effective use of household and community resources.     

The core of mentorship: medical students' experiences of one-to-one mentoring in a clinical environment

Mentoring has been used in different health care educational programmes, but the core of mentorship, i.e., facilitating the development of medical students' professional competence, has not been explored in depth in the literature. In order to create effective and meaningful mentoring programmes, there is a need for deeper knowledge of the meaning of formal mentorship and, for this, the students' experiences are important. A mentoring program was set up where all medical students were offered a mentor during their first clinical courses; years 3-4. The mentors were physicians and their role as mentors was to support the students and act as sounding-boards, not to teach or assess knowledge. This study aimed to get a deeper understanding of the meaning of mentorship seen from the perspective of undergraduate medical students. A qualitative approach with individual interviews (N = 12) and inductive content analysis was chosen to investigate and interpret the meaning of mentorship. The results comprise three overarching themes: Space, Belief in the future and Transition. Having a mentor gave a sense of security and constituted a 'free zone' alongside the undergraduate programme. It gave hope about the future and increased motivation. The students were introduced to a new community and began to identify themselves as doctors. We would argue that one-to-one mentoring can create conditions for medical students to start to develop some parts of the professional competences that are more elusive in medical education programmes, such as reflective capacity, emotional competence and the feeling of belonging to a community.     

Barriers to implementing WHO's exclusive breastfeeding policy for women living with HIV in sub‐Saharan Africa: an exploration of ideas,interests and institutions

The vertical transmission of HIV occurs when an HIV‐positive woman passes the virus to her baby during pregnancy, delivery or breastfeeding. The World Health Organization's (WHO) Guidelines on HIV and infant feeding 2010 recommends exclusive breastfeeding for HIV‐positive mothers in resource‐limited settings. Although evidence shows that following this strategy will dramatically reduce vertical transmission of HIV, full implementation of the WHO Guidelines has been severely limited in sub‐Saharan Africa. This paper provides an analysis of the role of ideas, interests and institutions in establishing barriers to the effective implementation of these guidelines by reviewing efforts to implement prevention of vertical transmission programs in various sub‐Saharan countries. Findings suggest that WHO Guidelines on preventing vertical transmission of HIV through exclusive breastfeeding in resource‐limited settings are not being translated into action by governments and front‐line workers because of a variety of structural and ideological barriers. Identifying and understanding the role played by ideas, interests and institutions is essential to overcoming barriers to guideline implementation. Copyright © 2012 John Wiley & Sons, Ltd.     

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.     

Undergraduate nursing students' experiences in a rural clinical placement

Objective: This paper draws on questionnaire findings and analysis of students' comments to demonstrate the aspects of rural placements that were effective in engaging students in the learning process. It also examined how a primary health care clinical placement in Aboriginal communities can provide nursing students with a rich and varied learning experience and an insight into the complex aspects of rural life including Aboriginal health. Design: A cohort of eight second‐year nursing students from the Australian Catholic University, North Sydney, in partnership with the Broken Hill University Department of Rural Health (BHUDRH), participated in a 4 weeks' rural placement in far western New South Wales. A pre‐test/post‐test questionnaire was used to capture their experiences with the students completing the questionnaires before and after their clinical placements. Such placements offer students opportunities to deepen their understanding of issues related to rural health in clinical, professional, social and community contexts. Results: The results suggest that clinical experience in rural areas can positively influence attitudes, preparedness for practice and engage students on many levels, deepened their understanding of rural communities and issues related to rural health. Conclusion: This group of undergraduate nursing students indicated they all had a positive learning experience in their rural clinical placement. The value of rural placements as a method for increasing nursing student's practical experience should be promoted.